Justice and Care

Two sides of the ethical coin

by Kendra G. Hotz

Jesus was busy, the woman knew, and needed to be about his important business. She only wanted to touch the hem of his garment, and the power that flowed through him could heal her of 12 years of bleeding. He didn’t need to know her name or her story. But Jesus felt the power flowing out, and he stopped and turned. He looked her in the eyes and asked about her and her needs. True healing went beyond impersonal competence. True healing called for attention to those in need, care and compassion. It called for a relationship. The woman’s condition would have marked her as unclean and left her an outcast. While impersonal healing would have brought justice by restoring her, a key component of the reign of God, Jesus also wanted to offer care.

How do we do justice for the vulnerable in our modern society? What does care look like?

To deliver good care, we need an integrated system in which those who set policy and make decisions work closely with and deeply respect the place of those who actually implement those decisions.

May and Mr. K

May is a certified nursing assistant (CNA) in a long-term care facility (LTC). Today she is dressing Mr. K and listening to him tell a joke. She leans in close to hear his soft voice and nearly gags at the foul smell.

Oral care is often the last part of personal care to be done, and by the time I get to it, I’ve been in the room for 15 minutes already and ten other call lights are going off. It seems like a quick task, so it’s easy to say, “I’ll get to it in a moment,” … and then never actually find time for that moment. When you’re scrambling just to change your people, making the time to do oral care is hard … Sometimes it is literally a choice between brushing Mr. K’s teeth or changing Mrs. L’s brief before she soaks through her pants. In other words: when you only have ten minutes, what is the most effective way to use them? Most often, we choose the big problems to tackle.

The other problem is that we get so used to dealing with emergencies, crunch-times and hard decisions. We get so used to cutting corners just to survive the day that we form habits around the emergencies. The little things that we had to drop during the crisis? We forget to pick them back up.

The problem of oral care is the problem of this broken system of long-term care, narrowed to razor-thin focus: too few aides taking care of too many residents. We have a system that punishes the aides who take the time to provide good care, and then punishes them again for providing mediocre care. And yet, for all that is true, Mr. K’s mouth still smells like something died in it … Being a CNA is, in so many ways, to be forever caught in the moment of drowning: my best isn’t good enough and yet my best is always required.

I laugh, like I got the joke. “Good one, Mr. K! Tell you what, while you think of another one, I’m going to brush your teeth, okay?” (May, CNA Edge Blog, January 5, 2017).

Like her co-authors on the CNA Edge blog, May is responsible for offering skilled, professional care of the most personal kind to LTC residents, who are mostly elderly and vulnerable. They rely on her to comb their hair, brush their teeth, change their briefs, and bathe them. But they also rely on her to listen to their stories, laugh at their jokes, and be present in their suffering. They rely on her to care for them and to care about them. Like Jesus, who turned to meet the woman with the issue of blood, the CNA is never content to offer care impersonally. Good care must be professional and competent, but it must also be personal and compassionate. Mr. K needs May to laugh with him as much as he needs her to brush his teeth.

In the relationship between the CNA and the residents, we see issues of both justice and of care. May’s ability to care effectively for her residents is challenged by external forces that she cannot control. The fact that she is stretched so thin between the competing needs of so many residents reflects the reality that the LTC is understaffed. But understaffing is connected to broader social, economic and political realities. There are too few CNAs partly because the position is not well compensated in spite of how crucial direct care workers are to the dignity, health and quality of life for aging residents. Many CNAs live in the economic margins and often hover on the brink of poverty in their own vulnerability. They may work second jobs to support their families or carry so many hours that they are too fatigued to care effectively. The work of a CNA is physically and emotionally demanding.

As a society we simply do not value this kind of caregiving enough to compensate caregivers adequately or to hire enough of them to ensure high-quality care. Why is it that the essential work of caring is so undervalued?

In Moral Boundaries: A Political Argument for an Ethic of Care, a groundbreaking study of the nature of caring work in America, Joan Tronto offered a penetrating analysis of care as a skill and a practice rather than simply an emotion. An ethic of care is easiest to understand if we compare it with the more common category that we think about when we do ethics: justice.

Arguments about justice have traditionally centered on the ideas of fairness, equality, and personal autonomy. When each person receives what is due him or her, that is a state of justice. However, there are many ways to parse what a person is due. Perhaps we should each receive “according to need,” or perhaps we should each receive “the same,” or perhaps we should receive “according to merit.” Many societies understand justice as distributing to each “according to inherited rank.”

