Depending on Practice: Paul Ricoeur and the Ethics of Care

Continuing on from recent discussions on the overlap between Paul Ricoeur’s philosophy and care ethics, this article will aim to clarify the status of practice in Ricoeur’s work. I will argue that even though Ricoeur’s philosophy is indeed marked by its “desire for a foundation,” as care ethicist Joan Tronto has pointed out, this aim is more of a fragile wager than a principle, and is always at risk of being overturned by practices and other worldviews. I will demonstrate this point by arguing that (1) Ricoeur’s hermeneutic approach to practice leads to the view that objective methods of knowledge and explanation are always grounded by the broader hermeneutic task of practical understanding and care for the self; (2) in moral reasoning, Ricoeur’s analysis of the conflict between respect for the rule and respect for persons results in his prioritizing of respect for the singular other rather than the universal rule, meaning that the other can always disrupt and reorient universal or foundational modes of reasoning; and finally (3) within healthcare relations Ricoeur aims to develop an alternative understanding of respect that places it in a dialectical relation with care. These practice-oriented readings of hermeneutics, morality, and respect aim to open up a dialogue between care ethics and philosophical approaches that have often been placed outside of care ethics.


RÉSUMÉ :
Poursuivant les récentes discussions concernant les recoupements entre la philosophie de Paul Ricoeur et les éthiques du care, cet article a pour objectif de clarifier le statut de la pratique dans l'oeuvre de Ricoeur.Je soutiendrai que même si la philosophie ricoeurienne est bien marquée par un « désir d'un fondement », ainsi que l'éthicienne du care Joan C. Tronto le souligne, cet objectif repose plus sur un pari que sur un véritable principe, et risque toujours d'être renversé par les pratiques ou d'autres visions du monde.Je démontrerai cela en soutenant trois arguments.1) L'approche herméneutique de Ricoeur concernant la pratique mène à penser que les méthodes objectives de connaissance et d'explication sont toujours soutenues par une tâche herméneutique plus large de la compréhension pratique et du souci de soi.2) En ce qui a trait au raisonnement moral, l'analyse de Ricoeur sur le conflit entre le respect de la règle et le respect de la personne accorde la priorité au respect de l'autre singulier plutôt que de la règle universelle.Ainsi, l'autre peut toujours perturber et réorienter l'universel ou les modes fondateurs du raisonnement.3) Réfléchissant aux relations thérapeutiques (healthcare relations), Ricoeur tend à suggérer une nouvelle compréhension du respect qui se place dans une relation dialectique avec le souci (care).Ces lectures -de l'herméneutique, de la moralité et du respect -orientées vers la pratique ouvrent la voie à un dialogue entre les éthiques du care et des approches philosophiques que l'on considère souvent éloignées de celles-ci INTRODUCTION Paul Ricoeur's philosophy has always taken the task of practical understanding seriously.The method pursued across his writings is one that eschews a more general or abstract approach to philosophical questions in favour of regional investigations into different paradigms and cases; investigations or "detours" from which we can then hopefully return anew to those foundational questions which give rise to reflection and interpretation in the first place.For Ricoeur, interpretation is a type of activity which combines reflection on ideals with practical engagement.We on the one hand always find ourselves equipped with questions, preferences, and vague ideals, due to our particular cultural backgrounds and traditions.On the other hand, through practical encounters with others these assumptions are altered, disrupted, and re-oriented towards new horizons.Variable, practical relations with others are what cause differentiation and enrichment of our shared understandings of broad terms such as "humanity," "respect," and "care." In a recent collection of articles on Ricoeur and care ethics (van Nistelrooij, Schaafsma, and Tronto, 2014;Hettema, 2014;Van Stichel, 2014;de Lange, 2014;van Nistelrooij, 2014) Joan Tronto raises a point regarding the crucial role of practices in the development of an ethic of care.She claims that care ethics should be viewed as a "practices all the way up" 1 approach to the task of living well and caring for the self and others.Contrary to this, she sees in Ricoeur's work and in the work of the articles on Ricoeur and care ethics the "desire for a foundation" as the motivation for philosophical and moral reasoning.Tronto writes, "most of the papers here make the claim that moral reasoning must rely upon some kind of foundation; in Ricoeur's work, that foundation grows out of the philosophical anthropology that he explicates.But this is a quite specific anthropology with which others may disagree" (van Nistelrooij, Schaafsma, and Tronto, 2014, p. 489).While Tronto's criticism is not unproblematic, insofar as she seems to neglect a more considered reflection on the subtlety of Ricoeur's anthropology of capability, she does nonetheless bring into focus how practices constitute an already ongoing milieu that is in one sense irreducible to any theoretical account of how the human might be in abstraction.When seen in this way, the focus on practice is therefore not essentially at odds with Ricoeur's anthropology of human capability.After all, capability is about what the agent can do, which is a form of practice.In other words, to be concerned with practice in relation to care ethics is only to investigate Ricoeur's anthropology as a situated action.In this article I want to assume the innate connection between a capability and practice in order to continue this discussion.Its main contribution will be to elucidate the relevance of Ricoeur's philosophy for care ethics via a hermeneutical analysis of practice.
