Introduction
How can public authorities ensure the effective implementation of policies that are likely to cause moral distress amongst employees? The retrenchment of the welfare state is a defining policy development in advanced welfare states. In the context of means-tested services and social insurance, budget cuts usually mean that caseworkers have to carry out more rigorous assessments. This can have profound consequences for their wellbeing. Previous research on moral distress has shown that cuts to social policy often result in tensions between policy ambitions and the moral convictions of public officials. Consequently, an increasing amount of research is examining the pressures experienced by caseworkers when implementing austerity measures. This literature describes the associated psychological stress, de-professionalisation and coping strategies experienced by caseworkers. (Grootegoed and Smith, Reference Grootegoed and Smith2018; Owens et al., Reference Owens, Singh and Cribb2019; Fenton, Reference Fenton2020; Malin, Reference Malin2020).
This article offers a different perspective. Rather than analysing moral distress as a consequence of austerity, it examines it as a management problem for organisations implementing cuts. As Vivien Lowndes and Kerry McCaughie (Reference Lowndes and McCaughie2013) have noted, the attitudes and choices of individuals working in public services are key to understanding how austerity programmes play out. If caseworkers are affected by anticipating the consequences for claimants who are denied support, this could undermine cost-cutting ambitions. Caseworkers may protest or use their discretion to mitigate the impact on applicants. Some may choose to look for a new job. Therefore, it seems plausible that organisations committed to introducing cuts would want to reduce moral distress. However, social policy research has yet to describe how, or indeed whether, public agencies do this.
In response to this research gap, this article examines the reorganisation of casework within the Swedish Social Insurance Agency (SSIA), Försäkringskassan, between 2015 and 2020 – a period in which the agency was tasked with implementing significant cuts in sickness insurance. During this time, the proportion of rejected applications from people with long-term illnesses increased fivefold (Altermark, Reference Altermark2020). Through an analysis of steering documents, official policies and qualitative interviews with caseworkers, I demonstrate that the changes introduced during this period were a response to the risk of caseworkers failing to implement stricter assessments due to sympathy for claimants. Drawing on Foucault’s (Reference Foucault1982:790) understanding of government as the structuring of fields of action, I identify four clusters of technologies introduced by the SSIA: (1) technologies reducing professional autonomy; (2) measures obscuring caseworkers’ individual responsibility; (3) ways of organising casework to make the consequences of decisions less visible; and (4) the introduction of an organisational ethos encouraging caseworkers to suppress their individual consciences in service of democratic ideals. Whilst the study cannot give definite answers regarding the extent to which the measures were deliberately designed to reduce moral distress or how efficient they were, the analysis reveals that the suppression of moral distress was an underlying principle in the management of caseworkers during this period.
These arguments introduce a new perspective on social policy retrenchment, drawing attention to the management of the emotional states of public officials when implementing austerity. In light of the financial pressures on public welfare and the ongoing prevalence of workfare and activation in social policy practice (see Huo, Reference Huo2009; Wright, Reference Wright2016), the themes explored in this article are likely to remain relevant in many welfare systems for the foreseeable future. Furthermore, the analysis informs broader discussions about the roles and responsibilities of public officials, particularly when they are expected to implement policies that they deem to be morally problematic. In contrast to academic discussions that attempt to identify principles determining when employees have a duty to disobey (see Delmas, Reference Delmas2018; Lundquist, Reference Lundquist1998), my argument is that the inclination to disobey due to moral distress can be targeted by steering.
The article is structured as follows. First, I discuss the concept of moral distress and its role in austerity research. Then, I present the theoretical perspective of government as the structuring of fields of action. The introduction concludes with a presentation of the methods and materials used. The empirical section presents four clusters of steering technologies that seek to reduce moral distress. This is followed by a discussion of how caseworkers adopt different roles in relation to these technologies. The concluding section discusses the broader implications of the argument.
Moral distress as a steering problem
The concept of ‘moral distress’ was introduced in the context of nursing. It was conceptualised by Andrew Jameton (Reference Jameton1984:6) as occurring when individuals are prevented from acting in accordance with their moral beliefs. Clearly, given this definition, the concept can be applied well beyond the empirical context of nursing, to a wide range of professions where institutional or practical constraints may prevent people from acting on their beliefs.
