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Moral Burnout

photograph of surgeon crying in hospital hallway

Many workers are moving towards a practice of “quiet quitting,” which, though somewhat misleadingly named, involves setting firm boundaries around work and resolving to meet expectations rather than exceed them. But not everyone enjoys that luxury. Doctors, teachers, and other caregivers may find that it is much harder to avoid going above and beyond when there are patients, students, or family members in need.

What happens when you can’t easily scale back from a state of overwork because of the moral demands of your job? It might lead to a specific kind of burnout: moral burnout. Like other varieties of burnout, moral burnout can leave you feeling mentally and physically exhausted, disillusioned with your work, and weakened by a host of other symptoms. Unlike other varieties of burnout, moral burnout involves losing sight of the basic point or meaning of morality itself.

How could this happen? Many people enter caregiving professions out of a desire to help people and do the right thing — out of a deep commitment to morality itself. When people in these professions find that, despite their best efforts, they cannot meet the needs around them, it can be easy to feel defeated.

Over time, the meaning of those moral commitments can become eroded to where all that is left is a sense of obligation or burden without any joy attached to it. The letter of the moral law has survived, but not its spirit.

Moral philosophers often try to defend morality to the immoralist who only cares about themselves and maybe the people around them. But it seems to me that there might be an equally strong challenge from the other side: the hypermoralist who tries to follow morality’s demands as best they can but who is left cold and exhausted, no longer seeing the point of morality though still feeling bound to its dictates. What might the moral philosopher say in defense to this kind of case? It seems that it depends on diagnosing what exactly has gone wrong.

So, what has gone wrong when “moral burnout” appears? First, it seems that, like in normal cases of burnout, the person is not receiving enough support or care themselves. This might be from a systematic failure, such as doctors being unable to get their patients the care they need due to injustices in the healthcare system. It could be from an interpersonal failure, where friends and family members in that person’s life fail to see their needs or adequately support them. Or perhaps it is from an individual failure, such as the person failing to reach out for or accept help.

The main problem is that there is a significant mismatch between the amount of morally significant labor that the person gives and the amount of support and recognition they receive.

This mismatch alone, however, is not enough to explain why the hypermoralist is left cold by morality. Sure, they may feel exhausted and disillusioned with their job or the people around them, but they might say something like “morality is still worthwhile; it’s just that other people aren’t holding up their end of the deal with me.”

What else is required to become disillusioned with morality itself? Especially for those who were raised to take all the responsibility on themselves, it’s easy to misunderstand morality as having to do only with duties to others and not at all with duties to oneself. In this case, the person can fail to properly value or take care of themselves, and lose sight of an important part of morality – self-respect. It is no surprise that this kind of person would become disillusioned.

Even for those who understand the importance of duties to oneself, it can be easy to fall into a similar trap of self-sacrifice if no one else will take responsibility for a clear and present need.

Another possibility is that, even though the person recognizes and works to fulfill duties of self-respect and self-care, they may find themselves caught up in a kind of rule fetishism, where morality becomes merely a list of moral tasks to complete. Self-care becomes another obligation to fulfill, rather than a chance to rest and recuperate. In this state, morality can seem to be a matter solely of burdens and obligations that must be completed, without the sense of meaning that one would normally get from saying a kind word, helping someone else, or standing up for oneself. Perhaps the hypermoralist has lost sight of the possibility of healthier relationships with others, or is unable to set healthy boundaries within their relationships or accept friendship and help from others.

Like friendship, morality is not transactional – it isn’t simply a set of tasks to complete. Morality is essentially relational.

Though praising and blaming ourselves and others for the actions we perform is a core part of our moral practices, these norms allow us to analyze whether we stand in the right relation with ourselves and with others. It is no surprise, then, that the hypermoralist has lost the meaning of morality if they have substituted its relational core of love for self and love for others with a list of tasks and obligations that lack relational context.

So, what can the hypermoralist do to regain a sense of moral meaning? The answer to that question depends on a host of considerations that will vary based on the individual in question. The basic gist, however, is that it’s vital to seek meaningful and healthy relationships and advocate for support when it’s needed. For example, a doctor in an unjust working environment might protest the indifference and profit-motivation of insurance companies who stand in the way of their patients getting the care they need. Ideally, this would not be another task that the doctor takes up alone but one that allows them to be in solidarity with others in their position — meeting people they can trust and rely upon along the way. Seeking out those meaningful and healthy relationships (moral and otherwise) can be tricky. But I hope for all of us that we can find good friends.

