Interdependent Citizens: The Ethics of Care in Pandemic Recovery.

The crisis of Covid-19 has forced us to notice two things: our human interdependence and American society's tolerance for what Nancy Krieger has called "inequalities embodied in health inequities," reflected in data on Covid-19 mortality and geographies. Care is integral to our recovery from this catastrophe and to the development of sustainable public health policies and practices that promote societal resilience and reduce the vulnerabilities of our citizens. Drawing on the insights of Joan Tronto and Eva Feder Kittay, we argue that the ethics of care offers a critical alternative to utilitarian and deontological approaches and provides a street-ready framework for integration into public health deliberations to anchor public policy and investments concerning the recovery and future well-being of America's citizens and society.

Brief reflections on lessons and questions posed by Covid‐19 for health, medicine, and bioethics

Pandemic confirms that we live in a nonideal world. Widespread and increasing need, insufficient and unevenly allocated critical resources, and mounting psychological strain all make us ever less like the rational, reasonable, and autonomous actors presupposed by most models of justice. As we imagine the long, uncertain recovery from catastrophe, we are faced with the reality of human dependency together with social inequity. We need a set of theoretical tools that takes this starting point as given.

Feminist care ethics provides these tools by connecting our intimate interpersonal obligations to our societal obligations. It challenges the temptation to treat our current predicament as exceptional: care ethics understands interdependence as a necessary aspect of the human condition and recognizes inequity as structural. The crisis of Covid‐19 has forced us to notice two things: our human interdependence and American society's tolerance for “inequalities embodied in health inequities,” reflected in data on Covid‐19 mortality and geographies. Care is integral to our recovery from this catastrophe and to the development of sustainable public health policies and practices that promote societal resilience and reduce the vulnerabilities of our citizens. By citizens, we mean all people who make up a society, recognizing that some members of society face barriers to political citizenship.

Joan Tronto and Eva Feder Kittay are two contemporary American philosophers whose ethics of care speak to the demands of this moment and the challenges of our collective future. Tronto is a political theorist, Kittay a moral philosopher, but both argue for the compatibility of care ethics and justice theory. Even a brief scan of their key insights suggests how the ethics of care offers a critical alternative to utilitarian and deontological approaches and provides a street‐ready framework for integration into public health deliberations to anchor public policy and investments concerning the recovery and future well‐being of America's citizens and society. For Tronto, care includes “everything that we do to maintain, continue, and repair our ‘world’ so that we can live in it as well as possible.” Crucial to Tronto's definition is that care is action; neither general endorsement (“caring about”) nor a caring disposition (“caring for”) constitutes care itself. Also crucial is the political context of care; for Tronto, care is “the work of citizens.” Care is the practical expression of the interdependence of citizens of a democracy. It is the work we do for each other and on behalf of our “world,” which may be a home, a family, a neighborhood, a city, a nation, a habitat, or the planet.

Care work occupies a precarious spot in our moral imagination and social policy. During the acute phase of the Covid‐19 public health catastrophe in the United States, care work had a heroic moment as we justly expressed gratitude and admiration for frontline workers. Yet care work is typically low‐status work: “dirty work,” women's work, immigrants’ work, families’ work. The marginal status of care work and of the carer is mirrored in the status of the populations perceived as being in need of care: older adults, people with chronic illness or disabilities, children.

We celebrate Covid‐19 carers as “heroes,” but we failed to care for them in advance of the catastrophe through adequate pandemic preparedness and early response. We identify populations as “vulnerable” or “at risk” concerning Covid‐19, but we failed to care for them in advance; instead, we entrenched social inequalities that make the lives of fellow citizens harder. Going forward, how should we take responsibility for the work that maintains, continues, and sustains the world, rather than turfing this work to “heroic” individuals with high social status and “invisible” (rather, visible but overlooked) populations with low social status? This is a question that policy‐makers responsible for pandemic recovery strategies should respond to concretely through attention to supporting the ability of fellow citizens in the care workforce to live as well as possible. Public health policy grounded in an ethic of care should encompass wages, working conditions, housing affordability and accessibility, food security, transportation, education, childcare, environmental protections, and protections for immigrants, in addition to health and health care.

For Kittay, the action—the “labor”—of care concerns the body of another, and the ethics of care “begins with embodied selves who are regarded as inextricably connected to other embodied selves.” Care work centers on the embodied individual and the conditions for the well‐being of this individual. For this person to flourish, her “genuine needs”—the things without which she would be harmed—must be met, and she must have access to ways to satisfy her “legitimate wants,” the things that “make it worthwhile for a person to get up every morning.” The act of care is “concerned with that person's welfare as it contributes to that individual's flourishing.” All people have genuine needs and legitimate wants, and all humans have periods of greater or lesser dependence on others; some individuals are totally dependent on others.

Kittay points out that all moral theories aim to prevent harm. Therefore, the ethics of care must safeguard the cared‐for person from neglect and the carer from exploitation; a decent and just society must not abandon either of these fellow citizens. Kittay's focus on embodiment echoes the language used by social epidemiologist Nancy Krieger, who frames injustice “embodied” as harm. In responding to and recovering from the Covid‐19 pandemic, we must face how our tolerance for inequality has harmed our fellow citizens: those institutionalized in long‐term care facilities, prisons, and detention centers; those members of poor and working‐class communities, especially communities of color, at disproportionate risk of chronic conditions; and those who are aging or immunocompromised. In Krieger's words, “Right now, people through their bodies are showing what the problems are in our society.”

The first phase of the Covid‐19 public health and economic catastrophe in the United States has relied on the metaphor of war and imprisonment to describe and shape experience: the frontline, the surge, battle fatigue, lockdown. As the catastrophe becomes less acute and more chronic, we may grow impatient with the “vulnerable” and the “at risk,” with those of us who are older, sicker, poorer, more disabled, more dependent, less “resilient.” We may be tempted to push care problems back to families; to avert our gaze from the problems of long‐term care facilities; to accept the exploitation of low‐wage, often immigrant workers as part of how our economy works; to avoid the responsibility of repairing a broken society.

We must resist these temptations. Favoring the mundane over the heroic, care ethics encourages us to see ourselves as part of networks of need and dependence and to imagine ourselves as interdependent citizens. Putting feminist conceptions of justice as care at the center of Covid‐19 recovery may help us to recognize that we all deserve to live in a decent and just society that cares about us, cares for us through its priorities and investments, and supports our ability to care for each other.