“Watchful waiting”: everyday ethical caring practices of general practitioners in cases of intimate partner violence

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  • 1 Vrije Universiteit Brussel, , Belgium
  • | 2 Maastricht University, , the Netherlands
  • | 3 Vrije Universiteit Brussel, , Belgium
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This article focuses on the ethical caring practices of general practitioners in dealing with intimate partner violence. In-depth interviews were conducted with general practitioners to inquire about their concrete experiences and conflicts, which were then submitted to a thematic analysis based on Tronto’s elements of an ethics of care. The results show the difficulties faced by general practitioners when it comes to clarifying their patients’ caring needs, determining what is meant by competent care and dealing with the conflicting expectations of the caregiver and care receiver particular to the issue of intimate partner violence.

Abstract

This article focuses on the ethical caring practices of general practitioners in dealing with intimate partner violence. In-depth interviews were conducted with general practitioners to inquire about their concrete experiences and conflicts, which were then submitted to a thematic analysis based on Tronto’s elements of an ethics of care. The results show the difficulties faced by general practitioners when it comes to clarifying their patients’ caring needs, determining what is meant by competent care and dealing with the conflicting expectations of the caregiver and care receiver particular to the issue of intimate partner violence.

Introduction

General practitioners (GPs) are often faced with ethical issues in dealing with intimate partner violence (IPV).1 Certain interventions, such as reporting cases to the police or writing injury reports, may pose liability issues for the GP or cause the patient additional harm, whereas non-intervention may ultimately result in death. Ethical issues in medical care are usually approached from a deontological perspective (Wolfson, 2007; Wagman et al, 2008; Bugarin-Gonzalez and Bugarin-Diz, 2014), focusing on the application of bioethical principles like autonomy, non-maleficence, beneficence and justice in determining how caregivers should act in moral-conflict situations (Cook and Dickens, 2009; Beauchamp and Childress, 2019). An ethics of care perspective, however, reorients the focus towards the ethical characteristics of caring practices like relationality and contextuality, and attends to the different values and corresponding attitudes of caregivers, such as trust, vulnerability and responsibility. This article examines the caring experiences of GPs in dealing with IPV from a care-ethical approach. A total of 17 in-depth interviews were conducted with GPs in Flanders, Belgium. Responses concerning the applied caring practices and difficulties were submitted to a thematic analysis, using Joan Tronto’s (1993) elements of an ethics of care as an analytical tool (Brannelly, 2006; 2015). The first section discusses the specific value of an ethics of care approach in relation to IPV. Then, the next section focuses on the methodological framework, after which our empirical findings are presented in connection to Tronto’s elements. Our findings show the difficulties faced by GPs when it comes to clarifying their patients’ caring needs, determining what is meant by competent care and dealing with the conflicting expectations of the caregiver and care receiver particular to the issue of IPV. This research thus provides insight in how GPs seek to provide ‘good’ IPV care and shows the added value of an ethics of care perspective to understanding the different moral dimensions of IPV care.

IPV and the ethics of care

Feminist perspectives have extensively discussed the limits of mainstream biomedical ethical approaches in dealing with violence against women. Such approaches often centralise the value of autonomy, to the detriment of recognising the varied way in which victims can exercise agency. Moreover, such approaches often wield a limited understanding of autonomy, such as complete independence and self-reliance, which is not always appropriate in situations of IPV.

Marilyn Friedman’s (2003) analysis, for instance, shows how respecting autonomy can be subject to different interpretations. Friedman acknowledges that IPV can undermine the autonomy of victims but adds that victims also express autonomy in different, complex ways, including the choice to stay in a violent relationship. However, professional caregivers may regard this choice as constituting self-endangering behaviour. The rational persuasion approach, through which professionals try to convince their clients to leave their partners or to file a complaint against them, is often considered a ‘morally permissible response’ (Friedman, 2003: 152). However, this approach fails to acknowledge victims as actual agents and discourages confidence building. Friedman therefore argues that care professionals should provide uncritical support because it is non-coercive and encourages the victim’s psychological abilities. This uncritical support on the part of professional caregivers should go hand in hand with a judicial response, which justifies mandatory arrest and prosecution of the perpetrator without the victim’s permission in order to prevent domestic abuse.

Following Friedman’s work, Virginia Held (2010) argues that an ethics of care could adopt a similar position, namely, that the law is only one way to respond to IPV and that providing care by means of uncritical support, counselling and shelter is equally important, and sometimes even more effective, when it comes to empowering victims. In her analysis of autonomy from an ethics of care perspective, Verkerk (2001) shows how this ideal can actually hinder professionals from providing care. She specifically criticises the tendency to abstain from care in cases where respect for autonomy could be used as an excuse for non-interference, stating that ‘respect for autonomy even seems to exclude a professional attitude of attentiveness and commitment’ (Verkerk, 2001: 292). Instead, she proposes ‘compassionate interference’ as an ethical practice of committed care that stems from the relationship between doctor and patient. Although this concept was coined in relation to mental healthcare, it allows reconsideration of the rational persuasion approach. It is also important to note that the term ‘care’ can be interpreted differently, including as protecting patients by reporting their case to the police, as encouraging patients to leave their partner or as incorporating more affinitive and relational forms of caring, such as uncritical support. Furthermore, as Held (2010) argues, an ethics of care corroborates research findings from studies that focus on how best to care for all those involved in family violence (victims, perpetrators and children). According to Held, the ethics of care presents norms and values to criticise developed practices that have become standardised and do not always consider the victim’s specific needs. Following this argument, the ethics of care could help in analysing the concrete caring practices of GPs dealing with IPV cases in relation to the challenges they face and how they can provide ‘good care’ in a normative sense. An ethics of care perspective provides critical insight into relationality and vulnerability, while also valuing care by politicising it (Tronto, 1993; Vosman et al, 2018). According to Vosman et al (2018: 406): ‘this politicisation can not only be achieved through critical theorising but also by looking empirically at care from within caring practices’.

