'If caring were enough, anyone could be a nurse' read a 1990's American nurse recruitment advertisement. It promoted nursing as an intellectual, science-based profession rather than a caring-based profession. The implication is that caring is no longer valued within our society.

But if that really is the case, why do politicians want to be seen caring for people? For that matter, why did commentators praise Princess Diana for being a 'caring' person?

Why care?

Caring is seen as something all healthcare professionals do. But young people appear to be increasingly reluctant to enter these careers, partly because they lack glamour and excitement and because they are also often poorly paid.

This could eventually lead to a growing disregard for the weak and helpless who are unable to contribute to a nation's wealth and productivity.

Unless caring becomes important we could end up in a society where we fear old age or sickness, because we know we won't be cared for. The question 'Why care?' is worth asking because it reveals the different ways that people approach ethical issues.

CMF File 1, Introduction to Ethics, gave a range of ethical frameworks. With these in mind, let's look at possible ways to complete the sentence:

It's right to care for people because...

All the options look alright at first, but a closer examination reveals some potential problems.

... it's a natural human instinct

This suggests that caring comes from a combination of hormones and the memory of being cared for as a child. The most obvious example of this is the natural protective instinct most parents feel towards their children.

The American feminist philo-sopher Nel Noddings is so convinced of the existence of this natural instinct, particularly amongst women, that she has argued for a complete ethical system based upon it. She proposes a feminine emotion-based approach to morality, as opposed to the masculine reason-based approach[1] . The problem is that simply being natural does not necessarily make a feeling right. A doctor may have a 'natural instinct' to ignore a rude smelly patient, though if she cares, she will still respond to the patient's needs.

... I'm a naturally caring person

This suggests that while you feel drawn to care, you don't think that others necessarily need to share your feeling. In fact, this argument is more often run from the opposite viewpoint: 'It's right for them - they have naturally caring personalities'.

Most of the people who care for the sick in hospital and at home are women. Can men legitimately argue that they are let off the hook because they are not naturally caring?

... it ensures human survival

This says that caring is driven by a sense of evolutionary self-interest. Human survival is the primary ethical value and we control and work out our own evolution[2]. What does this say to the mother who devotes years to the care of her severely handicapped child? This act of caring will not further the human race. So was her care misplaced? Surely, the best way to promote the survival of the human race is to look after healthy people and not to care for the sick or dependent at all?

At its extreme, this could lead to the extermination or enforced sterilisation of any with apparently 'faulty' genes, to control our own evolution as a race.

... it gives me satisfaction

This is another self-centred view of caring. The person does it because they gain satisfaction.

For many the satisfaction comes from a sense of personal development. Nursing training often has a maturing effect on students as they learn to respond to serious real-life situations, and many nurses say that their jobs are satisfying.

However, this lacks any compulsion to care. You could claim that if you don't want the satisfaction of caring, you don't have to do it.

And what of the person who has to provide to the point of exhaustion? Isn't this caring, even if it could hardly be called satisfying?

...it could be me one day

This motivation to care comes from our anxiety that we could be in a similar situation ourselves one day and would want to be cared for. So it is in our best interests to perpetuate the ethic of caring.

However, this does not provide us with any moral imperative to care for those who are in situations we are highly unlikely to end up in ourselves. For example, why care for drug addicts if you are not a drug addict yourself? Why bother caring for someone who has an inherited disorder you have not inherited?

..it expresses God's love

It's easy to say, 'it's right to care for other people, just because it's right'. But where does this assumption come from? Could this moral instinct have come from the God who created you?

The Bible says that God is good. For example, 'Give thanks to the Lord for he is good, his love endures forever'[3]. But what then is love?

At the heart of the Judaeo-Christian religion is the belief that God shows his love for people by caring for them. People are then encouraged to care for each other as an expression of God's love.

All people are made in the image of God - in many ways we are like him. This applies even to people who are easily dismissed either through gross disability or age. On top of this the Bible shows that God's son Jesus died for all human beings, even the most unlovely. If God cares for every human being, and if we are made to be like God, then we are made to care for each other.

The father of British medicine, Thomas Sydenham, also pointed out that: '[a doctor] must remember that it is no mean or ignoble animal that he deals with. We may ascertain the worth of the human race, since for its sake God's only begotten Son became man and thereby enobled the nature that he took upon him.'[4]

Here we find a consistent ethical basis for caring. The act of caring is 'right' in all circumstances, because the moral imperative and the equipping come from an external authority, God.

What does it mean to care?

Again there are several alternatives to consider:

Comfort or cure?

Curing people sounds exciting. Simply providing comfort like food, personal hygiene and pain relief is much less glamorous.

Consequently, money is allocated to research into potential cures for disease in preference to comfortable beds or appetising food for patients.

Sometimes terminally ill patients suffer discomfort in the pursuit of a cure. If the treatment only prolongs the patient's life for a few months, but makes those months a miserable experience, is this caring?

Care is different from cure. Care considers the needs of the whole person - cure just treats the disease. From the Christian worldview, it is clearly not wrong to desire cure. For example, Jesus felt compassion for the two blind men he met near Jericho and so he cured them[5]. But we try desperately to find a cure because we don't want to face up to the hard truth that we are mortal. Illness, ageing and death may be kept at bay, but they will never go away. Caring needs to occur whether or not there is a cure.

Dependence or independence?

A person can become too dependent on care and end up being dominated by the carer. This could arise from the person being unwilling to help themselves, or from the carer having a desire to feel needed. Most rehabilitation programmes aim to give maximum independence. However, if a person can't become independent, he or she could end up feeling worthless or a burden.

