A right to anaesthesia, a right to physician euthanasia?

In an editorial in Anaesthesia Julian Savulescu and Janet Radcliffe‐Richards suggest that many people who are against the deliberate killing of terminally ill patients who wish to die should have no objection to what is known as terminal sedation, bringing about unconsciousness for terminally ill patients until their natural death, see Anaesthesia . I agree with Savulescu and Radcliffe‐Richards that most people would accept that sedation for terminally ill patients is not wrong when death is imminent. In France in 2016 a law came into effect granting terminally ill patients the right to anaesthesia until death. Sinmyee et al go further and argue that a right to anaesthesia should be available to all patients who choose to end their life by starvation or dehydration, see Sinmyee . Would most people accept that sedation for terminally ill patients is not wrong when death is inevitable but not imminent? Perhaps a patient has a prognosis that he has only six months to live. Secondly would most people accept that sedation for terminally ill patients is not wrong when used to relieve suffering which they cause themselves by a refusal to eat or to drink? I’m not sure what most people would find acceptable in either of these scenarios. In this posting I will firstly briefly summarise the argument why it isn’t morally wrong to sedate terminally ill patients even if their current suffering is due caused by a refusal to eat or drink. I will then consider what implications accepting this argument has for accepting physician assisted suicide and voluntary euthanasia.

Let us accept that any competent person has right to refuse to take food and water. It might be objected that in some cases the person in question is unlikely to be competent due to eating disorders such as anorexia. However clearly this objection doesn’t carry much weight when considering terminally ill patients. Let us also accept that relieving pain is a legitimate end of medicine even when this lessens a patient’s life span. Let us still further accept that relieving pain remains a legitimate end of medicine even when this pain is due to self-harm. We treat drug users for their addiction. Lastly let us accept that if pain cannot be controlled by any other means that it can be controlled by deep sedation. It appears to follow that deeply sedating a patient suffering from a terminal illness, even if his immediate suffering is caused by his refusal to eat or drink, is a legitimate end of medicine. It follows that in these circumstances deep sedation would not be morally wrong.

Let us now consider how permanent deep sedation differs from death. For a dead person conscious life is over. Conscious life is also over anyone who will be deeply sedated until he dies. Of course for someone who is deeply sedated some important unconscious physiological processes such as breathing will continue. The same is not true of the dead. But do these unconscious physiological processes matter if someone will never resume consciousness or take part in life again? If they do matter who do they matter to? These unconscious physiological processes certainly don’t matter to the sedated person. If they doesn’t matter to the person involved why should they matter morally to others? It would appear to follow that there is no significant moral difference between being dead and being deeply sedated until death. If this is so is there any moral difference between a doctor deeply sedating someone until he dies and helping him die a good death if he requests help to do so? If dying and being deeply sedated until death are equivalent for moral concerns then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept physician assisted suicide PAS.

It might be objected that deep sedation involves no suffering whilst helping a patient to die might do so. However even if we accept this objection the above question might be reframed. Is there any moral difference between a doctor deeply sedating someone until he dies and deeply sedating someone prior to carry out his previously expressed wishes for voluntary euthanasia? If there isn’t any difference then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept voluntary euthanasia, which might require prior sedation, when requested by a terminally ill patient.

I now want to examine two major objections to the above conclusion. Firstly it might be objected that the above argument depends on the concept of a person and that when considering deep sedation and voluntary euthanasia we should consider human beings instead. My objector might argue that that matters is not whether a person continues to exist bur whether a human being continues to exist. What does it mean for a human being to continue existing? Is someone who will never regain consciousness but for whom unconscious physiological processes such as breathing continue still a human being? My objector might conclude the answer is obvious and is affirmative. However if we consider the concept of brain death commonly used in transplant medicine the answer is not obvious. Someone is brain dead if he has a permanent absence of cerebral and brainstem functions, however mechanical ventilators and other advanced critical care services can maintain unconscious physiological processes such as breathing for some time. Whether someone who is brain dead remains a human being is far from obvious for we can use his organs for transplant subject to consent. Why does brain death matter? It matters not simply because of a loss of cerebral and brainstem functions but because the implications of these losses. These losses lead to a permanent loss of consciousness. If the above is accepted then substituting human for persons doesn’t affect my original argument.