Tronto (1993), with her colleague Fisher, developed a theory of care that allows us to understand the complexities of good care as a continuing process. Tronto distinguished four dimensions and elements of care: attentiveness (caring about), responsibility (caring for), competence (caregiving) and responsiveness (care receiving). Attentiveness is considered to include not only the recognition of a person’s different needs for care, but also one’s ability to recognise these needs. Responsibility constitutes a call to action by taking up the responsibility of giving care, without having a formal obligation to do so (for example, in articles of law or job descriptions). Competence refers to the capacity to provide adequate care, while responsiveness considers the care receiver’s perception of the care provided.2 Tronto identifies moral failings in caring whenever one of these aspects receives insufficient attention. One may, for instance, recognise a patient’s needs and take responsibility but lack the competence to respond to the situation in an adequate manner. Tronto further argues that when analysing care, the societal, institutional and political context should always be considered. In relation to violence, the ethics of care also factors in stress due to oppressive social structures, which may either enhance or complicate violent situations (Held, 2010). In previous research, we also made a connection with the theory of intersectionality (Crenshaw, 1991; Sokoloff and Dupont, 2005). Indeed, the structural barriers that patients face in relation to their positionality often result in GPs adopting a caring disposition of just ‘being there’ because these patients have nowhere else to go since they are excluded from, or discriminated against by, the social health system (Vergaert et al, 2021). This analysis is similar to the presence-oriented approach developed by Baart (Baart, 2001; Timmerman and Baart, 2021), in which caregivers provide care by simply being present when a situation is insolvable or incurable. This presence generates an attitude of attentiveness and acceptance that endorses relationality between the doctor and their patient (Klaver and Baart, 2011).

Adopting an ethics of care perspective may thus also benefit medical care professionals who provide care in cases of IPV. As people’s local primary healthcare providers, GPs are ideally positioned for an early intervention in cases of IPV, prior to the intervention of more specialised services.3 Within this context of caring, and because of their profession as ‘generalists’, however, they may also encounter cases of IPV, without possessing the necessary expertise to respond to them (Potter and Feder, 2018). Furthermore, GPs often occupy a central position in the care provision of whole families, which results in a caring relationship that goes beyond the patient–doctor dyad. What follows are ethical challenges and questions as to how best to administer care in these cases, in which a care-ethical perspective would consider relationality, practicality, processuality and contextuality as vital constituents.

Method

This research was conducted in Flanders, the Dutch-speaking part of Belgium, and obtained ethical approval from the Ethical Commission of Human Sciences at Vrije Universiteit Brussel. An empirical qualitative design was chosen, following the argument that to comprehend care, one should look empirically to practices (Vosman et al, 2018). In addition, a qualitative approach offers in-depth understandings of the experiences and views of participants, which fits the scope of this research.

Empirical evidence was collected by the first author by means of 17 in-depth interviews with 18 GPs, focusing on their experiences with cases of IPV. The recruitment strategy consisted of convenience and snowball sampling. Sampling was purposive. During recruitment, several GPs contacted declined to participate because they felt that they did not encounter IPV in their practice or because they did not have an affinity with the subject. Therefore, we can assume that respondents included in our sample had some interest in the subject, as they chose to participate. We interviewed GPs from individual and group practices located in urban, suburban and rural environments. Six of the GPs worked in multidisciplinary practices providing free healthcare and were paid a fixed wage. The other GPs were self-employed and paid per consultation (either in an individual healthcare practice or in a group practice run by several GPs). Participants were between 28 and 70 years old; seven identified as male and 11 as female.

The first part of the interview was founded in a narrative approach to ethics (Ellos, 1998; Paulsen, 2011) in order to examine the concrete experiences and applied caring practices of GPs. Inquiring narratives add texture to detail and result in ‘relevance fixation’, that is, participants discuss experiences that they find are important to share (Frank, 2014). After some introductory questions (frequency of IPV in their practice, definition and so on), GPs were asked to share cases that they considered as exemplary for dealing with IPV, cases with difficulties and/or cases with a positive outcome. In the second part of the interview, elicitation techniques (Johnson and Weller, 2001; Barton, 2015) were used to evoke more tacit ideas about issues around IPV and healthcare. These techniques are known to facilitate inquiries about sensitive topics. Cards with statements based on the experiences, opinions and feelings of other GPs and professionals, either taken from the literature or based on previous interviews, were used to encourage participants to speak freely, thereby avoiding socially desirable responses, and to evoke critical and ethical reasoning. Examples of such statements are ‘My task as a GP is only to address the medical problem’ and ‘I cannot help the patient if they stay with their partner.’ Since the correct framing and introduction of this method are crucial, the interviewer explained how the statements were drafted and clarified that these statements are not necessarily representative of the position of the interviewer or the general public. Interviews lasted between 45 and 90 minutes. All interviews were audio-recorded and transcribed. Transcribing was used as a critical and reflexive process through which initial thoughts were noted and interview skills were evaluated. This process improved data collection, as it helped acquire more in-depth responses through continued fine-tuning of interview skills. In addition, even though this interview design could be considered as time-consuming for the participants, it also ensured the collection of thick data in a small number of interviews.

