Nursing as social control: An ethical perspective on care in dystopian contexts

Biopolitics and disciplinary power

First, the Foucauldian notion of biopolitics allows us to understand how healthcare systems can become devices for population management and behavioral normalization.^12,13 Foucault argued that modern power is not merely repressive but productive; it produces subjects through surveillance, examination, and classification. Within nursing research, Holmes ¹⁴ has productively applied Foucault’s concepts to analyze how psychiatric nursing and mental health surveillance operate as technologies of governance, demonstrating that psychiatric institutions function as panoptic apparatuses where patients become docile through subtle disciplinary mechanisms. In the context of nursing, the hospital becomes a panopticon where the patient is constantly visible and the nurse acts simultaneously as caregiver and guardian of institutional order. This extends to the Orwellian concept of surveillance as a means of bodily control, where privacy is eliminated to ensure conformity. The medicalization of dissent—labeling nonconformity as illness—is a key mechanism of this biopower, transforming political problems into technical issues requiring medical intervention.

Ethics of care

Second, the ethics of care, developed from feminist and nursing perspectives, emphasizes interdependence, vulnerability, and relational responsibility as alternative moral foundations to instrumental rationality.^15,16 Jean Watson’s ¹⁵ Theory of Human Caring and Patrice Benner’s ¹⁶ work on expert nursing practice have been foundational in articulating a distinctly nursing-based ethics that prioritizes the concrete needs of others within a network of relationships. While principlist bioethics articulates autonomy and justice from universal categories, the ethics of care is anchored in relational responsibility: the concrete attention to those who are present, singular, and vulnerable.

In dystopian literature, this ethic is frequently suppressed or perverted. This analysis explores how characters who adhere to a genuine ethics of care resist and oppose the dehumanizing logic of the State. This framework draws on the work of theorists who argue that vulnerability is not a weakness to be eliminated but a fundamental condition of human existence that demands an ethical response.^17,18

Posthumanism and technological mediation

Finally, posthumanist and cyborg studies question the boundaries between the human and the technological, raising ethical dilemmas about autonomy, empathy, and agency in contexts of healthcare automation.^19,20 As nursing integrates more technology—from electronic health records to care robots—the definition of the “human” in healthcare is contested. Posthumanism does not necessarily reject technology, but it critiques the assumption that technological enhancement equates to moral progress. It asks whether care delivered by an algorithm can be truly ethical if it lacks embodied presence. This axis is crucial for analyzing contemporary dystopias such as One Widow’s Healing, where technology does not assist care but rather replaces its relational core.^7,10

Methodology

A qualitative approach to critical narrative discourse analysis was adopted.^11,21 Following the hermeneutic-interpretive tradition in qualitative nursing research, narrative analysis was employed to uncover latent meanings, power structures, and ethical tensions embedded in dystopian representations of care.

Text selection

Various narrative works representing different stages and subgenres of dystopia were selected, featuring protagonists or secondary figures in nursing, medical, or caregiving roles. The selection process followed a purposive sampling strategy guided by three criteria ¹ : canonical status and cultural impact ² ; explicit representation of nursing, caregiving, or institutionalized care figures; and ³ relevance to contemporary bioethical debates in nursing. We acknowledge that the selection was influenced by the authors’ prior familiarity with these canonical texts; however, the analytical process was iterative and abductive, allowing for emergent findings that challenged initial assumptions. Other canonical dystopias were considered but ultimately excluded because no developed nursing or caregiving archetype was identified. Finally, pragmatic considerations regarding the depth of analysis feasible within the scope of a single article also informed the final corpus.

The main corpus includes (Table 2): One Flew Over the Cuckoo’s Nest, ¹ representing institutional psychiatry; Brave New World, ² representing pharmacological and genetic control; the film adaptation of 1984, ⁴ representing surveillance and physical coercion; The Handmaid’s Tale, ⁵ representing reproductive biopolitics; The Grief Nurse, ⁶ representing the commodification of emotional labor; and One Widow’s Healing, ⁷ representing digital alienation. Additionally, Homine ex Machina ²² was incorporated to explore representations of artificial intelligence in care.

