Fitting anger and patient wrongdoing

Introduction

Responding to the COVID-19 pandemic has been a severe challenge for healthcare systems and their employees. With multiple waves for over 2 years now, everyone working in healthcare has been stretched thin. Not only has the pandemic demanded their time and energy, threatened their health, and isolated them from loved ones but it has also made profound demands on their emotional lives. To take just one, particularly wrenching example, due to visitor restrictions nurses have at times been asked to hold iPads for dying patients so that family members could communicate with them virtually in order to send their last goodbyes. ¹

One thing that has greatly compounded the difficulty of this work has been the fact that though safe and effective vaccines became available a year into the pandemic, a substantial minority of the population has refused to take them. ² It is one thing to sacrifice time and energy, and put oneself at risk, to aid those suffering from a disease for which no effective mitigation strategy is available; it is a much more difficult thing to do so when those suffering could have taken relatively simple steps to drastically lower their likelihood of becoming gravely ill.

It is, therefore, not surprising to see doctors and nurses expressing anger toward those who refuse to get vaccinated. In a piece for Emergency Medicine News entitled “Why I’m Angry (Just Get the Vaccine!)”, for example, Dr Sandra Scott Simons writes movingly of the emotional toll the pandemic has taken on her, emphasizing in particular her anger and frustration. ³ “I feel angry that hospitals have no room to care for myocardial infarctions, surgical emergencies, and diabetic complications,” she writes, alluding to the fact that the heavy influx of patients with COVID-19 risks crowding out others. “I feel angry that the front line is becoming more and more exhausted while much of the general public is still ignoring our pleas for them just to get the darn vaccine.” Now, Dr Simons does not explicitly state any anger toward patients, only anger at the situation in general (lack of vaccine uptake; overtaxed institutions). Another doctor, however, is more direct: pulmonary and critical care specialist Dr Jason Chertoff is quoted in the Los Angeles Times as saying “I have resentment and anger toward patients not doing their part to curtail the spread of [the virus].” ⁴

Yet, both Dr Simons and Dr Chertoff express uneasiness with this anger. Simons calls it “something far more sinister than compassion fatigue,” while Chertoff states “I don't like what I’m feeling now,” noting that he has never felt anything bad toward lung cancer patients who were smokers. The anger these doctors are experiencing is thus understandable, perhaps even inevitable: but is it, nevertheless, morally fraught? Somehow in tension with their vocation? “We went into this career because we love people,” Simons writes. Are love and anger incompatible?

In this paper, I ask about the moral dimensions of anger on the part of healthcare workers toward patients they perceive as having engaged in wrongful behavior. For ease of exposition, I focus on the anger of doctors and nurses working in hospital settings. This anger, which has been repeatedly expressed in print throughout the COVID-19 pandemic, has received only cursory investigation in the literature.^5,6 Yet the topic is both ethically significant and complex, as I will show.

This may initially seem a strange topic. Clinicians, for example, are likely to quickly deplore such anger on the grounds that it risks making a bad situation worse. ⁷ Yet, this anger deserves philosophical notice for a few reasons. First, I note that (fitting) anger has many philosophical defenders, both ancient and contemporary.^8–11 Indeed, anger expressed in the right circumstances has experienced something of a rehabilitation of sorts in recent years, with many philosophers highlighting its positive aspects. These various positive qualities of anger—some instrumental, others intrinsic—suggest that healthcare worker anger deserves careful investigation. Second, even if we conclude—as I ultimately will—that the standard clinician assessment of such anger is correct, it still benefits us to see why and how anger can complicate delicate situations.

Third, there may be something unique about the circumstances of the pandemic that calls for moral investigation. Of course, no one speaks in favor of anger toward lung cancer patients who were smokers or gunshot victims who were involved in gangs, even if their actions may have contributed to their conditions—indeed, moralism, understood as “the illicit use of moral considerations” ¹² (e.g. applying moral concepts like desert or merit to patients) is widely rejected in medicine. And yet all of this outpouring of anger during the pandemic suggests perhaps vaccination is different. Compare smoking. Nicotine is a highly addictive substance that is difficult to quit even with strong social support. As will be explored below, this element of compulsion mitigates blameworthiness. Likewise, being involved with a gang is rarely a genuine choice. By contrast, getting vaccinated is relatively (in ways to be qualified later) simple—the shots are free and reasonably widely available. And unlike lung cancer or a wound, COVID-19 is a communicable disease. Remaining unvaccinated can be seen as willfully increasing risks for others, including healthcare staff. Moreover, our question here concerns not actions (making triage decisions on the basis of judgments of desert, for instance)—something we might think is plainly out of bounds in medicine—but rather attitudes. Thus, we might grant that moralism is to be resisted in medicine without thereby settling the question of this paper.

