Multiple Vulnerabilities in Medical Settings: Invisible Suffering of Doctors

Abstract

While there is a substantive amount of literature on vulnerability of different kinds of patients in different settings, medical professionals are usually considered as the ones who possess power and gain a privileged position. In this paper, we aim to demonstrate that in a certain context physicians-a social group which is usually referred to as "powerful"-consider themselves vulnerable, and this positioning may influence patients in turn. This perspective highlights the complexity of interactions within medical organizations and contributes to the studies of sensitive topics and vulnerable groups. We conceptualize vulnerability of doctors and discuss what can be problematic in powerful doctors' position. We describe some features of the post-Soviet context of Russian healthcare system and maternity care, both of which can be conceptualized as a hybrid of legacy of Soviet paternalism and new neoliberal reforms, managerialism and marketization. Empirical research is based on the ethnographic evidence from the study of a Russian perinatal center. In this article, we explore specific "existential" and "moral" vulnerabilities of medical professionals who routinely have to cope with multiple challenges, such as complicated clinical tasks, rigid control of different state bodies and emotional responses of suffering patients. We argue that there is a bond between the vulnerability of doctors and that of patients, whose position becomes more problematic as professionals become more vulnerable. At the end, we discuss methodological and theoretical implications of our research.

Full text

Societies 2020, 10, 5; doi:10.3390/soc10010005 www.mdpi.com/journal/societies
Article
Multiple Vulnerabilities in Medical Settings:
Invisible Suffering of Doctors
Daria Litvina *, Anastasia Novkunskaya and Anna Temkina
Faculty of Sociology and Philosophy, Gender Studies Program, European University at Saint-Petersburg,
191187 Saint-Petersburg, Russia; anovkunskaya@eu.spb.ru (A.N.); atemkina@gmail.com (A.T.)
* Correspondence: litvina.darya@gmail.com
Received: 14 November 2019; Accepted: 20 December 2019; Published: 25 December 2019
Abstract: While there is a substantive amount of literature on vulnerability of different kinds of
patients in different settings, medical professionals are usually considered as the ones who possess
power and gain a privileged position. In this paper, we aim to demonstrate that in a certain context
physicians—a social group which is usually referred to as “powerful”—consider themselves
vulnerable, and this positioning may influence patients in turn. This perspective highlights the
complexity of interactions within medical organizations and contributes to the studies of sensitive
topics and vulnerable groups. We conceptualize vulnerability of doctors and discuss what can be
problematic in powerful doctors’ position. We describe some features of the post-Soviet context of
Russian healthcare system and maternity care, both of which can be conceptualized as a hybrid of
legacy of Soviet paternalism and new neoliberal reforms, managerialism and marketization.
Empirical research is based on the ethnographic evidence from the study of a Russian perinatal
center. In this article, we explore specific “existential” and “moral” vulnerabilities of medical
professionals who routinely have to cope with multiple challenges, such as complicated clinical
tasks, rigid control of different state bodies and emotional responses of suffering patients. We argue
that there is a bond between the vulnerability of doctors and that of patients, whose position
becomes more problematic as professionals become more vulnerable. At the end, we discuss
methodological and theoretical implications of our research.
Keywords: vulnerability; maternity care; healthcare; doctors; perinatal center; suffering
1. Introduction
The goal of this paper is to examine an invisible vulnerability of doctors, whose power is usually
taken for granted by social researchers. We examine their vulnerability in the context of perinatal
center—one of specialized high-tech maternity care units in Russia. Vulnerability in social sciences is
frequently interpreted as a one-sided process within binary relationships: since doctors have a ruling
position, professional knowledge and agency, it is patients who are powerless and suffering. The
vulnerability of medical professionals is rarely discussed in studies of vulnerable groups and
sensitive experiences.
The term “vulnerable” is a concept that sometimes is used interchangeably with such terms as
“sensitive”, “hard to reach” and “hidden populations” [1] (p. 3). Vulnerability is defined as a lack of
autonomy and independence, bodily and psychological insecurity, marginalized or deviant status,
lack of acknowledgement within the society [1]. This term refers to individuals and social groups, as
well as to certain situations and topics. Researchers have been studying vulnerability in connection
to taboo topics that are emotionally overwhelming [2] (p. 6)—the ones concerning intimate,
discrediting or incriminating experience [2], such as death, grief, violence, AIDS, drugs and
homelessness. Vulnerable groups are exposed to discrimination, intolerant attitude, subordination.

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In particular, they include people who have certain health-related conditions, such as terminally ill
or mentally ill [3].
Doctors are rarely characterized as a vulnerable group, but within certain circumstances, they
can be recognized as “vulnerable”. However, based on analysis of the post-Soviet maternity care and
inductive analysis of empirical data, we argue that Russian doctors could systematically experience
vulnerability and that different kinds of vulnerabilities of doctors and patients are interwoven. Our
analysis deals with social and institutional (rather than psychological) dimensions of doctors’
vulnerabilities. Sociological discussion on vulnerability in medical settings is the starting point of our
research. Vulnerability is usually seen as an inherent quality of certain social groups (but not others),
while in our approach it has many dimensions and might be attributed to relatively “powerful”
groups.
Our research is aimed at examining social arrangements of interactions in medical organization,
feelings of its participants and barriers for patient-centered approach to maternity care in Russia.
Doctors in Russia have to satisfy contradictory clinical, bureaucratic and social requirements. The
social position of medical professionals is characterized by lack of autonomy and high level of
subordination. Their positioning is contextualized by such processes as hybridization of market,
contemporary managerial reforms and the legacy of soviet paternalism. ‘Unjust’ (from doctors’ point
of view) demands from patients, management and authorities; routine collisions with severe clinical
conditions; emotional situations and absence of various resources makes doctors vulnerable in special
ways, which we define as “existential vulnerability” and “moral vulnerability”.
The structure of this article is as follows. First, we describe data and method. After that, in
background section, we conceptualize vulnerability of doctors and discuss certain problematic issues
related to doctors’ powerful position. Then, we describe some features of the post-Soviet context of
Russian healthcare system and maternity care in particular. Perinatal center is considered as a special
case. Following empirical sections are based on the ethnographic evidence from the study of a
perinatal center. We introduce the analytical terms “existential vulnerability” and “moral
vulnerability”, which were inductively constructed to explore multiple challenges which medical
professionals routinely have to cope with. Then, we argue that there is a connection between
vulnerability of doctors and that of patients, whose position becomes more problematic as
professionals become more vulnerable. In the end we discuss methodological and theoretical
implications of our research, concerning (1) the subject of vulnerability, (2) meaning of the context in
exploring vulnerabilities or vulnerable groups, (3) interconnections between vulnerabilities of
doctors and those of patients and (4) the position and actions of the researcher in the empirical field
when dealing with multiple vulnerabilities.
2. Materials and Methods
The aim of this project is to explore various attitudes of medical professionals, patients, and other
actors in medical environment in order to identify potential tensions, conflicts and complaints in
medical settings and determine the ways to cope with them. We focus on the interactions between
medical professionals and patients, as well as between the staff members and different departments
of perinatal center.
The research has been built on fundamentals of institutional ethnography developed by Dorothy
Smith [4]. According to it, communication (a transmission of information and the ways actors
implement it to their work) links local practices with the broader institutional context [4] (p. 169).
Adapting the logic of the “extended case method”, this methodology allows us to study the
connections between macro-structural changes and practices at the micro-level [5,6].
This methodology provides opportunities to observe practices and understand the social
meanings and structures, which stand behind them. A comprehensive study of different social
perspectives allows us to identify organizational tensions in the Perinatal Center and explain what
challenges and at what levels (organizational, interactional) are systematically reproduced.
The empirical base of the study (2019) consists of:

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1. 33 sessions of ethnographic observations (including field conversations, field interviews,
analysis of material environment and documents) in one of the Russian perinatal centers. The
collective of three field researchers conducted 249 hours of observations, which were recorded
as 391 pages of field notes.
2. Observation at medical events (including conferences, seminars, trainings) at the research site
and in the other medical organizations.
3. Analysis of written complaints by patients.
The results of the current research have also been triangulated with the previously gathered
data. We did not include this data into analysis and do not refer to it in this article (as it does not
address its main questions and goals), but it contributes to our understanding of the social processes
within healthcare system in Russia:
1. Analysis of documents (State laws, orders and projects; online reviews (n = 35) (2018); posts of
flashmob “violence in delivery”(#nasilie_v_rodah) (n = 50) (2018))
2. Interviews with patients (n = 10) and healthcare professionals of perinatal center (n = 20) (2018).
3. 16 sessions of non-systematic observations at perinatal center (2018);
In the text we use the term “professionals” interchangeably with ‘medical practitioners’ to
denote doctors of different specializations, nurses and midwifes working in various departments. We
mostly focus on doctors—obstetricians, neonatologists, anesthesiologists, pediatricians and others.
On one hand, they are the ones who make decisions and take responsibility (both in front of
controlling bodies and patients) for negative effects of treatment, birth traumas, lethal outcomes, etc.
On the other hand, both in theoretical debate and empirically, they are more associated with power,
high status and emotional neutrality in medical institutions than nurses and midwives, who are less
powerful and more associated with care and involvement. In this article, we want to show that due
to these reasons “powerful” doctors are becoming vulnerable in a very specific way. At the same
time, we recognize the significance of nursing staff, who do a lot of emotional labor and faces different
challenges, and consider them as vulnerable too.
The research was authorized by the administration of the perinatal center and was approved by
the ethical committee of Saint-Petersburg Association of Sociologists (SPAS). All of the participants
were informed about the study and were guaranteed confidentiality and anonymity.
3. Background Section
3.1. Multiple Vulnerabilities in Healthcare
Despite the radical transformations of healthcare within the last decades globally, doctor–patient
relationships have been conventionally characterized by asymmetry in terms of power, agency,
knowledge and control. This asymmetry goes back both to a normative paternalistic model described
by Parsons (1951) [7] and to medical power and medicalization in Foucault’s terms [8] and their
numerous progenies. It implies a type of doctor–patient relationships, in which the patient seeking
medical help performs a “sick role”, which undermines his dependence on a doctor, vulnerability,
incompetence, and helplessness. While Parsons explained such distribution of power as a functional
and mutually beneficial cooperation, his concept has been widely criticized by scholars, who
interpreted such relationships rather as conflicting and problematic. As healthcare systems were
changing, the social positions of doctors and patients within them were changing too. The critical
view of social scientists also shifted from social roles and norms towards interactions, practices and
structural limitations. However, the idea of power as a part of medical professions was still a cross-
cutting issue for many scholars. One of the classics of sociology of medicine, Eliot Freidson, proposed
a conceptual model, in which an attempt to gain control over laymen (as well as to cure them)
characterizes medical professionals and their interactions with patients, which means that medical
experts’ authority and patients’ autonomy have been in conflict [9]. References to Foucault are
important for interpretation not only of patients as constructed though medicalization, normalizing

