Identifying vulnerable populations

Human vulnerability may indeed be a universal condition and a state from which we all deserve equal protection ( Kottow 2003 ; Masferrer & García-Sánchez 2016 ). Even so, as can be readily demonstrated, there are some people who are more vulnerable than others and who, for various reasons, are less able to protect their own interests when these are at risk of being harmed. Correct identification of these people is essential if the special protective responsibilities that others have towards them are to be realised in policy and practice.

Vulnerability can be individual (individual vulnerability) or aggregate (‘vulnerable groups’, ‘vulnerable populations’, ‘social vulnerability’) ( de Chesnay & Anderson 2012 ; Masferrer & García-Sánchez 2016 ; Mastroianni 2009 ). In the case of individual vulnerability, entities commonly identified (particularly in national research guidelines) include people who:

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  are very young and lack maturity (e.g. infants, children and young adolescents)

  
  
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  are highly dependent on medical care (and who may be unable to give consent)

  
  
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  have a cognitive impairment or who have an intellectual disability

  
  
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  have a mental health problem or illness

  
  
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  have a physical disability (and who are dependent on others for their daily care)

  
  
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  are very old, frail and isolated (e.g. the dependent elderly)

  
  
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  are of low socioeconomic status (e.g. the poor, homeless, and / or unemployed)

  
  
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  are serving a prison sentence for criminal offences (prison inmates)

  
  
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  are members of an ethnic minority group or population

  
  
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  are refugees, asylum seekers, displaced persons or stateless persons

  
  
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  (in Australia) identify as being Aboriginal or Torres Strait Islanders

  
  
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  (in New Zealand) identify as being Māori.

In the case of aggregate vulnerability , entire groups, populations and even countries can be characterised as being vulnerable – for example, groups and populations that are at risk of premature mortality or morbidity ( Purdy 2004 ), and poorer nations or countries that are at risk of exploitation by researchers (see examples given in Liamputtong 2007 ; Macklin 2003 ), drug companies, fast food companies, mining magnates and the like.

Vulnerability as a guide to action

Not all agree that vulnerability is a useful concept or even that it has a place as a guide to ethical conduct. Some critics argue that labelling individuals and groups as vulnerable may have the undesirable consequence of paradoxically stigmatising them and also risk their being marginalised on the basis of the very characteristics for which they have been deemed to be vulnerable (e.g. old age, disability, decisional incapacity). Thus, individuals and groups labelled vulnerable may find themselves also carrying the burden of what Martha Minow (1990 : 20) calls the ‘stigma of difference’ and the ‘moral pathology of prejudice’ that underpins it. (According to Minow, the stigma of difference is so potent that it ‘may be created both by ignoring it and by focusing on it’.)

Other critics, meanwhile, object to identifying people as vulnerable on grounds that it could seem patronising and condescending. Danis and Patrick (2002 : 320), for example, argue that ‘Labeling individuals as “vulnerable” risks viewing vulnerable individuals as “others” worthy of pity’, a view rarely appreciated (e.g. a healthy and active octogenarian may not appreciate being categorised as ‘vulnerable’ simply on the basis of his or her old age; likewise a pregnant woman, consenting to be interviewed for a research project, may not appreciate being categorised as ‘vulnerable’ simply because of being pregnant).

It is not clear that these and similar criticisms are sustainable, however. This is especially so when considered in relation to the possible link that exists between vulnerability and dehumanisation (to be considered shortly). Moreover, new and emerging works are increasingly suggesting that the notion of vulnerability not only gives functional structure to the moral obligations that people have towards others, but also inspires and requires them to engage in actions that respect, protect and remediate breaches of people’s human rights and social justice violations ( Andorno 2016 ; Masferrer & García-Sánchez 2016 ). The identification of vulnerability as a ‘missing feature’ of contemporary moral philosophy ( Hoffmaster 2006 ) and as an understated source of our ‘special responsibilities’ to protect others ( Goodin 1985 : 109) further challenges the criticisms raised by its detractors.

In light of these developments it can be seen that, despite the criticisms which have been labelled against it, the concept of vulnerability remains essential to contemporary bioethics ( Andorno 2016 ; Cortina & Conill 2016 ; Goodin 1985 ; Hoffmaster 2006 ; Masferrer & García-Sánchez 2016 ). It also stands as an extremely useful reminder to practitioners, policy makers and researchers alike that all human beings have the capacity to be ‘hurt or wounded’, that this capacity to be hurt needs constantly to be taken into consideration in their day-to-day practices and proceedings, and that attempts to define and protect ‘ vulnerable populations ’ through codes, standards and institutional regulations are not necessarily a case of ‘bureaucratic overreach’ ( Blacksher & Stone 2002 ; Goodin 1985 ). In short, contrary to the views of its detractors, the concept of vulnerability may, in practice, be the key to the prevention of ethics and social justice violations in both health and social care contexts.

