Might constraint be compatible with care? Home care as a situational ethics
Abstract
Respecting the autonomy and will of people has legitimately led to strictly control the use of constraint in care activities, and promote a care ethics centred around people's needs and wills. But constraint is underlying in any action aiming at making people do something, even with their consent, especially when their ability to evaluate what is best for them may be altered. Ceaselessly present in care, this ordinary, silent constraint should not be only deemed as a necessary evil to be prevented. In contrast with this legally-based view, the paper adopts a pragmatic perspective. Leaning on minute case studies carried out at disable people's homes, the empirical section takes up some key troubling moments between caregivers and patients as trials capable of revealing ‘constraint in practice’: a situation of uncertainty, doubt, hesitations on the appraisal of what is happening and how to deal with it, banning any clear-cut distinction between technical gestures and moral values. Having outlined the characters of such a ‘situational ethics’, the authors argue in conclusion that, provided caregivers are never quits with its use, constraint is compatible with care, and assume that care theories could fruitfully support this advocacy to ‘maintaining the trouble’ in care practices.
Introduction: is constraint acceptable in aid and care?
The answer to this general question seems relatively simple. Especially in the Western context of valuing autonomy, constraint – minimally understood as exerting pressure on others to make them act, to act in their place, or to prevent them from acting, without their consent – should not have its place in the aid relationship, except in exceptional circumstances and on specified terms, defined and regulated by law. This principle has been constantly reaffirmed internationally since the end of the twentieth century. For instance, the United Nations Convention on the Rights of Persons with Disabilities stipulates as the first general principle that ‘individual autonomy including the freedom to make one's own choices, and independence of persons’ must be respected (United Nations 2006).
In contrast, our inquiry consisted in observing how, confronted to difficult problems, caregivers themselves, beside other actors, use such open, even lose definitions of those notions, depending on the situations. In return, they contribute to forging their meaning after their effects. To the same extent as consent is not that easy to ensure, constraint is not a ‘yes or no’ action (Lovell 1996).1 We deliberately tried to put ourselves in the same position as caregivers who enter a patient's home: a situation of uncertainty, doubt, hesitations on the appraisal of what is happening and how to deal with it. Leaning on the observation of situations of care-giving at home, we paid special attention to moments of tension, when it is hard to get things done. We had access to a rich empirical material. Beside interviews, it includes both our descriptions of situations observed, and self-descriptions by the carers: to formulate this situation, they need to continuously mix a spontaneous, specific vocabulary – words that come to their mouth to describe what the problem is – and a more elaborated, institutional one, emanating from former debates, meetings and guides to good practice.
Indeed, it is now common-sense to acknowledge that people define the situations they are living in. But there is something more in the case of homecare. First, because such a theoretical stance, that may sound as soliciting the question or be but an abstract, ethnomethodological postulate, is in fact caregivers’ most concrete, continuous and necessary occupation: they constantly have to define the situation, because every gesture, every decision is urgent and may have painful consequences, challenging any clear and binary definition of constraint, as much as of the person's consent. Care consists in an uninterrupted series of problem-solving on the spot. Secondly, because most of those problems immediately contain moral, human, ethical components. ‘Does it hurt? Have I the right to do this? What does she really want?’ Moreover, both to us and to caregivers, it seems impossible in those situations to make any clear-cut difference between what would belong to a domain of facts, gestures, techniques, which would be easy to describe ‘from outside’, and what would belong to another domain, made of principles, values, rules and norms, which would be only reachable ‘from inside’ the carers’ heads, through interviews.
This is the two-fold argument of our paper: to first minutely describe the practical ethics that, in constraining situations, emerge from the activity itself; and then to show that such a ‘situational ethics’ is radically irreducible to predetermined principles or given norms, even if, depending on the situation, they may serve as support points. Principles do not govern action: action makes them relevant or not.
Consent versus constraint?
Let us first detail how much constraint has inspired public policies and the debates and controversies associated with them. Legal and regulatory texts stress the exceptionality of constraining practices. Coercion in aid and care, recognised as sometimes being unavoidable in specific situations, should remain limited to what is strictly necessary. Guidelines aim at avoiding abuse. Procedures and protocols are in place to identify and regulate constraint practices to ensure that they are justified and meet the requirements of traceability (O'Brien and Golding 2003). Constraint is denounced in reports from parliamentary investigations, when it is associated with instances of abuse, be they physical, psychological, sexual or financial (Hugonot 2007, Juilhard and Blanc 2003, Molinier 1999, 2009, Moulias 2008). However, boundaries between unavoidable and avoidable are questionable and difficult to enshrine in the legislation.2
There are other texts than the legal ones which, more positively, recommend or prescribe appropriate gestures for care under constraint. For instance, the use of restraint is regulated by caregivers themselves as they seek to define the legitimacy and limits of its use (Moreau 2011, 2016). Professional writings seek to positively prevent abuse by defining ‘best-practice’ for good treatment and promoting a professional culture based on attention to the needs and demands of the people, respect for their rights and choices, their autonomy and freedom. According to the ANESM (n.d.),3 ‘positive treatment is both positive approach and memory of the risk [of abuse]’. This positive approach to professional practices is strongly marked by the prospect of autonomy, legally defined as the capacity to decide and act for oneself. In the recommendations and best-practice guidelines, the issue of constraint then becomes very marginal. When it is mentioned, it is recalled that in case of conflict between security and freedom, ‘freedom remains the rule and restriction of liberty the exception’ (ANESM n.d.). The French law that recently introduced the license for psychiatric carers to use constraint specifies ‘only in last resort’ (16 January 2016), thus reaffirming that constraint cannot be considered a therapeutic care.
