Can Suffering Have an Ethical Value? Aaron Somerville Suffering and Hope Conference University of St.

Thomas November 10-13, 2005 It is never enough to know that one can act. Prior to acting, one must also know whether and how one should act. This ethical imperative applies equally to every sphere of human action. Therefore, it applies to actions taken within all medical specialties, including the promising specialty of palliative care. The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families ... through the prevention and relief of suffering.1 The concern of this paper is whether the stated purpose of palliative care, to improve the quality of life of patients and their families is potentially undermined by the proposed methodology, the prevention and relief of suffering. The argument is for the affirmative, for it will be taken as a given that the dignity of right action is the substratum of a life of good quality. Therefore an unethical life, in virtue of being unethical, is necessarily somehow debased and defective in quality. From this it follows that any methodology of treatment which leads a patient into unethical behavior would not only fail to improve the patients quality of life, but would in fact diminish it. Further, any treatment which permits a patient to persist in ethically defective behavior in some respect would diminish the patients quality of life proportionally to the gravity of the defect. In light of this, the question central to the ethical analysis of the methodology of palliative care is whether it is correct in all cases to administer treatment which prevents or relieves the patients suffering. In other words, the question is whether suffering can have an ethical value. If it can, then it follows that there is possibly some case or cases in which the prevention or relief of suffering is ethically and therefore medically, suboptimal or even illicit. The examination of this issue will constitute the content of this inquiry. This inquiry admits of the following divisions: first, suffering and ethical value will be defined. Second, an argument for the affirmative position will be given on the grounds that suffering may be formative of a positive ethical habit. Third, responses to general objections will be given. Fourth and finally, the conclusion will place the affirmative position in the larger context of treatment. II. Suffering can be defined as the experience of discomfort. Discomfort may be physical pain, either from injury or not, or mental distress. There are various words to describe these sensations: agony, anguish, sorrow, hurt, and so on. All of them may be considered
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From the World Health Organization website, http://www.who.int/cancer/palliative/definition/en/. Emphasis added.

forms of suffering. Suffering may arise in an instant, and it may linger or depart just as suddenly. It may be quite mild, or it may be substantial in its impression. Suffering is a phenomenon of the sensitive faculties. The sensory information of suffering, such as the signals in nociceptive and neuropathic pain is a brute fact, however subjective is the reception of such information. Phenomena such as sorrow or psychosis ought to be viewed the same way. It is evident that great strides have been made in the ability to control this information. Treatments ranging from analgesics to nerve blocks, from antidepressants to antipsychotic drugs and many others have all proved effective in the management of suffering. Therefore suffering admits of palliation. Ethical value can be defined according to activity or passivity. In the active sense, ethical value can be taken as having a weak or strong meaning. In the weak sense, ethical value applies to an action which instills or provides the occasion for the exercise of a virtuous habit of character. Plainly, not all such actions are licit. For example, an act of violence against a person provides that person with an opportunity for the exercise of fortitude. However, while that violent act has an ethical value for the victim, it is of course not licitly performed by the agent. That is why this sense of ethical value should be considered the weak sense, because according to this rationale every act of every agent has ethical value. In the strong sense, active ethical value applies to an action which is licitly performed and provides the occasion for the exercise of a virtuous habit of character. In other words, an act with strong ethical value is a virtuous act. Ethical value can also be taken in the passive sense, which can also be described as having a weak and a strong sense. The weak sense of a passive ethical value applies to cases in which a passion befalls some subject which instills in that subject or provides for that subject an occasion for the exercise of a virtuous habit of character. Likewise in this case, it is apparent why this sense should be called the weak sense, as it also applies to every situation in which an ethical agent experiences some passion. In the strong sense, passive ethical value applies to cases in which a passion befalls the subject which instills in the subject or provides for the subject the occasion for the exercise of a relevant virtuous habit of character. Taken in the weak senses, active and passive ethical value are attributable to any cases whatsoever which involve ethical agents. Therefore they are quite uninteresting to this inquiry because such broad application detracts from their gravity. The question at issue, whether suffering can have an ethical value, considered in light of the methodology of palliative care, therefore must be refined. It should be stated instead as whether suffering can have an ethical value both in the strong active sense and strong passive senses. Thus formulated, the present inquiry investigates whether an absolute application of the proposed methodology of palliative care, to prevent or relieve suffering, could potentially undermine the stated goal of palliative care, to improve the quality of life of patients and their families, in that it might sometimes be the case that for a caregiver to omit to palliate some kind of suffering in a patient has ethical value in the strong active and 2