I now want to consider a second objection to my argument that if we are prepared to accept deep sedation of the terminally ill patients until death that we should also be prepared to voluntary euthanasia for such patients. It might be objected that I have slipped too easily from considering PAS to considering voluntary euthanasia and that the two aren’t equivalent. PAS is self-administered whilst voluntary euthanasia is carried out by a physician. I made this move because it has been suggested that PAS might involve suffering by the terminally ill patient. As a philosopher I am unable to say much about whether PAS might involve suffering. However I can say something about the possible scenarios. Firstly if PAS doesn’t necessarily involve suffering then my original conclusion stands. Next let us assume that PAS involves some limited suffering. In this scenario it might be questioned whether a terminally ill patient needs to be fully anaesthetised for PAS to take place? Perhaps a patient’s pain might be alleviated without affecting his cognitive abilities allowing him to carry out PAS. Once again my original conclusion stands. Lastly let us assume that PAS involves suffering that cannot be fully alleviated without full anaesthesia. In this scenario PAS isn’t possible with full pain relief. In this scenario the question changes and becomes, if we are prepared to accept deep sedation until death then why shouldn’t we be prepared to accept voluntary euthanasia?

In order to answer the above question I want to consider two further scenarios. In both scenarios I will assume the patient is fully competent. In the first I will assume that the patient is capable of initiating the start of his anaesthesia before his physician takes over and delivers a fatal dose. In this scenario why is the patient initiating his own anaesthesia? I would suggest he isn’t only initiating a form of pain relief. He is only initiating pain relief in order to die. In this scenario the patient’s actions resemble those of a patient undergoing PAS.  However the two are not identical. In PAS the physician only supplies the means and need not be present at the time of death whilst in the above scenario the physician must not only be present but also deliver the lethal dose. Let us accept that the physician’s presence or lack of it is not relevant morally. However we must ask ourselves whether the fact that the physician supplies the means of dying differs in a morally significant way from the physician applying the lethal dose. It might be suggested that this a case in which we could use the principle of double effect to explain the difference. I would be reluctant to accept this suggestion. When supplying the means to die the physician involved in PAS has the intention of allowing the patient to kill himself, it isn’t a foreseen consequence of something else. The physician’s intention is the same whether he is involved in PAS or voluntary euthanasia as described in the above scenario. It seems provided the patient involved is able to initiate his own anaesthesia that there is no morally significant difference between voluntary euthanasia in these circumstances and PAS. Let us now consider a second scenario in which the patient is unable to initiate his own anaesthesia. I would suggest that there are no morally significant differences between a physician carrying out voluntary euthanasia on a terminally ill patient in this scenario and a physician suppling him with the means to carry out PAS provided the degree of voluntariness is the same in both cases. However is the degree of voluntariness the same in both cases? In the case of PAS the patient’s intentions seem to be clear because he initiates the dying process. If a patient can initiate his own anaesthesia I have argued he is initiating his death and once again his intentions seem clear cut. However if a patient is unable to initiate his own anaesthesia his intentions aren’t quite so clear cut. Perhaps this situation can be remedied by a rigorous consent process and a clear last directive. None the less differences remain between this scenario and the one in which the patient initiates his own anaesthesia and for this reason I would be reluctant to conclude that the scenario in which the patient is unable to initiate his own anaesthesia is equivalent to PAS. The above suggests some consequences for the process of deep sedation. Let us accept that the deep sedation of terminally ill patients who are unable to initiate their own sedation and voluntary are equivalent. It follows if we aren’t prepared to accept voluntary euthanasia we shouldn’t be prepared to accept deep sedation if the patient is unable to initiate his own anaesthesia.