For the purposes of this article, two problems arise with Jameton’s definition. It appears unnecessarily narrow in that it excludes situations in which agents lack a clear conviction about the right course of action, such as moral dilemmas (see Fourie, Reference Fourie2015). However, it also seems too broad, as it includes situations in which agents are not psychologically affected by their work. In response to these issues and in line with the work of Morley et al. (Reference Morley2019), I understand moral distress to be a particular type of psychological stress that arises from work situations with an ethical dimension. Other studies have used terms such as ‘ethical stress’ and ‘moral stress’ to describe the same phenomenon (see Grootegoed and Smith, Reference Grootegoed and Smith2018).
Several previous studies have highlighted the challenges faced by social workers when implementing cuts. There is a general consensus that austerity has significantly impacted frontline public sector workers, often resulting in de-professionalisation (see Owens et al., Reference Owens, Singh and Cribb2019; Malin, Reference Malin2020; Murphy, Reference Murphy2023). Grootegoed and Smith (Reference Grootegoed and Smith2018) describe how caseworkers manage conflicts between professionalism and cost-cutting, which forces welfare professionals to balance diminishing resources with citizens’ wellbeing. Hastings and Gannon (Reference Hastings and Gannon2022) discuss coping mechanisms for these situations, such as absorbing cuts by taking on additional responsibilities and working overtime to protect citizens from the effects of austerity. This may result in welfare professionals facing increasingly challenging working conditions. Fenton (Reference Fenton2020) points out the risk that welfare workers may internalise the logic of austerity by suppressing moral distress.
As mentioned earlier, this article adopts a different approach by focussing on public agencies implementing austerity programmes and suggesting that reducing moral distress could be crucial for them to successfully cut costs. A general insight in public administration research is that conflicts between policy decisions and professionals’ beliefs hinder implementation (see Ham and Hill, Reference Ham and Hill1984: 98; Lundquist, Reference Lundquist1987). Such conflicts may also arise when professionals anticipate that their decisions will cause suffering to citizens. One way in which officials can reduce distress is by using professional discretion to implement policies in ways that mitigate the effects on target groups, akin to the absorption strategy mentioned above. This type of discretionary decision-making is frequently discussed in literature on street-level bureaucracy (Lipsky, Reference Lipsky1980; Ellis, Reference Ellis2011; Tummers and Bekkers, Reference Tummers and Bekkers2014), which generally acknowledges that implementation must be examined from the bottom up, beginning with the circumstances and beliefs of frontline bureaucrats. Moral distress has also been described as increasing the likelihood of employees changing jobs or taking sick leave (see Mänttäri-van der Kuip, Reference Mänttäri-van der Kuip2016), which incurs additional costs for organisations.
For these reasons, organisations that are determined to make cuts have a strong incentive to reduce the moral distress experienced by their employees. The literature on austerity and moral distress needs to address whether and how public agencies do this. One of the key aims of this study is to pave the way for further research into how public agencies influence their employees’ consciences when implementing cuts.
Structuring fields of possible action
The fact that this study analyses efforts to prevent moral distress from obstructing implementation does not mean that it is a traditional implementation study, concerned with specifying the conditions for successful implementation or the causes of failure (see Hill and Hupe, Reference Hill and Hupe2022). Instead, the analytical ambition is to describe and expose the underlying logic of organisational techniques that affect caseworkers’ emotional states. This requires a theoretical approach that allows for discussion of the steering devices deployed by public agencies to manage moral distress, the underlying ideas and functions of these devices, and how they influence employees’ professional roles. Building on steering literature inspired by Michel Foucault’s work (Bevir, Reference Bevir2011; Dean, Reference Dean2009; Rose and Millar, Reference Rose and Miller1990; Rose, Reference Rose1999), I will use three concepts that address these needs: ‘technologies of government’, ‘rationalities’ and ‘subjectivation’.
In Foucauldian scholarship, ‘technologies of government’ typically refer to measures that influence the behaviour of targeted individuals (see Bevir, Reference Bevir2011; Rose and Millar, Reference Rose and Miller1990). Foucault’s work encompasses a variety of such technologies which operate by disciplining individuals, managing populations and orchestrating how people exercise agency within the norms, rules and ideals in which they are embedded. These technologies are characterised by the fact that they ‘act upon acting subjects’ (Foucault, Reference Foucault1982:789). Rather than forcing people to behave in certain ways, technologies of government target how agents understand themselves and how they choose to behave given this understanding. For Foucault, government is therefore not primarily about commanding subordinates or making laws, but rather about attuning the behaviour of subjects to fit a specific purpose. This is achieved through what he terms ‘the structuring of the possible fields of action of others’ (Foucault, Reference Foucault1982:790). The focus on ‘fields of action’ suggests that agency is situated and is always exercised in contexts that may be more or less conducive to producing certain outcomes. Some choices may be incentivised, certain decisions may be hardship-inducing, and there may be sanctions or punishments. There are also always norms about the appropriateness of different behaviours. Together, these factors constitute the field of action within which subjects act.
