Suffering and Character

These are questions that have to do with the bearing of moral ideals on certain kinds of lived realities. Philosophers interested in the virtues have traditionally taken a strong stake in anchoring them in such realities. The virtues are often conceptualized as qualities that help us manage certain spheres of experience where, as human beings, we find ourselves naturally challenged—such as our relation to our bodily appetites, our tendency to excessive self-love, or our fear of death. But when we look closely, what seems striking is the limited interest taken by many of the dominant frameworks in the experience of illness as a sphere that calls for special moral response. 

Aristotle, for example, pays it no attention in drawing up his list of the virtues in his Nicomachean Ethics. He dedicates an entire chapter to courage, a virtue that might appear broadly relevant given that it concerns the risk of bodily harm. But courage is exercised more specifically in battle—in situations “in which one can put up a fight” and reap a harvest of glory if victorious. It also focuses on the specific harm of death, regulating our fear of it as an event that may suddenly take place in the future, rather than on some type of ongoing pain experienced in the present. In all these respects, it couldn’t be further from the paradigm of illness. 

Aristotle’s oversight, to some, has seemed typical of a bias that affects not only historical but also contemporary writing on ethics. As Alasdair MacIntyre notes, moral philosophy—in which we might arguably include his own earlier landmark book on the virtues, After Virtue—exhibits a peculiar blind spot toward the phenomena of disability, injury, illness, and affliction. When the ill and the disabled do make an appearance, it is “almost always exclusively as possible subjects of benevolence by moral agents who are themselves presented as though they were continuously rational, healthy and untroubled.” The disabled are “them,” not “us.” In the same vein, Carel speaks of the “pathophobic prejudices that seem to run through much philosophical reflection on the good life,” which cement a focus on those fortunate enough to be endowed with robust forms of agency and capable of engaging in certain kinds of activities. The same emphasis on the young and healthy is reflected in a common picture of ethics in general and the virtues in particular as primarily tasked with restraining our unruly instincts, passions, and drives. From this perspective, the main problem is how to harness excess power, feeling, and desire rather than how to manage their atrophy or absence—something we are more likely to experience in times of poor health. 

This blind spot seems remarkable considering that virtually everyone who has ever lived has experienced or will experience illness at some point in their lives. Some have taken this to mark an important line of division between certain forms of philosophical and religious ethics. Philosopher of religion John Cottingham, for example, has contrasted Aristotelian virtue ethics—with its emphasis on activity, flourishing, and success—with Christian ethics, which pays greater heed to human vulnerability, weakness, and dependency. This is reflected in the more expansive list of the virtues drawn up by Christian thinkers, which includes humility and hope. The greater preoccupation with human dependency also provides a context for the stronger interest that religious traditions have shown in the virtue of patience. A good example is Thomas Aquinas, who makes a point of broadening Aristotle’s focus on the warrior’s courage through an analysis of patience. Patience “endures not only dangers of death”—the focus of courage—“but also any other hardships or dangers.” The word “patience” derives from the Latin term for suffering, pati. From an etymological perspective, as some scholars have noted, it may thus be simply described as the virtue of suffering well. 

Yet even theories that appear more sensitive to suffering as an object of moral consideration often turn out to harbor important limitations. This applies to the Stoics, whose philosophy—and heady image of ultimate fortification, where everything that matters is safe inside the citadel and anything outside the walls is abandoned to the enemy forces—is expressly designed to serve as a resource for confronting adversity. “Inside” and “outside,” to be clear, are not to be understood literally. Things typically placed “outside” the citadel include our own bodies, whose possible sufferings form an important Stoic preoccupation. But when talking about the topic, the Stoic emphasis is often on dramatic cases such as sudden injuries or death inflicted by others (death by beheading is one of Epictetus’s favorite examples)—cases not all that far from Aristotle’s paradigm of courage and more likely to inspire heroic sentiments about “squaring the breast” to fortune. The daily grind of chronic illness produced by natural causes, by contrast, does not seem at the forefront of the Stoics’ minds. 

Aquinas himself has important things to say about the different varieties of suffering in his Summa Theologica. Yet a similar observation can be made about his account of patience, which he characterizes as a virtue that helps us regulate the sorrow we’re inclined to experience when evils befall us. The sorrows in question are chiefly those “inflicted by other persons.” In analyzing patience, Aquinas thus seems more interested in how we might respond to what philosophers would call “moral evils”—harms we suffer at the hands of other human beings—rather than “natural evils,” the category that would include illness. 

