Nursing Ethics http://nej.sagepub.com/ Demarcation of the ethics of care as a discipline: Discussion article
Klaartje Klaver, Eric van Elst and Andries J Baart
Nurs Ethics published online 22 October 2013
DOI: 10.1177/0969733013500162
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Article

Demarcation of the ethics of care as a discipline:
Discussion article

Nursing Ethics
1–11
ª The Author(s) 2013
Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733013500162 nej.sagepub.com Klaartje Klaver, Eric van Elst and Andries J Baart
Tilburg University, The Netherlands

Abstract
This article aims to initiate a discussion on the demarcation of the ethics of care. This discussion is necessary because the ethics of care evolves by making use of insights from varying disciplines. As this involves the risk of contamination of the care ethical discipline, the challenge for care ethical scholars is to ensure to retain a distinct care ethical perspective. This may be supported by an open and critical debate on the criteria and boundaries of the ethics of care. As a contribution, this article proposes a tentative outline of the care ethical discipline. What is characteristic of this outline is the emphasis on relational programming, situation-specific and context-bound judgments, a political–ethical perspective, and empirical groundedness. It is argued that the ethics of care is best developed further by means of an intradisciplinary approach.
Two intradisciplinary examples show how within the frame of one discipline, other disciplines are absorbed, both with their body of knowledge and their research methodology.
Keywords
Disciplinary development, ethics of care, intradisciplinarity

Introduction
With a history of just a few decades, the ethics of care is a fairly young, emerging discipline within philosophical and theological ethics.1 It is rooted and further developed in feminist ethics, moral theory, theology, and philosophy.2,3 The ethics of care is a steadily evolving discipline that has moved far beyond its original formulations. Whereas the starting point of the ethics of care was the private realm of life, such as family and maternity, it has expanded gradually to fields of law,4 political life,5 international relations,6,7 nursing and medicine,8,9 and organization of society.10 The ethics of care evolves by adapting itself to those new fields coming in contact with other disciplines. This involves the risk of messing things up and becoming contaminated as a discipline. Therefore, the challenge for researchers in the ethics of care is to expand as a strong discipline with a clear identity.
The inspiration for this article springs from our discovery of shared feelings of tension in using several disciplines while working in the ethics of care, without being trained as an ethicist, and to find a disciplinary niche. As we each study a topic that appeared to be important from a care ethical perspective but that is not yet fully developed by it, we take advantage of knowledge from other disciplines. However, these
Corresponding author: Klaartje Klaver, Department of Culture Studies, Tilburg University, PO Box 90153, NL-5000 LE Tilburg,
The Netherlands.
Email: k.klaver@tilburguniversity.edu

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disciplines all have their own traditions, natures of existence of what is under study, and epistemological and methodological frameworks. Therefore, the challenge we face is to understand and, at least partially, integrate and mix the other frameworks with our own.11 Subsequently, since borrowing from and mixing varying disciplines and backgrounds carries the risk of losing the heart of the matter, we need to ensure we retain a distinct care ethical discipline.
In this discussion article, we elaborate on this tension. We first consider the question of disciplinarity in general. Second, we show how the ethics of care has been developed and continues to develop as a means of illustrating the problems and possibilities of multi-, inter-, trans-, and intradisciplinarity. In order to contribute to the further development of the ethics of care, third, we give a first attempt to demarcate the boundaries of an ethics of care. This is done by presenting four essential criteria that should sharpen our focus in developing an ethics of care as a discipline. Finally, we present two intradisciplinary attempts that keep the care ethical identity upright.

Academic disciplines are quasi-stable
What is a discipline? The Oxford Dictionary defines a discipline as an area of knowledge: a subject that people study or are taught, especially in a university. Krishnan11 lists six characteristics of an academic discipline. Not all disciplines have all six characteristics, it depends on their stage of development. A fullgrown discipline has (1) a particular object of research, (2) a body of accumulated specialist knowledge which refers to their object of research and is specific for their discipline and not shared generally with other disciplines, (3) theories and concepts that can organize the accumulated knowledge effectively, (4) specific terminologies or language adjusted to their research object, (5) developed specific research methods according to their research requirements, and (6) some institutional manifestation in the form of subjects taught at universities or academic departments.
Shneider12 believes that each scientific discipline evolves sequentially through four stages. Stage 1 introduces a new language to adequately describe the matter. At stage 2, scientists develop a toolbox of methods and techniques for each discipline. Most of the specific knowledge is generated at the third stage, at which the highest number of original research publications is generated. The purpose of the fourth stage is to maintain and pass on scientific knowledge generated during the first three stages.
This analysis of the development of disciplines tells us scholars that we need to know our position in the landscape of disciplines. In order to be able to appropriate and promote the methodologies, behaviors, and ways of thinking of our discipline, our work should be accompanied by mapping out the boundaries with other disciplines. However, this is not an easy task, as disciplines in general are quasi-stable. They are continually subject to the opening of new or revised ways of framing problems, theorizing, and investigating.
Because most disciplines have core and peripheral elements as well as highly specialized sub-fields, they are only partially integrated.13