Three key areas of Ricoeur's work will be explored through the article in order to defend his practice-oriented approach to philosophy.Firstly, his conception of the self will be explored alongside Michel Foucault's work on "technologies of the self" (Martin, Gutman, and Hutton, 1988;Foucault, 2005).In both these approaches the self is viewed as a non-objective, practical entity.To be concerned with the self is to move beyond epistemological questions towards practical questions.For Foucault knowledge of the self must be situated within the broader task of caring for the self, while for Ricoeur the self can only be understood through interpretation-that is, through situated readings and narratives.
Secondly, Ricoeur's account of respect aims to highlight its conflictual nature.The imperative to follow one's duty arises from the recognition of the capacity of the self to act autonomously.However, Ricoeur also emphasises the need for an understanding of respect that is aimed at recognizing the vulnerability of the self in its relation with others.I will argue that Ricoeur prioritizes this second notion of respect, and that this understanding of vulnerability is linked strongly to his concept of the singularity and irreplaceability of the other, which is encountered not through abstract reasoning but through practical relations.
Finally, Ricoeur's reflection on medical and ethical forms of caring directed toward persons with health conditions and impairments aims to outline a form of practical caring that includes "targeted respect."The notion of targeted respect challenges "vague" notions of respect, which see it as being owed to all persons equally.Instead, our understandings of respect owed should originate from a recognition and appreciation of the difference between the so-called normal and pathological.Respect and care are placed in a dialectical relation by Ricoeur; through a caring perspective we recognize certain needs of others, and this recognition in turn gives rise to a targeted respect, which values the difference between the diversity of needs that arise in various practical milieus.
Overall, the aim of this article will be to give an account of the ways in which Ricoeur comes to his conclusions about the crucial role of practice in hermeneutic understanding and ethics, in order to demonstrate that his work is open to dialogue with care ethics.Although his starting point is different from a care ethics approach, interestingly he arrives at a similar conception of practice.In this way, work on care ethics can be productively combined with Ricoeur's philosophy, both as a way of clarifying Ricoeur's own ethics and also as a way of adding a hermeneutic perspective to care practices.

(1) TECHNOLOGIES OF THE SELF-HERMENEUTICS ORIENTED TOWARD PRACTICE
Throughout this first section, I will argue that Ricoeur's hermeneutic philosophy is fundamentally oriented towards practice.I will first look at this orientation within Ricoeur's philosophy in terms of its understanding of practice as the way in which the self is mediated and becomes available (or manifest) for interpretation.In particular, through a comparison with Foucault, I will argue that the self is revealed in a practical context when those practices are aimed toward caring for the self.Although Foucault's term "technologies of the self" should be taken in a broad sense to refer to a multitude of methods of caring for the self (for example, keeping diaries, writing letters, and so on), I will focus on the ultrasound scan as one particular example of a technology in the more literal sense of the term.The concept of caring for the self in Foucault's work is not intended to be taken as being synonymous with the idea of care found the ethics of care literature.However, to the extent that it refers to a practically oriented self as opposed to a knowledge-oriented self, I believe it is relevant for a consideration of practical forms of caring.
In the introduction to Oneself as Another (1992), Ricoeur locates a hermeneutics of the self as existing between two traditions.On the one hand there is the Cartesian tradition, in which the 'I' is posited, and on the other there is the tradition of the "shattered cogito" (cogito brisé), which aims to draw attention to the ways in which the 'I' of the cogito is always posited through language and therefore is subject to dissemination and ambiguity (Ricoeur, 1992, p. 4-16).The hermeneutics of the self then involves the recovery of self-identity by taking a detour through linguistic interpretation.This aspect of the mediated self is also emphasized by Michel Foucault in his later work on the hermeneutics of the subject.
