Artificial intelligence (AI) can be harnessed to create sophisticated social and moral scoring systems—enabling people and organizations to form judgments of others at scale. However, it also poses significant ethical challenges and is, subsequently, the subject of wide debate. As these technologies are developed and governing bodies face regulatory decisions, it is crucial that we understand the attraction or resistance that people have for AI moral scoring. Across four experiments, we show that the acceptability of moral scoring by AI is related to expectations about the quality of those scores, but that expectations about quality are compromised by people's tendency to see themselves as morally peculiar. We demonstrate that people overestimate the peculiarity of their moral profile, believe that AI will neglect this peculiarity, and resist for this reason the introduction of moral scoring by AI. The potential use of artificial intelligence (AI) to create sophisticated social and moral scoring systems poses significant ethical challenges. To inform the regulation of this technology, it is critical that we understand the attraction or resistance that people have for AI moral scoring. This project develops that understanding across four empirical studies—demonstrating that people overestimate the peculiarity of their moral profile, believe that AI will neglect this peculiarity, and resist for this reason the introduction of moral scoring by AI.Morality holds a special role in our personal and social identities  particulNosedive, which depicts a world in which people rate every encounter they have with each other. But even in this extreme dystopian version, the scoring is done by humans and not by AI. We are inspired instead by applications where AI observes the online and offline behavioral traces of a human and collates all these traces into one or several moral scores. While much work has been conducted on the way humans judge the morals of machines , and these ratings are aggregated into a score that is shown to other customers, in order for these customers to anticipate the behavior of their driver  . Similarmachines , we focuBuilding on algorithms that extract personality profiles from online activity , 24, theIn this article, we seek to show that, reminiscent of the way people resist medical AI because they believe AI cannot grasp the peculiarity of their health status , people people are less likely to accept AI moral scoring if they expect AI to mischaracterize their morals), we asked a representative UK sample of 446 participants to rate how acceptable it would be for AI to score each of 17 psychological traits , and how good AI would be at scoring each of these traits.1 Moral and nonmoral traits were distinguished as in previous work , and all ratings of acceptability and quality were strongly correlated at the trait level .All analyses for studies 2a and 2b were preregistered , we had to construct participants’ moral profiles, ask them how prevalent they believed their moral profile was, and compare this subjective prevalence to some ground truth about the prevalence of the profile in the population. For this purpose, we used an existing data set from the Your Morals project  answered the same questions as respondents to the Your Morals project, were categorized into one of the 16 same moral profiles, and shown a summary of their moral profile , indicating that people underestimated the prevalence of their moral profile. Demographic covariates had no detectable effect on this underestimation . Study 2b  delivered very similar findings, as shown in Fig. B = 5.17, P < 0.001), indicating that people underestimated the prevalence of their moral profile. Unlike in study 2a, the model also detected significant effects of demographic variables. The underestimation effect was larger for males  liberals .All analyses for study 3 were preregistered  in study 1, and for claim 2  in studies 2a and 2b. Study 3 pursues three objectives. First, it provides a preregistered replication of study 1, whose analyses were not originally preregistered . Second, it seeks evidence for claim 3 ; and third, it seeks evidence for claim 4 .We obtained evidence for claim 1  = 56.06, P < 0.001).Participants’ responses provided clear support for claim 3. Figure B = −0.13, P < 0.001). However, visual inspection of Fig. B = 0.07, P = 0.282), but the red slope is, and it is steeper than the slope obtained in the preregistered analysis .Participants’ responses also provided support for claim 4, with a twist. As we predicted, the more trouble people believed that AI would have scoring unique profiles, the worse they thought AI would do at scoring their own profile  than positive moral traits (e.g. benevolence), but this may be a simple framing effect: for example, future research may find that people find it more acceptable for AI to score “antiracism” than “racism.” Furthermore, there may be individual and contextual variation in the degree to which some traits, like “aggression,” are perceived as negative.That said, the psychological acceptability of AI moral scoring may not be ensured by an improvement in its perceived accuracy—because of psychological biases, we documented in this article. We showed that people had a tendency to overestimate the peculiarity of their moral profile, which, in conjunction with their belief that AI would have trouble scoring peculiar moral profiles, led them to doubt that AI would score their morals accurately. This psychological bias compromises the future acceptability of AI moral scoring . Even if the average perceived accuracy of AI moral scoring improves with time, people may still feel too special for machines to score their personal morals. In other words, the psychological acceptance of AI moral scoring will unfold based on three factors. First, the perceived accuracy of the technology. Second, the tendency that people have to overestimate the peculiarity of their moral profile. Third, their belief that AI performs less well on peculiar moral profiles.While perceived accuracy will presumably increase with time, people's overestimation of their moral peculiarity may not, if we assume that this belief is part and parcel of people's general and enduring desire to be (moderately) unique . InteresWe examined attitudes toward AI scoring of “morals” in a broad sense that includes general moral character, specific moral traits, and moral values. Future research may find it necessary to adopt a higher resolution as the technology and its regulation unfold. For example, it may prove necessary to distinguish between the attitudes people have about AI scoring of the values they hold, and the attitude people have about AI scoring of their overall moral character—or to measure the attitude people have about AI scoring of specific psychological traits, as a function of how well these traits fit into the “moral” category, as well as their perceived variance and base rate in the population. In addition, we were careful not to claim that people resisted moral scoring by AI more than moral scoring by a person. We did not focus on that comparison because moral scoring by AI is mostly relevant in situations where human moral scoring is impossible or impractical, for reasons of scale, making the comparison moot. One possible exception would be a “Nosedive” situation where people rate their interactions with one another, and let machines aggregate the scores. As explained in the introduction, we left these situations outside of the scope of this article, but future research may consider the relative acceptability of moral scoring by AI versus massive peer-to-peer evaluation. Finally, our research investigated abstracted forms of AI moral scoring, rather than focusing on specific contexts such as dating or job applications. This seemed reasonable given the current difficulty of predicting which type of moral scoring will be the first or the fastest to spread, but future research may increase external validity by focusing on a specific application context.Although digital traces and machine learning have been used to successfully predict demographics like age, gender, and ethnicity, the assessment of moral traits and personal values is evidently more difficult , 41, 42.N = 446, Mage = 47.94, SDage = 15.98, females = 196; see Table 2 related to (i) mental health (e.g. depression), (ii) negative moral (e.g. sexism), (iii) positive moral (e.g. bravery), and (iv) other (e.g. leadership). This allowed us to situate the acceptability of AI-based scoring of moral traits relative to others, and the role of positive versus negative framing. The moral traits included loyalty, generosity, integrity, bravery, honor, benevolence, humility (positive), and aggression, sexism, and racism (negative). The mental health traits included depression, dementia, and social anxiety. Others included extraversion, confidence, orderliness, and leadership. Study 1 was also designed to assess our first claim: that there is a relationship between how acceptable one deems a measure to be and one's expectations for the accuracy of that measure.Study 1 asked a representative UK sample :Some people think that using AI to measure personal traits is acceptable, while others think it is not acceptable. Personally, how acceptable do you think it would be to use AI to measure the following traits? .Some people think that AI would produce good quality measures of personal traits while others do not. Personally, how good do you think AI would be at measuring the following traits? .N = 495 .From the participant's responses, we determined their moral profiles using four dimensions: care, fairness, loyalty, and authority. We removed one moral foundation to reduce the number of possible profiles, and opted to remove purity as it has been noted as the least coherent and least clearly moral of the supposed moral foundations . For eacAfter completing the two moral preference questionnaires, participants were informed about their moral profiles .Participants were then asked to read about moral profiles defined as “… a stable set of moral preferences and judgments. For example, the absolute and relative importance a person places on bravery, humility, generosity, honor, loyalty, benevolence, and integrity.” and provided with an example see Fig. . AdditioParticipants then responded to four questions about uniqueness neglect. For example, “Do you think the results of a moral profile—generated by Artificial Intelligence—would be more accurate if the profile being assessed was unique or typical? .” The scale direction was counterbalanced for half of the participants whose scores were subsequently reversed. “Uniqueness neglect” scores were the average of the four items; higher scores reflect greater uniqueness neglect. Finally, participants responded to the question “How good do you think Artificial Intelligence would be at measuring your moral profile? .”pgad179_Supplementary_DataClick here for additional data file.


As AI technologies grow to encompass more human-like generative capabilities, discussions have begun regarding how and when AIs may merit moral consideration or even civil rights. Brandeis Marshall argues that these discussions are premature and that we should focus first on building a social framework for AI use that protects the civil rights of all humans impacted by AI. Generative AI has accelerated the discussion around whether or not AI does, could, or should have civil rights. As scientists, we are asked to weigh in on such discussions without adequate grounding of the legal implications of our responses. We adopt a mindset that since we are trained in data, algorithms, and AI concepts we are equipped to discuss the intersection of data and AI applications with law and society. This mindset is crafted by tech culture’s “move fast and break things” philosophy that champions speedy calculated risk and tech-styled evolution, where nearly everything is a derivation of tech. “Move fast and break things” has become so entrenched in how we design, implement, and maintain digital systems. Moving fast and breaking things is normalized and accepted behavior when in practice, very few situations in society are conducted at this speed or scale. AI, in recent years, has been elevated toward the top of the social hierarchy. It has therefore become the prime next candidate to impose the “move fast and break things” philosophy by pushing for AI to be afforded some form of legal person rights. But this 30-years-in-the-making global conditioning that tech is by default trustworthy and superior has been more publicly and regularly challenged with increasing pressure for the tech industry to address existing algorithmic-based harms. And the calls for legal personhood for AI must be met with an equal dose of scrutiny.Civil rights for AI require an understanding first if AI, generative or otherwise, should be designated a legal person. A legal person, as described by US law, is a quantifying designation that refers to a human being or non-human entity that is treated as a person with limiting applications. Legal personhood variants have already been granted to nature, animals, and corporations. Some call for an extension of similar legally binding rights to be granted to AI systems, tools, and platforms.AI is commonly described as a computer program or series of computer programs that enable the mimicking of human behavior. An important but frequently overlooked condition is that AI is a docile yet mutable software that is built and adapted by people. AI feeds on data, i.e., content, which in turn fuels the algorithms and statistical models driving automation practices. We need to better unpack and explain the seemingly magical blackbox of AI.,,First, we should better understand data, i.e., content. Data and content are interchangeable. Data is the term most scientists and STEM professionals tend to use while content is most frequently used by non-STEM professionals. Data include text, images, audio, video, and other forms of data inputs . Digitizing all data types has proven very difficult, although capturing sound has seen the most consistent advancements. The amount of data, in all its different forms, has varying degrees of accuracy. There’s content based in fact (what we want), misleading content (misinformation), and malicious content (disinformation). Distinguishing among fact, misinformation, and disinformation is yet another hurdle that people have yet to overcome, so AI stalls by halluncinating as a result . It is clear that being a human being doesn’t guarantee legal personhood protections in all areas of civil rights for some groups. For birthing people, you have been granted the civil right to vote, but you aren’t able to receive the civil right to certain medical care. But if you’re a person not from a historically excluded group or not a birthing person, then your civil rights and personhood remain unaffected and protected. US legal personhood status and realization of civil rights, especially of human beings, has proven to not be a monolith. Our historical recap of the inequitable execution of civil rights reinforces the forced social structure that is compounded by intertwined political, economic, and legal factors.The same law can have disparate impacts on different groups of people. For example, in the case of child adoption, same-sex couples may face restrictions based on marital status and the US state law prohibitions for LGBTQ+ people while heterosexual couples don’t face the same obstacles. The foundation of imbalance in US law sits at the crux of multiple tensions for historically excluded groups. Prioritizing the most vulnerable populations by law helps to mitigate these tensions and harms while spotlighting unearned privileges. The skewed scales of legal personhood for all human beings need to be remedied first since, as history has shown us, technological innovations mirror our physical society. If we don’t recognize and fulfill the promise of comprehensive civil rights for all human beings, we are on track to further replicate those disparities in the law. We the people aren’t a monolith and nor should we be treated as such. We also shouldn’t enable any lines of code to limit us to operate as a monolith.The recommendations involve providing remedies that rectify the disparities with respect to full human civil rights under the law and instituting an AI responsibility framework that keeps humans in the loop. Executing the full civil rights of all human beings provides more equitable conditions for a blueprint for AI personhood in the law to exist. This blueprint for AI personhood could then better contextualize the racial, gendered, political, economic, and