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Essential Work, Education, and Human Values

photograph of school children with face masks having hands disinfected by teacher

On August 21st, the White House released guidance that designated teachers as “essential workers.” One of the things that this means is that teachers can return to work even if they know they’ve been exposed to the virus, provided that they remain asymptomatic. This is not the first time that the Trump administration has declared certain workers or, more accurately, certain work to be essential. Early in the pandemic, as the country experienced decline in the availability of meat, President Trump issued an executive order proclaiming that slaughterhouses were essential businesses. The result was that they did not have to comply with quarantine ordinances and could, and were expected to, remain open. Employees then had to choose between risking their health or losing their jobs. Ultimately, slaughterhouses became flash points for massive coronavirus outbreaks across the country.

As we think about the kinds of services that should be available during the pandemic, it will be useful to ask ourselves, what does it mean to say that work is essential? What does it mean to say that certain kinds of workers are essential? Are these two different ways of asking the same question or are they properly understood as distinct?

It might be helpful to walk the question back a bit. What is work? Is work, by definition, effort put forward by a person? Does it make sense to say that machines engage in work? If I rely on my calculator to do basic arithmetic because I’m unwilling to exert the effort, am I speaking loosely when I say that my calculator has “done all the work”? It matters because we want to know whether our concept of essential work is inseparable from our concept of essential workers.

One way of thinking about work is as the fulfillment of a set of tasks. If this is the case, then human workers are not, strictly speaking, necessary for work to get done; some of it can be done by machines. During a pandemic, human work comes with risk. If the completion of some tasks is essential under these conditions, we need to think about whether those tasks can be done in other ways to reduce the risk. Of course, the downside of this is that once an institution has found other ways of getting things done, there is no longer any need for human employees in those domains on the other side of the pandemic.

Another way of understanding the concept of work is that work requires intentionality and a sense of purpose. In this way, a computer does not do work when it executes code, and a plant does not do work when it participates in photosynthesis. On this understanding of the concept of work, only persons can engage in it. One virtue of understanding work in this way is that it provides some insight into the indignity of losing one’s job. A person’s work is a creative act that makes the world different from the way it was before. Every person does work, and the work that each individual does is an important part of who that person is. If this way of understanding work is correct, then work has a strong moral component and when we craft policy related to it, we are obligated to keep that in mind.

It’s also important to think about what we mean when we say that certain kinds of work are essential. The most straightforward interpretation is to say that essential work is work that we can’t live without. If this is the case, most forms of labor won’t count as essential. Neither schools nor meat are essential in this sense — we can live without both meat and education.

When people say that certain work is essential, they tend to mean something else. For some political figures, “essential” might mean “necessary for my success in the upcoming election.” Those without political aspirations often mean something different too, something like “necessary for maintaining critical human values.” Some work is important because it does something more than keep us alive; it provides the conditions under which our lives feel to us as if they are valuable and worth living.

Currently, many people are arguing for the position that society simply cannot function without opening schools. Even a brief glance at history demonstrates that this is empirically false. The system of education that we have now is comparatively young, as are our attitudes regarding the conditions under which education is appropriate. For example, for much of human history, education was viewed as inappropriate for girls and women. In the 1600’s Anna Maria van Schurman, famous child prodigy, was allowed to attend school at the University of Utrecht only on the condition that she do so behind a barrier — not to protect her from COVID-19 infested droplets, but to keep her very presence from distracting the male students. At various points in history, education was viewed as inappropriate for members of the wealthiest families — after all, as they saw it, learning to do things is for people that actually need to work. There were also segments of the population that for reasons of race or status were not allowed access to education. All of this is just to say that for most of recorded history, it hasn’t been the case that the entire population of children has been in school for seven hours a day. Our current system of K-12 education didn’t exist until the 1930s, and even then there were barriers to full participation.

That said, the fact that such a large number of children in our country have access to education certainly constitutes significant progress. Education isn’t essential in the first sense that we explored, but it is essential in the second. It is critical for the realization of important values. It contributes to human flourishing and to a sense of meaning in life. It leads to innovation and growth. It contributes to the development of art and culture. It develops well-informed citizens that are in a better position to participate in democratic institutions, providing us with the best hope of solving pressing world problems. We won’t die if we press pause for an extended period of time on formal education, but we might suffer.

Education is the kind of essential work for which essential workers are required. It is work that goes beyond simply checking off boxes on a list of tasks. It involves a strong knowledge base, but also important skills such as the ability to connect with students and to understand and react appropriately when learning isn’t occurring. These jobs can’t be done well when those doing them either aren’t safe or don’t feel safe. The primary responsibilities of these essential workers can be satisfied across a variety of presentation formats, including online formats.

In our current economy, childcare is also essential work, and there are unique skills and abilities that make for a successful childcare provider. These workers are not responsible for promoting the same societal values as educators. Instead, the focus of this work is to see to it that, for the duration of care, children are physically and psychologically safe.

