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Knowing-how to care
  1. Darlei Dall'Agnol
  1. Correspondence to Professor Darlei Dall'Agnol, Department of Filosofia, Universidade Federal de Santa Catarina, Processo 6671/2014-09, Florinopolis, Santa Catarina 88036001, Brazil; ddarlei{at}yahoo.com

Abstract

This paper advances a new moral epistemology and explores some of its normative and practical, especially bioethical, implications. In the first part, it shows that there is moral knowledge and that it is best understood in terms of knowing-how. Thus, moral knowledge cannot be analysed purely in the traditional terms of knowing-that. The fundamental idea is that one knows-how to act morally only if she is capable of following the right normative standards. In the second part, the paper discusses ways of integrating two expressions of moral knowing-how, namely caring and respecting into a coherent normative theory. It builds up the concept of respectful care as the central ingredient of such a normative theory. Finally, it illustrates how respectful care may transform some of our current clinical bioethical practices.

  • Ethics
  • History of Health Ethics/Bioethics
  • Philosophical Ethics

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Introduction

We humans are, as social beings, care-dependent creatures. Caring may, however, go wrong in many ways. For one thing, the care may be insufficient to fulfil basic needs of the cared-for. It may even be a cause of negligence or malpractice. Moreover, it may degenerate into forms of paternalism when the one-caring imposes her own views of the good on a vulnerable individual, for instance, a parent on a teenager learning how to be independent; a scientist on a research subject; a doctor or a nurse on a patient in need of medical attention, and so forth. Besides, caring may generate anxiety, that is, be accompanied by negative feelings that compromise the well-being of the one-caring. An important question then arises: under which conditions can we say that the one-caring knows-how to care in a proper way, for instance, respectfully?

In this paper, I would like to advance a meta-ethical theory, particularly to outline the main tenets of a new moral epistemology, which I call ‘practical cognitivism’, and to explore some of its normative and practical, especially bioethical, implications. Thus, in the first part, I will argue for the thesis that there is moral knowledge (pace ethical scepticism and non-cognitivism) and that it is best understood in terms of knowing-how. That is to say, moral knowledge cannot be analysed purely in the traditional terms of knowing-that. The fundamental idea is that one knows-how to act morally or knows-how to be a certain kind of person, and so on, only if she is capable of following the right normative standards (shortly, norms). In the second part, I will look for ways of integrating two expressions of moral knowing-how, namely caring and respecting into a coherent normative theory. I will show that respectful care must be a central ingredient of such a normative theory. I will finally illustrate how respectful care may transform some of our current clinical bioethical practices.

A new moral epistemology

To start with, consider this real-life bioethical case:Baby X was born on 1 March 2009 at the midwife-led maternity unity Y in the UK. Two weeks before, the mother complained that her baby was not moving as much. She also said that she was feeling unwell. She was checked, but nothing was identified. At this point, it would have been normal for care professionals to discuss whether she should continue with the plan to give birth at a midwife-led unit. There is no evidence, however, that any risk assessment took place. When the baby was born, she was cold and floppy and needed medical attention, yet the midwife placed her into a cold cot. It was only after 2 h that an ambulance was called. She was transferred to a hospital to be reviewed by a paediatrician. It was later revealed that baby X had suffered from anaemia caused by a substantial fetomaternal haemorrhage. Baby X would have had a chance of surviving had she been delivered in a hospital where she could have had blood transfusion or any other experimental procedure or treatment.

These are the basic facts of the case. Some ethical questions are: did baby X receive the care she was entitled to? If not, is this not disrespectful to her as a human being? How may one deliver the proper care baby X was entitled to? Did baby X wrongly die an avoidable death?

One of the main problems underlying insufficient, negligent care, or even supercare, that is, a paternalistic form of ‘caring’, is, most likely, a misunderstanding regarding the very kind of knowledge that is required to look after a vulnerable being properly. An incompetent carer, we might say, must know better. I believe this is the case not only in the technical sense, for instance, knowing-how to make a reliable diagnosis, but also in the moral sense. In this section, then, I will argue that caring presupposes a practical kind of knowledge, namely knowing-how and not only knowing-that. Now, even in philosophy, knowledge is sometimes defined in reductivistic ways obfuscating the nature of practical ways of understanding and acting. As Gilbert Ryle pointed out, this is a prejudice of the ‘intellectualist doctrine’,1 which tries to define intelligence in terms of apprehension of truths instead of apprehension of truth in terms of intelligence. We need, in order to avoid this inversion, to sort out a new kind of moral epistemology.

