The following article, which appeared in the second (revised) edition of the Encyclopedia of Bioethics (1995), was an attempt to capture highlights of the history of care prior to the advent of feminist thought in the early 1980s. In two articles immediately following this one, Reich set forth the history of care in contemporary feminist thought and contemporary medical and nursing ethics. This article will be re-published as a “classic article” in the Encyclopedia’s third edition.
by Warren T. Reich
From: Encyclopedia of Bioethics. Revised edition. Edited by Warren Thomas Reich. 5 Volumes. New York: Simon & Schuster Macmillan, 1995. Pages 319-331.
Prior to 1982 scarcely anyone spoke of an "ethic of care." The word "care" had never emerged as a major concept in the history of mainstream Western ethics as compared, say, with the concepts of freedom, justice, and love. Yet, starting with the 1982 publication of a book by Carol Gilligan that spoke of a care perspective in women's moral development and throughout the 1980s and into the 1990s, an ethic of care emerged very rapidly, questioning earlier assumptions and setting new directions for bioethics. (These contemporary publications and discussions will be reviewed in the third article in this entry.) One characteristic of the literature on an ethic of care is that it has paid virtually no attention to the history of the notion of care prior to 1982. Yet one finds in this history a broad range of meanings and models that both illuminate and challenge the emerging ethic of care.
The "Cura" tradition of care: Ancient Rome
Ancient literary, mythological, and philosophical sources form the roots of the "Cura" tradition of care, named after a mythological figure. The background for this tradition is found in the ambiguity of the term cura (care) in the Latin literature of ancient Rome. The term had two fundamental but conflicting meanings. On the one hand, it meant worries, troubles, or anxieties, as when one says that a person is "burdened with cares." On the other hand, care meant providing for the welfare of another; aligned with this latter meaning was the positive connotation of care as attentive conscientiousness or devotion (Burdach, 1923).
A literary instance of the first meaning of care -- the care that is so burdensome that it drags humans down -- is found in the work of the Roman poet Virgil (70-19 B.C.E.), who placed the personified "vengeful Cares" (ultrices Curae) before the entrance to the underworld. The philosopher Seneca (4 B.C.E.-65 C.E.), by contrast, saw care not so much as a burdensome force that drags humans down as the power in humans that lifts them up and places them on a level with God. For Seneca, both humans and God have reasoning powers for achieving the good; in God, the good is perfected simply by his nature, but in humans, "the good is perfected by care (cura)" (Seneca, 1953, pp. 443-444). In this Stoic view, care was the key to the process of becoming truly human. For Seneca, the word care meant solicitude; it also had connotations of attentiveness, conscientiousness, and devotion (Burdach, 1923; Seneca, 1953).
The struggle between the opposing meanings of care--care as burden and care as solicitude--as well as the radical importance of care to being human, were elements in an influential Graeco-Roman myth called "Care," found in a second-century Latin collection of myths edited by Hyginus (Hyginus, 1976; Grant, 1960). More than any other single source, this little-known myth, narrated below, has given shape to the idea of care in literature, philosophy, psychology, and ethics through the intervening centuries.
As Care (Cura) was crossing a river, she thoughtfully picked up some mud and began to fashion a human being. While she was pondering what she had done, Jupiter came along. (Jupiter was the founder of Olympian society, a society of the major gods and goddesses who inhabited Mount Olympus after most of the gods had already appeared.) Care asked him to give the spirit of life to the human being, and Jupiter readily granted this. Care wanted to name the human after herself, but Jupiter insisted that his name should be given to the human instead. While Care and Jupiter were arguing, Terra arose and said that the human being should be named after her, since she had given her own body. (Terra, or Earth, the original life force of the earth, guided Jupiter's rise to power.) Finally, all three disputants accepted Saturn as judge. (Known for his devotion to fairness and equality, Saturn was the son of Terra and the father of Jupiter.) Saturn decided that Jupiter, who gave spirit to the human, would take back its soul after death; and since Terra had offered her body to the human, she should receive it back after death. But, said Saturn, "Since Care first fashioned the human being, let her have and hold it as long as it lives." Finally, Jupiter said, "Let it be called homo (Latin for human being), since it seems to be made from humus (Latin for earth)" (see Grant, 1960; Shklar, 1972).
The meaning of the word "care" in this myth reflects the Stoic sense of an uplifting, attentive solicitude; it is in light of this positive side of care that we can understand the deeper meaning of the Myth of Care. Yet the word "care" is not without tension: The lifelong care of the human that would be undertaken by Cura entails both an earthly, bodily element that is pulled down to the ground (worry) and a spirit-element that strives upward to the divine (Burdach, 1923; Grant, 1960). The positive side of care dominates in this story, for the primordial role of Care is to hold the human together in wholeness while cherishing it. It is significant that a myth communicates the meaning of care, for one of the major functions of myths is to offer ancient narratives that make it possible for people to understand the meaning of their experiences regarding the basic characteristics of human life (Doty, 1991; Frye, 1971). The Myth of Care conveys an understanding of how care is central to what it means to be human and to live out a human life. It also provides a genealogy of care in light of which to rethink the value of care in human life.
Myths of origins have often been used to question the established order, both divine and human, and to establish radical moral claims, including claims about power and the social order (Shklar, 1972). Although several prominent political philosophies that have shaped much of modern bioethics are based on myths of origin that emphasize adversarial struggles as the starting point for human societies, the Myth of Care offers a subversively different image of human society, with very different implications for ethics in general and bioethics in particular (Reich, 1993). Indeed, the Myth of Care presents an allegorical image of humankind in which the most notable characteristic of the origins, life, and destiny of humans is that they are cared for (cf. Grant, 1960). At the same time, this gentle myth also speaks about the roots of power. Modern psychology teaches us that those who are cared for from birth (which is the image conveyed in this myth) develop the nurturing power to care for self and others. Furthermore, the fact that the myth's first human being is not named for the most powerful of the gods and goddesses, which would have been a symbol of being dominated by them, suggests that truly solicitous care protects humans from oppressive and manipulative power. The myth also suggests that humankind as a social totality is brought into the world and sustained by care. Since it binds humans together, care is the glue of society.
