Original paper

Between caring and curing

Michael H. Kottow MD MA (Sociology)
Professor, Medical and Philosophy Faculties, University of Chile, Casilla 16168, Correo 9, Santiago, Chile

Summary

Care and cure have been described as different kinds of ethical approaches to clinical situations. Female concerns in nursing care have been contrasted with masculine, cure orientated physicians attitudes. Ethics in such different voices may have sociologic determinants, but they do not represent intrinsic distinctions. Medicine has shown a divergent development, on the one hand stressing cure in a deterministic and instrumental way, on the other hand being aware that disease is as much a pathographic as a biographic, care-requiring existential situation. Disease is a breakdown of the living organism, to be cured by therapeutic efforts, but it is also the distressing failure of the lived body, requiring concern and care. Based on Lvinas ethics of encounter, it is suggested that any interpersonal relatedness is based on concern for the other, being grounded on an essentially ethical interaction. The clinical encounter is a paradigm of such ethics-based relationships, which necessarily builds on awareness of the other qua other, and is concerned with fullling the therapeutic mandate. Caring for the other means doing ones best to help her/him, so that care and cure are inextricably interwoven, although care is the more fundamental form of human relatedness. Thus, neither gender nor professional tasks can allow for a caring attitude to develop without curing concerns, just as trying to cure without caring is unthinkable. Keywords: care, cure, feminist ethics, lived body, living body.

Introduction
The difference between curing and caring in medicine has been often, but not unanimously, rejected as articial and unreal because both functions, intending to cure the sick and taking care of them, are supposedly

Correspondence: e-mail: guarvie@ctcreuna.cl

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no more than aspects of the same health care endeavours. In fact, the original meaning of the word therapeutics (therapea = to serve, to care) addresses both aspects of looking after the sick. The distinction between nursing cares, which certainly include curative actions, and medical practices that hopefully are not devoid of caring concerns, seems to have become obsolete and unwanted. Other views prefer to overstate the differences between care and cure, thereby resurfacing the idea of highly contingent forms of ethics in contextual dependence with the specic professional aims being pursued. Recent years have seen the rise of a specic ethics of care, although it remains far from clear whether caring is a principle, a rule, an action guide, or a virtue (Veatch, 1998). Furthermore, a number of articles, led by the now classical work of Gilligan (1982), have recognized and advocated differences in the activities, professions, social attitudes, interpersonal relationships and moral views of the genders. Thus, not only is the status of an ethics of care uncertain, but it also remains unclear what its relation is to other forms of ethics (Little, 1996). Is an ethics of care to be opposed to an ethics of justice, as originally proposed by Gilligan? Are feminine and feminist ethics equivalent in meaning? Should feminine ethics be equated with virtue ethics or is it rather a combination of both that yields an oxymoron suspect feminine virtue ethics of care? Could it be that some of these attributes cancel each other out, so that the quest for gender equality collapses into a defence of justice that is not opposed to but rather lies at the core of an ethics of care? This paper takes issue with the tendency to equate caring with feminist ethics, and curing with the masculine moral attitude as such, by arguing that they do not correspond to alternative forms of ethics. They rather represent different and complementary ways of looking at the ethical attitudes and structure of human interactions in general and the attitude of health care providers in particular.The reason to raise this issue lies in the unfortunate tendency to equate ethics of care with feminine attitudes towards the vulnerable, thus suggesting that the genders have different kinds of moral bre. Furthermore, the diffuse juxtaposition of care and cure may have to give way

to a hierarchical model, where care takes a more fundamental stance with regard to the pragmatic and contextual aims of cure. Disease has both organic and experiential components, as was explicitly recognized in the anthropologic form of medicine cultivated in post-war Heidelberg; such views are now held by some of the most prestigious bioethicists (Cassell, 1978; Thomasma, 1997; Reich, 1999). Recent developments in medical practice, nevertheless, are once again stressing organic and deterministic points of view, while neglecting the experience of being ill. Consequently, a curing medical attitude and a strand of principled, algorithmic form of bioethics expertise tends to overshadow the caring, relational, morally less structured but in no way less committed form of encountering the diseased. It is one of the purposes of the present paper to show that health care and medical therapeutics are based on human constants that are not gender specic, sociological data notwithstanding. Caring and curing are nondispensable aspects of the clinical encounter, which must both be incorporated and exercised by the therapeutic agent in independence of gender or profession.

