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JADED: INSTITUTIONAL OPPRESSION AND
MORAL DAMAGE IN HEALTHCARE

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JADED: INSTITUTIONAL OPPRESSION AND
MORAL DAMAGE IN HEALTHCARE

By

C hristy A. Rentmeester

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Department of Philosophy

2005

ABSTRACT

JADED: INSTITUTIONAL OPPRESSION AND
MORAL DAMAGE IN HEALTHCARE

By

Christy A. Rentmeester

This dissertation combines healthcare ethics, metaethics, moral psychology, moral
epistemology, and social and political philosophy with an emphasis on professionalism in
healthcare. In it, I explore the question When it is said that someone is “jaded, ” what
does this mean morally? I focus in particular on how becoming jaded can affect
healthcare professionals, and I argue that jading is a moral problem in the context of
healthcare for two reasons. First, professionals who care for society’s most vulnerable
members get morally damaged when they get jaded. Second, this moral damage can
affect patient care and collegiality among professionals for two reasons: jaded
professionals’ conceptions of what they’re responsible for narrows and jaded
professionals narrow the scope of moral particulars of situations they see as reasons to act
in the service of others. I characterize jading as a concept that best describes a process of
moral motivational erosion. I argue that an intemalist, cognitivist theory of moral
motivation best accommodates the idea that moral motivation is not an “all-or—none”
phenomenon but one which admits of degrees, and also best accommodates the central
role moral perception plays in healthcare professionals’ abilities to be morally responsive
to patients and colleagues. I then apply this theory to describe forms of moral damage
(loss of self-respect, alienation, and callousness) healthcare professionals suffer when

they work in conditions of institutional oppression. I suggest that resolving the problem

of j ading requires ameliorating conditions of oppression in healthcare education and in

the healthcare workplace.

TABLE OF CONTENTS

INTRODUCTION .................................................................................... 1
CHAPTER 1
“JADED” .......................................................................................... 2
LOOK! ........................................................................................ 4
JADED AS A FAMILY RESEMBLANCE CONCEPT” ...........9
TOWARD A FORMULATION OF PERCEPTION AS MOTIVATION. . . .. 1 5
CHAPTER 2
MORAL MOTIVATION UNDER NORMAL CONDITIONS ......................... 20
MORAL PERCEPTION AS MORAL MOTIVATION ............................... 21
HOW MORAL REASONS BEHAVE .................................................. 33
CULTIVATING GOOD MORAL PERCEPTION .................................... 45
CHAPTER 3
HOW THE JADED ARE MADE ........................................................... 56
FEATURES OF INSTITUTIONAL OPPRESSION ................................... 59
LOSS OF SELF-RESPECT AND ALIENATION ...................................... 74
CALLOUSNESS CAUSES MORAL MOTIVATIONAL EROSION. . . . ..86
CHAPTER 4
JADING IN HEALTHCARE PROFESSIONAL LIFE ............................... 108
DAMAGE TO HEALTHCARE PROF ESSIONS ................................... 109
AVOIDANCE NARRATIVES ......................................................... 121
GENERATING SOLUTIONS TO THE PROBLEM OF JADING. . . ..129
REIUVENATING THE JADED? ....................................................... 142
BIBLIOGRAPHY ................................................................................. 145

iv

INTRODUCTION

Suflering, vulnerability, and powerlessness are concepts that have appeared in
bioethics literature theorizing about patients’ experiences of modern healthcare. These
concepts have typically not appeared in bioethics literature on professionalism and they
have not typically been used to characterize healthcare professionals’ experiences of
learning and practicing modern healthcare. There is need, however, for a conceptual
framework in which the suffering, vulnerability, and powerlessness of healthcare
professionals can be accounted for, understood, and evaluated. In this dissertation, I
endeavor to develop a moral theoretical framework in which these concepts are best
understood as kindred to other concepts, like alienation, loss of self-respect, callousness.
Relationships among these concepts configure complex moral experiences in the lives of
healthcare professionals who work under conditions of institutional oppression and have
become or are in the process of becoming jaded.

This dissertation combines analytic moral philosophy, particularly metaethics,
moral psychology, moral epistemology, and social and political philosophy with
healthcare ethics; I explore the question When it is said that someone is “jaded, ” what
does this mean morally? I argue that jading is a moral problem in the context of
healthcare for two reasons. First, professionals who care for society’s most vulnerable
members get morally damaged over time when they get jaded. Second, this moral
damage can affect patient care and collegiality among professionals because jaded
professionals’ conceptions of what they’re responsible for narrows and jaded
professionals narrow the scope of moral particulars of ’situations they see as constitutive

of reasons to act in the service of others.

CHAPTER ONE: “J ADED”
“Andrea F ricchione” described a set of experiences that’s common among

students and professionals in healthcare. She reflected on her medical education:

When I arrived in medical school, I was eager to get involved, I was

excited about addressing important issues because, as medical students, I

was sure that we would have some clout and certainly a commitment to

the well-being of others.1
She suggested that being morally responsive to others is an important source of
enjoyment, self-worth, and self-respect for her, and that she was enthusiastic about
sharing her commitment to serving others with other medical students. But then she
described feeling conflict between the values that motivated her to attend medical school
and the ones she viewed her mentors and teachers endorsing: “People are rude, the hours
are long. . . [L]ife is brutal. . . [Mjedical school is an utter drain.” She also revealed ways
that she disengaged from activities that were important to her as a way of coping and as a
means of self-preservation:

In some sense I think activism is futile. It isn’t just that there will always

be more to do—it’s that most projects are BandAid treatments that provide

an opportunity to feel good about oneself that isn’t justified . . . [R]ather

than try to change everything that I consider wrong in the hospital or the

community at large, I just try to get through school.
On professionalism, Andrea said, “I do believe that habits formed now will rarely be
overcome in the future. So, I regret not having spoken up on more issues. But I was often

too tired.” She expressed hopelessness about her future, regret about her past, guilt, and

blame, which she directed toward herself.

 

‘ See Coulehan and Williams.

This set of phenomena Andrea described has been called disillusionment,
cynicism, but most commonly burnout in professional ethics literature.2 In this chapter, I
first differentiate among these concepts. I show how experiences like Andrea’s can be
described and understood as a narrative with important epistemic, emotional, physical,
and moral dimensions and then I show how each of these concepts is inadequate because
they don’t account well for moral dimensions, in particular. I argue that the concept

jading best represents significant moral dimensions of the plot of Andrea’s and other
healthcare professionals’ experiences—their suffering of moral damage and moral
motivational erosion—as they become educated and professionalized.

In the second part of this chapter, I broaden inquiry about the concept jading,
beyond professionals’ experiences in healthcare, to how it is used in various contexts in
ordinary language to refer to dulling perception and waning motivation. In the third part
of this chapter, I make a distinction between two different kinds of capacities for
perception—physical senses and moral senses. One specific moral sense, the sense of
moral responsiveness to others, is important in the context of healthcare professionalism.
To many healthcare professionals, being morally responsive to others is an important,
central feature of who they are; values of moral responsiveness to others—beneficence
and compassion, for example—guide these professionals’ perception of what they see
worth doing. I develop sets of hypotheses that incorporate this view of moral perception,

which I will argue for in Chapters Two and Three. The first set of hypotheses is about

 

2 See Campbell, D.A., et. al.; Farrington, A.; Guthrie, E., et. al.; Gundersen, L.; Jevne and Williams;
Murray, A., et. al.; and Spickard, A., et. al. for a sampling of literature of burnout in medicine and nursing.
See Cherniss for a study of burnout in other human service professions—teaching, public advocacy law,
and mental health. Some resources are also available on burnout in law enforcement. Burnout in ministry,
social work, and counseling is also referred to as “compassion fatigue.” See Charles R. Figley’s
Compassion Fatigue: Secondary Traumatic Stress Disorders in Those Who Treat the Traumatized. The
psychologist Christina Maslach has also published on the role of organizational structures in employees’
burnout.

how moral perception and moral motivation work under normal conditions and the
second is about how, when healthcare professionals work under conditions of
institutional oppression, they suffer moral damage and their moral motivation can erode.
First in this chapter, however, I consider what the concept jading means.

Part One: Look!

Ludwig Wittgenstein’s advice to philosophers is not to theorize, but to “look!”3
According to his ordinary language approach, philosophers are to observe how a concept
is actually used by people in specific linguistic contexts, interpret its meaning and
variations in meaning, and describe relationships among its variant meanings. Taking this
approach to the set of experiences Andrea described, one way we can interpret them is to
organize them into a story, the plot of which follows causal connections among her
experiences:

Andrea was eager and enthusiastic about practicing a healthcare

profession, but because she became disappointed and dissatisfied with

' what was happening to her as she became professionalized, she

disengaged with the activities of her chosen profession.
This narrative sketch suggests that disappointment, dissatisfaction, and disengagement
take place over time, not in a single event, and also suggests that these experiences have
important epistemic, emotional, physical, and moral dimensions. If any single concept is
to be used to characterize the whole of this set of experiences and applied to describe
similar experiences of others, it ought to be able to account for each of these dimensions.
As I’ll try to show, the moral dimensions of what happens to a person as she experiences

disappointment, dissatisfaction, and disengagement with her chosen profession are

particularly important—they can be sources of moral damage to the student or

 

3 66 of his Philosophical Investigations.

professional that impair her ability to respond to patients and colleagues. So far in the
literature on professionalism, concepts such as disillusionment, burnout, and cynicism
have been used to characterize this story; I’ll consider each here.

“Disillusionment” is a descriptor of the plot of Andrea’s experiences, which
addresses only its epistemic dimensions. This concept suggests that a person who
experiences these phenomena didn’t really know what being a student or healthcare
professional would be like when she decided to become one. For example, if Andrea used
“clout” to convey the impression that medical students have authority and respect, she
was disillusioned. Disillusionment is realized when a person acquires knowledge that
something is not what it seemed, when she sees that what she expected to be the case is
not the case. But, even if Andrea was disillusioned about having clout, there are several
other dimensions of her story’s plot that the concept of disillusionment does not capture.
Characterizing what Andrea described as only disillusionment seems to suggest what I’ll
call a “disillusionment-prevention” solution: schools that train healthcare professionals
need to make sure that people are better screened upon admission, such that only people
who really know what they’re getting into are the ones who are accepted into training
programs.

Disillusionment is a legitimate concern: when students are ill-informed about
what it means for them to practice careers as healthcare professionals or when they
exhibit self-deception in place of a realistic, reasonable, and attainable self-conception,
they ought to be encouraged to more carefully consider other career or education options.
Ultimately, however, even when disillusionment does play a part in a student’s or

professional’s disappointment with her education or professionalization, the

disillusionment-prevention solution does not work as easily as it may at first appear. The
disillusionment-prevention solution is problematic because it assumes at least three things
about the relationship between a person’s knowledge about what it means to take up a
profession and her ability to be a good practitioner of that profession. First, it assumes
that the features of professional life, which could at some point become unappealing to a
practitioner, are knowable at the time she embarks upon a career. Second, it assumes that
she (or anyone) is capable of knowing how she’ll be affected over time by those features
of her education or professionalization that she dislikes. These two assumptions reveal
that the disillusionment-prevention solution requires an impossibly high epistemic
threshold for applicants at professional schools to achieve and maintain about self-
knowledge. A third assumption is this: if an individual prospective practitioner is
disillusioned, she is solely responsible for being disillusioned. There’s at least one reason
to doubt the reliability of this assumption. If prospective students of healthcare
professions receive inaccurate information from current members of those professions
about what it’s like to practice, students are recruited to professions by “false
advertising.”4 False advertising inevitably fosters disillusionment and interferes with even
the most self-aware and responsible individuals’ abilities to make good career decisions
for themselves and maintain accurate self-conceptions.

Even if a person pursues a profession with full and true disclosure of what it’s like
to practice a profession and even if she could obtain near-omniscience about herself and
her responses to future professional challenges, the suggestion that disillusionment can be

prevented by better screening of applicants is flawed in other ways. The disillusionment-

 

‘ In our 2002 panel session at the annual meeting of the American Society for Bioethics and Humanities
(ASBH), Howard Brody emphasized the need for the medical profession in particular to maintain “truth in
advertising” to prospective students.

prevention solution also assumes that the profession itself and the characters of people
who practice it are static. But, a profession changes in many ways throughout a person’s
professional life, as does any individual person practicing that profession. Because the
concept disillusionment cannot account for these changes, only for the change in what the
practitioner comes to know, the only elements of the plot of Andrea’s experiences this
concept can account for well are the epistemic ones. Characterizing that plot as
“disillusionment” overlooks its emotional, physical, and moral dimensions.

Burnout has been used in the professionalism literature to describe emotional,
physical, and moral dimensions of the plot of experiences Andrea described. Emotional
dimensions in particular have been characterized psychologically and cognitively; one
article refers to practitioners’ “perceived clinical ineffectiveness, and a sense of
depersonalization in relationships.”5 Physical dimensions have been medicalized; the
same article refers to burnout as a “syndrome” with “symptoms and signs” of “poor
health, including headaches, sleep disturbances, irritability, marital difficulties, fatigue,
hypertension, anxiety, depression, myocardial infarction” that may lead to “alcoholism
and drug addiction.”6 These clinical descriptions of burnout suggest that burnout is a
medical problem that can be addressed by the western medical model of problem-solving.
But, in addition to these clinical descriptions, it’s also acknowledged that burnout has

moral features, insofar as it “represents a deterioration of values, dignity, and will.”7

 

5 Spickard, Gabbe, and Christensen, 1447.
6 Spickard, Gabbe, and Christensen, 1447.
7 Spickard, Gabbe, and Christensen, 1447.

This deterioration has been characterized as “cynicism.”8 But the concept
cynicism construes moral dimensions of the plot of Andrea’s and others’ experiences far
too narrowly. Cynicism connotes a person’s distrust in the possibility of goodness or
sincerity in oneself and other people. A cynic suspects hypocrisy to be pervasive; she
may subsequently be disparaging, contemptuous, and derisive toward others. While
cynicism certainly could be part of the moral fallout of the set of experiences Andrea
characterized, it describes only one possible resulting moral outlook that a person could
have after or during becoming disappointed in, dissatisfied with, and disengaged from her
education or work. Furthermore, there’s no good reason to assume that Andrea is cynical
or that everyone who has experiences like Andrea’s necessarily becomes cynical.
Catcgorizing her moral outlook as cynical leaves other morally relevant consequences,
outlooks, and feelings—like loss of self-respect, powerlessness, pain, alienation,
callousness, guilt, regret, fear, and resentment—unaccounted for. If any single concept is
to be used to characterize the plot of Andrea’s experiences and applied to describe similar
experiences of others, it ought to be able to account for the variety of moral
consequences, feelings, and outlooks too, because, as I’ll argue in Chapters Three and
Four, these are forms of moral damage that can be suffered by students and practitioners
as they become educated and professionalized as caregivers.

Overall, the concept burnout might appear to be the best candidate for describing
the plot of Andrea’s and other healthcare professional’s experiences. After all, it appears
more fi'equently than disillusionment and cynicism in the professionalism literature to

characterize the plot, and it can explain why a person would become disappointed in and

 

8 Spickard, Gabbe, and Christensen, 1447. Also in Testcrman, et. al. “The Natural History of Cynicism in
Physicians,” Academic Medicine 71 :S43-S45, 1996.

dissatisfied with her work as well as explain why a person would disengage from such
work. It does not, however, describe how a student or professional who suffers these
experiences is harmed. Neither does disillusionment nor cynicism. In fact, the best these
conceptions can do with respect to the moral dimensions of the plot of Andrea’s and
others’ experiences of disappointment and dissatisfaction is trace a path along a process
of moral damage and moral motivational erosion that ultimately results in
disengagement; none of these concepts can fully account in any detail how moral damage
and moral motivational erosion transpire.

To account well for the moral dimensions of the plot of Andrea’s and other
professionals’ experiences, a concept is needed that is capacious enough to account for
how they are morally damaged when they become disappointed in, dissatisfied with, and
then disengage from education, professionalization, or practice. I propose that the concept
jading can account for some of the most important features of how students and
professionals in healthcare are morally damaged by those experiences; in particular,
students’ and professionals’ abilities to respond to patients and colleagues who need them
to respond become impairedg. The concept jading is used in several contexts in ordinary
language to refer to different kinds of impaired responsiveness that come about from
dulling of perception, waning of motivation.

Part Two: “Jaded ” as a Family Resemblance Concept

Definitions of “jaded” in the Oxford English Dictionary and Webster 's list
synonyms referring to emotional and physical experiences such as being “worn out,”
“exhausted,” “fatigued,” or “sated.” Also listed are several adjectives that have

significant moral dimensions: “indifferent,” “calloused,” and “hardened.” This wide

 

9 In Chapter Three, I argue, in detail, about how this process of impairment transpires.

variation among meanings of these concepts suggests that jaded is not a concept easily
defined by a checklist of necessary and sufficient conditions. It is rather what
Wittgenstein calls a family resemblance concept, for which a “complicated network of
similarities overlapping and crisscrossing”10 constitutes its meaningfulness as it’s used in
various linguistic contexts. The network for jaded consists in a cluster, a family, of
related concepts, each of which carry somewhat different epistemic, emotional, physical,
and moral connotations. Jaded means different things in different contexts, but among
these different meanings, there are similarities, family resemblances. Here are a few
examples that show family resemblances among different meanings of jaded.ll
One example shows how the concept jaded can refer to physical satiety; Shel

Silverstein’s poem “Jaded” appeared in Playboy in December 1966.12 He begins:

Nothin’ to do but sleep in the sun

Nothin’ to think about but havin’ fun

Nothin’ to eat but filet mignon

I’m startin’ to think that I’m jaded.

Nothin’ in my pocket but dividend checks

Nothin’ to come home to but all kinds of sex

I’d try to explain but it’s too complex

And so is life when you’re jaded.
Silverstein describes his speaker’s satiety in physical sensory terms: feeling the warmth
of the sun, tasting filet mignon, and indulging in various forms of sexual stimulation. He

is, as he later notes, “overloved and overfed”l3 and lives in conditions of seemingly

ultimate surfeit. Getting jaded is problematized at one point in the poem too, as a source

 

1° Wittgenstein, 67.

" I don’t claim that these examples are authoritative uses of the term “jaded.” What would constitute an
authoritative usage of the term? I’m not sure, so I’ve looked to the dictionaries and to ordinary language
and I entertain a variety of uses (to avoid what Wittgenstein would call a “one-sided diet of examples”) to
demonstrate the term’s various, though related, meanings.

'2 The poem is also accessible over the intemet: www.banned-width.com/shel/works/jaded.html (accessed
25 February 2003).

‘3 Line 21.

10

of alienation among individual persons. Silverstein also suggests that when a person
becomes jaded, he becomes less capable of being moved by the needs and vulnerabilities
of others: he writes, “ . . . a man gets cruel when he’s jaded?“

Another example of cruelty concomitant with jading is a historical and notorious
one: Caligula, Emperor of Rome. His exploits, catalogued by Gibbon15 and fictionalized
in Robert Graves’s I, Claudius, consisted in orgies, in which children as well as adults
were raped. Gluttonous overabundance of food and wine was not atypical in the homes of
Roman emperors, but Caligula is depicted at one point in I, Claudius as demonstrating a
singular disregard for the objects he perceives via his senses, in this case: food. Carried
around by his attendants, he orders them to stop. He then orders one of them to give him
a piece of fruit, of which he takes one bite and subsequently discards, and then orders a
new fruit, bites once, discards, orders a new fruit . . . Like the speaker in Silverstein’s
poem, Caligula’s decadence led to and was indicative of his corruption.

If we think of cruelty and corruption like that of Caligula’s as the vilest degree to
which a jaded person may be morally damaged, we can also consider subtler degrees of
damage to a person who’s described as “jaded.” Edward Gorey, for example, draws a
picture of what it means to be jaded, in which being jaded is like feeling ennui. In the
picture, a caricatured woman lounges, toying with a long strand of beads, among her rich
furs and fabrics with silk tassels. She appears alienated from another figure in the
drawing, and looks indifferently away from this luxuriously robed servant who presents a

silver platter of elegant cuisine, the stuffed head of a boar. Gorey draws her mouth to be

 

" Line 16.
'5 Edward Gibbon, The Decline and Fall of the Roman Empire.

11

just a slit, 3 closed straight line; fine things neither stir her senses nor satisfy her needs,
they only bore her. His caption notes, “She toyed with her beads jadedly.”16

Other physical connotations of “jaded” have epistemic dimensions too. One is a
reference to a jaded person’s suffering the loss of the capacity to be stimulated or
shocked by what she sees. For example, referring to Artemisia Gentileschi’s 1620 Judith
Slaying Holofernes, Mary O’Neill wagers that this image is still moving, despite modern
persons’ numbness to what would have shocked previous generations:

Nearly 400 years later, even jaded citizens of the modern world are
startled by this image—a painting of the key moment in the story of
Judith, the Jewish widow who saves the city of Bethedia from attacking
Assyrians by murdering their commander.1

O’Neill uses the term “jaded” here to recommend that the capacity to be startled reveals
something about what you know and what you expect to recognize as shocking or
interesting. This epistemic dimension to the concept jaded is also in play in the next
example.

A young emergency department physician refers to a culture of having “immunity
to shock” among his colleagues:

I’ve thus far got the impression that it is very uncool not to be
jaded where I work. If someone thinks you’re shocked, disturbed, or hurt
by something you witness, it’s like you get demerits for being naive,
inexperienced, or—the ultimate bad—{he throws his hands up at the sides
of his head to make quote marks with his fingers) “emotional” or “lacking
objectivity.” As if caring for someone who just got shot, stabbed, or raped
is some sort of observer-independent science and we’re somehow above
having feelings about what’s going on. If you’re not like, “Oh, yeah. I’ve
seen this before: been there, done that,” then it’s like you haven’t
cultivated the right antibodies to shock, you’re not cool yet, you 're not
even good.

But I think there’s a real danger to acting like that around patients;
they’ll think you’re calloused, aloof, and arrogant. I don’t want to be like

 

'6 From his The Glorious Nosebleed, 1975.
'7 Page 52 of Smithsonian May 2002.

12

that! I think you have to find a way, as a professional, to be a person

around patients. I think some of the docs don’t know how to do that, and I

think they miss things because of it, too. 18
Like the citizens O’Neill refers to in the previous example, this physician thinks that,
where he works, what a person perceives to be shocking reveals something about what
she knows, about whether she remains deftly unmoved by the horrors of emergency
medicine. In this context, jaded is a feature of clinical culture, an aptitude; jaded is
callousness, but also a measure of coolness. The concept callousness draws upon a
physical metaphor; when a physical callous forms on a heel, it protects the person and her
foot from pain by desensitizing the tissues of the foot. This metaphor appears apt when
considering what this physician meant about dangers of becoming emotionally and
morally desensitized. Becoming emotionally calloused, makes a person harder, more
numb, and less susceptible to being hurt by what he perceives and witnesses in his daily
work. But, this physician doesn’t see desensitization as much of a benefit; he wonders Is
it an appropriate or good feature of professional practice?19 He worries that jaded
colleagues have a narrowed scope of perception; he’s seen them “miss things.”

In another example, a high-school teacher means something else by describing

herself as “jaded.” She remarks:

I just got hired. I was all excited about this job. And then, I discovered
why they call teaching a ‘load’. There’s a ton of grading, but I was

 

'8 This use of jaded came about in a discussion at the 2002 annual meeting of ASBH; this physician wishes
to remain anonymous.

’9 At this point, some will want to ask Is this emotional and epistemic hardening always bad, or can it be a
good, ejfective way for professionals to deal with suffering that healthcare professionals witness and
respond to in their work? One article (see McManus, Winder, and Gordon) for example, claims a
“significant causal pa ” between a caregiver’s “cynicism,” which they conceive as “depersonalization,”
and her experience of decreased stress. This may well be true. However, even if cynicism causes decreased
stress among caregivers, there does not appear to be any evidence that it makes them better caregivers. It
might indeed make them worse caregivers. As I’ll argue in Chapter Three, for example, callousness causes
faulty moral perception. A possible result of faulty perception is “missing things,” just what the emergency
medicine physician in the example is worried about.

13

prepared for that. I was less prepared for the pervasiveness of students’
behavioral problems. And I was not at all prepared for students’ parents’
behavioral problems! It’s so disconcerting when you call them to talk
about their child’s failure to do something and they get angry or they don’t
care. There’s no support when that happens, and students know it. If you
call their parents and don’t get anywhere with them, it’s just you against
them in the classroom. It’s impossible. I’m so jaded and I’ve only been
doing this for a year. I’ve got to find something else to do; I (just can’t deal
with being intimidated by 16 year-olds; it’s too exhausting.2

This teacher uses “jaded” to describe physical and emotional fatigue. Two senses of
fatigue in play here are getting tired and getting tired of something that interferes with her
ability to enjoy (or even accomplish) her job.

In another example, a healthcare professional refers to herself as “jaded.” When
one critical care time was asked how she saw herself as a nurse today and as a nurse
twelve years ago, she said this:

I’ve been more professionalized, but I feel less like a professional. I guess
I’m jaded. I mean, I have less autonomy now. I’m usually willing to do
what I’m told, but I never used to feel like thinking on my own and
figuring things out myself were actually discouraged. Now I certainly do.
There are so many people doing the telling, and so few of us actually
thinking. My job feels like “factory nursing” now, but I guess I’m resigned
to it. I have to be, but I don’t feel good about it. Patients don’t get what
they deserve, they don’t get what they need when their nurses and docs are
more like numbed factory workers than good professional caregivers.21
This nurse resigns herself to something in an attempt to become indifferent to what she
describes as the “factory” nature of her work. She has made a deliberate decision to try
not to be affected by it, and she describes this as part of what it means for her to have
become jaded.

In each of the above examples, “jaded” carries different connotations that make it

useful and descriptive within contexts that vary significantly. For example, “decadent”

 

2° This use of jaded is from a phone conversation I had with a friend. She wishes to remain anonymous.
2' This discussion also evolved at the 2002 ASBH meeting too; this nurse wishes to remain anonymous.

14

describes Caligula with accuracy, but not the emergency physician or the critical care
nurse; “alienation” and “insatiety” describes the state of the subject of the Gorey drawing
or the Silverstein poem, but not the state of the viewer of Judith Slaying Holofemes.
There are family resemblances among these concepts and among “decadent” in Caligula,
“ennui” in Gorey, “numbness” in a viewer of Gentileschi’s painting, “callousness” in the
emergency physician, “fatigue” in the teacher, and “indifference” in the critical care
nurse. What these examples have in common is that in each one, the concept jaded is in
play to refer to an epistemic, emotional, physical, or moral dimension of how a moral
agent’s poor perception corresponds to a failure to be moved to respond.
Part Three: Toward a Formulation of Perception as Motivation

Continuing my Wittgensteinian task of describing, I need to draw a distinction
between two categories of senses that have been in play throughout this chapter: physical
senses and moral senses. J ading means different things when applied to each of these
categories. The first category comprises the five physical senses—sight, hearing,
smelling, taste, and touch—that have to do with a person’s perception of particulars in
her physical world. Examples, discussed in the previous section, of objects of these
senses that moral agents can perceive were things like sunlight, food, and sex. When
moral agents become jaded with respect to perceiving objects of physical senses, these
objects are enjoyed too frequently or exist too abundantly and the capacity to perceive,
the physical sense, is over stimulated. Under conditions of surfeit, a person can
overindulge such that objects of perception diminish in value; when this happens, her

motivation to continue perceiving the same objects in the same ways erodes and she gets

15

jaded. This kind of j ading is represented in the Silverstein poem, the life of Caligula, and
the Edward Gorey drawing.

But, the nurse and physician in the examples don’t describe themselves as jaded
because their physical senses get over stimulated, and neither do other healthcare
professionals when they’re talking about their work. So, I’ll turn my attention to a second
category of senses, moral senses, one of which is the sense of moral responsiveness to
others. The physician and nurse in the examples use the concept jaded to suggest that
features of their work environment play important roles in determining whether they see
particulars well and are properly motivated to respond to others who deserve and need
moral responses. The emergency physician, for example, uses the concept jaded to
describe an implicit standard of callousness required to perform well in the environment
in which he works. But, he thinks jading is problematic because it appears to interfere
with a professional’s ability to respond with care to patients and colleagues. He suggests
that when morally relevant particulars are “missed,” a practitioner’s ability to respond to
others capably and effectively is undermined. To this physician, being jaded means being
calloused, which means having a dulled capacity to perceive particulars that matter.

The critical care nurse also uses “jaded” to describe her response to her working
conditions; in particular, she makes an analogy between being a professional nurse and
being a factory worker. Despite her crucial role in delivering critical care to patients, she
sees herself as a mere functionary in her work environment, deprived of adequate
opportunities to autonomously and creatively respond to what others need and deserve.
She suggests that she’s not free to act as she’s motivated to act, that she’s discouraged

from “thinking,” that she coped with restriction and discouragement by resigning to the

16

factory nature of her work environment, and that she has had to settle for only being
rewarded for taking orders and executing others’ decisions.

