Our conceptual model and empirical material prove that doctors—a powerful, resourceful, agentic group—can be vulnerable and acutely aware of their helplessness when faced with the inability to save or cure a patient (or her unborn/ baby). We refer to this vulnerability as “existential.” Another kind of vulnerability arises when doctors encounter “unjust” (in their terms) interpretation and evaluation of their actions. We label this vulnerability as “moral”. For instance, it inductively arises when doctors are assigned responsibility for situations they could not control, have to follow contradictory regulations or get baseless complaints from patients. Both unfair claims from patients and from regulatory authorities can have legal consequences, which create symbolic and real threats.
4.1. Existential Vulnerability of Professionals: “There Is Something That Will Never Be Forgotten”
Existential vulnerability concerns the fact that experience related to death is “universal”—as everyone sooner or later experiences helplessness in front of death or an unbearable suffering. Nevertheless, medical professionals perform a special role in these situations, and hence, they have very specific experiences, which make them vulnerable in a special way. First, their professional role appears to be limited by the opportunities of biomedicine, which objectively cannot manage every physical condition and save every patient, but professionals tend to take such “failures” personally and emotionally hard. This is exacerbated by the fact that in reproductive medicine, death or threat of death occur to “nonconventional” demographic groups (the ones who ‘should not’ die)—young women and babies. Second, contemporary demographic pronatalist politic of the state concerns the increasing the birth rates and attracts a lot of attention to maternity care. As a result, every case of maternal mortality (regardless of its inevitability and numerous complications) is becoming an issue for special attention from controlling and law-enforcement bodies and a potential legal threat for all professionals who were involved in the process of treatment.
Medicine in general and midwifery and obstetrics in particular are full of situations in which a patient feels pain, suffering and fear; experiences loss or encounters negative prognosis of the treatment. Situations, in which a patient feels herself most vulnerable, include complicated clinical cases, reproductive losses, abortions for medical reasons, complications of pregnancies and births, newborn malformations and birth traumas. Medical professionals aim at saving and helping in such situations, but sometimes it goes beyond their capabilities.
Our informants have reported that they make much effort to fix any health problems they face. However, doctors, midwives and nurses still encounter situations in which there are questions of existential character and in which they feel themselves hopeless while coping with patient’s death:
“Because anyways, there are many difficult ones [clinical cases]. On a certain stage, after all, I had another sphere of medicine, I didn’t lose as much as here, but here, the level of difficulty is so that loses are inevitable… And kind of night calls and screams… I mean there is something that will never be forgotten. That’s when we were sitting at the department, when we were running to the resuscitation [with the baby] on our arms, you realize that the baby is terminally ill… That’s why these are such hard, the most difficult moments”
(Interview with a pediatrician)
Doctors explain to us that they will keep on trying to save the patient even in a hopeless clinical situation or in situations with negative prognoses. In cases of lethal outcome, they feel their hopelessness and this experience leaves scars for the whole life:
“At the intern’s room we find out who passed away last week. A woman, right after the operation, a severe pathology, delivery at 34th week (pregnancy was contraindicated), the baby has probably survived, there are no complaints yet. It is said that doctors from different departments rushed there and some of them were only disrupting. Note: we had planned fieldwork on that day, but we were asked not to come”
(field notes, researcher’s observations)
Despite the fact that the situation was rather prospective (it became clear later, during the clinical examination of the case) and was not followed by relatives’ complaints or legal trial, many professionals got engaged; the case was widely discussed as stressful for the personnel. The physical condition of a woman carried fatal risks, “It was irresistible, there were no medical mistakes”, (field diary, conversation with a doctor). We (as outsiders) were asked not to come to the Center for some time, presumably not due to the fatal outcome itself but due to the emotional resonance and strains of professionals.
It is important to notice that existential vulnerability arises not only in cases of lethal outcome but also in cases of negative prognosis (both for health or for life quality) and risks of lethal outcome or grievous harm. Constant encounters with complicated clinical tasks, pathologies, deaths, severe physical conditions of babies, bad prognoses unleash the process of deep reflection:
“We don’t speak in a room (so that there is no noise), girls [young doctors and interns] are knitting octopuses, we speak, caress, hug, kiss. Treat babies with love. And we are very compassionate to these mothers. Pathology of nervous system is a trouble indeed. And we understand that this premature baby—we will nurse it. But what’s then?”