Vulnerability and nursing ethics

Vulnerability has been identified as an ‘understated foundation’ of ethical sensibility in nursing ( Nortvedt 2003 ) and as a construct that ought to have an important, if not pre-eminent, place in nursing ethics. There is a need, however, for nurses not only to learn about vulnerability and its importance as a foundational ethical concept, but also to feel it. This is because, as examples to be given in this and the following chapters of this book make plain, unless we feel our own vulnerability we will not be able to affirm either our own or others’ humanity. And unless we ‘recognise the depth and the breadth of our vulnerability’ we will not realise ‘how much we need the help of others to protect us from our weaknesses and our infirmities’ ( Hoffmaster 2006 : 44) or, conversely, how much others may need us to assist them when weak and unable to help themselves.

Until nurses recognise both the universal and particular vulnerability of people and the related moral obligations we all share to help and protect those who have become unable to protect their own interests, the risk of ‘vulnerability tragedies’ occurring and also being repeated will remain high. So too will the risk of nurses being left unnecessarily as ‘guilty bystanders’ to the plight of vulnerable people in hostile care environments ( Fitzgerald et al 2016 ). To help further explain why this risk exists, an exploration of the notion of dehumanisation and its underrecognised link to human vulnerability is warranted.

Humanness

In order to make sense of what dehumanisation is (commonly taken to mean the denial of humanness) an account of what is being denied – that is, what constitutes humanness – is first required ( Haslam et al 2008 ). ‘Humanness’ and what it means to be human are ‘slippery’ notions and have occupied the attention of philosophers for centuries. More recently it has been the subject of a growing body of research and scholarship in the field of social psychology, which is giving rise to new and important insights into the phenomena of humanness and dehumanisation, although this work has by no means settled ongoing debates about the subject ( Bain et al 2013 ; Kaufmann et al 2011a ). As Haslam (2013 : 36) notes, ‘one of the key developments in recent research and theory is that humanness is not a unitary idea’.

Conventional philosophical debates on what it means to be a human being have typically focused on drawing a distinction between an entity being genetically human and having personhood . Meeting the criteria of personhood has been quintessential to determining whether or not an entity ought to be categorised as ‘human’ and accorded moral status ( Bastian et al 2011 ). This distinction has had particular resonance in the abortion debate, whereby the human fetus has been characterised as genetically human, yet not necessarily as having personhood (this issue will be discussed in more depth in Chapter 10 ), and likewise debates about the use of anencephalic infants for organ donation to help overcome organ shortages for transplantation in infants ( Glasson et al 1995 ; John & Bailey 2018 ; Khan & Lea 2009 ; Nagakawa et al 2017 ; Shewmon et al 1989 ). On account of not having personhood, human fetuses and anencephalic infants have tended to be positioned as beings without moral status and thus without any of the moral rights that might otherwise be commensurate with an entity having moral status.

Debate surrounding the issues of abortion and the use of anencephalic infants as organ donors are just two examples that may help to explain why addressing the question of humanness is important. Specifically, it highlights the normative belief that the ‘qualities that make us human are also those that give us moral status’ ( Bastian et al 2011 : 469). This, in turn, highlights the moral problem that there is a relatively short step between denying people their humanness and denying them their moral status. As Opotow (1993) has observed, when people are portrayed as being outside of the category ‘human’ they lose all the protections that being human entails. This is because the denial of humanness places people ‘outside the boundary in which moral values, rules, and considerations of fairness apply’ and renders them ‘nonentities, expendable and as morally undeserving’ ( Opotow 1990a : 1). Moreover, if they are harmed as a result of their moral exclusion, it is likely the harms experienced would be construed by its perpetrators as being not only acceptable, but also appropriate and just ( Opotow 1990a ; see also Bar-Tal 1990 ).

The questions remain: ‘What is humanness?’ and ‘Is it something that one person or group can credibly deny another?’

Social psychologists suggest that, notwithstanding the difficulties in achieving a consensual definition of humanness, there are two senses in which humanness tends to be viewed, both of which serve the purpose of distinguishing humans from other entities ( Haslam 2006 ; Haslam et al 2008 ). The first sense, which contrasts humans with animals, is human uniqueness – meaning properties that are uniquely human and not shared by other beings ( Haslam 2013 : 36). An example would be the human capacity for complex emotions (such as disillusionment, felicity, embarrassment, optimism, admiration), which is in contrast to the basic emotions (such as anger, fear, sadness, surprise, pleasure) that other animals also share ( Leyens et al 2000 ). Other uniquely human characteristics that have been suggested include the properties of ‘civility [culture], refinement, moral sensibility, rationality, logic and maturity’ – properties which other species are presumed to lack ( Haslam 2006 : 257).

The second sense of humanness, which contrasts humans with inanimate objects (e.g. machines, robots and automatons), encompasses what is regarded to be typically human in that it reflects human nature ( Haslam 2006 ; Haslam et al 2008 ). Human nature , in this instance, may manifest as ‘emotional responsiveness, interpersonal warmth, cognitive openness, agency and individuality, depth [of character]’ ( Haslam 2006 : 257) – properties that robots and machines simply do not have.

Dehumanisation

Dehumanisation fundamentally entails denying the humanness of others. Such denial can take several forms, can be expressed in different ways and can result in extremely harmful consequences (e.g. ethnocide). If the effects of dehumanisation are to be mitigated then the phenomenon itself needs to be understood. Specifically, the different forms that dehumanisation can take, the different ways it can be expressed in everyday life, why it occurs, what its consequences are and how if at all it might be deterred all require examination. It is to examining these issues that this discussion now turns.