In this posting I have argued that the deep sedation of terminally ill patients should be morally acceptable. I further argued such sedation was a legitimate use of medical skills. I have also assumed that most people would find such sedation acceptable and less contentious than either PAS or voluntary euthanasia. If most people find PA and voluntary euthanasia unacceptable and deep sedation is a legitimate use of medical skills then such sedation should be an option for the terminally ill. I then examined the moral implications of accepting deep sedation. The main implications of this acceptance are summarised below.

1. If we are prepared to accept deep sedation for terminally ill patients until death then we should be prepared to accept PAS when this process does not involve suffering.
2. If we are prepared to accept deep sedation until death and PAS involves some suffering then we should accept PAS provided that this suffering can be controlled without anaesthesia.
3. If we are prepared to accept deep sedation until death and a patient is able to initiate his own anaesthesia then in these circumstances we should be prepared to accept voluntary euthanasia.
4. If we are not prepared to accept voluntary euthanasia then we should not be prepared to accept deep sedation until death when a patient is unable to initiate his own anaesthesia.

Assisted Suicide and a Life not Worth Living

Writing in theconversation  Lidia Ripamonti asks if assisted dying became legalised who should decide if a life is worth living. She is assuming that assisted dying would become available to those who have a life not worth living. It might be argued because of dangers of pressure being put on disabled people, the aged and those suffering from mental illness that any such decision should not be solely up to the patient. If not the patient who else can say her life isn’t worth living? Her medical team, her priest or a bioethics committee? Others telling a patient she has a life worth living when she has already decided her life is not worth living seems to be unacceptably arrogant. In philosophy how we frame a question is especially important if we want to draw meaningful conclusions. In this posting I will frame the above question slightly differently. I will then argue that in certain situations we should simply accept the patient’s decision.

If we simply accept the framing of Ripamonti’s question then it is possible to conclude that there may be dangers for the disabled, the aged and the mentally ill if assisted suicide became permissible. I now want to suggest that her question might be better framed Perhaps the question might be framed as follows. If assisted dying is legalised, who gets to decide if someone’s life contains unbearable suffering rather than her experiencing a life which isn’t worth living? It might be argued that if the permissibility of assisted dying is based on unbearable suffering that disabled people and those suffering from mental illness would be better protected because they can live enjoyable worthwhile lives. It might be suggested that others, such as a patient’s medical team, might be able to give an objective answer as to whether the patient is suffering unbearably. Unfortunately it seems impossible to give an objective answer as to whether someone’s suffering is unbearable. One person might find some suffering bearable whilst similar suffering would be unbearable to someone else. Whether suffering is unbearable is a subjective question. Others telling a patient that she doesn’t have unbearable suffering when she has already decided her suffering is unbearable seems to be unacceptably arrogant. It might be suggested that this difficultly might be addressed by replacing unbearable suffering in our amended question by unbearable pain. Perhaps we can measure pain objectively. I’m doubtful whether this might be possible but let us assume for the sake of argument that pain can be measured objectively. However even if this was possible it doesn’t help solve our problem. What matters to some is not the degree of pain alone or how long it will persist but someone’s reaction to it. As with suffering someone might find a pain bearable whilst someone else might find the same degree of pain unbearable. It appears to follow if we don’t want to be accused of arrogance that we cannot replace a ‘life not worth living’ with either ‘unbearable suffering’ or ‘unbearable pain’ in an attempt to reframe Ripamonti’s question.

Ripamonti is concerned that letting the patient solely decide if she has an unbearable life endangers the disabled, the aged and the mentally ill if assisted suicide became available. I accept that Ripamonti is correct provided assisted dying became available across a broad domain. I will now argue that in a restricted domain her concern seem much less pressing. No one is suggesting assisted suicide should be available to anyone who finds her life not worth living. Medicine is concerned with illness not social problems. Let us assume that assisted suicide should only be available to terminally ill patients capable of making a competent decision. If we strictly restrict the domain of patients who could avail themselves of assisted suicide in this way the disabled, the aged and the mentally ill would appear to have little to fear from the legalisation of assisted suicide. Unfortunately this restricted domain appears not to be restricted enough, some terminal diseases may kill someone but can take a long time to do so. For instance Stephen Hawking was diagnosed with motor neurone disease MND in 1963 but lived a highly productive life until his death in 2018. Perhaps then the domain of patients who should be limited to those who are autonomous with a terminal illness and who are expected to live less than six months. Accepting such a domain should protect those suffering from Alzheimers, the disabled, the aged and those suffering from mental illnesses.

