Healthcare and Compassion : Towards an Awareness of Intersubjective Vulnerability Comment on “ Why and How Is Compassion Necessary to Provide Good Quality Healthcare ? ”

How to instill compassion in a healthcare organization? In this article, I respond to Marianna Fotaki’s proposals in her piece, ‘Why and how is compassion necessary to provide good quality healthcare?’ by drawing on insights from organization studies. Following Fotaki, I argue that to instill targets and formal measures for assessing compassion would be problematic. I conclude by drawing on psychoanalytic and feminist theories to introduce alternatives, specifically proposing an approach that is grounded in a shared sense of a common, embodied precarity, which necessitates our commitment to preserving the conditions in which life might flourish.


Introduction: Compassion as a Moral Sentiment
In her article, Fotaki examines how compassion might become a moral sentiment, potentially contributing to the development of a system of norms and values within the National Health Service (NHS) and similar organizations. 1 She notes that compassion has the potential to form part of a foundation for ethics that might usefully guide health professionals in their daily practice.Central to her argument is the caveat that managers must avoid imposing new metrics of control, that is, new targets, if they are to effectively foster such an ethics.To do so, she feels, would merely exacerbate the kinds of self-centred, individual-focused behaviour that such targets were created to discourage.In my response, I examine her proposals with reference to insights from organization studies.In doing so, I find both support and supplementary ideas for her arguments.The issue of compassion in organizations tasked with the care of the sick, weak and vulnerable, has rarely been so topical.Successive stories of failures of care in the NHS, coupled with failures to protect the whistleblowers who tried to speak up about these, have lately dominated news reports.Unfortunately, such stories are not new.Scholars have long attempted to grapple with the question of how this can come about; what is it about large-scale organizations that can lead to a breakdown in individual compassion, as staff facilitate or at least look the other way, in cases of serious neglect and abuse?Studies detail breakdowns in care where organizations are charged with looking after vulnerable people, 2,3 including the psychiatrically ill, 4 children 5 and those availing of social services. 6

Organizations and Compassion: A Targeted Approach?
Central to debates is the well-rehearsed argument that organizations, by their very nature, can lead to dehumanization. 7The idea is that the simple act of doing one's job in a large organization, and following orders, can lead to behaviour that is instrumentally rational and focused on achieving narrow goals, as opposed to being aware of the consequences of one's actions.This has a particularly strong effect on the ethical behaviour of individuals in large bureaucratic systems, illustrated for example in Arendt's study of the Eichmann Holocaust trials. 8It is easy to suspend a personal sense of morality, and compassion, when the nature of one's job involves close attention to rules. 9,10f this is the case then how might we, as Fotaki asks, instill a greater sense of compassion in the organizations that we entrust with the care of our weak and sick?At first glance, the introduction of measures and targets that help to encourage people to act with greater compassion, appears somewhat tempting.However, previous studies of organizational processes indicate that such a move would paradoxically lead to a further alienation of a sense of compassion.It could perhaps render compassion impossible.Useful examples are given in studies of large-scale organizational abuses, and the attempts that were made to 'fix' the institutions in question such that abuse would no longer be allowed to happen.In a significant number of cases, after an inquiry has been held and a report issued, recommendations emerge that call for yet more rules and regulations.The idea is that the abuse was caused by absence of 'correct' rules, and will be eradicated if this is addressed.This view informed successive responses into abuse cases in UK health and social care organizations. 11,12he result is a renewed sense of security, with the hope that all will be well under the improved rules. 13This approach has had problems however, in some cases heightening the problems being experienced. 6Increased rules and regulations are seen to further remove a sense of humanity from those tasked with following them, 12 not least because of their role in exacerbating defensive anxieties. 14So it appears that increased targets and measures, even those imposed with the laudable goal of promoting compassion within organizations, may not be a useful way forward.

