Should a Good Healthcare Professional Be (at Least a Little) Callous?

Abstract

The term “callous” has not, to this point, been studied empirically or considered philosophically in the context of healthcare professionalism. It should be, however, because its uses seem peculiar. Sometimes “callous” is used to suggest that becoming callous confers a benefit of some protection against emotional distress, which might be considered expedient in the healthcare work environment. But, “callous” also refers to a person's unappealing demeanor of hardened insensitivity. The tension between these different moral connotations of “callous” prompts several empirical, psychological, and moral questions; I introduce and entertain a few here. I also suggest a distinction between callousness and inurement and argue for why this distinction is important to appreciate and uphold in health professions education.

Keywords:

• callous
• inurement
• professionalism
• moral perception
• moral damage

I. INTRODUCTION

In daily work, professional caregivers are called to witness human suffering and illness. They are also generally expected to learn not to be too bothered by what they witness. Physicians and nurses, in particular, are professionalized to subdue, control, and ultimately hide personal, emotional responses to situations' harrowing particulars when such responses could interfere with their abilities to render timely, competent healthcare to patients. This feature of professionalization strongly suggests that several empirical, psychological, and moral philosophical questions are worth asking about how and why students and young practitioners steel themselves against emotional distress, whether and when they become callous, ¹ and how their skills of perception might be compromised if they are callous.

II. QUESTIONS ABOUT BECOMING CALLOUS

“Callous” is sometimes used to describe a person's demeanor, as unfeeling or insensitive, for example. We might wonder whether a callous person can be empathic, we might wonder what she feels, or whether her feelings are intense, dull, expressed, or suppressed, and we might wonder whether there are relationships between being callous and being emotionally distant from patients, feeling burned out, or feeling anger toward patients, for example. But, my focus here is not on clinicians' feelings. Rather, it is on a clinician's capacity to sense and discern others' feelings, needs, deserts, or vulnerabilities; I will consider “callousness” as a condition of a capacity for moral perception, and I will consider factors other than clinicians' feelings that can interfere with their perceptions of others' feelings, needs, deserts, or vulnerabilities.

“Callousness” can characterize a range of demeanors. When a person becomes callous, she becomes hardened, desensitized, and possibly indifferent to another person's suffering. An extreme expression of callousness can even be contempt toward others who suffer. But, callousness can suggest that the very person who is callous has suffered, too. When a person is described as callous, such a description draws on metaphorical references to capacities for physical perception or a capacity to endure emotional strain: just as a callus on the body is an area of thickened skin that grows to toughen a well-worn area of the body (harpists' fingertips or pedestrians' heels, for example), “numbing,” an extreme of desensitization, is a concept frequently used to describe a person's response to distress or trauma. These meanings of callousness reflect common assumptions that being callous confers a benefit of protection against subsequent distress or trauma and that, in the context of healthcare, this protective benefit enables nurses and physicians to function effectively in the midst of distressing or traumatic conditions.

Are these assumptions about callousness true? It's not clear. At the very least, they raise a few psychological and empirical questions. Does being callous protect one from experiencing emotional distress? If so, what is the scope of such protection? Suppose a person becomes callous in response to one set of circumstances, which he experienced as distressing or traumatic. Does callousness confer protective benefit to him against emotional distress only in circumstances similar to those of the initial trauma, or in other situations too? Does a person become callous with respect to a specific field or pattern of particulars only? If so, how does callousness with respect to that specific field of particulars influence her perception of and responses to particulars in other situations?

In the context of healthcare, other questions—with empirical, psychological, and moral dimensions—arise. For example, Even if it's true that callousness protects a practitioner from experiencing emotional distress, does being callous enable a practitioner to be a better, more effective professional caregiver? If so, is “effective” defined in terms of endurance, in terms of compassion, in some other terms? Supposing callousness does confer protection against emotional distress that enables a caregiver to perform more effectively during, say, a trauma, might it also hinder that caregiver's ability to perform effectively in other situations that require sensitivity and empathy? More broadly, we can ask this question: How ought we to consider the relationship between callousness and healthcare professionalism?

This question is interesting and important because it invites us to account for and consider what appears to be a generally accepted belief among healthcare professionals, students of healthcare professions, and even patients, which is often articulated in this way: Some degree of callousness is necessary in healthcare professionalism. This question is difficult, too, because if we take seriously the belief that some degree of callousness is necessary in healthcare professionalism, it is hard to also take seriously another view, for which I will argue here: Callousness is a kind of damage to a practitioner's capacity for perception. I will try to show that the process of becoming callous is an incursion of moral damage, which can express as a reduction in a practitioner's sense of what she's responsible for. ² More precisely, callousness hinders a person's capacity for moral perception by limiting the scope of particulars she sees as constitutive of reasons to act in service to others.

The possibility of this kind of moral damage to healthcare professionals is a pressing concern; they are responsible for caring for people who are suffering and vulnerable. Furthermore, the problem of callousness as a form of moral damage is a particularly interesting, important, and complex one because we cannot accept both the belief that callousness is necessary for professionalism and the view that callousness is morally damaging to practitioners without also accepting corollary views that are logically awkward or morally problematic. As I've mentioned, the view for which I'll argue is that callousness damages a practitioner's moral perception by limiting the scope of particulars she sees as constitutive of reasons to act in service to others. This suggests that callousness renders a practitioner less responsive to others, and is, therefore, corrosive to healthcare professionalism.

It appears, then, that we cannot accept both the belief that callousness is necessary for healthcare professionalism and the argument that callousness is morally damaging to practitioners without also accepting the logically unusual corollary: That which is corrosive to professionalism is necessary for professionalism. Additionally, the moral problematic corollary that arises if we accept both the belief that callousness is necessary for professionalism and the view that callousness is morally damaging to practitioners is this: It is necessary that practitioners suffer moral damage as they become professionalized in healthcare.

Logically awkward or morally problematic corollaries can be avoided, however. First, we could revise the belief Some degree of callousness is necessary for healthcare professionalism. That is, perhaps what we really mean is that healthcare professionals need strategies for negotiating emotional distress in their work. Might not a different concept enable us to take seriously both healthcare practitioners' needs to have strategies for negotiating emotional distress and objection to the view that practitioners must suffer moral damage as they become professionalized? In the next section, I propose that the concept inurement holds promise to accommodate both of those points.