Stigma

Stigma (from Latin via Greek meaning ‘brand’ or ‘bodily sign’) is literally a distinguishing mark of social disgrace. It presupposes the acquisition of an attribute or attributes that others (usually those who are dominant members of a mainstream culture or group) find or regard as deeply discrediting (personally, socially and morally) and, importantly, who have the power to discredit those deemed ‘marked’ as socially disgraced ( Goffman 1963 ; Link et al 2004 ; Link & Phelan 2006 ). What is regarded as a ‘distinguishing mark of social disgrace’, however, and what impact it will ultimately have on people, will depend on the culture from which it has originated and what that culture deems as being ‘deviant’ ( Link et al 2004 ).

According to Jones and colleagues (1984) the incidence and impact of a given stigmatised ‘characteristic’ or ‘condition’ will depend on the following five dimensions:

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  ‘ concealability ’ – refers to how obvious a characteristic is and the degree to which it can be concealed from others

  
  
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  ‘ disruptiveness ’ – refers to ‘the extent to which a mark strains or obstructs interpersonal interactions’

  
  
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  ‘ aesthetics ’ – refers to the extent to which a mark elicits an ‘affective reaction of disgust’

  
  
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  ‘ origin ’ – refers to ‘how the condition came into being’ and particularly whether the marked person was responsible for the condition (e.g. whether genetic, accidental or self-caused)

  
  
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  ‘ peril ’ – refers to ‘feelings of danger or threat that the mark indicates in others’ (cited in Link et al 2004 : 512).

The process of stigmatisation becomes problematic when it evolves into a situation in which an individual is disqualified from full social and cultural acceptance on the basis of his / her carrying a given ‘distinguishing mark of social disgrace’ (e.g. being immigrant, disabled, homosexual, mentally ill, old, etc.) ( Goffman 1963 ). Inevitably this means that stigma almost always carries with it commensurate processes of discrimination – that is, the unfair treatment of persons on the basis of their ‘distinguishing mark(s)’. This treatment is unfair since judgments are made on the somewhat arbitrary basis of morally irrelevant distinguishing marks, rather than on moral considerations per se, hence the notion that stigma and stigmatisation are unjustly discriminatory. This outcome is unethical since, by focusing on one (or more) arbitrary characteristic(s) of a person (e.g. the marks that may ‘distinguish them’), stigma and discrimination undermine the moral worth (dignity) of a person (results in them ‘losing face’, if you will) and thus dehumanises the person. The stigmatising and (negative) discriminatory treatment of persons thus stands in contradistinction to the respectful treatment of persons – that is, responses to persons that are guided by moral considerations, not merely arbitrary ones.

It is important to note that stigma can involve both ‘public’ (public-stigma) and ‘self ’ (self-stigma) reactions. Public stigma has been described as comprising ‘reactions of the general public towards a group based on stigma about that group’, and as consisting of three elements – stereotypes, prejudice and discrimination – that occur in ‘the context of power differences and leads to reactions of the general public towards the stigmatized groups as a result of stigma’ ( Rüsch et al 2005 : 530, 531). Self-stigma , in contrast, refers to ‘reactions of individuals who belong to a stigmatized group and turn the stigmatizing attitudes against themselves’ ( Rüsch et al 2005 : 531). Like public stigma, self-stigma also consists of three elements: stereotypes, prejudice and discrimination, but with the notable distinction that all three tend to be strongly aligned with public stigmatisation, with individuals internalising the negative public attitudes against themselves; for example ‘That’s right; I am weak and unable to care for myself’ ( Rüsch et al 2005 : 531).

Prejudice and discrimination

The term prejudice (literally to ‘prejudge’ without adequate facts) may be defined as ‘any belief (especially an unfavourable one), whether correct or incorrect, held without proper consideration of, or sometimes in defiance of, the evidence’ ( Flew & Priest 2002 : 326). The counterpart of prejudice is discrimination . Discrimination, in turn, may be broadly defined as ‘the unfair treatment of a person, racial group, minority, etc., based on prejudice’ ( Collins Australian dictionary 2011 : 478).

Within the concept of discrimination, two forms are distinguished: direct discrimination and indirect discrimination, which may be either intentional or unintentional. In Australian and New Zealand jurisdictions (as well as in others, e.g. Canada, EU, Hong Kong, South Africa, USA), direct discrimination may be held to have occurred when a person (or group of people) with certain characteristics protected by law (e.g. their race, sex, pregnancy, marital status, family responsibilities, breastfeeding, age, disability, sexual orientation, gender identity or intersex status) is ‘treated less favourably than another person or group’ based on their personal characteristics – noting that some limited exceptions and exemptions may apply ( Australian Human Rights Commission nda ; New Zealand Human Rights Commission nd ). It needs to be understood that one does not have to have acted intentionally or to believe that one’s actions were not discriminatory for a complaint of discrimination to be upheld. Indirect discrimination (which is controversial in some jurisdictions) may be held to have occurred ‘when there is an unreasonable rule or policy that is the same for everyone but has an unfair effect on people who share a particular attribute’ (e.g. a public building that has only stairway access will disadvantage those who are wheelchair dependent for their mobility) ( Australian Human Rights Commission ndb ; New Zealand Human Rights Commission nd ). In short, although seemingly neutral, a policy or practice (e.g. stairway-only entry to a public building) may nonetheless indirectly discriminate against a person insofar as it has a ‘disparate impact’ on and causes ‘disproportionate disadvantage’ to that person compared with other cognate groups ( Collins & Khaitan 2018 ; Khaitan 2018 ). As in the case of direct discrimination, indirect discrimination can be established without reference to whether it was intentional or known; instead it is established by demonstrating a ‘disparate adverse impact’ ( Collins & Khaitan 2018 ) – for example, a wheelchair-dependent person being unable to access a public building because it has only stairway access.

