Pathological Altruism: Balancing Patient and Personal Priorities
December 2019 Issue
In 2011, Oxford University Press published a large volume titled Pathological Altruism, a collection of chapters by various authors on topics related to how doing good can cause harm. Altruism is defined in different ways throughout the book, but the common theme is that altruism involves "unselfish concern for the welfare of others" as well as actions that are beneficial to them.1 Our efforts to do good often have unintended and unanticipated consequences that are detrimental both to the object of the charity and to the person performing the good deeds. "Without an understanding of all aspects of altruism, misguided activities are perpetuated…it is vital to understand how attempts to do good can inadvertently worsen the very situation they were meant to solve, or create other problems…."2 The topic of the previous article in this series, "Toxic Charity," points out that charitable efforts can create dependency and only superficially address, or even exacerbate, the underlying causes of problems faced by those we are attempting to help.3 This article addresses one of the other problems that can be created: Pathological altruism can limit our own capacity to continue to do good in our role as healthcare professionals.
Professionalism and Self-sacrifice
Altruism is "a voluntary act that is an end in itself—it does some good to the other, is not directed towards self-gain, and generally implies some sense of self-sacrifice."4 Self-sacrifice is a core tenet of professionalism in any field, and particularly in healthcare professions. In an article that addresses the need to teach medical students a more nuanced and wholistic view of professionalism, two physicians and bioethicists, Howard Brody, MD, and David Doukas, MD, describe professionalism as "a trust-generating promise." "Professionalism represents a commitment to placing the interests of the patient ahead of those of the professional. Most definitions agree that the goal of the professional interaction is the benefit of the patient and only secondarily the benefit of the physician."5 According to Brody and Doukas, fulfilling this promise is a life-long commitment that requires developing the character that puts virtue into practice. "Being a virtuous professional requires doing the right thing (whatever puts the patient's interests first and foremost) in the right way and with the right attitude, and doing so consistently and reliably as an expression of deeply formed character; it requires getting medical virtues like altruism right into the marrow of one's moral bones."5
Brody and Doukas raise the important point that there is a limit to the self-sacrifice expected of clinicians, and ask this important question: "At what point…do the professional's own interests have a legitimate claim in patient care? How much is the professional expected to sacrifice to benefit the patient? When do lifestyle issues or moral commitments owed to other individuals supersede one's obligations to the patient?"5 There is often a tension between the needs of our patients, which to earn their trust we have promised to make a priority, and our own needs. At times this tension is played out in economic terms. As Brody and Doukas point out, "professionals are not independently wealthy, and someone must pay the rent and keep the lights on."5 They caution that while healthcare is a business, it "can never be merely a business."5 The economic realities of the modern healthcare system in which clinicians work "requires a greater examination of their ethical foundations and implications."5
Vilardaga and Hayes point to workaholism and excessive helping behavior as "socially well meaning but harmful and excessive forms of self-sacrificing that become more pervasive and problematic over time."4 At some point, the self-sacrifice expected of a healthcare professional changes into something unhealthy. Many examples of the tension between patient and provider needs can be seen in O&P clinical practice. Most patient encounters occur as part of a scheduled appointment. This organizes the day, allowing practitioners sufficient time to address the needs of each patient while maintaining a sustainable pace. Unscheduled encounters often result in significant readjustment of practitioner focus and priorities, and place significant time demands on the practitioner. Some patients repeatedly come into our practices without an appointment for nonurgent matters. Practitioners who continue to work these unscheduled patients into the schedule may be pressured to give less time to scheduled patients or abandon other priorities completely. At some point, even the most altruistic practitioner may reach his or her limit and ultimately become resentful of patients, employers, and coworkers. What began with an altruistic motive can turn into something darker.
Providing services in a timely manner can also cause tension between the needs of the patient and the practitioner. A patient's ability to function independently may depend on receiving O&P services within an expedited time frame. Completing work faster or working more hours to reduce the turnaround time between evaluation and delivery offers significant benefits to patients. Adjusting or repairing a device after normal business hours minimizes the time a patient must adapt to daily life without his or her orthosis or prosthesis. Practitioners routinely sacrifice their personal time by expanding their availability to accommodate these needs. Making decisions about availability is an important aspect of time and life management. It is worth considering how we make decisions about availability when a patient's own choices, including lack of adherence to the treatment plan, have resulted in the need for expedited care. How should we understand our commitment to putting the patient's needs first when a patient repeatedly forgets appointments, misuses the device, arrives to encounters inebriated, is belligerent, or fails to keep commitments to his or her own care in other ways? How should we consider obligations to our own health and well-being, such as daily exercise or going on vacations, or commitments to attend our child's school activities or our partner's birthday party in these situations? It is part of our professional responsibility to recognize that these tensions exist and require a nuanced understanding of professionalism and the altruism that is an inherent part of it.
