Ethics of Caring Conversation and Dialectic of Love and Justice

Introduction

Fredriksson and Eriksson’s ¹ ethics of the caring conversation is referenced in several studies. ^{2 –11} They develop the ethics by interpreting the caring conversation in the ethical terms with the help of Ricoeur’s philosophy, especially his concept of little ethics. The resulting interpretation is dense, full of references to Ricoeur’s major concepts and yet distinctively theirs. Since Ricoeur’s philosophy is complex, it is possible to put Fredriksson and Eriksson’s ethics in a further dialogue with some of his important ideas, that is, love, justice, and economy of the gift.

Attention is drawn to these ideas for, in developing their ethics, Fredriksson and Eriksson seems to emphasize caritas at the expense of justice. Therefore, a consideration of Ricoeur’s dialectic of love and justice should be able to help delineate some interesting aspects from their ethical interpretation of the caring conversation. In addition, Fredriksson and Eriksson, too, mention ideas similar to elements in Ricoeur’s economy of the gift, which happens to be a significant phrase that captures the dialectic of love and justice. The significance of the economy of the gift, and the dialectics, is undeniable as it is apparent in Ricoeur’s ¹² words, “… economy of the gift touches every part of ethics …” In addition, in what follows, it will be seen that Ricoeur’s analysis shows that caritas can be problematic in itself and needs to be mediated by justice to function on the moral plane.

The article starts with an exposition of Fredriksson and Eriksson’s ethics of the caring conversation. Ricoeur’s dialectic of love and justice is then explored. After that, a discussion is offered to bring Fredriksson and Eriksson’s ethics into a dialogue with Ricoeur’s dialectic.

Fredriksson and Eriksson’s caring conversation

In contradistinction to communication aiming to transmit information, conversation is preferred for its feature of relational interaction between nurses and patients. The caring conversation is explicated in its ethical context through a Ricoeurian framework with two questions in views, “What sort of person should nurses be?” and “How should they engage in caring conversations with patients?” ¹ The framework is primarily based on Ricoeur’s ¹³ concept of ethical intention, which is defined as “aiming at the ‘good life’ with and for others in just institutions.” The ethical intention is realized in the individual, interpersonal, and institutional contexts. Fredriksson and Eriksson focuses on the former two.

In the individual level, nurses aim at the good life as nurses, ones who alleviate suffering. The goodness of this goal is derived from the standard of excellence in nursing, which can be traced back to the concept of caritas in the Good Samaritan, for instance. ¹ This agrees with Watson, who in moving from her concept of Carative to Caritas, does not only identify the latter, or Caritas Processes, as the core of the nursing science but also the heritage from Nightingale. ¹⁴ The choices of goal and acts toward it presuppose autonomy. Through a hermeneutical circle, nurses interpret themselves back and forth between the ideal aim and real choices and thereby achieve self-esteem. ¹

The aim of good life is brought to the interpersonal level simply because a life cannot be good for oneself without also being so for others. In this level, solicitude—“being thoughtful and considerate” ¹ —comes into play as a fundamental aspect of ethical relationship that can be asymmetrical and non-mutual, symmetrical and mutual, or asymmetrical and mutual. The last one is of direct relevance to nurses as it is found between oneself and a suffering other. It is asymmetrical because one party helps the other. However, sharing with the suffering other her pain, the helping party is given much more in return in form of self-empowerment through an effort to draw upon her own strength in face of vulnerability due to mortality. ¹

Drawing upon Ricoeur’s little ethics, Fredriksson and Eriksson state that the ethical intention considered so far needs to go through the other two stages of morality and practical wisdom. In other words, the ethical intention is in the teleological level and it has to be driven through the deontological and phronetic levels. In so doing, the ethical aim is transformed into a norm, or morality, and the practical wisdom traces back from the norm to the aim to make a decision in a concrete situation, especially, of moral conflict. ¹

What sort of person should nurses be? It should now be clear that, in the individual level, aiming at a good life, that sort of person should choose caritas as her goal. The choice is a basis of her self-esteem, which is achieved when, exercising her autonomy, she interprets herself in the back-and-forth reflection between the goal and her acts. The Golden Rule is here introduced to bind the individual to the interpersonal level. The Golden Rule is reformulated by Ricoeur as “in order to hold others in esteem, ‘I’ must hold myself in esteem.” ¹ When self-esteem along with autonomy is universalized, they respectively become respect and responsibility, both of which are covered by the International Council of Nurses’ (ICN) Code of Ethics. Practical wisdom is necessary for realization of responsibility and respect for others. ¹