Practical cognitivism is the epistemic thesis that there is moral knowledge and that it is best understood in terms of knowing-how and not only in terms of knowing-that. The central idea is that a sound moral epistemology reveals that moral knowledge is mainly a matter of knowing-how to follow normative standards. Thus, a practical cognitivist does not deny that there is also moral knowing-that, for instance, that one must care for her daughter's well-being (there are, as we will see, many moral ‘language-games’), but rather argues that something else is needed: one must also know-how to do that. That is to say, practical cognitivism points out that there is more than one kind of knowledge and does not try to reduce moral knowing-how to knowing-that. Moral knowledge needs also to be clearly distinguished from other kinds of knowing-how, for instance, artisan skills, mere prudence, and so on. Thus, let me sort out the main features of this new moral epistemology. Hopefully, it will help us to understand what went wrong in the case of baby X and to avoid similar cases happening again. I will discuss in a more detailed way this bioethical case later, after establishing the basic ingredients of practical cognitivism.

To start with, let me sort out a provisory analysis of knowing-how. In order to do so, I will use Wittgenstein's project of a philosophical grammar, that is, his remarks on the rules for using the word ‘know’ as being closely related to that of ‘can’ and ‘be able to’ and, especially, his rule-following considerations.2 I will explore some implications of his rule-following remarks for ethics, but I will not commit myself to the view that moral life exclusively comprises rules. A moral system may indeed also include sentiments, rights, emotions, obligations, traits of character, values, and so on, as we will see regarding respectful care. Not all these elements need to be explained by referring to rules or be reduced to them. But moral rules do play a fundamental role in guiding a person's behaviour, in discriminating right from wrong, in justifying or in giving reasons for actions, and so on. Consequently, they are a necessary condition for holding persons accountable.

What is knowledge after all? Is knowledge always related to a propositional attitude, that is, having a justified belief? This seems not to be the case. In Wittgenstein's own words: “But there is also this use of the word ‘to know’: we say ‘Now I know!’ –and similarly ‘Now I can do it!’ and ‘Now I understand!’”.3 Thus, to have knowledge is not simply a matter of having justified true beliefs, but, more importantly, in the practical sense, of being capable of effectively doing something, for instance, mastering a technique such as handwriting, playing chess, and so on.

Despite the fact that providing a comprehensive taxonomy of all sorts of knowledge is beyond the limits of this work, I would like now to make some further distinctions, especially between tacit and explicit knowing-how. On the one hand, a person has implicit, non-codified, knowing-how when she performs an activity without having reflected on the norms involved. On the other hand, explicit knowing-how requires mastering the principles and rules constitutive of such activity. Now, procedural knowledge, most skills, moral knowledge, and so on, are subtypes of explicit knowing-how. Procedural knowledge or knowing-how to perform a task well, which is also sometimes referred to as ‘imperative knowledge’, involves mastering explicit norms, for instance, a child learning how to count using her fingers. Moreover, skills are also an expression of a special kind of knowledge, which is not only propositional. If we understand a skill as a learned ability with predefined goals, then it is best defined as a subspecies of knowing-know. There are, of course, all sorts of skills: psychological, social, and so on. To illustrate: professional interaction with patients requires learning effective rules for communication. It is crucial, however, to distinguish skills from moral knowledge as the latter manifests itself in the virtues. In an Aristotelian spirit, we may say that virtues are not just skills that are quick in operation, but virtues require deliberation and choice. Unfortunately, I cannot pursue this issue here (cf. Bengson & Moffett's excellent collection of essays for further discussion on kinds of knowing-how).4 Other differences between moral knowledge and the other sorts of knowing-how will become apparent in the next section.

