Journal ofMedical Ethics, 1996; 22: 83-89

Bioethics and caring

Stan van Hooft Deakin University at Toorak, Malvern, Victoria, Australia

AbstractThe author agrees with the critiques of moral theoryoffered by such writers as Bernard Williams andAlasdair MacIntyre, and uses ideas from Heidegger andLevinas to argue that caring is an ontological structureofhuman existence which takes two forms: caring aboutoneself (which he calls our "self-project") and caring-about-others. This dualform of caring is expressed onfour Aristotelian levels ofhuman living which theauthor describes and illustrates with reference to thephenomenon ofpain.

It is concludedfrom this analysis that traditionalnotions of morality as imposing obligations should giveway to an understanding of ethics as the social formsgiven to our caringfor ourselves andfor others. Anumber of implications for ethical theory are sketchedout with the conclusion that virtue theory should bepreferred and that the model could be worked out morefully to show that virtue theory can be internalist,particularist, pluralist, personalist and objectivist.

IntroductionBioethics is often seen as an instance of "quandaryethics"'I of which the purpose is to provide guidelinesfor the making of difficult decisions for which thereare no precedents arising from a pre-technologicalage. It is thought to require deductive thinking inwhich guidelines for a particular action are drawnfrom general principles or rules which tell us what itis obligatory or good for us to do. These principles orrules are said to be imperative, real, and universal andit is the task ofmoral philosophy, as it was of theologyin the past, to tell us what they are. For their part,bioethicists combine knowledge of these obligationswith knowledge of particular fields of endeavour suchas medicine and health care in order to solve thepractical quandaries which these fields throw up.

It follows that the quest for the "Foundationsof Bioethics" would be conceived as a quest for

Key wordsCaring; ethical theory; virtue; pain; human nature;particularism.

knowledge of the universal principles of morality.However, there has been much discussion in thephilosophical community in recent years aboutwhether such a quest could ever succeed.2 A keypoint that has emerged is that theorists should bemore concerned with what moves people to act wellin the way of "internal" motivations rather than withwhat they are obliged to do because of "external"impositions of duty.3 The quest for foundations inbioethics should no longer be the quest for any such"external" set of norms.

I would argue that what we do in situations ofmoral difficulty or practical quandary is an expres-sion of what we care about most deeply. It followsthat a quest for the foundations of bioethics will bean exploration of the ontological being of the agentand, through this ontology, of the deepest levels ofmotivation within the agent.

CaringWhat do I mean by "caring" in my title? Caring canbe thought of as behaviour or as motivation. Asbehaviour the word often refers to looking afterpeople and seeing to their needs, whether in thecontext of the health care professions, social work,teaching, parenting and other familial relationships,and so forth. As motivation the word can refer tobeing fond of someone, feeling sympathy or empathyfor them, being concerned for their well-being, orhaving a professional commitment to seeing to theirneeds. It can be said that the best caring profes-sionals exemplify both of these senses of the word.They are good at seeing to the needs of others andthey are motivated to do so by their caring attitude.4Such a person is described as a caring person.

In contrast to these familiar usages, I propose atechnical notion of "caring" in which that worddesignates a fundamental structure of human livingwhich would be the basis for these caring attitudesand behaviours and also for any sense of obligationthat we might experience as arising from traditionalmoral norms. I will be arguing that there is a basis forethics and hence for bioethics that is more funda-mental than either rules or virtues. After all, the

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84 Bioethics and caring

value of rules and of virtues must be assessable. Arule is a good one of it meets standards of rationalityor leads to approved consequences, and virtues areadmirable if they lead to a good life for the individualand society. These further goods are a yardstickagainst which both rules and virtues must bemeasured.My argument, developed fully in a forthcoming

book,5 is that it is a mistake to appeal to someobjective good to be this yardstick, whether such agood be the will of God, the Moral Law, thepreferences of rational individuals, or the self-fulfil-ment or happiness (eudaimonia) of agents. In orderfor any good or principle to be a yardstick againstwhich both rules and virtues can be measured, wemust care about it.

