Nietzsche, Sport and Suffering

   

Sport is a passion for many people in the past this was mostly men but this is changing and many women enjoy sport. In this posting I want to examine the reasons for this passion and what we find admirable about sportspersons. I will argue what we find admirable is that sport helps enhance character and that this enhancement is connected to some of Nietzsche’s thoughts about suffering and struggle. My discussion will be confined to sport but some of it could also be applied to the arts, especially music.

Nietzsche argued that which doesn’t kill you makes you stronger. He linked this to suffering which he argued makes someone a better person,

“Examine the life of the best and most productive men and nations, and ask yourselves whether a tree which is to grow proudly skywards can dispense with bad weather and storms. Whether misfortune and opposition, or every kind of hatred, jealousy, stubbornness, distrust, severity, greed, and violence do not belong to the favourable conditions without which a great growth even of virtue is hardly possible? (1)

It is important to note that Nietzsche is not saying all suffering benefits someone but that if she is to live up to her potential some suffering is necessary. Chronic illnesses doesn’t benefit the sufferer. However it is worth noting that some people such as Havi Carel argue that even chronic illness can bring some limited benefits (2). Let us agree with Nietzsche that some suffering can indirectly lead to some benefits. Consider the Eloi in H G Well’s book ‘The Time Machine’. The Eloi appear to lead a life of ease with no need to struggle in order to exist. However they lack natural curiosity and their lives seem to be lacking in some essential elements making such lives seem pointless to us. Of course the Eloi’s lives might seem pointless to us simply because they lack curiosity rather than because they fail to struggle to protect themselves from the Morlocks. I would suggest that if someone has to struggle in her life that she must consider how to overcome her problems and this facilitates her curiosity and by doing so might possibly even facilitate her wisdom. I now want to follow Michael Brady by arguing that suffering can facilitate other virtues. (3) I would suggest that if someone struggles to overcome her suffering that this struggle will enhance her courage, fortitude, resilience and patience. These virtues are instrumental virtues and that someone who possesses might be said to possess grit.  I would argue that we enhance these virtues by exercising them in much the same way as an athlete enhances her muscles by exercise. If someone struggles to overcome her suffering then she will need to exercise her courage, fortitude, resilience and patience. Of course no one admires someone simply because she suffers, one pities her. We admire someone who struggles to overcome her suffering. I would suggest that we should find her character admirable because it displays the above virtues. To summarise the above simply to suffer doesn’t benefit anyone, however if someone struggles to overcome her suffering she enhances some elements of her character helping her to flourish.

I now want to consider what we find admirable about sportspersons. Sport is connected to competition. I go out alone on my bike I am exercising rather than taking part in sport. Sport concerns competition. However sport is not simply about competition and winning for after all wars are about winning and wars aren’t sport. Winning is important in sport because it sets the goal in some competition. However wars are also about competition. The competition in war and sport differs. All competition is about winning but in war the way the war is won isn’t central whilst in sport winning matters but the way someone wins is of central importance. A war should be a just war but the rules of war play no part in the definition of war. If some country wages war by massacring innocent civilians and ignoring the rules of war we would still say it was waging war, we might of course add that it wasn’t waging a just war. Sport is by definition must be played according to some rules. Sport must also be fair. If a team of professional footballers play an under 13 years old girls team even if this was played paying scrupulous attention to the rules this game would not be regarded as sport. Fairness is central to the definition of sport and this is reflected in the organisation of sport. Able bodied Olympians don’t compete with Para-Olympians, heavyweight boxers don’t compete with lightweights and golfers have handicaps to ensure fair competition. Let us accept that sport is concerned with winning and fairness. Winning and fairness are in some ways an odd combination. We find fairness admirable because it fosters justice. We find winning admirable because it represents achievement. I would suggest that we find sportspersons admirable because the combination of winning and fairness found in sport allows them to exhibit and develop certain characteristics connected to good character. This suggestion seems to be supported by the way we talk about sport, especially football, we talk about determination, patience, courage and not letting one’s head drop which seems to me to be a form of resilience.

