Is It Okay For Clinicians To Feel Anger At Newly Ill Anti-Vaxxers

The Morality Of Clinicians’ Sentiment Of Comeuppance: Reflecting on Professor Arthur Caplan’s “Stop Gloating Over COVID Deaths Among Anti-Vaxxers”

Background

Art Caplan, a medical ethicist and Medscape columnist, recently wrote an OpEd entitled “Stop Gloating Over COVID Deaths Among Anti-Vaxxers.” In it, he addressed the potentially hostile mindset that a clinician might manifest in treating a newly Covid-afflicted and critically ill patient who had been an adamant anti-vaxxer. He described this clinician’s psychological mindset as “schadenfreude,” equated it with gloating, and opined that such was at its heart a manifestation of hatred and, by inference, ethically or morally unacceptable.

In this piece, I take issue with this.

Your Critically Ill Covid Patient, A Highly Vocal Anti-vaxxer

Imagine this scenario: you're a physician and you have a patient who is a vocal anti-vaxxer, anti-masker and anti-social distancer. And now your patient presents with symptoms of rapidly worsening Covid-related pneumonia and will need intensive care imminently. As a physician, you agree with the prevailing science and its recommendations including vaccination and boosters, masking, rigorous hygiene, and social distancing precautions.

What internal dialogue might you be experiencing? What feelings might be coming forward for you as you encounter this patient?

Prof. Caplan labels this physician’s mindset as “schadenfreude” and, equating it with gloating and inferring that it is a manifestation of hatred, essentially concludes that it is untenable from a medical ethics standpoint.

Caplan’s Erroneous Diagnosis and Then Clinician Shaming

It seems Prof. Caplan makes a compound error from the outset by a) designating the clinician’s response to the anti-vaxxer as “schadenfreude; “b) equating it with gloating; and c) inferentially labeling it as a form of hatred.

First, I believe he’s mistaken in his glib assessment of the content of the clinician’s response. (Admittedly, this succinct encapsulation was likely done for space purposes and to most efficiently make the association between the clinician’s angry sentiment and its proposed incompatibility with clinical professionalism). Second, his selected extract of this hypothetical clinician’s response leads him to erroneously designate this mindset as representative of schadenfreude. Third, he then erroneously equates schadenfreude with gloating. And lastly, he then infers that harboring such a “gloating as schadenfreude” mindset is a manifestation of hatred and thus unethical, as such hatred would be incompatible with the profession of medicine.

I think it’s very worthwhile examining each of his contentions more thoroughly as I believe each is fundamentally flawed and worse, lead one to a wholly unwarranted clinician shaming.

Anger Okay? Care Without Sympathy?

Two looming questions underlie this present essay. 1) is it OK in medicine to be angry at or about patients’ behavior that has led to their illness or injury? And 2) is sympathetic compassion a necessary component of medical care?

Citing an anti-vaxxer case and then theorizing a clinician interacting with such a case of a vocal anti-vaxxer, Caplan’s admonishing comments seem to imply that clinicians take pleasure or joy (“freude”) in the suffering (“schaden”) which accompanies the misfortune of another. And he then seems to imply that this erroneously attributed feeling state is unethical and therefore objectively shameful, or at least subjectively shame-able by his moral assessment.

Caplan seems to believe that clinicians’ feelings of anger and hurt and their unbeckoned sense of a sort of ironic karmic justice towards those newly ill anti-vaxxers, anti-maskers, anti-distancers is an example of schadenfreude. When you examine the operational understanding of schadenfreude, its core essence is the taking pleasure in another’s suffering. I believe this is not only a mistaken understanding of the complex nature of this and many other clinicians’ mindsets; it’s also hurtful in its pontifical accusatory tone.

Schadenfreude and Gloating vs. Sadism and Vengeance

While the term is not native to our culture, schadenfreude seems to connote the experience of - and more importantly - active entertainment of pleasure or joy in seeing another’s misfortune (but not per se in their suffering). It's important to distinguish this from sadism. In schadenfreude, one neither causes the misfortune or resultant suffering nor does one derive pleasure in the execution or witnessing of the suffering.

Gloating, which Caplan erroneously equates with schadenfreude, has a distinctly different connotation, its focus not so much on another’s misfortune but rather an outwardly boasting about one’s own good fortune.

