Dr. Lisa Freitag is a former pediatrician in Minneapolis, Minnesota. Her first guest post on modern medicine, ethics, and the reality of patient care is here.

Lisa Freitag says:

I am getting very tired of seeing the word “care” in medical advertisements. At least along the Minnesota freeways, it seems that only medical conglomerates and Republicans can afford billboards, so we see a lot of medical billboards. The medical complex is spending a lot of money bragging about how much a certain clinic cares for your family or how good some hospital is at caring for you in a crisis, but I’m not sure they know exactly what they mean by “caring.” It sounds good, though.

We know very little about care itself. The word is layered with meaning, sometimes referring to an emotion very close to friendship or even love, sometimes referring to a personality trait that leads a person, for good or ill, to put another’s interests ahead of her own. In medicine, it can mean everything from the admission’s clerk acting with the appearance of respect toward a patient, to the performance of highly specialized surgery without error. The implication changes depending on the advertisement.

Yet at the core of caring there is something that we all recognize when we see it: the ministering to another person who is in need, who is unable to perform life-maintaining actions because of illness or disability. What we recognize is an act of caring; someone in need and someone else willing do whatever it takes to take care of that need.

In order to make sense of care, of this recognition and meeting of needs, Joan Tronto, a political science professor at the University of Minnesota, has proposed a new way of breaking down the process of meeting needs into stages, or phases, of action. This framework can be used to analyze all types of caring, from feeding the hungry to cleaning up the environment, but it applies particularly well to the conglomerate of actions we call medical care. These levels help understand who in medicine is actually doing the caring, what that care entails, and why that care is undertaken. They are also quite useful for sounding intelligent while being snarky and cynical toward certain billboards.

Joan Tronto’s book is called Moral Boundaries: A Political Argument for an Ethic of Care. Routledge Press, 1997. The phases of care are only a small part of the book, which talks mostly about the reasons, historical and convenient, that keep care invisible. Since most caregiving is done by women and/or by members of disenfranchised minorities, the definition and recognition of care becomes a feminist and racial issue.

A society functions, at least in part, by recognizing and meeting the needs of its members. People need food and water and shelter; we need the laundry done and the dirt kept at bay. We need to be cared for when ill. Our particular society however has an odd sort of notion that we are all strong and independent, and that any sort of neediness makes us weak and inadequate. This has led to a denial of the necessity for care, as “strong independent” people assert our self-made “manhood” by refusing to admit to the care we are receiving, refusing to recognize that in fact we do have needs that us them less than fully independent. This poses a terrible dilemma for the supposedly independent person when illness makes him needy and vulnerable. This attitude relegates the act of caring, the fulfillment of certain needs and the people who meet them, to a position of invisibility, and is possibly the reason why doctors make such terrible patients.

Tronto’s first phase of caring is “caring about.” As the earliest phase, this one is the furthest from the actual meeting of needs. Nonetheless, it centers around the obvious fact that in order to meet a need, the existence of that need must first be noticed. Properly performed, the action of “caring about” requires an attentiveness to the world, an openness to seeing needs that present themselves. (It also requires noticing that needs of one’s own exist and are being met by others.) Right away, we can spot a problem in the medical system. We depend on people to recognize their own need and present themselves to a hospital or clinic to get help. Those who cannot do this are overlooked from the outset. Perhaps the intent of those caring billboards is to inform those disenfranchised people of the presence of help? I doubt it.

The second phase of caring is “caring for,” and requires beginning action toward the meeting of a need. The action does not have to be direct, but usually entails a willingness to shoulder some responsibility for care. Giving money to a charity, engaging in political activism, or volunteering in a homeless shelter all count. So does working in a clinic, administering a hospital, and even being CEO of a medical insurance company. People in all these roles have committed themselves to the responsibility of “caring for.” Here we begin to see what the clinics and hospitals advertising their care might mean. They are claiming to be willing to take the responsibility for meeting the medical needs of their patients.