Second, logically awkward or morally problematic corollaries might be avoidable if my argument that Callousness is a kind of damage to a practitioner's capacity for perception is wrong. If it turns out to be the case that I'm wrong, then it would appear that callousness might not have worrisome implications for healthcare professionalism. In hopes that I'm right, however, I'm going to argue that callousness does damage a person's capacity for moral perception, and I'll articulate a moral philosophical view that explains how it does.

Finally, one last way to avoid logically awkward or morally problematic corollaries would be to justify why students and young practitioners should become callous, despite that it's morally damaging, as they become professionalized. At the very least, such a justification would need to motivate the view that students' and practitioners' suffering moral damage is acceptable. I wager, however, that motivating this view persuasively is difficult because, if I'm right that callousness is indeed morally damaging to students and young practitioners, an argument for why the damage is worth it would only be convincing in the presence of at least two things:

1. evidence that the empirical and psychological assumptions about the protective benefits of callousness against emotional distress, which I've listed above, are true; and

2. evidence that the loss of acuity of students' and practitioners' capacities for moral perception makes them more capable, effective responders to patients' vulnerabilities.

In the absence of such evidence, we must abandon commitment to the claim that callousness is necessary for healthcare professionalism, and we must seek other ways of accounting for practitioners' needs to learn strategies for negotiating emotional distress in their work.

III. THE IMPORTANCE OF BEING INURED

As I've just suggested, inurement better captures the idea that healthcare practitioners need strategies for negotiating emotional distress other than callousness. Like callousness, inurement refers to a process of transformation to a capacity for perception. Unlike callousness, however, inurement does not necessarily suggest that the person whose capacity for perception is transformed acquires a demeanor of insensitivity or indifference toward others. Rather, inurement is a process of habituating oneself, mindfully, to respond to hardship, such that the conditions of hardship become more familiar, and therefore, less threatening and easier to negotiate. Inurement is a process of training, strengthening, and growth over time. If it is the case that healthcare professionals should become toughened and hardened in order to be good caregivers, they should become inured, not callous.

When concepts like “tough” and “hard” are used to describe what healthcare professionals need to be in order to be able to negotiate their jobs, they are metaphors for their needs to develop strategies for negotiating emotional distress in the conditions in which they work. These metaphors need unpacking because they mean different things in different circumstances. In some cases, for example, successfully negotiating emotional distress might mean, at least temporarily, hiding it. In other cases, successfully negotiating emotional distress might mean participating in a post hoc staff debriefing session. Generally, however, one way to define successful negotiation of emotional distress is this way: A practitioner successfully negotiates emotional distress when he can preserve a mindset of caring and maintain capacious perception despite that he works in emotionally distressing conditions.

A mindset of caring requires three things: appreciating what (clinically and morally) is at stake in a situation, knowing what to do, and responding to the particular vulnerabilities of those for whom a practitioner has duties to care. Capacious perception is an orientation of oneself toward those for whom a practitioner has duties to care, which is guided by the practitioner's belief that those whom she serves need and deserve her caring, competent responses. Inurement is the cultivation of strength, of endurance of emotionally distressing conditions, and it is a process of learning how to preserve a mindset of caring and learning how to maintain capacious perception, despite such conditions.

Insofar as inurement is a process of habituating oneself, it requires a student to be self-aware, self-reflective, and willing to examine how her capacity for perception and her demeanors toward others are influenced by her experiences of emotional distress. This suggests that schools of nursing and medicine should accommodate spaces in which students can cultivate self-awareness and self-reflection. That is, insofar as inurement can be taught, it should be taught formally; students and young practitioners need instructional forums in which they can process their experiences of emotional distress with professionals and mentors who are trained to facilitate exploration of their experiences of and responses to emotional distress in their training. In particular, students and young practitioners need mentors trained to facilitate reflection on how their experiences of emotional distress influence their patterns perception and their methods of discerning their patients' vulnerabilities.

Faculty of health professions schools can discuss and debate to what exactly their trainees ought (and ought not) to become inured. But, failure to cultivate students' inurement formally puts students and young professionals at risk for taking up callous patterns of perception, which they might see modeled informally. This is not to say that facilitating students' inurement guarantees that they will not become callous, but formal facilitation of inurement might generate more self-awareness about their own processes of professionalization, and it might make them better equipped to avoid common pitfalls. One such pitfall of merely informally encouraging students to “toughen” is that “toughness” is easily misconstrued by students and by students' mentors; mentors who do not understand what it means to be inured can model callousness instead, leaving some students and young practitioners with the impression that callousness is a suitable demeanor that expresses good clinical comportment. Formally designed curricula could at least have mechanisms of keeping poor modeling in check, and they would provide students a forum in which to evaluate whether their mentors are inured or callous. Without a forum in which students learn to discern the differences between inurement and callousness, they are not allowed any formal opportunity to consider whether the patterns of moral perception modeled by their mentors express good or poor moral perception. As I've suggested, and as I will argue in the fourth section of this paper, callousness expresses poor moral perception. But, before we can understand how moral perception can become poor and dysfunctional, we need to first understand how moral perception works when it works well.