God created us to be interdependent. For example, God created Eve with the words: 'It is not good for the man to be alone. I will make a helper suitable for him'[6].

The idea of interdependence may make us flinch. We attach so much value to independence that it appears to be an insult to be referred to as a helper or in need of help. When interdependence is working well, caring can be seen as enabling each other to live the fullest possible lives.

Professionalism or self-sacrifice?

For many healthcare professionals caring is part of a professional response. A nursing careplan, for example, itemises a series of interventions that promote the best interests of the patient. Caring is moved out of the sphere of morality and into one of professionalism. To be uncaring is to be unprofessional rather than immoral.

Some argue that professional care is a service that needs to be provided as efficiently and effectively as possible, where one stranger with resources helps another stranger in need. In this case it ceases to be the response of compassion from one human being towards another.

The opening statement of the UKCC Code of Professional Conduct for the Nurse, Midwife and Health Visitor (1984) reflects some of this viewpoint: 'Each registered nurse, midwife and health visitor shall act, at all times, in such a manner as to justify public trust and confidence, to uphold and enhance the good standing and reputation of the profession, to serve the interests of society and above all to safeguard the interests of individual patients and clients.'

Professional bodies become the ultimate reference point for 'right and wrong' behaviour. The ultimate fear is to be disciplined or struck off their register. This gives enormous power and responsibility to the governing bodies as they define what is right and wrong behaviour.

Being caring also becomes restricted to people in the caring professions. However, even they, once home from work, rid them-selves of any obligation to care.

Obviously a desire to be professional is praiseworthy. But as a sole motivation to care it could reduce patients to objects of professional practice, rather than fellow human beings in need. It strips caring of any notion of love.

Jesus set a model of caring that goes further than is demanded by professional requirements. He showed that caring is an expression of self-sacrificial love, deriving from God's character of love.

Quality or quantity?

In a society with many elderly people and life-support technology, the question of quality as well as quantity of life has become an issue of debate. Is it still 'caring' to sustain the life of someone who is in a persistent vegetative state, unable to move, eat, speak or wash themselves or apparently to respond to others? Should we aim to increase the quality or the quantity of a person's life?

One of the problems is measuring quality of life. Various systems have been tried, but they all tend to value people by asking how much they can achieve. A treatment is then measured by how much extra achievement it can allow the person.

From a biblical perspective, quality of life has far more to do with our spiritual lives, God's relationship with us, than it has to do with physical disease or limitations.

The high value of human life comes ultimately from God's decision to have a relationship with us regardless of our capacities. This can transcend physical disease or even severe disability.

Therefore someone's actual or potential relationship with God needs to be taken into account when assessing 'quality of life'.

Giving quality care also means providing appropriate care. It may not be possible to keep a person alive, but it may be appropriate to care for him or her at home or in a hospice, rather than a hospital.

Who should we care for?

This is the big question of resource allocation in the NHS today. Should we use medical or social criteria?

Social criteria have been used in the past. In the early 1960's a committee was set up in Seattle, USA, to make recommendations for kidney dialysis. It looked at aspects like the person's wealth, marital status, psychological stability, Scout leadership and church membership. It became known as the Seattle 'God' Committee, was strongly criticised, and closed down[7]. It's easy to disapprove of the idea of using social criteria, but medical criteria often merge into social criteria. For example, well-educated and affluent patients have the best chances of looking after themselves or their children. There may be no point starting a treatment if the patient is not able to keep up with all of its demands.

Consider this. If you were to enter a healthcare profession, would you be biased towards patients who fit the following criteria?

People:

• who will be restored to being productive in society?
• who are not convicted criminals?
• who are good-looking?
• who are our own relatives or patients under our care?
• who have not brought their illness upon themselves?

In response to a question about whom we should care for, Jesus told the story of the Good Samaritan who took care of a Jewish man who had been beaten up[8]. A modern day equivalent might be a Serb nursing a Bosnian Muslim. Caring should overcome all our prejudices.

Exercise You have two candidates for a kidney transplant. One is homeless and unemployed and has a 95% chance of surviving the operation; the other is a company manager and has an 85% chance of survival. Who should get the kidney?

Care defends the defenceless

The Bible warns that if we ignore God we will tend to ignore the needs of the most vulnerable and defenceless in our society. The prophet Isaiah rebukes Israel: 'Seek justice, encourage the oppressed. Defend the cause of the fatherless, plead the case of the widow'[9].

Who are the 'oppressed' and 'defenceless' in our society? The poor? The homeless? People with disabilities? Unborn babies? People who are frail and elderly? These are the people most likely to be unjustly discriminated against in the distribution of healthcare resources.

Who cares?

In countries with publicly funded health services like the UK it is easy to complain about inadequacies. However, resources are finite, and the demand for healthcare will always exceed them.

How can we meet the biblical demand to care for all? If the example of Jesus' caring is one of self-sacrificial love, are we not placing an enormous burden on the already over-stretched caring professionals and relatives, expecting them to 'go the second mile' when they are close to burnout themselves?

Perhaps the first step is to campaign for more national resources to be used in all aspects of caring, even at the expense of increased taxation.

Secondly, the whole community should provide 'care in the community'. We need to protect aspects of life that build communities and find ways of rebuilding a sense of community in areas of cities, towns and countryside where the drive to supply individual choice and privacy has destroyed it.

Far from being seen as a burden, the sick and vulnerable should be seen as a gift to all of us to learn how to care and to give the unconditional love to others which God gives to us. If we learn to care for them, as we would like to be treated ourselves, we need not want when it is our turn to be dependent.