This study focusses on technologies that affect the decision-making of SSIA employees by reducing their moral distress. This brings us to our second concept: the rationalities of such technologies. Following Mitchell Dean (Reference Dean1996), I understand rationalities of government as ways of problematising social life, delineating what constitutes a problem and often suggesting what the solution might be. Rationalities can thus be considered the underlying purposes that unite technologies by defining their overarching objectives. In this case, a central rationality can already be discerned in the formulation of the research problem: moral distress may cause caseworkers to be overly generous when assessing sickness insurance claims. However, as we will discuss in the empirical analysis, technologies can be grouped according to more specific rationalities, such as the importance of creating distance between caseworkers and claimants, or the need to obscure the individual responsibility of caseworkers. Importantly, rationalities should not be mistaken for intentionally designed strategies. Rather than taking the stated ambitions of steering measures at face value, an analysis of rationalities seeks to uncover the underlying logic of policies, whether they are intentionally designed or not.
Finally, Foucault’s conception of power and governance is productive rather than repressive (see Foucault, 1982; Reference Foucault1990). As described above, governments do not primarily decide how subjects act; rather, they shape the subjects that act by structuring their fields of action. Towards the end of his life, Foucault (see Reference Foucault1988; Reference Foucault1997:101–34) came to understand this process as a complex interplay between agency and the social structures within which individuals operate (Hartmann, Reference Hartmann2003; Collier, Reference Collier2009:95–6). Rather than viewing subjectivity as being determined by social and discursive structures, the concept of subjectivation denotes how individuals actively shape themselves in relation to existing power configurations. As we will see in the analysis, caseworkers develop their professional roles in different ways in relation to the SSIA’s internal steering.
In summary, technologies of government are interventions that shape the field of action of individuals, underpinned by rationalities that serve as their unifying purpose. Through processes of subjectivation, people adopt roles and behaviours in relation to the technologies of government that target them.
Method and material
This study emerged from a 3-year research project examining changes to the Swedish sickness insurance system. During initial interviews with caseworkers, several interviewees stated that empathising with sickness insurance claimants was viewed as problematic, as it could distort decisions and undermine the government’s goal of rejecting a higher proportion of claims. Given previous descriptions of casework within the SSIA, which emphasise the importance of thorough knowledge of the individual’s situation, flexibility and a willingness to guarantee the applicant’s rights (Melander, Reference Melander2013; ISF, 2018:16), it seemed that new ideals for caseworkers had emerged simultaneously with the government efforts to reduce costs. Following these initial observations, the idea that empathy could hinder the implementation of cuts became an important theme in the subsequent data collection.
From an early stage, it became clear that identifying an overarching plan behind the organisational changes implemented would be difficult. The reasons for the changes were rarely made explicit in internal documents, and official statements consistently described the reorganisation of the agency in broad terms, referring to the rule of law and democratic legitimacy. Furthermore, even if there had been a strategic plan to minimise the impact of moral distress, responsible managers and senior officials within the agency who could talk about it were notoriously difficult to access. In line with the Foucauldian approach described above, it made more sense to examine how casework was organised in an attempt to reconstruct its internal logic. Consequently, this analysis will not address the question of whether the SSIA intentionally reorganised casework to alleviate caseworkers’ moral distress. However, it will demonstrate that this was the actual logic behind the changes introduced.
This argument was constructed through the analysis of various types of source material. Firstly, the policy documents of the SSIA from 2015 to 2020 were examined. These documents contain internal guidelines for caseworkers administering the sickness insurance scheme, as well as official reports on the SSIA more broadly. Secondly, fourteen qualitative interviews were conducted with caseworkers, focussing on how they organise their work and the moral conflicts and challenges they experience when assessing sickness insurance claims. Participants were recruited through online advertisements and the interviews lasted between 45 minutes and 60 minutes. Thirdly, to validate my findings, I conducted a series of interviews with three senior SSIA officials. These interviews were intended to ensure that I had not overlooked any relevant material and that my interpretations of the internal processes within the SSIA were accurate. Finally, to supplement these data sources, I collected transcripts of focus group interviews with thirty caseworkers, which were conducted by the Social Insurance Inspectorate (ISF) and an official government commission. Unfortunately, these data do not provide much information about how the focus groups were assembled and how the interviews were conducted. Whilst they largely follow the same patterns as my interviews in terms of content, I have chosen to cite them only sparingly. The methodological approach and data collection have been approved by the National Ethics Board in accordance with Swedish law.