The care of souls tradition
The moral meaning of care is not only shaped by narratives, it is also historically embedded in practices such as the care of souls (cura animarum). The care of souls refers to the care of troubled persons whose difficulties--whether spiritual, mental, or physical--are approached in the context of the pursuit of the religious goals of life or, in nonreligious contexts, the search for ultimate meanings (cf. Clebsch and Jaekle, 1964; Browning, 1983). The care of souls tradition--the explanations offered in its literature and the interpretation of its practices--sheds light on the origins and content of contemporary ideas about care.
The word "care" in the care of souls refers both to the tasks involved in the care of a person or group and to the inner experience of solicitude or carefulness concerning the object of one's care. In the framework of the first meaning of the word, the care of souls consists of helping acts that are directed principally toward "healing" and the means by which healing is brought about, for example, reconciliation (including penitential reconciliation for those who have sinned), sustaining (including compassionate consolation), and guiding (spiritual and moral guidance).
The selection of the term "care of souls" to designate these activities (the word cura in the term "care of souls" is frequently translated as "cure" of souls) reflects the historical emphasis on a comprehensive idea of healing in the care of souls tradition (McNeill, 1951; Clebsch and Jaekle, 1964). Socrates regarded himself as the physician or healer of the soul, as did other philosophers (McNeill, 1951); and Gregory of Nazianzus (362 C.E.) said all pastors are physicians of souls, "who must prescribe medicines, or cautery, or the knife" (McNeill, 1951, p. 108).
The word "soul" in the care of souls can have a variety of meanings, depending on the philosophical explanation chosen or the religious tradition in which the term is used. John McNeill calls the soul "the essence of human personality" (McNeill, 1951, p. vii). It is spirit intertwined with the body without being a mere expression of bodily life. The soul is regarded as being susceptible to disorder and anguish, while being endowed with possibilities for well-being and blessedness. The care of souls, then, is the healing treatment of persons in those matters that reach beyond the requirements of physical life, in pursuit of the "health of personality" (McNeill, 1951, p. vii). But the welfare of the soul was not isolated: Caring for the healing of the soul, mind, and body have often been integrated (May, 1982). Thus, when we speak today of "the care of the whole person," we are speaking of something comparable to the ancient idea of the care of souls.
The care of souls conveys the primary message that there is invariably a hierarchy of values in what it is that humans choose to care about, and that among those values, care for the spiritual should be preeminent. Socrates exhorted his hearers in Plato'sApology "not to care for your bodies or for money above and beyond your souls and their welfare"; and in the Phaedo he argued that "the cultivation of the soul is the first concern" (McNeill, 1951, p. 20). Some scholars believe his exhortation greatly influenced the emergence of the idea of the care of the soul in ancient Greece and in Christianity (McNeill, 1951).
Another prominent feature of the care of souls has been the way in which it calls attention to the subjective experience of those who are suffering and their need for relief in the form of personal attention. In the Hebrew scriptures, the Psalmist speaks out of bitter anguish: "I looked . . . and beheld, but . . . no man cared for my soul" (Ps. 142:45; McNeill, 1951). The sufferer then appealed to the Lord to be his refuge in the land of the living. In the care of souls tradition, God, self, and other humans care for the troubled soul. The one who gives care must be very attentive to the needs of the individual sufferer. For example, Gregory the Great, renowned for his pastoral leadership in the Western church (590-604), taught that the guide of souls must be a compassionate neighbor to all, a shrewd observer, and watchful and discerning like the physician of the body (McNeill, 1951). But one problem remains constant: whether the sufferer will seek and/or accept care (McNeill, 1951).
The contrast between negative and positive care that one finds in Seneca and the Myth of Care was also presented by Jesus, who contrasted the heavy burdens (the "yoke") that many people bear--the worrisome cares of life--with relief or solicitous care (Matt. 11:28-30). He exhorted his followers not to be anxious about the necessities of life, but instead to trust that they would be cared for by the heavenly Father who knows their needs (Matt. 6:25-34; Davies, 1962).
The care of souls tradition produced three major bodies of literature that are of special historical interest to contemporary bioethics. First, casuistry arose within the context of the cura animarum. In contrast to the rigid ethics of the medieval penitential documents, in which priest-confessors were instructed on how to deal with various categories of sinners, casuistry had the objective of bringing the lives of ordinary people under the influence of religious and moral standards by emphasizing practical, case-based moral reasoning that avoided excessive abstractions and complications (McNeill, 1951).
Second, those who cared for souls cared for the sorrows and anxieties of individuals, partly by writing a body of so-called Consolation literature. For example, Seneca and Plutarch in the classical age and Cyprian and Ambrose in the third and fourth centuries C.E. composed Consolation literature, offering sympathy for the ills of life, suffering, and persecution (McNeill, 1951).
Third, in the fourteenth and fifteenth centuries, when the idea of death was so vivid, the care of souls tradition produced a vast Ars moriendi literature, commending the art of dying well (willingly and joyfully, rather than in despair) and how to help the dying person (Clebsch and Jaekle, 1964: McNeill, 1951).
Finally, care had the constantly changing function of sustaining souls through the pitfalls of the earthly pilgrimage of each period of history. For example, during the seventeenth and eighteenth centuries, sustaining the troubled soul became the dominant function of the care of souls. Because of the Enlightenment, hopes and human aspirations for this life ran very high, and pastoral sustenance attempted principally to keep believers mindful of their individual destinies beyond this life (Clebsch and Jaekle, 1964). This was precisely the environment in which care (Sorge) appeared in Goethe's Faust.