cultural disparate impacts. We’d be in a more informed position to assess whether pursuing AI personhood rights legislation makes sense.Since we haven’t figured out how to fully execute human civil rights, it seems premature to have AI personhood conversations. AI, if it were to have legal personhood status and be granted a form of civil rights, would need to address the established social structure along with the political, economic, and legal consequences. Those who operate AI have ignored confronting this structure and its ramifications. Here are three open challenges: (1) AI’s impact to systems, tools, platforms, and institutions has yet to be assessed. (2) The full scale of baked-in AI biases and inequitable power dynamics has yet to be acknowledged, accepted, or atoned. (3) AI has yet to be regulated in order to provide agile guardrails and compliance protocols. An AI responsibility framework, discussed below, can help us identify and assess the degree to which people and lines of code can close gaps, mitigate biases, and combat disparate harms posed by AI systems, tools, and platforms.AI, first, should have an established social structure. There should be more formalized methods for protective approaches to prioritizing legal personhood of human beings and preventative strategies related to political-, economic-, and legal-induced harms. Protective approaches could operationalize more transparency of AI use. The AI Dependency SpectrumData Conscience[creation of] a legal framework for tech probationary jail, short-term banning, and long-term tech incarceration for algorithms, processes, systems, and tools. Certain technologies need to be sidelined until their impact on society and its people can be determined. Place certain algorithms, processes, and tools in a virtual timeout where their functionalities are disabled and inoperable. This conduct is applied on social platforms when accounts/profiles are marked as incendiary. The same rules need to apply to tech products.Preventative strategies to combat a myriad of political, economic, and social harms could be executed more by the law. We would need to expand the implementation of punitive consequences for human harmful behavior of AI such as penalties, sanctions, algorithmic destruction,This would disincentivize heavy AI dependency use, e.g., AI-generated and AI-assisted, while encouraging equitable practices and human-driven decision-making competencies.For AI to achieve this established social structure by having effective data/AI transparency, accountability, and governance, it should legally take at least as long as Black women’s uninhibited right to vote in the United States (346 years = 1965 − 1619).


Healthcare workers are a susceptible population to be psychologically affected during health crises, such as the recent COVID-19 pandemic. Resilience has been pointed out in the literature as a possible protective factor against psychological distress in crisis situations. This can be influenced by internal and external factors, such as individual characteristics and organizational factors. Thus, this study aims to characterize the overall resilience levels among healthcare professionals in Portugal and to understand the perspectives of this healthcare workers regarding organizational factors that improve individual resilience. This is a mixed-method study: a first quantitative study using a cross-sectional design to administer the Resilience Scale for Adults (RSA) to 271 healthcare professionals , followed by a qualitative study through 10 in-depth interviews. The mean score for the total RSA was 178.17 (SD = 22.44) out of a total of 231. Qualitative analysis showed 4 major themes on factors that enhance resilience: “Professional’s Training,” “Support and Wellbeing Measures,” “Reorganization of Services” and “Professional Acknowledgment.” The findings may contribute to the development of targeted interventions and support systems to enhance resilience and well-being among healthcare workers. These findings can be explained by the occupational context of healthcare professionals that requires them to face several challenges in addition to those faced by the general population, such as fear and general uncertainty.57 Indeed, healthcare professionals are prone to direct exposure to pathogens, lack of or inadequate personal protective equipment, increased workload, burnout, or ethical issues related to decision making related to the well-being of their patients. In addition to these challenges, organizational issues such as the reorganization of workspaces and routines, or personal issues such as feelings of failure in the face of unfavorable prognoses or the lack of support caused, for example, by increased periods of separation from the family, contribute to an aggravation of the difficulties experienced by healthcare professionals.79The COVID-19 pandemic began in 2020 and since its onset millions of lives have been lost, public health systems have been in shock, and various economic and social disruptions have arisen.1012 Briefly, resilience can be defined as the ability to overcome adversity. However, Connor and Davidson believe that resilience is not a process, but rather a personality trait that encompasses a set of characteristics that enable individuals to cope with adversity and adapt to the circumstances. According to other authors, resilience may be influenced by internal and external factors, from individual characteristics, such as intelligence and problem-solving abilities, to contextual variables, namely family context, social context, and cultural and normative particularities.Building resilience in healthcare workers can protect them against negative job-related outcomes such as burnout, anxiety, and depression, and, as a result, enhance patient outcomes. There are protective factors that enhance resilience and improve adaptation to high stress and burnout situations in healthcare professionals. These include the provision of literacy and training, interventions to create a sense of readiness, psychosocial support and treatment, monitoring the health status of healthcare workers, paying attention to the type of tasks, the mix of tasks and responsibilities, and the intensity and burden of those tasks, as well as working patterns and conditions.19 These and other organizational factors seem to contribute to increased individual resilience of healthcare professionals, which may also lead to improved quality of health services.Studies have been conducted on the development of resilience, focusing on healthcare professionals.Given the data mentioned above, there is a need to focus research on resilience and recommendations to promote it, providing organizations and healthcare professionals with the tools to cope more effectively with adverse situations in the future. Thus, this study aims, based on the experiences of the COVID-19 pandemic, to characterize the overall resilience levels among healthcare professionals in Portugal and to understand the perspectives of Portuguese healthcare workers regarding the organizational factors that improve individual resilience. The specific objectives are: (1) to assess the overall resilience levels among healthcare professionals in Portugal, (2) to examine the relationship between resilience and demographic factors , (3) to explore the association between resilience and workplace factors , (4) to understand the mechanisms used by healthcare professionals to enhance their resilience and deal with the pandemic, and (5) to provide strategic recommendations for improving healthcare services.This study is part of the European project “Empower4Pandemias—Learning from Covid19.” Briefly, the main objective of the project is to pilot a blended learning training to enhance the resilience skills of professionals and decision-makers in the health and emergency sector and related public administrations to strengthen their individual and organizational resilience to better cope with a pandemic crisis. In this design, qualitative data (interviews) supplement quantitative data (questionnaires) to create a deeper understanding of factors that improve individual resilience. The study started as a quantitative study, with a cross-sectional design, administered the Resilience Scale for Adults (RSA) to identify the level of resilience of healthcare professionals. Then, a