Mere Sources of Error: Workers, Patients, and the Reductive Logic of Rationalized Healthcare

Abstract

This project represents a sustained critique of the reductive logic of rationalized healthcare delivery systems which reduces the individuality of both workers and patients to little more than problems for the system itself. Drawing on social theory and ethnographic data, I show that wherever clients’ needs or the caregiver’s empathic responses to those needs threaten the efficient working of the system, both are taken as aberrant, as “mere sources of error”.

In contrast to this systemic dismissal of workers’ empathic responses to the personal needs of patients, I consider the basis in moral philosophy for the view that workers’ caring impulses ground morality writ large and are essential in the provision of humane care. Hence, I argue, such feelings should be carefully heeded and cultivated rather than ignored and controlled. I also argue – in distinct opposition to modern managerial logic – that there are strong grounds, both moral and managerial, for less systemic control over caregivers’ time and practices. A reduction in central control is important not only because adequate care is time-consuming, but because unstructured time and space are necessary for the development of the sort of caring attitude that is essential for humane caregiving practices. Time and space are also key for the cultivation of phronēsis, a form of wisdom that enables one to discern when a system, not a person, has gone wrong, and when efficiency must be sacrificed in the name of humanity.

While such reflections apply to healthcare delivery systems generally speaking, the development of morally wise and caring workers is especially crucial for work done with persons suffering from severe and persistent mental illness (SPMI). Because such persons have been thoroughly marginalized in society, drawing them back into a community of care is essential to meeting their needs. Based on my own ethnographic observations, I contend that the ethos of Assertive Community Treatment (ACT) represents a refreshing departure from the rationalized treatment modalities that prevail in modern psychiatric facilities. The program, however, is becoming increasingly rationalized as it enters the mainstream, bringing pressure for more detailed management of workers’ activities. The encroachments that are likely to follow from this intensification of management may well erode some of the most morally valuable aspects of ACT work.