If we insist that teachers are essential workers, we should avoid ambiguity. We should insist on a coherent answer to the question essential for what? If the answer is education, then teachers, as essential workers, can do their essential work in ways that keep them safe. If we are also thinking of them as caregivers, we should be straightforward about that point. The only fair thing to do once that is out in the open is to start paying them for doing more than one job.

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Some Hospitals Sue Their Delinquent Patients. Should They?

photograph of coin jar spilling out on top of medical bills

Despite the passing of the Patient Protection and Affordable Care Act — i.e., Obamacare — in 2010, health care reform remains a contentious political issue. Costly procedures and huge medical bills still pose insurmountable financial burdens for many Americans — even those who are insured; thus, the appetite to ameliorate the pain remains. As reported in a recent CNBC article, a recent study concluded that 66.5% of all bankruptcies were related to medical issues. Whatever the positive effects of health insurance reform have been, it has not provided full protection for people from the threat of financial ruin because of unpaid medical bills.

Are there policies that healthcare systems and hospitals have instituted that may be exacerbating this problem? Indeed. Some hospitals will sue their patients for these unpaid medical bills, thus subjecting some patients to the additional expenses and stresses of navigating the legal system. Now, not all hospitals do this, and some hospitals sue their patients much more than others. A recent NPR article covered a study published in The Journal of the American Medical Association (JAMA) that showed that 36% of hospitals in Virginia sued patients and garnished wages in 2017. What’s more, just 5 hospitals accounted for more than half of the lawsuits, and all but one of these hospitals were non-profit institutions. As such, it is important to recognize this as a choice made by certain hospitals, rather than a widely accepted and unavoidable practice. In fact, hospitals have other choices to make regarding unpaid debts. These debts could be passed to collection agencies or written off as “bad debt.”

Hospitals, of course, face financial pressures of their own, and suing and garnishing to recoup unpaid medical debt is one strategy for easing these pressures. Hospitals defend the practice as both legal and transparent. Detractors claim that the practice violates the ethos of hospitals, understood as institutions that exist for the community benefit. We can approach the underlying divide in this debate in terms of whether healthcare is morally special. If health care is not special — if it is a normal consumer good just like other consumer goods — then it is fitting and proper to treat trade in healthcare goods as subject to contract law, where the courts play a vital role in ensuring fairness in economic relations. On the other hand, if health care is morally special — if it is not just like other consumer goods because it has some essential connection to the concerns of justice — then different rules governing economic conflicts in the exchange of health care goods ought to apply.

Presume that we are treat healthcare like any other good. By receiving healthcare services, customers implicitly agree to pay for them. By refusing to pay, they have broken this implicit contract. The courts exist as a transparent, politically legitimate, and unbiased enforcer of these contracts, ensuring that what debts have legally and properly been incurred do get paid. If service providers are not given the public assurance that they will be paid for the services they provide, then they would have to take on the extra risk of either losing out on payments or the extra burden of trying to collect on their own. Hospitals, thus, have a legal right to sue their patients, and it is fitting that they do.

If healthcare is a different kind of good — if healthcare is considered somehow special — then the above standard analysis of why service providers ought to have a right to sue no longer applies so neatly. Two observations can be made to suggest healthcare ought to be treated as special. First, healthcare exists to protect, maintain, and enhance a person’s health. Though through most of human history, our abilities to significantly affect the course of diseases had been limited, technological and social advances of the 20th and 21st century have produced a healthcare system that indeed can prolong the length and enhance the quality of lives. Having a life, of course, is a precondition of living a good life. Sickness and premature death limit the opportunities of living a life according to one’s life-plan. If justice entails the principal that society ought to foster equal opportunity, then healthcare has special moral significance because of its connection to health and, therefore, life opportunities. This is the basic argument made by Norman Daniels in his 1985 book Just Health Care.

Healthcare’s special status may also be rooted in vulnerability. The instinctive value we place on protecting our own health and well-being makes us vulnerable to exploitation when our health is threatened. The standard model outlined above presumes that the consumer will act rationally and take into consideration things like price and need when purchasing a product. And yet for the need of prolonging one’s own life and health, there is often no price we wouldn’t accept. This is not to say that reforms to the healthcare system that would force hospitals to be more transparent about price wouldn’t be a welcome change. Rather, I doubt that this change alone would significantly protect patients’ vulnerability to exploitation on this matter.

Considering these observations, one may argue, healthcare should be given a special status, and standard norms of contract law ought not to define the rights and responsibilities of providers in attempting to collect on medical debts. If we follow this line of argument, we are still stuck with the obvious rejoinder that providers deserve to be compensated for their vital labor. We should not expect them to work for free. I think this quite quickly pushes us down the path of envisioning publicly funded schemes to finance health care, whether that be a single-payer model or some other mixed system. If healthcare’s moral importance undercuts the private rights of economic actors in the healthcare market, then public obligations ought to step in to ensure a scheme that distributes care to those in need and adequately compensates the caregivers central to the system.

