I somehow found myself thinking about a passage from Hannah Arendt’s 1951 landmark Origins of Totalitarianism while I was at the Thames Valley Family Health Team conference a few weeks ago. (I posted more about the conference earlier.) The event was about delivering primary health care, and Arendt’s book is about totalitarian regimes, which makes following connection feel somewhat spurious at best. But there’s the kernel of an idea here that I need to flush out.
In the panel discussion, we briefly touched on the systemic stresses and pressures felt by healthcare providers. For instance, if your caregiver is rude, impatient, or insensitive, the ‘system’ might try to excuse the behaviour based on ‘bigger’ issues such as underfunding, understaffing, etc. But one of the panelists, my friend Bharati Sethi, called this justification into question. Is there ever a point where work-related stress legitimizes treating other people without basic human decency and dignity? Where else in society do we expect this equation to fly?
Case in point. Later that week I was in a bustling, understaffed pub with some friends. The immediate and multitude ‘job stressors’ at hand did not impede our server from treating us kindly and taking a personal interest in us. Paying attention to us was their job.
In the healthcare sector, there is a lot more at stake than getting the right pints to the right customers (as crucial as this is). Primary care often represents the front lines for responding to significant physical and psychological crisis. Decisions are critical. A server at the pub who pays close, friendly attention to the needs of their customers is a good employee. The doctor who brushes me off or doesn’t care enough to listen to my symptoms and the subtext of my story might be bordering on malignant practice.
This is where Origins of Totalitarianism comes in. (I should emphasize that my intent here is not to compare healthcare to totalitarianism in any general sense, but to interrogate a specific feature of bureaucracies at scale.) In explaining the logic of totalitarian regimes, Arendt points out that “before the court” of terror, everyone who carries out the brutal decrees of a totalitarian government is “subjectively innocent.” The murderers aren’t really murderers; they are just obeying orders from the next level up. Likewise, the ‘next level up’ are just intermediaries and themselves not even lifting a finger to inflict any harm. At the very top, it is not so much an individual in charge as some dictator executing “historical or natural laws” — “suprahuman forces” — that are made all the more self-evident by their execution. To carry out their atrocities regimes need to figure out a way to make everyone find a way to believe themselves innocent. (See Origins of Totalitarianism, page 465.)
I hope it is evident that I am not trying to make a one-to-one comparison here. The point is much more subtle. The idea that an individual caregiver in the healthcare system might blame their lack of empathy, compassion, or patience on ‘the system’ itself echoes a similar kind of systemic scapegoating. It is simply replacing ‘The devil made me do it,’ with ‘The system made me do it.’ This is a perennial issue with huge bureaucracies in general: the organization, the institution, the structure itself becomes an ‘it’ that is itself inscrutable and above punishment. Once ‘it’ is to blame, all recourses to social accountability are made null and void.
I don’t mean to belittle the importance of leadership and workplace environments. If you stress your staff, you shouldn’t expect to deploy a team of relaxed, sensitive, listeners onto the floor or into the clinic. But the problem, at every level of the equation, is the temptation to excuse poor human-to-human experiences on some ‘thing’ that we call ‘the system’ that is patently beyond any single individual’s control. If it is ‘the system’ that makes you maltreat people, you have caught a tiny glimpse, according to Arendt, of how totalitarianism gets away with evil.
Perhaps thinking about Arendt in the context of a complex healthcare environment offers us some ideas about contributing factors to inequitable and unequal treatment.
Later, in her 1963 book, Eichmann in Jerusalem, Arendt proposes the concept of the “banality of evil.” By ‘banality’ Arendt supposes that it doesn’t necessarily require a deranged sociopath to commit horrendous acts, just a simpleton who gets caught up in a narrative and executes a job description without thinking critically for themselves. In a healthcare context — where patients are often treated like widgets on a conveyor belt — perhaps we come to expect a kind of ‘banality of rudeness’ or ‘banality of impatience’ as staple features of bureaucracies. Perhaps this narrative about the nature of organizations is precisely the story we need to reimagine.