Goethe: A romanticist portrayal
The mythic idea of care made a major appearance in German literature in the eighteenth and early nineteenth centuries--a time when the meaning and relevance of myth were being rediscovered as never before--in the work of Johann Wolfgang von Goethe (1749-1832). Taking the Myth of Care from his teacher Johann Gottfried Herder (1744-1803)--specifically from Herder's poem titled "The Child of Care" (Herder, 1990)--Goethe wove the major themes of that myth into his masterpiece, the dramatic poem Faust (Grant, 1960; Burdach, 1923).
Dr. Faust, passionately committed to the pursuit of reason and science, also wants to be care-free, that is, free of the disturbing anxieties of care that the pursuit of his goals would entail in working with ordinary human resources. He enters into a pact with Mephistopheles (the devil). In exchange for the knowledge and magical assistance of Mephistopheles, Faust agrees to be his slave; it is agreed at the outset that Faust may lose his soul to the devil in the process (Goethe, 1985).
In the final act of the drama, Faust has become powerful and wealthy, the ruler of a flourishing land that he has reclaimed from the sea. He discovers that the deceitful Mephistopheles, working under orders from Faust, has horribly destroyed by fire the last cottage destined for demolition in the reclamation project; consumed by the flames was a peaceful old couple to whom Faust had promised relocation. Appalled by the horrific consequences of his thoughtless order, Faust breaks with Mephistopheles and his magic. He wants to stand before Nature as the "mere" human being he had been before his pact with the devil. This internal change sets the stage for the struggle over Faust's character, and for the appearance of Care (Goethe, 1959; Burdach, 1923).
Care (Sorge), a gray hag calling herself the "eternally anxious companion" ("Ewig ängstlicher Geselle"), chides Faust for never having known her: "Have you never known Care?" ("Hast du die Sorge nie gekannt?"). She denounces the darkness and ambiguity of Faust's soul--and blinds him because he refuses to acknowledge her fully. The terrible power of the burdens of Sorge's care almost overwhelms Faust but fails to conquer his soul. Linked with Faust's profound horror over his own crime, Sorge's denunciation has the effect of bringing about Faust's turn from burdensome care to the uplifting solicitude of positive care. His "striving," which led him to ruthless acquisition, the oppressive manipulation of masses of people, and the destruction of the old couple, is transformed during his blindness into a genuine solicitude for his people (Jaeger, 1968, pp. 41-43). Faust's experience of a new and very satisfying solicitude (the greatest moment of his life) is represented by his vision of millions of free people living in comfort and freedom on an earth that has been reconciled with itself through human effort.
Goethe's Faustian narrative demonstrates that striving for one's own life goals while shutting out a sometimes worrisome and painful concern for people and institutions results in terrible external and internal harm. In the pursuit of one's destiny, a human cannot avoid care. One must first deal with the heavy side of care, rejecting its power to engulf and destroy, and then convert this care, which is the root of all human striving, into a positive, solicitous concern for people and institutions. For Goethe, care becomes conscientiousness and devotedness (Burdach, 1923). At the same time, care relates in a fundamental way to the human condition, for it may be the key to one's moral "salvation," as it was for Faust. In contrast to today's tendency to associate care exclusively with interpersonal devotion, Goethe works out the meaning of care in a political setting; the problem for Faust is whether he will show solicitous care as a ruler. As a result, Goethe's portrayal of care has important implications for political philosophy.
Kierkegaard and Heidegger: Existentialist and phenomenological approaches
Kierkegaard. Søren Kierkegaard (1813-1855), the Danish philosopher and religious thinker, was the first major philosopher to make significant use of the notion of care or concern, albeit in embryonic fashion. Intimately familiar with the Sorge of Goethe's Faust (Collins, 1953), Kierkegaard offered creative philosophical explanations of themes that had appeared both in the Myth of Care and in Goethe: that care is central to understanding human life and is the key to human authenticity. The extensive influence of Kierkegaard's idea of care or concern on subsequent thought can be seen in the context of his role as father of existentialism: It was Kierkegaard's idea of the "concerned thinker," pivotal for his own philosophy, that became the central theme of existentialist philosophy and theology (Bochenski, 1968).
Concern and care in Kierkegaard's philosophy. Kierkegaard introduced notions of concern, interest, and care to counteract what he considered the excessive objectivity of philosophy and theology as they were formulated in the early nineteenth century. To recover the sense and significance of individual human existence that he believed modern philosophy's abstract and universal categories had obliterated, Kierkegaard called attention to what he saw as the missing element of concern or care in the kind of philosophical reflection that those systems utilized (Copleston, 1966).
Kierkegaard distinguished between disinterested reflection, on the one hand, and consciousness, which entails interest or concern, on the other. Reflection, he argued, focuses on the objective or hypothetical; it is a merely disinterested process of classifying things in opposition to each other (e.g., the ideal and the real, soul and body); it has "no concern with, or interest in, the knower" (Kierkegaard, 1958, p. 150), or with what happens to the individual person as a result of this kind of knowing (Kierkegaard, 1958).
Consciousness is inherently concerned both with the knower and with the collision of opposites that come to be known through reflection. Indeed, consciousness brings the merely objective elements of reflection into a real relationship with the knowing subject through care or concern (Kierkegaard, 1958). A personal (i.e., a concerned) relationship to truth is the basis of Kierkegaard's whole theory of knowledge (Croxall, 1958). For Kierkegaard the issue of concerned knowledge is a moral issue. To adopt the stance of the impersonally knowing subject rather than that of the concerned human being "as a refuge from the chaos and pain of life," he believes, "is cowardice and escapism" (Rudd, 1993, p. 28).
