John (not his real name, details changed) hates his job. He is healthy and comes in every few months to talk about getting off his anti-depressant. He thinks his boss is a jerk who makes him do demeaning things that should really be the job of the newer people on the team. He makes more than he thinks he could anywhere else because he’s been at this job a long time. Maybe, he thinks, his boss is trying to make him quit so he can be replaced with a cheaper, younger new hire. He wants to quit his job. He doesn’t want to take a decrease in income. Quit. Stay. Quit. Stay. He explains both points to me every time he comes in.
He’s so depressed he doesn’t do much besides watch TV when he comes home from work. He doesn’t mountain bike, which he used to love and he’s made no progress on that genealogy project he’s been talking about for a decade. He’s stuck. Clearly, the meds aren’t working sufficiently for him. We’ve changed them a couple times and that makes no difference. He’s tried therapy with three different therapists and that doesn’t seem to help. This is the type of patient to whom I suggest Stoicism.
Stoicism is not medicine, and I am reluctant to suggest it to anyone who seems to have an active medical issue. The idea of my patient going to the emergency room for treatment that I could have given them in the office if I hadn’t been too busy suggesting they give Stoicism a try is appalling. I’m a doctor, not a philosopher. I am competent to diagnose pneumonia, but am I competent to suggest or teach philosophy?
On the other hand, I think Stoicism works and would help a patient like John. Is it compassionate to withhold it? Just like, I don’t need to be a surgeon to diagnose appendicitis, I don’t need to be a philosopher to diagnose “needing a life philosophy.” But, if I’ve diagnosed his problem as “needing a life philosophy,” suggested he start exploring life philosophies, and then another doctor makes him better by giving him a pill that I could have prescribed, would he be justified to be upset with me?
A doctor’s business is care of the body, and my official title is “health care provider.” We can define “health” as broadly as we like, but I do not think it can be expanded enough to include “needing a life philosophy” and, yet, I see people who are suffering for lack of one. One of the ways I solve this problem is to have philosophy books in my exam rooms and to run late. It used to work better. Now that everyone has an iphone, I find people are more likely to be watching cat videos than taking advantage of a chance to read William Irvine for free.
Another of the ways I solve this problem is to preface anything I say about Stoicism by saying, “I am telling you this, not as your doctor, but as a fellow suffering human being.” These are my credentials for philosophy teaching. Sometimes life sucks and I’ve had to cope, too.
I have to prioritize what we are going to talk about with every patient. It is rare that I get to things like would you like a shingles vaccine and even rarer that I get to “wear your seatbelt.” I feel that I cannot help my patients with their existential issues until all of their physical issues have been addressed and yet sometimes the existential issues are driving the physical issues.
If I have a patient who is not healthy physically, I feel obliged to spend all of our precious time together talking about traditional medical topics. By coming to see me, my patient has declared in which realm they think their problem lies. If their teeth were troubling them, they’d see a dentist. If their soul was troubling them, a chaplain. At least in theory, if my patients were seeking a life philosophy, they would be at the philosopher’s office. Since they have come to a doctor’s office, we talk about their body, not philosophical issues.
Because of this, the rare healthy may get an inoculation of Stoicism from me. The unhealthy, who would benefit more from it, do not. The patient who would benefit the very most from a discussion of Stoicism rarely gets even a homeopathic dose of it from me. He (or she) is one who has recently been diagnosed with Something Bad. Having Something Bad means that now one probably knows what is going to kill one and using Google, one can easily find how long before 50% of the patients with one’s very own diagnosis die. Examples of Something Bad are: acute leukemia, metastatic colon cancer, severe COPD, or Lewy Body Dementia. There are plenty of others. A diagnosis of Something Bad challenges one’s life philosophy like little else.
Having your philosophical techniques honed before your doctor says “I don’t like the feel of this lymph node,” or “Let’s get a biopsy of that shadow on your chest xray” works better than scrambling around while you’re waiting, at home, awake at 2 am, for the results. If you haven’t gotten your diagnosis of Something Bad (yet), let’s stop wasting time! If however, you have recently been told you have Something Bad, do not despair. These techniques are just what one doctor wishes she could order and they will start helping you immediately.