(field notes, conversation with a neonatologist)
Different wards face hard cases, death and emotions of patients to different extent. In these terms emergency room or consultative-diagnostic department would dramatically differ from resuscitation or labor wards:
“Obstetricians always fight at the forefront for life and death”
(field notes, conversation with neonatologist)
“If for other departments clinical death is a stress, for us it’s a job. We are the most stressed department”
(field notes, conversation with intensive care nurse)
Doctors in perinatal center specialize in working with severe clinical cases; therefore, mortality, bad outcomes and poor clinical prognosis are always an inevitable part of their work. However, professionals tell about severe cases or loss with personal emotional troubles. They are worried, frustrated and it is hard for them to tolerate every case of maternal or neonatal death.
One of the emotional situations that we observed during the fieldwork was related to the potential threat for the life of a patient who refused to admit the problem and accept treatment. Professionals tell that they spent several working days on endless talks with the patient trying to convince her and one of the doctors “was so nervous that she couldn’t fall asleep and was walking the streets at night” (field diary, conversation with a doctor). Professionals feel and express the existential helplessness which is accompanied by the fact that in the context of lack of trust, patients do not believe in prognosis, and doctors cannot persuade them to act in a necessary way (from their point of view).
The situation was as follows. In the hospital there was a young woman who had just given birth in another hospital and was transferred to the perinatal center for clinical reasons. Doctors believed that there was a serious threat to her life. The patient was in the intensive care unit, subjectively felt normal and insisted on discharge from the hospital. Her husband also insisted on discharge and accused doctors of overdiagnosis and forcibly keeping the woman in the hospital:
“Husband: “She was living a normal life, you found heart [problems], that’s you who cannot decide, whether it is heart or kidneys… You make her, you forcibly hold her in the hospital… you can’t make her do something you want. She wants to go home, she is feeling good”
Doctor: “She has a risk of death”.
(field notes, researcher’s observations)
Professionals think that the decision of a patient is fatal—“They make a mistake which is the size of life” (field notes, conversation with a doctor). In this case, the doctor supposed that the patient did not realize the threat to her life despite the fact that she was given medical explanations many times. The patient and her husband relied on their previous lay experience and the experience of their social environment, interpreted the situation as an ordinary one and demanded to be discharged from the hospital. In a conversation with us, the doctor said: “We can expect nasty things, she will write to the President”, i.e., there is a potential possibility of complaints and follow-up checks, especially when there is a potential threat of maternal death, each case of which is controlled by the Ministry of health and regional authorities.
As a result, patients become even more vulnerable because numerous involved professionals use “aggressive” techniques to persuade patient in order to minimize medical risks and to subordinate patient to their decision. In the described situation the doctors and the patient do not come to an agreement, and the woman refuses to continue the treatment; however, after difficult negotiations with patients and consultations with different medical committees, professionals find a solution and transfer her to another hospital to which she agrees to go to (it is closer to home, though not specialized).
This situation is sensitive for medical practitioners not only because they can be legally prosecuted in case of death of the patient or serious harm to her, which they could predict but could not cope with, but also because they do not have enough authority and trust in the eyes of patients to protect them from lethal or disabling outcomes of clinical situations. This additional responsibility forces doctors to behave more assertively towards patients who do not believe and refuse to follow their recommendations. As a result of the lack of mutual trust, doctors are urged to use affective and “forceful” arguments, while patients respond to them with aggression and even greater distrust:
“[Doctors] are speaking quite rough… It was emotionally hard for me, maybe because of the hopelessness of the situation and inability to negotiate… Verbally doctors are threatening and bullying her to make her stay. Although—no doubt—they make it for her benefit and may be even saving her life. [One of the doctors] doesn’t sleep at night, [the other] is outlining his brutality”.
(field notes, researcher’s observations)
At the same time, neither doctors nor nurses have professional tools and special skills for communicating sensitive topics, which at the same time is a routine for them. Neither is there a practice of calling a mediator. This often affects patients, whose emotions remain unrecognized or ignored (perceived as grotesque, or demonstrative behavior). Topics related to ethics and communication with the patient are underrepresented in the curriculums of medical schools and colleges. Psychologists, who could provide both doctors and patients with professional help, can hardly get a position in hospital because they lack legal regulations of their work and trust within medical organizations. As a result, medical personnel can usually only count on their own experiences and collective practices while discussing difficult topics with patients. Moreover, they have to direct their efforts not to emotional assistance to patients and their relatives, to colleagues or themselves, but to protecting themselves and their professional collective from subsequent sanctions connected to maternity or infant death, and then, patients suffer more as they fell themselves helpless and cheated in such kind of communication.
4.2. Moral Vulnerability of Professionals
Moral vulnerability emerges when professionals face unjust evaluations and critical interpretation of their actions made either by regulatory and controlling bodies (with their constantly threatening sanctions) or by patients.