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medical gaze and power [8] but for understanding of both patients’ and doctors’ subjectivities as
constructed in medical settings and depending on each other [8].
At the moment, one of the most facilitated concepts both in public health and scholarly research
is a patient-centered model of medical care, which aims to establish egalitarian relationships between
patients and healthcare providers. However, the concept itself is still being discussed [10], and
practice, framed by this principle, has to deal with different limitations. Despite certain
organizational steps towards patient-centeredness in Russia, basic elements of asymmetry in patient–
doctor relationships remain the same as in the paternalistic model. Power and knowledge are still
exclusively attributed to professionals, and patients are still positioned in interactions as objects of
medical manipulations. Particularly, in the sphere of obstetrics and maternity care, which tends to be
the frontier of patient-centered change in a global context, in Russia the notion “doctor knows best”
is still quite relevant. According to sociologists and clinicians, women are mostly deprived of the
possibility to act, make decisions, withstand the aggressive manipulations from medical personnel
[11]. In many researches, a patient turns out to be a powerless and suffering figure.
Vulnerability of patients is evident not only due to their physical suffering but also due to their
subordinate social positions and respective emotional experiences. Loss of self is among the main
indicators. According to the study conducted by Kathy Charmaz [12], the main suffering of
chronically ill people could be described as the “loss of self” [12] (p. 168). As Ian Wilkinson and
Arthur Kleinman put it, “The most terrible and disabling events of suffering tend to involve us in the
experience of losing our roles and identities” [13] (p. 9). There are multiple ways of overcoming the
position of powerlessness for patents discussed in literature. Their subjectivity changes as they
receive voice, became storytellers, consumers, citizens [14–16]. Alongside with the fact that patient
gets agency through getting voice, neoliberal transformations in healthcare (both globally and in
Russia) also contribute to changes of a patient, who becomes not just a passive suffering sick person
but an active consumer, who has resources to make choices, to decide and to get actively involved
into the process of cure. In maternity care women make choices and become demanding consumers
[17].
By including patients’ perspective, voice and emotions into its scope, medicine takes a step away
from biomedical paternalistic model towards more egalitarian notions of medical profession and
principles of doctor–patient interaction. The relationships between doctors and patients are changing
as patients get more recognition, resources and power. The asymmetry of power and knowledge in
doctor–patient relations still persists, but the healthcare systems are changing. Moreover, within the
context of these changes, doctors become the ones who struggle for power, authority and professional
acknowledgement but, as we suppose, frequently appear to be vulnerable, lose their agency, get
existentially affected, feel injustice and suffering.
We assume that social scholars pay little attention to doctors’ experiences because of the binary
approaches towards understanding of suffering and vulnerability: since doctors have (rather)
powerful ruling position, knowledge and resources, it is patients who are perceived as powerless,
vulnerable and suffering.
Nevertheless, the vulnerability of medical professionals is frequently discussed in studies
dedicated to dealing with complicated clinical tasks, vulnerable groups and sensitive experiences, for
instance, in the case of disciplinary processes following patients’ complains [18], due to distress and
professional burnout, or as a result of being traumatized due to negative patient outcomes [19].
Vulnerability of medical professionals also has class, gender and specialization dimensions. For
instance, young female doctors, as well as nurses and midwives can experience more pressure due
to their subordinate gendered position. Some studies show that there is a connection between the
vulnerability of doctors and that of patients. Within the discipline of psychology, scholars describe
the phenomenon of countertransference [20] when doctor’s own problems or emotional responses
are translated to patients. In the opposite direction, patients’ responses and complaints can go beyond
the certain situation and negatively affect the professional identity of doctors [21]. Doctors can also
be seen as “second victims” of some adverse patient events, which happened due to a medical error
or to patient’s condition [19,22,23].

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There is evidence (mostly from psychological disciplines) that medical professionals experience
psychological difficulties while providing the end of life care (especially for children), dealing with
loss (for example, reproductive loss) or telling the “bad news” (e.g., [20,24]). Vulnerability of some
groups of professionals depends on workload, stress and possibilities for coping with it [25,26].
However routine emotions of medical professionals and their structural reasons have gained little
analytical interest within social sciences (one of the examples is [27]).
In this article we want to consider the situations, in which doctors in a Russian high-technology
perinatal center become vulnerable. These vulnerabilities are hard to determine as such a priori, but
they rather demand careful observation of practices and situations. We conceptualize vulnerability
of doctors as associated with a lack of professional autonomy, lack of trust and authority, institutional
complexity, the inconsistency of regulation and the ambiguity of rules. Vulnerabilities are expressed
in “existential” and “moral” modes. The vulnerability of doctors (and other healthcare providers)
usually remains invisible for both patients and public. We want to make it visible; for this, we will
try to overcome the duality of the patient–doctor relationship concept and show that both sides of
this interaction may be interpreted as powerful and vulnerable, and that these relationships are not
binary but more complex. Power is more diffusive as determined by numerous structural limitations
in concrete contexts.
Scholars of the Neo-Weberian approach in sociology of professions define professional power
of a doctor as that consisting of clinical autonomy, particular knowledge and competence in medical
diagnosing and curing, high social status and professionals’ closure [9,28,29]. However, in different
social contexts, the autonomy and powerful position of medical professionals can be challenged in
multiple ways by the marketization and managerialism. In Russia, beside marketization and
managerialism, we can also observe the effects of governmental paternalism [30], which
systematically restricts professional power and ability to make decisions but still assigns them the
main responsibility for healthcare provision. At the same time there is an extension of the scope of
doctors’ professional roles and obligations—they are expected to provide psychological, emotional,
administrative support of patients—which they are not always able to implement. In further section
we will describe the institutional context of Russian maternity care system, in which dominating
managerial regulation in combination with the new market mechanisms in healthcare, considerably
restrict professional power of doctors.
3.2. Institutional Arrangement and Change of Maternity Care in Russia Causing Professional Vulnerability
This section addresses the wider context of changing health and maternity care in post-Soviet
Russia and emphasizes how changes predetermine the emergence of multiple vulnerabilities in terms
of institutional complexity, the inconsistency of regulation and the ambiguity of rules. The tendency
of considerable transformation of the healthcare sector and professional work in it is a world-wide
phenomenon [31]. The neoliberal policy, which fosters the dominance of managerialism and market
principles of regulation and financing, can be considered to be a common trend in healthcare
worldwide [32] (p. 378). However, different social contexts constitute various configurations of the
maternity care and challenges, shaped by neoliberal policies. That of Post-Soviet Russia, which is
characterized by the quite limited professional autonomy of doctors, midwifes and nurses [33],
represents the case of the appreciable challenges emerging for professional work.
In general, maternity care in Russia mostly consists of state-funded and facility-based services,
which in many respects inherit the organizational arrangement and regulatory paternalistic
framework from the Soviet period [34–36]. As the whole system of Soviet healthcare, maternity care
used to be centrally regulated and highly standardized in terms of both the way of material provision
and medical practices.
Social researches analyze health care in Soviet times and later in post-Soviet Russia as
historically one of the most rigid bureaucratized systems [33,37]. Being overregulated and
centralized, following the state interests and goals, the system of healthcare (and maternity care in
particular) leaves little space for professional autonomy and institutionally remains insensitive to the
needs and circumstances of a concrete organization, professionals and patients. We add to this

