In this Module, you have learned about Virtue Ethics and spent time thinking about an article written on your applied ethics topic from the perspective of a virtue ethicist. In your i

6 Trust, Suffering, and the Aesculapian Virtues

Annette C. Baier

Aesculapius, son of Apollo, and pupil of centaur–physician Chiron, son of Chronos, was the Zeus-designated god of healing. What are the Aesculapian virtues, the vir- tues we want in those to whom we turn to heal and alleviate our ills? Aesculapius was son to serene, expressive Apollo, and pupil of the son of Chronos, god of time, and I shall suggest that both calm communicativeness and right timing are important vir- tues in healers. I have argued in a recent essay (Baier 2004) that virtues, or at least such virtues as show in our relations with each other, essentially are the wanted attitudes to the realization that we are in one another’s power. This combines the Aristotelian view that virtues are what enable us moderately social beings to flourish, or at least not languish, with the Hobbesian reminder that we can have reason to fear each other’s power. Virtues, on my analysis, are personal traits that contribute to a good climate of trust between people, when trust is taken to be acceptance of being, to some degree and in some respects, in another’s power. The Aesculapian virtues, therefore, will be those found in trustworthy healers, and will include due awareness of the power discrepancy that the doctor–patient relationship involves, the will to communicate appropriately with the patient, and to take timely action of various sorts. As will soon become abundantly clear, I am taking ‘healing’ to include relief of suffering, as well as restoration of health. In the latter part of this chapter I will discuss the disagree- ment on euthanasia, and consider what the trustworthy physician will do when her incurable and suffering patient requests that his life be ended.

In addressing these issues I shall be calling on personal experience, consultation with medical care experts, reading, and philosophical reflection on trust, and on life and death. My main concern is with what it takes to be a trustworthy health professional. But since physicians and nurses usually depend on managers and administrators for the conditions in which they work, I will also give some attention to managerial contributions to climates of trust in hospitals. Again, since trust is a relationship that depends on all parties to it, I will also allude to what patients can contribute. Unrealistic demands by patients, and over-readiness to lodge complaints, or, at the other extreme, undue respect for physicians, and reluctance to ask questions of them, just as much as incompetence in caregivers, their failure to communicate, or their inconsiderateness, can contribute to a climate of mistrust that is not only unpleasant for those involved, but unhealthy and dysfunctional.

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136 Annette C. Baier

I take trust to be acceptance of some degree of vulnerability to another’s power, in the confidence that this power will not be used to harm or hurt one (Baier 1995). A good climate of trust is one in which the vulnerability is mutual, and people can be encouraged to trust each other. To create and maintain such a climate, some empowerment of the naturally weaker is essential, and recognition of rights is an obvious way to do this. In a medical context, codes of patient rights, and the provision of patient advocates, serve this purpose, since patients are the naturally weaker parties, especially given the fact that their competence to know their own minds and to assert their rights will be determined by their physicians, the very ones against whose possible abuses of power such rights should protect them. This is why third parties, such as patient advocates, are so important. Respect for patients’ recognized rights is the first virtue of health professionals, but it needs to be accompanied by other virtues, such as informing them of their rights. Of course physicians too have rights, including rights against patients. If patients survive their medical treatment or mistreatment, and are wealthy enough, they can sue their physicians, and some suits may be malicious. (Physicians now need, and have, their own international Medical Protection Society.)

A trustworthy health professional is, among other things, a properly trained one, competent to do what she undertakes to do, but who is to say what the proper train- ing is, and who should verify that the credentials someone claims to have are genuine? The trustworthy hospital administrator verifies the claimed credentials of applicants for its positions. And what should patients do, if anything, to make sure that their physicians and nurses are properly qualified? How informed should we be about the record and qualifications of our physicians before we trust them to care for us? Obvi- ously if one is taken ill, or is injured, while in a foreign country, one would be foolish to postpone getting medical attention until one has made inquiries about the compet- ence of the local health professionals, but what about one’s home town? How many of us do anything whatever to check out the professional record of primary care phys- icians, surgeons, or other specialists, before becoming their patients? Would we be accepted as their patients if we were known to have done some prior detective work on them? Yet, at the very least, we should be able to know that they are properly qual- ified for the work they do.