IV. A VIEW OF MORAL PERCEPTION AND MORAL REASONS

The philosopher Jonathan Dancy (1993) argues that what a moral agent does when she recognizes particulars in a situation and discerns patterns of salience among them, she construes a reason to act, which motivates her to act. A moral agent's perception of particulars and construal of reasons is guided by what she cares about, what she thinks is worth doing. When she deliberates about which actions are worth doing, and about which actions are worth doing this way rather than that way, she considers which values are most important to endorse by doing those actions; actions are worth doing when they express values with which a moral agent identifies. The philosopher Harry Frankfurt suggests that identification happens when

[a] person who cares about something is, as it were, invested in it. He identifies himself with what he cares about in the sense that he makes himself vulnerable to losses and susceptible to benefits depending upon whether what he cares about is diminished or enhanced. Thus he concerns himself with what concerns it, giving particular attention to such things . . . Insofar as the person's life is in whole or in part devoted to anything, rather than being merely a sequence of events whose themes and structures he makes no effort to fashion, it is devoted to this. (1988, p. 83)

So, when a moral agent sees something she cares about as somehow at stake, in Dancy's language, that thing acquires salience: it “protrudes” in the landscape of a moral situation. In addition to guiding a moral agent's perception of what is worth doing, what she cares about guides how she sees an action worth doing. As Dancy suggests, patterns of salience among particulars configure not only “a reason for doing it, but [also] a reason for doing it this way rather than that” (1993, p. 117). That is, when a moral agent thinks about how to do an action, she considers questions about when to do it, where to do it, and what dispositions to adopt as she does it. She considers what her action expresses about who she is. ³

What a healthcare professional thinks he has a reason to do is also guided by his beliefs about what patients need and deserve from him. When a practitioner properly discerns particulars that configure what another person needs and deserves, he recognizes ways in which the other person is vulnerable to suffering; he concomitantly construes what he is responsible for, what he owes the other person. His responses are moral responses to moral reasons; responses rendered with care address his patient's particular vulnerabilities. As I'll try to show, when practitioners become callous, their capacities for moral perception erode, they miss or misconstrue reasons there are to act, and, as a result, they can fail to respond as they ought to. When practitioners become inured, however, their capacities for moral perception can be maintained as open and inclusive, despite emotional distress.

V. INUREMENT AND MORAL PERCEPTION

In some cases, inurement among healthcare professionals might be analogous to “tough love” by parents. Use of this analogy might appear to carry unappealing valences of paternalism. To be clear, however, I do not draw on this analogy to suggest that healthcare professionals ought to be like parents to patients, but rather to suggest that inurement is not an exclusively professional process ⁴ and to consider similarities between “tough love” and inurement as ways in which caregivers (nonprofessional and professional) can orient themselves toward those for whom they have duties to care in situations that are emotionally distressing. Consider, for example, the moral terrain parents negotiate when they punish a child; despite that the parent sees punishment as necessary, carrying out punishment can be emotionally distressing. If this analogy from parenting is apt for clinicians, it is useful insofar as it suggests that “tough love” is an orientation caregivers assume toward those for whom they have duties to care, which can be morally required and even morally excellent. “Tough love” might be skillfully done with nuanced feeling—perhaps with the thought, “I see that you're suffering, and I'm sorry you're suffering”—but delivered unwaveringly, decisively, with care.

Of course, there is at least one important distinction that must be drawn between parents, as nonprofessional caregivers, and healthcare practitioners. Love is what we expect in the personal context, of families, of parents as they go about the projects of caring for and raising children. It is not, however, what we generally expect, or what we should generally expect, of healthcare professionals responding to patients or colleagues. From healthcare professionals, we expect responses that are less than loving, but more than merely timely and competent. That is, we expect responses to be rendered with care, and caring responses are generated from a practitioner's mindset of caring and capaciously perceptive demeanor.

Emotional distress in the healthcare work environment can come from several different sources: working amidst tight time constraints, working long hours, witnessing human suffering and harrowing particulars of illnesses, negotiating communication on difficult and awkward topics with patients and their loved ones, experiences that one is not free to act as she is motivated to act, and inflicting pain. This last source of emotional distress illustrates particularly interesting features of how inurement can strengthen a practitioner's skills of moral perception. Some situations in which nurses and physicians experience conflicts between duties to respond to a patient's suffering and duties to do something else important that might inflict pain suggest circumstances in which healthcare professionals cannot care effectively for patients unless they are inured to emotional distress. For example, when a child receives an important shot, a nurse might experience emotional distress as she inflicts pain. Clearly she has a duty to administer that shot in a way that inflicts as little pain as possible, but regardless of how skillfully and compassionately the shot is given, it still might be unavoidably painful for the patient. Despite that the nurse hears the child cry and sees the child wince, she can still have a duty to press on. In such cases, successfully negotiating the emotional distress of inflicting pain means being able to “see beyond” certain particulars. Here, the phrase “seeing beyond” is a metaphor for a pattern of concomitant moral perception and value assessment.

Particulars like crying and wincing might appear prominently in the moral landscapes of most situations, and usually they configure reasons for healthcare professionals to act immediately to alleviate pain. In some situations, like those in which a healthcare professional must inflict pain in order to provide good care, a healthcare professional must “see beyond” these particulars, such that they appear only in the background of a situation's moral landscape. In such a situation, the nurse “sees beyond” her patient's crying and wincing by assessing these particulars' relationships with other particulars, such as medical necessity for a painful shot. When a professional caregiver is inured such that she can pursue important goals in caring for a patient that could she not pursue if she did not “see beyond” certain particulars (which might configure reasons to respond immediately in other situations), when her perception of particulars is guided by carefully considered assessments of values that contextualize that situation, it can be not only expedient but appropriate for her to inflict pain. If inflicting pain is a condition of emotional distress for that caregiver, then she must be inured to that condition if she is to provide timely, competent medical care for her patient.

This kind of a situation suggests how inurement can be a moral achievement. “Tough love,” for example, can be seen as a moral achievement when, though carrying out a child's punishment can be emotionally distressing for the parents, it can also be, according to the parents' perception, the most loving way to treat their child. Similarly, for the nurse who must administer a painful shot, her inurement is a moral achievement when, though inflicting pain is emotionally distressing, she maintains a mindset of caring—she appreciates what (clinically and morally) is at stake in a situation, she knows what to do, and she responds to the particular vulnerabilities of the patient for whom she has duties to care. Furthermore, simply that the nurse experiences emotional distress when she inflicts pain is morally important. We have good reasons, for example, to worry about healthcare professionals who do not experience emotional distress in situations in which they must inflict pain to give timely, competent medical care to patients. The caregiver's experience of emotional distress suggests that she appreciates the clinical and moral relevance of her patient's pain. How she responds to her patient's pain reveals morally relevant features of her character as a person and practitioner; her recognition of her patient's pain suggests she maintains capacious perception in her practice.