Disadvantage

Before concluding this section, a brief comment about the notion of disadvantage is warranted. Disadvantage, in its most basic sense, may be taken to mean a deprivation that is unfavourable or detrimental to a person’s interests. The notions of vulnerability, dehumanisation, delegitimisation, moral exclusion, stigma, prejudice and discrimination as discussed in this chapter are all correlated in important ways with the notion of disadvantage. In this instance, disadvantage correlates with the notion of equal opportunity and the ways and extent to which this is denied when people are dehumanised, marginalised and excluded from the moral community. Disadvantage, in this case, can result regardless of whether the processes of dehumanisation, delegitimisation and moral exclusion are covert or overt. This is because these processes disrupt what would otherwise be a level playing field and result in privileged groups (i.e. those with a social dominance orientation) accruing unearned advantages over those they have subordinated.

People who are subjected to dehumanisation, delegitimisation, moral exclusion, stigma, discrimination and prejudice are all vulnerable to being disadvantaged in terms of realising the health benefits commonly associated with having equitable access to the social, cultural and political conditions that promote safe and high-quality health care. It is for this reason that identification of and emphasis on the special responsibilities that others might have towards vulnerable populations are warranted.

Forms of dehumanisation

Research suggests that dehumanisation corresponds in varying ways to the two senses of humanness outlined in the previous section – that is, that which is uniquely human and that which reflects human nature or is typically human ( Haslam 2006 ; Haslam et al 2008 ). Accordingly, dehumanisation may take one or more of the following forms:

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  animalistic dehumanisation – whereby people are deemed to be more ‘animal-like’ than other categories of people, or summarily demoted to animal status (e.g. characterised as ‘rats’, ‘pigs’, ‘dogs’, ‘cows’, ‘asses’, ‘monkeys’, ‘spiders’, ‘snakes’, ‘parasites’, ‘cockroaches’ and other vermin)

  
  
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  mechanistic dehumanisation – whereby people are reduced or demoted to inert, unfeeling automatons (e.g. the biomedical characterisation of the human body as a ‘machine’ with ‘parts’ that require fixing, replacing, or removal; employees on an assembly line treated ‘as if’ they are robots)

  
  
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  superhumanisation – whereby people are either elevated to the status of and / or idealised as gods and angels; or derogated as satans, devils and demons (e.g. a philanthropist characterised as a ‘saint’ or ‘angel’, a fiend characterised as ‘the devil incarnate’, a murderer portrayed as a ‘monster’) ( Bain et al 2013 ; Bar-Tal 1989 , 1990 ; Haslam et al 2008 ; Hodson et al 2013 ).

Underpinning each of these forms of dehumanisation is a psychological process that Bar-Tal (1990 : 65) has termed ‘ delegitimisation ’, which he defines as the:

categorization of a group or groups into extreme negative social categories that are excluded from the realm of acceptable norms and / or values.

He explains that delegitimisation (also a type of stereotyping and of prejudice) has the following distinguishing characteristics (p 66):

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  it utilizes extremely negative, salient, and atypical bases for categorizations;

  
  
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  it denies the humanity of the delegitimized group;

  
  
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  it is accompanied by intense, negative emotions of rejection, such as hatred, anger, contempt, fear, or disgust;

  
  
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  it implies that the delegitimized group has the potential to endanger one’s own group; and

  
  
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  it implies that the delegitimized group does not deserve human treatment and therefore harming is justified.

The processes of dehumanisation and delegitimisation, in turn, rest on what Bandura (1999 : 193) has termed ‘ moral disengagement ’ (discussed earlier in Chapter 5 of this text). In this instance, moral disengagement sees perpetrators of dehumanisation cognitively restructure their inhumane conduct as being ‘benign and worthy’ via a complex interplay of the following processes:

moral justification, sanitizing language, and advantageous comparisons; disavowal of a sense of personal agency by diffusion or displacement of responsibility; disregarding or minimizing the injurious effects of one’s actions; and attribution of blame to, and dehumanization of, those who are victimized.

As will be considered shortly, because these processes operate and can be advanced in extremely subtle ways, they can often be difficult to detect and thus difficult to deter and remedy.