Kierkegaard also uses the notion of concern to express the nature of the human being and its moral choices. Humans are beings whose greatest interest or concern is in existing; concern or care is subjectively chosen as an intimate part of the individual's being (Kierkegaard, 1958; Stack, 1969). The individual gives form and direction to his or her life, and expresses his or her true self, not by being caught up in a large social system, but by exercising free choice and commitment (Kierkegaard, 1940; Copleston, 1966).
The fundamental question of ethics is: How shall I live? Objective reasoning plays a part in answering this question; but an ethical argument is valid only insofar as it articulates a concerned individual's search for meaning (Rudd, 1993). Thus, ethics starts with the individual. "As soon as I have to act, interest or concern is laid upon me, because I take responsibility on myself . . ." (Kierkegaard, 1958, pp. 116-117, 152-153). Without care or concern, action would not be possible: Concern is the impetus for the resolute moral action of the self-reflecting individual who acts with purpose (Stack, 1969). Always in the process of becoming, lacking the security of knowledge and facing contradiction, the human is constrained to mold his or her integrity through decision and action. One cannot do this without an "unrelieved and unceasing concern" for the passion and possibility of becoming oneself (Mackey, 1972, p. 71; Hannay, 1982).
Being burdened with cares; being cared for. Kierkegaard offers profound insights into the experience of being laden with cares and being cared for in writings that fall into the category of care of souls literature. He takes the traditional struggle between negative and positive care, previously discussed in the Myth of Care and in Goethe, in a new direction, by turning the subjective experience of worrisome care into reasons for caring for one's self and seeking the care of others.
In his writings on a biblical exhortation regarding human solicitude for material versus spiritual things (Matt. 6:19-34), Kierkegaard remarks that by contemplating the lilies of the field and the birds of heaven, who are not neglected, humans realize that even when they themselves are "outside all human care," neither are they neglected: They are still cared for by a caring God (Kierkegaard, 1940, p. 16). Humans must work to fill their needs; but the human capacity to be weighted down by material care is a mark of perfection, for it also signals the human capacity to cast one's care from oneself, find consolers, accept their sympathy, and choose a caring God (Kierkegaard, 1940). On the other hand, humans can trap themselves into a care-ridden state of mind by worrying about future needs, being convinced they need total security against their anxieties, feeling an exaggerated sense of self-sufficiency, and comparing themselves unfavorably to others (Kierkegaard, 1940).
For Kierkegaard, a special kind of anxious care is created when, in the course of an illness, the question arises whether the sick person is confronting life renewing itself or the looming decay of death. The pathos of this question, which is more moving than the prospect of a terrifying death, can move the sick person to reduce his or her resistance to accepting consolation from others (Kierkegaard, 1940). Finally, Kierkegaard remarks that caring for someone is not always a gentle art. When, for example, there is much that the sick person can do to improve his or her health, stern demands made by the authoritative doctor--sometimes even at the request of the patient--are the expression of concern for the anxious sick person.
Heidegger. For Martin Heidegger (1889-1976), one of the most original and influential philosophers of the twentieth century, care was not just one concept among many; it was at the very center of his philosophical system of thought. Conceptually, Heidegger was strongly influenced by Kierkegaard's teachings on concern and care; yet there is a notable difference. Whereas Kierkegaard saw care or concern always in an individualized, subjective, and psychological fashion, Heidegger used the word at an abstract, ontological level to describe the basic structure of the human self. Although Heidegger insisted that he was not speaking of concrete and practical aspects of care, such as worry or nurturing, it can also be argued that his writings on care do have existential moral significance. He certainly developed some ideas that provide useful insights for a practical ethic of care (Stack, 1969).
Heidegger's starting point and lifelong interest was the philosophical question of being--in particular, the question of the meaning of being. He used the term Dasein, or "being-there," to represent the human experience of being in the world through participation and involvement (Heidegger, 1973, 1985). Heidegger's interest was to show how care is the central idea for understanding the meaning of the human self, which is another word for Dasein. His philosophy explains how, at a deeper level than the psychological experience of care, care is what accounts for the unity, authenticity, and totality of the self, that is, of Dasein. Briefly, Heidegger claims that we are care, and care is what we call the human being (Gelven, 1989).
Heidegger explains the radical role of care by pointing to the tendency of the human self to turn away from its own authentic being to seek security in the crowd. It accommodates itself to what "they" think and forms its conduct in accordance with the expectations of public opinion. Care (Sorge) summons the self (Dasein) back from the feeling of insignificance and anxiety found in this flight from the self, and instead enables one to be one's own self, that is, to be authentic (Flynn, 1980; Martinez, 1989).
Heidegger also explains care in the context of openness to future possibilities. We are not simply "spectators for whom in principle, nothing would ‘matter'" (Olafson, 1987, p. 104). To say that the self (Dasein) is care means that we understand and care about ourselves-in-the-world in terms of being connected with what we can and cannot do. Because of the connectedness brought about by care, it matters that we can act, and we must act to choose among our own possibilities (Olafson, 1987). In so doing, Dasein chooses itself; and the meaning of its existence unfolds in every resolute act. This is all implicit in care (Martinez, 1989).
For Heidegger, care has the double meaning of anxiety and solicitude--the same duality we found among the Romans--and these two meanings of care represent two conflicting, fundamental possibilities (Heidegger, 1973). Anxious, worrisome care (Sorge) represents our struggle for survival and for favorable standing among our fellow human beings. It continually drives us to avoid the significance of our finitude, by immersing ourselves in conventionality and triviality, so as to "conceal from ourselves the question of the meaning of being, and in the process truncate our humanity as well" (Ogletree, 1985, p. 23). Yet care also bears the meaning of solicitude or "caring for" (Fürsorge): tending to, nurturing, caring for the Earth and for our fellow human beings as opposed to merely "taking care of" them. However, anxious care never totally dissolves: In the everyday world we cannot avoid the dual sense of care-as-anxiety and care-as-solicitude. Accepting the kinds of beings we are entails embracing a deep ambiguity in which we know that worrisome cares may drive us to escape and that solicitous care can open up all our possibilities for us (Ogletree, 1985).
