Keywords

The field of infant mental health, like bioethics more generally, has increasingly turned its attention to questions of justice, but this engagement has not always been explicitly linked to what is most distinctive about our work. Infant mental health is inherently relational (Emde et al., 2000), which requires a focus on interdependence in a way that may well be unique in professional practice. While there remains much work to be done to understand caregiving in diverse global contexts (e.g., Hrdy, 2011; Lancy, 2022; Rogoff, 2003), in this chapter we argue for an explicit engagement with this core aspect of our work as we build an ethics for our field. Perhaps uniquely among available ethical frameworks, the ethics of care (Held, 2006) centers our attention on relationships, but we find no mention of this framework in contemporary discussions of the ethics of infant mental health. Given the centrality of care work in our practices, for example, nursing, early care and education, psychotherapy, this is doubly unfortunate: We are at once depriving ourselves of an ethical framework that speaks directly to the heart of our work, and we are missing a valuable advocacy opportunity to elevate the importance of care in our broader society (e.g., Mahon & Robinson, 2011). It has, unfortunately, been common to contrast considerations of care and justice (e.g., Gilligan, 1993), but we argue here that a focus on both justice and care is not only possible (Tronto, 1994), but required, in thinking about the ethics of infant mental health. We begin, with a brief review of some recent ethical formulations for our work, which highlight the twin themes of justice and care that concern us in this chapter, before turning to consider the ethics of care and an approach to justice, the Capabilities Approach of Martha Nussbaum (2011), that is consistent with this ethics. We close with some of the implications of this approach, in both our research and our practice, especially as we build infant mental health practice for the global majority.

Justice and Care in the Ethics of Infant Mental Health

Recent years have seen several attempts to articulate approaches to the ethics of infant mental health. As Zeanah et al. (2023) note, these statements lack specific detail on the kinds of ethical dilemmas that often arise in work with infants and caregivers, for example, how to navigate conflicts between the needs of parents and those of children, but each of them is designed to guide advocacy for the needs of diverse children, families, and communities, and all are rooted in emerging knowledge from our field. The statements we review here include (1) the Diversity-Informed Tenets for Work with Infants, Children, and Families, (2) the WAIMH Position Paper on the Rights of Infants, and (3) the Code of Ethics now required for Endorsement in Infant and Early Childhood Mental Health by the Michigan Association for Infant Mental Health. Together, these recent statements serve to establish the importance of both justice and care in an ethics of infant mental health.

The Diversity-Informed Tenets were originally published in 2012, with the most recent version available at this writing dated to 2018 (Irving Harris Professional Development Tenets Working Group, 2018). Written with clear awareness of bias in developmental science (e.g., Bruno & Iruka, 2022; Henrich, 2020; Hrdy, 2011; Rogoff, 2003), the central principle for diversity-informed practice is that “self-awareness leads to better services for families,” and the tenets begin with the need for explicit reflection on our own cultures in the context of numerous, often intersecting systems of oppression. Additional tenets relate to (1) the stance toward infants, children, and families for diversity-informed practice; (2) principles for diversity-informed resource allocation; and (3) advocacy toward diversity, inclusion, and equity in institutions. Considerations of justice can be found throughout the Tenets, including explicit calls to champion children’s rights globally, work to acknowledge privilege and combat discrimination, recognize and respect nondominant bodies of knowledge, honor diverse family structures, allocate resources to systems change, make space and open pathways for historically and currently marginalized individuals and groups, and advance a just and equitable policy agenda for and with families.

A focus on justice is echoed in the WAIMH Position Paper on the Rights of Infants. Originally promulgated at the WAIMH Congress in 2014, and revised in 2016, the Position Paper on the Rights of Infants is designed as a supplement to the UN Convention on the Rights of Children because the Convention “does not sufficiently differentiate the needs of infants and toddlers from those of older children (World Association for Infant Mental Health, 2016).” The Position Paper begins with a recognition of the infant’s immaturity and dependence and includes specific reference to rights to sensitive and responsive caregiving, nurturance, and protection from abuse and neglect. Additional specified rights include those to citizenship and identity at birth, access to professional help in the context of trauma, and access to palliative care. The Position Paper separately details specific policy areas to be informed by these principles, including parental leave, provisions for continuity of care and adequate support in alternative care arrangements, education for parents on the needs of infants, emotional support for caregivers, and access to evaluation and treatment for both children and parents. As noted in the preamble and rationale, the Position Paper is an explicit advocacy position, informed by the science of infant mental health.

