I was giving a talk at a Catholic church just outside Chicago when one member of the audience stood up, apologizing because she had to leave. She explained that she was part of the "Quad Squad," a team assigned to help with round-the-clock care for quadruplets born a few weeks earlier to a couple who were members of the church community. Such voluntary caregiving—disproportionately provided by women—is invaluable, yet it commands little respect, argues Emily Abel in Hearts of Wisdom: American Women Caring for Kin, 1850-1940. Indeed, Abel writes, in this culture at this time we routinely "disparage the people who sustain life and nurture the weak." We prefer to maintain our illusion of independence in all things. No one wants to be dependent. In fact, it has even become the name of a syndrome—codependence—and is to be avoided at all costs. How strange that a state we all share—that of dependence on others—becomes a condition we first deny exists and then re-cast as pathological.

But the reality won't go away. Whether the focus is on preschool-age children or aging parents, practical questions of caregiving are central to many American households. And increasingly, scholars in many fields—moral theory, psychology, political philosophy, and more—are turning to the subject of care.

This current attention to care has many sources, but the most significant of these is feminist thought, in particular the evolving feminist debate over motherhood as the archetype of caregiving. Motherhood took a beating in 1970s feminist political tracts and treatises, which tended to see caregiving as a kind of servitude imposed on women by a patriarchal society. But the visceral antipathy toward mothering expressed by radical feminists helped to spur a reaction in the 1980s, when a few brave souls opined that perhaps the family was not the source of all political evil. Today exploration of mothering is widespread among feminist writers and scholars who are rethinking the world of women's work, seeing in the historic connection of women to caregiving a source of strength, a form of knowledge, and a claim to authority.

The anti-maternal camp didn't give up without a fight. Some spoke darkly of creeping "pro-natalism" in the women's movement. But the debate had shifted in ways both salutary and problematic. A problematic feature was an unfortunate tendency to counterpose "justice" (as an abstract "male" concept with pretensions to universality and even-handedness) to "care" (associated with keen attunement to the particular case and, of course, with women's work). Why it seemed a good idea to pit justice against care remains a mystery to me. Surely an interesting struggle from the beginning of Western philosophy to the present moment has been to bring justice and care, the many and the one, into a single frame. Surely egalitarianism need not mean homogenization and justice isn't reducible to a "male model" of reason, even-handedness, and impartiality. (Why is that a male model anyway?)

Responsible critics, by contrast to those who claimed that some weird "identification with patriarchy" explained the reevaluation of women's work, argued that proponents of a care ethic romanticized female feeling above ostensibly male abstract thought, reproducing the hoary dichotomies that feminism was supposed to be deconstructing in the first place. Care theorists replied by insisting that women's concentration on relationships and particular cases, on the attentive work of love, was a psychological achievement and an epistemological stance, not something hard-wired into nature. Men could get in on the act, too. If they did they became "mothers" as well. "Fathers" were still left out on the doorstep cooling their heels in many of these discussions, and attempts to bracket sticky questions of what male and female embodiment might have to do with psychologies and epistemologies couldn't be held at bay indefinitely. Still, it was a relief not to have mothers treated as a bereft, ground-down "sex-class" doomed to reproduce the system that had victimized them.

Important political questions about care began to be asked. For example, in Joan Tronto's 1993 book, Moral Boundaries: A Political Argument for an Ethic of Care, care as a political concept was defined as "everything we do to maintain, continue, and repair our 'world' so that we can live in it as well as possible." Antecedents to a perspective that had become a female preserve in current debates could be found, so she argued, in male Scottish Enlightenment thinkers who emphasized sentiment and saw the household as an antidote to the corruption and vanity of the public world. Many concepts of justice have been infused with imperatives associated with a care perspective and, for that reason, look very little like the "abstract" vision of justice feminist care ethics descried.

Thinking about care politically, rather than as a primarily psychological dynamic, meant you had to consider the nature of social responsibility. Who was responsible to whom and for what? What role should the government play in "nurturance"? Is government responsible for day-care in the same way that it is responsible for safety in the streets? Too frequently the slogan, now grown stale through excess of repetition, that "it takes a village to raise a child," seemed to mean that it took the vast panoply of various social service agencies and government bureaucracies to raise a child. In the name of care, it seemed, caregiving could became remote and formulaic. Moreover, "caretaking" could surely be as paternalistic (or maternalistic) as systems of "male dominance" feminists aimed to replace.

