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Home , Hamartia, Pity

Medicine, Health Care and Philosophy (2006) 9:141–153 Springer 2006 DOI 10.1007/s11019-005-8319-1

Scientific Contribution

Catharsis and therapy II: An Aristotelian account

Jan Helge Solbakk Section for Medical Ethics, Faculty of Medicine, University of Oslo, 1130, Blindern, NO-0318, Oslo, Norway (Phone: +47- 22844641; Fax: +47-22850590; E-mail: [email protected])

Abstract. This article aims at analysing ’s poetic conception of to assess whether it may be of help in enlightening the particular didactic challenges involved when training medical students to cope morally with complex or tragic situations of medical decision-making. A further aim of this investigation is to show that Aristotle’s criteria for distinguishing between history and may be employed to reshape authentic stories of sickness into tragic stories of sickness. Furthermore, the didactic potentials of tragic stories of sickness will be tried out. The ultimate aim is to investigate whether the possibilities of developing a therapeutic conception of medical ethics researched in a previous article on catharsis and moral therapy in may be strengthened through the hermeneutics of the Aristotelian conception of tragic catharsis.

Key words: Catharsis, , error, fallibility, , , hamartia, therapy, tragedy

Introduction in their teaching, i.e. on conceptual clarifications and purifications, on methodological case study The present article aims at investigating Aristotle’s analyses and on rational strategies and theories for controversial treatment of the notion of tragic resolving moral dilemmas, while neglecting the catharsis in the . There are three reasons for cathartic role that , fear and other painful limiting the scope to the Poetics. For a first, there emotions, such as e.g. and are reasons to believe that Aristotle’s conception of may in the process of moral discourse and poetic catharsis represents ‘‘some sort of response learning. In this way I also to show that the to Plato’’ (Nussbaum, 1992, p. 281). Second, in his possibilities of developing a therapeutic conception definition of tragedy in the Poetics, Aristotle makes of medical ethics demonstrated in a previous article a controversial connection between catharsis and on Plato’s conception of cathartic treatment and the emotions of pity (eleos) and fear (phobos).1 moral regimen may be strengthened through the Third, there are reasons to believe that an inves- hermeneutics of the Aristotelian conception of tigation of the emotional potential of Aristotle’s tragic catharsis. poetic conception of catharsis may lead to a more accurate diagnostics of the particular didactic challenges involved when training medical students Aristotle’s poetic account of cathartic treatment to cope morally with complex or tragic situations of medical decision-making; these are situations One argument that will be substantiated in this where one is forced to make decisions with paragraph is that Nussbaum is right in her claim potentially disastrous consequences for one or that Aristotle’s conception of poetic catharsis several of the parties involved, while at the same represents a response to Plato, notably to the time one is faced with the fact that the possibility of purist view of catharsis advocated in the Phaedo abstaining from making a choice or of making a and the Republic. On the other hand, by limiting choice not contaminated with some sort of error or her scope to the two most idealistic dialogues of guilt (hamartia) is non-existent.2 Plato, i.e. the Phaedo and the Republic, she fails to My claim is that lecturers in medical ethics acknowledge that the conception of cathartic mainly focus their attention on instrumental issues treatment suggested in the Charmides and the 142 JAN HELGE SOLBAKK