Heidegger also contrasts Besorgen (taking care of, in the sense of supplying the needs of others) with Fürsorge (solicitous care). The human self (Dasein), which is essentially related to others, enters the world of others by way of care in two ways. On the one hand, we can take care of the "what" that needs to be done for the other, in a rather functional way. This sort of minimal taking care (Besorgen) requires few qualities--principally circumspection, so that the service is done correctly. Yet other humans are never merely things like equipment that need to be taken care of in this way; for they, too, are selves oriented to others. Hence they are not simply objects of service but of solicitude (Fürsorge). Solicitous care is guided by the subsidiary qualities of considerateness and forbearance. But Heidegger insists that when someone nurses the sick body as a mere social arrangement, that is, without considerateness, the nursing care should still be regarded as solicitude, albeit a deficient solicitude, and never as (mere) service-care (Heidegger, 1973).
Heidegger also speaks of two extreme forms of solicitous care. Intending to show solicitous care, one can "jump in" and take over for the other, who then is dominated and dependent in the caring relationship. Doing what the other can do for himself or herself, the "solicitous" person is actually taking "care" away from the other. In contrast, Heidegger continues, there is a solicitous care that "jumps ahead" of the other, anticipating his or her potentiality--not in order to take away his or her "care" but to give it back. This kind of solicitude is authentic care, for it helps the other to know himself or herself in care, and to become free for care (Heidegger, 1973; Bishop and Scudder, 1991).
Heidegger's substantive development of the notion of care drew from and contributed to the "Cura" tradition of care. At the "highpoint" of his inquiry (Heidegger, 1973), Heidegger directly cited the Myth of Care as a primordial justification of his central claim that the human self (Dasein) has the stamp of care (Klonoski, 1984, p. 65). In spite of Heidegger's complexities, some writers are attempting to develop elements of an ethic of care from his insights; and some scholars, such as Anne Bishop and John Scudder, are utilizing Heidegger's ideas in their arguments regarding the moral practice of health care (Bishop and Scudder, 1991).
Rollo May and Erik Erikson: Psychological developments
Rollo May. Rollo May (1909-1994), a pioneer of the humanistic school of psychology, introduced to U.S. psychology the views of European existentialists. He made Heidegger's views on care more accessible to the average reader by pointing to their psychological and moral implications.
May's 1969 book Love and Will was written in a historical period in which, he argued, humans were experiencing a general malaise and depersonalization resulting in cynicism and apathy, which he regarded as "the psychological illnesses of our day" (May, 1969, p. 306). What the youth of the 1960s were fighting in their protests, May claimed, was the "creeping conviction that nothing matters..., that one can't do anything." The threat was apathy. Care "is a necessary antidote" to apathy, for care "is a state in which something does matter; care is the opposite of apathy." It is "the refusal to accept emptiness..., the stubborn assertion of the self to give content to our activities, routine as these activities may be" (May, 1969, p. 292). Care, regarded as the capacity to feel that something matters, is born in the same act as the infant: If the child is not cared for by its mother, it withers away both biologically and psychologically (May, 1969).
May was concerned that the idea of care would not be taken seriously if it were regarded as mere subjective sentiment. To counteract this attitude, he argued that care is objective. With care, "we are caught up in our experience of the objective thing or event we care about" and about which we must do something (May, 1969, p. 291). Following Heidegger and citing the text of the Myth of Care, May holds that care constitutes the human as human: Care is "the basic constitutive phenomenon of human existence" (May, 1969, p. 290). Drawing from these sources the idea that the human being is constituted in its human attitudes by care, May claimed: "When we do not care, we lose our being; and care is the way back to being." This has moral implications: "If I care about being, I will shepherd it with some attention paid to its welfare..." (May, 1969, p. 290).
We could not will or wish if we did not care to begin with; and if we do authentically care, we cannot help wishing or willing. Care makes possible the exercise of will and love; and it is also the source of conscience: "Conscience is the call of Care" (May, 1969, p. 290, quoting Heidegger). Care is a state composed of the recognition of a fellow human being, of the identification of one's self with the pain or joy of the other . . . and of "the awareness that we all stand on the base of a common humanity from which we all stem." Care of self psychologically precedes care of the other, for care gains its power from the sense of pain; but pain begins with one's own experience of it. "If we do not care for ourselves, we are hurt, burned, injured." And this is the source of identification with the pain of the other (May, 1969, p. 289).
According to May, care must be at the root of ethics, for the good life comes from what we care about. Ethics has its psychological base "in the capacities of the human being to transcend the concrete situation of the immediate self-oriented desire," and to live and make decisions "in terms of the welfare of the persons and groups upon whom his own fulfillment intimately depends" (May, 1969, p. 268).
Erik Erikson. Partly under the influence of Heidegger's philosophy, Erik Erikson (1902-1994) constructed a richly humanistic theory of psychosocial development in which care played a major role. Like May, Erikson made the idea of care more accessible to the average person; but he went far beyond all his predecessors by developing a fairly comprehensive psychological account of care that is relevant to many of the interests of contemporary ethics.
Based on his study of case histories and of life histories, Erikson developed a theory of psychosocial development in which the human life cycle has eight stages, each of them characterized by a developmental crisis or turning point. From the resolution of that crisis a "specific psychosocial strength" or a "basic virtue" emerges.
