[Feel free to submit a question for this column, but please consider that it has become very popular and there now is a backlog, it may take me some time to get to yours.]
J. wrote: I am a junior doctor working in the NHS in the UK. As you may know the NHS is under immense pressure currently. Winter is always a busy time for the NHS, but with an aging population, government cuts, shortages in staffing and a lack of social care this next winter is likely to be one of the NHS’s worst. These difficulties have a significant impact on NHS staff; especially those on the frontline. Doctors are having to treat more patients with less resources. In addition to these stresses, the NHS is an increasingly bureaucratic system and doctors find themselves frustrated by being unable to provide the care they want due to decisions outside of their control. Doctors are working in a time of increased litigation, which adds to the fear of making a mistake, not to mention this forcing doctors to practice “defensive medicine” which they see as being at odds with their normal duties of care. Medicine itself also places doctors under a great deal of moral strain by the very nature of seeing suffering and death on a daily basis. Suffice to say, being a doctor in the NHS is tough.
Because of all of this doctors are told they need to toughen up, to be more resilient. This idea of resilience, as a professional virtue for doctors, seems to me to resonate with Stoicism. I wondered what a Stoic conception of resilience might look like and how the Stoics might advise a doctor looking to be more resilient? I do worry however, that in asking doctors to be more resilient there might be a conflict with their other duties of care or professional virtues like compassion — how might a Stoic navigate this? Much of the joy and pleasure of being a doctor comes from interacting with patients, the very externals who might also be a source of distress for doctors needing to be resilient — again, how does a Stoic encourage distance from the same externals (patients) that doctors rely on for their professional job satisfaction?
I have a dear friend who I think of as a natural Stoic. For many years she used to work in the field on behalf of a humanitarian disaster relief organization. We talked several times about how she could bear to see so much misery, work under such stressful circumstances, including chronic shortages of funding and supplies, as well as the consequences of decisions made by other people and over which she had no control.
Her response could have come straight from Epictetus: you practice, every day, a combination of inner detachment and outward empathy, and you constantly remind yourself that what you are doing is worth doing despite the awful condition, that you are really making a difference in a world that needs it. The inner detachment is necessary because if you let yourself get too emotionally involved with the situation you undercut your own ability to deal with it. The outward empathy, of course, is because you are a human being dealing with fellow human beings in dire need. And the mindful reminder of why you are doing it is necessary to renew and strengthen your resolve to endure the situation in pursuit of a greater good.
Here is how Epictetus explains the combination of outward empathy and internal detachment:
“When you see anyone weeping for grief, either that his son has gone abroad or that he has suffered in his affairs, take care not to be overcome by the apparent evil, but discriminate and be ready to say, ‘What hurts this man is not this occurrence itself — for another man might not be hurt by it — but the view he chooses to take of it.’ As far as conversation goes, however, do not disdain to accommodate yourself to him and, if need be, to groan with him. Take heed, however, not to groan inwardly, too.” (Enchiridion 16)
This may sounds superficially like hypocrisy, but it is actually compassion. The Stoic is practicing his own philosophy by reminding himself that external things are preferred or dispreferred indifferents, but is also being careful not to thrust his philosophy on others, accommodating instead his own behavior to what may be more comforting and helpful to fellow human beings.
Seneca expresses a similar sentiment in this passage:
“[The wise man] will do willingly and highmindedly all that those who feel pity are wont to do; he will dry the tears of others, but will not mingle his own with them; he will stretch out his hand to the shipwrecked mariner, will offer hospitality to the exile, and alms to the needy — not in the offensive way in which most of those who wish to be thought tender-hearted fling their bounty to those whom they assist and shrink from their touch, but as one man would give another something out of the common stock — he will restore children to their weeping mothers, will loose the chains of the captive, release the gladiator from his bondage, and even bury the carcass of the criminal, but he will perform all this with a calm mind and unaltered expression of countenance.” (On Clemency, II.6)
Notice the point where he says that one should not act kindly towards others in an offensive manner, immediately then “shrinking from the touch” of those one is helping. We are talking true compassion here, not just a show of it to make oneself look good. But we are also talking about an inner Stoic attitude of calm, originating from the knowledge that one can only do what is under one’s control, coupled with a realistic appraisal of how the world works.
