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Abstract
Dehumanization is endemic in medical practice. This article discusses the psychology of dehumanization resulting from inherent features of medical settings, the doctor-patient relationship, and the deployment of routine clinical practices. First, we identify six major causes of dehumanization in medical settings (deindividuating practices, impaired patient agency, dissimilarity, mechanization, empathy reduction, and moral disengagement). Next, we propose six fixes for these problems (individuation, agency reorientation, promoting similarity, personification and humanizing procedures, empathic balance and physician selection, and moral engagement). Finally, we discuss when dehumanization in medical practice is potentially functional and when it is not. Appreciating the multiple psychological causes of dehumanization in hospitals allows for a deeper understanding of how to diminish detrimental instances of dehumanization in the medical environment.
A patient retorts to her physician, “I’m not a diabetic; I’m a person who also just happens to have diabetes.” A nurse sits with her back to her patient and types on a computer while asking, “On a scale of one to five, rate your pain?” An African American man comes to the emergency room with signs of a heart attack but is less likely than a white patient with the same symptoms to receive a medication that will break down blood clots.
Why does dehumanization in medicine happen? Rather than pointing fingers at individuals, we suggest that the primary causes for these outcomes result from structural and organizational features of hospital life, as well as from functional psychological demands intrinsic to the medical profession. They are the by-products of common and otherwise effective medical practices and institutional situations that facilitate the dehumanization of patients. Recent advances in the psychological and brain sciences, as well as our own speculation, allow us to explain what dehumanization is and suggest why it happens so often in modern medicine.
Assuming that not all dehumanization is necessary in medicine, this approach can suggest recommendations for improving clinical practices and patient care. We propose ways to humanize patient care through the incorporation of a number of simple, cheap, and effective organizational measures. The effects of these measures must then be studied experimentally in clinical settings as psychologists and physicians work together on the understudied but pervasive phenomenon of dehumanization in medicine.
Why Does Dehumanization Arise and Persist in Medicine?
Dehumanization in medicine does not necessarily result from malicious intent on the part of caretakers. Rather, unconscious, unintentional dehumanization of patients can occur as a by-product of the way humans’ evolved minds interact with present widespread social practices and functional requirements in hospitals. In this article, we explore six possible causes of dehumanization in medicine, three of which have little inherent functionality (deindividuating practices, impaired patient agency, and dissimilarity) and three of which may stem from their inherent functionality in the medical environment for problem solving (mechanization, empathy reduction, and moral disengagement). We will describe these causes and offer solutions for each cause. Finally, we will discuss the functionality and nonfunctionality of these causes.
Both deindividuation processes are endemic to the medical environment. The deindividuation of caregivers leads them to dehumanize, and the deindividuation of patients leads them to become dehumanized. Just as soldiers’ matching uniforms in battle diminish feelings of personal culpability for action, caregivers in hospitals become anonymized amid a sea of white coats, which subtly diffuses their individual responsibility toward patients. Patients, meanwhile, can become subsumed into the mass of barely dressed entities seeking help, appearing as faceless bodies rather than individual agents requiring empathy. Such deindividuation may be amplified for members of racial or ethnic minorities because people often view such groups as outgroups, rendering them lower in perceived heterogeneity (Anthony, Copper, & Mullen, 1992; Ostrom & Sedikides, 1992). When doctors see patients as generic, hyper-deindividuated members of minority, this can produce disparities in care such as reduced use of thrombolysis for myocardial infarctions among racial minorities (Green et al., 2007; White, 2011). In addition, when doctors make decisions about groups of patients versus individual patients, they spend less time assessing problems and order fewer additional tests (Redelmeier & Tversky, 1990), again pointing to detrimental effects of patient deindividuation.
Impaired patient agency
A second cause of dehumanization is the perception of patients as impaired in agency. This cause of dehumanization arises simply because settings such as hospitals are teeming with people whose capacities to plan, intend, and act (to be agents) are in fact impaired. In this way, patients’ loss of agency is an intrinsic by-product of the circumstances that in the first instance most often necessitate visiting a hospital. Being incapacitated because of traumatic injury; infection; drug use; chronic pain; or other cardiac, respiratory, renal, endocrine, oncologic, vascular, immunological, or neurological malady by necessity produces a diminution in a patient’s ability to plan, intend, or act. Thus, even if patients in fact lack these capacities, focusing on these inabilities may increase animalistic dehumanization (Haslam, 2006).