Ethics of care
A distinction between feminist and feminine ethics has been suggested. Feminism unveils and rejects gender discrimination based on the prejudice that women are biologically predestinated to bear and raise children and therefore to give priority to family and home concerns, which also happen to be less exciting, less lucrative and less prestigious than masculine endeavours in business, politics, academia, technical developments, and so on. The often rather aggressive tone of this ongoing controversy suggests that feminism is a political issue concerning social power, imbued with a penchant for more fairness and equality between the genders (Tong, 1996). Less combative feminine ethics defends the enrichment of ethical views and an enhanced sensibility to values addressed in interpersonal relations. Feminine ethics suggests that women have an original way of valuing ethical issues, which differs but is in no way inferior to the male perspective. Does this mean that

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women have privileged or perhaps even exclusive access to certain forms of sensibility, allowing them to command aspects of personal relationships to which men are insensitive? One unfortunate consequence of such a brand of feminine ethics would be the historical temptation to couple exclusive ethical features with certain specic capabilites, in other words, to value differently the female and the male approach to ethical questions, thus creating or supporting some kind of discrimination. Tying feminine virtue and care entails the risk of bias and, in fact, much that is being said and written about genders and ethics is implicitly or overtly skewed. Thus, Tong (1998) chides MacIntyre for proposing a male or masculine ethics because he approvingly emphasizes social practices that are just, courageous and honest, but fails to mention care (Tong, 1998, p. 146). In the same article, Noddings rather sexist distinction between eros, the feminine spirit and logos, the masculine spirit is approvingly presented (Tong, 1998, p. 146). The ontological background of these distinctions remains unsupported and deserves little credence. On the other hand, it seems reasonable to stay away from sociological explanations, because they tend to be circular: social facts supposedly are the product of gender bias and tend to full the prophecy that people are socialized in such a way that they perpetuate and remain true to this bias. If feminine writers continue to stress the greater afnity of women for the relational and emotional caring brand of ethics, they might increase the distance from the supposedly principled, skill orientated male physician. Gilligans warning against monopolic thinking renders due tribute to the fact that ethics of justice and ethics of care coexist in both genders (Carse, 1991; Sharpe, 1992). Feminist movements have oscillated from denying an essential difference between female and male ethical attitudes to, on the contrary, describing and emphasizing such a difference. Concern has also been shown that erasing the ethical differences between women and men might lead to a hardening of the status quo with its traditional male orientated discrimination against the acknowledgement of women as autonomous social agents.

Feminist writers are painfully aware that equating feminine ethics with care may deliver another blow to gender equality. The perverse conclusion, so they fear, may be that if women are good care-takers, let them do it while men go about the serious business of life. The time seems appropriate to untangle the issue of care from the concerns of feminism, and to accept it as a dimension that is essential to human relations and therefore open to all voices. Neither emphasizing gender-based differences in ethical sensitivity and moral attitudes nor insisting that the ethics of care is in any way a domain that comes more naturally to women, will help to establish the idea that homo ethicus is an anthropologic constant of which all rational human beings partake. A more gender neutral attitude will also stress that physiological and social differences have little to do with peoples capacity to practice what is good and right. Professions concerned with health and disease should not abound in discriminatory attitudes that believe women to excel by nature in caring for the sick, at the cost of being less gifted for the curing arts. All the more so, because being stricken by disease is both an experience and a morbid state, an instance of suffering that requires sympathy and rapprochement, as well as a case of organic dysfunction that requires cure.

