Levinas' Ethics of Caring: Implications and Limits in Nursing

O R I G I NA L A R T I C L E Levinas’ Ethics of Caring: Implications and Limits in Nursing Byung-Hye Kong*, RN, PhD College of Medicine, Department of Nursing, Chosun University, 375 Seosuk-dong, Kong-gu, Gwangju 501-759 Korea Nursing scholars consider caring a key concept in understanding what is involved in nursing and believe that it is a major issue in nursing ethics. In this paper, the moral characteristics required for nursing care are described and these characteristics are discussed on the basis of taking responsibility for the Other, as described in Levinas’ ethics. First of all, the altruistic aspect of care in terms of Levinas’ ethics is examined. That is, a nurse should meet the needs of a person who is suffering, respond to them morally, and take responsibility. Levinas puts an emphasis on passive sensibilities that lead a nurse to respond to the needs of someone who is suffering, and also on the moral responsibility that encourages a nurse to empathize with others. However, his ethics cannot explain clearly how a nurse, as a moral subject with autonomy, forms a caring relationship with others. [Asian Nursing Research 2008;2(4):208–213] Key Words caring, ethics, nursing INTRODUCTION Nursing scholars consider caring to be a key concept in understanding what is involved in nursing and they also believe it to be a major issue in nursing ethics. They describe caring as a fundamental moral value or a moral ideal for the protection, preservation, and improvement of human dignity (Fry, 1989; Morse 1990; Watson, 1988). Caring is a moral imperative, so nurses are expected to care for others altruistically as part of their duty (Watson). Moreover, most nursing scholars (Gastmans, 1999; Nortvedt, 1998) place an emphasis on moral sensitivity and responsibility in the act of caring. The reason is that appreciation of the plight of another necessarily involves emotional sensitivity, which exerts a moral pull on the caregiver. The capacity for caring extends from sympathy as a moral feeling linked to emotional involvement with a patient. Caring therefore includes moral feelings of responsibility, which occur after grasping the plight of the patient and responding to the patient’s needs and concerns. Nursing ethicists consider the characteristics of caring as a moral attitude within the ethics of virtue rather than as principle-based ethics (Gastman). According to traditional ethical theory, principle-based ethics stress the autonomous self and the role of reason in performing right actions and justice, like Kant’s ethics and utilitarianism. However, the ethics of caring emphasize the moral attitude which implies an interpersonal relationship and the role of moral sensitivity and responsibility for others. Based upon this understanding of caring, the moral characteristics of nursing care can be summarized as follows: (a) caring in nursing is a moral imperative; *Correspondence to: Byung-Hye Kong, RN, PhD, Professor, College of Medicine, Department of Nursing, Chosun University, 375 Seosuk-dong, Kong-gu, Gwangju 501-759, Korea. E-mail: [email protected] Received: April 11, 2008 208 Revised: April 21, 2008 Accepted: October 23, 2008 Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4 Levinas’ Ethics of Caring (b) caring includes moral feelings of responsibility for others, (c) a caring relationship is focused on the needs of a suffering Other. Therefore, it is necessary to have a new debate on ethical theories which support philosophically how care for others in nursing can have significant implications for the moral imperative and feelings in the human relationship. Thus this paper aims to examine and discuss the moral characteristics of caring according to Levinas’ ethics of the Other, because his ethics place an emphasis on the moral imperative as being responsibility for the Other and moral feelings on the basis of human affectivity. Caring in nursing Edwards (2001) characterizes caring action in the following ways. First, it is intentional. It is not only the belief after scrutiny that a patient has a need, but is also an action with the hope of helping him/ her. Second, caring action is relational. It stems from the relationship between the carer and the one being cared for. Such a relationship has been molded more by a concern for others and his/her need than by a concern for the nurse him/herself. Third, caring action requires that a person meet the needs or interests of others. That is the most crucial aspect of caring in a nursing situation. For nursing to meet the needs of others, a phenomenological appreciation of other people as human beings with human vulnerabilities is called for. This appreciation helps one to understand the person who is suffering in the process of life experience. Given that nursing action pursues health, it is necessary to grasp the experience of suffering of a human being with vulnerabilities because nursing care in that sense is based on the requirement to understand the need of a patient in suffering and pain, and to respond to it. Furthermore, care in nursing is extended to an obligatory moral dimension to respond fully and appropriately to a suffering patient. At this point, the role of emotion is to exert a moral pull on the nurse to respond to a patient’s needs.These emotions can include sadness, sorrow, anger, depression, compassion and joy, all of which constitute a strong emotional involvement on the part of the nurse. Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4 Such emotional involvement in a patient’s suffering can be shown in a nurse’s sympathetic awareness. Sympathy means a mental participation with those who are suffering. Sympathy is a sort of moral feeling because it proceeds to the moral aspect of responding to the call of others who are suffering. Moral feelings produce such a strong sense of obligation that a nurse cannot choose not to respond to and take responsibility for a patient’s call. Thus the ethical characteristic of nursing care lies in a nurse receiving a patient’s call, responding, and taking responsibility for it through emotional involvement with his/her suffering. In the act of caring, as described above, human beings should be understood as emotional beings with vulnerabilities. They have the capacity to suffer, to feel pain or pleasure. A nurse in the presence of a patient’s suffering is encountering human experience the full force of human emotions. The emotion produced in the nurse at this moment is an involuntary obligation and a non-optional responsibility (Nortvert, 1998). In the context of care for others in nursing, it is possible to study care in terms of responsibility for others using Levinas’ ethics. His ethics are grounded in the sensitivity to the faces of others with human vulnerabilities. These ethics do not arise from moral autonomy based on a subject’s rational judgment. Ethics here originate from having affection for the sick, the poor, and the alienated, and place an emphasis on an unavoidable obligation and responsibility to respond to their calls for assistance due to an interest in their faces. The obligation and responsibility come from outside, seeing the patient’s face at close proximity, and accompanying practice with time and endeavor, rather than coming from the subject’s autonomous moral judgment. Therefore, I will study the ethical foundation of caring based on Levinas’ ethics for the Other and will reveal the implications and limitations when Levinas’ ethics try to explain the moral characteristic of caring in nursing. Levinas’ ethics: sensibilities The first thing to consider when looking at Levinas’ perspective on human beings is that he understands 209 B.H. Kong them first as bodily entities before being subjects with rational thought and free will. He makes clear the meaning of sense in the human body which is a fundamental reality preceding rationality. While traditional ethical theories stressed a moral subject with rational thinking and autonomy and free will, Levinas’ ethics are based on the primacy of the Other—on heteronomy, which is the site of the ethical subject and provides a way to explain the originality of an ethical subject. It is therefore necessary to know what the ethical self is as a sensitive being and to know about the ethics of the Other. Levinas says that sensibilities help human beings transcend their selfish egocentrism to arrive at an ethical self who can accept the Other. The ethical self is formed only by meeting the Other. The ethical self recognizes a human as a being with a desire to meet the Other as well as being one with inner egocentricity. Human egocentricity fades when it meets the Other, or as it forms a relationship with another person. When this occurs, the self does not connect with the Other as an object of one’s desire or as compensation for what one lacks. A desire for the Other does not represent taking the Other into the self or identifying the self with the Other. Rather, this desire means openness and commitment to the Other, which enables one to transcend the self in the Other. The transcendence is shown as a way of self-openness, through “epiphany or hospitality towards others through opening my door” (Kim, 2001).The epiphany towards others means an appearance of infinity, which presents itself as the face of others “in the ethical resistance that paralyses my powers” (Levinas, 1991). How does the human being composed of flesh and blood have ethical relationships with others? The self who is exposed to others is a sensitive being with vulnerabilities which can be affected directly by others. Vulnerability in relationships with others is the part which connects one directly to others before active rational thinking starts, and is affected by those others (Levinas, 1978). This human being has sensibilities that mean he/she cannot be cold-hearted or feel free from anxiety, discomfort and burdens caused by others. Levinas refers to this status of sensitivity as closeness or proximity. It is the state of mind toward 210 others which facilitates or leads to approaching them. Deciding to get close to the Other can often be explained by the appearance of the Other’s face. What does their appearance tell me? The face is the direct and first word, a primordial ethical expression which has ethical orders and imperatives, such as “you shall not commit murder” (Levinas, 1991, p. 199). The epiphany of the face of the suffering Other is the first thing, as well as the ethical stem word, that appeals to us and orders us to act ethically. In other words,“the face opens the primordial discourse whose first word is obligation, which no interiority permits avoiding” (Levinas, 1991, p. 201). The face stares, appears and expresses itself to me. The discourse caused by the epiphany cannot be avoided by keeping silent. The appearance of the face is an obligation as well as an order which makes it impossible to avoid or destroy the appealing self, and it opens the primordial discourse. By responding to the face, I come to realize the obligation imposed on me by the Other, and to start discourse by speaking to them. Discourse is formed in a face-to-face relationship. The face thus binds us together by stimulating discourse. In discourse, speaking to the Other is to be in proximity to him/her, and the responsibility to respond comes from the subject’s passivity (Levinas, 1978). What then is the passivity of a subject? When I speak to the Other, I am exposed to them, called, and addressed by them, which means that the subject is exposed to the extent of sacrificing his or her needs and getting involved in their predicament rather than sacrificing one’s own predicament. Levinas emphasizes this ethical situation of calling as being more passive than anything else. In his ethical theory, the discourse is referred to as calling and responding to the Other in an asymmetrical relationship between the Other and oneself, in contrast to the traditional ethical sense of a dialogue, which occurs based on the rationale of a symmetrical relationship. It is not a reciprocal relationship, but an asymmetric one in which the subject is exposed to sacrifice on behalf of the Other, and in which the self comes to realize the obligation and urgency of the face, to respond to its expression and appealing, to welcome and speak, and thus to start discourse. Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4 Levinas’ Ethics of Caring Levinas’ ethics: responsibility for others Levinas characterizes responsibility for others caused by an ethical self in the following way: “In obsession is a responsibility of the ego for that the ego has not wished, that is, for the Other” (Levinas, 1978, p.114). The subject’s passivity is taken hostage by the Other and is required to take responsibility for them. The hostage faces unlimited responsibility. As long as we exist as hostages, the world has closeness affected by compassion, sympathy and forgiveness. The responsibility caused by the Other demands that we should take more responsibility for our own behavior, which asks for self-sacrifice even at the cost of one’s own life. Taking responsibility for the Other is to suffer vicariously and to make sacrifices on the Other’s behalf. Levinas (1978) describes this ethical responsibility as substitution. Substitution is to put oneself into the Other’s situation. This means the self is accused of what the Other does or suffers, or is responsible for what they do or suffer. For this reason, the relationship between the Other and self is asymmetrical, because the self should then exist on behalf of the Other, and not vice versa. As described above, Levinas claims that for everyone the ethical relationship arises in the appearance of the Other’s face, and that moral responsibility for the Other stems not from a subject’s moral autonomy but from the subject’s passive sensibilities towards the face of the Other. The passiveness of a subject means that when I am exposed to his/her gaze, I am influenced by him/her without intending to be and am supposed to accept him/her. Levinas writes that an ethical subject embodies human vulnerability shown to the Other, experiences vicarious suffering, and is taken hostage. In other words, the face tells me to protect and serve the Other because the Other, not I, becomes my master, thereby producing an ethical situation in which I cannot discard him/her. Levinas describes the situation thus: ‘I am persecuted on the Other’s behalf,’ or ‘I am exposed to the suffering of the Other’ (Levinas, 1978, pp. 113–118). Furthermore, he claims that when I go through vicarious suffering for the Other (when I am taken hostage by the Other) this world comes near to compassion, sympathy and mercy. It is vicarious suffering that accepts Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4 the Other and carries their burden of suffering. That is, commitment to the Other. That is what a moral subject is; it doesn’t appear until I move the center of my life to that of the Other. Levinas, in contrast to Kant who sets up moral responsibility based upon individual reason and autonomy, imposes the responsibility on the self’s sensibilities towards vulnerability, and stresses care, commitment and responsibility. In conclusion, according to Levinas, when the ethical self rooted in sensibilities is exposed to the Other, the self responds to the Other through openness, and offers sacrifice on his/her behalf. Moral responsibility and the response through the epiphany, expression and speaking face-to-face to the Other causes pain to the ethical self, and forces the self to make sacrifices. The ethical self with its sensibilities comes to spend one’s flesh and blood, time and endeavor, and to practice morality through openness, proximity and closeness as a result of looking at the face. Implications and limits of Levinas’ ethics in nursing What implications does Levinas’ ethical thinking have for the caring ethics of a nurse? His ethics for the Other places an emphasis on the moral responsibility of a nurse. A nurse should respond to the calling and crying of a patient with vulnerabilities. According to Levinas, moral responsibility for the Other is imposed not by autonomous thought which has one judge reasonably using the conscious mind, but by a self’s passive sensibilities influenced by the appearance of the face of the Other. It follows that a nurse’s responsibility for a patient’s need does come not from his/her autonomous thought but from the passivity possessed by a patient’s face and gaze. It means that in the nursing situation, moral sensibilities arise during the process of a nurse looking at a patient’s face, perceiving what the face expresses and responding to it. Rational judgment comes next and depends on how one answers the nursing call of the patient. A nurse with an open-minded attitude should listen to the patient’s appeal and have a sense of responsibility to respond it. A nurse should put her/himself into a patient’s situation and be responsible for his/her suffering and life condition, but not vice versa. The 211 B.H. Kong urgency of the responsibility arises from the nurse’s passivity that makes it impossible for the nurse to avoid the suffering. For Levinas, because the unlimited responsibility ethics for the Other arise from the facial appearance, a nurse’s moral responsibility is imposed in the process so that a nurse undertakes discourse with a patient face-to-face, and the responsibility does not result from one’s inner autonomous moral conscience. A nurse plays the role of substitute for a patient’s suffering, so he/she should exhibit devotion and mercy, which is not chosen in drawing an inference from rational thought. Ethics in nursing is not what one thinks on one’s own, but practical behavior in face-to-face situations. However, on