The final statement of ethics in infant mental health that we review is the one with the most explicit focus on the clinical work of our field, the IECMH Code of Ethics from the Michigan Association for Infant Mental Health (2021). Rooted in the practice of infant mental health, this code begins with the value of relationships, as the “primary instrument for growth and change.” This emphasis on relationships includes work to promote, support, restore, and sustain nurturing relationships for all infants, young children, and families, as well as collaborative interprofessional relationships, embedded in an understanding of the impact of past relationships on the present. Like other existing approaches to professional ethics, the code also includes values specifically related to professional practice, including integrity, confidentiality, knowledge and skill building, and, perhaps more uniquely, reflective practice. The IECMH Code of Ethics was revised in 2021 to include greater attention to diversity, equity, and inclusion and includes additional values specifically related to justice: (1) respect for ethnicity, race, culture, individuality, and diversity and (2) a commitment to dismantling inequities through social and racial justice work.

These recent articulations converge around an awareness that work with infants and their families requires a focus on relationships, but also the larger social and historical contexts in which these relationships are embedded, with clear and consistent emphasis on the inequalities that shape the lives of so many children and families and the need to respect diverse family and caregiving arrangements (e.g., Keren et al., 2019). This growing engagement with questions of justice is, of course, not unique to infant mental health, and several recent contributions to the literature in bioethics also center on the need to explore justice more directly. In bioethics, scholars have argued for a focus that extends beyond individual ethical dilemmas, be they between a clinician and a patient or between a researcher and a participant. While explicit consideration of justice in many of these individual interactions is possible, recent perspectives on justice call for a much broader and direct focus on the social and political dynamics that shape these individual interactions. Thus, King and colleagues refer to “lifeboat ethics,” where the circumstances leading to the limitations of the lifeboat are bracketed in order to consider the ethical dilemmas of individuals on the lifeboat (King et al., 2022), while Alex London argues that scrutiny on the interactions between a researcher and a participant, as is commonly the case in review by an Institutional Review Board as classically conceived, limit our ability to understand the broader forces that shape research agendas (London, 2022). While the ethics of care is not commonly referenced as a part of these considerations of justice in bioethics, we argue that there is no good reason for this, and especially not in the context of infant mental health, where care can and probably should be a central consideration in our growing engagement with social justice.

The Ethics of Care

In her overview of the ethics of care, Virginia Held locates its origin in the work of Carol Gilligan, specifically in her effort to understand the moral development of girls (Held, 2006). Originally motivated by what she perceived as bias in the judgment of girls’ moral development in the work of Kohlberg (1984), Gilligan’s research has been consistently oriented toward revealing what she characterized as “the different voice” of women and girls—a voice centered more on responsibilities and relationships than on rules and rights, more on the specificity of particular relationships than abstract principles (Gilligan, 1993). These observations were soon picked up in feminist philosophy, which articulated an ethics of care focused on our interconnections.

As Tronto (1994) notes, one of the unfortunate consequences of the way this ethics was articulated has been to make it easy to confine it to the private sphere of specific feminine caregiving relationships, blunting the potential of this framework in the public sphere of politics. Tronto argues for a reconfiguration of what she calls these “moral boundaries” to permit our thinking about care (and our responsibilities to each other) to have a more central place in our debates about politics, and we think the growing engagement of the infant mental health field with policy provides us with an important opportunity to do just this.

From Tronto’s perspective, four distinct phases of caring, as a practice, deserve attention: (1) caring about, which she links to the ethical dimension of attention; (2) taking care of, which she links to the ethical element of responsibility; (3) caregiving, which she links to the ethical element of competence; and (4) care-receiving, which she links to the element of responsiveness. The ethics of care, in Tronto’s formulation, thus provides us with an explicit way of evaluating our involvement in the relationships that are central to work in infant mental health. These dimensions are of relevance not only to practice—in foregrounding questions of competence and responsiveness—but also to policy—in emphasizing attention and responsibility.

