Healthcare Quarterly

Healthcare Quarterly 6(2) December 2002 : 62-65.doi:10.12927/hcq..16645
Perspective

House of Healing, House of Disrespect: A Kantian Perspective on Disrespectful Behaviour among Hospital Workers

Mark Bernstein and Rita Fundner

Abstract

Respect toward patients is one of the most fundamental and central tenets guiding both modern bioethical practice and the everyday behaviour of all healthcare professionals. However, similar courtesy and respect is often breached in day-to-day interactions between hospital workers. Many examples are relatively minor, while egregious examples such as gender discrimination and physical abuse do occur. The more egregious transgressions may be handled by formal processes, even legal proceedings. However, the innumerable smaller examples of disrespectful behaviour are ubiquitous and insidious in their erosion of a productive collaborative approach to patient care and other aspects of functioning within the institution. The authors briefly summarize some of the pertinent literature on this subject and analyze the problem of disrespect in the hospital with special focus on the issue as seen from the perspective of the moral philosophy of Immanuel Kant. Some simple recommendations for improving disrespectful behaviour amongst hospital workers are offered.

Introduction

Hospitals are relatively stressful working environments. Healthcare workers are dealing with a "commodity" that, after freedom, is arguably the most highly valued by most people - their health and well-being. There are work deadlines, some of which operate in terms of seconds or minutes, and numerous power struggles similar to those that exist in other large, complex non-medical organizations. Hospital-specific pressures include limitations on resource availability, having to face the inevitable triumph of insurmountable medical foes over our patients, and dealing with failure and mistakes (Bosk 1979; Hilfiker 1998). Furthermore, besides the arduous clinical responsibilities to patients, many hospital employees are overextended with administrative, educational and research responsibilities, for many of which they are inadequately compensated or are given inadequate time to perform as well as they wish. Finally, many healthcare workers are simply overworked and often fatigued, physically and/or emotionally. These factors add to stress levels and produce a climate ripe for disrespectful and sometimes abusive behaviour by well-meaning and hard-working professionals who have chosen to work in the most noble of professions.

Examples of simple discourtesy are extremely common; more serious offences such as gender or racial discrimination or physical abuse are uncommon but not rare. Examples of daily, common episodes of disrespectful behaviour include:
(1) a committee member fails to attend a meeting without sending regrets or a replacement; (2) an administrator fails to respond to a physician's request for information in a timely fashion; (3) a nurse manager complains about a surgeon to the surgeon's department head without first addressing the issue directly with the surgeon; (4) a physician misrepresents the truth to avoid the consequences of his or her actions; (5) a manager talks over and interrupts another speaking at a meeting; (6) a surgeon speaks condescendingly to a resident about a mistake; and innumerable others.

There is a substantial literature on the subject of satisfaction in the workplace and the role and importance of respect (see reference list). Entry of the words "workplace disrespect" as a search phrase yielded over 5,000 web pages per search engine used, and "workplace conduct," well over 600,000! Many hospitals have developed codes of conduct (see for example: <<a href="https://142.224.24.133/home/code_of_conduct/index.asp" target="_blank">https://142.224.24.133/home/code_of_conduct/index.asp>) articulating what kind of behaviour will not be tolerated in the institution and how certain behaviours will be punished, although most cases of disrespectful behaviour go unreported. Scholars have described in qualitative fashion the values that individuals working in healthcare organizations ought to hold dear (Reiser 1994).

In this paper we examine disrespect in the workplace from an ethical perspective, specifically, that embodied in the moral philosophy of Immanuel Kant.

Respect in the Medical Workplace - A Kantian Perspective

Immanuel Kant's writings contributed to the development of deontological ethical theory, which is one of the major moral theories to influence modern medical bioethics. Kant's writings on moral philosophy are translated in a number of volumes; the primary volumes we refer to are the Cambridge edition (Kant 1996) and the translation by Paton (Kant 1948).