Yet more important for the question that concerns me is a different limitation. The suffering to which our bodies expose us is after all not confined to the pain of sword wounds, broken bones, or even the chronic physical pain caused by illness. It also includes the impact of bodily events on our affective and cognitive condition. The nineteenth-century cause célèbre of medical science, Phineas Gage, carried the point single-handedly when an iron bar punctured his skull and set off a firestorm of psychological disturbances. But the more important facts are less sensational and, to many of us, too obvious to require special demonstration. We know that healthy individuals who do not normally suffer from major mental disorders can experience a range of psychological disturbances as a result of physiological factors and events. Think of the widely reported aftershocks of viral illnesses, including Covid, which include depression and the allusively named “brain fog,” the affective problems produced in many people by deficient sunlight in winter, the emotional and mental disturbances experienced by many women during menopause, or more simply the distorting effects caused by a drop in iron levels or thyroid function. 

These types of experience seem far from the thoughts of many premodern philosophers. Aristotle provides an unusually vivid illustration when talking about the virtue of temperance and our relation to pleasures. With pleasures, he comments, the main danger is excess. “People who are defective in relation to pleasures,” by contrast, “and enjoy them less than one should hardly occur.... If there is someone to whom nothing is pleasant, and nothing is preferable to anything else, he would be a long way from being human.” What Aristotle treats as a pure hypothesis sounds uncannily like a description of a condition often termed (ironically using a Greek term) anhedonia, which involves a substantial impairment in the ability to experience interest or pleasure. This symptom is one of the main criteria used to diagnose major depressive disorder. It can also be an ingredient, to varying degrees, in many of the other conditions just mentioned. Looking back, it is clear to me that it was an element in my own experience. 

A concern with this type of suffering also seems largely absent from the Stoic writings I’m familiar with. A telling piece of evidence is the one I’ve already mentioned: the Stoics’ heroic way of thinking about ethics. Rousing words about “squaring the breast to take... whatever fortune hurls at us” may seem incongruous when taken to refer to chronic physical illness. Taken as a reference to disturbances of our mental and emotional state, they seem positively outlandish. A similar point can be made about other important thinkers who approach the topic from a theological direction. When al-Ghazālī takes up the virtue of patience in The Revival of the Religious Sciences, for example, mental suffering is not an adversity to which he considers connecting its deployment. And while Aquinas has more to say about sorrow from a different angle in the Summa, his idea of patience as the virtue that regulates our sorrow over evils pointedly excludes the possibility that sorrow may not always be produced by evils—it might be, as it is in depression, the very evil itself. 

For the Stoics, the neglect of this type of suffering may reflect their special assumptions about the relations between body and soul. Traditional Stoic doctrine, as Pierre Hadot points out, drew a strong distinction between the two. At one point in his Meditations, Marcus Aurelius advises his reader: you’ll live life best if you separate your intellect, which is your true self, from “everything that happens to you, independently of your will, because of the body which surrounds you.” The implication seems clear: our mind is one thing and our body another; what happens to our body has no necessary bearing on the mind. 

Few of us today would be prepared to make such a claim. And to that extent, we will be much more inclined to raise a doubt about the basic tenet of Stoic philosophy and any other philosophy that shares its sympathies: inside the citadel—always under our control—is a part of ourselves that enables us to take the right attitude to everything we can’t control, including (apparent) evils that come to us from within our own bodies. A virtuous response is always possible. Once we accept that these evils include disturbances of our cognitive and emotional condition, this tenet begins to look less self-evident.

How we understand the challenge these phenomena pose will partly depend on how we unpack the idea of what it means to make a virtuous response. Theorists of the virtues commonly take them to be dispositions that manifest themselves on a plurality of different levels, including how we think, how we feel, and how we act. These dimensions are not entirely separate—what we feel, to take an obvious example, is shaped by what we think. But focusing on the former, many prominent views of what’s involved in responding virtuously to evils we experience would appear to incorporate an important emotional component. 

Take the Stoics’ “heroic” model of ethics. I have focused on the Stoics because they provide an especially striking expression of the viewpoint that interests me. But taken as a way of negotiating the relation between the domain of inescapable necessity and human choice, their viewpoint has found numerous adherents, many of whom evoke the same heroic paradigm. In The Varieties of Religious Experience, William James makes the point as part of a broader meditation on evil. “Much of what we call evil,” he comments, “is due entirely to the way men take the phenomenon.” All we need to do to disarm it, therefore, is change our attitude to it. Evil can “often be converted into a bracing and tonic good by a simple change of the sufferer’s inner attitude from one of fear to one of fight; its sting... turns into a relish when, after vainly seeking to shun it, we agree to face about and bear it cheerfully.” Confronted with such phenomena, our best bet is to “ignore their presence” and “despise their power.” 

