Against Compassion: Understanding Institutional Perfidy as
Evil
Wendy Austin
Abstract
If compassion is central to social life, it must be particularly necessary to the
institutions designed to care for the sick, the injured, and the disabled. Yet in
our interdisciplinary study of the compassion fatigue of healthcare
professionals, we learned from anecdotes of Canadian physicians, nurses,
occupational therapists, social workers, and psychologists that many of the
institutions in which they practice not only do not support compassionate
response to patients, but actively undermine it. In our attempts to understand
the reasons that this would be so, we recognized that the increasing
domination of corporate, commercial values and a drive to simulate the
marketplace within a tax-based, publically-funded system was literally
demoralizing healthcare professionals. It is as if those responsible for shaping
the institutional response to individual suffering are focused elsewhere: on
creating an efficient machine. It was difficult to resist comparisons of such
re-engineering of health care with Hannah Arendt‟s claim that “Evil comes
from a failure to think,” and her analysis of Eichmann as a shallow-minded
bureaucrat.
The principal investigator‟s previous research on ethical practice in
forensic psychiatric settings revealed that health professionals are uneasy
about and divided on the notion of evil. Some did not believe that evil
existed, while others found evil to be frighteningly ordinary. While no
participant in the compassion fatigue study used the word evil, the numbing
of moral response that occurred when efforts to respond to suffering were
continually thwarted may be considered a form of maleficence. This paper
explores the claim that acting against compassion is evil.
Key Words: Compassion, compassion fatigue.
*****
The evil in the world comes almost always from ignorance, and goodwill can
cause as much damage as ill-will if it is not enlightened.
Albert Camus1
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Against Compassion
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Compassion - recognition of the suffering of another, coupled with
the desire to alleviate it - is “a basic social emotion.”2 Schopenhauer would
have it that compassion is the ground of all moral action. 3 It is not far-fetched
to consider the institution of health care as compassion at the societal level,
the offering of comfort and care to those who suffer due to sickness, injury,
or disability. This claim seems particularly reasonable in terms of publicallyfunded systems, such as that of my country, Canada. As a Canadian nurse,
my patient care is to be, according to our Code of Ethics, “safe, competent,
compassionate and ethical.”4 The Code stipulates, “Nurses need to recognize
that they are moral agents in providing care …” and that we are to work with
others “to create the moral communities that enable ethical care.”5 The vision
of health care as grounded in a fiduciary relationship with the public is shared
across healthcare disciplines. When health care is re-engineered, therefore,
away from its compassionate origins in such a way that morality is
suppressed or manipulated into irrelevance, 6 something is very amiss. Such a
change, it seems to me, constitutes a breach of faith with those served.
Consequences of the rationalized re-engineering of health care and
its reformulation as a simulated marketplace can be found in healthcare
professionals‟ experiences of compassion fatigue. Literally de-moralized,
they, like canaries in a mineshaft, are collapsing from a toxic environment.
Compassion fatigue may be a societal “ethical canary,” 7 warning that
something in our society‟s unfolding is seriously wrong. The move away
from moral foundations of caregiving is so profoundly thoughtless that it
brings directly to mind Hannah Arendt‟s notion of the banality of evil and its
origins in “an inability to think,” particularly from the standpoint of others. 8
In this paper I will consider whether or not organizational constraints on
compassion in health care can be deemed evil. As Petruschka Schaafsma
notes in Reconsidering Evil, the word is increasingly used when we struggle
to make sense of negative phenomena that are “fundamentally scandalous.”9
Such struggle is the raison d‟être of this paper. I will begin with a brief
description of the rationalization of health care, informed by Bauman‟s
assessment of modernity, and then connect this to healthcare professionals‟
compassion fatigue as uncovered in our research. Finally, I will consider
whether it is meaningful to characterize an organizational culture as evil.
1.