The analytical process consisted of three steps. First, I examined the material, searching for technologies of government and thematically sorting organisational features and ideals about how casework should be conducted. This enabled me to identify the four clusters of technologies that structure the subsequent empirical section. Next, I used the concept of rationalities to clarify the problems to which these technologies responded. The empirical analysis below presents the steering technologies and rationalities of government together. The third and final step of the analysis focussed on how the interviewees responded to these steering mechanisms, how they viewed their work and the extent to which they supported the SSIA’s ambition to reduce the generosity of the sickness insurance system.
The main shortcoming of the study was the difficulty of recruiting managers, internal educators and centrally placed strategists – a problem that future research could hopefully address. Including interviews with managers or senior officials within the SSIA would have provided broader insights into the agency’s prevailing rationalities at the time. This would also have contributed to a more detailed understanding of how the implementation process unfolded.
The management of moral distress
Sweden is commonly associated with its universal social insurance system, which was established and expanded in the decades following the Second World War. However, since the 1990s, the country’s social insurance has become considerably less generous, primarily due to reductions in support for the sick and disabled (Altermark and Plesner, Reference Altermark and Plesner2025; Försäkringskassan, 2023). This article analyses the steering of caseworker decision-making between 2015 and 2020, during which time the Social Democratic government instructed the SSIA to reduce the generosity of the sickness insurance system. The centrepiece of this strategy was a quantitative target to reduce the average number of sick days by 10 per cent (Socialdepartementet, 2015a). An additional government memo (Socialdepartementet, 2015b) directed specifically at the SSIA clarified that the agency was expected to achieve this by interpreting the existing legislation more strictly, particularly with regard to individuals experiencing prolonged sickness absence.
In the coming years, the number of claims rejected after 180 days of sickness absence increased fivefold (Altermark, Reference Altermark2020). A discernible shift in the trend occurred only a few weeks after the government target came into effect (see Försäkringskassan, 2018). As Jacobsson et al. (Reference Jacobsson, Seing and Hollertz2020) describe, this was accompanied by a new culture gaining ground within the SSIA, centring on the risk of caseworkers being too generous. These changes prompted medical professionals to caution that these stricter assessments could hinder rehabilitation (Andersson, Reference Andersson2016; Chowra-Skoglund, Reference Chowra-Skoglund2017).
In light of previous research on moral distress, these events suggest that SSIA caseworkers were likely to experience hardship, feeling burdened by the expectation of implementing government-sanctioned cuts. Nevertheless, the SSIA managed to reorganise casework in such a way that a much higher proportion of claims were rejected. We will now discuss the technologies introduced during this period.
Diminishing professional autonomy
The first set of technologies to be discussed consists of organisational changes that decreased professional autonomy by standardising assessment procedures. These measures were central to the overarching strategy of introducing more rigorous eligibility evaluations. However, they were also implemented in response to the specific issue of moral distress.
Shortly after the government target was announced, SSIA established a new organisational and management structure, signalling the commitment of the director general and the board to meeting the government’s expectations (Försäkringskassan, 2016b). The new organisational structure was decidedly hierarchical and based on more detailed management of caseworkers. This was justified with reference to allegedly lacking uniformity in the assessment of sickness insurance claims (Försäkringskassan, 2016b; 2017a; ISF 2018:16:123). Around the same time, the SSIA’s legal department was tasked with drafting new guidelines for caseworkers (Försäkringskassan, 2016b, 2016c; ISF, 2018:16). The resulting document established a new way of assessing the legal right to sickness insurance. Compared with previous guidance documents, it placed a much stronger focus on the formal requirements for receiving support, particularly with regard to the medical certificate. Previously, the SSIA had designed the administrative process to assess the specific situation and needs of the individual. This meant that the mandatory medical certificate had to be supplemented with detailed knowledge of the applicant (see Melander, Reference Melander2013; ISF, 2018:1:121–123). Prior to 2015, caseworkers had become increasingly autonomous (Jacobsson and Johansson, Reference Jacobson and Johansson2025:41). This fostered a relatively high level of professional discretion, whereby caseworkers were expected to use their experience and knowledge to make informed decisions. In contrast, the 2016 guidelines focussed on the content required for a medical certificate to qualify for sickness insurance. Caseworkers’ main task became carefully scanning these certificates for the required components (Försäkringskassan, 2016c; ISF, 2018:16).