The theoretical debate stalled out at this point even as the solid work of social history has gone on. Rather than arguing the question of whether there is or is not a distinctive model of female moral reasoning linked historically to the task of care, social historians display concrete and various worlds of caregiving previously lost to historic awareness. Emily Abel's contribution occupies the middle ground between a straight empirical account and a philosophical argument. A professor of Health Services and Women's Studies at the University of California, Los Angeles, Abel brings to the project her experience as a receiver of care (in her fight against cancer) as well as a giver of care who, together with her siblings, tended to her mother until she died.

Abel poses and reposes a caveat that runs as a leitmotif throughout her book. It goes like this: Care can "reignite family conflicts, impose financial stress, and encroach on both work and leisure." But … caregiving can also be a "transformative experience, introducing us to new forms of human connectedness." The awkward "connectedness" is Abel's way of talking about situations in which human beings are compelled to recognize the essential sociality of the self and the intricacy of the webs that connect us one to another.

When you are young and healthy and an American, breathing the bracing air of individualistic freedom and being all that you can be, it isn't so easy to recognize that you owe your identity to others who have cared for you, educated you, and sent you on your way. Abel understands that Americans need reminding that illness and disability are constant features of human life, although the "dominant culture extols the virtues of independence, seeks distance from such basic life experiences as birth, illness, and death, and trivializes most unpaid work done by women in the home." It was the trivialization of that work that animated several generations of 19th- and early-20th-century feminists, not in order to phase out motherhood but rather to lift up the work of mothers in families and communities by recognizing and honoring this work as the civically vital contribution it was. Although the conditions caregivers deal with—birth, pain, infirmity, disability, and death—are constant, the context and meaning of care shift historically. New technologies profoundly alter care, for example.

Abel's book covers the mid-19th to the mid-20th century, a period that saw the bolstering of physicians' claims to authority over those of female caregivers. Powerful new medical technologies and the enhanced professionalization of medical training increasingly held sway. The broad contours of Abel's book feature themes and claims that highlight the interplay of traditional female modes of knowledge and the newly authoritative mode of "scientific" medicine that gained ascendance. The latter triumphed at the expense of the "emotional and spiritual aspects of caregiving" that had lent prestige to the "private world of caring," a world of "empathic knowledge" Abel distinguishes from "scientific rationality." More and more caregivers—the professional physicians—were distanced from the recipients of care—the patients. The upshot was a diminution of the emphasis female caregivers had placed on helping a person to prepare for death, an imperative tied to religious belief.

The "scientific rationality" mode has a hard time with death, preferring to fight it off as long as possible or to ignore it altogether. By contrast, empathic knowledge helped families and the dying person to take leave of one another in ways that permitted the normal grieving process to go forward: this, at least, is the broad contour of Abel's more theoretical formulations.

We meet some extraordinary women in Abel's pages. She devotes a chapter to one Martha Shaw Farnsworth, a "white woman from Kansas between 1890 and 1924," who cared for two husbands, an infant daughter, and a niece. (Abel's repetitious identification of caregivers by race is tedious when, given the context, it is quite obvious whether the women she is discussing are white or black.) Something like an apprentice system functioned as mothers transmitted their medical skills to daughters. Women routinely attended one another in childbirth and at the sickbed. Birth and death were communal events.

The singularity of devotion caregiving often required "exacted a terrible toll and conferred significant benefits," Abel insists. Diseases that felled individuals and entire families in the period she covers included pneumonia, typhus, typhoid fever, diptheria, scarlet fever, measles, whooping cough, dysentery, tuberculosis. During an epidemic, "women moved continually from house to house in the community, exposing themselves and their own families to disease." The overall picture that comes through is one of competence and determination. Caregiving, especially in time of epidemic, disrupted women's lives, breaking the rhythm of household and farming chores, including harvest and "putting up" fruits and vegetables. But it also offered women a broad sphere within which to display their special knowledge and to gain recognition as healers. In their journals, women note the pleasure they derived at supplying the needs of their loved ones.

