Contested care – how to approach it in a care-ethical way?

German, Canadian and Dutch academic teachers and students came together in a workshop on care ethics which was organized at the university of Vechta (Germany) on June 15, 2018.

It was a small scale exchange, with ample opportunity for discussion. Different national perspectives and diverse scientific disciplines were brought together in a discussion manifesting the multi-dimensionality within care-ethical considerations. The leading question referred to an issue that seems to be obfuscated in care-ethical discussions: how to think about conflict, tension and frictions within care and care ethics? What kind of epistemology is at stake?

Although the contributions were diverse, the relevance of two different dimensions emerged in all of them, firstly the particular, personal lived experience in care-situations and secondly the influential particular political context. The significance of the latter became evident in the comparison of different national (health)care-systems and their effects on the working conditions of care-workers. Whereas caring in a well-established institutional context can be defined as acting with a certain degree of professional autonomy, on the other hand caring activities in organizations with low status, may be framed as ‘labor’. The work of caregivers gets this label of ‘labor’, because it is related to a low degree of autonomy.

Contested Care in Canada

This is illustrated by the following example, contributed to Monique Lanoix: the Canadian long-term care for elderly people is not anchored as a civil right and therefore not part of the national health system. The Canadian homes for the elderly are privately organized as respite-care in case the elder cannot stay with his/her family. The care-workers who are in charge of the needy seniors are caught up in the small amount of time available for each individual; there is a tight minute-to-minute protocol with few options to choose from in unexpected situations. Thus dilemma’s occur and moral distress becomes a symptom of this ‘pathogenic’ vulnerability of the co-workers who, moreover, are frequently exposed to care-situations which the protocols do not address.

These issues arising from political considerations concerning national health-systems, are intensely linked to particular private-professional lived experiences. The care-worker who suffers from a ‘pathogenic’ type of vulnerability cannot gain any relevant experience bringing him/her closer to the patient, nor to adequate appraisal of given care. In addition, this problem is aggravated by the low status of professional caretaking when framed as ‘labor’, which results in care-workers frequently changing jobs. In doing so, their level of personal experience remains low. This is a structural problem. It cannot be solved by training-on-the-job in order to build up more professional experience, even more so if the experience gets lost through the fluctuation of the care-workers. Furthermore, one must distinguish between opportunities to obtain professional experience with all kinds of care-situations including the unexpected, in a long-lasting professional care-practice on the one hand, and in controlled short-time training situations on the other hand. Nothing can substitute good working conditions that safeguard care professionals from moral distress and job fluctuation, in combination with a certain amount of professional autonomy.

At this point we are back to the political dimension, more specific the social state-policy, in the manner it can be related to the personal-professional lived experience. Although the particularities of care-situations are unique, yet we cannot deny the far-reaching influence of social policy as shown above. When we take into account the political dimension as well as the conclusion that personal, lived experience is tantamount to making contact with ‘the (needy) other’ as key factor for caring activities: what does this mean for a ‘caring civil society’? Would social assistance activities, imposed on every citizen for a period of six months (for instance), foster this experience? Can working experience in a personalized way be imposed?

Contested Care in Germany

A different angle was taken by another contribution to the workshop, by Carolin Jendricke, who presented the research of her master thesis. Senior citizens’ homes in Germany have a legal basis on which they are financed. From the 1990’s on, inhabitants of Germany are compulsorily insured in case they will need care in old age. Tax money is used as well to finance these homes. Nursing care for senior citizens is therefore a state task; due to austerity the economization within care-institutions has been increasing in recent times. Objectives of good care are in danger of getting lost. The perception of the care provided must therefore be carefully examined.

Jendricke includes in her empirical research on the quality of the senior nursing homes the attention given to the resident as an important criterion for the quality of care. Strikingly, few complaints are expressed by the residents she interviewed. As a result of economization, these were seen as ‘customers’, who could by definition be expected to be so outspoken as to express their complaints. However, this post-war (German) generation which was questioned is not used to expressing objections. Thus, the absence of complaints says nothing about the quality of care, whereas in the economized concept, care is seen as ‘service-provision’ for assertive customers. Empirical research about personal perceptions of care can highlight nuances and reveal tensions caused by economization that is ongoing despite a presence of social state-policy.

