HOWARD J.CURZER
ABSTRACT. Care is widely thought to be a role virtue for health care professionals (HCPs). It is thought that in their professional capacity, HCPs should not
only take care of their patients, but should also care for their patients. I argue
against this thesis. First I show that the character trait of care causes serious
problems both for caring HCPs and for cared-for patients. Then I show that
benevolence plus caring action causes fewer and less serious problems. My
surprising conclusion is that care is a vice rather than a virtue for HCPs. In their
professional capacity HCPs should not care for their patients. Instead HCPs
should be benevolent and act in a caring manner toward their patients.
Key Words: care, ethics, virtue
It is quite possible that the best soldiers may
not be courageous.
Aristotle
INTRODUCTION
lama very good man, but a very bad wizard.
The Wizard of Oz
This paper focuses on a point at which three of the most
fashionable recent movements in ethics (virtue ethics, medical
ethics, feminist ethics) intersect.
There are some moral rules which people generally should obey
(Do not kill; do not steal; etc.)- But different rules apply to people
playing certain roles within the context of certain practices.
(Soldiers generally should obey orders given by their commanding officers, but civilians have no such duty; parents generally
Howard Curzer, Philosophy Department, Texas Tech University, Lubbock, Texas
79409-3092, U.S.A.
The Journal of Medicine and Philosophy 18: 51-69,1993.
© 1993 Kluwer Academic Publishers. Printed in the Netherlands.
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IS CARE A VIRTUE FOR
HEALTH CARE PROFESSIONALS?
52
Howard ]. Curzer
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should try to save their own children from a burning house before
they try to save other children; etc..) The set of rules which applies
to people playing certain roles is sometimes called a role morality.
Role morality can be approached via virtue ethics, too. There are
some character traits which, taken together, make someone a good
person. A person lacking these virtues is morally deficient qua
person. I shall call these general virtues. To be good at a role (to be
a good lawyer or a good parent, for example), requires a collection
of character traits which may be somewhat different from the
general virtues. I shall call these character traits role virtues. I shall
say with deliberate vagueness that role virtues are character traits
which help the person achieve the goal(s) of the role. The constellation of virtues of a particular role is not always the same as the
constellation of general virtues. To be good at a role might require
all of the general virtues plus other character traits. Florence
Nightingale suggests that this is true of nursing when she says
that "A woman cannot be a good and intelligent nurse without
being a good and intelligent woman" (Benjamin and Curtis, 1985,
p. 257). However, this is not true for all roles. Some role virtues
might not be general virtues and some general virtues might not
be role virtues. Indeed, role virtues might be general vices ai d
vice verse. The competitiveness that makes people good
businessmen might make them bad people, for example, and the
general virtue of benevolence might be a marketplace vice.
There are further complexities. A character trait may occupy
different places in the constellations of general virtues and role
virtues. Courage, for example, has a higher priority as a military
virtue than as a general virtue. Moreover, role virtues are often
narrower than general virtues of the same name. For example,
military courage, unlike general courage, is predominantly
courage in battle. Since roles are embedded in practices and
associated with institutions, role virtues are sometimes relative to
practices and institutions. The virtues of a teacher in a large state
university, for example, differ significantly from the virtues of a
teacher in a rural, one room elementary school house.1
The practice with which I shall be concerned is medicine of the
1990's in major medical centers of industrialized countries. This is
approximately the practice Veatch (1983, p. 188) calls 'stranger
medicine' because it is medicine practiced among people who are
essentially strangers. I do not think that what I have to say can be
applied in any straightforward way to third world medicine, 19th
Is Care a Virtue?
53
century American medicine, or small town modern medicine, for
example.2
The first step in approaching medical ethics from the perspective
of virtue is to ask, "What are the role virtues of physicians, nurses,
and other health care professionals (HCPs)?" Feminism has
prompted a partial answer to this question. Some feminists have
recently claimed that care is a virtue which has been somewhat
neglected, perhaps because it has been thought to be a feminine
virtue (Gilligan, 1982; Noddings, 1984). In particular, the following thesis has been advanced. (A) Care is a role virtue for HCPs
(Fry, 1989, p. 99; Pellegrino, 1987, p. 22). A good HCP must have
the character trait of care.
