THE MINOR KEY: PALLIATIVE CARE, THE VIRTUES OF CLASSICAL CITIZENSHIP, AND A NEW END-OF-LIFE CONVERSATION
Courage, friendship, honesty (truth-telling), and justice, also known as “virtues” in political theory discourse, were core values of classical citizenship. The virtues are integrally related to the concept—developed by Aristotle, St. Augustine, Thomas Aquinas, and the 20th century French Catholic philosophers—of the idea of the common good. We argue that the virtues are expressed in the praxis of palliative care, which contributes to the common good.
Palliative care (from the Latin word palliare, meaning to cloak) is a specialized area of health care that focuses on relieving the suffering of patients and their families experiencing advanced illness. Dr. Balfour Mount coined the
term in the mid-1970s. Palliative care in Great Britain grew out of a religious tradition and concerns about social solidarity, while the American palliative care movement grew out of legal and secular concerns, assertion of patients' rights, and debate over physician-assisted suicide (Fins, 2005, p. 14). Unlike hospice care, which it supports, palliative care is appropriate for patients in all disease stages. Most notably, it does not aim to cure illness: palliative care meets illness on its own terms and aims to relieve the suffering—physical, emotional, spiritual, and existential—that characterizes and accompanies both serious illness and the dying process. Ideally, palliative care is practiced by a multidisciplinary team: physician, nurse, pharmacist, psychosocial professional, chaplain, and volunteer. The patient or “unit of care” in the palliative care approach includes relevant family members and caregivers. Indeed, the long-term physical, mental, and spiritual health of family members and caregivers depends on seeing that their loved ones' suffering and symptoms are relieved, that opportunities to create meaning are made available, and that wishes to die at home or in hospice, rather than in a hospital or institution, are granted whenever possible. The discipline of palliative care also attends, crucially, to health care providers themselves, addressing burnout, conflict resolution, bereavement, and improving communication skills (Halifax, 2011). “This is the first discipline [to include] health care providers in its scope of attention” (Jazieh, 2012). In contrast with the biomedical model, where the operative unit is a binary (patient–physician) palliative care is paradigmatically practiced in, by, for, and as a community.
Palliative Care and the Virtues
Truth-telling or “parrh–esia” (Foucault, 2011) was a classical political virtue that can be loosely compared to the modern right to free speech, which is central to democratic citizenship. Establishing, revisiting, and revising patients' and families' goals of care through inclusive consultation, sensitive truthtelling, and ACP is also central to palliative care. In that it is conditioned by an ethic of truth-telling, palliative care both expresses and generates another of the virtues, known as “civic friendship” in the classical sense of philia, a “loving bond . . . involving altruism, reciprocity, and mutual recognition” (Konstan, 1997, p. 69). Friendship and honesty were considered core political virtues in the classical world, and are internally related to the common good: “Where there is justice, friendship is possible. And where there is friendship, there is the pursuit of the common good” (Smith 1995, p. 167).
According to Aristotle (1985, 212–213; Nichomachean Ethics, Bk.Viii, 9:35 1156b), “complete friendship is the friendship of good people similar in virtue; for they wish goods in the same way to each other insofar as they are good, and they are good in themselves. Those who wish goods to their friend for the friend's own sake are friends most of all; for they have this attitude because of
the friend himself.” This is closely related to the Buddhist concept of the spiritual friend (King, 1991, p. 119). The “goods” the palliative care team wishes for the patient and family (and ultimately, of course for themselves)—relief from physical, emotional, spiritual, or psychosocial pain—are “produced” in the community of friendship generated by the praxis of palliative care. The virtues condition the “energetic tone” of the family, the community, and even the polity as a whole when policies supporting palliative care ensure that it is fully integrated into the health care delivery system.
The core political virtue of civic friendship is classically twinned with the virtue of courage (tharsé–o). The courage of the soldier (the paradigmatic classi-
cal citizen) is the willingness to face death in battle, knowing he has the support and trust of the community he loves. The community, his group of comrades, is the wind at the soldier's back. The modern citizen/patient/community of the seriously ill has this same wind at its back when that citizen's fellows, her health care services, and her elected representatives treat her well-being, and that of her family, as their primary concern. The foundation of political courage, its molecular structure, is love and charity (caritas): love of country (patria), family, clan, and virtue (Viroli, 1995). That love can also be extended to suffering humanity, to our fellow inhabitants of the planet. These virtues are all immanent to the original institution of citizenship, which can be mapped in praxis onto international legal and biomedical regimes (Fins, 2005, p. xvi). The virtues we have identified are a synergistic source of authentic collective power for a terminally ill person and her caregivers: “communication confers communion and creates community” (Ward, 2000, p. 111). The Veterans Administration incorporates the virtues that have always been immanent to the soldier–citizen–polity continuum into its palliative care program for terminally ill soldiers through its Home-Based Primary Care and inpatient programs.