However accepting this strict domain causes additional problems which are not easy to resolve. If the domain is restricted to autonomous persons then this restriction protects those suffering from Alzheimers. We don’t, or can’t fully understand what it means to suffer from Alzheimers. But does it always protect children? Consider two patients suffering from terminal cancer both of whom suffer identical pain and find their lives not worth living. Let us assume that assisted suicide becomes permissible but is restricted by the above domain. Let us also assume that the first patient is an adult and as a result is able to end her suffering using assisted suicide. Let next assume that the second patient is a child who because of her suffering also wishes to relieve her suffering by ending her life. Children are not usually considered to be fully autonomous and we have restricted the domain of patients who can avail themselves of assisted suicide to those who are fully autonomous. It might be questioned whether we are really protecting the child. We certainly aren’t protecting her from pain and suffering.

I have argued that autonomous adults with a terminal illness with a prognosis that they will live less than six months and who believe that their life isn’t worth living should have a right to assisted suicide. However because I argued that assisted dying should only be available to autonomous patients creates difficulties and doesn’t protect some patients from pain and suffering. What sort of responses might be made to these difficulties? One response might simply be that I am wrong and that the decision as to whether a patient’s life is not worth living should not be solely up to the patient. Accepting this response would mean Ripamonti’s question becomes pertinent again, who should decide. However I would be reluctant to accept this response because of the reason given above. If someone who is expected to live less than six months believes her life isn’t worth living then it might be asked what pertinent reasons could have others advance to say her life is worth living? Of course others might advance other reasons pertinent to the impermissibility of assisted suicide but these reasons are not pertinent as to whether someone’s life is worth living. It would appear that the decision as to whether a patient’s life is not worth should be solely up to the patient. A second response might be to drop the requirement that the terminally ill patient must be autonomous. Of course how a decision is made to request assisted suicide matters. If such a decision needn’t be an autonomous decision should be replaced by a good decision, I have argued elsewhere that autonomous decisions need not always be good decisions wooler.scottus . Let us accept that a good decision is not simply some decisions regarded as a good decision by the decision maker. Others must also be able to regard the decision as a good decision. However if we accept the above the following might occur. The patient might make a decision that her life is not worth living which she believes is a good decision whilst others believe her decision is a bad one and not in her interests. Once again we might question whether the reasons others give for her life being worth living are pertinent. If others cannot give such reasons then there replacing an autonomous decision by a good decision becomes meaningless. I have argued that if assisted suicide became permissible that initially it should only be made available to autonomous adults with a terminal illness and a prognosis that they will live less than six months and who believe that their life isn’t worth living. I have further argued that who decides if a life isn’t worth living is the person living that life.

What can we learn from the above except that applied philosophy is a messy business? Can any practical conclusions be drawn from the above discussion? First I would argue that the discussion shows how a question is framed matters. Secondly a tight restriction on the domain of people who can avail themselves of assisted suicide gives rise to difficult questions. Such a restricted domain would protect the disabled from exploitation whilst enabling those disabled who meet the criteria to avail themselves of assisted suicide. However such a tightly restricted domain would not protect other vulnerable patients from suffering such as children and those suffering from dementia. None the less I would argue that it is better to protect a limited number of people from suffering than none. Perhaps more work might enable us to extend this tightly restricted domain to others but extreme caution would be needed.

The Philosopher's Dog

 

 A philosopher has a pet dog, does he do anything wrong? According to Gary Francione he does because a morally just world would have no pets, no aquaria and no zoos. Francione opposes pet ownership, zoos and aquaria because such things violate the fundamental rights of animals. In this posting I will only be concerned with pets and I will argue that Francione’s view is mistaken in cases involving some kinds of animals. I will next argue that the keeping of some pets can sometimes be mutually beneficial. Lastly in the light of these benefits I will consider the sort of animals it is permissible and possibly beneficial to keep as pets.