Inuring oneself to the emotional distress of inflicting pain on others is a different process of habituation than inuring oneself to, say, the emotional distress of witnessing others' suffering or the realities of illness or the emotional distress of working long hours. The emotional distress of working long hours, in particular, can generate a practitioner's own feelings of vulnerability: Long hours isolate practitioners from their friends' and family members' support, for example. Regardless of whether one considers working long hours to be exploitative or necessary to learning how to be a good healthcare professional (or both), a practitioner's ability to maintain capacious perception is of utmost importance if she is to effectively discern patients' vulnerabilities. Inurement, then, can also mean habituating oneself to “see beyond” one's own vulnerabilities. In terms of moral perception, this means cultivating and maintaining the ability to apply the belief patients need and deserve my caring moral responses generously over time, despite conditions in which the practitioner's own needs might not be met. That is, when a practitioner experiences the emotional distress of not having his own needs met, when working long hours, for example, his tendency (which I would expect to be a common tendency generally among human beings) might be to shift the focus of his perception from others to himself. Such a shift in moral perception can be facilitated when a practitioner applies the belief patients need and deserve my caring moral responses less and less generously over time.

In terms of moral perception, a practitioner's processes of inurement are

1. processes of habituating herself to apply beliefs about what others need and deserve from her broadly, inclusively, and generously; and

2. processes of resisting tendencies to apply those beliefs narrowly, exclusively, and parsimoniously, despite conditions of emotional distress.

This understanding of inurement as processes of habituating oneself over time to maintain capacious perception allows us to see how inurement can be considered as a moral achievement. In the context of healthcare professionalization, inurement suggests that a practitioner has learned to simultaneously negotiate emotional distress and maintain capacious perception, which can enable him to continue to maintain acute awareness of and sensitivity to patients' vulnerabilities, and to respond with care to patients over time. In stark contrast to inurement as a process of moral achievement, callousness is a process of moral damage, which erodes a practitioner's motivation to respond to others with care over time.

VI. CALLOUSNESS AND FAULTY MORAL PERCEPTION

One way a moral agent can express poor moral perception is by limiting the scope of particulars she recognizes as morally relevant and construes as constitutive of reasons to act. As I've suggested, a healthcare professional might internalize poor patterns of moral perception by applying the belief patients need and deserve my caring moral responses less and less generously over time. I suggested earlier that a student needs to be self-aware, self-reflective, and willing to examine how her capacity for perception and her demeanors toward others are influenced by her experiences of emotional distress if she is to become inured. I add now that she also needs to be willing to examine how she applies her beliefs and how those applications influence her construals of what patients need and deserve from her. Students and young practitioners come to their training with a panoply of beliefs; some are mere background beliefs and some are prominent identity-constituting beliefs. Either way, there doesn't appear to be any good reason to assume that bad beliefs would be any less a part of the panoply of beliefs for health professions students as they might be for any other segment of the population. What we call a “bad” belief in the context of healthcare, or in society generally, is a matter for debate, and I will not engage that debate in any depth here. Rather, for purposes of discussion about moral perception, I will not focus on the content of beliefs, but rather on their functions in moral perception.

That is, one way professionals can decrease the generosity with which they apply the belief patients need and deserve my caring moral responses to those whom they serve is by nurturing other beliefs, which might be bad beliefs, that function to diminish the salience of particulars that configure patients' needs, vulnerabilities, or desert of care. As the belief patients need and deserve caring moral responses becomes a less steadfast guide to a practitioner's moral perception, she is decreasingly likely to properly discern the moral import of particulars and construe moral reasons that are there to respond to patients' vulnerabilities in the situations she faces. Consequences for patients and colleagues can be serious.

Consider two cases, which can be considered clear cases of callousness. As clear cases, they serve the purpose of illustrating classic features and patterns of poor moral perception. Instances of callousness, or suspected instances of callousness, might be compared to these cases and reviewed based on whether and how they resemble these classic features and patterns of poor moral perception. Identifying erroneous construals of reasons there are for acting and understanding expressions of poor moral perception enable starting points for identifying particular beliefs that might misguide moral perception; these practices can be useful for clinical educators and mentors of health professions students and young practitioners, who have the goal of cultivating practitioners who are inured, not callous.

The first case involves Dr. Small, a callous, frustrated obstetrician in Anne Fadiman's The Spirit Catches You and You Fall Down (1997). This case consists of a series of statements he made in interviews with Fadiman. Consider a statement he made, which reveals the terms in which he sees Hmong patients:

You or I, we can't conceive of the degree of ignorance. [The Hmong] are almost a Stone Age people. Hell, they never even went to a doctor before. They just had a baby in the camp or the mountains or wherever the hell they came from. (Fadiman, 1997, p. 73)

Fadiman also reported his response to being asked about caring for Hmong patients during labor and delivery:

They don't do a damn thing you tell them . . . They just come in late and drop it out. In fact, they wouldn't come at all if they didn't need to get the birth certificate so they could get more welfare. (Fadiman, 1997, p. 73)

Fadiman also reported comments Small made about Hmong immigration to the United States:

I and my friends were outraged when the Hmong started coming here . . . Outraged. Our government, without any advice or consent, just brought these nonworking people into our society . . . [T]hese Hmong just kind of fly here in groups and settle like locusts. They know no shame, being on the dole. They're happy here. (Fadiman, 1997, p. 235)

Although Fadiman did not address Small's apparent ignorance of Hmong persons' service to the United States Government during the Vietnam War, ⁵ she did challenge his perception that Hmong people are happy in the United States. In particular, she wrote of having mentioned to Small the high rate of depression among Hmong refugees (Fadiman, 1997, p. 235). Small replied as follows:

What do you mean? This is heaven for them! They have a toilet they can poop in. They can drink water from an open faucet. They get regular checks and they never have to work. It's absolute heaven for these people, poor souls. (Fadiman, 1997, p. 235)

A second case with a callous practitioner is recounted as follows:

Jen Lane is called to the emergency department to see a patient with severe abdominal pain. She enters the room and sees Mrs. Millon, whom she seems to recall having seen a few weeks back for a head injury. She then sees Mr. Millon, who eagerly jumps up from his seat to introduce himself. He continues, “Thank you for coming so quickly, doctor. I'm very concerned about my wife.” Jen looks to her, recognizing bruises of several shades on her arms and neck, “Tell me what the trouble is, Mrs. Millon.” Mr. Millon pipes up, “She gets these terrible headaches and they make her dizzy and she fell down the stairs and rolled right onto her belly.” Jen looks at him, and then looks at Mrs. Millon, who quickly looks down. “Well, we'll need an MRI to get an idea of what's going on inside that belly. Wait right here and I'll make a couple calls and draw up some orders; I'll be right back.”

