ethics of care or solidarity pact?

Since the 1980s, patient support has been considered a form of care in its own right. This ethics of carewhich has become a key notion in philosophy, is nevertheless included in the solidarity pact which governs the French welfare state.

THE care, a philosophical notion of American origin which means attention, care, concern and solicitude, was first used by Carol Gilligan. She defined the ethics of care as the concern for others and the desire to maintain the links forged with them, carried by the girls. In the 1990s, Brnice Fisher and Joan Tronto completed this definition by emphasizing the interdependence of links between human beings as opposed to the atomized vision of the individual.

Its application to care in medical and paramedical practice has been widely studied. The ethics of care was then extended to all aspects of political and moral life. From then on, it applies to the person in general (and not just to patients) and to all living, working or private spaces.

Repair our world

Life expectancy improved considerably during the second half of XXe century, thanks to the discovery of antibiotics and progress in cardiovascular medicine. With the emergence of new cancers and chronic diseases, medical practice has had to adapt to new patients.

The logic of paternalism has been abandoned in favor of the logic of choice, the basis of which is a conception of the rational, responsible and autonomous individual, inherited from the philosophy of the Enlightenment. But this logic seems outdated today. It is opposed to the logic of carewhich involves taking seriously the physical and psychological needs of the sick: the art of care is toact without seeking to control.

In support of lifethe new work by Marie Gaille, philosopher and director of the Institute of Human and Social Sciences, offers a free commentary on the definition of care,

a generic activity that includes everything we do to maintain, perpetuate and repair our world, so that we can live in it as well as possible.

Its main hypothesis is that the ethics of care allow to nourish and renew reflection on the logic of carebased on the fact that the gestures of care all constitute forms of life supportbut also to enlighten and allow the questioning the normative orientations of current medicine and the way in which we collectively conceive its place in society today and for the future via the health system.

This commentary is methodologically based on the different aspects of the care (caring about Or worry about, taking care of Or take care of, caring Or provide care, caring democracy Or democracy of care) and on several situations in medical practice.

Support as a form of care

The first part is support for the incurably ill and the dying. THE renunciation healing by medicine date of the appearance of the epidemic of HIV. Doctors and patients are confronted together with something that is beyond them and have no other choice but to witness the progression of the disease. The accompaniment then appears as full form of care in end-of-life situations, then extended to all chronic and/or incurable illnesses and concerning all medical professions, from doctors to psychologists.

At the same time, the development of palliative care and the legislative framework for the end of life began in the 1980s and resulted in the Claeys-Leonetti law in 2016, which defined the conditions for supporting people at the end of life. Today, support is no longer reserved for palliative care; it is rather thought of as brand of a solidarity society. in this respect, it can be medical and extra-medical, such as life support activityand must respect the autonomy of the person.

How to define the autonomy of the person and the position of the patient in the care relationship is the subject of the second chapter. In 1947, the Nuremberg Code established the framework for patient consent to medical experimentation. Subsequently, several stages resulted in a decision shared between the doctor and the patient. The ethics of care allows a caring medical position adapted to the individual and the patient's time frame.

An example of application of care in the care relationship istherapeutic education, practice of providing information to patients with chronic illness and their loved ones or caregivers. It allows this practice to be situated within an individual and adapted care approach, with support and participation of patients for better therapeutic compliance and a better quality of life. She adds to this approach a learning partnership between the healthcare professional and the patient.

Set threshold

The care relationship is evolving, but how to provide it care? This question is the subject of the third chapter centered on the caring. The ethics of care introduced the cunning (mtis in Greek) in the dispensation of care, i.e.adjustment to the patient. Through this ruse, she reconnects with the medical art. Indeed, these adjustments by caregivers are no side specific to the relationship caregiver-sick, with the aim ofinvent a beneficial relationship.

However, there is a latent conflict, the patient confronting several caregivers and the caregiver several patients. This conflict is a safeguard against the illusion that support has become a consensual norm for addressing end-of-life situations.

Unfortunately, these adjustments remain difficult to achieve on a daily basis, due to lack of training of health professionals, illusion of the omnipotence of medicine and difference in personal conceptions of what is good life. The ethics of carewhose objective is to live as well as possible, makes a dialogue between the patient and the medical team necessary. This objective allows At care medical to deploy for all forms of life, whatever their “latitude”.

The fourth chapter explains this support for life in all its forms. In France, it was chosen to

consider that there does not exist a form of life which is worth living more than others and not to define in the law a threshold of life worth living or to associate the decision with a list of pathologies which would justify a decision to terminate a pregnancy, treatments, etc.

The patient and the doctor are therefore called upon to define this threshold, the personal or philosophical judgments of a life worth living so much plural, even antagonistic.

Currently, the ethical orientation Make live and let die seems to be predominant. But preserving life in all its forms can involve competing or even incompatible optionsthe most recent illustration of which is the variability of international responses to the covid pandemic, all aiming to preserve the greatest number of human lives. The ethics of careby its lack of definition of the life that it is good to support and by its injunction hold firmly the bar of indeterminacyallows us to keep this reflection alive.

The final chapter broadens the ethics of care a proposal for ecological medicine, linked to the idea of ​​planetary health. Interdependence, vulnerability and lack of hierarchy lives in support of which the care unfolds require to take into account the wild part of the world in the development of medical policies. Information and prevention policies on the medical risks of global warming could be the beginning of a response to this ambition for planetary health (and no longer centered on human beings).

Levinas's thoughts

According to Marie Gaille, the ethics of care allows us to renew ethical reflection in medicine, by establishing a living inter-individual and collective dialogue on present and future, local and global issues in medicine, with the aim of supporting life as good as possible in our threatened environment.

However, the adoption of the ethics of care in philosophy of medicine in France brings something new to thinking about care and the health system? The writings of Emmanuel Levinas on the interhuman bond, implying a responsibility for the care, attention and assistance that the vulnerability and mortality of others require for everyone and everywhere, already allowed for a renewal of care, as recommended by the author.

Let us also note that the ethics of care developed in the United States in the 1980s compensated for the lack of solidarity in a neoliberal society. The French institutional system is based on solidarity at all levels (between generations, between sick and healthy people, between parents and non-parents, etc.). However, the work establishes no link between ethics of care and disintegration of our solidarity pact and medical institutions, while a health system worthy of the name is by nature carrier and guarantor of a medicine of care.