Let us accept that one of the main reasons why we find participation in sport admirable is that it allows sportspersons to exhibit and develop character. In what follows I will only consider sport and the development or enhancement of good character. I have argued above that suffering helps develop courage, fortitude, resilience and patience. I now want to argue that sport develops these virtues by suffering. It might be objected that many professional sportspersons don’t suffer. Professional sportspersons are well paid, have trainers, dieticians, physiotherapists and even sports psychologists help them achieve their goals. I accept some sportspersons aren’t deprived people. However it is important to note that some people embrace sport as a way out of deprivation. For such people sport and suffering are directly connected. I now want argue that even well paid professional sportspersons suffer. What does it mean to suffer? To suffer means someone is in some unpleasant state she would rather not be in. This definition is not a complete definition of suffering but I believe it is adequate for the purposes of this posting. Sport helps develop good character because sportspersons have to struggle to master their sport and this involves courage, fortitude, resilience and patience. If someone is completely satisfied she has no need to struggle. Someone struggles only when she is dissatisfied with something. Being dissatisfied is an unpleasant state which someone wishes she wasn’t in. All struggling is a reaction to some suffering even if this suffering is mild. It follows that if what we find admirable about sport is that it enhances character and that this enhancement is achieved by struggling which is facilitated by suffering. This struggle might be of especial importance to disabled athletes as their greater struggle leads to greater character enhancement and empowerment.

I have argued above that one of the main reasons we find participation in sport admirable is that it helps sportspersons to exhibit and develop good character. It might be objected that I’m presenting a very limited picture. My objector might suggest that the main reason we find participation in sport admirable is that it simply that it allows sportspersons to exhibit their skills without any reference to character. I accept that people enjoy exhibiting or the exhibition of sporting skills. However I am examining what people find admirable about participation in sport and admiration isn’t the same as enjoyment. Do we really admire the exhibition of these skills without reference to character? Would we admire the exhibition of these skills if they were exhibited by a robot? Would we admire them if they had been acquired solely by the use of performance enhancing drugs? I would suggest we would not. My objector might respond by suggesting that we wouldn’t only because the use enhancement drugs is cheating rather than anything to do with sportsperson’s character. Cheating and character are linked. Let us assume some sport permits the use of performance enhancing drugs and that taking these drugs ceases to be cheating. I would suggest that we would find little to admire about participation in such a sport. Nonetheless might we find the exhibition of sporting skills involved in this sport enjoyable? Perhaps we might enjoy the exhibition as a spectacle but it would be hard to enjoy as a sporting contest as the any contest has moved from the sportspersons involved to the scientists producing the enhancers.

 

Let us accept that being involved sport helps fight obesity and fosters good health and for this reason active participation in sport should be encouraged I have argued that the reason why we find participation in sport admirable is that it allows sportspersons to exhibit and develop character. It might be objected that I’m idealising some impossible Corinthian picture of sport which has no relevance in the modern era. In response I point out that character matters to both to amateur and professional sportspersons. Andy Murray is a professional tennis player and I would suggest that we admire him just as much for his struggle to win Wimbledon as for the victory itself. If we accept that character matters in sport then we have a further reason to encourage active participation in sport. The struggle involved in sport helps to enhance certain virtues which are instrumentally useful to us. Clearly enhancing someone’s courage, fortitude, resilience and patience benefits her but I would argue such individual enhancement also benefits society as a whole. It follows society has an interest in promoting participation in sport and that government policies which reduce the sporting facilities which enable people to do so are mistaken. Playing fields and other sporting facilities matter. Of course not everyone wants to participate in sport but I would suggest that other activities involving struggle such as learning to play a musical instrument can be equally beneficial. In the light of the above discussion I would further suggest that some struggle in life is important for us all and can lead to more widespread benefits. In ‘The Coddling of the American Mind’ Haidt and Lukianoff endorse an anti-fragility type of parenting. (4) I would interpret anti-fragility parenting to mean not overprotecting or coddling children but rather encouraging them to struggle to achieve things in life. Socrates famously argued that the unexamined life wasn’t worth living perhaps a life without some struggle might be worth living but none the less be a deficient sort of life. Perhaps such a life might be worth living but would it be a happy life? Perhaps Seligman is right when he suggests that accomplishment matters for happiness if so a happy life requires some struggle, some suffering. Lastly I would suggest that whilst we admired Steven Hawking for increasing our knowledge of the universe that we also admired him because of his struggles to overcome adversity.

