There have been heated debates in contemporary moral philosophy concerning questions about the normative significance of proximity and distance in ethics. Historically, it has also been a long-standing issue dating back to Aristotelian ethics and its quarrel with the Stoics about the role of friendship and universal principles as guidance for normative considerations.1 In recent debates, the questions about proximity in ethics have been addressed by a variety of approaches in moral philosophy. These debates have focused on the significance of personal relationships as a basis for normative judgments, as well as debates about impartiality in ethics.2 3 The normative relevance of proximity and distance has been seriously questioned by prominent consequentialists such as Peter Singer4 and Peter Unger,5 and care ethicists’ elucidations of care and caring relationships within the context of politics and justice have influenced both modern moral psychology and philosophy.6^–8 What is more, a particular understanding of proximity is central to phenomenological and metaphysical approaches to ethics as outlined by Emmanuel Levinas, Knud E Loegstrup, Hans Jonas, Zygmunt Bauman, and the Norwegian philosopher Arne Johan Vetlesen.

The aim of this paper is to give an overview of the contemporary debates about proximity in ethics, focusing on the core elements of the most dominant positions. Second, we will amplify what is the fundamental nature of an ethics of proximity compared with other ethical theories. The picture drawn here is not a conclusive one. The paper can in no way give an exhaustive account of the very complicated and profound philosophical positions elaborated in the debates about proximity in ethics. But we will finally address what we assume to be the main problems and strengths pertaining to proximity as a basis for moral considerations and indicate some aspects that might have special relevance to a professional ethics in medicine and healthcare.

THREE VERSIONS OF AN ETHICS OF PROXIMITY

In this section, we outline the three most renowned ethical perspectives that take proximity to bear on normative ethical considerations. The first perspective is that of the mainly meta-ethical positions in ethics, represented by philosophical phenomenology. The second perspective is mostly related to psychologically and philosophically based analysis of emotions and human empathy, which are taken to form a basis for rudimentary moral sensitivity and motivation. Finally, we address the recent debates about personal relationships and partiality as constrained by impartialistic and universalistic considerations in ethics. It is important to say that an ethics of proximity is not a fully developed and exhaustive perspective in ethics. Rather, it is a perspective that draws on different positions and debates in contemporary moral philosophy.

Proximity as phenomenology and metaphysics

When Zygmunt Bauman, in his Postmodern ethics,9 solemnly states that “morality begins at home”, he is heavily influenced by the metaphysical ethics of Emmanuel Levinas and the phenomenological approaches to ethics envisioned by Knud E Loegstrup and Hans Jonas. These philosophies all seem to locate a basic ethical demand in the relationships between a human I and a Thou.10 However, whereas Levinas11 locates the ethical appeal of moral responsibility in the irreducible otherness of the face, which claims non-violence and responsibility for the other person, Loegstrup situates the ethical demand in relational interdependency and takes a basic human trust to condition our shared humanity.12 Jonas (obviously influenced by the ethical writings of Edmund Husserl) claims that the fundamental vulnerability and dependency of the newborn infant and its demand for protection and responsibility represent an essential moral reality.13

Despite the diversity of these philosophies, however, there are at least three basic concerns to be identified. First, we can place their ethics in the camp of meta-ethics, in the sense that they all try to investigate the basic sources of moral demands. Levinas argues that his ethics is not an ethics in the ordinary sense, but an ethics of ethics, an investigation of the phenomenon of ethics, or the meaning of ethics.11 He takes ethics to be irreducible to comprehension. Thus he opens the way for a non-cognitive understanding of moral responsibility in which the passivity of consciousness, as well as affect and sensibility, plays a significant role.14^–16 To Levinas, proximity is possible only as responsibility: “The Other cannot be with me without positing me as the one who has to be for him.”10 Loegstrup and Jonas, on the other hand, elucidate a fundamental moral demand in the empirical reality of a vulnerable being, claiming protection and responsibility.