Cases of ‘ordinary’ maltreatment, that which occurs but is veiled in daily life, are also tackled (Compagnon and Ghadi 2009). Violence of this nature, that is, indirect, was the target of disability studies, for whom the maladjustment of society is a form of domination by the able-bodied against the disabled (Crow 1996, Morris 2001, Shakespeare 2002). Theories of care are clearly in line with this view, even if the objective of autonomy does not figure as centrally: assuming that whatever they are, people are vulnerable and interdependent, the care theories defend a relational conception of the ‘self’, who depends upon others. Under these conditions, care practices do not so much aspire to restore autonomy as to improve the quality of these attachments, redefining subjects and objects by their relationships (Hennion 2010, 2015): the quality of the link cannot be updated through the application of general rules or principles of justice, which risk leading to the imposition of social and legal norms; it is performed in situ, in the attention to the unique needs of others, dialogic arrangements permitting them not to be experienced as constraints among others (Gilligan 1982, Molinier et al. 2009).
Tronto (1993) was especially committed to giving substance to a counselling focused on the identification and treatment of the needs of others, as she did in her identification of the four constituent phases of care practices: care about, taking care, caregiving and care receiving. Tronto moved away from care's mostly feminine character to emphasise the general aim of an ethics of care and attention, an articulation of autonomy and dependence, questions of justice, unequal distribution of care, and therefore the need to assume choices and conflicts – all of which are eminently political issues. French authors such as Paperman and Laugier (2011) identified better with Tronto's book. Garrau and Le Goff (2012) led to a two-fold appeal: first, the need to make inquiries – care is an activity that is inseparable from its principles, and can be observed only in particular situations – and, second, that they should be done through public debate on the common values it implies. Similarly, Kittay (2011) wondered how to take these needs into account when recipients of care are very vulnerable and dependent, so as not to act without their consent and not to constrain. By introducing the theory of capabilities into care, Nussbaum (2000) seeks to promote a ‘more just world’ based less on formal equality of opportunity than on supporting the poor and/or disabled person's capacity for action. How just this struggle to provide these people with specific means to choose their own life projects is, constraints are once again considered in a uniquely negative light, like a weight to be alleviated.
Back to real situations: care in practice
Prima facie, the legal status of constraint in the aid and care relationship was very clear: its use is either authorised and regulated in certain circumstances, or unlawful in all other situations, where it must be eradicated. However, as we have learnt from care theories and will observe more significantly even in care practices, the use of constraint cannot be analysed in as binary a way, with legitimate constraint and other illegitimate constraint. As Molinier noted (2013: 11), ‘care in practice is nothing like the theory’. It is indeed a ‘hot bed of conflict, tension, tugging, and of ambivalence […] a domain from which we cannot completely remove the dirty work’. It is not enough to identify needs and respond to them. People's consent is not always accessible, far from it (Eyraud and Vidal-Naquet 2008), so that it is never certain whether constraint can truly be avoided. According to some recent work carried out in health facilities, not only is constraint not ruled out, but it is an integral part of care professionals’ activities. In a survey of a long-term care unit, Lechevalier Hurard (2013, 2016) shows that a constraint that is neither therapeutic nor abusive forms part of the daily care of the elderly. What she refers to as ‘constraint work’ remains in the shadows because it does not fit into the scheme of well-treatment or care. If made too visible, it would even tend to disqualify professional practice.
Hence the purpose of our inquiry: is it possible to empirically observe these delicate decisions, obviously full with moral concerns and implications, without seeing them either as the mere obedience to rules or norms, or the result of piecemeal opportunism and sensitivity to context, which would be guided by nothing or is devoid of any moral requirement? Those constraint situations are a diffuse presence, not a well-differentiated act whose qualification is self-evident: how then, without making use of general principles, may one describe and exploit the wealth and moral density of singular experiences? To sustain the refusal of an abstract ethics – a founding gesture of care theory – some authors have spoken of ‘practical ethics’ (Damamme and Paperman 2010), arrangements (Eideliman 2009), or tinkering (Mol et al. 2010, who call for a detailed examination of ‘care in practice’): in our way, we also aim at rephrasing this difficult relationship between principles, standards and their translation into practical application.
Trials and debates: a methodology for investigating uncertain and involving situations
To investigate this, we observed the professional practices in the homes of people with disabilities and/or suffering from mental and cognitive disorders, attended by care, home-help and health services at seven sites with various social and urban characteristics. To be consistent with our approach, we managed to get access to patients by the same routes the services had followed. Each director selected cases, presented them to us, described why they found some of them more interesting than others: this was plainly a part of our work. Reciprocally, we organised meetings at each service to present our research to the assembled personnel, who commented and qualified the cases. It included considerations for our safety, for instance, or questions of timeliness, or confidentiality. We let this iterative protocol progressively determine which persons we would ask for a visit to their place with a manager or a professional, then, if agreed, for accepting our investigation and giving access to their files. Twenty case stories have been produced, produced according to the ethnographic method and deontological rules that we have specified in detail in our reports (Hennion et al. 2009, Hennion and Vidal-Naquet 2012). Finally, we repeated the process at the end of the inquiry: we presented drafts of the case stories at meetings with the personnel who passionately discussed them and, when possible, to the persons we had visited. All reactions were included in the final reports, and all cases have been fully anonymised.
To adjust the great importance granted to the details, those stories are lengthy: by case stories, we do not mean stylised cases refined to extract a clear lesson, but in recognition of the irreducibility of situations, cases that experience by experience, follow the deployment of a course of things that are always partly unexpected, borne of circumstantial events, taken by attachments that reveal themselves only when mobilised without ever being determined. The text length needed to do so being contradictory with the format of an article, we selected extracts enlightening the hypothesis of a situational ethics. While referring to six other examples from our inquiries, we rely here on two main and contrasting cases: Clint, a quadriplegic ‘expert’ in his own disability, knowing precisely what caregivers should do to support him in his life plan; and Mr Coq, a person with impaired mental capacity whose will, on the contrary, to make decisions is weak and life project seems indefinable.