The emergence of a care ethical discipline
The young discipline of the ethics of care was, with Gilligan’s14 methodological and epistemological critique of Kohlberg’s model on moral development, multidisciplinary from the start. As the ethics of care is emerging to a full-grown discipline, our concern is that this process will not become polluted. When looking at the development stages of Shneider,12 we believe that the ethics of care is now slowly moving from the second into the third stage. A language to describe new objects and phenomena was created in the past decades, and during the last years, most of the major methods and techniques were developed. This process is still ongoing, but in some places, the time has also come that researchers with their brand new toolbox enter the field to further study specific matters.
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It is in several ways that the ethics of care encounter other disciplines during this evolutionary process.
As we have seen, the multidisciplinary beginning was characterized by scholars from different disciplines who worked on various parts of a common problem. A multidisciplinary approach draws on knowledge from different disciplines but stays within the boundaries of those fields.15 Researchers representing different fields contribute methods and ideas from their respective disciplines toward the analysis of a particular research question.16 The idea is that a research problem is cut in pieces, and each piece will be addressed by an expert of one of the disciplines. One potential difficulty is the question whether problems can be cut in small pieces and be addressed in separated parts. The lack of shared vocabulary between the participants remains a challenge in such collaboration. In this kind of work, there is no integration of concepts, epistemology, or methodologies.17 The disciplinary perspectives are not changed, only contrasted.15
However, with the realization that multiple people were working on the same issues, and with the rise of a dialogue between them, the care ethical approach has taken on a more interdisciplinary structure nowadays. Interdisciplinary research also refers to the cooperation of multiple disciplines to solve a question, but it is different from a multidisciplinary approach in that the collaboration leads to new knowledge extensions that exist between or beyond the boundaries of the original disciplines. The interaction can vary between explicitly exchanging and integrating the concepts, methodologies, and epistemologies, resulting in a mutual enrichment.11,17
At the same time, we can also recognize forms of transdisciplinarity in the ethics of care. This means that at several places, scientists from different disciplines collaborate with nonscientists leading to an integration of needs, experiential knowing (‘‘know how’’), and scientific knowledge. The call for transdisciplinarity is also political in nature as it is about the democratization of science, the enhancement of its social embedding and legitimacy, and the revaluation of what counts as knowing or knowledge.17
We believe and encourage that the ethics of care is slowly moving toward intradisciplinarity, as all relevant knowledge sources and methods are combined in a coherent discipline. One scientific discipline may borrow methods and knowledge developed by another discipline for their own use.13 In an attempt to explain the differences between the varying forms of integration, Nissani18 offered the illustrative metaphor of mixing fruits. Fruit (apple, mango, orange, etc.) may be served alone (disciplinary), in a fruit salad (multidisciplinary), or blended as a smoothie (interdisciplinary). Extending this metaphor to intradisciplinarity, one might imagine using the smoothie as the basis for a new dessert. See Figure 1 for an illustration of the four forms of disciplinarity.
The development toward intradisciplinarity is more than an epistemological issue. It is also a practice of cooperation, and thus of deliberation: doing research together. In that sense, the discipline formation can hardly be seen as an idea-designed project. It is a practice, and we are, with other scholars, doing it. This also means that there is no authority above the parties that can decide what should be in or out of the discipline. Nevertheless, one can see that in the stages of discipline formation, knots are being cut.
Above all, in order to be able to cross a boundary, there need to be boundaries in the first place, and one needs to know where these boundaries are. This is also illustrated by the fact that hard sciences with welldefined boundaries would find it much easier to cooperate with other disciplines than the soft sciences, as the latter have far less defined boundaries and are therefore more penetrable and open to criticism.11 The lack of an open and critical debate about the delineation of the ethics of care invites us to work out four criteria, or rather fundamental ideas, that we believe must be recognizable in care ethical works. This tentative demarcation of an ethics of care may serve as an opening for further discussion on the care ethical discipline.