Deep caringCaring in my sense is developed from the ideas ofAristotle, Karl Jaspers, Emmanuel Levinas, andMartin Heidegger. It does not designate a motivationor a desire ofwhich an agent could normally be aware,but a deep and inchoate quest which does not havedefinable objects. It is the kind of quest that existen-tial phenomenologists like Sartre captured with termslike being-for-itself and being-for-others. But I prefer touse Heidegger's special ontological notion of care.6The phrase I use to distinguish this from the familiarconcept of caring described above is "deep caring".To use technical philosophical language, deep

caring is not intentional. It is not a quest for anythingspecific. But it provides the impetus for all ourconcerns, our objectives, and our desires. Its funda-mental purpose (but not conscious goal) is the for-mation and maintenance of both the integrity of ourselves and also of our relationships with others andthe world around us. I represent deep caring in thissense on the following diagram.Most of the content of this diagram requires

explication which goes beyond the scope of thispaper. It might also be interesting to explore how itdescribes levels of human living which can be dis-tinguished in a number of ways: as to their intellec-tual sophistication, as to the degree and kind of theirpresence to consciousness, as to their being individ-ualistic or communitarian, and so forth. But the firstcrucial point to note is that these levels are levels ofactivity; or even better, levels of engagement with aperson's environment in the richest sense of thatword. The model does not represent "parts of thesoul" in Aristotle's sense, as if it were describingparts of a living entity. What it is describing are levelsof functioning and engagement.

This is the meaning of the top line of the model inwhich the temporality (to use Heidegger's term) ofhuman existence is highlighted. What this means isthat a human being is constantly oriented towardsthe future and acting from out of its past. Thisnotion of the temporality of human living highlights

PAST < - PRESENT 4-I FUTURE

THE BIOLOGICAL LEVEL

A involuntary physical functions(for example, metabolism, instinctual drives, reflexes,etc)We share this level with plants.

THE PERCEPTUAL-REACTIVE LEVELinvoluntary ways of seeing and reacting to thingsaround us - consciousness(for example, learnt responses, emotions, desires,bonds of affection and group membership, etc)We share this level with animals.

THE EVALUATIVE-PROACTIVE LEVELvoluntary, purposive behaviour informed by plansand values and the rational pursuit of needs arisingfrom lower levels(includes most of what we do in our everyday,practical, self-conscious lives)This level is distinctively human.

THE SPIRITUAL LEVELthinking which integrates and gives meaning to allthe levels of our functioning(for example, creativity, play, morality, religion,transcendent or ultimate values)This level is uniquely human.

the dynamic nature of our being. We are constantlyengaged, constantly striving, constantly doing(except when we are asleep and not dreaming). Thephrase "human being" should be read as a verbrather than as a noun. It does not so much designatea biological entity as a mode of engagement with theworld around us.And this mode of engagement can be called deep

caring. The world, the future, and other people allmatter to us in some way. On my model, temporal-ity is the horizontal axis of our deep caring. Insofaras this caring is, by its very nature, an active engage-ment with the world, so our being is outwardlyoriented: a being-for-others.7And this deep caring can be described on the four

levels of the model. Many things in the world matterto us biologically. Our mothers when we are infants,the air we breathe, the food we eat, the sexualpartners with whom we mate are all things thatengage us because of the biological dynamic thatconstitutes our deep caring at this level.

Notice that it is difficult to describe theseexamples, especially the last, in purely biologicalterms. The further levels of our being and of ourcaring are engaged with these matters also. This isthe significance of the arrow on the left of the model.A fully functioning human being does not operate onany one of these four levels by itself. To be a "wholeperson" (if I may use that overworked phrase) is tobe engaged with the world at all four levels and to

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have those four levels interact with each other so asto constitute the meaning and significance of ourliving. I call this vertical cohesion of human being"integrity", and I suggest that integrity in this senseis the inchoate telos of deep caring. Insofar as ourdeep caring is oriented towards this integration ofour lives, I call it a "self-project".