 I won’t consider a virtue ethics approach to the keeping pets because whilst virtue ethics might have something to say about how we ought to treat pets it has little to say about the permissibility of keeping pets. Neither will I consider a consequentialist approach. It might be objected problems of hungry people and environmental harm means we shouldn’t keep pets for consequentialist reasons. In what follows I will assume that either these reasons can be overcome or balanced by the benefits of keeping pets. In what follows I will examine three objections to pet keeping based on animal rights. First, a right to be free. Secondly, a right not to considered as property. And lastly, a right not to be kept in a dependent state.

 Pets unlike wild animals are confined to our home or to its immediate surroundings. It follows pets are restricted by their keepers from roaming freely. It has been argued that the inability to roam freely causes pets distress and that this distress means pet keeping is wrong. However, we don’t allow young children and infants to roam freely. Many five or six-year old children would like at times to roam freely and feel frustrated when their parents prevent from doing so. Frustration is a form of distress. Nobody suggests we shouldn’t have children because we curtail their freedom to roam might cause distress. It might be argued by analogy that the same is true of pets. It might be objected that this analogy doesn’t hold because once children become adults they can decide where they want to go whilst the same doesn’t apply to pets. In response to this objection I would point out that children develop skills which means they can enjoy their freedom. Feral dogs are free from restrictions but unlike adult humans they don’t appear to have the skills to enjoy this freedom. Pet dogs appear to flourish better than feral dogs. What is true for dogs need not of course apply to all animals. Some animals we keep as pets might be happier and flourish better if they were free to roam. However accepting the above means that there is at least one kind of animal which is not damaged if its freedom to roam is curtailed. It follows the argument against keeping of at least some kinds of animals as pets based on restrictions to their freedom fails.

 A pet is sometimes considered as someone’s property and it might be argued that owning an animal is wrong. This argument is really two different arguments. First it might be argued that someone can do whatever he likes with his own property and that he shouldn’t be able to do anything he likes to any pets he keeps. This argument is clearly false. Someone can only do whatever he likes with certain forms of property. Someone may do whatever he likes with his table and chairs. Pets even if they are property are not the kind of things someone can do whatever he likes with. Pets are living things and because of this the law prevents pet owners from mistreating their pets. Secondly it might be argued the simple fact of being owned damages pets? Certainly if one person owns another being owned damages the second person. This damage is due to a lack of freedom. In response to such an argument I would point out most pets are not persons. One possible exception would be a great ape and accepting the above would mean that keeping a great ape as a pet should be impermissible. Secondly as I have argued above for some sort of pets a loss of freedom doesn’t of necessity cause harm. It appears to follow even if pets are in some way owned this ownership doesn’t give us a reason not to keep some kinds of animals as pets.

 Lastly let us consider the dependency argument. If some creature is dependent on another this dependence means it is in a vulnerable position. Let us assume that it is wrong to place some creature in a vulnerable position. It follows we shouldn’t place any creature in a vulnerable position and that because pets are kept in a vulnerable position that it is wrong to keep pets. I believe the above argument is unsound. The premise that is it is wrong to place any creature in a vulnerable position is false. Pets exist and for most pets to be allowed to roam at will this would increase their vulnerability. The above argument might be refined by replacing the above premise with a related one. Let us assume that it is wrong to create some creature which will be vulnerable in life. Accepting the above would mean we might keep our existing pets but it would be wrong to permit the creation of any more. Once again I find the refined argument unconvincing because I believe the revised premise is also false. Human beings are vulnerable. I believe that we do have a duty not to bring into existence any being we think would not find its life worth living. I believe that this duty cannot be extended into a duty not to bring into existence some creature which will have a life worth living but is vulnerable in some way. It would appear that the dependency argument does not give us reason to keep some kind of pets provided that our lifestyle permits us to attend to their needs.