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investigation how some features of the institutional arrangement of maternity care in Russia set
multiple vulnerability of health care practitioners.
We will analyze further how professionals became vulnerable in their routine working
interactions. Our main argument is the following. Clinical power of professionals in Russian
maternity care is limited not only by biomedical conditions but also by volatile non-flexible
contradictory managerial-paternalist state rules and norms from one side and growth of patient
demands from the other. Professionals often could not fulfill contradictory state’s rules or follow
consumers’ numerous demands, and they became vulnerable facing moral and legal injustice from
both sides—state bodies and patients. We will look shortly on legislative and institutional conditions,
pronatalist state concerns, volatility and paternalism of the health care as the main structural
conditions influencing on doctors’ position.
Legislative contradictions can be considered one of the key features of institutional and
organizational settings of health services in Russia. Perpetual change of the formal rules and
regulations aggravates the conditions of systematic uncertainties. As a result, healthcare
practitioners’ work consists of not only professional (clinical) responsibilities and managerial tasks
but also includes a lot of special structurally invisible efforts for coordination of routine activities in
order to bridge institutional and organizational gaps and manage uncertainties.
Institutional conditions, which advance professionals’ vulnerability, consist of the multiplicity
of the controlling bodies and ongoing strengthening of the State’s control over the sector of healthcare
and all the activities related to childbirth. Every medical organization is an object of intent attention
of the Ministry of Health, the Russian healthcare control and Russian consumer control bodies
(Roszdravnadzor and Rospotrebnadzor), fire inspection, etc., and, in case of negative outcome, of the
law enforcement officials.
With the statist turn in welfare policy of the Russian state [38], pronatalism has become a core
part of the state’s political agenda. Maternity care appears to be even more controlled and inspected
sphere, as it directly relates to the National priority of demography and growth of population [30]
and, hence, represents a particular concern of both the Federal and regional authorities and a
particular site of control. In particular, the rates of maternal and infant mortality serve as one of the
key indicators of the regional governors’ performance and efficiency. Hence, each case of maternal
death concerns not only medical but political agenda as well. Such state of affairs, triggered by the
demographical national anxiety, also predetermines the multiplicity of the state’s efforts to
‘modernize’ or somehow improve the system of maternity care and to make control more rigid and
detailed. In practice, all these efforts comprise another set of institutional uncertainties, which
enhance the professional’s vulnerability.
The path of the healthcare transformation started with the Soviet collapse in 1990s, when the key
trends of the reforms were the liberalization of material provision (in particular, cuts in state’s
expenditure on healthcare). Transformation in this period also launched the process of patients’
consumerization, in particular, resulting in transformation of providers’ power, authority, and
domination in their relationships with patients [39]. As a result, clinics and doctors became
dependent on volatile state funding and patients’ pocket money.
Another unintended consequence of this perpetual institutional change is that it increased
uncertainties and led to the emergence of new institutional and organizational gaps. Each of
numerous reforms taken in the sphere requires adaptation to the organizational settings of the
particular medical organization. The neoliberalization of the system joined with the extremely-rigid
bureaucratized way of its regulation, considerably restricting the range of such adaptive strategies.
For example, state orders limit both the options in medical equipment and medicines to be obtained
and the procedures of procurements of the state-funded organizations (most of the maternity units
in Russia). Healthcare practitioners are to manage compensation personally (to bridge the emerging
gaps) and appear to be in routine institutional uncertainty in their practical work.
Since the Soviet collapse, social processes such as the consumerization of patients’ behavior [17],
the commercialization of medicine [40], and the (neo)liberalization of healthcare regulation [41] have
been challenging an initially paternalistic state of affairs from different angles. Patient’s demand is

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rising for more person-centered and less medicalized approaches; care and patient-friendliness are
articulated as key components of medical services, and new institutions protecting patients’ interests
and wellbeing are appearing. However, paternalism in doctor–patient relations and that between the
state and healthcare practitioners remain an important feature of maternity care service provision,
arrangement and regulation. Russian regulatory and authority bodies at various levels target the
sphere of childbirth as a priority for their policies. Consequently, the state is rather reluctant to
establish more egalitarian relationships between key social actors interacting in this sphere.
Paternalism can thus be considered to be a core characteristic of healthcare in post-Soviet Russia, in
terms of both doctor–patient interactions and relations between the state and medical practitioners
as state employees.
Managerial control in combination with state paternalism frames every medical organization as
the site of endless control from the side of multiple state administrative bodies with contradictory
and volatile demands, who check increasing volumes of bureaucratic documentation.
In all the domains, doctor–patient relations in Russian maternity care have been transformed
throughout the last two decades. In particular, consumerization of patients’ behavior transforms
providers’ authority and domination, and maternity care remains a field of power struggle for
decision-making and ability to influence care provision and organization. But at the same time,
Russian childbirth services still remain a limited means of empowerment for patients and providers
[39], while the state, through the increasing control and bureaucratized machinery of regulation,
remains a dominant actor.
Within the last decade, we can observe a noticeable decline in trust to doctors and a growing
number of those, who “find it difficult to answer” [42], which indicates the complexity and
discontinuity of patient–doctor relationships. Since paternalistic model does not include much
explanation and communication, patients tend to fortify their opinions and decisions with
information from Internet sites, forums, blogs and channels. On the basis of this information, they
can make decisions to refuse medical manipulations, vaccination, drug intake or deny the disease
[43]. Besides, some medical professionals are aware of the interconnections between patients’ trust
and their compliance. Therefore, they are trying to implement models and protocols of
communications with proven effectiveness into their practice [44].
The crisis of trust to medical professionals encourages the growth of new market segments,
specialists of which pretend to have their own expertise in the field of maternity care. These include,
in particular, perinatal specialists (for breastfeeding, baby sleep, baby-bearing), doulas (assistants in
childbirth), specialists for postpartum recovery (“closing of birth”, bath rituals, massage). In some
cases, their opinion contradicts medical recommendations, which enhances distrust because, as a
result, more institutionalized medical help can be interpreted by women as unnecessary and
excessively medicalizing.
3.3. Perinatal Center in Russia as a Special Case
Since 2006 the state’s investments to the sphere of healthcare in the frame of the National
foreground Projects increased (‘Health’ initiated in 2006 and ‘Modernization’ in 2011–2013) and
women receive a choice of maternity hospital. During the 2010s, in the frame of the ‘Modernization’
program, many maternity facilities have been renovated across the country, and new Perinatal
Centers—the largest and the most technically advanced maternity hospitals—were constructed.
However, concurrently with the statist measures, several neoliberal policies have been implemented
as well, resulting in many cases in personnel and services cutbacks. In spite of the general rhetoric of
the financial support, most of the healthcare organizations in Russia became a subject of so-called
‘optimization’ and were forced to follow the self-maintenance logic in material provision, though still
considerably restricted by the bureaucratized managerial regulation [45,46]. Therefore, position of
healthcare organizations and professionals became even more unstable.
Risky cases are routed to a maternity facility equipped to assist with definite pathology, illness
or complication, each of which has different equipment and personnel and provides appropriate
services. The Decree № 572n, issued in 2012, specified the order of pregnant women’s hospitalization,

