On Perusing a Dictionary of Modern English Usage as It Pertains to Suffering

black and white book browse dictionary
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Deferring to the OED, Fowler’s* tells us not
To spell “inure” as “enure” for variant
Spellings are not needed; even if “inure”
Has two meanings, it is still only one word.
But who ever heard of “inure” relating to
Anything but some form of suffering?

Something quite beautiful and useful
Might well be put “in ure,” which just
Means we like this well enough to
Make a habit of it, and that cheers
Me up a little, as I had become inured
To “drudgery and distress” (Fowler’s
Example) and need reasons for joy.

You are thinking the primary usage
Became the primary usage because
The world has more misery than
Benefit, but maybe it is the other way
Around. Maybe language defines
Reality after all. If we had inured
All the good things all along,
Maybe we’d be in a better place.

If contemplating stuffy usage guides
Had inured, perhaps I wouldn’t have
Missed so many opportunities to be
Cheerful, to glide blissfully through
A life of Best Practices. Instead, I grew
Inured to heartbreak and dreary poets
Clamoring on about their lost loves.

*Fowler’s Modern English Usage, by H. W. Fowler, a handbook for pedants and arrogant copywriters.

Writing Through Illness and Grief Group

While mourning his daughter Tullia, Cicero took to writing a book of self-consolation. Thinking himself the inventor of this type of self-help, he said, “Why, I have done what no one has done before, tried to console myself by writing a book.” (This is quoted by Han Baltussen in the Nov. 2009 issue of Mortality in an essay titled, “A grief observed: Cicero on remembering Tullia.”)

I certainly don’t think Cicero was the first to console himself by writing, but he seemed to find it of value, and many after him have repeated the exercise. Writing can be a way of releasing out inner torment when faced with grief or illness.

If you use or have used writing as a consolation, I’d like to invite you to join the Writing Through Illness and Grief group on Facebook (https://www.facebook.com/groups/256668978211572/). If you are not on Facebook but are interested in participating in other ways, please contact me at Randall@ethicsbeyondcompliance.com.

The Ethics of Grief

It seems each time I attend a funeral, I overhear someone being criticized for grieving too subtly, too gregariously, too privately, or while dressed inappropriately. I dismiss the critics as judgmental and ignorant cranks who should have better things to do. We all know that each person grieves differently. We should all be allowed to grieve in our own time and in our own way.

But I wonder whether there is am improper way to grieve. Many of us tell our loved ones not to cry for us when we are gone. We’d rather imagine they will have a party to celebrate our life. We would like for them to pay tribute to us through their own joy. And when people ask us to do this, we promise them we will, even though we know we won’t. We make an impossible promise out of respect for those we love.

But some people take such promises seriously. This past week, I came across a paper by Amy Olberding that discusses different approaches to grief by Seneca and Zhuangzi. In letter 63, Seneca counsels his friend, “We, however, may be forgiven for bursting into tears, if only our tears have not flowed to excess, and if we have lost a friend, nor let them overflow.  We may weep, but we must not wail.” But Seneca goes on to confess that he wailed excessively over the loss of his friend, Annaeus Serenus.

Seneca
Seneca (Photo credit: tonynetone)wailed excessively over the loss of his friend, Annaeus Serenus.

He admits the power of his grief, but admonishes himself, “I must be included among the examples of men who have been overcome by grief.  Today, however, I condemn this act of mine.” In describing Seneca’s position, Olberding says grief for Seneca is “a form of self-injury that neither effect relief from pain nor alter the event that stimulated it.” As a Stoic, Seneca claims that death should not be seen as an injury, so it is wrong to grieve something that is not actually harmful. Many Christians find themselves in a similar state. Should we not celebrate someone’s passage to a blissful eternity?

