Traditional and Nussbaum's Transitional Anger

The world is an angry place and it seems this anger is increasing, see for instance why are Americans so angry? Anger is a basic emotion which goes back into our evolutionary past and is one of the five basic emotions everyone seems to recognise according to Paul Ekman’s studies. In the past anger must have served some useful purpose but is anger still useful in today’s culture? Martha Nussbaum defines two types of anger. Traditional anger which,

“involves, conceptually, a wish for things to go badly, somehow, for the offender in a way that is envisaged, somehow, however vaguely, as a payback for the offense” (1)

Nussbaum also defines transitional anger as follows.

“There are many cases in which one gets standardly angry first, thinking about some type of payback, and then, in a cooler moment, heads for the Transition.” (2)

According to Nussbaum traditional anger can transmute into transitional anger,

“quickly puts itself out of business, in that even the residual focus on punishing the offender is soon seen as part of a set of projects for improving both offenders and society.” (3)

The type of anger given to us by evolution appears to be traditional anger but we are no longer hunter gatherers and so perhaps traditional anger no longer serves its original purpose and we should always transmute it into transitional anger. Perhaps if such a transmutation is possible our society might become less angry. In this posting I will argue that whilst in most situations we should transmute our anger into useful action there are some situations in which it is right to maintain anger.

Stoics such as Seneca argued that anger is a dangerous emotion, a type of temporary madness and ought to be eliminated or controlled. Emotions aren’t simply somatic responses. According to Michael Brady emotions act as a kind of mental alarm. They do so by facilitating,

“reassessment through the capture and consumption of attention; emotions enable us to gain a “true and Stable” evaluative judgement.” (3)

Alarms need attending to and this requires action, anger requires attention and action rather than simply control or elimination. Simply controlling anger leads to resentment which is bad both for individuals and society. Traditional and transitional anger lead to different sorts of actions and I will examine the appropriateness of these different actions in our society.

If we accept anger is a kind of warning about some harm then this explains why being angry makes no sense in some situations. However if someone becomes angry when diagnosed with cancer her anger does not act as a warning. But anger isn’t just a general warning about any situation, it’s a warning about social situations. Anger should be a call to action connected to some wrongdoing. Anger as traditionally envisioned has a target and a focus. The target is the person or institution which inflicted the wrongdoing and the focus is the wrongdoing itself. This wrongdoing causes harm and the call for action created by anger seeks to address this harm. Traditional anger and transitional anger seek to address this harm in different ways. Traditional anger seeks to mend the harm done by making the offender suffer, changing the status of the offender. Nussbaum regards this as a kind of magical thinking rooted in our past. Traditional anger, as so conceived, is not only rooted in our past but deals with past harm, however the harm is done and making the offender suffer does not appear to mitigate this harm. Nussbaum argues we should reject such a concept and replace it by the concept of transition anger. Transitional anger doesn’t focus on status instead it focuses on future welfare from the start by trying to mitigate the harm involved. I agree with Nussbaum that our concept of anger sometimes needs updating but will argue that traditional anger still has an important part play.

Traditional anger is concerned with the difference in status between the target and the victim.  Concern for this difference in status can lead to non-productive behaviour. Nussbaum gives an excellent example.

“People in academic life who love to diss scholars who have criticized them and who believe that this does them some good, have to be focusing only on reputation and status, since it’s obvious that injuring someone else’s reputation does not make one’s own work better than it was before, or correct whatever flaws the other person has found in it.” (5)

Nussbaum’s example clearly shows concern with differences in status can lead to rather silly behaviour provided anger is only concerned with the past and present wrongs. If traditional anger is only focussed on past and present harms then perhaps we should always transmute our traditional anger into transitional anger provided of course we are the sort of creatures capable of carrying out such a transmutation. Greg Caruso believes empirical evidence suggests that the strike back emotion plays an important role in our moral responsibility beliefs and practices making such a transmutation difficult, see psychology today . However anger is sometimes focussed on the future, indeed if anger acts as some kind of alarm requiring action then it’s very nature means it must contain a forward looking element.

Let us accept that anger should trigger a forward looking element. However even if we accept the above it doesn’t automatically mean we should always try to transmute traditional anger into transitional anger. Nussbaum herself suggests that transitional anger,

“focuses on future welfare from the start. Saying ‘Something should be done about this” (6)

Let us now accept that transitional anger is forward looking by seeking to alleviate the harm which caused anger.

I now want to argue that the nature of the harm involved should determine whether traditional or transitional anger should be the appropriate response. Nussbaum uses a case of rape as an example.

“Offender O has raped Angela’s close friend Rebecca on the campus where both Angela and Rebecca are students. Angela has true beliefs about what has occurred, about how seriously damaging it is, and about the wrongful intentions involved: O, she knows, is mentally competent, understood the wrongfulness of his act.” (7)

Angela is justifiably angry but Nussbaum suggest nonetheless that she should try to transmute her raw traditional anger into transitional anger.