Explicit and subtle expressions of dehumanisation

Research suggests that dehumanisation can be expressed in various ways, ranging from the ‘obvious’, overt and explicit expressions of dehumanisation (the kind that has tended to receive the most attention up until recently) to the less obvious, covert and subtle expressions – the everyday expressions that often go unnoticed. In the case of overt and explicit expressions of dehumanisation, ‘othered’ people are consciously and deliberately described as ‘non-human’. There are many examples of this throughout recorded history, some of the most notorious modern examples being: the Nazi characterisations of Jews and Gypsies as ‘rats’ and ‘vermin’; the Hutu characterisation of Tutsis as ‘cockroaches’ during the Rwandan civil conflict, which saw the genocidal mass slaughter of between 500 000 and 1 million Rwandans (70% of whom were Tutsis); Africans being called ‘apes’; and indigenous Australians being called ‘monkeys’ ( Bain et al 2013 ; Bar-Tal 1990 ; Costello & Hodson 2009 ; Haslam 2013 ).

In the case of subtle or covert expressions of dehumanisation, people subtly downplay or attribute fewer ‘uniquely human’ qualities to others – usually members of an ‘out-group’ – that is, they portray them as being more ‘animal like’ than themselves. Also called ‘infrahumanisation’ ( Haslam & Loughnan 2014 ; Leyens et al 2000 , 2007 ), a distinguishing feature of subtle or covert dehumanisation (compared with its more explicit form) is that it tends not to be reported directly and is expressed by perpetrators without conscious awareness that their expressions are dehumanising ( Bastian et al 2011 ). Examples can be found in cases of stereotyping ‘people of difference’ ( Bastian et al 2011 ).

A stand-out example of the infrahumanisation of people is the dehumanising, stereotypical depiction, by the media and politicians, of refugees and asylum seekers as ‘queue jumpers’ and ‘cheats not willing to follow fair procedures’ ( Esses et al 2008 : 5). They are relentlessly portrayed as having ‘less capacity’ for complex emotions and moral values (‘be like us’), and as being primarily motivated by only the ‘basic emotions’ that animals share (e.g. fear and pleasure). The subliminal message here is that ‘these people’ ostensibly lack the moral motivations and personal control that a more ‘civilised’ and ‘cultured’ people (‘us’) would otherwise exhibit. Recall the ‘Children overboard’ incident discussed in Chapter 2 . This incident involved the public misrepresentation of photographic images and false claims by Federal government politicians that asylum seekers who were attempting to enter Australian territory ‘illegally’ by sea had ‘deliberately’ thrown their children overboard from the boat they were on so they would be rescued. It was later revealed and subsequently verified by a Senate Inquiry into the matter that no children had, in fact, been thrown overboard. This, however, did not stop politicians or the media from portraying them (‘demonising them’) as ‘faceless, violent queue jumpers’ and as people of poor moral character, as was widely quipped at the time ‘the kinds of people who would throw their children overboard’ ( Senate Select Committee on a Certain Maritime Incident 2002 : xxi).

In addition to being either explicit or subtle, researchers contend that expressions of dehumanisation may also be relative or absolute, a feature that must also be assessed when attempting to mitigate its effects. In the case of relative expressions , the target individual or group (usually an out-group or individual) is portrayed as being less than human ‘relative’ to another (usually the in-group or individual) ( Haslam 2013 ). In contrast, absolute expressions of dehumanisation are explicit: the target individuals or groups are characterised unequivocally as being animalistic, or devilish, or monstrous in and of themselves independent of comparisons that might otherwise be made with other beings or entities ( Haslam 2013 ).

It is important to clarify that, although the various ways in which dehumanisation can be expressed have been described in dichotomous terms (e.g. humanness / non-humanness, object / animal, explicit / subtle, conscious / unconscious, relative / absolute), as Haslam (2013) concedes, in practice its expression probably occurs along a continuum that encompasses subtle variations of all the dimensions identified. What these categorisations enable, however, is a better understanding of the phenomena at issue and whether the diverse forms that human denial can take are to qualify as cases of ‘dehumanisation’ ( Haslam 2013 : 42).

Why dehumanisation occurs

The causes of dehumanisation, the possible neural mechanisms involved and the psychological motivations for people to engage in harmful dehumanising behaviours are extremely complex, with some suggesting that the human brain has been ‘hard wired’ through evolutionary processes to favour in-groups (‘us’) over out-groups (‘them’) ( Greene 2013 ; Lee & Harris 2013 ). Although research on the subject is inconclusive, one thing is clear: everyone has the capacity to dehumanise others – especially those identified as being outliers to one’s own ‘in-group’ and hence labelled (often unconsciously) as ‘other’. Research also strongly suggests that when an in-group perceives that its resources and / or identity are threatened by an out-group, this often leads to a ‘rejection response’ and the dehumanisation of those deemed to pose the ‘resource threat’ or the ‘identity threat’ to members of the in-group ( Costello & Hodson 2009 ; Hodson & Costello 2007 ; Leyens et al 2000 ). Given this, it would be a grave mistake to assume that it is only the ignorant, the misguided, or the manifestly psychopathic individuals who are capable of denying ‘others’ their humanness and the moral protections and entitlements that come with this status. This is not to deny, however, that some people are more predisposed than others to perpetrate acts of dehumanisation, or that some are more motivated than others to expose and mitigate this predisposition.

