The Cost of Care: Exploring the Moral Side of Paradox Among Primary Medicine Doctors

Abstract

Organizational paradoxes are traditionally viewed as problems that defy logic, yet they may also challenge individuals’ moral beliefs and values. Drawing on interviews with primary medicine doctors in the United States (N = 24) and New Zealand (N = 26), our study focuses on the understudied moral side of paradox and how it relates to power relations. Specifically, we explore how power relations influence doctors’ experiences of a “morally asymmetrical” paradox—namely, an underlying tension between cost and care imperatives—where one pole (care) is seen as morally important while the other (cost) holds largely instrumental value. We find the cost-care tension is generative for doctors when they can engage both poles on their own terms, but triggers moral distress when structural power imbalances prevent doctors from engaging morally important care imperatives. We also show how doctors respond to such distress using three “moral boundary management approaches”— Moral self-differentiation, Moral dissociation, and Moral dissociation combined with extra-role moral engagement —whereby doctors’ (re)position their personal moral responsibilities in relation to their roles in the healthcare system. Altogether, our study advances understanding of the important yet understudied links among paradox, power, and morality.