English: Zhuangzi dreaming of a butterfly (or ...
English: Zhuangzi dreaming of a butterfly (or a butterfly dreaming of Zhuangzi) (Photo credit: Wikipedia)

And Zhuangzi, the Daoist, finds himself in a similar state. Zhuangzi taught that death is a mere transition to another state and nothing to grieve at all. Olberding says the Daoist views death as part of a “global harmony that sustains the natural world.” But when Zhuangzi’s wife died, he also reacted with extreme emotion. He said, “I with my sobbing knew no better than to bewail her. The thought came to me that I was being uncomprehending towards destiny, so I stopped.” Unlike Seneca, Zhuangzi did not express any self-recrimination over his grief.

Whether we consider it appropriate or not, the feeling of grief when something of great value is lost is universal. We are shocked when someone seems unaffected by the loss of someone who should be valued. With later reflection, we can reassess our grief and our loss more rationally and understand death in a larger context, especially if we have, indeed, learned to live without our valued loved one.

In Buddhism, Kisa Gotami also learns to reevaluate her grief after some reflection and guidance from the Buddha and her neighbors. Kisa Gotami had a young son who died, and she carried his body from person to person seeking aid to revive him. Finally, she was directed to the Buddha who asked her to obtain a mustard seed from every house where no one had lost a child, spouse, parent, or friend. After she couldn’t gather even a single seed, she judges herself for being selfish in her grief while remaining ignorant of the suffering of others.

The Buddha tells her, “In whatever manner people think a thing will come to pass, it is often different when it happens, and great is the disappointment; see, such are the terms of the world.” Even when death is expected, it is painful, but surprise intensifies the pain. The loss of young and healthy friends, siblings, and children often shatters the narrative people tell themselves about how the world works.

The advice of Seneca, Zhuangzi, and the Buddha all seem to be good advice, so long as we acknowledge that no human can suppress an immediate expression of extreme grief when faced with loss of someone so valued. As time passes, we may benefit from reminders that death is a transition, that death is universal, and that we can, indeed, live on after our loss. I do realize there are cases where survivors do not seem able to live on after loss, and compassion should move us to try to help those who are crippled by grief or loss of support.

It is true that people grieve in their own way and their own time, but compassionate care, free from judgment, might help people reach acceptance of the reality of a world that often seems to lack moral order, fairness, and predictability.

Grief and the problem of meaning making

Kurt_Vonnegut_at_CWRU
Kurt_Vonnegut_at_CWRU (Photo credit: david_terrar)

I’ve been reading Kurt Vonnegut again. It is a bad habit I started as a teenager. When I began reading Vonnegut, I was a classic example of a depressed teenager, or at least that was how I saw myself.

Looking back, I realized I had many reasons to be sad. Extremely sad, even. A friend had died in a motorcycle accident when a car pulled in front of him in our own neighborhood, and then my uncle, who was 25 years old, died in a fire that consumed the mobile home he was living in. Of course, a few other bad things happened, too, and the world just seemed a little crazy to me, not fair at all.

My confusion was confounded by the fact that I would often hear family members ask one another, “Do you think someone is trying to tell you something?” They searched each devastating event for a message from God. If something bad happened, it was because we had done something wrong. At church, I learned that all the pain, all the trials, and all the trauma was part of God’s plan, even if no mortal could make heads nor tails out of the plan. I hadn’t read Kierkegaard yet, but I was told to take a “leap of faith,” and then I was thrown off a cliff of faith.

Søren Kierkegaard (Copenhague)
Søren Kierkegaard (Copenhague) (Photo credit: dalbera)

So, around that time, I read about Kurt Vonnegut’s unlucky sister. In the prologue to Slapstick, he told of how while his sister, Alice, was dying of cancer, her husband, who was to take care of their children after her death, died on “the only train in American railroading history to hurl itself off an open drawbridge.” It was bad luck—bad enough to make you feel a little depressed.

But Vonnegut always made me feel better about things. He said, “Since Alice had never received any religious instruction, and since she had led a blameless life, she never thought of her awful luck as being anything but accidents in a very busy place.” Although I have received prodigious religious instruction and led a life full of blame, that one line has gotten me though many dark moments.