Sophist is fully compatible with Aristotle’s concep-  moral interpretations, including interpretations of tion of tragic catharsis introduced in the Poetics. catharsis as an education of the emotions, According to J. Hardy (Hardy, 1932, p. 16)  catharsis conceived of as the experience of emo- there is no passage in Greek more tional relief, famous than the ten words of the Poetics where  aesthetic interpretations or interpretations of a the notion of catharsis is dramatically depicted as dramatic or structural nature, and finally interrelated with the painful emotions of pity  complex or ‘holistic’ interpretations of catharsis. (eleos) and fear or terror (phobos). The passage In my analysis I nourish no ambition of being which throughout the centuries has given rise to able to settle the old controversy and determine such ‘‘a deluge of works’’ (German: ‘‘Flut von which of the interpretations of catharsis mentioned Schriften’’, Gudemann, 1934, p. 167), reads as best complies with Aristotle’s definition of tragedy. follows:3 My aim is of a rather different and more modest Tragedy is a representation of a serious, complete nature: to investigate the didactic potential of each which has magnitude, in embellished interpretation in illuminating the process of med- speech, with each of its elements [used] separately ico-moral discourse and learning. In other words, in the [various] parts [of the play]; [represented] by what I hope to achieve is to demonstrate how the people acting and not by ; accomplishing different interpretations of the notion of tragic by means of pity and terror the catharsis of such catharsis may be used to uncover and substantiate emotions. By ‘embellished speech’, I mean that the variety of forms of clarification and cleansing which has rhythm and melody, i.e. song; by ‘with involved in the process of medico-moral discourse its elements separately’, I mean that some [parts and learning. In doing this, I also hope to make of] are accomplished only by means of spoken clear why tragic stories of sickness should be verses, and others again by means of song. considered as the most prominent teachers and sources of medical ethical wisdom. In the secondary literature no substantial consen- sus has been reached as regards the exact meaning Medical interpretations of ‘tragic catharsis’ Aristotle attributes to ‘catharsis’ in his definition. On the contrary, a whole range of seemingly One of the most medically minded interpretations of disparate interpretations have been suggested, tragic catharsis, still vividly debated in the literature which I shall turn to in a short while. The notion was launched by J. Bernays, an uncle by marriage of as such, however, belongs, as mentioned in the Sigmund Freud. In an influential essay published in previous article, to a family of words (catharos, 1857 Bernays advances the argument that attending catharsis, catharmos) that were in use in many a tragic play may have a direct therapeutic effect on different contexts (Nussbaum, 1992, p. 280–281): the spectator, in the sense that it may clear and ‘‘everyday practical, educational, medical, reli- alleviate him from build-ups of undesirable emotions gious, literary’’. According to Nussbaum, there of pity and terror. Bernays draws support for his are no indications to suggest that ‘catharsis’ ever ‘‘pathological standpoint’’ (German: ‘patologischer became separated from its original family and Gesichtspunkt) from Politics VIII 7.1342a4-16 took on a different meaning. On the contrary, the (Bernays, 1857/1979, p. 158).4 In this passage, which ordinary meaning – i.e. ‘cleaning’ or ‘clearing up’ is quoted in the preceding note, Aristotle explains the – seems to have prevailed throughout. The meaning and role of catharsis in relation to pity and disagreement about ‘catharsis’ in Aristotle’s def- terror by making a comparison with the psycholog- inition of tragedy does not therefore relate to the ical healing process which people affected by hyster- formal meaning of the word, but to what kind of ical outbreaks of (enthousiasmos)undergo ‘cleaning’ or ‘clearing up’ Aristotle actually had in when cathartic songs are used as therapeutic devices. mind. Bernays takes this comparison to mean that Aristotle In the secondary literature it is possible to conceived of tragic catharsis as a therapeutic device distinguish between at least six different groups of in the treatment of pathological emotions: interpretations:  medical interpretations and interpretations of Catharsis then becomes a special type of iatreia catharsis as a natural process of discharge/release (which is why that term [meaning ‘healing’] is or outlet of emotions, used before it): turns to calm through  catharsis conceived of as emotional and intellec- orgiastic songs as sickness turns to health tual clarification, through medical treatment – not through any CATHARSIS AND MORAL THERAPY II 143