James’s picture of sporting confrontation evokes the warrior psychology at work among the Stoics. Step boldly toward things you dislike, and you’ll experience the thrill of victory. One reason, we may now say, why this picture seems so awkward applied to the case of emotional and mental disturbances as against the other standard examples that fill Stoic books—poverty, prison, obloquy, death—is precisely because of the way in which moral response is understood to be wrapped up with certain kinds of emotional states. We may wonder to what extent the person experiencing seasonal depression, menopausal anxiety, or post-viral brain fog can choose to “ignore the presence” of these phenomena. But the idea that they might have the capacity to respond to their suffering “cheerfully” or with an exulting thrill or “relish” would seem to conflict with what we know about the basic nature of these conditions. All of these emotional states have a positive quality; their experience involves a sense of pleasure. To that extent, they would seem to be inaccessible to sufferers of some of these conditions, including depression, one of whose hallmarks is lower mood and a reduced ability to experience positive mental states even in response to circumstances that would normally have a positive valence. 

This picture of virtue and its emotional content might not be shared by all virtue theorists. But a similar challenge attaches to other views, including religious ones otherwise remote from the ancient philosophers’ heroic model. In The Revival of the Religious Sciences, for example, al-Ghazālī considers what it means to exhibit the prized quality of satisfaction or contentment (riđā) in the face of undesirable events that God has ordained. Can we ever really be content, someone asks, with what’s undesirable or downright painful? As in his discussion of patience, here too, mental suffering is not at the forefront of al-Ghazālī’s mind. Our love of God and sustained awareness of His beauty, he replies, can silence or overcome our natural sense of repugnance. The ability to respond virtuously to suffering here seems to be grounded in a continued ability to experience beauty—an experience that, as al-Ghazālī makes clear elsewhere, is indissolubly tied to feelings of pleasure and joy. 

Al-Ghazālī also helps bring out a different but related challenge that concerns the cognitive dimension of virtue. Central to our ability to endure evils, his account of contentment suggests, is the ability to remain in contact with a higher source of value that we can perceive as outranking or outweighing those evils. Elsewhere, this idea takes shape as a more familiar insight about how our awareness of more valuable goods that lie in the future can help reconcile us to the experience of the present evils they depend on. Discussing the virtue of patience (śabr) in his Revival, he suggests that we consider “the recompense bestowed on the patient for the afflictions they endure.” We may then be able to “subdue our sense of repugnance” by reflecting on the future reward promised by God. 

Al-Ghazālī’s suggestion reflects the familiar “pain now, pleasure later” principle of delayed gratification that epitomizes a commonplace idea of self-control even more obviously than patience. In many parts of the Islamic tradition, the ability to weigh costs and benefits has been seen as fundamental to human rationality. Taken as a way of filling out the cognitive content of patience, al-Ghazālī’s consequentialist analysis (and its religious specification) might not unite other virtue theorists. But there is evidently something very intuitive about the idea that we might seek to sustain ourselves through suffering by focusing on possible goods that might flow from it. The thought of future possible goods also forms a key ingredient of another virtue, hope, which many would view as a central part of the virtuous response we can make to suffering. 

Yet in several of the disturbances I have named, the cognitive ability that all of these responses presuppose appears to undergo severe distortions. For example, psychology researchers have recently sought to refine the scientific understanding of the condition I mentioned earlier, anhedonia, by distinguishing between three subcomponents of the reward-processing system, often referred to as “wanting,” “liking,” and “learning”—or the appetitive, consummatory, and satiety phases of the pleasure cycle. “Liking” has to do with whether we experience a present stimulus as pleasant or rewarding. “Wanting” concerns our capacity to be motivated by future rewards. One way in which impairments in the latter manifest themselves is in a compromised ability to weigh costs against benefits in making choices. A recent study on major depressive disorder run by a team of American researchers found that subjects “were less willing to expend effort for rewards than controls” and “less able to effectively use information about magnitude and probability of rewards to guide their choice behavior.” More generally, it has been suggested that individuals with this type of impairment tend to “overestimate future costs, underestimate future benefits, or simply fail to integrate cost/benefit information in a consistent manner.”