Modernity and the Road to Perdition
In Modernity and the Holocaust, Bauman argues that rather than
understand the Holocaust as a singular historical event of madness, we need
to assimilate its lessons regarding modernity and society. 10 He points to the
social nature of evil: it was disciplined, rule-following persons who enacted
the horrors of the death camps, people who “whenever they took their
uniforms off, were in no way evil.”11 The insight that is most frightening,
Bauman believes, is not that such evil could happen to us, but that we could
do it. He concludes that “inhumanity is a matter of social relationships.”12
Wendy Austin
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Bauman accepts Levinas‟ notion that a human being‟s primary
existential attribute is unconditional responsibility to another, and he
describes the silencing of such responsibility when proximity is eroded. If the
social order produces distance between persons, moral indifference arises. He
argues that as we rationalize and technically augment social relationships the
capacity and efficiency of the social production of inhumanity grows.
Bauman describes modern civilization‟s “pursuit of artificial, rationally
designed order” as being accompanied by “the ability to act at a distance” and
“the neutralization of moral constraints.”13 And in systems where rationality
and ethics lie in different directions, humanity loses.14
George Ritzer shows the way that rationality and its enactment as
bureaucracy increasingly dominate our contemporary world: he calls it the
McDonaldization of society and shows how the desire for efficiency,
calculability, predictability, and control drive our organizations. 15 Variation
in the system is anathema: 16 actions and tasks are prescribed, outcomes
measured, and what cannot be controlled is excluded. Quantity, not quality, is
equated to success. Ritzer confirms that Weber‟s fears at the onset of the 20th
century were legitimate: all aspects of society are experiencing the
dehumanizing consequences of rationality. 17
2.
The Rationalization of Health Care
Although, as Stanley Reiser argues in The Ethical Life of Health
Care Organizations, health care has a compassionate purpose - to help
humanity preserve health and survive illness - that purpose is subverted as
experts in management and business assume institutional leadership.
Rationalized healthcare organizations commodify care and focus their
oversight on calculability (to count, actions must be countable), predictability
(care is standardized, routinized, deprofessionalized), and control (power is
centralized, top-down). As the hospital metamorphoses to McDonald‟s 18 the
administrative aim is for every patient/burger to be processed in the same
prescribed way. This includes engagement between patient and caregiver,
with communication being scripted by the organization (Would you like
empathy with that?), as if, as some nurses have decried, staff are “like some
audio animatronics characters in a Disneyworld display.”19 In the creation of
an artificial, manipulated world where emotional response is calculated and
managed, health professionals become morally neutral performers.
Meštrović uses Ritzer‟s notion of the McDonaldization of society to
elaborate upon what he terms the “postemotional society.”20 Rationality, he
argues, is extended to emotional life and thus synthetic, manufactured quasiemotions (happy meals of emotions) push away the possibility of authenticity
and become the basis for manipulation of individuals and society. Emotional
dis-order is forestalled as emotional exchange is routinized. The resistant
nurses, noted previously, realize the consequences of diminishing connection
between nurse and patient. Bertrand Vergely in his palliative care work, La
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Against Compassion
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souffrance, reveals what will be lost: “When the bond between the subject
and life is disrupted in suffering, it is through the nurse that it is renewed; he
or she helps the one who suffers become a being again in coincidence with
his or her life in one way or another.” 21 To help in this way requires
compassion; it requires moral imagination to see the suffering of the person
before you and the ability and resources to respond.
Hospitals are unlike other organizations, Daniel Chambliss declares
in his study of them: “as a normal part of the routine, people suffer and
die.”22 Healthcare professionals stand close to life‟s profundities: birth, death,
pain, joy, suffering. In their everyday world, they are to be with and for other
humans in need of their caring expertise. Within an institution that controls,
scripts, and diminishes such expertise, compassionate caring becomes
constrained and then seditious.