Professional knowledge may involve all sorts of knowledge. The exercise of modern medicine, for instance, requires different kinds of expertise. It certainly needs factual knowledge, especially scientific knowledge such as provided by chemistry, biology, and so on, for example, knowing that the blood is pumped by the heart to the arteries, the arterioles and the capillaries, and returns in the venous system to be oxygenated in the lungs. However, since healthcare professions also have a practical component, their goal is doing and not just knowing. Doing something involves knowing-how, for instance, bypassing coronary arteries, which is a technical kind of knowledge. They need practical skills too, which may improve upon new procedures for bypassing arteries. Moral knowledge is also required since what can be done, perhaps must not be done. Medicine can even be considered a form of wisdom, that is, it requires practical rationality and not only scientific knowledge. This is why, as was recently pointed out by Savulescu,5 philosophy is important for bioethics.

From this analysis, we may derive a definition of explicit knowing-how in these terms: it is ‘an acquired capacity to follow normative standards’. This definition establishes a rule for using the expression ‘she knows-how’ distinguishing its right from wrong uses. The above definition contains elements that clearly show that knowing-how is irreducible to knowing-that. I believe that people like Jason Stanley are mistaken in claiming the reducibility of knowing-how to knowing-that. Recently, he has argued, even against the strong evidence from neuroscience, that procedural knowledge is a kind of knowing-that.6 This is not the case since procedural knowledge, that is, knowing-how to perform a task well, involves above all the mastering of norms. Imagine you are going to learn a new game. You need certainly to practice how to follow the constitutive rules. That is to say, knowing-how is not just a matter of having beliefs in true propositions; it is a matter of mastering the norms necessary to perform activities, that is, being able to follow them effectively to get the desired results. It does not follow, however, that there is no need for knowing-that or that one is, pace Ryle, more fundamental than the other. On the contrary, knowing-how involves knowing-that. The basic point is just that they represent two different kinds of knowledge, which may well be characterised in terms of the distinction between practical and theoretical philosophy: the former deals with what ought to be; the latter is an inquiry into what is the case. And this is arguably the most important advantage of explaining moral knowledge in terms of knowing-how, namely ‘the problem of normativity’ (the way ‘ought-ness’ is sui generis and yet compatible with the natural world) is solved by introducing it right inside our analytical model. That is to say, it shows that norms are irreducible to facts.

If this is the case, then there is an important implication for current meta-ethical debates: we must, so to speak, turn the tables. Most present-day discussions are contaminated by the single (and false) presupposition that either there is moral knowledge or there is not; however, both sides, most cognitivists and non-cognitivists alike, think exclusively in terms of knowing-that. For instance, an intuitionist such as G.E. Moore (and many present-day intuitionists) has many problems in showing us how such knowledge is possible, so he finds himself postulating strange faculties or subscribing to queer entities.7 Many cognitivists follow the same path by trying to reduce ethics to empirical investigations naturalising morality and thus committing the naturalistic fallacy (a category mistake in my interpretation). But, on the other hand, non-cognitivists do not come out with better solutions despite the fact that they are successful in showing us that not all moral judgements are propositions in the strictest sense. The shared mistake is to assume just one kind of knowledge either in affirming (cognitivists) or denying it (non-cognitivists). Therefore, what we need is to twist the debate in the direction of knowing-how.

Let me then go back to practical cognitivism and deal with more epistemic issues surrounding it. First, there is the question of objectivity. Since norms are the basic ingredient of explicit knowing-how (as propositions are for knowing-that), it seems clear that the discussion of whether moral judgements are objective or not, according to a practical cognitivist, must be related to the kind of entity norms (principles, rules, etc) are. In this sense, it is not difficult to recognise that norms are objective in their own way, that is, if they are clearly formulated they coordinate the behaviour of all agents. To say ‘persons must keep their promises’ does not express subjective feelings, but objectively prescribes a specific kind of behaviour. That is why a non-cognitivist is wrong: following a rule (not merely acting in accordance with it) is a cognitive state. A norm presents a standard for agents to act accordingly. Thus, objectivity in ethics has nothing to do with finding queer objects ‘out there’, which supposedly must correspond to moral terms or concepts. On the contrary, it is a matter of recognising that moral norms direct behaviour. Thus, moral norms such as the fundamental principles of bioethics (eg, first, do no harm) are objective in this sense and once they are internalised they convert into attitudes, for instance, a caring one, which are not subjective either.