We used thematic analysis in NVivo, with specific attention to Tronto’s elements of an ‘ethics of care’ (Brannelly, 2006; 2015). Thematic analysis is a flexible process in which themes surfacing from the data are coded, grouped and compared (Braun and Clarke, 2006). The elements of an ethics of care were used to frame overarching questions and themes for analysis, such as: ‘How do GPs recognise needs?’; ‘How do they reflect about responsibility, and what does it mean to them?’; ‘How do they consider themselves as competent?’; and ‘In what way do they consider the patient’s reaction or receptiveness towards their care?’ On the basis of these questions, different themes surfaced in the cases and responses provided by the GPs. The emerging themes were grouped under the different elements. This type of coding was beneficial, as it offered a preliminary structure that could be adjusted and extended with additional themes emerging from the interviews.

Findings

The “gut feeling that something is not quite right”

The respondents make a distinction between, on the one hand, patients who directly request aid due to violence, name the violence as such and ask for support in the matter, and, on the other, patients who experience violence but do not formulate any concrete request. Most interviewees explain how they respond to needs in the first group, which they encounter infrequently, by attending to injuries, for example, and documenting these injuries, which may be used as evidence to file a complaint. Conversely, the interviewees also notice patients in the second group who visit them on a regular basis for care and support, without formulating any specific request, and whose needs seem unclear. Such patients can express a variety of complaints related to violence. Some GPs might use their experience and their knowledge of the patient to identify problems that are ‘not always given a name’ as indications of IPV. These problems require more ‘daily’ care, as illustrated in the following:

‘And then the daily “I can’t take it anymore”, all that. Not every day, but regular patients where you know what the deal is. I think I see women on a weekly basis who experience some small form of violence. But do you call it “fibromyalgia”, “chronic fatigue syndrome”, like “Everything hurts and I can’t take it anymore and I can’t go to work.” It’s not always given a name. But then, like, I know I once made a certificate, that it didn’t go well [in the relationship] and then she came here crying and now she has a headache. So, you don’t always have to name or label it, just ask how things are at home once in a while.’ (Dr Nadine)

Different respondents reported that they sometimes have suspicions or know about the violence because it is in the file, though it is not explicitly discussed during consultations. They explain that noticing IPV and the patient’s needs in this matter is also dependent on a “gut feeling that something is not quite right”. This gut feeling is also associated with caring beyond the patient’s medical needs. Indeed, GPs often try to adopt a holistic approach, with attention to social issues for which they distinguish different health consequences. They look beyond physical evidence like injuries and notice how a mental issue like burnout, for instance, may be associated with relationship problems and what it might mean for the patient if they were to leave their violent situation. Although several respondents explain that they find it difficult to understand why patients stay in an abusive relationship, they also recognise the shame surrounding this violence and the patients’ fear of consequences, such as retaliation, financial difficulties, losing the children, emotional difficulties or the difficulty of going through a divorce. Some respondents pay attention to particular vulnerabilities and structural factors,4 such as the lack of affordable housing or the non-intervention of other services, which contribute to the violent situation. Attentiveness is thus considered as recognising and showing empathy for the needs of those experiencing IPV. However, the recognition of those needs is challenging for GPs because their patients do not always specify their needs.

From “watchful waiting” to different kinds of referral

Facilitating disclosure or asking about IPV is one of the challenges discussed by GPs. For most respondents, this means asking carefully or indirectly about the difficulties in the relationship when suspicions of violence arise. As one interviewee explained, the recognition of violence is not so difficult, but the direct questioning can seriously affect or even terminate the doctor–patient relationship due to the sensitivity of the subject. Dr Marc, for example, discussed the risk of getting “kicked out of the house” when considering whether to address violence in the couples he treated:

‘But the actual problem is the subject you need to discuss with them. So, it’s really not hard to understand how, non-verbally, those partners interact with each other [violently], but if you sit down and start suggesting that their medical condition isn’t really the issue [but that the violence is], well, then you’ll get kicked out of the house, won’t you?’ (Dr Marc)

Interviewees mostly ask about violence indirectly, but this does not necessarily result in disclosure. Some respondents do not know what to do when the patient does not acknowledge the violence, or how far they should probe, while other respondents feel that nothing can be done in such cases. For several interviewees, the given care highly relies on the patient’s specific request, which obviously remains unclear without disclosure. When reacting to the statement card ‘I fear that discussing the violence would insult the patient’, the following interviewee explained that they also need to be mandated by the patient to take up a role in their situation: “I’ve had situations where people said ‘No’ [there is no violence], while I thought ‘Yes, I think it’s the case.’ But it’s nothing to do with fear. Of course, you need to be given a sort of mandate to play a part in it” (Dr Anna).

Different respondents explain how they remain cautious as long as the patient does not disclose anything. They try to be vigilant when they treat the patient, while remaining conscious of the situation. One interviewee used the expression “watchful waiting” to refer to the process of carefully building and maintaining a relationship of trust with the patient until they feel ready to disclose and allow for further uptake. Other GPs discuss this process as well:

‘That’s why it’s so hard and that’s why it actually depends on the patient themselves whether they want to undertake any steps or not, and I think that as a GP, it’s your task to build up trust with someone, that they’re open enough to tell you these things and talk about them with you, about what needs to be done.’ (Dr Amir)

It needs to be noted, however, that disclosure by the patient does not necessarily result in the uptake of care. This is where being mandated by the patient again plays a central part. Some respondents explain that they try to facilitate contacts with specialised services or the police when their patients are willing to do so. However, patients often do not want to undertake steps, which can be frustrating for our respondents: they feel responsible for the patient’s well-being but are not able or are not allowed to take further steps. In this case, respondents argue that the choice of the patient (autonomy) to do nothing prevents them from acting, which might result in a prolonged attitude of “watchful waiting” until patients feel ready to proceed.