Rationalized
healthcare
organizations
understand
ethics
predominately as compliance, as conformation to institutional rules and
regulations. 23 Ethical action is loyalty to the organization and being moral is
procedural; good and evil are irrelevant. Responsibility for becomes
responsibility to and there is, according to Bauman, ethical tranquilization
and moral deskilling.24 He resurrects the medieval term, adiaphoric, to name
the way moral significance is excluded when “targets” of organizational
operations become actors rather than human beings with moral significance. 25
Compassion is not at issue; it simply does not enter into the organizational
mindset.
This was poignantly illustrated recently in one of Canada‟s national
newspapers. A columnist writes of her experience with our healthcare
system, decrying its “awful disarray” and the domination of depersonalized
medicine. She describes her search for the nurse who was to bring analgesic
for her dying mother‟s excruciating pain. Once found, the nurse tells her,
“It‟s the end of my shift, and I have to do my charts.” Compassion is not
outlawed; it is simply that bureaucratic demands distance patients‟
suffering. 26
3.
Compassion Fatigue
Compassion fatigue is the term used by healthcare professionals to
name a phenomenon that comprises weariness, emotional disengagement,
and loss of compassion toward others. In our pilot study of nurses‟
compassion fatigue, nurses described it as “running on empty,” impotency,
and hopelessness.27 They began to shield and distance themselves from the
suffering of patients and their families. One nurse explains:
I started feeling like I couldn‟t give or open myself up to
interact with the patients and their families. It was like I
had to kind of shield myself because I was getting involved
Wendy Austin
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with them and I just didn‟t feel like I could give them
anything.28
In our interdisciplinary study of compassion fatigue among
Canadian health professionals, it was described as feeling totally drained,
spent, shut down, an empty shell.
I feel like I‟m just a bit of a zombie, no energy for anything. It
is not a physical tiredness, it is a mental tiredness but it is
also an emotional one. I feel just numb.
While it is argued by some that compassion fatigue is traumatisation
by exposure to a patient‟s suffering, 29 our research suggests that this is an
incomplete picture. For some, at least, the danger resides less in exposure to
suffering than in an inability to meaningfully respond to it. The shutting
down of compassionate response to pain and suffering, as demanded by a
rationalized, postemotional organizational culture, shuts down the caring
professional.
A palliative care physician participant reveals what practice is like
in such a culture. He describes the way he is expected to engage with a new
patient, a person who has been recently informed that she or he is dying. He
says:
You should see the stack of question forms and the
numerical scales of each of them.... I am walking into a
room where a patient is near the end of their life and their
suffering and I arrive with a pack of forms ... everything
has a number. They [the patients] are symptoms.
He explains the way that the dying person, in this initial assessment, is
required to rate a set of 13 symptoms on a scale of 1-10, as well as complete
a “huge questionnaire” and undergo a full mental status examination.
So that‟s my job. I would lose my job if I didn‟t do that.
But how much compassion does this show to the patient
who we are putting through this?
How can this physician empathically reach out to his dying patient with his
arms full of paperwork? His actions in overseeing the patient‟s correct
completion of these forms are to be kind, but the act itself belies real
kindness. How does he help his patient in the passage toward death when his
prescribed behaviour profanes its significance? In these organizational
demands lie evidence for Meštrović‟s argument that death, too, has been
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rationalized; in postemotional society death is to be ordinary, pedestrian, and
devoid of mystery. 30 Compassion fatigue overcomes this physician as he
finds that his actions, rather than being comforting, increase suffering. He is
made weary by his failing attempts to be the physician that he expects
himself to be. In the re-engineering of health care, both patient and
professional become faceless. Compassion fatigue is the result when
caregivers become too weary and too numb to carry on in a system in which
they are diminished as moral agents, a system that cannot function as a moral
community.
4.
Naming Institutional Perfidy as Evil
Perfidy has its roots in the Latin perfidus, meaning “to break
faith.” 31 Naming the rationalization of health care as perfidious seems
justified. It undermines healthcare professionals‟ promise of a fiduciary
relationship with those whom they serve and precludes an authentic
compassionate response to patient suffering. Can, this perfidy, however, be
called evil?