Integrity in my sense is not the achievement ofcontrol on the part of the higher levels of the modelover the lower levels. Aristotle's model of parts of thesoul was hierarchical and allowed him to say that thehigher parts should control the lower. In contrast, mymodel is "holistic". Our breathing is not controlled bythe higher levels of my model and yet is a matter ofdeep caring for us, as is evidenced by the shift in ourpriorities when we experience breathing difficulties.More ethically interesting biological functions such assex only become a matter about which we might askethical questions, such as whether control should beexercised over them, after they have been shaped byall the levels of our being so as to take on ethical sig-nificance. The question of whether a sexual desireshould be controlled is not a question that arises fromthe higher levels so as to be directed to the lower. It isa question about how one's integrity as a being whichfunctions at all four levels should be preserved.To illustrate the model, let us consider pain. Pain

is a biological phenomenon arising from dysfunctionsor lesions in the body. At level one of our being therewill be the cries and grimaces that are the involuntaryexpressions of pain. But pain is experienced and so islived out on the second level of our being. Atthis level there are not only feelings of pain anddistress, but also emotions and reactions which areconstituted socially and interpersonally but which areexperienced as arising pre-consciously. At this levelthere is suffering. The involuntary expressions of mypain will be partially a function of the cultural forma-tion that allows me to express my pain in that way. Inour society, for example, men are less likely toexpress their pain directly than women. Pain behav-iour is a learnt response and this learnt response is theexpression of our deep caring about pain at thesecond level of our being. And, given that we arerelated to others at all levels of our being, anotherexpression of our deep caring at this level will bespontaneous compassion with the pain of others.

At the third level of my model will be those manybehaviours of avoidance and palliation which consti-tute our rational and practical response to pain,whether that pain is actually being experienced ormerely being envisaged as a possibility in our lives.In the case of a particular pain episode, our visit to adoctor or our reaching for the aspirin will be ourliving out our deep caring about pain; our expressionof the fact that pain matters to us. Further, as wemove to the third level of our being, there will beindividual and collective deliberations and plans,ranging from buying more aspirin to setting uphospitals. The rational basis for this collective action

will be the recognition that others too can suffer painand that co-operation is needed to deal adequatelywith it. The social provision of health care is acollective expression of deep caring focused at thethird level of our being.

But most importantly, and most frequentlyneglected, there is the fourth level of our deep caringin which people will seek to integrate biological painepisodes and the sets of reactions and activities thatrespond to them into their conception of themselvesand of their deepest values and relationships. Peoplesuffering pain will seek to understand their sufferingin the context of their lives and beliefs. A religiousperson will see it as the will of God, whether as a testor as punishment. A secular person will see it as badluck or as an opportunity for personal growth, and soon. The number of ways in which pain can be givenmeaning and made into an integral part of the narra-tive of a life are many and varied. We should includethe ways people feel called upon to respond to thepain of others. The fourth level of our being will bethe level at which the whole set of reactions, feelingsand activities relating to pain will be given itsmeaning in ultimate terms.Deep caring is an engagement along both the

horizontal and vertical axes of my model. It is anengagement with the world, with the future and withothers, but, given the vertical axis, it is also anengagement the inchoate purpose or function ofwhich is the constitution of our integrity as wholepersons. Caring is both being-for-others and self-project. I said earlier that caring has no object; it isnot intentional. I am not now suggesting that it is thetrue object of our caring to live out our life over timeand to establish and maintain our integrity in doingso or to relate to others in determinable ways. Ourgoals and purposes are what they are given to us asbeing in our own self-consciousness (even if it maysometimes require difficult and honest reflection todiscover them). But that they matter to us arisesfrom a deeper and pre-conscious mode of our being.The caring which I am seeking to describe is not acaring about this thing or that, or about this personor that. And it is not a caring about ourselves andour integrity. If we care about anything or if we carefor anyone, it is because deep caring is the verynature of our being. These familiar and intentionalforms of caring are expressions of our ontologicalbeing as deep caring. The function of deep caring isto integrate our living and to give it world-relationaland intersubjective meaning.The way in which this function is exercised is for

our deep caring to be given form. The things in theworld, the projects, and the persons that we relate to,as well as the social solidarities and the faiths that wehave, give structure and direction to our deep caring.They are important to us because they are theoccasion for our inchoate caring to become focused.Our intentional concern for these things will then bethe expression of our deep caring.