In the seventh stage, "adulthood," the developmental crisis is generativity versus self-absorption and stagnation. Generativity--"the concern with establishing and guiding the next generation" (Erikson, 1987, p. 607)--encompasses procreativity, productivity, and creativity. It entails the generation not only of new human beings but also of new products and new ideas, as well as a self-generation concerned with further personal development. Generativity struggles with a sense of self-absorption or stagnation, "the potential core pathology of this stage" that might manifest itself through regression to an obsessive need for pseudo-intimacy (Erikson, 1982, pp. 67-68; 1963, pp. 266-268). The virtue or "basic strength" that emerges from this crisis is care.
Adult caring is "the generational task of cultivating strength in the next generation" (Erikson, 1982, pp. 55, 67-68; 1963, p. 274; 1978, p. 22); that task may be parental, didactic, productive, or curative (Erikson, 1982). For Erikson, care is "the concrete concern for what has been generated by love, necessity, or accident"; it is "a widening commitment to take care of the persons, the products, and the ideas one has learned to care for" (Erikson, 1978, pp. 27-28.)
The impetus to care has instinctual roots in the "impulse to 'cherish' and to 'caress' that which in its helplessness emits signals of despair" (Erikson, 1982, pp. 59-60). The infant's demeanor awakens in adults a strength that they need to have confirmed in the experience of care; conversely, maternal care enables the infant to trust rather than mistrust and to develop hope rather than a sense of abandonment (Erikson, 1987, p. 600).
The tasks of taking care of new generations must be given continuity by institutions such as extended households and divided labor (Erikson, 1987). "[A] man and a woman must [define] for themselves what and whom they have come to care for, what they care to do well, and how they plan to take care of what they have started and created" (Erikson, 1969, p. 395). Even if individuals choose not to have children, they have a relationship to "care for the creatures of this world" through participation in those institutions that safeguard and reinforce generative succession (Erikson, 1963, pp. 267-268). Some, like Gandhi, choose, as an expression of their care, to become "father and mother, brother and sister, son and daughter, to all creation..." (Erikson, 1969, 399). The task of taking care of the new generation also falls to organized human communities (Erikson, 1987); social and political leadership often entails giving direction to people's capacity to care (Erikson, 1969).
The framework for Erikson's ethic of care is one of dialectic dynamics, that is, it depends on a process of development and change through the conflict of two opposing forces; the moral task is to see to it that a new strength emerges. The negative aspect of adulthood (self-absorption) continues to interact dynamically with the positive aspects (generativity) throughout life (Erikson, 1963). Personal growth and the strength of care emerge from this conflict through an active adaptation that requires that one change the environment, including social mores and institutions, while making selective use of its opportunities (Erikson, 1978).
For Erikson, part of the ethics of care involves the struggle between the willingness to embrace persons or groups in one's generative concerns (a sympathic strength, which is the virtue of care) and the unwillingness to include specified persons or groups in one's generative concern (an antipathic inclination, which Erikson calls rejectivity). With rejectivity, "one does not care to care for" certain individuals or groups, or may even express hostility toward them (Erikson, 1982, p. 68). Because care must be selective, some rejectivity is unavoidable. "Ethics, law, and insight" must define the allowable extent of rejectivity in any given group. With the purpose of reducing rejectivity among humans, "religious and ideological belief systems must continue to advocate a more universal principle of care for specified wider units of communities" (Erikson, 1982, p. 69). Consequently, for Erikson, the ethics of care expresses itself in both "small but significant gestures" (Erikson, 1978, p. 15) and in global struggles against uncaring attitudes that contribute to the destruction of public and private morals.
Milton Mayeroff: A personalist vision
The 1971 book On Caring by American philosopher Milton Mayeroff (1925-1979) provides a detailed description and explanation of the experiences of caring and being cared for. Although he drew on several major themes from the history of the notion of care, he took the idea of care in new, personalist directions. Mayeroff's book is a philosophical essay that at the same time shares some of the characteristics of the care of souls tradition, inasmuch as Mayeroff's purpose was to show how care could help us understand and integrate our lives more effectively.
To care for another, according to Mayeroff, is to help the other grow, whether the other is a person, an idea, an ideal, a work of art, or a community; for example, the basic caring stance of a parent is to respect the child as striving to grow in his or her own right. Helping other persons to grow also entails encouraging and assisting them to care for something or someone other than themselves, as well as for themselves (Mayeroff, 1971).
The caring relationship is mutual: The parent feels needed by the child and helps him or her grow by responding to the child's need to grow; at the same time, the parent feels the child's growth as bound up with his or her own sense of well-being. Caring, Mayeroff says, is primarily a process, not a series of goal-oriented services. For example, if the psychotherapist regards treatment as a mere means to a future product (the cure), and the present process of therapeutic interaction is not taken seriously for its own sake, caring becomes impossible (Mayeroff, 1971).
According to Mayeroff, caring entails devotion, trust, patience, humility, honesty, knowing the other, respecting the primacy of the process, hope, and courage. Knowledge, for example, means being able to sense "from inside" what the other person or the self experiences and requires to grow. Devotion, which gives substance and a particular character to caring for a particular person, involves being "there" for the other courageously and with consistency. But caring does not entail "being with" the other constantly: That is a phase within the rhythm of caring, followed by a phase of relative detachment (Mayeroff, 1971).
Caring involves trusting the other to grow in his or her own time and way. There is a lack of trust when guarantees are required regarding the outcome of our caring, or when one cares "too much." One who "cares" too much is not showing excessive care for the other so much as deficient trust in the other's process of growing (Mayeroff, 1971).
In Mayeroff's vision, moral values are inherent in the process of caring and growth. When cared for, one grows by becoming more self-determining and by choosing one's own values and ideals grounded in one's own experience, instead of simply conforming to prevailing values. Mayeroff's moral approach to care is that of an ethic of response: He emphasizes the values and goods that are discovered in caring, and the fitting sort of human responsiveness to self and other that these engender. Care-related responsibilities and obligations--such as those that derive from devotion to one's children--arise more from internal sources related to character and relational commitments than from external rules (Mayeroff, 1971). When caring engages one's powers sufficiently, it has a way of ordering the other values and activities of life around itself, resulting in an integration of the self with the surrounding world.