My previous experience of the question of evil within health care
was framed in terms of the individual. In research on ethical forensic
psychiatric care, my colleagues and I asked forensic professionals if they
believed that they had encountered evil in their practice. Some were clear that
“evil” does not exist, others, that evil was frighteningly human, ordinary, and
a possibility for us all. A few said that they had “met the devil.” Their
divergent perspectives on evil are echoed in the academic literature where, at
best, the question of evil remains unresolved. Where there is a primary area
of agreement among professionals and academics, it is that the definitive
element to evil is a deliberate intent to cause suffering. To judge the
rationalization of health care as evil requires, it seems, not only a move to the
politics of evil,32 but the rejection of intent as necessary to it.
Hannah Arendt‟s body of work opens this possibility in the modern
understanding of evil. 33 She argues, based on her assessment of Adolf
Eichmann, that perpetrators of institutional evil can be thoughtless persons
who mechanically and without question apply policies the consequences of
which, so long as policy goals are met, do not influence their actions. There is
no evil intent on their part: their moral life is held separate from their
institutional role. 34 “This new type of criminal,” “terrifyingly normal,” 35
cannot understand that he or she is doing wrong. In this, Arendt says, is
revealed the banality of evil.36
Ronald Berger used social construction analysis to explore Arendt‟s
idea further, and found that Nazi bureaucracy relied upon authorization (i.e.,
roles could be fulfilled without a sense of personal responsibility);
routinization (i.e., decision-making gets minimized); and dehumanization
(i.e., the identity of the person acted upon is diminished).37 In Evil: A Primer,
William Hart describes similar strategies underpinning contemporary
Wendy Austin
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societies as hierarchy, standardization of procedure, and obedience are
increasingly deemed essential with little space allowed for individual moral
deliberation.38 According to Arendt‟s position, and to Bauman‟s work which
supports it, when such bureaucratic demands cause suffering, it can be called
evil.
The question remains, however, whether the re-engineering of
health care against compassion should be called evil. Is there not a danger of
naming evil too readily and thus diminishing its meaning? The suffering
which Arendt and Bauman address is the Holocaust. Should we not reserve
“evil” for acts that cause truly immense harm? It is Bauman, however, who
argues that “bureaucracy is intrinsically capable of genocidal action.” 39 It
may be that any hope for the diminishment of social evil lies in making it and the social values that perpetuate it - visible before vast harm is caused.40
If the movement against compassion and toward moral indifference in health
care is a sign (a dead canary?) that our society is in serious trouble, this needs
to be widely understood. Susan Neiman writes in Evil in Modern Thought
that “Surrendering the word evil to those who perceive only its simplest
forms leaves us fewer resources with which to approach the complex ones.”41
The sabotaging of compassion at a societal level is indeed complex, not only
in its indifference to suffering but in its creation of it. It seems necessary to
speak of it, for now, as evil. There is hope, however, that if evil is our word
for harmful, unintelligible phenomena, 42 the day may come that such
institutional perfidy no longer merits it. Made intelligible, it will be called a
crime.
Notes
1
A Camus, The Plague, R Buss (trans), 2001, Penguin, London, p. 100.
M Nussbaum, “Compassion: The Basic Social Emotion,” Social Philosophy
and Policy, vol. 13, 1996, p. 27.
3
A Schopenhauer, The World as Will and Representation, E. F. J. Payne
(trans.), Dover, New York, 1969.
4
Canadian Nurses Association, Code of Ethics for Registered Nurses, 2008,
viewed on 15 November 2010, <http://www.cna-aiic.ca/CNA/practice/
ethics/code/default_e.aspx>.
5
ibid.
6
Z Bauman, Modernity and the Holocaust, Cornell University Press, Ithaca,
New York, 1989, p. 214.