Research to date suggests that people who see animals as inferior to humans, who have a ‘social dominance orientation’ and who subscribe to ‘right-wing authoritarianism’ are more likely to engage in the dehumanisation of people outside of their in-group than are those who do not have such ideological orientations ( Haslam 2013 ; Hodson & Costello 2007 ; Leyens et al 2000 ). This is because people who hold these ideologies tend to see themselves as ‘superior’ to others and to value social hierarchies and group dominance. The world is seen as a competitive jungle, with ‘intergroup interactions perceived as zero-sum competitions over finite resources’ ( Haslam 2013 : 6) and over their social and political identities ( Bar-Tal 1990 ; Tajfel & Turner 1979 ). When out-groups are perceived as a threat, depending on the severity of the threat (whether real or imagined) this perception tends to be accompanied by fear, stress and feelings of uncertainty and vulnerability by the in-group ( Bar-Tal 1990 ; see also Becker 1973 ; Crimston et al 2018 ). This helps to explain why people with these orientations and dispositions tend to be associated with ‘prejudice towards a variety of outgroups, particularly subordinate and competitor outgroups’ ( Haslam 2013 : 6), for example immigrants and asylum seekers ( Esses et al 2008 ; Hodson & Costello 2007 ).

In contrast, people who have ‘inter-species’ empathy and concern (e.g. value and even anthropomorphise animals, and encourage perceptions of the similarities between animals and human beings), who emphasise inter-group similarities, and who have a low preference for and tolerance of social hierarchies and dominance tend to be less associated with prejudice and intolerance of out-groups and people otherwise deemed ‘different to us’.

In sum, there seems to be a link between a perception that ‘humans are different from and superior to animals’ and a disposition to dehumanise others, and especially people who are perceived as belonging to out-groups and as posing a threat to the in-group’s resources, identity and social–political standing. Conversely, those who hold beliefs about animal–human similarities are less predisposed towards and are less likely to dehumanise others – and indeed may actually foster out-group humanisation and the rehumanisation of those who have already been dehumanised – for example, immigrants (termed ‘immigrant humanisation’) ( Costello & Hodson 2009 : 17).

Consequences of dehumanisation

Some researchers contend controversially that not all instances of dehumanisation are harmful and, indeed, may even be adaptive and necessary ( Lee & Harris 2013 ). For example, a surgeon may not be able to perform effectively unless focused on the ‘mechanics’ of the human body and its constitutive parts that lay beneath his scalpel blade. Such instances tend to be the exception not the norm, however. Although unlikely to exacerbate an entity’s vulnerability per se, such instances of ‘benevolent’ mechanistic dehumanisation may nonetheless result in what some have termed ‘human dignity violations’, a form of dehumanisation that encompasses the humiliation and degradation of human beings ( Kaufmann et al 2011b ). Thus, the diligent surgeon may well have performed a perfect surgical procedure and prolonged the life of his patient, yet may still have committed a dignity violation – albeit one that was unintended: the patient, stripped of her body part (a limb, a breast, a sex organ, the side of her face), although grateful for her life-prolonging treatment, may nonetheless feel degraded and ‘less than human’ on account of losing the part that has been amputated and the function it once afforded.

Putting aside what might be termed ‘benevolent mechanistic dehumanisation’, dehumanisation remains morally problematic. The main reason for this, as suggested in the opening paragraphs to this discussion, is that it justifies what Staub (1990) and Opotow (1990a , 1990b) call ‘ moral exclusion ’ and the related moral harms that would otherwise be considered unconscionable. As noted earlier, moral exclusion occurs when:

individuals or groups are perceived as outside the boundary in which moral values, rules, and considerations of fairness apply . Those who are morally excluded are perceived as nonentities, expendable, or undeserving; consequently harming them appears acceptable, appropriate, or just. [emphasis original] ( Opotow 1990a : 1)

Opotow (1990b : 174) explains that moral exclusion emerges when ‘ group differences (or “we–they” distinctions) are salient and when difficult life conditions (such as harsh social circumstances, destructive conflict, or threat) exist’ [emphasis original]. It can also emerge where there are perceived conflicts of interests that give rise to group categorisations , which in turn ‘contribute to moral justifications for unjust procedures , which can themselves be injurious and which permit other harmful outcomes to ensue’ [emphasis original] (p 174).

Opotow concludes that what primarily makes moral exclusion problematic is not only that it enables the unjust and even brutal treatment of others considered ‘less than human’ and inferior, but also that it is insidious and difficult to detect. This is because its justifications are largely unspoken on account of being based on shared social perceptions that are ‘institutionalized, invisible, and accepted as if inevitable’ ( Fine 1990 : 111). Opotow (1990a : 13) cautions, however, that:

moral exclusion is neither an isolated nor inexplicable event, but occurs with great frequency, depends on ordinary social and psychological processes to license previously unacceptable attitudes and behaviour, and can cause great harm, from personal suffering to widespread atrocities.

