Power, othering, and slurs in the clinic: undermining the capacity for care
Alison Reiheld

Over at the Feminist Midwife, we find a valuable post on WHY something that may seem prima facie wrong is, in fact, wrong.  In an entry called “Patients Are Not Bitches, and Thoughts Medical Othering,” Feminist Midwife considers a case she witnessed:

This image shows a woman with damp brown hair and pale skin standing next to a hospital bed with her arms on the bed and her head bent down. Her expression is one of concentrated effort. Her shoulders are bare, and in the foreground of the image we see a shoulder clad in the classic blue of set of scrubs. Medical equipment can be seen, out of focus, in the background of the image.

Recently, I overheard fellow providers refer to a laboring person as a bitch…. This actual event happened quite a while ago, but it’s taken me this long to separate my anger from the situation, to be able to calmly break apart all of the reasons why I felt that way. The exact circumstance was a room full of female Residents and one female midwife, referring to a patient who was disagreeing with a care plan and declining recommendations. Multiple providers in the room called the patient a bitch. They said it disparagingly toward the patient, and in comradery with each other.

The use of slurs or other demeaning speech to patients, families, or even providers is no new thing.  We do well to  give it thought, and to pay close attention to how it reinforces existing power structures. Feminist Midwife addresses this directly, with respect to gendered slurs such as “bitch”, in the blog entry linked above:

When women are assumed to be kind and caring and acquiescent and present for others, the moment they stand up for themselves and acknowledge their own existence and needs and individuality, the unnatural aspects of those actions are identified, called out, put down, and policed. And one act of policing is by calling them names, and push them back into the fictional box from which they strayed. Bitch, slut, cunt. Undo your behavior and get back to how society assumes you are to be.

 As feminist philosopher Marilyn Frye observed of race in her essay “On Being White”, following on from Simone de Beauvoir’s similar insights, white women can gain safety and security by allying themselves with white men against non-whites and against other women. Similarly, it follows that women of any race can gain some security by allying themselves with dominant gender norms. What kind of safety and security can be gained by female health care providers using gendered language to put themselves on the side of women-behaving-well instead of women-behaving-badly?  How is the possibility of care damaged?  Playing into this kind of self-preservation preserves also the damaging power structures that hurt women generally and marginalized groups specifically.

In addition to these  considerations about power and hierarchy, we can add concerns about vulnerability. Patients in general are in a vulnerable state, patients in crisis all the more so. And I propose that laboring women are indeed vulnerable patients in crisis.  Many medical ethicists argue that vulnerability incurs special obligations on those able to mitigate the vulnerability or at least render care and support to vulnerable people. In a 2009 IJFAB article which I find myself drawing on often in my work, Florencia Luna draws our attention to the notion of layers of vulnerability which compound upon each other, some of which we can remove, others of which we can render less harmful, and still others we can refuse to be an agent of adding.   But we needn’t go to theory to get this kind of force of argument. Rather, we need only appeal to the common aphorisms, “don’t kick someone when they’re down” and “don’t add insult to injury.”

In closing this short reflection, I give you a case I often uses in teaching medical ethics (the “BFD” case), and which I think about often when I think about how we treat each other and patients.

A former med ethics student of mine, A.M., was shadowing a cardiologist and a cardiac surgeon at Sparrow Hospital in Lansing, MI, and had scrubbed in on surgery several times.  She also worked in the Sparrow ED as support staff (she, herself, wants to be a cardiac surgeon).  A few years ago, she was on shift when a man came in reporting of chest pain and numbness in his left arm.  He had probably had a myocardial infarcation (MI; heart attack).  AM overheard one of the ER nurses discussing the patient’s complaint with a colleague, and at one point the ER nurse said “BFD” (big f-ing deal) and rolled her eyes.

Perhaps we use an ethic of care as we render care, holding relationships–including the patient-provider relationship–as central to moral action.  Perhaps we simply strive to satisfy basic principles of medical ethics such as beneficence and non-maleficence and justice and autonomy. Perhaps we seek to balance this with maximizing the good for everyone affected, in a kind of utilitarian mindset. We could name any number of other ethical theories, and draw also on political theories about oppression and power.  But I cannot think of a single theory that would find to be good the nurse’s behavior in the “BFD” case, or the kind of name-calling and power-placement involved in the case introduced by Feminist Midwife.  

I can see how the individuals involved might be motivated to act in such a way, and even to hold such attitudes. I can see how one power dynamic I haven’t yet discussed could be the need to support one’s peers in the face of difficult interactions with patients.  But reducing the patient to the difficult one is a kind of othering–you  can’t expect to change who a person is–that inhibits the possibility of care, whereas positioning the interaction with the patient as the difficult part can allow for support and also constructive alterations that might improve the interaction for both the provider and the patient.

Feminist Midwife’s own analysis of the power dynamics in play, here, and of how we respond to anger, is spot on.  Let us watch out for the pull of othering as a way of preserving ourselves, for in truth it does only harm.

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Power, othering, and slurs in the clinic: undermining the capacity for care — 1 Comment

  1. Thank you for Marilyn Frye’s revelation that white women can avoid white male put-downs by all ting themselves with the males’ expressions of racism. I’ve often marvelled at white women’s anti-female behavior, at the motivation behind remarks like “I vote for X because my husband tells me to.” Frye’s observation helps my understanding and my empathy.

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