The physician and nurse in these examples both use the concept jaded to describe
ways in which features of their work environments interfere with their abilities to be
morally responsive. With these descriptions of how jaded has been used in ordinary
language to describe relationships among a healthcare professional’s conception of
himself as morally responsive and his ability to perceive, be moved, and respond to
others, sets of hypotheses can be formulated, which try to fit these concepts of self-
conception, self-respect, perception, and motivation into a theoretical framework that can
be used to further explore the phenomenon of j ading. A first set of hypotheses is this:

For many moral agents who are healthcare professionals, being morally
responsive to others is an important part of who they are and what they
think is worth doing. When a moral agent exercises the sense of moral
responsiveness to others, she exercises her capacity to perceive reasons to
and reasons how to respond to others morally. She construes reasons by
perceiving particulars in clinical situations and discerning patterns of
moral relevance among them. Under normal conditions, her perception of
a reason to respond motivates her to act, to respond to another person—a
patient or colleague—with care. When she is free to act as she is
motivated to act, her actions endorse values of moral responsiveness—
beneficence and compassion, for example—and express who she is and
what she thinks is worth doing; this generates self-respect for her.
In Chapter Two, I’ll argue for a view of how these hypotheses hang together; in
particular, I ’ll argue for an intemalist, cognitivist, realist moral theoretical framework that
supports a view of how moral motivation works when it works normally. Under normal
conditions, a healthcare professional is free to act in ways she endorses as expressive of
who she is when she perceives moral particulars there are to be seen and when she is able

to act as she’s motivated to act. A second set of hypotheses describes a process by which

moral motivation erodes under conditions of oppression:

l7

But, if her work environment restricts her perception or her ability to act
as she’s motivated to act, she is situated to suffer forms of moral damage,
which can take several forms, such as loss of self-respect and alienation. A
professional who has suffered one or several forms of moral damage over
time can respond by reducing the degree to which she sees moral
responsiveness to others as importantly and centrally constitutive of who
she is and what she sees worth doing. When a moral agent reduces the
degree to which being morally responsive to others is important to her, she
narrows the scope of what she sees herself responsible for, and she can
become calloused. Callousness causes faulty moral perception: when a
person becomes calloused, she narrows the field of particulars that
configure other persons’ desert and need of her responses and constitute
reasons to act. When the scope of what a moral agent counts as a reason to
act is too narrow, she won’t be motivated to act despite the presence of
reasons to act. She will fail to respond to reasons there are for acting in
service to others.
In Chapter Three, I’ll apply the moral theoretical framework I argue for in Chapter Two
and I’ll argue for how these hypotheses hang together theoretically given that framework.
I argue for a view of how, when healthcare professionals work under conditions of
oppression in healthcare organizations, they suffer moral damage and their moral
motivation to respond to others who deserve and need moral responses erodes. I argue for
a view of how they can become, in a word, jaded.

In this chapter, I have followed Wittgenstein’s advice. I’ve described the plot of
experiences of becoming disappointed in, dissatisfied with, and disengaged from
healthcare education and professionalization and argued that these phenomena are best
characterized by a family resemblance concept, jading. I’ve also developed sets of
hypotheses which, as I’ll argue, contain the conceptual apparatus needed to describe
jading in greater detail, and account more adequately (than concepts disillusionment,
burnout, or cynicism) for processes of moral damage the jaded suffer. Preventing moral

damage among professional caregivers ultimately lies in changing conditions of

institutional oppression in healthcare professionals’ work environments, as I’ll try to

18

show in Chapter Four. But we can’t change working conditions in healthcare
organizations until we understand how they’re oppressive and understand how oppression
incurs moral damage and moral motivational erosion. Furthermore, we can’t understand
how moral motivation erodes until we understand how it works when it works normally;

this is the task of Chapter Two.

19

CHAPTER TWO: MORAL MOTIVATION UNDER NORMAL CONDITIONS

In the last chapter, I characterized jaded as a family resemblance concept that
describes a process of moral damage and moral motivational erosion over time. Before
we can understand how moral motivation erodes, however, we must first understand how
moral motivation works under normal conditions. Concisely, the claim I argue for in this
chapter is this: moral motivation works normally when a moral agent is moved to act by
her perception of the morally relevant particulars that constitute her reasons to act.
Supporting this claim requires me to argue for three things: an intemalist conception of
moral motivation, an account of how moral reasons behave, and an account of how moral
agents learn moral perception.

Arguing for an intemalist conception of moral motivation in Part One, I respond
to the strongest objections to intemalism and develop a conception of moral motivation
not as an “all or none” phenomenon, but one that admits of degrees of forcefulnesszz.
Establishing the idea that moral motivation admits of degrees will be important to
understanding how moral motivation erodes; in the next chapter, I examine the conditions
under which moral motivational erosion can occur. In Part Two of this chapter, I draw on
Jonathan Dancy’s work to develop an account of what moral reasons are and how they
“behave.” From Dancy, we learn that one of the most important features of a moral
reason is that it is contextualized within a narrative description of a situation. I argue that

moral reasons are real and that who moral agents are, what they think worth doing, and

 

22 This way of thinking of the nature of moral motivation was generated and encouraged by my reading of
an article by James Lindemann Nelson, “The Social Situation of Sincerity: Emma and Ethical Formation.”
Drawing upon Sabina Lovibond’s discussion of the nature of moral beliefs and Jane Austen’s character’s
development in the novel, he suggests that the nature of the connection between how intensely a moral
agent thinks or is convinced by a moral belief and how strongly she experiences a motivation to act upon
such a belief is graded, not all-or-none. His view relates moral belief to moral motivation; here I apply his
view to a discussion of the nature of the connection between moral perception (reason-recognition) and
moral motivation.

20

how they’re trained guide their perception of particulars, their experience of value of
those particulars, and their construals of moral reasons that are there for responding to
others with care.

In Part Three, I examine the concept training more closely. Particularly, I focus
upon how teaching and modeling patterns of perception are dimensions of training
individual healthcare professionals to respond to others morally. Under normal
conditions, a moral agent who is a healthcare professional is expected to be motivated to
respond with care to others; as I’ll argue, if she is to respond well, she must be trained to
perceive and construe particulars in clinical situations that configure others’ desert and
need of her caring response. I draw on Aristotle and Wittgenstein to discuss how students
of healthcare professions learn good patterns of perception when they are effectively
modeled by their mentors and teachers. I also draw on Michael R. DePaul’s work to
develop a conception of how moral perception is a capacity that is not static, but
dynamic, a capacity to be refined and cultivated throughout one’s education,
professionalization, and practice.

Part One: Moral Perception as Moral Motivation

There are several different accounts of the relationship between perception and
moral motivation, and they generally fit into one of two camps. Intemalism holds that a
moral agent’s recognition of a reason to act is sufficient to motivate the moral agent to do
that act.23 Externalism denies the sufficiency of this connection between recognition of a

reason to act and motivation to act, and holds that a moral agent might recognize a reason

 

23 Intemalism is the idea that reasons directly motivate action. (Intemalism developed as a refutation of the
Humean notion that motivation comes from desire, an idea that’s one kind of externalism.) One way for an
intemalist to account for how reasons directly motivate action is by developing theories of the relationship
between perception and motivation. One such theory is developed in Jonathan Dancy’s Moral Reasons,
which I draw upon in this work.

21

to act but not be motivated to act. The extemalist maintains that something in addition to
recognition of a reason to act is required to motivate a moral agent to act.

An intemalist theory of motivation substantiates a direct connection between
perception and motivation, and appears, therefore, to be the most convenient one for me
to use to account for the kind of moral experience of j ading. But extemalists maintain that
intemalists cannot account for the existence in moral life of three types of cases, and that
these undermine the intemalist’s claim that perception is sufficient for moral motivation.
The three cases are these. First, cases of evil are those in which a moral agent recognizes
what is right to do but is motivated to do an action she knows to be wrong because it is
wrong.

Second, akrasia typically refers to cases of weakness of the will, terms which
have been used to describe at least two different phenomena, between which I will draw a
distinction in an attempt to make a clarification about the nature of moral motivation.
Akrasia refers to cases in which a moral agent recognizes what is right to do but is
nonetheless not motivated to do it; I’ll call this the strong sense of akrasia. Akrasia also
refers to cases in which a moral agent recognizes what is right to do but nonetheless does
not do it; I’ll call this the weak sense of akrasia.

The third type of cases that the extemalist puts forth to undermine the intemalist’s
claim that perception is sufficient for motivation is accidie. Accidie refers to a special
instance of akrasia, specifically akrasia caused by a mental state, such as depression.“

Suffering accidie, a moral agent recognizes what is right to do, but does not experience

 

2’ On page 5 of his Moral Reasons, Jonathan Dancy suggests that depression may be such a condition in
which the moral agent suffers accidie.

22

motivation (or does not act)”. If an intemalist cannot account for how these three types
of moral agents—evil, akratic, or accidic moral agents—are morally motivated in terms
of perception only, she must concede that extemalism is right; she must concede that
something else is needed, in addition to perception, for moral agents to experience moral
motivation.

Evil is much less like jading than are akrasia and accidie, as I’ll explain shortly,
so I’ll deal with it first. The intemalist can account for evil by clarifying the sort of
problem evil is. Jonathan Dancy, for example, suggests26 that evil has to do with what a
moral agent believes—whether she accepts moral propositions that other moral agents
do—and not with whether or how her motivation to act corresponds to recognizing a
reason to act. That is, the question to ask about an evil moral agent is not Why is she not
motivated? but rather Why does she not accept or understand the moral propositions that
most moral agents do? This latter question is appropriate to ask about evil because if a
moral agent does not accept or understand moral propositions that other moral agents do,
we would not expect her to be motivated by them (even if we expected her to behave as if
she were motivated by them). Since the case of evil has to do with whether particular
moral beliefs are accepted or understood, Dancy suggests that its proper place is in the
debate between cognitivism and noncognitivism and not in a debate about how moral
motivation works. If, as it appears, the case of evil is really best placed in discussions of
moral belief than it is about moral motivation, it does not threaten the cogency of the

intemalist’s view of that perception is sufficient for moral motivation.

 

25 As I’ve just said, akrasia has two senses; it sometimes describes a lack of motivation and sometimes
describes a lack of action.
2" Dancy, 5.

23

There is no question about whether akrasia and accidic are properly placed in
discussions about moral motivation, however. As I’ve just said, akrasia refers to cases in
which a moral agent recognizes what is right to do but is nonetheless not motivated to do
it and also refers to cases in which a moral agent recognizes what is right to do but
nonetheless does not do it. The strong sense of akrasia refers to the first kind of case, and
it denotes a disjunct between perception and motivation, which is a problem for the
intemalist. The weak sense of akrasia refers to the second kind of case, and denotes a
disjunct between perception and action, which, as I’ll try to show, is not a problem for the
intemalist.

Let’s consider the strong sense of akrasia first, since this is the most serious threat
to the intemalist’s claim that perception is sufficient for motivation. The extemalist
claims that akratic and accidic moral agents recognize what is right to do but are
nonetheless not motivated to do it; the extemalist thus presents cases in which it appears
that reason recognition is insufficient for moral motivation. Dancy recommends a first
move for intemalists to handle these cases; he questions whether akratic and accidic
moral agents actually exist. That is, he suspects that “too much is being made of
phenomena which need to be distorted if they are to serve in the extemalists’ purpose.”27
I’m going to entertain Dancy’s suspicion; wondering whether akratic and accidic moral
agents really exist is, I think, a fair move and not a merely dismissive one because at least
two questions should be asked about akrasia and accidie. It is supposed that alcratic and

accidic moral agents recognize reasons but are not motivated by them. This supposition

raises a first question: Does “not motivated” mean not motivated at all?

 

27 Dancy, 5.

24

Let’s assume for sake of argument that it is true that there are moral agents who
recognize reasons to act but are not at all motivated by them to act. A second question
can still be asked: What counts as good evidence that a moral agent experienced no
motivation at all? Assume firrther for sake of argument that the most reliable indicator of
a moral agent’s experience of no motivation at all to act, despite the recognition of a
reason to act, is a moral agent’s self-report. So, an akratic or accidic moral agent would
be a person who reports, “I recognized a reason to do X, but I experienced no motivation
at all to do X.” The intemalist will ask the self-reported akratic or accidic moral agent the
same second question she asks the extemalist: What counts as good evidence that you
experienced no motivation at all to do X, despite that you recognized a reason to do X?

Let’s consider a possible candidate for a feature of the akratic or accidic moral
agent’s experience that could count as good evidence that the self-report of “recognizing
a reason to act but not being motivated at all by it” is indeed true. Suppose the self-
reported akratic moral agent says, “I experience recognizing a reason to do X as
completely separate and not linked in any way to any experience of motivation to do X.”
The intemalist must now decide whether she trusts this moral agent to be a reliable
assessor of her own experience of the relationship between reason-recognition and moral
motivation. If the intemalist trusts this moral agent’s experiential report to reflect the true
nature of the relationship between reason-recognition and motivation, she must concede
that the extemalist is right that something in addition to reason-recognition is necessary
for a moral agent to be motivated. Furthermore, in the absence of a good reason not to

trust that a moral agent’s self-report is a reliable gauge of the mutual exclusivity of

25

reason-recognition and motivation, the intemalist ought to concede that the extemalist is
right.

But, even when the intemalist trusts the moral agent’s self-report that she
experienced no motivation at all to act because she has no good reason to doubt her
epistemic authority or her authority to make claims about her internal states, a conceptual
question still remains: What does it mean to experience the recognition of a reason as
mutually exclusive from any experience of motivation? Indeed, this question is the most
important one in the debate between intemalists and extemalists about how moral
motivation works under normal conditions. It may appear that the intemalist simply begs
the question at this point. But, I am not simply begging the question here because, in the
second and third parts of this chapter, I’ll argue for a view of moral perception and moral
motivation in which what it means for a moral agent to recognize a reason to act is to
experience value of morally relevant particulars that configure that reason to act. If this
view I argue for is correct, then it doesn’t make sense to claim that reason-recognition is
mutually exclusive from the experience of moral motivation, although it would make
sense to claim that moral motivation wasn’t experienced forcefirlly enough to prompt

action.

So, I’ll devote sections two and three of this chapter to developing an intemalist
framework of how moral perception is moral motivation, which serves as a careful,
detailed response (if not a refutation) to the extemalist’s charge that akratic (in the strong
sense) moral agents exist. But first, in this section, it is also worth the intemalist’s time to
consider the weaker sense of akrasia, in which a moral agent experiences a disjunct

between perception and action. In this case, it would be reasonable to conceive the akratic

26

moral agent as one who would claim “I experience recognizing a reason to do X as
completely separate and not linked in any way from any experience of motivation to do X
because I did not experience motivation forcefully enough to actually do X” This kind of
akrasia does not preclude the moral agent’s experience of at least some motivation to act
based on her perception of a reason to act. That is, the fact that she does not act could
mean that she wasn’t motivated at all to act, or it could also mean that she simply didn’t
experience moral motivation forcefully enough to act.

An intemalist must carefully draw and maintain a distinction between the two
different senses of akrasia because there are three different connections that should be
appreciated in discussions of how moral motivation works: the connection between
reason-recognition and motivation to act, the connection between motivation to act and
acting, and the connection between reason-recognition and action. Failure to distinguish
among these precedes failure to appreciate which connections are severed and how
completely or incompletely they are severed when moral agents don’t experience moral
motivation properly. Regardless of what philosophers call phenomena—akrasia, accidie,
or weakness of the will—that can be described in terms of these connections, their
disjuncts, and the severity of their disjuncts, it seems clear that in order for the extemalist
to refute the intemalist’s claim that perception is sufficient for motivation, she must
present a moral agent who experiences a complete disjunct between reason-recognition
(perception) and motivation to act. A moral agent who experiences an incomplete
disj unct between reason-recognition and motivation to act, but a complete disjunct
between reason-recognition and acting is not such a moral agent whose existence refutes

intemalism. Interestingly, however, such a moral phenomenon is of the utmost

27

importance to the intemalist because it suggests the graded character of moral motivation.
That is, a moral agent who recognizes a reason to act can experience motivation to act,
even if such motivation is insufficient to prompt her to act. Furthermore, the idea of
“insufficient motivation to act” suggests that something happens to the connection
between perception and motivation, but it does not suggest the absence of a connection.28
For example, when moral motivation doesn’t work properly, the connection between
moral perception and moral motivation might erode under certain conditions.

What I’ve tried to show so far is that if akrasia refers to a disjunct between
perception and motivation, that the intemalist can only maintain the claim that perception
is sufficient for motivation if she can show that perception is motivation, which I’ll try to
do by further drawing upon Dancy’s view of moral perception and moral reasons in
sections two and three of this chapter. I’ve also tried to show so far that if akrasia refers
to a disjunct between perception and action, then there’s good reason to think that moral
motivation is the kind of phenomenon that is not “all or none,” but one that admits of
degrees of forcefulness. Furthermore, I’ve suggested that if akrasia is a disjunct between
perception and action but not between perception and motivation, the intemalist position
appears to be vindicated. If the intemalist’s position is indeed vindicated in this way, the
intemalist has more work to do in developing a conception of moral motivation that

accounts for moral motivation as the kind of experience that is graded, not “all or none.”

 

2’ At this point, an extemalist could say, “But, if the connection between perception and motivation is so
threadbare, is it not reasonable to say that something, in addition to recognizing a reason to act, is needed to
motivate a moral agent forcefully enough to act?” I think an intemalist could be pressed to agree, but she
would have fought well to get the discussion of moral motivation to this stage of forcing acknowledgment
of the character of moral motivation as graded and not “all or none.” Acknowledging the graded character
of moral motivation gets us to the point at which we can consider the social dimensions of moral
motivation: Under which kinds of working conditions, for example, can moral motivation erode? I take up
this question in Chapter Three.

28

A good starting point is closer examination of the kind of experience akrasia is, if it is a
disjunct between perception and action.

Consider, for example, a person who repeatedly says, “Great Aunt Helen is
getting quite old; I must visit her. I’ve been meaning to do so for quite some time, I just
never seem to get around to it.” This person may be said to be weak—willed with respect
to visiting her great aunt in the following way. She recognizes a reason (or several
reasons, such as the need to say “Goodbye” to Great Aunt Helen before she dies, or the
belief that one ought to spend time with one’s frail elders) to visit her great aunt, which
she conveys in the proposition that Great Aunt Helen is old. She experiences motivation
to visit her, which she conveys in the proposition that she means to visit her. Yet, she still
does not visit Great Aunt Helen.

About such a person, the extemalist could say that this moral agent is not really
motivated at all to visit her great aunt—that she says she means to visit her, but she really
doesn’t at all—and the extemalist might be right. In fact, the extemalist would be right if
moral motivation were the kind of thing that could be understood only as an “all or
none,” really there or not at all there phenomenon. But, there’s another way to
understand this moral agent’s experience of motivation. Suppose, for example, that this
moral agent doesn’t visit her great aunt because she’d rather watch television on one
occasion, because she needs to pick up her brother on another occasion, because she
needs to study on yet another occasion. A myriad of things to do present themselves to
her and she must decide how her commitment to each activity competes with her
commitment to visiting her great aunt. In such a case of competing commitments

(regardless of the merits of those commitments), she could be understood as only weakly

29

motivated to visiting her great aunt. If it is the case that she is only weakly motivated, it is
an overstatement to say that she is not motivated at all. Overstating moral motivation as
entirely lacking simply mischaracterizes moral motivation as “all or none” when it is (as
I’ve just argued) really the kind of phenomenon that’s best characterized as an experience
of degrees of forcefulness. Even if the degree of motivation a moral agent experiences is
slight, it is enough to maintain the sufficiency of the connection between reason-
recognition and the experience of moral motivation, and this suggests that intemalists are
correct that moral perception is sufficient for moral motivation. It also suggests that
competing commitments are the kinds of things that could generate incomplete
disjunction29 between the connection between perception and motivation. Competing
commitments can be internal to a person—a person can be committed to watching
television and to visiting her aunt—or they can be external to a person and take the form
of a threat or susceptibility to loss30—a person with a gun to her head would suddenly
develop a commitment to saving her life that competes with commitments she had before
being threatened. Competing commitments are one kind of external, social influence on
whether moral agents’ experience moral motivation under normal conditions, which I’ll
take up in greater detail in Chapter Three.

At this point, we should be able to see how my discussion of the kind of

phenomenon jading is merges with my discussion of the kind of phenomenon moral

 

29 This brings up a possible source for a fourth objection from an extemalist who wants to show that
intemalists are wrong. If an extemalist can come up with a case in which the connection between
perception and motivation is eroded such that the disjunction of their connection is completely severed and
the extemalist can show that a moral agent recognizes a reason to act and experiences motivation to act
despite the severed connection, then the intemalist would have to concede that the extemalist is right. In
such a case, if one could be found, something else in addition to perception would appear to be a required
for motivation, unless that something merely restores perception.

3° In Chapter Three, 1 show how co-optation differs from weakness of the will: the moral agent is subject to
significant losses such that she is essentially forced to act other than she would be motivated to act were she
free.

30

motivation is.3 1 If, as it seems, the intemalist can indeed explain the strongest of the
extemalist’s objections—cases of evil, akrasia, and accidie——we can safely commit to the
intemalist’s View: the reasons we see for acting constitute our motivation to act. And if,
as it also seems, the intemalist can explain cases of akrasia by conceiving moral
motivation as admitting of degrees of forcefulness, then moral motivational erosion over
time appears to be the kind of moral experience an intemalist theory is conceptually and
theoretically equipped to handle. I therefore submit a refinement to this intemalist view:
the reasons we see for acting constitute our motivation to act, but perception can be
damaged and motivation can erode.

I must clarify that an intemalist theory of moral motivation—on which moral
perception is moral motivation—will be most useful in theorizing about the moral
problem of j ading with a concomitant view of perception in which moral agents evaluate
the moral relevance and assess the moral weight of particulars in moral situations; this
theory of perception only makes sense on the supposition that cognitivism is true.
Cognitivism is the view that moral claims have truth values. Cognitivism means then,
that moral agents can evaluate moral claims and that a moral agent can’t evaluate
particulars’ moral relevance irrespective of knowledge and beliefs she has about those
particulars and the contexts in which they are perceived. For example, suppose a moral

agent, upon perceiving a particular feature of a situation and deeming it to be morally

 

3 ’ At this point, one may wonder if my theory of how jading transpires depends upon the truth of
intemalism. It does, I believe, but this is not to say an extemalist account of jading isn’t possible. The
intemalism I motivate in this dissertation holds that desires and beliefs guide perception. An extemalist
account would look very different from mine, but I don’t yet see a good reason for why one couldn’t be
developed. I expect an extemalist account would have to explain what happens to a moral agent’s desire,
belief, or whatever it is in addition to perception that the extemalist holds is necessary to motivate a moral
agent to act, such that the desire, belief, or something else no longer motivates action. If my accounts of
damage (loss of self-respect, alienation, and callousness) in Chapter Three are right, the extemalist would
have to show that loss of self-respect, alienation, and callousness somehow eliminate desire, belief, or
something else despite that a practitioner recognizes a reason to act.

31

relevant, thinks, “I ought to do X about what I see here.” A cognitivist holds that moral
agents recognize, hold beliefs about, know things about, and evaluate properties of moral
reasons—their goodness, badness, rightness, wrongness, justice, injustice, truth, and
falsity, for example. The statement “I ought to do X about what I see here” suggests that a
moral agent knows, or at least believes, something about X being the right thing to do.32
Responsibly presupposing cognitivism in an intemalist theory of moral
motivation means acknowledging that two important moral epistemological questions
arise here: What does a moral agent know or believe about the rightness of X? and How
does she came to know or have beliefs about X ’s rightness? 33 If the reasons a moral agent
sees for acting constitute her motivation to act, and if moral agents’ knowledge and
beliefs guide their moral perception, then moral agents’ knowledge and beliefs also guide
their moral motivation. So, how students and professionals acquire knowledge and beliefs
and what they come to know and believe must be integral parts of a moral theoretical
framework that is equipped to generate understanding of the problem of j ading. Some of
what students and professionals in healthcare come to know and believe will be discussed
in Chapter Three, and how students and professionals learn moral perception will be
developed in Part Three of this chapter. In this section, however, I need only to establish
that if we’re to adopt an intemalist view of the relationship between reason-recognition
and moral motivation, we presuppose the truth of cognitivism and are committed to the

view that moral perception (and therefore moral motivation) is guided by a moral agent’s

 

’2 Contrarily, a noncognitivist holds that to say “I ought to do X” simply means “I have a disposition to do
X.” According to the noncognitivist, being disposed to do X does not mean that the moral agent knows or
believes anything about X. She can adequately account for her action without knowing or believing
anything; she need only say that she was disposed to do it.

33 In his 1975 article (see bibliography), Joseph Margolis suggests a distinction I draw upon here. He
thought, at the time, that this was an often overlooked complexity in the debate between cognitivism and
noncognitivism: that a person knows or believes something doesn’t entail how she knows or comes to
believe it.

32

knowledge and beliefs about what’s right and worth doing. An intemalist, cognitivist
view of moral motivation suggests, then, that if students and professionals in healthcare
are going to recognize reasons to act and be motivated to respond to them properly, they
should see well, be taught to see well, and be taught to evaluate how their knowledge and
beliefs guide how they see and how they attribute value to particulars.

Accepting an intemalist, cognitivist view of moral motivation only helps us
understand part of the phenomenon of jading, the part that has to do with the relationship
between moral perception and moral motivation. But, as I suggested earlier in this
section, the connection between motivation and action is important too. J ading also has a
social component that has to do with this connection, particularly between a moral
agent’s motivation and her freedom to act as she’s motivated to act. I’ve tried to establish
thus far that when moral motivation works normally, a moral agent is moved to act by her
perception of morally relevant particulars that constitute her reasons to act. This view
gives us a large portion of what we need to theorize about and understand the moral
problem of jading. But, if we’re to fully account for the kind of problem jading is, we
must understand the conditions under which moral agents’ moral perception is damaged
and the conditions under which moral agents are not free to act as they’re motivated to
act; these will be closely examined in Chapter Three. First, however, more must be said
about moral reasons and how moral agents perceive reasons to and reasons how to
respond to others with care under normal conditions.

Part Two: How Moral Reasons Behave
As I’ve just argued, to perceive moral reasons is to be motivated to act on them.

This section will discuss the nature of moral reasons, and the next section will discuss

33

how moral agents learn to see them. About the nature of moral reasons, we can ask at
least two questions. The first is What are moral reasons? This question seeks after the
metaphysical status of moral reasons; as we’ll see shortly, one way to respond to this
question has been to think about moral reasons as the kinds of things that are to be
discovered in the world, as Richard Boyd does. Another way to respond to this question
has been to think about moral reasons as the kinds of things that have different
significance to different moral agents, depending upon whether a moral agent’s
perspective is impartial or personal, as Thomas Nagel does. Jonathan Dancy asks a
different question about moral reasons, however: How do moral reasons behave?34 In
pursuing this latter question, I further draw upon Dancy’s particularism to develop this
conclusion: a moral reason is not just anyone’s moral reason, but my moral reason to
respond in this way, at this time, to a configuration of particulars that I experience as
motivational, given how I’ve been trained to see and given which values guide my
perception. That is, who I am, what I care about, what I’m committed to, and how I’ve
been trained to see determine whether and how well I’ll see reasons there are (and
whether I’ll be motivated properly).

But first, this view of moral reasons I endorse raises an important question: How
can a view of moral reasons dependent upon whether and how well I see them be realist?
The view I endorse appears at first to vulnerable to a weighty criticism: that it is merely
subjective. A merely subjective view of moral reasons is problematic because such a
view holds that moral reasons are mere products of the minds of moral agents with no
real connection to the world in which those moral agents negotiate their lives. As I’ll

argue, however, this View of moral reasons I endorse is not merely subjective. To

 

3‘ In Moral Reasons.

34

understand why it’s not merely subjective, it’s helpful to begin by first understanding a
contrasting view of moral reasons, moral reasons as objectively real, held by Boyd. After
understanding the poles of strong objectivity and mere subjectivity, I try to negotiate a
middle position for a realist view of moral reasons that takes moral perception to be of
utmost importance in construing them properly.

Boyd thinks of the practice of morality (which he conceptualizes as the making of
moral judgments, statements, and theories) as analogous to the practice of science:35
theories describe phenomena in the world that occur independently of our theorizing
about them. What follows fiom Boyd’s view is that the plausibility of our theoretical
explanations is heavily reliant upon the methods we use to learn about phenomena truly
occurring in the world. Employing theories as descriptive and epistemic tools succeeds,
according to Boyd, “because, and to the extent that, currently accepted theories are
relevantly approximately true” and “because there is a dialectical relationship between
current theory and the methodology for its improvement.”36 Boyd’s view is that moral
practices of developing theories, rendering judgments, and making statements are at least
no less accurate ways of learning about the moral phenomena of the world than are
scientific ways of learning about the physical phenomena of the world. This view is a
strong objectivist moral realist one. That is, Boyd holds that moral agents are detached

from moral reasons and that moral statements are either true or false and their truth or

falsity generates facts about whether actions are right, wrong, good, bad, just, or unjust.