The word 'care' is used in a variety of ways. Among other
things 'care' might mean 'minister to' (take care of the sick), 'to
take an interest in' (care about freedom), or 'to have a liking for'
(care for chocolate).
Of course, 'care' in thesis (A) does not mean merely 'minister
to'. If thesis (A) is to be a non-trivial claim, then the character trait
of care must include caring about as well as taking care of. I can
take care of someone I do not care about, perhaps even someone I
despise. HCPs should not only behave in certain ways toward
patients, but HCPs should also care about patients.
Nor can 'care' in thesis (A) mean merely 'take an interest in'.
Heidegger uses the term 'care' roughly this way. For Heidegger
'care' refers to a morally neutral stance all people constantly have
toward all sorts of things (Heidegger, 1962). In thesis (A),
however, the term 'care' refers to a morally positive relationship
with people and perhaps animals. Thesis (A), moreover, presupposes that some people are more caring than others and some are
uncaring.
Frankena's use of the term 'care' meets these conditions. He
defines care as non-indifference or respect for persons (Frankena,
1983, p. 71-75)? But one can be dispassionately non-indifferent.
One can take an interest in people without liking them. One can
act in ways which respect rather than violate the autonomy of
people without wishing them well let alone being emotionally
attached to them. But this cannot be what 'care' means in thesis
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I hate definitions.
Benjamin Disraeli
54
Howard J. Curzer
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(A), and this is not what the feminists mean by 'care'. If 'caring'
meant merely respecting people's personhood, then there would
be no different voice. The ethics of care would be no different
from the ethics of justice. Feminists would merely by Kantians,
and thesis (A) would be trivial.
Note that respect for persons is not the same as benevolence. A
benevolent person not only respects the autonomy of others, but
also wishes them well and tries to help them even on certain
occasions when he or she has no duty to do so (Wallace, 1978, pp.
128-131). Note also that benevolent people need not 'have a liking
for' the objects of their benevolence. It is perfectly possible to be
benevolent even toward people one dislikes.
As the feminists, the advocates of thesis (A), and I use the term,
'care' means 'have a liking for' a person, caring for that person.
Care, unlike benevolence, involves emotional attachment. But
what sort or level of emotional attachment?4 Emotional attachments toward other people can be arranged roughly by degree
ranging from dispassionateness through the attachment typically
felt for mere acquaintances, the attachments typical of mild and
close friendships, all the way to the attachment typical of love. As
the feminists, the advocates of thesis (A), and I use the term, 'care'
involves not just the mild emotional attachment that we feel for
the acquaintance, but considerably more emotional attachment.
Care involves at least as much emotional attachment as is typical
of mild friendship.5
Roughly speaking, the number of objects of attachment is
inversely proportional to the degree of attachment. A person with
the general virtue of care typically cares a lot for a small circle of
intimate friends and family, somewhat less for a larger circle of
ordinary friends, and does not care for everyone else. (The caring
person may be non-indifferent or even benevolent toward
everyone else since dispassionate non-indifference and even
dispassionate benevolence is possible, but the caring person is not
emotionally attached to everyone else.) The objects of the medical
virtue of care are, however, a different group of people from the
objects of the general virtue of care. Clearly, if care is a virtue for
HCPs, then the objects of care for HCPs are predominately the
patients.
Therefore, if care is a role virtue for HCPs, then in their professional capacity HCPs should not only minister to (take care of)
and take an interest in (care about) their patients, but they should
Is Care a Virtue?
55
also have a liking for (care for) their patients. And not just any
degree of liking. Thesis (A) implies that HCPs should be significantly emotionally attached to their patients.
Jane Austen
'Caring' is a term so loaded with positive connotations that to
criticize anything related to it is risky. No one wants to be perceived as 'against caring' so I must proceed cautiously. Of course,
I think that caring is a general virtue. Of course, I think that caring
is a role virtue for some roles (e.g. parenting). Nevertheless, I
think that thesis (A) is false. Care is not a role virtue for HCPs.
Indeed, it is a vice. In their professional capacity, doctors, nurses,
and other HCPs should not care for their patients.6
This is not the completely counterintuitive claim that HCPs
should be uncaring brutes indifferent to the fate of their patients.