1. The Gay Science : First Book, 19
2. Havi Carel, 2013, Illness, Routledge
3. Michael Brady, 2018, Suffering, Oxford University Press
4. Haidt  & Lukianoff, 2018, The Coddling of the American Mind, Penguin Press

What do We Mean by Hope

In this posting I want to examine what we mean by hope. Firstly I will suggest that the traditional philosophical definition of hope is an inadequate one. I will then argue that if desire in the traditional definition is replaced by ‘caring about’ or loving that we will have a more complete definition. I will move on to consider whether hoping is beneficial and hoping might be encouraged.

What do we mean by hope? Intuitively someone hopes for some outcome if he desires that outcome. However hope is not the same as expectation. If some desired outcome has a 0.9 probability does someone really hope for this outcome or does he expect it. I would suggest that if the desired outcome materialises then how he feels will differ depending on whether he hoped for the outcome or expected it. If he hoped for the outcome he will be pleased whilst if he expected the outcome he will still be pleased but to a much lesser degree. Similarly if the expected outcome doesn’t materialise he will be disappointed whilst if he had hoped for the outcome he will again be disappointed but to a much lesser degree. In the rest of this posting I will assume if the desired outcome has a probability of 0.5 or greater that someone expects that outcome and someone hopes for some outcome when the probability is less than 0.5. According to the traditional philosophical definition of hope someone hopes for some outcome when he desires this outcome which has a low probability of being actualised. Unfortunately as pointed out by Adrienne Martin such a definition might also be used to define despairing (1). Martin uses the example of two terminally ill cancer sufferers to illustrate her point. Both are offered treatment in a trial which offers a very small probability of achieving a good outcome. Let us assume that the probability of a good outcome due to their participation in the trail is 0.01. One sufferer nonetheless sees this low probability as offering hope, he might believe this low probability licences him to hope, whilst the other sufferer sees this low probability as a reason to despair. Both sufferers accept the same probability and both desire the good outcome but one hopes and the other despairs. It follows even that both a desired outcome and a low probability are necessary conditions for hope they don’t offer sufficient conditions to define hope.

How can we explain the difference between hope and despair? It might be argued that the difference can be explained by what our attention is directed at. Let us assume emotions matter because they capture our attention. It might be suggested that the difference between hope and despair is simply that the hopeful person undertakes some actions, even if this is only imagining a better future, whilst the despairing person simply does nothing. This suggestion may well hold in some cases but not in all. For instance our despairing cancer patient might make plans to end his life because he despairs of his future. Emotions not only capture our attention but also focus it. I now want to argue that the main difference between hope and despair is the focus of our attention. This focus is sometimes converted into action by the despairing person and always converted into action, even if this action is merely imagining the good outcome, by the hopeful person. The focus of the hopeful person is on the good outcome and he acts accordingly whilst the focus of despairing person is on the bad outcome and she acts accordingly.

It might be objected that the focus of a hopeful or a despairing person should be on the probabilities rather than the outcomes and that their actions should accord with these probabilities. Indeed it might be argued that the actions of the hopeful and the despairing should be identical in identical situations. However in practice even if two people agree about the probability of some outcome their subsequent actions often differ significantly. I now want to suggest that this difference is due to how they value the outcomes. How someone reacts to some situation might be based on the probabilities of the different outcomes and also on how he values these different outcomes. Let consider another of Martin’s examples. Let us assume the if someone buys a lottery ticket one possible outcome is losing £2 and the other is winning £1000,000. I have suggested that the difference between hope and despair is caused by the difference in how much someone values the different outcomes. In what follows it will be assumed that to value something means that someone ‘cares about’ or loves that thing. Some might care greatly about winning £1000,000 whilst regarding the loss of £2 as insignificant. At this point it might be objected all I am really saying is how much someone hopes depends on how much he desires the different outcomes. If my objector is correct and ‘caring about’ is just some extra strong desire then ’caring about’ cannot account for the difference between hope and despair. The fact that someone desperately desires some outcome might be a cause for despair when he considers the slim probability of the desperately desired outcome materialising. In response I would suggest ‘caring about’ is not the same as desiring. An addict might desire drugs but wishes he didn’t, taking drugs is something he doesn’t value or care about.