qualitative design was followed based on in-depth interviews to explore the organizational factors associated with their individual resilience. The quantitative phase was held between April and May 2023 and the qualitative phase was conducted between May to June 2023.This is an explanatory sequential mixed method study that combines quantitative and qualitative methodologies. which showed that for a total of114 000 health professionals, the sample size should be 246. In stage 2, participants were recruited through the non-probability purposeful sampling method which aimed to select individuals with the highest and lowest resilience scores in the previous survey.The study participants for the 2 stages were healthcare professionals . The inclusion criteria outlined for this study were having worked in healthcare services during the COVID-19 pandemic in Portugal. For the survey, the sample number was deemed sufficient based on the sample calculation formulaThe questionnaire was composed of questions reviewed by experts and was organized into 3 sections: (1) sociodemographic data, (2) work-related issues during the COVID-19 pandemic, (3) Resilience Scale for Adults. is a self-administered questionnaire that assesses several characteristics of resilience, containing items that in their original structure are organized into the following 6 factors: Perception of Self (PoS), Planning for the Future (PF), Social Skills (SS), Family Cohesion (FC), Social Resources (SR), and Structured Style (StS). This scale can be applied to adults in any context. Regarding the total score of the scale, each question is rated on a Likert scale, ranging from 1 to 7, with higher scores meaning higher levels of resilience. There are 17 items that should be inverted. To obtain the score for each factor 1 should calculate its average or use the total value. This scale is validated for the Portuguese population and has a very good internal consistency with a Cronbach alpha of .94.The Resilience Scale for Adults (RSA)Supplemental Material) consisted of open-ended questions related to key areas of interest about the healthcare workers and lived experience during the pandemic. The interview was divided into 7 sections: (1) General questions about roles and responsibilities, (2) Experiences about the initial phase of the pandemic, (3) Work routines and challenges during the COVID-19 pandemic, (4) Patient care during the pandemic, (5) Organizational support, and (6) Individual skills and stress.The interview guide .t-student and 1-factor ANOVA tests. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 27.0 for Windows and a .05 alpha.For quantitative study, descriptive analyses were used to characterize the sample, the result of the RSA and the 6 subscales. Pearson’s correlation coefficient was used to assess the association between total scale and subscales values and age, years of working as a healthcare professional, number of working hours per week, and how they perceived their health during the COVID-19. Comparisons of resilience total scale and subscales were performed using independent  Initially, a pre-analysis of the transcripts was performed through a free reading and relevant data were organized into meaningful codes. These codes were classified into potential resilience-related themes and their influence on health workers’ experiences during the COVID-19 pandemic. The emerging themes were reviewed by reading through all codes and the entire data set to confirm thematic validity and, after this validation, they were defined and named. The interviews, transcription, and thematic analysis were performed by the principal investigator and a research assistant, both occupational therapists. Results were discussed until a consensus on interpretation was reached. The codes and themes were reviewed by 2 other researchers prior to reporting. The thematic analysis was conducted using the software WebQDA.For qualitative study, verbatim transcriptions were made based on the interview recordings. Interview transcripts were analyzed using thematic analysis.n = 63) had a master’s degree, and 7 (2.60%) had a Ph.D. Most of the individuals were allied health professionals, 201 (74.20%), 43 (15.90%) were nurses and 10,00% (v = 27) were medical doctors or psychologists. During the COVID-19 period, participants worked mainly in secondary care institutions 103 (38.00%) or in long-term care 82 (30.30%), with 69 (25.50%) working in the private sector and only 16 (5.90%) in primary care settings and, in the same period, 92 (34.20%) worked shifts. The average quality of health of healthcare professionals during the pandemic was 6.47 in 10.P = 0.05According to P < .034). Also, a significant difference in total resilience was found between occupations, with nurses presenting the lowest levels and medical doctors/psychologists the highest (P = .018). Differences between occupations were also found in PoS, PF and FC subscales , all with nurses presenting the lowest resilience results. In PS subscale, resilience has significant differences according to education level, with those of higher education schools presenting higher resilience (pFC = 0.002).For the total scale, a significant difference in resilience values according to education level was found, with those with a higher degree (Doctorate and Master) presenting a higher resilience than those with a Bachelor’s degree . A positive correlation between how participants rate their overall health during the COVID-19 pandemic and PF, SC, and PS subscales and total RSA scale were found . Values in bold indicate significant P = 0.05.Through the analysis of the interviews, 4 categories emerged that intend to reflect the perspectives of healthcare workers in Portugal regarding organizational factors that improve individual resilience: “Professional’s Training,” “Support and Wellbeing Measures,” “Reorganization of Services” and “Professional Acknowledgment” .because (. . .) the more informed we are, the better we’ll be, right?” (P1) and the better a crisis will be experienced in the future, such as a new pandemic “training people to be able to deal better, to be able to face it is an important strategy for overcoming a general crisis, right?” (P8). The training could be focus on general competences, namely crisis and disaster management, but also in specific personal skills such as stress management. The areas of training highlighted by the participants are shown in Professional’s training was a theme addressed by all participants. They considered that training is fundamental for changing practices and attitudes that can influence resilience. Participants highlight that the more information and tools they have, the better the care provided will be “If the professionals, those who are exactly in the field are given the best conditions to work, at the bottom of the chain, in the pyramid, everybody wins” (P7); “I think the more, and it’s scientifically proven, that the more time we give people to do what makes us happy, the more productive people are going to be” (P1).Following professional training, participants consider that alongside the training, there should be a focus on supporting the well-being of healthcare professionals. This support can focus on measures to promote employees’ well-being or the delivery of specific psychological support. The participants of this study considered that health services benefited from having healthcare professionals more satisfied with working conditions and more professionally and personally fulfilled. Thus, the participants, based on the support they felt was lacking during the pandemic, identified some support and well-being measures that they considered could be useful for professionals and consequently would influence care delivery “organize themselves somehow for us to have some time when we could do something, some kind of activity where we could relax, even if it was just for 15 minutes.” (P3)The participants consider that health institutions should allow health professionals to have time to perform meaningful activities within the work environment to increase their well-being “If he/she then has no time to be with his family, to be with himself, to do absolutely nothing” (P4), it is difficult for him/her to feel well.Outside of the work environment, but related to the demands of that same environment, the participant considered