Rather my claim is that they should not become significantly
emotionally attached to their patients. Suppose, for example, that
Anne is a doctor who does everything a doctor is supposed to do
in the right way, at the right time, etc., except that she does not
care for her patients. Her diagnoses are accurate. Her therapies are
effective. Her manner is warm and friendly. She communicates
well with her patients. And so on. In general, Anne wants to
improve the overall length and quality of life of her patients and
acts effectively to do so. But she does not regret the suffering and
death of her patients any more than she regrets the suffering and
death of other people's patients because she is not significantly
emotionally attached to her patients. It would be very strange to
say that Anne is not a good doctor. Yet that is what we would
have to say if (A) care is a role virtue for HCPs.7
I shall argue for my claim in two stages. First, I shall show that
care causes serious problems both for caring HCPs and for cared
for patients. Second, I shall argue that (Bl) benevolence is a role
virtue for HCPs and suggest that (B2) benevolence disposes HCPs
to perform caring acts (acts typically performed by caring people).
My argument for (Bl) will consist in showing that benevolence
causes fewer and less serious problems than care.
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General benevolence, but not general
friendship, makes a man what he ought to be.
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Howard J. Curzer
DRAWBACKS OF CARE
She loves you. And you know that can't be bad.
Let me begin with a small but important point. Contrary to what
is commonly believed, being cared for is not always intrinsically
desirable.8 In any given case, whether being cared for is intrinsically desirable depends on various factors within the situation.
Anyone who has been the object of unrequited love can testify
that being cared for can be a burden as well as a good. As
feminists have emphasized, it is not always desirable to be cared
for solely because of one's appearance. Finally, like other human
emotions, care can assume twisted forms which torment the cared
for person. Some varieties of sadism, for example are really
manifestations of care. The desirability of being cared for is a
function of who is doing the caring, why one is cared for, and how
the care is manifested. Moreover, even if the who, why, and how
of caring are OK, being cared for can be an intrusive invasion of
privacy. Some people may not want to become an object of
significant emotional attachment by the members of a whole
medical team overnight.
It is not a great pleasure to bring pain to a friend.
Sophocles
Although caring usually benefits the person cared for in various
ways, it has some straightforward, bad consequences, too. Caring
makes some desirable actions more difficult and less frequent.
Consider hurting someone for whom you care, causing intense
physical pain. Consider communicating very bad news to
someone for whom you care, causing intense mental anguish.
Hurting patients and communicating very bad news to patients
are things that HCPs frequently should do. They may be more
reluctant to hurt patients for whom they care even when doing so
is therapeutically indicated. They may be more reluctant to tell
patients for whom they care very bad news even if the patients
should know the truth. Similarly, caring usually makes it harder
to withhold or withdraw treatment, deny patient's requests, etc.
Yet these acts, too, are appropriate in some situations. Being cared
for is, therefore, not always an unmitigated good.
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The Beatles
Is Care a Virtue?
57
/ love you. You belong to me.
Paul in Breakfast at Tiffany's
[the HCP] may relish a caring relationship and foster patient dependency to meet
his or her own needs for caring, thus interfering with treatment goals that work
toward patient autonomy and health.
Of course, all this is a long way from a demonstration that the
disadvantages of being cared for outweigh the benefits. Indeed,
what I have said so far suggests important ways in which care is
beneficial. The cases where reluctance to hurt inspired by care
saves patients from unnecessary pain probably far outnumber the
cases where this reluctance deprives patients of painful, but
overall beneficial therapy. So far I have merely shown that being
cared for is not always purely good either intrinsically or instrumentally.9
Love your neighbor as you love yourself.
Jesus
The character trait of care involves emotional attachment to a
person. We do not feel this attachment to others just because they
are people. Instead, we feel it because of the particular people they
are, because of particular facts about them. We care for others qua
individual rather than qua person. Indeed, the injunction to care
for patients often functions as a way of stressing that patients
should be treated as individuals rather than mere numbers.
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Caring also makes some undesirable actions easier and more
frequent. Consider deceiving someone for his or her own good.