However, once mandated, taking up care manifests itself in different forms. Mostly, it is associated with referral, which is reliant on the patient’s consent as a competent adult. We identified three different types of referral in the reports of our respondents: (1) overbearing referral; (2) neglecting referral; and (3) consenting referral. Each of these types represents a different way of assuming responsibility. For the first type – overbearing referral – GPs take over the referral and put a lot of time and energy in the case, fully taking the responsibility upon themselves. In ‘neglecting referral’, GPs merely provide the contact details of the specialised services and leave the uptake to the patients. In ‘consenting referral’, doctors and patients act together, and GPs turn over responsibility to their patients, while also continuing to support them in their help-seeking process. The same respondent who coined the term “watchful waiting” had previously lost a patient because her referral was experienced as overbearing. She regretted that her patient never returned to the practice because she could then have at least “kept an eye open”. However, some respondents also indicate how patients place a lot of responsibility on them by wanting GPs to take over:

‘People still often give us the feeling that we carry a great responsibility when it comes to making decisions. I often get asked, and so, I presume, do other colleagues, “What would you do in this situation?” or “How would you handle that?” It’s very hard to answer those questions.’ (Dr Nele)

The risks of referral are also mentioned in relation to mandatory reporting since professionals are legally obliged to report dangerous situations to the police or court.5 For some of our respondents, questions arise about if or when they can report a dangerous situation, though for most respondents, this does not create a particular dilemma since it concerns adult patients who should be able to decide for themselves whether they should report matters. Some other respondents feel that they would be able to assess the necessity to report a situation correctly. In most interviews, GPs would report their patient’s case with the latter’s consent, which corresponds to ‘consenting referral’. Reporting without consent is considered as possibly harmful to the relationship between the patient and the GP. Several GPs explained that they would rather remain their patient’s confidant and at least “keep an eye open” than lose them by breaking a bond of trust.

Facilitating disclosure, asking about IPV and referring the patient could all be considered as a form of responsibility. However, responsibility is dependent not only on the GP’s willingness to take up care, but also on the wishes of the patient.

Handing back responsibility

Although reporting IPV to the law does not always seem an issue, it still raises questions about safety. Different respondents have genuine concerns for the safety of some of their patients, for whom they fear a deathly outcome. One way to cope with this issue is to explicitly communicate their fears to their patients, something they feel they can do because of their relationship with the patient or their status as doctors. They express that they are worried for their patient’s safety. By inquiring about safety, responsibility is given back to the patient, as is explained here:

‘Then I’m faced with the dilemma of whether it’s safe to allow this woman to go home. So, I ask her the question: “Is it really safe for you to stay at home like this? Are you thinking about harming yourself? Can you guarantee me that you’re not going to…?” You ask that question to place the blame on her or, actually, hand the responsibility back to her.’ (Dr Jolien)

This fear once again makes GPs question their responsibility as regards the limits of their care. However, some are able to cope with this by sharing responsibility with colleagues. Through shared care, the caring is submitted to a form of evaluation: the checks and balances are discussed and shared with colleagues, which helps the respondents to feel more confident about their caretaking.

Most respondents consider that they can offer minimal support and try to provide safety in the best possible way, in accordance with their patient’s autonomy:

‘You can always support the victim and make sure to ask them, “Don’t you need to go somewhere?” I think the most important thing is to put safety first. I always try to make sure the victim is as safe as possible. That’s what care is at that moment. If it’s an acute situation, of course.’ (Dr Joris)

Yet again, respondents question how intrusive their caregiving should be in these cases and whether they can persuade their patient to leave their partner. For some, there is a sense of ambivalence, even when they fear a deathly outcome for their patients. Some respondents doubted whether there truly is anything they could do to prevent this, as a GP, even after assessing the patient’s safety. There is a genuine fear that cannot always be resolved by handing responsibility to the patient: “I’m actually more afraid, in today’s society, of domestic homicides. Like that couple I was talking about, the one where I said ‘This just isn’t healthy’. I was scared that if those people didn’t break up, we’d have domestic homicide or a murder–suicide” (Dr Annelien).

The response to this fear seems to be to focus on everyday caring rather than approaching the police or taking the matter to court. Beyond handing back responsibility to the patient, caring is considered as remaining available and making sure that the patient has somewhere to go to: “I just try to be there for them, so they don’t have to face things alone” (Dr Sarah). Concern for the patient’s well-being and life sparks a sharing of responsibilities, either with colleagues or the patient themselves. When GPs feel unable to take up care, remaining available seems to be the best approach to responsible caring.

