Un-Mixing the Sexes

The coalition government is finalizing plans for swingeing cuts in the public sector.   Nonetheless, in one part of the National Health Service costs are set to rise: for the Health Minister has confirmed that the government is phasing out mixed-sex wards. 

Almost all wards are now segregated by sex, but those mixed-sex wards that remain are thought to be difficult and expensive to convert.   Surveys suggest that although it’s not the most significant concern patients have about hospital care, it ranks quite high – especially for female patients.    The BBC quoted a woman treated on a mixed-sex ward:  ‘I didn’t feel comfortable with men there.  You weren’t properly dressed and sometimes they did procedures at your bedside and the curtains weren’t properly closed’.

Given the cost of converting the remaining wards, the question is how seriously we should take such feelings.  The Health Minister said that having to share a mixed-sex ward was an ‘indignity’.   If that’s how people feel, it reflects British cultural norms.   Views on the extent to which men and women should share facilities will vary wildly depending on whether you’re talking to people in Riyadh or Copenhagen.  

There are, no doubt, many patients who find it an ‘indignity’ to have to share a ward with any patient, regardless of the sex of that patient.  There are many people who would find it an indignity to be treated by, or operated upon, by a member of the opposite sex.  

The health service always has limited resources, and budgets are going to be particularly tight over the next few years.  The money used to convert mixed-wards could be diverted instead on, say, equipment that improves health outcomes.

So to what extent should politicians and NHS managers pander to a patient's sense of ‘indignity’?

I only ask.

  • Facebook
  • Twitter
  • Reddit

13 Responses to Un-Mixing the Sexes

  • The question of dignity is an interesting one and it seems to be gathering momentum on both side of the pond. As you rightly mention, indignity is a fairly ambiguous term that can span a very wide variety of experiences. It is interesting how we seem to give credit to the indignity of a woman treated in mixed ward but refute as nonsense (if not outright offensive) the indignity of a white supremest being treated by a black doctor. Although this hasty example is not a perfect one, we can easily imagine where two different people both feel equally indignant but where only one case arouses a call for response.

    Herein, I think, rests the fundamental question. Is indignity subjective or does it have some objective characteristics? In a liberal society such as the UK, the US, and Canada (the ones I have experience with, but there are others of course) there is a deep commitment for the State to be as impartial and objective as possible, at least in principle. If indignity is subjective, this seems to be beyond th reach the sphere of the liberal State. To include it would inevitably and ultimately lead to favoring some version of the good life. But at the same time, with a public health care system, the State has not option but to have a position on dignity. Its a little easier in the States where the question can be left for the market to decide.

    At the same time, however, its hard to see how indignity can be cast in an objective light. Well, to be fair, its quite possible. Even if we may not arrive at a criteria for indignation that would include all persons (strong universality) it is quite possible to propose criteria that would include all reasonable persons (weak universality). The problem, however, is that it is not at all likely that weak version of the indignity criteria will no doubt leave out some acts, situations and contexts that some people will perceive as indignant while also including some such instances that other consider to be completely normal. Eventually, policy would have to make a judgment call and delineate what is and what is not indignant and there will always be opposition as to where the line is to be drawn.

  • Dennis J. Tuchler says:

    Has anyone studied the effect on outcomes of being in a mixed-sex ward as opposed to a single-sex ward? Under publicly-supported health care, it seems that the limited resources should go to the most important outcome-affecting matters first. If we are in a private hospital in the US, I think the calculation should be the same, with the occupant of the mixed-sex ward perhaps compensated by a slight reduction in hospital costs.

    Dignity is a serious matter, of course. The patient isn’t a mechanical monster requiring repair, but a human requiring treatment and healing. However, as I suggested, this is also a matter of finances and the fulfillment of the general goals of the hospital.

    The problem may involve questions of justice (the fair allocation of resources), but it also relates to the ethics of serving persons in mixed-sex wards (the behavior of physicians, surgeons and nurses when they care for patients in those wards).