passive senses. The burden of the affirmative position, therefore, is to establish that there might be a case such that it would be licit for the caregiver to omit to palliate some suffering and that this act would constitute a relevant form of ethical instruction. It is to this task that the inquiry now turns. III. The burden of the affirmative position is twofold. First, it must establish that it would be potentially licit for a palliative caregiver to omit to palliate some suffering. This means that it will have to be shown that such an omission is not necessarily illicit. Second, it must establish that to experience suffering would be potentially ethically instructive and relevant. This means that it will have to be shown that such a passion could result in positive ethical formation and that such formation furthermore would be pertinent to the patients quality of life. It should be kept in mind for both of these lines of inquiry that they concern the possible, not the actual. In other words, the affirmative position is not concerned with any particular case of suffering and whether it is palliated. The only concern of the affirmative position is to establish in principle that it might be choice worthy at some time under some circumstances for a palliative caregiver to omit to palliate some suffering. As to the first point, whether it would be potentially licit for a palliative caregiver to omit to palliate some suffering, three levels of specificity must be considered. Most generically, whether it is ever licit for any agent to omit to prevent or relieve some other agents suffering. Less broadly, whether it is ever licit for a medical caregiver to omit to prevent or relieve a patients suffering. Finally, and most specifically, whether it is ever licit for a palliative caregiver to omit to prevent or relieve a patients suffering. For the purpose of this inquiry, an act will be considered licit if it intends a good end and conforms to all pertinent ethical principles, which include fundamental ethical principles as well as professional ethical principles insofar as they apply. At the most generic level, the question is whether it is ever licit for any agent to omit to prevent or relieve someones suffering. First of all, there are two senses of omit which are relevant. The broad sense of omit applies to any omission whatever, and in this way it is clear that it is licit to omit to prevent suffering. This is because if it were not so then any action which did not constitute the prevention of suffering, for example sleeping or labor, would be illicit, which is absurd. What applies here, rather, is the more narrow sense of omit, in which there is ethical proximity of the omitting agent to the suffering agent, qua suffering. In other words, there is some tie of responsibility of the particular omitting agent to the particular suffering agent. For, speaking in the broad sense of omit, although it is licit to omit to relieve some generic agents suffering (though it is not licit always to omit to relieve suffering, since every agent has a duty of almsgiving and social justice), it is nevertheless sometimes the case that a particular agent is bound to relieve the suffering of a particular other agent. For example, if a wife enters the kitchen and finds that her husband has set himself on fire, she is ethically bound to extinguish him. 3

Likewise, this would apply if the same woman found a guest, or a stranger, or even an enemy in such a state. However, as has been said, she is not therefore obligated to go to every place in the world where there is someone on fire in order to extinguish them. This is due to the relation of proximity which obtains in the first cases, but does not obtain in the latter cases. Let us suppose that an agent standing in a proximate ethical relation to a sufferer chooses to omit to relieve or prevent the suffering. It stands to be established whether such an action could intend a good end and whether it could simultaneously conform to basic ethical principles. This is the case for the following reasons. First, sometimes it is necessary to undergo some suffering to attain a good end, which cannot be attained without suffering. Therefore, if that good is to be chosen at all, choosing it will result in suffering. For example, suppose an athlete must train to compete in an event. The training required, however, is very strenuous, due to the nature and competitive circumstances of the event. In this case a trainer, who along with his athlete chooses the good of competing for victory in this event, will at times omit to relieve the athletes suffering, which is under the stain of the training, in order to perfect the athletes faculties. In such a case, even though in a moment of weakness the athlete may beg the trainer to relent, the suffering is necessary for the end, and both the athlete and trainer in retrospect ought to be glad of it. Thus it is possible to intend a good end, for a good purpose, even if the omission of the prevention or relief of suffering is entailed in the intention. Second, such cases conform to basic ethical principles. For while suffering in itself is an evil, nonetheless it is the case that we must sometimes avoid pleasure, which we naturally seek, for some ethical reason, and pain, which we naturally avoid, must sometimes be chosen for some ethical reason. The cited example of the training athlete works for this as well. Next, the specifically medical cases must be considered. Is it ever licit for a medical professional to omit to prevent or relieve the suffering of a patient? Clearly, there are numerous cases where it is not only licit but standard practice. As everyone knows, many medical procedures are painful or require the consumption of unpleasant substances. For example, a bone marrow biopsy hurts. However it is sometimes necessary, even if only to establish that an already complete or ongoing treatment is in fact working. In this case, supposing that the treatment is working it is pain inflicted upon the patient that might not have been inflicted. Nevertheless, it serves an important role in the care of some patients, and therefore under those circumstances, and despite the pain that it inflicts, the procedure of the bone marrow biopsy is choice worthy. Indeed, no credible physician would deny this. But the suffering associated with a bone marrow biopsy could be prevented, in that the procedure might not be undertaken at all, or it could be relieved, in that it might not be completed in the hopes of sparing the patient the pain of the entire procedure. These things are not done, however, because the successful practice of medicine sometimes requires the infliction of or omission to, prevent or relieve suffering. Now, taking the example further, it would generally be thought illicit for the physician 4