How should nurses engage in caring conversations with patients? The caring conversation is classified as the asymmetrical and mutual relationship. The reformulated Golden Rule as the norm of reciprocity prevents the asymmetry from allowing domination of nurses over patients. Through the norm, the patients are held in esteem. The caring conversation is a context in which the nurses’ goal of caritas, self-esteem, and autonomy are realized, through an exercise of practical wisdom, in the forms of Golden Rule, respect, and responsibility. ¹ Therefore, in caring conversations, nurses are to engage reciprocally, respectfully, and responsibly. In the conversations so engaged, the nurses listen to narratives that the patients tell and, in the meantime, interpret themselves. In doing so, the nurses enable the patients to regain their autonomy and self-esteem.

Something akin to Ricoeur’s concept of economy of the gift is alluded to in the latter part of the article. In the asymmetrical relationship with patients, nurses initiate by giving part of their self by virtue of their availability and “wholeheartedly making room for” ¹ the patients who, then, accept the gift by sharing with the nurses their suffering. The patients’ acceptance of the nurses’ invitation restores reciprocity in this asymmetrical relationship. The conversational mode of caring, it is asserted, enables full realization of such reciprocity. ¹

As a whole, it can be observed that, out of the three levels of Ricoeur’s little ethics, Fredriksson and Eriksson focus on the first one when they develop the ethics of the caring conversation. In the aiming for a good life with and for other in just institution, caritas is introduced as the goal and, later, as gift giving. This is the only feature that distinctively belongs to nursing. Self-esteem and autonomy on one hand and respect and responsibility on the other are derived from their interpretation of Ricoeur’s theory in the context of the above two questions. A consideration of Ricoeur’s dialectic of love and justice can offer further interpretive possibilities to this distinctive feature, caritas, the Latin translation of agape.

Ricoeur’s dialectic of love and justice

In this section, Ricoeur’s analysis of the creative tension between love and justice is delineated. His analytical trajectory comprises establishing love and justice as polemics, offering a middle term to mediate between them and, thereby, forming a creative tension, or a dialectic. Polemicized, love and justice are shown to be governed by opposite logics, consecutively, that of superabundance and that of equivalence. Through his reading of the Sermon on the Plain in Luke, Ricoeur offers a middle term to mediate the tension. That middle term is called “economy of the gift.” All of these give a deeper understanding of love, justice, and something beyond these two, that is, mutual recognition.

From Fredriksson and Eriksson’s conclusion that nurses ought to show caritas toward their patients, it may follow the same question as the one raised by Ricoeur, ¹² that is, how it is possible to command love as “there seems to be something scandalous about commanding love, that is, about ordering a feeling.” This remark denotes separation between love and moral imperative. It is worth noting here that the love in question differs from the aforementioned solicitude in that the latter presupposes an interdependence between self and the other while the former can operate despite the other as evident in the commandment to love one’s enemies. Consequently, a question arises as to how caritas, or love, can feature in any moral imperatives, including that offered by Fredriksson and Eriksson.

To answer this question, Ricoeur makes a detour through an interpretation of the Sermon on the Plain in Luke, in which two seemingly contradictory commandments are found side by side, one that demands love for enemies and the other that instructs the Golden Rule. ¹² How can one be commanded to love one’s enemies no matter what at the same time as being commanded to treat others in the reciprocal manner? How can the commands for asymmetrical and symmetrical mode of relation be so juxtaposed?

To solve this paradox, Ricoeur ¹² offers a dialectic, which means “… the acknowledgment of the initial disproportionality between our two terms and, on the other hand, the search for practical mediations between them …” However, Ricoeur’s analysis shows that a study of the relationship between love and justice does not only shed light on the paradox but also perversion when each stands on its own. The dialectic solves the paradox at the same time as it solves the perversion. The resulting dialectic can be captured by the phrase “economy of the gift.”

Love, in the sense of caritas or agape, is characterized by a logic of superabundance due to its being unconditional and all-encompassing to the point of abolishing the distinction between friends and enemies. Therefore, Ricoeur ¹² states that love is hyperethical. In other words, it transcends ethics. As hinted above, this seems to put Fredriksson and Eriksson’s ethics in a difficult position for its inclusion of caritas as one of the main elements. What is an implication of the hyperethicality? Consider the practice of unconditional love along with the Golden Rule and the rule of legal and distributive justice.