Care and Capitalism

A third contribution by Beatrice Müller takes an even closer look at economization, in its political dimension. To what extent can care and capitalism go hand in hand? In a capitalistic context the position of the welfare state is affected, because capitalism has a tendency to frame care activities as solely physical. The above mentioned German long-term- insurance for the old age confirms this at an empirical level: criteria for the allocation of care focus on physical needs. As a result, the care activities have to be structured according to the Taylorist work classification in order to get funding for them. This puts all relational aspects of care under severe pressure. Although recently dementia, as a mental disease, was included as a criterion for care needs of the elderly, it still remains to be implemented, due to a strong formalized approach of care.

The same trends as in the example of Canadian care for the elderly come to the fore: protocols and formalization of care activities have a life of their own, which devalues care activities. Also the state involvement in the care needs of the elderly, as is imminent in Germany, does not in itself counteract these trends. In terms of a care-ethical perspective on this phenomenon: the personal, political and economic dimensions are intertwined. The dimension ‘care relationship’ is part of this puzzle.

Pitfalls of Relational Ontology

The fourth contribution by Jorma Heier questions the focus on the dimension of ‘care relationship’ from yet another angle. Where care ethics puts forward a ‘relational ontology’, it risks strengthening power relations. A glance into history can uncover the pitfalls of such an ontology. After all, in the colonization era relational concepts such as responsibility were abused. The presupposition of relational ontology paves the way for an ethical presumption of responsibility, while paternalism can also be hidden underneath. During colonization, for example, entire population groups were deprived of their own identity, after which the colonizers showed responsibility to mitigate the consequences. This responsibility did not arise from a voluntary relationship that was accepted and appreciated by both sides. Rather, the basis for this relationship was violence.

This awareness should first be developed in order to prevent paternalism from becoming the basis for action again. Current discussions on global development aid still do not tackle this issue with sufficient understanding and awareness.
This contribution shows how in a historical perspective power structures and tensions within care-contexts may become transparent, which would otherwise remain hidden in a dimension that appears to be ‘relational’. The historical dimension is care-ethically relevant at this point.

Blind Spots of Care Ethics

This leads us to the last contribution by Frans Vosman, on the blind spots of care ethics. Normative claims in care ethics can narrow the vision of what care is about, while yet, as was also clear from the discussion in this workshop, it is precisely the complexity of care that overthrows all common concepts, including some normative care-ethical concepts. Developing one’s own theory, if empirically informed, can reveal nuances – no longer seen due to normativity.

‘Power’ and ‘community’ are concepts that require further theoretical underpinning to become useful for care ethics, if care ethics is to focus on the real life situations in which care-receivers and care-providers find themselves, often in institutional contexts. To what extent do the latter develop their own ethos, and how can the moral distress discussed above be understood in this context? Relating these issues to the actual social welfare state: what, now, are the essential aspects of institutions? What does it imply if social welfare institutions will be replaced by the much discussed ‘community’ in current social policies, ‘the community’ which has to carry the burden of care? Do theories that take a ‘we’ for granted overlook real tensions? The ‘community’ is also seen as a relational solution to care questions by care ethicists, but if this harmonious ‘we’ does not exist, what role, then, do social institutions play? In the meantime institutions tend to vanish, that is they tend to lose their institutional character (i.e. on a political basis) and become mere organizations ruled by economical and managerial considerations. One does not have to take struggle as the starting point for inter-human coexistence, however it is necessary to bring real, empirically demonstrable contradictions to the attention, more than some care-concepts are able to.

This workshop unfolded the multidimensionality of care ethics – including the political dimension. The lived experience got a prominent position as a starting point and final destination for research activity.

Silke Jacobi

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