Béatrice Han-Pile On The Ethics of Powerlessness

Can philosophy help care for the terminally-ill?

Béatrice Han-Pile is a professor of philosophy at the University of Essex and principal investigator on a AHRC-funded project on The Ethics of Powerlessness: the Theological Virtues Today.

Han-Pile studied philosophy, history and literature at the Ecole Normale Supérieure and was awarded a Fellowship from the Thiers Foundation while completing her doctoral thesis on Michel Foucault. Before arriving at Essex, she taught in France at the Universities of Paris IV-Sorbonne, Reims and Amiens, as well as teaching at University of California, Berkeley as a Visiting Scholar twiceover. Her writing primarily focuses on Foucault, Nietzsche, Schopenhauer, Heidegger and aesthetics. She is a regular contributor to the BBC's flagship arts and culture radio programme, In Our Time.

Speaking over Skype,  we discussed how the Ethics of Powerlessness project investigates the meaning and appropriateness of the strict division between agents and patients, the nature of medio-passive agency amongst terminally-ill patients and recovering addicts, as well as the possible roles of the theological virtues in contemporary secular thought and public policy.

—David Maclean


DM: Philosophically speaking, what is powerlessness?

In the simplest terms, it’s the inability to bring about a change that you would like to see happen in your life. So for example, say that you are chronically ill and would like to get better, but you can’t make yourself better; or that someone you love is in trouble and you would like to make things better for them but you can’t. These are situations of powerlessness.

Then there are experiences of powerlessness, and this is what we are mostly interested in. Such experiences often map onto situations of powerlessness, but not always. We can feel powerless even if we are not objectively in a situation of powerlessness: think of a child who has the capacity to jump a ditch but feels powerless because the ditch seems too wide to her. Experiences of radical powerlessness involve seeing something that you would like to happen and feeling that there is absolutely nothing you can do to realize it. Experiences of relative powerlessness occur when we feel that there is something we can do to realise the desired outcome but that this would not be enough to secure it. You can experience both radical and relative powerlessness at the same time, in relation to different things: for example, in the case of an incurable illness like diabetes you may feel that you are radically powerless over the fact that you have the disease; but you may also feel that you are only relatively powerless in relation to therapeutic options, since you will be involved in the protocol. Experiences of powerlessness (radical or relative) are usually perceived as difficult and painful.

DM: That sounds like the extremities of angst as the likes of Kierkegaard described it, where one feels powerless over one’s life and the anxieties that brings. Does this idea of powerlessness have its antecedents with the more Existentialist thinkers?

Well, it depends on what you mean by anxiety. For Kierkegaard it is a profoundly ambivalent experience, a sympathetic antipathy and an antipathetic sympathy, as he puts it. In some cases experiences of powerlessness can be like that. If we consider the example of Alcoholics Anonymous and their Twelve-Step program, the first step is to admit that one is powerless over one’s addiction and that one’s life has become unmanageable – and if your life is unmanageable, then that’s extreme powerlessness. And yet Alcoholics Anonymous members report that there is a  sense of relief that comes with that acknowledgement. So the acknowledgement of powerlessness can be both an expression of distress and something positive: it can mirror the ambivalent structure of anxiety in Kierkegaard. But that is taking anxiety in a special sense, not the everyday sense of worrying about or feeling overwhelmed by life in general. 

kwame portrait 2 SUGGESTED READING Cosmopolitanism and the Mixed Blessings of the Windrush Scandal - An Interview with Kwame Anthony Appiah By  Having said that, I think that experiencing anxiety (in the ordinary sense) in relation to one’s perceived powerlessness is very common. Almost all of us encounter situations where our power to act is limited or even negated – whether through our work, social lives or familial relationships – and this often makes us very anxious. But I would not want to say that we are necessarily anxious about powerlessness: for a religious person powerlessness is to a good thing, something to seek with God, not something she would be anxious about. You could take another, very different example from Stoicism. I find the reflections in Greek and Roman Antiquity on powerlessness very interesting because the historical context at the time (e.g. much more modest technological developments, in particular in medicine) made powerlessness a much more prominent feature of daily life, something that was encountered almost routinely. And if you think of the Stoic response to these encounters, their view was that since much in our lives is outside of our control, we’ve got to distinguish what depends on us from what doesn’t depend on us. And then we’ve got to value only the former. What ultimately matters is the power of our judgment, and it is in our power to judge that external events (such as illness, the death of someone I love) do not affect me: my powerlessness to change the course of events does not matter. It’s another example where the recognition of powerless doesn’t necessarily generate anxiety (unless one wants to construe the Stoic strategy as a way to cope with anxiety by repressing it). 

