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By Rebecca Farrington, Louise Tomkow, Gabrielle Prager, and Kitty Worthing.
Healthcare professionals are increasingly expected to be hardy and ‘suck it up’ to survive in complex and demoralising workplaces. As NHS clinicians, we saw staffing shortages and limited resources firsthand during the COVID-19 pandemic. These experiences magnified our scepticism about the onus on us, as individuals, to be ‘resilient’ as a solution to both the workforce crisis and wider societal problems.
Our paper ‘In critique of moral resilience’ describes the responses of NHS staff faced with navigating COVID-19 and caring for one of the most disadvantaged groups in our society – people seeking asylum housed in contingency accommodation. The staff we interviewed provided a social commentary on the state-sponsored neglect of vulnerable migrants in the UK. We don’t overlook this, but we focus on healthcare professionals’ understanding, responses and negotiation of their roles in this ‘Hostile Environment’.
Resilience was clearly important to staff for self-preservation, but so was an ability to see the limits of a biomedical approach to social suffering. The concept of moral resilience helped to unpick this but was not enough to describe the ideological changes and challenges to systems made by staff using their new insights. They did put up with the difficult bits of their work, and we describe how they survived. However, these coping actions alone did nothing to change the status quo in the political and social systems causing the underlying health problems. Some staff we interviewed made positive changes in the lives of the people seeking asylum through activism to improve their health and wellbeing. We found that the concept of resilience failed to capture these important moral actions: advocating beyond the clinic, beyond just doing their best on the job.
The popular focus on resilience is here to stay in much of our work and home lives, but we encourage caution in using it as a broad-brush solution to complex problems. Healthcare providers who see and yet continue morally problematic care in the name of resilience might be thought of as complicit in social suffering. Does moral resilience just promote acceptance of the status quo, even when it feels unbearable? What cost does this fixation on resilience bring to both care providers and patients?
Reflecting on our work in clinical medicine, research, and medical advocacy, we recognise that some of our most effective improvements to social conditions have been through collective action and joint resistance. In times of increasing moral outrage, such as against the UK government’s illegal migration bill, this feels a more appropriate response than just sucking it up in the name of resilience in the hope that we will survive.
Authors: Louise Tomkow1, Gabrielle Prager1, Kitty Worthing2, Rebecca Farrington1
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The post Does our preoccupation with resilience mean we must tolerate the morally intolerable? appeared first on Journal of Medical Ethics blog.
By Joshua Parker and Ben Davies
Like many public services, the UK’s National Health Service (NHS) is under increasing resource pressure across the service. Acute services are under strain, with every stage between dialling 999 and getting into a hospital bed taking longer. Waiting times are also up for non-urgent care: 7 million people are on a waiting list in England, while General Practitioners (GPs, the UK’s primary care physicians) are exceeding safety limits and still not managing to meet demand. These measures are only proxies; the underlying concern is that failures in these metrics betray failures of quality and safety.
In part this is due to chronic under-investment made worse by a range of factors: greater demand generated by Covid and lockdowns; increasing complexity with an ageing patient population; more medical ability due to developments in medical technologies; and staff shortages that are in part a result of the UK’s departure from the European Union. However, some may argue that the pressure is also a sign that the NHS is trying to do too much in straitened times, and perhaps even that the scope of what a health system is responsible for has been expanded too far.
The idea that we should rein in the responsibilities of a particular public sector is not confined to health. It may be tempting to categorise problems as health needs because for many people there is a health ‘halo effect’: we tolerate less inequality in health than we do in other areas, and NHS spending is often protected (at least superficially) from political cuts. There are two ways a healthcare system might limit this to produce better equilibrium between supply and demand. Both use thresholds to contract healthcare’s scope and get a firmer grip on overstretched services. One threshold borrows from the philosophical idea of ‘sufficiency’: ensuring that resources are targeted at those who are badly off, or who have severe need. To simplify, a sufficiency threshold is an imaginary boundary: those whose health is below the boundary are entitled to certain services until they reach the desired health level. We could phrase this in terms of need: somebody is unwell, so they need healthcare until the need has been satisfied. The other threshold constrains the issues that are legitimate problems for a health service. This concerns the scope of healthcare. We might think of these two thresholds as a vertical and horizonal threshold. The vertical threshold is about “how much?” and the horizontal asks “what kind of problem?”.