The main rationale for this was that stricter assessments required more detailed management. As research into street-level bureaucracy has demonstrated, discretion is frequently employed to circumvent or reinterpret policy reforms (Hill and Hupe, Reference Hill and Hupe2022). However, standardisation techniques can also be viewed as a more specific response to the issue of moral distress. If there is only one way to assess sickness insurance claims, caseworkers have fewer reasons to feel remorse about their decisions. Furthermore, standardisation implies that caseworkers are interchangeable; if they were to resign or act contrary to policy, they would simply be replaced by someone else following the same rigorous guidelines. Thus, standardisation implies that caseworkers cannot affect the fate of applicants much.
Obfuscating individual responsibility
As discussed above, previous research has identified concern for those receiving support as a source of moral distress. Therefore, technologies designed to make caseworkers feel less responsible for the consequences of rejected applications could potentially reduce their moral distress.
The obfuscation of responsibility within the SSIA relates to the standardisation of casework, as described above. As previously mentioned, the organisational changes within the agency were embedded in an internal discourse of ‘equal treatment’ and ‘uniform decisions’. Professional discretion was associated with an overly generous interpretation of the law. This was a point that was repeatedly emphasised by managers and in internal communications (Jacobsson and Johansson, Reference Jacobson and Johansson2025). Consequently, it became easier for caseworkers to view themselves as merely implementing the will of the legislator. This is evident from several interviews in which caseworkers state that the new method of assessing applications was in line with the very strict legislation.
You have 180 days, and thereafter there cannot be a single job on the labour market that you can do if you are to get sickness insurance after that, and that is a very strict and narrow insurance. (Interviewee 1)
As it stands, way too many people get sickness insurance after day 180. We are too generous in our assessments.
Interviewer: Too generous in relation to what exactly?
In relation to the rules, to the requirements that we are to work with. That there is no right to sickness insurance after day 180.
(Government commission focus group – Alvik)
Interestingly, these descriptions are not correct. According to the legislation (SFB 210:110) and the Supreme Administrative Court’s ruling on the matter (HFD, 2018 ref. 51), the evaluation that a person can perform any existing job in the labour market was never sufficient to deny sickness insurance. However, if caseworkers believed that the legislation required this, they were not responsible for the consequences. Whilst the hardships experienced by claimants may be seen as unfortunate, it is not the role of caseworkers to determine the design of the Swedish sickness insurance system:
It is always most challenging when I must make a decision that will affect an individual negatively, I may, for example, decide on denying sickness insurance provided the medical facts. To communicate this, because I understand that the decisions that I make, provided the legislation, strikes very hard at people. […] Oftentimes, I can feel that I wished that the law was something else. (Interviewee 7).
This line of argument recurs throughout the material. As a discursive device, it deflects responsibility from the caseworkers to the legislators. The efforts of the SSIA head office to emphasise that the legislation required very strict assessments provided caseworkers with a justification for actions that were repeatedly described as burdensome in the interviews. Indeed, this enabled several interviewees to express sympathy for claimants whilst simultaneously describing themselves as being forced by the legislation to reject the applications of individuals who were genuinely too unwell to work.