The question relating to the philosophical problem of truth may have a similar (dis)solution. What we must mainly be concerned with, from a cognitivist point of view, is not whether all our moral judgements correspond to facts in the world, but whether a system of norms is coherent and helps us achieve our goals. That is to say, we may assume here a minimalist approach to moral truths. As Wittgenstein noted while commenting on Broad's threefold classification of theories of truth as correspondence, coherence and pragmatic: “We can say that the word [‘truth’] has at least three different meanings; but it is mistaken to assume that any one of these theories can give the whole grammar of how we use the word, or endeavour to fit into a single theory cases which do not seem to agree with it.”8 I believe that contemporary philosophy has overlooked the importance of this remark. The truth of moral sentences depends on the language-game in which they occur.

To recognise this point, let me examine more deeply Wittgenstein's notion of language-games applying it to moral language. A moral system may comprise the following language-games: (i) imperative moral language-games (comprising sentences enunciating principles—general guides for action—such as ‘do no harm’ and particular rules that prescribe or make permissible specific acts, for instance, ‘do not cause physical injury’, ‘do not cause offence’, etc); particular rules may be said to be true if we accept principles and they cohere with them; (ii) evaluative moral language-games (sentences to assess certain forms of behaviour, attitudes or qualities of an agent's character such as ‘Peter is a good fellow’); these sentences may be true in the correspondent sense if they describe accurately what a person is, for instance, whether an agent is an honest person; and (iii) performative moral language-games (sentences that themselves express actions we do, for instance, a person at her wedding saying ‘I promise to ….’); these sentences can be said to be true in a pragmatic sense. Consequently, there are countless moral language-games.

The main theoretical advantage of applying the concept of language-games in ethics is to get us to realise that particular words do not have a moral meaning in themselves, but they may function as such, for instance, the word ‘no’ can be used in a normative-language-game as a moral imperative. That is to say, the atomistic investigation of the meanings of ‘good’, ‘right’, and so on, considered in isolation is misleading and we are better off with a systemic approach to moral language using the notion of language-games.

Let me now make clear why the acceptance of this multiplicity of moral language-games does not imply radical relativism. First, I was using different meanings of ‘true’, relating it to different kinds of language-games. Thus, it is important to stress that Wittgenstein rejects a theory of truth, but not that moral judgements cannot be true or false. Thus, if we accept the prima facie principle of non-maleficence ‘do no harm’, then we must also follow particular rules such as ‘do not cause pain’, ‘do not cause suffering’, and so on. In this sense, norms form a coherent web of guiding directives for our actions. In a minimalist sense, they can be said to be true, just as it may well be true that an evaluative moral judgement is in accordance with what is stated.

Norms are, then, objective and may even be said to be true, but that is not to argue that norms are not revisable. A practical cognitivist may well be a fallibilist, and she may not be foundationist about the justification of accepting norms. As for beliefs, we may constantly revise our norms, correcting them, perfecting them. For instance, the principle of non-maleficence can be rewritten in terms of ‘do no more harm than benefit’, asking a subject of scientific research or a patient herself to say what counts as harm. The rules related to it may also be rewritten and improved. This adjustment is an ongoing project. Does that imply radical relativism? I will try to show now that this is not the case.

A practical cognitivist may be considered a realist in the relational sense. That is to say, it is compatible with what Peter Railton calls ‘an objectified subjective interest’ for an individual A+. Railton describes A+ in this way: “give to an actual individual A unqualified cognitive and imaginative powers, and full factual and nomological information about his physical and psychological constitution, capacities, circumstances, history, and so on.”9 I would like to add, complementing Railton, A+ must also have knowing-how in a high, excellent degree. In other words, knowing-how presupposes the exercise of full capacities in order to act morally or have the appropriate attitudes. What counts as real (eg, the ingredients of one's welfare), then, is what is established from the point of view of A+ and not from an independent realm of values ‘out there’.

