Today the Care Quality Commission published its findings of 100 unannounced inspections of hospitals in England focusing on how we care for the elderly in hospital. It identified 55 as “alarming”, the examples cited made disturbing reading. This comes in a long line of deep concerns including the Castlebeck care home scandal, Mid Staffordshire NHS Foundation Trust, Bristol Royal Infirmary children’s cardiac surgery unit and Alder Hey.
Common features included an institutional “acceptance” of poor practice leading to untimely death, suffering. A common response to these events seems to be: “how can they have done this …”, or “how can this happen …?”
In asking the same question I thought it might be useful to take a different stance and to consider the work of Hannah Arendt. In doing so I sense that somehow we are either asking the wrong question or we have not thought of the assumptions that lie behind it.
Arendt was a political theorist whose work and personal life was influenced by the many tragedies of the 20th century, notably the treatment of the Jews in Europe and World War Two. But it is her insights of people that I would like to draw on as opposed to any abstract theory.
It was in 1963 that Arendt found herself in Jerusalem reporting on trial of Adolf Eichmann, the person who largely was held responsible for administering the extermination of millions of people in the concentration camps, the majority of whom were Jewish, a community of which Arendt was a part. In drawing on Arendt’s coverage of the Eichmann trail I am not attempting to compare the scope or the nature of suffering (after all how can such events be compared with each other apart from
in the most crass numerical sense).
Instead I am considering Arendt’s insight into the interconnectedness of people and how we are all involved, in some way or another, with each other. In this sense the question “how can this happen …?” changes. It moves from implying a separation of the “disgusted” from the “disgusting” towards one whereby we all have a role to play, along with personal responsibility.
In Arendt’s account of the trial there are several relevant themes that occur to me. In raising them here I inevitably do not do justice to her argument or the detail of her description. I would urge readers to take the time to read her account. The first thing that resonates with me is Arendt’s description of Eichmann. He was someone who was keen to progress in his career, not particularly bright, and made the most of the opportunities presented to him. I get no sense that Eichmann started his life as inherently evil. Instead Arendt points out that he developed a thorough knowledge of Judaism and had friendly acquaintances amongst the Jewish community. This quality was recognised by his Nazi party colleagues who came to see him as an expert in such matters which in turn was recognised with promotion and additional responsibilities. Secondly, as the war progressed, the whispers of the horrors of the concentration camps tacitly filtered into the German community. This resulted in the camps being moved further East beyond the border. Thirdly, and controversially (an issue that I will come back to), was the participation of the communities most disastrously affected by the camps being party to the implementation. All of this started several years before the start of the war whereby there was an interconnected “slow boil” of changing attitudes, particularly for Eichmann, his Nazi colleagues and more widely in society. I am not suggesting that all parties had an equal voice and ability to change the course of those events, that is plainly not the case, but there was interconnectedness between people.
So how does Arendt’s account, help with the question posed? It is important that we recognise that we all have a role to play, albeit with differing power and knowledge to
change the course of events. For example, if one looks through the Francis Report in the Mid Staffordshire case, it is clear that many knew something was wrong, both amongst staff and the wider community.
With this in mind we cannot, in response to such events, set up and rely on detached approaches of inspections and checks run by appointed inspection Quangos. By this I mean the application of systems whereby we are not constantly holding them to account as well as those communities of which we are all part. In other words, the setting up of an inspection system should be seen as an addition to, not a replacement of, a continued challenge and questioning; a challenge and questioning by all, and
for all to have their voices heard. For example, if we visit or work in a care home, we must all be constantly alert to the sights and sounds, smells that might speak to our intuition that something is not right. An inspection report of “acceptability” has little relevance to the lived experience of what is actually happening at the time. As for those inspection bodies we need to constantly hold them to account – how they work, how they listen to issues being raised, the resources that they can deploy and how much time they actually spend on the ground, experiencing the world of those being cared for. In addition, any form of self regulation of institutions wholly inspecting their own services needs to be challenged. Failure to do so would risk missing the deteriorating norms and cultures to which people can become blinded to, even in good faith.
What I’m describing, in practical terms, is how we are all part of an ongoing process and we all have power and responsibility, albeit not in equal measure; the implied separation of the “disgusted” from the “disgusting” is false and dangerous. This brings me back to Arendt and the reaction to her comments on the Eichmann trial. The idea that the parties had interconnected roles and responsibilities was not well accepted, although she made her case meticulously. It seemed to benefit most people after the event to draw a clear distinction between those who “did” and those who were victims. Perhaps this is not unreasonable given the events she was commenting on. However, to do likewise in health and social care would do all a disservice; patients, the cared for, and staff communities alike. It was Arendt who coined the phrase “the banality of evil” to describe its constant presence in the mundane ongoingness of everyday life, a presence that we all have a role in combating.
Further Reading
Arendt, H (2000) Banality and conscience: the Eichmann
Trial and its implications, in Arendt, H (2000) The Portable Hannah Arendt,
London: Penguin Classics
Francis, R (2010) Independent Inquiry into Care Provided
by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009, Department
of Health, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018
Dr Robert Warwick 