Fostering Norms in Contemporary Organizations
If this is the case, we need another approach.Fotaki calls instead for the promotion of 'prosocial behaviour' and the development of organizational norms and environments that would foster this.In understanding how this might take shape, it is useful to draw once more on organization studies, this time on insights from psychoanalytic approaches.][17][18] Schwarz, 19 for example, is particularly interested in the question of organizational norms and how these relate to individuals and their moral actions.He studies the ways in which actions by loyal members of an organizations, which are seen as antisocial and wrong by the outside world, are actually an effect of processes of socialization in which such behaviours are instilled as part of commitment to the organization.Psychic ties of commitment, perceived as feelings of 'loyalty, ' are key here, and this works because organizations provide what he terms 'an organization ideal, ' a phenomenon that essentially represents an ego ideal for people in the organization. 19Schwarz is interested in the ways in which people divest themselves of ethical responsibility because of the sheer strength of this ideal, an implicit bargain is set up in which the employee assumes that all responsibility for anti social behaviour is taken by the organization, and in fact that the organization absorbs all guilt that would be otherwise felt by employees.Under this view, loyal individuals are less likely to criticize their organization, as it represents something of a projection of the ego ideal. 19In addition, Schwartz notes, threats to the organization ideal represent threats to the ego ideal and therefore can result in antisocial action.In such situations, organizations can come to form their own moral communities, adopting a defensive stance towards the rest of their community and society more generally.Overall, the stronger the identification, the more loyal the employee, and hence the greater ease with which the employee can diverge from 'normal' moral decisions and carry out organizational injunctions, regardless of how unacceptable they might be.Studies such as Schwarz's adopt a psychoanalytic lens to reveal the darker side of employee loyalty and commitment, but can such an approach lead to a consideration of how alternative, prosocial behaviours described by Fotaki can likewise be instilled and tied in with organizational loyalty?For example, if the organization with which the individual identifies possesses a strong culture of compassion and altruism, perhaps organizational identification will lead to compassionate behaviour at least toward some of the organization's stakeholders.To explore this idea further, insights from psychoanalytic feminist theorist Judith Butler resonate.Butler's work represents a longstanding engagement with questions of how subjects identify with social norms and how relationships with others are implicated in this. 20r recent work on precarity invokes a new 'ontology of the subject' that is grounded in the idea that we are inescapably embodied beings, 21 and the bodies we inhabit eventually decay and die.To live an embodied life necessarily means to be vulnerable: to war, famine, poverty and physical hurt; 'to live is always to live a life that is at risk from the outset, ' she notes, a life that can be 'expunged quite suddenly from the outside and for reasons that are not always under one's control.' 21 This embodied sense is shared by all, and the only thing, for Butler, that can ameliorate vulnerability is our acknowledgement of those others upon whom we depend.Our bodily, vulnerable beings are necessarily and inescapably interdependent. 20,21his common and intersubjective condition of precarity, necessitates our commitment to preserving the conditions in which life might flourish.This forms the basis for a future politics and ethics in which preservation of life, based on the generalizable condition of precarity we all share, might take precedence.

Prosocial Behaviour and Healthcare Organizations
How might such a perspective be fostered in healthcare organizations?One approach perhaps lies in recent investigations of 'prosocial organizational behaviour' (PSOB).This is described as positive behaviour undertaken at the discretion of the individual employee, which involves willingness to not only fulfill one's role but also to exceed 'normal' expectations and, for example, volunteer one's time to help others, suggest improvements to the organization, and assist coworkers.Recent studies suggest that human resource management (HRM) functions in healthcare organizations can play a role in fostering this kind of behaviour among clinicians and practitioners. 22efore embarking on such interventions however, a number of points are important to note.First, such interventions ought not to take the form of 'strong' cultural programming.As noted by Willmott 23 and others, even apparently benign efforts to increase employee loyalty and commitment can be seen as manipulative and exploitative.Second, in considering the concept of prosocial behaviour, it is helpful to draw as Fotaki does here and in other work, 16,24 on feminist philosophy, not least the psychoanalytic idea that the aim of ridding the subject of all forms of aggression and exclusionary impulses towards the other, is an illusory goal. 20,25Under such a view, subjects (including those who work in healthcare) possess the potential for compassion and new forms of 'beingwith' the other, just as they experience inherent impulses for domination and more negative effects.Similarly, vulnerability as described by Butler can make us sensitive to the needs of the other but equally, under conditions of psychological defense, the denial of our own vulnerability can blind us to the vulnerability of the other.Again we see the ambivalence with which the other is inescapably viewed.Any approach to fostering 'prosocial behaviour' must, therefore, facilitate this inescapable ambivalence and tension on the part of the subject.The question is how to enable an environment in which such compassionate, 'transubjective' encounters can nonetheless take place, 25 grounded in the primary affect that our shared precarity as vulnerable subjects engenders. 21uch an approach would be valuable in the workplaces that play such an important role in our society, 24 not least our healthcare organizations.

Conclusion
Fostering compassion in healthcare is clearly a valuable goal.Rather than adopting targets and measures in order to achieve it, the development of 'prosocial' norms of intersubjective engagement might offer a valuable way forward.Such attempts must however incorporate an awareness of the ambivalence of the subject's impulses towards the other, and must likewise avoid the danger of imposing, from without, manipulative attempts at cultural programming.