Dissimilarity
A related cause of dehumanization is physician–patient dissimilarity, which manifests in three primary ways. First is through dissimilarity in illness—patients, by their very nature of being ill, become less similar to one’s prototypical concept of human. Second is the labeling of the patient as an illness, rather than as a person who has a particular illness. Third is through power asymmetries common to the physician–patient dyad.
Illness makes people simply appear less similar to the average, well-functioning human. Given that illnesses often alter appearance, behavior, and basic human functioning, patients are likely to be dehumanized.
Second, the effect of perceived dissimilarity on dehumanization is exacerbated when patients are labeled as their illnesses (see, e.g., Shem, 1980, 1997). Labeling a person as a “schizophrenic” rather than as “a person with schizophrenia,”Such labeling encourages perceptions of the patient as the disease itself rather than as a fundamentally human entity stricken by the disease.
Finally, dissimilarity in power between doctor and patient can have additional, specific effects on dehumanization. The doctor–patient relationship is typically a relationship between superior and subordinate. Patients visit physicians because of illness; illness is inherently a state in which one has lost some power and control over their lives The control and power afforded to doctors in this relationship constitute a major determinant of dehumanization—mastery—which can then facilitate dehumanization of patients Participants in the senior surgeon role chose a more physically painful treatment option and described the patient in more dehumanized terms (e.g., cold, lacking in depth and sensitivity) than did participants in the low-power role. This study shows how power can facilitate dehumanization in the medical context. Given that power asymmetries are inherent between doctor and patient, dehumanization may emerge simply from the nature of this relationship.
Functional causes of dehumanization
Mechanization
Dehumanization in medicine also stems from factors intrinsic to the functional demands of the medical profession. One example is the diagnostic and therapeutic necessity of mechanization, thinking of patients as mechanical systems made up of interacting parts. Treatment of people as mechanical systems often results in a particular form of dehumanization—objectification—in which others are viewed as being incapable of emotional responsiveness or interpersonal warmth Some minimal level of dehumanization thus exists in clinical contexts because mechanization benefits these tasks. As a result, caretakers commonly refer to patients in depersonalized terms, using acronyms, the body part being operated on, or the name of their disease.
A similar focus applies to medical treatments. Mechanization is apparent in any surgical or interventional setting: Puncturing the body’s envelope requires a focused and transient reduction of a person to their less-than-well-functioning parts. Pharmacological treatments require translating subjective symptoms and responses into the actions of cellular receptors, molecular agonists and antagonists, and biochemical feedback loops. Even personalized treatment in psychotherapy is no exception, as psychotherapeutic treatments must inevitably explain some subjective phenomena in terms of more abstract, impersonal principles in the service of therapeutic outcomes .
Empathy reduction
This finding raised further questions about the nature of physicians’ empathy. Perceiving pain in others typically involves two steps. First, people engage in emotional sharing of another person’s pain and then cognitively reappraise this emotion The physicians had apparently become so successful at empathy regulation that they did not have an empathic response requiring cognitive reappraisal.
Physicians’ decreased empathy for pain has multiple causes that likely stem from medical training itself. For example, medical training encourages the regulation of negative emotional responses for the purposes of efficient problem solving. Specifically, by dampening pain empathy, one also dampens feelings of unpleasantness that arise from perceiving others’ pain. In addition to neuroscientific evidence, behavioral and psychological evidence also suggest that there seems to be something intrinsic to the problem-solving demands of complex clinical tasks that diminishes empathy and increases dehumanization. The problem-solving benefit of dehumanization may be especially important when the pressure to deliver efficient and effective care is high. Humanizing patients can increase stress, and medical caregivers use dehumanization spontaneously as a method to cope with stress .