Jen leaves the room, closes the door, and sighs. “I hate these cases,” she thinks. “What am I supposed to do for these women who can't help themselves? I feel sorry for her, but what an idiot! Why doesn't she leave this guy?”

In contrast to robustly responsible professionals, who apply concepts of need and desert generously, and maintain the scope of their moral perception as broad, capacious, and inclusive, Small and Lane are callous and express damaged moral perception. Both practitioners apply concepts of desert and need meagerly, and the scope of particulars they see as constitutive of reasons to act in service to their patients is narrow, limited, and exclusive.

But isn't Small just racist? And might not Lane just be frustrated with a bad recurring situation? Their remarks are not, after all, directed at their patients. Why should we consider Small and Lane to be callous? These questions necessitate the introduction of a few important distinctions. First, callous remarks need not be directed at particular persons in order to be callous; they are callous because they express patterns of narrow moral perception, instead of capacious moral perception, and meager, instead of generous, application of the belief patients need and deserve my caring moral responses. Even if callous remarks do not express as callous actions, they can nurture unprofessional, uncaring demeanors: contempt, disrespect, or discourtesy toward others (perhaps some particular others). Furthermore, callous remarks suggest that a practitioner might see herself responsible for less when serving those about whom she has made such remarks. Actually, Small probably is racist and Lane very likely is frustrated; in these cases, callousness is a species of racism and an expression of frustration. Explaining callousness in terms of damaged moral perception allows us to consider how racism, frustration, and other attitudes, emotions, and demeanors can interfere with caregivers' abilities to discern what patients need and deserve from them and their abilities to respond with care to them.

I've just suggested that differentiating among a callous person, a callous act, or a callous remark doesn't make much difference in terms of the moral agent's perception, though these differentiations do suggest that callousness can vary in scope. With respect to a person, callousness describes a demeanor as well as the condition of her capacity for moral perception. Interestingly, a person can be callous generally or with respect to certain fields of particulars only; she might express damaged moral perception in some contexts and express perfectly functional moral perception in others. For example, suppose Small is a caring physician for his white suburban patients or for his Mexican immigrant patients. This might suggest that he ought not be categorically described as “callous,” but it does not suggest that he's not callous with respect to his Hmong patients.

Looking more closely at Small's and Lane's patterns of moral perception, we can see how they misconstrue reasons there are to respond, how they fail to discern the moral relevance of particulars that configure the vulnerabilities, desert, and need of those for whom they have duties to care. Consider Small's moral perception first. Notice some of the features of Hmong patients' experiences Small regards as relevant: how much formal education a patient has had, whether a patient was apprised of modern technology, or whether a patient has ever visited a physician to give birth to a child. He construes these particulars to configure a general impression of Hmong patients as noncompliant; his remarks appear to track a pattern of moral reasoning that reflects the belief noncompliant patients fall outside the scope of those human beings deemed deserving of caring responses. ⁶ In this case, this belief diminishes the salience of particulars that configure Hmong patients' needs, vulnerabilities, and desert of care.

Small's views of Hmong people as subhuman and as invulnerable to embarrassment reflect other racist, bigoted beliefs. His story of Hmong people in U.S. society represents them as insects; this allows Small to easily separate the kind of person he is from the kind of people he thinks the Hmong are. He represents Hmong persons' needs as less sophisticated than his; he suggests, for example, that their needs beyond elimination and hydration are irrelevant and not worthy of response. Small not only appears to lack compassion for Hmong patients, he quite clearly mocks their poverty. He also appears to maintain firm beliefs about what he thinks are Hmong obstetrical patients' intentions to live on welfare. He draws the conclusion that their lives in the United States are “heavenly,” reasoning peculiarly that poverty leads to bliss, rather than vulnerability, marginalization, and need.

Consider Lane's patterns of poor moral perception, too. In Lane's case, her response might be medically appropriate; there is an obvious medical reason to assess what's going on inside the abdomen of a person who has abdominal pain and has just allegedly fallen down the stairs. But Lane fails to recognize the moral reasons that there are to respond to Mrs. Millon. She suspects that Mrs. Millon is a victim of violence in her home; she notices the particulars there are that could configure that suspicion. For example, she sees that Mrs. Millon presents to the emergency department with injuries and bruises twice in just a few weeks, that Mr. Millon usurps his wife's invitation to speak, and that Mrs. Millon has trouble maintaining eye-contact. But, Lane ought to construe these particulars such that they configure a reason to speak with Mrs. Millon alone and give her an opportunity to explain events that led to her injuries. There can be other moral reasons present in this case too, which Lane fails to recognize and consider acting on: a reason to report suspected spousal abuse to law enforcement authorities, a reason to call a social worker, a reason to remove Mrs. Millon from the company of her husband, who appears to be a significant threat to her personal safety. Furthermore, she never opens a dialogue with the person for whom she has a duty to care: her patient, Mrs. Millon.

To be charitable toward Lane, we might appreciate that there are probably a number of high-urgency cases demanding her time in the emergency department. But Lane's demeanor toward Mrs. Millon does not simply express that she is busy. Rather, Lane's remark expresses the influence of a bad belief: the belief that women who are victims of violence in their homes are stupid. This belief functions to guide Lane's perception such that Mrs. Millon appears, according to Lane, to be unwilling to leave an abusive relationship; as a result, Lane draws the irrelevant and unhelpful (and wrong) conclusion that her patient is just an idiot. By seeing Mrs. Millon as an idiot, Lane excludes her from the realm of people whom she sees as deserving of closer attention and more sophisticated care.