7
Margaret Somerville, a Canadian ethicist, notes that some societal issues are
“ethical canaries” and we need to be particularly attentive to them. See M
Somerville, The Ethical Canary: Science, Society and the Human Spirit,
2000, Viking/Penguin Canada, Toronto.
2
8
Against Compassion
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8
H Arendt, Eichmann in Jerusalem: A Report on the Banality of Evil, 1963,
Penguin, New York, p. 49, original italics.
9
P Schaafsma, Reconsidering Evil: Confronting Reflections with Confessions,
2006, Peeters, Leuven, Belgium, p. 5.
10
Bauman, op. cit., p. viii.
11
ibid., p. 151.
12
ibid., p. 154, original italics.
13
Z Bauman, Life in Fragments: Essays in Postmodern Morality, 1995,
Blackwell, Oxford, p. 195.
14
ibid., p. 206.
15
G Ritzer, The McDonaldization of Society, 6th ed., Pine Forge Press, Los
Angeles, 2011.
16
V Shannon & S French, „The impact of the re-engineered world of healthcare in Canada on nursing and patient outcomes,‟ Nursing Inquiry, vol. 12,
no. 3, 2005, pp. 231-239.
17
M Weber, Essays in Sociology, H. H. Gerth & C. Wright Mills (eds),
Routledge, Oxford, 1991.
18
Ritzer, op. cit.
19
“Newton-Wellesley RNs oppose Wal-Martization of nursing practice,”
Massachusetts Nurse: The Newsletter of the Massachusetts Nurses
Association, vol. 77, no. 3, 2006, p. 13. The Disney corporation is actually
hired by some health authorities to help create patient-staff scripts.
20
S Meštrović, The Postemotional Society, 1997, Sage, London.
21
B Vergely, La souffrance, quoted in Phenomenological Approaches to
Moral Philosophy: A Handbook, J. Drummond, & L. E. Embree (eds),
Kluwer Academic Publishers, Dordrecht, The Netherlands, 2002, p. 529.
22
D Chambliss, Beyond Caring: Hospitals, Nurses, and the Social
Organization of Ethics, University of Chicago Press, Chicago, 1996, p. 16.
23
L Weber, Business Ethics in Healthcare: Beyond Compliance, Indiana
University Press, Bloomington, Indiana, 2001.
24
Z Bauman, Liquid Fear, Polity Press, Cambridge, UK, 2006, pp. 87-89.
25
Bauman, 1995, op. cit., pp. 196-197, original italics.
26
M Wente, „Three days in a hospital,‟ The Global and Mail, 26 February
2011, p. F9.
27
W Austin, E Goble, B Leier & P Byrne, „Compassion Fatigue: The
Experience of Nurses,‟ Ethics and Social Welfare, vol. 3, no. 2, 2009, pp.
195-214.
28
ibid., p. 204.
Wendy Austin
9
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29
C.Figley, Compassion Fatigue: Coping with Secondary Traumatic Stress
Disorder in Those Who Treat the Traumatized, Brunner-Routledge, London,
1995.
30
Meštrović, op. cit., p. 128.
31
Oxford English Dictionary, 3rd ed, “perfidy,” n., online version November
2010, viewed on 15 November 2010, <http://www.oed.com:80/Entry/117882>.
32
B Lang, „Hannah Arendt and the Politics of Evil,‟ Judaism, vol. 37, no. 3,
1988, pp. 264-275.
33
ibid., p. 271.
34
Arendt, 1963, op. cit.
35
ibid., p. 276.
36
ibid., p. 252, original italics.
37
R Berger, „The “Banality of Evil” Reframed: The Social Construction of
the “Final Solution” to the “Jewish Problem,”‟ The Sociological Quarterly,
vol. 34, no. 4, 1993, pp. 597-618.
38
W Hart, Evil: A Primer, St Martin‟s Press, New York, 2004, p. 95.
39
Bauman, 1989, op. cit., p. 106, original italics.
