Caring and Contemporary Medicine

Whereas nursing is often associated with a caring function, doctoring has traditionally been associated with a curing function. However, the tendency to associate caring exclusively with nursing is misleading for a variety of reasons (Jecker and Self). First, both doctors and nurses are engaged in caring for patients. In addition, assigning caring activities to nurses and curing activities to doctors is misleading because certain meanings of curing are actually derived from caring. Thus, the Latin definition of cure comes from the word curare, meaning "care, heed, concern; to do one's busy care, to give one's care or attention to some piece of work; or to apply one's self diligently"(Oxford English Dictionary).

Although there has been less explicit attention to an ethic of care in medicine than in nursing, caring for patients represents a central component of ethics in medicine. Caring is inextricably linked to the physician's obligation to relieve suffering, a goal that stretches back to antiquity (Cassell, 1982).

There are several more specific ways in which an ethic of care becomes manifest in the practice of medicine. First, caring is manifest in the activity of healing the patient. Whereas curing disease typically requires the physician to understand and deal with a physical disease process, healing requires that the physician also respond to the patient's subjective experience of illness (Cassell, 1989). For example, healing a patient who is suffering from a serious infection requires not only administering antibiotics to kill bacteria but also addressing the patient's feelings, questions, and concerns about his or her medical situation. In cases of serious illness where cure is not possible, caring for the patient may become the primary part of healing. For example, when patients are terminally ill and imminently dying, physicians' primary duty may become providing palliative and comfort care. Under these circumstances, healing emphasizes touch and communication, psychological and emotional support, and responding to the patient's specific feelings and concerns, which may include fear, loss of control, dependency, and acceptance or denial of death and final separation from loved ones.

Caring is also evident in what Albert Jonsen calls the "Samaritan principle: the duty to care for the needy sick, whether friend or enemy, even at cost to oneself" (p. 39). The tradition of Samaritanism dates to the early Christian era and the parable of the Good Samaritan described in the Gospel according to Luke; it persists during the modern, secular era as a central ethic for medicine. Jonsen argues that although the original Christian parable of the Samaritan refers to giving aid to a particular individual, the ethical tradition of Samaritanism within medicine bears relevance to entire groups of patients. So understood, Samaritanism underlies the physician's broader social duty to care for indigent persons. In contrast to the past, when physicians provided charity care for indigent persons without financial remuneration, universal health insurance is the norm in most developed countries. Therefore, in contemporary times physicians are generally compensated for their services through a private or government health insurance mechanism. In the United States, however, large numbers of patients continue to lack health insurance. A principle of Samaritanism continues to be evident in the legal and ethical requirement that U.S. physicians provide emergency treatment to any patient regardless of the patient's ability to pay for care. A stronger Samaritan ethic, mandating access to all forms of basic healthcare, would require, in the United States, successful implementation of healthcare reform.

A third way in which caring is manifest in the ethics of medicine is through the healing relationship of doctor and patient. Edmund Pellegrino and David Thomasma regard this relationship as one of inherent inequality because the patient is vulnerable, ill, and in need of the physician's skill. In light of the patient's diminished power, Pellegrino and Thomasma argue that the physician incurs a duty of beneficence, a duty requiring the physician to respond to the patient's needs and promote the patient's good. Other ethical values in medicine can presumably be derived from the physician's primary duty of beneficence. For example, according to Pellegrino and Thomasma, a duty to enhance patients' autonomy is based on the duty to benefit patients.

Some, Sharpe for example, have sought to identify the principle of beneficence that Pellegrino and Thomasma delineate with an ethic of care. However, beneficence and care differ in crucial respects. Whereas a principle of beneficence identifies promoting the patient's good as a requirement for right action, an ethic of care is a type of virtue ethic that is basically concerned about the affective orientation and moral commitment—that is, the concern—of the one who cares. For example, a physician may perform actions that promote a patient's good, and thus meet the requirement of beneficence, without caring about or feeling any commitment toward the patient. If this analysis is correct, then actions that fulfill the principle of beneficence do not necessarily fulfill standards associated with an ethic of care. An ethic of care suggests both a feeling response directed to the object of care and a commitment to ensuring that things go well for that person.

Despite the integral role that an ethic of caring plays in medicine, contemporary physicians sometimes neglect to offer adequate palliative and comfort measures to patients. This may stem from a failure to teach and nurture empathy in medical education (Spiro et al.) and from financial incentives that discourage spending time at patients's bedsides and getting to know patients as persons. In addition, physicians may overlook caring for patients when conflicts exist about the use of futile treatments (Schneiderman et al.). For example, members of the healthcare team may become distracted debating the appropriateness of high-technology interventions and neglect to care for patients's spiritual and emotional needs.

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