We start to learn Kant's moral philosophy in Groundwork of the Metaphysics of Morals (1948). His main thesis is that the moral worth of an act is not in the outcome it produces but whether it is done from a sense of duty or obligation. "A human action is morally good … because it is done for the sake of duty" (1948: 19). "An action done from duty has its moral worth, not from the results it attains or seeks to attain, but from a formal principle or maxim - the principle of doing one's duty whatever that may be" (1948: 20).

Kant is very clear about the respect due human beings. He articulates this in the section in The Metaphysics of Morals entitled On Duties of Virtue toward Other Human Beings Arising from the Respect Due Them. "Every human being has a legitimate claim to respect from his fellow human beings and is in turn bound to respect every other ... he is under obligation to acknowledge, in a practical way, the dignity of humanity in every other human being. Hence there rests on him a duty regarding the respect that must be shown to every other human being" (1996: 579). He speaks of modesty as "willing restriction of one's self-love in view of the self-love of others" (1996: 579), indicating that we must often put others' needs ahead of our own. He refers to the kingdom of ends in stating: "Humanity itself is a dignity; for a human being cannot be used merely as a means … but must always be used at the same time as an end" (1996: 579). This is very relevant when we speak of disrespect in the workplace. Many examples of disrespectful behaviour arise from the power struggle between subordinates and superordinates, or between peers, in which one is attempting to gain the upper hand of control or strive toward self-promotion by using the other as a means to his/her ends.

Kant recognizes that it is acceptable to have a low opinion of someone or inwardly look down on them, but if the outward manifestation of this is disrespectful behaviour, it is nevertheless an offence. In other words, we should treat with dignity those with whom we don't agree. He also admonishes us to treat with dignity those who may be inferior or who have committed an error. "On this is based a duty…to not censure his errors by calling them absurdities, poor judgment…but rather to suppose that his judgment must yet contain some truth …" (1996: 580). In other words, give people the benefit of the doubt, and if they have frankly erred, don't treat them disrespectfully but with understanding. This is in line with sound behavioral modification practice where positive reinforcement is more effective than punishment and saving face typically benefits both parties.

Kant speaks of other character traits that we know to be germane to disrespectful behaviour. Many examples of disrespect are centred around lying and Kant is categorical in his condemnation of lying. He states that "the greatest violation of a human being's duty to himself … is the contrary of truthfulness, lying. In the doctrine of right an intentional untruth is called a lie only if it violates another's right; but in ethics where no authorization is derived from harmlessness, it is clear … that no intentional untruth in the expression of one's thoughts can refuse this harsh name" (1996: 552). Lying … need not be harmful to others in order to be repudiated … the speaker may even intend to achieve a really good end by it" (1996: 553). By this statement it appears that Kant is categorical in his condemnation of the act of lying; there appear to be no exceptions. However, depending on interpretation, he does seem to imply that a discretionary use of lying might be acceptable to save hurting someone's feelings or to protect others (Kant 1996: 554). In the real world, situational ethics often prevail and a "white lie" is required to save hurting a colleague's feelings. Furthermore, truth can be personal and subjective and is not always as obvious as it was in Kant's world.

An important trait that would prevent much disrespectful behaviour is beneficence, about which Kant writes passionately. "… beneficience is the maxim of making others' happiness one's end, and the duty to it consists in the subject's being constrained by his reason to adopt this maxim as a universal law (1996:571). "To be beneficient, that is, to promote according to one's means the happiness of others in need, without hoping for something in return, is everyone's duty" (1996: 572). Imagine what the workplace would be like if we were able to live up to the standards of duty Kant set regarding one's beneficence to others!

Kant also speaks of gratitude, which "consists in honoring a person because of a benefit he has rendered us …Gratitude is a duty" (1996: 573). The opposite of gratitude is ingratitude, which is certainly a source of disrespectful behaviour. "When ingratitude toward one's benefactor extends to hatred of him it is called ingratitude proper, but otherwise mere unappreciativeness. It is, indeed, publicly judged to be one of the most detestable vices" (1996: 577). An example of this would be when we fail to acknowledge or thank someone who has done something positive on our behalf. How often do any of us properly thank or acknowledge our superordinates or our subordinates when they do positive acts on our behalf, often on a daily basis for years on end? For example, many managers hear from their charges only when all is not well, but silence or the open expression of discontent is the general response while managers tirelessly and successfully fight daily battles on behalf of their colleagues.