Let me, now, if this conclusion is right, show which path we may follow to construct a normative ethics based on knowing-how to care. There are certainly different kinds of knowing-how and also different kinds of care, for instance, natural care and moral care. There are, perhaps, only family resemblances between them. Thus, it is important to distinguish moral knowing-how (eg, to care for someone for her own sake) from non-moral knowing-how (eg, caring for a particular book). In this sense, I would like to adopt here a specific use of the word ‘moral’, which is after all a common sense use that is also assumed in many empirical studies of morality, namely as a synonym for altruistic behaviour. To be more precise, and given that there is also the morally relevant case of self-care, I would like to use the following criteria to distinguish moral from non-moral kinds of knowing-how: in the former case, it presupposes a special kind of valuation, namely the ascription of intrinsic value; in the latter, there is no such assumption. This is the domain of morality: from Aristotle's conception of praxis, through Kant's definition of a categorical imperative, to Wittgenstein's notion of absolute values, morality is a domain composed of intrinsic values. Self-care or caring for others are, consequently, expressions of the intrinsic valuing of a vulnerable being.

I will use now this criterion to distinguish moral norms from non-moral ones. For this purpose, I will refer to Wittgenstein's Tractatus. He wrote: “When an ethical law of the form, ‘Thou shalt …’, is laid down, one's first thought is, ‘And what if I do not do it?’ … There must be indeed some kind of ethical reward and ethical punishment, but they must reside in the action itself”.10 The distinctive feature of a moral law is, then, that it commands an action as good in itself. In other words, a moral rule is a categorical not a hypothetical norm. In his Lecture of Ethics, Wittgenstein makes the distinction between a relative and an absolute use of moral words. His example is this: suppose I had told somebody here a preposterous lie and he came up to me and said ‘You're behaving like a beast’ and then I said ‘I know I'm behaving badly, but I don't want to behave any better’, could he then say ‘Ah, then that's all right’? Certainly not; he would say ‘Well, you ought to want to behave better’. It seems clear that moral knowledge relates to an intrinsic valuation: the ascription of what is good in itself or right in itself. In this sense, there is no priority between right and good because both may be defined in terms of value. This is important in realising how we can overcome the dichotomy between deontology and teleology/consequentialism in normative ethics: both rightness and goodness are instantiations of intrinsic value. I will argue for this in the next section, showing how care and respect can be integrated into normative ethics, for instance, when one knows-how to care respectfully.

Respectful care in bioethics

Let me now illustrate in a more detailed way how practical cognitivism, that is, the epistemic theory that says that moral knowledge is knowing-how, interprets two important moral attitudes, namely caring and respecting. These notions are the foundations of bioethics, the field with which I am most concerned here, and are the basic building blocks of a common morality. Just to be clear: I am not assuming that respecting and caring are the only intrinsic valuations, but there is no doubt that they represent the kind of knowledge a practical cognitivist holds to be central to morality. In this section, however, I will particularly look for the conditions required for knowing-how to care in a respectful manner.

To start with, consider the predominant bioethical approach, namely the theory called ‘principlism’ based on the prima facie norms of respect for autonomy (a person's choices must be considered), non-maleficence (harm must be avoided), beneficence (more benefits than otherwise must result from our actions) and justice (a distribution is a fair one if it gives equally to equals and differently to non-equals). This approach is, meta-ethically speaking, intuitionist (there are several principles and no way of ranking them), and this may lead to arbitrary applications, as perhaps baby X shows. On the other hand, if we want to avoid both paternalism (eg, Pellegrino's model of beneficence-in-trust, which still gives more weight to the traditional Hippocratic principles)11 and individualism or indifference (eg, Engelhardt's autonomism, which gives absolute priority to personal consent),12 we need to integrate both care and respect to create the main core of a common morality. This is not the idea of the morality as some bioethicists hold is necessary. In their book Bioethics,13 Gert, Culver and Clouser present, as an alternative to the predominant bioethical theory, common morality as a public system for all, which manifests itself in different cultures. Such morality comprises several moral rules such as ‘Don't deceive’, ‘Don't kill’, ‘Keep your promises’, and so on, which supposedly are part of all existent moral systems. This idea was incorporated into principlism by Beauchamp and Childress, who describe it in these terms: “It is not merely a morality, in contrast to other moralities. The common morality is applicable to all persons in all places, and we rightly judge all human conduct by its standards.”14 Grounding principlism in common morality seems to be a remedy for many meta-ethical problems; however, it may bring new ones. Consider, for instance, the issues involved in the end-of-life processes, the problems surrounding the euthanasia debate: either in prolonging life or shortening it. When futility of any treatment is the case (a cure is not possible), a person has the moral right to refuse extraordinary means to keep her alive. In order to respect her as a person, this right must be granted, but it does not follow that she must not be cared for. How then to provide her with real respectful care? For one asking for it, palliative care is the way to value her for her own sake and to show respectful care and caring respect. For those asking for assistance to die, the only way to value them intrinsically is to provide a dignified way of passing away, but this is something the proponents of the common morality argued was against the rule ‘don't kill’ in medical contexts. Medicine is, however, a social practice and its goals may change. Thus, it seems clear that we should look for better ways of integrating care and respect. Let me then ask: under what conditions does one know-how to care for a vulnerable individual respectfully?