One of the possible overlaps between Foucault and Ricoeur's understandings of the self is found in their respective characterizations of truth.Although Ricoeur is critical of Foucault's earlier ideas of epistêmê, he does express admiration for his later texts on the care for the self (Ricoeur, 1998, p. 79).For both thinkers truth is never something immediately given; instead it can only be achieved through struggle or work.Both are agreed on the need to rethink the Cartesian moment in philosophy as a moment in which the ego replaces the self, and the need for detour, mediation, and transformation in the process of self-understanding or self-development gets forgotten. 2 Johann Michel has convincingly given an overview of the two philosopher's shared approaches to technologies or practices of the self in a chapter titled "The Care of the Self and Care for Others" in Ricoeur and the Post-Structuralists, in which he sets out to "provide a Foucauldian reading of Ricoeur's philosophical anthropology" (Michel, 2014, p. 103).The main overlap between the two thinkers is the way in which the self can never be reached through knowledge alone, but can only find itself in embedded practices or techniques.For Ricoeur, The first truth-I am, I think-remains as abstract and as empty as it is invincible; it has to be "mediated" by the ideas, actions, works, institutions, and monuments that objectify it.(Ricoeur, 1970, p. 42) Michel reinterprets this claim through Foucault's notion of care so that, "one can say that Ricoeur reproaches Descartes for putting the care of the self outside of his attempt to establish the first truths" (Michel, 2014, p. 105).Viewing Ricoeur's work through Foucault leads us to characterize Ricoeur's turn from phenomenology toward "hermeneutic phenomenology" (which supplements a phenomenological search for immediate meaning with detours through psychoanalysis, structuralism, religious discourse, and so on), as an attempt to re-spiritualize the concept of the self.Phenomenological analysis is replaced with the work of interpretation and understanding: The philosophy of mediation to which Ricoeur is allied thus implies that the subject-who, in reality, is not a subject in the substantialist sense of the term-must be transformed in order to attain greater transparency about itself.This call for transformation is something that Ricoeur calls a "task," because the coincidence of the self with itself is not given.By espousing a mediate philosophy of the subject, he thus requires each person to take care of the self through a work on oneself, a progressive transformation of oneself that is inherent in all forms of spirituality.(Michel, 2014, p. 107) Although many of Ricoeur's own detours involve investigations into epistemological or methodological approaches to understanding (whose motivations are summarized by his dictum "to explain more is to understand better"), Michel argues that to label Ricoeur as an epistemologist would be to miss the broader point of his philosophy (ibid., p. 110).Instead, these endeavours should be understood in the sense of the gnôthi seauton (know yourself), which Foucault has shown was placed within the larger project of epimeleia heautou (care of the self) in ancient thought. 3Therefore, the search for knowledge of the self is necessary, but must be understood as one particular 'technique' in the spiritual practice of caring for the self: "the access to a greater truth about oneself presupposes a transformation of oneself" (ibid., p. 111).According to Foucault, knowledge 'for its own sake' results in the neglect of the particular self: Knowledge will simply open out onto the indefinite dimension of progress, the end of which is unknown and the advantage of which will only ever be realized in the course of history by the institutional accumulation of bodies of knowledge, or the psychological or social benefits to be had from having discovered the truth after having taken such pains to do so.(Foucault, 2005, p. 19) The spiritual cost of knowledge accumulation is felt at the level of practical care for the self.In her article on Ricoeur and care ethics Petruschka Schaafsma also notes that Ricoeur's detours into so-called objective methods of knowledge are only formal investigations into structure which must then be re-located within a wider practical approach to understanding: In relation to this approach via the object, Ricoeur also goes into its abstract character.He admits that analysing the human power of knowing means being directed only at the framework of our life-world.This still needs to be filled in with affective and practical aspects of our life and with the presence of other persons to whom we are related.(Schaafsma, 2014, p. 159) The inseparability of (objective) explanation and (practical) understanding for Ricoeur means that no science or technology can claim to be completely neutral and, similarly, no philosophical analysis can claim to be free of presuppositions.However, detours through objective methods can still be valuable for practical understanding, as long as they are related to the wider hermeneutic project of understanding practical relations better and cultivating the aim of living well.
In terms of care ethics, two paradigmatic examples of technologies of the self might be birth control and abortion, whose availability shifted the way women participated in moral decision-making, When birth control and abortion provide women with effective means for controlling their fertility, the dilemma of choice enters a central area of women's lives.Then the relationships that have traditionally defined women's identities and framed their moral judgements no longer flow inevitably from their reproductive capacity but become matters of decision over which they have control.(Gilligan, 1982, p. 70) According to Gilligan, the introduction of these technologies into women's lives resulted in both the revealing new layers of their previous socially-determined roles as passive carers (their role as other) and also their capacity for a new type of moral decision making (their role as self): order to refocus debates on technology away from abstract questions regarding whether or not technology as a whole is moral or ethical, toward questions on the ways in which we can better use individual technologies to shape or reshape our sense of moral identity: Technological ascesis…consist in using technology, but in a deliberate and responsible way, such that the "self" that results from it-including its relations to other people-acquires a desirable shape.Not the moral acceptability, then, is central in ethical reflection on technology use, but the quality of the practices that result from it, and the subjects that are constituted in it.(Verbeek, 2008, p. 23) In his postphenomenological analysis of ultrasound, Verbeek shows how this technology helps to shape the fetus both as a person and as a patient.Furthermore, it helps to shape the relation between the unborn and the parents.In these ways, it takes on a moral significance within the lives of the people involved in the pregnancy.Through its mediation of reality it (re)presents us with an altered view of the unborn, as closer to being a 'person,' "a Fetus of 11 weeks old measures about 8,5 cm and weighs 30 grams, but its representation on the screen makes it appear to have the size of a newborn baby" (ibid., p. 15).The ultrasound also represents the unborn "independently" of its mother, or as independent of its mother (ibid).The interface then results in a generation of "a new ontological status of the fetus.Ultrasound imaging constitutes the fetus as an individual person" (ibid., p. 16).The ultrasound also adds to the unborn's status as 'patient' in that it is used to scan for abnormalities: "Ultrasound imaging lets the unborn be present in terms of medical variables, and in terms of the risks to suffer from specific diseases" (ibid.).
Interestingly, this description of the ultrasound, as shaping both the unborn as person and as patient unites in one device the two traditional spheres of life, whose division is often challenged by care ethics; the political/institutional/public sphere, and the home or private sphere, with the work of care traditionally being restricted to the latter.In the case of the ultrasound, we find present within one technology the cultivation of private care 4 alongside the demand for professional care, with the result that the boundaries between the two become challenged.