In other ways, too, caseworkers were targeted with technologies that relieved them of responsibility. Other organisational changes meant that individuals were increasingly sharing responsibility for decisions with colleagues. One of the most significant of these changes concerned the role of ‘specialists’, a group within the agency that had previously offered advice on difficult and complex cases. After 2015, this group became more prominent within the organisation, and according to the interviews, was responsible for relaying management directives on how casework should be carried out. Caseworkers who felt uncomfortable with the stricter assessments could turn to the specialists for validation. Several interviewees explained that, although the formal responsibility for decisions lay with the caseworker, the specialists were pushing for stricter assessments:
We don’t sit here and require complements to be able to grant sickness insurance. We do it so that we can make a correct judgement concerning whether the claimant can get support. But the guidelines have been much stricter from specialists and managers regarding how we should work. (Interviewee 9)
Another aspect of the SSIA’s internal reorganisation was that caseworkers started working in teams. These teams were encouraged to discuss challenging cases and provide mutual support. Several interviewees described how teams work jointly on cases:
Some do individual cases, but my team works with shared ‘views’, so that we are in everybody’s. It could be me or a colleague that makes the assessment, it does not matter. It is not ‘mine’ or ‘yours’, but ‘ours’. This contributes to uniform decisions, that we work on each other’s cases all the time. We start to think more alike. (Interviewee 3)
Although clients were assigned a specific caseworker, teams would, in practice, share responsibility for their cases. Given the emerging culture within the agency that emphasised stricter assessments as a testament to impartiality, this meant that close colleagues would often confirm that rejected applications were correct (see ISF, 2018:16:123; Jacobsson and Johansson Reference Jacobson and Johansson2025:77–78). In their ethnographic work, Jacobsson and Johansson (Reference Jacobson and Johansson2025:60) demonstrate that team meetings were crucial in fostering positive emotions regarding the introduction of stricter assessments, where ‘showing good numbers’ instilled a sense of pride amongst team members. Managers issued a steady stream of directives emphasising that the agency was accepting too many sickness insurance applications and that a lower acceptance rate was necessary (Jacobsson and Johansson, Reference Jacobson and Johansson2025:45, 59–60). Consequently, rather than taking individual responsibility for denying support to individuals, SSIA caseworkers were encouraged to view themselves as part of a collective mission to implement stricter assessments.
In summary, technologies designed to remove responsibility addressed the issue of caseworkers feeling guilty about the consequences of their decisions for claimants. Sharing responsibility with colleagues and superiors, or being led to believe that rejected claims were dictated by legislation, could lessen the burden and reduce moral distress.
Distancing caseworkers from applicants
Another consequence of the reorganisation of casework during this period was that the impact of rejected claims became less apparent to caseworkers. Before the government’s aim to reduce the cost of sickness insurance, the SSIA’s main objective was to win the trust of claimants. The main way of achieving this was to meet with people applying for support and explain decisions. This meant that caseworkers gained in-depth knowledge of individuals’ circumstances, enabling them to understand the potential consequences for those who lost support. If the distance between caseworkers and claimants was increased, this could lessen moral distress.
From 2015 onwards, the SSIA drastically reduced the number of face-to-face meetings and interviews with claimants (ISF, 2018:16). As the above description of the standardisation of casework suggests, not much information other than the medical certificate was needed in most cases anyway. The following quote aptly captures this:
So, I feel that the human being, the human being on sickness insurance is not that important to communicate with. What matters is the certificates that we get. The medical professional, that is, the person we communicate with and thereafter, we can call the individual and let them know that they will not get any sickness insurance payments. (ISF focus group 2)
This changed the nature of casework, shifting the focus from relationships with people in need of support to administrative paperwork and judicial assessments based on medical documentation. Claimants were relegated to the periphery of the administrative process whilst their medical certificates took centre stage. This shift was also reflected in the way interviewees talked about their professional role. The importance of remaining emotionally unaffected by the job was a recurring theme in the majority of interviews, whilst getting too close to candidates was often described as unadvisable.
Thus, the rationality behind increasing distance was to reduce moral distress by making it more difficult for caseworkers to discern the potential ramifications of rejecting sickness insurance applications. This was achieved by reducing the number of meetings and conversations with claimants. In turn, this approach was justified by the idea that medical certificates were sufficient for assessing entitlement to support.
Introducing a new ethos
The above technologies were combined with a normative steering component. All of the caseworkers interviewed expressed a strong desire to serve the public. To prevent moral distress, the SSIA had to manage staff in a way that aligned this willingness with the need to reject a greater proportion of sickness insurance claims.
As we have already discussed, the idea that stricter assessments were backed by legislation obscured responsibility. At the same time, the SSIA emphasised that implementing stricter assessments was a democratic duty. After 2015, the agency rebranded itself as first and foremost committed to administrative quality and judicial competence. The annual reports from this period describe how the increasing number of rejected claims was a consequence of improvements in the quality of the assessment process:
It is encouraging that we can see a positive development of the rule of law in our quality assessments. Among other things, this affect the average number of sick days in the population, which has been decreasing for the first time since 2010. (Försäkringskassan, 2018)
Rule of law has a positive development within the sickness insurances. Sickness absenteeism is on a historically low level and the average number of sick days in the population has decreased further. (Försäkringskassan, 2020)
This enabled caseworkers to view themselves as contributing to the democratic decision-making process by conducting assessments that adhered more closely to the law. Whilst many caseworkers said they felt some rejected claimants were genuinely too ill to return to work, they could also take pride in denying these people support, as this meant they were upholding the legislators’ intentions. Managers emphasised this as well (see Jacobsson and Johansson, Reference Jacobson and Johansson2025:129). Sometimes, this meant that caseworkers had to suppress their personal feelings.