 

’5 I refer to his article “How to Be a Moral Realist,” which appeared in 1988 in Geoffrey Sayre-McCord’s
edited compilation Essays on Moral Realism (Cornell University Press). I’m using the article anthologized
in Moral Discourse & Practice: Some Philosophical Approaches, edited by Stephen Darwall, Allan
Gibbard, Peter Railton (Oxford University Press, 1997).

’6 Boyd, lll (italics not included).

35

But, it’s difficult to see how it makes sense to conceive moral reasons as detached
from ourselves or detached from the contingencies of being ourselves. A problem with
Boyd’s strong objectivist moral realism is that it doesn’t ring true with our moral
experience of situations in which moral agents personally relate to (not detach from)
moral reasons. Thomas Nagel is another obj ectivist moral realist, but his brand of realism
allows for moral agents’ personal connections to some moral reasons. Like Boyd, he
thinks moral reasons are objective and discoverable, but unlike Boyd, Nagel conceives
morality as a kind of objective “standpoint” from which we understand the world. Nagel
thinks that the objectivity of our standpoint increases as we “step back” from our views
of things such that we gather a new view that contains the old view. By continuing to
“step back,” the old view becomes increasingly subjective as it acquires new frames of
reference. He suggests that morality is real with respect to the lived experience of human
beings but not as objectively real as, say, the science of physics because, according to
Nagel, physics occupies a wider, broader sphere of reality. Nagel proposes that we “think
of reality as a set of concentric spheres, progressively revealed as we detach gradually
from the contingencies of the self.”37 According to Nagel, all moral agents are not equally
detached fiom all moral reasons, however; he suggests that moral reasons there are for
acting “look different,”38 according to whether a moral agent’s perspective is impartial or
personal. He argues for the importance of distinguishing between the perception of moral
reasons there are for acting from the personal point of view and an impartial point of
view and says “the special personal perspective of agency has fundamental significance

in determining what people have a reason to do.”

 

37 In The View From Nowhere (Oxford University Press, 1986) Nagel makes these points on page 5.
3’ Nagel said this in one of The Tanner Lectures on Human Values, “The Limits of Objectivity,” which is
included in Thomas Beauchamp’s Philosophical Ethics (3rd Edition, McGraw Hill, New York, 2001).

36

So, Boyd’s strong obj ectivist moral realism holds that moral features of the world
exist independent of moral agents’ thoughts, beliefs, feelings about, agreement on,
resistance to, or consensuses about their presence or relevance, and Nagel’s moral realism
allows for the importance of moral agents’ perspectives in determining what individual
moral agents have a reason to do. But what it is about a “perspective” that enables moral
agents to recognize and differentiate among moral reasons to which they’ll respond
personally (with care) or impartially? Healthcare professionals, for example, must be able
to see reasons there are for responding to others with care despite that they don’t have
personal relationships with those patients. What I suggest with this observation is that the
personal perspective of moral agency is only one kind of perspective that carries special
obligations for moral agents to respond with care in moral situation in which what others
need and deserve configure moral reasons that are there. Furthermore, a healthcare
professional’s obligations to colleagues and patients can only be carried out properly
when that professional has received training in recognizing whether, when, and how to
respond. That is, a View of moral reasons that takes obligations like those of healthcare
professionals seriously is not only one on which moral reasons are real and not only one
on which moral reasons to respond with care can be recognized by moral agents with
personal stakes in situations, but one which takes seriously that moral agents must be
trained to see well if they’re to respond to reasons there are for acting.

So far, I’ve tried to motivate a realist view of moral reasons that places great
importance upon moral agents’ abilities to see well. This is not a subjectivist view of
moral reasons; that is, I do not conceive moral reasons as real only insofar as we relate to

them and I do not hold that moral reasons are products of the minds of moral agents with

37

no real connection to the world in which those moral agents live. That is, in the
conceptual space between moral reasons as merely subjective and moral reasons as
strongly objectively, moral agents’ abilities to perceive particulars in situations, to have
knowledge and beliefs about particulars by which she assesses the relevance of
particulars, to construe these particulars such that they configure reasons, and to be
moved by those reasons demand a middle ground to be negotiated. One view of moral
reasons that negotiates a middle ground between moral reasons as strongly objective and
moral reasons as merely subjective would be one that takes moral reasons to be real
insofar as they are there to be perceived and also takes our practices of perceiving them
and interpreting relationships among the particulars that configure them to be important.
Such a view of moral reasons allows us to give appropriate heft to the notion that moral
agents, though fallible, are capable of moral knowledge about the worlds in which they
negotiate moral understandings, and that moral agents have to learn to perceive
particulars well and learn to recognize and construe relationships among particulars well
in order to make good of moral life. This is the particularist view of moral reasons”,
which Dancy calls reasons holism“).

On a particularist view of moral reasons, “the behaviour of a reason (or of a

consideration that serves as a reason) in a new case cannot be predicted from its

 

’9 This is the view of moral reasons Dancy develops and draws upon in his Moral Reasons.

’0 Dancy contrasts his view of reasons holism to a different view, reasons atomism, which holds that moral
reasons behave the same way, regardless of context. That is, the atomist holds that some reasons always
carry a particular valence. For example, while the particularist and atomist might agree that killing in self-
defensc is the best thing for a moral agent to do in a situation, all things considered, the particularist could
say that killing was the right thing to do, given the situation’s context, while the atomist would say that,
even thOugh it was the best thing to do, killing is always wrong or at least always wrong—making when it is
a feature of any moral situation. To a partiuclarlist, no action is always anything (except context
dependent). Furthermore, the atomist would argue that because some action is always wrong-making, it can
generate other considerations. For example, the atomist would argue that killing in self-defense might have
been the best thing to do, but the family members of the person killed deserve an apology from the moral
agent who killed.

38

behaviour elsewhere.”41 That is, moral reasons don’t behave uniformly or consistently
because something that counts as a morally relevant particular in one situation might not
be a morally relevant particular in another situation. On this view of moral reasons, to be
motivated to act is to see the reasons there are for acting in this situation, given these
particulars, so moral agents experience moral motivation differently in different contexts.
On a particularist View of moral reasons, discerning a moral reason means a moral agent
must do two things: see the particulars there are to be seen in a situation and properly
construe configurations of moral relevance among those particulars.

At this point, we’re ready to undertake a question I introduced at the beginning of
this section, Dancy’s question about the nature of moral reasons: How do they behave?
Concisely, reasons behave in contexts. On reasons holism, moral situations can be
narratively modeled; we can offer narrative descriptions of what we see and experience.
Dancy prefers to think of this modeling as a story rather than, say, a list of particulars,
because particulars that are there to be seen exist in contexts, in relationships to one
another. These relationships feature some particulars as more significant than others, and
thus contribute to a situation’s overall shape”. That shape, according to Dancy, is a
description, a construal of what’s going on in a situation.

Discerning a moral situation’s shape properly is important because its shape,
described narratively, is the moral reason a moral agent gives for acting. For example,
when a moral agent

see[s] an action’s being right or one which ought to be done as identical
with the shape of the circumstances—[she sees] what it is about them

 

" Dancy, 60.
’2 Dancy, 113.

39

which calls for action. To see the action as required by the circumstances
is to see the situation as having a certain shape.43

What it means for a moral agent to give a reason for acting (or for having acted) is to
explain how she sees (or saw) the particulars of the situation as taking shape. When she
gives a reason for having responded to a situation they way she did, she explains how she
saw the situation and the arrangement of particulars within it.

So, moral reasons consist of configurations of particulars within narrative
descriptions of moral situations. When a moral agent perceives a particular of a situation
as salient, she perceives that particular as “stick[ing] out or protrud[ing].”44 That is, moral

agents’ narrative descriptions of situations are not merely lists of properties “in flat

”45

profile; rather, they are landscapes, structures that reveal proportion, background, and

foreground. As Dancy says:

Some [features] are more salient than others. Salience is a practical notion
here . . . To see a feature as salient is to see it as making a difference to
what one should do in the case before one. Since there are normally
several different salient features related to each other in various ways, a
full view of the circumstances will not only see each feature for what it is
but will also see how they are related to each other. Such a view will grasp
the shape of the circumstances. From saliences we move to shape. A
situation has a shape in the sense that its properties have a practically
related profile. There are the properties which are here non-salient; they
are as it were on the valley floor. Rising from that level are the various
peaks, major or minor, which are the properties which make a practical
difference to the case. When we come to give a description of the
situation, the various saliences (i.e. the shape of the situation) make a
difference to how we should go about it. . . What we are doing is telling
the story of the situation, and our narrative has to follow the shape that the
situation has. By the time we have mentioned every salient property, we
have said enough to show how we see the situation and hence the reasons
we find here for the action we do.46

 

‘3 Dancy, 115.
“ Dancy, 112.
‘5 Dancy, 112.
‘6 Dancy, 112.

40

When a moral agent explains how she sees a situation as taking shape, which particulars
she sees as salient may be revealed by the order in which she presents details, which
details are included or excluded, how those details are represented, and what sorts of
roles she articulates them as playing with respect to one another.

What I’ve shown so far in this section is that seeing well is important on a
particularist, reasons holism account of moral reasons because a moral agent’s response
to a set of circumstances is merited in light of what she sees; getting moral perception
right matters because the presence and shape of moral reasons constitute our moral
motivation. If a moral agent fails to see a particular of moral relevance, she fails to
perceive a feature of a situation that makes a difference, and she won’t be motivated
properly. But, moral agents can construe particulars as assuming different shapes,
different possible configurations of salience, and several construals are possible,
depending on how moral agents assign relevance to particulars. How are moral agents to
know whether and which construal of saliences among particulars best represents what’s
really going on in a situation?

Dancy suggests that moral agents’ descriptions of what’s going on in moral
situations need to be put to interpretive scrutiny. Discernment of configurations of
salience among particulars is not an exact science, it is interpretive and comparative.
Deliberations about what to do, whether taking place in groups of people or in a single
person’s mind, moral agents compare, revise, and refine how they see situations shaping
up:

One picture has the facts in one shape, and the other has them in another.
In choosing between these, the question is which picture is the more

41

compelling. I see this question as analogous to the question which
narrative is the more compelling.47

When a moral agent assesses which narrative description of a situation is more
compelling, she considers not only which particulars she sees, but how they’re to be
counted as salient with respect to one another. What it means to experience a particular as
salient and a construal as compelling is, according to Dancy, to experience value: “The
experience of value is the experience of a situation as calling for a certain response, and
we can see this as a disposition in the case to extract a merited response from us.”48 A
moral agent’s response to a situation is called for in light of her experience of moral
value; her perception and construal of particulars’ salience is her experience of moral
reasons’ motivational force.

As the need to compare narrative construals of moral situations suggests, there is
variation among what moral agents interpret as salient, what they experience as reasons
to act, and how forcefirlly they’re motivated by their recognition of reasons to act. One
source of this variation is moral agents’ different conceptions of which actions are worth
doing, which actions are worth doing this way rather than that way, and which values are
most important to endorse by doing those actions. Actions are worth doing when they
express values with which a moral agent identifies. Harry Frankfurt suggests that
identification happens when

[a] person who cares about something is, as it were, invested in it. He
identifies himself with what he cares about in the sense that he makes
himself vulnerable to losses and susceptible to benefits depending upon
whether what he cares about is diminished or enhanced. Thus he concerns

himself with what concerns it, giving particular attention to such things . .
. Insofar as the person’s life is in whole or in part devoted to anything,

 

‘7 Dancy, 117.
‘8 Dancy, 161.

42

rather than being merely a sequence of events whose themes and
structures he makes no effort to fashion, it is devoted to this.49

What a moral agent cares about guides her assessments of the moral relevance and
salience of particulars and guides her perception of what she thinks she has a reason to
do. When a moral agent sees something she cares about as somehow at stake, that thing
acquires salience, it “protrudes” in the landscape of a moral situation, guides how she
sees the situation as taking shape, and configures her construal of a reason to respond. In
addition to guiding moral agents’ perception of what is worth doing, what moral agents
care about guide how they see an action worth doing. As Dancy suggests, patterns of
salience among particulars configure not only “a reason for doing it, but [also] a reason
for doing it this way rather than that.”50 That is, when a moral agent thinks about how to
do an action, she considers questions about when to do it, where to do it, and what
dispositions to adopt as she does it. She considers what her action expresses of her; she
considers who she is as she does it.“
For example, consider a physician’s experience of telling an unsuspecting patient
that she’s pregnant.
A patient misses a period, and she thinks it’s just because she’s really
stressed out. Sometimes, the patient is right. Other times, I learn that she’s
pregnant. I’ve been in this situation before, and you never know if a
patient is going to be ecstatic or devastated when you tell her that she’s
pregnant. What I like to do is talk with her about how she feels about it,
present some of the options she has, and just try to be supportive of
however she feels about it. In my experience, most women learn they’re
pregnant when they’re alone, or at least alone with me, and many of them

don’t have many supportive people in their lives, and if they do, they’re
not with them when I tell them about the pregnancy. So, I like to stay with

 

‘9 Frankfurt 1988,83.

5° Dancy, 117.

5 ' In her Moral Understandings, Margaret Urban Walker emphasizes that “a persistent history of valuation
that can be seen in a good deal of what a person cares for, responds to, and takes care of” is expressive of a
moral agent’s “own narrative of moral identity” (112).

43

these patients and see how they’re doing with the news. I just think it’s
important and the right thing to do when you tell someone news like that.

As this example illustrates, this physician sees a reason to tell a patient she’s pregnant;
she also sees a reason how. That is, this physician thinks it’s important to do the action of
delivering news with care. Doing the action with care is different from doing the action
impersonally, for example, and is expressive of who this physician is; she’s a person who
sees herself as a person who cares deeply about being morally responsive to others.

What I’ve tried to show so far is that what moral agents’ care about guides how
they perceive and construe particulars of moral relevance, how they configure reasons to
and reasons how to act, and how they experience those reasons as morally motivationally
forceful. But, how moral agents see and how they are motivated are not the only factors
that influence how an action gets done. The environment in which moral agents act does
not always enable or allow them to see well or to act as they’re motivated to act. Consider
the following continuation of the above physician’s experience:

But, things get so hectic; I don’t have time anymore. Now, I tell a patient
she’s pregnant, I give her some papers that have lists of websites and I
give her some brochures that talk about abortion and adoption and
parenting. She walks out looking dazed and I walk out feeling like I’ve not
done my job very well.
Because she works in an environment in which she is always pressed for time, she isn’t
really free to act as she’s motivated to act. She still does an action, she delivers the news
about the pregnancy, she acts on a reason to. But she doesn’t act how she’s motivated to
act; in the environment in which she works, she isn’t free to act in a way she endorses as
expressive of who she is and what she cares about. Her moral agency is restricted. Over

time, this and other kinds of restrictions to moral agency can damage moral agents. How

such restrictions incur damage to moral agents that can result in moral motivational

44

erosion will be explored in the Chapter Three. First, however, more can be said about the
importance of cultivating moral agents’ perception such that they learn to see well; this is
the subject of Part Three.
Part Three: Cultivating Good Moral Perception

So far, I’ve argued that that perception is constitutive of moral motivation and that
moral reasons are configurations of salience among particulars in moral situations. In this
section, I argue for what it means to perceive particulars well. To do this, I draw upon
Aristotle’s view of how a person becomes virtuous to develop a conception of one way
healthcare professionals learn to see moral reasons well and be morally responsive to
others. Then, I draw on Wittgenstein to develop a conception of how practitioners learn
practices of perception as they become socialized into a healthcare profession, a
particular form of life, as he would call it. Finally, I draw upon Michael R. DePaul’s
model of perceptual refinement52 to argue that maintaining the capacity to see particulars
well requires a person to pursue experiences that develop his perceptual faculties.

Aristotle holds that virtue acquisition is facilitated by good teaching and is
developed through experience.53 In particular, developing virtue requires habituation. On
the Aristotelian conception of habituation, a person must see good habits modeled over
time and she must also choose54 (and continue to make a series of choices over time) to
develop her character such that she makes a practice of doing actions expressive of good

judgment55 and appropriate disposition.56 Knowing which actions are expressive of these

 

52 In his Balance & Refinement: Beyond Coherence Methods of Moral Inquiry (Routledge, 1993).

‘3 NE 1103‘14-1103525.

5’ As Aristotle says, “our characters are up to us” (NE 1114all 3).

5’ NE 1104'1-1105"20.

’6 NE 1 lO4b9-1105'15. (Susan Stark, in her “Virtue and Emotion” Nous 35(3):440—455, 2001, suggests that
we need frequent reminding of the importance of emotion in Aristotle’s conception of virtue and
appropriate disposition. She argues that the concept emotion need not refer to only one emotion, but that

45

things is not knowledge of rules or principles, however.57 Rather, as John McDowell puts
it, “Occasion by occasion, one knows what to do, if one does, not by applying universal
principles but by being a certain kind of person: one who sees situations in a certain
distinctive way.”58

So, if we consider a virtuous healthcare professional to be the kind of person who
cares deeply about being morally responsive to others, she must learn to see in a certain
distinctive way such that she’ll be motivated to respond with care to patients and
colleagues who deserve and need her to respond. We may conceive of a caring response
as an expression of a professional’s relationship with another person—a patient or
colleague. So too, we may conceive of a caring response as characterized by the manner
in which it is rendered by the professional; a practitioner should have a disposition of
concern for the well-being of the patient or colleague to whom she responds. Further
sketching an Aristotelian picture of what it could mean to exercise moral responsiveness
to others virtuously, we may consider seeing well and learning to see well as virtues
central to a practitioner’s idea of what constitutes good practice of healthcare.

On this Aristotelian conception, we can conceive the capacity to be morally
responsive to others as a capacity for perception. We can also conceive that capacity as
one which a person ought to commit himself to refining, through special training, if he

wants to become a virtuous practitioner who perceives particulars well and is motivated

properly to respond to others with care. This brings us to a particularly important

 

being virtuously motivated requires us to feel conflicting emotions and appreciate how acting virtuously
can makes us vulnerable to loss.)

’7 NE 1109b11-27.

5’ McDowell, 347. (“Virtue and Reason” The Monist 62(3):331-350, July 1979.) John McDowell noticed
the similarities between Wittgensteinian and Aristotelian approaches to training long before I did (pages
337-338.) I draw upon his insights here.

46

similarity between Aristotle’s conception of virtue acquisition and Wittgenstein’s
conception of what it means to be trained in the use of a language: one needs good
teachers.
Wittgenstein, for example, presents the idea that learning a language is part of
how a person learns a form of life: “the speaking of a language is part of an activity, or a
form of life.”59 Wittgenstein suggests that one learns to judge well—not just apply
rules—when one acquires a language. He explains that a person learns to judge well
[n]ot . . . by taking a course in it, but through ‘experience’.——Can someone
else be a man’s teacher in this? Certainly. From time to time he gives him
the right tip—This is what ‘learning’ and ‘teaching’ are like here—What
one acquires here is not a technique; one learns correct judgments. There
are also rules, but they do not form a system, and only experienced people
can apply them right. Unlike calculating-rules.60
In learning to judge when and how to use words, one learns how to participate in a form
of life, how to take-up this form of life. She learns to participate in language by adopting
practices that others who participate in the language also adopt. On Wittgenstein’s view,
a person is not merely speaking, she is doing, practicing: “Words are deeds.”61 That is, to
take-up a1 form of life is far more complex than rule-following; it is engagement in a
process of socialization, in which a person is guided by others already socialized into the
form of life, in which a person learns habits of seeing and habits of figuring out how to
know what to do.

In healthcare education, students learn how to know what to do in just this way.

They learn patterns of moral perception, how reasons to act get configured, how

 

59 23 Philosophical Investigations.
6° Page 227, Philosophical Investigations. Wittgenstein is talking specifically about judgment and feeling in
this passage. I’m applying what he says to developing a conception of what it means for a healthcare
professional to learn judgment and perception in a process of professionalization.

I 546 Philosophical Investigations.

47

judgments are rendered, and how actions are done. Much of this professionalization in
healthcare education takes place according to the “watch one, do one, teach one”
paradigm. For better or worse, as a pedagogical method, this “watch one, do one, teach
one” paradigm is heavily reliant upon modeling.62 How well patterns of perception are
modeled by students’ teachers and mentors in institutions in which they are taught situate
how well professionals develop the ability to perceive particulars there are to be seen,
construe them in different ways to experience their value, and respond with care. They
learn to practice a form of life, a healthcare profession, they learn to be the kinds of
people to respond in this way and that way.

Suppose a young practitioner is the kind of moral agent who chooses to learn to
be morally responsive to others, she wants to learn to see well and to practice virtuously.
What are particular practices of perception that she must learn? Several diagnostic
practices alone require practitioners to assess particulars——facts about physical symptoms
and reports of experiences of illness, for example—and construe configurations of
salience among them. Another practice, poignantly exemplary of the complex of skills
that must be modeled well in order to teach a student to perceive well, is breaking bad
news to patients and to those with whom patients have significant relationships.

Robert Buckrnan’s How to Break Bad News explains how moral perception
should be modeled by teachers and mentors of medical students in particular. Buckman
suggests ways in which a practitioner must perceive morally relevant particulars and use

her imagination if she is to properly deliver bad news. He emphasizes, for example, that

 

62 Much has been written on modeling in medical education. See Paice, Heard, and Moss; Hensel and
Dickey; and Brownell and C6té on modeling and professionalism generally. See Burack, et. al. and Branch,
et. al. on modeling and learning moral dimensions of medical practice. See articles by Erde; Yamey;
Satterwhite, Satterwhite III, and Enarson; Feudtner, Christakis, and Christakis; Hundert, Hafferty, and
Christakis; and Stern on the role of poor modeling in influencing medical professional development.

48

y”63 is the most important kind of perception in the task of delivering

“listening activel
bad news, which he sees not only as “a divulging of information,” but as “a therapeutic
dialogue: by which [caregivers] listen to, hear, and respond?“ Buckman carefully lays
out how listening is done well: a professional must prepare to listen well by setting a
physical and emotional context that will support a therapeutic dialogue. Setting up the
context means preparing an environment in which particulars of moral relevance may be
revealed. Whether the physician is well-placed to see (or hear) what moral particulars
there are to been seen (or heard) depends importantly upon how well she prepares and
situates the environment. One dimension of quality of the environment is its physicality.
(Is it quiet? Is the pager off? Are there chairs upon which each member of the conference
may sit at the same level?) Another dimension of quality of the environment is the
method by which the physician maintains the capaciousness of the dialogue. That is, does
it remain an open dialogue? Buckman suggests, for example, that how the physician asks
questions can determine whether the dialogue will stay open; closed questions requiring
only brief responses won’t maintain openness well. Rather, a physician must ask
questions that invite participants into the dialogue to reveal particulars of moral
relevance—patients’ feelings, needs of partners and family members and friends, end-of-
life desires, and sources of anxiety.

Buckman also suggests that bad news delivery can only be done well when
physicians are imaginative, such that they can derive and compare a number of construals

of the particulars that have been revealed and adopt different perspectives—especially of

the people receiving bad news—from which to view different configurations of salience

 

‘3 Buckman, 43.
6’ Buckrmn, 65.

49

among particulars when facilitating the dialogue. For example, he mentions a scenario in
which a patient says, “I was so upset I could hardly breath [sic].” To which he says a
physician responded, “Did you get any chest pain with that shortness of breath?”65
Buckman problematizes this physician’s lack of imagination and suggests that this
physician seems only to consider one way in which the particular, hardly being able to
breathe, counts as a morally relevant one to which she’s supposed to respond: this
physician’s response reveals that she thinks the person receiving bad news is suffering
from a physical problem. But her construal of particulars doesn’t represent the situation’s
shape properly. The person receiving the news isn’t suffering a physical problem; she’s
suffering emotional distress. If the physician had a more capacious imagination, she
might have construed that particular’s salience properly, given a description of the
situation that accurately represented its shape, and responded properly.

Buckman also illustrates other ways in which imagination is necessary to getting
the perception and construal of moral reasons right. When he emphasizes listening as an
important form of perception, he suggests physicians “listen for the buried question.”66
That is, a physician has to hear what a patient has to say and also be imaginative about
possible meanings bad news has for receivers of bad news. Buckman suggests a
physician should be able to imagine how patients might respond to bad news and be able
to imagine caring ways to respond to those reactions.67

According to Buckman, bad news delivery is an example of a category of tasks,

part of the form of life of healthcare practice, that can’t be done well without a

practitioner’s getting a good education about how to do it. Good educational modeling

 

6’ Buckman, 60.
6° Buckman, 51.
67 Buckman, 53-63.

50

then, requires that physicians who are mentors to students must not only be good at
delivering bad news, they also have to be good teachers of how to set up an environment
in which morally relevant particulars may be openly revealed, and they must demonstrate
the importance of acute perception and active imagination in the process of being able to
navigate a way to respond with care to people receiving bad news.

As an example of learning a dimension of what it means to become socialized into
healthcare practice as a form of life, bad news delivery is a good example. As Buckman
makes plain, learning how to deliver bad news well requires more than just knowing
things; it requires that a practitioner learn what else she needs to know. She has to learn
how to reveal other particulars there are to be seen that she’s not yet seen. She must get a
feel for that to which she ought to be sensitive. Buckrnan’s examples suggest that we
ought not think of moral perception as something static, as something a moral agent just
keeps or maintains. Rather, moral perception is dynamic, it must be cultivated to become
and continue becoming capacious, incisive, and revelatory.

As Michael R. DePaul argues, one way to cultivate moral perception is to engage
in “the seeking out of appropriate experience.”68 That one must seek suggests the kind of
person a person should want to become if she’s to see moral reasons there are for acting
and exercise moral responsiveness to others virtuously. That is, it is not enough to
possess past experience or even to be able to see, hear, and understand information; one
who is virtuously morally responsive knows how to learn that which she has yet to learn
and how she may become sensitive to that which she is presently or was previously

insensitive. In so doing, she expands the scope of things about which she learns to care.

 

6“ DePaul, 202.

51

She must seek experiences that do not “simply supply information,” but serve to
“somehow alter the nature of [her] perceptual faculty?”9
One kind of experience DePaul suggests for refining perception is reading
literature, but a person could engage in other experiences that perform some of the same

functions of which DePaul thinks literature is capable. According to DePaul, reading
some literature is a useful kind of experience for refining moral perception because it
“engage[s] our emotions to the degree that seems necessary for the proper functioning of
our capacity for moral judgment.”70 Emotions may be engaged in other ways too, of
course, and there are other forums in which emotions’ functioning in moral discernment
may be considered and evaluated. The main thing is that time and space is made and kept
for healthcare professionals to engage in such forums of considering and evaluating their
emotions and refining their moral perception.71

DePaul also suggests that literature serves other functions. Literature is useful in
refining moral perception because literary representations of situations are “far less
complex than real situations.”72 Seeing complex situations represented more simply than
they occur in real life serves to enable a reader to focus acutely on particular dimensions
of that situation, which concentrates one’s attention upon discriminating among her
responses, assessing ranges of emotions, realizing limitations to the scope of her

perspectives, or finding points of departure for imagining alternative configurations

among the particulars she sees.

 

‘9 DePaul, 204.

7° DePaul, 205. Martha Nussbaum also suggests how literature engages emotions in her Love ’3 Knowledge
(Oxford, 1990) and, in her later Upheavals of Thought (Cambridge, 2001), one of the things she argues for
is that emotions’ import in moral judgment needs greater attention in moral philosophy.

7’ In Chapter Four, I argue that (and suggest ways in which) curricula in medical education in particular
should emphasize perceptual refinement.

’2 DePaul, 205.

52

DePaul’s explanations of the kinds of experiences that refine perception are
intended to motivate the idea that what we perceive influences how and whether we
consider what we believe to be warranted. He argues that we maintain our beliefs,
background knowledge, and moral judgments in dynamic equilibrium; and this
dynamism is important because it enables us to account for how changes in our beliefs
and acquisition of new knowledge inform perception and judgment. On the intemalist,
cognitivist conception of moral perception and moral motivation I’ve argued for in this
chapter, we understand that a moral agent’s motivation is constituted by what she sees,
and that which particulars she construes as salient is guided by what she cares about,
what she believes to be important, what she sees worth doing. Part of what moral agents
learn in the process of socialization into healthcare professions is what she ought to see as
relevant, or what she ought to be compellingly motivated by. If a moral agent is the kind
of person who wants to be virtuously morally responsive to others, she must be the kind
of person who seeks experiences that refine her capacity to perceive particulars and
broaden the scope of what counts as worth caring about. She must be the kind of person
who casts a wide net for the kinds of features of moral situations that constitute reasons to

respond with care to patients and colleagues.