It is one thing, however, to recognize the importance of care. It is quite another to understand the specific issues that can arise in acting on the basis of this value. As Zeanah et al. (2023) note, there remains significant work to do in fleshing out an ethical framework for the challenges that arise in infant mental health practice, but it seems clear that this conceptualization of care, intended to move the construct from the private sphere of home and family to the public sphere of policy and professional practice, can offer important guidance on what we need to attend to in crafting an ethics that fits our understanding of our interconnections and needs for care. And it is specifically in regard to needs for care that we can link, explicitly, to the questions of justice that have become so prominent in our advocacy.

Needs for Care and the Capabilities Approach

Tronto (1994) observes that if we define our needs for care too abstractly we will fail to specify how to meet these needs, but if we define them too concretely, then we might fail to provide broader guidance for social policy. While much work still needs to be done in this area, Tronto (1994) does suggest that the Capabilities Approach (CA) of Nussbaum, originally articulated in the context of international development and its implications for women (Nussbaum, 2000), provides us with a potential way to navigate at least some of these tensions.

In a recent articulation of the Capabilities Approach, Nussbaum (2011) argues that the approach is focused on understanding social orders in terms of what each person, as an end in themselves, is able to do and to become within them. It is, thus, an explicit operationalization of a conception of justice focused on what it takes to be able to pursue one’s life projects (or, in the negative, the ways in which this can be denied). Following Sen (1999), this approach focuses on choice or freedom, recognizing that different individuals will have different values, but that they cannot pursue their own projects without certain fundamental capacities.

Nussbaum currently proposes ten areas of capability that she argues deserve universal consideration. While some of these capabilities, including (1) life itself; (2) bodily health; and (3) bodily integrity are probably readily understood, others may benefit from some elaboration here. These include several capabilities most closely connected to the goals of infant mental health intervention, that is, (4) those related to the senses, imagination, and thought, by which she means the ability to imagine, think, and reason, informed and cultivated by an adequate education; (5) those related to the emotions, by which she means the ability to love and grieve, with freedom from excessive fear and anxiety, which depends crucially on the relationships where these emotions can develop; (6) practical reason, by which she means the ability to form and pursue a conception of the good in life; and (7) affiliation, which includes the ability to connect with others and to be free from discrimination. She rounds out her list by including capabilities related to (8) living with other species, (9) play, and (10) having control over one’s political and material environments. This conceptualization of capabilities is designed explicitly to serve as a way of judging the justice (or injustice) of different social orders, providing metrics that can be used in evaluating their progress toward cultivating these capabilities in individual citizens.

Originating, as it does, in the context of global debates about human rights and international development, the Capabilities Approach is explicitly designed to be general and relevant across numerous cultural contexts, but continued discussion about the ways in which these capabilities are shaped in specific cultural contexts is important. An international interdisciplinary association, the Human Development and Capability Association, provides a natural venue to continue these discussions and we would suggest, as well, that WAIMH, especially in continuing the discussion that started with the Position Paper on the Rights of Infants, might also take these questions on as a regular feature of its biennial congresses. Indeed, this dialogue has already started to occur (e.g., Gaskins & Keller, 2019; von Klitzing, 2019).

The Capabilities Approach provides us with an important framework for investigating questions of justice that is rooted in an understanding of human development and flourishing, but it does not, by itself, provide us with more general guidance for navigating some of the more complex aspects of our interconnections and responsibilities to each other, even if the capabilities are explicitly connected to human development. As many have noted, understandings of caregiving that are modeled simply on the relationships between mothers and children in nuclear families do not represent global norms (e.g., Hrdy, 2011; Lancy, 2022; Rogoff, 2003), and it would be a mistake to build an ethics (or indeed a practice) for our field with only this relationship in mind. But a broader focus on relationships is quite consonant, indeed more consonant, with global experience than is one based on individual rights.