  • Peter Wicks says:

    This is clearly a good and interesting question, and what I think it does in particular is to reveal a collision between ethical principles (or “values”) that in themselves are, or at least seem to be, uncontroversial, such as (i) in the interest of people’s physical well-being we want to deliver health outcomes cost-effectively, and (ii) in the interest of peace, harmony and people’s psychological well-being we want to accommodate each other’s preferences and sensitivities.

    What would really interest me, though, is further reflection and discussion on the extent to which it is possible and/or worthwhile to define more fundamental principles from which these two (and other relevant ones) can be derived, and which might then shed some light on how we should weigh them against each other. My own inclination, while insisting that ultimately ethics can only be a matter of choice, and not of absolute truth, is that some sophisticated version of utilitarianism is the most promising approach. But I would be interested to read others’ views on this.

  • Peter Wicks says:

    Let’s take as a starting point the admittedly vague idea that we are, in some general sense, trying to maximise total well-being. I think i basically mean psychological rather than physical well-being. The two “values” I refer to above can then be derived from this principle (and again this is all very fuzzy: obviously more work would need to be done to make it more precise) via the following empirical claims (i.e. beliefs about reality that can, at least in principle, be tested empirically):

    (i) Psychological well-being depends, at least in part, on physical well-being
    (ii) given that budgets are limited, physical well-being can be maximised by maximising the cost-effectiveness of health care
    (iii) accommodating each other’s preferences and sensitivities increases psychological well-being both directly, and indirectly by promoting peace and harmony.

    One conclusion one might draw from the above is that, if what we are really interested in is indeed psychological well-being as opposed to physical well-being per se, we probably need to take more care of people’s sensitivities than a more narrowly utiliitarian view of health care might suggest. One might also add that there is ample evidence that psychological well-being, as well as depending in part on physical well-being (you at least need to be alive and conscious), is also a key factor determining physical well-being. I didn’t include this among the empirical claims listed above because it’s not strictly relevant in deriving the two values I had mentioned previously, but it would seem to weigh in favour of taking account of people’s sensitivities.

    But again, what really interests me is not so much the issue per se but rather the style of argumentation, and the extent to which we think it is possible and/or desirable to conduct such discussions n the context of a coherent logical framework.

  • Peter Wicks says:

    Just seen the date by the way. It gave me pause. Nine years ago….

  • Anthony Drinkwater says:

    Interesting discussion, Peter.
    Let me try to move forward the notion of the style of argumentation :
    First, perhaps we could be clearer on the concept of what constitutes “health” or “well-being” (I’ll assume the two to be synonymous, but others could of course disagree). I’m inclined to believe that the Cartesian distinction between psycholgical and physical health is artificial and simplistic. Even a dualist will have to admit, as you state yourself, that the two interact in both directions.
    If this is accepted, then we do not have a clash between utilitarianism and another source of values : we no longer have “maximise ressources to ensure physical health” versus “I have a right to my dignity”.
    So what do we have ?
    A real complex world with values that can, and often do, conflict. In which ethics can never give solutions but can help by teasing out the differences between reason and emotion, by looking at the logic and consistency of arguments, by revealing contradictions or non-sequiturs…

    I would suggest that the form of argument in settling such conflicts is going to move very roughly as follows :
    1 Overall, what is the correct balance between private dignity and efficient treatment?
    2 In answering this the context is going to pay an enormous role : for example in an emergency (having being rescued from drowning, an earthquake, in wartime …) dignity is going to rate pretty low on most people’s scale compared to being kept alive and reciving only the most basic treatment.
    3 Generalising from this, we end up with a hierarchy of needs such as Maslow’s, which will imply a ranked list of values to respect (or not) according to our ability to meet them, which is context-dependent.

    In a perfect world everyone might have the possibility of having all their values respected (although personally I doubt it). Until then, we are left with the messy business of trading. I don’t see any approach helping us to do this other than some form of utilitarianism.

    Incidentally, in the case covered in the original post, I am sceptical as to whether in fact mixed wards are cheaper than segregated ones, but that’s another question ..