40
L Cosner, „The Visibility of Evil,‟ Journal of Social Issues, vol. 25, no. 1,
1969, 101-109.
41
S Neiman, Evil in Modern Thought, Princeton University Press, Princeton,
New Jersey, 2002, p. 286.
42
Bauman, 2006, op. cit., p. 54.
Bibliography
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Experience of Nurses.‟ Ethics and Social Welfare, vol. 3, no. 2, 2009,
pp. 195-214.
Bauman, Z., Modernity and the Holocaust. Cornell University Press,
Ithaca, New York, 1989.
—, Life in Fragments: Essays in Postmodern Morality. Blackwell,
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—, Liquid Fear. Polity Press, Cambridge, United Kingdom, 2006.
10
Against Compassion
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Berger, R., „The “Banality of Evil” Reframed: The Social Construction of the
“Final Solution” to the “Jewish Problem.”‟ The Sociological Quarterly, vol.
34, no. 4, 1993, pp. 597-618.
Camus, A., The Plague. R. Buss (trans.), Penguin, London, 2001.
Canadian Nurses Association, Code of Ethics for Registered Nurses, 2008.
Viewed on 15 November 2010, <http://www.cna-aiic.ca/CNA/practice/
ethics/code/default_e.aspx>.
Chambliss, D., Beyond Caring: Hospitals, Nurses, and the Social
Organization of Ethics. University of Chicago Press, Chicago, 1996.
Cosner, L., „The Visibility of Evil.‟ Journal of Social Issues, vol. 25, no. 1,
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Figley, C., Compassion Fatigue: Coping with Secondary Traumatic Stress
Disorder in Those Who Treat the Traumatized. Brunner-Routledge, London,
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Hart, W., Evil: A Primer. St Martin‟s Press, New York, 2004.
Lang, B., „Hannah Arendt and the Politics of Evil.‟ Judaism, vol. 37, no. 3,
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Neiman, S., Evil in Modern Thought. Princeton University Press,
Princeton, New Jersey, 2002.
“Newton-Wellesley RNs oppose Wal-Martization of nursing practice.”
Massachusetts Nurse: The Newsletter of the Massachusetts Nurses
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and Policy, vol. 13, 1996, p. 27.
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viewed on 15 November 2010, <http://www.oed.com:80/Entry/117882>.
Wendy Austin
11
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Ritzer, G., The McDonaldization of Society, 6th ed. Pine Forge Press, Los
Angeles, 2011.
Shannon, V, & S French, „The impact of the re-engineered world of healthcare in Canada on nursing and patient outcomes.‟ Nursing Inquiry, vol. 12,
no. 3, 2005, pp. 231-239.
Schaafsma, P., Reconsidering Evil: Confronting Reflections with Confessions.
Peeters, Leuven, Belgium, 2006.
Schopenhauer, A., The World as Will and Representation. E. F. J. Payne
(trans), Dover, New York, 1969.
Somerville, M., The Ethical Canary: Science, Society and the Human Spirit.
Viking/Penguin Canada, Toronto, 2000.
Vergely, B., (1997) La souffrance. Quoted in Phenomenological Approaches
to Moral Philosophy: A Handbook, J. Drummond, & L. E. Embree (eds),
Kluwer Academic Publishers, Dordrecht, The Netherlands, 2002, p. 529.
Weber, L., Business Ethics in Healthcare: Beyond Compliance. Indiana
University Press, Bloomington, Indiana, 2001.
Weber, M., Essays in Sociology. H. H. Gerth & C. Wright Mills (eds),
Routledge, Oxford, 1991.
Wente, M., „Three Days in a Hospital.‟ The Global and Mail, 26 February
2011, p. F9.
Wendy Austin is a Professor of Nursing at the University of Alberta and the
John Dossetor Health Ethics Centre in Edmonton, Alberta, and holds the
Canada Research Chair in Relational Ethics.