DM: A great deal of the Christian theological tradition deals with situations of powerlessness, and this is something that you explore in your work with Aquinas’ philosophy of the theological virtues. Could you explain how these ideas complement the project?

In that tradition, the theological virtues are understood as virtues of powerlessness. There’s a contrast between the Greek cardinal virtues – of prudence, justice, temperance and courage– and the theological virtues of faith, hope and love. The cardinal virtues depend upon us, e.g. it’s up to you to be just or temperate. But the theological virtues do not, or least not solely: you can’t make yourself love someone or believe something. So the theological virtues are virtues of powerlessness because they need to be bestowed by God and to be infused by grace if we are to exercise them: the Christian awareness of this double dependency brings with it an acceptance that we are not in control when we love, hope or have faith.

When you talk to people at the end of life, there’s a clear divide between those who are religious and those who are not. In the first case people tend to express hope and faith (in the afterlife, for ex). For people who are not religious love tends to be dominant, in particular the thought that it is better to have loved and been loved than not have known love. Love for partners and children too. Either way it is striking that faith, hope or love tend to come to the fore as what matters most at the end, when one is powerless, regardless of whether one is religious or not. It suggests that there may be something about the theological virtues that may make them helpful beyond their original theological framework.

DM: The philosopher Havi Carel has written quite extensively on the topic of illness and one’s phenomenological relationship to the world, describing it as a disruptive event that closes the possibilities available to us and our view of the future. One of the stated aims of your project is influence policy in regards to the treatment of patients in these situations. What do you feel is lacking in current practice?

First I’d like to pick up on the point that Havi makes about the closure of possibilities, because in my view it is an important one, and perhaps the most radical expression of lived powerlessness: people in situations of extreme powerlessness feel that nothing of importance is possible for them anymore, and this can manifest itself unconsciously, through their use of grammar. Allow me to illustrate this from my own experience: in relating to people whom I loved and who were very close to the end, I found myself several times hesitating to use the future tense when speaking to them. This was not a conscious choice on my part. Once I noticed this, it dawned on me that I was picking up on a feature of my interlocutors’ own speech: they did not use the future tense anymore, or very little, and I was unconsciously and sympathetically mimicking them. What was expressing itself through this avoidance of the future tense was that they had become unable to project themselves into the future. And likewise, I was avoiding talking about plans or future events so as not to implicitly drive home to them that while I understood myself to have a temporally indeterminate and extended future, they did not. In such situations, there’s a strange dynamic towards aphasia that develops: the scope of what you can say dwindles, you stick to talking about the past or the present and in the end you say less and less. It made me keenly aware of how implicitly future-oriented our use of language is, and how terrible it is to be deprived of this futural orientation.

In my view that is one of the most profound, and profoundly upsetting, aspects of illness as a disruptive event as Havi describes it, an extreme form of powerlessness that manifests itself in this primitive and powerful way, namely the manner in which a person uses tenses when they speak. For the person who is not ill but relates to a very ill person, and feels powerless to help them (powerlessness in the second person rather than in the first person), there’s also a second order worry that attaches to the mimicking itself. It is that going along with future tense avoidance because you don’t want to cause pain to the other person may in the end be doing them a disservice. Perhaps what they need from you is precisely to use the future tense so as to restore a sense of open possibility. To this day I don’t know what the right thing to do is, and circumstances often do not help one decide.

To get back to your question about current practice in the NHS, when we originally thought about the project, it was not long after the crisis relating to the Liverpool Care Pathway for the Dying Patient, which was a set of guidelines for the care of people at the end of life. I won’t rehash the controversy here but suffice it to say that there were aspects of the guidelines that were deemed wrong, or badly applied: communication in particular was poor. After we started the project and got to speak with people working on the frontlines –doctors, nurses, physiotherapists, etc – the picture that emerged was that the fragmentation of the NHS services introduced in 2012 has made it very difficult for carers to gain a holistic picture of who provides what care, and to know where they can turn to for support. There are resources and communication problems within the NHS, and between the NHS and social services, in particular when it comes to such matters as patient discharge: a hospital may say that a patient is able to go home but if the patient can’t care for themselves and social services do not have the resources to provide support, the patient stays in hospital even though they don’t need to, and blocks a bed. And it’s nobody’s fault: it’s a consequence of limited resources in the system. But there’s certainly a perception amongst healthcare workers that this fragmentation has only complicated matters.