ordering the bone marrow biopsy to further order that the patient not receive any pain medication during or after the operation. All other things being equal, there is no reason why the patient should be subjected to that additional pain. If the patient, however, had a certain condition which contraindicated the use of the more effective pain medication, the patient would naturally be prescribed less effective pain medication. Therefore, the physician would omit to prevent or relieve a certain amount of pain because to prevent or relieve more which would be possible with the more effective medication would cause some other graver evil to befall the patient. Therefore it is not only licit in medicine but oftentimes a required practice to omit to prevent or relieve some suffering for a patient. Of course, this assumes that the proper care is taken by medical professionals, just as in any other case of establishing what constitutes licit conduct by medical caregivers, which leads this inquiry to the precise point at issue: is potentially licit for a palliative caregiver specifically to omit to palliate a patients suffering? Given that it is firmly established that it would be potentially licit for a generic medical caregiver to do so, the question is whether there obtains any specific ethical issue for a palliative caregiver that would render such a normally potentially licit act as illicit. This would have to derive from the end of palliative care, which is to improve the quality of life of the patient and patients family. The question therefore is whether it is possible to improve quality of life by the omission to palliate some suffering. This would only be impossible, in principle, if suffering itself presented an insuperable impediment to the improvement of the quality of a persons life. But this is manifestly not so. For it is at least possible for a person to improve their quality of life in spite of suffering. Therefore, it is possible to improve ones quality of life when suffering nonetheless obtains. For example, a sufferer might find their quality of life improved through appropriate interactions with their family. This is because proper and functional familial interaction is salutary to mental health. Therefore it is possible for quality of life to be improved even when suffering obtains. So it is not in principle illicit for a palliative caregiver to omit to palliate some suffering, if only that suffering stands to improve the patients quality of life. The possibility of the latter stands at last, therefore, to be proved. Since it has been shown that it is not necessarily illicit for a palliative caregiver to omit to prevent or relieve some suffering, it remains to show that some suffering could improve the quality of a patients life (and by extension, the quality of life of the patients family). The question therefore is whether the passion of suffering is potentially ethically instructive and relevant. As to the question of instruction, this is easily shown to be possible. A number of virtues, fortitude most especially, arise precisely from a persons experience of suffering. For such virtues concern the manner in which the agent copes with such experiences, whether it is particularly one or the other aspect of coping, such as bravery or endurance or the sympathy that moves one who has suffered to have mercy upon other people due to their status as sufferers. Manifestly, suffering is not only ethically instructive, but necessary for the habituation of the full range of sufferingdependent virtues.

