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Extending the Boundaries of Care: Medical Ethics and Caring Practices
  1. A Bradshaw
  1. A.Bradshaw{at}

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Edited by T Kohn and R McKechnie. Berg Press, 1999, £42.00 (cloth), £14.99 (pb), pp 206. ISBN 1-85973-141-4

The title of this book embraces a subject that is very topical in the field of health care. It is a collection of papers most of which were initially presented at the Centre for Cross-Cultural Research on Women. All but one of the authors are women. The papers themselves are very disparate, covering diverse topics in a variety of ways. Subjects covered include a daughter’s story of her mother’s dying and death from undiagnosed Creutzfeldt-Jakob Disease; the problems for parents raising triplets; issues arising from the Depo-Provera contraceptive debate; the nature of human rights in relation to medical care; disease prevention; methods of research in relation to HIV and men who have sex with men, and nurses’ moral/political voices as expressions of care. Each writer’s subject of focus demonstrates their own personal interest, even passion, within health or social care—hence their own deep concern or “care”. As a consequence it is difficult to find a unifying thread in the book, which is perhaps why the particular title was chosen. In their introduction, the editors attempt to frame and explore what they consider the book’s common theme, “the way `care’ is conceptualised and practised”. They are keen to stress that the focus is not abstract ethical issues related to care but the real ways in which individuals and groups grapple with situations involving care. This is no constructed consensus, rather authors struggle in a discussion that extends and refines the caring boundaries. In their view health care models are socially constructed. Models of care, definitions of care, technology and its effect on care, gender roles in care, and the nature of care itself for the receiver, are amongst the issues that arise, and are discussed and explored in the chapters. As the editors acknowledge, however, it is very difficult to define this abstract concept, “care”, and this difficulty is exemplified in the book. Indeed, the central question about the book is whether it does in fact achieve what it sets out to do in its title, notably to extend the idea of care, and relate it sufficiently to underlying ethical positions. The problem is that the concept of “care”, has now come to hold a variety of meanings. Contrast the following two examples. The poignant and moving account given by a professor of anthropology (Judith Okely) of her mother’s illness, her dying and her death embodies, for the author, an idea of care as compassion and kindness. This she illustrates by practical examples, such as “a voice of warmth” (page 39): the unseen voice on the telephone of a matron of “a geriatric ward” (sic) describing to the daughter the detail of the workings of her mother’s catheter. Equally moving is the description of the care assistant who cried as the daughter cut a lock of her dead mother’s hair as a remembrance. For another writer (Jan Savage), the focus is on the caregivers, how nurses understand “closeness”. This gives rise to the author’s argument that the moral basis of care involves that which is overtly political, in this case, the rights of nurses to greater autonomy. With so many different viewpoints on show, the editors recognise “the apparent chaos created by fragmenting of old boundaries” (page 11). Yet, what might be irreconcilable on paper, is certainly quite clear, even consensual, when care is needed in the reality of everyday life. Arguably, when you and I and our loved ones, whoever we are, from whichever gender, race, culture or society, have occasion to require “care”, we will know, as Okely does, exactly what it is that we are receiving, and whether it is as we expect to receive it; and we may find that the “old boundaries” are not so fragmented as the editors of this book might think.