Moral exploitation

The standard picture of exploitation is that it involves taking unfair advantage and, ‘is to use another person’s vulnerability for one’s own benefit’.3 In other words, exploitation typically involves an exploiter playing on an individual’s vulnerability to garner an unfair benefit. Sometimes, the victim benefits from the transaction or relationship along with the exploiter, thus providing an incentive to engage. In such cases the transaction is exploitative because the victim benefits in a disproportionately minor way compared either to the benefit for the exploiter or in terms of the costs the victim incurs: a classic case is that of ‘price-gouging’ where an emergency is used to significantly inflate the price of life-saving resources.4 Most often, however, exploitation leaves the victim worse off.4 Importantly, exploitation can be entirely voluntary, involving a victim’s consent and hence distinguishing exploitation from other forms of wrongdoing like coercion or deception.

The discussion of exploitation thus far is compatible with differing theories of exploitation whose proponents disagree on, among other things, what exactly counts as ‘unfair’ advantage. Michael Robillard and Bradley J Strawser use this as a foundation to develop their theory of ‘moral exploitation’.5 In all accounts of exploitation a ‘currency’ is exchanged, normally a good or service; for example, physical labour, money, the use of a person’s body and so on.4 6 7 Yet, material goods and services may not be the complete picture. As Robillard and Strawser point out, the currency of exploitation can be extended to include ‘moral burdens’. Robillard therefore explains that moral exploitation is ‘where an exploiter takes unfair advantage of an exploitee’s vulnerability… to compel that agent to accept additional decision-making, moral responsibility and/or emotional guilt that she would not otherwise accept were she not vulnerable’.8 In discharging these burdens the exploiter gains, not materially, but by escaping the downsides of bearing the moral burdens.

Robillard identifies three interrelated moral burdens transferred during moral exploitation: additional moral deliberation; additional moral responsibility; and the emotional consequences of involvement with difficult moral situations.8 These burdens are what make moral dilemmas hard and carry the risk of making the wrong decision, of being held blameworthy and having to deal with the psychological consequences. When there are weighty decisions looming, these are concerns we would all rather not shoulder and the exploiter benefits by avoiding these.

An example that Robillard and Strawser use to explain the concept of moral exploitation is that of ‘academic misconduct’.5 In this example, a senior academic forces a junior academic to make a difficult moral decision involving a cheating student in exchange for tenure. The junior academic is forced to deliberate over what the right course of action is and thereby takes on the associated responsibility and emotional consequences.

Are junior doctors vulnerable?

The concept of vulnerability is key to any exploitative interaction. Here, I clarify the factors making junior doctors vulnerable. Alan Wertheimer formulates vulnerability in terms of limitations along certain dimensions that restrict a person’s reasonable options. Examples of such resources include economic, epistemic, emotional or physical constraints.4 For instance, a migrant worker may not have sufficient legal standing to demand a fair price for their labour; struggle to find work elsewhere, and cannot simply refuse to work until a fair price is attained. This leaves the worker economically vulnerable and without a reasonable way of preventing themselves being exploited for their physical labour. Considering only traditional dimensions of vulnerability, doctors are the antithesis of vulnerable in light of their education, socioeconomic status and the level of trust they hold in society. Reflecting on the activities of doctors, it is difficult to see how they could be vulnerable.

It is undeniable that doctors, including juniors, hold a lot of power within society. However, there is a specific sense in which doctors can be vulnerable to exploitation. Indeed, many of the individual factors making junior doctors vulnerable are shared with other healthcare professionals but the specific combination of components of a junior doctor’s role sets them apart as especially susceptible.