Toward a More Relational Approach to Ethics

An emphasis on relationships is not, of course, limited to infant mental health practice. It is foundational to the practice of marriage and family therapy, and the so-called relational turn in psychoanalysis makes many of these same points (e.g., Benjamin, 2018; Mitchell & Black, 2016). An emphasis on the importance of relations has long been central to anthropology as well (e.g., Strathern, 2020), and arguably the most frequently drawn contrast between the west and the rest in cross-cultural psychology concerns the uniquely individualistic focus in Europe and North America, which contrasts sharply with the more interconnected vision of self found in the global majority (e.g., Henrich, 2020). While any number of examples bear upon this point, we offer a perspective that has emerged from Critical Indigenous Studies as a particularly clear philosophical articulation of a more relational perspective.

In a recent contribution to the Oxford Handbook of Critical Indigenous Studies, the philosopher Kyle Whyte (2021) draws a contrast between what he calls “crisis epistemology,” in which imminent threats like climate change justify a wide range of departures from the requirements of social relationships, and what he calls “epistemologies of coordination,” which characterize the respect, in Indigenous communities, for kinship, connection, and social responsibilities, even in the face of imminent threats. While Whyte’s specific points about epistemology are interesting, it is his point about the ongoing and persistent importance of social relationships and responsibilities in the ethics of contemporary Indigenous communities that deserves special attention here: even (perhaps especially) in a time of crisis, interconnection and responsibility remain of paramount importance.

The need for ethical principles that elevate connections between people in Indigenous communities has recently also been explicitly recognized by Bobby Saunkeah et al. (2021). In addition to the well-known principles of respect for autonomy, nonmaleficence, beneficence, and justice (e.g., Beauchamp & Childress, 2019), Saunkeah and colleagues argue that work in Indigenous communities requires considerations of the additional principles of sovereignty and solidarity, to capture important relational and group dynamics in tribal communities. While sovereignty refers to the ability of communities to make their own decisions, asserting the right of self-determination and autonomy for groups, solidarity refers to the duties, within communities, to support the community and its individual members (Saunkeah et al., 2021). As Saunkeah and colleagues note, in the context of work with US Native Nations, “solidarity involves two key aspects: the collective responsibility to defend and promote the conditions for the group to flourish, and the collective responsibility to care for the particular needs of the most vulnerable members of the group (Saunkeah et al., 2021, p. 9).” A related observation characterizes the approach to justice in the posthumously published work of Iris Marion Young, Responsibility for Justice, where she grapples with the interdependent nature of structural inequality and the difficulty of assigning individual blame. She argues, instead, for an approach that is less focused on assigning guilt and more focused on the obligations we have for improving the situations of those oppressed by the structures in which we participate, which she calls the “social connection model of responsibility (Young, 2011).”

There is, then, no shortage of moral discourse for infant mental health to connect to as we articulate the implications of our relational approach, and the prominence of these themes in Indigenous moral discourse underscores the ways in which our practice can connect with a more widely shared view that recognizes that we are not, nor have we ever been, isolated moral agents. In a recent review of Indigenous concepts of wellbeing, Jessica Saniguq Ullrich (2019) argues for what she calls the Indigenous Connectedness Framework, emphasizing the need to embed child wellbeing in the wellbeing of the collective, and five forms of connectedness: spiritual, environmental, community, intergenerational, and family. If we continue work in this vein, we suspect there will be many ways to connect care to human flourishing in ways that, like the Indigenous Connectedness Framework, emphasize the fundamental importance of our connections to each other. We close this chapter by returning specifically to the field of infant mental health and one of the ways this awareness has already informed our advocacy work, by taking up the example of trauma-informed care.