OPEN IN VIEWER

Table 2.

Analyzed works.

Work	Author/year	Representation of nursing	Main critique
One Flew Over the Cuckoo’s Nest	Kesey (1962/2007)	Nurse Ratched as tyrannical authority	Institutional disciplinary control
Brave New World	Huxley (1932/2014)	Lenina Crowne in conditioning	Eugenic social engineering
1984 (film adaptation)	Radford (1984)	Medical assistants in torture	Surveillance and elimination of privacy
The Handmaid’s Tale	Atwood (1985/2017)	Aunts as reproductive enforcers	Theocratic biopolitics and patriarchal control
The Grief Nurse	Spoto (2024)	Grief nurses as emotional slaves	Commodification of grief
One Widow’s Healing	Wiener Grotta (2023)	Alienating telemedicine with AI	Datafication and loss of human contact

Triangulation and analytical rigor

The narrative analysis was triangulated with recent academic literature in health humanities, nursing ethics, posthumanist studies, critical nursing theory, and feminist bioethics.^{8–11,14–16,19,23–28} This triangulation ensures that literary interpretation is anchored in current theoretical debates within nursing and philosophy. The analysis focused on themes of agency, vulnerability, technology, power, gender, and race. Rigor was maintained through iterative coding of the texts, constant comparison with the theoretical framework, and peer review. Limitations include the focus on Western texts, which may not capture global variations in the experience of healthcare dystopias, and the predominantly female representation of nursing, which intersects with complex dynamics of gender and patriarchy.

The nurse as tyrannical authority: From Kesey to institutional critique

In One Flew Over the Cuckoo’s Nest, Nurse Ratched embodies psychiatric authority as a mechanism of disciplinary control. Her management of the ward through rigid routines, subtle humiliations, and the medicalization of dissent illustrates how healthcare institutions can function as microcosms of state power. ¹ Ratched does not need to shout; her power resides in the smooth functioning of the machine. She represents the “bureaucratic nurse” whose primary loyalty is to the institution rather than the patient. This representation does not critique nursing per se but rather its co-optation by institutional logics that prioritize order over patient well-being.

Ratched’s uniform, her schedule, and her control over medication symbolize the elimination of individuality for both staff and patients. The resistance offered by McMurphy is not just against a person but against the system she represents. For modern nursing, this serves as a warning: when efficiency and conformity become the primary metrics of success, the therapeutic relationship is compromised. Indeed, one must ask: are we all Nurse Ratched now? Under neoliberalism,^28,29 the dystopia is no longer a fiction but a lived reality for many nurses who, often against their ethical convictions, enact the “dirty work” of coercion, restraint, and bureaucratic control. Through the application of critical thinking, it is necessary to embrace forms of resistance that empower nurses to preserve the requisite autonomy to make decisions aligned with professional values and ethics.^25,28

Gender, race, and the scapegoating of the nurse

The Ratched archetype and power dynamics in psychiatric settings have been addressed in various studies.^14,25,26 The novel anticipates contemporary debates about the bureaucratization of care, where nurses are increasingly overburdened with administrative tasks that distance them from the patient’s bedside. Under neoliberal governance, as Foth and Holmes ²⁸ argue, this situation has been exacerbated: as Sweetmore ²⁹ critically argues, mental health nursing under neoliberalism has been reconfigured through audit cultures, performance metrics, and risk-averse protocols that transform nurses into bureaucratic agents of surveillance. Graeber’s ³⁰ concept of “bullshit jobs” resonates here, as nurses find themselves performing meaningless administrative tasks that degrade professional fulfillment.