We usually in effect delegate the checking of credentials to regulatory officials, but some sort of check on their performance, by someone presumed to be trustworthy, is also in order. To check up on someone is to show some hesitancy about trust- ing them. And here we are faced with the regress of distrust—the more we insist on checking, the more people there are to be checked up on, and security becomes a vanishing goal. At some point, we just have to trust the checker, and, for the average patient, there is no particular reason to think that the most reliable checker is oneself. We are forced to rely on the medical profession itself, on hospital administrators, and on government agencies, so should be loud in our criticism when any of these fail us in this vital matter. (I am not going to address the question of whom we must trust for a sufficient provision of health-care workers, important as that issue obviously is, but restrict my remarks to trust in those who are provided. But it is very easy to see that if there are not enough of them to meet needs, then they will be overworked, exhausted,

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Trust, Suffering, Aesculapian Virtues 137

possibly resentful, and so less than reliable in their service to those who must rely on them.)

We hope for a sufficient supply of properly trained physicians and other health workers. What sort of training, beyond the obvious, such as training in the recognition of the symptoms of meningitis and other immediately life-threatening conditions, do we want our physicians to have had? And what sort of regular retraining? Most medical schools now put some emphasis on communicative skills in addition to scientific training and clinical know-how. It is fairly obvious that some human-relations skills are part of what it takes to be a good physician, and that these cannot always just be grafted on to a good medical scientist, as an afterthought. Some aptitude for dealing with people should be a minimal requirement, not an optional extra, in a successful entrant to medical school. If fear and distrust are to be avoided in hospitals, there must be something of the human touch in physicians, surgeons, and other experts. (In the nursing profession its importance has long been recognized.) For fear, even terror, is what results when a person is subjected to procedures, sometimes painful ones, that she does not comprehend, for reasons she has not been made to understand. A significant number of the complaints made by hospital patients (about 12% in my local hospital) directly concern poor communication, and a much higher proportion (up to 70%) have been judged to have that as their background cause (data from Denys Court, of the Medical Protection Society, New Zealand branch, and from Ron Paterson, New Zealand Health and Disability Commissioner).

And what sort of training is needed to address the ethical questions I am addressing? I should emphasize that I am a philosopher, not a social scientist nor a person with any special knowledge of the health professions, and I am acutely aware of the limitations this imposes. The interrogative mood dominates in this essay, and not all my questions are rhetorical. I find the issues I am addressing very difficult, and, because of their seriousness, sometimes difficult to address with detachment. (Hence the indignant rhetorical questions, later in this essay.) To prepare myself to write on this hard topic, I have, of course, read books and articles by physicians, and I have consulted with several physicians, including experts in palliative care, with two lawyer–physicians, with a midwife who is a hospital maternity manager, with two nurses, a patient advocate, a government health official, and a hospital manager of clinical services. This consultation gives me, at best, some second-hand knowledge. I did, decades ago, while a student, work for a short while as an unqualified night nurse in a private hospital. I found that experience very stressful, and resigned after the first death that occurred while I was on duty. (So I do not lack sympathy with those health professionals who want, at all costs, not to be thought responsible for a patient’s death.) Apart from that brief nursing stint, my only first-hand knowledge of health professionals, with their strengths and their weaknesses, comes from experience as a patient, and as a concerned relative of several patients, with all the limitations that implies. Still, my own experiences in hospitals inevitably influence my views, and the strength of my feelings, so I will mention some of them.

Thirty years ago I was by my mother’s hospital bed when she died, choking on her own blood, after two long weeks of post-surgical agony. The surgery had been for

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138 Annette C. Baier

cancer of the esophagus. After her death I wrote to her surgeon, saying that his was a terrible profession. I wrote that he had tortured my mother by his refusal to admit that the surgery had failed, and by his consequent unwillingness, despite our plead- ing, to give much morphine, on the usual grounds that, while relieving her suffering, that would have depressed her breathing. (This man, decades later, was honored by the Queen of England for his services to the hospice movement, but I am told it was surgery he himself underwent, not my charges, nor those of his other patients or their relatives, that led to his change of heart.) Palliative care, I am assured, has come a long way since my mother’s death, but part of the problem is of deciding when post-operative care should become palliative care, and when that becomes terminal care. Care of those who have not been cured had not advanced discernibly when my nephew eight years ago died of a brain tumor, after two operations, the second to treat an infection arising from the first. His complaints about his terrible headaches were treated as mere malingering, and it was only when the infection worked its way out to the skin that the second surgery was done. He was a young man in his early thirties, a long distance runner, and of course was depressed at his steadily worsening condi- tion. He made several unsuccessful suicide attempts, before finally, in an emaciated state, dying a morphine-hastened death in hospital. The morphine, of course, was officially given to relieve his suffering, not to give him the death he had for months so desperately sought. For it was deemed unethical, and was in any case illegal, for any physician to administer euthanasia on request.