 I have argued that there are no reasons why we shouldn’t keep some types of animals as pets. I now want to argue that there are some good reasons for some people to keep some types of pets. Someone might keep a pet to showcase a lifestyle. Macho man keeps a big strong dog to demonstrate the sort of person he is. For such people pets have much the same status as their jewellery. I don’t believe keeping a pet to showcase a lifestyle is a good reason to keep a pet. Indeed I would suggest that this is a poor reason to keep pets because if someone wants to showcase the sort of person he is he should demonstrate this by his actions rather than his possessions. In spite of the above it should be permissible for such people to keep pets provided that they look after them well.

 One concern of moral philosophy is human flourishing. I now want to outline four empirical reasons why keeping pets might help some people to flourish. Firstly there seems to be a connection between keeping a pet with both physiological and psychological health, see the psychologist . Secondly keeping a pet might be useful in counteracting loneliness among some people, especially the aged. For instance walking a dog besides being beneficial to health increases the possibility of social interaction. Moreover even if someone is unable to exercise a dog keeping some sorts of pet might create a bond which could be useful in counteracting loneliness. Thirdly keeping a pet might be useful in a child’s development and help him to flourish for three reasons. Firstly children who actively care for pets, such as regularly walking a dog, might be more likely to develop a notion of responsibility. Secondly a more developed notion of responsibility might also foster a ‘caring for’ attitude. Thirdly there is some evidence that interaction with a pet might benefit some autistic people by reducing anxiety, see how animals can help autistic children . Verbal communication with a pet is a one way process. Lastly I would suggest that underlying all these reasons is a basic human need to love and be loved. This love of course isn’t romantic love but a very basic need to care about something. Indeed I would further suggest a failure to care much about anything is a failure to be fully human, someone who doesn’t care acts robotically or like a zombie. Caring about, or loving, makes us human and in some cases the keeping of a pet might help foster this caring about. Much more speculatively it might even be suggested that terrorists are unlikely to keep pets or have kept pets as children. Maybe loving a cause tends to exclude someone from loving a pet and vice versa.Perhaps this somewhat bizarre suggestion could be tested empirically.

 Let us accept that it is permissible, perhaps sometimes even desirable, for someone to keep a pet. However does this apply to all animals or only to a subset of animals? What sort of animal it would be morally permissible to keep as a pet? I argued above it is permissible to restrict the freedom of certain animals such as dogs. Dogs, cats and perhaps a few other animals such as horses have adapted their way of life so they can still flourish when restricted by humans. Most wild animals would not cope well if their freedom was restricted and it would be wrong to keep such animals as pets. Let us accept that it is only morally permissible to keep as pets animals that can still flourish when restricted by humans. I now want to consider a slightly different question. What sort of animal might benefit someone if kept as a pet? I have argued above that our need to love and be loved gives us a reason to keep pets. What does accepting the above tell us about the sort of animals we should keep as pets? Let us examine our need to be loved first. Intuitively a dog can love someone whilst a fish can’t. Why is this so? I would suggest the reason is evolution has changed some animals so they can adapt to our lifestyle. Someone merely feeds fish and cleans their tank because fish haven’t adapted to our lifestyle. The same isn’t true of dogs. If we accept the above, then the type of pets we have reason to keep for the benefits they give us is limited. We have reason to keep dogs, possibly cats or even ponies but not many other kinds of animals. We definitely don’t have reason to keep snakes or fish based on our need to be loved. However, we don’t simply have a need to be loved we also have a need to love, to care about something. Is it possible to love a snake or a fish? I will now argue it isn’t. I would argue if we love something we must be capable of benefiting what we love. By love I mean ‘caring about’ and not simply ‘caring for’. Of course ‘caring about’ and ‘caring for’ are connected and there is a spectrum between these two forms of caring. However, if I care about something I am benefitted when what I care about is benefitted and harmed when what I care about is harmed. The same is not true for ‘caring for’ something. I can benefit a fish by feeding but not feel benefited myself. Let us consider benefits in more detail. If someone plays with a dog and a ball he is happy because his dog is happy, much the same applies to someone stroking a purring cat. However, someone might know what harms a fish or snake but he has little or no idea about what makes these creatures are happy. She doesn’t know what benefits these creatures besides ‘caring for’ their basic needs. Someone might care for such creatures but he can’t ‘care about’, love them. It follows someone’s need to ‘care about’ love cannot be satisfied by keeping animals like fish and snakes as pets and that this need to love cannot used as a reason to justify keeping them as pets.