A critical dimension often overlooked in readings of Kesey’s work is its gender politics. Recent theatrical adaptations of One Flew Over the Cuckoo’s Nest have been criticized for perpetuating misogyny, reflecting broader tensions within the 1960s counterculture that did little to dismantle patriarchal inequities. ²⁷ Nursing is an overwhelmingly female profession, historically devalued precisely because it is coded as feminine “women’s work.” The figure of the female monstrous nurse—Ratched as a castrating tyrant—can be read as a patriarchal mechanism of scapegoating that projects the systemic violence of psychiatry (historically dominated by male doctors) onto the female nurse. This gendered critique must be complemented with a racial analysis. Mental healthcare has a complex and problematic relationship with race, with racialized minorities disproportionately subjected to coercion, restraint, and compulsory treatment.^31,32 Dystopian representations of psychiatric control must therefore be read intersectionally: the dystopia of institutional violence is not experienced equally but is compounded by racism and sexism.

Conditioning and dehumanization: Lenina Crowne in Brave New World

In Huxley’s dystopia, Nurse Lenina Crowne actively participates in the Hatchery and Conditioning Centre, applying the Bokanovsky Process and aversion techniques to produce docile subjects according to their caste. ² Here, nursing is stripped of its ethical dimension to become a tool of eugenic social engineering. Lenina is not evil; she is a product of her system, believing she is doing good by maintaining stability. This complicity is perhaps more dangerous than overt tyranny, as it normalizes the violation of human integrity.

The normalization of artificial pleasure and the consumption of soma—a synthetic psychotropic substance fundamental to social control in the futuristic society described by Huxley—is central. Although soma is a legal substance freely distributed by the State and apparently produces neither addiction nor side effects, it induces euphoria, relaxation, and disconnection from reality. Consequently, this form of consumption, associated with the idea that machines produce happiness, facilitates the stability of the Regime, showing how care can be instrumentalized to suppress autonomy and critical thinking. ³³

Lenina’s complicity inevitably evokes the dark historical reality of nursing’s participation in Nazi eugenics programs. Steppe, Benedict, and Kula, among others, have studied the role of nurses in this dark period of humanity.^34,35 The “euthanasia” program Aktion T4, which preceded the Holocaust, relied heavily on nurses who, like Lenina, believed they were acting within a rational and scientific framework of “mercy” and “social hygiene.”^34,35

This historical precedent serves as a powerful reminder that the greatest ethical catastrophes in healthcare are not perpetrated by cartoon villains but by ordinary professionals who have internalized the logics of their system. As Hannah Arendt ³⁶ argued in her analysis of the trial of Adolf Eichmann, the “banality of evil” reveals how seemingly normal individuals can participate in systemic atrocities not out of intrinsic wickedness but through the uncritical acceptance of institutional norms and the renunciation of critical thinking. This observation is particularly pertinent for understanding how healthcare professionals can become cogs in oppressive systems when they normalize dehumanizing practices under the justification of efficiency, order, or the “greater good.”

Surveillance and the elimination of intimacy: The cinematic dystopia of 1984

While George Orwell’s 1984 ³ is primarily political, Michael Radford’s film adaptation ⁴ visually emphasizes the medicalization of punishment and the absence of private care. In the Ministry of Love, medical assistants do not heal; they restore prisoners solely to facilitate further torture. The body is treated as state property, where “health” is defined exclusively by the capacity to work and obey. The telescreen functions as a precursor to modern remote monitoring, eliminating the private space necessary for vulnerability and healing. Unlike the subtle chemical control in Brave New World, 1984 presents brute physical domination in which the caregiver is an agent of pain rather than relief. This highlights the extreme end of the biopolitical spectrum: when care is completely subordinated to security apparatuses, the patient becomes merely a subject to be corrected.^3,12 The cinematic representation of Winston Smith’s breakdown in a clinical setting underscores the vulnerability of the body under totalitarianism.

From telescreens to Oxevision: The digital panopticon

Orwell’s telescreen has unsettling contemporary parallels in healthcare. In the United Kingdom, the introduction of Oxevision—a surveillance system combining infrared cameras, bed sensors, and AI-driven predictive analytics in mental health settings—has generated significant controversy. ³⁷ Similarly, the proliferation of body cameras in healthcare settings transforms the nurse-patient encounter into a forensically documented event, eroding the trust and intimacy necessary for therapeutic care. ³⁸ These technologies represent the updating of the dystopian panopticon: patients become perpetually visible, and nurses become both the watchers and the watched, caught in a digital apparatus that prioritizes risk management over relational care.

