Thoughts on Medical Ethics

On Power and Pride


Today scrolling through my twitter feed I came across this post by a registered nurse in the United States. I thought I might explain why I found it upsetting.

This attempt at humour (and a worryingly successful one considering how many times it has been retweeted) is not dissimilar to the jests of other healthcare workers in some regions. These EMS T-shirts also betray a dark attempt at humour which relies on suggesting malice or performing an act that is socially unacceptable as its punchline.

Standing back, one has to ask why healthcare workers in some disciplines and regions feel the need to use this type of humour, and why it is attractive and common amongst their communities of practice? Anecdotally I see this occurring particularly in allied health fields in developed nations. Perhaps those in developing regions are better appreciated by their communities due to the general public’s increased exposure to, and experience of life-threatening disease?

I would like to suggest that health care workers who feel a sense of frustration at their role-identity can seek to right their perception of a power imbalance by asserting dominance over others in a para-occupational capacity. This nurse who feels that there exists an injustice at their role-identity, perhaps due to a lack of respect and appreciation by their community/society and colleagues, is now expressing that frustration through dominance over a patient; in this case, the ability to inflict excess pain as revenge for an apparent slight or inconvenience. Now, I’m not suggesting that this individual would actually *do* that to a patient, but rather that the notion of being *able* to do that to someone creates a feeling of control and power, which might be lacking in their usual role; that their frustration at a patient could, should they choose, be vindicated through inflicting pain.

The problem I see is that, even if we assume that this is all “harmless joking”, and that these healthcare workers would never actually perform such an act on a patient (which would constitute assault or medical mal-practice) it suggests that there is a real issue here that needs to be dealt with.

In a situation where the individual feels that they are lacking in respect, appreciation, or power; there is an automatic need to correct for this by asserting dominance over more vulnerable individuals. In healthcare, the most vulnerable individuals are patients.

Any situation where a healthcare worker must needlessly exert dominance over a patient is harmful; especially when the power gradient in healthcare already creates this structure.

When listening and believing patients is perhaps the most unselfish and ego-less activity one can engage in (performative acts of compassion are quite easy), I worry that in a situation of perceived injustice; this will be the first thing to go.
I submit that the egoistic clinician is less likely to consider alternative diagnoses which disagree with their primary differential; especially when patients disclose more information after an initial diagnosis is already anchored to.

( [I hope] I don’t need to expand on why patients with a history of being assaulted or abused are harmed by this kind of joke; and become less trusting of the healthcare system.)

So, I believe the issue is that healthcare workers in situations where they feel unjustly deprived of acknowledgement/respect/appreciation can attempt to correct for their feeling of impotence/un-appreciation by considering their ability to exert dominance over others. And that this is often expressed through humour and revenge against “bad patients” as a socially acceptable conduit. However, ultimately, this is a mal-adaptive response and engenders a culture which harms patients and promotes unethical and anti-professional thought and action.