What this final issue turns on, then, is the question of whether such suffering could be ethically relevant, namely instilling or providing the occasion for the exercise of some virtue which pertains to the patients quality of life. Conceivably, there are some forms of ethical instruction which would be irrelevant or at least non-relevant for a particular patient. For example, if a condition gravely impedes a patients sex drive, there is little need to instruct that patient in the rigors of chastity. More to the point, if a patient is already resolutely chaste or temperate, instruction in chastity or temperance is not particularly necessary. In such cases to go so far as to withhold palliation would seem disproportionate to the needs of the human person. However, a persons quality of life does depend upon the possession of certain virtues which pertain to that persons daily situation of living. For example, a person deficient in fortitude will suffer disproportionately much over a lesser amount of pain. Such a person may be miserable because of pain which should only cause a virtuous person to be uncomfortable (as is evident among children). This person must build up the virtue of fortitude because its absence provides a distinct impediment to happiness. Likewise, an excessively irascible person will be unhappy when he or she perceives that obstacles are present. However, life is fraught with obstacles. Such a person must learn to confront and accept obstacles rather than fleeing from them, for instance into medication. Furthermore, many situations in life, such as a persons final arrangements, require lucid reasoning and moral deliberation. A patient cannot perform such actions if in an overly medicated state. There are many possible examples, indeed too many to list. The point is that in a given case there will be some virtues necessary to the quality of life of a particular patient. When those virtues are found lacking, to improve the patients quality of life instruction in and the occasion of exercise of those virtues must be provided to the patient. In some cases, it will be necessary to omit to palliate some suffering, whether that be a particular whole phenomenon of suffering or merely a certain degree of suffering, in order to make improvement of character or situation possible for the patient. Some examples can be provided which serve to illustrate this point. Consider the case of a man suffering from a serious depression. It may be that the underlying pathology is one which is resistant to treatment, and palliation is the only viable recourse. Therefore, a course of antidepressants may be indicated. However, it could be that the pathology is a result wholly of human artifice, such as when the man has suffered a grave betrayal by a trusted friend. In this case, the course of antidepressants would only obscure the manifestation of the symptoms, and for as long as he continued this course and never confronted the root cause, which he would likely not do in the absence of the symptoms, the pathology would persist. Whereas the appropriate course for the man would be to meet his problems rationally, and as it were to grow up. This he could only do by suffering through the symptoms. Further, consider the case of a man who has led a questionable life. Suppose that he is on his death bed and in extreme pain. If he partakes of pain medication proportionate to the level of his suffering, he will not be lucid. But lucidity is precisely what his situation demands, for he will be entirely unable to examine his life and his conscience in such a medicated state. But it is gravely defective for a man to die without such an examination. 6

Treating him merely as a patient, perhaps that would be hard to see; however, treating him as a human being makes it obvious. IV. While it would be beyond the scope of this inquiry to deal with every conceivable objection, several potentially common objections may nonetheless be considered. First, that suffering always reduces a persons quality of life. Second, that suffering, as a brute phenomenon, is not itself instructive. Third, that the families of patients will likely oppose any omission to palliate suffering. Fourth, that it is inappropriate for a palliative caregiver to make decisions about patient care based upon judgments regarding a patients ethical constitution. As to the first objection, that suffering always reduces a persons quality of life, it must be conceded that discomfort is an evil and arises from an imperfection. Therefore in a perfect state of life it would be absent. This does not mean, however, that to attain a higher perfection of the faculties, suffering is dispensable. For example, to struggle with a difficult proof in geometry can bring mental discomfort. However, this discomfort is necessary to attain the perfection of knowing the proof, given that the discomfort only arises because the person attempting the solution is already in an imperfect state in relation to it, namely, ignorance. So while suffering in itself may be an imperfection, sometimes an imperfection is necessary move an imperfect being from something less perfect to something more perfect. The imperfection in question, suffering, is thus not desired for itself, but for the effect it produces. Things work this way in the natural world as well, such as when an impure substance is subjected to the stress of calefaction in a crucible in order that the impurities can be stripped away from the substance itself. So the substance is not subjected to calefaction for any reason intrinsic to calefaction or to the utility of the substance, but because of the external circumstances which will promote a greater utility in the substance. Under the right conditions, suffering can work just like this, under the right conditions. Alternatively, as has been made plain, sometimes the omission to palliate suffering may be because to palliate it would cause some other impediment to the patient. As to the second objection, that as a brute phenomenon suffering is not instructive in itself, this is obviously true but it has no force. It is the reception of suffering which can be instructive and not the phenomenon itself. It is quite possible to endure suffering, or to receive any other potentially instructive phenomenon, in a manner which is not instructive. This sort of defective reception bespeaks a further defect in the recipient, just as when an ignorant person is not only ignorant of the subject matter being taught, but also resists the opportunity to learn. This only goes to show that not everyone who is in principle teachable will in actuality be taught. This in no way contradicts the affirmative claim that suffering may instill or provide occasion for the exercise of a virtuous habit of character. It only adds the precision that the suffering must be received correctly to be effective. 7