a practical level, this application of Levinas’ responsibility to care has a couple of limitations, namely the passivity of the ethical subject and asymmetrical Other-centered ethics. First, let’s think about a nurse’s passive ethical situation based on the notion of ‘passive sensibility of a body’. Levinas’ ethics have to be passive because they are the answer, in obsession of the sensibilities, to the calling or asking of the face rather than arising from inner autonomy. For Levinas, a nurse’s ethical situation cannot be avoided because a nurse must answer a patient’s call without inner optional autonomy. However, this raises another question. Is it only responsibility resulting from sensibilities towards a patient’s suffering that makes it possible for a nurse to take care of the patient when she or he also has to think seriously and morally about deciding what rational nursing is, and even when he/she has to choose moral decision-making? It is important that a nurse has sensibilities which make him/her meet and approach the face of a patient, and it is also important that a nurse with moral autonomy should appreciate the suffering of a patient in the context of a moral relationship. A nurse is to be influenced by and obsessed with the face. However, a nurse should go beyond that. In other words, a nurse needs to reflect autonomously within his/ her conscience on what the face means. Such reflection helps a nurse form a caring relationship with a patient. Second, it might be seen as controversial to say that an ethical subject engages in vicarious suffering. That 212 kind of suffering is central to Christian tradition, but it is very unusual in philosophy. Is it really possible that a nurse takes on the suffering of a patient in a clinical setting? It is obvious that Levinas does not suggest that substitutive suffering should be a universal ethical norm, but he describes suffering as something that helps a self restore its own ethical subject. However, if a nurse has to experience the suffering of a patient vicariously in order to restore his/her ethical subject that seems to go too far. That is reminiscent of the Christian ministry’s attitude inspired by Jesus Christ who bore everyone’s suffering. One criticism, therefore, of Levinas is that his ethics demand a degree of self-sacrifice which could be too much of an obligation for the autonomous professional nurse. CONCLUSION I have studied the moral characteristics of care in nursing through nursing theories, and have also discussed aspects of Levinas’ ethics for the Other. The characteristic of care in nursing is a sort of moral response to a patient in suffering, which constitutes the process of understanding of and emotional involvement with those who are suffering. Also, care is understood as the moral ideal of protecting, preserving and enhancing human dignity. In this paper, I have looked at nursing ethics as the ethics of responsibility for others from the perspective of Levinas’ ethics, which demands that a nurse should listen to those who are suffering and respond to their call. His ethics on the basis of sensibilities accentuate the nurses’ moral responsibility which prevents them from turning away from the ethical situation and compels them to listen to patients’ suffering and respond to their call. All of this is caused by meeting a patient face-toface. In Levinas’ ethics, the unlimited responsibility for the Other stems from the emotional appearance of the face, just as a nurse’s moral responsibility results from addressing and answering the face, not from his/her inner autonomous moral judgment. A nurse should, as a substitute for patients’ suffering, offer devotion and mercy, which is not chosen according Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4 Levinas’ Ethics of Caring to his/her own decision but is direct practice caused by bodily sensibilities. However, his ethics for the Other raises a couple of questions. First, is it possible for nurses to take the patients’ place in order to bear their suffering? It might be possible that we should expect nurses to bear suffering vicariously in a religious tradition that has an emphasis on altruistic self-sacrifice. Next, is it unavoidable that nurses have passive sensibilities? In other words, should nurses accept patients’ suffering without their own autonomy? I claim that nurses, in many nursing situations, should overcome their own passive sensibilities, keep a reflective distance, and preserve their own autonomy to help them reflect on the situation morally. It is a primary and basic duty that nurses should not avoid a patient’s call, but rather accept it. Furthermore, it is necessary that nurses should be qualified with a conscience and moral autonomy in order to provide a caring relationship and action. In conclusion, I have tried to examine the ethical characteristics of nursing care from the perspective of Levinas’ ethics for the Other. As far as we know, according to Levinas, nursing ethics as ethics of caring for the suffering Other provide the most primary and basic ethical language and obligation. However, at the secondary level, it is necessary that nurses have their own autonomous morality, because they can then perform caring actions when they possess autonomous critical thinking and an attitude that enables them to imagine patients’ suffering. They can then decide Asian Nursing Research ❖ December 2008 ❖ Vol 2 ❖ No 4 upon an appropriate care plan. In that context, as the search continues for a philosophical foundation to support the ethical characteristics of care in nursing, a theory which bolsters a subject’s moral autonomy should also be explored to serve as an addition to the Other-centered ethical perspective based sensitivity. REFERENCES Edwards, S. D. (2001). Philosophy of nursing: An Introduction. London: Palgrave. Fry, S. T. (1989). Toward a theory of nursing ethics. 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