Verbeek also shows how this aspect of the ultrasound, which at once calls attention to the unborn's status as person and as patient, raises important moral questions regarding the new practical relation which is established between the unborn and parent(s) (and it is the relationship with the parents that is key here for Verbeek since, in liberal democratic societies, the parents are the final decision-makers in relation to the unborn).On the one hand, the mother is now deprived of her special relation to the unborn, shifting the privilege of having knowledge about the unborn to healthcare professionals.But on the other hand, these detaching effects have their counterpart in an increased bonding between mother, father, and unborn.(Ibid., Another effect can be that, due to establishing the individuality of the unborn, the mother's womb is now re-interpreted as the environment of the fetus, "and while the fetus is constituted as a vulnerable subject, its environment is potentially harmful" (ibid., p. 17).This is an interpretation which in turn constitutes the ultrasound as a mode of "surveillance" (Ibid.).Fathers, through having more visual contact, can feel like they have a larger role in the practice.For example, because of the medical status of having a sonogram made, fathers are more easily allowed to take a few hours off to attend the examinationwhile accompanying their partners to take the regular midwife visits is usually a bigger problem for employers.(Ibid.) Through the creation of these new practical relations and moral subjectivities, this technology can have concrete effects.The most clear being its effect on the decisions regarding abortion.
Verbeek's postphenomenological analysis of ultrasound does indeed demonstrate that, independently of abstract questions regarding the precise nature of technology, an ethical evaluation can be carried out at a practical level.Although he only focuses on one particular practical configuration (for example, he describes the ultrasound experience as something that two parents participate in), his approach shows how a consideration of practices and technologies can lead to a consideration of the moral subjectivities created through these practices, even without the support of more abstract or conceptual reflection.(

2) PRIORITIZING THE OTHER
If it can be convincingly argued that Ricoeur's epistemology of the human and social sciences is circumscribed by his larger concern with the self when it comes to the case of his arguments about morality this point may initially seem harder to prove.Given that care ethics poses itself as an alternative to deontology and that Ricoeur accords a large role to moral reason in his ethics, where it serves as a 'sieve' or test that ensures equal consideration for all persons, the question will remain as to whether or not these two positions can be reconciled.In her book Caring Democracy (2013), Tronto wants to fundamentally rethink the heterogeneity of traditional understandings of justice and a care ethics approach to living well together in a political society.From a care ethics perspective, how can a liberal approach to justice, which is centred around the principled fair treatment of each individual as deserving of equal consideration, co-exist with a caring democracy, which accepts that something like a Rawlsian 'original position' obscures the factual diversity and inequality of human social relations?Following the first section's argument for a possible orientation within Ricoeur's philosophy towards care for the self, this section will look at one of the ways in which Ricoeur's ethics is oriented toward giving priority to the singular other.Ricoeur's approach to morality and justice is notable for its attempt to mediate between more abstract or principled approaches to equality and the practical plurality and asymmetry of social relations.Just as hermeneutics is guided by the broader, fragile, task of practical care for the self, Ricoeur's ethics is guided by its attempt to seek out and discern the singular other in practical situations, even at the expense of the moral law.
In "Ricoeur and the Ethics of Care," the authors draw inspiration for their argument from the following quote: Here I shall attempt to bring to light the simple fact that the practical field is not constituted from the ground up, starting from the simplest and moving to more elaborate constructions; rather it is formed in accordance with a twofold movement of ascending complexification starting from basic actions and from practices, and of descending specification starting from the vague and mobile horizon of ideals and projects in light of which a human life apprehends itself in its oneness.(Ricoeur, 1992, p. 158) This statement is used in order to demonstrate that Tronto's argument for a 'practices all the way up' approach to care ethics, need not be at odds with one inspired by Ricoeur's conceptual thinking.Rather the two can be seen as different movements-upwards and downwards-that both contribute constructively to the shaping of the important intermediary zones between practices and the abstract ideals.
(van Nistelrooij, Schaafsma, and Tronto, 2014, p. 485) I will try to add to this argument by showing that, later in Oneself as Another, the need for this dual movement becomes even more evident, since it leads to the understanding of the other as irreplaceably singular, rather than as someone to be subsumed under a general 'rule.'Furthermore, it is only in light of these "important intermediary zones" between conceptual thinking and practices that the human capacity for phronêsis is actualized.