The Dichotomy of Control
A common starting place for Stoic reading is Epictetus’ Enchiridion which opens with “Some things are in our control and others not.” Because there are two options, it is called the dichotomy of control: thing are under one’s control or they are not under one’s control.
Having Something Bad is not under one’s control. Some Bad Diagnoses have risk factors which are under our control: smoking, sun tanning, or excessive drinking, for example. However, which person with the risk factor gets the disease and which doesn’t is not under our control. Every smoker, regardless of their level of smoking knows a smoker who smoked more and died at an old age from something completely unrelated to smoking. “It’s not fair. How come they didn’t get lung cancer and I did?” Every cardiac patient who eats well and jogs daily also knows a dozen obese people much older than him who have not exercised since their youth and who do not have cancer. Certainly, there are risk factors, but who gets a particular Bad Diagnosis and when is a matter that is not under our control.
Bill Irvine uses the idea of a trichotomy of control (some things are partially under my control). I happen not to find this extra division helpful, but some people do. I would grant that sometimes having Something Bad is sometimes partially under my control, but certainly not fully. Whether or not I smoke is under my control, but whether or not I get lung cancer, regardless of how much I smoked, is not.
I observe that people who remember that getting their Bad Diagnosis is out of their control tend to do better. “Getting lung cancer was out of my control. I have it. The more energy I waste in thinking about why I got lung cancer, the less I will have available for figuring out what to do about it.”
When I consider my own history, I can feel very upset that my mother died at 39. Why did she get such a bad diagnosis? On the other hand, I can recall that I have taken care of children with cancer who died before graduating from high school. Why was she spared this fate, a precondition for my very existence?
An exercise that I find helpful is to turn “Why me?” around into “Why not me?” Whenever I wonder “Why me? Why did my mother die when I was seven?” I can challenge myself with “When my mother died is out of my control. Why was I lucky enough to have my mom for seven years? Plenty of women die in childbirth. This was equally out of my control.”
A very easy step from “Why not me?” is to gratitude. Continuing the personal example above, I am grateful my mom was alive for my first seven years.
If you wonder how important the classical Stoics thought gratitude was, read the first book of Meditations. Marcus lists people and situations he is grateful about. This goes on for page after page.
I do find that patients who are more grateful are happier. There is research supporting this that you can google easily.
If you have just gotten a Bad Diagnosis and wants to start developing a gratitude practice, consider what getting your diagnosis exactly a year ago would have meant for you. Consider what getting it during an earlier season of your life would have been like. It may come easily to you to be grateful that you did not get your diagnosis as you were helping plan your child’s wedding last year. Perhaps you will simply feel gratitude for the ensuing year of everyday experiences you have had and the bigger store of wisdom and coping skills you have attained.
Another easy way to identify things you are grateful for is to consider the things you will be saddest to let go of whenever you die. Those are, in all likelihood, things you are grateful to have now.
Fasting, Taking Cold Showers, and Other Tough-Guy Techniques
The Stoics, and especially their philosophical cousins the Cynics, emphasized trials of doing without various niceties of life to help one recognize how few the true needs are. They would fast for a while or eat only lentils, sleep on the ground, or do without servants. One would be able to recognize that, while a soft bed is comfy, it’s not at all required. Gratitude for that soft bed would come more naturally. Whether or not you sleep on whatever bed you have is completely under your control, unlike your Bad Diagnosis. The practices build on each other naturally.
Having practice with what is essential and what is not can be helpful when one is called upon to make medical decisions. The treatment of Something Bad may require one to reclassify some bodily functions from essential to non-essential. It can be surprising to learn which of the things you thought you required prior to getting your diagnosis is actually nice, but not necessary. Your disease may ask you “what is life without the nicety of a functioning anal sphincter?” And you will have to answer in order to choose your treatment path.
You will have to make decisions in coping with Something Bad. Some doctors disagree with me, but I think it is helpful to notice when there is a choice to be made and to be explicit that one has made a choice. If you have a diagnosis of Something Bad, you have likely made some choices already. Most people with Something Bad have chosen to work up their symptoms. Some people with incredibly severe symptoms prefer not to know more and do not take the steps you may have taken to get your diagnosis. Or maybe you opted to have a mammogram. Not everyone does. Chances are good you’ve made a number of choices already. Chances are good you have many, many more choices yet to make.