Thus, because this anger is so widespread, and because the circumstances of the pandemic seem relevantly different from other cases of (putatively) blameworthy patients—and because, finally (and crucially) emotional exhaustion is one of the chief reasons driving the “great resignation” from nursing and other healthcare professions—the topic seems ripe for ethical investigation. Before beginning, however, I note a few caveats. First, this paper does not offer an analysis of anger, but rather makes use of an intuitive conception of the emotion (understood to encompass related states like rage, indignation, etc.). Second, I will elide the distinction between feeling anger and expressing it. It might be thought that this is a significant oversight: perhaps it is wrong to express anger yet permissible to feel it, for example. But given that it is quite difficult for an angry individual to suppress expression of the emotion, I think the distinction can be safely ignored in what follows. Moreover, the main morally relevant consequences of anger that I will discuss pertain to feeling the emotion, and if it is deemed best not feel anger, then it of course follows that it is best not to express it either. Finally, I will focus my discussion on feeling anger toward patients in the moment. That leaves open the question of the moral status of feeling anger toward such individuals after the fact, after hours, etc. I suspect that what is ultimately concluded against anger in the moment speaks against anger after the fact as well—for example, a person angry after hours may well bring that anger back to work with them inadvertently—but I do not —directly address this question in the paper.

The paper proceeds as follows. First, I explain the concept of “fitting emotion” and then assess whether it might ever be fitting to feel anger toward unvaccinated patients. I argue that in a large variety of cases, they are not appropriate candidates for anger, but there is, at least conceivably, a subset who are. But this does not settle the question of whether reason ultimately blesses the feeling or expression of anger toward such individuals, and after careful consideration in light of recent philosophical defenses of anger's value, I go on to argue that it does not. It is better if nurses and doctors do not feel (let alone express) such anger in hospitals and other care settings. Because of this, and because our emotions are not always under our direct control—particularly when we are tired, stressed, and overworked—I conclude by arguing that these facts strengthen the (already urgent) need for the provision of resources by healthcare institutions to help overtaxed employees.

The COVID-19 pandemic will pass, and with it hopefully the specific relevance of this paper. However, I hope that this paper is useful beyond its immediate context in three ways. First, I aim to provide a schematic for assessing the emotion of anger in healthcare specifically—a topic of significant concern. ¹³ Second, the paper provides tools for thinking about the moral dimensions of emotions in healthcare generally: it might be usefully extended, for example, to explore nurses’ or doctors’ fitting sadness or anxiety. Third, and finally, I hope the paper provides a somewhat novel reason on behalf of more institutional support for healthcare workers’ mental health, a concern that will certainly outlast the current pandemic.

Fitting emotion and unvaccinated patients

Perhaps, the most basic question that can be asked in a normative assessment of emotion is whether it is fitting or apt with respect to its object. ¹⁴ Though it may in some ways initially appear strange to think of emotions as objects of critique (particularly moral critique), a bit of reflection reveals that it is quite common to criticize the correctness of emotional responses: consider familiar examples like saying “you shouldn't be afraid of that” or “that joke isn't funny.” There is no space here for a detailed analysis of the nature of emotion, so I will focus here on two things. First, these critical practices presuppose that emotions are about something—they have “intentionality” in philosophers’ parlance. Unlike a tickle or a twinge, emotions represent their objects: my fear of a snarling dog is fear of that dog. Second, emotions are a kind of evaluation of their object. An emotion is not barely representational, as an experience of red is; it is a kind of “seeing as.” Thus, for example, to feel amusement at a joke is to evaluate the joke as having a certain property, namely, funniness. An emotion is fitting when the object so-evaluated really does possess the relevant property: fear, for example, is not fitting with respect to bunny-rabbits, because they lack the relevant evaluative property which individuates fear. On the other hand, fear is fitting with respect to poisonous snakes, because they do have the property fear attributes to them.