What I’ve argued in this chapter is that moral motivation works normally when a
moral agent is moved to act by her perception of morally relevant particulars that
constitute her reasons to act. I’ve provided an intemalist, cognitivist conception of moral
motivation, a particularlist account of how moral reasons behave, and an Aristotelian and

Wittgensteinian account of how moral agents learn moral perception. Now, suppose we

53

have the kind of healthcare practitioner to whom it is deeply important to respond to
others with care. She sees well, perceives particulars that are there to be seen, construes
them appropriately, is properly motivated, and responds to patients and colleagues with
care; we have a virtuous practitioner. We do not, however, have a practitioner immune to
becoming jaded.

So far, we have mainly considered factors internal to the moral agent that affect
his moral motivation. But, even the most virtuous practitioner will not experience
motivation to respond if she works in an environment that interferes with her ability to
see well or with her freedom to act as she’s motivated to act.73 Factors external to the
moral agent that interfere with her ability to perceive particulars well disrupt the
connection between perception and motivation. Organizations situate the social
dimensions of a practitioner’s experience of moral motivation by structuring their work
environments. When practitioners work in conditions that restrict their capacities to
perceive well or their freedom to act as they’re motivated to act, practitioners can suffer
loss of self-respect and can be vulnerable to other forms of moral damage too.

A For example, whether a moral agent sees well and is free to act as she’s motivated
to act can depend upon the environment in which she works. If a clinician works in an
environment supportive of his moral agency, he’s free to respond to patients and
colleagues as he’s motivated to respond, he endorses his actions as expressive of who he
is, and his actions generate self-respect for him: these are the normal conditions under

which moral motivation works properly. If, however, a clinician works in conditions that

 

73 As Aristotle noted, even virtuous people cannot perform the finest of actions when they lack “external
goods” (NE 109951).

54

are oppressive, he’s situated to suffer moral damage, to experience moral motivational

erosion. He could be getting jaded. This is the subject of Chapter Three.

55

CHAPTER THREE: HOW THE JADED ARE MADE

I’ve introduced the problem of jading as a philosophically rich one, containing
epistemic, emotional, physical, and moral dimensions. Described narratively and in the
context of healthcare, jading characterizes a process of moral damage and moral
motivational erosion. Near the end of the first chapter, I gave a working description—in
the form of two sets of hypotheses—of how jading happens over time. In the second
chapter, I argued for a view of how the first set of these hypotheses hangs together
theoretically, by endorsing an intemalist, cognititivist theory of how moral motivation
works when it works normally and a particularist, reasons holism view of moral reasons
and an Aristotelian, Wittgensteinian conception of how moral agents train their moral
perception. I concluded that moral motivation works normally when a moral agent is
moved by her perception of morally relevant particulars that constitute her reasons to act
and that what moral agents care about guides how they perceive and discern particulars as
relevant and constitutive of reasons to act. But, as I also suggested in my second set of
hypotheses, there are significant social dimensions, one of which is the environment in
which moral agents work, which also affect whether they see well, are motivated
normally, and are able to act as they’re motivated to act. In this chapter, I apply what I
concluded in Chapter Two and argue for how this second set of hypotheses hangs
together theoretically to provide a moral philosophical picture of what happens to a
person when she becomes jaded.

In Part One of this chapter, I provide examples of working conditions in
healthcare organizations. I show how such conditions pit professionals against one

another and against patients and place healthcare professionals in double binds.

56

Furthermore, systems of rewards and penalties within the healthcare work environment
can co-opt individual professionals, as well as generate conflict among the values by
which professionals are motivated and those they’re rewarded for endorsing. I argue that
these four conditions—pitting, double binds, conflict among values, and co-optation—
restrict a professional’s moral agency and that when these conditions persist as regular,
systemic, structural features of the healthcare work environment, that work environment
is oppressive.

In Part Two, I consider ways in which individual professionals can be morally
damaged by oppression within healthcare organizations. A moral agent suflers moral
damage when she loses self-respect, becomes alienated, or becomes calloused. In this
part of this chapter, I discuss the first two types of moral damage. In attempts to cope
with institutional oppression, a practitioner can try to assimilate and adjust herself to the
conditions in which she works. But, when assimilating and adjusting require her to resign
her view of herself as a capable, effective”, morally responsive professional, she can
suffer the first kind of moral damage, loss of self-respect. Resignation can incur loss of
self-respect by producing infiltrated consciousness”, which happens when a practitioner
comes to view himself in morally degraded terms reserved for workers like him in the
healthcare workplace.

The second form of moral damage is alienation. Alienation is a disruption of the

normal connection between a moral agent’s identity and her actions. It’s a growing gap

 

7’ Capable and eflective are two important dimensions of the self-conception of a person who sees herself
as morally responsive to others. My use of these concepts is inspired by Margaret Urban Walker’s
discussion of how moral agents chart their responsibilities to others on pages 82-95 of her Moral
Understandings. She explains several “forms of connection” a moral agent experiences when she sees
herself as responsible for rendering a moral response to others; capability and effectiveness are two of
them.

7’ Nelson, 21.

57

between who she is and what she does, and it’s produced when practitioners experience
moral distress, which Judith Andre describes as “a sense of complicity [that] is not
uncertainty about what is right but the belief that one is virtually forced to take part in
what is wrong.”76 Practitioners experience moral distress when they are co-opted into
acting in ways they are not motivated to act.

Not all practitioners experience their working conditions as oppressive, however,
and even among those who do, not all practitioners suffer moral damage incurred by
oppression in the same ways. But the consequences for professionals who are morally
damaged by institutional oppression are significant. One of the most significant is that
professionals can respond to the conditions in which they work by reducing their
involvement in their work. In Part Three, I argue that when professionals reduce their
involvement in the work of professional caregiving, they reduce the degree to which they
see moral responsiveness to others as importantly and centrally constitutive of who they
are. I try to show that this reduction can mark not only a shift in self-conception; it also
tracks shifts in moral perception. In particular, a moral agent who reduces the degree to
which moral responsiveness to others is importantly and centrally identity-constituting
can become calloused.

Callousness produced when practitioners reduce the degree to which moral
responsiveness to others is importantly and centrally constitutive of who they are can take
three different forms: callousness as a form of evil, epistemic callousness (callousness
due to ignorance or poor training), and callousness as a form of weakness of the will.
These forms of callousness express as poor perception, a third form of moral damage. If

what I argued in Chapter Two is correct—that perception is moral motivation—then it

 

’6 Andre 2002, 122.

58

should follow here, as I’ll try to show, that damaged moral perception is moral
motivational erosion. When calloused, a moral agent sees poorly and she’s not properly
moved by particulars that are there; the normal connection between perception and
motivation erodes. As a result, she can fail to act despite the presence of moral reasons,
she can fail to respond to patients and colleagues who deserve and need her responses.
Part One: Features of Institutional Oppression

Healthcare organizations—both sites for educating students of the healthcare
professions and sites where healthcare is given to patients—structure the environments in
which healthcare practitioners work. Those working conditions play an important role in
making it possible for practitioners to see well and be properly morally motivated to
respond to patients and colleagues with care. In this section, I describe cases77 that
illustrate four prevalent features of working conditions in healthcare organizations:
practitioners and patients are pitted against one another, they are situated in double binds,
they experience conflict among values they’re motivated by and values they’re rewarded
for endorsing, and they are co-opted. These features of work environments restrict
students’ and practitioners’ moral agency and can incur moral damage and moral
motivational erosion over time. Because moral damage suffered by individual
professionals is generated within networks of interrelated forces and barriers produced
and maintained as persistent, regular, systemic, structural features of healthcare

organizations, I characterize such working conditions as oppressive.

 

77 The cases I develop here are not intended to be a comprehensive description of all of the kinds of
working conditions that restrict practitioners’ moral agency and make them vulnerable to suffering moral
damage. I chose these cases because they allow me to easily show four dynamics of oppression clearly.
Certainly a myriad of other cases in social work, nursing, medicine, pastoral care, and mental health will
have some or all of these dynamics in play too.

59

I draw upon the concept of oppression to describe working conditions in
healthcare because past philosophical work on this concept has supplied the theoretical
apparatus needed to represent how structures of institutions can restrict and damage
individuals who live and work within them. In Marilyn Frye’s landmark article
“Oppression,” for example, she began by considering the terrn’s root word, press:
“Something pressed is something caught between or among forces and barriers which are
so related to each other that jointly they restrain, restrict or prevent the thing’s motion or
mobility.” 7" Something pressed is, as she says, molded, immobilized, reduced by these
forces and barriers. That these forces and barriers are structural—they constitute a
network and are interrelated—~is the source of the most important distinction between
what it means for a moral agent to suffer an offense and what it means for a moral agent
to suffer oppression. Oppressions impose offenses, but not all offenses are oppressive. In
other words, offenses can be individual events that impose suffering upon an individual
or they can be individual events that impose suffering upon an individual because that
individual is situated among interrelated forces and barriers that are maintained to keep
her or him vulnerable to harms and censures and to co-opt him or her into participating
in the maintenance of those forces and barriers. Offenses of the latter type are products
of oppressions, and individuals suffering these kinds of offenses are victims of

Oppressions.79

 

7" In her The Politics of Reality (1983), Frye argues for a definition of oppression. Her work on oppression
initially addressed the kinds of forces and barriers that produce and maintain sexism, but her project was to
clarify the use of the concept in language, and since she has, the concept has been used to scrutinize
historical, social, and economic dimensions of several different Oppressions. The quotation is from p. 2.

79 This is, of course, not to say that groups of folks categorized as “healthcare professionals” are oppressed
in the same ways or to the same extents that people who are members of social categories like “women,”
“black people,” “Native Americans,” or “Untouchables” are oppressed. Members of healthcare professions
are not, by virtue of their membership in that group, underprivileged in ways members of these latter social
groups are, by virtue of their membership in those groups, underprivileged. I help myself to the concept of

60

Frye explains that a person won’t recognize whether or how certain conditions are
oppressive by looking microscopically, at the single instances in which offenses occur.
Rather, one must look macroscopically, at how individual offenses are structurally related
to one another, if one is to cultivate an understanding of how the forces and barriers
individuals face can restrict and damage a moral agent. As Frye suggests, “One must look
at the barrier or force and answer questions about it. Who constructs and maintains it?
Whose interests are served by its existence?”80

Asking these questions about the forces and barriers within the working
conditions in healthcare organizations suggests some initial points of departure for
considering how healthcare professionals’ identities are molded, immobilized, and
reduced to maximize the efficient operation of the organizational systems31 in which they
work. Some forces and barriers take the form of explicit policies, but they also manifest

themselves as implicit expectations and norms about the kinds of behaviors that are seen

 

“oppression” not to illustrate that healthcare professionals are oppressed by their membership in the
category of “healthcare professionals,” but rather to illustrate and analyze ways in which structures of the
healthcare workplace constitute systems that damage individual moral agents within those systems. The
literature on “oppression” is the best one to draw upon for this task because it is most theoreu'cally
gguipped to enable this sort of philosophical analysis in the context of healthcare.

Frye, 14.
8‘ I intend the term “organizational systems” to be construed broadly here and throughout this work. That
is, an organizational system of healthcare consists not only of healthcare institutions, but of relationships
among healthcare institutions and of relationships among healthcare institutions and governments at the
state and federal levels. For example, the current dominant economic macro-structure of healthcare
organizations in the United States is capitalist, and this is significant in configuring how individual
institutions operate, what their priorities are and how they are ordered, and how burdens of caring for
different classes of American citizens are distributed. Institutions that care for wealthier Americans
(particularly Americans with employer-sponsored health insurance) generally are less understaffed than
many state or federally operated facilities (particularly those that care for the greatest proportion of poor
Americans) and offer a wider array of services to patients and staff, and occupy new, often impressive
buildings, for example. These differences between institutions that care for mostly wealthy people and
institutions that care for mostly poor people suggest that different moral landscapes tend to appear in
different organizations, and that these differences are not just functions of a particular institution’s goals
and patterns of decision-making. Rather, particular institutions’ goals and patterns of decision-making
persist in a broader framework in which the United States Government makes policies about how it cares
for its citizens.

61

as appropriate. The following cases82 illustrate some forces and barriers in play in the
structures of typical, daily work environments83 of healthcare students and professionals.

Case 1

Jill Hall is head nurse at a nursing home in a major metropolitan
area. She’s just been informed that she needs to lay off two of her
colleagues, who were just hired six months ago. Talking with her fiiend
she says, “We already have more patients than we can handle! Pretty soon .
the staff will be me and a few minimum-wage nurse’s aides. And then
what will happen to these patients?” A few days later, Jill receives a phone
call from one of the hospital’s risk management officers: “Yesterday we
received a complaint from a patient’s daughter. She said her father
urinated in his bed; he waited for an hour for a nurse to help him to the
toilet, but no one ever came. She’s threatening to sue for negligence.”

Jill is upset, “What was I supposed to do? IfI had the time, I’d
gladly help patients to the bathroom. But I have ten different things that all
need to be done right now every minute of my shift. I knew he had to pee,
but Mrs. Gollub had to get her medication, Mr. J amin needed a new IV,
Dr. Lamm wanted the night report on Mr. Fritz, and I had to teach Jamie
how to do the telemetry on some new machine. If I do one thing, I get
sued for not doing something else. If I do something else, I still get sued
for not doing something else. If I could do everything at the same time, I
guess I’d have a chance at being a good nurse.”

Case 2

Jean Mombas is a physician and Chris is a third-year medical
student. They have been reviewing their next patient’s chart and are about
to walk into the room where he’s waiting for them. They plan to tell him
some bad news today: biopsy results indicate lung cancer with metastases
to the liver. As they approach the door to the patient’s room, Jean’s pager
sounds. Jean responds, “I’ve got to answer this. You’re on your own. You
don’t have to do anything clinical, just tell him. Meet me in the ER in 10
minutes.”

“Wait,” Chris calls after Jean, “I’ve never had to do this before.
What should I . . .” Jean interrupted: “Look, if you’re not up for this, you

 

’2 These stories belong to no one particular person, most are not direct quotations, and they should not be
understood as social science research in any rigorous sense of what constitutes statistically significant
empirical evidence or qualitative human subject research in social sciences. I invoke these stories for
purposes of general illustration and representation of the experiences and working conditions of
professionals in healthcare. I characterize events and experiences culled from colleagues in medicine,
nursing, pastoral care, and social work, for example. Some stories also characterize events from my own
experiences in clinical ethics and medical humanities rotations and consultations.

’3 By calling these cases typical, I do not mean to suggest that working conditions in all healthcare
organizations are oppressive or equally oppressive in degree or oppressive in exactly the same kinds of
ways. I do suggest, however, that these cases describe realities in healthcare work environments that are
pervasive and regular, not unique or irregular.

62

shouldn’t have chosen to do this rotation. I don’t have time to hold you by
the hand. Just tell him.” Jean walks briskly away and the patient peeks out
from behind the partially opened door and asks, “Tell me what?” Chris
enters the room, and thinks, “I shouldn’t have made Jean angry.”

Case 3

Providers’ Network uses 91 percent of its net revenues to run its
health care facilities and 9 percent to cover administrative costs. Bonuses
to physicians within the company depend upon Network’s profitability
and upon whether physicians’ management of patient care is deemed cost-
effective. Physician Sal Ginn routinely phones Network to obtain approval
for procedures on patients, and this time one of Sal’s patients receives
approval for a biopsy, but is denied coverage for the pathology
laboratory’s evaluation of the sample. The patient cannot pay the lab fee
but is very nervous about the results. Sal writes an appeal, asking for
Network to cover the lab fees, but it is denied. Sal wonders whether to
appeal to Network’s chief medical reviewer (and risk having this request
count against her in her year-end bonus), to send out the sample to a non-
Network lab (and cover the cost herself), or to reconsider if the biopsy is
really necessary. About the choice, Sal says, “It feels so childish to have to
make appeals, but they force us to do this. It makes me feel like I’m either
cheap or sloppy.”

Case 4

Alex Xing, a first-year resident, begins walking toward the
cafeteria. Jen Lane, an attending physician, says, “Hey, where are you
going? Radar needs you to sign something.” “I’m just going to grab some
lunch. I’ll be right back. I haven’t eaten for seven hours. I feel like I’m
going to keel over.” Jen looks askance, “Right. I’ll remember that on your
evaluation. Oh, and by the way, did you forget that Mrs. Kern is allergic to
sulfa drugs? Your order for Bactrim could have made big trouble if Pat
hadn’t caught it. If you keep making bone-headed screw-ups like that,
Xing, you might as well call your attorney right now.”

Alex was horrified. “Oh, my god,” he thought, “I can’t believe I
did something so stupid. I could have killed my patient. I am the worst
doctor on earth.”

Adopting a macroscopic view of these cases, we see important structural

similarities among them. First, in each case, a practitioner is situated such that she is

pitted against others. Pitting happens when a moral agent cannot do something she is

required to do (in these cases, to carry out a duty to others or to follow the command of a

person superior to her in rank) without compromising her own well-being or the well-

63

being of another person who, like her, is vulnerable to losses.“ In the first case, Jill
cannot respond to one patient without neglecting another patient. In the second case,
Chris cannot do what he is told by Jean to do—to “just tell him”—without doing a
disservice to the patient by doing a bad job of delivering bad news. In the third case, Sal
works in an environment in which she is obviously required to make good judgments
about patient care, but her authority to implement care according to her best professional
judgment is restricted. As a result, Sal cannot do what she needs to do for her patient
without compromising her own job security or without compromising her patient’s trust
in her. In the fourth case, Alex cannot do what Jen requires of him without compromising
his own well-being; what Jen requires is that Alex continues to work despite that he
needs to eat.

A second structural similarity among the cases above is that each moral agent is
situated within a double bind.85 Double binds describe situations in which a moral agent
is restricted by forces and barriers—policies and norms—in the organizational context
which a practitioner works, such that the only actions open to her are those from which
she’ll suffer harm, censure, or both. The moral agent cannot do any action from which
she will not suffer, so double binds are frequently called “no-win” situations. In the first

case, for example, Jill’s work environment is structured such that she is in a double bind.

 

8’ Outside the context of healthcare, this feature of oppression has been written about extensively and
variously in philosophy and literature and has many representations in popular culture. Claudia Card refers
to a gray zone as a particular a feature of oppressions in which oppressed persons are required to oppress
others like themselves. The history of cultural imperialism has numerous examples of pitting as a feature of
oppression too. As Britain ruled India, for example, Hindus were pitted against Muslims; amidst the
forging of these divisions, Britain conquered the nation as Indians of both religions fought amongst
themselves instead of uniting to resist British usurpation of India’s sovereignty and resources. Frederick
Douglass writes extensively in My Bondage and My Freedom of how slaves were pitted against one
another to fight for the favor of their masters. In one of the early scenes of Ralph Ellison’s Invisible Man,
whites are entertained by black men boxing; Ellison represents in this scene that pitting black men against
one another is a form of recreation for the oppressor.

8’ Frye, 3-4.

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She works in a department that is understaffed, but she is expected to provide services as
if it were adequately staffed. As a result, Jill feels that no matter how much she
accomplishes or what she chooses to do first, it is not enough to relieve her of the threat
of being sued. In the second case, Jean (who has lots of training in medicine but likely
very little training in teaching) is expected to teach inexperienced medical students and
respond to emergencies at the same time, and Chris is expected to learn the practice of
medicine while also being expected not to need any instruction or mentorship in
delivering bad news to patients. Jean must choose between failing to show up for an
emergency and failing to teach a student; Chris must choose between upsetting a teacher
and placing himself in a patient care situation in which he knows he doesn’t know how to
properly do what he’s asked to do. In each of these cases, a practitioner or student

”86 among possible actions, each of which has a consequence flom which she or

“chooses
he (and her or his patients) will suffer.

When practitioners’ decision-making takes place within organizational structures
in which they are pitted against one another and placed in double binds, they are not flee
to do what they’re required to do and do right by themselves and their patients at the

same time. A macroscopic view of these cases reveals that each one is not just a single

instance of a practitioner having a hard time in some particular situation, but that these

 

’6 The presence of a choice sometimes conveniently masks the oppressive nature of double binds by
creating the illusion that a moral agent’s choosing is an exercise of fleedom (or an expression of desire).
Critics of this liberalist conception have pointed out, however, that oppression allows only for apparent
fleedom that renders oppression invisible. Critical race theorists, feminists, class theorists (critics of
capitalism among them), and critics of cultural imperialism, for example, have argued that a choice
between two methods by which one will be annihilated is a no real choice at all, much less a choice that is
made fleely. Furthermore, these critics of a liberalist conception of choice as a sufficient condition for
fleedom have questioned whether a choice is an exercise of freedom if a person making that choice is
excluded flom participating in the previous decisions that situated that choice. Frederick Douglass, for
example, could choose whether to be a field slave or a house slave, but he couldn’t choose whether to be a
slave.

65

cases have structural similarities. Forces and barriers in these cases are policies and
norms that promote profit-oriented values—values of low cost and high productivity of
services. These policies, norms, and values produce and maintain conditions of
understaffing, overworking, and poor teaching in which professionals and students are
pitted against themselves and their patients and stuck in double binds as persistent,
regular, systemic features of their work environments.

Profit-oriented values can promote effective operation of healthcare organizations
if they are properly balanced with humanitarian values central to healthcare professions,
particularly values of moral responsiveness to others—like beneficence and compassion,
for exampleu-which are identity—constituting values for many healthcare professionals.
But if profit-oriented values are not properly balanced with humanitarian values central to
healthcare professions, individual professionals are forced to assume the moral burden of
negotiating conflict among these values as a persistent, regular, systemic, structural
feature of their work environment as they try to carry out their everyday professional
duties to colleagues and patients.

Conflicts between profit-oriented values and the values of moral responsiveness
to others represent an unusual irony in healthcare institutions. In a practice environment
in which organizations identify more strongly with profit-oriented values than with
values of moral responsiveness to others, and individual practitioners identify themselves
more strongly with values of moral responsiveness to others than they do with profit-
oriented values, practitioners can experience conflict between the values they’re
motivated to endorse in their actions—values they see as constitutive of who they are and

what they do that guide their perception of reasons to and reasons how to respond to

66

patients and colleagues—and those they actually do endorse when they work in
oppressive conditions in which their moral agency is restricted. When this happens,
organizations hamper practitioners’ abilities to practice as they’re motivated to practice
and to respond with care to patients and colleagues because practitioners must devote
time and energy to negotiating conflicting values instead of caregiving.

Negotiating conflict between profit-oriented values and values of moral
respsonsiveness to others requires a practitioner to undertake the labor of justifying her
view of the moral landscape of situations. When organizations’ perceptions87 of situations
are guided by profit-oriented values and practitioners’ perceptions of situations are
guided by values of moral responsiveness to others, this is not necessarily a bad thing.
But, it usually does mean that the two parties will discern differently the patterns of moral
relevance of particulars that are there to be seen in clinical situations and that they will
construe differently the reasons there are for acting in those situations. When this
happens, the two parties must reflect upon and justify their views of those situations, but
this is not always problematic either. Indeed, as I argued in Chapter Two, the narratives
different parties assemble to explain how they see situations must be discussed, and
perhaps argued for and about, in order to figure out which party’s representations of a
situation and construals of salience among particulars in a situation most closely reflect

what’s actually going on in a situation.

 

’7 By saying that organizations have perceptions and see, I ascribe a kind of moral agency to organizations.
As I suggested in the first section of this chapter, organizations comprise moral agents making decisions
that configure how the organization operates day to day. Insofar as organizations have power to implement
such decisions, I ascribe to them a kind of moral agency. (Current US. law endorses a similar view that
organizations have agency: corporations, for example, are considered legal persons.) What kind of moral
(or legal) agents organizations are and how such collectives can or ought to be held morally (or legally)
accountable for decisions they implement and values they endorse are questions in a much broader
literature of social and political philosophy that would take me well beyond the scope of this work. (See
Rovane in the bibliography on the topic of collective agency, as one work on this topic.)

67

However, when a practitioner negotiates conflict between profit-oriented values
and values of moral respsonsiveness as a persistent, regular, and systemic feature of her
work and when she feels that she must fight organizational norms and policies to endorse
values central to her identity as a professional caregiver, conflict between practitioners’
values and organizations’ values is morally problematic. This is because comparisons of
narrative construals of the reasons there are for acting work best when the parties that
disagree about which features of cases are most salient enjoy equal power to endorse their
perceptions of what’s worth doing in those cases. But, as the cases I’ve just discussed
suggest, practitioners and organizations typically don’t have equal power in healthcare
organizations. So, when conflicts between profit-oriented values and values of moral
responsiveness persistently and regularly express fundamental differences between
professionals’ and organizations’ practices of moral perception and views of what’s
important, value conflict generates a sense of powerlessness among practitioners.

Powerlessness comes flom inequity in how power is distributed. In healthcare
organizations, practitioners have power, but groups of decision-makers in organizations,
usually administrators, distribute power, set the terms under which practitioners can
exercise power, and set the terms under which practitioners are rewarded or penalized for
particular actions. That is, practitioners typically don’t have power equal to that of the
organizations in which they work; often, they don’t have adequate power to endorse their
views of what’s worth doing, particularly when being penalized for acting as they’re
motivated to act means suffering significant losses.

As a result of an individual practitioner’s having less power to endorse his view of

what’s worth doing, he may not be well situated within the organization to have what he

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sees as his reasons for acting taken seriously. Furthermore, if he negotiates conflict of
values regularly, he is constantly reminded that, though he may try to justify his way of
seeing moral situations, the importance of what he sees may be, flom the organization’s
perspective, dubious or superfluous. Over time, the persistent experience of not having
one’s views of situations taken seriously can make a practitioner feel like she is acting
mainly out of others’ views of what’s important and that she is a mere functionary who
“mediates decisions of others.”88 When professional caregivers are subject to penalties
for acting as they’re motivated to act and rewarded for doing actions that express others’
views of what’s worth doing instead of their own, they are rendered powerless, and they
are disrespected.

In the first case, for example, Jill knows patients are ill served when her
department is understaffed, but she is too busy providing care to change the conditions
that subject her to fear and expose her patients to danger. Jill is powerless to adequately
respond to patients’ needs; she’s overworked to keep organizational costs low and profits
high. Instead of responding as she’s motivated to respond she’s pressed to respond to as
many patients as she can as fast as she can; that’s what she’s rewarded for. The potential
penalties maintain her in a double bind: if acting as she’s motivated to act is seen by the
organization for which she works as her working too slowly, she could be censured, but
despite incentive to work speedily, she fears working too hastily could result in
malpractice. A system of rewards and punishments implemented by others renders her
powerless; double binds keep her powerless.

In the second case, Chris realizes he doesn’t know how to deliver bad news well

and he also knows that patients can be harmed when bad news is delivered poorly. He’s

 

3’ Young, 56.

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aflaid of making mistakes and also aflaid of being perceived as insubordinate, incapable,
or uncooperative by Jean. So, he’ll warily execute Jean’s orders even though he knows
he’s not yet well suited to do so. Sal, in the third case, doesn’t appreciate feeling cheap
and obviously isn’t comfortable feeling negligent either, and she’s stuck with both
feelings every time she makes an appeal and yet she must submit to and participate in the
process of making such appeals because she’s penalized if she doesn’t.

The fourth case illustrates a special instance of dehumanizing powerlessness.
Alex must choose between forgoing nourishment and being reprimanded for taking the
time to feed himself. Jen’s threat implicitly requires Alex to go hungry. Subordinates in
medical education—students and residents who take orders flom attending physicians,
for example—are routinely required to go on (for extended hours) without food, to go on
without urinating,89 to go on without sleeping.90 As students and young physicians
undergo their training to care for patients, ironically, they are required within healthcare
organizations to be complicit in their own dehumanization”, and they’re rewarded for

being submissive in their processes of dehumanization.

 

’9 One young resident explained to me how she commonly makes the decision not to drink anything during
her shift after one experience. “This one attending looked down her nose over her glasses at me after I
retumed flom a much-needed pee. It was like she thought I was supposed to ask her permission or just hold
it for the next three hours. I felt like a kindergartener.” Also, one study suggests that “dehydration [and]
ongoing exertion and starvation” to be “common” among residents; see Parshurarn, et. al. (2004).

9° It is true that some healthcare professionals (participants in long surgeries, for example) must be able to
sustain long periods without eating, sleeping, or using the bathroom, but this does not seem to constitute
adequate evidence that such deprivations ought to be par for professional healthcare training in all
specializations. Furthermore, in addition to forms of powerlessness in which subordinates are required to be
complicit in their own dehumanization, powerlessness also is imposed more viciously in a number of cases.
There is a significant literature on abuse in healthcare work and education environments, and we should
keep in mind the unknown number of abuses—harassment, intimidation, and battery (any unwanted
touching)—that go unreported because subordinates fear reprisal.

