Is Caring a Virtue?

Philosophical and ethical issues Journal of Advanced Nursing, 1998, 28(3), 466–472 Is caring a virtue? Peter Allmark MA RNT RN Nursing Lecturer, University of Sheffield, Sheffield, England Accepted for publication 21 January 1998 ALLMARK P. (1998) Journal of Advanced Nursing 28(3), 466–472 Is caring a virtue? The significance of the question ‘Is caring a virtue?’ lies in the fact that both the ethics of virtue and the ethics of care have been proposed as alternatives to what may be termed ‘bioethics’. The ethics of care has been of particular interest to nursing theorists, especially those who want to say that there is a body of distinctively nursing ethical theory which is different from bioethics. In answering the main question there are three supplementary aims: first, to explore the relationship between virtue ethics and the ethics of care, it is suggested that caring is not a virtue, but that the virtues involve caring correctly; second, to give a broad outline of what is meant by an ethics of virtue, including what it means to care correctly; and third, to examine implications of the theory for nursing. Keywords: ethics, virtue, nursing, care, education INTRODUCTION The significance of the question ‘Is caring a virtue?’ lies in the fact that both the ethics of virtue and the ethics of care have been proposed as alternatives to what may be termed ‘bioethics’. By ‘bioethics’ is meant the application of mainstream ethical theories to problems in health care. The ethics of care has been of particular interest to nursing theorists, especially those who want to say that there is a body of distinctively nursing ethical theory which is different from bioethics. Such writers do not wish to say simply that nursing ethics deals with different topics from bioethics, but that it deals with those topics in a different way (Fry 1989, Harbison 1992, Johnstone 1995, Bradshaw 1996). The ethics of care is appealing to nurses partly because it seems to offer a different way of doing things from mainstream ethics, partly because it is linked to feminism (and nursing is a female dominated profession), partly because of the belief that care is, in some way, central to nursing. There has also been some, although much less, interest in virtue ethics amongst nurses (Brown et al. 1992, Anne-Scott 1995). Correspondence: Peter Allmark, 15 St Albans Road, Sheffield S10 4DN, England. 466 In answering the main question there are three supplementary aims: first, to explore the relationship between virtue ethics and the ethics of care; second, to give a broad outline of what is meant by an ethics of virtue; and third, to suggest some of the implications virtue ethics has when applied to nursing. The key source is Aristotle’s virtue ethics as developed in the Nicomachean Ethics. As there are numerous editions of this work, specific passages of that work are referenced by the customary Bekker system (e.g. 1134a12) used almost universally. RELATIONSHIP BETWEEN CARING AND VIRTUE Let us begin with preliminary ideas about the relationship between virtue and caring ethics. There are at least two similarities. First, both are proposed as alternatives to mainstream ethical theory by which is meant the application of consequentialism, deontology and combined theories to ethical questions. The ethics of care grew from criticisms of a Kantian theory of moral development offered by Kohlberg (Gilligan 1984). Virtue ethics, whilst having ancient origins, particularly in the work of Aristotle, has re-entered discussion of ethical theory since a paper by Anscombe (1958), followed up by influential © 1998 Blackwell Science Ltd Philosophical and ethical issues work by, amongst others, Geach (1977), Foot (1978) and, especially, MacIntyre (1985). Such writers are invariably critical of modern ethical theory. The key to MacIntyre’s criticism of modern ethical theory is that since the Enlightenment there has been a loss of the sense of a goal (telos) in ethics. Take the central ethical term ‘morally good’ as an example. The term good appears to make sense only when it is applied to something with some sort of a goal. Hence we can make sense of the ideas of a good knife, nurse, assassin and so forth. Yet modern ethical theory tries to suggest where it is applied morally, as in a ‘good person’, good is uniquely detached from the sense of a goal. Instead it is suggested that, in some way, ‘pure reason’ can detect what is good. MacIntyre suggests this cannot be done, ethics is teleological of its nature. Some evidence of this is seen in the intractable nature of ethical dispute. Where ethics is detached from its telos it becomes impossible to negotiate between one person’s notion of ‘good’ and another’s. There was a time when it was fashionable to write ethical analyses of the form ‘a utilitarian would say this, a deontologist that, a principlist the other; and I think this, but of course there are no right answers’. Such an exercise seems a model of futility. Second, the two theories seem to share a number of positive features; an emphasis on the importance of character, particularism (the