 In conclusion it seems that it is perfectly permissible for a philosopher to keep a dog as a pet. It might also be desirable in some cases for some people to keep a pet, especially children. However the sort of animals it is permissible to keep as pets is limited to those animals who have been shaped by evolution to fit our lifestyles.

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

Honour in a Cosmopolitan Society

In the western world the idea of honour seems to be becoming less important. Politicians make promises and feel no shame when they break them, others offer apologies without feeling any sense of shame. In a new book Tamler Sommers argues that honour matters. Let us accept that honour matters. Sommers argues that in our cosmopolitan culture we have replaced honour by dignity and that this replacement damages society. In this posting I will argue that some of the goods honour delivers can be outweighed by other goods delivered by a dignity based culture. I will then argue that honour can matter in a dignity culture albeit in a modified form.

Why does honour matter? Sommers lists three main disadvantages of living in a culture without honour. Firstly he argues that such a culture makes us fearful. Secondly he argues that the rampant individuality of contemporary western leaves us without a sense of solidarity. Lastly that such a society diminishes the power of shame. Honour matters to Sommer because it gives us courage to combat fear, it helps to form our identity and it gives us a stronger disposition to feel shame. Honour matters because these goods are valuable.

Let us accept that courage is valuable, Martha Nussbaum like Sommers argues that we are damaged by living in a fear driven culture (2). However it might be argued that in a cosmopolitan society courage has diminished because the need for courage has diminished. For herders or hunter gatherers courage helped them to survive in a harsh environment. For a citizen in ancient Greece or Rome courage helped flourish in brutal times. However most of us no longer need courage to survive even if we might need it to flourish. Perhaps as the need for courage diminishes so does its value. It might be concluded that in a cosmopolitan society because we have less need for courage that this is on balance a good thing. It might be objected that some inner city dwellers live in a harsh and brutal environment which means that the need for courage remains. Perhaps this is one of the reasons why gangs persist in these areas. I would suggest what this objection shows is not that there is still an undiminished need for courage in a cosmopolitan society but rather that the domain of such a society is limited. A truly cosmopolitan society must address the needs of all of its citizens. I would further suggest that in an efficient cosmopolitan society which addresses the needs of all its citizens that there is less need for courage and that as a result the value of courage diminishes.

However even if it is accepted that there is less need for courage in a cosmopolitan society this does not imply we have no need for courage. It is sometimes remarked lose it or use it. If there is less need for courage in such a society does this damage our capacity to display courage when needed? I am prepared to accept it does but would suggest that any harm done by a lack of courage in a dignity based society is more than offset by living in a more peaceful society which protects its citizens. Perhaps the harm done by living in a fearful society might be better addressed by hope supported by faith as suggested by Nussbaum (3). In this context faith might regarded as the realistic optimism of Tiberius. Nonetheless I still believe courage should be fostered. Our educational systems seem to be becoming solely concerned with preparing people for work rather than life perhaps with more emphasis on sport and perhaps even the teaching of philosophy might foster courage.

