Introduction

In this blogpost I will discuss restrictive practices in the disability sector from the point of view of care ethics. I will begin by outlining what care ethics is, and how it differs from traditional philosophical conceptions. I will then move on to describing restrictive practices from the point of view of policy, and how the policies rely on an implicit philosophy which misunderstands lived human experience and hence offers impractical policy advice.

Care Ethics

Care ethics is a philosophy which focuses on our dependent and relational nature as human beings. The philosophy opposes itself to the Cartesian tradition which conceives of humans as disembodied agents who make their decisions based on logical dispassionate reasoning. In her 1982 book ‘In a Different Voice’ psychologist Carol Gilligan distinguished between male and female ways of reasoning. She argued that male ways of thinking were individualistic and rationalistic while female thinking was more relational and interpersonal. She also claimed that female thinking focused more on care than male thinking.

            There has been a healthy debate on the degree to which Gilligan’s essentialist psychological speculations stand up to critical scrutiny. But I will bracket that question for the purposes of this blog-post. Whether people agree with Gilligan’s essentialist theories of human nature or not, empirical data strongly indicates that the majority of care burdens falls on women’s shoulders. And this fact clearly has had an impact on our philosophical conception on the nature of ethical theorising.

            Descartes is a paradigm example of the modern western philosopher. His atomistic emphasis on reason and his disembodied conception of the mind creates a picture of man as an isolated independent figure who uses the power of reason to deduce the nature of reality. On this Cartesian picture, the body and the mind are separate entities.

            A substantial proportion of the great philosophers in the western cannon were not family men. And those who did have families, were affluent people who relied on their wives and servants to provide the majority of care for their children. So, it is unsurprising that care wasn’t high on the philosophical agenda[1]. To the great philosophers, care was an unimportant background task performed by those, who they believed to be lesser people, primarily women. Eva Kittay puts the point cogently:

“There is a plausible explanation for why there is little in the long history of moral thought that highlights care, whether as a virtue or as the basis for right action. Very few of those who have penned moral theories have been women or had access to the experiences of women when not in the company of men. Women, moreover, have been in a position neither to make decisions in the sphere that men have dominated, nor have they been sufficiently independent of a man’s power to say what it is that they really think. The systematic moral scrutiny applied to promises, contracts, and conduct in battle and business was not applied to areas that men didn’t occupy, like care for children and the ill. (Kittay 2019 p. 166).

This lack of emphasis on the importance of care as an ethical concept feeds into the objectivist paradigm which treats humans as independent, disembodied, rational Cartesian egos.

            Care ethics with its emphasis on relationships, dependency and embodiment provides a corrective to traditional philosophy. Gilligan opposed her care-ethics to what she called the justice paradigm (Kittay 2019 p. 166). A large proportion of the justice paradigm is the social contract theory. This theory which involves a paradigm of self-sufficient individuals coming together to agree on rules they have to live by. It has been noted by critics of the social contract theory[2], that the theory leaves out people with an intellectual disability as being active agents in construction of a social contract.

            Utilitarian philosophy with its emphasis on objective context independent moral rules, and deontology with its moral obligations and universal rules are often pitted against each other as alternative ethical frameworks. While the two systems are obviously opposed to each other in terms of the importance of consequences to our ethical systems they do share one thing in common; both think that it is possible to discover context independent moral rules which can govern our behaviours.

            Care-ethics with its focus on interpersonal context dependent factors in ethical deliberation represents a different more grounded way of thinking about ethics. Policies which deal with ethical issues are sometimes vague about their underlying philosophical justifications. But despite the fact that they appeal to things like universal rights, the primary mode of policy guidance is led by a kind of crude utilitarian calculus. In the next section I will discuss this crude utilitarian calculus in relation to restrictive practice and discuss how care-ethics offers a corrective to this idealistic approach.

Social Care and Care Ethics

            In the Social Care field restrictive practices are a source of embarrassment. Official guidance is to try and drive out restrictive practices entirely. However, it is acknowledged by practitioners in the social care field that sometimes these practices are necessary. But a practice that, for example, restricts a person’s movement against their will, is a violation of their human rights. To justify these practices policies appeal to pragmatic and utilitarian considerations which in effect argue that the harm done by the restrictive practice is less than the harm that would be caused if it wasn’t implemented.

Utilitarian arguments can be used to justify draconian practices. This is something that has long been noted in other areas of ethics. It is easy to throw out justifications for draconian actions which have with blasé appeals to utilitarian considerations. Thus, people have often justified dropping a nuclear bomb during WW2 on the grounds that doing so saved countless lives. But the truth is we cannot realistically calculate how many people could have died if the bombs were not dropped.

            Likewise, in the case of restrictive practices, the pretence that we can objectively calculate that a restrictive practice is justified because of numbers assigned on a risk assessment is idealistic at best. Assigning numbers on a page gives an appearance of objectivity which my not be present. It could be argued that we can estimate the potential risk of damage, if an incident occurs, and estimate the likelihood that the person engaging in the risky behaviour, and with this data we can estimate the overall danger. With this in place if the probability of someone being seriously hurt is extremely high then a restrictive practice may be justified.