So, the job requires a broad set of competences?
Yes, and a high level of integrity. Sometimes, you get cases where you feel that this person is probably very sick, but the doctor’s certificates does not show that. In those cases, I need to work with the material that I have and not my gut feeling or my sense of how I think that the sickness insurance system ought to work. (Interviewee 8)
Interestingly, the meaning of ‘integrity’ is reversed in this quote from its common usage. Instead of acting in accordance with one’s moral principles despite formal requirements, the quote suggests that ‘integrity’ means overriding one’s moral intuitions to comply with organisational goals.
In this way, the rationality behind the normative steering in the post-2015 SSIA was to give employees a sense of purpose that would take precedence over concern for claimants. Caseworkers’ willingness to serve citizens could be aligned with the government’s cost-reduction target if they believed that stricter assessments were the legitimate outcome of democratic processes. However, as noted above, the new method of assessing eligibility for sickness insurance was in fact at odds with the legislation (HFD, 2018; Mannelqvist, Reference Mannelqvist2019). The SSIA responded to the government’s goal of reducing costs by introducing stricter requirements that were not supported by law, whilst encouraging employees to suppress any reluctance by presenting the application of these requirements as a service to democracy.
The subjectivation of caseworkers
The remodelling of the ‘field of possible action’ through the above-described technologies had implications for the expectations and ideals surrounding caseworkers. Administrators of sickness insurance were expected to be distant and detached from claimants. They were expected to separate their personal feelings from their professional role and carefully follow internal guidelines rather than exercise professional discretion (see Jacobson et al., Reference Jacobsson, Seing and Hollertz2020; Jacobsson and Johansson, Reference Jacobson and Johansson2025).
However, this does not mean that all caseworkers adapted effortlessly. Indeed, almost all interviewees expressed concern about the consequences for sick claimants who lost support. Despite the increased distance and reduced contact, there was a general awareness that many people in need of economic support could be severely impacted.
I like my job and 95% of it is great fun, where you help people understand the sickness insurance system and move along in their lives, so there are lots of positives. And then we have this small share that is not very fun, because I am still a human being. But I am employed to do this job. I am not hired to be a fellow human. And this may sound harsh, but I must relate to my role as a professional, otherwise I cannot have this job. (Interviewee 7)
Similar lines of reasoning recur in a number of the interviews. Two ways of responding to the insight that sick people may experience serious harm can be discerned amongst the interviewees. First, around half of the interviewees describe actively seeking to distance themselves emotionally, in line with the ideals emphasised by managers and in internal training programmes (Jacobsson and Johansson, Reference Jacobson and Johansson2025). Although members of this group may be concerned about applicants, they often refer to the distinction between their personal and professional roles. Feelings of moral distress were considered a personal matter, whereas their decision-making as caseworkers was seen as part of their professional role. This split between professionalism and personal feelings was supported by the above-described technologies of government.
The other group is critical of the new approach to assessing sickness insurance applications. They do not view moral distress as something that can be overcome, nor do they subscribe to the ideals of impartiality within the SSIA. All respondents in this group describe themselves as being antagonised to varying degrees. Examples from the interviews include being reprimanded for making decisions that were considered too generous, being ostracised at work and being forced to undergo special internal training, as described by one interviewee: ‘In the period when I closed the most cases, I was questioned for not handling cases as being a means tested insurance, that is, that I did not reach a good number of denials. (Interviewee 10).’
All of the caseworkers in this group were either on sick leave, leave of absence or had resigned from the SSIA. Many of them admitted that they had made decisions they could not justify.
There are no significant differences in how these two groups describe the organisation of casework. The main difference concerns the extent to which the organisation of casework actually reduces moral distress, that is, how their subjectivation process plays out. Defenders of the SSIA describe themselves as separating their professional role from their personal feelings, believing that increasing distance from applicants is beneficial. In contrast, critics present themselves as no longer able to work in the SSIA precisely because they cannot cope with the burden of making decisions they cannot stand behind.
When comparing the characteristics of the members of these groups, the main difference concerns when case workers started at the SSIA. Almost all of the critics started at the SSIA before stricter assessments were introduced in 2015. They were therefore socialised into the role of case worker at a time when there was still a strong focus on personal meetings and individual assessments. By contrast, interviewees defending the agency had worked there for a shorter period, receiving their training in an environment designed to produce a higher proportion of rejected applications.