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Implications for ethicsAnd so it is for ethics. Ethics is an expression of ourdeep caring in the sense that it is a socially con-structed form through which we constitute theintegrity of our being and the quality of our engage-ment with the world and with others. This does notimply egoism. I am not saying that while being seem-ingly concerned for ethical values, one is actuallyonly concerned for one's own integrity or relation-ships. What one is actually, consciously, and authen-tically concerned with is the ethical object of one'scurrent projects. But the force of one's concern, itsengine so to speak, is one's own nature as deep andinchoate caring: one's fundamental and inescapableengagement with self and world.How does this help us understand ethics and, by

implication, bioethics? In a paper that is already tooschematic, I can only give a sketch of an answer byalluding to a number of current debates in ethicaltheory and indicating how my model might berelevant to them.

1. My model can be used to suggest that mostethical theories are reductionist in that they highlightjust one of the levels of human existence rather thanall four. If ethical theory, along with ethical agency,is an expression of our deep caring, and if my modelgives a holistic picture of four levels of that deepcaring, then we would expect that ethical theorywould be an expression of all those four levels in mymodel. However, I would suggest that this is seldomthe case.An extreme example would be sociobiology,

which explains ethics in terms of geneticallygrounded traits. Such a theory is clearly reductionistin that it focuses only on the biological level of ourbeing. But various forms of intuitionism and emo-tivism would be reductionist in a similar way. Thesecond level of our deep caring is where our sociallyformed reactions and pre-conscious intuitions cometo expression. On my model, moral convictions andintuitions which seem self-evident and inescapableto an agent would be seen as only a part of ethicallife. I would place most rationalistic ethical theorieson the third level of our being. Consequentialismrequires us to deliberate about actions in relation totheir outcomes and this activity is an expression ofthe third level of our deep caring. And in mostversions of utilitarianism, happiness seems to me tobe a third level value. It is at the fourth level of ourbeing that we adhere to values in an ultimate com-mitment. For example, a deontologist might adhereto the value of duty in an ultimate way and variousethical theories of a Platonic stamp (includingChristianity) involve a,faith in ultimate values orsources of value.My model would suggest that no ethical theory

could be an adequate expression of our deep caringif it did not relate to all four levels of our being.Moreover, no description of ethical agency (or moralpsychology) could be complete if it did not show

how such agency was an expression of all four levelsof our deep caring.

2. My model gives us the subjective and motiva-tional basis for ethics, and hence for bioethics, whichI have argued we need. In doing so, it supports"internalists" in their debate with "externalists".8Extemalists believe that there is a distinction betweenknowing what is the right thing to do and wanting todo it. Along with a belief, there must be a relevantdesire if an action is to occur. A belief cannot motivateby itself. Hence a beliefabout the world (that a patientis suffering, for example) is not, by itself, a motivationfor acting. One must also have a desire (whether it bebased in compassion, or in a moral principle ofbeneficence, or whatever) to cause one to act.My model departs from this explanatory

paradigm of human action.9 On my model, thehuman subject is not an ontological isolate compris-ing a combination of cognitive input and conativeoutput. By virtue of our ontological being as deepcaring, we realize ourselves by reaching out to theworld and to others. We are primordially intersub-jective and related to our world. The world is alwaysalready meaningful rather than a neutral field avail-able to our scrutiny and evaluation. In this sense Iam an internalist. If the situation is such that I am ina position to help, my belief that another is sufferingis a moral reason for me to act and will be immedi-ately motivational. The suffering of another typicallycalls out to us immediately for a response. (We are,of course, free to reject this call, but at a cost to ourintegrity as self-project and being-for-others.)