My experience when I myself was the patient (in Britain, in Australia, in the U.S., in New Zealand), in much less dire circumstances, has been generally good, at the receiving end of excellent care, effective pain relief, and considerate treatment, even from grossly overworked emergency department staff. But one recent unhappy exper- ience made me ponder the question whether individual virtues in health-care workers are enough to ensure good care, if the organizational structure in which they work is defective. Or should I say if the managers are failing in their professional role, and are lacking the special virtues their job demands? For successful care of a patient, includ- ing communicative success, requires not merely a physician’s will and ability to give appropriate medical treatment, and to explain it to the patient, but reliable access to the means of giving that treatment, and to the means of getting timely information to a patient.

Here is the story of what led me to these thoughts. I had been admitted to my local hospital after a four-hour ambulance trip, following an internal bleed, one that neces- sitated blood transfusions. Since the bleeding into the stomach was continuing (and maybe because my eighteen transfusions were depleting the blood bank), surgery was planned to investigate the cause of the bleeding, and try to stop it. (A longer than usual gastroscopy, not much fun to undergo, had, because of blood clots in the stom- ach, failed to disclose the source of the trouble, and had reactivated the bleeding.) I had been given a careful explanation of what surgery was planned, what risk was involved, and what ‘discomfort’ to expect after the operation. I had signed the con- sent forms, after a very long discussion with the ward’s helpful resident surgeon, in the small hours of the night. I was told to expect surgery during the next night. I lay in the ward waiting to be taken off to theatre, and lay and lay, for an endless and sleepless

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Trust, Suffering, Aesculapian Virtues 139

night. My inquiries to nurse and house surgeon as to what was happening were met with: ‘We don’t know, there is no response from the gastro-surgical unit.’ My initial resolve to be calm and accepting did not extend to being calm enough to forget the matter and sleep, so my night was very unpleasant. It was not until next day that I learned that an industrial accident had led to all operating theatres being needed for emergency surgery on the victims, so that the gastro-surgical team had gone home. And my own blood count in fact improved during that night of waiting, so it was decided to put my surgery on hold until diagnostic tests could be done. I tried to receive this news graciously, but felt some resentment about the anxious waiting that I had already been put through, unnecessarily, or so it seemed to me. For, had I been told of the surgical emergency, and the consequent cancellation of my own operation that night, I could perhaps have slept, or at least lain in less anxious sleeplessness.

Why was I not informed at the time that my surgery that night had been cancelled? Who, if anyone, should have let me know what was happening? Quite possibly there was no one whose appointed task it was to get word to the medical ward about the changed surgical priorities. I certainly did not know whom, if anyone, to blame, and tried not to blame anyone. (It did not occur to me to lodge a complaint, and certainly no one suggested that I consider that, although the New Zealand hospital I was in is governed by an official code of patient rights, whose last-listed right is the right to complain. But no copy of this code lay with the Gideon Bible by my hospital bed, and I was not mobile enough to see the copy posted on the wall by the ward’s reception desk.) Hospital procedures may not have given the job of informing patients whose surgery has been unexpectedly cancelled to anyone in particular, especially not in con- ditions where the surgical services were being taxed to the limit. Proper principles of triage would not assign high priority to this job. Yet it would have taken merely a mes- sage to the ward, and this need not have been done by any of the overtaxed workers in the surgical units, but by some porter or telephone worker. The people in the ward, nurses and house-surgeon, did try to find out what was happening, but given the casu- alty victims with whom the hospital was coping, the surgical units were overwhelmed, and not answering the phone. My interests got lost in the shuffle, as by correct triage principles they should have, if anyone’s had to. (I am told that sometimes those await- ing surgery wait as long as three days, on nil-by-mouth, so my unpleasant wait was nothing exceptional. But it was not the delay as much as the lack of information that I felt aggrieved about.) To minimize avoidable anxiety, in such circumstances, differ- ent procedures would have to be in place, and that might take initiative and skill in design of procedures at the administrative level. The high incidence, in U.S. hospit- als, of death from medical error, making the risk of such death greater than that of death on the roads, was judged to be due not to ‘bad apples’ among the physicians, but mainly to procedural defects (Gawande 1999). To remedy that, we need initiative and vision at the managerial and administrative level. Their special virtues are vitally important if the virtues of the other experts in hospitals are to deliver their best yield in keeping patients’ trust. I trusted my surgeon, later, to operate on me, to remove the by-then-discovered tumor, but it took an effort to do so, since, rightly or wrongly, I could not help thinking that my interests could not have been of great importance to him on the night of the cancelled surgery. This was doubtless unfair, but it is not so

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140 Annette C. Baier

easy to be scrupulously fair when one is weak, dependent, and vulnerable, as hospital patients typically are.