Moral disengagement
Countless medical procedures, such as administering foul-tasting medicine, proctology examinations, or open-heart surgery, necessarily involve inflicting pain. Thus, dehumanization likely also results from physicians’ need to suspend themselves temporarily from their role in committing harm, a process related to empathy reduction. This sort of moral disengagement, “the disengagement of moral self-sanctions from inhumane conduct” (Bandura, 1999, p. 193), often serves either to justify past or prospective harm. Physicians consistently find themselves in both contexts, and the need to minimize the guilt of inflicting pain (even pain necessary for treatment) likely increases dehumanization. Dehumanization that involves viewing others as incapable of fully experiencing joy, pain, and desire makes it easier to hurt them without causing feelings of personal distress. Research has shown that people deliver more electric shock to others when those others are first dehumanized (Bandura et al., 1975) and that they dehumanize victims of violence perpetrated by one’s ingroup as a means to justify violence (Castano & Giner-Sorolla, 2006). In a study of the criminal execution process, prison guards, inmate support staff members, and the actual executioners reported their attitudes regarding inmates and the execution process. The executioners (those directly involved in the killing of inmates) reported the most dehumanization toward inmates, suggesting a need to justify harm through this form of moral disengagement (Osofsky, Bandura, & Zimbardo, 2005). Although physicians’ daily procedures are far less cruel than execution, they likely could not operate effectively without minimizing the discomfort that accompanies inflicting pain on others.
Mechanization, empathy reduction, and moral disengagement all have functional aspects. To some degree, all three will likely continue to be a tenacious part of clinical medicine because of the way humans must think about other human bodies when trying to heal them. However, more research is necessary to understand whether dehumanization is absolutely necessary for delivering care, or merely expected for delivering care. Some forms of ostensibly functional dehumanization (such as those that increase psychological distance between doctors and patients) may in fact be worth altering. For instance, one study that examined the effects of adding a photograph of the patient’s face onto radiological CT scans by randomly assigning some radiologists to examine the scans accompanied by the patient’s face and some radiologists to examine the scans without a face attached. The radiologists who assessed the scans with patient faces gave more accurate diagnoses and fostered improved patient outcomes (Turner & Hadas-Halpern, 2008). With this intervention, radiologists wrote longer reports, reported more details, considered each CT scan in a more unique fashion, and expressed more empathy to patients. These results suggest benefits for effective patient care by reducing dehumanization even for physicians and health care workers (e.g., radiologists, pathologists, technicians) that do not directly and consistently interact with patients.
Finally, and perhaps most critically, research needs to determine which of the factors that cause dehumanization are functional and which are not. By examining outcome measures such as accuracy in diagnosis, quality of documentation in doctors’ medical notes, patient-reported satisfaction, and patient adherence to treatment can determine whether factors such as mechanization and moral disengagement do in fact improve care. Similarly, by assessing these outcomes, researchers can determine whether factors such as deindividuation and diagnostic labeling are indeed nonfunctional. Furthermore, research can determine the precise circumstances that optimize the effects of these factors. Factors such as moral disengagement are likely far less beneficial when applied outside of their functional context or for longer durations than necessary. This article, as well as the present empirical literature, focuses on the dehumanization of patients, but it is also important to understand whether physicians themselves are dehumanized (e.g., as we suggest, via deindividuation) and, if so, what effects this process has on physicians and patients. Finally, researchers can examine these factors across personal and social contexts to determine how the predicted effects of these factors vary across national cultures, individual differences, medical specializations, types of training programs and practice settings (surgical vs. inpatient vs. outpatient), and the type of health care practitioner involved (e.g., doctors vs. physician assistants or nurses or technicians). This article provides a novel framework for examining each of these important issues, with the hope and expectation that psychology and neuroscience can be used to inform and optimize medical practice.
Acknowledgments
Both authors contributed equally to this article and the order of names in the byline is alphabetical. We gratefully acknowledge Barbara Spellman, Nick Haslam, Harold Bursztajn, Marc Hauser, Davy Lauterbach, Darrin Lee, James McIlwain, Steven Pinker, and Kyle Thomas for their helpful and insightful comments and suggestions.
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