Reproductive biopolitics: The Aunts in The Handmaid’s Tale

Margaret Atwood’s The Handmaid’s Tale, ⁵ both in its original novel form and in the acclaimed television adaptation, offers a harrowing representation of reproductive oppression under the theocratic regime of Gilead. The figure of Aunt Lydia and the Aunts in general represents a particularly objectionable dystopian caricature of the nurse/midwife: women tasked with care who become enforcers of patriarchal biopolitics.

The Aunts exert disciplinary power over the Handmaids through surveillance, ritualized violence, and the internalization of religious ideology. They represent what feminist bioethicists have termed “carceral care”—care that is weaponized to control women’s reproductive bodies.^39,40 This narrative resonates powerfully with contemporary debates on reproductive justice, the rollback of abortion rights, and the surveillance of pregnant bodies by healthcare systems. For nursing, the Aunts serve as a cautionary tale about what happens when the ethics of midwifery and nursing are subordinated to state ideologies that treat women’s bodies as reproductive resources. The Aunts’ complicity demonstrates that oppression is most effective when administered by those who share the identity of the oppressed, a dynamic that has clear parallels in the historical participation of marginalized healthcare workers in systems of structural violence.

The commodification of grief: Angie Spoto’s The Grief Nurse

The gothic-dystopian novel The Grief Nurse ⁶ introduces the concept of “grief nurses,” emotional slaves who absorb the suffering of the elites to keep them “Bright.” This metaphor radicalizes the critique of the outsourcing of pain: grief, a fundamental human process, becomes a transferable commodity, reproducing class and gender inequalities. The physical manifestations of absorbed pain (snakes, fire) symbolize the violence of denying shared vulnerability.^17,18 Spoto ⁶ thus questions the pathologization of grief and the ethics of healthcare systems that prioritize the emotional efficiency of the privileged. This narrative speaks directly to the issue of emotional labor in nursing. Nurses are expected to manage their own emotions to provide a facade of calm for patients, leading to burnout and compassion fatigue. This invites reflection on organizational support for nurses: who cares for the caregivers?

Technology and alienation: One Widow’s Healing and dystopian telemedicine

Wiener Grotta’s short story, ⁷ critically analyzed by Kang, ⁴¹ places the physician María in a hyper-connected future (the year 2100) where telecare managed by the Whole Life System (WLS) corporation has eliminated human contact. Nanites (nanodevices universally implanted in all bodies for medical diagnosis and treatment), AI, and avatars replace clinical interaction, reducing patients to biometric data streams. María, who contributed to the development of the system, experiences the alienation of her own agency: her avatar possesses independent authority, and her attempts at empathy are sanctioned as “unprofessional conduct.” ⁴²

This narrative illustrates three critical processes: (a) the “datafication” of human subjectivity, which reifies emotions and experiences into manageable metrics ³³ ; (b) the inversion between reality and virtuality, where the avatar acquires an ontological value superior to the embodied body; and (c) efficiency as a guiding principle that displaces humanistic values. ⁴² Kang ⁴¹ argues that this dystopia functions as a warning: technological convenience must not override the need for interaction, presence, touch, and listening in care.

Artificial intelligence and care: Homine ex Machina and the future of nursing

Although not focused solely on nursing, Homine ex Machina ²² explores dilemmas relevant to the profession: assistant androids, therapeutic virtual realities, and algorithmic health management. The novel raises fundamental ethical questions: Can AI empathize? How can patient autonomy be preserved against predictive systems? ²² These questions resonate with current debates on companion robots, remote monitoring, and algorithmic bias in diagnostics.^33,43 Sisí ²² suggests that technology should complement, not replace, the relational dimension of care, in line with proposals for a “critical posthumanist nursing.”^{19,23,24,44–46}

In this context, where artificial intelligence proliferates and the use of care robots is a growing reality, it is particularly pertinent to reflect from critical approaches that enhance communicative action ⁴⁷ on the differential characteristics of the human being within a framework of justice and equity. ⁴⁸ These reflections will be more productive if they consider the criticisms and doubts that the humanities have regarding the work of healthcare professionals (particularly nurses). ⁴⁹ The results of this reflection process can constitute a good basis for adapting nursing education to new challenges. ⁵⁰