The knowledge implicit in caring for a vulnerable individual (a human being or even a sentient non-human animal) is knowing-how to increase her well-being and also prevent loss of well-being, not just in the technical sense of doing what must be done to cure her if she is a patient/subject of research, but it is also in the moral sense, which presupposes an intrinsic valuation: the person's welfare must be fostered because it is good for her own sake. If there is no such evaluative attitude, there is no moral worth in caring for her. Here, we must also remember that there is a distinction between natural and moral care. Thus, knowing-how to act morally involves an intrinsic valuation: a person knows-how to care if she answers in the appropriate way, for instance, sympathetically, to an individual's well-being and acts accordingly protecting it, fostering it, and so on, doing whatever is necessary for the vulnerable's own sake. An ethics of care (as represented by the works of Gilligan,15 Noddings,16 Lindemann,17 etc.) is arguably a consequence of practical cognitivism. I am not assuming here, however, the particularist assumptions generally subscribed to by most defenders of an ethics of care. In fact, a norm such as the non-maleficence principle mentioned above is always applicable in any case where caring is at stake. No one knows-how to care if she produces more harm than benefit and, if the above criterion is the right one, no one knows-how to care, in the moral sense, if she does not increase an individual's welfare or prevent loss of welfare for cared-for own sake.

As we saw in the previous section, professional medical knowledge involves all sorts of expertise. Now, regarding knowing-how to care, we may also distinguish between common moral knowledge and professional moral knowledge. For this proposal, it is crucial, for instance, to bear in mind the differences between general and specific beneficence. According to Beauchamp and Childress,18 specific beneficence rests on special relations, contracts or particular commitments and it is directed at specific parties such as children, patients, and so on; on the other hand, general beneficence is directed beyond special relationships to all persons. In this sense, healthcare professionals have specific obligations of beneficence through taking on a role. Consequently, moral knowing-how to care professionally is, in some sense, agent-relative despite the fact that, as Darwall has correctly pointed out, reasons to care are agent-neutral.19

Before developing further other normative implications of practical cognitivism, let me give one more example of moral knowing-how: a person knows-how to respect another person only if she is capable of deferring to her rights. In other words, in order to respect another person, one needs to recognise her as a person (a free agent and a holder of rights and a bearer of obligations) and to revere to her rights for her own sake. The so-called ‘respect for autonomy’ in bioethics that amounts to self-determination may here be a particular right a person has, but there are many others. A patient, as a person, has many rights: to advocacy services, to meet with clergy, to information, and so on, and not just to receive the necessary and basic care. Thus, instead of respect for autonomy at the foundations of bioethics, one must think in terms of respect for persons, which is another fundamental norm. An ethics of universal respect (as represented by the works of Tugendhat,20 Dworkin,21 Darwall,22 etc) may also be seen as a consequence of practical cognitivism. That is to say: a person knows-how to respect only if she recognises the other person's rights and has the relevant moral attitude of deferring, protecting, fostering, and so on, them because they are their rights. If such intrinsic valuation is not implicit, there is no moral value in her actions even if rights are not directly infringed.