Second, they all seem to endorse a version of realism in ethics, in which a fundamental moral reality can be accessible by human experience and perception. Levinas speaks of a particular form of experience in which the subject is not the autonomous author of moral responsibilities; rather responsibility is laid upon a subject that is addressed by the ethical authority of exteriority, of the face. The subject made responsible in Levinasian ethics is a subject made vulnerable by the vulnerability of the other person. A point about realism in ethics here, and which might make it plausible to place Levinas within a realist framework, is that moral demands issue from sources of which the subject does not have definitive control and which the subject has not created. This is particularly evident in the way the newborn child paradigmatically voices an ethical demand of protection and care, according to Jonas, but also in how Loegstrup portrays the sources of ethics in relational interconnectedness and human interdependency. A realist view here would argue that moral properties exist independently of subjective consciousness and of particular situational evaluations or appraisals.17

Third, proximity is central to these philosophies in the way that the dyadic relationship is the paradigmatic background for understanding fundamental ethical motivations. Levinasian proximity implies our ethical relationship to an Other,18 an experience, emotionally as well as bodily.19 To Jonas, proximity is a motivation evident in responsibility for the vulnerable child. Loegstrup argues that vulnerability is evident in all kinds of human relationships. In emphasising relational interdependency as a most fundamental part of being human, some conceptualisation of proximity follows from Loegstrup’s ethics: “We do indeed constitute one another’s world and destiny. That we usually ignore this fact can easily be explained: It is a common observation that the most elementary phenomena of our existence are the ones we are least aware of.”12

The relevance of proximity to normative ethics strongly relies on a precise clarification of the term proximity itself, be it relational, spatial or temporal. However, proximity is not thematised in these theories in any precise or inclusive manner. Rather, it is portrayed as based on the dyadic relationship between an I and a Thou. Vetlesen is the one who has most prominently argued that “an ethics of proximity regards the close relationship between an I and a Thou to be the basic ethical relationship. The human being’s primary experience of being an ethical subject as well as an ethical addressee is seated within the relationship between the I and a Thou. This experience is sensible and emotional as well as cognitive.”20

Still, it is fair to say that these theories of fundamental ethical properties inspired by philosophical phenomenology are among the first to take relational proximity to ground our basic ethical motivations. So far they appear to illustrate one way in which proximity has relevance for an understanding of our basic ethical conceptions of interpersonal and relational responsibilities.

Proximity and moral motivation—the perspective from relational psychology and philosophy psychologically inspired

An additional way in which proximity has a bearing on basic ethical questions is how modern moral psychology and psychologically inspired philosophers focus on the role of human emotions and empathy as meriting importance in moral perception and motivation. A central insight within Aristotelian ethics is that human emotions inspire and enlighten the moral sensitivities that are necessary for human flourishing within relationships based upon friendship and interpersonal ties. But also within prominent theories about the relationship between human emotion and moral agency, proximity in a relational, spatial and temporal sense is central. In particular, various theories about moral perception and moral sensitivity argue for the salience of emotional affect as central to moral concern and responsibility.21 22 Cognitivists in the theories of emotions, such as Martha Nussbaum, argue that it is implausible to disconnect the affective component of emotional sensitivity from its cognitive content. Feeling immediate compassion for the suffering of another is already a sensation based upon interpretation. Vetlesen seems to argue that emotional receptivity and our way of being affectively involved in the world is the fundamental structure of moral responsibility altogether: “I argue that our ability to feel, which rests on the faculty of empathy, provides us with our principal mode of access to the domain of human experiences and that without an access to this domain, we would remain blind to the specifically moral character of situations where the weal and woe of others is somehow at stake.”21

Researchers on empathy also emphasise the experience of empathic emotional distress (affective empathy) as a crucial prerequisite of concern for others. As Hoffman claims: “Empathic distress is a multidetermined, hence reliable human response. The three preverbal modes are crucial in childhood, especially in face-to-face situations, but they continue to operate past childhood and provide an important involuntary dimension to empathy throughout life. They not only enable a person to respond to whatever cues are available, but they also compel him or her to do that—instantly, automatically, and outside of conscious awareness.”23

What is essential in all philosophically and psychologically inspired theories about emotions is that they take the affective way of relating to the human condition of other persons to be fundamental for moral responsibility and for a moral part-taking in the world. Typically empathic affective responses take place within human and relational proximity. Moral responses can cover vast distances, as when the media show the suffering of a child in a country far away. But central to these theories is that moral responsiveness and moral development are strongly related to relational proximity and human interconnectedness and care (where face-to-face encounters are essential) from early childhood on. However, whereas motivational psychology focuses on our moral sensitivities and how these resonate in proximity, an ethics of proximity might also inhabit more distinct normative implications.