  • Peter Wicks says:

    Many thanks for this Anthony. I think I agree with a lot of this. In particular, yes the distinction between psychological and physical health probably is artificial and simplistic, but that doesn’t necessarily mean that it is entirely useless. It at least has very common currency. The important point, on which I think we both agree, is that to the extent that it is at all meaningful to distinguish between them they are in any case inextricably linked.

    I don’t want to common in a lot of detail right now, but one thing I think may be missing from your schema is a mechanism for agreeing on what values we would ideally like to respect if we had the necessary resources. A related point is that I believe that values can be expressed in a sufficiently general way to be applicable to a very wide range of situations. One could, for example, define “dignity” in such a way that it implies different things in urgent and non-urgent situations.

    In any case this is exactly the kind of discussion I’m interested in having…

  • Peter Wicks says:

    (I meant “comment” rather than “common” in the above post of course.)

    Some further reactions Anthony.

    “A real complex world with values that can, and often do, conflict.”

    Yes, of course.

    “In which ethics can never give solutions but can help by teasing out the differences between reason and emotion, by looking at the logic and consistency of arguments, by revealing contradictions or non-sequiturs…”

    That corresponds very closely to my own position. I would only question the phrase “never give solutions”: it depends on solutions to what. But I think you’ve defined very well what, from my perspective, ethics can and should try to deliver.

    On your schema:

    To get to point 1 you first have to have boiled the discussion down by identifying the values that appear to be conflicting. I agree that we don’t necessarily have a clash between utilitarianism and other values (it really depends on how you define utilitarianism), but we do at some level have a conflict, or at least an apparent conflict, between a desire to maximise resources to certain well-defined (and preferably measurable) health outcomes and the desire for (and perceived “right to”) private dignity, which could be valued because of its effect on well-being (physical and/or psychological) or for its own sake, or for some other reason. Only once this is clarified does it really make sense to talk about finding the correct balance between private dignity and efficient treatment.

    On your second step, see my previously comment about context. In practice of course I agree that context plays an enormous role, but this does not in itself help us to determine the basis on which we decide what the “correct” balance actually is. (Correct from whose perspective, and according to which criteria?)

    On your third point, I don’t quite agree that Maslow’s pyramid “will imply a ranked list of values to respect”. Suggest, certainly, but I think imply is too strong. We still need, in my view, to understand *why* we value private dignity, and even why we value efficient treatment. The structure I’m proposing is to define a more fundamental value or values that seem to be underpinning our moral intuitions in both cases, identifying the empirical beliefs that lead us then to the more specific values in question (in this case private dignity and efficient treatment).

    One final comment. To the extent that I agree with the statement, “I don’t see any approach helping us to do this other than some form of utilitarianism,” the above schema is meant to illustrate the form of utilitarianism I have in mind, and how it applies to a specific situation. To what extent this always needs to be made as painfully explicit as I am doing is a moot point, but I definitely do think it’s important to train ourselves (and each other) to think more clearly about these issues. Otherwise there *is* another approach that will be used in practice, as they have been throughout history, namely some combination of power politics and war. (Which can be fun, but not if you’re one of the victims.)

  • Thanks for all your comments.

    Obviously, as Anthony and Peter point out, it’s not easy to draw a distinction between psychological and physical well-being. But, as Dennis points out, a patient’s sense of dignity is surely something that a health service ought to concern itself with.

    I don’t believe that most people have purely utilitarian intuitions here. Thanks to Dmitri for the example of the white supremacist. We’d not agree to separate wards by race, even if the majority of white people in hospital were outraged and upset at sharing facilities with black patients. On the other hand, it presumably costs a small amount of money to put doors on hospital toilet cubicles: yet this is a cost that we all (presumably) think is worth meeting. Patients would feel that open toilet facilities was an affront to their dignity: and most of us would agree.

    So we don’t think we ought to pay an extra cost to satisfy the patient who feels it an indignity to share a ward with members of a different ethnic group. But we accept the idea that we should pay an extra cost so that people can use the bathroom in private. We need a criterion, or criteria, to distinguish these two cases.

  • Peter Wicks says:

    David,

    “We’d not agree to separate wards by race, even if the majority of white people in hospital were outraged and upset at sharing facilities with black patients.”