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depending on the risk of complications or pathologies associated with pregnancy or childbirth [47].
As a result, since 2012 maternity care has adopted the three-level system of medical facilities, which
provide different services, have different equipment and receive different financing (with a fixed
price for services at each level) in accordance with their assigned status. Large maternity hospitals
and perinatal centers constitute the third level of maternity care and work as medical organizations
that ensure life-saving interventions for mothers and newborns. Women with high-risk pregnancies
are admitted to such facilities, which are equipped with advanced technologies and highly skilled
personnel.
Such a position of a perinatal center within the whole system of maternity care in Russia
predetermines its organizational and institutional specificity, which in turn enhances the
vulnerability of professionals working in it. The setting of a perinatal center—a particular kind of
maternity facility, which deals with medical complications and pathologies—is associated with the
high probability of having emotionally sensitive and even traumatic experience by pregnant women,
women in labor and young parents. Such type of organizations by design accumulates the most
complicated childbirth cases, and the probability of the fatal outcomes here is much higher than in
any other maternity facility. As a result, it increases the emotional burden of healthcare practitioners,
who inevitably deal with life and death issues.
Being the most technically developed, often the largest maternity facilities in a region, and
providing multiple medical services, all perinatal centers represent a very complex organizational
structure, which requires complex intraorganizational coordination and coordination with different
regions of the country. Depending on the medical specialization and the presence of the research or
scientific activities, perinatal centers can consist of dozens of wards and departments and hundreds
of medical personnel and technical staff. In practice, this considerably increases the organization and
coordination of personalized work of health practitioners and managers, sometimes, taking most of
their time and attention. In addition, a perinatal center symbolically and institutionally appears to be
at the cutting edge of the maternity care in Russia, and hence, is a subject of even more increased state
interest and control.
New perinatal centers since 2012 deal with those cases of childbirth, which are associated with
the risk of complications estimated during pregnancy. This measure implements prenatal state goals
and, as statistics demonstrate, has decreased the rates of maternal and infant mortality in most of the
Russian regions [48]; however, it unintentionally has led [45,46] to the centralization of maternity care
and deterioration of the healthcare accessibility in regional peripheries.
4. Results
Our conceptual model and empirical material prove that doctors –a powerful, resourceful,
agentic group—can be vulnerable and acutely aware of their helplessness when faced with the
inability to save or cure a patient (or her unborn/ baby). We refer to this vulnerability as “existential.”
Another kind of vulnerability arises when doctors encounter “unjust” (in their terms) interpretation
and evaluation of their actions. We label this vulnerability as “moral”. For instance, it inductively
arises when doctors are assigned responsibility for situations they could not control, have to follow
contradictory regulations or get baseless complaints from patients. Both unfair claims from patients
and from regulatory authorities can have legal consequences, which create symbolic and real threats.
4.1. Existential Vulnerability of Professionals: “There Is Something That Will Never Be Forgotten”
Existential vulnerability concerns the fact that experience related to death is “universal”—as
everyone sooner or later experiences helplessness in front of death or an unbearable suffering.
Nevertheless, medical professionals perform a special role in these situations, and hence, they have
very specific experiences, which make them vulnerable in a special way. First, their professional role
appears to be limited by the opportunities of biomedicine, which objectively cannot manage every
physical condition and save every patient, but professionals tend to take such “failures” personally
and emotionally hard. This is exacerbated by the fact that in reproductive medicine, death or threat
of death occur to “nonconventional” demographic groups (the ones who ‘should not’ die)—young

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women and babies. Second, contemporary demographic pronatalist politic of the state concerns the
increasing the birth rates and attracts a lot of attention to maternity care. As a result, every case of
maternal mortality (regardless of its inevitability and numerous complications) is becoming an issue
for special attention from controlling and law-enforcement bodies and a potential legal threat for all
professionals who were involved in the process of treatment.
Medicine in general and midwifery and obstetrics in particular are full of situations in which a
patient feels pain, suffering and fear; experiences loss or encounters negative prognosis of the
treatment. Situations, in which a patient feels herself most vulnerable, include complicated clinical
cases, reproductive losses, abortions for medical reasons, complications of pregnancies and births,
newborn malformations and birth traumas. Medical professionals aim at saving and helping in such
situations, but sometimes it goes beyond their capabilities.
Our informants have reported that they make much effort to fix any health problems they face.
However, doctors, midwives and nurses still encounter situations in which there are questions of
existential character and in which they feel themselves hopeless while coping with patient’s death:
“Because anyways, there are many difficult ones [clinical cases]. On a certain stage, after
all, I had another sphere of medicine, I didn’t lose as much as here, but here, the level of
difficulty is so that loses are inevitable…And kind of night calls and screams…I mean there
is something that will never be forgotten. That’s when we were sitting at the department,
when we were running to the resuscitation [with the baby] on our arms, you realize that
the baby is terminally ill…That’s why these are such hard, the most difficult moments”
(Interview with a pediatrician)
Doctors explain to us that they will keep on trying to save the patient even in a hopeless clinical
situation or in situations with negative prognoses. In cases of lethal outcome, they feel their
hopelessness and this experience leaves scars for the whole life:
“At the intern’s room we find out who passed away last week. A woman, right after the
operation, a severe pathology, delivery at 34th week (pregnancy was contraindicated), the
baby has probably survived, there are no complaints yet. It is said that doctors from
different departments rushed there and some of them were only disrupting. Note: we had
planned fieldwork on that day, but we were asked not to come” (field notes, researcher’s
observations)
Despite the fact that the situation was rather prospective (it became clear later, during the clinical
examination of the case) and was not followed by relatives’ complaints or legal trial, many
professionals got engaged; the case was widely discussed as stressful for the personnel. The physical
condition of a woman carried fatal risks, “It was irresistible, there were no medical mistakes”, (field
diary, conversation with a doctor). We (as outsiders) were asked not to come to the Center for some
time, presumably not due to the fatal outcome itself but due to the emotional resonance and strains
of professionals.
It is important to notice that existential vulnerability arises not only in cases of lethal outcome
but also in cases of negative prognosis (both for health or for life quality) and risks of lethal outcome
or grievous harm. Constant encounters with complicated clinical tasks, pathologies, deaths, severe
physical conditions of babies, bad prognoses unleash the process of deep reflection:
“We don’t speak in a room (so that there is no noise), girls [young doctors and interns] are
knitting octopuses, we speak, caress, hug, kiss. Treat babies with love. And we are very
compassionate to these mothers. Pathology of nervous system is a trouble indeed. And we
understand that this premature baby—we will nurse it. But what’s then?” (field notes,
conversation with a neonatologist)
Different wards face hard cases, death and emotions of patients to different extent. In these terms
emergency room or consultative-diagnostic department would dramatically differ from resuscitation
or labor wards:

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“Obstetricians always fight at the forefront for life and death” (field notes, conversation
with neonatologist)
“If for other departments clinical death is a stress, for us it’s a job. We are the most stressed
department” (field notes, conversation with intensive care nurse)
Doctors in perinatal center specialize in working with severe clinical cases; therefore, mortality,
bad outcomes and poor clinical prognosis are always an inevitable part of their work. However,
professionals tell about severe cases or loss with personal emotional troubles. They are worried,
frustrated and it is hard for them to tolerate every case of maternal or neonatal death.
One of the emotional situations that we observed during the fieldwork was related to the
potential threat for the life of a patient who refused to admit the problem and accept treatment.
Professionals tell that they spent several working days on endless talks with the patient trying to
convince her and one of the doctors “was so nervous that she couldn’t fall asleep and was walking
the streets at night” (field diary, conversation with a doctor). Professionals feel and express the
existential helplessness which is accompanied by the fact that in the context of lack of trust, patients
do not believe in prognosis, and doctors cannot persuade them to act in a necessary way (from their
point of view).
The situation was as follows. In the hospital there was a young woman who had just given birth
in another hospital and was transferred to the perinatal center for clinical reasons. Doctors believed
that there was a serious threat to her life. The patient was in the intensive care unit, subjectively felt
normal and insisted on discharge from the hospital. Her husband also insisted on discharge and
accused doctors of overdiagnosis and forcibly keeping the woman in the hospital:
“Husband: “She was living a normal life, you found heart [problems], that’s you who
cannot decide, whether it is heart or kidneys… You make her, you forcibly hold her in the
hospital…you can’t make her do something you want. She wants to go home, she is feeling
good”
Doctor: “She has a risk of death”“ (field notes, researcher’s observations).
Professionals think that the decision of a patient is fatal—“They make a mistake which is the size of
life” (field notes, conversation with a doctor). In this case, the doctor supposed that the patient did
not realize the threat to her life despite the fact that she was given medical explanations many times.
The patient and her husband relied on their previous lay experience and the experience of their social
environment, interpreted the situation as an ordinary one and demanded to be discharged from the
hospital. In a conversation with us, the doctor said: “We can expect nasty things, she will write to the
President”, i.e., there is a potential possibility of complaints and follow-up checks, especially when
there is a potential threat of maternal death, each case of which is controlled by the Ministry of health
and regional authorities.
As a result, patients become even more vulnerable because numerous involved professionals
use “aggressive” techniques to persuade patient in order to minimize medical risks and to
subordinate patient to their decision. In the described situation the doctors and the patient do not
come to an agreement, and the woman refuses to continue the treatment; however, after difficult
negotiations with patients and consultations with different medical committees, professionals find a
solution and transfer her to another hospital to which she agrees to go to (it is closer to home, though
not specialized).
This situation is sensitive for medical practitioners not only because they can be legally
prosecuted in case of death of the patient or serious harm to her, which they could predict but could
not cope with, but also because they do not have enough authority and trust in the eyes of patients
to protect them from lethal or disabling outcomes of clinical situations. This additional responsibility
forces doctors to behave more assertively towards patients who do not believe and refuse to follow
their recommendations. As a result of the lack of mutual trust, doctors are urged to use affective and
“forceful” arguments, while patients respond to them with aggression and even greater distrust:

Societies 2020, 10, 5 11 of 17
“[Doctors] are speaking quite rough… It was emotionally hard for me, maybe because of
the hopelessness of the situation and inability to negotiate… Verbally doctors are
threatening and bullying her to make her stay. Although—no doubt—they make it for her
benefit and may be even saving her life. [One of the doctors] doesn’t sleep at night, [the
other] is outlining his brutality” (field notes, researcher’s observations).
At the same time, neither doctors nor nurses have professional tools and special skills for
communicating sensitive topics, which at the same time is a routine for them. Neither is there a
practice of calling a mediator. This often affects patients, whose emotions remain unrecognized or
ignored (perceived as grotesque, or demonstrative behavior). Topics related to ethics and
communication with the patient are underrepresented in the curriculums of medical schools and
colleges. Psychologists, who could provide both doctors and patients with professional help, can
hardly get a position in hospital because they lack legal regulations of their work and trust within
medical organizations. As a result, medical personnel can usually only count on their own
experiences and collective practices while discussing difficult topics with patients. Moreover, they
have to direct their efforts not to emotional assistance to patients and their relatives, to colleagues or
themselves, but to protecting themselves and their professional collective from subsequent sanctions
connected to maternity or infant death, and then, patients suffer more as they fell themselves helpless
and cheated in such kind of communication.
4.2. Moral Vulnerability of Professionals
Moral vulnerability emerges when professionals face unjust evaluations and critical
interpretation of their actions made either by regulatory and controlling bodies (with their constantly
threatening sanctions) or by patients.
4.2.1. “Big Brother Is Watching You”
Doctors constantly feel themselves objects of all-round control. They tell about their precarity
and insecurity under controlling gaze, which is perceived as a threat to their professional status and
personhood in general. Threat is a kind of “outer force” (“God forbid something happens”), which
lies beyond the professional’s control and creates the feeling of hopelessness:
“I say personal insecurity when you realize that in case, God forbid, something happens,
nobody will be on our side, nobody will help” (Interview with a doctor)
“Nobody will protect doctors” (field notes), “nobody advocates for physicians in front of
the public” (Interview with a pediatrician)
Doctors are meant to strictly follow the laws, recommendations, procedures and rules. As we
described earlier, they have constantly been controlled by various authorities (such as SanPiN,
Rospotrebnadzor, Ministry of health), which produce the rules that rapidly change and sometimes
contradict each other. This is one of the consequences of ongoing reforms and hybridization of
governmental paternalism and new managerialism. The legal insecurity and vulnerability are
generated by multiple institutional circumstances, uncertainties and organizational gaps, which in
turns are produced by conflicting legislative requirements, organizational rigidity and material
constraints that professionals are talking about (see section 3). Professionals constantly feel their
precarity in such conditions. In addition, the control over doctors is strengthened by the promotion
of state demographic priorities of increasing fertility and growing attention to maternity care.
Professionals say: “Big brother is watching you” (field notes). During the fieldwork, we could
regularly see health practitioners discussing future inspections and dangers they can possibly bring:
“Fines are inevitable. [The nurse] believes that they just have to reconcile with it. The only
question is about the size and the legal subject—a (physical) person or a corporate body
(organization). Sometimes it is easier just to put the responsibility on oneself than to arrange
an administrative commission” (field notes).