Trauma-Informed Care

While the ethics of care is rooted in an understanding of feminine roles in our society, the infant mental health community is well aware that care is far from inevitable. Any number of causes and conditions can shape suboptimal and even destructive patterns in caregiving relationships (e.g., Mate & Mate, 2022; Van Der Kolk, 2014), much of which are rooted in the broader dynamics of inequality that shaped the articulation of the Diversity-Informed Tenets. In the United States, the National Child Traumatic Stress Network (2016) has provided important guidance for those working in child and family services regarding the assessment and treatment of trauma that draws on an awareness of protective and resilience factors and recognizes the impact of intergenerational trauma. Importantly, and consistent as well with the Infant and Early Childhood Mental Health Code of Ethics, this work is also mindful of the need for coordination, that is, relationships, across systems of care and the need to also attend to the impact that working on trauma has on staff.

In the United States, discourse about trauma-informed care draws on a set of principles, articulated by the Substance Abuse and Mental Health Administration (2014), which include the following: (1) safety; (2) trustworthiness and transparency; (3) peer support; (4) collaboration and mutuality; (5) empowerment, voice and choice; and (6) cultural, historical, and gender issues. From the perspective that informs this chapter, it is important to note that each and every one of these principles is rooted in our interconnections and in our responsibilities as caregivers and our hope is that the focus on care and human flourishing that we have argued for here will allow us to extend this important work toward broader social and cultural transformation, addressing trauma at its source (Manchanda, 2013).

The field of infant mental health is rooted in an awareness of the importance of care and the moral implications of our interconnectedness and our responsibility for justice understood in its connections to human flourishing—a perspective closely aligned with what the philosopher Lorraine Code has called “ecological thinking (2006).” Our effort to center this work on care solves some problems, but it most definitely raises others. We highlight two as we close this chapter.

The Way Forward

If we move forward in the direction of an ethics based on care and human development, we will obviously need to carefully grapple with our growing awareness of bias in the knowledge base that informs our interventions (e.g., Morelli et al., 2018). Because our work is global, any effort to articulate ethical principles must rest on careful cross-cultural dialogue about what caregiving should look like and how this is connected to the goals of human development. In this chapter, we pointed specifically to a growing engagement with questions of interdependence in Indigenous communities (e.g., Ulrich, 2019; Whyte, 2021). WAIMH, with its growing global engagement, can and should take a central role in these dialogues, some of which undoubtedly flow from our initial advocacy efforts in the Position Paper on Infants Rights (e.g., Gaskins & Keller, 2019; von Klitzing, 2019), but it is quite clear that a broader participatory approach will be required to truly hear and learn from global experiences.

The second concern we would highlight is the very real danger, already well known in our work, of the costs of caring. We would be loath to think that the ethical framework we have articulated here could be read in any way as a call to deny the needs of our workforce in addressing the profound needs for care that we know exist. Indeed, there would be little value in recommending an ethics of care for others if we did not extend this responsibility to ourselves as well. This need is explicitly recognized in the NCTSN recommendations for trauma-informed systems of care, and we would suggest that our commitment to reflective supervision, explicitly articulated in the Infant and Early Childhood Mental Health Code of Ethics and ensconced in the related system of professional endorsement, needs to be an explicit component of our engagement with our interdependence, even as we recognize the need for greater specificity regarding what reflective supervision is and what it can accomplish (Zeanah et al., 2023). We would be remiss here, as well, if we did not also emphasize the ongoing struggles of the care workforce for adequate compensation and the need for continued advocacy from our field for recognition of the centrality of care work in our society (e.g., Mahon & Robinson, 2011). Indeed, one potentially beneficial consequence of reframing our discussions in terms of care and flourishing might be to focus more attention on these crucial concerns.

Summary and Key Points

In this chapter, we have reviewed recent statements related to the ethics of infant mental health, underscoring their emphasis on justice. We sought to root this concern with justice in what we see as a central concern in infant mental health, that of care, connecting these statements to that evolving literature on the ethics of care (e.g., Held, 2006), and we argued that an approach to justice, rooted in care, can be found in the Capabilities Approach of Martha Nussbaum (2011). There are obvious connections between our approach and the WAIMH Position Paper, which argues for what we believe infants need, but we also recognize that this work requires a more complete engagement with the complexities of caregiving across cultures (e.g., Gaskins & Keller, 2019; von Klitzing, 2019). We closed with the example of trauma-informed care as one way of making a commitment to caring central to policy and practice.