Each time, key moments have been identified that for all or only part of the interactors, are lived as being trials, or challenging tests: unexpected refusals, violent reactions, inability to perform any act, disagreement over the attitude of a professional, manifestations of mood, feelings of discomfort over the course of affairs, etc. The concept of a trial highlights these tense moments of uncertainty, forcing things to be said (Boltanski and Thévenot 2006, Callon et al. 2009): in these instances, the best way to proceed is not sufficiently informed by routine and by standards; the exact content of what will cause problems is not given a priori nor the resources made available to address them and find solutions. However, action cannot be suspended, inaction is itself action. As moments that force a reaction, trials are an opportunity to describe things, to revisit past events, without having a definitive explanation; choices are expressed, ways of doing things discussed. Trials interest us from an empirical point of view because they show the issues or invisible constraints when everything is going well.
But trials involve the actors, including researchers, also from another angle, though less often addressed: it is a moment we experience, and a demanding one, especially when the restrictive nature of the acts carried out appears. The discomfort engages feelings, physical reactions. The body speaks as much if not more than reason. The actors find themselves in a quandary and their personal ethics are mobilised. Thus, they too are going through an ordeal, facing difficulties relating to sensitive issues; but also because it is a test that indeed they experience: it elicits sentiments about what must be done, and it causes feelings, emotions, disorders. It affects both morality and morale (Hennequin 2012, Peroni and Roux 2006, Ravon and Vidal-Naquet 2016).
From empirical cases, we will think of constraint as ‘constraint in practice’, indeterminate in its nature, uncertain in its effects, diffuse in its application. But because nothing follows the general rules and what happens continuously rouses the unexpected, the narrative that we have tried to produce results by no means in confessing a failure to say anything about it. They do not imply renunciation of the analysis in favour of a plea for the case-by-case or a well-deserved tribute to the know-how of people. By following step by step the events driving change in a situation, we are aiming for the opposite assumption: that of a situational ethics that the course of action itself expresses. To put it bluntly, ‘ethics are already in it’. The actors are moral actors, even if they do not obey principles that can be expressed in a detached manner, general or absolute, or just clear enough. There are no grounds to deny their ethical concerns (by analyses that reduce their behaviour to social determinants), nor to tear it from the course of action and confuse it with an examination of conscience in a confessional. Our methodological and theoretical aim is to seek the modalities of an account that is compatible with the active presence of immanent ethical situations.
In conclusion, far from doing away with the ethical and political burden that question of constraint bears, we will support the proposition that, on the contrary, it is embodied in the very acceptance of this uncertainty, in the concern for the consequences of acts for which it is impossible to assuredly judge the exact extent: it is the maintenance of trouble surrounding care itself which most respects its at once realistic and normative aims (Dourlens and Vidal-Naquet 2016).
At home with caregivers: how ‘care in practice’ deals with constraint?
Clint: when the aided is over-helpful
The Health Service Centre professionals (HSC) would do well to make of Clint an activist or model: ‘The service learned a lot from the treatment [of Clint], we realised we were at fault on a lot of things’ (caregiver). It is indeed not difficult to make an emblem of Clint, despite his reservations about it: ‘I do not want to be the standard bearer for the disabled’, he said. Quadriplegic for nine years after the motorcycle accident he had when he was 26 years-old, he is a young and determined disabled person. The attention he requires from the caregivers for every slight detail strikes everyone. Very meticulous, he knows what he wants. A painful event that he resented helped him know what he wanted to avoid at all costs. He is very sensitive to bedsores because he does not feel the warning signs. Two nurses pressed for time, and hey presto, four years ago he found himself in hospital for six months. Every cloud has a silver lining: he learns a lot from the rehabilitation service which he finds ‘over-skilled and hyper-professional’; it includes the issue of ‘extreme surveillance’. At home, he endeavours, like an occupational counsellor, to tell caregivers how he wishes care to be administered. He permanently pays attention to everything they do and intervenes at the slightest deviation: the crease in the trousers, the condom catheter not quite rightly positioned, dirty water emptied in the sink and not in the toilet. He checks that rashes he cannot see have been detected. All this, he manages to pass on to the aides sensitively. ‘Clint is also well aware of how to send us messages, about why something is needed. It's true that he did not submit this to us in the form of an order. In the end, it is clever, because somehow, he led us to do that, making us understand that all these details are for his wellbeing’ (carer). Constraint seems irrelevant, since it is Clint who directs the operations, who knows exactly what he needs and has devised various ‘tricks’, not only to no longer be hassled during the day, but also to avoid any incident that could be punishable by six months in hospital.
Clint has set the standard in the service: he is autonomous despite his dependency. If his executive capacities are reduced, his decision-making abilities are certainly intact. He directs operations expertly. While some caregivers, especially those who do not deal with him, are afraid of being ‘instrumentalised’, overall the collaboration here is deemed exemplary by professionals. But we will see that even in his case it would be too easy to jump to the conclusion that constraint is absent: through his activism, Clint has rather redistributed it between care partners in his favour; this balance which constrains them, must be accepted by the caregivers and the slightest hitch can make it tumble down again.
Nevertheless, back at the office, the discussions focus mostly on interventions ‘that go wrong’, those that give rise to tensions, and conflicts that may lead to the rupture of the relationship. In such cases, patients – and sometimes their loved ones – are challenging caregivers’ ways of doing things. The fact that these people were applicants for aid does not guarantee that thereafter, day after day, they will allow themselves to be cared for or that they will not adopt behaviour that makes the activity of caregivers impossible. Caregivers strive to fulfil their mission despite everything, not to throw in the towel at the slightest refusal. They do use constraint, feeling at the same time uneasy with what they have done. They then consider that ‘the visit goes wrong’, that the aid-relationship is a bad one, that they have ‘failed’ the test. They look for reasons; they talk in the office. They explore other ways to do things to avoid every visit turning into a power struggle.