The normative debates about proximity and relationships

A substantial argument in which relational proximity is taken to be essential for moral considerations follows from a critique of ethical consequentialism by the American philosopher Samuel Scheffler.24 Scheffler’s argument parallels the emphasis that care ethicists put on the moral significance of our relational humanity and relational interdependence (Nortvedt P, Care, sensitivity and the moral point of view. Unpublished manuscript 2006). However, quite distinct from care ethicists and the phenomenologists, Scheffler investigates the normative implications of relational bonds and duties. His argument has two important tenets.

First, he argues that personal relationships have normative significance and that one has particular responsibilities towards particular persons on the basis of one’s relational attachment.24 Scheffler’s basic argument is that our personal relationships generate associative duties and that these duties cannot be fully reduced to distributive considerations, that is, taking the interests of all relevant parties into account.24 According to Scheffler, personal relationships and loyalties generate obligations that legitimately may serve as bases for unequal treatment. In fact—and this is the second tenet in Scheffler’s argument—it is the essence of our interpersonal relationships, it is what constitutes them that they serve as reasons for preferential treatment: “Interpersonal relationships could not play the role they do in our lives, and in some cases could not even exist, unless they were treated by the participants as providing such reasons.”24

What supports this argument is a philosophical anthropology that sees human relationships as central to and constitutive of our social and historical identity and inseparable to our being the persons we are in the first place.24 We are constituted by our relationships. We are born into them as well as gradually socialised into them, but they are not unconditionally of our own making. It is the nature of the relationship and the value we place upon it, and have reason to place upon it, that gives rise to our associative duties.24 The normative significance of the relationship is inextricably and necessarily dependent upon the non-instrumental value of the relationship. The questions unanswered by Scheffler are what role proximity plays in the normative valuing of our relationships, and to what extent proximity and distance have any normative implications when it comes to considerations of distributive justice.

Another argument has been voiced by Bernard Williams. Williams has been a central critic of impartiality in morality and has launched a certain defence of partialist considerations where a notion of relational proximity is essential.2 His argument focuses on the relationship between personal integrity and the demands that impartial ethical theories may impose upon persons. Williams’s most famous view is that always thinking impartially about one’s attachments, personal projects and relationships tends to undermine a person’s integrity, a person’s sense of self, and to further distance persons from their humanity. Always to calculate in terms of what is right from an impartial or consequentialistic standpoint with regard to one’s relationships is to misunderstand what human relationships and attachments are about and tends to alienate persons from their deepest human convictions and attachments. It means disregarding the intrinsic value of relationships altogether.

Central to Williams’ argument is that it is essential to the integrity of persons that a certain partiality be regarded as legitimate. It is central to our humanity that personal attachments and loyalties can be accorded a normative value, and hence impartial considerations cannot fully undermine the value of our personal relationships and attachments. Relational closeness has a normative value. It is a substantial argument here that deontological and consequentialist moralities cannot fully account for this value of personal relationships.

To sum up: There are three different notions of proximity within the various ethical perspectives here elucidated. First, within the metaphysical and Levinasian account, proximity cannot be understood in any concrete, temporal or spatial sense. Proximity in the Levinasian sense is metaphysical closeness, closeness understood as vulnerability. Within the more concrete phenomenological conception of Jonas and Husserl, on the other hand, intentionality is inescapable. Rather, sensibility—to be addressed by the child’s human vulnerability—is a moral demand depicting the specific moral reality of the child. This is also true within Loegstrup’s account of relational interdependence, where basic trust and vulnerability are an inextricable part of any human encounter.

Within theories of human empathy and psychologically oriented theories of moral motivation, proximity is meant to emphasise the motivational component of emotional affectedness displayed by the distress (mental as well as physical) experienced by the concrete and immediate encounter with human suffering and vulnerability.