3. There is debate as to the nature of moralobligation or "practical necessity". Against thosemoral realists who would give a metaphysical ground-ing to moral obligation, Bernard Williams has saidthat the feeling that we "must" do something "goes allthe way down". '0 My model suggests what this mightmean. Our ontological being as deep caring canexpress itself imperiously when objects with which weare engaged and our integrity are at stake. Moral"oughts" are an expression of deep caring.

4. My model allows us to explain why not allmorally significant actions are matters of obligation.Some actions are good but supererogatory. Suchactions will have been culturally shaped as expressionsof our deep caring as being-for-others but withoutengaging our deep caring as self-project to the sameextent.

5. My model also allows us to explain why someactions are marked by deontological constraint.Actions that we would under no circumstances do -

actions which are unthinkable- are actions whichwill have been culturally shaped as expressions ofour deep caring as self-project but without engagingour deep caring as being-for-others to the sameextent.

6. My model is consistent with ethical theoriessuch as those of Hume and J S Mill that appeal to"natural sympathy" or a "natural motivation to be

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ethical" as basic to morality. "I But there is theimportant difference that deep caring is an inchoateand non-intentional comportment which is con-cerned both with self and with others. It can beexpressed as sympathy in the context of situationsthat call for it, but it might on other occasions beexpressed as anxiety for oneself. And in each case,however, such reactions will be expressions merelyof the second level of our being.

7. My model can throw light on the currentdebate between those who argue for a "differentvoice" in ethics as theorised by Carol Gilliganl2 andthose who argue that Lawrence Kohlberg has fullydescribed moral development along Kantian lines.Gilligan has suggested that, when making ethicaljudgments, girls are more concerned with maintain-ing caring relationships and bonds than with follow-ing general rules. It would be too easy to say thatGilligan's concepts are appropriate for describingthe second level of our being where our bonds andrelationships come to expression, while Kohlberg'sdescribe the third (or perhaps, fourth) level ofrational thought. Both theorists purport to describethe same thing; namely, the growth and develop-ment of our moral thinking. It might also betempting to see my model as a developmental oneand to suggest that the women studied by Gilliganarrested their development at the second level, whileKohlberg's subjects went on to develop levels threeand four. But my model is not developmental orhierarchical. Rather it hypothesises a deep level ofcaring in all human beings which comes to expres-sion at various levels. It is possible that social forma-tion will favour one form of expression over another,and it is likely that such social formation will differbetween people in gender-specific ways. (However,there is no suggestion in my model that deep caringis a feminine quality.) Gilligan is right to havereminded us that expressions of deep caring at thesecond level of our being are as valid as expressionsat other levels. However, it would be reductionist tostress this level to the exclusion of others.

8. My model suggests an account of the purposeof ethics as an expression of our deep caring. Deepcaring is concerned with solidarity with others(especially those with whom one has some bond)and with integrity. Ethical discourse is a way ofseeking to secure this solidarity and integrity in theface of actions, ways of life, or personal characteris-tics which might threaten them. While there aremany theorists (especially in the field of bioethics)who see the purpose of ethical discourse as the for-mation of social policy and law, and while I wouldnot deny that this purpose has importance, I wouldplace the stress on the personal point of view.Engagement with public policy issues is an expres-sion of deep caring chosen as a vocation by some,but, by virtue of their ontological place in a realm ofintersubjectivity, everyone has a stake in articulatingtheir ethical lives in public discourse.

9. To those who argue about whether the basicmotivational structure of human lives is altruistic oregoistic, I suggest that deep caring looks bothoutwards and inwards at the same time. Not beingintentional, deep caring cannot be described aseither altruistic or egoistic. It is an ontological modeof being which is both self-project and being-for-others. This is not to deny that social formationmight favour one orientation over the other. But inthe hidden depths of our being, we are neitherexclusively altruistic, nor exclusively egoistic. In anideally formed human being, integrity and solidaritywill be equally strong motivations.