that they should also be able to enjoy more time for meaningful activities, “I think that psychological support is fundamental, [. . .] we have an office, but I mean, it’s not enough for the whole hospital, one person for a whole hospital is impossible” (P2).Moreover, they also consider that there is a gap in the psychological support provided to health professionals, either by the absence or by the inability to respond to all the needs that should be addressed, since they consider that it would bring many benefits for the mental health of professionals, “We don’t have the working conditions. It’s far short of what is needed, what was needed, what would be needed” (P9). From this, the following restructurings arise:All participants mentioned that, in order to really achieve changes that are impactful and sustainable, there is a need to promote a restructuring of the services, without which it will be very difficult to implement the other measures identified. Those measures should include changing working methodologies and schedules, making physical spaces more functional, implementing telehealth and other technological innovations, and improving organizational hierarchy. Participants consider that there is a need for an adjustment in the organization of health services to improve working conditions for professionals, “I think it is important in Portugal to have formalization of work methodologies and I think this has failed miserably” (P4); “In terms of service organization I think we lack protocols” (P1).Working methodologies: “Having availability of places for example for group interventions” (P10); “I think that it only occurred to me the issue of beds and the number of vacancies that are needed [. . .]so that there wouldn’t have to be all this confusion with patient transfers and insufficient numbers of beds” (P5).Physical spaces: “I think that telemedicine has helped a lot” (P1); "Health professionals (. . .) were realizing that there are certain things they can do remotely.” (P5).Telehealth: “I think that working shifts is not beneficial, although there is this need it ends up not, not, not being beneficial" (P1); “The excessive load that we are daily is big and so we had to decrease the load” (P5).Schedules: “There should be organizational charts of priorities at the level of health professionals” (P2); “The leaderships are very closed” (P7).Organizational hierarchy: ““I don’t think these people are ever going to be valued enough. They will never be given the appreciation and I don’t mean the gratification, but at least the appreciation of what they did that I don’t think anyone is very aware of” (P5); “We went through complicated times, not tearing others apart, not tearing other professions apart, but I think that valuing our work more was perhaps the most appropriate measure (P3).The participants’ self-perception of a devaluation of their social role was almost universal, and particularly so during the pandemic period. It is their opinion that, as healthcare professionals, they play a primary role in society and are constantly exposed to risks and situations of pressure and stress. These issues during the COVID-19 pandemic were even more evident, however, the participants consider that neither during this phase nor before had sufficient recognition and appreciation of their work - The support that should have been done and that should have been taken advantage of this opportunity to receive was an effectively remunerative support” (P1).According to the participants, this acknowledgment can be done in several ways and one of them is monetary rewards - “It always feels good to hear a thank you from a manager, doesn’t it?” (P7).Similarly, participants indicate that comforting expressions and gestures of appreciation are always gratifying to be received - “Thus, the participants show the importance that self-perception of recognition and appreciation as professionals and people has in contributing to the promotion of resilience.This study examined the resilience levels of healthcare professionals in Portugal and followed up with a qualitative study using in-depth interviews to understand their perspectives regarding organizational factors that improve individual resilience.2628 Nevertheless, there is a diversity of experiences, practice roles and care routines among health professionals that results in different levels of resilience. According to the results of this study, nurses had lower resilience levels in opposition to psychologists and physicians, which had the highest RSA score. Several studies30 conducted with nurses showed also lower levels of resilience compared to other occupations. This may happen, since these professionals were in direct contact with patients and perform several functions, such as administering medication, performing vaccinations, performing physical examinations, and heavier workload due to working in shifts. In addition, nurses assumed a more active role in the COVID-19 pandemic, compared to other healthcare professionals, and their occupational balance was altered. Also, the COVID-19 pandemic made nurses constantly fear contracting the virus and infecting their families, a distress that is higher for healthcare workers in emergency services.First, the results evidenced that the sample resilience level was moderate. Some international studies assessed healthcare professionals’ resilience and their levels were moderate to high. as this study confirmed. The moderate levels of resilience among physicians were not expected, which, according to the literature, is one of the professional groups with lower resilience, with a burnout prevalence ranging from 0% to 80.5% and other mental health problems such as depression and anxiety. These problems were especially prevalent during the COVID-19 pandemic. Despite the moderate levels of resilience presented by the physicians in this sample, the authors verified, that one of the worst values of resilience was from a female physician. During her interview it was possible to observe that the high levels of anxiety and fatigue complaints were due to a lack of professional support from a supervisor, high workloads, with many hours without breaks; complaints that were supported by the literature. According to a systematic review and meta synthesis of qualitative studies, healthcare professionals’ resilience stems mostly from their professional identity, collegial support, effective communication from supportive supervisors, and the flexibility to engage in self-care and growth experiences. The literature outlines that the characteristics that promote high levels of resilience are self-efficacy, optimism, and adaptive coping strategies. Healthcare professionals with a high level of self-efficacy are more likely to implement effective strategies to deal with certain challenges, taking measures to cope with adversities.40Psychologists are expected to have extensive knowledge in several areas associated with mental health, namely in the use of adaptive coping strategies that allow managing emotions in a positive and meaningful way,17 The training subjects are diversified which highlights the need for great variety in terms of the knowledge and skills required of professionals, since training is a predictor of professionals’ readiness for conducting advance care planning in terms of perceived relevancy, willingness, and confidence. Providing information through videos and pamphlets has been shown to be an effective strategy for managing stress in health professionals. Similarly, training of healthcare professionals on this topic could be delivered using digital tools and approaches such as mindfulness, promotion of self-care, psychological counseling, information from the different platforms and organizational support services.44Nevertheless, the organizational factors have a higher impact on the promotion of individual resilience as well. Through our interviews, the participants highlight the importance of professional training, measures to increase support and well-being, the need to reorganize services, and professional acknowledgment. Moreover, the literature suggests the implementation of resilience-oriented interventions through education and training to strengthen healthcare workers’ defenses against various mental and psychological consequences of the pandemic The participants confirmed