            All of this sounds reassuringly objective. However, in reality things are not that simple. When we are estimating the probability of a behaviour occurring, we can appeal to previous incidents over the last 12 months to estimate the probability of the behaviour. But the probability of a behaviour has to be specified against a set of background conditions. If I drink coffee every morning at 8am the probability of me drinking it tomorrow would be high; but if I fell into a coma the night before I won’t be drinking coffee tomorrow. On a Bayesian analysis you can also calculate the odds of me falling into a coma. And factor it into your overall analysis of the probability of my drinking coffee tomorrow. But there will always be some uncertainty.

            In the case of restrictive practice similar considerations apply. If we take the case of self-injurious behaviour. If a service-user is engaging in severe self-injurious behaviour every day that could cause them serious damage, then then the probability that they could hurt themselves tomorrow would be high. However, when you factor in background conditions, things change. In his ‘Care Ethics and Restraint in Residential Child Care’ Steckley notes that there is good empirical evidence that Snoezelen and sensory rooms can result in a reduction in the need for restrictive practices (Steckley 2015 p 200). Furthermore, he notes that things like staff training, unit culture, therapeutic approaches and primarily relationships are potent causal features of reducing restrictive practices (ibid p. 200). When one tries to factor these things into our background conditions which may change the probability of a behaviour occurring things get tricky. It is hard to assign a number to a culture changing, or to a relationship between a service user and a staff resulting in changed behaviour. And this is where the false objectivity of the implicit utilitarian calculus which is appealed to in our restrictive practice policies gets exposed. Hiqa 2019 note:

“The use of a restrictive practice is warranted when there is a real and substantive risk to a person and this risk cannot be addressed by a non-restrictive means.” ( Hiqa 2019 p. 5)

But as we have seen above despite the objective sounding language it is extremely difficult to calculate when a risk is extremely high and cannot be addressed using non-restrictive mean.

Social Care practice in Ireland is replete with concepts such as person-centred planning, community inclusion etc. And these concepts find their way into policies. But policies are also written with calculations designed to implemented in an efficient black and white manner in Capitalist market. And this black and white philosophy is not flexible enough to do justice to concepts such as person-centred care etc. The black and white philosophy may fit people who are “rational, autonomous, capable of making a choice, possessed of adequate information” (Toronto 2010 p. 159). Toronto notes that a lot of service users do not fit the above description. But the truth is we all don’t always fit the above description. As our discussion of restrictive practices above indicates we sometimes act on inadequate information and our choices aren’t always strictly rational. Holland notes that the quality of care suffers when it is considered a commodity not a process. (Holland 2010. pp. 163-166). And I think this is true in terms of policies when they are constructed according to strict utilitarian or deontological principles. The value of care ethics is that it focuses on our human and dependent nature. One difficulty with this conception is that we live in a world run according to rabid-Capitalism and this Capitalist system with its focus on the bottom line will find care-ethics with its ambiguities and focus on context a difficult philosophy to adapt.

Conclusion

In this blogpost I discussed care ethics and how it differs from traditional philosophical conceptions of ethics. The traditional conception of philosophy was contrasted with care-ethics with its focus on dependency, context and the body. To illustrate the importance of care ethics for the social care field the author discussed care ethics and restrictive practices. It was demonstrated that absolutist ethical positions written into policies cannot cope with the ambiguities of the real world while Care Ethics is much better equipped to deal with these ambiguities. However, given the current economic order we all live in Care Ethics is unlikely to make it into social care policies any time soon.

Bibliography

Gilligan, C. (1982) In a Different Voice: Psychological Theory and Women’s Development. Cambridge, Mass. Harvard University Press.

Holland, S. (2010) “Looking After Children and the Ethic of Care”. The British Journal of Social Work. 40. No6 pp 1664-1680.

Kittay, E. (2019) Learning From My Daughter: The Value and Core of Disabled Minds. Oxford. Oxford University Press.

Nussbaum, M (2011) Creating Capabilities. Cambridge MA: Belknap Harvard.

Nussbaum, M (2006) Frontiers of Justice. Cambridge MA: Belknap Harvard.

Nussbaum, M (2013) Political Emotions. Cambridge MA: Belknap Harvard.

Rawls, J (1971) A Theory of Justice. Cambridge MA: Harvard University Press.

Steckley, L. (2015). “Care ethics and physical restraint in residential childcare”. In M. Barnes, Brannelly, T., Ward, L. & Ward, N. (Ed.), Ethics of care: Critical advances in international perspective (pp.195 – 206). Bristol: Policy Press.

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[1] Kittay (2019) notes that reflection on care wasn’t entirely absent from the western philosophical cannon some philosophers such as Plato, and Heidegger did consider the concept of care however their abstract reflections don’t touch on the concrete responsibilities in relation to care that recent feminist philosophers in the care ethics tradition have been concerned with.

[2] See Nussbaum (2006, 2011, 2013)