Transforming Care: A Christian Vision of Nursing Practice (17 page)

In this chapter we will develop two central values that are shaped by
the Christian faith and discuss their relevance to a Christian understanding of nursing practice. The two values we will be focusing on are deeply
rooted in the Christian tradition: care and justice. The way in which we develop these values, moreover, varies from the way in which principles of
biomedical ethics are often articulated. This difference is due in part to our
attention to how the Christian faith qualifies our values, but it is also due
to our attention to the nursing context. Biomedical ethics often focuses on
four principles: respect for autonomy, nonmaleficence, beneficence, and
justice (Beauchamp and Childress 1994, 38). Autonomy often functions as
the premier value of the four, and its application, therefore, concerns primarily issues such as informed consent. But, as we have already seen in the
second chapter, the Christian faith prompts us to acknowledge that our
personhood is deeply interdependent. Respect for autonomy, for the
Christian, needs to be grounded in respect for persons as image-bearers of
God and as vulnerable and interdependent members of the human community. Christian faith offers a similar qualification of the principles of
nonmaleficence and beneficence, which we develop in this chapter in
terms of care. Finally, the principle of justice needs to be reconceived in
light of our knowledge of God's character and with attention to particular
issues in nursing practice.

Both care and justice are central issues in nursing practice, and they
are also crucial for thinking about nursing from a Christian perspective
because they reflect two central ethical concerns that we are consistently
shown in Scripture - God's concern that justice be done, and God's
loving-kindness and mercy. We need both concepts to have an accurate
sense of who God is and of how to structure our own lives, and if we lose
sight of either we end up with distortions in our thinking. Without a clear
sense of God's love and care for creation we are likely to envision a God
who is just but cruel, a harsh and unloving God who delights in dealing
out punishments whenever possible. Without a clear sense of God's justice
we are likely to end up with a picture of a God who is mushy and sentimental, one who is unable to distinguish between right and wrong at all, or
who can distinguish but can't really do anything about it.

As we try to think about our own moral life, we will find the same situation. We need a proper balance between a strong opposition to evil and
a readiness to reach out in loving care. When we think about the dilemma
that faced the nurses in our example at the beginning of the chapter, we
can see that Annette offers a response that reflects caring. She wants to
make sure that client care doesn't suffer. But, as Tanisha reminds her, there
are issues of justice here as well, signified by the contracts the nurses
signed. This tension is one that has marked the practice of nursing since its
inception, but it is not one that can (or should be) resolved by giving up on
either principle (Andolsen 2001). We need both concepts, justice and care,
to make sense of our moral experiences, and though we will treat them
separately, neither can be fully expressed without the other (Bubeck 1995,
220; Baier 1995, 53).

We will begin with care, because it is a term that is used widely and naturally in the nursing context. What exactly is meant by the term care? Care,
first and foremost, connotes concern for the well-being and flourishing of
someone or something. When we care for clients, we are concerned that
their health care needs be met, that they are enabled to understand their
own situation and to make decisions that will allow their lives to go well
within the limitations they may face. So the most basic sense of care involves an active concern for the preservation and (where possible) the growth or development of someone or something (Carse 1996, 96; Noddings 1984, 31).

Care also necessarily involves both attitudes and actions. If I care
about something, my attitude toward it must be one of concern, but concern by itself is not enough to count as care. Concern must be active. If I
say I care about something but fail to act
in any way, then I cannot really be said to
care unless there are extenuating circumstances. For the Christian nurse, this connection between care and action is
grounded in the recognition of the goodness of creation and its Creator and gratitude for redemption that we noted in the
first chapter. Love for God never exists as
simply an inner feeling; love for God expresses itself in how we respond to those
people around us in whom we see God's
image. If we are not responding to them with love and care, our claim to
love God is cast in doubt (1 John). Likewise, when we think about how
God responds to us, we recognize that God's love is active, in the continued creative activity of sustaining creation and in the incarnate presence of
Christ with us.

Further, because Christians recognize that creation is a good gift
from God, it is appropriate to reach out in care and love to others. There
is something good in the other that care responds to, and should respond
to. But more than this, faith in the basic goodness of God allows the
Christian to respond with care even when that may seem a bit foolish or
even misguided. We don't have to limit caring responses only to those we
think will care for us in return, since care offered to another is also always
offered to God.

Care begins, then, with response to another. Theorists such as Joan
Tronto have called this basic sense of care "caring-giving" (Tronto 1994,
107). It involves the hands-on, active response to someone who is in a situation of vulnerability or need. We've noted, then, three of the fundamental
aspects of care: care is called for when someone has needs or vulnerabilities; an agent must recognize and be concerned about those needs; and the
agent's concern must be active. But we need a fourth component for an adequate account of care, and that involves the response of the person receiv ing the care (Noddings 1984, 73). In the ordinary case, the person cared for
must recognize the action as one that aims at her or his good and respond
appropriately in order for the complete action to be one of care. This response is crucial because it prevents care from becoming control. Of
course there will be cases where no deliberate response is possible - when
caring for comatose individuals, for example. But whenever care is given
appropriately, the care-giver watches to see that it is having the proper effect, so that, even in cases where the cared-for cannot respond, the caregiver should see a response. The response may be as simple as a bedsore
that begins to heal, or as complex as a client who begins to challenge the
authority of care-givers because she is regaining a sense of autonomy; in
either case, the care and the response to it are appropriate.

Caring is directed toward
persons in their full individuality, motivated in part by
a concern for their wellbeing and tending with any
luck to produce good
consequences.