belief that specific rules cannot be applied to all, or perhaps any, ethical problems), the recognition of a role for emotion in ethical decision making. It is tempting therefore to suggest that there is a close relationship, perhaps to say that care is a virtue and the ethics of care a subset of the ethics of virtue. It will be suggested that the relationship is more complex than this. Caring is not a virtue, but having a virtue involves caring about the right things in the right way. By exploring virtue and virtue ethics we are able to see precisely why any ethics of care is likely to be very problematic and how virtue ethics may overcome some of those problems. WHAT IS A VIRTUE? A virtue is a quality possessed by something which helps it fulfil its function well. Examples typically given to illustrate this are the virtue of sharpness in a knife, or of ruthlessness in a sniper. But such virtues are only instrumentally good, it is obviously not good for the knife to be sharp, neither may it be good for the sniper himself to be ruthless. There is another sense of ‘virtue’ which belongs to natural things, plants and animals, and which is attached to a sense of good which is categorical, not instrumental. For natural things there is an end which is unconditionally good for any member of the species (Whiting 1988). Their function is to go through the changes necessary to meet this end. Is caring a virtue? Take the example of an acorn (Megone 1997). An acorn can become many things; food for Piglet, manure, a withered sapling, a strong oak tree. Very few acorns will become strong oak trees, but Aristotle maintains that it makes sense to say that that is what acorns are for, their end. Therefore their function is to go through all the various changes required to become such an oak tree. In going through these changes the acorn realizes its virtues. As natural things, people also have an end and a function. The end we all share is eudaimonia. This is a difficult concept that is at the heart of Aristotle’s ethics. We shall see at least part of the problem in our discussion of ‘the right cares’. One problem is what is the appropriate English translation. Approximately it means to live a flourishing, good, happy life, but I shall transliterate. As with acorns, it is possible that very few of us will achieve our end, eudaimonia. Whilst we share this end, we all have very different ideas of what it might entail; some value wealth, some, friendship, others, sexual conquests and so on (1095a17–21). Whatever the case, most of the things we do intentionally are done either as constitutive or instrumental means to eudaimonia. For example, a nurse might do some extra bank shifts to save money to go on holiday. In this case the nurse would see doing the extra bank shifts as instrumental means to eudaimonia, going on holiday as constitutive means. The human function is linked to the human end. The function we all share is the use of reason to decide on the means to eudaimonia, this is the key thing which distinguishes us from other things, our distinctive mode of activity (1097b33–1098a4) (Clark 1972, Whiting 1988, Reeve 1992). If this is our function then a good person will fulfil this well, in other words she will reason well about living well. In doing this she will realize certain virtues, human virtues. So, in human beings, virtues are qualities which are necessary in order to reason well about living a good, flourishing life. These virtues are potentially present in most human beings, just as most acorns have the potential to develop into oak trees. What specifically are these qualities? WHAT ARE HUMAN VIRTUES? Most of us would regularly talk of people being good or bad. When asked to give reasons we would talk of certain qualities such as kindness, selfishness, courage, timidity, even-temperedness and so forth. All of these would make reasonable candidates for virtues and vices. However, the list of candidates for virtue may vary greatly between people; some may say a good person is one who is ruthless, hard, cruel, fearless. Can we say they are wrong, that their vision of a good life is flawed? Can we identify a list of qualities which we know are necessary for eudaimonia and which are therefore virtues? Aristotle says that we can, © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(3), 466–472 467 P. Allmark but that we need to look more closely at our ideas of eudaimonia, of the good life. The starting point for classical ethics was not the question ‘what should I do?’ (the typical question asked in modern ethics), but rather ‘how should I live?’ (Williams 1987). In other words, the purpose of ethics was to identify the best, most satisfying life for someone to lead. This is far from an academic question; if we do all indeed share the end of eudaimonia then it is one which all of us are addressing when we choose to act one way or another. In answering the question we can go wrong in at least two ways. For a start, we can choose the wrong means to achieve those goals we believe are constitutive of eudaimonia. This seems obvious. For example, someone might decide that helping the poor is part of eudaimonia, but wrongly believe that the best way to do this is to gamble all spare money on the lottery so that he may give the profits to the poor. But we can go wrong in another way, that is, by choosing the wrong goals. For example, Aristotle would say that hedonism is just such a mistake (1095b17–20), a life spent pursuing pleasure will not be living well. This second point is more controversial, but virtue ethics probably stands or falls upon its veracity (Hutchinson 1986). Eudaimonia is not just achieving your goals, it is choosing the right goals and achieving them. So, in reasoning about eudaimonia we choose our goals as well as our means. We are now in a better position to describe a human virtue. It is a stable state of character concerned with choice. It needs to be stable because eudaimonia involves choosing right consistently (1100b18–24). It is concerned with choice because our function is rationally to choose the means to eudaimonia, so our virtues will enable us to do this choosing well. Doing this involves not only making the right choices but doing so for the right reasons, that is, with the right motivation. For example, someone who chooses to do something right not because he thinks it is right but rather because he feels he cannot get away with doing wrong cannot be said to be living well. It is an important characteristic of Aristotelian virtue ethics that living a good life is not about conquering wicked desires, rather it is about not having such desires at all. A virtuous agent chooses the right things happily. Why, though, do we choose to do anything at all? It is, says Aristotle, because we desire something and we see a certain action as a way of getting it. And why do we desire things? Because we see them as either good in themselves, worth having, or as a means to something good. The sort of things we see as good vary from one person to another, allotments, families, cars, alleviating suffering, gourmet food and so on. These are the things we care about, our values. So, if virtue is concerned with choice, ensures right choice, and choice arises from our values, what we care about, then a virtuous person is one who cares about the right things in the right way. 468 IS CARE A VIRTUE? What, then, is the relationship between virtue and care? To answer this question we need first to look at what it means to care. Whilst care and its cognates (such as ‘caring’, ‘careful’, ‘institutional care’) are used in a wide variety of ways, there seems to be a core definition (Griffin 1983). There are two aspects to this: $ $ The cognitive aspect. If one cares about something one sees it intellectually as of value, concern or interest to you, one sees some good in it. The emotional aspect. If one cares about something one feels, or is disposed to feel, an array of emotions in relation to it, for example sorrow or anger at injustice done to a person one cares about, or at destruction of a thing one cares about, pity when someone one cares about fails to thrive, joy when they do thrive, and so on. It is from these emotions arise most of our desires, and it is from our desires arise our actions. There are many things about which we care. If we did not have such ‘cares’ or values then our actions would be completely without direction. However, morally, the things we care about can be good, bad, or indifferent. It is a major flaw in the ethics of care that it focuses on ‘care’ and ‘caring’ as being good in itself. But almost all bad actions as well as good ones arise from care. Hence: Hitler may well have cared for the success of the German people just as fervently as Mother Teresa cares for the comfort of the destitute in Calcutta. But would that have made him a virtuous man? (Hudson 1993 p. 344) To be good, caring must be directed at the right things. It must also be directed in the right way; it is right for parents to care about their children, for example, but if that care is of such a nature that the child is stifled then that care is not good. We may now describe the relationship between virtue and care. A virtuous agent makes the right choices because she has the right desires. These desires arise because she cares about the right things in the right way (to the right extent, if you like). This is why each virtue is connected by Aristotle to a specific emotion or area of emotions. For example, the virtue of courage is linked to fear, the virtue of temperance to bodily pleasures, even-temperedness to anger and so forth. An example using the virtue of courage may help illustrate how this works. We tend to think of courage as overcoming fear and confronting something which endangers us in some way. Thus someone who notices a small child running along the central reservation of a motorway may stop her car, run across the road to the child, and hold onto the child until help arrives. This seems courageous. But what if someone is driving along the same road and notices today’s newspaper in the central reservation. He stops the car, runs across the road and picks it up to take © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(3), 