4.2.1. “Big Brother Is Watching You”
Doctors constantly feel themselves objects of all-round control. They tell about their precarity and insecurity under controlling gaze, which is perceived as a threat to their professional status and personhood in general. Threat is a kind of “outer force” (“God forbid something happens”), which lies beyond the professional’s control and creates the feeling of hopelessness:
“I say personal insecurity when you realize that in case, God forbid, something happens, nobody will be on our side, nobody will help”
(Interview with a doctor)
“Nobody will protect doctors” (field notes), “nobody advocates for physicians in front of the public”
(Interview with a pediatrician)
Doctors are meant to strictly follow the laws, recommendations, procedures and rules. As we described earlier, they have constantly been controlled by various authorities (such as SanPiN, Rospotrebnadzor, Ministry of health), which produce the rules that rapidly change and sometimes contradict each other. This is one of the consequences of ongoing reforms and hybridization of governmental paternalism and new managerialism. The legal insecurity and vulnerability are generated by multiple institutional circumstances, uncertainties and organizational gaps, which in turns are produced by conflicting legislative requirements, organizational rigidity and material constraints that professionals are talking about (see Section 3
). Professionals constantly feel their precarity in such conditions. In addition, the control over doctors is strengthened by the promotion of state demographic priorities of increasing fertility and growing attention to maternity care. Professionals say: “Big brother is watching you” (field notes). During the fieldwork, we could regularly see health practitioners discussing future inspections and dangers they can possibly bring:
“Fines are inevitable. [The nurse] believes that they just have to reconcile with it. The only question is about the size and the legal subject—a (physical) person or a corporate body (organization). Sometimes it is easier just to put the responsibility on oneself than to arrange an administrative commission”.
“I ask her [the nurse] why is this so bad (about administrative commission). Is it because there are so many violations or because they cannot be fixed? She says yes, there are too many inconsistencies, which she (and nobody) doesn’t know how to fix for the period of inspection. “My fantasy is not enough to pull the wool over inspectors’ eyes! (she means—how to represent themselves in the best way for the inspection””.
Our data supports the claim that formal requirements are often contradictory and cannot be met in full due to circumstances which are beyond professionals’ control. In emic terms, the phrase of the doctor would be “the chaos is everywhere within the medicine” (field notes). Professionals act in patients’ interests and cope with gaps in their professional daily routine by frequently breaking certain formal rules and recommendations. Consequently, they can potentially be accused or sanctioned. Professionals clearly understand it and say with irony that: “my task is to prepare everything for the prosecutor so that he can’t get to me” (field notes).
Take the example of solving a problem of insufficiency of medications and equipment, which is derived from the organizational inability to buy them quickly. The doctors can face the two options: not to follow clinical recommendations and cure the patient with available treatment or search for the prescribed recommended medication by using informal instruments. For instance, professionals sometimes make purchases themselves, which is considered illegal:
“Nurses buy containers and special tools with their money. This weekend they plan to go shopping together”
“They [parents] bring [money] to the discharge—doctors leave it in the department for medications. [My relative] brings suitcases of a foreign medicament. Resuscitation [department] also brings it from vacation. Sometimes we buy it ourselves”
(field notes, conversation with a doctor)
“They borrow [medication from other departments], but this is a serious violation of rules”
Professionals are vulnerable also due to the risk of detention for informal payments, which are explained by low wages and a necessity to survive: “There is informal money, and that’s life. And so how could one live on these wages, when you need to feed the family” (field notes, conversation with a doctor). This is a hidden topic which is ambivalently evaluated in medical community (about informal payments see [39
Moral panics in media incite mistrust and aggression towards medical professionals. Cases of infant and maternity death, birth traumas and various iatrogenic conditions regularly become a topic for massive public debates. All together, the increased attention of the Investigating Committee, media coverage and institutional controversies comprise the particular settings, which stimulate patients’ complaints and invent new forms of control but leave little opportunity for medical professionals to deal with it. The control becomes more pervasive due to new instruments, such as audio- and video-recordings of sessions with patients, online sites for commenting on and evaluating doctors and medical organizations, professional associations aimed at representing the interests of patients (League of Protectors of Patients, Investigation Committee). At the same time, medical professionals lack resources and social and professional support, to protect themselves in situations of legal prosecution or media scandals, which makes them feel constantly vulnerable. On the one hand, patients try to get a voice and empowerment, which were unachievable within the paternalistic model. On the other hand, mistrust makes them more demanding and blocks the possibilities for dialog, cooperation and compliance. Some patients are conscious that doctors and medical organizations are very sensitive to complaints and therefore try to get profit during the process of cure (extra services or financial compensations). This practice was reflected in terms used in medical environment—“the patients’ terror” and “an extremist patient”.