the importance of promoting balanced and positive routines for healthcare professionals, such as days off allowing that the professionals can engage in self-care activities and have healthy lifestyles, such as maintaining proper nutrition, a good sleep routine, exercising, and establishing social connection. In addition, social support is crucial for individuals’ well-being and mental health and the evidence reports that the existence of a wider social network is associated with greater resilience. Furthermore, several studies have shown that social support, mainly from family and friends, has a positive relationship with the mental health of healthcare professionals, especially during traumatic and stressful events.49 Subsequently, establishing social contacts, even if in a different way than usual  was essential to promote healthy emotional states in healthcare professionals. Some of these topics are part of sub-scales that make up the RSA and may explain the differences found.Under the circumstances of a pandemic, appropriate measures should be established to ensure the well-being of healthcare professionals in the work environment. Some support and well-being measures were identified as an inevitability, which is corroborated by other studies that also point to the strengthening of psychological care services for teams of healthcare professionals as an important measure, since healthcare professionals’ need more mental support from superiors and services. It is essential that leaders and managers of healthcare services use this learning experience to improve services organization.Services reorganization was also mentioned by several participants. Working methodologies, physical spaces, schedules, organizational hierarchy, and information storage were emphasized. The COVID-19 pandemic promoted the adoption and development of organizational innovations that could improve access to primary healthcare by removing, at least temporarily, certain barriers.52 Studies report the need to provide economic incentives to professionals during health crises, ensuring their motivation. On the other side, working in a high-quality facility increases worker satisfaction and willingness to remain in the profession. Hence, evidence suggests that, for instance, a high level of satisfaction with the work has a significant impact on providing better patient care as well as reducing the risk of professional burnout of nurses.Moreover, professional acknowledgment was an aspect that emerged in the participants’ discourse revealing some dissatisfaction with their profession, both in terms of remuneration and appreciation. Regarding dissatisfaction, recent studies showed that the main reasons for dissatisfaction were excessive working hours, insufficient remuneration, too much administrative workload and few opportunities for promotion . Another study found out that workplace civility and gratitude have a significant impact on job satisfaction and patient safety.Concerning appreciation, this emphasis on the importance of public recognition of the work of healthcare professionals has also been highlighted in the literature. Shan et al argue that positive public responses, such as encouragement, acknowledgment, and material donations, boosted the work engagement and well-being of healthcare professionals.This study is not without limitations. The study was conducted many months after the coronavirus pandemic onset, and this possibly affected not only the participants’ ability to proper recall those specific times, but also the reliance on self-reported data. Additionally, the study’s findings may not be generalizable to all healthcare professionals in Portugal, as the sample may not be fully representative of the entire population. However, the current study has shed light on the importance of addressing organizational factors to improve individual resilience.Further studies exploring resilience levels and associated factors among healthcare professionals in different countries or regions are required. Additionally, comparing resilience levels across different healthcare systems, cultural contexts, and socio-economic backgrounds can provide a broader perspective on the role of organizational factors in shaping resilience among healthcare professionals.This mixed-method study aimed to assess the overall resilience levels among healthcare professionals in Portugal and gain insights into their perspectives on organizational factors that enhance individual resilience. Through the quantitative was found that the level of resilience was moderate, with the lowest levels manifesting in nurses. Subsequently, a qualitative phase led to the emergence of 4 major themes which were highlighted as responsible for greater resilience: “Professional’s Training,” “Support and Wellbeing Measures,” “Reorganization of Services,” and “Professional Acknowledgment.” Some of the mechanisms used by healthcare personnel to boost their resilience and deal with the pandemic were looking for psychological and family support, reorganize personal and work routines, seek for professional training in different areas such as crisis and stress management, and taking care of themselves using personal protection.The findings of this study hold significant implications for the development of targeted interventions and support systems aimed at enhancing resilience and promoting well-being among healthcare professionals. By improving resilience levels, these professionals are more likely to experience positive effects on their mental health, job satisfaction, and on the overall quality of healthcare provided to patients. It is crucial for organizations and policymakers to consider these findings when designing strategies to support healthcare workers, not only in times of crisis but for the smooth running of health services on a daily and continuous process.Click here for additional data file.Supplemental material, sj-docx-1-his-10.1177_11786329231198991 for Healthcare Professionals’ Resilience During the COVID-19 and Organizational Factors That Improve Individual Resilience: A Mixed-Method Study by Raquel Simões de Almeida, Ana Costa, Inês Teixeira, Maria João Trigueiro, Artemisa Rocha Dores and António Marques in Health Services Insights


However, the role of the body in terms of how it can or does contribute to a patient’s capacity for, or exercises of their autonomy in clinical decision-making situations has not been explicitly addressed. The approach to autonomy in this paper is aligned with traditional theories that conceive autonomy in terms of an individual’s capacities for, and exercises of rational reflection. However, at the same time, this paper extends these accounts by arguing that autonomy is, in part, embodied. Specifically, by drawing on phenomenological conceptions of the experience of autonomy, we argue that, in principle, the body is a necessary component of the capacity for autonomy. Secondly, through the presentation of two different cases, we highlight ways in which a patient’s body can contribute to the autonomy of treatment choices. Ultimately, we hope to encourage others to explore additional conditions under which a concept of embodied autonomy should be employed in medical decision making, how its underlying principles might be operationalised in clinical situations, and its consequences for approaches to patient autonomy in healthcare practice, policy, and law. Indeed, apart from relational theorists taking into consideration the impact of interpersonal and social relations on autonomy  and more recent phenomenological conceptions of mind, language, and action , is a sufficient condition for the capacity for, and exercise of autonomy. Indeed, even for phenomenological conceptions of autonomy, the capacity for reason is a necessary condition for one’s capacity for, and exercise of one’s authority over one’s actions Crowell .courses of action—weighing evidence and considering reasons for going on in one way or another”  of the Mental Capacity Act 2005 as the capacities to understand, retain, use, and weigh information relevant to a decision and communicate that decision. Similarly, as G. Owen Schaefer, Guy Kahane, and Julian Savulescu  argue, when it comes to medical ethics, competence conditions tend to refer to “reasoning capacity”, specifically, the cognitive capacities needed for an individual “to properly comprehend the options ahead of them, evaluate different options, deduce appropriate courses of action, weigh consequences, etc.” These approaches are broadly line in with certain phenomenological interpretations of the capacity for reason to the extent that, according to the phenomenologist Steven Crowell, such interpretations understand it as the capacity for “articulat[ing]  Crowell , 202.Thus, even for phenomenological approaches to autonomy, the capacity for autonomy is still partly determined by first-person, cognitive conditions linked to one’s capacity for reason. Furthermore, when it comes to the exercise of autonomy, standard approaches in bioethics, medical law, and classical phenomenology are united to the extent that they recognise that whether one exercises one’s autonomy or not depends, in part, on those motivating attitudes and experiences in which one discovers oneself to be an ineliminable ground of one’s decisions and actions. Thus, the exercise of autonomy, even of a phenomenological kind, is constituted by cognitive processes of rational self-reflection.However, for phenomenologists, there is also an important non-cognitive dimension to autonomy that, as a matter of principle, cannot be accounted for by appealing to the capacity for, and process of cognitive reflective self-awareness.primary intentional and meaningful access to the world is always through, and in relation to one’s body . Secondly, my cognitive access to my values, desires, and motivations is dependent on contextualised, practical bodily engagements, that is, bodily comportments and practical actions that are always part of a context which I identify as significant and meaningful for me  are the related concepts of “absorbed coping” and “practical identity.” In the rest of this section, we will articulate these two phenomenological concepts and outline how they explain one’s ability to disclose one’s motivating attitudes.Key to understanding why, for phenomenologists, practical bodily engagements are the primary means of accessing one’s Hubert Dreyfus, a phenomenologist and classical phenomenology scholar, endorses the concept of “bodily intentionality” . However, Dreyfus extends the concept in one important sense: intentional bodily engagements through which one interprets phenomena as inherently and immediately meaningful are to be understood as “a steady flow of skilful activity in response to one’s sense of the environment” Dreyfus , 81. In one’s sense of the environment” [emphasis added] . Such descriptions include doctor, mother, lover, liberal, runner, cyclist, cynic, autistic, and so on. As Crowell acknowledges, most people’s practical identity is an evolving, complex constellation of many descriptions. Furthermore, such identities are practical to the extent that “they are not primarily objects for theoretical contemplation, nor merely social roles that are attributed to us in a third-person way, but are expressed in what we do” . Indeed, descriptions will be associated with some “constitutive standards” for practical action by which one can assess oneself or be assessed by others as succeeding or failing to embody a particular description (ibid.). But even constitutive practical actions  will be expressed by individuals in specific ways. Moreover, given that an individual inhabits many descriptions, some will be valued more than others and thereby feature more prominently in an individual’s intentional bodily engagements, meaning that everyone will have their own unique practical identity, expressed in specific ways.As these examples imply, how we express absorbed coping through our intentional bodily actions is specific to each of us. According to Dreyfus, one’s fluid, skilful actions are always “in response to  Dreyfus , 81. Thi Dreyfus . Accordi Dreyfus , 218, ontrying to be a carpenter; being one  is an issue for me, is at stake in what I do” . Furthermore, because we embody a specific practical identity with its own skilful, fluid bodily expressions, the state of bodily unity that we achieve through absorbed coping will be specific to each of us. In other words, we achieve practical “equilibrium” or “poise” in our environments through our own bodily mannerisms, comportments, practices, and routines.Returning to the question of why, for phenomenologists, one’s practical, cognitively unmediated bodily responses to one’s sense of the environment interpret values, desires, and motivations as being authentic, the point is that one’s skilful, fluid, and intentional actions  are expressions of one’s practical identity. Through embodied expressions of my practical identity, I am accessing and disclosing my own values, desires, and motivations because my practical identity already provides me with these reasons for acting in certain ways Crowell , 243. AsHaving outlined the concepts and central principles of bodily intentionality, absorbed coping, and practical identity, and the ways they relate to one another, we can infer from these discussions three phenomenological implications of pre-reflective, intentional bodily action for the concept of autonomy.as values, as one’s values, and as values that make sense in terms of the other attitudes and commitments that one holds, is dependent on having a practical identity, which is expressed through intentional bodily engagements with one’s environment. As a matter of phenomenological principle, individuals without a practical identity  would have no reasons for acting and, relatedly, no values, desires, or motivations on which to reflect when exercising their autonomy in decision-making situations  exercise one’s autonomy, but where we’re required to reflect on our reasons for action and communicate an explicit choice. This question raises complex issues, requiring detailed analysis as well as illustrative examples, so we afford it its own section.According to the phenomenological principles of bodily intentionality and absorbed coping, our authentic motivating attitudes are disclosed to us and enacted even before we come to reflect on or rationally respond to them. But what happens when we are required, as patients, to consent to or refuse a particular medical intervention or choose from a range of treatment options? It is nonsensical to suppose that our bodily engagements are a sufficient condition for exercising our autonomy in these contexts because, firstly, such enactments of our values and desires are—despite being the basis of our cognitive reflections—pre-reflective and non-cognitive. In addition, making medical decisions in relation to a specific condition will, for most of us, not be part of our everyday practices . When we are required to take responsibility for ourselves , we experience a cognitive disengagement from our everyday fluid, skilful practices of absorbed coping and are solicited by the situation to choose to make a choice , it implies that, in most instances, there is no apparent reason to look beyond traditional cognitive approaches to autonomy prevalent in the medical ethics literature.Assuming that, for most people with relatively minor and easily treatable medical conditions, exercising autonomy in treatment contexts will primarily depend on their rational reflections on their motivating attitudes, the discussions in section one raise theoretically interesting and, at least in bioethics, previously unexplored ideas and claims about the source of our authentic reasons for action. However, even though having a practical identity and thereby the capacity for bodily intentionality is, in principle, a necessary component of one’s capacity for autonomy, it is not yet clear why the body can play a substantive role in medical decision making.adequately explain why each patient is unable to exercise their autonomy nor adequately account for those conditions that need to be satisfied so they can genuinely exercise their autonomy in these specific medical decision-making contexts. Moreover, to avoid unwarranted and unnecessary paternalism or substituted decision making and, as relational theorists of autonomy have convincingly argued  when a patient experiences bodily disunity and expresses themselves in ways which a clinician judges to be indicative of irrationality and/or a lack of autonomy; and (ii) when a patient experiences bodily disunity as a result of the condition with which they