Bioethics ISSN 0269-9702 Volume 17 Number 1 2003 CARE AND THE PROBLEM OF PITY PATRICK BOLEYN-FITZGERALD ABSTRACT In recent years philosophers and bioethicists have given considerable attention to the concept of care. Thus we have seen important work on questions such as: whether there is a uniquely female approach to ethics, whether ethics should be partial or impartial, and whether care must be supplemented by justice. Despite this valuable and extensive work, however, some important distinctions have gone largely undiscussed. This paper tries to fill a gap left in our understanding of the concept of care itself by distinguishing between compassion and two kinds of pity. While all three are kinds of caring, we should not give them similar moral evaluations. Consequently, the distinction between compassion and different kinds of pity gives us an important insight into the question of whether we can consider care a virtue for health care professionals. INTRODUCTION In this article I distinguish between three types of caring ± fearful pity, aloof pity, and compassion. The distinctions have their roots in Buddhist psychology, but they are also useful for the question of whether we should consider care a virtue. Because both fearful pity and aloof pity burden patients, we cannot plausibly consider them virtues for health care professionals. Compassion, however, avoids the problems associated with both kinds of pity and remains a plausible ideal. We do not, therefore, merely want health care professionals to care about their patients, but rather we want them to care about their patients in a particular way. DEFINING CARE Some of the most interesting philosophical work on the ethics of care has been work defining the notion of care itself. Nancy ß Blackwell Publishing Ltd. 2003, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 2 PATRICK BOLEYN-FITZGERALD Jecker and Donnie Self describe a crucial distinction when they differentiate `caring for' and `caring about.' A health care professional cares for a patient when she `engages in a deliberate and on going activity of responding to the patient's needs.'1 Since the duties of some health care professionals do not involve patient contact, not all health care professionals should `care for' patients. Nonetheless, this kind of caring is unquestionably part of medicine. Health care professionals whose jobs involve patient contact certainly should care for their patients in the sense of providing for them. While the notion of `caring for' creates little philosophical controversy, Jecker and Self's second sense of care creates much. Health care professionals can `care about' their patients as well as `care for' them. Here Jecker and Self follow Stanley Hauerwas and suggest that `caring about' involves an `attitude, feeling, or state of mind directed toward the person or circumstance.'2 Helga Kuhse argues similarly that this kind of caring involves an `emotional response' to the patient.3 It is at this point where most of the philosophical controversies arise over caring in medicine. An emotional response is a broad term open to a wide variety of interpretations. What kind of emotional response should we call caring, and what conclusions should we draw about the moral status of this emotional response? The most well known answer to this question comes from Nel Noddings. Noddings argues that caring involves `engrossment', `the one-caring is engrossed in the other.'4 Many philosophers have interpreted this literally, and Noddings' citation of Martin Buber's I-Thou relationship encourages this interpretation. She states, `When I receive the other, I am totally with the other. The relation is for the moment exactly as Buber has described it in I and Thou.'5 We will look at possible alternative interpretations later in the paper, but for now we should note that this common interpretation of engrossment would make it problematic as a goal for health care professionals. To mention just one potential problem, the idea that health care professionals should be 1 N. Jecker and D. Self. Separating Care and Cure: An Analysis of Historical and Contemporary Images of Nursing and Medicine. Journal of Medicine and Philosophy 1991; 16: 295. 2 Ibid. p. 62. 3 H. Kuhse. 1997. Caring: Nurses, Women, and Ethics. Maldon, MA. Blackwell Publishers: 146. 4 N. Noddings. 1984. Caring: A Feminine Approach to Ethics and Moral Education. Berkeley, CA. University of California Press: 33. 