    How do you know? This is counterfactual. Basically you are imagining here a parallel universe where a majority of white people (in the UK? where are we talking about here?) don’t want to share facilities with other ethnic groups, but which is otherwise broadly similar to the one we actually live in, and which in particular contains us, blogging away, with our modern views of morality and race relations. It’s not without value but we shouldn’t assume that in such a society we would have the same moral intuitions that we actually do today in this real universe. It’s a bit like comforting yourself with the thought that if you’d grown up in 1930s Germany you wouldn’t have joined the Nazi Youth. Perhaps you would have. Perhaps I would have. In any case there are tricky questions of identity that creep in when one considers such questions (who is the “we” that would not agree to separate wards, and how are those fictitious people related to the actual “we” that are currently exchanging views on this blog?)

    In any case the difficulty in drawing a distinction between psychological and physical well-being was not the main point I was trying to make (it was a point that Anthony made, and with which I agreed). My main purpose in these comments has been to explore a methodology for putting discussions such as this one in the context of a more explicit logical framework. I would have been (and would still be) interested in your reaction to this attempt.

    But if you just want a criterion to distinguish between the race analogy and the mixed ward case, here’s one. The indignity felt by a white supremacist is presumably based at least in part on a concept of superiority, and it is this that we find objectionable. By contrast the indignity felt by a woman being treated in the presence of male fellow-patients is based on values like modesty and decency. So the criterion could be that the perceived “indignity” must not be based on a concept of superiority. Maybe we can have a special ward for radical feminists and male chauvinists. Perhaps a more interesting question is whether it’s OK for homosexual men/women respectively to be treated in the same ward as members of their own sex. There are obvious links here with the “don’t ask, don’t tell” debate.

  • David Edmonds says:

    Peter

    Thanks for your long and thoughtful note.

    I’m not a moral relativist. You pick me up on the ‘we’. I mean, baldly, that it would be wrong to separate wards by race, even if in the past people believed it was acceptable, or even if a majority believed it was acceptable today.

    I’m not exactly sure what you mean by asking whether such matters can be settled within a coherent logical framework. I raised an issue which appears to involve us having to choose between two ends. (1) We normally, and rightfully, care about a patient’s sense of dignity, privacy, modesty etc. (2) We care too about a much more narrow conception of physical well-being – has the patient’s broken arm been set.

    Sometimes we’ll want to give a higher priority to one of these than the other. In Dmitri’s race case, I wouldn’t want to pander at all to a patient’s sense of indignity at having to share a mixed-race ward.

    Yes, we want a coherent, logical way to resolve such issues. One possibility is that there is one value (e.g. wellbeing), to which all other values are subservient. I don’t accept this: but such a theory would provide clear-cut answers (theoretically). Another possibility is that there is no overarching value, but nonetheless there might be an algorithm which allows us to weigh different values (equality, justice, liberty, utility etc.) and reach a conclusion. I’m not sure I accept this either.

    How about we start with something far less ambitious? Assume it costs money to separate wards by sex, and assume that patients want the wards they’re in to be separated by sex. One question we can ask is whether the mixed-sex ward issue more closely resembles the toilet-cubicle case, or whether it more closely resembles the race case. Resembles in what sense? What are the pertinent factors to consider?

    Somehow policy-makers have to work out how to spend public money. Whatever your meta-ethical position, I’m assuming you too wouldn’t want money spent on separating the races, but you would think it’s acceptable to spend money so that patients have some bathroom privacy. Where do mixed-wards fit into the spectrum?

    Sorry: this is a quickly penned response. I hope it goes some way to answering your questions.

  • “So we don’t think we ought to pay an extra cost to satisfy the patient who feels it an indignity to share a ward with members of a different ethnic group. But we accept the idea that we should pay an extra cost so that people can use the bathroom in private. We need a criterion, or criteria, to distinguish these two cases.”