Concluding discussion
The analysis presented shows that the rationale behind the reorganisation of casework within the SSIA was to reduce moral distress. Empathy with applicants was viewed as problematic and threatening to rigorous assessments. According to the agency’s prevailing view, the ideal caseworker is able to set aside their personal feelings when making decisions on applications. The underlying logic of the technologies introduced after 2015 was to facilitate the compartmentalisation of empathy and concern for applicants. In line with Foucault’s understanding of government as ‘the conduct of conduct’, an ensemble of incentives, organisational features and ideals created a field of action conducive to producing a higher proportion of rejected claims by diminishing moral distress.
The analysis cannot provide a definitive answer on the success of these measures. Estimating the long-term effects of the organisational changes introduced is complicated by the fact that the shift towards stricter assessment stopped during the pandemic. No new direction for the Swedish sickness insurance system has emerged since then. However, the significant number of interviewees who defended the agency and described how they aspire to put their personal feelings aside when making assessments indicates that the technologies used did have an impact. Similarly, Jacobsson and Johansson’s (Reference Jacobson and Johansson2025) ethnographic study of caseworkers and managers concluded that the detached, professionalised and distanced role of caseworkers became dominant within the agency after 2015. During this period, there was relatively high staff turnover within the agency (Altermark, Reference Altermark2020), meaning that the proportion of employees familiar with the system prior to the introduction of stricter assessments gradually decreased. Judging by my small sample of interviews, moral distress appears to be an important reason why people chose to leave. Consequently, critical caseworkers were replaced by new employees socialised into the detached professional role.
What we do know is that the stricter assessments during this period had significant consequences for people with long-term illnesses who relied on sickness insurance. The dramatic increase in rejected applications meant that many people on long-term sick leave suffered economic insecurity, even if they did not ultimately lose support (Kaluza, Reference Kaluza2018; Altermark and Plesner, Reference Altermark and Plesner2022). Many of those who were denied sickness insurance during this period were too unwell to return to work and often ended up relying on other welfare systems, such as social assistance (Altermark, Reference Altermark2020). Our previous work shows that this often led to a deterioration in health associated with economic crises and depressive episodes, sometimes even with suicidal thoughts and suicide attempts (Altermark and Plesner, Reference Altermark and Plesner2022). It was these kinds of consequences that the internal steering of the SSIA sought to shield caseworkers from.
The analysis raises broader questions about the politics of austerity and democracy beyond the case examined. The experiences of the caseworkers interviewed highlight the tension between the different expectations placed on public servants in democracies. It is reasonable to expect officials to obstruct, blow the whistle or refuse to follow orders when the consequences are too severe or undermine basic democratic values (see Lundquist, Reference Lundquist1998). In constitutional democracies, social rights are generally considered to take precedence over the will of political majorities, particularly if decisions are not properly debated or are based on false premises. Therefore, it is sometimes democratically justifiable for caseworkers to obstruct. However, public officials also have a democratic responsibility to implement decisions, even if they disagree with them. Caseworkers cannot routinely set aside existing rules in favour of compassion when making decisions about welfare support. The SSIA’s references to impartiality and the rule of law are compelling because they resonate with this democratic intuition.
The role of caseworkers necessarily involves balancing these expectations and assessing their relative strength in light of changing contextual and individual factors. Rather than looking for a foolproof principle that determines when there is a responsibility to intervene, it seems that caseworkers need to develop reflective qualities that can help them make sound decisions whilst taking into account legislation, political will and the rights of applicants. I suggest that moral distress can be an important resource in this regard, prompting professionals to reflect on their roles and obligations. Public agencies that encourage reflexivity when such feelings arise and are prepared to address them may be less likely to engage in practices that undermine trust in the democratic system. This is particularly important in the context of welfare cuts, which tend to affect stigmatised groups who are often not heard in debates about public policy. Caseworkers are often very well positioned to understand how cuts will affect individuals from these groups. A concerning aspect of the SSIA’s internal management is that it treated moral intuition and empathy towards people dependent on the sickness insurance system as flaws to be overcome. A key area for future research is developing ideas on how caseworkers’ consciences can instead be utilised as a democratic resource in the context of austerity politics.
Funding statement
The research was funded by Forte (ref: 2017-02098).
Competing interests
The author declares no conflicts of interest.
Ethics statement
The project was approved by the Swedish regional Ethics Board.
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