What is the difference between desiring something and ‘caring about’ something? It might be suggested that ‘caring about’ something has more persistence than desire. However some desires are quite persistent. A drug addict’s desire for drugs might be a persistent one. I would suggest that whilst persistence is a necessary condition for ‘caring about’ is not a sufficient one. However the drug addict example does suggest one way caring about might differ from desiring. Someone simply has desires and these need not be endorsed whilst what someone ‘cares about’ is endorsed at some in some way. On my interpretation of Martin she might believe such endorsement might be achieved by the carer being able to give reasons for what he ‘cares about’. If we accept the above then for someone to hope means he cares about some outcome which has a low probability and he is able to give reasons for his ‘caring about’. I’m doubtful whether Martin would accept such a position. This definition is a variation of the traditional definition in which desiring has been replaced by ‘caring about’ and to ‘care about’ some behaviour means to be able to endorse this behaviour at some higher level by giving reasons. A second way caring about differs from desiring is that caring about is connected to someone’s agency. What someone cares about is a persistent way of behaving which is endorsed by the carer being satisfied with his behaviour. This idea of ‘caring about’ or loving is that of Harry Frankfurt. In this context satisfaction doesn’t involve some smug feeling but entails an absence of restlessness or resistance to his behaviour. Frankfurt argues that to ‘care about’ something is to love that thing in some way. He argues the nature of a lover’s concern means that she identifies herself with what she loves (2). It is now possible to introduce a second definition of hope based on the traditional one. Someone hopes for some outcome which has a low probability of becoming true if he ‘cares about’ that outcome and ‘caring about’ means he is satisfied with his actions and identifies himself by his ‘caring about’, his behaviour is focussed on that outcome.

Does it make any difference which amended version of the traditional definition we adopt? Both definitions licence us to hope. It seems plausible that someone might be able to hope for some outcome without being able to give reasons for his hope, ‘I just hope that’. Martin might object that even if someone can’t fully articulate his reasons for hoping that nonetheless he has some underlying reasons supporting his hope. However it seems possible that someone might hope for some outcome simply because he is a hopeful person. It might then be argued that if we accept that someone may hope for some outcome simply because he is a hopeful person that we should adopt the second of our two amended traditional definitions of hope. Hoping is not the same as being an optimist. Let us accept that an optimist is a hopeful person. Perhaps an optimist might be better defined as someone who has a disposition to hope. If we accept the above definition then an optimist is defined by reference to hope. Unfortunately we cannot define hope by reference to a hopeful person for to do so would mean we had already defined hope. In the light of the above it might appear that to that we should adopt the first amended definition of hope. Someone doesn’t have to be an optimist to hope for some outcome he only has to ‘care about’ the outcome and to be able to give reasons for his ‘caring about’. At this point it might be objected that a pessimist might also hope for some outcome by ‘caring about’ that outcome and justify his ‘caring about’ by simply being satisfied with his actions. I am somewhat reluctant to accept the above, can someone really be said to be satisfied with his actions he is unable to give reasons for his satisfaction? For this reason I would suggest that the first amended traditional definition of hope should be adopted. For someone to hope for some outcomes means that he ‘cares about’ for this outcome which has a low probability of becoming true and ‘caring about’ means she is able to give reasons for her hope.

In what follows amended definition of hope will refer to the first amended version of the traditional definition of hope unless stated otherwise. Two important points can be made about accepting this definition. Firstly optimism remains closely connected to hoping. It would seem probable that because an optimist has a disposition to hope that he will also have a disposition to seek reasons to justify his hope. Secondly I agree with Korsgaard that our actions are connected to our identity. Actions without reasons aren’t really actions at all and are something akin to a twitch. It follows if reasons are connected to action then they are connected to agency. It further follows hope is connected to agency.