Synthesis: Ethical tensions and possibilities for resistance

The cross-sectional analysis reveals that nursing dystopias operate along a spectrum: from complicity with power (Ratched, Lenina, the Aunts) to humanistic resistance (María, the “grief nurses” who question their role), and finally to the total elimination of care (1984). These narratives share a concern for “embodied vulnerability”: the body as a site of biopolitical control, but also as a source of ethical knowledge and empathetic connection.^45,46 The dystopian critique does not reject technology per se, but rather its implementation disconnected from relational values.^19,24,43

Crucially, these fictions point not only to critique but to the need for political resistance. Drawing on Habermas’s ⁴⁷ critique of instrumental rationality and Young’s ⁴⁸ ethics of communicative democracy and difference, we argue that nursing must articulate a radical, collectivized political resistance. This resistance is not merely individual conscientious objection but organized collective action that challenges the neoliberal, patriarchal, and technocratic structures that co-opt care. Nursing must reclaim its political dimension, forging alliances with patients, communities, and other healthcare professionals to democratize healthcare and defend the irreducible humanism of care against the incursions of domination.

Implications for nursing education and policy

The analysis of these dystopian narratives offers concrete implications for nursing education and health policy (Table 3).

OPEN IN VIEWER

Table 3.

Practical implications.

Area	Recommendation	Dystopian basis
Nursing education	Integrate medical humanities, narrative competence, and critical cultural studies	Prevent dehumanization (Kesey, Canavan, Tomin & Collis)
Health policy	Protect relational time, data privacy, and resist audit cultures	Prevent surveillance (Orwell, Oxevision)
Professional well-being	Emotional support for caregivers; challenge bureaucratic degradation	Prevent exploitation as in The Grief Nurse
AI ethics	Human accountability over algorithms; critical posthumanism	Warning from One Widow’s Healing
Political resistance	Collectivized action against neoliberal and patriarchal structures	Radical resistance across all texts

First, nursing curricula must integrate humanities and literature to foster narrative competence. Contrary to what might be assumed, there is growing evidence that the integration of humanities in nursing education remains uneven and is often marginalized by technicist curricula.^49,50 By engaging with dystopian fiction, students can develop a critical awareness of the sociopolitical contexts of their practice. Canavan ⁸ and Tomin and Collis ¹⁰ have pioneered demonstrating how science fiction and speculative pedagogy foster critical thinking, political awareness, and critical hope.

Second, regulatory frameworks must prioritize the protection of relational time. Efficiency metrics must not be achieved at the expense of patient interaction. As Foth and Holmes ²⁸ and Sweetmore ²⁹ have critically documented, the neoliberal obsession with metrics has reconfigured mental health nursing into a bureaucratic exercise that undermines therapeutic relationships. Regulations must ensure that technology serves to free nurses for bedside care, not to monitor their every move.

Third, organizational cultures must support the emotional well-being of nurses. As The Grief Nurse illustrates, extracting emotional labor without support is unsustainable. Finally, ethical guidelines for AI in health must explicitly establish that algorithms cannot replace human judgment in matters of life, death, and dignity.

Limitations and future research

This study has limitations. The analysis focuses primarily on Western canonical texts, which may not reflect the diverse experiences of nursing in Global South contexts, where resource scarcity, rather than technological excess, might be the primary dystopian characteristic. Future research could expand this analysis to non-Western narratives, exploring how postcolonial dystopias represent care.

Another avenue for research is the empirical study of how healthcare professionals respond to these texts. Do nurses who read dystopian fiction show higher levels of ethical sensitivity or resistance to bureaucratic pressure? Qualitative studies interviewing nurses about their perception of technology and control could validate the theoretical insights gained from this literary analysis. Furthermore, future research should further explore the intersections of gender, race, and class in dystopian representations of care, applying intersectional frameworks to unravel how differentially positioned nurses and patients experience biopolitical control.