The question that then can be asked is, “How well are they performing the caring act for which they have taken responsibility?” Within the medical system, many ethical concerns are raised by this seeming commitment to caring. We can ask whether a commitment to caring can be real if there is also a responsibility to their shareholders to make money. This what is called in academic ethics circles a “conflict of interest.” We can ask whether the responsibility the system takes for the health of the patient actually matches the goals of that patient. We can ask if the advertising itself is a demonstration of caring. Might it be an attempt to invent needs which they can then meet for us?

Of course, at some point, the meeting of needs requires actual work, some action pointed directly at the person in need. Tronto calls this third and most critical phase “caregiving.” For care of the truly ill or disabled, this phase is intense and all-important. If someone does not give the medicine, change the bandages, or perform the therapy, care does not happen. Caregiving also includes less distinguished but no less important tasks: bed linens must be changed, messes cleaned up, and bedridden people guided to the bathroom. All this must be done competently, with efficiency, and kindness, and an attention to the continuing needs of the patient. We are of course talking largely about nursing as the core of medical caregiving.

It is a puzzle to me where doctors fall on this caregiving spectrum. They do not provide much in the way of hands-on care, with the possible exception of surgical procedures. They have taken a particular form of responsibility for care, which largely entails coming up with some death-delaying cure. For the most part, they breeze into the patient’s room, ask a few questions, poke around a bit, and then write orders which are carried out by someone else. They do not give the shots, bring clean towels, or answer the call of that little bedside button. Most especially, they do not empty bedpans. This supposedly most caring of professions seems to me to involve very little caregiving. Doctors, in fact, barely notice that such things are needed in order for care to be accomplished.

The fourth stage of care is “care receiving.” Its inclusion on the list implies several things about care that might be uncomfortable. Tronto’s intent is to answer the concern of some feminists (and other ethicists) that unwanted care is paternalistic, and therefore not true care. She calls for the recipient of care to report back on whether the help received was actually what was needed or desired. I think this stage also implies that the care-receiver has some duties in the process of care, and that a person in need can be either helpful or obstructive in receiving care. I must reluctantly conclude that, yes, it is possible to be a bad patient.

So what are we to conclude from a giant billboard that claims, “I CARE” along with a photograph of a guy in a white coat smiling benevolently? Certainly they don’t mean to imply that the doctor will come change your bedpan. Possibly he will remember your medical history, if he reads your chart first. Most likely it means that he is an expert in something that you should hope you never need anyone to know. Is that truly caring? And how about the statement, “WE CARE,” with the logo of a clinic or insurance company attached? Do they care about you, or intend to care for you? Are they actually a home health nursing agency, from which you might get some actual caregiving? Well, sometimes they add a bit more information to make it easier. If there is another statement, something like “Its All About Caring,” it means that they have passed some sort of customer satisfaction survey. If they add that they are “Number One in Heart Care” it means that they do tons of heart procedures, and would really love for you to need one too, but only if you have the insurance to pay for it. And of course, if they say, “Caring for the [Name Your Town Here] Community” it means that they have just opened up a new clinic on Main Street, and are really hoping that you come to it so they can pay for the construction. Some of those might actually care for you even if you arrive without money or health insurance.

Of course, caring still goes on, 24/7, as caregivers around the world work directly to meet someone’s needs. Parents change diapers and give nighttime feedings, nurses change dressings and pass medications, and daughters bring dinner to their aging mothers. None of those doctors and clinics and insurance companies are doing any of this, except to sometimes prescribe procedures to be done by others. The work of caring happens out of their sight, and they barely acknowledge its existence or its necessity. “WE CARE” all right.

Of course the last “WE CARE” sign I passed contained the logo of the Minnesota School of Business. I have no idea what they could possibly mean by this, who they might care for, or why they think we need to know. Caring, I guess, is in fashion.