Let us accept without any argument that despair is bad. It follows when faced by troubles we can act in two ways. We simply accept these troubles and accommodate our behaviour accordingly or if there is some small probability that these troubles might pass could we hope for this outcome. A stoic would argue that whilst we shouldn’t despair we should accept these troubles and accommodate our behaviour accordingly and not make ourselves vulnerable to disappointment by hoping. However it seems to me a life in which we try to curtail our hopes would be an incomplete sort of life which fails to grasp all that life might offer. An optimist would hope. What reasons do we have to foster hope?

I will now briefly outline four ways in which someone’s hope might benefit him when focussed on outcomes which matter to him, I then outline one reason why someone’s hope might benefit someone else when focussed on that person. Firstly in certain cases like Martin’s cancer example hope might have some placebo like effect. Simply hoping for some outcome might make that outcome slightly more probable. Secondly hoping might help us cope better with some trial we are undergoing. For instance someone suffering from cancer might feel better when coping with his cancer if he has some hope rather simply accepting his condition. Such hope of course shouldn’t be some Panglossian type of hope which pays no attention to outcomes other than the desired one. Thirdly, and more importantly, hope may further someone’s ends. If hope is connected to ‘caring about’ as I have argued above then to hope means to take means to achieve these ends when this is possible. Someone cannot be said to ‘care about’, love, something if he takes no steps to further the end he loves when this is possible. For instance, if when released from prison an offender takes a hopeful attitude to his reoffending his hope might encourage him to take steps to stop himself from committing further crimes. However it might be possible for someone to desire something and takes no active steps to fulfil his desire, he might believe the object of his desire as too hard or too improbable to achieve. Fourthly, and also importantly, hope supports someone’s agency or autonomy and combats both cynicism and passivity. If someone becomes overly cynical or passive then he has fewer reasons to act. Someone starting on a diet with a cynical attitude is unlikely to succeed. If someone sees few reasons to act then this lack of reasons damages his sense of agency. Frankfurt regards someone who has no sense of agency as a wanton (3) and as I have argued elsewhere such a person might suffer from the unbearable lightness of simply being. Someone suffering from cancer might see himself as simply a sufferer. Lastly I would suggest that someone’s hope is focussed on another person the expression of his hope might benefit that person. If someone hopes that someone else will do the right thing he sends a signal to the other that she has faith in him, he encourages her. For instance if a mother hopes her child will do his homework she signals her faith in him to do so. Signalling one’s hope in this way might encourage Mark Alfano’s factious virtue .

In the light of the above reasons for being hopeful it might be assumed that we should encourage people to hope. However this isn’t straightforward and I will now examine two objections to accepting this assumption. The first might be termed the stoic objection. A stoic might argue someone shouldn’t hope because the low probability of the desired outcome being actualised means he is setting himself up for disappointment and that the disappointment will harms him. Perhaps my stoic is right to some degree and some sort of Panglossian hope is harmful. Perhaps completely unrealistic hopes removes us too far from reality and damages agency. However as I have argued above a more measured form of hope enhances someone’s agency. The real enemies of agency are boredom and despair. The second objection against encouraging hope is that such encouragement simply doesn’t work. I have argued that hope is based on ‘caring about’ rather than on desires. It might then be argued that coming to ‘care about’ is not simply a matter of choice but is constrained and hence not responsive to encouragement (4). If a virtue is something that helps us to flourish and something we can cultivate then if we accept the above hope is not something we can cultivate as we can’t encourage it. This objection carries some weight if we adopt the second amended definition of hope based on someone being satisfied with his hope. However if we adopt the first amended definition then caring about is endorsed by reasons and this means that we can give reasons to encourage and support ‘caring about’, reasons to encourage and support the virtue of realistic hope.

 

1. Martin, Adrienne. 2014, How We Hope: A Moral Psychology (p. 11). Princeton University
2. Harry Frankfurt, 2006, Taking Ourselves Seriously, , Stanford University Press  2006, p 41
3. Frankfurt, 1999, Necessity, Volition, and Love. Cambridge University Press, page 106.
4. Frankfurt, 1999, page 165