    Let us imagine the following wishes :

    List A
    I don’t want to be placed in the same ward as a black
    I don’t want to be placed in the same ward as a Chinese
    I don’t want to be placed in the same ward as an atheist
    I don’t want to be placed in the same ward as an Islamic
    I don’t want to be placed in the same ward as a homosexual
    I don’t want to be placed in the same ward as a Jew
    I don’t want to be placed in the same ward as an AIDS victim

    List B
    I don’t want to use the toilet in front of another person
    I don’t want to appear naked in front of another person
    I don’t want to appear suffering in front of another person

    I think we would agree that none of the situations postulated influence physical treatment, except insofar as the situation could provoke severe mental distress, which could in turn retard recovery.
    (I leave this aside, because it poses other questions that would take us too far for a short post – for example, how far should we accept an irrational prejudice/desire/value of a mentally ill person being treated in a psychiatric hospital ?)

    The difference between lists A and B seems to me that those in list B are based on a value of human privacy, which is a necessary condition for autonomy, which itself is an essential component of human dignity. And most of us would agree that if, to borrow from Rawls, we did not know what sex, nationality, sexual orientation, social position etc we were going to have in life, we would accept this as a universal value.

    Those in list A are probably different in that this Rawlsian test would fail, as the values are all culturally dependent.

    Remains the original question of same sex wards : into which of the above lists would this fall ?
    I would suggest that it falls into neither, but more nearly into list B, as the gender distinction is present in all cultures, and thus acquires a form of universality.

    I know that this is far from a complete answer, but does it go in the directions you are looking for, Dave and Peter ?

  • Peter Wicks says:

    Sorry for the delay in responding.

    First in response to David: the schema I’m proposing seems to me to be over-ambitious only if we insist that the resulting answer will be the “right” one in some absolute sense, in which case can one not reasonably argue that it is moral absolutism that is over-ambitious rather than an algorithmic approach? If I was seriously suggesting that you could in practice make this a purely mathematical procedure then indeed this would be over-ambitious (although this does not stop people trying e.g. in the context of impact-assessing policy initiatives). But I’m not: what I am suggesting is basically a logical structure within which to frame debates, which will otherwise inevitably contain a fair degree of subjectivity.

    Perhaps this is just the way my brain works, but the problem is that I don’t really see a convincing way to answer your core question (where do mixed wards fit into the spectrum between racial segregation and toilet cubicles) without putting it into some such logical structure. More importantly, I fervently believe that being as explicit as possible about what we value and why is essential if our global civilisation is to steer itself more-or-less intact through the next few decades.

    Two further points.

    Firstly, I think the distinction between one over-arching value and many values with agreed weightings may be spurious in the sense that the first is an essentially linguistic and the second an essentially arithmetic way of expressing the same thing. There would have to be some (overarching) value determining the weightings, or to put it another way once the weightings have been agreed on it should be possible to come up with some kind of (linguistic) justification for them, which then becomes your overarching value.

    Secondly, I’m not saying this is your case, but some people seem to object to moral relativism on the grounds (or define it to mean) that you don’t really believe in anything. I think this is a misunderstanding. One can “believe in” one’s values in the sense (ultimately the only important one) of putting them into practice (for sure it’s a different kind of “belief” than belief in empirical assertions) with great passion and commitment, without regarding them as absolute. The advantage of this, from the perspective of my own values and beliefs, is that you don’t go into some kind of neurotic defense mode every time you come across somebody with different values. That’s the kind of moral relativism that I espouse.

    Now in response to Anthony: the distinction between lists A and B is certainly important and enlightening, but I agree more with your statement that the question of mixed wards falls into neither list than that it fits “nearly into list B”. I would say it falls into list C, namely: I don’t want to be placed in the same ward as some of the opposite sex / race / religion / etc. This list is segregationist but does not necessarily apply superiority of one sex/race/religion than over another. Several considerations nevertheless distinguish gender from race and religion. One is that biology has divided us very neatly into two sexes, with very little ambiguity. So it’s a natural division in a way that skin colour and beliefs are not. I also think there are important differences in the extent to which gender (basically through the effect of testosterone in development) influence both physiology and psychology and the more superficial and/or complex (non-dualist) effects of skin colour, ethnicity and beliefs. But the reality of homosexuality does complicate the picture in my view.

Authors

Subscribe Via Email

Affiliations