Finally, relational proximity is our moral responsibilities constituted by the relational bonds to concrete others based on interpersonal ties. Relational proximity is thus “thick” and not strictly situational. Rather, it is shaped by a more or less lasting connection to others within family and group affiliations, taking human bonds to emanate from interpersonal experience and communication.

THE ESSENCE OF AN ETHICS OF PROXIMITY

What, then, is essential to the perspective of proximity in ethics? How can it be distinguished from other moral theories, or other moral perspectives? There are two important distinctions between an ethics of proximity and other ethical theories (widely understood), both concerning moral reasons. The first distinction deals with questions of normativity. When trying to explain and ground our basic moral interests, the point of departure for impartial moral theories is objective moral reasons. Objective or agent-neutral reasons “must express values that are independent of the particular perspective and system of preferences of the agent”.25 An ethics of proximity, however, challenges agent neutrality as the ultimate and autocratic perspective from which moral reasons are legitimised. Instead it implies that proximity to the sufferer gives rise to moral reasons. From Scheffler’s position, we have seen that relationships that are valued non-instrumentally generate special moral duties, duties that cannot be fulfilled without at the same time giving normative value to partiality. Though not addressed explicitly by Scheffler, it seems plausible to argue that these significant relationships do necessitate relational proximity.

Also from the phenomenologists, as well as from moral psychology, it might be argued that some kind of proximity to the particular person’s suffering and pain generates a moral reason to want to relieve, and try to relieve, a particular suffering for a particular person’s own sake. This is so because, as Thomas Nagel puts it: “… he wants to be rid of this pain unreflectively—not because he thinks it would be good to reduce the amount of pain in the world”.25 Christine Korsgaard argues that “pain and reason share a reflective structure. A reason is an endorsement of an impulse; a pain is a reaction to a sensation ….” Obligation is the reflective rejection of a threat to your identity. Pain is the unreflective rejection of a threat to your identity. So pain is the perception of a reason, and that is why it seems normative.26

Now, when Korsgaard argues that pain is a perception of a reason, she argues from the individual point of view, that is, my pain is a threat to my identity and my perception of my pain is a perception of my reason to want it to be relieved. But this leaves unanswered what it is in witnessing another’s suffering that gives me a moral reason for helping that person. Also, if proximity to suffering and the sufferer has normative significance, some form of partiality seems to follow (we will return to the issue and problems with partiality in the next and the last section).

The second distinction we want to illuminate is a distinction vital to settle a meta-ethical question. For moral reasons to be legitimised from traditional moral theories, they must be rationally and impartially considered through heteronomously or autonomously given duties, permissions or prohibitions. But traditional moral theories have failed to give an adequate account of what constitutes moral reasons in the first place. It is also hard to see how Korsgaard addresses this difficulty convincingly. In The possibility of altruism,27 Thomas Nagel says that altruism as perception of another’s pain is a perception of a reason. Nagel seems to argue that moral reasons, even if orchestrated by situational immediacy and human sensitivity, have to be explained by ways of rational imagination and role-taking: “Sympathy is not, in general, just a feeling of discomfort produced by the recognition of distress in others, which in turn motivates on to relieve their distress. Rather, it is the pained awareness of their distress as something to be relieved.”27 According to Nagel, these kinds of reasons are altruistic in so far as they have recourse to moral imagination and the ability to put oneself in another person’s place. Hence, “pained awareness” as a reason for human assistance is based on a capacity to recognise the objective interests of others as part of our shared humanity. Correspondingly, then, moral reasons do not reside in, are not intrinsic to, prereflective and situational sensibilities. Affective sensibilities can enlighten and generate genuine moral reasons by way of perception and motivation but do not themselves serve as reasons.

