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 patient’s 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 patient’s 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 patient’s 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.

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

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

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

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. arise precisely from a person’s experience of suffering. 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. Manifestly. to be proved. it is possible to improve one’s quality of life when suffering nonetheless obtains. As to the question of instruction. For such virtues concern the manner in which the agent copes with such experiences. But this is manifestly not so. this is easily shown to be possible. For example. there is no reason why the patient should be subjected to that additional pain. This would have to derive from the end of palliative care. it remains to show that some suffering could improve the quality of a patient’s life (and by extension. So it is not in principle illicit for a palliative caregiver to omit to palliate some suffering. a sufferer might find their quality of life improved through appropriate interactions with their family. but necessary for the habituation of the full range of sufferingdependent virtues. just as in any other case of establishing what constitutes licit conduct by medical caregivers. if suffering itself presented an insuperable impediment to the improvement of the quality of a person’s life. however. A number of virtues. For it is at least possible for a person to improve their quality of life in spite of suffering. 5 . This is because proper and functional familial interaction is salutary to mental health. Therefore. whether it is particularly one or the other aspect of coping. All other things being equal. Since it has been shown that it is not necessarily illicit for a palliative caregiver to omit to prevent or relieve some suffering.ordering the bone marrow biopsy to further order that the patient not receive any pain medication during or after the operation. suffering is not only ethically instructive. Of course. if only that suffering stands to improve the patient’s quality of life. The possibility of the latter stands at last. If the patient. had a certain condition which contraindicated the use of the more effective pain medication. which is to improve the quality of life of the patient and patient’s family. which leads this inquiry to the precise point at issue: is potentially licit for a palliative caregiver specifically to omit to palliate a patient’s suffering? Given that it is firmly established that it would be potentially licit for a generic medical caregiver to do so. fortitude most especially. The question therefore is whether it is possible to improve quality of life by the omission to palliate some suffering. Therefore. 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. The question therefore is whether the passion of suffering is potentially ethically instructive and relevant. Therefore it is possible for quality of life to be improved even when suffering obtains. Therefore it is not only licit in medicine but oftentimes a required practice to omit to prevent or relieve some suffering for a patient. the quality of life of the patient’s family). therefore. the patient would naturally be prescribed less effective pain medication. in principle. this assumes that the proper care is taken by medical professionals. This would only be impossible.

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

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

it should be noted that the orientation of palliative care is not to treat the patient solely as a patient. it should at least be admitted that this is possible. from which lucidity the patient’s family will benefit in that they will thus be able to maintain a meaningful relationship with the patient. it is possible that the case may arise when it is the correct choice to omit palliation to some degree. In such cases it is clear. for example when the full measure of medication is withheld from the patient so that he or she may remain lucid. such as the overseeing physician. In other cases. Obviously. that families will likely oppose any decision to omit to palliate a patient’s suffering. 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. but as a human being. Fourth. such as the consultation of the caregiver with other assisting or directing caregivers. 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. The claim is that a palliative caregiver is not qualified to make these sorts of judgments. simply as a topos for battling an illness or relieving pain. and that the family’s wishes cannot take precedence over this. medical questions. when the omission to palliate is not indicated. only that such a decision is not in principle illicit. the family would be quite right to oppose it. 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. the well-being of the patient overrides the whims of the patient’s family. that is.As to the third objection. and so the specialization of palliative care would not even be viable if medical professionals were limited to judgments of a purely medical nature. strictly speaking. 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 patient’s 8 . again. but the family of the patient nonetheless opposes this. As to the force of the objection. it has never been claimed in this inquiry that every palliative caregiver should have the discretion to omit to prevent or relieve some suffering. all the normal conditions for a licit patient care decision apply. or that they could be made lightly and without rigorous fact finding and consideration. it should be admitted straightaway that this is a strong objection. However. Insofar as the patient’s caregivers are acting according to proper legal and professional guidelines. however. that the overriding concern is the perfection of the patient as a human person. Questions about what constitutes quality of life. 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. palliative caregivers. which admittedly concern matters that are not strictly medical. However. Yet these questions inescapably arise. in some cases it will be of obvious benefit to the family. must of necessity make decisions that extend beyond the sphere of the purely medical. Nowhere has it been claimed that such decisions could omit the proper channels. as to the objection that it is inappropriate for a palliative caregiver to make decisions about patient care based upon judgments regarding a patient’s ethical constitution. Further. It is merely the position of the affirmative that such decisions are not in principle illicit. Still. Just as the night nurse is not empowered to order a complex surgery.

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

Aaron Somerville Center for Thomistic Studies Houston.quality of life is bound up with the perfection of the human cognitive faculties. be they quantitative or emotional or spiritual. Texas 10 .