10. There is a debate as to whether ethicalobligations are "real" from an impersonal point ofview. Realists would argue that impartial thinking or"the view from nowhere" gives us a surer grasp ofwhat is morally required of us than a point of viewwhich takes account of our particular and personalrelationships and properties. I favour the personalpoint ofview.'3 Insofar as it is our integrity and inter-subjective solidarity which lie at the heart of ourconcerns, the scope of our moral obligations willemanate from our being so as to embrace thosewhom we love, for example, with greater urgencythan those we do not. Moreover, insofar as we mightbe committed to ideals of justice at the fourth level ofour being, the call upon us of those who sufferinjustice will be more urgent than of those who suffersimple need.

This does not mean that the call upon us of morallysalient features in a situation are not "objective".They are there to be apprehended by anyone with theeducated sensitivity required to sense them.'4 Theethical formation which we receive in our communi-ties and the ethical discourse of these communitieswill create a set of standards of moral excellencewhich will be objectively present for us in our lives.

11. My model is descriptive of our ontologicalbeing and gives an account of our obligations. Assuch it is not prescriptive. Rather than telling uswhat we should do, my model explains why we havethe moral notions that we do. By showing how allfour levels of our being come to expression in suchnotions, my model explains why ethics matters andwhy morally relevant situations call out to us so as todemand our response.

12. It follows from my model that moral educa-tion would not consist in the explanation of moralprinciples or instruction in moral theory, but inshowing how the deep caring of the moral neo-phytes can be fulfilled in a variety of ways in avariety of situations. As opposed to a teaching thatwould address only the third level of our being,moral education will consist in showing what ismorally salient in a situation. Rather than teachingmedical or nursing students about the principle ofbeneficence so that they will know that they oughtto respond when a patient is in pain, one wouldteach those students what pain is and means so that

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they will respond to it in accordance with all fourlevels of their natures as deep caring. This teachingwill be phenomenological, reflective and anthropo-logical, rather than instruction in moral theory. It isa consequence of my "internalist" position that anyagent who understands a situation as involving painthat she can alleviate, will be moved to do so. If shewere not so moved she would not have understoodthe situation correctly, with regard to its moralsalience. So moral instruction must aim to enablesuch understanding of the situation. 15

13. There is currently a debate about whether wealways apply a single set of moral principles and asingle form of moral judgment in various situations.Those who deny this are "pluralists". Pluralists arguethat we may think deontologically in some situations,consequentially in others, while in others again wemight be more concerned to preserve or developvirtue. Again, some pluralists point to a number ofincommensurable overarching values or principleswhich might guide our lives (and which, on my model,would be operative at the fourth level of our being).My model is pluralist. Rationalism is no more the finalarbiter ofmoral norms than emotivism or intuitionismwould be. My four-level model embraces all of theseapproaches at the various levels but sees them all asexpressions of deep caring as self-project and as being-for-others. As such it provides a theoretical basis forpluralism in that it gives various ethical theories their(limited) place as expressions of deep caring.

Insofar as I argue that moral theory and moralthinking are culturally formed contingent expres-sions of deep caring, the importance and value of ourlives centre on integrity and solidarity rather than onthe ways we might have developed for achievingthese, or the values we might have articulated inorder to express them. There might be a number ofgeneralisable decision procedures, or rules of thumb,or ideals of character for solving ethical dilemmas.But what matters is that each situation calls out to usin its own terms and calls out to all four levels of ourbeing. What being ethical calls for is that one acts soas to constitute and preserve one's being as self-project and as being-for-others.