Criteria for the further development of an ethics of care
In our opinion, the following four features are necessary to speak of an ethics of care: (1) relationship-based programming, (2) recognition of situatedness and contextuality and therefore judgments are not
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Figure 1. Four disciplinary approaches.

generalizable (particularity), (3) care ethics is a political–ethical discipline, and (4) the theory is empirically grounded or at least informed. The first three criteria are in agreement with the international development trends of the ethics of care. We present our specific interpretation of these widely held assumptions. In the context of this discussion article, we have furthermore added the fourth criterion of groundedness. However, it is possible that other care ethicists might argue for other directives. Carefully inventing the criteria of the ethics of care is work in progress that we think should be more transparent. The criteria will now be further explored. 1. As was carefully thought out by Gilligan14 and Noddings19 and later widely adopted, the ethics of care focuses first and foremost on an ethical emphasis on relationships. Persons, communities, and organizations are conceptualized as relational and interdependent.20,21 Care is fundamentally relational and by using the term ‘‘relationship-based programming,’’22,23 we conceive this relational aspect quite radically, assuming that relationships have five major functions in care. First, the relationship is a source of knowing: it tells us what is needed.24,25 Second, the relationship functions as the restraining framework for the tuning of care: it tells us how much to give, when to stop, and so on.26 Third, the relationship is the place where one receives recognition and care.27 Fourth, the relationship acts as the source of legitimation.28,29 Fifth, the relationship can be a stage at which the other can appear in a broader sense instead of through the lens of diagnosis or preset categories.30–32
2. Second, the ethics of care is context-bound and situation-specific.33 One can discern three forms of context: the physical context such as the place where you live, the social context that assumes that everyone is in a relational network, and the historical context that takes into account someone’s
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biography. The more details one abstracts, the more one goes away from the situation. Ethical thinking should therefore be as specific (nonabstract) as possible. As a result, arguing in the ethics of care is not based on principles, but rather on basic insights or understandings. Generalizability of judgments is not a substantial criterion in the ethics of care. Moral judgment can be found in the decisions in specific situations. This is again a radical aspect, as it means that care needs local validation of meanings. Local validation means that the outcome of care can only be known through the receiver’s experience, which itself is embedded in and dependent on relationships (criterion 1).
3. Third, the ethics of care is a political ethics. It reconceptualizes traditional notions about the public and the private.20 The scope is broader than personal relationships; it also turns to institutional and systemic realities. As such, it is a critical and in its essence a political–ethical approach.27,34 As a political ethics, the ethics of care examines questions of just institutions in a decent society, including the distribution of social benefits and burdens, legislation, governance, and claims of entitlement. Professional care is considered to be a formalized activity, which is always embedded in larger social practices and relational networks. These latter networks provide the particular context in which the moral good can emerge.35 Thus, the ethics of care places individual actions of human beings in a broader framework of attentiveness, responsibility, competence, and responsiveness.33
4. Fourth, and this characteristic is derived from the previous ones, the empirical and ethical knowing are specifically related to each other. As ideas exist in a particular context and unfold their meaning there, the ethics of care should emphasize the empirical, detailed study of practices. The good is emergent and shows itself in practices: good is what turns out to be good.35 This implies a revaluation of the epistemological process. It is not just about rational approaches and decontextualized abstract knowledge; rather emotions and tacit knowing are also valued as important epistemological sources, which therefore have to be critically cultivated.20,21,35 In care ethical literature, care is most often defined as a value, disposition, or virtue, and is frequently portrayed as an overlapping set of concepts.20 We associate ourselves with one of the most popular definitions of care, offered by Tronto,33 which construes care as ‘‘a species of activity that includes everything we do to maintain, contain, and repair our
‘world’ so that we can live in it as well as possible. That world includes our bodies, ourselves, and our environment.’’ This definition posits care fundamentally as a practice. Understanding care as a practice rather than a virtue or motive resists the tendency to romanticize care as a sentiment or dispositional trait, and reveals the breadth of caring activities as globally intertwined with virtually all aspects of life. The term ‘‘practice’’ brings in the elements that will continue to be important when it comes to the understanding of care, such as criteria (what is good care?), virtues (excellent properties or characteristics of caregivers), responsibilities (who does what?), and values (what is care actually about?).36 This should encourage care ethicists to undertake research in practices with professionals, patients, and their fellows. To strengthen ethical normativity, we believe ethics of care should be as much empirically grounded as possible. For methodological issues, this would mean a reciprocating movement between critical conceptual, hermeneutic, phenomenological, and qualitativei empirical research. It is not easy to provide guidelines for what is (part of) the ethics of care and what is not. There are many publications that are grouped under the ethics of care, but most authors are not explicitly concerned with the question why and how their work stands in the care ethical tradition. Therefore, an interesting question would be whether it is possible to tentatively say something about the landscape of the care ethical i The choice for research methodology depends on the research question. Quantitative methodologies may also be helpful to explore what is going on in ethically sensitive care practices, but qualitative research lends itself better for reconstructions of the meaning of lived experiences.37