That brings us to the patient virtues that are needed if there is to be a good climate of trust in hospitals and other places where health care is given. Is patience a virtue in a patient? Should I just have waited patiently until someone did see fit to tell me that my surgery had been postponed or cancelled, and why it had? And should I have trusted that my real interests were safe, before, during, and after surgery, whether that was planned but cancelled, or planned and carried out? Maybe my anxiety the night I expected but did not get surgery did me no physical harm, and maybe I should have trusted that, if anything really affecting my interests had been at stake, I would been given more attention. But anxiety, just as much as physical pain, is something we hope our physicians will help us to minimize, not increase. It does not seem to me that patience is always a virtue in a patient, especially a suffering patient, and certainly not that implicit trust, rather than vigilance, is in order when one has no choice but to put one’s life and well-being in the hands of medical experts. Patients, as well as hospital administrators, have some responsibility to protest when things seem to go wrong, and perhaps I should have lodged a complaint about my unpleasantly anxious night, as much for the sake of future patients, as to express my own grievance. Patients have some responsibility to lodge complaints, and to communicate their fears and concerns, not just passively wait for professionals to ask questions of them, and give them information. But equally clearly, some patience, and some trust, is called for, on the part of patients. Threats to sue do not improve mutual trust. Nor is impa- tience going to get one moved up the triage ordering at an emergency department, or alter the urgency classification of one’s awaited surgery. Displays of impatience, by patients, hinder rather than help health-care workers to do their job properly. But even there, as my next little story of another unpleasant night in hospital will show, a person can perhaps be too patient.

On a recent occasion, after accompanying my husband, who was suffering from an acute infection, to hospital by ambulance, I spent twelve hours, from 6 p.m. to 6 a.m., sitting by his bedside in the emergency department, before he was admitted to a ward and I was told to go home. The admitting doctor, seeing my exhausted face as I sat on the hard upright chair where I had spent the night, said: ‘They should have sent you home hours ago.’ But ‘they’ were too busy that night to think about me, and I was not their charge. It was for me to ask them if I should go, not for them to look after me as well as their patients. In fact I think they welcomed my staying, since I could do little unskilled things for my husband, things that otherwise they would have had to do. And I stayed, because I wanted to be sure that he was being looked after. But perhaps I overdid the patience and would-be helpfulness that night. Hand- ing over to the professionals, trusting them, and going home to get enough sleep to be able to play my role as hospital visitor next day, might have been better. The vir- tues needed in those receiving health care, and in their concerned relatives, are those that are functional for the care of patients to go best. And that takes some but not too much patience, some trust but not uncritical trust.

I was not seriously harmed by either of my very unpleasant recent nights in my local hospital. Physicians and nurses have the job of looking after their patients’

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Trust, Suffering, Aesculapian Virtues 141

serious health interests, not making them or their relatives feel good. Relief of pain and other forms of distress is an acknowledged part of their responsibility, but only, it seems, if that does not threaten health or life. It is the prolongation of life, not the relief of suffering, that is the time-honored goal of the medical profession, the main goal recognized in the Hippocratic oath. And even Aesculapius had to be punished by Zeus for finding a way to make humans immortal, so he too seems to have thought life-prolongation to be an important goal, perhaps the main one. This ordering of priorities is the reason why professional medical associations typically oppose the legalization of voluntary euthanasia, and claim that it would be ‘unethical’ of doctors to end their suffering patients’ lives, even when begged to do so. Certainly we would not be able to trust physicians who were overeager to administer euthanasia. Nobel prize winning novelist Coetzee has one of his characters, a helper at an animal rescue center, with the job of ‘putting down’ animals no one can care for, respond, when asked if he does not mind this task, ‘I do mind. I mind deeply. I would not want someone doing it for me who didn’t mind. Would you?’ (1999: 85). Those whom we can trust to administer euthanasia will indeed be restricted to those who do mind doing what they do. Yet, as the memory of my mother’s and my nephew’s terrible suffering makes me ask, who can trust a physician who refuses to relieve suffering, however great, if that is thought to interfere with even the faintest chance of success of treatment, or, who, once that chance is gone, refuses to shorten the suffering, even after the wish to end life has been repeatedly expressed by the patient? If anything is ‘unethical’ behavior in physicians, it surely is letting their patients suffer, refusing their desperate requests for assistance in hastening death, when other ways of ending suffering are failing. The general recognition by bio-ethicists that compassion is a virtue in a healer is accompanied by occasional warnings to physicians against ‘pseudo-empathy’ with their incurable patients, against empathy that might lead them to a too ready agreement with a patient’s expressed view that death may be the best option (Muskin 1998). We find warnings to physicians not to take patients’ requests for assistance in hastening death as necessarily anything more than a sign that they are suffering from clinical depression, or even as invitations to be contradicted, as pleas to authoritative father figures for reassurance that their life is still worth preserving (Meier, Myers, and Muskin 2000: 185–8). Suffering is not being taken very seriously, as long as claims to intolerable suffering are treated with such patronizing disbelief. The deck is stacked against the suffering person who wants her life to be ended if her very expression of this wish is likely to be taken to show that she is clinically depressed, and so without power to give or withhold consent to any medical measure.