“Angela is likely to take a mental turn toward a different set of future-directed attitudes. Insofar as she really wants to help Rebecca and women in Rebecca’s position …..  helping Rebecca get on with her life, but also setting up help groups, trying to publicize the problem of campus rape and to urge the authorities to deal with it better.” (8)

Let us assume O was Rebecca’s boyfriend, sees he acted wrongfully, is remorseful and is no more likely to rape someone in the future than anyone else. With these caveats in place then punishing O will not lessen the harm done to Rebecca and I am inclined to agree with Nussbaum that Angela would be right to transmute her traditional anger into transitional anger. Such a transmutation might prove difficult due to angers usefulness in our evolutionary past and even if such a transmutation could be achieved such a case should still involve justice. In these circumstances I would suggest the justice should be restorative justice.

Some harms are not physical, some involve intimidation and others involve recognition. In what follows I will argue that maintaining our anger, rather than transmuting it, is a more appropriate response to both of these harms. In some sports a bad tackle by player A might injure player B, the physical injury inflicted by A cannot be undone by B causing A to suffer, but if A’s purpose was to intimidate B then B’s retaliation causing A to suffer might well target A’s intimidation. Maintaining traditional anger would be more appropriate in this situation than transitional anger. A wife’s abuse by her husband in order to intimidate her might also be better adressed by maintaining traditional anger, provided of course this is possible. Intimidation whilst a serious problem is not a widespread problem. A failure to recognise the rights of others is a more widespread problem. This failure might be due to inconsideration, a lack of attention, or even intentional. Let us reconsider Nussbaum’s example. Let us assume O doesn’t recognise the wrongfulness of his actions and also doesn’t recognise women merit the same status as men. In this scenario it seems to me that maintaining traditional anger would be a more appropriate response than transitional anger. I accept that the harm done to Rebecca cannot be undone by making O suffer, nonetheless O’s continuing failure to recognise women as having the same rights as men might be targeted by making O suffer, might be addressed by traditional anger. It appears in cases in which anger is generated by a lack of recognition that raw traditional anger ought to be the appropriate response. Anger in this situation must still be transmuted into action appropriate to gaining this recognition and this action might justifiably include inflicting harm on the offender in order to achieve this recognition. I believe the above appearance needs to be qualified. At the beginning of this post I remarked people appear to be getting angrier, perhaps this anger is because our society is not very good at recognising individuals. Useful anger must be effective anger. I would suggest targeting society using traditional anger is not useful and it would be better to employ transitional anger. The boundary between offenders who should be targeted by traditional anger or transitional anger is hard to define. Clearly society as a whole should be targeted by transitional anger and some individuals by traditional anger but what about corporations and other organisations?

What conclusions can be drawn from the above? Dylan Thomas asks us “not go gently into that good night but rage, rage against the dying of the light.” If anger is an alarm then rage, anger, at those things we can do nothing about is inappropriate. Anger if it is to be a useful emotion must be capable of being transmuted into something else. It follows in situations in which a transmutation of any sort is impossible anger that is not a useful emotion and should be avoided provided this is possible. Secondly there are some situations in which the focus of anger is not ongoing and transitional anger seems the right sort of anger to employ, once again provided this is possible. In such situation the infliction of harm on the wrongdoer seems to be pointless. Retributive justice might require some harm but I am considering anger in isolation from justice. I have suggested above that in such situations restorative rather than retributive justice would be more appropriate. According to Nussbaum in such situations anger should be transmuted into actions aimed at a set of projects for improving both offenders and society. Lastly there are situations in which the focus of anger is intimidation or a failure of recognition, in these situations traditional anger ought to be employed and the infliction of harm on the wrongdoer might be appropriate. In this situation the aim of anger mustn’t be payback but recognition and the anger employed should be transmuted into actions appropriate to achieving this recognition. 

1. MARTHA C. NUSSBAUM, 2015, Transitional Anger. Journal of the American Philosophical Association, page 46.
2. Nussbaum, page 53.
3. Nussbaum, page 51.
4. Michael Brady, 2013, Emotional Insight; The Epistemic Role of Emotional Experience, Oxford University Press, page147.
5. Nussbaum, page 49.
6. Nussbaum, page 54.
7. Nussbaum, page 46.
8. Nussbaum, page 49

