Sorush Rokui is a 4th year medical student at the University of British Columbia.
Contrary to contemporary understanding of stoicism and the modern use of the adjective ‘stoic’, stoicism is minimally concerned with the stern renunciation of emotional responses. While tolerance and self-control are important elements of the philosophy, stoicism may be best understood as a means to a virtuous life through the recognition of what is within versus outside of our control. Understanding both our environments and ourselves is imperative to steering our work, our relationships, our expectations, and – perhaps most importantly – to determining where and how we can contribute to the greater good. Below is an incomplete exploration of how the stoic perspective may benefit the medical trainee in 2020.
Distilled to its most basic elements, stoicism is about the dichotomy of control: the acknowledgement that there are certain things that are within our control, and others that are outside of it. In general, we are in control of our beliefs, behaviours, judgments, perceptions, and desires; conversely, our reputation, and the thoughts, beliefs, and behaviours of others are outside of our control. The responsibility of stoic individuals is to classify the elements of their lives accordingly in order to invest their time and energy into things that can be modified by their investment. It is imperative to recognize that our ability to convert things across the dichotomy of control is generally very limited.
The dichotomy of control can be applied to interactions both with patients and ourselves. Consider two scenarios:
- A 68-year-old male of elevated BMI, with substantial smoking history, poorly controlled hypertension (175/95 mmHg), and type II diabetes (HbA1c 9.2%) refuses lifestyle modification advice and pharmacologic management from his physician; at present, he is asymptomatic.
- Since the onset of pandemic-related restrictions in clinical duties and practice, the clinical duties of a medical trainee have been either drastically modified, or completely uprooted. The trainee’s sense of purpose has waned, and they wonder when they will be able to return to normal life and if the pandemic will affect their career prospects.
We can reasonably discern the aspects of each scenario that we can control. While our preliminary reaction to the patient might be frustration, anger, or confusion, these feelings are rooted in the false belief that we have control over another individual’s behaviour. Is it not angering, after all, that an individual would refuse life-improving and life-extending treatment? For better or for worse, the reality is that we have only partial control over the direction of conversation for a fraction of the patient’s day. Thus, to expect every patient to be 100% compliant with each of our suggestions is probably unrealistic. However, we have absolute control over the language that we use to communicate with the patient while he is in the office; we have control over the types of questions we ask the patient; and we have control over the emotions we project toward the patient; all of which may have real effects not only for the patient’s acute experience, but also his longitudinal trust in healthcare.
In matters that concern our own lives, it is even more difficult to remain resolute in our acknowledgement of the dichotomy of control. As medical trainees, we often endorse the notion that much of our success is due to our own volition, our own strong will and discipline. Any barriers to our ambitions appear to set ablaze the script of our lives. The pandemic has caused curricular reform, cancellation of electives, and a loss in the momentum of sharpening clinical acumen, and there is no degree of individual will or discipline that can reverse a global pandemic. Perhaps this circumstance can serve as a reminder that much of how our life has advanced has been a push and pull – or perhaps more aptly, a “grasp and let go” – of control. While we may have put ourselves in positions to succeed throughout each stage of our lives, it was largely the decisions of others – admissions committees, student body voters, high school teachers, coaches, etcetera – that propelled us into the positions that we currently occupy, and will occupy in future stages of our professional and personal lives. Relinquishing a desire for control over the pandemic is the only reasonable course of action, given that we never had control over most of the logistics of our experience to begin with.
It goes without saying, of course, that maintaining these beliefs in control is progressively more challenging the worse the situation becomes. If this patient was to suffer from a STEMI, ischemic stroke, or pulseless limb in the coming months, we would feel an understandable culpability in his misfortune. Similarly, if an applicant goes unmatched this upcoming cycle, they may feel a certain anger toward the lack of visiting electives they had this year.
But the reality is that these are narratives. While it is cognitively soothing to attribute a single event to a single cause, the lives of ourselves and others are multifactorial and complex. We may never know why the patient lost his leg, or why we went unmatched. Stoicism, let alone the dichotomy of control, has no response for this.
Its only response is simple: over what part of this situation do you have control?
What a beautiful and wonderful description of a feeling I really did not know how to articulate in the spring of 2020. Thank you for this brilliant piece!
My original comments were aimed, albeit indirectly, at that stoic principle which stands as a corollary to the first distinction referenced by Sorush (between that which can be controlled and that which cannot) : That we are free to frame our response to uncontrollable things.
Thus, stoicism is not only about accepting that which one cannot change. It is also about how those things will affect us. Whether or not we will allow those things to discourage us, and dissuade us from perseverance or action.
To take one example, in the following text, Marcus Aurelias is saying : 1. pain is real and (perhaps) uncontrollable , but, 2. I have the power to prevent pain from negatively impacting me.
“Pain is either an evil to the body- then let the body say what it thinks of it- or to the soul; but it is in the power of the soul to maintain its own serenity and tranquility, and not to think that pain is an evil.”