As to the third objection, that families will likely oppose any decision to omit to palliate a patients suffering, it should at least be admitted that this is possible. However, in some cases it will be of obvious benefit to the family, for example when the full measure of medication is withheld from the patient so that he or she may remain lucid, from which lucidity the patients family will benefit in that they will thus be able to maintain a meaningful relationship with the patient. In other cases, when the omission to palliate is not indicated, the family would be quite right to oppose it. Still, it is possible that the case may arise when it is the correct choice to omit palliation to some degree, but the family of the patient nonetheless opposes this. In such cases it is clear, however, that the overriding concern is the perfection of the patient as a human person, and that the familys wishes cannot take precedence over this. This is no different than when a family might oppose any sort of treatment which strikes the family members as repugnant but is nonetheless in the best interests of the patient. Insofar as the patients caregivers are acting according to proper legal and professional guidelines, the well-being of the patient overrides the whims of the patients family. Fourth, as to the objection that it is inappropriate for a palliative caregiver to make decisions about patient care based upon judgments regarding a patients ethical constitution, it should be admitted straightaway that this is a strong objection. The claim is that a palliative caregiver is not qualified to make these sorts of judgments, which admittedly concern matters that are not strictly medical. However, it should be noted that the orientation of palliative care is not to treat the patient solely as a patient, that is, simply as a topos for battling an illness or relieving pain, but as a human being. This integrated approach bespeaks the necessity for certain palliative caregivers to make quality of life judgments which themselves of necessity extend beyond the sphere of the purely medical. Questions about what constitutes quality of life, or whether it is a life of a higher quality to be painless and in a fog of medicinal confusion or to be in pain and lucid are not, strictly speaking, medical questions. Yet these questions inescapably arise, and so the specialization of palliative care would not even be viable if medical professionals were limited to judgments of a purely medical nature. Further, it has never been claimed in this inquiry that every palliative caregiver should have the discretion to omit to prevent or relieve some suffering, only that such a decision is not in principle illicit. Obviously, all the normal conditions for a licit patient care decision apply, such as the consultation of the caregiver with other assisting or directing caregivers. Just as the night nurse is not empowered to order a complex surgery, so a hospice attendant is not empowered to order the discontinuation of medication in order to help instill the habit of fortitude in a patient. Nowhere has it been claimed that such decisions could omit the proper channels, or that they could be made lightly and without rigorous fact finding and consideration. It is merely the position of the affirmative that such decisions are not in principle illicit. As to the force of the objection, again, palliative caregivers, such as the overseeing physician, must of necessity make decisions that extend beyond the sphere of the purely medical. To say that any particular physician is not qualified to make such decisions only amounts to saying that this physician is not qualified to oversee a patients 8

palliative care, not that it is impossible that any physician would be so qualified. Quality of life is not a purely medical issue, yet it is the end of palliative care. Therefore the specialization requires the exercise on the part of the relevant caregivers of wisdom and prudence, in just the same way that a judge in a law court must consider additional factors beyond the established laws when sentencing a convicted man, such as the social impact of the decision and the good of the convict. These sorts of considerations are entailed in the judges duty, but they are not, strictly speaking, legal considerations. Quality of life depends upon the possession of relevant virtuous qualities of character. If a physician is serious about promoting the quality of life of the patient, such concerns must be taken into account. V. It remains only to situate the outcome of this inquiry within the context of treatment and palliative care. It is reasonable to ask what the practical outcome of this argument should be taken to be. The practical outcome is simply that there are times when other concerns override the general methodological principle of preventing or relieving suffering. For example, a man who has been given a great amount of pain medication may not be lucid enough to properly bid goodbye to his family, or to make his final confession to his priest. Basic quality of life considerations in such a case take precedence over the desire to relieve the patients pain, and so in such a case a large dose of pain medication is not indicated. What is indicated is to allow the patient to die with dignity and freedom. Even if the patient were to dismiss his family or priest and request the medication, it would be the physicians responsibility to at least attempt to impress upon him the worthiness of making his final dignified acts. Likewise, it may be the case that a particular patient is seen to have a need to examine certain troublesome issues of character. If the level of medication required to fully relieve the patients pain would render such examination impossible, some amount of the medication probably ought to be omitted. And if a patient demonstrates a gross defect of fortitude, such that he or she cannot endure an amount of pain which ought to be able to be endured by a person in that position, it may be advisable to limit the patients access to medication in order to coax him or her into a more resolute habit of character. The possible cases that might arise are functionally infinite. Judgments about the cases must be made individually and with consultation from all the relevant participants in a patients palliative care. However, it may be the case that sometimes the way to improve the patients quality of life is not to prevent or relieve a certain amount of suffering, but rather to take some other action. This is the case because every human person is unique, both in character and in situation. To treat a patient as a human being, and not merely as a patient, is the great promise of the medical specialty of palliative care. To fulfill that promise, the caregivers within that specialty will have to be prepared to admit that a single methodology is inadequate to address the full spectrum of situations and patients. Quality of life is about more than pain and pleasure. If it were not so, pigs would be the most laudable creatures on this planet, and humans the most pitiable. A truly human 9

quality of life is bound up with the perfection of the human cognitive faculties, be they quantitative or emotional or spiritual.

Aaron Somerville Center for Thomistic Studies Houston, Texas

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