First, it is apparent that the Golden Rule cannot be applied if one practices the unconditional love. Second, even though Ricoeur admires St Francis, Gandhi, and Martin Luther King, Jr for their strict practice of the commandment of love, he points out that, when it comes to general implementation of legal and distributive justice, being hyperethical, love can impede justice. That is because, governed by the logic of superabundance, love disrupts reciprocity, which is a defining feature of justice. When justice is ignored, love may lead to non-moral, or even immoral, acts. ¹² For instance, with strict adherence to the unconditional love, one may help a murderer escape despite his crime.

Is this to say that, to preserve ethics, love must be discarded and justice must gain the ground? According to Ricoeur, it is not only love but also justice that is prone to a similar perverse interpretation. Justice is governed by a logic of equivalence, which is opposite to the logic of superabundance. Taking distributive justice as an ideal, Ricoeur ¹² explicates the rule of justice through a dialogue with Rawls’ conception of society as a system of distribution of goods and burdens, rights, and duties. This conception has an advantage in that it brings from reciprocity to mutuality. That is, it allows us to see the rule of justice:

… oscillate[s] between the disinterested interest of parties concerned to increase their own advantage as far as the accepted rule will allow, and a true feeling of cooperation going as far as the confession of being mutual debtors to one another. ¹²

A reading of the Sermon on the Plain in Luke gives Ricoeur a clue. He observes a sequence of Luke 6.27-30 (“Love your enemies, do good to those who hate you …”); Luke 6.31 (“Do to others as you would have them do to you.”); Luke 6.32-4 (“If you love those who love you, what credit is that to you? …”); and Luke 6.35 (“But love your enemies, do good, and lend, expecting nothing in return …”). The sequence casts a picture of the two types of logic taking turn to gear each other to the right direction. Whence comes the dialectic. The two disproportional terms need each other to prevent themselves from perversion. Justice must be mediated by love since “… if [justice] were not touched and secretly guarded by the poetics of love, … it would become merely a subtly sublimated variety of utilitarianism …” ¹² Meanwhile, love must be mediated by justice as Ricoeur ¹² puts it, “… love is hypermoral, it enters the practical and ethical sphere only under the aegis of justice.”

The dialectic between love and justice can be captured by the economy of the gift. ¹² According to Wall, ¹⁵ one of the difficulties in understanding the phrase “economy of the gift” is that, even though appears in many of Ricoeur’s writing, it is never given any systematic treatment. Hall ¹⁶ explains that it should be understood as being metaphorical and therefore producing a new meaning that facilitates better understanding. Although the phrase is the same as the one that Mauss uses to call a primitive form of economic activity, it is not the same. It is difficult to think of “gift” and “economy” together since generosity and exchange operates on different planes. Taking an advantage of the difficulty, Ricoeur uses the tension created by juxtaposition of gift and economy to throw light on aspects of reality. The nature of love and justice is one of those aspects.

According to Ricoeur, the term “economy” indicates an exchange, which is governed by the logic of equivalence while the term “gift” belongs to the practice of gift giving, which is governed by the logic of superabundance. The phrase does not only capture the dialectic but can also lead us to a concept of mutual recognition. Exploring the enigma of gift giving and returning, Ricoeur tries to figure out why one feels obliged to give in return after having received a gift. His analysis shows that, when the giver gives without expecting anything in return, she gives part of herself in the sense that she puts herself at risk by making herself vulnerable. Out of love, the receiver is aware of the giver’s vulnerability and, consequently, shows recognition by giving in return and so giving rise to an economy. The second gift is no less than the first gift—“a kind of second first gift” ¹⁷ —since the receiver who gives in return puts herself at risk of not being recognized. Both parties, therefore, share mutual recognition. ¹⁷

In the next section, the love that is situated in this creative tension, when it comes into a dialogue with Fredriksson and Eriksson’s notion of caritas in their ethics of the caring conversation, can highlight the role and different levels of justice, and throw light on aspects of practical wisdom and a general direction of how to cultivate caritas.

Discussion and conclusion

Caritas is the important feature of Fredriksson and Eriksson’s ethics of the caring conversation. It is considered to be a starting point for nurses to be the sort of person they should be. That is, when they choose caritas as the value that defines their good life, they exercise their autonomy and move on to develop self-esteem, which become respect and responsibility in the interpersonal level.