In Robillard’s work on moral exploitation, he expands the dimensions of vulnerability to include moral commitments. It is in this more limited context that the necessary features of junior doctors’ role and the accompanying moral commitments render them vulnerable. Rosalind McDougall argues that junior doctors’ ‘position generates a unique set of ethical issues… made up of issues associated with each of their various roles and also with the occupation of multiple roles.’9 These roles are:

• Responsible clinician: junior doctors play a substantial role in the delivery of healthcare and are a core part of patient care. Importantly, their moral commitments to patients are the direct result of them having some responsibilities. They have the same moral duties to patients as any other doctor.

• Subjugate learner: junior doctors are of the most junior rank within a medical team. While junior doctors have immense knowledge, they remain epistemically limited in terms of practical experience to help them deal with the complexities of modern medicine. They therefore exist as part of a hierarchy, and as a result of their inexperience must be taught, supervised and follow the commands of their seniors. As trainees, they have a role as a learner.

• Human resource: the junior doctor role includes service provision. This is especially true in a publicly funded healthcare system like the National Health Service. It means that where junior doctors are placed and some of the roles they undertake will be determined by their hospital for the good of the community. This also places doctors in a system of healthcare that is extremely challenging, that can place multiple conflicting demands on doctors and presents a seemingly endless volume of work.

Each role is moral in nature. Each has a distinct set of values and expectations embedded within it that place different demands on junior doctors. Indeed, in a different context, McDougall has assigned a specific set of virtues to each position.10 Every doctor shares the roles of responsible clinician and human resource. It is as subjugate learners, however, that differentiates junior doctors. This additional element contracts through training resulting in some junior doctors being more vulnerable than others. Nurses’ position within the hierarchy opens up a parallel vulnerability with junior doctors. Though this results from nurses’ epistemic position and unique role rather than inexperience and educational needs. With this in mind, how nurses’ vulnerabilities lead to moral exploitation, in reality, may not always track junior doctors.

It is my contention that the normative demands of each role and the conflicts that creates leave junior doctors vulnerable in the sense of open to exploitation. Their various roles pull in different directions. Multiple competing obligations can leave junior doctors without reasonable options, unable to refuse certain additional obligations and as such, vulnerable. To use an example involving a traditional currency of exploitation, junior doctors’ role conflicts could leave them open to physical exploitation. By working in a system that provides them almost endless work, caring for patients who are sick and for whom they are at least partly responsible and, especially if they are more junior, by being inexperienced in terms of prioritising important tasks results in junior doctors working extra unpaid hours. Their moral obligations to patients, to provide a service and their perceived role within the hierarchy can leave them without the option to prevent their time and labour being taken advantage of. While junior doctors’ role obligations can leave them open to exploitation along lines of traditional currencies this will not be explored further. My aim is to discuss whether having multiple different roles and in sometimes having to attempt to balance the conflicting moral demands of these, junior doctors are vulnerable to being compelled to shoulder additional moral burdens.

Are junior doctors morally exploited?

Medical practice is intimately connected with human well-being. Medicine aims to improve health or longevity which is instrumental in maintaining or improving well-being. This leaves a doctor’s work as being deeply moral in nature. Doctors decisions to give or withhold a treatment partly depends on the empirical facts like effectiveness. But this only takes one so far. In deciding to act or not, doctors are employing values too. Deciding to provide chemotherapy, for example, also says something about the value of a person’s survival and whether that is good all things considered. Medical decision-making relies on an understanding and application of both facts and values.11 The nature of doctors’ work makes it impossible for them to avoid moral decision-making whether in high-stakes or more everyday decisions. Not only does every clinical decision have some ethical component but even interactions with patients can be subject to ethical analysis. This is the realm of ‘microethics’; where ostensibly minor subtleties arising from inside the doctor–patient relationship effects the patient’s interests.12 Importantly, the volume and significance of the moral decision-making in medicine marks out doctors from other professionals.