To assess whether anger toward the unvaccinated might ever be fitting, then, we must determine what property it is evaluating its targets as having. According to the philosopher Zac Cogley, to feel anger is to construe one's situation “as containing wrongful conduct.” ¹⁵ When I am angry with my spouse because of something they said, I construe their comments as wronging me; likewise, when you are angry that I unplugged your laptop without asking, you construe my actions as wronging you.

Now, as noted above, sometimes our emotions can be unfitting or inapt: that is, sometimes when we are angry at others—for ease of exposition I’ll restrict my comments to anger at agents—we get it wrong. If what anger constitutes is an evaluation that an individual has engaged in wrongful conduct, then we get it wrong when their conduct isn't wrongful. I’ll understand this as meaning that their conduct is not blameworthy. When a parent is angry at a small child for something they did, we instinctively understand that this anger—though very often understandable—is nevertheless inappropriate. That is because the child is not blameworthy for what they’ve done. Similarly, blame, and therefore anger, is inappropriate when my cat knocks something off the shelf, or a dog begins barking loudly at a passerby. These things can easily make a person angry, but such anger is not fitting: feeling angry with a misbehaving cat is like being afraid of a mouse. This framework easily extends to fully competent adults. A friend trips and spills his drink all over my shirt: hot anger flashes through me. However, I quickly realize that such anger is entirely inappropriate to feel toward my (probably mortified) friend. He has done nothing wrong.

Such conditions which cancel the assignment of blame (and thereby cancel the assessment of wrongdoing) are known as excusing conditions. Ignorance can excuse, for example, as can coercion; we don't blame those who don't—or at least couldn't reasonably have been expected to—know better, nor do we blame people who do hurtful things because they are compelled to. And when such excusing conditions are present, feeling anger is inapt.

To assess the moral status of anger toward unvaccinated patients, then, we must first ask whether any such excusing conditions apply to them. In many cases, they do. As noted, non-culpable ignorance excuses agents from blameworthiness, and many individuals who resist vaccination do so because they trust (purported) authorities who have led them astray. ¹⁶ It is not blameworthy to act on the advice of perceived experts—whose views, in many cases, may be corroborated by other authority figures one trusts. Thus, many unvaccinated patients are not blameworthy on account of non-culpable ignorance.

Now, someone might dispute this. Weren't there plenty of other, more clearly reputable authorities like the Centers for Disease Control from whom individuals should have gotten their information? Perhaps they are blameworthy for bad epistemic practices. In response, two points are in order here. First, some of the apparent authorities advocating refusal of vaccination had many, if not all, of the imprimaturs of medical authority. These were doctors and scientists who one might think it is rational—particularly for a novice—to trust (or at least accord significant weight to the opinions of) on matters of vaccination. It is therefore reasonable to assume that many unvaccinated individuals were faced with a “two expert problem.” When faced with conflicting testimony from two alleged experts, it can be rational to simply suspend judgment. ¹⁷ Given that only one of the two expert counsels undertaking a given action (whereas the other counsels simply refraining from action), it is plausible that suspension of judgment entails maintaining one's status quo, that is, remaining unvaccinated. But, second, even if one rejects the claim that it was rational to follow the advice of any of these alleged experts, it should be noted that this only shows that the unvaccinated may be judged blameworthy for bad epistemic practices (i.e. trusting the untrustworthy) and not for doing what is rational given their advice. Thus, the unvaccinated may be said to have acted rationally on bad evidence, and therefore while it might be fitting to be angry with them for trusting the false experts (though again, I think in many cases this is dubious) it is not fitting to be angry with them for acting rationally in light of the testimony of those false experts.