The problem with Nagel’s position is that the link between the formation of reasons, rationally grounded, and the more or less prereflective and innate impulses leading up to the formation of reasons seems unexplained. The fact that a pained awareness becomes a reason for wanting to help the person in pain is still not given a plausible explanation. Our view is that it is perhaps impossible to ground moral reason in our reflective rationality. There seem in fact to be an inborn and to some extent a prereflective impulsive capacity to identify with pain and suffering, following not from reasons of shared role taking, but from reasons intrinsically grounded in human sensibility. The pained awareness cannot be separated from the something to be relieved by way of rational or deliberate reasons, because reasons as role-taking will already arrive too late on the scene. As psychology has explained, moral sensibilities show ways in which altruistic motivation is preintentional and prereflective. Nagel’s rational account (and dominant meta-ethical conceptions with him) ignores this dimension of moral life. Whereas the connection between the upheaval and its motivational set as a reason for helping the sufferer seem to be inseparable, a rational account of reasons cannot explain this notion of a prereflective inseparability between affect and moral motivation. It seems to leave unexplained the distance between the upheaval and the happening, on the one hand, and the rational formation of reasons that follows from them.

Williams points to such a problem in his reply to Korsgaard’s position on normativity: “Even if there is (which of course I doubt) a consideration linking practical identity in a sense that is inescapable with acknowledgement of others in a sense that is morally sufficient, how can this link be mobilized normatively in reflection, so as to answer Korsgaard’s own very radical question?”28

Levinas seems to provide an answer to this tricky meta-ethical problem. He argues that moral reasons are inseparably linked to the formation of intersubjectivity as sensibility.

A core aspect of intersubjectivity is that the other person addresses me in an ethical sense. In his doing so, in what Levinas calls a heteronomous experience, a moral responsibility for the other is placed upon me. But according to Levinas, it is not identification with the suffering of another that is the source of reasons. On the contrary, it is the confrontation with alterity that constitutes the ethical move of subjectivity. A subject’s encounter with the otherness of the suffering person, that is, a consciousness’ running up against the other, not as a theme or a re-presentation but as an infinite and irreducible Other, sets the scene for ethical responsibility. This encounter with otherness that opens the way for ethical responsibility is not on the basis of intentionality, but on the basis of a prereflective and preintentional sensibility.14 Levinas, then, in a way seems to break with a dominant rationalistic tendency in meta-ethics and links the question of ethics to an understanding of the primordiality and origin of human consciousness in ethical sensibility.

THE NORMATIVE SIGNIFICANCE OF AN ETHICS OF PROXIMITY

What are the problems with an ethical perspective that takes proximity as having normative significance? The main problem is how the perspective of proximity possibly conflicts with an impartial notion of fairness and distributive justice. Truly our moral intuitions in many cases coincide with how we engage in a world of interpersonal relationships and personal closeness. But as proponents of impartialist moralities have emphasised, morality and our moral concerns have to reach out to those suffering far from emotional bonds and attachments.4 5

What constitutes our humanity in any sense of proximity can serve as basis for preferential treatment. The problem is that arguments for partiality tend to disvalue the need of others who stand outside our relationships. Some might claim, as Singer4 does, that morality has a strong claim on us in the sense of disqualifying relational duties as action-guiding in a normative sense. They are strong and ontologically shared intuitions, but to the extent to which they serve as basis for unequal treatment they should be questioned, even if this means endorsing more demanding notions of moral responsibility. Taking our common humanity seriously, should we not endorse a moral conception claiming that “our obligation to help a stranger in another country is as great as the obligation to help one of our own neighbors or compatriots”?4

But of course this is a problem for an ethics of proximity only in so far as the perspective tends to establish normative conclusions distinct from a more action-guiding stance. If this ethical perspective mainly aspires to certain meta-ethical and metaphysical assumptions about the sources of moral demands, it cannot claim to have extensive normative conclusions drawn from it. But then its problem concerns its limitations as a normative theory. Then it cannot aspire to be a more comprehensive ethical perspective at all.

Conversely, it has the ability to explain the sources of some of man’s deepest moral intuitions and convictions and how we are motivated morally in the first place. Its strength also lies in the aspirations of bridging the gap between moral philosophy and moral psychology. To the degree to which the perspective of proximity takes human experiences and emotions to reflect our moral motivations in the first place, this can be important as part of a more moderate normative aspiration of the perspective of proximity in ethics. It might be able to provide some arguments for a certain priority to relationships and the legitimisation of a certain loyalty towards our associates. In particular, this question is significant for a professional ethics in healthcare, taking moral obligations to be based upon obligations of role and perceptions of need. This turns us to a question not properly addressed by an ethics of proximity, that is, the relevance of the perspective of proximity to medicine and healthcare.