In caring conversations, the autonomous and self-esteemed nurses are obliged to treat patients respectfully and responsibly, which is made possible by practical wisdom. The patients so treated in the context of the caring conversations is hoped to regain their autonomy and self-esteem. This implies that the patients’ practical wisdom needs to be promoted in the to and fro of the conversation. However, this portrays an asymmetrical relationship between the nurses and the patients, which may cause the conversations to fall into communication. Caritas comes into play again to restore reciprocity. It comes in the form of a gift. Such re-introduction of caritas into the scene implies that Fredriksson and Eriksson do not consider it definitive the idea of the nurses receiving in return self-empowerment in face of the patients’ vulnerability of the mortal conditions.

Ricoeur’s notion of the economy of the gift can explain the enigma of such gift giving and returning, which helps us see how reciprocity, or mutuality, is restored. Through this notion, it becomes evident that caritas also comes from the side of the patients, who respond to the nurses’ vulnerability after giving the patients part of their self. In other words, it grounds the patient’s “second first gift,” and motivates the exchange, which leads to mutual recognition. Love and justice are here present. Caritas can be well understood through its underlying logic of superabundance. It can be so fully governed by the logic that it differs from solicitude. The latter is embedded in the ethical intention, which presupposes existence of others and justice as is obvious in its “with and for others in just institutions” while the former is primordial and hyperethical, able to stand out of a relationship with justice and prone to reduce and dominate others. Therefore, when caritas is mentioned as the nurses’ aim, what should it be understood?

On one hand, Fredriksson and Eriksson derive it from nursing’s standard of excellence. On the other hand, its institutional status is problematized by Ricoeur’s analysis of love, which shows its primordiality. However, this does not pose a serious question since, as Ricoeur points out, love transcends its hyperethicality when it is guided by justice. Since caritas as the standard of excellence is in the ethical sphere, it must be under the guidance of justice. Therefore, when Fredriksson and Eriksson state their focus is not on the element of “just institutions,” their introduction of caritas as the central feature brings along justice as the logic of equivalence that mediates the logic of abundance. This point about just institutions, or structural justice, will be discussed again later.

Therefore, the hyperethical caritas helps us make sense of the nurses’ initiation of the gift whereas the ethical caritas explains the transformation of the hyperethical caritas, through the mediation of justice, into the aim of nursing practitioners in the ethical sphere. The interaction between love and justice is spiral. The caring conversation is prevented from falling into communication by an ethical intention characterized as distinctively belonging to nursing through a choice of caritas as an aim of the good life. As shown above, the ethical intention so characterized presupposes justice. In turn, the caring conversation, as stated by Fredriksson and Eriksson, is a context for full realization of reciprocity, a form of justice. In addition, through such realization, the caritas that initiates the caring conversation is more and more mediated by justice. The highlighted role of justice reminds that, upholding caritas, nurses need to balance between the logic of superabundance and the logic of equivalence. It requires practical wisdom, which helps find “just” the right point of balance. Also, this shows another aspect of the exercise of practical wisdom apart from that emphasized by Fredriksson and Eriksson in nurses’ self-interpretation.

When the hyperethical caritas becomes visible like this, a question follows of how to cultivate it so that it turns the wheel of economy of the gift. This brings us back to Ricoeur’s remark on the peculiarity of commanding love. How can the feeling be commanded? Ricoeur ¹² goes through a sophisticated analysis with theological overtone. However, it suffices here to state that “the commandment to love is love itself, commending itself.” Such love is expressed in value in all things in the world—“an object of solicitude, of respect and admiration” ¹² —and of infinite possibilities as the source of hope. All of these are given. Therefore, “since it has been given you, give …” (italic original). Nurses’ caritas is, thus, the second first gift. To care for patients is to realize an economy in response to the first gift. Moreover, the caritas is also originated in “the hyperethical feeling of the dependence of the human creature,” ¹² which, in part, has something in common with the vulnerability in face of mortality, that of which nurses are reminded by suffering patients. If nurses put themselves in the perspective of superabundance and dependence—of the gift from the world and the dependence on the gift, caritas arises in them.

In addition, some points related to care ethics and just institutions deserve further discussion here. Before Fredriksson and Eriksson’s related ideas are considered, a detour is made through other scholars. To begin with, according to Lachman, ¹⁸ while most nurses are familiar with Watson’s caring theory, they are not well aware of the development of ethics-of-care theory that begun in Gilligan’s ¹⁹ In a Different Voice. Lachman marks the evolution of the ethics-of-care theory with four significant contributors. Apart from Gilligan, they are Tronto, ²⁰ Little, ²¹ and Gastmans. ²² Lachman shows through application of Tronto’s theory that, similar to the caring theory, the ethics of care can provide nurses with a helpful guidance in patient care.