If we now ask what kind of moral system we can build from practical cognitivism, one possible answer is this: on the one hand, since there is not just one single conception of well-being or even a single consensual set of claim rights, then we are bound to accept some sort of pluralism; on the other hand, if we want at the same time to avoid an extreme form of ethical relativism, then we must build up a common sharable morality (henceforth, CS-Morality), which has, so to speak, a ‘transcendental’ function: it makes possible the pacific and cooperative coexistence of persons even if they belong to different moral systems (Christians, Agnostics, Buddhists, Atheists, etc). Thus, a CS-Morality allows for a limited kind of pluralism, although it restricts unreasonable axiological systems. Now, respectful care and caring respect are the core of this minimalist public system of morality. As we have seen, both caring and respecting are expressions of intrinsically valuing an individual and/or a person and that is why they are moral attitudes. Despite the fact that there is no space here to argue for this in a more detailed way, I am assuming that care and respect are complementary aspects of moral life at the foundations of what I have called ‘a CS-Morality.’ Moreover, in this system, care and respect limit each other avoiding both paternalism and individualism in bioethics and in other domains of life. This remark applies to an intersubjective or social sphere, but it is also true of self-regarding concerns. That is to say, both self-respect and self-care are expressions of moral attitudes in the above defined sense.

How then can we now integrate care and respect into a solid normative ethics? Apart from principlism, there are currently important projects being carried out that are trying to overcome the dichotomy between kinds of deontology (Kantianism, contractualism) and consequentialism. For instance, Derek Parfit, in On What Matters, proposes a Triple Theory in normative ethics holding that “an act is wrong just when such acts are disallowed by the principles that are optimific, uniquely universally willable, and not reasonably rejectable”.23 I believe that we can amend Parfit's Triple Theory to include virtue ethics, the other major normative ethics in contemporary philosophy. According to virtue ethics, an agent is always obligated to, as Roger Crisp puts it,24 act as the virtuous person would act. This is also a purely formal criterion as it is ‘optimific’, ‘universally willable’, and so on, and can be incorporated into a renewed Triple Theory in this way: act under norms that are optimific, universally williable and would not be rejected by a virtuous person. Now, respectful care is the kind of moral attitude that is based on norms that are optimific, universally willable and would, certainly, not be rejected by a virtuous character. Therefore, the amended Triple Theory seems to provide the right balance between caring and respecting.

I believe, however, that we are still far from having a clear understanding of what respectful care actually requires. This is perhaps one reason why some of our practices may go wrong and we fail to deliver proper care as the case of baby X clearly shows. I hope here to make a small contribution to this topic by calling attention to some elements we need to consider in order to build this new bioethical concept, namely that of respectful care. There is little doubt that baby X should not have been delivered at a midwife-led unit. This was disrespectful to the baby herself. True care needs not only good intentions or nice feelings (sympathy), but also real conditions to benefit a vulnerable individual at risk of losing her life. The attention needed to improve a patient's well-being, to restore her health or simply to protect her from further harm must be accompanied by effective knowledge, both scientifically and morally speaking, and by material conditions. There are many mistakes that care is subject to. Technical errors, for instance, in diagnosis, are not the only ones that may occur. There can also be moral failures.

As we have seen in the first part, knowing-how to care is not just a question of having justified true beliefs, but requires the effective capacity of following some normative standards. Practices such as playing chess, diagnosing diseases, and so on, require the development of relevant skills. In the same way, acting morally requires acquiring knowing-how, for instance, to care for a vulnerable individual for her own sake. Thus, caring and respecting are mastered by training/practicing in order to develop the necessary capabilities to benefit a person's well-being and not with informational knowledge only. Moral training consists in teaching normative standards by given examples, inculcating rules and principles, punishing wrong doings, and so on, so that the apprentice internalises them up to the point they are part of her own character. Moral education also involves learning-how to respond appropriately to the special value persons have. Only then one knows-how to act morally and will develop the relevant moral attitudes.

Moral sentiments such as sympathetic concern are also a condition of proper care. Sympathy is just a natural sharing of feelings and emotions, both negative and positive, any social animal is capable of. It is immediate and involuntary rising out of our intersubjective interactions. In the human case, it is sometimes accompanied by empathy, that is, by imaginatively placing oneself in another person's shoes and simulating how she feels. Although they are certainly essential for proper caring, sympathy and empathy may not be sufficient. Moreover, feelings are sometimes misleading and may even compromise proper care. If one allows oneself to be guided just by anxiety, one may end up acting wrongly. Thus, empathy must be tempered with reflection on what is really best to benefit the patient's well-being, for instance, to effectively improve her health. Recalling the case mentioned, midwives were probably very sensitive, but perhaps lacked the material conditions to effectively benefit baby X's well-being.

