Care Ethics and Care Contexts: Contributions from Feminist Philosophy

The substantial and insightful articles in this special issue address different cultural, societal, and regulatory problems of health care in contemporary medicine. They include expectations of what good care is, challenges arising from social contexts, and embedded norms affecting practices of care. To these empirical studies, I wish to contribute a perspective from feminist philosophy and care ethics that engages with issues in these articles.

Carol Gilligan's relational care ethics and Susan Sherwin's approach to a global feminist ethics of health care are my entry points for that discussion. In In a Different Voice: Psychological Theory and Women's Development, Gilligan ([1982] 1993) examines moral judgment empirically and discusses ethical reflections in children, adolescents, and adults, critiquing gender-biased ideals of good moral reasoning. She rejects the view that the most advanced form of moral judgment is characterized by an emphasis on general principles of individual rights and justice. In its place she provides an ethics of mature care, which is grounded in knowledge of, and respect for, others—as well as for oneself. I add to this concept of relational ethics the problematizations of health care ethics that Sherwin introduces in No Longer Patient: Feminist Ethics and Health Care (1992), her analysis of medicine and care as forms of power. There she examines medical care practices specifically and problematizes the inherent and external power dynamics that shape them. These power dynamics include carers' as well as institutional control over the bodies and minds of patients, but also the status and role of expert knowledge in society. Moreover, the global power dynamics between countries and economies surrounding medical technologies and how they affect care practice. The articles in this volume explore such dynamics and illustrate the poignancy of Sherwin's critique as well as the persistent deficit in what, using Gilligan's terminology, I call mature care practices in medicine. Sherwin argues that medicine facilitates the persistence of entrenched inequalities of gender, race, and class within and between countries via ideas of disease and normality. Intersectional feminist and postcolonial critique informs her model of a feminist health care ethics, in which she widens Gilligan's mature care approach to reflect on and oppose violent or patronizing practices in medical care within and between societies.

The predominant model of biomedical ethics addresses "good care" mostly as a relationship between physician and patient. The basic framework for contemporary medical ethics that is still widely referred to has been articulated by Beauchamp and Childress (1983). They identify four principles that ought to guide how a medical professional treats a patient, viz. autonomy, beneficence, nonmaleficence, and justice. The first three principles are about a relationship between two people. The last, justice, puts the patient in competition with many others for medical care and is commonly understood to be about the fair allocation of scarce resources. This set of principles addresses foremost physicians. It places them at the center and in charge of managing the patient relation as well as the resources they have at their disposal, including their time and priorities in treatment choices.

Translating such ethical principles into any concrete application inevitably means adapting them to local historical, sociopolitical, and economic conditions. Social status and power in all their forms—such as gender, class, race and ethnicity, age, and citizenship—come to matter for medical care in practice.

From the feminist perspective I adopt, the articles in this volume present several challenges to the standard model of medical ethics. My aim is to explore how and what these in-depth studies on care contexts and feminist health care ethics can contribute to one another. To do that, I draw out aspects from the articles that contribute to critical discourses about medical ethics, and underscore the need for mature and fairer health care.

1 Problematizing Care

I begin by noting three main challenges to basic assumptions of classical medical ethics brought to the fore in the articles collected here. The first two show the paradoxical effects of recent technological options on ethical considerations in health care, the third challenges the central position of the physician.

The effects...