In the subsection titled "Respect and Conflict," Ricoeur reflects on the opposition between the first and second formulations of Kant's categorical imperative.He admits from the outset that for Kant there is no opposition, but demonstrates that this is because Kant precisely does not follow the model of upward and downward movement outlined above.In relation to the above quote from Ricoeur, the "vague and mobile horizon of ideals and projects in light of which a human life apprehends itself in its oneness" is represented here by the term "humanity," whereas the practical level is represented by the conflicting problem of human plurality.Again, for Kant, there is no opposition, "to the extent that humanity designates the dignity by reason of which persons deserve respect, despite-so to speak-their plurality" (Ricoeur, 1992, p. 262).However, Ricoeur identifies two possible paths that one can take when interpreting the Kantian maxims: the ascending route guided by the test of universalisation, and the descending route guided by the application of the maxims to concrete situations.The ascending route detaches the maxim from the concrete situation, from which it was originally derived, and elevates it to the status of a rule.So, metaphorically speaking, we have a constant upward movement: we have social practices, from which maxims of action are derived, and which are then subjected to the higher test of universalisation.Ricoeur, on the other hand, argues for the more productive and circular second route, as it is the second route which leads to a recognition of otherness and solicitude: The wrong done to others as other than myself could perhaps not appear along the first path moving from action to maxims and from maxims to the criterion that tests their moral tenor.It could only be visible along the second path, the complement of the first, along the descending path of concretization, of application in the strong sense of the word.(Ibid., p. 265) The idea of treating the other always as an end and not only as a means leads to a confrontation between the universal rule and the very otherness of the other person.This otherness by definition resists the test of universalisation, and can only be encountered on the practical level.Justice, for Ricoeur, then becomes something like the communal or institutional safeguard of this second route, since questions of justice arise in light of the conflict produced between respect for the law and respect for persons.For example, in the case of promising, if a promise is considered in an isolated way, under the guidance of the test of noncontradiction at the level of 'rules,' it runs the risk of being rendered meaningless, of having no "grist to grind" (ibid., p. 263).It is only in a context with the other than me that the act of promising takes on any real significance, "a commitment that did not involve doing something that the other could choose or prefer would be no more than a silly wager" (ibid., p. 267).Ricoeur draws on Gabriel Marcel's term disponibilité (availability, disposability) to highlight this; Ricoeur writes (quoting Marcel), "In a sense", he wrote in Being and Having, "I cannot be faithful except to my own commitment, that is, it would seem, to myself."But here arises the alternative: "At the moment of my commitment, I either (1) arbitrarily assume a constancy in my feelings which it is not really in my power to establish, or (2) I accept in advance that I shall have to carry out, at a given moment, an action which will in no way reflect my state of mind when I do carry it out.In the first case I am lying to myself, in the second I consent in advance to lie to someone else." (Ibid.) According to Marcel the solution to the above problem of self-constancy over time in relation to promising is that "all commitment is a response" (Marcel, 1949, p. 46), which in terms of morality means that all understandings of "capability to be moral" need to be rooted in practices or a lifeworld that is populated by others.An analysis of moral reasoning cannot just take 'intention' as its basis, but needs to show the ways in which intention and practical responsibility toward the other are conflictual.In the case of promising, the institution or practice in which the conflict appears is language itself.Justice, in this case, is the figure of the witness to the promise which, taken at its most paradigmatic, is language as writing.
They key point in this discussion though is found in the following remark regarding the conflict between the idea of humanity and the factual reality of human plurality: Respect then tends to be split up into respect for the law and respect for persons.Under these conditions, practical wisdom may consist in giving priority to the respect for persons, in the name of the solicitude that is addressed to persons in their irreplaceable singularity.(Ricoeur, 1992, p. 262, my italics) This aspect of Ricoeur's approach to morality attests most forcefully to the possibility of dialogue with care ethics.In the end, he accords priority to the practical deliberation of subjects found within singular situations, rather than to the abstract or conceptual reasoning that derives rules.Although he indeed argues for the necessity of both approaches to practice, the conceptual movement downward, and the practical movement upward, it is telling that the singularity of individual situations and conflicts is given slightly more weight than the rulebased reasoning.I would claim that ultimately Ricoeur's prioritizing of the singular other here marks a movement from knowing to understanding, from the know-how of rules and their applications to the need to open oneself to the other in the hope for an event of understanding.
Ricoeur's approach links up with Selma Sevenhuijsen's introduction to her book Citizenship and the Ethics of Care: Feminist Considerations on Justice, Morality and Politics (1998).Sevenhuijsen discusses a case in which a female nurse in Delfzijl "confessed to killing nine patients suffering from severe senile dementia out of a sense of pity" (Sevenhuijsen, 1998, p. 2).However, rather than subsuming the case under a general moral theory, whereby the nurse's actions would be said to be categorically immoral, Sevenhuijsen argues that what is needed in relation to such a case is a deeper sense of understanding rather than abstract reasoning.Sevenhuijsen is not trying to show that the nurse's actions were either right or wrong; instead, she merely wants to point out that abstract moral deliberation results in an obscured and impractical framing of the situation.For example, a perspective on the case from within the practice of caring yields a more complex and more accurate understanding of the context: A social worker who is interviewed about the case lacks the customary arrogance of experts who wonder how this nurse could ever have let herself go so far.She interprets the nurse's actions rather as a sign of her loneliness and stress, signals which should have been picked up more effectively by her team leaders.