The lived body

Much has been said about the human body as experience rather than object; too much, in fact, if it is accepted that the body qua organism cannot be an object of discourse for the simple fact that there is no external vantage point from which to predicate about ones body; as in any other observational system, a detached view is hampered by an unconquerable blind-spot. No subject can exhaustively talk about her body, for being a subject means being part of this body, not its external observer. This observation had been anticipated and amply discussed by MerleauPonty (1945), who described the experiences of anosognosia and of the phantom limb in amputees as examples of the double-layered experience of the habitual and the actual lived body. The formula of the lived body has gained acceptance in what is a free

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but adequate translation of the German concept of Leib (Plgge, 1967; Spicker, 1976; Leder, 1984). This Leib or lived body cannot be fully observed, because it is lled with opaqueness, dark zones and distortions produced by excessive nearness. One of the rst physicians to speak of the lived body was the German internist H. Plgge (1970) who expanded on MerleauPontys observations on the amputated phantom limb, stressing that the loss of an extremity could foster the incongruent feeling that the limb remained attached and was painful. These psychological and clinical observations exemplify the disparateness between the organic living and the experientially lived body. Efforts have been made to specify the experience of the lived body and, although illustrative, they are incomplete and wanting. The lived body is not only the medium through which I apprehend the world but also the means by which I purposefully interact with it (Toombs, 1999); it is also the sole vehicle to initiate acts or refrain from doing so. It is a reality perceived from within, this internal vantage point delivering information that is privy to the self and not otherwise obtainable. The lived body is referentially egocentric, that is, distances, events, time sequences are related and therefore relative to ones experienced body. Things are high, or distant, momentous or trivial, recent or far in the future, all in reference to ones own body. The body is not only an organ of the will but also of realization. Actions occur if and when the body decides to act, and a love affair, an exciting trip or the gratifying reading of a book will only occur if the body performs in accordance with decisions of the will. Since the nineteenth, but most decidedly since the twentieth century, the human body has been reied in a number of ways. Aesthetic values, physical feats, extraordinary performances, durability and longevity have all been celebrated to the utmost. The scientic view has to a great extent cultivated the analogy of the body as a machine, with exchangeable parts. The support of prosthetic devices and the overall attitude that function is more important than experience, have led to the view that the bodys physiologic parameters are to be safeguarded even at the cost of quality of life. The Cartesian view of the body as a machine

has been exacerbated by the predominance of instrumental reasoning. A profound contradiction ensues between increased awareness of the lived human body, and the more instrumental view that the living body is subject to the laws, aws and repairs of biologic mechanisms. This controversy creates severe tensions between the ways we understand disease and the goals of the health-care professions.

Disease: organic vs. experiential

Concepts of disease have been rather oblivious to the fact that conscious humans are aware of both being a body and having one.1 The body is the locus of personal experience as well as a biological system that may be subjected to a will, but the body also constitutes the scenario of its own collapse. The classical ontologic concept of disease was based on the belief that for some reason morbid entities took residence in the body and unleashed a bellicose medical reaction that aimed at destroying the noxious intruder, killing invasive cells or microorganisms, and ghting against infection. The more recently developed physiologic concept of disease recognizes a set of functional norms and morphologic features that are characteristic to the species, the deviation from which constitutes disease (Boorse, 1975). In a less known denition by K. Goldstein (1995), disease is understood as a loss or deviation of parameters that were particularly habitual for and characteristic of the affected individual. Shortness of breath after climbing a ight of stairs is a functional insufciency if the same person was previously able to accomplish this feat without effort. Such a view stresses the often neglected biographic strand in disease, which

The English language makes a distinction between disease an

organic derangement and illness the experience thereof. Krankheit, enfermedad, doenca, maladie are denominations that include both the objective and the subjective elements. Some authors even differentiate sickness as a third, eminently social, entity. Schaffner (2000) has recenty referred to a value-free concept of disease, as opposed to the value-laden view. The whole semantic question is far from settled, as expounded in Twaddle & Nordenfelt (1993).