People are more willing to deceive paternalistically those for
whom they care than strangers. The caring relationship serves as a
sort of justification. Some people sometimes think that caring for
someone entitles the caring person to some control over the life of
the cared for person. The nurse who enters the room without
knocking because she thinks herself entitled to a friend's liberties
is a minor example. The doctor who prescribes a placebo for the
patient's own good is a more serious example. In general, caring
for a person seems to make paternalism easier and more frequent.
Yet paternalism is seldom appropriate for HCPs.
Morse et al. (1990, p. 11) mention another common way in
which caring yields undesirable consequences.
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Howard J. Curzer
What would happen to me if I loved all of the
children I said goodbye to?
Mary Poppins
One of the major problems facing HCPs is the problem of burnout. There are many causes of burnout, but one of them is surely
getting significantly emotionally involved with patients, i.e.
caring. Caring contributes to burnout in a variety of ways. First,
the HCP can bring his or her patients' problems home only so
long before giving up on the profession. People have only a
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Since care requires an emotional investment based on particular
facts, since we care for people as individuals, HCPs cannot care
equally for all patients. A patient may be difficult for me to care
for because he or she reminds me of an old flame who jilted me,
has a sour personality, or has irritating mannerisms and bad
breath. A patient may be easy to care for because he or she shares
interests with me, is physically attractive, or has a great repertoire
of jokes. It would require a saint to care for some really disgusting
patients. Unrepentant child molesters, serial killers, highly
manipulative sadists, etc. get sick and become patients just like the
rest of us. As Downie and Telfer (1980, p. 91) observe "[S]ome
things are clearly not psychologically possible. A caring worker
cannot be in love with all his clients. Nor can he even like them
all." The character trait of care requires us to care for people as
individuals rather than merely as persons, and this, in turn,
implies that we care for people unequally and that there are some
people for whom we do not care (Noddings, 1984, p. 18). Of
course, this is not an objection to the general virtue of care, but it
is an objection to the thesis that (A) care is a role virtue for HCPs.
The fine talk of caring for patients as individuals conceals a
nasty reality. To accept it is to endorse and encourage favoritism
in health care. In practice, such talk encourages the HCP to take
care of patients only insofar as the HCP likes the patient. The
HCP, however, ought to be as impartial as possible toward
patients. Note, moreover, that the patient's race, sex, and age are
sometimes relevant to the ability of HCPs to care for the patient.
Favoritism opens the door to even more unsavory practices such
as racism, sexism, and ageism. These 'isms' have no place in the
health care setting. Care is a problematic character trait for HCPs
since it endorses and encourages these 'isms'.
Is Care a Virtue?
59
A doctor who treats himself has a fool for a
patient and a quack for a doctor.
Anonymous
Objectivity is a central virtue for every professional, especially for
HCPs. Loss of objectivity decreases the accuracy of diagnosis, the
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limited tolerance for sharing sorrow and suffering. Emotional
resources often get used up. Second, caring increases the vulnerability of the person who cares. To care for someone is to make
an emotional investment which often becomes costly if the object
of care dies, suffers, does not live up to expectations, rejects the
care, recovers and departs, etc.. Caring people get burned. Third,
not only the practice of caring, but the very ideal of caring causes
burnout. Some HCPs feel guilty about their inability to care for all
of their patients equally. This guilt contributes to burnout. Thus,
care causes burnout through emotional exhaustion, vulnerability,
and self-recrimination (Maslach, 1982, pp. 2-14).
Burnout harms both HCPs and patients in direct and obvious
ways. Burned out HCPs often suffer physical and psychological
deterioration. Their patients, family, and friends also suffer. So do
institutions and practices with which the burned out HCPs are
associated. Emotional exhaustion leads people to quit. It thus
exacerbates the shortage of HCPs (especially nurses), making the
remaining staff more inadequate and overworked. Sometimes
quitting is the lesser evil. Emotionally exhausted HCPs who
remain often unconsciously adopt various counter-productive
coping strategies to minimize their emotional investments in their
patients. These strategies undermine the ability of the HCP to
deliver health care while exacerbating the original problem.
Vulnerability leads to negative assessments of patients. "They are
all trolls". It leads to detached, callous attitudes and responses to
patients. Moreover, vulnerable people tend to strike back indiscriminately. They sometimes blame and punish not just the ones
they cared for but also others. They often adopt vindictive attitudes toward people, in general. Self-recrimination, like emotional exhaustion, often leads to counterproductive coping
strategies. Negative attitudes toward oneself take the joy out of
one's own life and undermine the health care delivery process.