Callous practitioners, like Small and Lane, express faulty moral perception because they nurture beliefs that function to mute the salience of particulars that configure their patients' needs, vulnerabilities, and desert of care. It is not clear, however, that they are callous in the same ways, and distinctions among at least three forms of callousness are important to draw. These distinctions are important because they suggest different degrees to which Small or Lane might be to blame for their callousness and different degrees to which Small and Lane might be in need of help and good mentorship. Distinguishing among different forms of callousness can help clinician educators and mentors canvass and identify how health professions students and practitioners might internalize bad beliefs and practices of poor moral perception. Learning how callous students or practitioners could become poorly habituated in their practices of moral perception provides some insight into how to guide them to improve their skills of moral perception.

VII. CALLOUSNESS AS A FORM OF EVIL, EPISTEMIC CALLOUSNESS, AND CALLOUSNESS AS A FORM OF WEAKNESS OF THE WILL

Additionally, distinctions among these types of callousness are important because identifying how a practitioner is callous can help to clarify who's responsible for her callousness and what can or ought to be done to help her improve her moral perception. Furthermore, drawing distinctions among these different forms of callousness sheds light on possible sources of responsibility for the production, persistence, and promulgation in healthcare organizations and schools of medicine and nursing of beliefs that diminish the prominence of certain particulars in the moral landscapes of situations or disproportionately magnify the importance of others.

I'll consider callousness due to evil first. The philosopher Jonathan Dancy suggests that moral agents can be described as evil when they don't or won't accept moral propositions generally accepted by others as guides to their moral perception (1993, pp. 5–6). According to this conception of evil, evil is a cognitive problem, not a problem of motivation or will. If Small and Lane are callous because they are evil, their callousness can be explained by the fact that they don't or won't accept moral propositions—that immigrants are morally equal to citizens, for example, or that victims of violence in the home are not intellectually inferior patients—that guide how most of their colleagues negotiate clinical moral life. ⁷ Small's comments appear to communicate his belief that Hmong people are racially inferior to him; insofar as his behavior suggests that he doesn't accept the proposition that all patients, regardless of ethnicity, need and deserve his caring responses, his callousness could be considered a form of evil. But, there are also other ways to account for his and Lane's callousness.

A second form of callousness is epistemic callousness, callousness due to ignorance or poor training. If Small doesn't know his views are socially, politically, culturally, and historically ignorant, racist, and classist, and if Lane doesn't know her views are sexist and dismissive of social and psychological dimensions of what it means to be a victim of violence in the home, these are epistemic problems generated by tremendous failures in their educations. Furthermore, if Small and Lane are callous due to ignorance and poor training, their epistemic callousness would not be an epistemic problem only; ethical questions about why these practitioners are ignorant and why they are poorly trained clearly remain. So, to fully consider how healthcare practitioners can be epistemically callous, we need to account for at least three different loci of culpability and responsibility for a single practitioner's epistemic callousness: the individual practitioner, her profession, and the organizations in which she works.

Professions and organizations have responsibilities to curb the epistemic problem of ignorance insofar as they have duties to train practitioners to discern patients' desert and need of healthcare broadly, capaciously, and inclusively. Furthermore, they should try to identify when practitioners' moral perception is too narrow, identify when practitioners apply beliefs about what patients need and deserve too meagerly, identify which beliefs interfere with good moral perception and the ability to construe reasons there are for responding to patients' vulnerabilities, and identify which kinds of particulars get missed or misconstrued when practitioners express poor moral perception. That is, professions and organizations need to develop ways to improve how nurses and physicians discern salience and patterns of relevance among particulars and evaluate how they experience value of particulars in clinical situations. ⁸ That could mean employing multidisciplinary—social, political, historical, cultural, ethical, and spiritual—approaches throughout health professions education and a wide variety of pedagogical strategies, too.

For example, if Small is epistemically callous, his narrowed scope of moral perception might be due to ignorance about and poor training in discerning moral value in the historical, political, social, and cultural dimensions of the life experiences of his patients and in understanding how his Hmong patients' life experiences influence their healthcare. His ignorance in these areas might not appear to affect his medical judgment about what to do for patients, but it certainly reflects his narrow view of what they need and deserve from him. Also, Lane appears to be poorly trained in appreciating how complex psychological and sociological issues in family violence affect victims' behavior. Her ignorance about these issues renders her ill-equipped to field her patient's abuse history and competently address fundamental threats to her patient's safety.

Organizations and professions tolerate (and might appear to endorse) these forms of ignorance that affect patient care if they fail to educate professionals adequately about how to recognize and discern moral value in social, political, historical, cultural, ethical, and spiritual particulars in the stories of patients' experiences and illnesses. How moral value and moral weight ought to be assigned to particular social, political, historical, cultural, ethical, and spiritual features of patient's situations is a matter for debate. But allowing students to remain ignorant of the fact that such features do indeed shape situations, and allowing their beliefs about such features to go unexamined, constitute terrific failures of their health professions educations.

In other cases, the kinds of particulars callous moral agents can fail to discern as relevant can vary widely. How actively and frequently their professions, fellow professionals, organizations, and societies endorse or challenge different beliefs (and patterns of perception guided by those beliefs), how strongly those beliefs are held, and how importantly and centrally those beliefs constitute individual professionals' identities are other sources of variation that influence which kinds of particulars practitioners are competent to discern well. For example, Small seems to maintain the belief that he is entitled to choose which persons are worthy of his services based upon morally irrelevant particulars—where they came from, how much formal education they have, whether they've ever seen an obstetrician before, and whether they receive or ever received money from the government. Do professions and organizations tolerate or endorse this belief or approve of how it guides his moral perception and clinical discernment? If not, they need to assume a significant role in rooting it out and revealing it to be an unacceptable belief behind which ignorance and poor training are no longer allowed to hide.

In addition to professions and organizations, individuals also have responsibilities to do what they can to avoid epistemic callousness; a practitioner must cultivate and maintain broad, capacious, and inclusive moral perception if she is to see reasons there are for acting in service to others. For a moral agent to cultivate and maintain his ability to see well, he must learn self-reflexivity and be open to healthy self-scrutiny (and, in many cases, open to scrutiny from colleagues and patients). He must learn to recognize and consider sources of his own ignorance, and he must learn how to come to know what he doesn't know. For example, Small's views of his Hmong patients could be perpetuated by ignorance of the political context of Hmong patients' experiences and by ignorance of why Hmong people were considered by the United States Government and other countries' governments to be refugees, not necessarily voluntary émigrés; he needs to learn to recognize how these views interfere with his ability to be responsive to patients for whom he has a duty to care. If and when he becomes aware of how his views make him callous, he should make a choice (or a series of choices) to refine his perception ⁹ —to acquire sensitivity to particulars in situations in which he deals with patients whose backgrounds and ways of seeing are significantly different from his own.