9' These conditions have somewhat improved since the Accreditation Council for Graduate Medical
Education (ACGME) restricted residents’ working hours to an average of eighty per week. Also, there is
significant variation among different institutions that train residents in the degrees and kinds of intimidation
and dehumanization that is tolerated. However, it could be argued that the limitation of the eighty-hour
work week was imposed by the ACGME more out of a concern for patients’ safety and curbing costly
medical error than out of a concern for residents’ well-being. Even so, it may be safe to suppose that the

70

Iris Marion Young calls powerlessness one of the “faces” of oppression, and she
argues that the most important source of moral agents’ powerlessness is their exclusion
flom processes of decision-making about policies, systems of rewards and penalties, and
the conditions in which they live and work.92 Powerlessness of healthcare professionals
like those in the cases recounted above can be seen in their having to carry out others’
decisions and endorse others’ views of what’s important when they see that doing
something else or doing something some other way is more worth doing. None of them
are positioned to authoritatively change their situation such that they would be flee to
exercise autonomy in their decision-making, to be creative about resolving problems in
their work, or to express their views of what’s important and what’s worth doing through
their actions. Furthermore, moral agents made vulnerable to harms and censures if they
do not mediate others’ views of what’s worth doing stay vulnerable as long as they are
denied the authority to change the conditions that expose them to those harms and
censures.

How do students and practitioners respond to subjection to harms and censures,
disrespect, and powerlessness? Over time, a practitioner could respond to powerlessness
by “cutting back”93 involvement in her work; what happens morally to a practitioner who
reduces involvement in her work will be considered in Part Three of this chapter. In
addition to reducing one’s involvement in professional caregiving, there are significant

emotional features to being rendered powerless. Practitioners can feel pain, humiliation,

 

eighty-hour work week restriction has improved residents’ well-being. But, it still wouldn’t follow
necessarily flom their improved-well being that the eighty-hour work week restriction is humanely
adequate or that it adequately improves the quality of residents’ lives.

92 Young, 56. Young attributes the experience of powerlessness to the kinds of workers she calls
“nonprofessionals.” As I’m showing here, however, I see no good reason to preclude powerlessness flom
the realm of professionals’, particularly healthcare professionals’, experiences.

93 The sociologist Cary Cherniss uses this term in Beyond Burnout.

71

anger, and flustration when they lack power. Furthermore, these emotions can direct
shifts in the focus of one’s perception flom the vulnerabilities of others to the
vulnerabilities of oneself. As Judith Andre suggests, these emotions can muddle one’s
perception and one’s experience of value of particulars that configure others’
vulnerabilities and their need and desert of a response. She says of pain in particular,
“Pain makes it hard for one to look outside oneself, and distorts what one sees.”94
Persistent and regular conflict among values can cultivate powerlessness in ways
I’ve just described, and it can also co-opt practitioners. Co-optation happens when a
moral agent appears (flom a microscopic point of view) to choose something fleely but
really does not make the choice fleely; because of how that “choice” is situated in a
larger structural milieu (which can be appreciated flom a macroscopic point of view), the
moral agent is forced95 to act other than how she is motivated to act. When a moral agent
is co-opted, she acts other than she’s motivated to act because a competing moral reason

emerges to effectively silence the moral reason that would motivate her to act if she were

flee. In the environment in which she works, she is not flee because she is subject to

 

9‘ Andre 1992, 149.

95 My use of the concept force here refers to a moral agent’s compulsion to act that does not come flom her
perception of what’s worth doing but flom something external to her, an incentive or threat for example,
that restricts her ability to act freely. For example, a practitioner could be moved to do action A in a certain
way because she sees a reason to do it. If she does action A in a way other than how she’s motivated to do
it or if she does action B, she might do so either because she is weak-willed or because she is being co-
opted. A case of a moral agent being forced to act may appear to be another case an extemalist could use
against an intemalist. I suggest that it is not, however, a problem for the intemalist’s view because, given
the particularist view of moral reasons I defended in Part Two of Chapter Two, I interpret the intemalist’s
claim to be this: recognizing a reason to act is sufficient for moral motivation to do that act in this way.
Recall that on a particularist view of moral reasons, a moral agent has a reason to and also a reason how to
do an action. That is, the intemalist’s claim may refer to the motivation to do action A in this way, but not
to action A done that way or to action B, unless the moral agent sees a different reason to do action A that
way or a different reason to do action B. Graphically, recognition of reason“ is motivation,“ to do action A
in way 1 and recognition of reason/(2 would be motivation“ to do action A in a different way, way 2, and
recognition of reasons would be motivations to do action B. So, that a moral agent committed action B or
action A in way 2 does not count as evidence that the connection between reason“ and motivation“ to do
action A in way 1 is severed.

72

significant losses if she does not respond to the reason that silences the reason for doing
the action that would be most worth doing under normal conditions.96

In an oppressive organizational structure, she can act as she’s motivated to act
only insofar as that action would maintain policies and norms that endorse values and
carry out decisions of others who manage a system of rewards and penalties that promote
profit-oriented values more than they promote values of moral responsiveness to
vulnerable others. Organizational structures that pit practitioners against one another,
place them in double binds, and force them to negotiate conflict among values co-opt
professionals by requiring their participation in this system, which is implemented and
maintained to influence decision-making and micromanage behaviors of practitioners by
providing incentives and creating and exploiting their vulnerabilities to losses. In other
words, practitioners are rewarded for mediating the decisions of those (administrators, for
example) who benefit most and are themselves rewarded when services are produced at
high volume with low costs.

A microscopic view of each of these cases leads one to believe that practitioners
and students have and make decisions fleely when they accept rewards or penalties; they
appear, flom the microscopic point of view, to be flee to decide what they will do and
how they will do it. But a macroscopic view of these examples reveals that such choices
are situated within a network of interrelated forces and barriers—policies and norms, for
example, which produce and maintain the system of rewards and penalties—that co—opt
practitioners in healthcare organizations into maintaining the very features of the system

by which they are oppressed. A macroscopic view reveals that a practitioner’s moral

 

9’ That the moral agent is vulnerable to significant losses distinguishes the kind of phenomenon co-optation
is from the kind of phenomenon weakness of the will is.

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agency is flequently restricted and that he is not always flee to act as he’s motivated to
act. Furthermore, a macroscopic view suggests that practitioners, unflee and persistently
and regularly pressed to negotiate conflicts among values, are more easily “managed”
and co-opted into participating in the mediation of decisions that are not their own.

There may be practitioners within healthcare organizations who are not morally
damaged by pitting, double binds, value conflict, and co-optation. But those practitioners
whose fleedom to act as their motivated to act is restricted by these features of their work
environment ought to be recognized, as I’ve argued in this section, as features of
institutional oppression. As moral agents who work in conditions in which they are pitted
against one another, stuck in double binds, pressed to negotiate conflicts between values
they’re motivated by and values they’re rewarded for endorsing, and co-opted into
participating in a system of rewards and penalties that keeps them vulnerable to losses,
healthcare professionals are victims of institutional oppression. These practitioners’
vulnerability to moral damage—loss of self-respect, alienation, and callousness—is
generated and maintained by a system of oppression, a structure of policies and norms
that restrict their abilities to act as they’re motivated to act that subjects them to penalties
if they refuse to be overworked. Not only are they powerless and vulnerable, they could
be well on their way to becoming jaded.
Part Two: Loss ofSelf-Respect and Alienation

This section explores two forms of moral damage suffered by institutionally
oppressed healthcare professionals. The first is loss of self-respect, which is a change for
the worse in a moral agent’s self-conception, and the second is alienation, which is a

disruption of the normal connection between a moral agent’s identity and her actions. I

74

argue here for a view of how loss of self-respect can be produced by infiltrated
consciousness, which can he suffered by professionals if they resign themselves to
working in oppressive conditions. I also argue here for a view of how alienation is
produced by moral distress, which can be suffered by professionals when they are co-
opted.

Before discussing how infiltrated consciousness produces loss of self-respect, the
first form of moral damage, I need to clarify the relationship between oppression and
resignation. Resignation is part of a moral agent’s response to powerlessness that is
cultivated under conditions of oppression; it is a moral experience in which a person
ceases to hope that she can get what she wants. To be clear, however, resignation does
not always incur moral damage to the moral agent. Whether resignation is damaging
depends upon what a person wants and what she is resigned to when she ceases to hope
that she can get it. Resignation is not damaging, for example, when a person realizes she
can’t get what she wants by doing what she’s doing right now, makes a decision to stop
doing what she realizes isn’t generating self-respect, and either pursues what she wants
by doing something else or changes what she wants.

So, if a healthcare professional is powerless and she sees herself as incapable and
ineffective in her work environment, we could ask her at least three questions that
initially appear to suggest ways of relieving powerlessness. The first is this: Why not
change jobs within healthcare? One who asks this question supposes that changing jobs
within healthcare professions enables her to work in conditions better than those in the
examples in the first part of this chapter, and that she is more likely to be able to be and

see herself as capable, effective, and morally responsive in a different job. But if there is

75

not significant variation among healthcare organizations—if pitting, double binds,
conflicts of value, and co-optation persist as typical, pervasive features of working
conditions in healthcare organizations—then changing jobs may relieve powerlessness
only for a lucky few.97

Even conceding that changing jobs wouldn’t reliably relieve powerlessness for
anyone at all, we could still ask a second question: Why not change professions? Here the
supposition is that changing professions is a possible solution to alleviating
powerlessness. Perhaps. But, changing professions means giving up years of study,
training, and professional skill-building. This isn’t a realistic option for many
professionals, and even many students”, who have invested their lives in learning how to
be healthcare professionals.

So, if a practitioner is rendered powerless within his work environment, powerless
to change the work environment, and subject to significant losses if he tries to leave that
work environment, he might resign himself to working in that environment despite its
oppressive nature. But, when a practitioner resigns himself to working under oppressive
conditions, he ceases to hope to get what he wants. If what a practitioner wants is a
conception of himself—as a capable, effective, and morally responsive person who does

what he sees as worth doing—but he ceases to anticipate that such a self-conception is

 

97 I do not suggest that a job change can never do any good at all or contribute to increased job-satisfaction,
but I do suggest that a job change is not an option that will bring about long-term resolution to the
conditions that generate loss of self-respect for the majority of people who work in those conditions.
Furthermore, job-change can worsen the working conditions of that majority who can’t or don’t change
jobs; I explore this in the next section of this chapter and also in the next chapter.

98 I recall a conversation I had with a colleague about a discussion he had with his medical students. He
asked them, “If you had it to do over again, would you choose to be trained as physicians?” He was
shocked to find that over half admitted they would not. When asked why they would not quit medical
school and pursue a different living, they said they felt “locked in” to continuing their medical education
and training because they felt it was the only kind of career in which they could pay back the debts they’d
accrued thus far in their educations.

76

one he can maintain in his work environment, then a third question is raised: Why not
change your self-conception? That is, one way a practitioner could resign a view of
himself as capable, effective, and morally responsive would be to internalize a view of
himself as a mediator of others’ decisions that better accommodates working in an
environment designed more for maximizing profit-oriented values than it is for
facilitating skillfirl, caring responses to vulnerable patients who need and deserve caring
responses. He may change his self-conception to one that can be maintained under
oppressive working conditions: one that is damaged. When he intemalizes a reduced,
molded view of himself, his consciousness is infiltrated; and infiltrated consciousness
produces loss of self-respect.

A moral agent suffers a loss of self-respect when she suffers a change for the
worse in her view of herself. A change in a practitioner’s self-conception is morally
damaging when her new self-conception incorporates morally degraded terms reserved
for workers like her by the oppressive organization in which she works. The terms of a
practitioner’s self-conception incorporate moral degradation and disrespect, for example,
when they represent her as a functionary and not as a moral agent. When a practitioner
who sees herself as a capable, effective, and morally responsive in her work environment
comes to see herself as incapably (or at least significantly less capably) and ineffectively
(or at least significantly less effectively) morally responsive, she has internalized a
reduced view of herself. Such a reduction to the terms of a practitioner’s self-conception
is morally damaging when the degraded terms describe a self-conception that can’t

generate self-respect for her.

77

What I’ve tried to do so far in this section is show how powerlessness, generated
under conditions of oppression, can cultivate resignation, and the first form of moral
damage, loss of self-respect. Specifically, I’ve been describing how infiltrated
consciousness produces loss of self-respect, which can be characterized in greater detail
by looking closely at Andrea Fricchione’s case and the cases in the first section of this
chapter. Recall flom Chapter One, Andrea’s self-conception changed during medical
school: “[R]ather than try to change everything that I consider wrong in the hospital or
the community at large, I just try to get through school.”99 In adopting for herself a self-
conception that was degraded flom being an agent of positive change in hospitals and
communities to a conception of herself as just trying to survive, she internalized a view of
herself as reduced, molded, and powerless. In particular, she internalized the view of
herself in terms tacitly reserved for medical students like her throughout healthcare
organizations: medical students occupy the lowest position in the hierarchy of authority
and respect among personnel in healthcare organizations. Andrea suffered moral damage
when she internalized this view because her self-conception and her self-respect became
gaming chips in her struggle for self-preservation.

Infiltrated consciousness can also be seen when Jill, Chris, and Alex each come to
think of themselves as morally unworthy: they believe they are exclusively at fault in the
situations they negotiate. Each of these is a case of infiltrated consciousness because all
of them come to view themselves in the erroneous, disrespectful, morally degrading
terms by which their oppressors view them. In the first case, Jill assesses her abilities as a
nurse according to the standards of the organization in which she works; she works in an

environment in which she feels she can only succeed if she can do everything all at once.

 

’9 Coulehan and Williams, 599.

78

From the macroscopic view, of course, it’s easy to see that no one can do everything all
at once, and the organization maintains an impossibly high standard of what it means to
function successfully as a nurse. But Jill adopts only a microscopic view of herself and
concludes that she is defective; she is situated such that she blames herself for what has
gone wrong in her work environment. Chris, in the second case, also believes he has done
something wrong; he believes he’s at fault for Jean’s becoming angry and he feels guilty
about it. Alex, in the fourth case, comes to see himself as “the worst doctor on earth,” and
he feels horrible about having endangered the safety of a patient.

Infiltrated consciousness produces loss of self-respect and damages moral agents
not only because they internalize erroneous, disrespectful, morally degrading terms for
their identities that perpetuate self-blame and guilt. It also keeps practitioners “in their
place” as mediators of others’ decisions and limits their abilities to understand their self-
conceptions as infiltrated by perpetuating microscopic vision among them. That is, as
long as practitioners continue to see their situations microscopically only, they won’t see
themselves as oppressed and they won’t, therefore, come to see the need to resist forces
in their work environments that keep them oppressed. As I’ll discuss in the second part of
the next chapter, infiltrated consciousness and microscopic moral vision are actually
cultivated (informally) in practitioners’ education and professionalization.100 But first,
more can be said here about how microscopic moral vision smoothes the infiltration of
practitioners’ self-conceptions.

From the microscopic perspective (whether assumed by the moral agent or an

observer—say, the woman who sees the nurse as responsible for not taking her father to

 

'00 In Chapter Four, I’ll argue that macroscopic vision is one form of perception refinement that ought to be
cultivated in educating and professionalizing clinicians.

79

the toilet), only individual moral agents appear to be at fault; the organization’s
responsibility for the failures of understaffing, overworking, and poor clinical teaching is
invisible flom the microscopic perspective. That is, it is easy for Jill, Chris, and Alex to
appear to themselves to be exclusively at fault and to have failed in their situations when
they view their situations microscopically. It is only flom a macroscopic perspective that
the organizational, structural flaws that configure these cases are visible: individual moral
agents are pitted against one another, structurally situated in double binds that they are
powerless to remedy, and co-opted. Jill and Chris really have little or no fleedom to do
something right in their situations and Alex (pressed to work by intimidation, despite
being tired and hungry) works in conditions ripe for medical error. But, until Jill, Chris,
Alex, or the observer learns to adopt a macroscopic view of the situations in which
caregivers’ fleedom to act as they’re motivated to act is restricted, they are likely to
continue to see themselves in erroneous, disrespectful, morally degrading terms. As long
as these practitioners see themselves in those terms, they can’t generate much self-
respect. But, flom the perspective of an oppressive organization, self-respect is a
dangerous thing because self-respect nourishes resistance to the forces that promote
profit-oriented values, and such resistance is costly.

In addition to loss of self-respect, oppressive working conditions in healthcare
organizations can cultivate a second form of moral damage among practitioners:
alienation. The nurse in the example in Chapter One, who describes herself as doing
“factory nursing,” can be seen in moral terms as suffering a growing gap between who
she is and what she does, as suffering a disjunction of the normal connection between her

identity and her actions.

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Before discussing alienation as a second form of moral damage, however, I need
to clarify the relationship between oppression, co-optation, and moral distress. As I’ve
discussed in the first section of this chapter, when healthcare organizations create and
sustain work environments in which practitioners negotiate conflicts among values
persistently and regularly, practitioners can be co-opted. Systems of rewards and
penalties in particular are intended to co-opt by influencing practitioners’ decision-
making and behavior by providing incentives and exploiting their vulnerabilities to
losses. Some practitioners do not see themselves as co-opted, and some may not mind
being co-opted even when they know they’re co-opted. But among those who know
they’re co-opted and do mind it, they generally resent it because they see themselves as
mere functionaries, as mediators of others’ decisions. In particular, a practitioner can
resent co-optation when she is forced to do things she does not see worth doing or when
she is forced to do them in ways she does not see worth doing. In other words, she can
resent suffering moral distress. Recall flom the beginning of this chapter, that moral
distress is a sense of complicity in doing wrong; it comes not flom uncertainty about
what is right, but rather flom one’s belief that one is forced to participate in doing what is
wrong. ’0’

In the terms assembled in Chapter Two, what it means for a moral agent to be cc-

opted is for her to be forced to act for reasons that are not her own.102 Under normal

 

‘°' Andre 2002, 122.

‘02 Co-optation can also force practitioners to act for reasons that are not their own and of which they may
not be fully aware. Consider, for example, how healthcare organizations accept pharmaceutical companies’
sponsorship money for conferences, lunches, and (flequently elaborate) dinners in exchange for
opportunities to directly access and advertise to physicians (particularly PGY-l and PGY-2 physicians,
those in the first or second year of training after medical school) who work in those organizations. Those
physicians are frequently ignorant of the fact that their participation in pharm-sponsored conferences,
lunches, and dinners is the currency of a larger exchange between the organizations for which they work

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conditions, a moral agent is moved to act based upon what she perceives, and her
perception is guided by values she believes to be important. She is motivated to act for
this reason, in this way, at this time; she is motivated to act such that her action expresses
values she endorses as constitutive of who she is. But if she feels co-opted into doing a
different action or co-opted into doing an action differently flom how she’s motivated to
do it, she acts for reasons other than her own, she suffers moral distress, and that can
produce alienation.

Alienation happens in at least two different ways: a moral agent is co-opted into
doing an action improperly or co-opted into doing an action she sees as wrong. The first
kind of co-optation happens when a moral agent is motivated to act based on his
recognition of a reason to respond in a situation, but is not flee to respond based on his
recognition of a reason how to respond. This kind of alienation can happen when an
organization’s system of rewards and penalties endorses the idea that responding
impersonally—merely responding—is just as good (or better) than responding with
care.103 Here, the reason to do something is the only part of a reason that is recognized,
flom the organization’s perspective, as worth acting upon; the organization’s system of
rewards and penalties does not appreciate differences between the moral worth of
impersonal responses and the moral worth of responses rendered with care.

From the practitioner’s perspective, however, reasons how to render responses are

important because they express who she is and what she sees as worth doing in particular

 

and the companies for whom those organizations secure the benefit of including particular pharmaceutical
roducts in prescription formularies.

03 An organization’s systems of rewards and penalties are not always explicit. For example, we would not
expect a healthcare organization to have an explicit policy that would say something like this: “responding
irnpersonally is just as good or better than responding with care.” But systems of rewards and penalties can
be experienced by practitioners within those organizations as implicit mandates that co-opt just as
effectively or more effectively than explicit policies.

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cases. Recall that in Part Two of the last Chapter, I argued that moral agents perceive
actions as worth undertaking when they identify with values at stake in the situation. That
is, a moral agent identifies herself with what she thinks is worth doing, what she thinks
she has a reason to do, given her professional training. In addition to arguing that what
moral agents care about guides their perception of what is worth doing, I also argued that
what moral agents care about guides how—where, when, and with which dispositions—
they see actions worth doing. In configuring a reason how something ought to be done, a
moral agent considers what her action expresses of her; she considers who she is as she
does it.

When practitioners are co-opted into doing an action improperly, in moral terms,
their reasons how to do an action are viewed by the organizations in which they work as
superfluous to reasons to just get an action done. As we observed in the example (in Part
Two of Chapter Two) of the physician who must flequently tell unsuspecting patients
that they are pregnant, when she works under conditions in which she is rushed, she
delivers the news—she does the action there is a reason to do—but she’s unflee to
deliver the news in a way she endorses as expressive of who she is and what she cares
about. A reason to tell the patient she is pregnant is that the patient has a right to know
this information. But this physician doesn’t see the patient’s right to know as the only
morally relevant particular of the situation to which she needs to respond. She recognizes
particulars and is motivated not only to honor the patient’s right to know but also to
deliver the news with care. But, the organization situates the physician under such tight

time constraints that the physician is not flee to act how she’s motivated to act, and under

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such constraints, this physician is alienated and she feels that she does her job
improperly.

What seems to matter most to the organization that creates and supports working
conditions like these tight time constraints is that she responds in a way that endorses
high productivity of healthcare services and is minimally costly for the organization. But
flom the perspective of this physician, how she responds matters deeply; delivering the
news this way is worth doing and delivering it another way—too quickly, for example—
is not worth doing (or at least not as worth doing) because doing it that way is to do it
improperly. When a practitioner, like this physician, is co-opted into doing an action
improperly, her moral motivation doesn’t work normally. Normally, she’s motivated by
what she sees, but under the conditions in which she works, what moves her to act instead
is pressure—produced by the organization’s systems of rewards and penalties. She is co-
opted into knowingly doing an action improperly. In moral terms, co-optation is one
thing that produces disruption of the normal connection between perception and
motivation. Doing an action in a way other than how she is motivated to do it produces
alienation because the action does not express who she is or what she sees as important.
Over time, co-optation generates moral distress, which produces alienation.

Alienation happens in another way too. When a practitioner is co-opted in a
different way—forced to act despite that she sees reasons against acting—she acts for
reasons other than her own and she suffers moral distress. This dynamic is in-play most
clearly in cases of futility. In such cases, a moral agent does an action or series of actions
because she’s co-opted into doing some action she sees as pointless, and therefore, not

worth doing or she’ co-opted into doing some action despite that she sees reasons against

84

doing that action. A recent article discusses a case in which caregivers were co-opted into
providing services they thought were futile.104 They were co-opted into continuing to
treat a patient who was not getting any medical, cognitive, emotional, or moral benefit
flom their actions; the patient’s parents were unwilling to consent to discontinuing
treatment, and the organization in which these caregivers worked allowed the parents to
demand that treatment be continued. Practitioners in this case were merely mediating the
decisions of others, they were morally distressed because they acted for reasons that were
not their own; they didn’t see their actions worth doing because those actions, though
they could be done capably, were not recognized as effective responses to their patient’s
needs; they were futile.

Other instances of moral distress that can produce alienation happen when a
practitioner is co-opted into wronging others or herself. In Jill’s case, for example, she
knowingly participates in a set of conditions in which patients are endangered and their
safety is compromised. Alex, in the fourth case, participates in his own dehumanization
in order to avoid firrther censure flom Jen. Over time, these kinds of moral distress can
cultivate feelings of guilt, incur loss of self-respect, and generate alienation.

What I’ve tried to do in this section is canvass different ways in which
powerlessness and co-optation can incur two forms of moral damage: loss of self—respect
and alienation. Not all practitioners who work in oppressive conditions in healthcare
organizations experience these forms of moral damage, and even among those who do

suffer either or both of them, they do not all experience them in the same ways. For

 

’04 See Levi, et. al. In this article, my response to this case emphasizes the importance to the caregiver that
her capacity for moral responsiveness to others be meaningfully employed. This article examines jading in
the context of futility only, but as I’m developing in this chapter, futility is just one type of alienation,
which is only one possible part of the process of moral damage a moral agent suffers when she becomes
jaded.

85

example, practitioners may not be equally bothered or damaged by the same features of
their work environments. Another source of variation among whether and how
practitioners lose self-respect and become alienated is that their identities are constituted
by more than just moral responsiveness to others; practitioners can generate self-respect
flom other identity-constituting features too, and how much they do so can affect how
loss of self-respect or alienation will morally damage them.

But, there is yet another form of moral damage institutionally oppressed
practitioners can suffer, even if they never suffer loss of self-respect or alienation.
Practitioners who do not lose self-respect or become alienated can still become calloused.
Part Three: Callousness Causes Moral Motivational Erosion

So far in this chapter, I’ve canvassed different members of the family of
experiences that can be part of the process of jading: conflicts among values (particularly
profit-oriented values of low cost and high productivity and values of moral
responsiveness to others like beneficence and compassion), co-optation, powerlessness
(and the pain, humiliation, anger, and flustration it can generate), and forms of moral
damage (like loss of self-respect and alienation). Finally, in this section, I consider
another important member of the family of concepts in play when “jaded” is used to
describe a healthcare professional’s process of moral damage and moral motivational
erosion over time: callousness.

The social scientist Cary Cherniss observed that practitioners “cut back”
involvement in their work when they felt that their abilities to meet their own needs were

compromised by their work environment. By reducing their involvement in their work,

86

according to Cherniss, these professionals began “looking out for number one,”105 for
themselves. He observed too that “cutting back” corresponded to shifts in professionals’
self-conceptions. In particular, he remarked that those who entered a profession because
they “want[ed] to serve others” became those who “began to focus more and more on
their own needs, and . . . increasingly came to resent how little those needs were being
met.”106

As Cherniss characterized it, a professional’s “cutting back” appears to be
different flom loss of self-respect or alienation because he represents it as a conscious re-
focusing of perception flom others to oneself. In moral philosophical terms, when a
practitioner “cuts back,” she reorients herself to the project of caring for others.107 In this
section, I’ll try to show that what a practitioner does morally when she reduces
involvement in her work is narrow the scope of what she sees herself responsible for.
This narrowing of responsibility limits the field of particulars a moral agent sees as
constitutive of reasons to act. When she limits her moral perception by excluding
particulars that configure what others need or deserve, she is calloused. When a
practitioner “cuts back” because she’s calloused, her moral perception is damaged. As I’ll

argue, calloused practitioners’ moral perception is damaged because they fail to

recognize morally relevant particulars or don’t construe them properly. A likely result of

 

'05 Cherniss, 42.

'°° Cherniss, 42.

’07 It’s important to remember that a practitioner can reduce her involvement in her work in a number of
ways and in response to a number of factors, not all of which will have to do with becoming calloused. This
is important because a practitioner’s reduction in involvement in professional caregiving will not always
mean she’s becoming jaded. (She could, for example, be retiring.) Even when reducing involvement in her
work is part of the process of becoming jaded, her experiences over time that prompted her to reduce
involvement in her work may be very different flom others who reduced their involvement because they’ve
suffered oppression and moral damage. Variations among experiences in the process of becoming jaded
remind us that jading is a family-resemblance concept, one characterized best not by a list of necessary and
sufficient conditions but as Wittgenstein says, by a “complicated network of similarities overlapping and
crisscrossing.” “Cutting back” and callousness, at this point in this chapter, are being added to the cluster of
concepts that characterize the process of jading.

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having damaged moral perception is that practitioners fail to respond to reasons there are;
this has serious consequences for calloused practitioners’ patients and colleagues.

Before considering how callousness expresses damaged moral perception, it’s
worthwhile to first consider in more detail what it could mean morally for a practitioner
to “cut back.” In moral philosophical terms, we can think of possible benefits to
practitioners—like Jill, Jean, Chris, Sal, and Alex—of reducing involvement in their
work. For example, reducing involvement in work could make them less vulnerable to
suffering loss of self-respect or alienation. That is, when a moral agent reduces
involvement in her work by reducing the degree to which she sees being morally
responsive to others as importantly and centrally constitutive of her identity, she could be
trying to reduce the degree to which being hurt, frustrated, and angered (by having her
moral agency restricted under conditions of oppression) incurs damage. Reducing her
involvement in her work could be something she feels she must do to survive; perhaps
then, responding to others morally should become less importantly expressive of who she
is and what she sees worth doing.

Recall from Chapter One how medical student Andrea Fricchione, for example,
described “cutting back” as a way of coping with the demands of her work. She described
what she felt as a need to “just to make it through school,” and she recounted having
made a choice she thought might enable her to do so; she said, “I decided to focus more
on my own life.”108 In moral philosophical terms, this is a shift in focus, a re-direction of
moral perception flom the needs of others to the needs of oneself. What Cherniss
describes as “looking out for number one” can indeed be an effective way for students

and practitioners to self-preserve and cope. Interestingly, a practitioner who consciously

 

“’8 Coulehan and Williams, 599.