14. In relation to the debate between "general-ists" and "particularists", I would acknowledge theimportance of the latter.'6 A generalist holds that amoral judgment or decision takes the form of adeduction from general principles or rules, while aparticularist stresses the sensitive attention that amoral agent should give to the morally salientfeatures of the situation. These approaches need notbe mutually exclusive, but there is an issue indescriptive moral psychology as to which takespriority. Given my conception of human being asinvolving a primordial orientation towards othersand towards oneself, caring attention to the situationwill be a framework in which any judgment ordecision takes place.A moral agent may use moral principles to

articulate her motivational stance in any given situa-tion and she may even express her thinking during orafter the decision by way of a practical syllogism, butthese will be forms given to her pre-conscious deepcaring. Such forms are learnt in a given culture. Inour post-enlightenment culture, most of us learn toexpress our deep caring in response to morallyrelevant features of a situation by thinking ofprinciples, rules or virtues. In another culture agentsmight respond in terms of what they take to be thewill of the gods. And even understanding what ismorally relevant in a situation will be a culturallylearnt response operating at the second level of ourbeing. What is regarded as a routine matter in oneculture, might be a matter that calls for moraldeliberation in another. The more individualistic aculture is, the greater the scope for asking whatought to be done.

Generalist ways of thinking are appropriate at thethird level of our deep caring, while particularist waysof reacting are expressive of the second level. A fullethical theory will embrace both approaches.However, ethics is important in particular situationsrather than as a matter of theoretical discourse. Whatwe care about deeply is our integrity and our belong-ing. These are particular. Our concern with generalethical norms is derivative from this particularity.

15. In the debates between "virtue ethics" and"rule-based ethics". I would side with the propo-nents of virtue. If the choice here is between con-sidering what a moral agent should be rather thanwhat he should do, then my model focuses on thefirst. The fundamental moral motivation is the twinmotivation of preserving relationships and integrity.This is an orientation to what we should be. Whatwe should do becomes a derivative question thatgains its urgency from this deep caring.

Indeed, I would suggest that virtue-based ethicaltheory might be the only adequate way of holisticallyembracing all four levels of our deep caring. The keyidea of virtue theory is that something deep withinan agent comes to expression in moral action. Whatthis something deep is will be described on mymodel as involving all four levels of our being. Withthis model virtue theory can be internalist, particu-larist, pluralist, personalist, and objectivist.The rule-based ethicist says that we must make

our ethical decisions on the basis of reasons. And ifthese reasons are to sway us, or to explain andjustify our actions to others, then they must begeneral. That is, they must be understandable byother people in terms of how they apply to such sit-uations in general, and agents must understandthem and be prepared to apply them in othersimilar situations. On the other hand, virtue ethicsis "particularist". What a virtuous person is able todo is to attend to all the morally relevant features ofa particular situation and respond to them appro-priately. She may not be able to say why she actedas she did and she may not be able to say ahead of

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time how she would act in a situation like the one atissue. Nor would she be able to say that she wouldact that way again in a similar situation (given thatthere can be morally salient differences in similarsituations).

This point can be brought out with an analogy.Tom loves Mary. Jim asks Tom, why do you loveMary? Tom is unable to answer clearly, but whenpressed he says that Mary has a sweet dispositionand lovely hair and a cute smile. Jim now says thatJill has a sweet disposition and lovely hair and acute smile too. Why doesn't Tom love her as well,or instead? If love were based on reasons, this pointwould confound Tom because reasons are generaland what applies to one case should apply to otherswhich are similar. But love is not like that. It is par-ticularist. Something deep in Tom is attracted toMary and reasons are only a superficial gloss onthis. My point is that moral decisions are particu-larist in just this way. Something deep in the agentresponds to what is morally relevant in the situation(the pain of the patient, or their loss of hope, say).The agent might be able to give no clear reason forher decision and offer no clear principle that she isfollowing or would follow in similar circumstances.All that can be said is that this "something deep"motivates the agent to do what she sees is best. Thisis her virtue.

But is such a non-generalisable account of anyuse to us? This depends on what we think ethicaltheory is for. If it is to give us guidance as to what weshould, in general, do, then such a notion of virtueis useless. Because it does not trade on generalreasons, it cannot offer guidelines or even rules ofthumb. If these are what we want, then an ethics ofduty is what we need. But if ethical theory is forgiving us a description of moral psychology (andthis is of practical importance for understandingmoral education), then it should accept the particu-larist nature of moral decisions. The discourse ofbioethics may contribute a general form to theinchoate desire to create and preserve relationshipsand integrity, but there is no ultimate guidance andno safety offered by the pronouncements of profes-sional ethicists.

