Rethinking dehumanization, empathy, and burnout in healthcare context

Abstract

Dehumanization has been characterized as common in medical settings, despite limited work directly examining this. In this context, everyday dehumanization is believed to be largely unconscious and unintentional, resulting from a variety of factors often related to structural and organizational aspects of healthcare. This article adopts the patients’ and the healthcare providers’ perspective to explore how dehumanization can have helpful and hurtful effects on patient outcomes and provider well-being. Future directions include more direct assessment of dehumanization in healthcare settings, centering the needs and experiences of people with mental illness and comorbid conditions, and improving our understanding of dehumanization relative to emotion regulation processes.

Research on dehumanization has mainly focused on the idea that it serves the function of derogating others, facilitating aggression or harm to other people. However, dehumanization is not always motivated by immoral behavior or social rejection. There is another function of dehumanization that has recently started to be explored: avoiding suffering and the personal costs involved in helping or seeing other human beings suffer. In other words, people can dehumanize others as an emotional regulation strategy, thereby avoiding feeling emotionally exhausted and overwhelmed by seeing others suffer [1,2]. And undoubtedly there are contexts in which seeing other people suffer is inevitable and expected, like the medical setting. Healthcare professionals routinely face the difficult and stressful task of accompanying and providing care to people who are in pain, suffering and close to death. This article examines the patients’ and the healthcare providers’ needs and perspectives to explore how dehumanization can be both helpful and hurtful in different medical contexts. This article proposes we reconsider the study of dehumanization in healthcare by framing dehumanization as an emotional regulation strategy used by healthcare providers. Furthermore, we analyze different aspects that could increase the risk of patients being dehumanized and discuss some invisible consequences of dehumanization in treatment, health, and quality of care. In doing so, we summarize the studies that explore dehumanization in healthcare by adopting the patients’ and the healthcare providers’ perspective and propose future research directions.

Dehumanization in the Healthcare Context

In the seminal work about dehumanization in medicine, Haque and Waytz [3] proposed a set of functional and non-functional causes that can explain dehumanization in the healthcare context. Among the functional causes, they first point out that the fact of focusing on body parts (instead of the whole human being in front of us) can favor tasks related to diagnosis and location of pathology, fulfilling the function of increasing the effectiveness in clinical diagnosis. Second, dehumanizing patients may allow healthcare professionals to dismiss the stress that comes from constantly perceiving patients’ pain and suffering: With lower stress levels, they can offer better care to their patients. In addition, healthcare professionals can regulate their negative emotions derived from exposure to situations of suffering and pain, or from inflicting harm on patients (especially with some treatments), by avoiding involvement in social cognition processes of their patients. In this sense, dehumanization would be a strategy that is activated to avoid the affective costs of providing help [1] or a strategy to reduce feelings of guilt that arise from inflicting pain on others.

Ten years later, many of the theoretical postulates on dehumanization in the healthcare context have not been empirically verified. The few studies carried out have shown controversial results about the role of inferring mental states of patients in the wellbeing of health professionals. While some studies indicate that inferring mental states of patients (i.e., humanization) has a positive effect on healthcare professionals’ wellbeing [4,5], other studies suggest that healthcare professionals need to reduce the inference of patients’ mental states (i.e., dehumanization) to regulate their own emotions towards suffering, death and pain [e.g., 6].

Part of these mixed findings could be explained by the complex and diverse nature of the relationships between patients and healthcare providers. In this sense, the type of demand or task that healthcare professionals face can determine whether it is appropriate or not to infer the mental states of patients to improve performance and reduce emotional exhaustion [5]. In this way, flexible social cognition (and flexible dehumanization of patients) may promote optimal decision-making and performance in various situations in the medical context [2].

Identifying Aspects of Dehumanization That Are Helpful and Hurtful

When considering the helpful and hurtful aspects of dehumanization in the healthcare context, it is important to center the needs and perspectives of both patients and healthcare providers. Specifically, healthcare providers may dehumanize patients to cope and regulate their own emotional responses and improve their performance [1–3,7,8].