Caring for the whole family through ‘multiple partisanship’

Several GPs notice the caring needs of the patient’s partner and their family as a whole. Our respondents explained how they often have an overall view of their patients’ lives, jobs or living situations. In many cases, GPs know both partners, as well as their children, which helps them to assess the family’s situation and needs. Some GPs are attentive to the children and seem less reluctant to act when children are involved. Some interviewees also pay attention to the perpetrator’s needs, for example, by asking themselves such questions as: ‘Why is that person violent?’; ‘Have they got a job?’; and ‘What issues are at stake for them?’ In other interviews, respondents mention how they treat perpetrators, though that does not necessarily mean that they consider their needs. Several respondents highlight ambivalence in dealing with the perpetrator when they are also their patient. As GPs, they are obliged to provide care for every patient, but some respondents explained that they find it difficult to remain ‘neutral’ once they know what the perpetrator has done; they might remain professional but find that they limit their efforts or invest less in the doctor–patient relationship. Other respondents argue that they find it very important to maintain their relationship with the perpetrator, not only as a way of caring for the perpetrator, but also as a way of caring for the victim. Other respondents feel that it is important to support both parties:

‘Yes, of course, I find that [the relationship of trust] very important, definitely. But in both directions, right? I’d like to keep the aggressor close to me as well. That’s why I wouldn’t immediately take the position of leaving that person. Because it’s also important when someone’s expressing aggression towards someone else, of course, there can be aggression from both sides, but I find it important to keep them [aggressor] close to me too.’ (Dr Andreas)

Remaining ‘neutral’ recurred in several interviews because, as the caretaker of an entire family, GPs need to consider the different parties involved. One GP in particular explained how he has become part of the family system because of the long period of caregiving. As he knows the whole family, he feels that competent caregiving can be found in multiple partisanship6 and in being open to the whole family. For this GP, competent caring includes strengthening the self-sufficiency of his patients and remaining available for the whole family, without “choosing sides”. These findings show that competence also goes beyond the doctor–patient dyad and that caring for the whole family, recognising and considering their needs, triggers a neutral positioning as a form of competent care.

Being competent: “It’s so complex that it doesn’t always depend on you”

Different respondents recognise the needs for specialised support, such as therapy, and also acknowledge that they do not have the competence to offer such support. Interviewees explained how they do not know how to offer psychological counselling, but there may be something positive in their patient coming to talk to them, as explained by the following interviewee: “Yes, it’s not easy. In the end, it’s good that you can try and help people that way. I mean, I’m not a psychologist, I try to show some empathy and to listen and to give them a chance to vent, but yeah, I’m not a psychologist” (Dr Annelien). Although respondents explained that they are not trained to provide counselling, some do this anyway because the patient does not want to rely on anyone else. Consequently, the relationship of trust makes it easier for the GPs to “just do it themselves”. There may also be cases in which specialised services are simply unavailable. As described by Tronto (1993), this creates a moral failing when it comes to competence since the GPs recognise their patient’s needs and want to take responsibility but lack the competence, training or tools to offer the right support. This is dependent not only on the GPs themselves, but mostly on the context and the resources available to them. Difficulties concerning referral emerge in cases where GPs do not know where to ask for advice or where to find specialised counselling or lawyers. Certain interviewees refer to the lack of free and accessible counselling since many patients do not have the financial means to pay for counselling. If their experiences with referral have been positive, respondents seem to feel more competent in responding to IPV. This also depends on the type of healthcare practice that GPs work in: several respondents explained how they feel more competent because they have a nurse, social assistant or psychologist in their practice on whom they can rely, or colleagues whom they can ask for advice.

Another resource issue is related to time. Several respondents deplore the time-consuming aspect of IPV cases and recognise the need to give patients more time, though this does have financial implications for GPs who are self-employed. One doctor explained how she sometimes harbours suspicions but finds it more ethical to defer asking about violence when time is lacking. This particular respondent considers a lack of time as a form of incompetent caring and thus withholds any questions about violence if she cannot provide enough time to care: “You can’t go fishing about if you don’t have enough time afterwards to answer those questions. For all you know, the patient might break down completely, start crying, and then you’re looking at half an hour at least” (Dr Manon).

Concern for the outcome of the provided care is crucial in ethical caregiving. Several respondents consider referral as a way of competent caregiving, but from an ethics of care perspective, this requires follow-up and consideration for the outcome. Most of our interviewees are conflicted when they do not know the outcome of their actions or when their referral is not taken up by other services. After reading the statement card ‘I feel competent enough to deal with IPV’, one respondent explained that she does feel competent but that competence depends not always on her alone, but also on the context and the patient: “But I’m not scared, in a case of partner violence, of throwing myself into it and dealing with it. But it’s so complex that it doesn’t always depend on you. It doesn’t always depend on you and then I read that word ‘competent’” (Dr Nadine).

Competence is also connected to communication skills, about which our respondents generally feel confident. For many, experience also plays a crucial role, as they gradually learn to improve their relational skills in order to be more efficient or to be less invested. In that way, self-care or self-protection could also be considered as an important factor in caregiving, as several respondents have learned that they cannot be too emotionally invested because that would prevent them from doing their job or even living their life: “My responsibility simply ends with taking care of certain things, making appointments, being somewhere, calling someone, making someone go somewhere, but beyond that, no. If you carry that with you, well, you’d never be okay. You’d never be able to sleep again” (Dr Amir).