(Ibid., p. 3) The article writer who has interviewed the social worker, eschews external or abstract ethical language in favour of a meditation on the practical experience of being a caregiver: Because the journalist has chosen to write an 'inside' story from a nursing home, the 'killing nurse' incident is described in a different moral vocabulary than that used in ethical discussions about the authority to end life.While it would not have been at all difficult to depict the nurse as a 'murderess' (the associations with the stereotypical image of the female poisoner are obvious) and out-rightly to condemn her behaviour, the reader is asked for understanding instead; understanding for the heavy burden carried by those who care for psychogeriatric patients and for the joys and sorrows which are inseparably linked to their daily routines.(Ibid.) In a similar way, but from an approach that originates within the conceptual or abstract sphere, Ricoeur comes to a corresponding conclusion about the limits of moral reasoning in certain situations.In the case of a patient who is terminally ill, Ricoeur reflects on whether or not the moral duty to always tell the truth still holds.He argues that such a rule can never be applied universally in these endof-life situations, but rather it is left up to practical wisdom to guide action and understanding: In such cases, one must have compassion for those who are morally or physically too weak to hear the truth.In certain other cases, one must know how to communicate this truth: it is one thing to name an illness, it is another to reveal the degree or seriousness and the slight chance of survival, and yet another to wield the clinical truth as a death sentence.But there are also situations, more numerous than is thought, where telling the truth may become the opportunity for the exchange of giving and receiving under the sign of death accepted.(Ricoeur, 1992, p. 269-270) Following this quote, Ricoeur also adds in a footnote that the question of euthanasia should be discussed in the same spirit.However, as the above quote demonstrates, the moral imperative to tell the truth can indeed be a guide for action; it merely has to be weighed against the more conventionally compassionate alternatives.So in this sense, Ricoeur's understanding of phronêsis can become compatible with an ethic guided by caring practices, if these practices are understood as an approach to the other which accords more priority to respecting the demands originating in their needs, rather than the demand or imperative originating from the abstract moral law.Perhaps we could also add Sevenhuijsen's term "judging with care" (Sevenhuijsen, 1998, p. 5) to Ricoeur's "practical wisdom" in order to shift the decision-making process involved in practical deliberation toward a care ethics approach. (

3) CARE AND RESPECT AS RESPONSES TO ILLNESS
As we have seen above, in terms of ethical self-understanding and the moral conflict between respect for the rule and respect for persons, Ricoeur's philosophy in not only a practice-oriented philosophy but is also one which could be supplemented productively with insights from care ethics.In this final section, I will look more closely at the interrelationship between care and respect using Ricoeur's analysis of the pathological as that which demands both care and a recognition of difference.
In his essay on physical and mental disability, "The Difference between the Normal and the Pathological as a Source of Respect" (Ricoeur, 2007), Ricoeur aims to rethink our understanding of the respect owed to persons with illnesses.
In light of the analysis of moral reasoning in section two, the term respect should be taken to be ambiguous, and indeed semantically has more in common with the term care used in care ethics than the term respect as it operates in ethical traditions that take autonomy to be synonymous with "choice."From the outset of the essay this sense is confirmed: "The goal of the reflections I propose to present is to begin to lay the basis for the respect-and, beyond such respect, for the friendship we owe to the physically and mentally handicapped, as well as to all others struck by infirmities" (Ricoeur, 2007, p. 187, my italics).Instead of the "vague" notion of respect for every person, Ricoeur wishes to develop the idea of a "targeted respect," which arises from a recognition of the pathological state-not as a deficient state, but as structurally different and with its own internal worth (ibid.).Or, in other words, in the case of illness, respect should not be derived from abstract or theoretical considerations, but from an appreciation of the practical environment in which the patient lives.Ricoeur's analysis of the normal and the pathological proceeds across three stages: (1) the biological, (2) the social, and (3) the existential.These stages are not successive but represent "an intertwining of simultaneous values, ones that we can distinguish only for the sake of our argument" (ibid., p. 189).
(3.1)The Pathological as a Shrunken Milieu At the biological level, the definition of the pathological as univocally deficient is put into question through revealing the role of "selection" in marking out the pathological.A purely observational method, which in advance selects the criteria of what constitutes the 'normal' and the 'pathological,' imposes its own value system onto the relation between the "living creature and its milieu" (ibid., p. 187-188).An alternative method begins instead by emphasizing the importance of the selection process undertaken by the subjects themselves: "One observes how the organism itself defines its milieu through selecting what are to count for significant signals" (ibid., p. 188).Ricoeur draws on Georges Canguilhem's term "vital value" to characterize this selection process and to describe the way in which "the living creature brings its own norms to the evaluation of situations, whereby it dominates its milieu and accommodates itself to it" (Canguilhem, 1992, p. 146, cited in Ricoeur, 2007, p. 189).The notion of the normal at this level is difficult to determine; it can either refer to the norm in the sense of the statistical average, whereby a deviation in a selection process would be a deviation from this average, but it can also refer to the norm in the sense of the idea of health, whereby health refers to the living creatures' ability to withstand changes in its environment.In the second case, that of 'health,' an illness or deficiency would be that which forces the living creature into a "shrunken milieu" (ibid., p. 190).The term "shrunken milieu" characterizes the pathological at the biological level and importantly can be read in two ways: "Read negatively, the pathological signifies a deficit or deficiency.Read positively it signifies another, an other organization, one that has its own laws.Yes, another structure in the relationship between the living creature and its milieu" (ibid., p. 190-191).