AcknowledgementAn earlier version of this paper was read at a sessionentitled "Foundations of Bioethics" at the secondIntemational Congress of the International Associ-ation for Bioethics in October 1994, in Buenos Aires,Argentina. I am grateful to the editor ofJME and tosome anonymous reviewers for helpful comments.

Stan van Hooft, MA, PhD, DipEd, is Lecturer inPhilosophy, Faculty ofArts and School ofNursing, DeakinUniversity at Toorak, Malvern, Victoria, Australia.

References and notes1 Pincoffs E L. Quianidaries enid vlirtues. Lawrence,

Kansas: University Press of Kansas, 1986.2 The most notable examples of this trend are Williams B,

Ethics anid the limnits of philosophyN, London: WilliamCollins, 1985, and Maclntyre A, After virtuie: a stludx' illmiioral theory, London: Duckworth, 1981. For a morerecent discussion of more limited scope in which impar-tial reason is criticised as a basis for ethical judgment, seeMacLean A, The elin;iiinationi of miiorality: reflectionis o11 uitil-itarianisnm anid bioethics, London and New York:Routledge, 1993.

3 Even recent discussions of 'virtue ethics' can fail to notethis distinction. The demand to be virtuous is oftenseen as just another external demand rather than onethat arises from the motivational structure of the agent.(For example, see Louden R B, On some vices of virtueethics and Beauchamp T L, What's so special about thevirtues?, both in Haber J G, ed, Doing anid being: selectedreadinigs in miioral philosophy, New York: MacmillanPublishing Company, 1993.

4 I discuss this further in my Caring and professionalcommitment, The Auistralianljourn1ial ofadvaniced niursin1g,1987; 4, 4: 29-38.

5 Van Hooft S. Caring: an essay i)l the philosophl of ethics.Niwot, Colorado: University Press of Colorado, 1995.

6 Heidegger M. Beinlg anid time [trans by Macquarie J,Robinson E]. Oxford: Basil Blackwell, 1973: sections64 and 65.

7 I am not using this phrase in the somewhat defensiveand solipsistic way that Sartre uses it in his analysis of'The Look' in his Beinig anid niothingniess [trans byBarnes H], New York: Washington Square Press,1966: 340 ff.

8 For a thorough exposition of this debate see Dancv J,Moral reasons, Oxford: Blackwell, 1993.

9 The paradigm that both beliefs and desires are neededto explain actions was articulated by Donald Davidsonin recent times in his Essays oni actionis anzd evenits,Oxford: Oxford University Press, 1980, but is at least asold as Hume.

10 See reference (2): Williams B: 188.11 Mill J S. Utilitarianism. In: Ryan A, ed. Jtohn Stuiart MWill

anid Jereimy Benitham;i, uitilitarianiism;i anid other essays.London: Penguin Books, 1987: 303.

12 Gilligan C. Ini a di/jerent voice: p.schological theory amidzuonlen s developm;ienit. Cambridge, Mass: HarvardUniversity Press, 1982.

13 For an interesting discussion of these issues see Blum LA. Vocation, friendship, and community: limitations ofthe personal-impersonal framework in his Moral percep-tioli and particlularity. Cambridge: Cambridge UniversityPress, 1994: 98-123.

14 The nature of this objectivity is explored by Julius Kovesiin his Moral minoiouis, London: Routledge & Kegan Paul,1967. Following Wittgenstein, Kovesi develops the ideathat moral notions are objective although tied to thepractices of particular language communities.

15 I have developed these ideas, without the aid ofmy model, in my Moral education for nursingdecisions, Jounrmal of advanced nuiir.sing 1990; 15: 210-5.

16 For an introduction to the particularist position, seereference (1 3): Blum L A, Iris Murdoch and thedomain of the moral: 12-29.

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