Over the years, I’ve heard many people tell me that bad things were part of some tortuous plan by some deity or other, I’ve heard that children are only on earth as a “loan” from God, and I’ve heard that God won’t give us more than we can handle. It seems to me that people routinely get more than they can handle. Many people die from stress-related illness or suicide, brought about by despair and a massive inability to cope with life’s tribulations.

Ah, but the people who didn’t survive just didn’t have enough faith to get by. The message I got from this was: “Be strong—or God may kill you.” If I had no faith in the purely accidental nature of bad luck that I learned from the Vonneguts, I am not sure I could have survived my life, which really only has the normal amount of sorrow and trauma. I haven’t been spectacularly unlucky, even by first-world standards.

Thanks to some of the interpretations I have heard of the meaning of traumatic events, I get a little nervous when anyone starts talking about making meaning of suffering. I’m quite happy to believe that suffering is just one of the vagaries of an existence fraught with peril. According to a paper by psychologist Robert Neimeyer and his coauthors, people have an intense need to “make meaning” after an extreme event disrupts their life narrative. Through a process of making meaning, individuals are able to restore a coherent narrative of their lives.

Part of the problem, it seems, is that most people believe the world has a certain moral order, and that people who are good will be rewarded with positive outcomes. So, when bad things happen, we will surely ask, “Why me?” This is a question Alice Vonnegut never asked herself, according to her brother, anyway. The horrible luck she had did not interrupt her narrative because her narrative was one of randomness and accidental events.

Regardless of what narrative one tells regarding the moral order of the universe, many people do see their own moral or spiritual growth as a result of suffering. Indeed, when we meet young people who are self-satisfied and callous, we often think that they will grow as they meet with grief and loss, and that growth will bring wisdom. It is good to know that our loss can make us better people, but I can’t think of a time when I would not give up my personal growth in order to have a loved one restored.

It seems somehow wrong, ethically wrong, to look toward loss as an opportunity for growth, but we do not seem quite so bothered by looking backward to a loss as a catalyst for growth. Herein lies some of my discomfort with focusing too clumsily on making meaning—it almost implies approaching loss by asking, “What can I get out of this?” Alternatively, it invites people to celebrate what they gained from loss. This, in itself, can create moral distress.

To be sure, psychologists such as Robert Neimeyer emphasize accompanying the grief-stricken on their own journey without guiding them down any particular path. People will, naturally, have to determine what their loss means and also what meaning they assign to life after their loss. If they fail to find any meaning, they may lose their lives all together.

In the quest for meaning, though, I hope we can accept that we live in a world full of hazards, and they do not affect us in any rational order. It turns out that some really awful people live rather charmed lives, and the purest and most compassionate people in the world suffer, though not always.

If we have the strength, we put one foot in front of another one more time. And, maybe, once again.

The ethics of eating talking plants

In a blog post on The Atlantic Wire, Sara Morrison writes,

“Just when moral vegetarians thought their meal of choice wasn’t sentient, it turns out that plants can totally talk to each other. Even weirder, they communicate through underground fungi. So mushrooms aren’t cool to eat, either. Sorry.”

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Because that is how simple moral reasoning is. Morrison assumes, with no evidence, that moral vegetarians base their decisions on whether animals can communicate. This may be because others such as Descartes have denied that animals can have thought without language. Descartes further argued that without thought animals could no more experience suffering than a machine could. Perhaps to make a point, or not, he described some rather vivid scenes of vivisection.

But it is a mistake to think ethical vegetarians are motivated by Descartes’ thinking. We tend to think more along the lines of Jeremy Bentham, who famously said:

“Is it the faculty of reason, or, perhaps, the faculty of discourse? But a full-grown horse or dog is beyond comparison a more rational, as well as a more conversable animal, than an infant of a day, or a week, or even a month, old. But suppose the case were otherwise, what would it avail? the question is not, Can they reason? nor, Can they talk? but, Can they suffer?”