This establishes that at least some unvaccinated patients are not blameworthy and that therefore anger is not fitting toward them. Other excusing conditions which may apply to certain patients are hardship or inability. For hardship, imagine a patient is unvaccinated (or, possibly more likely, inadequately vaccinated) because she lives in an underserved rural community and must travel a long distance to get the shot. Further, suppose that she has a job (or multiple jobs) along with children, all of which demand a great deal of her time and energy. Anger seems plainly inappropriate in such a case. As for inability, some individuals simply cannot get vaccinated: due to allergies, for example. Again, anger is wholly inapt for such individuals. Finally, we should include among our excusing conditions the justified mistrust felt by some black persons toward the medical establishment given historical misconduct and ongoing racism. ¹⁸ Such individuals are acting rationally, attempting to protect themselves from an establishment that has often inflicted grave harm on them or their communities. It does not seem appropriate to feel anger toward them in light of this—their actions are not wrongful.

However, it is perfectly conceivable that there are some patients for whom no such excusing conditions apply. We can easily envision someone who simply refused—in the face of all evidence and with full understanding—to get vaccinated due to sheer laziness or obstinacy. Now this individual presents in the hospital emergency room. The hospital is already straining under the weight of the pandemic; beds are scarce, and the staff are exhausted. Surely it is at least fitting to be angry with such a person? That is, surely individuals such as this have done something wrong?

I concede that it is reasonable to suppose that they have. Nevertheless, as I will show in the next section, that does not settle the question of whether it is all-things-considered correct to be angry with them. Indeed, as I will argue, the balance of reasons speaks against anger even in this situation.

Anger and the moralistic fallacy

In a well-known paper, the philosophers Justin D’Arms and Dan Jacobson pointed out that an emotion's fittingness can be assessed independently of other normative questions we might ask about it. In other words, to say that a given emotion is fitting doesn't settle the question of whether reason—all things considered—favors feeling or expressing it: to conflate questions of fittingness with other concerns (e.g. moral concerns) is to commit what they call “the moralistic fallacy.” ¹⁹ In fact, “an emotion can be fitting despite being wrong to feel.” ²⁰ Consider a situation where fear is fitting: for example, you are hiking and come across a bear in your path. Fear is fitting in this case because of the threat posed to you (it correctly appraises its target as dangerous). However, our emotions are governed by a variety of different norms—prudential norms, moral norms—and these must be weighed in the balance along with norms of fittingness. In this case, it is very plausible that prudential norms favor not expressing (and as best one can, not feeling) fear. Instead, you ought to make a big show of strength in order to scare the bear out of your path. Anger is no different from fear in this respect: it, too, is governed by norms of prudence and morality in addition to fittingness. Therefore, having settled the question of fittingness, the final, crucial step in a moral assessment of healthcare workers’ anger toward unvaccinated patients is an assessment of the moral reasons for and against such anger.

Philosophers friendly to anger note that it can have a variety of benefits across several dimensions, most notably motivation and communication. Motivationally, anger can be a spur to reform unjust circumstances or institutions, or to stick up for oneself.^21,22 It motivates people “to engage with perceived wrongdoers” rather than passively acquiescing. ²³ With respect to communication, anger can communicate the message that a wrong committed against oneself will not be allowed to invalidate one's dignity: as Myisha Cherry writes, “perhaps through anger, the angry agent brings the wrongdoer from a position of superiority – from which the wrongdoing occurs – to a position of equality.” ²⁴ In addition, anger can communicate to wrongdoers a demand that they recognize and acknowledge their wrongdoing, while also communicating to third parties that they, too, should adopt these demands. ²⁵

Moreover, some philosophers hold that anger can be intrinsically valuable. According to Amia Srinivasan, “there is more to anger, normatively speaking, than its effects.” ²⁶ Srinivasan's discussion focuses particularly on political anger, which she notes is often criticized for being “counterproductive.” ²⁷ Women who are angry in response to sexist injustice, for example, are often counseled that such anger impedes their goals, that “feminist progress would be swifter if only they would be less shrill about it.” ²⁸ Setting aside the issue of whether this counterproductivity critique is correct or not on the merits—that is, whether such anger really does impede progress toward political goals—Srinivasan lodges two criticisms of it. First, it risks overlooking the intrinsic value of fitting anger itself: “getting angry is a means of affectively registering or appreciating the injustice of the world,” she writes. ²⁹ This appreciation has value over and above epistemic value—that is, it is not valuable merely because it represents that one knows that a given situation is unjust. It is valuable in its own right. Srinivasan asks us to imagine a person who knows that, for instance, sexism is unjust, and who acts to ameliorate it, but who is nevertheless “left entirely cold” by it. Such a person, Srinivasan claims, is “missing” something, something of value: “it would be better, ceteris paribus, if she were capable of feeling anger towards the injustice she knows to exist.” ³⁰