Moral Distress and Autonomy

In Ian McEwan’s book 'The Children’s Act' we have a clear example of moral distress. A judge has to make a decision which is in a child’s best interests when these conflict with his parent’s autonomous wishes. This posting will consider moral distress. What do we mean by moral distress? Moral distress was defined by Jameton as a phenomenon in which someone knows the right action to take, but is constrained from taking it. (1) Moral distress is usually considered in a medical setting but can occur in other areas. For instance a soldier might feel moral distress when carrying out an order which she believes to be morally wrong. It is important to clearly differentiate between distress in general and moral distress. For instance a nurse might be distressed because she feels empathy for a patient’s suffering. However her distress isn’t moral distress. It is also important to be clear about difference between distress caused by moral dilemmas and moral distress. For instance someone might feel distressed because she must either lie to a friend or cause her friend to suffer. She doesn’t know the right thing to do and is experiencing a moral dilemma but not moral distress as defined above. A nurse helping to resuscitate a terminally ill patient suffering great pain might become distressed because she feels she is carrying out an action which she believes is wrong, is suffering moral distress. Moral dilemmas are self-imposed. Moral distress is imposed on the sufferer by others. Both moral dilemmas and moral distress can cause moral injury which can be harmful but in this posting I will only be concerned with moral distress.

What sort of others can cause moral distress? I would suggest moral distress can be caused by two sorts of others. Firstly it can be caused by some authority. This might happen when there is a difference between what someone believes is the right thing to do and what some authority with power over her wants her to do. For example a soldier might suffer moral distress when ordered by her superiors to shell a village which she believes contains a large number of civilians. In a healthcare setting if systems are set up to provide good ethical guidance for healthcare workers this form of moral distress might be reduced. Such guidance might be particularly important during health care emergencies such as the covid-19 outbreak. Secondly moral distress can be caused by respecting someone’s autonomy. For instance a nurse who continues to give a competent patient treatment, which she believes is futile and causes suffering, because the patient requests that her treatment continues.

Most work on moral distress focusses on distress caused by authority. In this posting I want to consider moral distress caused by respecting someone’s autonomy. I will argue that sometimes such distress is sometimes inevitable and difficult to reduce. Someone suffering from moral distress believes she is being asked to do something she believes is wrong. This wrong can take two forms. Firstly respecting someone’s autonomy means that she is asked to do something which conflicts with her beliefs. Secondly respecting someone’s autonomy forces someone to do something wrong by preventing her from acting beneficently. It might be suggested that one way of averting moral distress is for the person suffering the distress to opt out from carrying out the action which is causing the distress. However opting out isn’t easy for someone who believes in respecting autonomy. I would suggest that if you care about someone then you must care about what they care about to some degree even when what they care about conflicts with your beliefs. Caring about someone makes opting out of helping an autonomous person achieve her goals difficult. Caring about differs from caring for. I can care for someone whilst ignoring her wishes but this form of caring is caring in much the same way as someone cares for a child or even a dog. Caring about someone means that the cared about person’s autonomous decisions must carry some weight to the carer and cannot be easily dismissed by the carer. I would further suggest that someone cannot feel genuine empathy for someone if she doesn’t care about what the person she feels empathy for cares about.

Let us assume that respecting autonomy matters and that autonomy is a useful. First let us consider someone who is in moral distress because respecting someone’s autonomous decision means she feels she is prevented from acting beneficently. For instance the nurse in the example I have used above. I would suggest that if the nurse accepts that respecting her patient’s autonomy matters that her moral distress is inevitable. It might be objected that my suggestion depends on a particular account of autonomy and that if we adopted a different account her distress could be avoided. I am using a primitive or Millian account of autonomy. My objector might then suggest that if we adopted a substantive account of autonomy which requires that an autonomous decision must be in a patient’s best interests that the conflict between acting beneficently and respecting autonomy would disappear and with it the moral distress. In response to my objector I will now argue that if we accept a substantive account of autonomy that this account becomes redundant. Let us assume that an autonomous decision isn’t simply some decision made with only reference to what the maker cares about but must also concur with some substantive norms. An autonomous decision must be a good decision. However if we accept that an autonomous decision can’t be a bad decision then the whole idea of an autonomous decision isn’t really much use and we can simply replace all autonomous decisions by good decisions. Let us consider a nurse caring for a terminally ill patient who has one treatment option withdrawn, which the patient desires, because it is regarded as a futile option. If the nurse in question believes in a substantive account of autonomy then this option withdrawal against the patient’s wishes means she will feel no moral distress due to a failure to respect patient autonomy; the patient’s wishes weren’t good wishes because the treatment option was futile and hence weren’t autonomous wishes. If we accept a substantive account of autonomy then the idea of an autonomous decision becomes redundant and can be replaced by a good decision. If we accept that autonomy matters we must be prepared to accept that autonomous decisions can be bad decisions. We must be prepared to accept a primitive account of autonomy. Accepting that autonomous decisions can be bad decisions means that respecting autonomy and acting beneficently will sometimes clash causing inevitable moral distress. It might be argued that opting out of acting might combat this moral distress. I would argue that this option isn’t available in a caring setting. In a caring profession caring about what someone believes to be wrong way is better than not caring at all. It follows that respecting autonomy in a caring profession sometimes makes moral distress inevitable.