Is Sommers right when he suggests that the rampant individuality of contemporary western leaves us without a sense of solidarity? It might be argued that a dignity culture means that all are valued. Perhaps all being valued gives all of us a basic sense of solidarity. However this is a very basic sense of solidarity and I accept Sommers is right and that rampant individualism can damage solidarity. A sense of solidarity can have various roots. It might be rooted in a profession, a religion, class, a nation or even a tribe. However even if a sense of solidarity has benefits it might have shallow roots. Let us accept our identity is linked to solidarity. We identify with those who are similar to us. If our sense of identity is rooted in some class, nation or tribe then our identity is passively determined and our sense of solidarity is easily acquired. Such a sense of dignity might increase solidarity with our own in group but lessen our sense of solidarity with others and lead to a decrease in toleration. Perhaps these harms outweigh the solidarity an honour culture fosters. Can a dignity based culture deliver a sense of solidarity other than a very basic form? In a dignity based cosmopolitan society we determine our identity to some degree. We might do so explicitly by choosing profession, such as joining the police force, or choosing a religion, perhaps by becoming a Buddhist. We might also do so implicitly by the actions we choose. I would suggest that if we choose our identity, even if our choice is implicit rather explicit, that we are more authentic than if are identity is acquired passively by being, born in some particular place or class. I would argue that even if solidarity is of value that the loss of solidarity in a cosmopolitan society might be more than offset by the value of authenticity. However at this point courage re-enters our discussions for someone wants to be true to himself must have the courage of his convictions. Does someone in this situation really need raw courage or would fortitude be more useful? I would also argue that a cosmopolitan society might increase a stronger sense solidarity in some cases. I have suggested above if we passively acquire our sense of solidarity that this is easily acquired. I have suggested that identity and solidarity are linked. If our sense of identity is based on partly on the choices we make we might feel a stronger sense of solidarity with those who have made a similar choice rather than those who are simply members of our class, nation or tribe.

Sommers argues that we are less likely to experience shame in a dignity culture than in an honour culture. I agree with Sommers that the ability to feel some form of shame is valuable but what form of shame? What do we mean by shame? I have previously argued that there are two types of shame. Firstly David Velleman defines shame as “anxiety about social disqualification” (4). This seems to be the sort of same fostered by an honour based culture. Secondly shame might be defined as someone’s anxiety about harming the things he cares about or loves and is linked to character. If we accept Velleman’s account of shame then a cosmopolitan society does indeed damage our ability to feel shame. A cosmopolitan dignity based culture seeks to include rather than exclude. But is Velleman’s type of shame really valuable? Consider a high caste Brahmin in India who has come into contact with something unclean and feels no shame. Has he done anything wrong and would social disqualification ever be valuable in this scenario? Shame is valuable but I would suggest that the type of shame which is valuable is linked to character. But shame linked to character is linked to authenticity which is perhaps best fostered in a cosmopolitan society than an honour culture. If we accept the above then shame matters and the shame that matters is connected to character. Such shame is not the shame fostered by an honour basis.

Let us accept that Sommers is right and that a loss of a sense of honour damages society. He argues honour is connected to being a member of some organisation such as a profession, a religion, class, a nation or even a tribe. If honour is only connected to some social group then in a dignity based society honour becomes irrelevant and fades away. I have argued if honour depends on the above bases that the goods delivered by a cosmopolitan outweigh the damage done by losing our sense of honour. Sommers argues that honour is damaged by an excessive focus on dignity. Perhaps it’s not our excessive focus on dignity but our excessive focus on rights, rather what it means to be a good person, which damages our sense of honour. I would suggest being a virtuous person is connected to being a good person. I would further suggest that being virtuous is not incompatible with living in a dignity or rights based society. I would still further suggest honour can be based on acting virtuously. Indeed it might be argued that virtue based ethics is impossible without some idea of honour. Moreover acting virtuously sometimes requires courage, gives us a sense of identity and if we fail a sense of shame. Such thoughts might have pleased Jane Austin. If we accept the above that being honourable means acting virtuously then honour is possible in in a dignity based or rights based society. Perhaps to promote honour we don’t need to encourage a greater sense of solidarity in our cosmopolitan society as suggested by Sommers but rather by encouraging people to be good persons by acting virtuously.

1. Tamler Sommers, 2018, Why Honor Matters, Basic Books, chapter 2
2. Martha Nussbaum, 2018. The Monarchy of Fear, Oxford University Press
3. Nussbaum , chapter 7
4. David Velleman, 2009, How We Get Along, Cambridge University Press, page 95