466–472 Philosophical and ethical issues home. This does not seem courageous, it seems foolhardy in the extreme. Yet this person took exactly the same risk with his life as the courageous one. Thus courage involves confronting fear, taking risks, but only for good reasons. The courageous agent cares the right amount about the welfare of the small child, the foolhardy agent cares far too much about saving money. To answer the question upon which this paper is based, care is not a virtue, but the virtues reflect the things a virtuous agent cares about, which are the right things to care about. Caring is not good per se, it is simply something all of us do, good and bad. The ethics of virtue focuses on the agent, the things she cares about, and the way she expresses that care. Virtues are settled tendencies to act and feel rightly and arise in an agent as she comes to care about the right things in the right way. It seems likely, given some of the similarities between virtue and caring ethics, that caring ethics will be subsumed into virtue ethics as theorists ‘unpack’ what is meant by care, caring and so on. There is evidence for this in the work of Putnam (1991) and Blustein (1991), although both might question this interpretation. THE RIGHT CARES What precisely are the right things to care about, and what is the right way to care? To answer this by saying ‘care about the things, and in the way which the virtuous agent cares’ would seem circular and trivial. Yet to some this seems to be Aristotle’s answer. We are told that eudaimonia is activity in accordance with virtue in a full life (1098a15–18), in other words, it is the life of the virtuous agent. Then we are told that virtues are settled tendencies to feel and act rightly, and that what this means is essentially, to feel and act as a virtuous agent would (1107a1–2). This is indeed a circular argument and would be a problem were it not for the fact that we have independent information about the concepts contained within it, in particular, about eudaimonia. What is that independent information? To answer this we need to return to some points and questions raised earlier. It was said that an agent can go wrong both in their choice of instrumental means and of constitutive means (what we think of as our goals in life) to a good life. But left unanswered was the question of how we know one vision of eudaimonia and of the virtues is better than another. How do we know, for example, that it is worthwhile risking one’s well-being to save the life of a small child, but not to save the cost of a newspaper? What can we say to those who find pleasure in inflicting pain on others? There are, perhaps, at least two different answers given by virtue ethicists to this question. But both answers appeal to standards outside of virtue theory itself (Hursthouse 1987). The first answer says that we can see that such people Is caring a virtue? do not, in fact, flourish. They may die hounded, or unhappy, for example. It might be objected that this is patently untrue, that many bad people manage to achieve most of their aims and die content. To this objection it might be replied that virtue theory only requires truth for the most part, that for the vast majority of people virtue is rewarding and vice is not. Unfortunately this seems to leave the question of how we know one set of beliefs about virtues and eudaimonia to be better than another almost unanswerable. How can we ever know how many good as opposed to bad people flourish? The second answer also says that we can see that such people do not, in fact, flourish, but for different reasons. The key thing one should ask is not whether bad people die content but whether one envies them. It is to be hoped that very few of us do. We may envy their wealth, perhaps, but we would not wish to become like them, cruel, ruthless, whatever. Thus the answer to the question, why do we know one vision of eudaimonia is better than another is that we know we could not be happy any other way. Thus, when a normal, reasonably good person is asked why they don’t routinely lie, cheat, steal, kill or whatever, their answer will be something like ‘I just couldn’t live with myself…’ or ‘It wouldn’t even occur to me to…’. Such an answer will have no rational appeal to a vicious agent, but then no answer would. If someone gets enormous pleasure out of bullying others then it is hard to imagine any rational argument (other than that you’ll be caught and punished) which would persuade them it is not pleasurable. Good moral reasons do not appeal to bad people. In both these answers, and in answers which combine them, eudaimonia is an independent concept, knowledge of which is available to, at least, virtuous agents. Virtue ethics does not tell us what eudaimonia consists in, rather a vision of it is already existent amongst the good and those aspiring to be good. Is this idea feasible? Sartre (1975) famously gave an example of a young man in the Second World War who is forced to choose between fighting for the Resistance or looking after his elderly mother. This is presented as an example of how we have to create our values and ethics for ourselves, how no rules can help our choice, how we are completely free to choose. ‘If values are uncertain, if they are still too abstract to determine the particular, concrete case under consideration, nothing remains but to trust in our instincts.’ (Sartre 1975 p. 355). But what is interesting in this case is that the young man perceives only two options. There are many other possibilities: he could kill his mother, join the Gestapo and go and drown a few kittens. He does not see these options because he is a reasonably good person who shares something of the view of the good life. His view is not complete, and perhaps that is why he still suffers dilemmas. Arguably, however, the view is not ‘complete’ even in the fully virtuous agent (Broadie 1991). Nonetheless, the view is there. © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(3), 466–472 469 P. Allmark IMPLICATIONS The suggestion that caring is not a virtue has some importance in nursing, particularly nurse education. Caring has long been thought to be a concept at the heart of nursing, sometimes to be the thing which distinguishes nursing from other professions. The critique of caring ethics from a virtue ethics perspective implies that this is not at all the case. Caring is at the heart of all professions, assassins care about killing well and collecting maximum profit, supermarket managers care about providing a cheap and efficient service to attract customers and maximum profit. What distinguishes nurses from other professions? It is not simply that nurses care, everyone does, rather it is the objects of their care and the way it is expressed which is of importance. It might be objected that we do use the term ‘caring’ as a term of moral approval, both of individuals and professions. Everyone would be familiar with the idea that nursing is a caring profession, for example. Why is this so? Virtue ethics suggests that there are sets of things about which we should care, and ways in which we should care for them. These will be the cares, or more familiarly the values, which virtuous agents share. Probably high amongst these will be caring for and about the dependent and the ill. Hence the term ‘caring’ is regularly attached to individuals and professions (such as nursing, social work, physiotherapy and medicine) who care for them. It follows from this that nurses need to put aside their infatuation with the concept of care itself, concentrating instead on what they care about and the way they express that care. Focusing on nurse education I shall suggest two particular effects that this might have. Goals Earlier it was said that MacIntyre (1985) criticizes modern ethics for its attempts to develop and sustain a conceptual framework in the absence of a goal or telos. The same criticism could probably be made of much nursing theory. From the perspective of virtue ethics we should not be asking the question ‘What is nursing?’. This is the question which encourages us to look for some essence and usually offers an answer focusing on ‘caring’ (Kurtz & Wang 1991, Bryckzynska 1992, ) or, even, ‘loving’ ( Jacono 1993). Virtue ethics seems to suggest that, with practical disciplines such as nursing or ethics, we should not ask first ‘what is it?’ but rather ‘what is it for?’. In the case of ethics the answer virtue ethics offers is, it is for eudaimonia. With nursing we have yet to answer the question because we have not asked it clearly enough. Virtues before principles and rules Earlier it was said that virtue ethics emphasizes character, particularism and the role of emotions. A virtuous agent 470 is one who has the right cares, or values, hence feels and then acts rightly in the particular situation. Aristotle considers that life is too capricious for precise rules concerning conduct. To do the right thing you must be the right sort of person rather than follow a particular set of rules. Nonetheless, a virtuous agent does have knowledge of what is good, even though it is not in the form of a stateable propositional content. McDowell (1979) says that acceptance of the idea of this form of knowledge, practical knowledge, is blocked by deep rooted prejudices we have about rationality, that for an action to be rational it must stem from the application of formulaic universal principles. In reality there are no such principles, rather there is a ‘cottoning on’ to shared forms of living. In this context the simple statement ‘But can’t you see that is wrong?’ is an appeal to reason. At least two questions arise which are of importance to nursing faced with this view of practical knowledge. The first is, is the knowledge of the virtuous agent also a necessary part of a good nurse’s knowledge? The second is, if so, how can we inculcate such knowledge? The first question can be restated as simply, does the good nurse need to be a good (virtuous) person? A similar question has been discussed in the case of surgeons by Cassell (1987, see also Pellegrino 1985). He suggests that, given the ends of surgery, certain human vices, such as arrogance and compulsiveness, may be virtues in the surgeon. Interestingly, asked whether caring was important to outcome, he cites one surgeon who ‘said dismissively ‘‘Sounds like something that would come out of a nursing study!’’’