Defining and performing shame

Those who study shame must first define the term. Yet doing so presents a challenge. Most scholars agree that it is complex and contested. Those who define it too precisely have struggled to accommodate the range of experiences and interpretations that others have cited outwith tightly drawn definitions of shame. Those who take a more open approach to defining shame are criticised for imprecision. For the purposes of this paper, shame is understood as having the features that are identified most frequently in the literature, namely its phenomenological character, effect on identity and dependence on witness by, or exposure to, the judgement of others.17

The relationship of shame to other emotions tends to be one of distinction in the literature, but some commentators have focused on the relationship of shame to guilt. Guilt is characterised as internal and usually located in a specific incident. In contrast, shame is described as external and public. It is the observation of others, be it potential, perceived or actual, that distinguishes shame. Covington18 notes:

shame (is)…the emotion that is paramount in defining our humanity. Shame implies an exposure of lack, of inadequacy, and of injury that is extremely painful… It is about one’s self as a person.

For Lazare,19 the tripartite relationship between empathy, guilt and shame is essential to understanding and improving medical interactions. The reach of shame is deeper than guilt, extending to, and threatening, an individual’s sense of self and identity. Ofri,20 discussing Lazare’s work, articulates it thus:

Guilt is usually associated with a particular incident and can dissipate when the issue is resolved. But shame reflects a failure of one’s entire being. While guilt often prods a person to make amends, shame induces them to hide (p. 128).10

The dramatic form offers a valuable lens through which to consider shame in medicine. Theatre and medicine are both ‘seeing places’ where objective observation, subjective interpretation, established sight lines and blind spots collide. The clinical and the theatrical depend on a shared endeavour which is inherently human and active.21 Medicine, like dramatic performance, depends on performances before audiences who evaluate and legitimise practice.22 A play creates a contained world within which ideas, concepts and existential conundrums can be examined.23 Difficult questions about identity, complicity, moral choices and vulnerability are, literally, brought into the light on stage. Our experience in the theatre speaks to what Morgan describes as the ‘emotional and evaluative’ character of shame, which is, he suggests, ‘reflexive and yet social, requiring that we look at ourselves and the way others view us at once and dialectically’ (p. 14).10

In Tiger Country

Nina Raine’s Tiger Country was first produced at Hampstead Theatre in 2011 and revived at the same theatre in 2014. The play was performed in a traverse configuration, staging that acknowledged both watching and being watched. It is a piece that is grounded in the realities of clinical work. The author and cast spent time with clinicians and that authenticity infuses the play’s language, preoccupations, staging and pace. The title refers ostensibly to a surgeon making an incision close to an artery. Yet, throughout, the audience sees that anybody in healthcare is in Tiger Country. The play reflects the front and back stages24 and the theatrical symbolism of clinical work. In Tiger Country, emotional, psychological and physical exposure is common for both patients and clinicians alike. To survive in Tiger Country, people have to perform, and those performances are imbued with shame. Tiger Country poses difficult questions about the burden of clinical work, the weight of expectations, ambitions, vulnerabilities and ideals, the stigma of illness, and the inadequacies of a healthcare system.

Shame, identity and professional survival

Tiger Country opens in an operating theatre and the audience are introduced to doctors learning their craft. Emily, in her second foundation year of training, is shown being taught to scrub in by Mark. In a short exchange, sexism, humiliation and hierarchy are evident. Mark is derogatory about his female senior, Vashti, and he compares Emily’s efforts to put on her scrubs to the stereotype of a woman preoccupied with clothes. In theatre, Emily is grilled on anatomy while Mark is put down by Vashti. Casual sexism abounds: from comments on the choice of music to remarks about the prevalence of oestrogen. It is not incidental that the operation is an orchiectomy. The threat to masculinity and the defensive misogyny with which that threat is met are underpinned by a sense of profound shame, shame that is both induced in others and felt as a response.

Although there is a large literature exploring the emotional impact of clinical training and practice,20 25–28 shame has been largely overlooked by those who teach medical students and trainee doctors.29 An emotion that has been described is humiliation,30–32 particularly in training.33–35 The relationship of humiliation to shame is less well-articulated. It is suggested that humiliation, particularly where it is focused on an individual’s identity, such as her gender, personality or ethnicity, has considerable potential to induce feelings of shame. That shame will be felt by the recipient of the humiliation, but may also be experienced, even if not acknowledged, by the perpetrator too. The shame that can imbue medical education and training is a recurrent theme throughout the play, reflecting work showing that shame is a common experience.36