Our respondents also reflected upon their task as GPs in offering a solution to their patients’ situation. This is where they can feel conflicted: they want to solve the issue for their patient but see no other way out than leaving their violent partner. Focusing on helping their patient leave sometimes results in the lack of recognition for other caring needs and may therefore lead GPs to the conclusion that they may not be able to help their patient if they stay in their relationship. Here, caring runs the risk of failing since it is also important to respect the patient’s position in the matter. Interviewees who argue that it is not their job to solve this issue or change the relationship recognise that the care they provide does not exclusively depend on them and seem to feel more competent when it comes to everyday caring (by ‘being there’). They may feel conflicted about the patient’s wishes, which contrast with their own values, but they do not necessarily feel conflicted in their caregiving, as they tend to abandon solution-driven care. Some of these respondents seem more adaptive in the care they provide by helping their patients change their mind and attitude, without pushing their patients, and by informing them that they are always welcome, regardless of their decision. Competence is thus considered as going beyond solution-driven care and as referral with follow-up or concern for the outcome. This is dependent not always on the GP alone, but also on the availability of specialised services. Furthermore, the complexity of the issue requires a competence that is not only adaptive, but also presence-oriented.

Speaking from the ivory tower: assessing power as responsive caring

Most respondents recognise the vulnerability of their patients, but few reflect upon the possible negative impact of their interventions, though this could be considered a form of responsiveness. Also, this negative impact is reflected upon by GPs in terms of concrete consequences, but they do not always recognise the impact of the more powerful position they have in relation to their patients. In connection to the overbearing referral discussed earlier, some respondents state that they had pushed some of their patients into undertaking steps and then lost those patients, or that those patients later expressed regret or fear: “And she finally did take the step, after I insisted for quite some time that she should file a complaint with the police. And she’s done that now but she really regrets it because she’s very scared of being stalked and threatened constantly” (Dr Jolien). One could interpret this as non-responsiveness at the time of the intervention by not being aware of the care receiver’s response to this intervention or what impact it could have. Some GPs have the impression that they make more effort to change their patients’ situation than the patients themselves. One GP mentioned how some of her patients were baffled by her directness in a previous consultation: “Yes, some patients do come back to it afterwards, like ‘I was actually pretty shocked’. But that’s the only way you can get in, right?” (Dr Jolien). This GP expressed some dismay at their patient’s dismissal of their advice, which, in turn, legitimises directness so that the patient will listen. On the other hand, other respondents are reluctant to give advice since they are aware of their position of superiority and that their intervention may be interpreted by patients as though they are being judged:

‘But then when you get someone who’s in that situation … I’m not going to tell them “That would never have happened to me”, it’s not like that’s going to help those women. You are kind of speaking from your ivory tower in a way, like “It won’t happen to me.”’ (Dr Nadine)

The preceding quote reflects how some GPs consider their status as being part of the “ivory tower” or intellectual elite, that is, as people who think certain issues will not happen to them. However, for this particular GP, such an attitude is counterproductive for her patients. Some respondents acknowledge their status as a GP, which gives them a privileged position or a level of authority that makes it more acceptable to intervene. Yet, while GPs have some authority, most of them feel reluctant to give advice.

In relation to responsiveness, this means that GPs adapt their caregiving to being present and open-minded instead of being intrusive, sometimes after learning that their intervention had a negative impact. The interpretation of this element in our findings is complex because what the GP considers as the best response might not fit the desires of the patient or might come across as condescending. Therefore, responsiveness should also relate to awareness of power dynamics and the patient’s needs.

Discussion and conclusion

Tronto’s elements are part of a caring process that is clearly reflected in our findings. Our respondents are attentive towards the different needs of those experiencing IPV, but we can also recognise a failure in attentiveness that reflects the inability to understand why victims stay in violent situations. However, most interviewees recognise other needs, and even if they are unaware of their patients’ specific needs for care, they often take up responsibility to care. Through our interviews, we learned that there are several issues with responsibility, which our respondents try to cope with in different ways. In the case of IPV, one might not consider the care given by GPs to be part of their job description since it is a relational or social problem and GPs should only attend to their patients’ medical issues. However, this does not seem to be the case for our respondents. Based on our interviews, we recognise different ways of ‘caring for’ through facilitating disclosure, relationship building and providing care for all parties involved. However, the uptake of care by GPs does not necessarily mean that they are competent to do so. In the case of IPV, the morality of competence lies in the type of caregiving that goes beyond tending to wounds, such as listening, being available or referring patients to the right services. When it comes to caring for an entire family, competence may be considered by some as attaining an attitude of ‘multiple partisanship’. Even if respondents consider themselves as competent within the framework of their capabilities as primary healthcare professionals, one could also criticise this disposition because feeling competent does not necessarily mean that professionals are competent or that their competence only depends on them. Furthermore, approaching competence from an ethics of care perspective should also consider the caring context, in which we recognise a moral failing. The lack of available free counselling is typical in this respect. The element of responsiveness is difficult to analyse in the narratives, as it focuses on their professional awareness of the perceptions of the care receiver and how the latter responds to their caregiving. Remaining available for the patient or being open-minded towards their choices could be considered as a form of responsiveness. Additionally, the fact that the care provided by GPs is dependent on the specific request of their patients to take up responsibility could also be regarded in terms of responsiveness. This is not without problems since it shows the extent to which care is related to the autonomy of the patient. Responsiveness is particularly difficult because the course of action that is considered by GPs to be the best for their patients does not always coincide with the patients’ needs and desires.