Do not give up when ‘things go wrong’
Mrs Morel's being taken into care is recent. Returning home after hospitalisation for a stroke, she benefits from the intervention of an HSC. The 60-year-old couple lives in a nice house, and the husband takes care of his wife. Nevertheless, the service had warned us that the case is not an easy one, ‘This is a lady who is a bit difficult, we don't have an easy relationship, it's … it's particular’. The toileting scene that follows seems to prove her right. From the first moments in the bathroom, a dispute breaks out with the caregiver. Rushing out, the carer calls to her husband, ‘it's going wrong’ and explaining that she needs a hand. Thanks to the help from her husband, she finishes the toiletry duty, despite the cries and the refusal of the elderly woman. Later, the caregiver talks about her dissatisfaction. She used constraint, without having the same legitimacy as at the hospital: ‘It is we who are in people's houses, and already that makes a big difference because it's true that in hospital … is not good but well, we manage a little more, maybe … to control people, or rather, to get what we want more because they are not in their home’.
This episode is considered at the office. To justify herself, the carer says she had succeeded in ensuring the elderly woman made her toileting, despite her refusal, and that this was the mission assigned to her. ‘But I do not do it for pleasure’. In the team, they look for the reasons for the use of coercion. Could it not have been avoided? Certainly Mrs Morel is a difficult case. But more precisely, a procedure may have been ill-performed at a previous time in the toileting? Has the caregiver been sufficiently careful with the still-painful, head-scar? Yes, she knows, she is very careful. The lack of affinity is explored. ‘But we cannot change the organisation of the team at the slightest dissent’. The carer will make another attempt before reviewing the situation: ‘… and then we'll see. I do not know. […] If it's really awful. If I can avoid it, I will not take that turn constantly. Right, so I hope … I'll try to suit her’.
The arrangements are not always possible and sometimes because of tension, difficulty putting up with constraint on both sides, it creates a rupture. We are told that several services have had to give up intervention for Mrs Gentil, an upper-class old lady heavily handicapped who lives alone, and requires a lot of aid. She is judged by carers to be ‘manipulative’, ‘authoritarian’, ‘bitter’, ‘challenging’, ‘always criticising’. But she finally got along quite well with a young unexperienced, lower-class caregiver who spontaneously found the right way to react, by responding on the same cheeky tone: in the end, it didn't displease the cantankerous lady, caught out at her own game. How to prescribe such a solution in good-practice handbooks!
The low level-constraint
Interventions that ‘go wrong’ are not always the centre of discussions: it is mostly the case when no solution is found, and professionals run out of steam, and endure stress. Apart from these critical times, fortunately, ‘things are going better’. Does this mean then, that no constraint is exerted? All interventions would approach the ‘ideal’ interventions for which Clint would be a prime example? It is difficult to measure these issues without coming back to concrete situations. Thus the ‘exemplary’ case of Clint: he seems to decide everything, even the caregivers’ smallest gestures. Has he become for all the only master, somehow autonomous by delegation (Jacqueline 2006), suffering no constraint on the part of caregivers? It would be misplaced to go that far, simply because Clint can no longer control his body. Like everyone else, he must submit to his bodily constraints, except that, being a quadriplegic, he cannot do without the cooperation of others for even the most intimate acts of his personal life, like satisfying his natural needs. Gestures to constrain the operation of his body are largely delegated to caregivers. Complicated, intrusive, humiliating gestures. The very fact that someone other than oneself executes them is very restrictive, and all the tact of caregivers is to act as if this constraint does not exist. We realise when we ask the caregiver to describe in detail the successive gestures. She must try several times because she forgets what exactly she does and cannot recall much of the order in which she does it. Everything is so automatic. It is as if the constraining dimension to all these intrusive actions – putting in a suppository, awaiting the arrival of stools, wiping the person, disposing of their faeces – disappears behind the routine and mingle with every-day, natural functions, which demand no particular attention and are not shared with others.
The collaboration developed by Clint and his carers did not result in eliminating constraint, but relegated it so much that it is forgotten. One does not delegate his body to others as one might with a car that needs fixed. The routine that removes the delegated constraint requires continuous monitoring by Clint. Caregivers do not always do exactly what is needed. The slightest awkwardness reminds him of his body's powerlessness, that others have in their hands, and his ‘decision-making capabilities’ are brutally employed to their limits. Finally, in the long term, the division of labour that we observe in the moment was not given at the start, it is the result of a crossed-learning as much on the part of Clint, for acceptance, as on that of the caregivers, who are initially suspicious and anxious not to be ‘instrumentalised’. The fact that it took constant effort from Clint and his helpers, proves ab absurdo the constraining nature of common practices that simply never appeared before someone like Clint gradually imposed other ways of carrying out treatment, that involve letting the patient define their needs for themselves.
Furthermore, Clint does not always get things right. He also manages a relationship and must compromise. More than a freedom from constraint, it is right to analyse the case as a fight to push it back, reallocate it differently, by pointing to the ability to split into two roles that allows Clint to be on side with his own caregivers and implement joint management of the constraint situation. In this sense, his case is effectively rare: such collaboration is not easy to build. All caregivers do not have the same tact nor the same affinity with their patient. It takes very little in these situations where tactlessness gives rise to constraint. And one cannot ask carers to be tactful, that in itself would not be tactful. So it is in the unspoken, in allusion, via indirectness, that these things are expressed. Clint himself must not just say what he wants and rather learn how to say things: ‘Patients must employ a psychological approach toward caregivers in order to successfully get what they want’.