The ambiguity of the term pathological leads to two corresponding demands, the demand for care and the demand for respect.Care is aimed at treating the illness, whereas respect is a way of viewing the relation between the pathological and the normal as one in which different phenomenological lifeworlds possess their own "vital value" regardless of their "shrunkenness."This notion of respecting the differences in the 'deviations' from the norm also guards against the "insolent aspect of health, which tends to turn the norm in the sense of an average toward the norm in the sense of an ideal" (ibid., p. 191).In her work on disability and care ethics, Eva Feder Kittay adopts a useful deconstructive term which also attacks this "insolent aspect of health," the term "temporally abled" (Kittay, 2011, p. 50), which is echoed in Ricoeur: "Growing old may provide a favourable case for calling into question this insolence, which ancient and medieval moral thinks called concupiscencia essendi, misplaced pride in existing" (Ricoeur, 2007, p. 191).
(3.2) Social Esteem Whereas at the biological level 'normal' functioning meant the ability to tolerate changes and adapt to different environments, at the social level the 'norm' is defined analogously in terms of the ability of a person to live well with others.
In current social organizations, this idea of the normal is often associated with autonomy in the sense of being able to direct one's own life: In an individualistic society that emphasizes the capacity for autonomy, of being able to direct one's own life, and incapacity that reduces one to a state of tutelage in the double form of assistance and being controlled will be taken to be a handicap.Health, too, then is socially normed, as is sickness, as is the demand for care and the expectation that goes along with this demand.(Ibid.,p. 192) This can lead once again to a univocally negative understanding of the pathological, particularly in the case of psychiatric illnesses.The exclusionary aspect of the ideal of the normal or the 'healthy' has historically led to the stigmatization of mental illness and has placed the psychiatric hospital alongside the prison: "The psychiatric hospital and the prison, for the collective imagination, are not part of the city.Symbolically they exist outside the city walls" (ibid., p. 194-195).
As was the case at the biological level, where the pathological in the sense of a deficit led to the demand for care, at the social level medical institutions arise as a way of caring for the patient and treating illness, through the sharing of knowledge about cases and the best methods of treatment, the development of competent and caring professionals, and so on.However, when this practice is tied to the norm of 'health' and divorced from a recognition of and respect for 'deviations' from the norm, it can lead to exclusion and a hegemonic view of illness.
The solution for Ricoeur is to accompany the demand for care with the demand for respect and recognition: How are we to reach, beyond the disease, the patient's still-possible resources of the will to live, of initiative, of evaluation, of decision?In other words, how can we make up for the deficiency of the other person, the patient, without excluding him or her?To pose such a question is already to indicate a willingness not to allow the act of social exclusion to penetrate to the heart of the medical consultation.(Ibid.,p. 194) The respect owed here, as I have already mentioned, is aimed also at "friendship," so that we should not understand Ricoeur as opposing respect to institutional forms of healthcare, but rather as showing how respect and the recognition of difference lead to a concept of care that aims to treat both the illness of the patient and recognize his or her own social worth: "The task for physicians, carers and friends is to compensate for lost functions, without, however, extinguishing the other's own initiative that remains crucial for their self-esteem" (Junker-Kenny, 2014, p. 295). (3. 3) The Existential Struggle For Recognition Finally, at the existential level, the pathological is understood as a loss of one's own self or sense of identity.This universal threat of despair could perhaps be seen in cases of care fatigue or compassion fatigue, and for Ricoeur it is "a threat inscribed in each of us, once we begin to consent to sadness, to fatigue, to discouragement" (ibid., p. 196).In Petruschka Schaafsma's article on care ethics and Ricoeur she argues that Ricoeur's philosophical anthropology demonstrates the inseparability of despair and hope, of finitude and infinitude.In viewing the pathological only in terms of illness or the demand for care, we run the risk of objectifying those suffering from illness or having to exist within a shrunken milieu.In relation to care ethics and the focus on developing a "weak anthropology" 5 originating in practices, Schaafsma writes: "In particular, the attention given to human vulnerability and mortality may run the risk of connecting human beings in a 'sad' human condition, a fate from which one cannot escape" (Schaafsma, 2014, p. 165).For Schaafsma, Ricoeur is intentionally countering this threat of objectification in his reflection on the more primordial resources of the human and the dialectic between finitude and hope.
At the existential level, the demand for respect originating in those suffering from despair is answered not just through caring for the others' psychic state, but also through the sharing of the resources of hope and courage.The professional physician or carer is entrusted with this task in an institutional setting when they "find [themselves] given the charge to compensate for the deficit in the patient's self-esteem and courage by a kind of shared esteem, what we could call a supplementary or supplementing esteem" (Ricoeur, 2007, p. 197).So, once again, care is taken not just in its medical sense, but in a dialectical relationship with respect, so that the shared aims of both care and respect are friendship, mutual hope, and self-esteem.
Across these three stages, the notion of targeted respect that is developed leads to an understanding of respect that is rooted in a relation with care, rather than in universal principles.However, just as universal concepts of respect need to be grounded in practical caring relations, care understood solely as a response to the empirical demands resulting from states of illness or suffering needs to be grounded in an appreciation of the value of the difference between the pathological and the normal.Ethically, the aim of respect is then refigured as the cultivation of care and friendship and, correspondingly, the aim of practical care becomes part of the struggle to recognize the singular, and transcendent, worth of each individual within a practice.

