A clinical catharsis: Moral distress and the uses of tragedy in palliative care

Introduction

Palliative care clinicians have witnessed much tragedy and moral distress during the COVID-19 pandemic. This much is obvious. But the very obviousness of such a statement suggests something less immediately clear: that there is a relationship between tragedy, moral distress, and palliative care. In this essay, I will make two main arguments. First, that Greek tragedy offers strong parallels to moral distress. Second, that tragedy offers two primary methods of responding to this distress: emotional catharsis and ethical reflection. Through these arguments, I hope to show that palliative care clinicians are not alone in their experiences of moral distress, and that there is comfort, understanding, and human connection available even in the tragic moments of medical practice.

Antigone as an example of Greek tragedy

Antigone, written by the ancient Greek tragedian Sophocles, takes place after Oedipus Rex, a play in which Oedipus, King of Thebes, fulfills a terrible prophecy precisely by trying to avoid it. Oedipus Rex ends with the protagonist blinding himself and leaving Thebes; and in the period between Oedipus Rex and Antigone, Creon, the brother of Oedipus’ wife, rules over the city while Oedipus’ sons come of age. The younger son, Eteocles, eventually claims the throne and exiles his older brother, Polyneices, who then gathers an army and attacks Thebes, eventually confronting Eteocles in battle, where the two die at one another's hands.

In the opening scene of Antigone, Antigone and Ismene, the daughters of Oedipus, discuss a new edict from Creon, who is once again King of Thebes. Creon has ordered a proper burial and funeral for Eteocles but has denied any burial for the traitor Polyneices. Instead, Creon orders that he be left “unburied, a corpse for birds and dogs to eat, a ghastly sight of shame” (Jebb, 2019).

Defying Creon, Antigone covers the body of Polyneices with dirt and sand, a makeshift burial for which she is arrested. Haemon, Creon's son and Antigone's husband-to-be, pleads for mercy on her behalf, but Creon orders that she be buried alive. The prophet Tiresias later informs Creon that the gods are displeased with his actions and, in a tragic reversal, Creon attempts to save Antigone, only to learn that she is already dead and that Haemon has taken his own life out of grief. Creon also learns that his wife, Eurydice, has taken her life as well, and the king is led away in sorrow and confusion: “I know not which way I should bend my gaze, or where I should seek support; for all is amiss with that which is in my hands” (Jebb, 2019).

In the following sections, I will depict tragedy as an ancient precursor to the modern concept of moral distress. The point of this essay is not to suggest direct analogies between the events or persons in Antigone and those in medical practice, but to offer tragedy as another tool for the training and support of modern palliative care clinicians.

Tragedy and moral distress

Moral distress arose in the nursing literature in 1984, defined by Andrew Jameton as “(a) the psychological distress of (b) being in a situation in which one is constrained from acting (c) on what one knows to be right” (Jameton, 2017). One concrete example of moral distress is that of a nurse who is constrained to provide painful interventions to a dying patient, even though curative efforts are almost certain to fail. These situations existed prior to the pandemic; but in our present moment, there seems a deeper need to understand, and manage, the psychological and spiritual pain lambent in them.

Palliative care clinicians are familiar with moral distress — especially of late, having had to find ways of acting on what they, their colleagues, and their patients believe to be right amid the constraining realities of the COVID-19 pandemic (Evans et al., 2020; Wiener et al., 2021). Antigone may be instructive as they continue in this crucial task.

In the play, both Creon and Antigone pursue their convictions, but those convictions are undermined in myriad ways. Antigone places family duty above legal abstractions but in so doing acts against Creon, her uncle, and her actions contribute to the eventual destruction of her family. Creon, on the other hand, fixated on the “abstract integrity of the civilized order,” ultimately “disregards the equal importance of the family's integrity for the survival of the state,” and one can hardly imagine that Thebes is better off for his civic obsessions (van den Berge, 2017). Yet the ancient Greek notion of Fate hangs over all of this, and we are led to wonder whether the characters have any choice over their actions, as the chorus sings that “mortals have no escape from destined woe” (Jebb, 2019). Thus, we see that both tragedy and moral distress involve suffering, constraint, and the problem of acting simultaneously for and against one's ethical convictions.

The two categories are also related emotionally. Like tragedy, moral distress is “associated with guilt, frustration, helplessness, and anger” (Kherbache et al., 2021). A clinician struggling with moral distress may feel as though they have indeed undergone a tragic experience, as though structures beyond them have precipitated an unjust fate. Both the clinician and the tragic hero are filled with emotional and psychological turmoil, and the question for both is this: What does a good life mean when suffering is inevitable?

Catharsis, ambiguity, and the uses of tragedy

Greek tragedy was meant, among other things, to enact an emotional “catharsis” in the audience, purging spectators of their private and public agonies (Sewall and Conversi, 2021). Aristotle viewed this catharsis in medical terms, and tragedy can therefore be seen as a treatment for moral distress (DuBois, 2002). In the early months of the pandemic, for instance, Theater of War for Frontline Medical Providers staged virtual performances of Sophoclean tragedies, forging “a common vocabulary for … understanding, compassion, and a renewed sense of community” among medical professionals (Rushton et al., 2020). These productions were predicated, in part, on the idea that clinicians may “find comfort in discovering that they are not alone in their moral discomfort” (Rushton et al., 2020). In the future, such performances could provide further opportunities to strengthen resilience and build community amid moral distress. One could imagine, for instance, a Sophoclean performance being held (in person or virtually) during a palliative care grand rounds session.

Yet tragedy can also serve to develop more nuanced modes of ethical thinking, not least in medical ethics. As one scholar writes, there is wisdom in the tragic idea that no “amount of circumspect, utilitarian reasoning can guarantee” the fruition of our desired ends — that there is an “unpredictability and inherent ambiguity” in life (Sansom, 2010). Creon and Antigone both desire their conception of the good, and both are constrained by tragic circumstances to somehow act against that conception. We can neither wholly praise nor wholly reproach either character. But having seen their fate, we may resist a rigid adherence to any single way of ethical thinking in palliative care, whether consequentialist or deontological.

The clinician-ethicist Robert Truog offers one example of this. As an intensive care specialist, Truog cared several times for a 2-year-old boy with severe neurological problems whose medical providers “recommended redirecting his care toward comfort and palliation” (Truog, 2010). The parents, however, “continued to insist that everything be done,” and one evening, during an admission to the ICU, a “code blue” was called for the boy. Understanding the parents’ desires, Truog instructed his team to provide resuscitation. The boy died. “None of us felt good about what had just happened,” Truog writes, but when the parents arrived, the father turned to Truog and said, “I want to thank you. I can see from this that you really tried; you didn't just give up and let him die.”

There are arguments against Truog's decision. His direction of ICU staff for a “futile and brutal” effort limited their availability for other patients. He may indeed have placed those staff members in moral distress. But Truog feels that “we did the right thing for this patient and family on that evening.” His awareness of the constraints around him, and his sense of compassion, led him to make a difficult but caring decision. We may never know if it was the “right” decision, but that is a fact of ethical ambiguity. Though some clinicians may have chosen a different course, Truog provides an example of the honesty, openness, and humility of the Greek tragedians.

Conclusion

Amid the uncertainty and moral injury of the COVID-19 pandemic, we should remember that moral distress has long been part of the human condition. Our task is to recognize the emotional, ethical, and structural factors at play among our moral conflicts, and to seek hope within our human limits: hope for comfort, for understanding, for catharsis. Palliative care may promote this hope by using tragedy as an art form, a mode of ethical training, and a method to connect after much disconnection.