The conviction that life has meaning corresponds with the feeling of being uniquely needed by something or someone and of being understood and cared for. Mayeroff concludes that the more deeply we understand the central role of caring in our own life, the more we realize it is central to the human condition (Mayeroff, 1971). Mayeroff's idea that care is central to the human condition reaches back through several philosophers to the Myth of Care, while his rich descriptions of the nature and effects of care set the stage for an ethic of care in the contemporary health-care setting.
Sympathy. The history of the ethics of sympathy provides useful insights for the developing notion and ethics of care. A number of philosophers writing between the end of the seventeenth century and the beginning of the twentieth--principally Joseph Butler (1692-1752), David Hume (1711-1776), Adam Smith (1723-1790), Arthur Schopenhauer (1788-1860), and Max Scheler (1874-1928)--developed an ethic of sympathy. Taken from the Greek word sympatheia, meaning "feeling with," sympathy referred to a "felt concern for other people's welfare" (Solomon, 1985, p. 552).
There are several reasons for considering some highlights of an ethic of sympathy in the context of this article. First, there are some links between care and sympathy: Some of the authors who have developed the notion of care include sympathy, empathy, or compassion as elements of care, for example, Rollo May and Milton Mayeroff; yet sympathy differs from care, for care has a deeper role in human life, is broader than sympathy in its tasks, and entails a more committed role with other people and projects. Second, the ethics of sympathy offers sustained philosophical examination of issues that are of interest to the ethics of care, which has been subjected to relatively little systematic philosophical inquiry. In particular, an ethics of care has much to learn from an ethics of sympathy regarding its most distinctive formal feature: It is based on a fundamental human emotion that is viewed as the central feature of the moral life and the basis of an ethic--a fundamental characteristic that it shares with the ethics of sympathy.
Accordingly, there are questions significant for an ethic of care that could be examined in the context of the ethics of sympathy. For example, there is the question regarding justification for the use of a passion or emotion such as care as the starting point or central point in ethics. Joseph Butler, writing in the sympathy tradition, argued against the view of psychological egoism, which asserted that we cannot be motivated simply by a concern for others, for human psychology is such that we cannot help but act in our own interests when we act on emotion. Against this, Butler argued that passions and affections, which are "instances of our Maker's care and love," contribute to public as well as private good and naturally lead us to regulate our behavior. Benevolence for others and the self-love that prompts care of the self are distinct; they are not in conflict; and they are both governed by moral reflection or conscience. David Hume went much further: Passions, or moral emotions, are primary, for they alone move humans to action; reason must serve the passions by providing the means for achieving the ends that sentiment selects. Consequently, moral judgments, which are the motives moving us to action, must be based primarily on moral sentiments or feelings, not on reason (Hume, 1983; Raphael, 1973).
Another question is whether an altruistic virtue traditionally regarded as soft could have much effect on the ethics of the practice of medicine, which emphasizes principles and objectivity. A comparable issue arose particularly in the writings of John Gregory (1724-1773), a prominent Scottish physician-philosopher, who applied the ethics of "sympathy" and "humanity" (the paired terms were taken from David Hume) to the medical care of the sick. Gregory held that the chief moral quality "peculiarly required in the character of a physician" is humanity, namely "that sensibility of heart which makes us feel for the distresses of our fellow creatures, and which, of consequence, incites us in the most powerful manner to relieve them" (Gregory, 1817, p. 22). The moral quality paired with humanity is sympathy, which "produces an anxious attention to a thousand little circumstances that may tend to relieve the patient" and "naturally engages the affection and confidence of a patient, which, in many cases, is of the utmost consequence to his recovery" (Gregory, 1817, p. 22).
Gregory speaks of the development of a balanced skill of medical compassion in the clinician: Physicians who are truly compassionate, "by being daily conversant with scenes of distress, acquire in process of time that composure and firmness of mind so necessary in the practice of physic. They can feel whatever is amiable in pity, without suffering it to enervate or unman them" (Gregory, 1817, p. 23). In this way, Gregory closely tied the virtue of sympathy to the art of medicine and to medical benefit, while answering the objection that sympathy causes an emotional imbalance in the practitioner.
Not only does Gregory defend the role of the "soft" altruistic virtue in medicine; he pointedly identifies the core of the objection against them. Rejecting as "malignant and false" the view that compassion is associated with weakness, Gregory argues that rough manners are "frequently affected by men void of magnanimity and personal courage" in order to conceal their defects (Gregory, 1817, pp. 22-24). Men can gain from women both "humanity" and "sentiment," qualities that are at the very core of the moral life (Gregory, 1765).
Attention. Attention (or heed or regard) has, for centuries, been one of the meanings of care; it remains an element of care today. To care for someone is to pay solicitous attention to him or her and to have a disposition of attentiveness. To take good (conscientious) care of a patient means to be attentive both to the needs of the patient and to the duties of proper care. The "attending physician" is one who has primary responsibility for the care of, and is ready for service to, the patient. Thus, the notion of attention is not only a concept parallel to care; it is an ingredient in care. The philosopher Gilbert Ryle says, "To care is to pay attention to something..." (Ryle, 1949, p. 135).
The most significant and stimulating thinker on the topic of attention was Simone Weil (1909-1943), a French philosopher and mystic who makes attention the central image for ethics. Attention, she explains, is a negative effort consisting of suspending one's thought, leaving it detached, empty, and ready to receive the being one is looking at, "just as he is, in all his truth" (Weil, 1977, p. 51).