The first type of moral exploitation to consider is transactional: where a senior doctor forces a junior doctor to take on some discreet decision; via the hierarchy, for example. The gradient of the hierarchy alone makes it difficult for them to refuse and their reliance on seniors for support, mentorship and education intensifies this. Other options are to simply refuse, but this is not viable because of their duties to their patient. They cannot just down tools either. Some decisions ought to be made by a senior doctor because of their significance or complexity. The consequences of decisions with these characteristics also underpin why one might wish to avoid such decisions. The junior could plausibly also benefit, perhaps by actually making the right decision with all that entails for the patient and the possibility of impressing their senior. Decisions can be offloaded onto junior doctors because their multiple roles restrict their options to refuse. This is unfair not because junior doctors should never make moral decisions but because the kind of decision ought to be made by a senior doctor. When junior doctors are left with decisions commensurate with their knowledge and experience they are not morally exploited. Hence, senior doctors can delegate moral decisions in so far as they are of an appropriate calibre for the junior without concerns of taking unfair advantage.

Moral decision-making and the consequent responsibility and emotional elements are an inescapable part of doctoring. This means that moral burdens embedded within a role can be shifted rather than as a necessary aspect of a discreet decision. Reports from the Royal College of Physicians (RCP) and the British Medical Association both found that ~70% of doctors report working on understaffed rotas.13 14 This leaves junior doctors covering absent doctors’ workload. They cannot refuse this because the work simply would not get done and that conflicts with their duty to patients. Their employer is often unable to find appropriate cover. Again, junior doctors role as subjugate learner limits the chance of senior cover. Imagine that in the average day, a junior doctor’s workload encompasses Y moral decisions and microethical interactions.2 These all lie within that doctor’s competence. Say that junior doctor’s colleague is off and there is no cover, or that they work on a rota with a permanent gap, they gain not only additional cognitive and physical workload but moral too. They have 2Y moral decisions they have to make and they have been burdened with this in a way they could not refuse.

The calibre of moral decision-making expected varies with seniority. As doctors gain the relevant experience, knowledge and skills they are expected to take responsibility for increasingly difficult and complex decisions including moral decisions. According to the RCP 18% of junior doctors report working at a level above their career stage.13 This phenomena of having to ‘step up’ and inhabit a role above their current grade happens most often during on-call working. Again, rota gaps and staffing issues are the culprit and therefore junior doctors’ vulnerability mirrors the preceding case. Stepping up results in them taking on a different standard of moral burden, one disproportionate to their experience and training.

These examples of transactional moral exploitation involving discreet decisions or specific roles rely heavily on the hierarchy as a source of vulnerability. Each species of moral exploitation could accrue to other healthcare professionals who occupy the base of the hierarchy. Nevertheless, of those healthcare professionals finding moral burdens shifted down the hierarchy, those forced on junior doctors are weightier and therefore also unlikely to transcend interprofessional roles. In the following section, I will also draw attention to how junior doctors’ role as a learner also alters their experience of moral exploitation. Finally, I explore a type of moral exploitation that I believe affects all healthcare professionals and is non-transactional.

Sometimes the ‘rules of the game’ can be such that whole groups are exploited. Structural exploitation describes properties of institutions where the system disadvantages groups.7 The structures within the NHS are the formal and informal rules that determine the environment and opportunity space in which decisions are made and care provided. By its very nature, the systems within the NHS are the result of political forces. Currently, the NHS is facing crisis due to mismatches between rising demand and inadequate funding.15 Consequently doctors and nurses must make difficult moral decisions, shoulder the responsibility and cope with the moral distress that working in a system unable to tolerate the demands placed on it produces. Healthcare professionals at the coalface become ‘shock absorbers’ as they attempt to provide care within a broken system.15 Healthcare professionals are morally exploited by structures that force them to bear moral burdens that could be avoided were the political climate and therefore the system different. Unlike transactional exploitation discussed above, this relates to healthcare professionals relationship with a system where moral exploitation happens to groups not individuals because of structural phenomena built into the NHS system. All healthcare professionals are vulnerable to this by virtue of working within the system.

