Together with my colleagues Andries Baart and Jan den Bakker, I wrote an article in which we presented the Care-Ethical Model of Quality (CEMQ). We did that against the background of the Covid-19 pandemic and used the pandemic to illustrate the fruitfulness of CEMQ in describing, interrogating, evaluating, and improving existing care practices.

We submitted the article to a peer-reviewed journal. Because of Covid-19, the journal urged us to publish it as a preprint, so that others could benefit from it. The article is now under review. Below the (slightly edited) introduction:

The Covid-19 pandemic is a tragedy for those who have been hit hard worldwide. At the time of writing, the total number of confirmed cases is almost 9.5 million and more than 480 thousand people have died (according to the Coronavirus Resource Center of the John Hopkins University: https://coronavirus.jhu.edu/map.html, accessed 25 June 2020). Many people are experiencing difficult times, not only physically but also mentally and socially. Large numbers, not suffering from Covid-19 itself, are also experiencing hardship because of the measures taken, measures that make them unemployed, kill their businesses, isolate them from relatives and leave them without the care they need. That is the case in Europe and the USA, but even more so in poverty-stricken and bombed Yemen, the overcrowded favelas of Rio de Janeiro, the slums of Mumbai or the townships of South Africa. At the same time, the Covid-19 pandemic is also a test of our concepts and practices of what good care is and what it requires, and how quality of care can be accounted for.

At the moment of writing, we are still not out of the Covid-19 crisis and it is too early to have a complete overview. What we have seen until now is quite ambiguous, showing at least two contradictory sides to every issue. On the one hand relational caring was easily put aside when social distancing was being used to fight a threat to the physical health of particular groups of people labelled as ‘vulnerable’, especially those living in institutionalised settings. But on the other hand, we also see a growing realisation that social distancing is detrimental to the physical and mental health of other groups of vulnerable people, particularly those living at home and deprived of their usual care, and that people are finding ways to be physically near them. Across the world, we saw the criterion of safety becoming dominant, overruling all other quality criteria and shutting off political-ethical thinking. However, at the same time we also see people standing up for other quality criteria based on relationality, not only in regard to their family but also on a macro level, for instance in regard to refugees.

We have seen how social forces have been operative, for example in the introduction of (limited) market competition and just-in-time production and delivery in healthcare, but we also see firms finding ways to help healthcare organisations by producing protective equipment for free or at cost price. We saw care organisations being judged on whether they have followed rules, especially when mortality rates are well above average, but we also saw, in the Netherlands, the Inspectorate and the Care Assessment Center putting their rules and systems aside, and providing room for the practical wisdom of care professionals. In many countries around the world, we have seen variants of a total lockdown, based on distrust and repression of the population. In other countries, we see variants of an intelligent lockdown, built on trust and encouraging a sense of responsibility among the population within a guiding framework. We do not know yet which kind of lockdown will turn out to be most adequate, but the crisis raises questions about the kind of society we want to move forward to.

The crisis and the way it is handled, also raises questions about the kind of ethics we need. The Dutch care ethicist Frits de Lange points out that in the Covid-19 crisis the two fundamental moral approaches of modern society hold each other in a stranglehold: Kantianism and utilitarianism. Whereas Kantianism, with its focus on the absolute value of the individual, was leading in the first phases of the Covid-19 crisis, utilitarianism, with its emphasis on the greatest utility to the greatest numbers, becomes leading in het next phases of the Covid-19 crisis. Both, however, have no eye for how we as humans are physically entangled with each other and with our environment (https://ethicsofcare.org/which-lives-should-we-save-in-corona-times/).

With De Lange, we think we need an ethics that has an eye for this and that takes the practice of caring as a starting point to think about society. Care ethics is such an ethics.
In this paper we present and elucidate a way of thinking about quality that can:

• do justice to relational caring, also in times of Covid-19;
• give voice to care receivers and those closely involved with them according to their concerns;
• perceive mismatches, without disregarding rules, guidelines, protocols and so on
• appreciate the practical wisdom of care professionals in view of the uniqueness of each and every case.

Instead of thinking about care in healthcare and social welfare as a set of separate care acts, we think about care as a complex practice of relational caring, crossed by other practices. Instead of thinking about professional caregivers as functionaries obeying external rules, we think about them as practically wise professionals. Instead of thinking about developing external quality criteria and systems, we think about cultivating (self-)reflective quality awareness. Instead of abstracting from societal forces that make care possible but also limit it, we acknowledge them and find ways to deal with them. Based on these critical insights, a Care-Ethical Model of Quality (CEMQ) was developed that can be helpful to describe, interrogate, evaluate, and improve existing care practices. It has four normative layers or entries (see also figure):

(i) the care receiver considered from their humanness;
(ii) the caregiver considered from their solicitude;
(iii) the care facility considered from its habitability and
(iv) the societal, institutional and scholarly context considered from the perspective of the good life, justice and decency.

The crux is enabling all these different entries with all their different aspects to be taken into account. In Corona times this turns out to be more crucial than ever.

Guus Timmerman, research fellow of the Presence Foundation

Timmerman, G., Baart, A., & den Bakker, J. (2020). Cultivating quality awareness in Corona times. Preprint (under review; submitted: 27.05.2020). https://doi.org/10.20944/preprints202006.0267.v1

Photo above: ©Nicola Powys at Unsplash