Some examples may help. As each threshold is, to a certain degree, socially constructed the thresholds can be flexible, shifting in response to resources, demands, changes in social attitudes, and so on. Take the vertical threshold. One way of contracting a health service is to lower this threshold meaning that the numbers of people severe enough to merit certain treatments goes down. For example, GPs might find thresholds for having referrals accepted by specialists becoming stricter, and more referrals thus being rejected. It might be that to have a referral accepted, the patient’s symptoms must be especially severe, or the likely diagnosis especially concerning, or that ever-increasing treatments must have been trialled in primary care first. Other examples could be provided: patients’ thresholds for seeking medical attention may go up meaning they present sicker; doctors’ thresholds for initiating certain treatments or investigations may also go up. The underlying point is the same however that the sufficiency threshold is being shunted down, resulting in the threshold for which people can access certain medical treatments dialling up. In turn, this helps a healthcare system spread is limited resources – in terms of healthcare professionals time, diagnostics, ambulances, treatments etc – further.
The horizontal threshold seeks to constrain the scope of a healthcare service by differentiating between ‘genuine’ health needs, and needs which are better dealt with in other ways. Implicit in this version of the argument is the idea that the health service has been over-extended. For some this might be framed as medicalisation, the march of medicine into non-medical areas. Of course, this raises some difficult questions around the concepts of health, disease, illness, disability and so forth. Nevertheless, where there is a certain fuzziness around these concepts a healthcare system under strain can use this to narrow its scope. For instance, one GP writes that loneliness, infantile colic and premenstrual mood swings are all forms of medicalisation but more importantly, that these issues gum the system up preventing healthcare professionals dealing with the ‘real’ problems. One concerning consequence of this narrowing of scope is that aspects of care within healthcare are stripped away. Perhaps infantile colic is a normal part of early life, but part of what GPs provide is not just technical knowledge in how to manage this but care in providing reassurance.
Primarily, we are aiming to show that the more theoretical world of philosophical discussions about sufficiency and need can help describe these issues facing the health service. The further question is what to make of this phenomenon. To a certain extent, reshaping this sphere of concern for a health service along the vertical and horizontal axis is inevitable and to a degree, having some flexibility in the system may also be desirable. Nonetheless, there are certain risks worth noting.
Lowering the vertical threshold straightforwardly can make people worse off. Going back to the referrals example, if GPs’ gatekeeping role is more stringent and its harder to get patients into the system, some of these patients will be made worse off by this. Furthermore, there is a difference between taking sufficiency as our ultimate aim, and as an explicit target. For instance, one common objection to the idea of sufficiency in political philosophy is that it seems to arbitrarily abandon those who sit just above a sufficiency threshold. What this tells us is that even if we take a sufficiency-based view, that does not mean that we should only focus on those who are currently below whatever threshold we have decided on; we also need to pay attention to those who are at risk of falling below it.
Pulling in the horizontal threshold also, similarly, may leave individuals worse off by restricting the scope of help that healthcare offers. There are also obvious concerns about a healthcare system so highly pressured that professionals are not able to provide aspects of care and can secure only the technical aspects of diagnosis and treatment. Importantly, providing care provides other opportunities. Much of the valuable work that GPs do is, we might say, finding needles in haystacks. Shrink the haystack and needles will be easier to find; but some needles will be left out of the search altogether. That’s not to deny that resource shortages may demand a rollback of services. But if the health service is forced to limit care either vertically or horizontally, this should not be seen as trimming an over-extended service back to its proper function. Rather, it should be seen for what it is: a hard choice to prioritise the urgent over the important.
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