Suffering, illness, search for meaning Psychological aspects of the principle of beneficence Mgr. Miloš Mauer, Dep. of ethics, 3.LF UK.

Suffering, illness, search for meaning

Psychological aspects of the principle of beneficence

Mgr. Miloš Mauer, Dep. of ethics, 3.LF UK

Principle of beneficence

• Principle comes already from Corpus Hippocraticum, nowadays is known from the Beauchamp and Childress analysis of four basic ethical principles (published 1985).• This principle means, according to them: „moral obligation to act for

the benefit of others“. • The term beneficence connotes in english acts of mercy, kindness and

charity. Forms of beneficence also typically include altruism, love and humanity.

Nonmaleficence vs. Beneficence

• Negative prohibition of action vs. present positive requirements for action• Rules of nonmaleficence must be followed impartially, rules of

beneficence don´t need to be followed impartially• Legal prohibions of certain forms of behaviour vs. no legal

punishment when someone is not behaving according to this principle (Beauchamp and Childress, 2009)

The core of the principle of beneficence is to relieve suffering

and to promote health.

However, the main problem of medicine is, that it doesn´t understand well this principle from the point of the patient, because suffering is mainly subjective and psychological state, it is something more than

disease, more than diagnosis. Except of really acute states, there is need for empathy and

understanding how patient suffer and what he/she really needs.

In other words, medicine often treats disease, not illness.

Disease is scientifically based diagnosis made by doctor, illness is the state of the patient, who feels that there is something wrong with his health. In reality, these two concept can differ, so someone cane have disease according to medicine, but can fell healthy, or someone can fell ill, but according to medicine should be healthy.

What are the main aspect of human suffering, regardless of the specific

reason?• Feeling of helplessness

• Feeling of loneliness, stigma • Unability to avoid thinking about mortality

• Feeling of reduction (usually to some somatic aspect of our being)• Feeling of guilt

• Feeling of lost of meaning, or problems with finding of any meaning

• What is our biggest fear in our human life? Is it our mortality, end of life, coming to nothingness?

• Some says, that it is someting else, we fear that our life will not be full (in czech we says, that someone old died in the fullness of his/her

days), that it will not be meaningfull, that we doesn´t leave a „footprint“ in this world.

• S. Kierkegaard says, that our biggest fear is, that we will not become ourselves in our lives….

Helplessness

This is basic feeling we have, when we suffer. It means that we don´t see any way how to deal with it, we feel passive, influenced by too strong

outer conditions.

It is a subjective lost of power over ourselves and over our environs. In czech f.e. „nemoc“ (disease) means literally „not power“.

Passivity is one of the ethymological meaning of the word „patient“. This word has however another, more positive connotation, „to be patient“,

e.g. patience, forbearance, which are qualities we need when we are ill.

Syndrom of learned helplessness

• When we experience the feeling of helplessness often, or very intensively, we can uncounsciously learn to be helpless and we behave helplessly even in problematic situations, with which we can deal effectivelly. In other words, we doesn´t believe that things will go well again and this presumption can cause our failure. • This syndrome is proved experimentally by M. Seligman (1975, USA),

who made experiments firstly with dogs (getting electrical shocks), later this experiments were made with other animals and also with people (not getting shocks, but the procedure was analogical).

Consequences of learned helplessness for patientaccording to M. Seligman

• Depression, fatigue, apathy• Bad compliance with medical stuff• General increase of various diseases or symptoms (psychosomatic

mechanisms)• In critic health state it can cause even death, especially for people

which have not much coping mechanisms and control over their environs, low self-sufficiency, such as children, elderly people etc.

•We can feel helpless also in situations, when there is something very important

happening, for example, medical treatment, and we don´t have any

control, any influence on the treatment. We can than feel helpless

regardless of the result of the treatment!

Feeling of helplessness is the core of the suffering• Often it is part of the serious illness and main aim of the medicine is

to help to relieve it.• Many times, however, can be helplessness caused by medicine itself,

by the approach to the patient. • Patient can fell helpless in many situations, when they don´t have

enough informations, enough respect, they can´t actively participate in the treatment, they are reduced to their diagnosis etc.• Medicine often increase helplessness, because it doesn´t deal with

the subjectivity of the patient, with his/her unique suffering.

Stigma

• Means „sign“, in ancient Greece it was a physicall sign on the body, meaning that the person is somehow morally bad, f.e. criminal etc. • F.e. Mylady from Three Musketeers had stigma on her shoulder (burned

lilly), which meant she was prostitute before.• Nowadays it means also symbolicall stigma. Stigma means, that the

person is for the others different, somehow not fitting, not belonging to the society, somehow morally bad. (Classical sociological work on this topic is from E. Goffman, 2003).• Expelling from the society is probably the oldest existing punishment, in

the past, it usually meant death,not only because of limiting means for survival, but also psychological death. We are social beings.