By analysing the narratives of GPs in view of Tronto’s elements, several challenges were recognised in the caring practices of GPs. We can highlight practices of not only good care, but also moral failings when these elements do not receive enough consideration. The complexity of IPV makes it difficult to align professionals’ preferences about what should be done with the wishes of their patients, which, according to our respondents, often remain unclear. Thus, questions arise around the right care that needs to be given. However, in these cases, the question should perhaps focus not on what the right thing to do is, but rather on how one can provide the best possible care. In this respect, respondents, especially those who are not solution driven, try to provide care through ‘being there’, which is reminiscent of the presence-oriented approach, in which care coincides with being present when a situation is insolvable or incurable. We recognise this attitude in one of our respondents, who refers to this type of care as “watchful waiting”. One could also criticise this approach, however, especially in cases of IPV, of which research and numbers show that victims suffer severe consequences. Our findings reveal that there is a genuine fear among some professionals for possible deadly outcomes, while relying on the autonomy of their patients as competent adults prevents them from acting. We relate this to the importance that is attributed to respecting autonomy, which remains foregrounded in medical care. Thus, we can ask ourselves whether different interpretations of autonomy, such as those suggested by Friedman (2003) and Verkerk (2001), can help professionals to offer good care in cases of IPV. Verkerk explains how professionals in psychiatric care suggest ‘compassionate interference’, in which ethics of care and autonomy are connected, which allows professionals to assume a more active and directive role. In connection to our data, GPs are often hesitant to act in a directive way because they fear they might lose their patient, though some narratives also reveal a compassionate interference according to which GPs clarify their opposition towards violence and refer their patients to the police or specialised services. However, again, the caring context is significant here, as the lack of uptake by other services creates a major issue that is related to a political context where policies do not provide sufficient support for care services and healthcare professionals are not always able to respond to IPV in an adequate manner. A moral failing is thus recognised, which is not just due to the professional themselves. In many ways, GPs also need to be protective of their own needs if they want to offer competent care. Self-care and self-protection surface where GPs become distant as a way of self-protection. This corresponds with the moral dilemmas of care described by Tronto (1993), such as the sublimated needs of caregivers and detached care. Thus, the elements of care provide relevant insights concerning the ethical challenges faced by GPs in IPV cases, as well as the ways in which they try to provide good care for their patients by focusing on everyday care. Furthermore, other institutions’ lack of response and availability impact care significantly, which points to the remaining policy implications of dealing with IPV.

Notes

1

We use the term ‘intimate partner violence’ instead of ‘domestic violence’ or ‘violence against women’ because we explicitly focus on violence between adult (ex-)partners and the ethical implications, which differ from violence or abuse towards children – by which we do not deny the impact and victimisation that happens when children are witnesses of violence. We also use the term because it is inclusive as regards those on the gender spectrum who do not identify as women.

2

In 2013, Tronto (2013) added the fifth element of ‘solidarity’, or ‘caring with’, meaning that consistency with democratic commitments to justice and equality is necessary to meet caring needs.

3

GPs in Belgium work in either free healthcare practices or are self-employed and paid per consultation. The compulsory health insurance system in Belgium should guarantee the patients’ reimbursement for most of the consultation fee and ensure equal access to healthcare. However, equal access is contested since research has shown that healthcare is not equally accessible to different groups (Van Roy et al, 2018; Cès and Baeten 2020).

4

A more elaborate analysis (in Dutch) of the impact of structural factors and the difficulties for GPs through the lens of intersectionality can be found in Vergaert et al (2021).

5

Research has shown that mandatory reporting with competent adults is ill-advised because the possible benefits do not outweigh interference with the decision making and autonomy of the patient (Feder et al, 2013).

6

This attitude is connected to the fundamental methodological principle of ‘multi-directed partiality’ of contextual therapy, developed by Ivan Böszörményi-Nagy (1986).

Funding

This work was supported by the Belgian Federal Science Policy Office under Grant BR/174/A4/IPV-PRO&POL.

Conflict of interest

The authors declare that there is no conflict of interest.

References

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    • Export Citation
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    • Search Google Scholar
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  • Wagman, J., Francisco, L., Glass, N., Sharps, P.W. and Campbell, J.C. (2008) Ethical challenges of research on and care for victims of intimate partner violence, Journal of Clinical Ethics, 19(4): 37180.

    • Search Google Scholar
    • Export Citation
  • Wolfson, S.A. (2007) Screening for violence and abuse through the lens of medical ethics, DePaul Journal of Health Care Law, 11: 1.

  • Baart, A. (2001) Een Theorie Van Presentie [A Theory of Presence], Utrecht: Uitgeverij Lemma.

  • Barton, K.C. (2015) Elicitation techniques: getting people to talk about ideas they don’t usually talk about, Theory & Research in Social Education, 43(2): 179205.

    • Search Google Scholar
    • Export Citation
  • Beauchamp, T. and Childress, J. (2019) Principles of Biomedical Ethics, Oxford: Oxford University Press.

  • Böszörményi-Nagy, I. and Krasner, B. (1986) Between Give and Take: A Clinical Guide to Contextual Therapy, New York: Routledge.

  • Brannelly, T. (2006) Negotiating ethics in dementia care: an analysis of an ethic of care in practice, Dementia, 5(2): 197212. doi: 10.1177/1471301206062249

    • Search Google Scholar
    • Export Citation
  • Brannelly, T. (2015) Mental health service use and the ethics of care: in pursuit of justice, in M. Barnes, T. Brannelly, L. Ward and N. Ward (eds) Ethics of Care: Critical Advances in International Perspective, 21932.

    • Search Google Scholar
    • Export Citation
  • Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology, Qualitative Research in Psychology, 3(2): 77101. doi: 10.1191/1478088706qp063oa

    • Search Google Scholar
    • Export Citation
  • Bugarin-Gonzalez, R. and Bugarin-Diz, C. (2014) Ethical issues in health care of gender violence, Semergen, 40(5): 2805. doi: 10.1016/j.semerg.2014.03.011

    • Search Google Scholar
    • Export Citation
  • Cès, S. and Baeten, R. (2020) Inequalities in Access to Healthcare in Belgium, Brussels: European Social Observatory.