The relief of suffering, including migraine pain, menstrual pain, and acute arthritis pain, does not seem to be given very high priority in medical research, nor in decisions about government subsidies for medicines. (I have known two migraine sufferers who were driven to suicide to end their pain, one by shooting herself in the temple during an attack.) Must an understanding of the causes of pain be left to torturers, as understand- ing trust was largely left to con-artists and terrorists (Baier 1995)? Even if suffering is part of the human condition, it is surely the business of the medical profession to understand pain and its causes, and to do whatever can be done to minimize or end it.

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142 Annette C. Baier

Before the advent of anesthesia, physicians had to be capable of inflicting great pain, but now there is no excuse for them to let their patients suffer, and only the excuse of illegality for their refusing to help patients to end their suffering when hope of cure is gone. Would it help enable physicians to speak up for euthanasia, and be personally willing to assist a patient to die, when the patient seriously requests that, if death were reconceptualized as permanent general anesthesia? Anesthesia is the spe- cialty of those who work in pain clinics, and who oversee pain relief after surgery, so it would not be a great extension of their field to make them the ones trusted to administer voluntary euthanasia. Even after the advent of anesthesia, electric shock treatment for mental illness was for decades given without it, so trainee doctors had to steel themselves to witness, and help give, some very cruel forms of treatment.

Labor and childbirth can be extremely painful, and I gather that, although more and more women, especially women physicians, are opting for epidural anesthesia in labor and childbirth, the medical profession is not rushing to make its use routine. A midwife of twenty years’ experience explained patiently to me that labor pains are ‘natural’, and unlike other pain in not being a signal of something wrong. She also explained that the use of epidural anesthesia in labor can weaken muscle contractions, and so lead on to the need for further undesirable ‘interventions’, to forceps births, sometimes to emergency Caesarian section. And for epidural anesthesia to be even an option, the birth must be taking place in a hospital, with anesthetists available. For all these reasons, most midwives and obstetricians encourage its use only for what are expected to be particularly difficult births, prearranged to occur in a hospital. But not all long labors and difficult births are expected in advance, so many women will still have to console themselves during severe labor pains with the thought that this pain is natural, and with the hope that there is to be a ‘happy outcome’ (although there is also a not insignificant risk of postnatal depression). Some women, after one exper- ience of ‘normal’ birthing without anesthesia, now opt for Caesarian section for any subsequent pregnancy, so memorably dreadful is their experience of labor and par- turition. Labor can go on for days. Even for gastroscopies, whose length is measured in minutes, patients have to be held down. It is not surprising if many health profes- sionals have had to develop a certain degree of callousness, just to do the job expected of them. But such callousness, however functional in some contexts, surely cannot be deemed an Aesculapian virtue.

Socrates, when about to drink the hemlock, said to his friends that he owed an offering to Aesculapius. Barbiturates of the sort recommended by the Hemlock Soci- ety, for use by those who judge they have suffered enough, are not always obtainable by those who want to self-administer them. For example, in New Zealand, even sym- pathetic physicians cannot prescribe them to patients. So what do New Zealanders do when they judge that their life is no longer worth living, indeed is intolerable? Refuse liquids until they lapse into unconsciousness (about one week), then die (after about another week)? Or, if not willing to keep going for another week (or in ignorance of this method), jump off a roof, or try to drown themselves in a nearby creek, like my nephew? Resort to plastic bags? Desperate people are often entirely dependent on the compassion of relatives, who risk prosecution for manslaughter if they actively assist, or depend on their primary care doctors, who can (and often do) rely on the dubious

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Trust, Suffering, Aesculapian Virtues 143

doctrine of double effect to prescribe lethal doses of painkilling drugs, or on nurses and physicians in hospitals and hospices, who can, in the same way,

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