An art of composing
Using collaboration to make constraint bearable is not always successful. In many cases, carers and patients do not share the same point of view. Caregivers are there in fact to support patients in achieving various tasks of their daily lives, but also to ensure that the assisted persons are acting in the direction of their best interests. If professionals recognise that the patients are the best judges on the matter, they can also think that the decisions they take or threaten to take are contrary to the patients’ interests. Simply following the patients’ decisions, whatever they may be, would be satisfying one's self with a lazy definition of the principle of autonomy, notably when they are vulnerable and their capacities for discernment are weakened. Caregivers emphasise dialogue and persuasion to get patients to freely accept and submit to the constraints their situations demand and to continue to take treatment, have basic hygiene, a balanced diet, manage their budget, etc. Still, if a lot of resources are mobilised under these arguments, they may nevertheless seem like imposed norms. For caregivers, one of the challenges is how to combine constraint and autonomy, underpinning the exercise of any possible constraint with the decision of the person being helped, that is to accompany the internalisation of certain constraints and thus increase their capacity for action or their capabilities (Nussbaum 2000), without restricting their freedom.
Sometimes a more or less formal contractual approach also slips into everyday help when it is a part of the aid procedures themselves. Mr Coq is a man in his thirties supported by HSC. He suffers from mental illness, with no precise diagnosis but nevertheless quite debilitating, resulting in daily instability and lack of will. He is divorced and may only receive his children every other weekend. He was also diagnosed with diabetes. Taking his poor diet into consideration – he drinks 12 litres of Coca-Cola a day, and has no dietary discipline – HSC establishes a contract with him that defines a balanced diet as one of the intervention's objectives. To achieve this goal, the contract stipulates that HSC's staff visit his home three times a week. The first time to set a menu for the week, the next day to accompany him to the supermarket, and the third time to help him cook. The menus are not imposed, but discussed at length with him. This involves taking Mr Coq's preferences into account, along with nutritional and financial requirements and the needs of his two children whom he receives at his home every 15 days.
Discussions are long, arbitrations do not come easily, the various constraints are difficult to integrate, but in the end, through discussion, Mr Coq writes down his menu for the week in a notebook. The supervised grocery-shopping that takes place is guided by the menus written the day before. Carers go to Mr Coq's home and in his presence, begin with a stock-inventory. They look in the cupboards and in the fridge. This stocktaking can be an opportunity to give advice, something the professionals call ‘reframing operations’. One carer noticed the left-overs of a pasta dish, and advised: ‘The next time you make pasta, Mr Coq, try to put a little less in. It is best to eat everything and leave nothing’. From this inventory and the menus established the night before, a shopping list is made. The prescribed list becomes quasi-contractual, written by his own hand under the watchful and caring eyes of the aid-professionals. The list is entrusted to Mr Coq, who must find the products in the neighbouring Lidl. The carers accompany him and ensure that operations are conducted in accordance with the list. The issue is that he masters his purchases as best he can, does not yield to impulse buys as he passes the shelves, and that the total amount of purchases does not exceed the €15 in his pocket. The carers leave him to it, but do check with their calculator. From time to time, they ‘refocus’ Mr Coq when he exceeds the planned quantities. He is tempted by the chips section. ‘No, Mr Coq, you know that chips are not on the list’. To which he replied: ‘But it's for the kids, they like that’. Tremors that the carers seize upon to address the issue of paternal authority: ‘Mr Coq, you are the father, it is up to you. You must know how to show your children that you are in charge’.
This time, the chips do not enter the shopping trolley. Mr Coq seems to accept the calls to order. As practitioners often remind him, it is he who made the list with his own hand. By not being allowed to buy chips he is only obeying himself. It would be as wrong to speak of the exercise of direct constraint here as it would be to deny that the concept is at the heart of the care process: we find the idea of a split again, this time sought by carers, between a Mr Coq giving in to his impulses too much and a sensible Mr Coq, who knows how to restrain himself – but indeed requires a lot of ‘reframing’ for this. This report emphasises the coercive aspect but the ambivalence goes both ways: that day, following Mr Coq to the check-out, the caregivers suddenly find that he has forgotten the Coca-Cola bottle, which was most certainly on the list. Will they take the opportunity to fight his favourite addiction? Not at all, ‘Well, Mr Coq, you've forgotten the most essential … your bottle of Coca Cola!’ They also know how to play the first Mr Coq against the second.
Navigate between what feels good for people and what matters to them
The contractual approach can be more widespread. This is the case when referring to oral commitments that have been made in the heat of a discussion. For lack of being able to convince dependents to adopt a particular behaviour, rather than exerting pressure which is always likely to provoke an incident, carers look to at least get a commitment ‘to do it later’, which creates a new resource on which they may rely later. ‘But remember, you promised yesterday to tidy-up the house today’. Pressures or constraints exercised in such situations do not all impinge upon commitments of a contractual sort. Patients may have projects they take on and which, to be completed, require that they accept certain obligations. Professionals can refer to them to justify the use of constraint if it is deemed necessary. The project, formulated when the mental faculties of individuals are not too altered, becomes a kind of informal, ‘anticipated directive’, which can be employed by taking into account what people hold dear.
Mrs Case repeatedly affirmed over a long period of time, both to relatives and care professionals that she does not want to finish up in a nursing home. What matters to her is to stay home despite having Alzheimer's. The 70-year-old lady lives alone in her flat, close to her three daughters who are said by the service to be kind-hearted and very attentive to her. But she was found one day, disoriented, beside a busy road. It is no longer safe for her at home, she can get out at any time and endanger herself. Her daughters are hesitant. They know how much remaining in her home means to Mrs Case. In order to help her avoid the retirement home, they finally decide to lock her in her home. After some internal debate and discussion with the daughters, HSC accepts this in the end, but rapidly everyone wonders about the approach (Hennion and Vidal-Naquet 2015).