But, suppose Small isn't a very reflective person, he brushes off others who try to render his callousness visible to him, and he never becomes aware of how his views interfere with his ability to respond to patients. This could be a point at which we would see that Small's callousness isn't epistemic callousness, or at least not epistemic callousness only: Small could be callous not because he's ignorant or poorly trained, but because he's weak-willed. ¹⁰

Suppose, for example, a colleague says to Small, “I think you'd have a better understanding of what your Hmong patients need and deserve if you learn more about what they've experienced and why they're in the United States,” and another colleague says to Lane, “I think you need to learn more about why victims of violence in the home can have a hard time leaving their abusers. It's not as simple as you think.” Suppose further that Small responds by saying something like this:

I know my colleagues think I'm racist and insensitive and that I don't understand “Hmong culture.” They give me the standard liberal mumbo jumbo. But, you know what? I'm not the problem; they are. I don't need to learn about them, and I don't want to.

Suppose, too, that Lane responds as follows:

Look, it's simple. These women just need to leave. Take the kids, do whatever, just get out and go to a shelter for a while until you can find a safe place to live. I know there are seminars on stuff like this, but I really don't have time, and I don't think there's much more I could learn that would be helpful.

Responses like these suggest a variety of possible problems with Small and Lane, and they amplify the need for moral self-reflexivity among healthcare professionals. That is, a responsible healthcare professional (even if not a virtuous one) ought to care about eliminating beliefs that prevent him from discerning particulars' moral relevance properly, ought to see ignorance as unacceptable, ought to be moved to (at least) reflect upon his patterns of moral perception if important others—like patients or colleagues—confront him about being callous, and ought to be moved to refine his perception if he's not seeing well.

If a practitioner is complacent or apathetic ¹¹ about her failures of moral perception and fails to make any efforts to reflect upon or refine her perception, continued failures of moral perception are no longer manifestations of epistemic callousness, but of callousness due to weakness of the will. For those whose callousness is due to weakness of the will, poor practices of perception will continue, reasons there are for acting will continue to be missed, and the vulnerabilities of weak-willed practitioners' patients will continue to go unrecognized. Colleagues with broader, more capacious, and more inclusive moral perception might be able to pick up the slack of weak-willed callous practitioners. But if they can't, patients will get poor care and colleagues might resent callous practitioners for not doing what they ought to do: see well, learn to cultivate and maintain capacious moral perception, respond to reasons that there are, and don't leave moral reasons there are to respond with care to patients to be acted upon by colleagues.

VIII. CODA

Having differentiated between inurement and callousness, and having canvassed three different kinds of callousness, I have tried to argue for reasons why one can respond, “No!” to the title question, “Should a good healthcare professional be (at least a little) callous?” The argument I've motivated suggests that inurement more accurately describes what we really hope to articulate when we express the belief that healthcare professionals need strategies for negotiating moral distress as they go about the work of caring for patients. Furthermore, I provided reasons why inurement should be formally taught in health professions curricula. If learning how to negotiate emotional distress is left to informal modeling only, poor modeling can't be identified as problematic, and students and young practitioners are left at risk for internalizing bad beliefs and poor patterns of moral perception and for suffering moral damage.

I have suggested that institutions that educate health professionals should formally train and guide students and young practitioners in becoming inured and in developing good skills of moral perception. After all this, however, one might well wonder How well ought healthcare professionals be expected to see morally? Do we expect healthcare professionals to be moral agents on whom nothing is lost? Additionally, one might well wonder whether mere differences among different moral agents' perceptions or differences among different moral agents' beliefs about what's important could generate unjust accusations of callousness toward people whose beliefs or patterns of moral perception are unusual, idiosyncratic, or simply expressive of viewpoints not held by a majority of moral agents: When might differences of moral perception among moral agents be attributable to one or more of them being callous, and not to more benign sources?

First, the inclination to define good moral perception in Jamesian terms, to define a person as having good moral perception only if she is a person “on whom nothing is lost,” ¹² must be resisted. To define good moral perception in this way is to set the threshold of what constitutes good moral perception too high and to require healthcare professionals to be, perhaps, morbidly sensitive. Rather, I propose that if it is reasonable to expect that healthcare professionals can be called upon to respond to others with care, then it is reasonable to expect that healthcare professionals encourage, among themselves, practices of capacious moral perception and cultivation of patterns of perception that enable discernment and appreciation of particulars that configure reasons there are to respond to others with care. It is also seems reasonable then, to expect institutions that educate healthcare professionals to devote enough of their curricula to teaching and modeling good patterns of moral perception and to invest in development of forums in which beliefs, which are produced and promulgated formally and informally as healthcare students and practitioners are professionalized, can be investigated, analyzed, and openly considered.

Second, the question of whether and when differences among moral agents' perception is attributable to callousness prompts consideration, once again, of Jonathan Dancy's view of moral perception and moral reasons. Dancy reminds us that we should expect that moral agents' descriptions of what's going on in situations will differ and call for discussion (and maybe even vigorous conflict) about what's at stake morally in those situations. Discernment of configurations of salience among morally relevant particulars, and determination of just which particulars are indeed morally relevant, are not exact sciences; they are interpretive and comparative. Deliberations about what to do, whether taking place among individuals, among groups, or in a single person's mind, moral agents compare, revise, and refine how they see situations shaping up:

One picture has the facts in one shape, and the other has them in another. In choosing between these, the question is which picture is the more compelling. I see this question as analogous to the question which narrative is the more compelling. (Dancy, 1993, p. 117)

When moral agents assess which narrative description of a situation is more compelling, they must sometimes give arguments for why and how particulars are to be counted as salient with respect to one another. As the need to compare narrative construals of moral situations suggests, there is variation among what moral agents interpret as salient, what they experience as reasons to act, and how forcefully they're motivated by their recognition of reasons to act. One source of this variation is moral agents' different conceptions of which actions are worth doing, which actions are worth doing this way rather than that way, and which values are most important to endorse by doing those actions.