THE RELEVANCE OF AN ETHICS OF PROXIMITY FOR PROFESSIONAL HEALTHCARE ETHICS

It can be argued that the phenomenological nerve of deontological constraints issues from a “certain claim of immediacy”.25 This claim of immediacy, that is, of being motivated by the concrete hurt of others, is not basically cognitive by nature, but has certain roots in human (emotional) affectivity and empathy.21 Emotional capacities of sensitivity are important and integral parts of clinical wisdom and moral competency in healthcare. Clinical experiences of medical care and nursing care strongly resonate in the moral demands of illness and suffering. Undoubtedly, these are experiences and obligations constituted by relational, as well as spatial and temporal, proximity to the patient. Hence, an ethics of proximity emphasises and elucidates the significance of moral sensibilities as central to moral judgments and clinical wisdom in healthcare.

Another question becomes how an understanding of proximity in ethics might apply to a plausible notion of justice in healthcare. This question brings to bear the notion of partiality and impartiality in healthcare. It is a salient principle in medical ethics and in nursing care that the concrete and actual patient has priority.29 What does this mean within the impartialist considerations of professional healthcare ethics? Can healthcare personnel favour a patient on the basis of relationship or on the basis of empathy?

In general, no. A professional ethics is significantly different from our common morality of care in that it is by nature distinctively impartially oriented. It is and must be the medical needs of the patient that merit attention, and not the relationship to a particular nurse or a doctor. A nurse–patient or doctor–patient relationship is not a constitutive part of the life of the involved parties. Still, it might be argued that the relationship between a patient and a healthcare worker has an intrinsic normative value, provided the relationship is valued non-instrumentally.30 Moreover, from Scheffler’s argument considering the normative value of significant relationships, it can be argued that a professional relationship of this kind cannot be valued non-instrumentally without simultaneously generating a special normative responsibility towards the particular and concrete patient. This responsibility cannot be totally overruled by impartial claims for distributive justice in healthcare.30

A further question is how an account of an ethics of proximity can be applied to an institutional system of healthcare where impartial considerations of medical needs and severity of illness, as well as principles of equality and distributive justice, are underlying and conducting values.

One way of approaching this difficulty is by arguing that the operating conditions of medical care in healthcare services must balance considerations of care for non-admitted patients and those already admitted to institutional care, but in a way that principally and to some degree benefits, or at least does not harm, the latter. From an ethics of proximity, being relationally, spatially or temporally grounded, there are at least two significant considerations that need to be taken into account when striving to balance considerations of particular care and distributive justice. First, a balance between proximal care and care for unrelated others must leave room for proper attention to actual patients admitted for care. This must imply a quality and standard of care that includes not only vital medical care, but also some basic needs for nursing care, and showing trust and empathy for the concrete other patient as well as for the patient’s relatives. From an ethics of proximity, it means that there should be a priority to the relational and particularistic care itself that cannot be fully overridden by impartial justice.

Second, some ethical values are fundamental in medical care and nursing care. Respecting and maintaining the patient’s dignity and integrity express values inextricable from particularised proximal care. These values may be portrayed from the perspective of moral realism, as for instance in Loegstrup’s account of trust and vulnerability, but also from moral psychology, where facing the suffering of a concrete other is conceptualised as a source of human distress and moral responsibility. Besides, as mentioned previously, the relationship between the concrete patient and the healthcare worker can in itself be said to have a normative intrinsic value. Jeopardising these values will simultaneously endanger the foundation upon which professional ethics are built. It may also be argued, from the perspective of Williams, that for the individual healthcare giver, jeopardising professional ethics and values intrinsic to it will undermine that person’s integrity.

This does not greatly clarify what justice amounts to in various distributive contexts within healthcare, but it indicates the idea that justice, politics and economy must give a priority to relational care for the particular and concrete patient. This does not mean for a medical ethics that actual and concrete patients always shall have precedence over suffering remote persons. It only implies that institutions must strive to organise their care and their distribution of resources so that the balance of justice with care always secures a basic standard of proper care and attention to the concrete other. How such a balance can be secured concretely in various contexts of care is a pressing issue for an ethics of care and justice in modern healthcare.