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discipline by using these initial criteria for some care ethical publications. One would probably find that some of these publications lay at the heart of the discipline and others on the boundaries, which makes it all the more striking that the authors barely reflect on the care ethical nature of their work. However, to make such a comparative attempt is beyond the scope of this article.
As a further contribution to the debate on the criteria and boundaries of an ethics of care, our own studies will be presented in the following section. We propose that we have found two intradisciplinary paths that meet the care ethical criteria.

First path: recasting
As we have seen, intradisciplinarity means that within the frame of one discipline, other disciplines are absorbed, both with their body of knowledge and their research methodology. Analyzing according to that discipline automatically implies analyzing with the attuned other sources of knowing. In the study of one of the authors of this article (Klaver), attentiveness is the core concept of the research project. We will show how insights on attention coming from varying disciplines are recast and as such integrated in a care ethical study of attentiveness.
Tronto33 has shown that the process of care starts with the recognition of a need, and the first moral aspect of caring is therefore considered as attentiveness. Furthermore, from research into the experiences of care receivers, we know that good care is about recognition: it comes to the experience of being seen.27,28,34 This means that attentiveness and care are internally connected: without attentiveness, good care cannot exist.7,33,38
Despite the importance of attentiveness, it is, as an ethically relevant concept, hitherto poorly defined and little studied.39 Therefore, an empirical study is undertaken to describe how attentiveness appears in care practices. On the basis of experiences of patients and caregivers in a hospital, Klaver tries to describe the nature, elements, and determinants of attentiveness, thereby having an eye for political aspects such as power relations or how oppressive systems work. The study does not aim to provide general statements about attentiveness, it rather describes how it comes to the fore in different situations. The practical purpose of this undertaking is to provide more grip on the difficult concept of attentiveness, in order to be able to understand and analyze care situations under this perspective.
As a background for this study, a theoretical framework is developed providing the sensitizing concepts necessary to study attentiveness empirically. As attentiveness is studied by many different disciplines, this framework is fed by insights from psychology, philosophy and phenomenology, theology, spirituality, and literature and art theories.39,40 However, the researcher has a care ethical interest in attention. This means that the ethics of care, with the criteria described in this article, serve as a selective mechanism and synthesizing power: it helps to determine what insights on attentiveness or attention are and are not relevant—and why it is so. Insights from other disciplines are rewritten to fit in this care ethical framework. We call this type of integration recasting, a word often used for an object of metal that is given a different form by melting it down and reshaping it.
In the psychological literature, attention or attentiveness is understood as the cognitive process of selectively concentrating on one aspect of the environment while ignoring other things. In philosophy and phenomenology, attention is closely related to consciousness and perception. In spiritual and theological literature, attentiveness is understood as a necessary way of doing or being if we are to know other people or things. In this way, a notion of attentiveness seeks to unite contemplation and action. Attentiveness is sometimes even regarded as a ‘‘lifestyle.’’ It is an important concept in, for instance, mindfulness, which is a Buddhist concept that is now broadly conceptualized as a kind of nonelaborative, nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is. The importance of notions from literature and art theories lies especially in the aspect of openly observing. It is what happens when people break through established patterns of observing, naming, thinking, and handling.39
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Because the literature on attention is very diverse and the consulted authors do not refer to each other, the recasting is accompanied by comprehensive reflection on the research problem and perspective. Through the juxtaposition of all angles, one obtains a multitude of ways to think about attention, but no single perspective that is useful for the study of attentiveness in professional care practices. The absence of such a common tradition in the perspectives discussed constitutes a difficulty, on the one hand, and it is an advantage, on the other hand. The difficulty is that the researcher should act as mediator between the different perspectives and should make up for the dialogue that does not exist. The advantage is that the points of agreement and disagreement can be selected in accordance with what can help the researcher to understand the findings from her care ethical type of interest for attentiveness.
One example is the idea coming from psychology that the caregiver can focus his attention on a patient.
This idea of focusing is integrated in the framework, but only after the realization that something can only be attention if the patient experiences it like that. In other words, in psychology, attention is defined by the person who is attentive, but in a care ethical framework that focuses on relationships, attention is understood as something that exists between people. It needs both a giver and a receiver. Yet, the psychological idea of focused (and distracted) attention has been retained.