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In response to the ethical vegetarian’s focus on suffering, some philosophers such as Daniel Dennett have shown that it is at least possible that animals can experience pain without the attendant suffering that vegetarians assume. It is possible that animals are automata that respond to pain without being aware of it, just as we may roll over in our sleep when we become uncomfortable (Dennett’s example). We can feel the pain and respond to it with no awareness whatsoever. (Interestingly, Dennett seems pretty sure dogs, and no other animals, may experience suffering in an otherwise uniquely human way.)

So, ethical vegetarians are stuck between those who claim that plant communication implies suffering that make moral demands on them and people who deny that clear expressions of pain are conclusive evidence that any given creature actually experiences suffering. For me, I’m quite content to assume that plants are not suffering until they express their suffering in a less ambiguous manner (or someone manages to measure it in a more convincing manner). At the same time, I’m content to assume animals with a nervous system similar to mine and pain expressions similar to mine are experiencing some kind of suffering that is enough to motivate some moral concern on my part.

At any rate, I can’t imagine how an indifference to the appearance of suffering can be something to go around bragging about. (And one final note: I really don’t understand vegetarians who are inexplicably eager to explain that they have no concerns whatsoever about the suffering of sentient beings but are only trying to lose weight or something.)

The proper way to grieve for a child

I hate Galveston.

When I look out over the seawall, I find no peace in the sounds of wind and wave or comfort in the roiling swirls of water gently crashing into the jetties. I see only the bodies of children being dragged and slammed with senseless violence against the sand just beneath the waves. As I look out over the Gulf of Mexico, I see only a sadistic child-eating monster mocking the hole in my chest.

And May is the cruelest month, because it was Mother’s Day in 1992 that I lost my niece and nephew to the powerful spring rip tides along the coast of Galveston. My niece, Cindy, who was seven, was pronounced dead on the beach, but my nine-year-old nephew, Doug, was flown to John Sealy hospital and placed on life support. Although the doctors offered us no hope of his recovery, he was kept on life support for 72 hours to monitor his brain activity.

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The only photo I have of Doug and Cindy, from 1990.

During that agonizing 72 hours, we did what most families do. We held his hands, stroked his hair, talked to him, read to him, took him his favorite stuffed bear, massaged his legs, and loved him with every ounce of strength we had. At the moment they stopped life support, the Galveston radio station played his favorite song, “Born in the USA.” Yes, we were on the radio. We were on the news. Our family’s grief was broadcast on the nightly news. I avoided the cameras, but the children’s father was there, tears cascading down his face, explaining how he felt about the death of his children. Who needed this explanation?

Perhaps it is surprising, and perhaps it is not, that I decided to enter the medical humanities program at the University of Texas Medical Branch in Galveston. I spent years driving to Galveston and going into the hospital where my nephew died. Sometimes I avoided the building, but other times I went there and sat in the garden specifically to think of what had happened before. When I completed my required ethics practicum, I went on rounds with the doctors in the pediatric ICU—of all places.

As part of this experience, I was able to witness conversations with doctors and the parents of children who would never recover. The doctors were kind, caring, and professional, and every word destroyed me a little. I imagined the conversations the doctors and nurses must have had regarding my family in 1992. I imagined how they debated the proper course to take: how long to keep him on life support, how to break bad news to the family, and how to prepare for the death of a nine year old. I had thought this experience might help me come to grips with my past trauma, but I honestly cannot say it did.

As medical humanists, we study the ways people make meaning of suffering, but I want to tell you with great heartfelt certainty—there is no meaning in the death of a child. And when you try to make meaning of it, you rob me of my grief. I am entitled to my grief. My pain is my own. When you tell me the children were on loan from God, and he has called them home, I am only amazed that you worship a monster and call it God. When you tell me they are in a better place, I want you to know that the world they left behind is immeasurably worse for their absence. When you tell me anything, you amplify my pain and submerge me in the depths of despair with no comfort and no meaning.