Indeed, the confinement reveals to be not easy to live with on a day to day basis, for neither Mrs Case who cannot hold back the tears when the door closes, nor her carers who are not very proud of their ploys to avoid facing up to the problem. Are we not committing a legal and ethical misconduct by depriving Mrs Case of one of her fundamental rights, the freedom to come and go as she pleases? For now, however, the solution put in place seems the lesser of two evils. This woman has expressed her will many times, this seems able to guide a substituted judgement for her, along the lines of what is important to her: insofar as avoiding the nursing home, Mrs Case would probably have made the same decision. One can almost consider that, despite appearances, the constraint is voluntary. What follows will prove the verdict wrong. Mrs Case continues to resist. HSC changes tack. Giving up and putting themselves in her place, they favour responding to her perceived needs. Following several incidents – Mrs Case eventually tries to escape through the first floor bathroom-window – they decide to act against her will but ‘for her wellbeing’ (Béliard et al. 2015). The elderly woman who wanted to stay at home finds herself in a long-term living centre. One of us visited her. She was unrecognisable, aggressive, desperate, when seen in the hospital, she was considered as being particularly ‘oppositional’. The service took note of the failure: Mrs Case's wishes had not been respected, nevertheless the solution that was imposed is unsatisfactory. The question of evaluation is bluntly posed to the service, which examines ways of estimating the least bad solution between choices that all involve a high degree of constraint.
The person's claimed or perceived best interests are a crutch for caregivers. They are forced to employ this, as we have seen, when patients no longer have the capacity for discernment. But they also act according to ‘best interests’ in many other situations, when assisted people can still express themselves and define their preferences, and have the ability to make their own decisions: often these decisions do not appear anymore reasonable, especially when sooner or later they are likely to harm the person. Resources used, such as contracts, projects or reasoning, run out, or are not (or no longer) employed. To not abandon aid and to influence the behaviour of people, to make them do that they do not necessarily want to do for their wellbeing, caregivers resort to trickery. With cunning, in whatever form and whoever initiates it (dependents and carers alike employ it), the constraint seems evaded, or at least not out in the open, this reduces any possible tensions. To give but a short example: it had been impossible to get Mr Hasard, a young bachelor with mental weaknesses who is under guardianship and has a meagre allowance for the week, to not spend all his money on games as soon as he received it. Not to worry, HSC made the appointment on the day he receives his money, at the exact moment that he comes out of the bank (HSC explained that no other day was possible), in order to accompany him to do his shopping and try and save some money.
But trickery is not always successful in masking constraint. It fails most spectacularly when it is identified as a ploy and the person being duped recognises the stratagem. The unmasking of constraint then deteriorates relations and undoes the trust necessary for the aid relationship. Such is the price of trickery, for example when it is used to enable the doctor to make a house call under the pretext of treatment, when in reality it is to conduct a forced hospitalisation. Beyond such extreme cases, where the trick itself is not far from forcing, the use of virtually continuous cunning, in many forms ranging from complicity to duplicity, shows just how present constraint is in the care relationship. The problem becomes the terms and evaluation of its use. To extend the analysis to the use of trickery, the question becomes: under what circumstances and to what extent can trickery allow constraint?
Mrs Mule did not ask for anything. She did not need help, living alone despite being 87-years-old and in the formative stages of Alzheimer's. It is her family who asked for aid from HSC after noting more and more serious problems in her daily life, concerning meals, hygiene, or medication. In various forms, she offers the same reception to professionals: what are you doing here? ‘But what are you meddling with, I dress alone, I go to the bank, the pharmacy […] you're bothering me’. The caregivers tried to explain the value and necessity of what they are doing, but attracted scathing remarks on their way of doubting people's ability, ‘No means no! It is unbelievable to want to force people in such a way’. The particularly delicate moment of toileting almost always results in the same scene: ‘We went in front of the bathroom door, we had prepared some cleaner clothes, look, we prepared these, does that suit you? … and I was behind a bit, going like this gently on the back [she makes the gesture of pushing slightly] … straight away, she struggles, she resists, she knows very well, yes, yes. We cannot force her, it is not possible. That's out of the question, it cannot be done, it is just not possible’ (nurse). The carer's scruple? Note however the double meaning of ‘not possible’, at first physical and then ethical. We are certainly on the knife-edge of constraint: if Mrs Mule had let it happen, the ethical concerns could have been relegated to the background. One has to give her a shower, but how far can one go? Seduce her with the beautiful clothes spread out in the living room, but that trick does not work. Pure force? No, they are not in the hospital, as they are well aware. But why not try to prod her a little bit, to give her a little decisive nudge (Thaler and Sunstein 2008), that sugar coats the constraint?
If the nudge does not work well with Mrs Mule, it is more successful with Mr Ali, this former boxer is also affected by Alzheimer's. He does not hesitate to show his fists when he disagrees. He does not like leaving his house though walking is part of his prescribed rehabilitation care. But he loves taking the bins out! To make him go for a walk, the carer avoids frontal activity. She entices him with the rubbish chute. Once at the bottom of the building, she does not hesitate to give him a nudge insisting that he make her go around the block, which he will end up being only too happy to do. The success of this act makes both coercion and trickery that has permitted it disappear after the fact.
Discussion: ‘not everything that counts can be counted’ (an aphorism attributed to Albert Einstein)
As we have seen, during the course of their duties, aid actors are asked to do certain things – or refrain from doing others. Problematic situations abound. They relate to acts for which the stakes are of varying importance: do not respond to a gesture of annoyance; pretend not to see something embarrassing, conversely hide what you do; use tricks to help get medication taken or care accepted; push the person slightly to the bathroom; avoid explanations, make decisions that cannot be fully discussed, or for the sake of maintaining a relationship, accept doing favours that are not really warranted or turn a blind eye to behaviour that is hygienically or morally reprehensible (Molinier 2009). Whether the issue be considerable (refusal of treatment, alcohol consumption, infliction of physical harm, departure to institutions – or refusal to leave and go there), or whether it simply involves fleeting moments of happiness or distress, care is full of such delicate situations, requiring reactions on the job, ranging from pure reflexes to more premeditated acts. Some of those reactions lead a discussion; other reactions remain forever in the secret of the relationship, or are just forgotten as soon as they have occurred.