With respect to policy, we have had some input into the NICE guidelines on Improving Supportive and Palliative Care (Update). The draft guidelines were promoting the thought that the purpose of healthcare at the end of life should be to help the individual to live actively: the term ‘active’ or its cognates were repeated about 10 times in the document. In our view, however, there is no reason to assume that living actively is an appropriate goal for everyone at the end of life. The emphasis on activity can be misplaced: some people may prefer to spend time with their friends, family, to have time for themselves and reflect on their lives, etc. We suggested that NICE should replace ‘actively’ with ‘well’ so as not to assume (or impose) a premium on activity and they accepted the change, so we were really pleased by that. But I think that picks up on another aspect of the current system which is the constant emphasis on the notion of patient choice, or specifically the idea that more choice is always better. In some cases it may be true, but in other cases it is not, if only because patients can feel disempowered by the prospect of making these choices. Part of our aim in thinking of an ethics of powerlessness is to avoid assuming that activity and autonomy should always and unquestioningly be prioritized.

joshua sortino 431615 unsplash SUGGESTED READING The Harms of the Concept of PTSD By Patrick Bracken  Now, obviously we can’t tell healthcare professionals how to do their jobs because we don’t have the competence and that’s not our place, but there are two things we can do. One is to help with communication by clarifying some of the concepts in the NHS literature, and the other is to illuminate what it means to experience oneself as powerless. This way patients may understand their own experiences better, and carers may become more sensitive to what is experienced, and so respond accordingly. Articulating the lived aspect of an illness, and in particular the powerlessness that is experienced in such situations, helps re-humanise medical practice by allowing carers to see beyond the illness into the world of the person who is ill. During the early stages of our project, we wrote two technical reports: one on ‘Experiences of Powerlessness at the End of Life’, based on testimonies from patients and carers, and another on ‘The Phenomenology of Powerlessness’. We presented the results of the research in a number of forums and the responses that we had were very positive. One participant in particular told us that she could have never put her feelings into words but that we had ‘nailed it exactly’. So I think that’s one way we can help: by putting experiences of powerlessness under a magnifying glass and hold that up for people to see, on the assumption that the more you understand a phenomenon, the better equipped you are to deal with it.

DM: That brings us back to the issue of the dichotomy of control, as its presented to the patient through the choices presented to them. The first step in Alcoholics Anonymous is to admit one’s own powerlessness, which is something that many lay people and philosophers balk at. Do you think that attitude is unhelpful in these situations?

It’s difficult to speak in generalities, but one of the first things I noticed in thinking about powerlessness and control was the profound influence of the Enlightenment on our attitudes towards these issues. I refer here to the ideal of an autonomous person who can make their own decisions and act in accordance with their own principles. There is an implicit understanding in our current culture that if you are such a person, then you can live a good life. This understanding is expressed in such sayings as ‘where there is a will, there is a way’ and the like. And this extends into philosophy, because ethics often takes it for granted that the ethical subject is exactly this sort of person – a person in control who can make rational decisions and follow through with their actions. And of course, in situations of powerlessness, these are the exactly the things you can’t do – you can’t take control, you may not have choices, or these may be poor choices, and even if you do have choices and they are not all poor then you may not have the strength to follow through. Just think of the addict who decides they will stop, and before they know it, they’re on to their next hit.