Emotion regulation refers to the process by which individuals influence what emotions they have, when they have them, and how they experience and express them [9]. It is an important way through which individuals can internally control their emotional responses and behavior to align with current goals [10]. When the goal is to perform surgery well, for example, seeing the human body as a machine can help the surgeon manage their distress and maintain focus on the surgical procedures [2,3,11]. Preliminary work supports that dehumanized perceptions and decreased prosocial behavior may be associated with the use of proactive emotion regulation strategies like psychological distancing and reappraisal [7,11–14] though studies also show that reappraisal can be associated with increased empathy and prosocial behavior [e.g., 15]. Indeed, the modulation of the degree to which a person (such as a healthcare provider) infers the mental states of another (a patient) occurs early in the emotion-generative and regulation process [9], and has been shown to have downstream effects on experienced emotional states like compassion [1].

Is dehumanization a necessary process to improve performance in medical contexts? Is it inevitable to suffer negative consequences when displaying empathy towards patients? Research in medical contexts shows that the role of mental state inferences and empathy is very controversial. On the one hand, some studies have shown that being empathic has a positive impact upon healthcare professionals, who can be more effective and provide better care, experience better wellbeing and less distress, and experience burnout to a lesser degree [4,5]. On the other hand, several studies suggest that healthcare professionals reduce their empathy and the inference of mental states in patients to regulate their personal emotions toward suffering, death, and pain, as well as to improve their performance [2,6]. For example, mechanization and empathy reduction associated with dehumanization may facilitate medical problem solving and accurate diagnosis [3,11]. To date, and despite its importance for both patients and healthcare professionals, very little empirical research exists on flexible social cognition in medicine. The process of perceiving someone as more or less human has been described as flexible and likely to have evolutionary benefits [1,2]. A flexible approach to perceiving patients as human beings or not (focusing or not on their cognitive and emotional experiences), could lead to having a humanized or dehumanized perception of the same person, depending on the context, the type of interaction that the healthcare professional and the patient must establish, and the professional’s own demands and needs [2,3]. In this line, it needs to be better understood how the process of dehumanizing patients may affect the healthcare provider’s and patient’s well-being depending on the specific situation they are in.

Dehumanization, Stigma and Comorbidity

While patients may benefit from aspects like improved diagnosis of their conditions and increased provider performance, research has shown that feeling dehumanized in the healthcare context can have serious consequences for patients [16]. Feeling dehumanized can generate negative self-assessments among patients [17] in already complex and vulnerable situations. Further, it is to be expected that higher levels of dehumanization in the medical context will negatively influence communication between patients and healthcare professionals, which may have an impact on the degree to which patients adhere to their medical treatments [16]. Indeed, dehumanization during medical visits has been shown to lead to reduced adherence to treatment, relapse for those with substance use disorder, reduced satisfaction with care and poorer health outcomes [18,19]. Further, dehumanization can negatively impact a patient’s informed decision-making and autonomy [20]. On the other hand, the awareness of being dehumanized (metadehumanization) can elicit negative reactions like sadness, shame, self-consciousness, and lower self-esteem [17,19] and can contribute to self-dehumanization [17,21]. Self-dehumanization has been shown to be associated with self-harm behaviors [22] and reduced social interaction [23].

A particular focus is needed on patients with mental illness and those with comorbid conditions who potentially face multiple sources of dehumanization (e.g., being a patient, having a mental illness, having a physical illness), probably as a consequence of stigmatization [6,20]. Stigma is a social process of labelling, othering, and devaluation that may be either anticipated or experienced [24,25] and overlaps conceptually with dehumanization [26,27]. For example, mental health-related stigma has been associated with less access to care and poorer quality of medical care [24,25]. Individuals with a mental illness commonly report that their physical healthcare needs are not adequately met, including not having their physical symptoms taken seriously when seeking care for non-mental health concerns [24].

Individuals with multiple comorbidities often report feeling like a burden and report little integration across care services [24]. Comorbidity is particularly common among individuals with low socioeconomic status and among racial and ethnic minorities who are most impacted by structural inequalities [28]. This creates situations where certain patients may experience additive or cumulative dehumanization that could contribute to poorer health outcomes and well-documented health inequities in medical care [20]. While not much work has looked at cumulative or intersecting dehumanization in medical contexts, there is some preliminary work. For example, one study reported that individuals with a mental illness who belonged to a lower socioeconomic status were dehumanized more by community members compared to individuals with a mental illness who belonged to a higher socioeconomic status [29]. The authors pointed out that a higher degree of suffering may be associated with more dehumanization from others.