Even the resignation before the reality of death (which we see so prominently displayed in the texts of Epictetus, for instance), is not simply a willingness to die. It is actually a strategy for living, in spite of the FEAR of death.
In fact, that is the central point. Stoicism is a strategy for living. It is not about giving in, or about giving up. Once that point is reached, then all bets are off. Philosophy is no longer of any use to anybody.
Again from Marcus Aurelius on the relation of pain to death and the will to live :
“The pain which is intolerable carries us off; but that which lasts a long time is tolerable; and the mind maintains its own tranquility by retiring into itself, and the ruling faculty is not made worse.”
It is truly sobering, for me, to read a statement like that, coming from someone who knew severe pain in the pre-scientific world. It is actually very hard (perhaps impossible) to really relate. However, my reading of this, is that as long as the pain itself does not actually kill us, then we are still “in the game”.
And as for the value of that game : the fact remains that in a materialist universe (even more than in a spiritual one), death is a really big deal. It is (in such a case) literally to extinguish a unique light of consciousness from the world. And perhaps as a result : experience shows that most people, are simply not willing to die ; are ready, indeed, to continue living, even if for a very brief time, and even under conditions which exterior observers have difficulty themselves in witnessing.
Yes, it is easy to imagine circumstances (where as you say) “I would not want to “soldier on”. However, that reflection comes at a comfortable distance from the reality of death. Closer to the end, however, and whatever we might think of these things now, most people will not “go gently into that good night”.
In the Netherlands, for instance, where euthanasia has been legal for nearly twenty years (and is no longer controversial in the medical landscape), only 4% of all deaths go that way. And even in the most likely group, which is to say terminal cancer patients, only one in ten accept the offer of euthanasia. Fully 90% refuse.
In short, what society says about suffering at a distance, and what real people choose close up, are two very different things.
Or as our Roman Emperor, puts the matter :
“It is a shame for the soul to be first to give way in this life, when thy body does not give way.”
Gordon Friesen, Montreal
Marcus Aurelius in his Meditations says, “How vividly you realize that no other condition of life is as conducive to philosophy as that in which you now find yourself”. I am thankful that you, at your early stage of life and career have taken that Stoic’s advice to heart and that you have prompted us to ponder whatever circumstances, controls or lack thereof we all are experiencing now.
Got to disagree with Gordon, although perhaps I misunderstand his conclusion. I’m fairly stoic but can certainly imagine conditions where I would not want to “soldier on”. Gaining the ability to legally and humanely end one’s own life is for me shifting something important into the realm of things you can control. This is a good thing.
I am very glad to encounter a fellow adept of the stoic school !
I do not wish to comment on your most timely analysis of the Trainee’s situation, but rather to recall a particular thought of the emperor-philosopher Marcus Aurelius (121 – 180 A.D.) which is very useful in medicine, and the communication of which might greatly benefit many of your patients.
Marcus Aurelius suffered from severe migraine at a time when there was no treatment for it. It was, according to his self-reporting, a very debilitating condition. Therefore, he knew first-hand — omnipotent dictator that he might have been — the experience of true helplessness before a real, and very painful, disability. And yet he managed to overcome that condition to an admirable extent and continued his imperial duties with minimal interruption. How ?
His problem, as he saw it, was to resolve himself to his condition, so that he might pass beyond it (within the limits set by the disability itself).
To do this, he drew a distinction, which is of the greatest possible importance for any suffering patient : between the suffering directly caused by the illness ; and the suffering caused by the mere consciousness of being ill.
So simple yet so brilliant !
Suffering, from the illness, is inescapable. And the damage caused is real : Inability to work ; inability even to leave bed ; the fear of embarrassing relapse at any time.
It is natural, in such a case, to be despondent. It is natural to worry about the judgement of other people. To make comparisons between what is and what might have been. But on this score, our worthy Roman is inflexible : suffering from the simple fact of BEING ill, is useless, unnecessary, and for the thoughtful man, avoidable.
After all, what is wrong with being sick (or otherwise disabled) ? It is perfectly natural. It is something that can happen to anyone. It is not the result of any personal weakness or fault. (Or in the ancient vocabulary : there is nothing DISHONORABLE in the fact of being ill. And the virtuous man has nothing to reproach himself, other than vice and dishonor). There is therefore, nothing WRONG with being sick. Nothing to be ashamed of. Nothing to regret.
That is the essential liberating thought : the disabled and dependent individual has absolutely nothing to be ashamed of. He or she is of equal moral worth to any other individual. He has an equal right to live. There is, therefore, no reason to despair. There is no reason to hide. No reason to make excuses or compromises. From this point on, all of one’s energy is available to the task of palliating the real and inescapable effects of the illness ; to living as long and as fully as one possibly can.
There is, in the estimation of this timeless intelligence, no reason to fear suffering in life. No reasonable expectation of living any life without suffering. No reason, in fine, to ever consider shortening our lives because one wishes to spare the narrow-minded prudery of those who find OUR suffering unbearable.
Stand up. Stand out. Soldier on !
Thank you again for evoking these most powerful thoughts.
Gordon Friesen, Montreal