Perhaps confusing also is the implication of the presence of vengeance in the experience of schadenfreude. Vengeance is basically the willful retaliatory behavioral manifestation of anger. It’s the intentional taking of a course of action which seeks to cause the misfortune and resultant suffering. (The occurrence of vengeful thoughts is not the same as vengeful behavior.)

However, distinguishing it from sadism, it doesn’t undertake the action in order to take pleasure in it. It’s rather to cause a select other a measure of misfortune and suffering comparable to that one has experienced; it is a personally executed para-judicial retaliatory punishment for the misfortune and suffering perceived to have been caused by the other.

Schadenfreude as a Normal Psychological Process

Interestingly, even if the cited clinician’s mindset met the schadenfreude criteria (which I don't believe it does), Rabbi Harold Kushner [“When Bad Things Happen To Good People”] feels that schadenfreude is a normal and even healthy psychological reaction. He thought it might actually represent a natural feeling of psychological relief that it wasn’t you to whom the misfortune occurred.

Perhaps It’s Not Schadenfreude, or Gloating, or Sadism, or Vengeance

However, I don’t think any of these - gloating, schadenfreude, sadism, and vengeance - accurately characterize this and other clinicians’ mindsets.

No clinician I know takes pleasure in another’s suffering or seeks vengeance. No clinician boasts about how right they were to take precautions to an ill patient who presents for treatment. All of these are fundamentally antithetical to the core values one professes as a clinician.

Now, if a clinician actively went out of their way to cause another to contract Covid, e.g. knowingly infecting a vaccine resistor, or thwarted their receipt of the vaccine, then we’re talking about a variety of psychopathy that would rightfully be judged to be cruel and wicked, i.e. evil. But we’ll leave that for another essay.

Is Caplan’s Clinician Shaming Warranted?

But before we attempt to more accurately name this mindset, let’s examine the judgmental shaming accompanying Prof. Caplan’s misattribution.

Apart from the definitional quibbling, as a psychiatrist, I have major concerns more broadly about feelings and sentiments as automatically possessing moral weight and as being inherently indicative of an unhealthy mental state.

A Feeling State Is … A Feeling State

First, feeling states are, for the most part, not chosen. A feeling state, i.e. an emotion, is a composite bodily and mental response to a perceived experience. It’s reflexive and involuntary. The feeling itself is a crucially important form of psychologically relevant information directed toward our mind’s emotional intelligence processing apparatus. Emotional reactions are essentially the affective equivalent of neurologically-based primary sensory pickup like touch or smell. That I experience pain on touch or detect a noxious odor on smell is simply a biologically neutral event presenting the sensate creature with life-protective information; it has no moral component. It's simply neurobiological information.

It’s one thing to broadly label certain clinicians’ mindset toward those who resisted vaccination and then got ill as “schadenfreude;” that’s simply misattribution. The accompanying problem is that he assigns moral value to the mindset. Moralistically judging such a mindset to be akin to sinfulness is as fundamentally flawed as the Catholic Church’s earlier stance that simply to have lustful thoughts and sexual longings is a sin. A more informed church recognizes that the thoughts and longings are biologically inherent; they're essentially autonomous. It’s what we do with those thoughts and feelings and longings that determines the moral significance of the response.

Apart from the erroneous “schadenfreude” attribution and assignment of moral wrongness, I believe his reductionistic simplification misunderstands the more complex and nuanced nature and cascade of intrapsychic events - the internal dialogs and accompanying emotions - which are tightly packaged as an aggregate mindset and reflexly occur in witnessing the self-neglect-based demise of another.

Take a moment to imagine this non-Covid scenario: a person, despite abundant well-founded warning, continues to smoke three packs of cigarettes a day. He/she then develops inoperable lung cancer.

What might you expect that patient’s physician’s personal emotional reaction or psychological sentiment will be in response to that medical development? It’s the same as any other experience when one has, upon solid, well-accepted reasoning, warned another of a bad outcome from their irresponsible behavior.

Should it really be surprising that the physician’s private internal dialogue might be “so, how many times have I tried to tell you!?” “What prevented you from hearing me? What do you expect me to do now? Are you expecting me to feel sympathetic to your plight?”

I would be willing to venture that this is a nearly universal sentiment cascade. Mind you, it's an internal dialogue flow, not one necessarily spoken to the patient.

Consider for a moment any of innumerable catastrophic outcome scenarios that resulted from poor judgment.