Terminally ill patients and the right to try new untested drugs

In the United States nearly half of the states have passed a “right to try” law, which attempt to give terminally ill patients access to experimental drugs. Some scientists and health policy experts believe such laws can be harmful by causing false hopes and even suffering.  Rebecca Dresser argues that states should not implement such laws due to dashed hopes, misery, and lost opportunities which can follow from resorting to unproven measures, see  hastings centre report . For instance, someone might lose the opportunity to spend his last days with his family in a futile attempt to extend his life. In this posting I want to examine the right of terminally ill patients to try experimental drugs which have not been fully tested.My comments here will only apply to experimental drugs but I would suggest that they could equally apply to all experimental treatments such as the use of Crispr gene editing tools. In what follows experimental drugs will refer to new drugs which have not yet been fully tested. Of course pharmaceutical companies must be willing to supply these drugs. I am only examining the right of patients to try experimental drugs which pharmaceutical companies are willing to supply and not patient’s rights to demand these drugs. In practice pharmaceutical companies might be unwilling to supply such drugs because of a fear of litigation, I will return to this point at the end of my posting.

I fully accept Dresser is correct when she asserts that experimental drugs might cause dashed hopes, misery, and lost opportunities. Untested drugs can cause harm. It is this harm that forms the basis for not allowing terminally ill patients access to these drugs. I now want to examine in more detail the harm that access to experimental drugs might cause to the patients who take them. I will then examine how access to these drugs might harm future patients by distorting drug trials.

How might access to experimental drugs harm the patients who take them? Firstly they might further limit a patient’s already limited lifespan. Secondly they might cause a patient greater physical suffering. Lastly they might cause him psychological suffering by falsely raising hopes and then dashing these hopes if they fail. I will now examine each of these three possible harms in turn. Previously I have argued that terminally ill patients, those suffering from Alzheimer’s disease and other degenerative conditions should have a right to assisted suicide, see alzheimers and suicide  . If terminally ill patients have a right to end their lives it seems to follow that the fact that experimental drugs might possibly shorten someone’s life does not give us a reason to prohibit the taking of such drugs. It might be objected that someone taking a drug to end his life and someone taking an experimental drug to extend his life have diametrically opposed ends. However, even if this is true a patient taking a drug to try and extend his life should be aware that it might do the opposite. Provided a patient is reasonably competent and aware that such a drug might shorten his life it should be up to him to decide if he is prepared to accept the risk of shortening his life in order to have the possibility of extending it. It might now be objected that by providing experimental drugs to someone we are not acting in a caring way, we are not acting beneficently. In response I would argue the opposite holds and that if we prohibit the use of these drugs we are caring for patients rather than caring about them. Caring for differs from caring about. If I care for a dog I must care about what is in its best interests. If I care about a person I must care about what is in his best interests and what he thinks are in his best interests. Failure to do so is a failure to see him as the sort of creature who can decide about his own future and displays moral arrogance. I have argued elsewhere that If I care about someone in a truly empathic way I must care about what he cares about, rather than simply what I think might be in his best interests, see woolerscottus . It appears to follow that competent patients should not be prohibited from taking experimental drugs which might shorten their lives provided they are aware of this fact. After all smoking shortens many smokers’ lives but because we respect autonomy smoking is permissible.

It might be objected that the above argument is unsound as often terminally ill patients are not the sort of creatures who can really make decisions about their own future. The above objection as it stands is unsound as the terminally can make some decisions about their treatment. For instance, it is perfectly acceptable for a patient to choose forgoing some life extending treatment in order to have better quality of life with his family. The above argument can be modified. It might be argued that terminally ill patients are not good at making decisions about their future or lack of it. This might be caused by stress, a disposition for false or exaggerated optimism and an inability to understand probabilities. In response I would point it is not only the terminally ill but the public and some doctors who are not very good at understanding probability, see Helping doctors and patients make sense of health statistics . Nonetheless false optimism remains and this false optimism might distort a terminally ill patient’s decision making capacity. What exactly is meant by false optimism? Is it just a failure to understand probability or is it someone assigning different values, weights, to the things he finds to be important? No decisions are made without reference to these weights, our values, and it follows changing our values might change the decisions we make without any alteration to the probability of certain events occurring. What might appear to us as false optimism might be someone giving different weights to what he finds to be important. I would argue we must accept that the terminally ill have a right to determine their own values and assign their own weights to things they find pertinent to their decision-making for two reasons. Firstly, we should recognise that the terminally ill remain the sort of creatures who can and should make decisions about their own future. Secondly, most of us are in a state of epistemic ignorance about what it means to experience terminal illness and if we criticise the values of the terminally ill we are guilty of epistemic arrogance. It would appear if we accept that the terminally ill are the kind of creatures who can make decisions about their own future the fact that experimental drugs might shorten their lives does not give us reason to prohibit them from using such drugs.