CONCLUSION
Ricoeur's philosophy does, at times, try to mediate between practical understanding and ideal formulations, to the extent that differences emerge between his approach and a care ethics 'practices all the way up' approach.Nevertheless, his distinctive value from a care ethics perspective lies in the way his analysis of the epistemological sciences, moral reason, and the role of respect in healthcare demonstrates that approaches which may at first appear too 'abstract' in relation to care ethics, actually depend heavily on insights gained from practice.This ethical deconstruction of pure reason can be seen as originating within a hermeneutic understanding to language and discourse, which actively seeks out concrete cultural and practical symbolic meanings in order to provoke reflective thought.Self-understanding is always practical; it does not appear as a 'first truth'; rather it emerges gradually through the experiences of interpretation and action within different contexts.Although the aim of such an activity is often the final development of a shared foundation or background, which would serve as a way in which to understand being as a whole, within Ricoeur's work itself this "desire for a foundation" is always understood as a fragile or insecure way of guiding interpretation.This can be seen in the ambiguity of Riceour's hermeneutics, which both apprehends this wholeness of being, but also actively seeks out otherness and disruption.
In Ricoeur's work, the self is always mediated through concrete, practical relations with others.Objective explanations always need to be referred back to the diverse and, more often than not, asymmetrical relations of the lifeworld.Furthermore, the field of action and practice is one which is variable; new technologies provoke new orientations and even new senses of moral identity.An adequate moral philosophy would have to take these shifting factors into account.The emphasis on the perpetual conflictual nature of moral reason highlighted in Ricoeur's work aims to capture both the guiding role of ideals or horizons of action and the vulnerability of these ideals when confronted with the solicitude that stems from the other.The tension between our personal desires or aims and the solicitude stemming from the other is a purely practical one for Ricoeur; it can only be resolved through a practical wisdom that can anticipate variable subject matters, and which is bound to human life experience.
Finally, Ricoeur's own work on care and respect in the context of healthcare relations can prove a useful concrete example of the ways in which moral concepts such as respect can be rooted in practical understandings of life.
Ricoeur's phenomenological approach to the experience of suffering and illness argues that the 'pathological' need not be understood in a purely pragmatic or empirical sense as that which demands care and restoration.Rather, the recognition of the diversity of ways of being-in-the-world leads to the view that the experiences that deviate from the 'norm' of health have their own "vital value" and their own internal claim to be worthy of respect.In this way, the term care can be expanded to include ways of both treating a patient well and recognizing the patient's singular worth.Furthermore, since Ricoeur's analysis includes not only the biological and social senses of care, but also the existential, these notions of care and respect can be extended beyond institutional settings towards an appreciation of the fact that everyone needs care.This is true both in the sense of human confrontations with 'despair,' and in the sense that we all experience shrunken milieus at different times in our lives.The sensitivity needed to recognize these concrete situations of need gives rise to a caring perspective, which aims to 'supplement' esteem and function, while also respecting the internal worth of these practical environments.

NOTES
1 "To try to capture the basic difference between the approaches found in care ethics and Ricoeur, it might be useful to start with a more general point.To capture it intuitively, we might recall the famous philosophical joke: 'an ancient belief is that the universe rests on an elephant's back, which, in turn, stands on the back of a turtle, but what supports the turtle?One uncompromising answer is that there are turtles all the way down.'On the contrary, the claims of care ethics might be described as 'practices all the way up.'"(van Nisterlrooij and Schaafsma, 2014, p. 489) 2 "It seems to me that the 'Cartesian moment,' again within a lot of inverted commas, functioned in two ways.It came into play in two ways: by philosophically requalifying the gnothi seauton (know yourself), and by discrediting the epimeleia heautou (care of the self)."(Foucault, 2005, p. 14) 3 For example, in preparation for visiting the oracle, one had to examine oneself so that this knowledge would lead to more precise questions aimed at a more profound spiritual transformation: "As for the gnothi seauton, according to Roscher it would mean: When you question the oracle, examine yourself closely and the questions you are going to ask, those you wish to ask, and, since you must restrict yourself to the fewest questions and not ask too many, carefully consider yourself and what you need know."(Foucault, 2005, p. 4) 4 "It is not surprising, then, that a print of the first sonogram is often included in the baby album as 'baby's first picture.'" (Verbeek, 2008, p. 16) 5 For Annelies Van Heijst in the book Professional Loving Care (2005), "A different kind of anthropology should be developed, specified as 'weak,' in distinction to a 'strong' one 'with a great many normative assumptions and a detailed list of features that characterise the human being.'Astrong anthropology is problematic, according to Van Heijst, 'given the pluralism in society.' " (Schaafsma, 2014, p. 153) Interpretation begins from this vulnerable space of fragmentation and constitutes a recovery through practical engagements with cultural works, technologies, and other people.Our understandings of what it means to care arise from these practical networks of relations.As can be seen in the case of the ultrasound scan, new technologies add new practical variables to these relations, meaning that our interpretative and moral frameworks must remain open enough to incorporate shifting moral identities at the practical level.
Both Verbeek's analysis of technologies of the self and Gilligan's outline of the practical, as opposed to theoretical, questions opened up through new technologies are in line with Ricoeur's hermeneutic conception of the self as always fragmented.