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becomes of great importance when discussing prognostic probabilities and therapeutic alternatives, and when evaluating quality of life decisions. Being ill is always an experience that relates actual disabilities or deformities with previous states of the individual. The subjective sensation of disease is based on the awareness of being a lived body that has become vividly present and uneasy because it has developed or been overcome by unpleasant sensations, at the same time resisting the usual commands of the will. The opaqueness and clumsiness of a damaged body becomes an obstacle interfering between intention and actual performance. To elaborate this point, it may be reasonable to assert that disease is an experience, which health is not. The healthy body is not aware of its privilege, it is a lived body that functions smoothly but has no primary awareness of doing so. Being at ease means being immersed in something else other than oneself, it means ex-isting. You walk unconsciously, you see and even think without taking notice that you are doing so. But, when the body malfunctions, when pain or disability appear, the body becomes acutely conscious of its disorder, it becomes dis-eased. In disease, the body becomes aware of a change in its functions and its diminished capabilities of adaptation. Only a disabled person registers the distressing height of a curbstone, the too rapid sequence of trafc lights, the suddenly excessive weight of a bag or the smallness of newspaper print. The self becomes the subject that apprehends the body in its inadequateness. The diseased lived body is distressingly conscious of its disorder and of the need to reformulate its relationship with the outside world. A new signicance is given to the diseased persons situation in the world. The point to be made is that although disease presents as an organic disorder it is, above all, an existential crisis because the living body ceases to function as a given, healthy and unobtrusive reality, rather becoming a nuisance that expends anguish, pain and limitations. The experience of the lived body is transformed, creating either an incongruence between the habitual and the actual between the expected and the feasible, or leading to a change in the lived bodys being-in-the-world.

These major adjustments to profound changes in the experienced and in the performance of the body require an hermeneutic understanding much more naturally focused by caring attitudes than by curing efforts. However much the medical humanities have tried to enrich the scientic paradigm of clinical medicine, the trend towards a positivist approach to disease and its treatment seems to prevail: Medical indications bespeak the ideally objective and scientic interpretation of the patients story/history, signs and symptoms (Daniel, 1994). No wonder, that [I]n medicine, diagnosis means identication, in biomedical terms, of pathology . . . the patients unique, subjective experience what having the disease means to the person actually suffering from the disease is irrelevant to diagnosis (Donnelly, 1994). In fact, there appears to be an explicit insistence on the organic character of medical practice: The embodied text of medicine is different: it is actually, physically transformed as a consequence of interpretation. That is, diagnostic interpretation leads to treatment and thus to subsequent changes in the person-as-ill. This description is preceded by a more rotund one: [T]he doctor looks not only for disease per se but especially for treatable disease (Leder, 1990, p. 18). All this is in line with some major developments of contemporary medicine, like imagery, computer diagnostics, telemedicine, evidence based clinical knowledge, and efforts to read patients ailments as derangements of the organism, disease of the living body to be repaired and cured, its parts replaced according to need. If modern medicine has its primary focus on organs and diseases . . . and largely ignores the diseased patients feelings and emotions(Cooper, 1994, pp. 159160), then we are witnessing a growing hiatus between care as concerned with the lived body and cure and its aim to treat the living body. The efforts of the rst part of this paper tried to untangle the ethics of care from their feminist support by showing that care is an essential and primary quality of interpersonal relatedness. Unfortunately, the high-tech development of medicine tends to bond curing endeavours with the living body. The lived bodys experiential quality is hardly taken into account by the physicians reconstructive efforts and

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therefore requires above all a caring and supportive form of therapy. By rehearsing the distinction between the lived and the living body, it becomes obvious that members of the healing professions are holistically concerned with caring and curing the lived body and the living body. Perhaps one could venture to improve on the formula which states that medicine is a craftsmanship that involves healing the body with the body (Pellegrino & Thomasma, 1981), by saying that medicine is the effort to cure the living body by taking care of the lived body. In this view, it becomes necessary to stress that nursing efforts and medical endeavours have the same realm of concerns, at best differing in the skills employed.