Societies 2020, 10, 5 12 of 17
“I ask her [the nurse] why is this so bad (about administrative commission). Is it because
there are so many violations or because they cannot be fixed? She says yes, there are too
many inconsistencies, which she (and nobody) doesn’t know how to fix for the period of
inspection. “My fantasy is not enough to pull the wool over inspectors’ eyes! (she means—
how to represent themselves in the best way for the inspection”” (field notes).
Our data supports the claim that formal requirements are often contradictory and cannot be met
in full due to circumstances which are beyond professionals’ control. In emic terms, the phrase of the
doctor would be “the chaos is everywhere within the medicine” (field notes). Professionals act in patients’
interests and cope with gaps in their professional daily routine by frequently breaking certain formal
rules and recommendations. Consequently, they can potentially be accused or sanctioned.
Professionals clearly understand it and say with irony that: “my task is to prepare everything for the
prosecutor so that he can’t get to me” (field notes).
Take the example of solving a problem of insufficiency of medications and equipment, which is
derived from the organizational inability to buy them quickly. The doctors can face the two options:
not to follow clinical recommendations and cure the patient with available treatment or search for
the prescribed recommended medication by using informal instruments. For instance, professionals
sometimes make purchases themselves, which is considered illegal:
“Nurses buy containers and special tools with their money. This weekend they plan to go
shopping together” (field notes)
“They [parents] bring [money] to the discharge—doctors leave it in the department for
medications. [My relative] brings suitcases of a foreign medicament. Resuscitation
[department] also brings it from vacation. Sometimes we buy it ourselves” (field notes,
conversation with a doctor)
“They borrow [medication from other departments], but this is a serious violation of rules”
(field notes)
Professionals are vulnerable also due to the risk of detention for informal payments, which are
explained by low wages and a necessity to survive: “There is informal money, and that’s life. And so
how could one live on these wages, when you need to feed the family” (field notes, conversation with
a doctor). This is a hidden topic which is ambivalently evaluated in medical community (about
informal payments see [39]).
Moral panics in media incite mistrust and aggression towards medical professionals. Cases of
infant and maternity death, birth traumas and various iatrogenic conditions regularly become a topic
for massive public debates. All together, the increased attention of the Investigating Committee,
media coverage and institutional controversies comprise the particular settings, which stimulate
patients’ complaints and invent new forms of control but leave little opportunity for medical
professionals to deal with it. The control becomes more pervasive due to new instruments, such as
audio- and video-recordings of sessions with patients, online sites for commenting on and evaluating
doctors and medical organizations, professional associations aimed at representing the interests of
patients (League of Protectors of Patients, Investigation Committee). At the same time, medical
professionals lack resources and social and professional support, to protect themselves in situations
of legal prosecution or media scandals, which makes them feel constantly vulnerable. On the one
hand, patients try to get a voice and empowerment, which were unachievable within the paternalistic
model. On the other hand, mistrust makes them more demanding and blocks the possibilities for
dialog, cooperation and compliance. Some patients are conscious that doctors and medical
organizations are very sensitive to complaints and therefore try to get profit during the process of
cure (extra services or financial compensations). This practice was reflected in terms used in medical
environment—”the patients’ terror” and “an extremist patient”.
4.2.2. “An Extremist Patient”

Societies 2020, 10, 5 13 of 17
Another type of injustice and vulnerability is related to the rise of complains and grievances of
patients, many of which are deemed as unfair by physicians. Professionals take complaints very hard
as they can lead to administrative and material sanctions. Patients are becoming more demanding in
their ethics and style of communication and self-sufficient explanations. The principle “Doctor knows
best” does not work universally any more. Patients are trying to get more control over the situation,
evaluate doctors and hospitals, describe their experience, write down comments on the Internet.
Patients are becoming more exacting as consumers [39].
For medical professionals in Russia this is a relatively new situation, and they often feel
themselves helpless victims of unrealizable demands and injustice and unready to solve the problem.
They distinguish a certain type of patient, which represents a threat—these are “aggressors” or
“extremists”. They write complaints to different controlling bodies and online sites. According to
professionals, they act aggressively, behave unethically, make unrealizable demands and “biased”
complaints:
“Oh, mother, within three days she managed to write eight complaints to all instances of
the world! Listen, we…we are absolutely unprotected from this. A person can write
anything: a positive feedback, a negative feedback. I like—I didn’t. Absolutely biasedly”
(Interview with an administrator)
“The doctor says: a mom was brawling (today) because she didn’t get the medication. It
costs 16,000 rubles; we ordered it; it will be delivered (in a few days). But she wants to get
discharged on Saturday, because of the birthday. She says: “Take it wherever you want, at
least buy it and pay it yourself”” (field notes).
Complaints lead to reputational loses and emotional costs. We were told about a complaint,
which was considered unsubstantiated. The doctor, who was mentioned in the complaint, was taking
the situation very hard and was even about to quit the job:
“There were two proceedings. The doctor had been going crazy all five days before that.
She was sending messages to me: “Maybe I should quit my job?”… Reputationally this is
very painful… not to crush this person” (Interview with an administrator).
Complaints can also be made on the basis of communicational and service problems. The doctor
tells about a complainant who considers,
“The childbirth went well, thanks to your specialists”. And then, somebody didn’t open the
door in a right way, somebody offered something wrong, something that made them
indignant and provoked to [write down] two pages. They didn’t like the magnet key (for
exit) for some reason; I mean, and so on… You were not served? What you were not served?
In what way you were not served? … Do you understand that all this, in truth, deeply hurts
medical practitioners” (Interview with an administrator).
Hospital meal, late discharge, intrusive photographers in a check-out room and other reasons
which lie beyond the responsibilities of a health practitioner, can become a basis for a complaint. The
aim of “patients-aggressors”, who are selfish as considered by professionals, is to get financial profit
or moral satisfaction.
Doctors are in a situation where they are becoming more controlled by the patients; they can be
complained about every single moment. Every patient can record a conversation and post it on the
Internet: “Patients are taking pictures of us with their mobile phones, and we feel and consider this”
(field notes, conversation with a nurse).
According to our data, lack of trust and absence of compliance become a background for blaming
physicians for negligence, disregard or dishonesty. During a fieldwork, we repeatedly observed how
hard it can be for doctors to conduct a dialog with patients, especially those in a critical or threatening
situation. Doctors who are striving to solve difficult clinical tasks describe their job as physically hard
and emotionally charged, frequently telling about emotional burnout. Patients often do not
appreciate their efforts—they do not see and cannot evaluate the complexity of this work under the