With the goal of professionalization before them, physicians criticized the influence of untrained caregivers and even nurses, especially during childbirth. Still, the realm of practical experience represented by women caregivers retained a great deal of respect among ordinary people throughout the 19th century. In the 20th century, that respect drained away as practical reason gave way to new techniques.

Abel traces this history of change and loss in the journal of Martha Shaw Farnsworth, which came to more than 4,000 pages. Farnsworth's story is one of "suffering, perserverance," of "nursing sick and often dying babies," of responding to new techniques and the social mobility that broke up the old world of caregiving by weakening the "bonds of interpendence among many women."

At one point, Abel makes a move that problematically overstates her case. She claims that the "virtues of rationality, objectivity, neuturality, and universality" spelled doom for women caregivers. This is unfortunate. "Scientific rationality" of a cramped sort, unattuned to varieties of ways of knowing, need not be equated with the undeniable virtues of rationality, objectivity, and universality per se. These latter virtues, in turn, do not rule out particular needs, claims, and commitments tout court. Here Abel veers dangerously close to the "male rational/female feeling" dichotomy critics of the care perspective rightly decry.

It is scientism, not "Enlightenment values" as such, as Abel suggests, that privileges one way of knowing above all others, downgrading women's traditional approaches to medical care in the process. As intergenerationally transmitted healing practices were disparaged, a reductionistic form of biologically based scientism triumphed. Overstating, no doubt, but pointing to a real tendency, Abel claims that this triumph "rendered irrelevant the patient's emotional and moral state, interaction with providers, and physical surroundings"—all of which were central, indeed the heart of the matter, for women caregivers.

The federal government got into the act, too, setting up a Children's Bureau headed by former Hull-House resident Julia Lathrop. Hard-won maternal practices were demoted in favor of "scientific motherhood." A pre-Spock book, The Dangers of Too Much Mother Love, sold like hotcakes in the 1920s and 1930s. Mothers and grandmothers were chided for being "doting," "over-solicitous," and "blindly fond." Even rocking, cuddling, playing with, and singing to infants fell under a pall of suspicion. In 1923, a president of the American Academy of Pediatrics wrote that infants and young children "suffer from the attention showered on them by the parents, numerous friends and relatives."

Pressing a thesis argued eloquently by the late Christopher Lasch (though he is nowhere credited in these pages), Abel discerns growing doubts among women about the value of generations of practical wisdom as they, too, fell under the spell of the expert culture. The costs to women themselves were high, for their authoritative claims to healing and caregiving could not, and did not, survive. With an official governmental imprimatur, manuals on child-rearing "undermined women's faith in their own judgment" and, by urging mothers to shun the advice of relatives, neighbors, and friends, "experts may have increased women's sense of isolation."

Abel references the thousands of frightened, desperate, curious women who wrote the Children's Bureau, the volume of missives reaching 125,000 a year. These letters reveal women turning themselves into nervous wrecks over such matters as the possible lasting consequences of a child's refusing to drink milk from a cup or stubbornly clinging to either the breast or the bottle. Inevitably, the new science of child-rearing oversold itself, so much so that many women believed they had been promised perfect children if they followed expert advice and grew angry when doctors told them there was no way to remove birthmarks or freckles.

There are also desperately sad tales of families resisting institutionalization of their children, the treatment mandated for a variety of conditions and ailments, including tuberculosis. One Italian family whose saga Abel details couldn't bear to part with their little girl, so they took her to live with a relative in New Jersey in order to get the mandated exercise and fresh air. This prompted the New York Charity Organization Society to "report the case to the Society for the Prevention of Cruelty to Children, requesting it to find a way to take Maria 'by force' to the hospital." The spcc said it had no jurisdiction in New Jersey. There matters remained until the family made the mistake of bringing Maria home to New York for a visit, where the authorities' jurisdiction pertained. The unhappy child was forced into a hospital where, pining for her family, she died.

Many parents in this era found themselves under attack for excessive "emotionalism" if they refused to institutionalize their children. The director of social service work at Youngstown Hospital in Ohio described parents as "prejudiced by their love for their child," conceding that "although it may be more of an animal love than human it must be recognized."

