By Michael B. Friedman

There is much to like about Arthur Kleinman’s brilliant work, but what I have always liked the most is his insistence on exploring the moral dimension of medicine and other helping professions. So, both as a social worker and as a family caregiver, I was enticed by the title of his recent lecture at Columbia University’s School of Social work, “Caregiving as Moral Experience.”

Kleinman told his Columbia audience that he had come to see caregiving as central to human morality in part because of his experience of caring for his wife when, suffering from early onset Alzheimer’s disease, she became increasingly disabled and ultimately died.

Caregiving, Kleinman said, “is an existential act that defines our humanity…, a basic response to the…human condition, … a basic aspect of … ethical aspiration, and … a truly worthy object of ethical commitment.”

“In practice”, he added, “[caregiving is] not a “burden” but a “way of being.”

Caregiving may be a way of being, but as I listened to Kleinman, I couldn’t quite give up the idea that it also becomes a draining burden on almost everyone who does it. Mary Mittleman’s studies, for example, show significantly elevated risks of mental and physical disorders and of burn-out among caregivers of severely disabled loved ones. Caregiving is tough, and many people provide care not because of profound affection, which appears to have been the case for Dr. Kleinman, but more because of a sense of obligation.

Can Kleinman’s philosophically profound and important observations help with the painful moral quandaries many of us who are or have been family caregivers experience about the extent of our caregiving obligations? And don’t the obligations of caregiving also warrant exploration?

In addition to seeing caregiving as central to moral experience generally, Dr. Kleinman identifies it as the fundamental moral component of the helping professions. He finds it troubling that the medical profession, for example, has become so focused on technical skills that it tends to neglect the importance of caregiving in the relationship between doctor and patient.

We social workers, too, should consider this question. Is the current emphasis on scientific, evidence-based practice driving us away from our moral roots? Does the current effort to “reform” the health care system to increase access to care, improve quality, and contain costs actually interfere with our ability to care about our patients/clients as human beings, to appreciate their lived experience, and to be “present” for them during times of terrible distress?

I think that reform is essential and, in any case, many of the old ways are being displaced by newer, more efficient and effective ways of serving people. But I also think that Dr. Kleinman is right to point to what may be lost in this era of transformation.

A final thought. I very much appreciate the respect that Dr. Kleinman has for social workers. It is, frankly, rare among physicians. And I like it that he sees social workers as having key roles in a health system that might be built more on caregiving than on technology.

But the social work roles he noted in his lecture are limited—“navigators of health care systems, integrators of multi-discipline team care, and advocates and supporters of family caregivers.” These are roles that leaders in the social work community have been stressing as the future of social work for a very long time, and they are indeed important roles. But they are neither roles at the highest level in health care systems nor the roles that many clinical social workers seek to play ultimately. Doctors can be doctors, as we know, but it’s tough to have a viable career as a social worker just providing direct service.

Dr. Kleinman has presented us social workers with very significant challenges—to explore the moral dimensions of our work and to develop a viable vision of a profession that will be at the forefront of health care reform without losing our moral core. I hope we are up to the task.

Michael B. Friedman has worked in the field of mental health for over forty years as a direct service provider, an administrator, a government official and as an educator. He is an adjunct associate professor at Columbia University’s School of Social Work and Mailman School of Public Health.

Photo credit: Sights and Scents at the Cloisters: for people with dementia and their care partners, by K. Kendall via Flickr (CC BY 2.0).

Related link:

Aging Well Is Not an Oxymoron, Says Professor Friedman

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