Consider, for example, that an observer suspects a practitioner is callous. We need to consider several possible explanations if we're to get a solid understanding of whether this practitioner is callous. One possible explanation is that the practitioner and the observer simply don't share an understanding of what's going on in the situation and they need to discuss or argue about how the story of what's going on ought to be told. It could also be the case that one (or both) of them is wrong about what's going on and neither one is telling a story that accurately represents the moral landscape of the situation. It could also be the case that the practitioner did respond to moral reasons in the situation, but the observer didn't recognize her actions as responses or appropriate responses. It could also be the case that one (or both) of them is wrong about how the moral landscape of a situation ought to be represented because one (or both) of them express poor moral perception. If this latter possibility is the case, poor moral perception could be an expression of callousness, particularly if discrepancies between the observer's and the practitioner's story of what's going on in this situation center upon whether the belief patients need and deserve caring moral responses should be applied generously or meagerly.

ACKNOWLEDGMENTS

I'm grateful to my colleagues, particularly Richard O'Brien, Jos Welie, and Amy Haddad, and students at Creighton University Medical Center for their enthusiasm, industriousness, and curiosity. Hilde Lindemann Nelson, James Lindemann Nelson, Howard Brody, and Judith Andre at Michigan State University also gave remarkably and generously of their time (and ink) as I inquired after the moral meaning of callousness and other forms of moral damage. Thanks also to the Anderson Foundation, which sponsored a fellowship and supported my work at Lehigh Valley Hospital in Allentown, Pennsylvania. Encouraging and challenging questions from Joseph Vincent, Stephen Lammers, and Patricia Lyndale were invaluable, as were the comments of several anonymous reviewers.

Notes

1. Though commonly used as an adjective, “calloused” is an erroneous misspelling of “callous.” Interestingly, “callous” is sometimes also a misspelling of the noun “callus.” Though rarely used as a verb, “callous” means “to make callous.” Thus, the common phrase “becoming callous” appears redundant. However, “becoming” describes a transition, so “callous” in the phrase “becoming callous” is used properly as an adjective that characterizes a transition in a person's demeanor.

2. Callousness is only one form of moral damage. I canvass other forms of moral damage, like a change for the worse in self-conception, elsewhere. I also consider changes in moral perception that are not forms of moral damage.

3. In her Moral Understandings (1998), Margaret Urban Walker emphasizes that “a persistent history of valuation that can be seen in a good deal of what a person cares for, responds to, and takes care of is expressive of a moral agent's own narrative of moral identity” (p. 112).

4. Nor is it a process only for healthcare professionals. Other professionals—like teachers, police officers, or ministers, for example—are also sometimes described as professionals for whom it is expedient to be callous. These professionals, like healthcare professionals, are called upon, with varying degrees of intensity and regularity, to respond morally to those whom they serve. I would argue that these professionals could also benefit from being formally trained to appreciate distinctions between inurement and callousness.

5. Fadiman contextualizes the story of Hmong people as patients in the United States in many ways. One of them is how she situates their experiences as patients in the broader social and political context of relations among Southeast Asian nations and the United States from the 1950s to 2000. Chapters 10, 12, and 14—“War,” “Flight,” and “The Melting Pot,” respectively—address these dimensions of Hmong patients' experiences.

6. An interesting question arises here: When, if ever, do patients' noncompliance make them less deserving of care? Even if it is argued that noncompliance renders a patient less deserving of care in some cases, however, it still might not follow from such an argument that caregivers become less obliged to recognize or appreciate patients' vulnerabilities and need for care. Making that case might suggest the problematic view that noncompliant patients deserve less percipient (or impercipient) professional caregivers.

7. Questions can be raised here: How are decisions made, and who decides, which beliefs count as generally acceptable guides to clinical moral perception? I address this question in my upcoming discussion of epistemic callousness by suggesting that professions and organizations have responsibilities to track and reflectively consider which beliefs are (and which beliefs should be) produced and promulgated in institutions of healthcare education and professionalization.

8. It's useful to point out here that healthcare professions and organizations do seem to value this kind of education for practitioners. Though much less emphasis is placed upon teaching practitioners to discern moral value in what they learn, such that what they learn actually improves their moral perception, there are some seminars that do focus upon something frequently called “sensitivity,” as in “sensitivity training.” Such seminars sometimes have to do with race, gender, ethnicity, socio-economic status, and disability and seem to be intended to get participants to acquire new ways of seeing and thinking about people different from themselves in these varieties of ways. Courses that have evolved in medical schools in the last decade seem also to have a goal of developing moral perception, particularly ethics and humanities courses that emphasize empathy. More attention can be devoted to students' consideration of how ignorance, poor training, and bad beliefs interfere with their moral perception and their colleagues' and mentors' moral perception.

9. Fadiman reveals how several healthcare professionals who cared for their patient, Lia Lee, engaged in just this kind of perceptual refinement. For example, they read books and also consulted anthropologists and social workers who specialized in working with Hmong refugees in Merced, California.

10. There are two senses of what it means to be weak-willed. The first describes a failure to be motivated to act, despite recognition of a reason to act; a second describes a failure to act, despite recognition of a reason to act and despite the experience of at least some motivation to act.

11. Some forms of apathy could be categorized as evil. If, for example, a person is homophobic, knows she treats gay and straight people differently, doesn't care how her views interfere with her discernment of particulars about other people to whom she has professional responsibilities, or doesn't care (or doesn't care enough) if gay people are ill-treated as a result of her callousness, her homophobia expresses refusal to accept or disregard for the generally accepted moral proposition that a patient's patterns of sexual desire ought not be used to construe whether, when, and how a person needs or deserves healthcare.

12. This refers to the character, Adam, in Henry James's novel The Golden Bowl. Readers might also recognize the phrase from the philosopher Martha Nussbaum's 1990 essay, “‘Finely Aware and Richly Responsible’: Literature and the Moral Imagination.”