Thus, ironically, caring for people often leads to burnout which
often leads to treating people in uncaring or even hateful ways.
60
Howard ]. Curzer
The logic underlying an ethic of care is a
psychological logic of relationships which
contrasts with the formal logic offairness that
informs the justice approach.
Carol Gilligan
HCPs who care for their patients naturally tend to take their
primary allegiance and duty to be toward their own patients
rather than other people's patients or the community. Naturally,
they try to get the best for their own patients. They tend to put
their own patients first. This poses two problems in a situation of
scarce resources. First, caring drives the cost of health care up.
Second, caring impairs the ability of HCPs to allocate resources
according to need. In other words, caring produces inefficiency
and unfairness.
Consider the following oversimplified situation. The best
therapy (BT) for a certain disease (D) is new, scarce, and very
expensive. The second best therapy (SBT) is much cheaper, but
not much worse except in a few cases. If doctors each care for their
own patients, then they will tend to prescribe BT for their patients
when the cost of BT is covered by third party payers. This will
cause insurance or tax rates to go up, and therefore will cost many
people a great deal. Overall, the community would be better off if
doctors would prescribe SBT although the patients with D would
usually be slightly worse off.12
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correctness of treatment decisions, the success rate of procedures,
etc.. In general, objectivity is necessary to provide the best medical care.10 Emotional ties to patients tend to compromise the
objectivity of professionals. Other things being equal, the degree
of objectivity about a patient is more or less inversely proportional
to the degree of emotional attachment to the patient. Thus, doctors
are warned not to treat themselves, their family members, or their
friends as patients. They are too emotionally attached to self,
family, and friends to be objective. Their caring prevents them
from providing the best medical care to the ones for whom they
care. Therefore, it seems bizarre to suggest that HCPs should care
for their patients, for this implies that they should abandon their
objectivity, compromise their professional judgment, and, in
general, decline to provide their patient with the best medical
care.11
Is Care a Virtue?
61
ALTERNATIVES TO CARE
To bear the unbearable sorrow
the Man of La Mancha
It would be very odd if a character trait that led to burnout, bias,
injustice, and inefficiency was a virtue. All of these drawbacks,
however, do not, by themselves, show that care is a vice for HCPs.
After all, in addition to these drawbacks, care has many obvious
advantages which I have not mentioned. If all of the alternative
character traits have worse drawbacks and/or fewer advantages,
then care will turn out to be a virtue after all. So I must show that
there is a better character trait for HCPs to have than care.
One way out of the problems of favoritism, burnout, objectivity
loss, etc. is to say that HCPs should combine something like care
with something like professional distance. Maslach (1982, pp.
147-148), for example, recommends the attitude of 'detached
concern'.
This recommendation is ambiguous. It might mean that HCPs
should adopt a watered down version of what I have been calling
care. HCPs should have a positive emotional attachment to their
patients, but that attachment should be much less than the emotional attachment associated with caring. If this is what 'detached
concern' means, then Maslach's recommendation is not significantly different from my own. (See below.)
However, Maslach's recommendation might be that HCPs
should simply add a buffer of professional distance to undiluted
care. HCPs should maintain a substantial emotional attachment to
their patients, but somehow temper that attachment with detachment. If this is what 'detached concern' means, then it is not a
viable or even intelligible recommendation. It is an oxymoron.
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If doctors each prescribed BT for their own patients, then the
distribution of BT would be based on the access of physicians to
BT rather than according to need, desert, etc.. So a few people
who desperately need BT (because they are allergic to SBT, for
example) will not get it because the supply of BT will be exhausted. If doctors did not care for their patients, these all-toocommon problems would arise less frequently. So these problems
undermine the claim that care is a role virtue for HCPs.
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Howard J. Curzer
Like oil and water, detachment and concern do not mix. The
recommended attitude is impossible to adopt because detachment
and concern are incompatible.