Denigration based on gender, ethnicity and the perceived status of different clinical professions is constant in the dialogue. Mark taunts Emily that she won’t achieve her ambition of becoming a surgeon, but will instead end up in ‘GP land’ (p. 49).10 Twenty-five years before Tiger Country was written, Sinclair observed in his ethnography that ‘General Practice (is)…among the very-lowest-status segments of medicine as seen from the teaching hospital’,37 noting that one of the reasons that general practice was so perceived was due to the high numbers of women in the specialty. Sinclair’s findings, particularly in relation to gender in the medical workplace,38 have been replicated.39 Tiger Country repeatedly exposes the gendered dimension of medical work: James tells Emily that as a ‘young-laydee doctor’ (p. 28),10 she will be taken less seriously. The male consultant welcomes James to his skiing party while ignoring Emily, and later invites James for a drink after work (p. 80)10 but again excludes Emily.

The intersection of ethnicity, gender and hierarchy that has been described in empirical analyses40 41 of healthcare work is embodied in the character of Vashti in Tiger Country. She strives to make her mark in surgery as she vacillates between ignoring overt sexism, defending her territory in the operating theatre, asserting her authority over her male junior and disguising her vulnerability. The tension between difference and conformity is constant,42 leading her eventually to ask:

what is it about this place that makes you into the opposite of what you are? Pretend you’re a man if you’re a woman, pretend you’re English if you’re Indian. I mean listen, listen to the voice I’ve invented for myself (p. 104).10

When Vashti requires the help of her male senior, her exposure is painful. In the staging of the play, Vashti is frozen to the spot after her consultant has corrected her error. The audience knows that Vashti’s shame is physical and psychological. It is palpable and visible. It is a response that reflects the shame that many doctors feel when they have made a mistake.43–47 Vashti’s shame is that of someone whose identity has persistently been derided and judged to be inadequate. Her response to the failure in surgery reaches well beyond the incident. Her shame is performed before us and it is, literally, paralysing.

The next scene is the cardiology clinic where we meet John and Mr Mercer, who is well-known as an actor in a medical drama. The interaction (Raine, p22–25)10 allows for a paradoxical exploration of emotion and vulnerability in medicine. The expression of vulnerability in healthcare is rarely described, although the papers that exist suggest it may be helpful for both the clinician and the patient.48 It is Mr Mercer who acknowledges how distressing he has found working on upsetting scenes in dramatised medicine. As a simulated doctor, he is free to express the emotion that actual doctors cannot. In a scene where actors play actors playing doctors, the layers of role and performance are both reinforced and deconstructed as an example of the type of seeing that Tony Kushner identifies as unique to theatre:

People always have to see double which is critical consciousness and it teaches you to see dialectically. It teaches you to understand both the manifest appearance of things and also their actual content.49

The potential for shame attached to care is a recurrent theme in Tiger Country. The senior doctors emphasise repeatedly to their junior colleagues that to care too much is to compromise professional and personal survival in medicine (p. 100).10 Emily, as the most junior character in the play, most explicitly fears and feels the burden of her role as a doctor, yet she is met only with what Paddison has described as ‘emotional sanitization’.50 She worries explicitly about those she might harm and the pressure of making decisions about other people’s lives. When she confides in her boyfriend, he is blunt that error and death are unavoidable. He refers to his own dysfunctional reliance on alcohol in the early days of his first clinical job. Later, Emily is called to lead the resuscitation of a young woman who, at 24, is the same age as her. Such is her distress that Emily imagines she can see the dying woman whom she is attempting to resuscitate, an enactment of McCarthy-Jones’ hypothesis about the relationship between shame and hallucinations.51 Emily’s despair both during and after the failed resuscitation is overwhelming. What Emily experiences is a poignant insight into the phenomenon of moral distress, which has been described in a range of healthcare settings.52–54

The language Emily uses is redolent with shame. She describes herself as ‘sick’, ‘dirty’ and ‘broken’ (pp. 106–108)10. Her despair goes to the essence of who she is, as a person and as a doctor. It is a pivotal moment in the play as she reveals a mistake in her personal, as well as her professional, life. She admits that she no longer feels able to do the job and expresses her fear at what medicine is doing to her compassion, empathy, integrity and commitment to caring. Emily’s shame is informed by her failure to meet her own expectations, the dismissal of her emotions by her colleagues, the public nature of the failed resuscitation attempt and the inadequacy of the resources available to support her. It is a potent mix. Emily’s shame, like Vashti’s, is physical, emotional and existential. Emily is standing in the stance she took when she was learning to scrub in, except now she is doing so to protect herself and to defend what little of her remains ‘clean’ in a toxic environment.