Another important trait Kant considers a duty is sympathetic feeling. Sympathy with and compassion for patients' suffering is the motivating force that brings healthcare providers into the very environment we are examining. But what about our compassion and empathy for our co-workers? Kant states: "But while it is not in itself a duty to share the sufferings (as well as the joys) of others, it is a duty to sympathize actively in their fate; and to this end it is therefore an indirect duty to cultivate the compassionate natural feelings in us" (1996: 575). This ability to feel sympathy is one of the features that distinguishes us from sociopaths. Many instances of disrespectful or uncaring behaviour toward co-workers would be averted if we sympathized with someone we disagreed with or who has committed an error. Sometimes we demonstrate unsympathetic behaviour by failing to distinguish ourselves from our team members in holding others up to our own very high standards.

The opposite of sympathy is malice, according to Kant, and unfortunately examples of overtly or covertly malicious behaviour are not uncommon in the workplace. Kant states it well when he says: "… we feel our own well-being and even our good conduct more strongly when the misfortune of others or their downfall in scandal is put next to our own condition, as a foil to show it in so much the brighter light" (1996: 577). In other words, benefitting from others' misfortune to make ourselves look better - again, a common occurrence in complex organizations like hospitals - is to be decried.

Kant also described three specific vices that violate duties of respect for other human beings: arrogance, defamation and ridicule. Arrogance is: "… the inclination to be always on top … a kind of ambition in which we demand that others think little of themselves in comparison with us" (1996: 581). This is a major pitfall in goal-oriented, hard-driving, high-powered people and arguably the commonest motivating negative force in hospital personnel, giving rise to instances of disrespectful behaviour. Defamation is: "… the immediate inclination, with no particular aim in view, to bring into the open something prejudicial to respect for others" and ridicule is: "… wanton faultfinding and mockery, the propensity to expose others to laughter, to make their faults the immediate object of one's amusement …" (1996: 582). We have all witnessed or even been objects of arrogance, defamation, and ridicule; sometimes the expression of these can be very subtle. Unfortunately, some highly intelligent people are predisposed to expressing their mental acuity through cutting humour and sometimes painfully accurate insight, untempered by humility or sensitivity.

Finally, at the end of The Metaphysics of Morals, Kant includes an appendix entitled "On the Virtues of Social Intercourse" that, loosely interpreted, nicely depicts the kind of community our hospitals could aspire to be. "It is a duty to oneself as well as to others not to isolate oneself but to use one's moral perfections in social intercourse … to cultivate a disposition of reciprocity - agreeableness, tolerance, mutual love and respect …" (1996: 588). The complexity of organizations starts with the family and ends with the global village, with complex organizations like hospitals somewhere in between. All of these would be better places if they were characterized by agreeableness, tolerance, mutual love and respect.

Discussion

Every organization that has human beings as workers and a social order experiences regular episodes of less than optimal behaviour by workers toward each other. This is the nature of human behaviour and it is hard to imagine any family unit or workplace being devoid of examples of this. Perhaps we expect more of people working in hospitals because they are, after all, employees within institutions in which everyone is oriented towards the noblest of goals, that of helping improve the health and welfare of fellow human beings. However, hospitals are also full of aggressive, goal-oriented, administratively and academically ambitious individuals, many of whom wield considerable power within and outside the organization. These individuals have many of the vices Kant described and it would be naive to think that noble institutions like hospitals would have any better track record of behaviour than other complex organizations.

