Ethic of Care or Solidarity Pact?

About: Marie Gaille, En soutien à la vie. Éthique du care et médecine, Vrin

Care, a philosophical concept of American origin that evokes attention, concern, and solicitude, was first used by the psychologist Carol Gilligan in the early 1980s. [1] Gilligan presented the ethic of care as the concern for others and the desire to maintain the bonds forged with them. In the 1990s, Berenice Fisher and Joan Tronto further elaborated this ethic by emphasizing “the interdependence between human beings against the vision of the atomized individual.” [2]

The ethic of care was initially adopted in medical and paramedical practice, attracting the attention of many researchers. It was then extended to all aspects of political and moral life. Today, it applies to the person in general (and not just to patients) and to all living spaces, including work and the private sphere.

Repairing Our World

Thanks to the discovery of antibiotics and advances in cardiovascular medicine, life expectancy improved dramatically in the second half of the 20^th century. This, however, led to the development of new cancers and chronic diseases, which forced medical practitioners to adapt to new types of patients.

Over time, the medical profession abandoned the paternalistic logic in favor of the logic of choice, which is based on the conception of the rational, responsible, and autonomous individual inherited from Enlightenment philosophy. Yet, the logic of choice now seems outdated. It is increasingly being replaced by the opposite logic of care, which entails taking seriously the physical and psychological needs of patients. As Annemarie Mol observes, the art of care is to “act without seeking to exercise control.” [3]

In her new book, En soutien à la vie (In support of life), Marie Gaille, philosopher and director of the CNRS’s Institut des sciences, humaines et sociales, freely defines care as:

[A] generic activity that includes everything we do to maintain, perpetuate, and repair our world, such that we can live in it as well as possible.

According to Gaille, the ethic of care helps to renew reflection on medical practice, insofar as medical acts “all constitute forms of support for life.” It also enables the “interrogation of the normative orientations of contemporary medicine and the way in which we collectively conceive of its place in present and future society through the healthcare system.”

Gaille’s commentary builds methodologically on the different aspects of care (caring about, taking care of, caregiving, caring democracy) and on a wide range of medical situations.

Accompaniment as a Form of Care

The first aspect of care examined by Gaille is the accompaniment of terminally ill and dying patients. The “renunciation to cure” dates back to the start of the HIV epidemic. At the time, physicians and patients were “confronted with something that [was] beyond them and [had] no choice but to observe the progression of the disease.” Patient accompaniment then appeared as a “form of care in its own right” in end-of-life situations. It was subsequently extended to all chronic and/or incurable diseases and came to involve all healthcare professionals—from physicians to psychologists.

Palliative care and the regulation of end-of-life decisions were initiated the 1980s and culminated in the 2016 Claeys-Leonetti law, which defined the conditions for accompanying dying patients. Today, “accompaniment is no longer limited to palliative care”; it is conceived rather as the “hallmark of a solidary society.” As an “activity in support of life,” accompaniment can be either medical or non-medical and must respect the autonomy of the person.

The second chapter is devoted to individual autonomy and to the place of the patient in the care relationship. In 1947, the Nuremberg Code established the framework for patient consent to participation in medical experiments. This framework then gradually evolved into shared decision-making between physicians and patients. The ethic of care now allows for a benevolent medical stance that is adapted to the individual and to the temporality of the patient.

An example of the application of care to the patient-practitioner relationship is “therapeutic education,” which consists in providing information to chronically ill patients and to their relatives or carers. This practice is part of an individually tailored approach that builds on accompaniment and patient participation to improve compliance and quality of life. Therapeutic education also entails a learning partnership between the healthcare professional and the patient.

Defining the Threshold

The patient-practitioner relationship is evolving, which raises the question of how care should be provided today. The third chapter explores this question by focusing on caregiving. Here, Gaille observes that the ethic of care introduces a form of “cunning” (métis in Greek) in the practice of caregiving: an “adjustment to the patient.” Through this cunning, the ethic of care reconnects with the medical art. As “side-steps” specific to each patient-practitioner relationship, adjustments by caregivers are aimed at “creating a beneficial relationship.” [4]

There is nevertheless a latent conflict in the care relationship, for the patient is seen by several caregivers and the caregiver sees several patients. Yet, as Gaille makes clear, this conflict is “a safeguard against the illusion that accompaniment has become a consensual standard for dealing with end-of-life situations.”

Unfortunately, adjustments are difficult to make on a day-to-day basis due to insufficient training of healthcare professionals, the illusion of medical omnipotence, and differences in personal conceptions of what constitutes a “good life.” The ethic of care, whose aim is to ensure that every person can “live as well as possible,” requires a dialogue between the patient and the medical team. It also entails “the extension of medical care to all forms of life and in all parts of the world.”

The fourth chapter analyzes the support of life in all its forms. In France, it has been decided to:
[C]onsider that there is no form of life worth living more than others, and to refrain from defining a legal threshold for a life worth living or from establishing a list of pathologies that would justify a decision to terminate pregnancy, treatment, etc.

The patient and the physician are called upon to define this threshold, as personal or philosophical judgements of what constitutes a “life worth living” are “plural, even antagonistic.” At present, the ethical orientation of “making live and letting die” seems to predominate. Yet, preserving life in all its forms can involve “competing and even mutually incompatible options.” The most recent illustration of this is the variability of international responses to the covid pandemic, all of which were aimed at “saving the greatest number of human lives.” The ethic of care, which lacks a definition of a life worth supporting and enjoins us “to firmly hold onto indeterminacy,” keeps this reflection alive.

The final chapter proposes to extend the ethic of care to a model of “ecological medicine, based on the notion of planetary health.” Given the interdependence, vulnerability, and non-hierarchical nature of “the lives that care strives to support,” medical policy should take into account “the wild side of the world.” The pursuit of this model of planetary health (as opposed to the current model centered on human health) could begin with information and prevention policies aimed at raising awareness of the medical risks associated with global warming.

The Thought of Levinas

According to Gaille, the ethic of care can help to renew ethical reflection in medicine by fostering a rich inter-individual and collective dialogue on local and global medical issues of the present and the future. The aim is to facilitate the support of life—as good a life as possible in our threatened environment.

Yet, does the adoption of the ethic of care in the philosophy of medicine bring anything new to current reflection on the healthcare system in France? Levinas’s writings on the inter-human bond, according to which the vulnerability and mortality of the other demand of everyone everywhere a responsibility of care, attention, and assistance, have already instigated the very renewal of care that Gaille calls for.

Finally, it should be noted that the ethic of care emerged in the United States in the 1980s as a way of compensating for the lack of solidarity in a neoliberal society. By contrast, the French institutional system is founded on solidarity at every level (between generations, between the sick and the healthy, between relatives and non-relatives, etc.). Regrettably, the book lacks a discussion of the links between the adoption of the ethic of care in France and the breakdown of our solidarity pact (and therefore of our medical institutions), despite the fact that a healthcare system worthy of the name should by its very nature be the bearer and guarantor of a “medicine of care.”