So situations of powerlessness are situations in which we do not feel autonomous, and obsessing about or seeking to reinforce control is often the wrong thing to do in these situations. And this is at least for two reasons. One is that this may just set people up for failure because by emphasizing the need for control you may be asking them to exercise precisely the thing that they lack in situations of powerlessness. The second reason is that focusing on control can be a way for the addict themselves to deny the reality of the problem. If we take the case of the Twelve Steps, from the perspective of the programme hitting rock bottom means realising that you don’t have any choice: you’ve lived a large part of your life thinking you had control and could stop whenever you wanted but then suddenly realize that this is not true, and that the very idea you were in control was, in fact, damaging because it hid the extent of the problem. Similarly, when faced with circumstances which severely constrain what we can do, it is not always helpful to obsess about re-establishing control as this may prevent a person from acknowledging the reality of the new situation, and from moving forward. For example, when very self-reliant and dominant persons find themselves faced with circumstances of powerlessness, they often react by becoming even more controlling and bitter at the situation, because they can’t do the things they had previously enjoyed. And this prevents them from adapting to the new circumstances, and can make them difficult for others to relate to. By contrast, letting go of control, or accepting that they do not have control in the same way as before – which is an incredibly hard thing to do – may allow them to discover new possibilities, and so re-empower them. For example, they may become willing to accept help and consequently discover aspects of their personality that they didn’t know existed and indeed, new aspects about the people who come forth to help them. They may acquire a different sense of time, stop trying to plan for everything and learn to live in and enjoy the good sides of the present more. Letting go of the obsession for control can open up possibilities for something new, and also for self change. These are of course little vignettes, but hopefully they offer some vistas on the viability of alternatives to merely reinforcing control.

DM: For the outside observer, do you think that moralizing attitudes towards powerless individuals as you describe them are something we would best be rid of? The philosopher Harry Frankfurt might suggest that we would do better to view these individuals by the desires that they desire to have, rather than negative actions they may presently take.

In reply to that last point I would say that people can desire to have desires that are not all that good for them. Just think of the example of the happy addict: an individual who use drugs heavily and is happy doing so. They are powerless, but possibly unaware of it or not particularly bothered by it. It’s a case where even if one took the line you evoke and argued that we must focus on second order desires and how they relate to first order desires rather than on actions, there would not be much difference because the second order desires are in line with the first order desires, and with the actions.  

addiction SUGGESTED READING Are Addicts Truly Powerless? By Daniel Morgan  With respect to the issue of moralizing, one very interesting thing that came out when we first started talking to patients was that they were very upset at the idea of being described as powerless. They saw it as a stigma and a negative label, and would commonly react by saying, “No, I’m not powerless!”. So we quickly realized that these individuals were taking the idea of being powerless as a negative judgment about themselves, whereas no such evaluation was intended from our part at all. So we changed our approach and asked if they felt they were in a situation of powerlessness, rather than being powerless. To this new framing of the question, they universally agreed. And so we learned to take this into account. We found that speaking of situations of powerlessness rather than of powerlessness in general has three advantages: first, it is not perceived by the relevant persons as reflecting negatively on them. Second (and correlatively), it suggests that it is not their fault that they feel, or have cause to feel, powerless; it’s the way things are and they shouldn’t feel guilty about that. So talking about situations of powerlessness helps to alleviate some of the implicit guilt we feel when our powerlessness makes us ‘let down’ others or ourselves. Third, experiencing powerlessness in general is experiencing a relation to the possible in which most (or all, in cases of extreme powerlessness) options available to a person feel blocked, closed. Taking a more particularist approach, and talking about situations of powerlessness rather than about powerless helps to circumscribe the possibilities affected to a particular area or moment in a person’s life. People may acknowledge that they are in situations of powerlessness in specific respects while leaving open (and preserving) other possibilities in their lives.

Now, I would like to make it clear that that we do not want to speak for people in situations of powerlessness as if we were in their shoes, so to speak: this would be presumptuous and offensive. We have empirical studies to rely on, of course, but these work for statistics from large groups and do not capture individual experiences. What we want to do is to draw attention to what it feels like to be powerless, good or bad, so that powerlessness can be helped or valued depending on the circumstances. The feeling of powerlessness is very painful but properly understood and related to, it can also be an important factor of change and growth (as in successful cases of recovery from addiction).

Finally, it is certainly not the case that I think that control is bad per se or that letting go or acceptance are always good. There are plenty of cases where accepting or letting go are not the right thing to do (in situations where a person is ruthlessly exploited, for example). But in situations of powerlessness, where standard forms of control are not possible, I believe that in order to remain agents we need to rethink how to exercise our agency in a way that does not presuppose or require control. From this perspective, exploring what is involved for agents in accepting and letting go affords a good way forward.

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