My proposal replaces the thesis that (A) care is a role virtue for
HCPs with the thesis that (Bl) benevolence is a role virtue for
HCPs, and since patients are generally best helped by caring
actions, that (B2) benevolence disposes HCPs to perform caring
acts. Benevolent behavior in the health care context is caring
behavior. So I am advocating a shift from an ethics of care, to an
ethics of care behavior. My suggestion is that HCPs should act as if
they cared for patients as individuals, but it is not necessary or
even desirable for them really to care for patients. HCPs should
act as if they are significantly emotionally attached, but in fact
should involve their feelings relatively little. They should be no
more emotionally attached to their own patients than to someone
else's patients or to the proverbial man on the street. HCPs should
do the things that a person who really cared would do in the way
that such a person would do them.13 They should take special
note of individual differences among patients, adopt an informal,
friendly manner, take an interest in non-medical aspects of
patients' lives, etc. (Downie and Telfer, 1980, p. 91). They should
hug patients who need to be hugged. But they should not really
care.
OBJECTIONS TO MY PROPOSAL
A good tree does not produce decayed fruit
any more than a decayed tree produces good
fruit.
Jesus
Someone might object to my proposal by claiming that HCPs
cannot consistently provide caring actions without actually caring.
This objection is not without force. It must be conceded that, other
things being equal, a person who really cares for patients will be
able to treat patients in a caring manner more consistently than a
person who does not really care for patients.
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Hypocrisy is not generally a social sin, but a virtue.
Miss Manners
Is Care a Virtue?
63
Yfhy Grumpy, you do care!
Snow White
Another objection to my arguments is that they seem to imply that
parents should not care for their children. Actually, however, my
arguments do not really have this implication. Parents have many
fewer children than HCPs have patients. And, of course, parents
do not see their children rarely and only in institutional settings as
HCPs see their patients. The dangers of favoritism, burnout,
inefficiency, and unfairness are, therefore, much less for caring
parents than for caring HCPs. The danger of objectivity loss is
greater, but is compensated for by the fact that a parents have
greater knowledge about their children than do HCPs about their
patients. Thus, the drawbacks of care are much less for parents
than for HCPs; so much so that the advantages of care outweigh
the drawbacks for parents. Parents should care for their children
although HCPs should not care for their patients. (Day-care
workers seem to me to be a borderline case.)
Men become gods by excess of virtue.
Aristotle (NE VH1)
But clearly the virtue we must study is human virtue.
Aristotle (NE 113)
There is a sense in which courage is not a good character trait for
an unjust person to have. It is better for an unjust person to be
held back from robbery by cowardice than to go on to become a
bold knave. Nevertheless, we call courage a virtue because it is a
good character trait for a person with all of the other virtues to
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But other things are not equal. As I have mentioned above,
caring HCPs are at higher risk of burnout, and burnout typically
leads to treating patients in an uncaring manner. So although
caring HCPs may act more caring at the beginning of their careers,
benevolent but uncaring HCPs are more likely to act in a caring
manner throughout the course of their careers.
Moreover, caring for patients is by no means the dominant
factor in the ability to treat patients in a caring manner. If getting
HCPs to treat patients in a caring manner is the goal, then it
would be much more effective to train HCPs in certain techniques
than to urge HCPs to care for their patients.
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Howard J. Curzer
[Ivan llych] wished most of all... for someone
to pity him as a sick child is pitied.
Leo Tolstoy
My proposal seems to be open to an objection which has
bedeviled Kant's theory of moral worth. Sometimes what a person
wants and needs is to be cared for. Mere caring words and actions
springing from some other character trait such as dutifulness or
even disinterested benevolence will not do.
I shall not contest this claim here, though I do believe it is more
controversial than some seem to think. Instead, I shall merely
observe that it does not follow from the fact that patients have
certain needs that it is the function of the HCP to meet these
needs. After all, it is not the function of the HCP to meet all of the
needs of the patient. To assume that providing emotional attachment to patients is part of the HCPs job description would beg the
question of whether care is a medical virtue.
Alienation appears not merely in the result
but also in the process of production.