presenting and will never again be able to embody the practical identity they had before the onset of that condition. The common factor in these cases is the patient’s experience of “bodily disunity”. As explained above, when one is skilfully engaged in a practice in a way that is unmediated by cognitive states and processes , one achieves a state of “equilibrium” or “poise” with one’s body and one’s bodily engagements with one’s environment. This state of “bodily unity” is, from a phenomenological perspective, considered to be normatively significant for two reasons; firstly, according to Kong , 80, we Seb is a 22-year-old with autism. Nevertheless, he is high-functioning, generally competent, and demonstrably able (under the right conditions) to understand, retain, use, and weigh medical information and communicate treatment decisions. Seb has no underlying health conditions or any other cognitive or somatic impairments. Seb goes to his GP seeking treatment for what turns out to be a minor, early-stage staph infection on a small part of his torso. The waiting room is noisy and busy. Given the sheer volume of patients and the complexity of some of the cases, Seb’s GP is running 45-minutes late. Seb’s case is comparatively straightforward, so, when he enters the treatment room, the GP quickly diagnoses the issue, rapidly informs Seb about the diagnosis and his treatment options, and recommends a short course of antibiotics. While informing Seb about the condition and the associated treatment recommendation, the GP notices that Seb is repetitively and rhythmically “flapping” one of his arms. Conscious of the number of patients he has to attend to, the GP presses Seb for an answer about whether he agrees to the treatment recommendation. Continuing to “flap” one of his arms, Seb begins to make repetitive, rhythmic “clicking” noises with his tongue. The GP, once again, presses Seb for an answer. Seb’s movements become more emphatic and his vocalisations louder. The GP asks Seb whether everything is okay. Seb says “yes,” but still does not provide an answer to the GP’s treatment recommendation. The GP tells Seb that he will call Seb’s mother and discuss the diagnosis and treatment recommendation with her. He instructs Seb to return to the waiting room. Overwhelmed by the noisy and busy waiting room environment, Seb leaves the surgery.Before proceeding with a phenomenological analysis of this case, it is worth pointing out that the following discussions will not be directly concerned with the GP’s actions. We have discussed some of these issues elsewhere , indicating some form of cognitive impairment, or in their failure to exercise those capacities for some unrelated (epistemic) reason . When considered in relation to a framework that identifies autonomy purely with capacities for reason and cognitive processes of rational reflection, seemingly irrational or socially unacceptable behaviours could be judged as offering support to this assumption and, as a matter of principle, lead one to infer that the patient, rather than being temporarily inhibited from making an autonomous decision, is cognitively incapable of making such a decision altogether. For instance, although some individuals with autism can be cognitively impaired . After several consultations with her GP, a rheumatologist, and a neurologist, Mairéad has recently been diagnosed with fibromyalgia—a common cause of chronic diffuse pain, for which there is currently no cure. Mairéad’s GP informs her about the implications of her condition and her treatment options, which include different sets of medications and psychological therapies. The GP makes the point that no matter which set of treatments Mairéad chooses, she will need to make lifestyle changes, specifically, refraining from the types of physical exertion required, and physical joy created by her usual recreational activities. Mairéad is extremely upset. She later describes her experience as “having the whole world pulled from under me.” She informs the GP that she “can’t decide.” The GP says that it is important to start treatment as soon as possible. Mairéad says that needs to “think about it.”One might query the autonomy basis for Mairéad’s inability to decide upon a specific set of treatments. Again, if we go by conventional approaches and conceive autonomy purely in terms of cognitive capacities and cognitive processes, we might infer that Mairéad is, at that moment, unable to understand, retain, or epistemically use the pertinent medical information provided by the GP. In other words, like with the previous case, purely cognitive approaches to autonomy would lead us to look for the source of the inhibition at the level of the patient’s competence and exercise of their epistemic abilities. However, the concept of embodied autonomy gestures at a more fundamental reason for Mairéad’s response and her inability to choose at that moment in time in a way that one would reasonably consider to be a genuine exercise of her autonomy.A substantive part of Mairéad’s practical identity is bound up with her recreational activities, which she describes as her “way of life.” She expresses her practical identity and achieves a state of bodily equilibrium or poise in her environment though these routine activities. As a result, Mairéad’s inability to partake in her usual bodily practices at the level she did prior to the onset of her symptoms leads her to experience a general sense of bodily disunity. Because of her practical identity, her body is still disposed towards her usual recreational activities. At the same time, because of the pain, fatigue, and depression, her body is unable to act on those dispositions. Concurrently, she experiences uncontrollable movements, including clenched jaw, furrowed brow, pacing, fidgety hands, crossed arms, foot-tapping, and restless legs. Furthermore, her experience of bodily disunity is compounded when she receives the news from her GP that she is no longer able to partake in sporting activities.As explained in section one, as a matter of phenomenological principle, an individual’s practical identity provides them with reasons for acting Crowell , 243, anGiven that authenticity is a necessary criterion of the reflective process that contributes to the exercise of autonomy and given that such a reflective process presupposes pre-reflective access and engagement with one’s authentic values through bodily actions associated with one’s practical identity, Mairéad would need to redefine her practical identity in order to make a genuinely authentic and autonomous treatment decision. As Diana Meyers claims, because “we define ourselves as we act…we cannot redefine ourselves without altering our patterns of action” Meyers , 46. ThiWe have argued that, in principle, the body is a necessary component of the capacity for autonomy. Through the presentation of two pseudo-anonymised, part-fictional cases, we have also highlighted some of the implications of a phenomenological conception of embodied experience for our understanding of patient autonomy. As we have made clear, the body’s role in autonomous treatment choices will depend on a number of factors, including the patient’s condition, their characteristics, and features of the clinical encounter. We have argued that when a patient experiences bodily disunity and expresses themselves in ways which a clinician judges to be indicative of irrationality and/or a lack of autonomy, or when a patient will never again be able to embody the practical identity they had before the onset of the present condition, the autonomy of their treatment choice can substantively depend on their bodily capacities and expressions and the ways these relate to the patient’s mental capacity and cognitive processes. The phenomenological principles employed as the basis of an embodied approach to autonomy entail that physicians and medical staff should be disposed to be attentive to their patient’s state of bodily (dis)unity, on the basis of which they are able to express their practical identity and access their authentic values, desires, and motivations that inform treatment decisions. Without consideration of these principles, we are unable to adequately explain why a patient is unable to exercise their autonomy or develop theoretically robust healthcare mechanisms to support patient autonomy in these instances.