When we feel stigmatized as patients?• Our illness is not known in the society, so for others we are „strangers“• People think, that we caused our illness by our improper behaviour, like

AIDS syndrome etc. • Our illness brings some symptoms, like disfiguring etc., which are for the

people very hard to even see and think about.• If we see person with a serious illness, it often brings to us unpleasant

feelings that we also are vulnerable, mortal, it could happen also to us. This is so unpleasant, that we usually deal with it by the stigmatizing of the other. In other words, we start to think that it cannot happen to us, because we are good persons, but the other, well, maybe there is something wrong with him/her anyway, and that is why it happened to him/her.

Stigmatizing of the patient is often made also by the medical staff, for the same reasons, as mentioned

above. •Very often is stigmatization made by reducing patient

to the disease a and by banalizing of his subjective, often psychological problems.

•Patients are often stigmatized in the medicine, because in this enviroment is often stigmatized „soul“

or „psyche“ as such!

Search for meaning of the suffering

Basic questions in the beginning are:

Is this something relevant in medicine?If this is relevant, how can practically doctors approach this dimension

of the suffering?Does it mean, the we must study philosophy, psychology or religious

studies, or that the patient must have some knowledge in these fields?

V. E. Frankl – Man´s search for meaning

Many answers we can found in the books of this author. According to this doctor, everybody has need for meaning in his life. However, it is

not just some philosophical theory we must have, it is mainly a feeling, experience of meaningfullness.

Meaningfullness cannot be found in a book, cannot be given by others to us in a form of advice etc.

„It is not us, who lay questions to the life, it is the life itself, who questions us“ (Frankl 2006).

In other words, it is the way, how we face our fate, demands of our life. It is also the purpose, for which we are living.

V. E. Frankl - life

• V. E. Frankl – neurologist and psychiatrist, had his practise in Vienna in the beginning of the 20th century. As a jew, he was departed with his family to he Auswitz concentration camp during WWII. He survived the camp and moreover, he was able to observe other people, think about what is helping them to survive. He wrote a book on this topic after the war: .Saying Yes to Life in Spite of Everything: A Psychologist Experiences the Concentration Camp", known in English by the title Man's Search for Meaning (1959).• He founded new form o psychotherapy, which he called

„Logotherapy“ (logos means „meaning“ in old Greek), he treated many patients to find or regain meaningfullness in their lives.

Noogene neurosis and Existencial vacuum.• Noogene neurosis according to Frankl means, that people suffer from

not having meaningfullness in their lives. According to him, this is a basic need of everybody. People, which feel a meaning, are generally stronger, and as he shows even in medical experiments, such people have more capacity to heal from illness or to avoid it, or to deal with obstacles in their lives, which would be impossible for others.• Existencial vacuum according to Frankl means, that people doesn´t

have any meaning in their lives, but they don´t suffer because of it, they deny this need. However, they are inside somehow empty, without values in their lives, they just do what other do, they are not individuals in proper sense.

Guilt

• Search form meaning is however, not always so dominant. Or it takes another form. Sometimes we doesn´t want complex explanations, and we are trying to find some simple cause for our suffering.

• Often it means to find somebody to blame, sometimes it can be even ourselves. • The feeling of guilt can be increased also by improper approach of medical stuff. • Feeling of guilt is almost inevitable, when we suffer. We ask ourselves: „What did I do

wrong“, many times we think, that we had to do something wrong, like child, which thinks that he/she is ill, because he/she was naughty. We often have this attitude not only to the parents (when I will be good, they will like me, when I will be bad, they will punish me), but later also to the World, Fate, or God.

• Medical stuff can not be judge to the patient, however, it happens many times, because judging brings a kind of relieve to the medical stuff, when dealing with serious suffering.

Cause and meaning

• Looking for the cause of the suffering and looking for the meaning of the suffering are two diferent things!• Medicine can sometimes find a cause (but not allways), but even if it

find some, it doesn´t have to be meaningfull for the patient automatically. Cause is f.e. pathological process, working in our body because of some heredity factors. Meaning is the story of our life and the way, how is the illness part of that story, it is the way how the things are connected, so it can help us to accept them and find a strength to go further.• Medicine cannot find meaning for the patient, but it can support

him/her to find some!

Theory of vital engagement

• Nakamura and Csikszentmihalyi created this theory in 1975 in USA.• According to them, for feeling of meaningfullness is very important

the dimension of acting.• Sometimes meaningfullness can be a side result of some kind of our

action. • „One of the main ways, how people find meanings in their lives, is

deep engagement in activities, which are possible for them. Even evident trivial activities can become meaningfull over time, when they are done with care and concentration“ (2003).

Vital engagement

• Is: „Relation to the world, which is characterized by the experience of flow and meaningfullness“ (Nakamura, Csikszentmihalyi, 2003).

Theory of flow is the previous work of these authors. „Flow“ means in short words submerging to some activity, which bring us pleasure, feeling of harmony). See some children playing, or older people making some hobby they like, and probably most of them experience the Flow.The main question than is, how can have a patient experience of this kind?

Helping to vital engagement in the hospital

• Occupational therapy• Play therapy• Physiotherapy• Support psychotherapy• Visits to patient• Patient has infromation about treatment, can choose between various

treatments• Participating of the patient in the treatment (can he help with removing a

bandage f.e.?)• Stimulating enviroment in the hospital, so everyone can find something to do

in accord with his character