A brief analysis of the pertinent literature (random sample of 500 titles, selected from an initial search universe of 5,380 items, search topic: "disrespect in the workplace," on the Google search engine) indicates that at least half of the articles currently available on-line deal with various aspects of violence, including sexual harassment, anger management, verbal abuse, conflict management, manipulation, bullying, deception and pornography. Violence represents an extreme of disrespect and must be addressed through the rule of law.

The second-largest group of articles, roughly 30%, deals with disrespect in business contexts and the role of diversity. Themes include professional behaviour and morale, gender roles, race relations, human rights, political power, labour relations and cross-cultural communication.

While the larger, systemic concerns must be addressed at the institutional level through policy, investigation and reform, the more day-to-day issues have a profound and similar impact. They limit the ability of individuals to work effectively and the ability of teams to meet their service targets. These issues would be under-represented in both the electronic and the peer-reviewed conventional literature.

The human resources literature offers a full range of simple guidelines of conduct that reinforce day-to-day kindness, sensitizing individuals to one another's uniqueness and elevating civility and tolerance to a high value among peers (see for example: <<a href="https://www.cmu.edu/cmnews/021009/021009_code.html" target="_blank">www.cmu.edu/cmnews/021009/021009_code.html> or <<a href="https://www.hr.uwa.edu.au/policy/toc/perform_mgt/conduct_workplace" target="_blank">www.hr.uwa.edu.au/policy/toc/perform_mgt
/conduct_workplace>). In this context, listening well becomes more important than speaking. Managing expectations becomes as important as keeping promises. Helping each other be right and giving loyalty to the absent builds trust as well as flexibility. Maintaining the self-confidence and self-esteem of others by focusing on the situation, issue or behaviour, not on the person, when delivering negative feedback enables people to take risks and learn. Being willing to give "I" messages and to take ownership of personal actions and feelings creates a climate of openness and honesty in which not knowing becomes a window of opportunity rather than a sign of weakness.

We propose a brief set of guidelines, some general and some specific, that would materially decrease the level of disrespect among workers in the medical workplace and that we believe Kant would have approved of.

  1. Treat yourself and others in everyday interactions with dignity, respect and sensitivity.
  2. Be wary of holding others to standards that you feel you yourself meet but that may be impossible or even undesirable for them.
  3. Answer phone calls, e-mails, and other forms of communication in a timely manner. If you don't have an answer immediately at hand, acknowledge receipt of the other's query and let him or her know you're working on it.
  4. Attend meetings and discharge other commitments on time; if you can't make it, ask someone to attend on your behalf or, at minimum, send your regrets.
  5. Include all stakeholders in discussion of a problem or a decision. Make all information transparent and public to all those who could conceivably have an interest in knowing it or being part of the process to develop it.
  6. Acknowledge others for a job well done, privately or publicly, as appropriate.
  7. If you are in conflict with a colleague, speak to him or her directly; don't go above him to his superior until you've explored his side of it. Get all the information before you accuse a colleague of misbehaving.
  8. When you make a mistake, acknowledge it and say, "I'm sorry."
  9. When others make a mistake, forgive them and try to understand what motivated the error. Try to be tolerant of minor examples of disrespect that may represent honest oversights by colleagues.
  10. When you witness or experience an egregious transgression, have the courage to confront the offender and report it to higher levels if needed.

We do not propose by any means that this is an exhaustive or comprehensive list. We suggest that it could be used as a starting point for healthcare workers in hospitals to be more conscious of the necessity to show the same respect to their peers and co-workers that they do to their patients. An ethically robust and respectful work environment may well help produce an institution in which healthcare delivery is improved and in which those at all levels working very hard to deliver it enjoy greater satisfaction in the workplace.

About the Author(s)

Mark Bernstein is a Professor in the Department of Surgery at the University of Toronto and a neurosurgeon at the Toronto Western Hospital. He is currently completing an MHSc in Bioethics at the Joint Center for Bioethics at the University of Toronto.

Rita Fundner is a senior Human Resources practitioner and management consultant with experience in government, corporate and community settings. She is currently completing her CHRP designation.

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