88

reduces his involvement in his work as a means of self-preservation could do so to
deliberately separate who he is flom what he does, to willfully become alienated.

Even if we acknowledge that alienation could be a coping strategy for oppressed
practitioners, we must still consider important moral consequences to a practitioner’s
cutting back or willful alienation, one of which is that his moral perception can become
damaged. If what I argued in Chapter Two is correct, a reduction in the degree to which a
practitioner sees moral responsiveness to others as identity-constituting corresponds to a
reduction in importance and centrality of the roles values of moral responsiveness to
others—like beneficence and compassion—play in guiding perception of what count as a
reason to act. When a practitioner reduces the degree to which being morally responsive
to others is seen as importantly and centrally constitutive of who he is, even if reducing
what he sees himself responsible for is something he should do, these values become less
steadfast guides to his perception of particulars. This could result in caregivers’ becoming
less capable, less effective, and less morally responsive to patients and colleagues who
need and deserve his responses.

Another moral consequence of a practitioner’s making moral responsiveness to
others less importantly constitutive of who she is is that she will likely be less apt to
refine her perception, less apt to seek out experiences that maintain the scope of
particulars she’s moved by as broad, capacious, and inclusive. Expanding the scope of
particulars a moral agent sees as constitutive of reasons to act broadens the range of
situations to which she’ll see herself responsible for responding. But a practitioner who
reduces the degree to which being morally responsive to others constitutes his identity

seeks not to expand, but to reduce the range of situations to which he sees himself as

89

responsible for responding. In seeing himself as responsible for less, he narrows the
scope of particulars by which he will be motivated to respond to others with care. A
moral agent with a diminished sense of responsibility will be moved by fewer and fewer
particulars as he reduces involvement in professional caregiving more and more. When
his sense of responsibility is dull rather than robust, his moral perception is dull rather
than acute. A practitioner who “cuts back” likely has little or no incentive to refine her
moral perception, so it will remain dull.

Another consequence to others of a practitioner’s reduction of his involvement in
the work of professional caregiving, even if it’s the best thing for him to do, is that fellow
practitioners are left with an increased load of responsibilities to respond to patients and
one another. This consequence plays out as a practitioner’s decision to remove herself
flom moral landscapes in which she expects certain kinds of particulars to be pervasive.
Cherniss observed, for example, that some professionals “cut back” involvement in their
work by leaving public service-oriented jobs to take more lucrative, high-paying jobs

.109 In the context of healthcare in particular, some nurses

with private companies instead
and physicians leave practice in public hospitals and clinics because private practice is
believed to be indicative of higher status within their professions; private jobs pay more
and are therefore seen by some to be more rewarding. In moral philosophical terms, a
healthcare practitioner who makes a transition flom public to private practice shifts the

focus of her moral perception by choosing the kind of moral landscape in which she’ll

work. She chooses to situate herself in moral landscapes she expects will be shaped by

 

'09 Cherniss sees four different ways in which this occurred; professionals developed new types of goals.
He calls these “going for the gold” (pp. 52-53), “the search for greater intellectual stimulation” (pp. 54-55),
“seeking status” (pp. 55-56), “becoming one’s own boss” (pp. 56-57), and “looking for less difficult
clients” (pp. 57-59).

90

some particulars and not others. That is, a transition flom public to private work, is
generally accompanied by a transition in the wealth of the patients professionals serve.
Poor uninsured people can’t afford to go to private clinics, so professionals who leave the
public clinics serve them much less flequently. When a professional transitions flom
public to private practice, the particulars of dealing with poor patients drop out of the
moral landscapes of most of the clinical situations she sees. Making the choice to go into
private instead of public practice is a way of excluding a field of particulars (commonly
associated with dealing with patients who are poor) flom the moral landscapes one sees
during the workday. Alternatively, a practitioner could also remove herself flom
situations in which she’ll expect to see particulars commonly associated with patients
who are immigrants, or she can remove herself flom situations in which she’ll likely have
to see the particulars associated with treating poor single mothers. 1 '0
Making a transition in the situations in which a practitioner situates herself is a
form of “cutting back” when it is the result of a practitioner’s decision or series of
decisions that responding to certain particulars is less worth doing. A moral agent can
have good reasons for making such an assessment that responding to certain particulars is
less worth doing and for making a transition in the moral landscape in which she situates
herself. But such decisions and transitions have important consequences for fellow

healthcare professionals and for entire healthcare professions (some of which I’ll discuss

in the first section of the next chapter), and for the public: choosing private instead of

 

no I do not endorse the view that healthcare professionals ought never be able to situate themselves among
certain kinds of particulars in their work. I do suggest, however, that such choices are not without
consequences to other professionals and patients and should be considered accordingly. This issue raises
many questions: Do all healthcare professionals have equal opportunities to make choices about the kinds
of particulars to which they’d like to be exposed? Ought healthcare professionals be afforded the
opportunity to choose among the particulars to which they’d like to be exposed? If so, which criteria for
such choices should count as legitimate and fair to colleagues and patients? Ought a practitioner be allowed
to implement such a choice among particulars whenever she wants?

91

public practice reflects the view that service to the poor is deemed less important to one ’s
own practice, but somehow important enough to be left to one’s fellow practitioners in
healthcare professions and organizations who do serve the poor.

So far in this section, I’ve tried to show that even when a practitioner “cuts back”
involvement in her work because she thinks it is the best thing she can do, there are three
important moral consequences: values of moral responsiveness to others become less
steadfast guides to moral perception, a practitioner who’s “cut back” is less likely to
refine her moral perception, and a practitioner who’s “cut back” by reducing the scope of
what she sees herself responsible for leaves a greater burden for her colleagues.
Furthermore, if a practitioner “cuts back” to the point at which he sees himself
responsible for responding to less than he should, the scope of what he sees himself
responsible for is too narrow.

Consider, for example, that an observer suspects a practitioner is calloused
because she has not responded to reasons there are. We need to consider several possible
explanations if we’re to get a solid understanding of what callousness is and how it
expresses poor moral perception. One possible explanation is that the practitioner and the
observer simply don’t share an understanding of what’s going on in the situation and they
need to discuss or argue about how the story of what’s going on ought to be told. It could
also be the case that one (or both) of them is wrong about what’s going on and neither
one is telling a story that accurately represents the moral landscape of the situation. It
could also be the case that the practitioner did respond to moral reasons in the situation,
but the observer didn’t recognize her actions as responses or appropriate responses. It

could also be the case that one (or both) of them is wrong about how the moral landscape

92

of a situation ought to be represented because one (or both) of them has damaged moral
perception. If this latter possibility is the case, faulty moral perception could be an
expression of callousness. So, When is poor moral perception an expression of
callousness? Consider two cases.

The first case involves Dr. Small, an obstetrician in Anne Fadiman’s The Spirit
Catches You and You Fall Down.”1 This case consists of a series of statements he made
in interviews with Fadiman. Consider a statement he makes, which reveals the terms in
which he sees Hmong patients:

You or I, we can’t conceive of the degree of ignorance. [The Hmong] are
ahnost a Stone Age people. Hell, they never even went to a doctor before.
They just had a baby in the camp or the mountains or wherever the hell
they came flom.l
Fadiman also reports his response to being asked about caring for Hmong patients during
labor and delivery:
They don’t do a damn thing you tell them . . . They just come in late and
drop it out. In fact, they wouldn’t come at all if they didn’t need to get the
birth certificate so they could get more welfare.113
F adiman also reports comments Small made about Hmong immigration to the United
States:
I and my friends were outraged when the Hmong started coming here . . .
Outraged. Our government, without any advice or consent, just brought
these nonworking people into our society. . . [T]hese Hmong just kind of

fly here in groups and settle like locusts. They know no shame, being on
the dole. They’re happy here.1 1"

 

”I Anne Fadiman’s superb The Spirit Catches You and You Fall Down: A Hmong Child, Her American
Doctors, and the Collision of Two Cultures was published in 1997 by Farrar, Straus and Giroux.

"2 Fadiman, 73.
“3 Fadirmn, 73.

1" Fadiman, 235.

93

Although F adirnan does not address Small’s apparent ignorance of Hmong persons’
service to the United States Government during the Vietnam War1 ’5, she does challenge
his perception that Hmong people are happy in the United States. In particular, she writes
of having mentioned to Small the high rate of depression among Hmong refugees.l ’6
Small replied as follows:

What do you mean? This is heaven for them! They have a toilet they can
poop in. They can drink water flom an open faucet. They get regular
checks and they never have to work. It’s absolute heaven for these people,
poor souls.117

A second case is recounted as follows:

Jen Lane is called to the emergency department to see a patient
with severe abdominal pain. She enters the room and sees Mrs. Millon,
whom she seems to recall having seen a few weeks back for a head injury.
She then sees Mr. Millon, who eagerly jumps up flom his seat to introduce
himself. He continues, “Thank you for coming so quickly, doctor. I’m
very concerned about my wife.” Jen looks to her, recognizing bruises of
several shades on her arms and neck, “Tell me what the trouble is, Mrs.
Millon.” Mr. Millon pipes up, “She gets these terrible headaches and they
make her dizzy and she fell down the stairs and rolled right onto her
belly.” Jen looks at him, and then looks at Mrs. Millon, who quickly looks
down. “Well, we’ll need an MRI to get an idea of what’s going on inside
that belly. Wait right here and I’ll make a couple calls and draw up some
orders; I’ll be right back.”

Jen leaves the room, closes the door, and sighs. “I hate these
cases,” she thinks. “What am I supposed to do for these women who can’t
help themselves? I feel sorry for her, but what an idiot! Why doesn’t she
leave this guy?”

Small and Lane are both wrong about what’s going on in their situations. Two
ways a moral agent can be wrong about what she sees going on in a moral situation is to

fail to see particulars and to fail to discern particulars’ moral relevance properly.

 

“5 Fadiman contextualizes the story of Hmong people as patients in the United States in many ways. One
of them is how she situates their experiences as patients in the broader social and political of relations
among Southeast Asian nations and the United States flom the 19505 to 2000. Chapters 10, 12, and 14—
“War,” “Flight,” and “The Melting Pot,” respectively—address these dimensions of Hmong patients’
experiences.

“6 Fadiman, 235.

”7 Fadiman, 235.

94

Particulars can be discerned as having more or less moral relevance than they actually do,
or they can be discerned as morally relevant when they are not morally relevant at all, for
example. Understanding how moral agents improperly construe particulars’ moral
relevance requires us to take a closer look at cognitive dimensions of a moral agent’s
perception of particulars and experience of value of those particulars.

In section two of this chapter, I suggested that one of these important cognitivist
dimensions is that a moral agent has to believe certain things about herself in order to
respond to others with care—that she is capable and effective, for example. Other
important cognitivist dimensions of a moral agent’s perception of particulars and
experience of moral value of those particulars can be considered by asking this question:
What does a moral agent have to know or believe about someone else to respond to that
person with care? One belief central to the concept of what it means for a moral agent to
respond to another person with care is this: the person to whom the moral agent responds
needs her response and deserves to have her needs responded to. l ’8

That is, part of what it means for healthcare professionals—like Small and
Lane—to properly construe the moral landscape of a situation and properly render a
moral response is for her to discern others’ need and desert accurately. These concepts
are important for moral perception in the context of healthcare because when a
practitioner properly discems particulars that configure what another person deserves and
needs, she recognizes ways in which the other person is vulnerable to suffering and

concomitantly construes what, in her role as a practitioner, she is responsible for and

 

“8 There are practical constraints preventing all persons’ needs flom being responded to in all cases, of
course, but this is not an obstacle to establishing that holding this belief is central to a moral agent’s ability
to recognize particulars that constitute another person’s need or desert as morally relevant particulars that
shape reasons to act in service to others.

95

what she owes the other person. Her responses, as a healthcare professional, must address
the other person’s particular vulnerabilities if they are to effectively alleviate her
suffering. But, Small and Lane both fail to apply these two concepts as they draw up their
narratives of what they see, and that is why their poor perception reveals them to be
calloused.119 So, a practitioner’s faulty moral perception is an expression of callousness
when she misapplies concepts of need and desert as she construes moral reasons to
respond to their patients.

Robustly responsible professionals firlly engaged in their work can apply concepts
. of need and desert broadly, and the scope of their moral perception can be maintained as
broad, capacious, and inclusive. But, a calloused practitioner applies these concepts
narrowly, the scope of what he sees as a reason to act is narrow, limited, and exclusive.
Looking closely at Small’s and Lane’s patterns of moral perception, we can see that they
misconstrue reasons to act because they fail to discern the proper moral relevance of
particulars that configure others’ desert and need. Consider Small’s moral perception
first. The kinds of particulars Small perceived as morally relevant were how much formal
education a patient has had, whether a patient was apprised of modern technology, or
whether a patient has ever visited a physician to give birth to a child. Discerning these
particulars as most morally relevant appears to allow Small to easily separate the kind of
person he is flom the kind of people the Hmong are. Furthermore, Small configures these

particulars such that Hmong patients fall outside the scope of those human beings

 

”9 Readers familiar with Anne Fadiman’s book may agree that Small, as he appears in her book, is
arguably not calloused, but simply a bigot and a racist. I have helped myself to Fadiman’s rendering of
Small and adapted him for my own purposes. Later in this section, I imagine some of his possible responses
and I offer callousness as a possible explanation for his faulty moral perception. Later in this section, when
I characterize different forms of callousness, I will also consider the effects of bigotry and racism on moral

perception.

96

deemed worthy of care. Because Small believes Hmong patients are noncompliant and
uncooperative, he construes them as undeserving of his moral responses. Small’s
conception of Hmong obstetrical patients’ intentions and his beliefs about the kind of
people and patients the Hmong are configure what he sees them deserving. He therefore
misconstrues what Hmong people deserve as human beings and patients; as a result, he
fails to carry out his responsibilities to treat them as he treats other patients who are not
Hmong.

Small also misconstrues the needs of Hmong patients. He views Hmong people as
subhuman and as invulnerable to suffering embarrassment. His story of Hmong people in
US. society represents them as insects. Small not only appears to lack compassion for
Hmong patients, he quite clearly mocks their poverty. What he construes as morally
significant is that Hmong people get what they don’t deserve; he draws the conclusion
that their lives in the United States are “heavenly.” He fails to construe poverty as a
morally relevant particular that configures a Hmong patient’s vulnerability and need.
Instead, what he sees as morally relevant about their needs is that Hmong persons’ needs
are already met, their needs beyond elimination and hydration are irrelevant and not
worthy of response. With respect to fields of particulars associated with treating Hmong
patients, he is calloused, and as a result, he’s not motivated as he ought to be as a
professional caregiver to respond with care to patients who are vulnerable, in need, and

120 of his professional service.

deserving
Consider Lane’s patterns of moral perception too. In Lane’s case, her response

may be medically appropriate; there is an obvious medical reason to assess what’s going

 

'20 Even if a patient refuses a physician’s or nurse’s services or isn’t compliant with their advice, it is still
required that professionals see clearly and recognize reasons to offer services, based upon a patient’s
vulnerability, need, and desert of professionals’ responses.

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on inside the abdomen of a person who has abdominal pain and has just allegedly fallen
down a stairs. But Lane fails to recognize the moral reasons that there are to respond to
Mrs. Millon. She suspects that Mrs. Millon is a domestic violence victim; she notices the
particulars there are that could configure that suspicion. For example, she sees that Mrs.
Millon presents to the emergency department with injuries and bruises twice in just a few
weeks, that Mr. Millon usurps his wife’s invitation to speak, and that Mrs. Millon has
trouble maintaining eye-contact. But, Lane ought to construe these particulars such that
they configure a reason to speak with Mrs. Millon alone and give her an opportunity to
explain a possible alternative version of events that led to her injuries. There can be other
moral reasons present in this case too: a reason to call the police, a reason to call a social
worker, a reason to remove Mrs. Millon flom the company of her husband, who appears
to be a significant threat to her personal safety and stability.

With respect to the field of particulars that give shape to the stories of women
patients who suffer domestic abuse, Lane is calloused. She judges them as unwilling to
leave abusive relationships, but fails to discern particulars that could configure victims’
reluctance to leave their abusers. Furthermore, she never opens a dialogue with the
person for whom she has a duty to care, her patient, Mrs. Millon. Rather, Lane draws the
irrelevant and unhelpful (and wrong) conclusion that her patient is just an idiot. By seeing
Mrs. Millon as an idiot, Lane excludes her flom the realm of people whom she sees as
deserving of closer attention and more sophisticated care; Lane also excludes her flom
the realm of people who have needs she sees herself as capable of addressing

competently and effectively.

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So far, I’ve tried to show how Small’s and Lane’s patterns of perception are faulty
and expressions of callousness. It is not clear, however, which forms of callousness are
expressed in these cases as faulty moral perception. I canvass three different types of
callousness in what follows: callousness as a form of evil, epistemic callousness
(callousness due to ignorance or poor training), and callousness as a form of weakness of
the will. Distinctions among these types of callousness are important because they can (if
known) help those who observe callousness figure out who’s responsible for a
practitioner’s callousness and what ought to be done to help that practitioner see better, to
help her refine her moral perception.

The first kind of callousness—callousness due to evil—is most easily rejected as
accurately descriptive of Small’s or Lane’s callousness, so I’ll consider it first. If Small
and Lane are calloused because they are evil, their callousness is indeed an ethical
problem and also a metaethical problem, but as I explained in the first part of Chapter
Two, it is not a problem that has to do with moral motivation. Evil doesn’t cause a
disjunct in the normal connection between perception and motivation; rather, evil has to
do with why moral agents don’t or won’t accept the same moral propositions that guide
how most other moral agents negotiate moral life.

Recall flom Chapter One the story of Caligula, who is an example of someone
who was calloused not because he suffered moral motivational erosion, but because he
was evil. He was evil because he didn’t appreciate the humanity and vulnerability of
people in ways most people do, and he didn’t feel any remorse about the fact that his
victims suffered as a result of his actions. Callousness in the case of Caligula was no

failure of perception, and was therefore not an instance of moral motivational erosion.

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Rather, Caligula’s callousness was due to his (generally unacceptable) belief that he was
entitled to impose suffering on others for his own pleasure and gain.

As I also recounted in Chapter One, one of the linguistic uses of the concept
“jaded” is to describe just this sort of evil callousness.121 But, “jaded” is used in many
other contexts that do not have to do with evil, so there are other forms of callousness to
be considered if callousness is to be one of the concepts among the family of concepts
that characterize the process of j ading, particularly in the context of healthcare.
Furthermore, I generally assume that healthcare professionals are not evil and do not
subscribe to beliefs like Caligula’s. So, if Small and Lane are calloused, there are other
ways of thinking of them as calloused.

So, let’s consider the second form of callousness, epistemic callousness,
callousness due to ignorance or poor training. For example, if Small doesn’t know his
views are socially, politically, culturally, and historically ignorant, racist, and classist and
if Lane doesn’t know her views are sexist and dismissive of social and psychological
dimensions of what it means to be a victim of domestic violence, these are epistemic
problems generated by tremendous failures in their educations. But if Small and Lane are
calloused due to ignorance and poor training, their epistemic callousness would not be an
epistemic problem only; ethical questions about why these practitioners are ignorant and
why they are poorly trained clearly remain. So, to fully consider how healthcare

practitioners can be epistemically calloused, we should account for at least three different

 

’2' This suggests that “jaded,” as it is used in language, describes a broader spectrum of phenomena than
just the kind of moral motivational erosion I’m trying to describe, or “jaded” is misused as a descriptor of
Caligula or someone like him. In this work, I address only forms of jading that are moral motivational
erosion because this is the form of jading that characterizes important experiences in the moral lives of
many healthcare professionals.

lOO

loci of culpability and responsibility for a single practitioner’s epistemic callousness: the
individual practitioner, her profession, and the organizations in which she works.

First, recall my discussion of disillusionment flom the Chapter One. I
characterized disillusionment as an epistemic problem, which professions and
organizations work to address by screening applicants to schools of healthcare
professions. Schools of nursing and medicine, for example, must make sure applicants
are entering a healthcare profession for the right reasons, and they must try to find out
what applicants know and think about what it means to practice a healthcare profession.
Just as professions and organizations have responsibilities to curb the epistemic problem
of disillusionment, they have responsibilities to train practitioners to discern patients’
desert and need of healthcare broadly, capaciously, and inclusively. Furthermore, they
must be able to identify when practitioners’ moral perception is too narrow and when
practitioners don’t know how to assess certain kinds of particulars they ought to know
how to assess. That is, professions and organizations need to invest not only in
developing methods to improve how practitioners learn nursing and medicine, but also in
developing ways to improve how nurses and physicians discern salience and patterns of
relevance among particulars and evaluate how they experience value among particulars

in clinical situations.122 That could mean employing multidisciplinary—social, political,

 

'22 This point will be further developed in Chapter Four. It’s useful to point out here, however, that
healthcare professions and organizations already seem to value continuing education for practitioners.
Seminars and workshops offer Continuing Medical Education (CME) credits, which physicians, for
example, are required to earn in their careers. Though much less emphasis is placed upon teaching
practitioners to discern value in what they learn, such that what they learn actually improves their moral
perception, there are some seminars that do focus upon something frequently called “sensitivity,” as in
“sensitivity training.” Such seminars sometimes have to do with race and gender and seem to be intended to
get participants to acquire new ways of seeing and thinking about race and gender. Courses that have
evolved in medical schools in the last decade seem also to have a goal of developing moral perception,
particularly ethics and humanities courses that emphasize empathy. More attention can be devoted to

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historical, cultural, ethical, and spiritual—approaches throughout health professions
education and a wide variety of pedagogical strategies too.

For example, if Small is epistemically calloused, his narrowed scope of moral
perception is due to ignorance about and poor training in discerning value in the
historical, political, social, and cultural dimensions of the life experiences of his patients
and in understanding how his Hmong patients’ life experiences influence their healthcare.
His ignorance in these areas may not appear to affect his medical judgment about what to
do for patients, but it certainly seems to affect his moral judgment about what they need
and deserve. Also, Lane appears to be poorly trained in how to appreciate how complex
psychological and sociological issues in family violence affect domestic violence
victims’ needs and behavior. Her ignorance about these issues renders her ill-equipped to
field her patient’s abuse history and deal competently with her patient’s fundamental
safety. Organizations and professions tolerate (and may appear to endorse) these forms of
ignorance that affect patient care if they fail to educate professionals adequately about
how to recognize and discern value in social, political, historical, cultural, ethical, and
spiritual particulars in the stories of patients’ experiences and illnesses.

In other cases, the kinds of particulars calloused moral agents can fail to discern
as relevant and construe as salient can vary widely. How actively and flequently their
professions, fellow professionals, organizations, and societies endorse or challenge
different beliefs (and patterns of perception guided by those beliefs), how strongly those
beliefs are held, and how importantly and centrally those beliefs constitute their identities

are other sources of variation in which kinds of particulars practitioners are apt or inapt to

 

designing these courses about how to get students to consider how ignorance, poor training, and bad beliefs
interfere with their moral perception and their colleagues’ moral perception.

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discern well. For example, Small seems to maintain the belief that he is entitled to choose
which persons are worthy of his services based upon morally irrelevant particulars—
where they came flom, how much formal education they have, whether they’ve ever seen
an obstetrician before, and whether they receive or ever received money from the
government. Do professions and organizations tolerate or endorse this belief? If not, they
need to assume a significant role in rooting it out and revealing it to be an unacceptable
belief behind which ignorance and poor training are no longer allowed to hide.

In addition to professions and organizations, individuals also have responsibilities
to do what they can to avoid epistemic callousness. As I discussed in the last section of
Chapter Two, a practitioner’s capacity for moral perception must be maintained as broad,
capacious, and inclusive if she is to see well. Part of what it means for a moral agent to
maintain his ability to see well means revealing sources of his own ignorance and
learning how to come to know what he doesn’t know. To do this well, practitioners have
to be reflective and open to healthy self-scrutiny (and, in many cases, open to scrutiny
flom others). Small’s views could be perpetuated by ignorance of the context of who
Hmong people are and why they were considered by the United States Government and
other countries’ governments to be refugees, and he needs to learn to recognize how these
views interfere with his ability to be responsive to patients for whom he has a duty to

123

care. If and when he becomes aware of how his views make him calloused, he should

 

’23 A problem is, however, that Small might not be a self-reflective person and he may never become aware
of how his views interfere with his ability to respond to patients. This is why I also just tried to show that
professions and organizations are additional loci of responsibility for epistemic callousness. Having three
loci of responsibility for callousness that comes flom ignorance and poor training means that the duty of
self-reflection is not just for individuals; professions and organizations have to have forums in which they
consider whether and when ignorance and poor training are to be tolerated.

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make a choice (or a series of choices) to refine his perceptionm—to acquire sensitivity to
particulars in situations in which he deals with patients whose backgrounds and ways of
seeing are significantly different flom his own.
But, suppose Small isn’t a very reflective person, he brushes off others who try to
render his callousness visible to him, and he never becomes aware of how his views
interfere with his ability to respond to patients. This could be a point at which we would
see that Small’s callousness isn’t epistemic callousness, or at least not epistemic
callousness only: Small could be calloused not because he’s ignorant or poorly trained,
but because he’s weak-willed.
Suppose, for example, a colleague says to Small, “1 think you’d have a better
understanding of what your Hmong patients need and deserve if you learn more about
what they’ve experienced and why they’re in the United States,” and another colleague
says to Lane, “I think you need to learn more about why domestic violence victims can
have a hard time leaving their abusers. It’s not always as simple as you think.” Suppose
further that Small responds by saying something like this:
I know my colleagues think I’m racist and insensitive and that I don’t
understand “Hmong culture.” They give me the standard liberal mumbo
jumbo. But, you know what? I’m not the problem; they are. I don’t need to
learn about them and I don’t want to.

Suppose too that Lane responds as follows:
Look, it’s simple. These women just need to leave. Take the kids, do
whatever, just get out and go to a shelter for a while until you can find a
safe place to live. I know there are seminars on stuff like this, but I really

don’t have time and I don’t think there’s much more I could learn that
would be helpful.

 

'2’ There are several healthcare professionals in Fadiman’s book who engage in just this kind of perceptual
refinement—they read books and also consulted anthropologists and social workers who specialized in
working with Hmong refugees in Merced, California.

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Responses like these reveal that Small and Lane know about but choose not to examine
their colleagues’ complaints about their callousness.

When they choose not to refine their (faulty) moral perception with respect to a
field of particulars that important others125 have observed them as being improperly
motivated to respond to, their decisions are not irrelevant to the lives of those important
others. A practitioner approached by an observer who thinks she is ignorant or poorly
trained with respect to a certain field of particulars could respond in a ntunber of ways
and with a range of dispositions flom stubbornness to contrition. But, as I argued in
Chapter Two, she ought to want to keep her perception broad, capacious, and inclusive,
so as to be properly motivated to respond to the field of moral reasons there are (provided
that her conception of what her professional responsibilities are is reasonable). A
responsible healthcare professional (even if not a virtuous one) ought to care about
eliminating beliefs that prevent her flom discerning particulars’ moral relevance properly,
see ignorance as unacceptable, be moved to (at least) reflect upon her patterns of moral
perception if someone conflonts her about being calloused, and be moved to refine her
perception if those patterns reveal that she’s not seeing well. If a practitioner is

‘26 about her failures of moral perception and fails to make any

complacent or apathetic
efforts to reflect upon or refine her perception, continued failures of moral perception are

no longer manifestations of epistemic callousness, but of callousness due to weakness of

 

'25 Particularly when those “others” are people who are affected by a practitioner’s poor perception—like
patients and colleagues—such comments, like those at the beginning of the previous paragraph, ought to be
taken seriously, carefully considered, and acted upon in some way that demonstrates the practitioner’s
having taken them seriously and carefully considered them.

'26 Some forms of apathy could be categorized as evil too. If, for example, a person is homophobic, knows
she treats gay and straight people differently, doesn’t care how her views interfere with her discernment of
particulars about other people to whom she has professional responsibilities, or doesn’t care (or doesn’t
care enough) if gay people are ill-treated as a result of her callousness, her homophobia is disregard like
Caligula’s and a form of evil.

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the will. For those whose callousness is due to weakness of the will, poor practices of
perception will continue, reasons there are for acting will continue to be misconstrued,
and the needs and desert of that practitioner’s patients and colleagues will continue to go
unrecognized. Other colleagues with broader, more capacious, and more inclusive moral
perception might be able to pick up the slack of weak-willed calloused practitioners. But
if they can’t, patients get bad care and colleagues can resent calloused practitioners for
not doing what they ought to do: see well, learn to refine and maintain openness of moral
perception, respond to reasons that there are, and not leave those moral reasons to be

acted upon by others.