This kind of evidence suggests that the cognitive operation that al-Ghazālī places at the heart of patience—which evokes future rewards of unusually elevated magnitude and probability—may be unachievable for people experiencing these conditions. One of James’s informants in his early discussion of physiologically caused anhedonia put it directly when reporting that “every idea of heaven was taken away” and heaven no longer seemed a place “worth going to.” Speaking from a more phenomenological perspective in his recent study of depression, philosopher Matthew Ratcliffe refers more sweepingly to the loss of “a sense of the future as a dimension in which significant possibilities can be actualized”—possibilities perceived as in some way “good.” Such a sense, he suggests, is a necessary foundation of the capacity for hope, so its transformation can effectively “prohibit the possibility of hoping.” This defective relation to future possibilities, he points out, is paired to a broader erosion of the sense of agency and the scope for practical action. If patience depends on our ability to entertain a particular representation of the future, our ability to exercise it would seem as doubtful as our ability to exercise hope.

These kinds of considerations—many of which articulate aspects that I can see reflected in my own experience—challenge the idea of a virtuous response from a number of directions. Taken together, they suggest that the inner citadel is far from impregnable. Character, whatever we may wish to believe, cannot always be exercised. The citadel lets in a draft.

One reason, of course, why we might wish to believe that character can always be exercised—or molded in positive new ways—is because it holds out the promise that suffering has not been in vain. It allows us to make sense of what might otherwise seem a meaningless experience. This is clear from the role the idea has played in religious quarters as a way of negotiating the problem of evil. The Christian worldview, Hick points out, can’t make room for the idea of “finally wasted suffering.” Something similar could be said about other monotheistic worldviews. In the Islamic world, “futile” or “vain” was recognized as a central moral category by Mu¢tazilite theologians: suffering must have a return, and one that could not have been gained without it. But a number of religious thinkers have acknowledged that not all suffering is equally easy to fit into this positive or productive mold. Hick himself grappled with the idea of apparently “dysteleological” suffering, when life’s challenges seem “so severe as to be self-defeating when considered as soul-making influences,” and when affliction seems like a purely destructive process that “may crush the character and wrest from it whatever virtues it possessed.” 

It is telling that a number of those who have taken an interest in the transformative potential of illness have treated mental suffering as a problematic case. Both Carel and Kidd, for example, openly omit it from their accounts of the positive transformations—including the transformation of character—that illness might catalyze, focusing exclusively on bodily illness. Tasia Scrutton, a philosopher of religion who has written extensively on Christian views of depression in the context of defending her own view of suffering as potentially transformative, makes the point especially clear. Whether suffering can transform us, in her view, depends on the response we make to it. But to her it seems obvious that in some forms of mental suffering, notably severe depression, the possibility of responding well or badly closes up. The fact that—as Ratcliffe noted—individuals perceive their agency to be diminished is of the essence here. The perception that we lack choice has a direct bearing on whether we actually have choice and are able to exercise it. In some conditions, moral choice is simply not available to us. The space for ethics is not always open; sometimes morality comes to an end.

From one angle, this idea might be so obvious as to seem trivial. How could anyone in their right senses ever think otherwise? The idea that moral agency is always open to us would only seem tenable to someone willing to overlook the realities of human life, including the extreme forms of suffering we may experience, the dramatic alterations of consciousness to which they can expose us, and the ultimate fact of death. As James put it in his Varieties of Religious Experience, the “athletic attitude” of morality—with its striving, straining, and emphasis on personal effort and will—always eventually “breaks down even in the most stalwart when the organism begins to decay.” What the person “sicklied o’er with the sense of irremediable impotence” needs is not moral exhortation but consolation and acceptance of their powerlessness. What they need, in short, is a kind of surrender. For James, where morality ends is precisely the point where religion takes over.

But what exactly does it mean to make such a surrender—to draw the curtain down on ethics? These are decisions we regularly take in certain contexts, for example when we declare people suffering from certain kinds of mental disorders incapable and we shield them from the ordinary legal consequences of their actions. The cases I have had in mind here, including my own experience, are not of this extreme type. They fall on a more nebulous part of the continuum between complete health and debilitating illness. This is one reason why the space for the question I have been asking arises. But more importantly, unlike those other cases, here it is not a question of assessing the moral capacities of other agents on the basis of their observed behavior and responses. It’s about making such a judgment about ourselves from the inside. For me, right now, morality has come to an end; moral choice is no longer possible to me. What would it mean to make that judgment?