Patients who take experimental drugs might cause themselves physical harm. The first principle in medical ethics is to do no harm, non-maleficence, so it might be argued that the prescription of such drugs by medical practitioners should be prohibited. The above argument is unsound. Chemotherapy harms patients but this harm is offset by its benefits. Let us accept that an experimental drug might harm a patient but that it might also benefit him. Indeed, such drugs are only tested because it is believed that they might benefit patients. The above argument might be modified. It might now be argued that that the prescription of experimental drugs by medical practitioners should be prohibited until such a time as the benefits of taking these drugs can be shown to offset any harm they cause. However, the above argument is also unsound. Chemotherapy does not always benefit patients and so does not always offset any harm it causes. If we accept the above argument then we should prohibit chemotherapy, such a suggestion is nonsensical. However, the modified argument might be still further modified. It might now be argued that that the prescription of experimental drugs by medical practitioners should be prohibited until such a time as the benefits of taking such drugs can be shown to offset any harm they cause in the majority of cases. This further modified argument is about how much risk patients should be exposed to.

The reason we don’t want to expose patients to excessive risk is because we care about them. However we don’t prohibit paragliding because we care about those who participate. Who should determine what risks are acceptable? I can use the same argument I employed above, showing that patients have the right to risk shortening their lives if there is some limited chance of life extension provided they understand the risk involved, to deal with the risk of patients harming themselves. I would suggest that if we prohibit the use of experimental drugs which might harm patients but also might benefit them that once again we are caring for patients rather than caring about them. I argued above that we should care about people in a different way to the way we care for dogs. Failure to do so is a failure to see patients as the sort of creature who can make decisions about their own future and displays moral arrogance. If patients understand the risks involved it should be up to patients to decide if they are prepared to accept these risks. The last way the use experimental by patients might harm them is by causing psychological suffering by raising false hopes and dashing these hopes if these drugs fail. I believe in this context the above argument can once again be applied and I will not repeat it. To summarise it would seem that possible harm to actual patients is not a reason to prohibit access to experimental drugs provided patients are aware of this possible harm.

Even if we accept the above somewhat tentative conclusion it doesn’t follow that we don’t still have a reason to prohibit access of experimental drugs to terminally ill patients. Future patients might be harmed because the effectiveness of drugs might not be fully tested in the future. Drug trials are expensive and if pharmaceutical companies can rely on data obtained by using a drug on terminally ill patients then they might be reluctant to finance fully fledged trials. Doing so might lead to two problems. Firstly, some drugs which appear not to harm terminally ill patients might harm other patients. The long term effects of a drug, which extends a patient’s life in the short term, might not become apparent. Secondly some drugs which do not appear to have any effect on terminally ill patients might be effective on less seriously ill patients. Such drugs might not become available to future patients. Can these two problems be solved?

Regulation might solve the first problem. Experimental drugs might be used on terminally ill patients if they desire them but their use should not be permitted on other patients until after undergoing a full clinical trial. It might appear that because there are less terminally ill patients compared to other patients that pharmaceutical companies would continue to conduct full clinical trials on experimental drugs. However this appearance might be unsound. Pharmaceutical companies might try to extend the definition of a terminally patient so as to continue using some drugs without them ever having to undergo a full trial. This problem might be overcome by regulatory authorities insisting that experimental drugs are only used on those who are terminally ill. Applied philosophers might aid them in this task by better defining what is meant by terminal illness. The well-known physicist Stephen Hawking has motor neurone disease and it is probable that this disease will kill him but at the present he would not be classed as terminally ill. Terminal illness should be defined by how long someone will probably live rather than the probability that his illness will kill him. Perhaps someone should not be considered to have a terminal illness unless it is probable that he has less than six months to live. Let us consider the second problem. Might some pharmaceutical companies be tempted not to fully trial some drugs which might benefit some patients on the basis of incomplete evidence gathered from their use on terminally ill patients? Once again regulation might solve this problem. I would suggest that provided that terminal illness is defined tightly enough that this problem shouldn’t arise. A tight definition of terminal illness means fewer terminally ill patients for pharmaceutical companies to test drugs on forcing them to conduct full clinical trials. To summarise once again it appears harm to future patients does not give us reason to prohibit access to experimental drugs for the terminally ill provided that terminal illness is tightly defined.

Lastly at the beginning of this post I suggested that in practice pharmaceutical companies might be unwilling to supply experimental drugs due to a fear of litigation. It should be possible to overcome this fear if patients are required to sign a comprehensive consent form making it clear not only that there are risks involved but also that these risks include as yet unknown risks.

The above discussion leads to the rather tentative conclusion that the terminally ill should not be prohibited from trying experimental drugs subject to certain safeguards. These are,

1. Terminal illness must be clearly and tightly defined. Philosophy can play an important part in doing this.
2. No drugs which have not been fully tested should be used on non-terminally ill patients except for the purpose of testing
3. Any terminally ill patient taking an experimental drug must sign a comprehensive consent form in the same way patients taking part in trials do. This form must make it clear that they are prepared to accept as yet unknown risks.