Like Lachman, Van Stichel ²³ starts from In a Different Voice when she explores the ethics of care in the context of the debate between care and justice. However, Van Stichel covers more contributors to the ethics of care. Apart from Tronto, they are Bubeck, ²⁴ Clement, ²⁵ Held, ^26,27 and Noddings, ²⁸ for instance. Despite her paper’s title on Ricoeur’s contribution to care ethics, Van Stichel ²³ states that “it is impossible to jump easily into conclusions about the divergences and convergence between care ethics and Ricoeur.” However, care ethicists can benefit from a dialogue with Ricoeur since “he relates to different aspects, to various care ethicists in different ways.” ²³ Similarly, Hettema ²⁹ proposes that Ricoeur can offer “food for thought in care ethics.”

Both Van Stichel and Hettema pay attention to Ricoeur’s thoughts and their possible contribution to the ethics of care. Although directly addressing Ricoeur’s dialectic of love and justice, the former approaches the issue from the angle of love while the latter is engaged with justice. Van Stichel attempts to map the dialectic onto the debates between love and justice, which comprises stances that range from one that insists on opposition to one that maintains complementarity or intersection between the two. While she finds convergences between Ricoeur and some aspects of all of these different stances, she identifies some divergences. That is, while Ricoeur’s concept of love as agape is ideal, caring is practical. In addition, she thinks that Ricoeur’s concept of love “calls for unbridled self-sacrifice,” ²³ which is critiqued by the care ethicists. Meanwhile, Hettema focuses on Ricoeur’s structural, or ethico-juridical, concept of justice. He points out that, based on the interdependence between autonomy and vulnerability, such concept of justice provides space for caring. ²⁹

Similar to Hettema, Fredriksson and Eriksson focus on justice in its structural sense when they touch upon the third element of the ethical intention, “in just institutions,” by showing that, in the care setting, this element is related to the ICN Code of Ethics, which is against discrimination, for instance, by age, color, race, gender, and culture. In addition, when it is narrowed down to the context of caring conversation, it is mainly concerned with language. The point is to have language, or discourse, that does justice to patients in such a way that their suffering can be voiced or not silenced by nurses’ use of professional language or preferences for particular forms of narrative expression. However, Fredriksson and Eriksson acknowledge that it is difficult to sufficiently treat this element because it requires consideration in the structural level that is beyond the interpersonal sphere, the proper context of the questions what kind of person nurses ought to be and how they should engage in caring conversation. ¹

The analysis of Ricoeur’s dialectic of love and justice so far shows that, apart from the structural sense of justice, which Hettema, and Fredriksson and Eriksson focus on, there is the other sense, the one that permeates caritas, prevents it from perversion, and preserves it as it ought to be. This also counters Van Stichel’s criticisms. If, driven by caritas, caring is practical, so must be justice, which is part of that very caritas. Moreover, Ricoeur’s dialectic of love and justice also points out how to cultivate love through an understanding of the economy of the gift, the mediation between love and justice. In addition, but for justice, love as caritas does not lead to “unbridled self-sacrifice,” a form of perversion.

When this other sense of justice is highlighted, it is worth noting that, in Watson’s Caritas Processes, the first one—“practicing loving-kindness and equanimity for self and other” ¹⁴ —seems to be in agreement with Ricoeur’s dialectic of love and justice. Loving-kindness and equanimity are influences from Buddhism, ³⁰ according to which equanimity plays a role similar to Ricoeur’s justice in that it keeps loving-kindness on the track of virtue. ³¹ This idea may contribute to further elaboration of the concept of equanimity, which does not seem to receive a clear definition. ^14,30,32

To conclude, the dialogue between Fredriksson and Eriksson’s ethics of the caring conversation and Ricoeur’s dialectic of love and justice leads not only to a disclosure of the other aspects of caritas and its relationship with justice but also to an awareness of the nurses’ need to strike a balance between love and justice on one hand and to cultivate love on the other. It is recommended here to further study to find out how to create such a balance, especially in the conversation, or exchange of narratives, with patients, and also to seek a way to cultivate caritas to initiate and sustain the economy of the gift. In addition, it is recommended that a study is conducted on how Ricoeur’s dialectic between love and justice may elaborate the element of equanimity in Watson’s caring theory.