Anthropology of caring
The pristine and unsupressable character of relatedness (Leder, 1999), explains how caring is an ontologic trait of being human, as has been very movingly elaborated by the Lithuanian-French philosopher Lvinas (190895). He grounded his philosophy in the ethical moment of the interpersonal encounter, when the I rst meets the other who faces me, that is, who presents his visage on which the need of protection is engraved. The I responds ethically by recognizing this call for help and going out of itself extroverting thus disregarding all self-interest in an effort to provide the other with protection (Lvinas, 1985). This moment of care emerges simultaneously with the encounter of two human beings. Care is at the core, it is the essential bond any two people create and it gives them substance as persons who have accepted the call to take care of the other. In a recent book, Laurie Zoloth (1999) has very convincingly introduced this Levinasian thought into the medical realm under the name of Ethics of Encounter. The perils of considering care as a constant and self-evident feature of human beings behaviour and/or motivation, is illustrated by the concept of deep caring recently coined to account for a fundamental ontological . . . nature of our being (Van Hooft, 1996, p. 85). Such caring is described as lacking an object and being non-intentional, but how can someone care unless they care for or about a specic

object or an identied living being? Non-intentional, unfocused caring contributes little to ethical clarity and, in fact, most ethical reections turn out to be oblivious to an underlying, pervasive deep caring. Quite to the contrary, a reasonable reading of Lvinas pristine encounter suggests that a caring attitude is basic to and denitory of human beings need and willingness to relate. Caring is essentially intentional and orientated to develop a full interest in the original sense of inter esse towards a specic reality external to our selves. One can always choose to reject the responsibility of being concerned and becoming engaged, but that means living what Kierkegaard (1944) used to call an aesthetic life, devoid of morality and therefore doomed to solitude and despair. Being voluntary, one may fail to adopt this caring commitment, but this would result in an ethically callous and starkly instrumental form of interaction. That is why Lvinas believes that only if the caring moment occurs will the ethical concern for the other obtain. Care appears as the crucial form of human interaction, making it impossible to imagine substantial intepersonal encounters that could lack this basic element. However, care is not a given, it is the result of the willingness to relate with concern and quality: care is ethical because it is chosen. Inasmuch as care is thus valued, it must be placed at the core of the asymmetric, help-seeking, benecient therapeutic encounter.

Care in medicine
The question of cure or care, as alternatives, as complements or, possibly, as lexically ordered ways of dealing with disease, remains distressingly unanswered as cure is rashly offered by the health care professions, in a seemingly endless upwards spiral towards higher efciency levels, more perfect restitutions, enhanced states of well-being. Offers and demands rise constantly, to the point where patients expect the best and acrimoniously sue when disappointed. The clinical encounter is thus in danger of changing from a duciary and benecial relationship, to one marked by a climate of caution, distrust and belligerence, as contractual commitments remain unfullled.

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Even if all parties involved act in good faith, contemporary medicine still insistently pursues a curative effort that stresses at least two things: rst, cure is to be achieved at all costs, even if the price is high, the patient is wary of the resultant quality of life, or the perils of futility lurk. Second, the patient necessarily is seen as an organism to be repaired and less as a person experiencing the humiliations and tensions of disease. Curative efforts operate in indifference of the lived body, they transform it into an object-body, they retrieve organic features and normalize parameters often at the cost of unchanging or at times even increasing existential dis-ease. Patients may come to feel more threatened by therapeutic propositions than from the underlying disease, as illustrated by the fact that prolonged terminal treatment is one of the most dreaded scenarios people envision in their future. Thus understood, there is a vast arena of exalted promises and unfullled needs in curative efforts, whereas it seems that not much more than lip-service is rendered to the caring aspects of therapy. One could, in fact, go further and state that the organic, deterministic brand of current medical thought has taken over increasingly greater areas of pathology, at the price of leaving an enormous residue of chronic, disabled and deeply deteriorated persons, who are now dumped in the lap of care institutions, with little concern for their well-being and still less nancial support. Sociological studies have repeatedly shown the medical neglect suffered by patients deemed to be incurable or chronically deteriorated. This development has articially sharpened the distinction between curing and caring, having done little to support and respect the latter. If curing and caring in medicine are two distinct, perhaps independent and even hierarchically ordered areas of therapy, the question arises if they are served by different kinds of health care providers and if the classic distinction holds true, that physicians are preferably engaged in curing whereas the nursing profession is more attuned to caring. There is no denying that Hippocrates is considered the father of medicine just as Florence Nightingale created the nursing profession by taking care of the wounded in the Crimean war. Sociological evidence conrms that