The view that, on a limited reading of his dense philosophy, I take from Kant is that, in one important sense, this judgment is in fact not entirely available to us. We are beings “who cannot act except under the idea of freedom.” To the extent that we are practical agents, who deliberate about what to do, we can only consider ourselves to be free—free to choose between different options available to us. This is not to say that our sense of our own agency can’t contract, sometimes dramatically, under different circumstances, including those Scrutton and Ratcliffe describe. But for most of us, so long as we’re capable of posing a question about the extent of our freedom, this judgment can’t be made and stably maintained without profound tension. This entails that, whatever the real limitations to our powers that might be recognized from a perspective outside our own, a good response is something for which we can’t help continuing to strive. It also entails that we can’t entirely insulate ourselves from attitudes of critical self-assessment, including the type of self-doubt and discontent that formed part of my own experience. It may be an added source of suffering, but the judgment that we have no choice is unlivable. 

Does this mean that during such experiences we’re doomed to strive without success in the face of frustration and without chance of satisfaction—unable to attain any part of the kind of “beautiful” attitude for which I yearned? Scrutton, for her part, thinks that the limited response open to those undergoing certain kinds of mental suffering does not put paid to the idea that such experiences could nevertheless prove transformative. But locating this potential may require looking outside the moment of experience itself. How our experiences shape us depends not only on the choices we make while we are undergoing them but also on the choices about how to negotiate them that we make after they’re finished. Scrutton cites Catholic priest Henri Nouwen, who described his experience of depression as a “time of purification” and “spiritual renewal.” In the journals he kept at the time, we hear him counseling himself: “Your future depends on how you decide to remember your past.”

Ethics doesn’t end; it is only interrupted. This thought may not be great comfort in the present while the experience lasts. Taken as a thought about a positive future prospect that constitutes an object of hope, it may in fact be inaccessible. If making a “beautiful” response means entertaining certain kinds of thoughts and emotions, such options may not be available at the time of experience for reasons I’ve recounted. The idea of “beauty,” which worked itself inextricably into my own reflections at the time, raises many questions. Beauty is often thought of as a function of appearance. Connected to virtue (a philosophically unfashionable but time-honored move), it would seem to be a function of how virtue appears to an imagined or actual other. Virtue theorists, I noted earlier, have commonly understood virtue to be a disposition with a range of expressions, including how we think, what we feel, and how we act. These aspects are knitted together in ways that are hard to unpick. Yet when we look again at some of the sources I considered earlier, what seems striking is the emphasis they place on those aspects of virtue that relate to its bodily expression. 

When, for example, Epictetus writes,“I must die. But must I die bawling? I must be put in chains—but moaning and groaning too? I must be exiled; but is there anything to keep me from going with a smile, calm and self-composed?” it is not obvious that the responses he is urging are to be located chiefly on the inside, in the private domain of our thoughts and feelings. More than anything, they spell out a picture that stands before our eyes in a full-bodied, three-dimensional form. Aristotle speaks of bearing misfortunes with “good grace”—euschēmonōs: literally, “with a comely form.” On one level, Epictetus simply fills out that form.  

We see something similar in al-Ghazālī. Unpacking the virtue of patience in his Revival, al-Ghazālī is suddenly confronted with a question that goes to the heart of the matter. When adversity strikes, how can we choose not to feel a sense of repugnance? Psychological reactions like these are simply not in our control (ghayr dākhil fī al-ikhtiyār). The question echoes the earlier one about contentment. But here al-Ghazālī’s reply is different. A person counts as patient, he explains, not when they remove these feelings but when they avoid a number of other things, including “tearing their clothes, smiting their cheeks, complaining excessively, advertising their dejection, and diverging from their habitual ways of dressing and... eating.” These aspects are all within our control. 

Most—though not all—of the things al-Ghazālī recommends represent forms of external behavior. We may not be able to control what we feel; patience, for us, will always have the phenomenology of hardship. But there is some kind of control we can always exercise over what we do. The elements al-Ghazālī names add up to a picture of physical self-command not far removed from what Epictetus provides. In al-Ghazālī’s case, it is not a stretch to connect this to the Qur’anic concept of “fair” or “fitting” patience (12:18, 12:83, 70:5), which commentators linked to a similar kind of outward self-restraint. It is a picture, in both cases, of dignity—dignity taken as a bodily discipline and external decorum rather than a posture of the soul. 

Read this way, these thinkers hold out an understanding of what it might mean to exercise virtue in adversity that seems more modest and therefore more achievable. It is open to question whether even this more modest conception, if achieved, could be experienced as beautiful by those to whom it matters most immediately. Looking back in the light of day, I can see that the inability to find satisfaction, register achievement, and perceive anything as well-formed was a central part of my experience, and one that no doubt many others have shared in even unhappier forms. For suffering of the type I have been focusing on, the harder question might be not whether we can respond beautifully but whether we can know it. But the desire to put beauty into suffering might after all be a desire to make suffering something other than it is—something we ardently wish we didn’t have to experience.