MIKE MARTIN

Four components, then, are necessary for care: vulnerability, concern,
action, and response. Failures of care can occur at any one of these points.
Right from the start an individual may fail to, or refuse to, see another's
need or vulnerability. Jodi Halpern notes
that health care workers often turn away
from clients who are in strong states of
hopelessness and fear. The care-givers find
the emotional states so disturbing that
they tune them out and cut the client off
from emotional attentiveness (Halpern
2001, 9). While the response is understandable, Halpern argues, a better response is to allow oneself to understand
the emotional states, because such empathy can provide better knowledge
of the client's condition and better responses to the client's needs.

If someone does see the need, she or he may be wrong about what an
appropriate response might be. Daniel Chambliss notes that nurses sometimes estimate that as many as 50 percent of clients are noncompliant in
some way, and he argues that this suggests something other than ignorance
or self-destructiveness on the part of the client. Instead, he suggests, the
client may have goals other than those of the care-givers. "From the patient's point of view," he writes, "the staff may be boldly noncompliant
with the patient's own wishes. But `noncompliance' in the hospital means
`noncompliance with medical authority.' The very term defines medical reality as the dominant one" (Chambliss 1996, 138). What we have here is a
failure to communicate, of course, but we also have a disagreement about what the appropriate response is to clients who want to make their own
decisions.

Four Components of Care:

• need or vulnerability

• perception and concern

• appropriate action

• response

Paternalism - that is, acting against the client's wishes for the (perceived) good of the client (Beauchamp and Childress 1994, 274) - is a
constant temptation for health care workers. As we noted in our discussion
of nursing as a social practice, the nurse is highly educated, and health
forms the central value of her or his professional role. But clients may have
other central values, and often they do not care as much about health as
nurses wish they would. In such cases the very characteristics that make
someone a good nurse will also tempt him or her to paternalism. But good
care requires an involved stance of care for the client in ways that allow the
nurse to act as advocate for the client, not for him- or herself (Tanner et al.
1996, 211.)

Even in cases where the need is seen and the action taken is appropriate, the person who receives the care may not recognize it as caring and
may reject it or experience it as an unwarranted intrusion. Care-givers are not the
only people who can be wrong or confused about what is appropriate care in a
variety of situations. Clients can also fail.
Since this is a discussion of nursing ethics,
we will not focus on client responsibilities,
but it is worth noting that clients sometimes make care-giving very difficult.

All of these are points at which care can fail. But it is also important to
note that in many cases care does occur, is appropriate, and is experienced
as care by the one who receives it. We can recognize the way care is supposed to be and use that picture to understand where care goes wrong or
fails.

Care-giving, however, though it is the most basic sense of care, is not
the only sense that is important for our purposes here. There are many
needs and vulnerabilities in our world that we cannot address directly.
When I walk past an elderly man sleeping on the street, I may not be in a
situation to respond to his needs or to offer him any assistance. But I may
still recognize that he has needs that are clearly unmet, that his humanity
calls out to me to respond to him in some way. In these situations an individual may find herself or himself caring about something rather than directly giving care (Tronto 1994, 106). When we care about something, we recognize that there is a need or a vulnerability that should be addressed.
We will not always be in a situation to address that need completely on our
own. The recognition of needs that leads to caring about is properly connected to political action because there are so many needs that no one person can respond to all of them (Tronto 1994,139). If we care about homelessness, for example, we need to think about how mental illness, lack of
access to prescription drug plans, and homelessness all fit together. On
March 6, 2003, The New York Times reported that the state of Oregon had
managed to cut rates of homelessness by offering prescription coverage
under its Medicare program. Unfortunately budget cuts at the national
level threatened to make it impossible to continue to cover prescriptions
for the poor, and the state foresaw an increase in homelessness as a result.

North Americans confuse
care with control.

PATRICIA BENNER

Four Kinds of Care:

• care-giving

• care-receiving

• caring about

• taking care of

Care is a central aspect of our ethical framework from a Christian perspective because of the centrality of care in the picture of God we are given
in Scripture. The God who is revealed to us is a God who creates and sustains all that is, who cares for the needs of songbirds and wildflowers, who
even counts the hairs on each human head. This is a God who is portrayed
as weeping over the destructive nature of human choices, as mourning
with those who have lost loved ones, and as incensed at the destructive nature of so many of our choices. Further, this is a God who loved so deeply
that, in the person of Jesus Christ, he became incarnate and walked among
us, suffering what we suffer, even enduring an ignominious death for the
sake of sinners. As followers of this Christ we are likewise called to reflect
the sort of love he offered us and to respond to our neighbors (even our
neighbors who are enemies) with love. In one of the most memorable passages of the New Testament, we see Jesus explaining to us how this love
should be expressed. In the discussion recounted in Matthew 25, Jesus describes the sheep and the goats, and he
distinguishes them in terms of the care
they have offered to others. The sheep are
those who fed the hungry, offered a drink
to the thirsty, or provided clothing to the
naked, and the goats are those who failed
to offer such care.

Care, then, should be a central focus
of the Christian life, and the fact that it is
also a central concern of ethical analyses of nursing practice is a welcome
feature of contemporary analysis. But things are not always as they should be; because we care, this also leads us, with God, to lament the brokenness
of creation. Care would always be an appropriate response; even in a world
that was not broken by sin it would be appropriate to see others' needs and
meet them. But the brokenness of our world means that the care we are required to give is often needed because of sinful and destructive choices we
and others have made, and it means that the care we give will never, ultimately, be enough. It also means that when we care, we can do it wrongly
and in ways that are not going to lead to the good of the other. Our caring
can be paternalistic, might evidence the "conceit of philanthropy," or
might lead to "compassion fatigue" when we are confronted with the reality of too much need in the face of too few resources. Acknowledging the
pervasiveness of sin leads to a chastened notion of what care can accomplish and the dangers it poses as well as the need for it.