By their influence on the wellbeing and independence of people, these reactions have an immediate moral significance (Baszanger et al. 2008; Damamme and Paperman 2010; Garrau and Le Goff 2012). But this element is not assessed in light of general principles well or badly applied, or in reference to good practice standards: the choices made are meaningful only in relation to the circumstances. They often refer to contradictory requirements, which are not possible to reconcile without trickery, delay-tactics and determination of their importance at a particular time (Eyraud and Vidal-Naquet 2012). Standards are antagonistic or at least uncertain and fragile (Dourlens 2008, 2011). In practice, care work requires extensive arrangements and lots of tinkering (Mol et al. 2010); moreover, as the action cannot be divided into sequences, but rather stretches in time and space into a myriad of gestures and acts for which the ethical issues are not immediately perceptible, the reasons of the choices made are never completely formulated.4
The activity of aid is faced with particular intensity in what could be called an underlying ethical-obligation, that is always ready to manifest itself, because of the irreducible tensions to which it is subject. To help someone is always, to some extent, playing with what they can accept: there is a big difference between the formal agreement obtained from the person being helped – an agreement that is also not so easy to assure – and the fact that when this does happen they tolerate such care: putting up with a pervasive presence, agreeing to no longer be master in their own home or not be able to do what they want. Helping a vulnerable person means being constantly torn between conflicting requirements: ensuring the safety and wellbeing of the person while respecting his/her will as much as possible, listening to his/her requests while being forced to bear in mind that s/he has problems, seeking their autonomy while trying to make her/him do things s/he does not like or s/he does not see the need for; or, controlling their means of payment, ensuring medicine has been taken correctly, their outings and the use of their keys, etc., so exercise some ‘constraint labour’ (Lechevalier Hurard 2013) whilst having a laissez-faire approach (Velpry 2008).
These tensions, including the coupling security/autonomy, make even the most innocuous gestures susceptible to create hindrances, failure, to provoke a strong reaction, or conversely to make the carer uncomfortable and generate feelings of annoyance, saturation or exhaustion (Ravon et al. 2008, Ravon and Vidal-Naquet 2016). To avoid constraint which violates the principle of autonomy, and laissez-faire which waives security or safety, causes ambivalent behaviours to proliferate – we mean by that the thousands of ways to get things done, little lies, tact, misleading actions, ways to say, to say without saying exactly, to suggest, to manage to be left alone to do something. We call such conduct, which contains an element of duplicity, trickery – a word whose ambivalence allows a combination of deception and skill. Indeed, it submits caregivers to ethical tests. By what right can we go around deceiving people ‘for their own good’? On what grounds can we make them do something that they have not asked to do, according to a conception of their wellbeing (Callon and Rabeharisoa 2004, strongly emphasised this point in the famous case of Gino)? Or, conversely, let them take a risk they can realistically neither measure nor assume? How can one respect their freedom or their will, when these remain elusive? Far from being settled by a yes or a no, these issues leave the actors in doubt: it is never possible to be sure to have done something well.
The solution consisting of, on the one hand, keeping the ideal principle of rejection of constraint intact and on the other, leaving the practice to work itself out on a daily basis with the difficulties of its implementation is unsatisfactory (Avril 2006). As care theorists have pointed out, care cannot be reduced to abstract principles; it is deployed in the activity itself. In order to be attentive to the attachments of individuals (Hennion 2010, 2015, Hennion and Vidal-Naquet 2015), associating the interrogations raised by the theories of care and a pragmatic approach to the aid relationship is then fertile ground: on the one hand, it is essential not to start from a philosophical statement of ethical principles but from a real investigation of the activity itself, as the social sciences demand; but on the sociologist's part, the effort is no less, given the redefinition of the discipline: s/he must be convinced of the need to reintroduce an ethical interrogation to the analysis by learning to consider the choices and commitments made during the course of action, rather than being content with raising the values and norms of the actors from outside; as if this data were fixed and could be detached from practice and defined from outside by their content.
Conclusion: care as maintained trouble
In conclusion, we are thus brought back to our original question. If one recognises that constraint is inevitably present in care and assistance relationships, how should one think about it? And, given its share of residual arbitrariness and the dissatisfaction it leaves behind, is it possible to articulate constraint within the ethics of care?
On the first point, we have found that constraint is not considered in and of itself. It is as if, because we want to rid the aid relationship of it, we also rid ourselves of constraint as a theoretical problem. However, there is a real paradox, notably in relation to one founding gesture of care theories. Underestimating constraint, reducing the darker side of concrete situations, focusing the discussion on the principles and best practice in an effort to make it go away, is this not paradoxically treating constraint in the same way as formal theories of justice, that care theories criticised, dealt with dependency? Against the unilateral moral valorisation of autonomy, Gilligan (1982) managed to value dependence, both in the methods (focusing on actual practices at the expense of abstract principles) and arguments (not to confuse autonomy and sufficiency, recognising the vulnerability of each, assuming the positive value of the very fact of depending on others, and on this basis, advocating a collective solidarity). For that, it does not mean that care waives the moral and political value of autonomy: transformed in order to take people's needs into account, it has created autonomy in dependence, and not against it. Is there also space for care which, similarly, is conceived of and realised within constraint, and not against it?
This problem does not mean denying the harshness of particular situations, people's suffering, the difficulties of care under the pretext of recognising the vulnerability and interdependence of all. Much like a return of the repressed, the issue has already arisen in these terms in debates between care theorists, relating specifically to dependence itself, especially in extreme cases. Kittay (2011), for instance, whose daughter suffers from a severe mental disability, but also Molinier et al. (2009), on sensitive or shocking cases, have impelled such a cry of protestation: the dependence of a child on his mother is not the same as the daily struggle to live with a being entirely dependent on oneself, overcoming discouragement and exhaustion, dealing with emergencies, hazards and endless new problems however we can, and facing physically and morally arduous treatments both for patients and caregivers.