Weil says that solving a philosophical problem (including one dealing with morality) requires a kind of caring contemplation: "clearly conceiving the insoluble problems in all their insolubility, ...simply contemplating them, fixedly and tirelessly, ...patiently waiting" (Weil, 1970, p. 335). Being attentive is being open to illumination (Weil, 1978, p. 92); we should look at these problems "until the light suddenly dawns" (Weil, 1952, p. 174). What we sometimes fail to see is what Weil perceives: that solving moral problems sometimes entails facing mystery. Thus, to discover what is causing a person's suffering and how to respond to it, the caring nurse may need to employ Weil's contemplative attention to all details; and even that exercise of attention is itself a caring act.
Attention offers a powerful approach to ethics. For example, Simone Weil thinks of equality and justice not as abstract concepts or principles that serve the well-ordered society; she conceives of them as virtues that can only be illuminated and developed through attentive knowledge. Thus, for Weil, equality is a certain kind of attention, "a way of looking at ourselves and others" (Teuber, 1982, p. 223). Respect for another person is not respect insofar as the other has a rational nature or is a person: Weil states bluntly that she could put out a man's eyes without touching his person or personality. Rather, we show respect for individuals in their concrete specificity: "There is something sacred in every man, but it is not his person [nor] the human personality. It is this man. . . . The whole of him. The arms, the eyes, the thoughts, everything . . ." (Weil, 1981, p. 13). Respect for others is based more in compassion than in awe for personhood, and compassion does not depend on familiarity: We can and should foster compassion for individuals who are very different from ourselves (Teuber, p. 225).
Attention is also a key part of the practice of compassion. Weil explained that those who are suffering "have no need for anything in this world but people capable of giving them their attention." She contended that the capacity to give one's attention to a sufferer is a very rare and difficult thing; "it is almost a miracle; it is a miracle . . ." (Weil, 1977, p. 51).
Attention and the equality it discovers do not suffice for all problems in ethics: They do not in themselves define any principles for adjudicating conflicts; but they can and do convey certain attitudes and forms of conduct without which we would lose sight of the meaning and substance of our obligations and rights (Teuber, p. 228). In addition, Weil's sort of attention can show us duties we did not see before (Nelson, 1992, p. 13) and can instruct us in the skills required for caring.
In a variety of settings--mythological, religious, philosophical, psychological, theological, moral, and practical--the notion of care has developed throughout history, influencing moral orientations and behaviors. The tasks for the future will be to more fully understand the richness and complexity of the history of the idea of care, do justice to the texts that have imaginatively portrayed it and the thinkers who have made this idea central to their work, and enter into dialogue with them.
This history reveals, not a unified idea of care, but a family of notions of care. Yet it is a fairly closely related family, for the ideas of care are united by a few basic sentiments, some formative narratives whose influence stretches over time, and several recurring themes. Furthermore, in the history of the English word "care," this single word serves a range of meanings but with a subtle coherence.
The meanings of the word "care" fall into four clusters. The basic meaning is associated with the origins of the word, which are found in the Middle High German word kar and more remotely in the Common Teutonic word caru, meaning "trouble" or "grief" (Simpson and Weiner, 1989, pp. 893-894). Correspondingly, the primary meaning of the word "care" is anxiety, anguish, or mental suffering. A second meaning of "care" is a basic concern for people, ideas, institutions, and the like --the idea that something matters to the one who is concerned. Two other meanings of care, sometimes in conflict, are found at a more practical level. One is a solicitous, responsible attention to tasks--taking care of the needs of people and one's own responsibilities; and the other is caring about, having a regard for, or showing attentive care for a person, for his or her growth, and so forth. In a sense, all the meanings of "care" share to some extent a basic element: One can scarcely be said to care about someone or something if one is not at least prepared to worry about him, her, or it. The truly caring health professional is one who worries about--is concerned about--his or her patients, especially the patients who cannot take care of themselves.
Several distinctive features stand out in this history of care. The metaphysical and religious dimensions of care appear forcefully and repeatedly in history, emphasizing that care is essential to understanding humans and the human condition. The history of care shows that, at one level, care is a precondition for the whole moral life. It also manifests various frameworks for an ethic of care, including evolutionary ethics, virtue ethics, an ethic of growth, an ethic of response, and duty ethics, yet one does not find a formal and systematic ethics of care in the sources examined.
Repeatedly in this history one encounters a dialectical element in which pairs of ideas of care struggle against each other: care as worry or anxiety versus care as solicitude; the care that enables growth versus the effort to care that robs a person of self-care; or taking technical care of the other versus caring about the other. There is much to learn from history about the dark side of care and how humans might deal with it.
A key historical puzzle is why the notion of care has not become better known and has not exerted more influence in ethics, in view of its highly significant, if somewhat limited, history. The answer lies, in part, in the fact that care has always been a minority tradition of thought and practice. As this survey exemplifies, care is a deeply engaging emotion/idea that has confronted and challenged rationalist, abstract, and impersonal systems of thought, with far-reaching social, political, ethical, and religious implications. In this sense, care has had a countercultural role.
More recently, care may be acquiring a "mainstream" importance, especially in the area of the ethics of health care. The following two articles will show how some elements in the history of the idea of care have become ingredients in an emerging ethic of care in the context of health care, while other historical elements have been overlooked.
All ethics assumes a vision of the human condition. The ethics of care rests on a vision of the capacity to care or be concerned about things, persons, a whole life-course, a society, one's self. The history certainly is not compatible with reducing care to caregiving. The Myth of Care suggestively offers a care-based genealogy of morals that is deeply ingrained in human psychology, anthropology, religion, and altruistic service. The philosophical and psychological developments in the idea of care have built on this basic vision of being well cared for. That the history of the idea of care also suggests many practical ideas--for example, the call and the limits of taking care of others; dealing with the negative side of care; and the intergenerational function of care--makes it all the more useful for a contemporary ethic of care.
-- Warren Thomas Reich
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