Second, being forced to choose between achievement of one's political goals (and the amelioration of the injustice perpetuated against oneself) and one's fitting anger constitutes a kind of injustice, which she calls “affective injustice.” ³¹ Affective injustice “forces people… into profoundly difficult normative conflicts—an invidious choice between improving one's lot and justified rage.” ³² One is forced to resist feeling what one knows is fitting, appropriate, or called for, which constitutes “a sort of psychic tax.” ³³

So much, then, for the case for anger. What of the reasons against? Here, I will focus primarily on one important reason for speaking against anger, namely, the close connection between anger and a desire to punish. Numerous philosophers have observed that anger seems to have a very close relationship with a desire for retribution and punishment.^34–36 Indeed, the view that anger is “at its core, vengeful” is so widespread that the philosopher Laura Silva calls it “the orthodox view.” ³⁷ I will argue that this connection provides decisive reason against nurses and doctors giving vent to their anger in clinical settings.

Now, there is much controversy over the nature of this connection between anger and a wish to punish. Some hold that this relationship is so tight as to be essential: according to Martha Nussbaum, for example, it is part of the very concept of anger that it involves a wish for its target to suffer. ³⁸ Yet, this view is persuasively criticized by both Srinivasan and Silva. Srinivasan observes that it seems perfectly possible to be angry with a friend because that friend has betrayed you and to merely want “the friend to recognize the pain she has caused [you].” ³⁹ Similarly, Silva argues that anger can motivate not a desire for vengeance, but simply “recognition” that the offending party has committed a wrong. ⁴⁰ In addition, she undermines the purported necessary connection between anger and a desire for punishment by reviewing a raft of empirical data concerning “anger's behavioral pluripotency.” ⁴¹ Anger it appears can motivate a variety of actions, not all of which are punitive.

This rethinking of anger is highly welcome in many contexts—for example, with respect to anger in the political realm. But I do not think it gives us reason to think that anger in healthcare contexts on the part of nurses and doctors is a good thing. Rather, I contend that the reasonable possibility that anger might motivate punitive desires is enough to outweigh any potential reasons in its favor in the healthcare setting. (I submit that the reasonableness of this possibility is reflected in the fact that nearly the entire Western tradition links the two states, often so closely as to be conceptually connected). That is for reasons having to do with the role of healthcare workers, the high-stakes and high-pressure setting, and the vulnerability of one's patients.

First, the role of nurses and doctors. ⁴² The primary duty of healthcare workers is to heal: taking on the role of a healthcare provider is taking on an obligation to promote patients’ welfare. Thus, anything which conflicts with this obligation is inconsistent with that role. But insofar as anger motivates a desire to punish or get even, it risks interfering with that role. The high-pressure setting compounds the worry, for when a person is both under great pressure and feeling angry with the person one is supposed to be helping, it is plausibly that much harder to keep one's professional obligations foremost in mind. Perhaps my outpatient doctor—who shares the same healer role as an in-patient nurse—can allow herself to be angry with me for willfully ignoring her advice without that anger interfering with her discharging her duties (though even there we may think it best if she can avoid being angry), but this seems far less plausible, for example, an ICU nurse dealing with a very sick patient. The high stakes make the case against anger even stronger. That this is a high-stakes setting—one where lives are on the line—makes precision and clarity of mind essential. Anything that might interfere with or cloud one's judgment is to be avoided. Finally, consider vulnerability as such, outside the context of healthcare. Suppose my perfectly healthy, perfectly rational, and coherent friend wrongs me. Now, if we assume that anger motivates punishment, I may be inclined to retaliate against this friend. Set aside whether such a retributivist impulse is laudable—even rational—either in this case or in general. It isn't likely that I will (or can) do much great harm to this friend (even if I am extremely angry). Now suppose I am angry with a friend who is quite ill. If, again, I am motivated to punish, I could in this case gravely harm my friend, even if I do not mean to do so. In both cases, we might think that the balance of reasons counts against being angry, but I submit that the reasons are stronger in the latter case.