It is unclear whether having multiple mental illness diagnoses (e.g., depression and substance use disorder) or comorbid conditions (e.g., depression and diabetes) can influences the degree to which a person is dehumanized. Preliminary work suggests that individuals with a physical illness may be dehumanized less compared to those with a mental illness. Specifically, individuals with alcohol use disorder or schizophrenia were dehumanized more by healthcare professionals than patients with cardiovascular disease and no mental illness [18]. Another consideration is how dehumanization interacts with mental and physical illness comorbidity. Patients with more mental and physical comorbidity may elicit higher levels of dehumanization that could amplify the negative effects of being dehumanized. For example, when a patient has a mental illness diagnosis, a medical condition may be missed altogether due to mental health-related stigma and dehumanization [25]. These interactions should be better understood to maximize the provision of quality care, particularly for those with mental illness and comorbid conditions.

Future Directions and Challenges in the Study of Dehumanization in the Healthcare Context

Dehumanization in medical settings continues being a challenge for research, with multiple topics that require specific attention. Undoubtedly, more research is needed to explore dehumanization as a process that facilitates emotion regulation and coping in medical contexts [5,6]. This may help us better understand the helpful and hurtful effects of dehumanization for healthcare providers and patients. Dehumanization appears to be related to emotion regulation strategies that are proactive, healthy and associated with better outcomes for the actor [7,11–14].

Since the link between different components of empathy and burnout is complex [30], being involved in a continued empathic activity could cause progressively increased psychological distancing from patients and ultimately dehumanized perception of them. Future studies should continue exploring the cognitive and emotional costs that different dimensions of empathy have for healthcare professionals and its relationship with the dehumanized perception of patients.

It is important that studies continue to examine the impact of dehumanization on the quality of care to facilitate finding a balance between a provider’s ability to effectively perform their clinical work and the well-being of patients [3,16]. Understanding dehumanization as a typical human response that can improve performance and well-being, may help medical systems and healthcare providers better manage the helpful and hurtful effects of dehumanization on patients and health outcomes. In this line, the organizational level of analysis needs to be integrated. Particularly, it should be explored what organizational and structural issues (e.g., provider workload, autonomy) may be most strongly linked to dehumanization so that the need for dehumanization by medical staff can be better managed. Besides, and in line with preliminary studies [5], the effect that different empathic components and dehumanization towards patients could play in developing burnout, turnover intentions and other health problems should be deeply explored, especially with longitudinal studies.

Not only dehumanization but also perceived dehumanization (i.e. meta-dehumanization) should be considered a central patient-reported outcome that can be linked to health outcomes and health inequities [20,27]. There is also a need for further qualitative research to better understand the various experiences and barriers experienced by patients to improve care. Centering the experiences of people with specific diagnoses could help healthcare providers better characterize and address stigma and dehumanization in medical settings. In this vein, and despite the previous reviews on mental illness related dehumanization in medical settings [20,26], there are important gaps in the literature that need more attention. For example, many of the studies examining dehumanization in health-related contexts use student or community samples, limiting our understanding of dehumanization in real world medical settings. It is also essential to examine how comorbid conditions, and particularly comorbid mental and physical conditions, are related to dehumanization in medical settings. We may observe an incremental relationship in that more dehumanization is directed at those with more comorbid and stigmatized health conditions. Further, given that individuals with comorbid mental and physical conditions tend to have worse health outcomes [31,32], it is vital to identify whether dehumanization in medical settings plays a role in this. Further, the presence of comorbid conditions and dehumanization should also be examined in relation to health inequities, especially as members of vulnerable populations are more likely to be diagnosed with comorbid mental and physical conditions [28,33,34].

Finally, further scientific examination of potential cumulative effects of dehumanization, and the effect of reduction in empathy and mental state inferences in relation to medical performance and well-being, is mandatory. Otherwise, scholars would share theoretical models suggesting complex relationships that are not based in empirical evidence. Specifically, future studies should continue to explore the causes and consequences of dehumanizing and being dehumanized considering specific conditions like stigmatized health conditions, comorbidity, clinical tasks and roles, time of experience, organizational factors or individual differences in emotion regulation strategies and needs.

Conclusions

Dehumanization appears to be highly relevant to several important psychosocial aspects of medical care including quality of care, health inequity, health behaviors, and person-centered care. With its roots in social psychology, an interdisciplinary approach to the study of dehumanization in healthcare context would lead to a deeper understanding of the complexity of this social phenomenon, integrating the patient and the healthcare provider perspectives and needs. Future research will help to integrate what we know about dehumanization in medical contexts in behavioral health and medical care.