For charity workers as state paid caregivers, tubercular people were "menaces who should be segregated from their families and the rest of society." As well, according to Abel, "charity workers assumed that poor women were too emotional, ignorant, and fatalistic to deliver good care." Caregivers sometimes fought back, pointing out that children often grew sicker in the hospital. Abel breaks the reader's heart with stories of parents trying desperately to retrieve homesick children or to prevent the institutionalization of a child, stipulated routinely for children with disabilities. (Of course, some parents rushed to send their disabled children off to an institution.)

Under the sway of Social Darwinism, the last decades of the 19th and early decades of the 20th centuries also witnessed alterations in the rhetoric deployed to refer to children with epilepsy and "feeble-mindedness." Once called "afflictions," various maladies and conditions now labeled a child a "defective." An affliction had been taken as a sign from God; each child had value. But a defective child is, as Abel writes, a "lemon, like a bad car." Indeed, the 1892 annual report of the Board of Directors of the Illinois State Institution for the Feeble-minded referred to the inmates as the "waste products of humanity" and a "menace" to society. The grief attendant upon separation of families from the "waste product" they had given birth to was laid at the doorstep of "maternal overemotionalism." Official institutional caregiving reinforced a burden of shame carried by families with a "defective," associated in the public mind with "vice, immorality, failure, bad blood, and stupidity."

The knowledge mothers evoked where their disabled children were concerned was haughtily dismissed. One mother insisted there were capabilities her son possessed that didn't show up on iq tests, ending her plea with: "My boy is very dear to my heart." But it was easier by far to acquiesce in the culturally reinforced view of a child as a waste product, fit only to live out a life in an institution, than to recognize that this was a human being wounded in many ways but capable of tears, laughter, love, of responding to sights, sounds, textures. The goal was "hand them over and forget about them." Still, desperate mothers queried: could not something be done for a "Mongolian type child"? And the doctor writes back, no, there isn't, and that is why he must be institutionalized.

When parents complained of abuse in the institutions to which their children had been sent, as they noticed scrapes, bruises, soiled clothing, lice in hair, and even broken bones, these were dismissed or explained away. Most appeals for better treatment or release were fruitless. Abel accepts the grief-stricken assessment of parents that their child died from a broken heart; that a child's condition deteriorated the moment he or she was institutionalized.

Much has changed in our attitude toward persons with disabilities, and for the better. There are all sorts of folks experimenting with all sorts of approaches to medicine, too. But the world of caregiving shows remarkable continuity from 1840 to the present. Caregiving takes time. It is now a lonelier endeavor than it was in the 19th century, when giving care was a communal activity. The upshot is that Grandma is sometimes dropped off at the er for the weekend with a "breathing problem" or some such because exhausted families need a bit of time off. Surprisingly, Abel doesn't mention the networks of sustaining and supporting care available through churches. Nearly all churches of a reasonable size feature support for caregivers as a social ministry, of which the "Quad Squad" I mentioned at the outset is a representative example.

As she concludes, Abel fumbles the ball a time or two. Hoping she won't be set upon by the voluptuaries of progress, she goes through the by-now ritualistic caveat: I am not now nor have I ever been a member of the nostalgia-for-a-mythical-past party. She repeats yet again the basic yes and no: caregiving is often depleting and exhausting but it provides important gratifications. She references feminist texts that portray women caregivers negatively, as slavishly tending to others because they are forced to by "oppressive ideological and material forces," even though the weight of her own book undermines such simplistically freighted formulations.

Almost as an afterthought, Abel strings together a garland of hoped-for broad reforms that come out of nowhere and are never argued for, simply listed as so many desiderata. Much of this tends toward the formulaic—"eradicating the gender division of domestic labor," for instance. Who can possibly be opposed to nostrums like spreading the work of care more equitably, or adopting policies that address the needs of caregivers? Telling us we ought to embrace diverse family and community arrangements adds nothing to the discussion because this isn't an issue she addresses in any detail or offers compelling arguments for or against. Her book would have been better off without such bumper-sticker afterthoughts, for the strength of Hearts of Wisdom at its best is the concreteness of Abel's case studies and her archival evidence. A grocery list of vague nostrums only detracts.

Jean Bethke Elshtain's most recent book, Just War Against Terror: The Burden of American Power in a Violent World, was published by Basic Books in April. An earlier work, Jane Addams and the Dream of American Democracy (Basic Books, 2003), bears directly on the themes taken up in this review essay.

Copyright © 2003 by the author or Christianity Today/Books & Culture magazine.
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