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Does Care Require Personhood? The Ethics of Robot Caregiving

Smiling caregiver embracing happy senior woman in nursing home

Emerging technologies have presented people that require daily medical services with a wider range of options. For example, Rudy the healthcare robot can be purchased by a patient for $5,000 or leased for $100 a day. Though these numbers may seem high, the average cost of at-home medical care provided by a human caregiver is $4,099 a month. Rudy offers care at a significantly lower cost. Rudy can perform a wide range of tasks including wound care, ostomy care, and the administration of injections. Often, patients simply need assistance getting out of bed to use the restroom at night, and as round-the-clock medical assistance is particularly expensive, Rudy can be there for the basic nighttime needs of patients at a fraction of the cost.

For people who suffer from depression, anxiety, or related mental health challenges, there is PARO, the robotic therapy seal. In a promotional video for PARO, a research scientist makes the remarkable claim that “PARO has a value system that includes enjoying being stroked and disliking being hit.” The personality of the seal is determined by what its owner likes. When the seal is stroked, the behavior that preceded the stroke will be reinforced, and the seal will engage in that behavior more frequently. As a result, the patient can guarantee that the robotic seal will exhibit behavior that they find soothing or uplifting. The psychological results are similar to the results produced by therapy animals, but without the uncertainty that comes along with the spontaneous behavior of a living creature. The robot is particularly effective in providing psychological relief to patients with dementia.

Relatedly, Same Day Security recently raised 35 million dollars for its Addison project. Addison is a virtual healthcare companion who appears on ten-inch screens strategically placed around one’s home, asking patients regularly about whether they’ve taken their medication, exercised, or consumed healthy meals. Addison can detect motion and can guide patients through exercise routines. Addison can also track vital statistics and keeps records of those statistics to share with the patient’s doctor, should the patient choose to do so.

For a number of reasons, these technologies appear to many to be a step in the right direction. Many sick people who require frequent care don’t have family members that can reliably provide that care, and the cost of personalized care can be quite steep. But it’s more than simply a matter of cost. Medical procedures involve the care of bodies and a person’s body is something over which they frequently want to retain some privacy. These procedures are very personal procedures, and the involvement of another human being can sometimes be quite jarring and even humiliating. Each of these potential solutions – Rudy, PARO, and Addison – is incapable of taking the kinds of attitudes toward human bodies that a patient might fear. If a patient is humiliated in the presence of a robot caregiver, they’ve made a category mistake.

Another benefit of robotic and virtual technology when it comes to healthcare is that robots won’t be affected by the stress inherent to the healthcare system. Even the most professional human healthcare providers can respond poorly to the difficulties posed by ill health. Understandably, patients aren’t always capable of responding to their medical problems with good humor, and this can be difficult to navigate for a human caregiver. Robot caregivers are in a better position when these difficulties arise.

In cases in which a patient cannot afford a professional caregiver, the responsibility often falls to family members. If a patient is elderly, their children frequently step in to provide the care. These adult children often have careers and families of their own, and the new responsibility of providing care for an ailing parent can be a significant stressor. What’s more, this burden tends to fall disproportionately on the shoulders of the patient’s female children. When career and other personal sacrifices need to be made to make time for caregiving, it is more often females who make those sacrifices. Robot caregivers provide a potential solution for everyone, and help to lessen the disproportionate burden placed on women.

These new trends in healthcare technology might be useful for other reasons. Many countries, like China, have rapidly aging populations. By the middle of this century, 450 million people in China will be over the age of 65. There simply aren’t enough caregivers to satisfy the needs of all elderly patients. This trend is exacerbated by people having fewer children in order to reduce carbon emissions. When populations start having fewer children, they also ultimately have fewer young people to provide care as older generations age. Robot caregivers can potentially solve this problem.

Others are not so impressed with this technology. They argue that care relationships are, fundamentally, relationships between persons. While PARO, Addison, and Rudy provide services for patients, they aren’t actually providing care for patients. Care requires attentiveness to needs and a genuine willingness to satisfy those needs for the good of the person in need. We are falling short of our duty to patients if we provide them, merely, with service, when every person is deserving of care.  

It may well be the case that these technologies are less expensive for patients, and that’s important. But the fact that robot care is less expensive might be viewed as an indictment of our health care system rather than an argument in favor of a robotic solution. Perhaps instead we should support elected officials who plan to pass legislation to make health care affordable for everyone. We could lessen the burden on family members by creating a system in which real human professionals were affordably available to anyone in need of their services.

For patients who desire increased privacy, robotic health care could continue to be an option. It shouldn’t be the case, however, that patients are essentially coerced into choosing a less intimate form of care simply because they cannot afford the alternative.