➡A pediatrician repeatedly warns fiercely patriotic “right to bear arms” parents about household gun safety, and their young child - the pediatrician’s patient - then shoots and kills a sibling with an unsecured weapon.

➡A driver, adamantly refusing to wear a seatbelt, crashes into a tree while driving at high speed and suffers a permanent brain injury.

➡An adolescent, despite warnings by his or her parents and teachers about dangerously senseless challenges on social media, gets permanently paralyzed doing a high-risk stunt.

In each of these, the clinician who encounters such an outcome will predictably have some variant, internally held, of the "I warned you…" reaction. Nearly invariably, there is some component of anger, sadness, and hurt associated with such regret.  But let’s be clear -  that’s not the same as pleasure or joy or boastful pride.

So, I don't think this phenomenon is accurately conveyed by the terms schadenfreude or gloating. Nor do I think it invokes moral weight or deserves moral shaming.

So, what is it?

I suspect the closest our language might come to capturing this complex reactive mindset is by the term “comeuppance” which suggests one’s acknowledgment of a punishment or fate that one feels someone deserves. Various dictionaries offer synonyms that capture its essence: just deserts; deserved fate; their due; just punishment; and retribution are a few.

But even here, I’m inclined to see the representative clinician’s mindset as a more complex and nuanced "sentiment package" than that understood by comeuppance.

The English language doesn't yet have a term for this composite reactive mindset. It's not that you feel that a person has received a punishment or fate that they deserved. Rather, it's a compound sentiment package consisting more of forlorn regret combined with puzzled incredulity that one resisted seeing the likely outcome of their actions that they were repeatedly warned about and urged to take action on. It's as if you were screaming "what did you not understand? What prevented you from hearing me, from anticipating this as an outcome despite my and many others warning you about it?"

Understandably, the nature of the clinician’s emotional response depends upon whether they have assessed that the stricken person was truly ignorant and incapable of understanding (e.g. cognitively or mentally impaired - a state of invincible ignorance), or whether they were reckless and defiant - a state of vincible ignorance.¹ In the former case, a clinician’s response would predominantly be that of pity or regret, a form of sympathy for another’s plight. In the latter, it is likely pity combined with anger at the other’s recklessness and disregard of the health and safety of self and others. It's anger at their selfishness and seemingly willful misinformed worldview.

There are abundant internal dialogues and accompanying emotions the clinician is likely experiencing in such a psychological event. And while they may vary in particulars from person to person, they have common thematic elements.

For example, here are three:

“You got the outcome you warranted for your irresponsible behavior.”

Here, there’s anger at your not listening to me. But sometimes not even anger as much as matter-of-fact absence of compassion or even pity. Such may be a state of active emotional disinvestment, much as a judge might experience in sentencing a recalcitrant and remorseless criminal.

“I’m sorry to see you’ve gotten sick and may now die, but you were repeatedly warned and this is the dire result from the choices you made.”

Here, there is a) sympathy for the fact of your illness, a form of sadness; b) vindication that I was right to warn you; c) crestfallen regret for you that you didn’t follow my advice; and d) anger that your choices have imposed upon me and caused me and my colleagues and our families immense burden, worry, and grief. All these feelings are going on concurrently and mostly unconsciously.

"And there's not much I can do about it now. But your presentation makes me prioritize your care now perhaps to the detriment of others.”

Here we have the experience of helplessness which is a form of pain. And we also see anger at being imposed upon.

Additionally, because clinicians are "not supposed to feel angry," there is likely an accompanying shame about having such a feeling. One is now further bogged down by fighting with oneself about the justification of the feeling of anger and its seeming non-compatibility with the profession of medicine. You have to admit, psychologically it's quite a conundrum. The patient's presentation has caused me a clinician to be at war with myself. This non-articulated and non-resolved internal conflict extracts an extremely high psychic energy cost.

Consider also the case when the clinician feels residual anger from prior hurtful verbal attacks by the newly afflicted on the clinician or other respected medical authorities who issued the warning, e.g. calling them ‘libtard’ or ‘snowflake’ or even taunting them. It would be unreasonable to expect any other than a “comeuppance” type mindset - one harboring the sentiment that you’ve now gotten your “just desserts”.

Comeuppance Is Normal, Even Healthy

I believe the experience of comeuppance is not only a normal psychological response but even a healthy one.