Karl Marx
My theses that (Bl) benevolence is a role virtue for HCPs, and that
(B2) benevolence disposes HCPs to perform caring acts would
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have. Similarly, perhaps care is not a good character trait for
HCPs who are susceptible to burnout, bias, objectivity loss, etc. to
have. But people are all not equally prone to these things. If the
ideal HCP is well defended against the dangers of care so that its
advantages outweigh its disadvantages, then is not care a virtue
for HCPs?14
As usual when doing virtue ethics we must have recourse to the
notion of a range of normal character traits. HCPs who are not
susceptible to burnout, bias, objectivity loss, etc. while practicing
modern medicine in major medical centers are vanishingly rare.
There may well be a few extraordinary individuals for whom care
is overall beneficial. But a character trait which is only good for a
moral saint or superman to have is not a virtue. Instead a virtue is
a character trait which is good for a normal good person to have.
As I have shown, the character trait of care is not good for a
normal HCP to have, so care is not a virtue for HCPs.
Is Care a Virtue?
65
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solve the problems of favoritism, burnout, objectivity loss, etc. Of
course my proposal has its own drawbacks, (a) From the HCPs
point of view, the HCPs would be required to fake it on a regular
basis, to live a lie. The peril of burnout would be replaced with the
evils of alienation, (b) From the patient's point of view, patients
might believe that HCPs care for them even though the HCPs do
not really care. The perils of favoritism and objectivity loss would
be replaced by the evils of deception, (c) Finally, there is a risk that
HCPs will accept my rebuttal of the thesis that (A) care is a role
virtue for HCPs while rejecting (Bl) and (B2). Unscrupulous or
incautious HCPs might use my arguments that HCPs should not
care for their patients as rationalizations for acting in uncaring
ways toward their patients.
Now these are real dangers, but I do not think that they are very
serious, (a) People who meet the public (e.g. salespeople) are often
required to smile when they feel surly, be helpful to people they
despise, etc.. This does not typically produce intolerable tension or
psychic trauma. Nor is the performance of caring actions likely to
cause HCPs to become confused whether they care for certain
patients.
(b) In our society caring acts are performed by a wide range of
professionals and institutions. Customers and clients are well
aware that these acts are often performed without attachment,
that they are just part of the job. Indeed, people are often somewhat cynical about such acts. Patients will not leap to the conclusion that HCPs, whom they meet for relatively short blocks of
time in professional contexts, care for them. HCPs will not typically deceive themselves or their patients by performing caring
actions. In the relatively rare cases where there is a significant
chance that patients might be misled by caring actions the HCPs
may ward off misunderstandings by stating up front in a gentle
way that they are not intending to befriend the patient, but are
merely doing their jobs.
(c) Finally, almost any doctrine can be intentionally or accidentally twisted into a rationalization for something repulsive. I can
only emphasize that my thesis does not justify or excuse HCPs
who act in uncaring ways. HCPs should perform caring acts for
patients. They just should not care for patients.
66
Howard J. Curzer
CONCLUSION
Money can't buy you love.
The Beatles
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Let us step back for a moment and look at the larger context. We
have been discussing an aspect of the HCP/patient relationship.
My suggestion is compatible with the consumerist, freemarket
model of the HCP/patient relationship, but the thesis that (A) care
is a role virtue for HCPs is not compatible with this model.
According to the consumerist model it is unreasonable to expect
the HCP to care for the patient for the same reason that it is
unreasonable to expect the HCP to love the patient. Emotional
attachment is not the sort of thing which can be bought and sold.
Thesis (A) is compatible only with the paternalistic model, I think.
So to advocate thesis (A) is indirectly to endorse the paternalistic
model of the HCP/patient relationship. But the paternalistic
model endorses some fairly unsavory practices. Thesis (A) is
tarnished by the company it keeps.
Another aspect of the larger context is the enormous recent
change in the nature of the health care delivery system. Most
people's health care needs used to be met by the old family doctor
who was also a family friend. (Or at least this is what most people
'fondly remember'.) Qua friend the old family doctors cared for
their patients. These solo practitioners have now been replaced by
health care teams within health care institutions. The HCP no
longer sees the patient frequently in a variety of different settings
as part of an ongoing multifaceted relationship. Instead HCPs
typically see their patients only rarely, only professionally, and
only within an institutional setting. This change of the institutions
and practices of health care exacerbates most of the drawbacks of
care mentioned above and tips care over the edge from virtue to
vice for HCPs.