Doctors at the NHS should remind themselves of the environment in which they work. Of course politicians will make self-serving and shortsighted decisions about funding and priorities. That is what they do, and to expect anything else is foolish wishful thinking. Marcus is clear on this point:
“Where is the harm or the strangeness in the boor acting like a boor? See whether you are not yourself the more to blame in not expecting that he would err in such a way. For you had means given you by your reason to suppose that it was likely that he would commit this error, and yet you have forgotten and are amazed that he has erred.” (Meditations, IX.42)
Should anyone at this point feel like this is all proof that the Stoics did not care for human emotions and were trying to navigate life as Mr. Spock from Star Trek, let me remind you of a few things Seneca says, explicitly addressing this point:
“The first thing which philosophy undertakes to give is fellow-feeling with all men; in other words, sympathy and sociability.” (V. On the Philosopher’s Mean, 4)
“Am I advising you to be hard-hearted, desiring you to keep your countenance unmoved at the very funeral ceremony, and not allowing your soul even to feel the pinch of pain? By no means. That would mean lack of feeling rather than virtue.” (XCIX. On Consolation of the Bereaved, 15)
“It is possible for tears to flow from the eyes of those who are quiet and at peace. They often flow without impairing the influence of the wise man — with such restraint that they show no want either of feeling or of self-respect.” (XCIX. On Consolation of the Bereaved, 20)
Bottom line, man, I am in awe of what you guys do, and I can’t imagine having the inner strength of doing it myself. I’ve seen doctors within the Italian public health system take care of my grandparents and then my parents to the best of their abilities, despite similar constraints imposed by funding and bureaucracy. I’m very glad there are people like that in the world, or like my friend the natural Stoic who devoted ten years of her life, at great personal risk, to help thousands of strangers. Keep doing what you are doing, practice Stoic mindfulness by repeating to yourself the precepts I mentioned and re-reading the relevant passages, and know that countless people will forever be grateful for what you do.
I can only echo Massimo’s appreciation.
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As always, great post. Speaking as a fellow physician I think appreciating the difference between empathy and compassion is important. In Paul Bloom’s “Against Empathy” he makes a very forceful argument for how empathy ( i.e. truly feeling what another feels) can be more harmful than good and in fact lead to bad choices. In his first chapter he seems to be pointing towards Stoic principles when he states” I’ll argue that what really matters for kindness in our everyday interactions is not empathy but capacities such as self-control and intelligence and a more diffuse compassion.” Hard to be a physician without compassion, but too much empathy can be debilitating. As a younger physician at times I felt the needs of my patients so much that I would sometimes take unnecessary short cuts to help them in their particular situation. Fortunately, I’ve learned. Compassionate wisdom ranks over empathy.
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Thanks for the appreciation. Interestingly, I’m working on a post on empathy vs sympathy, including a brief commentary on Bloom’s book as it relates to Stoic philosophy. Stay tuned, probably in a couple of weeks…
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That same principle of inner detachment and outward empathy is what I came to practice in medicine long ago, and I commend your support of it. What is more commonly popular is the show of empathy and compassion without the acts of empathy and compassion. And when patients often see through this, the staff act stunned that their drama has been exposed, and then become angry that the patient refuses to cooperate with what they believe to be appropriate medical care. I abandoned the idea of faking a friendly rapport with patients, as if I was a cheap con man addressing every stranger as “buddy,” and would just level with them honestly.
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To be a good human being in any sense including as a Stoic requires compassion, that’s just the way it is. Having had personal experience of very difficult family illness to deal with, the doctors, nurses, auxiliaries, chaplains indeed everyone I encountered in the NHS are amazing and compassionate in the above sense. Indeed I try to practice a compassionate approach to everyone and everything I do as we only live in the present and we all rely on the goodwill and compassion of strangers at all times even if we don’t realise it.
Indeed, compassion is a natural human attribute, as the Stoics themselves recognized. But that doesn’t mean that one should let one’s feelings be run over by the situation and lose track of how to act rationally.
Empathy is an instrumental good. Being able to ‘walk in another’s shoes’ is a valuable trait noticed mostly for its absence. I’ll guess that it something like health. Not exactly virtue but I really want to have it.
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