There is another necessary ingredient for proper care. Apart from sentiments such as sympathetic concern and empathy, the recognition of the patient as a person is essential. Without making here a detailed analysis of what a person is, let us assume that a person is a bearer of rights and/or obligations. Thus, a patient has not only the basic right to health assistance, but other rights as well, such as to give informed consent, to call for a second opinion, to have her privacy protected, and so on. To respect a person is not only to fulfil our obligations regarding improving health, but to be careful not to violate other rights as well. Consequently, it seems clear that in the case of baby X proper care was not delivered because not all rights were respected. If the mother was complaining before giving birth, a second opinion should have been sought. Both parents and midwives should have remembered this and requested an obstetrician's review.

There is another condition necessary to give caring a full moral sense. The one-caring must benefit the cared-for because this is good for the patient's own sake. This is the right thing to do. Thus, morality requires evaluating intrinsically a vulnerable individual or a person. If the one-caring ‘cares’ for the vulnerable out of self-interest only, then ‘caring’ has no moral meaning. If the one-caring is only concerned with earning money or not losing her job, then caring may not only go wrong from a technical point of view, but could also represent a moral failure. Health sciences and practices, as many philosophers have argued, are moral enterprises. Therefore, to achieve its moral goal, caring needs to proceed with an intrinsic valuation.

Taking into account the results of the two sections, we may now say that W knows-how to care for X respectfully iff:

  1. W sympathises with X, but also recognises her as a p (person);

  2. X's well-being needs attention and p has, among others, a basic right to health assistance;

  3. W fulfils her obligations benefiting X for her own sake.

By definition, then, respectful care causes an increase in one's well-being or prevents a fall in welfare for one's own sake without violating other rights.

A CS-Morality (granted, not the eternal and immutable morality), based on respectful care, is greatly needed nowadays for bioethics in our globalised society. It is also the best candidate to provide the political foundation for justifying a State and its institutional policies enforcing many forms of caring. Thus, a CS-Morality may adopt the following political principle: “individuals have a right to equal concern and respect in the design and administration of the political institutions that govern them”.25 That is to say, caring and respecting requires: healthcare policies (preventive care, primary and acute care, social services for those with disabilities, etc), basic education for all (teaching useful skills, cultivating artistic talents, giving physical training, etc, and enforcing one's own sense of responsibility), public safety (protection from different kinds of harm), and so on, for all vulnerable human beings. In this sense, a CS-Morality may be based on egalitarian and universal norms. It is also the best candidate for providing the juridical foundation to guarantee the respect for other basic rights such as the freedom to pursue one's ideals, life projects, and so on, and other fundamental liberties such as property. Last but not least, a CS-Morality guarantees mutual respect among persons, limiting doctrines (eg, traditional practices, religions, etc), which are incompatible with the above-mentioned moral attitudes.

Final remarks

To finish, let me go back to the baby X case once more. As has become clear, baby X's ‘care’ was disrespectful in many ways, for example, a second opinion should have been sought, the baby should not have been delivered in a midwife unit, and so on. The conclusion cannot be otherwise: poor care, as provided in this case, is very disrespectful indeed. I believe that baby X died an avoidable and wrongful death. Apparently, both parents and midwife professionals did not care for the baby's own sake. That is to say, this case clearly shows a lack of respect as an expression of an intrinsic valuation, that is, of not knowing-how professionals ought to behave for the patient's own sake. As the health ombudsman report now reveals, the baby's records are of a poor standard and even inaccurate in some places. There is no doubt that the midwife missed key signs that the baby was unwell, so she did not care for the patient's best interest. If we are to avoid such cases occurring again, we have not only to improve the material and the scientific conditions to provide proper care, but we need also to add a moral dimension to caring: delivering it respectfully.

Acknowledgments

A previous version of this paper was presented at the University of Hull in the Department of Politics, Philosophy and International Studies on 3 November 2015. I would like to thank Professor Nick Zangwill for the invitation and the audience for the lively and interesting discussion. I would also like to thank CAPES, a Brazilian federal agency, for supporting my research project “Care & Respect: Re-thinking the meta-ethical and normative basis of bioethics” at the Oxford Uehiro Centre for Practical Ethics throughout 2015.

References

Footnotes

  • Funding Coordenação de Aperfeiçoamento de Pessoal de Nível Superior.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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