In this chapter, I have argued for a conception of how moral agents can become
jaded over time. I’ve tried to show how institutional oppression in healthcare
organizations can situate professionals to suffer several different forms of moral damage.
I have applied an intemalist, cognititivist theory of moral motivation and aparticularist,
reasons holism view of moral reasons to show how moral motivational erosion can
transpire when practitioners respond to institutional oppression by reducing their
involvement in their work. I’ve argued that reducing involvement in professional
caregiving can prompt a practitioner to narrow her view of what she’s responsible for.
When a practitioner’s sense of responsibility narrows such that she’s not responding
when there are reasons for responding, her moral perception is damaged. When she
misapplies concepts of need and desert of in her construal of reasons, her damaged moral
perception is caused by callousness (due to ignorance or poor training, or to weakness of

the will). On an intemalist, cognitivist theory of moral motivation, a process of moral

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damage over time that results in faulty moral perception is a process of moral
motivational erosion.

With this understanding of how the process of j ading transpires, we can begin to
think more broadly about the effects jading has on entire healthcare professions, how
professions respond, whether those responses are adequate, and what else needs to be

done to resolve the problem of jading. These are the topics of Chapter Four.

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CHAPTER FOUR: J ADING IN HEALTHCARE PROFESSIONAL LIFE

I have argued for a moral philosophical understanding of jading as a gradual
process of moral damage and moral motivational erosion a practitioner suffers over time.
I have thus far focused mainly on how jading can affect individuals, but in this chapter, I
consider ways in which moral damage of jading ramifies more broadly. In Part One, I
argue that jading damages healthcare professions by eroding three things central to
healthcare professionalism: collegiality among practitioners and students, control over
defining the terms under which healthcare professions operate, and mentorship of young
practitioners in the practice of serving others well. These forms of damage to professions
perpetuate a vicious circle; as I’ll show, they are products of j ading and they
simultaneously foster jading by exacerbating conditions of institutional oppression and
inhibiting individual practitioners’ abilities to cultivate good moral perception and
macroscopic views of situations in which their moral agency is restricted.

Healthcare organizations and professions appear to have at least some awareness
of the problem of j ading and the damage it incurs. Evidence for this exists in the
narratives that have evolved as responses to individual practitioners’ and students’
becoming jaded and suffering moral damage. In Part Two, I examine what these
narratives say and do. I argue that these narratives exacerbate the problem of j ading
because they indict individual practitioners as sources of the problem of jading instead of
acknowledging that they are sufferers of it and they avoid the systemic nature of the
problem of j ading and institutional oppression that cultivates it. I call these narratives,

therefore, avoidance narratives. I argue for a view of how these stories endorse

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conditions of institutional oppression that generate infiltrated consciousness and
alienation.

In Part Three, I consider possible solutions to the problem of jading. I first ask the
question What do healthcare organizations owe students, practitioners, and patients? I
then propose that generating solutions to the problem of jading should begin by charting
the responsibilities of organizations. Specifically, I argue that institutions in which
students and young practitioners are educated and professionalized into healthcare have a
duty to teach good patterns of perception to students and young practitioners. I raise
several questions that can be used to assess the success of institutions in carrying out this
duty, and I suggest reforming current curricula to better integrate courses in ethics and
humanities such that students may refine their moral perception by being taught to
expand the scope of particulars by which they might be moved, but also to see
macroscopically. I also argue that charting the responsibilities of organizations to
ameliorate the problem of jading requires consideration of the roles of governments and
professions in advocating for professional caregivers and patients. I raise questions that
focus upon relationships among practitioners’ working conditions, patient safety, quality
of patient care, and alternative economic macrostructures of the system of healthcare.

Finally, in Part Four, I consider whether the jaded can be rejuvenated.

Part One: Damage to Healthcare Professions

As students become healthcare professionals, what else do they become? If what
I’ve argued so far is right, they can become jaded over time. I suggested in the last
chapter that entire healthcare professions can be harmed in the process of j ading too.

Professions are harmed, as I’ll argue here, because jading is corrosive to at least three

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important dimensions professionalism: collegiality, control over the terms under which
the profession operates, and mentorship of young members of professions in serving
others well.

Collegiality has to do with how professionals treat themselves, other
professionals, and students. Professionals and students who have suffered oppression and
one or several of the forms of moral damage I’ve discussed can be bitter and resentful
toward those with whom they work and those whom they serve. 127 Interestingly,
however, bitterness and resentment appear to be regarded as rites of passage in the
process of professionalization. Consider the following example of a medical student’s
experience with a veteran nurse.

I was doing a write-up in this patient’s chart, detailing a discussion the
attending physician and I had just had with a patient. This patient was
really flail and there had been some confirsion about whether the team
would do CPR if her heart stopped. We realized that no one had discussed
this with her, so we didn’t know what she wanted. After our discussion,
we learned that she wanted very much to be DNR if her heart stopped. So,
I was writing this up in the chart: that we had the discussion, that she
wanted to be DNR. I’m trying to be thorough and clear and do what I’m
supposed to do, right? But, this was my first rotation and my first time
writing anything in a chart, so it’s taking me a little longer than it takes
others, I suppose. Well, this nurse sees me hovering over the chart trying
to put my words together, and she says, with this mock surprise, “Oh, my!
Writing in the chart, are we? Actually attempting to communicate with
those of us who do the hour-to-hour care! It’s so cute to see the young
ones trying to be nice. Thank you, dear. Now, run along with the doctors.
I’ll take care of this in the chart and make sure it gets done right.” I was
really embarrassed. I think she thought I was trying to insult her or
something. I didn’t know what to do, so I just apologized, signed the chart
note, and left.

This example reveals a couple of things about how collegiality among physicians and

nurses has been damaged over time. Furthermore, when collegiality has eroded, in cases

 

'27 I do not claim here that bitterness and resentment can only come flom jading or that jading is the only
thing that can damage collegiality, but only that bitterness and resentment are two things that jading can
spawn.

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like this one, professionals and students are ensnared in a loop of perpetual moral
damage, a vicious circle. Bitterness and resentment is damage wrought by jading, but it
also generates jading. Damaged collegiality draws upon practitioners’ oppression and
their powerlessness, pain, frustration, anger, and callousness; it is well fed by tension
among practitioners and students (and patients) pitted against one another. Worse,
without a macroscopic view of cases like this one, practitioners and students won’t see
that working conditions in healthcare organizations actually promote conflict among
them. So, they won’t recognize or resist the forces in their work environment that pit
them against each other; they’ll stay stuck in this loop and they’ll stay vulnerable to
suffering continued damage.

In addition to perpetuating a vicious circle of moral damage, jading as an informal
rite of passage in healthcare professionalism is a seriously dysfunctional model of
professionalism. This particular episode shows, for example, how dysfunctionalism in
nurse-physician relationships are re-enacted in nurse-medical student relationships. The
nurse conceives of herself as someone who’s expected to make up for the errors of
physicians, and she seems clearly to resent it. The bitter, resentful nurse seems to treat the
medical student the way she has been treated by physicians. She belittles the medical
student, for example, by calling her “cute” and a “young one.” The medical student, upon
receipt of her bitterness, conceives herself as having done something wrong and as
someone predestined to be an insulting screw-up in the eyes of fellow professionals,
despite her intentions and actions in the future.

Damage to collegiality is perpetuated because these dysfirnctional relationships

are endorsed as normal when jading is seen as a rite of passage; the possibility that such

lll

dysfirnctionalism would or should be problematized is not even considered because they
are accepted as parts of standard (even if informal) professionalization. Over time,
professionals are taught to internalize these dysfunctional forms of interacting with
fellow professionals; bitterness and resentment then become occupational dispositions
that can guide habits of poor perception throughout entire careers. Bitterness and
resentment breed poor habits of perception that are corrosive to collegiality because
practitioners’ abilities to relate to one another as similarly situated, similarly vulnerable
colleagues and to see each other in light of values such as charity, humility, and solidarity
diminish.

The value of charity, for example, supports collegiality because when a
practitioner views a colleague charitably, she sees others (generally) as those who,
probably like herself, are trying to do their best and care deeply about doing their best.
The value of humility promotes collegiality because it places importance upon the
practitioner’s ability to appreciate that one’s own susceptibility to making mistakes and
committing errors is no less that one’s colleagues’. The value of solidarity promotes
collegiality too, by supporting an understanding that you and your colleagues all
negotiate similar conditions of institutional oppression in healthcare organizations, and in
promoting this understanding, solidarity is a value that enables collective, organized
resistance to oppression.

Corrosion of solidarity has a particularly unique effect on a healthcare
professional’s perceptions of herself and her colleagues: when trapped in a double bind,
for example, she sees herself as alone. She may think, “Why does this always happen to

me? Everyone else seems to be dealing just fine.” Thinking herself alone and perceiving

112

that she’s trapped in a double bind because she ’s doing something wrong, she might fail
then to recognize the similarity of her experiences to those of her colleagues, who work
within the same oppressive organizational structures, and could be wondering the same
things about themselves. When professionals see themselves as alone, as not having
solidarity with colleagues, they don’t have power to unite and actively resist the forces
that place them in oppressive double binds. Alone, a practitioner tends to blame herself.
The value of solidarity facilitates collegiality because it can interfere with conscientious
practitioners’ tendencies toward self-blame, it impedes infiltrated consciousness, and it
authorizes resistance. Organized with colleagues, a practitioner tends to recognize that
the problem is one flom which she and others suffer, not one that she created. As a group,
as a critical mass of individuals uniquely skilled and not easily replaced, they can resist
the implementation of decisions and policies that produce and maintain their oppression,
and resist restrictions on their fleedom to act as they’re motivated to act.

When collegiality among practitioners is damaged such that they do not view each
other with charity, humility, and solidarity, young practitioners are especially vulnerable
for three reasons: they are just beginning their process of socialization into healthcare
practice, they may be particularly eager to internalize patterns of perception that are
accepted parts of that socialization, and their youth often corresponds to their being ill-
equipped to recognize dysfunctional patterns of relating to colleagues or to their abilities
to be critical of them. Even if students and young practitioners do recognize parts of their
socialization as dysfunctional and are critical of them, they are also particularly ill-
equipped to resist or change them because they have little power and authority, and

they’re taught to accept powerlessness as proper and normal. Furthermore, they are

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vulnerable to losses if they resist, try to assert their humanity, or reject their debased
status. If perceived by their mentors as uncooperative or unwilling to be professionalized
as those mentors were professionalized (even if they were professionalized poorly or
suffered)‘28, they are labeled “unprofessional,” “lazy,” and perhaps, “noncompliant.”
When students and young practitioners learn dysfunctional ways of interacting

with one another and poor habits of perception, they can also learn dysfunctional ways of
seeing their own responsibilities as professionals. This too has obvious corrosive affects
on healthcare professionalism. For example, the nurse in the above case belittles the
medical student by showing that she has very low expectations for her. Low expectations
reveal tendencies of underestimation; for a person who cares deeply about being seen by
colleagues as someone who cares and wants to do well and right, to be underestimated is
to suffer a form of humiliation. This nurse seems to imply that when the medical student
learns how she’s supposed to act, she’ll know she’s not expected to communicate with
nurses by making clear, thorough notes in the chart, and that she’s not expected to really
care. This medical student characterized her experience of an interesting tension: senior
healthcare professionals’ tended to underestimate her devotion and sense of responsibility
while simultaneously chiding her for having a more robust sense of responsibility than
they did:

I can’t tell you the number of times nurses and docs made fun of me for

doing what I thought I was supposed to be doing. When I’m trying to be

clear and thorough, they say things like, “Oh, I used to do that when I was
young” or “You’re still young.” It’s like my sense of responsibility is

 

'28 The quip, “I went through it, so you should too,” is often relayed to students who question their rites of
passage. This appears to be a variation of the “Are You Tough Enough?” avoidance narrative, which I will
discuss in the next section. For now, however, I suggest that, given the problem of jading, the fact that one
person “went through it” may very well be a good reason against having another person go through the
same thing.

114

something I’m supposed to grow out of. It’s like, if you’re not jaded and
cutting comers, they think you don’t know what you’re doing.

Perhaps because they have been learning the profession only a short time, students have
suffered less moral damage; they seem to be resented for having more of what veteran
practitioners could see themselves as having lost: self-respect. This student is chided
simply for being young, and ridiculed for not having endured the rites of passage endured
by veterans . . . yet.

When collegiality erodes and relationships and habits of perception among
professionals and students are dysfunctional, other dimensions of professionalism
deteriorate too, particularly the control healthcare professionals have over the terms under
which daily work of the profession operates. Rushing practitioners to see too many

’29, and pressing residents to work 80-hour

patients per hour, understaffing departments
work weeks are features of institutionally oppressive working conditions that come flom
over-emphasis upon profit-oriented values and under-emphasis upon values of moral
responsiveness to others. Under such conditions, practitioners do not have time to
actively engage with and reflect upon their work, and they can become alienated. When
they are alienated, who they are divorces over time flom what they do, they become less
invested in what they do and less expressive of caring moral responsiveness.
Furthermore, without active engagement with and reflection upon their work,

practitioners are unlikely to recognize when and how much they are mediators of others’

decisions.

 

'29 Understaffed departments appears to be another part of the vicious circle of damage to healthcare
professions, with respect to the cmrent shortage of nurses throughout the country. The shortage contributes
to understaffing, the understaffing contributes to individuals being overworked, and the fact that nurses are
overworked makes it difficult to recruit new nurses into the profession, which perpetuates the shortage of
nurses. The same vicious circle appears to play out in another problem: rural and urban clinics are
understaffed and inadequately equipped, but suburban healthcare sites continue to succeed and add new and
varied services.

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For example, physicians are frequently ignorant of their roles in exchanges
between the organizations for which they work and pharmaceutical companies that
contract with them for, among other things, access to “prescribers.” Organizations secure
the benefit of including particular pharmaceutical products in prescription forrnularies
and pharmaceutical companies—while appearing to physicians to be offering “flee”
lunches, dinners, pens, sticky-note pads of paper, or golf outings—pay organizations to
allow them access to physicians at Grand Rounds and other venues typically reserved for
formal teaching.

How organizations and pharmaceutical companies do business reveals how both
have morally degrading views of physicians as mediators. To pharmaceutical companies,
for example, physicians are viewed as executors of prescriptions, human billboards upon
which logo-donning pens and tags can be attached, and as authorities who can generate
“consumers’” trust and prescribers’ loyalties. To the organization, physicians are viewed
as one kind of currency in a larger exchange with a pharmaceutical company. But, the
physician may not recognize how she is viewed in these degraded terms. Or, she doesn’t
mind so much that she is viewed in those terms or she doesn’t think those terms are
degrading at all. The physician might see herself as someone whose alliance is courted.
After all, she gets a flee stethoscope, she’s treated to lunch, she gets a few “flee” samples
to give her patients, she gets “gifts” that are easy to enjoy and immediately enjoyable.
Furthermore, she’ll take that stethoscope because it’s convenient and she’ll eat that lunch
because she’s hungry. But she might not recognize convenience and hunger as two
important features of a compelling invitation to participate, legitimate, and mediate a

lucrative exchange and she might not recognize that, flom the perspective of a

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pharmaceutical company that spends and gains millions on advertising, her alliance can
be purchased quite cheaply. Given her important role as prescriber, she benefits
comparatively meagerly, and her patients benefit even less. Microscopically, the
physician appears to be an autonomous (not co-opted) decision-maker who knows very
well how to and what to prescribe for patients, and she could appear as such to her
patients too. Macroscopically, however, she is a mediator of others’ decisions executed at
the organizational level, one at which she’s probably not invited to participate. She does
not take part in negotiating the terms of which prescribing behaviors she’ll be rewarded
or penalized for or what forms those rewards and penalties will take. Instead, she’s
relatively powerless; she can choose only whether to take what they’re giving.

If a professional is so alienated that he does not or can not recognize
organizations’ and pharmaceutical companies’ views of him as a mediator, he also will
not recognize himself as co-opted or his identity as infiltrated. From the microscopic
perspective, he appears to himself to be perfomling his functions rather well, and maybe
rather enjoying it too. He does not see himself as committing wrong to others or himself.
This is part of why it is incredibly difficult to convince doctors that taking apparent gifts
flom pharmaceutical companies is wrong; they don’t see their participation in accepting
apparent gifts as banning themselves or their patients, they see their participation as part
of what they do when they’re functioning as they’re supposed to. They don’t see,
however, that they flequently function as mediators. In fact, professionals can often
appear to be insulted, and they become angry, when an attempt is made to get them to see
their roles as mediators (not as authoritative decision-makers) when they interact with

pharmaceutical companies. This further sublimates the problem that, macroscopically, the

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definition of what it means to function in healthcare organizations has been gradually
changed over time to meet the needs of companies, not patients, and not professionals
who serve them.

When alienation is widespread throughout professions, professions are less
powerful advocates for their members, less capable of defining the terms of patient care,
and less capable of changing unacceptable working conditions. The healthcare
professions become less capable of advocating for the values of those professions if
individual professionals are alienated flom themselves and flom one another.130 Also,
healthcare professions become less capable of recognizing policies and norms in
organizational structures that undermine professional values and the abilities of
individual professionals to endorse those values. When practitioners are alienated,
healthcare organizations are more flee to stray further out of touch with the traditional
values (beneficence and compassion, for example) of healthcare professions and many
individual healthcare professionals, exacerbating the burden on individual practitioners to
negotiate conflicts among values of their professions and those of the businesses that
employ them. When practitioners are alienated, professions can lose control over the
terms of operation of their profession without knowing it. Or, worse, professions can lose

control over the terms of operation of their profession, know it, and either not admit their

 

'30 One study, for example, exanrines how nurses become less involved in resolving ethical dilemmas when
they feel that they “do not have the autonomy and organizational influence necessary to carry out their
professional responsibilities for patients” (5). See Penticuff and Walden.

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complicity in doing wrong131 or be so co-opted and steeped in the problem that they have
too much to lose132 by trying to stop it.

In addition to being corrosive to collegiality and corrosive to professions’ abilities
to control how healthcare professions operate, jading is also corrosive to professionalism
because it interferes with individual professionals’ abilities to be good mentors of what it
means to serve others well. Practitioners who have significantly reduced the degree to
which they see the sense of moral responsiveness to others as importantly and centrally
constitutive of their identities are not good models to young professionals of what it
means to be collegially and actively engaged in service to others who are vulnerable,
sick, and suffering. Earlier in this chapter, I used an example, which illustrated that when
jading is modeled as a rite of passage in healthcare professionalization, a sense of
responsibility is seen as a mark of naiveté and incompetence. Because part of the moral
damage of jading is that practitioners reconceive their responsibilities and duties toward
others, such that they see themselves as responsible for less and owing others less, such
damage can compromise patient care, compromise how individual professionals relate to
patients, and compromise the public’s image of healthcare professions. For example,
healthcare professions acquire reputations for harboring members that are jaded, aloof,
arrogant, and unresponsive, and patients learn that it’s too much to ask for the time and
attention of overworked professionals.

If young professionals learn how to be morally responsive flom jaded mentors,

they learn narrowness of moral perception, they learn exclusive rather than inclusive

 

’3 ' See Carl Elliott’s “Pharma Goes to the Laundry: Public Relations and the Business of Medical
Education” in The Hastings Center Report 34(5): 18-23, September-October 2004.

'32 For example, some institutions have so much to lose by cutting off relationships with pharmaceutical
companies that entire departments’ functioning (including patient care in some cases) would be seriously
hampered by the loss of pharmaceutical companies’ funding.

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ways of applying concepts of desert and need, they learn to miss or misconstrue morally
relevant particulars. An instance of how narrowness of perception is taught, to young
physicians in particular, is when attending physicians model an increasingly pervasive
kind of practice of healthcare, legalistic practice. Legalistic practice happens when a
practitioner does an action or series of action she knows is unlikely to benefit her patient
or an action she knows she is unlikely to learn something new about how to help her
patient, but she does that action anyway out of a sense that doing it will make her appear
“thorough” and “covered” flom an imagined legal point of view. This kind of practice
models habits of perception that come flom fear. Fear can disrupt the normal connection
between perception and motivation because fear narrows moral perception. That is,
because practitioners are aflaid of being sued and because they are taught over time to be
aflaid of being sued, they come to view their patients as threats. This narrows moral
perception by drawing the practitioner’s gaze to herself, drawing her concern toward
protecting herself such that what patients need and deserve easily falls outside the scope
of what she will recognize as a reason to respond to another person. When a practitioner
practices legalistically, the source of her motivation to act is fear, not the particulars of
another person’s suffering or illness. This is not to say that practitioners ought never be
concerned about being sued, but simply to reveal how legalistic practice shifts and
narrows practitioners’ moral perception, and also to problematize the zeal with which
legalistic practice is taught to young practitioners without considering those
consequences. After all, narrowed moral perception itself is a moral liability and could

fester into a legal one.

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Open, capacious, inclusive moral perception enables practitioners to field the
information they need to treat patients well, to make good judgments, and to cultivate
good relationships with patients. Practitioners good at moral perception cultivate the best
opportunities to be capable, effective healers who are guided by what they think is most
important to responding to a person with care. Practitioners motivated by fear, however,
merely mediate others’ views (often views of those who are not healthcare professionals,
but attorneys whose client is not a patient or a practitioner, but an organization) of what’s
important. The fear that motivates legalistic practices of perception renders practitioners
functionaries; this fear is so powerfirl in some cases that it renders some of them slaves.

So far in this chapter, I have argued that jading damages healthcare professions by
eroding collegiality among practitioners and students, the control professions have over
defining the terms under which they operate, and professions’ abilities to mentor young
practitioners in the practice of serving others well. But, healthcare organizations and
professions appear to already know about the problem of j ading. Perhaps you’ve heard
the stories?

Part Two: Avoidance Narratives
In this section, I explain and analyze stories that have evolved in the “hidden”133

1””4 curriculum of healthcare education and professionalization. These stories

or “inforrna
attempt to address moral damage practitioners suffer in their socialization processes. But,
as I’ll argue, they represent the view that j ading happens because there’s something

wrong with an individual practitioner rather than the system in which she works. These

stories have been and continue to be promulgated throughout healthcare organizations

 

133 See Coulehan and Williams.
'3’ See Hundert, Hafferty, and Christakis.

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and schools. But, as part of informal curricula, these stories are not explicitly
acknowledged as parts of professionalization, and therefore not subject to formal
processes of evaluation used to scrutinize and revise content of formal curricula in
healthcare education and professionalization. These stories, thus, easily remain invisible,
as does the harm they do. Here, I try to render these stories visible, expose how they
misrepresent what’s really going on with the problem of jading in the context of
healthcare, and reveal how these misrepresentations promote institutional oppression and
exacerbate moral damage among healthcare professionals.

Concisely, the most pervasive feature of these misrepresentational stories, which I
call avoidance narratives, is the view that the problem of j ading is a problem generated
by individuals. Avoidance narratives endorse the view that when an individual
practitioner suffers in the work environment, it is because there’s something wrong with
him or with what he’s doing or with what he’s not doing; it is his fault. Avoidance
narratives represent other oppressive views of practitioners too. For example, these
stories promote the view that individual practitioners should resign themselves to the
conditions in which they work and that practitioners ought to stay “in their places” as
mediators of policies that endorse profit-oriented values more than they endorse values of
moral responsiveness to others.

Avoidance narratives’ focus upon faults in individuals functions to render the
pervasive, systemic nature of institutional oppression and the moral damage oppression
incurs over time invisible. These stories effectively avoid attributing to organizations
(insurance and pharmaceutical companies, professional schools, hospitals, clinics, for

example) and governments (federal, state, and local, for example) their share of

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responsibility for moral damage and moral motivational erosion of professional
caregivers. As I’ll show in my analysis of different kinds of avoidance narratives, these
stories also assume that working conditions in healthcare organizations are normal,
acceptable, desirable, and beneficial to students and young practitioners who are learning
their professions and that policies and values of healthcare organizations and
governments generally work well to promote the interests of practitioners and patients.

In her article, “Recapturing the Soul of Medicine,” Rachel Naomi Remen
emphasizes the importance of preserving meaning and a commitment to service in the
practice of medicine. She includes a brief story about a doctor who suddenly experiences
an epiphany about his work and his relationship to it. Upon delivering a baby girl, “he felt
a familiar sense of satisfaction at his own competence,”13S but this familiarity was also
accompanied by surprise. Remen characterizes this surprise as follows: “He feels
changed by this moment. In that flash of recognition, he felt years of cynicism and
fatigue fall away and remembered why he had chosen this work in the first place. As he
put it, ‘It all suddenly seemed worth it?”136

Remen does well to draw attention to positive experiences that healthcare
professionals enjoy in their work. Yet, we do well to remain critical of the ways these
experiences are represented in this story and ask whether one moment can really melt
away years of cynicism and fatigue, particularly if cynicism and fatigue are sequelae of

jading over time. This is not to deny that experiences like facilitating the birth of a child

are truly meaningful, but to emphasize that we must recognize that this “It all suddenly

 

"5 Remen, 5.
'36 Remen, 5.

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seemed worth it” story is a misrepresentation of the problem of jading that has all the
symptoms of an avoidance narrative.

Even supposing this story is a true representation of how one moment can make
years of drudgery ‘Vvorth it,” this problem remains: Why should a practitioner have to
endure years of drudgery just to experience one moment of “worth it?” This story
misrepresents the problem of jading subtly and effectively by misrepresenting the kind of
thing a career is: this story promotes the assumption that a career is a sum of the worth of
particular ends. But, a career is not a linear sum of the worth of a day’s work; a richer
conception of what a career is accounts for what it means to a moral agent for her to
engage over time in the pursuit of a career and its ends. By representing a career as the
kind of thing that can be made worthy by one good day’s work, the problem of jading is
apparently absorbed, rendered invisible. That is, there are no concepts in the story that
enable an account of the value over time of a career, and therefore, the value of a career
over time never appears as something that is at stake. As a result, a practitioner who
practices a career in healthcare cannot be represented as a person significantly vulnerable
to damage over the time of that career; the problem of jading appears nonexistent.

It may certainly be the case, as Remen suggests, that healthcare professionals

..137 and “renew [a] sense of calling.”138 But, these suggestions also

need to “find meaning
misrepresent what the problem is for healthcare professionals. That is, the “It all suddenly
seemed worth it” story suggests that practitioners somehow fail because they just aren’t

trying hard enough to look for meaning or renewal. However, if what I’ve argued

throughout this work is correct, the problem is not that healthcare professionals aren’t

 

"7 Remen, 4.
133 Remen, 5.

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‘

looking to have meaningful experiences or careers; the problem is that they are steeped in
an environment that endorses policies and values that cultivate powerlessness, loss of
self-respect, alienation, and callousness more than it cultivates opportunities for
meaningful interactions among professionals, colleagues, and patients. Additionally,
though they have important roles in shaping the work environments of healthcare
professionals, organizations and governments are conspicuously absent flom this story.
Their absence creates the illusion that they have no responsibility for pervasive
institutional oppression that makes generating meaning in healthcare practice more
difficult that it should be.

In addition to the “It all suddenly seemed worth it” story, there are at least three
other avoidance narratives that ought to be rejected too. The second is the “You’re not
jaded, you’re just disillusioned” story, which goes like this: applicants to professional
schools are disillusioned about what it is to practice professional caregiving and they
should be screened better during the admissions process. Reasons this story
misrepresents the problem of j ading have already been discussed in Chapter One. Recall
that I argued that disillusionment is an epistemic problem and jading is a moral one. This
story misrepresents an ethical problem, jading, as an epistemic one, disillusionment. This
misrepresentation is serious because it invites the hearer to think of the problem of jading
in wrong, oversimplified terms—that is, only in the terms of what a person knows or
doesn’t know. Disillusionment can be a real problem, but as I’ve argued, it is not problem
of jading. Mistaking jading for disillusionment, as this avoidance narrative does, renders

the sources of the problem of jading in the context of healthcare, institutional oppression,

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invisible and leaves only individual practitioners to blame, creating the illusion that
jading is a simple problem about a person who didn’t know enough about what to expect.

A third avoidance narrative is the “Good gone bad” story, and it gets played on
these variations: professionals lose their ideals, professionals become less virtuous
people, professionals’ characters go bad, professionals just don’t care anymore‘”. Each
of these notions of what happens to the characters of healthcare professionals should be
discredited because they are forms of a reasoning error called victim-blaming. This
reasoning error is one of the hallmark features of an avoidance narrative, and it’s worth
more attention here because victirn-blaming isn’t just a misleading reasoning error; it’s a
product and tool of institutional oppression.

