Jesudason E. Ethical problems with kindness in healthcare. J Med Ethics 2022; DOI: 10.1136/medethics-2022-108357. Online ahead of print.

Kindness is optional, not obligatory.

Kindness - related etymologically to kin and our kind - is generally thought to be a virtue. Related to empathy (putting oneself in another's shoes) and compassion (sharing distress, a sense of solidarity and possibly a call to action), kindness may be considered more discretionary than either. Doing someone a kindness, for instance, has an element of doing a favour and hence tends to favouritism.

If kindness, therefore, can be considered discretionary and not an obligation to be provided to all, then ethical issues become apparent. With regards to justice, as an example, the hosting of Ukrainian refugees has been a good example of kindness and mitigates harm to the majority and is difficult to argue against in general. At a deeper individual level, however, African students fleeing Ukraine have been sent to the back of queues in favour of white refugees and kindness can be seen as discretionary. Jesudason argues that promotion within the NHS may also be an example of not dissimilar unjust discretionary kindness.

Healthcare regulation is also impacted by kindness and non-maleficence. Harms may be caused by the discretionary kindness of deciding who and who is not referred to the various regulatory bodies. Hospital directors may be reluctant to press charges against longstanding colleagues and friends. The Bristol Children's Hospital enquiry for instance used the term club culture to define the in-group of doctors who protected each other with 'in-kind benefits, at the expense of the children and families.'

The conflict of kindness and autonomy is illustrated by the issue of overseas aid. It is kind to give to those worse off than oneself, but if aid organisations are paternalistic in their distribution of the assistance, then the autonomy of the recipients is infringed.

'Healthcare professionals are perhaps vulnerable to the seductive belief in their own kindness,' Jesudason writes. 'Practitioners may view themselves as particularly virtuous - when in fact they may sometimes be seen as quite self-serving.' A belief in their own sense of virtue may lead to an expectation of perks and favours but without recognising that these go un(der)offered to others.

Discretionary kindness may therefore lead to the formation of in-groups and out-groups. Future research on policy development should include outgroups to ensure that discretionary kindness is distributed fairly and that harms are mitigated. Greater inclusion of ingroups would remove the repeated focus on minoritised groups and help to determine how kindness (or perhaps kin-ness) is distributed in healthcare.