the nursing profession is a realm of feminine activity, whereas the leading positions in medicine are occupied by men. These are not philosophical arguments however, in no way do they show that men are unable to care, nor that women lack the abilities to concentrate on the more technical aspects of therapeutics or to occupy positions of the highest responsibility in health care. Granted that caring and curing have not been traditionally and consistently fused into one activity or attitude, it still may be unwise to go to the other extreme and widen the gap between the two therapeutic approaches. Something of the sort occurs if linguistic nuances are upgraded to categorical differences, as when caring about is contrasted with caring for (Jecker & Self, 1991). In such a language game, the usual form of caring and curing, where one of the terms is deemed to be weak or amiss, the authors suggest a tetrad of articially characterized health care alternatives: caring for and about patients, caring for but not about, caring about but not for, and caring neither for nor about. The brief presentation of Lvinas philosophy concerning the other, as well as his insistence that the initial and the ultimate experience is the ethical encounter with the other, whose visage is pleading for diaconal concern, should situate care as a transcendental feature of interpersonal relations. Care is the necessary condition for facing the other, all the more so if the other is vulnerable, is explicitly asking for help, and is directing his request to those who have adopted the therapeutic role that sustains medical practices. Understanding care as a transcendental feature of the healing relationship denitely excludes any bias that might link care with gender or profession.

Conclusions
The meaning and substance of human encounters is reached by a caring attitude to each and every participant. In fact, any human act, but especially so if it concerns living beings, must be thoughtful and concerned, lest it be trivial, harmful, destructive or even cruel. The interaction of professional health providers with patients is especially dependent on the need

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to cultivate awareness and concerned care for the vulnerability shown by the diseased. As suggested in referring to the lived body, both reality and ones relation to it qua agent as well as qua patient/recipient are created for each person anew. The lived body is the hallmark of a self and of its narrative (Ricoeur, 1992). If cure orientated medicine reies the body and reads it as a text of malfunctions and disabilities, it is solely interpreting a living organism and neglecting the singularity of the lived body. All the more so, if the physician is exclusively interested in treatable diseases, because he will extend his neglect to all those manifestations he cannot cope with. Reinstating these philosophical elaborations to the more pragmatic eld of medical and nursing ethics, it seems foremost evident that health providers are clinically committed to help their patients, that this help entails curative efforts to alleviate their suffering, as well as looking after their well-being in a concerned attitude of care that is quintessential to the clinical encounter. All this constitutes one undivided form of giving health care services in an ethically acceptable way. The distinction between medical know-how and nursing skills is more a technical than an ethical one, and there is obviously no good reason, beyond biased social conventions, why men should not give efcient and humane nursing care, or women become well-trained, highly skilled physicians; because all of them, men and women, nurses and physicians, are committed to providing considerate therapeutic services to the sick. Rather than being two distinct aspects of the therapeutic enterprise, caring and curing should be seen as mutually supportive and equally indispensable forms of approaching the sick. The clinical encounter becomes mutilated and ethically suspect if care is not aimed at curing the discomfort, the disease, the symptom just as curing is harsh and less efcient if performed in a callous and careless manner. The distinction runs in the attitude, which should be one of doing good its consequentialist aspect and doing it well a virtue orientated aspect but it is absolutely oblivious of the gender or the profession of the person providing health care services.

Beyond the perhaps obvious and trivial quest for the intertwining of care as an attitude to alleviate and improve the ill, with curing as a concerned and committed form of palliating or healing the diseased, this paper insists that caring is by far the more fundamental trait of human relatedness, therefore not a privilege of the female gender nor of any specic profession. Care is the most appropriate way of encountering the lived body, and even if medicine must ultimately fail in keeping the living body well and alive, it will have accomplished its goal if all those involved have stood by their patients in a compassionate and trustworthy form. A case could plausibly be made for medicine to moderate its curative ambitions and to downplay the excessive expectations it has been fostering (Callahan, 1999), but care cannot be limited or conditioned, lest a fatal blow be dealt to humaneness itself.

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