Emily’s and Vashti’s responses speak to the distinction that some commentators have drawn between guilt and shame.55 Fraser and McLaughlin56 suggest that guilt may lead to prosocial behaviour, for example, improvement, rectification or remediation, whereas shame tends to lead to antisocial behaviour such as defensiveness, covertness and withdrawal. Davidoff too considers that the effect of shame is negative and compromises efforts to improve care.57 In contrast, a smaller number of writers58 have suggested that shame has moral purpose, particularly in the context of prompting social and political action, global advocacy59 and public health.60 One study suggests that those who experience and can acknowledge feelings of shame may eventually go on to perform better in a specific clinical task.61

Illness and shame

The shame of illness infuses Tiger Country. Many years after Jeffrey’s classic paper62 on ‘normal rubbish’, the characters denigrate and mock certain patients, including those who are overweight (pp. 37, 82),10 the elderly (pp. 39,  99),10 those with impaired cognition and mental health problems (Raine, p60),10 and women with gynaecological problems (pp. 31).10 Patients who have long-term or chronic illness report feeling shame following interactions with doctors63 64 as do those who are at risk of being labelled by clinicians, for example, in relation to their sexual health or reproductive history.65 Even where patients are sympathetic in Tiger Country, the construction of the medical role as omnipotent, resilient, clean and healthy in contrast to the dependent, vulnerable, sullied and sick characters is evident. The drive to maintain that distinction informs the ways in which Raine’s medical characters shift from rational evidence to an almost evangelical faith in the power of medicine that the audience knows to be impossible and unfounded (pp. 24, 27, 36–37, 57–58).10

When John, the cardiology registrar, reveals that he is unwell, Raine shows us the shame that doctors can feel when they find themselves in the ‘kingdom of the sick’.66 The reluctance of doctors to admit to being unwell is well-documented.67–71 A sick doctor is, it has been suggested, an ‘anomalous’ patient.72 For a doctor to act as a patient is often difficult, with some preferring to treat themselves or to seek informal advice from a colleague.73 John is no different. He approaches a colleague to confide that he has a lump in his neck. John’s language seeks to minimise his symptoms, even as he palpates the growth himself until the conversation is curtailed by the repeated interruptions of John’s bleep (p. 33).10 Later, in clinic, it is a patient, not one of his colleagues, who observes that John is unwell, although he dismisses her concern about his appearance as a symptom of being a doctor not of being a patient (pp. 52–53).10 When a colleague tells him the results of his biopsy, we witness the shame John feels at joining the kingdom of the sick. He refers to his cells as ‘ugly’ and deplores being ‘one of them’ (original emphasis) meaning, of course, patients (p. 65).10 John cannot reconcile being both a doctor and a patient; as well as revealing lymphoma, the cellular markers threaten his identity. Like many sick doctors, the weight of the disease informs his perception of his identity, status and even moral worth.74 75

It is only towards the end of the play that some of the characters can admit painful truths about medicine and its limits. When Vashti, bruised by, and ashamed of, her failure to protect her aunt from poor care, meets Mr Mercer he, once again, acts as a conduit for an honesty that is not usually permissible in Tiger Country. Finally, Vashti acknowledges not only that medicine eventually fails us all, but that she too is fallible, vulnerable and human. Yet that humanity is what enables her to provide care, compassion and comfort when there is no more treatment to offer.

Healthcare systems and shame

A third manifestation of shame in Tiger Country relates to systemic expectations, organisational structures and resource constraints. Throughout the play, there are references to the inadequacies of equipment (pp. 44, 17–18, 32, 83–88),10 available beds (pp. 11, 14, 57, 82),10 and the organisation and availability of staff (pp. 29, 33, 68, 71, 73, 75–77, 99, 104),10 culminating in James telling Emily ‘there isn’t enough NHS’ (original emphasis) (p. 81). The costs of drugs are referenced with a mixture of pride—that the National Health Service is available to fund treatment for everyone who needs it—and shame—that medicine can be so expensive in a resource-constrained system (pp. 22, 124).

The notion that there are systemic influences that create the circumstances for individual shame in healthcare has been identified,76 77 particularly where there is a dissonance between expectations, for example, targets (pp. 61, 77),10 78 and a clinician’s values.79 The discourse about the healthcare system throughout Tiger Country is of pride and shame in tension.80 Even the most cynical characters are proudly committed to providing care to whomever walks through the door according to need. Yet refrains about the obstacles and limitations that compromise care recur in the play. It is the clinicians’ powerlessness in the face of these systemic and organisational barriers that contributes to their shame.