Codependency is a term used to describe a relationship that is based on an unhealthy balance of needs and commitments. This concept is commonly used to describe the way an individual attempting to help someone who is struggling with alcoholism can actually enable their drinking. Research on this phenomenon is inconsistent, with lack of consensus on the definition, but codependency has been described as "behavior on the part of a person that enables another's highly dysfunctional behavior" and "a dysfunctional empathic response, a misplaced mutual aid endeavor in which the main defect is an inability to tolerate negative affect in the important other."6 It may seem extreme to apply this concept to the behavior of clinicians, but how often does our concern that a patient or referral source will be dissatisfied if we make healthy personal choices influence our decision to make unhealthy ones? Seeing a patient after hours on an occasional basis could be considered acceptable self-sacrifice. Doing so repeatedly for a patient who is chronically late or repeatedly comes in without an appointment may not only begin to impact a clinician's well-being, but it may actually reinforce the patient's habit of not scheduling an appointment or arriving on time.
An important consideration in each case is what circumstances contributing to this pattern are outside of the patient's and practitioner's control. The patient may struggle to make and keep appointments as a direct consequence of his or her pathology, lack of a support network, or other factors that the patient cannot easily change.
The practitioner must realize that he or she cannot control or mitigate every factor that contributes to a negative experience for a patient. For most patients, O&P care is a necessary but insufficient determinant of quality of life and well-being. While our professional services (backed by our promise to put the needs of the patients first) are an important factor, they are not the only ones. Drawing healthy professional boundaries involves understanding that our professional shoulders are not broad enough to bear responsibility for the totality of a patient's well-being. Many of the challenges that patients encounter are outside of our scope of practice to address directly. "Simply being connected to or involved in the care of a dysfunctional individual does not make one codependent. It is continuing the relationship in a manner that overtly supports the dysfunctional behavior that makes one codependent."6
In an article titled "Professionalism: Good for Patients and Health Care Organizations," Michael Brennan, MD, and Verna Monson, PhD, present a case "for why developing a strong culture for organizational professionalism nurtured by trust promotes organizational and individual resilience."7 The authors affirm both that professionals are expected to place "the needs of patients and society ahead of all other considerations" and that "physician well-being is essential to their expression of their professionalism and capacity to provide compassionate and effective patient care."7 They identify "joy, interest, and caring" as prevalent emotions in high-performing organizations, and burnout and compassion fatigue as significant barriers to fulfilling professional obligations.7 According to Brennan and Monson, "well-being implies an individual's capacity to find meaning and purpose in work and life and achieving a sense of thriving…. Burnout, the antithesis of individual well-being, involves a dampening of emotions such as empathy and compassion, also called compassion fatigue."7 The demands of a busy clinical practice are only one factor that contributes to practitioner well-being. Meeting practitioners' needs for autonomy, competence, and relatedness equips them to meet these demands while maintaining a healthy sense of well-being. (See text box below.) "People who have their basic needs met will be more engaged, both cognitively and emotionally."7
Practitioners derive professional and personal meaning and satisfaction from improving lives. One of the reasons we chose this profession is that our work has a direct, and often immediate, positive impact on the lives of individuals. However, even he most committed professionals experience challenges honoring their professional commitment when repeatedly faced with the common and extraordinary clinical challenges. The time pressures and lack of adherence mentioned above are only two of many ways that patient care can be hindered by factors within a patient's control but outside of the practitioner's control. At times, the altruistic core of professionalism creates an impulse to address factors outside of our direct control to reduce discomfort and maximize our patients' function. Grappling with these tensions in the light of our personal and professional boundaries opens the door to a variety of choices related to how much to sacrifice in each particular case.
Brody and Doukas remind practitioners "how hard it is to keep one's public promise to put the interests of patients first, as the maintenance of public trust requires. To do this not only on good days, but also on bad days when we are tired and irritable and no one is watching, requires more than simple rules; it requires that we devote ourselves to becoming certain sorts of persons. If students [and experienced practitioners] engage in honest reflection, they will agree that little in their previous lives has taught them to be the sorts of persons who routinely put the interests of others first, even if to do so requires some significant sacrifice."5 An ethical standard for professionalism that balances the priority of the patient with honest reflection about our personal and professional capacity allows us to make decisions that sustain our ability to provide compassionate and effective care to the largest number of people for the longest time. This reflection is particularly important if we discover we have lost the joy, interest, and caring that we should experience in our role as healthcare providers.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 25 years of experience in patient care and education.
1. Oakley, B., A. Knafo, G. Madhavan, and D. S. Wilson, editors. 2011. Pathological Altruism. Oxford University Press.
2. Oakley, B., A. Knafo, M. McGrath. 2011. Pathological Altruism–An Introduction. In Pathological Altruism, 3-9.
3. Brinkmann, J. "Toxic Charity: When Doing Good Does Harm." The O&P EDGE, October 2019. https://opedge.com/Articles/ViewArticle/2019-10-01/toxic-charity-when-doing-good-does-harm.
4. Vilardaga R., S. C. Hayes. 2011. A Contextual Behavioral Approach to Pathological Altruism. In Pathological Altruism, 31-48.
5. Brody H, D. Doukas. 2014. Professionalism: A Framework to Guide Medical Education. Medical Education 48(10):980-7.
6. McGrath M., B. Oakley. 2011. Codependency and Pathological Altruism. In Pathological Altruism, 49-73.
7. Brennan M. D., V. Monson. 2014. Professionalism: Good for Patients and Health Care Organizations. Mayo Clinic Proceedings 89(5) 644-52.