4.2.2. “An Extremist Patient”
Another type of injustice and vulnerability is related to the rise of complains and grievances of patients, many of which are deemed as unfair by physicians. Professionals take complaints very hard as they can lead to administrative and material sanctions. Patients are becoming more demanding in their ethics and style of communication and self-sufficient explanations. The principle “Doctor knows best” does not work universally any more. Patients are trying to get more control over the situation, evaluate doctors and hospitals, describe their experience, write down comments on the Internet. Patients are becoming more exacting as consumers [39
For medical professionals in Russia this is a relatively new situation, and they often feel themselves helpless victims of unrealizable demands and injustice and unready to solve the problem. They distinguish a certain type of patient, which represents a threat—these are “aggressors” or “extremists”. They write complaints to different controlling bodies and online sites. According to professionals, they act aggressively, behave unethically, make unrealizable demands and “biased” complaints:
“Oh, mother, within three days she managed to write eight complaints to all instances of the world! Listen, we… we are absolutely unprotected from this. A person can write anything: a positive feedback, a negative feedback. I like—I didn’t. Absolutely biasedly”
(Interview with an administrator)
“The doctor says: a mom was brawling (today) because she didn’t get the medication. It costs 16,000 rubles; we ordered it; it will be delivered (in a few days). But she wants to get discharged on Saturday, because of the birthday. She says: “Take it wherever you want, at least buy it and pay it yourself””.
Complaints lead to reputational loses and emotional costs. We were told about a complaint, which was considered unsubstantiated. The doctor, who was mentioned in the complaint, was taking the situation very hard and was even about to quit the job:
“There were two proceedings. The doctor had been going crazy all five days before that. She was sending messages to me: “Maybe I should quit my job?”… Reputationally this is very painful… not to crush this person”.
(Interview with an administrator)
Complaints can also be made on the basis of communicational and service problems. The doctor tells about a complainant who considers,
“The childbirth went well, thanks to your specialists”. And then, somebody didn’t open the door in a right way, somebody offered something wrong, something that made them indignant and provoked to [write down] two pages. They didn’t like the magnet key (for exit) for some reason; I mean, and so on… You were not served? What you were not served? In what way you were not served? … Do you understand that all this, in truth, deeply hurts medical practitioners”.
(Interview with an administrator)
Hospital meal, late discharge, intrusive photographers in a check-out room and other reasons which lie beyond the responsibilities of a health practitioner, can become a basis for a complaint. The aim of “patients-aggressors”, who are selfish as considered by professionals, is to get financial profit or moral satisfaction.
Doctors are in a situation where they are becoming more controlled by the patients; they can be complained about every single moment. Every patient can record a conversation and post it on the Internet: “Patients are taking pictures of us with their mobile phones, and we feel and consider this” (field notes, conversation with a nurse).
According to our data, lack of trust and absence of compliance become a background for blaming physicians for negligence, disregard or dishonesty. During a fieldwork, we repeatedly observed how hard it can be for doctors to conduct a dialog with patients, especially those in a critical or threatening situation. Doctors who are striving to solve difficult clinical tasks describe their job as physically hard and emotionally charged, frequently telling about emotional burnout. Patients often do not appreciate their efforts—they do not see and cannot evaluate the complexity of this work under the conditions of institutional contradictions and multiple all-round control. Patients, who are physically and emotionally vulnerable themselves, are suffering of neglect, discomfort, and misunderstanding.
As a result, a lot of (potential and real) situations of discontent and complaints are based on a conviction that the doctor is dishonest and acts in his or her own interests. Patients tend to see deception when the actions and interpretations of doctors remain unclear, confusing and contradictory to their own life experience.
Therefore, doctors, whose social position is provided with power, resources and competence, in some cases appear to be vulnerable both in terms of existential events, which are out of their control, and in terms of unjust evaluations of their actions and sanctions against them; their power and resources appear to be insufficient. Vulnerability of professionals remains invisible as it does not correspond with their social position. However, it negatively affects the patients. For a doctor who is herself hardly struggling with existential situations and threatening sanctions, it is difficult to provide sufficient support to suffering patients or their relatives. A doctor who does not have the opportunity to act in the best interests of a patient or has to break the law in order to do so can only aggravate the vulnerable position of a patient. Therefore, as a result of doctors’ vulnerability which is related to institutional and organizational contexts, patients become even more vulnerable.