The “Good gone bad” story is, perhaps, the most insidious avoidance narrative
because it does not merely misrepresent the problem of j ading. This story works in
tandem with erosion of the value of solidarity, which I discussed in the first part of this
chapter, and actually generates microscopic vision, infiltrated consciousness, and
alienation, which I discussed in the Part Two of Chapter Three. It does so by exploiting
conscientious individuals’ tendencies to blame themselves and by inviting powerless,
hurt, angry, flustrated, co-opted, alienated, and disrespected individuals, who are pitted

against one another, to blame themselves and each other for their suffering. The “Good

 

'39 This particular charge, that professionals become apathetic, can be addressed in terms similar to those I
used in Chapter Two to defend an intemalist view of how moral motivation works against the extemalist’s
claim that moral agents can see moral reasons to act and yet are not motivated to act. The extemalist, for
example, may claim that healthcare professionals’ apathy, their not caring to act, is a form of seeing a
reason to act yet not being motivated to act. If the extemalist is right that a professional’s being apathetic
means she’s not motivated to act at all, then apathy would be evidence that moral perception is insufficient
to account for moral motivation. However, if the intemalist view I defended in Chapter Two is right, the
intemalist responds to the extemalist’s charge (that a professional is not motivated at all when she’s
apathetic) by showing that apathy could be an instance of poor perception. Restoring good perception then,
would restore normal moral motivation. An apathetic practitioner could also just not be motivated
forcefully enough to act, but, as I argued in Chapter Two, this is a case of weakness of the will, which
simply suggests that moral motivation is not an “all-or-none” phenomenon, but a phenomenon best
characterized as graded, occurring in degrees of forcefulness.

126

gone ba ” story exploits conscientious individuals’ tendencies to feel guilty, punish
themselves, and alienate themselves flom others because it invites a practitioner to take
up reduced (and often inaccurate) conceptions of himself: I ’m not virtuous anymore, I’m
not a good nurse, I’m not a good physician, I ’m not a good enough person for this sort of
work.

When practitioners focus only upon themselves and see themselves as reduced or
as agents of wrong-doing, their views of what’s happening are likely to stay microscopic.
That is, while microscopic vision keeps alienated professionals preoccupied with self-
loathing and self-blame, a macroscopic view of what’s going on—that they’re suffering,
damaged, and jaded because they’re oppressed—is difficult to acquire. Not actively
engaged in the activities of their work or with colleagues, not able to recognize co-
workers as similarly suffering and similarly reduced, alienated practitioners are not likely
to unite to organize resistance to the policies and norms that keep them oppressed, make
them jaded, and tell them they’re to blame for it. As long as those who are suffering self-
blame suffer alone, the “Good gone bad” narrative does its work: it quells resistance.

The last avoidance narrative is the old “Are you tough enough?” story, also
known as the “Stress is good for you” or the “That which does not kill you makes you
stronger” story. It too ought to be rejected. This story misrepresents the problem of j ading
by simply denying that jading is damaging. It says: jading is not a harm at all, rather,
jading shows that practitioners are tough and can handle the stresses of professional
caregiving. “Jaded ” is a hard-won patina that announces, “I ’ve seen it all. There ’3 no
curve you can throw that I can ’t hit. ” Harsh working conditions make good

practitioners; those who can ’t handle it should get out of the field. This story also invites

127

a damaged practitioner to think of himself in reduced terms: I’m just not tough enough to
do this sort of work.

As I’ve argued throughout Chapter Three, however, being jaded does not make
practitioners smarter, more incisive, or more acutely perceptive; rather, to be jaded is to
have suffered, to have one’s perception damaged, and to have one’s motivation to
respond to others with care eroded. There is no good evidence that establishes that
depriving people of sleepm, making people work eighty hours per week (even on
average)”’, understaffing floors and departments, or placing students in situations they’re
not prepared to negotiate actually improves professionals’ abilities to be better caregivers
or improves the care patients receive. These conditions hamper professionals’ abilities to
respond with care to patients and they incur moral damage to individual practitioners and
their professions. And, indeed . . . some of those who can ’t handle it DO get out of the
field, but the field of healthcare does not appear to be better off when they leave. . . and

neither do patients.

 

140 An article in the October 28, 2004 issue of The New England Journal of Medicine adds even more
evidence in support of the claim that residents’ sleeplessness jeopardizes patients’ safety. A report on All
Things Considered during the same week showcased this report. Interestingly, a statement sounding very
much like a possible variation on the “Are You Tough Enough?” avoidance narrative was voiced in support
of not having residents work fixed shifts with limited hours. This statement expressed the idea that having
residents work in shifts inflinges upon caregivers’ abilities to sustain continuity of care. Without looking to
the literature on the nature or frequency of errors generated by shift transitions, I’m inclined to suggest that
nurses have modeled shift work rather well, with respect to the quality of patient care and patient safety,
over several years. Additionally, perhaps the question should be posed to patients: Whom would you prefer
to be writing orders for your care: a physician familiar with your case on her 30'" hour or one you ’ve not
seen before on her I " hour? In raising this question, I may be presenting a false dichotomy, and I don’t
suggest that this question has an easy answer, but I do suggest that how patients consider it ought to be
taken into account.

141 Even with the recent mandate flom the ACGME restricting organizations flom pressing residents to
work more than 80 hours per week, this is not enough to end institutional oppression of healthcare
professionals. It is an improvement, but only a small one that is yet another piecemeal revision to a system
of education and professionalization, which I’ve argued can be harmful and which I will also suggest, in the
third section of this chapter, may be obsolete. Mill workers, garment workers, and other tradespersons
earned the right to a 40-hour work week in the labor movements of the 19303; professionals who take care
of the sick and vulnerable are far behind them in terms of protecting what has been established as
foundational fair labor practice standards.

128

So long as avoidance narratives persist in the shadow curricula of healthcare
education and professionalization, damage suffered by practitioners will remain an
invisible, acceptable, rite of passage endorsed by healthcare professions and
organizations. Recognizing these stories as misrepresentations that mask the
responsibilities of organizations and governments, mask their roles in institutional
oppression of healthcare professionals, and mask professions’ and individual
practitioners’ needs to advocate for themselves and their patients can be seen as a first
step to resolving, over time, the problem of j ading.

Part Three: Generating Solutions to the Problem offJading

In Part Two of Chapter Three, I canvassed three things we could ask professionals
who are powerless in their work environment: Why not change jobs? My not change
professions? Why not reduce the standards of your conception of the kind of professional
you can be? In addition to these, there is another important question that remains unasked
about how to relieve practitioners’ powerlessness and suffering of moral damage as they
work in healthcare organizations. This question needs closer attention: Why not change
the healthcare work environment?

Avoidance narratives put the spotlight on the first three questions, those that focus
upon individuals’ responses to institutional oppression and moral damage. But, as I’ve
tried to show in Part Two of Chapter Three, these questions are the wrong ones to ask
because they focus on individual practitioners and not how the systems in which they
work generate damage. Furthermore, as I’ve tried to show in Part Two of this chapter,
avoidance narratives need to be rejected because they render the systemic nature of the

problem of jading invisible. To seriously and genuinely address the problem of jading we

129

need to do the hard work of reforming the healthcare work environment, and we have to
hold organizations and governments significantly responsible for problematizing existing
policies and norms that are oppressive and sources of damage, supporting the cultivation
of healthier policies and norms, and, as I’ll discuss next, delivering on what they owe
students and practitioners. After all, who benefits most flom keeping things the way they
are?

If what I’ve argued throughout this work is right, practitioners and patients
certainly don’t benefit enough flom the current organizational structure of the healthcare
workplace. I propose a starting point for thinking about how to change it for the better.
First, we should ask What do healthcare organizations owe students of the healthcare
professions and young practitioners? Much has been said in bioethics, in literature on
professionalism, and in the oaths and codes of nursing, medicine, and social work about
what professionals owe others. But, what healthcare organizations owe those whom they
teach, employ, and serve receives little of the needed focused and sustained attention;
their responsibilities must begin to be charted. First, I suggest that we consider the duty
of institutions of healthcare education to teach good patterns of perception.

As I argued in Section Three of Chapter Two, one way good patterns of
perception are taught is by modeling. This suggests that a first step in designing curricula
that teach good moral perception is to eliminate practices of disrespect and disregard of
students. Much evidence suggests that “medical training often wounds and diminishes”142

students learning to become professional caregivers. About this, Judith Andre asks What

can be done to lessen the pain of medical education? ’43 Sensibly, she suggests that

 

”2 Remen, 4-5.
"3 Andre 2002, 151.

130

insulting, humiliating, yelling at, and depriving students of sleep need to be eliminated.
Furthermore, these practices need to be recognized for what they are: abusive and
oppressive. At the very least, healthcare organizations owe students accountability and
assurance that these practices are unacceptable and unnecessary and that those mentors
who model such practices as acceptable or necessary are substandard practitioners whose
methods are not tolerable and ought not be tolerated. Obviously, those directly
responsible for abusing students should be disciplined, and policies that enable and
endorse abuse and oppression or try to render abuse invisible should be rejected too.
Establishing this minimum threshold of accountability, which would be a first
step in charting organizations’ and governments’ responsibilities to marginalize abusive
mentors and to reject policies that perpetuate oppression, acknowledges that healthcare
work environments situate how practices and habits of moral perception get cultivated.
Organizations that educate healthcare professionals should also consider the following
questions to consider how the content of their formal and informal curricula shape
practices and habits of perception. These questions focus in particular upon evaluating
how well formal and informal curricula cultivate students’ reflection about the kinds of
practitioners they want to be and how well they see different fields of particulars.
Do students see the skills they’re taught as useful?
Are students protected flom being placed in situations that they are not yet
skilled or competent to negotiate?
Are students allowed ample time to be reflective about what it is they’re
doing with their careers?
Are students granted ample time to relate to and spend time with people,
outside the realm of professional education, who are significant to them?
What ought to be changed if students feel that their humanity is
undermined by their training?
Do students see their mentors modeling good patterns of perception?

Are mentors modeling behaviors of professional practice that students will
want to endorse in actions of their own?

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Do students receive guidance in assessing which kinds of particulars they
see well or poorly?

Do students receive guidance in how to refine their perception with
respect to certain fields of particulars to which they are insensitive?

Do formal curricula conflict with persisting shadow curricula?

One way institutions of healthcare education have tried to facilitate students’
cultivation of moral perception in recent years has been by integrating humanities courses
into biomedical sciences-dominated formal curricula. Opportunities to study ethics and
humanities have been added only piecemeal to current curricula, however, and as Carl
Elliott suggests, these have been inadequate for preparing young healthcare professionals
to recognize and address macroscopic problems in the current system of healthcare:

In America, we build shrines to technology in urban ghettos; we deify
medical specialists; we sue them mercilessly when they fail us; we
bewitch ourselves with magical instruments of diagnosis and therapy; we
devise an ingeniously brutal and degrading way to train our doctors and
charge them upwards of $100,000 for the privilege; we willfully ignore the
poor, and pay our doctors the highest incomes of any doctors in the
world—and then we try to correct the situation with an ethics consultation
service and a few hours of humanities in the medical curriculum? The
suggestion might be funny if it were not made with such sincerity.144
As mere supplements, ethics and humanities courses often do not get a big enough
portion of curricular time to demonstrate genuine, sincere attempts——by institutions of
graduate medical education, for example—to cultivate a particular kind of moral
perception, macroscopic vision.

Macroscopic vision is part of good moral perception because seeing
macroscopically enables students and practitioners to more accurately appreciate their
roles in the systems in which they work. As Elliott suggests, the current system of

healthcare education does not teach macroscopic vision well, in part, because it has not

effectively integrated the kinds of courses into curricula that can be effective in

 

‘“ Elliott, 22.

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cultivating a macroscopic view of the system of healthcare: ethics and humanities
courses145 . Study of ethics and humanities can cultivate students’ abilities to see
macroscopically because they focus upon critical reading, close examination of how
experiences and situations are represented and interpreted, and upon appreciating
multiple layers of complexity and multiple perspectives of what’s going on in a particular
case and what’s going on with systems in which it is situated. But, ethics and humanities
are usually only sparsely sprinkled atop curricula heavily laden with courses that promote
(and perhaps even demand) only focused, microscopic perception: anatomy,
pharmacology, and neurophysiology, for example.146 As a result of being so sparsely
integrated, ethics and humanities courses in medical schools, for example, are flequently
taught in ways far inferior to how they are taught to undergraduates.

That is, teachers of medical humanities courses are sometimes encouraged to
make readings and assignments in these courses short and not too “time-consuming.”
Teachers of medical humanities are sometimes encouraged not to underestimate medical
students’ unwillingness to engage thoughtfully with reading, writing, or thinking
critically. But these trends are problematic. This latter trend in particular perpetuates a
stereotype of medical students as uninterested in ethics and humanities, uncritical, and

sometimes uncaring; it does a disservice to medical students who are humanists and do

 

”5 This is not to say that ethics and humanities courses are the only kinds of courses that can cultivate
macroscopic vision. Courses in public health and epidemiology, for example, could do this too.

”6 Curricula that promote learning the biomedical sciences are influenced by the Flexner Report of 1910.
That these curricula are so representative of that old model could be an indication that it’s extremely
effective and useful, or, given the problem of jading, could be an indication that it’s obsolete and in need of
being revised to integrate courses that teach skills of moral perception, particularly macroscopic vision,
well. I do not suggest, of course, that the biomedical sciences are unimportant; surely students must learn
these sciences well to practice effectively. I do suggest, however, that they also need skills of moral
perception to practice effectively, and that courses that teach these skills are not well integrated into most
current curricula, and that there are better ways for institutions to carry out their duties to teach students to
see well.

133

want to engage thoughtfully in discussions of ethics, literature, or history and it does a
disservice to students who want to cultivate their skills of perception and reflect on how
these disciplines inform their practices. This trend also implicitly endorses an oppressive
and inaccurate vision of medical students as people who are not thinkers but functionaries
whose time is owned by people other than themselves, who learn to merely manipulate
and mediate medical technology and do what they’re told. Organizations that educate and
professionalize medical students and young practitioners owe them an education that
enables them to resist the stereotypes these trends propagate and to resist the limitations
those stereotypes can impose on their views of themselves, their views of what they’re
capable of, and their views of who they are and can be. Enabling students to resist those
stereotypes means teaching them how to cultivate macroscopic vision such that they can
begin to recognize when they’re being treated like or viewed as mediators by others and
when they’re being taught to see themselves as functionaries in the healthcare workplace.
Teaching ethics and humanities well not only can cultivate students’ macroscopic vision,
but also nourish their conceptions of themselves as and their abilities to become
thoughtful, engaged, humanitarian healers.

So far in this section, I have tried to how that, as we consider how the healthcare
workplace could be changed to eliminate oppression of healthcare professionals, we see
that healthcare organizations’ and governments’ responsibilities to healthcare
professionals and patients need to be charted. I’ve suggested that one important
responsibility to chart is what healthcare organizations owe students and practitioners as
they are professionalized. I’ve argued that they have duties to teach good moral

perception, particularly macroscopic vision. Additionally, we can ask another question to

134

help chart responsibilities in the system of healthcare: What roles ought professions and
governments assume in advocating for professional caregivers and patients? Within the
history of modern healthcare in the United States, processes of certification and licensure
had to be invoked to grab power and shares of the healthcare marketplace away flom
bone-setters, sellers of snake oils, and others. But the healthcare marketplace isn’t the
sole dominion of licensed practitioners anymore; with the exception of state or federally
funded facilities, its shares are primarily owned by profit and nonprofit corporations who
employ those practitioners.

As I argued in Chapter Three, corporations can significantly circumscribe the
scope of practitioners’ decision-making authority in ways that limit practitioners’ abilities
to act as they’re motivated to act and to act in their patients’ best interests. Corporations
can do this by imposing systems of rewards and penalties that force practitioners to
participate in promoting values of economic efficiency, whether it is by working sixteen-
hour days or by not informing a patient about a treatment that’s more costly for the
organization than some other treatment. Economic forces that drive (profit and nonprofit)
corporate healthcare toward efficiency are the same forces that can co-opt practitioners,
and make them jaded. So, as I suggested in Chapter Three, balance among profit-oriented
values and values of moral responsiveness to others is critical.

As I argued in Part Two of Chapter Three, practitioners are not well-situated to
resist forces that drive economic efficiency and endorse profit-oriented values, and they
have little or no time to assemble an inflastructure for resistance when they are still
pressed to work eighty-hour weeks and care for patients in understaffed departments.

This raises a number of issues as we consider what healthcare organizations owe

135

practitioners. But first, professions must acknowledge that their practitioners only rarely
own their own labor and that the conditions of deprivation and overwork result, in part,
flom the predominantly capitalist organizational macrostructure that drives healthcare as
a “market.” Under the business of managed care, doctors, nurses, and therapists are de
facto workers, and they have little or no control over capital, other resources, or how they
are allocated. Bureaucratization of health care service delivery has defined
responsibilities in terms of profit-oriented values. Re-aligning the moral weight of values
in healthcare, such that values of moral responsiveness to others and service to patients
are balanced well with profit-oriented values, requires professionals in healthcare to
identify themselves as needing to resist collectively and as uniquely powerful to carry out
such resistance: because of their exclusive possession of skills, they are not easily
replaceable and have significant negotiating power.

But, getting some clinicians to recognize themselves as compromised, co-opted,
or oppressed is difficult. This is, in large part, because practitioners, particularly
physicians, have not rooted out a prominent avoidance narrative. This avoidance
narrative renders invisible the fact that most physicians do not own their own labor or
have enough decision-making authority over the terms in which they are rewarded and
penalized and it promotes an obsolete view of physicians as still enjoying the same
professional autonomy that their predecessors enjoyed in the era before managed care and
formularies (that are designed, negotiated, and endorsed by corporations, not by
practitioners with everyday patient care responsibilities). Consider this following
variation on the “Good gone bad” avoidance narrative:

. . . [P]rofessionals cannot displace the moral failings of the professions
onto others—on society, other professions, government, economics, the

136

marketplace, and so on. No one can make the conscientious professional

do what she thinks is not in the interests of the patient or client. Can

anyone force [caregivers] to follow a policy damaging to their interests?"
If caregivers are moral agents with the fleedom and authority to align their professional
responsibilities, the answer to this question would be a resounding, “No!”

This selection invites a person to think that conscientious professionals cannot be
co-opted by the systems in which they work simply because they are conscientious.
However, as I’ve tried to show in Chapter Three, most caregivers inflequently contribute
to decisions about the conditions of operation that situate their professional choices, and
their interests and those of their patients are compromised all too often. Recall that part of
what I argued in Chapter Three is that professionals’ choices are not always truly their
own, no matter how conscientious or virtuous they are. The sooner students and
professionals reject avoidance narratives and learn to adopt macroscopic views148 of the
organizations in which they work and how they are placed within them, the sooner they
can recognize and organize collectively and actively to resist and change working
conditions, policies, and norms that compromise their abilities to act as they’re motivated
to act.

What sorts of changes should collective organized resistance be expected to
cultivate in healthcare as an alternative to the current system dominated by corporations
and corporate models of workplace efficiency? What kinds of economic macrostructures
are best for healthcare? Transitioning the United States healthcare system, for example,

flom a primarily capitalist multi-payer system of insurance companies and employers to a

 

147

Pellegrino and Thomasma, 157.

”8 For example, exercising students’ critical thinking skills and developing their abilities to better
recognize the social, political, economic, and moral dimensions of their work are things that ethics and
humanities courses, when well designed, can do very well.

137

primarily socialist single-payer system in which a government regulates what companies
can charge for services, pharmaceuticals, and other treatments may be a way in which
professions could gain more control over their working conditions149 and a way in which
all citizens have access to at least basic healthcare services. Government assumption of
significant responsibility for the healthcare coverage of citizens and for public health
could bring clearer definition to the scope of responsibilities of caregivers15 0, who would
be more like professionals engaged in civil service than like employees of corporations.
But, changing the macrostructure of healthcare organization does not necessarily
change oppressive working conditions in the system of healthcare that generate jading.
Greater government control over healthcare costs or government ownership of healthcare
systems doesn’t guarantee that working conditions will get better for healthcare
practitioners. Governments could still fail to fund or regulate healthcare properly, for
example, and practitioners could still be pressed to work long hours in understaffed
departments to keep the healthcare system afloat. Just as a single-payer system ought not
be assumed to be a panacea, corporations and those with corporate savvy ought not be
assumed to be necessarily unhelpful in making working conditions in healthcare

organizations better.

 

"9 Some hold the view that government regulation in healthcare would undermine professions’ control over
working conditions. I propose that a refrnement of this view may be helpful in considering whether
government regulations would help or hinder professions’ control over the working condition of their
members. That is, to say that government regulation in healthcare would undermine corporations ’ abilities
to influence how professions operate sounds more accurate to me. Some will think this is a good idea and
some will think it’s a bad idea. But, my point is that if government could regulate what pharmaceutical
companies can charge for drugs, for example, this could remove what I’ve just argued is a significant
source of healthcare professions’ susceptibility to being co-opted as mediators of pharmaceutical
advertising campaigns, and thereby restore professions’ abilities to be authoritative, trustworthy groups,
which comprise individual practitioner members that can (without having to negotiate conflicts of loyalties
or interests) safely, responsibly, and cost-effectively use pharmaceutical technology in the care of
vulnerable patients.

'50 Clarifying the scope of healthcare professionals’ responsibilities could be helpful in assessing whether
their self-conceptions, organizations’ expectations, and the public’s expectations of what healthcare
professionals do are reasonable and attainable.

138

Profit-oriented values, particularly cost-effectiveness, are important values in
healthcare service delivery; they just ought not be pursued overzealously at the expense
of healthcare professionals’ moral characters or patients’ well-being. Business people
with management acumen could contribute to cultivating a broader social perspective of
trends in how members of the public and professions relate to healthcare organizations.151
Organizational ethicists and those trained in business administration could contribute to
developing strategies for dealing with questions that require a macroscopic view of how
corporations, federal, state, and local governments, the public, and healthcare professions
must work together to resolve them. Such questions that could be taken up with this
multi-disciplinary approach, to more fully characterize what healthcare services are
valuable to professional caregivers and patients and what healthcare organizations owe
professional caregivers and patients, are these:

How can organizations be better structured to fairly and equitably
distribute moral and legal risk throughout an institution’s work
environment?

When are there relationships between j ading and medical errors, which
incur moral and financial damage to organizations, professions,
individual practitioners, and patients?

Are recent trends of increasing public interest in alternative healing related
to patients’ perceptions of practitioners as jaded?

So far, I’ve canvassed a few of the questions and issues that are raised when we
consider how to chart healthcare organizations’ and governments’ responsibilities to

students and practitioners, citizens and patients. Regardless of the macro-level economic

principles that drive systems of healthcare in the future, healthcare institutions have

 

'5 ' Furthermore, managed care organizations could market different models of healthcare service delivery,
and examine which forms work best in different populations. Recently, the American Academy of Family
Physicians assembled task forces to consider alternative models of family medicine practice. Their The
Future of Family Medicine Report, distributed in early April 2004, proposed one such model, which they
called a “medical home.” It’s possible that managed care companies could market a model such as this one,
or a different one, just as they market present forms of service delivery.

139

duties to grant nurses, physicians, and other healthcare professionals the most significant
share of authority and power in deciding what’s worth doing in their professional work of
responding morally to patients who deserve and need their services. My emphasis thus far
upon organizational reform may at first appear to neglect the roles individual
professionals can assume in addressing the problem of jading. To address this concern, I
refer once again to the work of the sociologist Cary Cherniss.

Cherniss’s study of professionals’ responses to burnout, which I drew upon in
Chapter Three, suggests that some individuals found “antidotes” to burnout. Each
antidote had to do with an individual’s ability to cultivate meaning in her work. Cherniss
described cultivation of meaning as a person’s feeling like she makes a significant
impact, ability to be intellectually challenged in doing what she does, ability to negotiate
change and avoid boredom, and her ability to cultivate special interests in professional
activities.152 Cherniss observed in his study “five who prevailed,”153 and each of these
people prevailed because of their ability to cultivate meaning in at least one of these
ways. What’s important about what Cherniss observed is that cultivating meaning
requires an individual to relate to her work environment, and individuals have most
positive relationships with their work environments when they enjoy autonomy,
administrative support, and supportive, stimulating relationships with colleaguesm

Cherniss’s work suggests that individuals respond to their work environment—an
individual-to-organization direction of fit. Certainly, I endorse the view that individuals

can work on their own to respond as best they can, and they ought to try to do so.

 

'52 These are discussed in Chapter 10 of Cherniss’s book.

'53 His observations of these five are in Chapter 9 of his book.

'5’ Cherniss defines autonomy as “fleedom flom” several things. He proceeds to list several ways in which
individual professionals’ autonomy is restricted. He also lists dimensions of administrative support on page
149 of his book.

140

Furthermore, as I argued in Chapter Two, caregivers’ capacity for moral perception must
be maintained as capacious and inclusive if they are going to see particulars there are to
be seen (and be properly motivated). So, practitioners have an obligation to maintain the
capaciousness of their moral perception. My emphasis upon organizations is intended to
point out, however, that organizations ought not be seen as having no responsibility for
how individuals respond to their work environments. There must be an organization-to-
individual direction of fit too—organizations should support and maintain work
environments that facilitate, not hamper, individual professionals’ abilities to respond
with care to each other and to patients.

This latter direction of fit model that I’ve called for here will need to be fought for
in institutions of healthcare education and service delivery. Individuals can strive to
cultivate meaning in their work and can develop dimensions of their identities outside of
their work to lead fulfilling lives. But, as I’ve argued, individuals are the sufferers of
j ading, not the generators of it. Individual professionals must acknowledge the systemic
nature of the problem of j ading and cease to blame themselves for problems generated in
an environment ripe for practitioners’ errors and neglect of patients. This is not to say that
individuals ought never be held accountable for poor practice, but to draw attention to the
fact that poor practice is situated in a context of broader systemic failures, and that those
who design and manage organizations must also be held accountable for those failures.
As I’ve argued here, generating solutions to the problem of jading means not only
understanding how individuals suffer and respond to damage wrought by institutional
oppression in healthcare; it means charting organizations’ responsibilities to change the

healthcare workplace for the better.

141

Section Four: Rejuvenating the Jaded?

In addition to considering how the problem of jading in healthcare organizations
can be resolved, another question remains about jading: Can practitioners who have
become jaded and suffered moral damage be rejuvenated? The description of j ading I’ve
sketched in this work and the moral theoretical understanding of j ading I’ve argued for in
this work substantiate the view that the jaded are made by oppressive forces in
institutions that harm even the most virtuous practitioners. But, it does not seem to follow
necessarily flom what I’ve argued that a person can become jaded only flom institutional
oppression or that an individual person will be rejuvenated when institutional oppression
is eliminated or that an individual person will be rejuvenated by removing herself flom
oppressive working conditions.

What seems, then, to be most pertinent is to ask this: What would constitute
rejuvenation in the life of an individual practitioner who has suffered the process of
jading? If rejuvenation is a matter of restoring or cultivating the ability to be motivated to
respond to reasons there are for responding to others with care, then my theory of j ading
seems to accommodate rejuvenation. That is, on this conception, rejuvenation is a certain
kind of repair to damaged moral perception. If my intemalist, cognitivist theory of how
moral motivation works normally is right and if it follows flom that theory, as I’ve
argued it has, that damaged moral perception is moral motivational erosion, then a jaded
practitioner could, at least according to this theory, be rejuvenated by learning to see
well, or by learning to see well again.

However, whether what is tenable in theory is tenable in practice is a matter of

how deeply a practitioner has been damaged by the process of becoming jaded. As I’ve

142

tried to show, moral damage endured in the process of becoming jaded takes place over
time. It seemsreasonable to think then, that if moral repair is possible, that it too will take
time—~perhaps a year, perhaps five or ten years, perhaps a career, perhaps a lifetime.
Even given such time, repairing moral damage is no easy fix. As I’ve tried to show, the
moral damage incurred in the process of j ading is not just damaged moral perception (and
I developed most fully a conception of only one kind of damage to moral perception, the
kind expressed by callousness). But, powerlessness, loss of self-respect, and alienation
are also forms of moral damage that can ramify broadly and deeply in the lives of
healthcare practitioners.

That is, moral damage can be damage to relationships and to families, not just to
individuals. The process of j ading over time and the moral damage suffered don’t have
finite durations either. Pain, humiliation, flustration, anger, loss of self-respect,
alienation, resentment, regret . . . How long do those last? Without casting doubt on the
possibilities of rejuvenation, we must not oversimplify moral damage wrought by
institutional oppression or underestimate the complexity of the project of moral repair of
people who’ve become jaded under those conditions. Ultimately, where moral repair
means learning to see well, this requires capaciousness of perception, sustenance of
beliefs in oneself as capable and effective, and sustenance of the belief that responding to
others morally is still worth doing. These three things that may not be easy for the

severely damaged to embrace, even if warily.

What I’ve offered here is a picture of how jading transpires and I have described a

family of concepts that are in play when we talk about what it means to become jaded.

143

I’ve tried to forge conceptual relationships among moral perception, moral motivation,
and action in individual moral agents. I’ve also tried to show how institutional oppression
cultivates damage to moral agents by supporting conditions in which their fleedom to act
as they’re motivated to act is restricted, their conceptions of what they’re responsible for
get altered, and their moral motivation is eroded. The distinctions I drew should be useful
in revealing more threads of inquiry for further scholarship and research to be taken up
by other philosophers, empirical researches, legal specialists, and professionals in

healthcare education.

144

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