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Dependency Work: A critical exploration of Kittay's perspective on care as a relationship of power
Michael Fine
Department of Sociology and Centre for Research on Social Inclusion, Macquarie University, NSW
Abstract
The emergence of a specialised field of care research is a relatively recent development, owing much to feminist scholarship and the increasing prevalence of women in the public domain. This paper briefly outlines two of the most influential approaches to the more general field of care research, comparing them with research on professional relationships in formal health care settings.
While gender operates as an explanatory factor in each of these approaches, issues of power and domination, which feature strongly in the health sociology literature, are largely avoided in the research on care. Kittay's approach to the theory and analysis of care is a notable exception. Using her recent work as a central focus, this paper explores the social position of care givers and receivers. Examining the nature of power within and surrounding care relationships, Kittay makes an important distinction between the inequality of power and the exertion of domination. Her argument has much to offer sociological research in the field of care, but her avoidance, and at times, confusing use of the concept of 'care', and of the terms 'power' and 'dependency', present some difficulties.
To clarify the potential of her contribution, a critique is offered which compares her approach to the analyses of power by Lukes and Foucault.
Keywords
sociology, care, dependency, power, the body, ethics of care
Article Text
The field of medical/health sociology has long been concerned with the power of medical practitioners (Parsons 1957; Freidson 1970a, 1970b; Illich 1975; Ashley 1976; Willis 1983). Most analyses, until recently, identified a link between the dominance of medical professionals, and their access to and control of medical knowledge. The powerful position of the medical profession, evident at the micro-level of interpersonal relations between professionals, their patients and other health care staff, is widely seen as reflecting its broader social position. This is bolstered by, and derives in large part from, the profession's receipt of monopolistic powers from the state over the application of scientific medicine. The power of nurses has been portrayed as subordinate and circumscribed, reflecting the gendered division of labour in health care, which in turn reproduces the gender relations of advanced industrial capitalism more generally. With few exceptions, the social relations of unqualified staff have been ignored. One of the more notable of these can be found in Erving Goffman's (1968) account of 'total institutions' (such as mental asylums), where senior psychiatric professionals are seemingly powerless to intervene in the abuse of patients by ward staff. A central, if little acknowledged, feature of Goffman's analysis, is the suggestion that ward staff are in a position of power over inmates, a situation deriving from their collective control of strategic resources and institutional processes.
More recent accounts in the sociology of health identify a process of significant change in health care arrangements. These include growing financial pressures on health services, increased state regulation through ongoing processes of restructuring, and, in both Australia and the USA, new patterns of corporate control in health care (Ritzer and Walczak 1988; Freidson 1990; Collyer and White 1997, 2001; White and Collyer 1998; Brock et al 1999; Blattel-Mink and Kuhlmann 2003; de Voe and Short 2003). Together with increasing consumer activism, and the impact of feminism and social movements in the field of disability and old age, the dominance and power of the medical profession is increasingly seen as contested and under threat. While reference to gender typically concerns the differential power of male and females, gender can also be played out in other ways, as shown in a recent study of the conflict and a power struggle between nurses and nursing assistants in the Norwegian health care system (Dahle 2003). Although, as the author notes, 'caring work is culturally coded as female', the definition of knowledge and professional skill serves to demark the professional boundary between two female occupational groups. Documenting the professionalisation of care work, Dahle notes how registered nurses in Norway have sought to maintain professional control over 'basic care', which involves all work concerned with the patients' bodies. Work involving more 'housewifely' tasks (cleaning, making beds), is in turn assigned to nursing assistants, effectively excluding them from what the assistants see as direct responsibility for care. In this predominantly female social order, care is being defined as a prestigious activity involving direct contact with patients.
The volume of sociological studies examining professional relationships in the formal health care sector reflects, in part, the significance of institutional health service provision in contemporary Western societies and its powerful position in the academy. Yet, although most care is provided through and within the family, there is little research on care and informal caregiving that explicitly addresses care as a relationship of power. At home, caregivers are typically, although not exclusively, women (Barrett and McIntosh 1982; Finch and Groves 1983; Dalley 1988; Baldwin and Twigg 1991; AIHW 2003). Most of the social research on informal caregiving has been conducted since the mid-1970s, and arguably the very field of research and theory on the topic of care, has been either the product of feminism or informed by feminist scholarship. This work suggests that care-giving activities have been hidden in the private sphere of the family, and were opened to scrutiny by the movement of married women into the public sphere of employment and politics. While it is not possible in a short space to do justice to debate on the meaning of the term 'care', or to the impressive and quite extensive body of work on care that only developed in the final decades of the twentieth century (see Thomas 1993 and Bowden 1997 for an overview of much of this research, and also Reich 1995 for an account of the historical applications of the notion of care), two major and contrasting perspectives stand out.
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At the same time, Kittay provides a rationale for practical social intervention to overcome the inequality faced by both caregivers and care receivers, offering a normative justification for public support of care and the upholding of the rights of caregivers to participate fully in social life. But the implications of her approach go well beyond this. Instead of care being seen as a specialised domestic activity, a kind of social 'afterthought' outside the 'mainstream' realms of economics, politics and knowledge production, it can be seen through her perspective as a central activity of human social life.
This is not to suggest that Kittay's approach to care is unproblematic. As Lukes (2005: 109) admits of his earlier work, the pared down, ideal-type analysis of power reflects the application of conventional philosophic logic. This has major limitations when applied to the complexities of social life, which cannot be understood simply in terms of dyadic pairs. Similarly, Kittay's simple paradigm of a two-person care arrangement dependent on, and accountable to, a single provider, is simply not amenable to addressing and explaining the manifold complexities associated with care in contemporary Western societies. Nevertheless, Kittay's work provides significant analytical tools for understanding care in ways that avoid sentimentality, the portrayal of caregivers as victims of the system, and the recipients as social burdens. Further, Kittay's analysis of care bridges the gap between accounts of formal and informal relations of care. Arguably its most significant contribution is its identification of the important and fundamental place that care, and arrangements for the support of care, plays in social life.
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