Deterring dehumanisation

Dehumanisation is a malevolent process: it unjustifiably denies the humanness of ‘others’ and, by virtue of this denial, justifies harming or at least failing to protect the significant moral interests of those targeted. Targeted individuals and groups are not the only ‘victims’, however. Research has shown that when people dehumanise others they also dehumanise themselves ( Bastian et al 2011 , 2012 ); likewise, in harming others, perpetrators harm themselves ( Rodriguez 2017 ). Thus denial of humanness is a double-edged sword that cuts both ways: not only does it risk the self-perpetuation of the dehumanisation–delegitimisation–moral exclusion cycle that ultimately will harm the moral interests of us all, but it also risks the corruption and decline of our moral systems generally and their capacity to cultivate peaceable bonds between people in the interests of promoting human welfare and wellbeing.

As examples to be given in this chapter and the following chapters will demonstrate, dehumanisation and the moral exclusion it justifies needs to be detected and deterred ( Opotow 1990b ). This is particularly so in health care domains where the processes of dehumanisation and moral exclusion have resulted in disparities in access to and the beneficial outcomes of quality health care. The question remains, however, how might dehumanisation be detected and deterred, if at all? In attempting to answer this question, attention will be given to the following four strategies:

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  addressing the root causes of dehumanisation

  
  
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  fostering the moral inclusion of ‘out-groups’ and individuals

  
  
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  detecting and exposing instances of dehumanisation

  
  
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  energising dissent.

Addressing the root causes of dehumanisation

Little is known about the mechanisms that might help to reduce and deter dehumanisation, with some authors acknowledging that the problem is ‘a knotty one’ owing to the interrelated complexities that drive it ( Haslam & Loughnan 2014 : 417). Even so, evidence is growing that various mechanisms can be used to help reduce the incidence and negative impact of dehumanisation ( Haslam & Loughnan 2014 : 417–18) and that addressing the ‘root cause’ of dehumanisation is an important starting point. Endeavours could begin, first, by redressing the ‘hierarchal divide between humans and animals’, which has enabled the ‘justified’ oppression and subjugation of people deemed to be ‘animal-like’ ( Costello & Hodson 2009 : 5). Processes by which this hierarchy could be redressed might include emphasising empathic attitudes towards the similarities (e.g. sentience, cognitive abilities and relative moral intelligence) as opposed to the differences between humans and animals. Research has revealed, for instance, that some social mammals (e.g. gorillas, elephants, wolves, rats, bats and others) exhibit a range of cooperative ‘moral’ behaviours akin to those exhibited by humans – for example, justice, empathy, forgiveness, care, trust and reciprocity (including helping each other when in trouble) ( Balcombe 2016 ; Bekoff & Pierce 2009 ). Far from being a case of anthropomorphising animals, scholars in the field remind us that ‘humans are animals too’, so it should not come as any surprise that animals and humans exhibit a similar range of moral behaviours. They have gone on to conclude that many animals have moral intelligence and are in essence ‘moral beings’, which means that human beings ‘are not alone in the moral arena’ ( Bekoff & Pierce 2009 : 152; see also Balcombe 2016 ).

In light of the above insights and observations, there is room to conclude that the moral gap between humans and other species – if it exists at all – has been overstated. By emphasising animal-to-human similarities, a humanisation process can be activated and engaged, which, as one Canadian study has found, can prompt heightened empathy and stronger inclinations to perceive members of both an in-group and an out-group (e.g. immigrants) ‘as belonging to the same inclusive ingroup’ ( Costello & Hodson 2009 : 17).

Fostering moral inclusion

Commensurate with the above, a second strategy to deter dehumanisation is to consciously and actively foster moral inclusion and the rehumanisation of dehumanised individuals and groups. According to Opotow (1990a : 4) moral inclusion may be taken as comprising the following ‘coherent cluster of attitudes’:

• 1.
  

  believing that considerations of fairness apply to another

  
  
• 2.
  

  willingness to allocate a share of community resources to another, and

  
  
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  willingness to make sacrifices to foster another’s wellbeing.

How best to cultivate these and related attitudes, however, remains the subject of ongoing debate. Even so, there are a number of processes that are germane to fostering in people a disposition towards the virtue of moral inclusion and to expanding people’s ‘moral circles’ to be more inclusive of entities that otherwise lie outside their ‘in-group’ ( Crimston et al 2016 , 2018 ); these include:

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  making a commitment and actively seeking opportunities to become more familiar with the life-ways and world views of those who have been ‘othered’ (see, for example, the Australian television series ‘Go back to where you came from’, which sought to give Australians from various walks of life an opportunity to challenge their preconceived notions about refugees and to gain insight into what it is ‘really’ like to be a refugee or asylum seeker fleeing a troubled land; this series can be viewed via http://www.sbs.com.au/goback/ . (See also Ai Weiwei’s 2018 epic film ‘Human Flow’, which documents the plight of the world’s 65 million people displaced since World War II; this film provides an opportunity to challenge the prejudices and biases held against refugees and asylum seekers, and the cruel and spiteful treatment they are too often exposed to. Information about this film can be viewed at https://www.humanflow.com/ .)