Societies 2020, 10, 5 14 of 17
conditions of institutional contradictions and multiple all-round control. Patients, who are physically
and emotionally vulnerable themselves, are suffering of neglect, discomfort, and misunderstanding.
As a result, a lot of (potential and real) situations of discontent and complaints are based on a
conviction that the doctor is dishonest and acts in his or her own interests. Patients tend to see
deception when the actions and interpretations of doctors remain unclear, confusing and
contradictory to their own life experience.
Therefore, doctors, whose social position is provided with power, resources and competence, in
some cases appear to be vulnerable both in terms of existential events, which are out of their control,
and in terms of unjust evaluations of their actions and sanctions against them; their power and
resources appear to be insufficient. Vulnerability of professionals remains invisible as it does not
correspond with their social position. However, it negatively affects the patients. For a doctor who is
herself hardly struggling with existential situations and threatening sanctions, it is difficult to provide
sufficient support to suffering patients or their relatives. A doctor who does not have the opportunity
to act in the best interests of a patient or has to break the law in order to do so can only aggravate the
vulnerable position of a patient. Therefore, as a result of doctors’ vulnerability which is related to
institutional and organizational contexts, patients become even more vulnerable.
5. Discussion and Conclusions
This article contributes into the contemporary discussion on vulnerability of medical
professionals. We are reacting on two trends in literature on vulnerability. The first one focuses on
deprivation, marginalization, disadvantage, poverty and social problems [49]. Doctors cannot be
attributed to this group. Another trend considers stress and burnout of professionals, but ignores
structural and contextual basis for their vulnerability. Our research aims at filling in this gap.
We set the task to examine an invisible vulnerability of a group, which is considered as powerful
and resourceful, doctors in Post-Soviet context, in a special site, perinatal center. As a rule,
vulnerability is attributed to patients (especially such as terminally and mentally ill) as passive and
not enough knowledgeable help recipients. In spite of the politics of neoliberal choice and
empowerment of patients’, their agency and resources are restricted; they experience bodily and
emotional suffering. Within binary approaches to the understanding of power relations, doctors are
opposed to patients—they have power, agency, they are not supposed to suffer and are not
considered vulnerable. We critically refer to this point.
Our first conclusion refers to the subject of vulnerability. It is methodologically important not to
define certain groups as (not) vulnerable by default. Such artificial narrowing of the field of analysis
might derive into disregard for “unexpected” forms of vulnerability. We have to be sensitive to
practices, interactions and emotional displays of all the participants, not only the ones who are
determined as a priori less powerful. During an ethnographic fieldwork we discovered multiple
vulnerabilities whose boundaries are transparent. Doctors are conventionally perceived as powerful
and affectively neutral, but in a number of situations, they lose power, cannot manifest their agency
and face lack of resources. Their sufferings (existential and moral), as a rule, are invisible, denied and
ignored.
Our second conclusion relates to the meaning of context in exploring vulnerability and
vulnerable groups. In a context of hybridization of paternalism, managerialism and marketization of
Russian healthcare, doctors feel the injustice of increasing and constantly changing requirements
from different instances, which cannot be simultaneously met as they contradict each other. Doctors’
autonomy is restricted, their actions are regulated by multiple and frequently contradicting rules; one
can hardly influence one’s own working conditions or choose optimal treatment strategies for
patients. As a result, doctors turn out to be not only existentially vulnerable but they feel themselves
legally insecure and experience injustice—that is moral vulnerability.
Our third conclusion is that patients who a priori can be vulnerable, in certain conditions might
suffer even more because of (subjective) insufficiency of care and lack of attention from vulnerable
doctors. Due to the low level of mutual trust, some patients (“extremists” in emic terms) accuse

Societies 2020, 10, 5 15 of 17
doctors of deception or neglecting their interests. Doctors consider such complaints unjust. They
make more efforts to protect themselves from sanctions than to support their patients.
Our last conclusion concerns the position and actions of the researcher in the empirical field
when dealing with multiple vulnerabilities. We recognize this position as complex and ambivalent.
On the one hand, the vulnerability of informants is associated with sensitivity, which they do not
want to show, and it can be emotionally difficult or dangerous to openly discuss it. Or just the
opposite, the stories and the situation become emotionally oversaturated. Moreover, the researcher
experiences emotional difficulties during such conversations or observations, which are not always
easy to cope with. Cases of existential vulnerability also create additional challenges and limitations
for accessing the field and collecting empirical data—in an emotionally overcharged situation, a
sociologist in the field as an outsider creates extra burden for participants, so she probably will be
excluded from the most problematic situations.
Author Contributions: Conceptualization, D.L., A.N. and A.T.; methodology, D.L., A.N. and A.T.; analysis, D.L.,
A.N. and A.T..; investigation, D.L., A.N. and A.T.; data curation, D.L. and A.N.; writing—original draft
preparation, D.L., A.N. and A.T.; writing—review and editing, D.L., A.N. and A.T.; supervision, A.T.; project
administration, D.L.; funding acquisition, D.L., A.N. and A.T. All authors have read and agreed to the published
version of the manuscript.
Funding: The research was funded by the Russian Science Foundation (Project No 19-78-10128).
Acknowledgments: We would like to acknowledge health care practitioners of the perinatal center for their
organizational support and their time spent on the participation in the research. We also would like to thank our
colleague, the head of the project funded by RSF, Ekaterina Borozdina, for the financial support of the research.
Conflicts of Interest: The authors declare no conflict of interest.
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