We can see the justice of God proclaimed throughout the prophetic books of the Hebrew Bible and in Jesus’ ministry in the Gospels. God’s justice provides the conditions of flourishing for every member of society. It is marked by shalom—peace, reciprocity, and delight. God’s justice pays special attention to the most vulnerable, to the poor, the elderly, the widows, and all on the margins of social power. God’s justice is a power that empowers.

This is different from the way we think about justice in American society. Our system is rooted in the notion that we are equal based on our individual freedoms, which we understand to mean personal autonomy. I should be free to act as I will, insofar as my action does not impinge on the will of another, because I am a free and independent agent. A corollary of this belief is that I do not owe anything to others, and they do not owe me anything beyond what we need to establish a common order that allows each individual to pursue “happiness.” Whatever goods I have, I must earn by my own effort. I may, out of a sense of charity, decide to share my goods with another, but no one should compel me to do so. If I care for another, that is a matter of personal affection, and should not enter into public policy.

This description is overdrawn, of course, but we recognize the contours of a deeply American sensibility in an image of the rugged individual. But this is an illusion. The reality of a human lifespan reveals to us that we are more interdependent than autonomous. We cannot survive as infants and children without the care of others, and in our declining years we depend on others to care for us again. In between, many circumstances may make us depend on others. This model of justice cannot help us make sense of what May and her colleagues do when they bathe and dress their residents or listen to the jokes of Mr. K. We need an account of the care they offer that is responsive to the human lifespan and to the reality of our interdependence. And this care is not simply an emotion felt by those closest to us. Care also refers to the concrete actions that others take on our behalf. What we share as much as a desire for independence is the reality of shared vulnerability.

Shared Vulnerability

Tronto argues that perhaps our equality is truly rooted in that shared vulnerability. If it is, then we need an ethic of care as much as we need attention to justice. And we need to value care in ways that are not strictly determined by market forces. We need, in other words, a model of care that aligns more closely with the justice of God and with the shalom of the reign of God. In Moral Boundaries Tronto outlined four phases of care. In a later work, Caring Democracy, she added a fifth.

  • Phase 1. We simply become attentive to a need. We care about it. There is an emotional component to this care. Our sensibilities are drawn to a need, and we wish to meet it.
  • Phase 2. We take responsibility for meeting a need. We want to take care of it. Often those who take care of things are in positions of relative power and privilege. They make decisions and set policy. If they are inattentive to or disconnected from the on-the-ground realities of delivering care, they cannot be truly responsible in their exercise of power.
  • Phase 3. We give care. This is a direct form of action that meets a need.
  • Phase 4. We seek the response of the care recipient. Was the care delivered? Did it meet a need? Without this response, we cannot know whether we actually cared or not. We might have felt caring, but if a need was not met, then our action was not, in fact, care.
  • Phase 5. We move explicitly into the realm of the social and structural. We care with others and, in doing so, form relationships of solidarity where the power and privilege of those who take responsibility is used to empower those in need. Direct care workers are at the table where decisions are made and are compensated in ways that allow them to provide for their families, to enjoy some leisure time, and to exercise social power of their own.

To deliver good care, Tronto argued, we need an integrated system in which those who set policy and make decisions (those who “take care of” things) work closely with and deeply respect the place of those who actually implement those decisions and do the work of hands-on caregiving. The direct caregiver, after all, is in the best position to relate to those who receive care and to assess whether the intended care reached its aim. When care is integrated and when the hierarchies between “taking care of” and “caregiving” are broken down, care is delivered skillfully. In her gentle laugh at Mr. K’s joke, May’s reflection bears this out. We see her caring with skill even when she is too exhausted to feel the emotion of care.

At root, an ethic of care calls into question the hierarchy that devalues direct care workers and that disconnects policy and decision making from the experiences of those who implement and live with the consequences of those policies and decisions. The ethic of care that Tronto outlines offers us vocabulary and nuance for making sense of how we deliver care in our society, but it also gives us tools for advocating a path forward that more closely reflects both the justice and the mercy of God. Seeking the reign of God will lead us to realign our social resources not simply so that Mr. K is better cared for, but also so that May is supported and valued in her work.

In short, if we are to live into the justice of God’s shalom, we need to learn to care.

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