  • Cook, R.J. and Dickens, B.M. (2009) Dilemmas in intimate partner violence, International Journal of Gynecology & Obstetrics, 106(1): 725. doi: 10.1016/j.ijgo.2009.03.011

    • Search Google Scholar
    • Export Citation
  • Crenshaw, K. (1991) Mapping the margins: intersectionality, identity politics, and violence against women of color, Stanford Law Review, 43(6): 124199. doi: 10.2307/1229039

    • Search Google Scholar
    • Export Citation
  • Ellos, W.J. (1998) Some narrative methodologies for clinical ethics, Cambridge Quarterly of Healthcare Ethics, 7: 31522. doi: 10.1017/S0963180198703123

    • Search Google Scholar
    • Export Citation
  • Feder, G., Wathen, C.N. and MacMillan, H.L. (2013) An Evidence-based response to intimate partner violence: WHO guidelines, Jama, 310(5): 47980. doi: 10.1001/jama.2013.167453

    • Search Google Scholar
    • Export Citation
  • Frank, A.W. (2014) Narrative ethics as dialogical Story‐telling, Hastings Center Report, 44(s1): S1620. doi: 10.1002/hast.263

  • Friedman, M. (2003) Autonomy, Gender, Politics, New York: Oxford University Press.

  • Held, V. (2010) Can the ethics of care handle violence?, Ethics and Social Welfare, 4(2): 11529. doi: 10.1080/17496535.2010.484256

  • Johnson, J.C. and Weller, S.C. (2001) Elicitation techniques for interviewing, in J.F. Gubrium and J.A. Holstein (eds) Handbook of Interview Research: Context and Method, Thousand Oaks, CA: SAGE Publications,  pp 491514.

    • Search Google Scholar
    • Export Citation
  • Klaver, K. and Baart, A. (2011) Attentiveness in care: towards a theoretical framework, Nursing Ethics, 18(5): 68693. doi: 10.1177/0969733011408052

    • Search Google Scholar
    • Export Citation
  • Paulsen, J.E. (2011) A narrative ethics of care, Health Care Analysis, 19(1): 2840. doi: 10.1007/s10728-010-0162-8

  • Potter, L. and Feder, G. (2018) Healthcare responses to domestic violence: why and how, in S. Holt, C. Överlien and J. Devaney (eds) Responding to Domestic Violence: Emerging Challenges for Policy, Practice and Research in Europe, London: Jessica Kingsley Publishers, pp 292324.

    • Search Google Scholar
    • Export Citation
  • Sokoloff, N.J. and Dupont, I. (2005) Domestic violence at the intersections of race, class, and gender: challenges and contributions to understanding violence against marginalized women in diverse communities, Violence Against Women, 11(1): 3864. doi: 10.1177/1077801204271476

    • Search Google Scholar
    • Export Citation
  • Timmerman, G. and Baart, A. (2021) Research methods for research on presence, in E. Du Plessis (ed) Reflecting on Presence in Nursing: A Guide for Practice and Research,  Newcastle: Cambridge Scholars Publishing, pp 90109.

    • Search Google Scholar
    • Export Citation
  • Tronto, J.C. (1993) Moral Boundaries: A Political Argument for an Ethic of Care, New York: Routledge.

  • Tronto, J.C. (2013) Caring Democracy: Markets, Equality, and Justice, New York: NYU Press.

  • Van Roy, K., Vyncke, V., Piccardi, C., De Maesschalck, S. and Willems, S. (2018) Diversiteit in Gezondheid en Gezondheidszorggebruik: Analyse Van de Data uit de Belgische Gezondheidsenquête [Diversity in Health and Health Care Use: Analysis of the Data from the Belgian Health Survey], Ghent: Ghent University.

    • Search Google Scholar
    • Export Citation
  • Vergaert, E., Withaeckx, S. and Coene, G. (2021) Betrokken vertwijfeling: een intersectionele analyse van partnergeweld in de huisartsenpraktijk [Involved concern: an intersectional analysis of intimate partner violence in the general practice], Tijdschrift voor Genderstudies, 24(2): 197212. doi: 10.5117/TVGN2021.2.008.WITH

    • Search Google Scholar
    • Export Citation
  • Verkerk, M.A. (2001) The care perspective and autonomy, Medicine, Health Care and Philosophy, 4(3): 28994. doi: 10.1023/A:1012048907443

    • Search Google Scholar
    • Export Citation
  • Vosman, F., Timmerman, G. and Baart, A. (2018) Digging into care practices: the confrontation of care ethics with qualitative empirical and theoretical developments in the Low Countries, 2007–17, International Journal of Care and Caring, 2(3): 40523. doi: 10.1332/239788218X15321005652967

    • Search Google Scholar
    • Export Citation
  • Wagman, J., Francisco, L., Glass, N., Sharps, P.W. and Campbell, J.C. (2008) Ethical challenges of research on and care for victims of intimate partner violence, Journal of Clinical Ethics, 19(4): 37180.

    • Search Google Scholar
    • Export Citation
  • Wolfson, S.A. (2007) Screening for violence and abuse through the lens of medical ethics, DePaul Journal of Health Care Law, 11: 1.

  • 1 Vrije Universiteit Brussel, , Belgium
  • | 2 Maastricht University, , the Netherlands
  • | 3 Vrije Universiteit Brussel, , Belgium

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