Patients will frequently come to me and say, “I have no choice. The oncologist says I have to do this medication or surgery or radiation treatment.” Nothing could be further from the truth. You do have a choice! You don’t have to do anything you don’t want to do! It’s your body! What the cancer doctor is saying is that if you do this treatment, it will give you an increased likelihood of living longer, or better. You are deciding (or are allowing the cancer doctor to decide for you) that the nuisance, pain, discomfort, nausea, whatever of this treatment are worth the likely benefit. Because you are making this choice, you really are in control. You are not in control of what benefit you actually get from the treatment or how bad the side effects are for you, but it’s your decision to do the treatment.
My observation is that people who realize that they made a choice are less disturbed by their symptoms. Yes, I have not been able to eat for three days, but that is a side effect of this chemo. I chose this chemo knowing it would be tough because it would give me a better chance of living longer.
Some people decide that the potential to live longer is not worth the loss of function it would require. Some people decide that it is. Having been the one to make that decision for themselves, however, makes the suffering which ensues from whichever choice they have made much more tolerable. The Stoic practice of finding out how much one can do without can help inform these decisions. Sometimes how little one needs to be happy is a shock.
Once I took care of a young woman who would die soon if she didn’t accept being fed through her veins. She and her husband had owned a restaurant together. Eating and drinking had been such an important part of her life that she was not sure that life would hold any meaning if it continued beyond the point where she could eat and drink. She said no. Her husband begged her to try, however, so she did. The next time I saw her, she was beaming. “It is so intimate to have him hook me up every night and give me what I need. I love it. It has brought us closer.” She lived another very happy, very intimate six months.
Something Bad will demand that you consider what delicacies of life are actually essential. It may be that you will determine that life without functioning bowels or bladder or eating or walking or seeing is actually perfectly acceptable. Or it may be that you will decide such a life is not acceptable.
Stoics may take cold showers, but patients with Something Bad are cutting to the bone. They often discover that very basic things healthy people consider essentials are actually niceties.
People often identify Premeditatio Malorum as the distinctive Stoic practice. The Stoic imagines their fear (my cancer will progress) in as great a detail as they can tolerate (I will be unable to control my bowels, I’ll have to use a bag, I’ll be too weak to take care of it myself, my family will have to do it for me, I’ll be so embarrassed) and then considers this state in light of their basic virtue (will I still be able to be wise, just, courageous, and equanimous in this state? Clearly, I would be.
The opportunities to practice these virtues would be multiplied, not diminished. Thus my basic value is not decreased.) Not all patients would view the maintenance of virtue as the thing that keeps their life worth living, but the question one asks can be adapted for what is important to the individual doing the exercise. The practice remains very valuable if one remembers to do the whole practice and doesn’t allow one’s self to start in the middle or get side tracked before the conclusion.
This first step is not a Stoic step. Starting here will allow you to adapt the exercise for your own belief system, if it is a non-Stoic belief system. If one is a Stoic, one believes that virtue is the only good. Being virtuous is what gives one’s life meaning. If one does not believe this, the work starts here. The beginning step is to figure out what one’s deepest hope is, or possibly what one feels one specifically offers to the universe. For some people this can be accessed as what gives their life meaning. If I were doing this practice by myself, I might write the answers down on an index card. These deep issues are where you’re going ultimately. If this seems like too abstract an idea for your life, keep reading anyway. Give me a chance to bring it down to the concrete and accessible. We’ll get there. I have helped people with all kinds of belief systems with this exercise. I bet you’ll find it helpful, too.
The thing about having Something Bad is that you know Bad Things are coming. You are quite likely to die from Something Bad and in fairly short order. This fact—death is in sight—sits at the back of the mind of every patient with Something Bad. Every patient I’ve ever met does the “identify your fear” part of Premeditatio Malorum instinctively. Going the next step and determining that their virtue, or whatever gives their life meaning, would not be affected by the losses they are imagining is what makes this practice special. Doing the middle steps only can get people into trouble and the patients that I see who are having the hardest time are often those who get stuck, wandering in the fear part of this practice.