Adding to the case against anger in this context is the fact that the motivational and communicative benefits that often speak in its favor do not apply. Anger may well be beneficial in virtue of its tendency to move individuals to stand up to injustice, but there is no need for such motivation here: there are no actions the targets of this anger can take to desist from wrongdoing or make amends. Moreover, those who note anger's motivational benefits also point out that part of what makes it so useful is its tendency to make individuals heedless of costs: angry individuals, for example, are often motivated to engage in “altruistic punishment,” that is, punishment of wrongdoers which does not benefit the punishing party and indeed may be costly. ⁴³ But this kind of heedlessness runs strongly counter to the job description of a doctor or nurse, particularly one working with a potentially very sick patient in a high-pressure setting. Now, it is important to note that anger's primary effect here appears to be promoting heedlessness with respect to costs to oneself. Therefore, one might wonder if that is truly incompatible with the professional obligations of nurses or doctors. However, I think it is. For example, anger could lead one to ignore or discount risks to reputation or even employment in quest to punish perceived wrongdoing, costs we do not want healthcare professionals to be less mindful of. This, in fact, is precisely how anger may make a bad situation worse. Anger's communicative benefits are similarly otiose in this context. There is no useful purpose being served by communicating to very sick individuals that they have erred, nor do others need to be brought around to this view.

To conclude this discussion, let us return to the issues of the intrinsic value of anger and of affective injustice raised by Srinivasan. We can readily accept that anger has a kind of intrinsic value while nevertheless supposing that its value is outweighed in this context. Moreover, and importantly, this value is not, as in the cases Srinivasan is concerned with, outweighed by prudential concerns, but rather by moral ones. For the reasons already canvassed, the balance of moral considerations speaks against anger: thus, unless the intrinsic value of anger is very great, we can assume that it is outweighed. This does not strike me as any sort of injustice, but rather is the kind of professional sacrifice (if sacrifice is even the right word) that we justly expect from healthcare professionals.

I conclude that moral reasons count heavily against feeling anger in the settings under consideration even where it is fitting. In the penultimate section of the paper, I will explain how this fact adds additional moral urgency to the need for greater institutional support of nurses, doctors, and other healthcare workers.

Obligations of institutions

It has now been shown that it would be better for healthcare workers not to experience anger toward patients, even when those workers are correct in perceiving their patients as having engaged in wrongdoing. Importantly, there is now a large literature on emotion regulation, one which investigates strategies to help individuals manage their emotions and also highlights the ways in which various situational factors can lead to failures of emotion regulation.

I contend that the onus is on healthcare institutions to make use of the findings of this literature to help their employees better manage their emotions in the moment. This can mean more extensive training in emotion management in order to help employees learn the kinds of strategies—for example, reappraisal—that help downregulate anger. ⁴⁴ It can also mean mitigating the situational factors—like poor sleep quality brought on by long hours, too much stress, or not enough time off—that cause failures of emotion regulation. ⁴⁵ Factors like burnout or compassion fatigue are often cited as reasons speaking in favor of greater institutional support of healthcare workers, and rightly so; however, I have shown that defusing deleterious healthcare worker anger toward patients is another important factor. This will benefit both the employees themselves and the patients they care for.

Conclusion

I have argued that healthcare worker anger toward the willfully unvaccinated in the midst of a global pandemic deserves a fair hearing, particularly in light of the philosophical rehabilitation of anger in recent years, but that careful consideration ultimately returns the result that such anger is indeed misplaced. This result furnishes additional urgency for greater support for the emotional well-being of healthcare employees.

I close with two observations about what I have not shown. First, I have not shown that there is some other attitude, dissimilar enough from anger to lack its drawbacks but similar enough to have some of its virtues, which might be called for in these circumstances. Some philosophers have explored the possibility of a kind of “moral sadness,” for example, and I leave it for future research to explore its appropriateness in these contexts. ⁴⁶ Second, I have not shown—nor do I want to show—that anger is not fitting and, indeed, fully appropriate, with respect to other, related targets, for example, those who have led individuals choosing to remain unvaccinated astray. In fact, I wholly concur with Dr Matt Morgan when he writes “I am angry with the liars, not those who have been lied to.” ⁴⁷ By no means is all anger morally troublesome.