What does someone grieving the death of a child need? Solitude. And comfort. Silence. And conversation. A distraction. A project. Time to do nothing. Time to think. Time to cry. Time to scream. Time to fall apart. Time to get it together. There is nothing you can do. But, really, you should try. And you should know when to back off.

I can remember talking to priests, ministers, social workers, counselors, and well-meaning friends. No one can really offer any comfort, but a few people managed to refrain from intensifying the pain. In particular, Robert Schaibly, who was the minister at First Unitarian Universalist Church in Houston at the time, offered sincere condolences with no advice, no explanation, and no demands. He was empathetic and shared my pain without taking it as his pain. No other clerical person I met was able to achieve something that seems so simple. Perhaps the simplest acts require the greatest art.

Jana Pochop on Death and Dying (in song)

For most of human history, it was ordinary for families and even close friends to be present for the death of a loved one. People knew the sights, sounds, and smell of death. For a sick person to die alone would be considered an extreme misfortune. But the 20th century moved death from home to hospital. As Philippe Aries wrote, “The hospital is the only place where death is sure of escaping a visibility—or what remains of it—that is hereafter regarded as unsuitable and morbid.” While it was once a great tragedy to die alone, many now consider it a tragedy when one must be present for the death of a loved one.

To be sure, no one who witnesses the death of a loved one escapes trauma. Death is painful, and even those who are prepared for it often panic at the last moment. When people plan to die at home but end up dying in a hospital, caregiver panic is frequently the reason. The last moments of life can be excruciating to watch, and caregivers often call an ambulance to bring relief for their loved ones.

Caregivers who have a home healthcare provider to reassure them do much better. When the family knows the process is normal and unavoidable, they are able to brace themselves against the pain and endure it to the end. The advantage of hospice over home death is that professionals are responsible for all medical decisions, and the family can focus on comforting their loved one, grieving, and saying farewell.

I’ve thought a great deal about this process and how it may improve our society if we once again become familiar with death and dying in a more personal manner. I honestly believe this experience gives people a deeper experience of life, grief, love, and loss. I’ve read about it, and I’ve written about it, but I was surprised to hear so many of my thoughts on the subject expressed in a folk song of just a few minutes.

Last night I went to see a performance by Susan Gibson, an extremely talented singer/songwriter. During the second set, Gibson invited Jana Pochop on stage to sing two songs. The first was about what you will do in the moment when your soul leaves your body. The imagery was compelling and profoundly sad. When this song is available, I would recommend it to help families prepare for the imminent death of a loved one. I also believe the song will be appropriate for a medical humanities curriculum.

I didn’t intend for this blog to ever have anything to do with folk music, but I also did not anticipate folk music intersecting my interests in medical humanities, caregiver narratives, home/hospice death, and survivor stories. The following video is not of the song in question, but it gives you an idea of Jana Pochop’s talents.

How happy should you be?

I’ve never considered myself a strict Utilitarian in the narrowest sense of the term, but I always believed that suffering is generally a bad thing and that relieving suffering when possible is morally laudable. I still believe this for the most part, but lately I see myself in a dilemma of sorts. I have rejected all arguments for the necessity of suffering offered by theodicists, for I do not find belief in God to be more plausible based on the idea that suffering is the product of love and mercy from a being who only wants to motivate spiritual development and love for the good in people. I would be more able to imagine a merciful God who neglected to create life at all out of concern that life would entail suffering.

Given the fact that life with its attendant suffering is here (and unnecessary, in my opinion), I find myself agreeing that suffering does seem to be an essential element in developing any sort of moral worth. When I’ve met people, usually quite young, who have never faced financial difficulty, disease, or loss of a loved one, I generally find these people to be underdeveloped. They also seem unaware of the basic truths of life. The lack of suffering in their own lives makes them indifferent to the suffering of others. While most people believe we can’t take all the problems of the world on our shoulders, we also believe it is wrong to be “too happy” in the face of pain and suffering, but it is our own suffering that brings meaning to our experience of the suffering of others. We can never know the pain of others, but our own pain can make us care about what others may be experiencing. I realize some people experience pain and remain stubbornly egocentric, but I believe those who never experience any pain are likely to be incapable of placing any value on the pain of others. At least, they are unable to develop a fully empathic individuals.