It’s really an instinctive form of emotional intelligence, reminding oneself of the rightness of one’s decision-making, both for oneself and for warning another. It’s essentially an unconscious, self-reinforced form of learning, embedding into one’s long-term memory the situational correctness of one’s reasoning process.

Experiencing the Reactive Mindset of Comeuppance Does Not Warrant Moral Shaming

Definitional issues aside, whether we term this psychological response mindset schadenfreude, gloating, or comeuppance, I believe admonishing people for feeling this way amounts to an unwarranted scolding, at that one based on a fundamentally flawed moral conceptualization of the phenomenon that is not well-grounded psychologically.

Understanding the Normalcy of Comeuppance

Healthcare workers have a right to feel comeuppance. They after all have put their lives on the line in trying to prevent the spread of this lethal epidemic and are keenly aware of the personal risks and extraordinarily stressful work demands they've been asked to undertake. Acknowledging the normalcy of this quasi-comeuppance response also helps them make sense of why they - as customarily deeply compassionate, health-caring people - may not feel so compassionate towards those who have defiantly resisted taking the vaccine while also mocking and taunting those who did and who used recommended precautions.

After all, they heeded these warnings specifically so as to protect others - including these very patients - and have worked tirelessly to effortfully treat and try to save from agonizingly breathless and desperately lonely death those afflicted. It should go without saying that witnessing such patient anguish while feeling helpless to alter the tragic course of a never-before-encountered life-threatening, rapidly progressive, highly contagious illness takes a huge toll on each and every healthcare provider. There is no way it cannot. But even pre-pandemic, the effect of a patient’s death on healthcare staff is seldom spoken about in medicine. The prevailing ethic seems to be that clinicians are supposed to be stoic.

Perhaps a deeper affective component of the comeuppance reflexive mindset is anger at being forced yet again to effortfully care for and then helplessly witness the recklessly spread Covid-caused death of the very patients directly under our care, especially those who exercised precaution or who through no fault of their own were unable to access the vaccine or booster or were medically at increased risk. Witnessing their non-chosen bind and intense need for our concentrated care actually invokes something comparable to a moral injury within the clinician. It causes us to view the willfully unprotected as a potential disease vector and morally responsible assailant to our vulnerable patients to whose care we're deeply committed. The protective response of a caring clinician is identical to that of a parent caring for their child and protecting them from harm.

It would be demanding sainthood if one expected a healthcare clinician to feel only compassion and not some element of the angry, sad, and hurt feelings generally accompanying comeuppance, even if only subconsciously, as they dealt with a newly critically ill patient who had actively resisted taking repeatedly urged precautions for themselves and others while verbally demeaning those who did.

It’s Okay To Practice Emotional Ecology

I could even imagine a scenario where, in order to continue to perform one’s clinical healthcare work as a physician, nurse, or any other direct care professional, a clinician would have to let go of forcing oneself to feel sympathetically caring toward such patients while he/she delivered the requisite healthcare they’ve been trained to deliver to the best of their ability. In other words, they’d allow themselves to go about their healthcare work in a way that upholds their adherence to the highest standards of clinical professionalism but does not demand emotional labor, i.e. manifesting sympathy or compassion, in the delivery of appropriate medical care to that person. To me, if that compassionate sentiment is not naturally present, giving oneself permission not to contrive it is a wise conservation of their compassion capability. Remember, clinicians are human too, and we all have a finite emotional reserve. The well can indeed run dry. And when it does… you're used up. You're the equivalent of a severely wounded soldier who can no longer remain on the front.

So I would urge Prof. Caplan, please, let’s not confuse the psychological phenomenon of comeuppance and its more complex variant as described here with boastful gloating or vengeful schadenfreude. It’s most definitely neither of these. It’s more likely a normal and even healthy clinician sentiment occurring in the service of maintaining psychological ecology and is not deserving of shame. Adopting such a condescending moralizing tone with its implied scolding is ill-founded and hurtful and, well, demoralizing.² And it does little to lessen clinicians’ already immense pool of psychological distress.³

1. Some would argue that impulsive recklessness is not self-chosen and therefore invincible. But at some point, one either subscribes to a free will self-directedness or we're all just helpless objects moved about by forces out of our control, no different than the ricocheting spheres in a pinball machine.

2. For those not familiar with the current conceptualization of burnout, demoralization is one of its core features.

3. Please see the 7 part “Matrix of Clinician Distress” series elsewhere on this blog.