  
  
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  searching for similarities and shared human experiences

  
  
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  adopting a pluralistic perspective (see Opotow 1990b : 176–7)

  
  
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  engaging in mindful practice aimed at fostering a sense of compassion for those who are vulnerable to dehumanisation (see, for example, the Compassion Cultivation Training (CCT) program founded in 2008 and developed by the Center for Compassion and Altruism Research and Education (CCARE) at Stanford University School of Medicine; this can be viewed at: http://ccare.stanford.edu/education/about-compassion-cultivation-training-cct/ ; see also the use of mindfulness to cultivate compassion ( DeValve & Adkinson 2008 ) and to reduce stress and anger ( Bergman et al 2016 ) in members of the US Police force).

Detecting and exposing instances of dehumanisation and moral exclusion

As suggested earlier in this discussion, dehumanisation (especially its subtle form) can be very difficult to detect. Even those who have been the targets of dehumanising processes may not always recognise it as such and, instead, through a process of internalised dehumanisation (whereby they internalise the very norms and beliefs systems that victimise them), blame themselves for the way they are treated ( Opotow 1990b : 176). Because of this and also because of their felt vulnerability at the hands of the perpetrators, victims of dehumanisation might not always be able and / or willing to give voice to and expose their plight. For example, asylum seekers and detainees awaiting the outcome of their visa applications to stay in a host country, or charitable organisations supporting marginalised people that are dependent on government funding, may understandably be reluctant to speak out and expose their situation. There is, however, another category of persons who can take a proactive stance in detecting and exposing instances of dehumanisation and moral exclusion, notably bystanders .

A ‘bystander’ may be defined as any member of society who is neither a victim nor a perpetrator, and who witnesses the injustice of dehumanisation and moral exclusion but is not directly affected by it ( Opotow 1990b ). Bystanders can be individuals, groups, professions and even whole nations. Opotow (1990b : 176) argues that among the actions that bystanders can (and ought) to take is: first and foremost to detect the problem, define it and provide an early response to it (this is crucial to the process of ‘reinstating victims in the moral realm’). Following this, bystanders then need to ‘call attention’ to the injustices witnessed and assert the inhumanity of the actions promulgated by the perpetrators – whether these are individuals, groups, governments or entire nations.

According to Opotow (1990b) bystanders are in an ideal position to take such a proactive stance as, from their vantage point, the injustice that victims of dehumanisation and moral exclusion experience ‘is less personally threatening to them’ and hence more easy to recognise ( Opotow 1990b : 176). Bystanders, however, must do more than just ‘passively observe’, recognise, and expose the injustices of dehumanisation and moral exclusion; they also need to actively combat it. This is because merely exposing dehumanisation might not be sufficient to generate the public outrage otherwise necessary to demand reform of the societal and political structures and processes that otherwise enable and sustain the whole sophisticated dynamic of dehumanisation and moral exclusion of ‘othered’ people.

Energising dissent

Those who do not agree with conventional ideologies that underpin the dehumanisation and moral exclusion of ‘othered’ people need to ‘energise dissent’ ( Martin 2007 ) and strategically resist pressures to conform to the status quo ( Opotow 1990b ). This can be done by dissenters using unofficial channels to share with likeminded people the information they have and their interpretations of ‘what is going on’, something that is now relatively easy to achieve via the use of social media. As their actions and views gain traction, it will become increasingly difficult for them to be credibly ignored, notwithstanding the tactics that might otherwise be used by opponents intent on spreading misinformation (‘fake news’) and disrupting and discrediting them.

Information sharing, exposing injustices to the public, and providing credible explanations for ‘what is going on here’ will not, however, be sufficient to energise dissent. This is because perpetrators of injustice use powerful methods to reduce and even suppress public outrage ( Hamilton & Maddison 2007 ; Martin 2007 ) or, conversely, provoke extreme right wing authoritarian populism to energise dissent in the ‘wrong direction’, as has occurred via the activities of groups such as Cambridge Analytica (see Persily 2017 ). As Martin (2007 : 63) reveals:

They cover up evidence and information about the event, devalue the target, reinterpret what happened, use official channels to give an appearance of fairness, and intimidate or bribe participants and observers.

Martin (2007) goes on to argue that dissenters must combat these powerful methods, which are cleverly used by perpetrators to reduce public outrage (refer back to the ‘children overboard’ incident, cited earlier and, more recently, see the ABC-TV Four Corners program ‘Democracy, data and dirty tricks’ regarding the tactics used by Cambridge Analytica – available at: http://www.abc.net.au/4corners/democracy,-data-and-dirty-tricks:-cambridge/9642090 ). To this end, he proposes the following five corresponding approaches ( Martin 2007 : 63):

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  ‘expose the actions’ (this is essential to enable people to be as well informed as is possible)

  
  
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  ‘affirm the value of the targets’ (this is essential to counter the denigration of targets)

  
  
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  ‘interpret the situation as unfair’ (the damaging consequences of what has been done and the vested self-interests and denial of responsibility, ultimately, cannot be kept hidden – ‘truth will out’)

  
  
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  ‘mobilise support and avoid or discredit official channels’ (be aware that ‘official channels’ can be cumbersome, take time and can distort the issues in favour of maintaining the status quo)

  
  
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  ‘resist and expose intimidation and bribery’ (every time a progressive bystander speaks out, it makes it easier for others to do the same).

These and other strategies will be considered further later when discussing specific individuals and groups whose dehumanisation and moral exclusion give rise to special responsibilities for members of the nursing profession.