All of this is said really to argue against the idea that we should be as cheerful as possible at all times. An old movie asked what is so bad about feeling good at a time when gloominess was trendy. Now, especially in the U.S., we have banished sadness, even when sadness is appropriate. We rush to the pharmacist when we experience the loss of a loved one, the breakup of a relationship, or even more minor life changes. We are attempting to deny the experiences that make us human.

My feeling on this surprises me. When I was much younger, I read many of the existentialist philosophers. I knew then that the brute force of one’s own existence could lead only to anxiety and, in the words of Sartre and others, anguish. I remember now that Heidegger would have us find an authentic existence by contemplating our own death, an experience that pushes the superficial features of life out of our consciousness. Camus would have us constantly justify our existence by defending our choice to not commit suicide every day. For Sartre, the happy people could not be said to even exist in any meaningful sense–just automata going through the motions of life.

When I think of what it means to love or care about someone, I can’t imagine this emotion without pain. (I must add that I wish I could write this without hearing the strains of “Love Hurts,” but so be it.) We love our parents, our children, and, of course, our lovers, and each relationship is laced with deep pain, fear, worry, and uncertainty. The joy we get from these relationships can’t possibly outweigh the pain, but we find it worth the effort. Perhaps the pain intensifies the joy. It may be that the more pain we feel, the more we love. The more we love, the more we care for others. The more we care for others, the less pain we hope they will feel.

I’ve led myself to a paradox I cannot resolve. And I feel vaguely peaceful about it.

The Ethics of Medication

Yesterday, I went to the doctor, and he prescribed medication for reflux disease. When I went to pick up my prescription, the cashier told me the pharmacy could not fill it until they received authorization from the doctor. I asked whether the doctor’s prescription was not authorization. It turns out, according to the pharmacist, that the insurance company will not pay for the medication without a written justification from the doctor.

Rather than needing doctor’s authorization, the insurance company was rejecting his authorization. So, I get no treatment for my reflux, which hardly seems fair, but the situation is exasperatingly complicated.

It could be that my doctor, under the influence of pharmaceutical reps, prescribed an expensive medication that is no more effective than cheaper alternatives. If so, it may be in the best interest of everyone, except the doctor and pharmaceutical company, to reject payment for an expensive medication that offers no additional benefits over other medications. Praise to the insurance company for holding the line on costs.

It may be that the doctor knows that the new and expensive medication is more effective and has fewer side effects than alternatives. He may have prescribed what he feels will promote my health and healing better than any other treatment available. In this case, all thanks go to my doctor, and the insurance company is really quite evil.

Or, it could be that the insurance company rejects any expensive treatment with the hope that patients will give up and find cheaper treatments or go without treatment. This, of course, might save money in the short run, although rejecting claims costs money in itself. Sometimes, rejecting a claim is more costly than simply paying it. the amount of staff time and resources tied up on this one prescription is enough to give one pause. The pharmacy says the insurance company won’t pay for the prescription, but I did not press them on how they know this. It is possible they simply consulted a list of preferred medications. It may be that they checked a computer database. Or, they may have actually made a phone call. Any of these options require employee time.

After determining that the drug was not a “preferred” drug, the pharmacy faxed a form to my doctor. If things go as planned, a member of the doctor’s staff will obtain a statement and signature from him before completing the form and faxing it back to the pharmacy. This is an inefficient system at best.

In this case, the patient, me, is going without treatment for reflux, which is causing real problems and can lead, if untreated, to serious problems such as esophageal cancer, which frequently terminates in death. So, who is to blame for the suffering of the patient? Greedy pharmaceutical companies? Doctors under the influence of greedy pharmaceutical companies? Greedy private insurance companies? Or pharmacists who raise problems when there is no problem? I really don’t know the answer.