Expecting contemporary HCPs to care for their patients is as
unreasonable as expecting love from a prostitute. In both cases the
relationship seems intimate, but the exchange of money, the
infrequency of contact, and the one-dimensionality of the relationship makes the relationship purely professional. Emotional
attachment is incidental and destructive to the practice.
Is Care a Virtue?
67
NOTES
1
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I take no position here on whether general virtues are relative to practices
and/or institutions.
2
The importance of this qualification was suggested to me by Kai Wong.
3
The title of my paper gets its maximum shock value when 'care' is understood
in this sense. If the alternative to being a caring HCP is to be an uncaring,
indifferent one, then of course HCPs should care for their patients.
4
A virtue is not merely a disposition to act in certain ways. It also involves
having the right habits of passion, belief, desire, taste, and motive. To paraphrase
Aristotle, a caring person, a person with the virtue of care, is a person who tends
to form and maintain caring relationships with the right people, in the right way,
with the right emotions, etc.. So we must ask "What are the right emotions and
who are the right people?"
5
Of course this does not imply that caring relationships are friendships.
Friendships are two-way relationships, but caring relationships need not be twoway.
6
This claim implies that being a good HCP is incompatible with being a good
person (and parent) or that it is possible to possess the general virtue of caring
(and the parental virtue of caring) without caring for patients. I believe the latter
implication to be correct.
7
Of course my opponent might say that people such as Anne do not exist. I shall
try indirectly to show that they do.
8
The belief that being cared for is intrinsically desirable is often coupled with
some fairly wild claims about the wonderful consequences of the caring relationship. Jean Watson, for example, claims that "In a transpersonal caring relationship, a spiritual union occurs between the two person where both are capable of
transcending self, time, space, and the life history of each other" (Watson, 1988,
p. 66). Lenninger claims that "[T]here can be no effective cure without care"
(Lenninger, 1985, p. 210). I shall not bother to debunk these wild claims.
9
Of course, this is true for 'being the objecf of most virtues as well as vices. So
far I have merely tried to raise the question of whether care is an overall good. I
have merely tried to show that the answer is not obvious.
10
It sometimes said that objectivity is somehow antithetical to treating a patient
as an individual. The idea is that an objective, scientific approach involves
subsuming patients under general laws, classifying patients together with others
with similar diseases and situations. It tends to put patients into pigeon holes
and ignores the individuating details among patients. A subjective approach, on
the other hand, focuses on what is unique about each patient. It tends to pick up
important facts which the objective approach misses.
This is a mistake. What is actually going on here is that a sloppy objective
approach is being contrasted with a careful objective approach. The former
approach is called 'objective' and the latter approach is called 'subjective'. But
there is nothing subjective about carefully seeking all of the details about each
patient. Indeed, a truly subjective approach tends to miss things, for a subjective
68
Howard J. Curzer
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approach takes the biases of the investigator to be central guides of the investigation rather than obstacles to be overcome.
11
It might be argued that nurses are different from other professionals in that
objectivity is not central to or even part of nursing. This is a dangerous line of
argument for it undermines the claims of nursing to be a profession. But it is also
mistaken. Clearly, nursing includes tasks such as watching for particular
symptoms and general changes in the overall health of the patient, administration of medication, performing and assisting in the performance of procedures,
transmission of information between patient and doctor, etc.. These are tasks for
which objectivity is crucial.
12
In some cases the patients with D would be better off, too (perhaps because of
economies of scale in the production of SBT). In these 'prisoner dilemmas' cases,
if doctors each care for and prescribe BT for their own patients, the best interests
of everyone, even the patients, are defeated.
13
Does this mean that benevolent, but uncaring doctors would prescribe BT
rather than SBT for their patients? No. Unlike care, benevolence does not involve
favoritism. Benevolent doctors will try to do what is best for all concerned rather
than giving preference to the interests of their own patients. Thus, they will
prescribe SBT.
14
This objection was suggested to me by Walter Schaller.
7s Care a Virtue?
69
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Fabric of the Patient-Physician Relationship, D. Reidel Publ. Co., Dordrecht, pp.
187-207.
Wallace, J.: 1978, Virtues and Vices, Cornell University Press, Ithaca.
Watson, J.: 1988, Nursing: Human Science and Human Care, National League for
Nursing, New York.