A solution could come from an effort to clearly distinguish these types of constraint and treat them differently: extreme or ordinary cases, constraint within execution or decision-making; physical or moral; with the person's agreement or disagreement; unequal possibility of knowing what their needs are, etc. As we have seen this analysis is useful from a legal and social perspective. But in practice, it once again does away with constraint as a common basis for support and care activities. In a binary way, if the person still enjoys their full decision-making abilities, it amounts to considering the constraint is no longer such, and in extreme cases, that it is only a functional necessity to be regulated. A clarification of this sort is inadequate in understanding and carrying out care work in the field. In large part, this work consists precisely of ‘aiding in an uncertain world’ (to parody Callon et al. 2009). In accordance with the results of other empirical studies that we mentioned as well as the experience of caregivers, our examples show that most of the time constraint appears in a disseminated form (it belongs more to situations than it calls a specific act that can be qualified in isolation), indeterminate (it is difficult to measure its exact nature), situated (the same gesture, the same attitude does not have the same scope with regards to relations, background, and the context in which they operate). Uncertainty is the rule, not the exception, when in action as well as in hindsight. It is true in extreme cases and in institutions, it is even more so in the daily work of home help where it is often unclear whether care consists of letting people act for themselves, getting them to act, acting on their behalf or preventing them from acting.
That is what we must think of including in the care perspective: why not apply the same reasoning to constraint as that of dependence? That is to say, by first recognising the reality; treating it as a constitutional uncertainty, and then with the aim of examining the possibility of care that integrates constraint, instead of denying or relegating it to borderline cases. After having first fought against autonomy to defend interdependence, theories of care refined the argument and presented it more as promoting another, richer definition of autonomy, including dependence. What they thus did on the ‘positive’ side of things, that is, a paradoxical defence of autonomy through the acknowledgment of dependence, why not do it also on the ‘negative’ side of things: namely, to acknowledge the constraining part of care so that by taking into account both the autonomy and dependence of people, care theories better define care practices? To not do it, would mean a return to the same opposition that care theorists’ activism and engagement had gone beyond, between the philosopher's idealism setting out principles from textbook cases, without confronting the field, and the willingly critical realism of the sociologist who describes actual practices, and swiftly unveils a hidden logic, power relations, ulterior motivations or professional issues from the actors’ discourse. Far from renewing this dualism (values without facts, facts without values), our pragmatic perspective is an attempt to render detailed investigation of concrete situations and formulating ethical issues they raise inseparable – while stressing the continued uncertainty of the solutions implemented and the necessity of their ever open revisability. These depend each time on the individual case, they do not obey principles, they do not conclude without persistently high uncertainty as to their relevance.
Does this mean that, as much on the field as in the analysis, nothing can be done but rely on the opportunism of each case and the inanalysable know-how of the care professionals? Not at all. Between the explicit principles and visual navigation, there is a space where what we call ‘situational ethics’ can be deployed: acts, decisions, judgements are fed by everyone's experiences, their attachments, skills, and, conversely, they are maintained by debates, discussions, more or less formalised exchanges based on experiences of real ‘professional ordeals’ for carers (Ravon and Vidal-Naquet 2016, Vidal-Naquet 2014). Uncertainty and ‘normative fragility’ (Dourlens 2011) do not involve advancing at random, without asking questions, but rather they imply developing an attention that is not necessarily taken at face value, which maintains a kind of level of uncertainty in the assessment of action that is proportional to that of the situations themselves, and nourishes the possibility of reviewing it.
This situational ethics is not comfortable, it maintains the trouble, the inconvenience, dissatisfaction, and recurring doubt about the appropriateness of ones’ behaviour, both about an isolated decision and the management of a relationship over the long term. However, one may ask in conclusion if it is not within the trouble itself, the fact of still being worried, that strong ethical value resides. Care theories are largely based on the notion of concern: concern for the needs of others, concern for the quality of aid. This discomfort, this feeling of dissatisfaction linked to the ever somewhat arbitrary dimension of what to do in order to help someone, can be considered beneficial: it is a form of concern, it results in an action that can never be entirely convenient, it is always couched in doubt. The word ‘trouble’ not only refers to a kind of individual disorder, experienced within carers, although this aspect certainly exists: it can be expressed, discussed collectively or established (Dewey 1927), not only to share the anxiety, which can make it more bearable individually but also and above all to keep concern for others awakened, and learn to distinguish, through debate and on the basis of more or less uncertain justifications, the constraint that is acceptable from that which may not be. It is the role of meetings, practice analyses, workshops and writings, as well as maintaining informal exchanges between carers. These various instances of action are pooled and institutionalise the trouble, which gives it another social and legal dimension. Giving way to the possibility of personal or legal remedies from patients, they support the introduction of ‘contestability’ (Pettit 1999). Nevertheless, ‘contestability’ is not decreed either: it is still the fact of feeling worry, this time seen as political concern, which can support the ability to contest and ensure that the care relationship does not turn into a domination relationship. Maintained within the heart of the activity, trouble is perhaps what allows care practitioners to guard against over-confidence in the care relationship, which would be likely to weaken the attention afforded to the needs of others.
Is never being quits with the use of constraint, a way to make it compatible with the care? Why not? Care itself needs care.
Acknowledgements
First of all, we warmly thank the people and services who welcomed us and gave us time and attention, and the participants in the presentations that followed the inquiry. For highly valuable comments and criticism, we are especially grateful to the caregivers and patients who engaged actively in those discussions, to the invited researchers for most welcome comments on an ongoing inquiry, and to colleagues from the CSI, for enriching debates. The analysis benefited from discussions within the Collectif Contrast research group. Finally, special thanks to our two anonymous reviewers and the editors for the impressive work made. All names have been anonymised except some meaningful familiar names carers give to patients according to their age, position, and character. The cases, carried out with the helpful participation of Franck Guichet, Léonie Hénaut, Florence Paterson and Julien Sauvebois, come from two inquiries founded by the French Haute Autorité de la Santé and the French Ministry of Health.