5 Ibid. p. 32. ß Blackwell Publishing Ltd. 2003 CARE AND THE PROBLEM OF PITY 3 engrossed in their patients' lives seems unrealistic. It is not clear how a health care professional could develop this kind of relationship with all of her patients. Given this difficulty, it seems counterproductive to consider this kind of caring a goal for health care professionals. As Kuhse points out, exhorting health care professionals to strive for this kind of caring sets them up for failure.6 While literal engrossment is problematic as a virtue for health care professionals, not all philosophical interpretations of `caring about' would require a health care professional to become engrossed in her patients. Howard Curzer suggests that caring means to `have a liking for' which involves a kind of `emotional attachment.'7 This interpretation leads us down a very different path in our attempt to fill out the rather vague phrase `emotional response.' Health care professionals could have a liking for their patients without having to develop a relationship as intimate as engrossment. Thus, if we think that caring means to have a liking for, we might avoid the problem of unrealistic expectations. This new interpretation of caring, however, has its own problems. In fact, Curzer claims that it has so many problems that it should be considered a vice. Caring as emotional attachment leads to bias, burnout, injustice and inefficiency. It leads to bias because health care professionals cannot care equally about all patients. `The fine talk of caring for patients as individuals conceals a nasty reality. To accept it is to endorse and encourage favouritism in health care. In practice, such talk encourages the [health care professional] to take care of patients only insofar as the [health care professional] likes the patient.'8 It leads to burnout because the sharing of sorrow is taxing. Health care professionals will be greatly burdened by attempting to share in the suffering of their patients and in addition they may `feel guilty about their inability to care for all of their patients equally.'9 It leads to injustice and inefficiency because health care professionals will elevate the interests of their patients above the interests of other individuals in the community. While Curzer has identified some real and some potential problems with caring, there are also serious problems when health care professionals do not care about their patients. The 6 Kuhse, op. cit. note 3, p. 149. 7 H. Curzer. Is Care a Virtue. The Journal of Medicine and Philosophy 1993; 18: 54. 8 Ibid. p. 58. 9 Ibid. p. 59. ß Blackwell Publishing Ltd. 2003 4 PATRICK BOLEYN-FITZGERALD most obvious problem is that patients typically want ± and sometimes need ± care. It can be quite distressing to interact with someone who does not respond emotionally, especially when one is in the vulnerable position of being ill. Merely acting in a beneficent way may not be enough to put a patient at ease. Second, there are good reasons to think that `caring about' is a necessary part of `caring for.' In an interesting observational study conducted by Mina Mills, Huw Davies and William Macrae, for example, health care professionals who did not `care about' their patients did a particularly poor job of providing palliative care for the dying. While some of the patients in the study did receive an acceptable standard of care, many did not. Those patients who received substandard care received poor oral hygiene, often did not have their thirst quenched, were given little encouragement to eat, and were isolated at the end of their lives. The authors found that these deficiencies in palliative treatment correlated with medical professionals who did not show characteristics of caring about their patients. The professionals who did give adequate care `showed characteristics that identified them as ``caring'' people: for example, they spent time with a patient, addressed the patient by name, established eye contact, touched the patient, and asked open ended questions and waited for an answer.'10 In other words, when patients were `cared for' by medical professionals who exhibited characteristics of `caring about' them, they received an acceptable standard of care. When patients were `cared for' by medical professionals who did not exhibit characteristics of `caring about' them, they typically did not receive an acceptable standard of care. This really should not surprise us. In many cases empathy may be the only way that a health care professional can understand patient needs. For example, if a patient has a hard time verbally expressing his thirst, then empathy may be the only way that a nurse will know he wants water. Thus, even though it may be useful to make a conceptual distinction between `caring about' and `caring for', there are times when these two senses of caring cannot be practically separated. Sometimes `caring for' requires a kind of `caring about.' Finally, in many cases it will be impossible for the health care professional not to have some sense of `caring about', not to have some emotional response to the patient. To hold up the ideal of emotional separation may be as unrealistic as engrossment. We 10 M. Mills, H. Davies and W. Macrae. Care of Dying Patients in Hospital. British Medical Journal 3 September 1994; 309: 584. ß Blackwell Publishing Ltd.