Second path: reconfiguration
The second author (E.V.E.) takes another route to integration of the bodies of knowledge of different disciplines into the ethics of care. This route is what we call reconfiguration. The focus of the study is the transition of care practices in a general hospital to practices of Professional Loving Care (PLC). PLC is a care ethical view on professionalism and can be defined as a practice of care in which competent and compassionate professionals interact with people in their care; to them tuning in with the needs of each individual patient is a leading principle and if necessary they modify the procedures and protocols of the institution; the main purpose of this type of caring is not repair of the patients’ body or mind, but the care-receivers’ experience of being supported and not left on their own; important, too, is that all people concerned in healthcare (professionals, care-receivers and their relatives) are able to feel that they matter as unique and precious individuals.21

Little is known about the way existing practices of care can be changed in order to provide good care in line with the ethics of care. In this project, Communities of Practice (CoPs)41,42 are used to induce bottom–up changes in the hospital. CoPs can be defined as ‘‘groups of People who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis.’’41 Special attention is paid to the orientation of the CoPs to develop normative, reflective professional practice.
An initial Care Ethical Learning Model is developed by the researchers43,44 based on earlier experiences with transitions in care45 and on an extensive literature study. The model uses knowledge from the ethics of care but also concepts of social learning theory and change management theory.
The route of reconfiguration relates the different concepts in our model in a new constellation to each other so that it becomes a care ethical model. Each separate concept is not specifically a care ethical concept, but reconfigured it is a care ethical concept. The Care Ethical Learning Model is a reconfiguration of eight concepts. Those eight concepts are chosen in the light of the four mentioned criteria for an ethics of care. Some of them are strongly interwoven with the ethics of care, such as relationality, normative-reflective professionalism, and the axis personal—political. A learning model also needs a specific epistemological understanding, and this understanding is explained by the concept of cultivating and extracting tacit knowing. The other four concepts are chosen as pillars, which contribute (integrated learning, practice-theory ratio, and multilevel
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Figure 2. Care Ethical Learning Model.

transformative learning) to or offer resources (Bildung) for care ethical learning. See Figure 2 for an illustration of the Care Ethical Learning Model.
The direction of the learning is to develop normative-reflective professionalism. This is a kind of professionalism which specifically aims at relational programming and enables professionals to make their judgments in a specific situation with an eye for the context of the situation. The concept integrated learning is about learning processes which take place in real and complex practices. The focus is not only on learning but also on developing normative-reflective professionalism, professional identity, quality improvement, and innovation. Those parts cannot be seen separately but are in constant relation and interaction with each other. Furthermore, the (social) learning concepts such as multilevel learning, Bildung, and cultivating and extracting tacit knowing are embedded in a relational, political framework. Multilevel learning is a nonhierarchical four-level concept. This concept not only focuses on (1) learning competencies but also on (2) reflection on the level of intensions and guiding principles, and (3) reflection on the paradigms of healthcare. The fourth level is learning how to learn and to reflect on each of the three earlier mentioned levels.
Bildung is a coherent set of group activities to develop individuals by offering more than only cognitive resources. Also cultural (plays), narrative (books), and emotional registers are nurtured. Bildung within this learning model focuses on developing critical thinking and the ability for care professionals to morally judge. This contextualization follows the care ethical criteria. Learning can initiate profound personal and institutional changes. The revaluation of tacit knowing and emotions can also be seen as political: it is about tampering with existing hierarchic epistemological structures. Within the complex Care Ethical Learning
Model emergent properties can only be understood by looking at the relations between the concepts. The nonlinear mutual influential relationships between the concepts make it specifically care ethical.

Conclusion
How care ethicists can be open and critical about the care ethical nature of their work is a challenge for care ethicists today. By describing disciplinary development in general, positioning the ethics of care, presenting different forms of disciplinary integrations, and the proposing of a tentative demarcation of an ethics of care, an attempt has been made to offer a way to deal with this challenge. The tentative outline of the care ethical discipline could be used as a viewpoint from which to reflect on this difficult question. What is characteristic
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of this outline is the emphasis on relational programming, situation-specific and context-bound judgments, the political–ethical perspective, and empirical groundedness. As a further contribution, our own two studies were presented, which are two intradisciplinary approaches that keep the care ethical identity upright. We believe that scholars should continue on this path when it comes to developing the ethics of care. There could be other ways to deal with the problem though, which reaffirms the need for further discussion on this topic.
Declaration of conflicting interests
The authors declare that there is no conflict of interest.
Funding
Partial financial support was provided to Eric van Elst from Kennisklik (Centre for Knowledge Transfer),
Tilburg University.
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