My objector might accept a primitive account of autonomy but still suggest that moral distress is not inevitable. She might suggest that autonomy is connected to of my “real self” as opposed to my empirical or actual self. She might proceed to suggest that if we did so my ‘real self’ wouldn’t make bad decisions and that respecting autonomy wouldn’t lead to moral distress. This might lead to the position where someone might think it right to ignore an agent’s intuitively autonomous decision because she believes it does not reflect his real self. I would reject my objector’s suggestion for two reasons. Firstly the world is populated by real people rather than idealised people. Secondly if we accept autonomy is only connected to idealised people who don’t make bad decisions then once again the concept of autonomy becomes redundant and can be replaced by good decision making,

Let us now consider cases where respecting someone’s autonomous decision causes moral distress because it conflicts with the distressed person’s beliefs. For instance a nurse’s religious beliefs might mean she believes we must do all we can to maintain life. Let us assume that she is nursing a terminally patient who isn’t in pain and is expected to continue enjoying a reasonable standard of life for some time. Let us also assume that this patient has made a last directive stating that if she goes into cardiac arrest that she isn’t to be resuscitated. The patient goes into cardiac arrest and the nurse suffers from moral distress because she can’t resuscitate her. Our nurse’s distress is caused by respecting her patient’s autonomy expressed in the last directive. I would suggest that in such scenarios respecting autonomy makes moral distress inevitable. Once again an objector might reject my suggestion. She might attempt to do so not by suggesting that we replace a primitive concept of autonomy by a substantive one but by limiting the domain of autonomous decision making. The domain of autonomous decisions is limited to those decisions which don’t clash with certain basic or religious beliefs. In the example used above the nurse might not suffer moral distress due to respecting autonomy because she believes the patient’s decision isn’t really an autonomous decision because it doesn’t belong in the domain of autonomous decisions. She may of course be forced to respect it by authority. Most hospitals have a policy to respect patients’ last directives. However the basic cause of her moral distress remains respecting patient autonomy. There are two arguments against accepting my objector’s suggestion. Firstly it might be argued that restricting the domain of autonomous decision making removes the importance of autonomy and makes it peripheral to our lives. Someone might end up in a situation in which she could autonomously decide to have an ice cream but couldn’t autonomously decide to have sex if she wasn’t married. Autonomy is about self-government and self-government must of necessity include those decisions which are central to our lives. If the nurse above suffers no moral distress due to respecting autonomy by adopting a limited domain of autonomy then her lack of distress is due to her adopting a deficient idea about the domain of autonomy. Secondly I would argue that any such limitation autonomy is really a surreptitious attempt to reintroduce a substantive concept of autonomy. The domain of autonomous decisions is limited because a larger domain would permit some people to make bad decisions. It is now possible to employ the argument used above against substantive accounts of autonomy. If autonomous decisions cannot be bad decisions then the concept becomes redundant. It follows that respecting someone’s autonomous decision inevitably causes moral distress when the decision conflicts with the respecter’s beliefs.

I have argued that the moral distress caused by respecting autonomy is sometimes inevitable and must simply be accepted by us as the price we pay for viewing other people as the sort of creatures who can decide how to live their lives. We may of course try to get someone to change her mind but if we can’t then respecting her as a particular person and not some idealised person means accepting her decisions and sometimes that means accepting moral distress.

1. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall