Cynicism as a strategic virtue

Abstract

The art of medicine Cynicism as a strategic virtue Doctors are often forced to negotiate between imperatives of policy and the demands of good practice. Cynicism arises in the welter of diffi cult feelings elicited by such contexts, and is widely assumed to be bad for patients, national health systems, and for the clinicians themselves. Cynicism is typically regarded as a cause of distrust, professional misconduct, and a pathway to burnout. It is true that untempered cynicism can have these consequences. However, much of the cynicism seen in contemporary health care is not untempered, nor is it simply negative or unprofessional behaviour. Rather than simply the shrivelled hope of good practice, we argue that more balanced forms of cynicism can support rather than undermine quality of care. Readers will be familiar with accusations of cynicism as a pervasive problem for the medical community. One example may be found in the Francis Report, a public inquiry into the Mid Staff ordshire NHS Foundation Trust in the UK, where failures of care led to deaths of patients and mistreatment amounting to cruelty. Robert Francis's conclusions highlighted an " institutional culture that ascribed more weight to positive information about the service than to information capable of implying cause for concern " , citing " assumptions that monitoring, performance management or intervention was the responsibility of someone else " . At fi rst glance it might appear that cynicism is partly to blame. Part of the response to the Francis Report has followed this logic: distrust in clinicians' moral sense and their concerns about the context of their practice combined with trust in abstracted audit systems that are valued as providing a more robust safety-net than clinicians. This outlook argues that the moral insuffi ciency of clinicians can only be guarded against by metrics of oversight. According to this outlook, cynicism is taken to be no more than indiff erence and fatalism. Negative feelings are assumed to be capable only of negative outcomes, and index of moral decline at the level of individuals. But this is not how things work. A common complaint against managerialism in health services is that interests of economics and measurement are seen to supersede those of care. The clinical workforce, brought up to believe they were working for the care and treatment of patients, fi nd themselves caught by the need to balance the books. In this context, they have to discover a diff erent kind of practice for themselves and manage their expectations of themselves, their colleagues, and their organisations. This discovery is the ongoing, lived negotiation of the distance between policy and practice. In such contexts, cynicism can form part of a protective response to the discrepancy between policy and practice. It can allow clinicians and other health-care workers room to manoeuvre, so that they can register the moral dimension of their work as it is formed and deformed within the uneven, unpredictable reality of health-care organisations. To criticise cynicism as the problem would be to mistake the immune response for the disease. It treats as a disorder what is in fact a common part of the emotional toolbox used by clinicians and allied practitioners to stave off despair. Health-care organisations, in the UK at least, have become increasingly objectifying and unpredictable institutions, developing metrics instead of critical engagement. Cynicism serves as both a protection from, and an expression of, this logic. One reason is that, in general terms, cynicism represents an aff ective bargain made with life about caring. Far from synonymous with indiff erence or fatalism, we suggest that cynicism is a kind of optimism: not an optimism of wild and open possibilities, but an optimism of critical distance, keeping one from being hurt by something cared about. This is opposed to cynicism as a fi xed state that responds to every circumstance in the same way, and which we characterise as unalloyed cynicism. When cynicism is disparaged, criticisms often refer to unalloyed cynicism, while tarring all forms of cynicism with the same brush. Such criticisms miss the strategic use of cynicism, as part of a wider emotional toolkit, which we wish to highlight here. Such strategic uses of cynicism can be readily recognised when they are tempered in relation to something else. So, for instance, wry cynicism can allow clinicians to regulate their expectations of their organisation, making the double binds of practice more bearable, within an overall commitment to the organisation, its goals, and the needs of patients. Thoughtful cynicism can inform responses Diogenes (1860) by Jean Leon Gerome