. One might imagine other vices as being useful in other professions, dissembly to estate agents, perhaps. Thus whether or not a nurse needs to be virtuous will depend on the end or telos of nursing. As I have already stated that the question of what is the telos of nursing has yet to be adequately addressed I can offer no more than this. My own feeling is that nursing may be one of perhaps few professions where there are no vices which are useful in achieving its ends. This should be an enviable position if it is true that vices cause noneudaimonious lives. The second question is difficult, but also important. It may have been noted by the reader that Aristotle’s view of practical knowledge bears a striking resemblance to Benner’s (1984) view of the intuitive knowledge of the expert nurse. An important point for Aristotle is that practical knowledge is a type of knowledge, not a gift. ‘Intuition’ unfortunately conveys a slightly magical air. However, experts in many areas have a type of ‘intuition’, an art-dealer, for example, would have an intuition about whether a painting is a genuine or a fake, irreducible, perhaps, to any set of rules. The problem is that if there is a large part of nursing knowledge which is of Aristotle’s ‘practical knowledge’ type, unreducible to stateable propositional content then how may it be taught. In fact, ‘How may virtue be taught’ is one of the oldest questions in © 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(3), 466–472 Philosophical and ethical issues philosophy (e.g. Plato’s Meno). Recently Carr (1995, 1991) has written extensively on the subject. Although his focus is on children rather than the adults of varying maturity dealt with in nursing education what he says may be relevant. Getting emotions right involves the cultivation of sympathies, such as anger at injustice, compassion for the ill and suffering. Most nursing students will already be on the right lines and, where they are, it is a matter of reinforcing such feelings. Suitable mechanisms for this might be reflection on incidents from their own practice, or the use of fiction. Role modelling also seems central to the task of educating virtue, we learn virtues from virtuous agents, just as we learn skills from skilful ones. Is caring a virtue? As to the third aim, it was suggested that the realization that caring is not a virtue is of central importance in regard to the focus of nursing theory, that it implied a need to switch from a focus on nursing’s essence to its purpose. It was also suggested that the recognition of a type of practical knowledge which does not have a stateable propositional content might have implications for the teaching of nursing itself, and for the teaching of ethics in nursing. In the latter case one central question was whether the goals of nursing were such as to imply that a good nurse would be also a good person, or would be someone who would have a separate body of ‘nursing virtues’. It was suggested that this question could not be answered at the moment. SUMMARY AND CONCLUSION It has been suggested that caring is not a virtue, but that virtue involves correct caring. Three subsidiary aims were outlined in the introduction. First, to explore the relationship between virtue ethics and the ethics of care. Second, to give a broad outline of what is meant by an ethics of virtue, including what it means to care correctly. Third, to examine two implications of the theory for nursing. Let us summarize what has been said in relation to the first two aims first. A virtue is a quality which enables something to fulfil its function well. Something with the relevant virtues is a good example of its kind. Aristotle applies the concept to natural things by suggesting they have specific ends and functions, hence virtues. The end for human beings is eudaimonia, that is, to live well. Hence our function is to reason well so that we choose to do the things instrumental to, and constitutive of, eudaimonia. Our virtues are, abstractly, whatever we need in order to fulfil this function. To know what they are more specifically requires us to examine eudaimonia. Aristotle suggests that eudaimonia is not just achieving the ends you happen to have, but is also having the right ends. A successful vicious person does not achieve eudaimonia. Having the right ends is linked to agents’ emotional lives. The virtuous agent’s emotions are in good order; she cares for the right things in the right way. The ethics of care wrongly focuses on care itself, suggesting that it is good to care. The ethics of virtue focuses on the nature of the care, where it is focused, and how it is expressed. As it does not make the fundamental error of caring ethics, virtue ethics is the better theory. However, when exploring what ‘right caring’ means it appears that Aristotle gives a trivial, circular argument. 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