The wrongs of moral exploitation

A second task of this paper is to explain what is wrong with morally exploiting junior doctors. Taking unfair advantage is a core feature of exploitation and it is the use of vulnerability to take advantage that many see as being paradigmatically wrong with exploitation. This is essentially true of moral exploitation and the penultimate section will flesh out some of the disadvantages suffered as a result.

Moral exploitation puts junior doctors in an impossible situation. When they are compelled to make difficult moral decisions junior doctors risk doing the wrong thing. Reducing a junior doctor’s vulnerability means abandoning at least one of their roles thereby providing reasonable options to resist exploitation. However, in doing this, she falls short of the standard expected from her role’s perspective and thereby fails as either a good doctor, a good team player, a good learner or some combination of these.16 They therefore become stuck between being morally exploited and risking moral error, and resisting the exploitative force meaning a transgression against the values core to being a responsible clinician, subjugate learner or human resource. The situation seems impossible from the junior doctor’s perspective because internal tensions in their moral commitments mean they are compelled into a tragic situation where every option risks some sort of moral failing. Where junior doctors are in a position of ‘unavoidable moral failure’,17 whatever course they choose leaves a ‘moral remainder’18 or ‘moral residue’19 in terms of the lingering regret and guilt over the chosen action.

In the vast majority of cases, doctors are trying to do the right thing. Nevertheless, they will sometimes do wrong and like all mistakes in medicine, moral errors can be costly. It seems reasonable to suggest that experience will help reduce the risk of moral error. Junior doctors’ role as subjugate learner suggests that they are more likely to make errors generally including moral errors. If moral exploitation places patients at greater risk of moral error by virtue of who is making the decisions it seems reasonable to suggest that patients are wronged by being unnecessarily exposed to this.

Perhaps, however, the junior doctor actually makes the best moral decision. Furthermore, maybe the morally exploited junior doctor decides on a superior course of action compared with any alternative decision-maker. Now it seems difficult to complain that anybody is made worse off or treated unfairly. Making high-stakes moral decisions carries an emotional burden. Robillard and Strawser categorise these as ‘moral injuries’; described by Nancy Sherman as, ‘experiences of serious inner conflict arising from what one takes to be grievous moral transgressions that can overwhelm one’s sense of goodness and humanity… In some cases the moral injury has less to do with specific (real or apparent) transgressive acts than with a generalized sense of falling short of moral and normative standards befitting good persons’.20 Moral injuries, as a concept developed in a military context, have not featured significantly in discussions of healthcare professionals’ experiences. The impossible situation outlined above provides ample opportunity for a junior doctor to feel they have fallen short given the numerous normative standards demanded of them. As Sherman notes, this does not rely on them actually having fallen short. Within healthcare, moral distress outdates the concept of moral injuries and while an in-depth comparison of these concepts is outside of this paper’s scope, they are not dissimilar.21 In broad terms, moral distress is psychological distress in response to difficult moral situations.21 Again, moral distress is a likely consequence of compelling inexperienced doctors to make difficult moral decisions, even when they do the right thing. There may be some overlap between moral injuries and moral distress in terms of what is actually experienced by the practitioner. Nevertheless, reflecting on these concepts highlights that there can be serious emotional consequences resulting from the moral work of doctors and that junior doctors are predisposed to experience these and less equipped to process them. What concerns me about this is the injustice of thrusting individuals into situations where they are very likely to experience these emotions regardless of the outcome through exploitive pressures. This seems all the worse given the exploiter is more likely to avoid moral distress or moral injuries.

The final wrong of moral exploitation builds on this idea that moral burdens should be distributed more proportionally. Doing the right thing often requires resources in addition to the emotional. Communicating with patients and their families, gathering information, reflecting on this and coming to a decision before finally putting this into action takes time and energy. Loading these onto a busy doctor not only compounds concerns over error considered above,22 but it seems unfair for a single doctor to do the lion’s share of the moral work given what is entailed.