If I happen upon a patient who is suffering because they have started down this path and gotten lost, I will spend the time with them to get them unstuck, even if it means I will be running late for the patients who come after them. This is very important work to do. Patients who are stuck here have imagined the thing they are most afraid of in great detail. I ask them to look at it and listen to what they say. Starting with the first step “what makes life meaningful to you?” would be greeted with derision or possibly anger. But that is what I am trying to figure out with the hurting person in front of me.
People will often tell me things like, “I worry how my kids will grow up without me to watch over them.” (Their worry might be can my kids grow up well without me? or it might be how will my kids survive the viciousness of the world? or it might be will my kids feel the abandonment of my death so acutely that they will be unable to trust others in the future?) Sometimes I hear “I don’t want to burden my loved ones with cleaning me up when I can’t control my bowels any more.” (Their question is something like “Will my family still love me if I am helpless or disgusting?” Or it might be “Do people love me only because I am strong and independent?”) I try to explore these things to learn what is the deepest belief or wish. Oftentimes, the patient cannot put words to it themself. I take my best stab at what it might be and then wander around with them until by a change in their demeanor I can tell we’re close.
Stoics find it helpful to realize that they will still be able to be virtuous even if their worst fear comes to pass. Christians could gain comfort from premeditatio malorum by recalling that they can still love Jesus even if their worst fears come to pass. Often there is a deeply held belief like “If I were a good mother, I would find a way to keep from dying,” that is causing pain. It can be tough to find, but doing this work will help ultimately.
The final step in premeditatio malorum is to consider what impact on one’s deepest hope is caused by the fears that one is ruminating upon. For the woman who believes “if I were a good mother, I’d find a way to keep from dying,” I would concentrate on helping her find ways to be a good mother after her death (writing letters or other means of posthumous communication, perhaps). For the person who is worried about who will help guide their children after their death, we might identify people who could help and figure out if giving her children this list or talking to the potential helpers or some other action would be most helpful. For the person who wondered if he’d be loved in his weakened state, we’d consider times that others were loved when they were weak, perhaps, or possibly an open conversation with the patient’s family about what her he was likely to need, what they thought they would be able to do that their abilities have nothing to do with their love for him, and where else they might get help would likely ensue.
After we have identified the painful belief, visited the worst fear in great detail, figured out what is essential to do, figured out that we have control over at this point and made some plans to do those things, I circle back and try to help the patient see that the thing they were most in fear of is not a threat. Usually they have figured this out for themselves already.
Call Things After Their True Natures
One of the funny places in the Meditations is where Marcus describes sex as friction followed by mucous. The technique of describing things prosaically can be helpful when one has Something Bad. “A single cell has decided its chances are better if it goes it alone,” “They’ll put a little tube into my kidney that will poke out my back and drain my urine directly into a bag,” “I’m done breastfeeding babies, so those parts have outlived their utility.”
Meditate on Your Mortality
Stoicism emphasizes the reality that we are all well on our way to death. Really meditating on this requires a certain amount of courage as well as imagination for the average person. A Bad Diagnosis sets one’s imagination on fire and provides the courage needed to get started. It is much easier to always be aware of the fact that I am dying if I know there is only a fifty percent chance I’ll be alive in five years. Prioritizing one’s life as though one is going to be dead soon tends to produce decisions oriented towards the deeper desires. Remembering that one will be dead soon tends to cause one to consider how one will be remembered by loved ones after one’s death. Acting in a way that seems likely to cause good memories in the future is also likely to cause a better today. Thus, the person with the Bad Diagnosis benefits from regarding their imminent death.
Different people have different hopes for the time around their death. I hope yours is as easy and as meaning filled as you would like it to be. My observation is that these practices help when you get a Bad Diagnosis. And, what is Life but a universally fatal condition? What diagnosis could be worse than Life? Our Bad Diagnosis is coming soon enough. Let’s get practicing.
Mary Braun, MD is a primary care physician in rural New Hampshire specializing in internal medicine and palliative care. In childhood, Mary began practicing an intuitive form of Stoicism to cope with being orphaned. She discovered Stoic philosophy in middle age. She applies ideas from Stoicism not only for her own life but also to help her patients.