treatment, but through one that employs cathar- without turning tragic catharsis into a therapeutic tic means to fight off illness. Thus the puzzling device reserved for emotionally unbalanced people, piece of emotional pathology is explained: we can has been suggested by H. Flashar (Flashar, 1956, pp. make sense of it if we compare it with a patho- 12–48). His alternative is to unravel the medical logical bodily reaction ... basis of Aristotle’s understanding of pity and terror ... operative in both clauses. Flashar finds that in prevalent pre-Aristotelian views of the effect of ...catharsis is a term transferred from the physical (in particular those of and Plato), to the emotional sphere, and used of the sort of pity and terror are always associated with a set of treatment of an oppressed person which seeks not somatic symptoms: Terror (phobos), with cold shiv- to alter or to subjugate the oppressive element erings, tremblings, quiverings of the heart and but to arouse it and draw it out, and thus to raising of the hair; pity (eˆleos), with weeping and achieve some sort of relief for the oppressed tears in the eyes. Furthermore, he finds that the way (Bernays, 1857/1979, p. 159–160). these emotions and their related symptoms are The main problem with Bernays’ psychopatholog- represented in these descriptions evokes the causal ical interpretation is that it makes of the ancient account and explanations present in several treatises Greek theatre a medical theatre, i.e. a forum to of the Hippocratic corpus, where terror and its which emotionally unbalanced spectators can turn related symptoms are viewed as a consequence of an in order to have their build-ups of undesirable excessive abundance of chill, while pity and its emotions of pity and terror aroused and thereby somatic manifestations of weeping and tears are cleared away. Consequently, tragic catharsis explained as effects of an excessive abundance of emerges as something reserved for emotional humidity. Finally, Flashar turns to the writings of lunatics rather than for spectators with a healthy Aristotle and demonstrates convincingly that Aris- psycheˆ. As observed by Lear: totle in his description of pity and terror, and altogether in his theory of emotions, relies on the ... the only reason for thinking that catharsis is a same medical categories and causal accounts and cure for a pathological condition is that Aris- explanations as his predecessors. totle’s primary example of catharsis is a cure for The implications of this alternative approach is religious ecstasy. However, even if we accept that not an understanding of catharsis wholly different religious ecstasy is a pathological condition, the from that advocated by Bernays: What Flashar’s idea that catharsis is meant to apply to a patho- approach reveals to us is the abundance of medical logical condition can only be sustained by ignor- conceptions and forms of explanation in the core ing an important claim which Aristotle makes in of Aristotle’s general theory of emotions. Conse- the quoted text. Having begun his discussion of quently, tragic catharsis continues to mean ‘clear- catharsis with the example of those who are par- ing away’, though not any longer in the sense of ticularly susceptible to religious frenzy, Aristotle ‘‘emotional pathology’’ advocated by Bernays goes on to say that the same thing holds for any- (Bernays, 1857/1979, p. 159), but in the psycho- one who is influenced by pity and fear and, more somatic sense informed by Aristotle’s general generally, anyone who is emotionally influenced theory of emotions, i.e. of a normal process of by events. In case there should be any that discharge of the emotions. As observed by Lear, Aristotle means to include us all under that cate- support for such an interpretation may also be gory, he continues: ‘and a certain catharsis and drawn from the fact that Aristotle’s most frequent lightening with occurs for everyone’ use of ‘catharsis’ is in relation to forms of discharge (Lear 1992, p. 316–317). characteristic of normally functioning bodies, i.e. Moreover, this psycho-pathological interpretation of menstrual discharge, of seminal discharge as is also clearly at odds with the statement made well as of discharge of urine (Lear, 1992, p. 315).6 shortly after in the Politics according to which the theatre is a forum for everyone, the free and Tragic catharsis as emotional and intellectual educated as well as the artisans, labourers, and the clarification like (Politics VIII 7.1341a17-21).5 An alternative approach to the catharsis clause in One of the first scholars to suggest that tragic Politics VIII 7.1342a4-16 and consequently to Aris- catharsis means emotional and intellectual ‘clarifi- totle’s definition of tragedy in Poetics 1349b25-30, cation’ was L.A. Post. His translation of the which appears to do justice to the medical allusions catharsis clause reads as follows: 144 JAN HELGE SOLBAKK

‘‘Tragedy produces its clarifying effect by ... tragedy teaches the by example – or bringing to bear on the mind imaginary scenes of counter-example – to curb its own emotions and and terror, thus freeing it from preoccupation the faults which they may cause: We learn with similar emotions of its own’’ (Post, 1951, through catharsis to avoid passions which can p. 267). L. Golden, the most outspoken represen- lead to suffering and tragedy (Halliwell, 1986/ tative of a cognitive interpretation of tragic cathar- 2000, p. 350–351) sis, argues that this is the reading that best A more elaborate and refined version commented complies with the general line of argument in the on by Bernays originates from G.E. Lessing. In his Poetics: Hamburgische Dramaturgie Lessing states that by ... from Chapter 1 of the Poetics (47a13-16) we tragic catharsis Aristotle simply meant the ‘‘meta- know that poetry is a form of mimesis [i.e. imita- morphosis’’ of strong emotions into : tion]; from Chapter 4 (48b4-19) we observe ... Since, to be brief, this purification consists in that the essential pleasure and goal of mimesis is a nothing other than the metamorphosis of the pas- learning experience; in Chapter 9 (51b5-10) this sions into , and since according to our phi- point is confirmed and clarified when we are told losopher every virtue stands between two that poetry is more philosophical and significant extremes, it follows that tragedy, if it is to change than history because it aims at the expression of our pity into virtue, must be capable of purifying universals rather than particulars...in Chapter 14 us of both extremes of pity; and the same is true (53b10-14) we are told that the specific pleasure of of fear (Lessing, (1767–8/1978, p. 380).8 tragedy is derived ‘from pity and fear through mimesis’ and so we conclude that the goal of Bernays’ blunt comment on this interpretation is tragedy must be an intellectually pleasant learning that it turns tragedy into a ‘‘moral house of experience concerned with the phenomenon of correction which must have ready a remedy for pity and fear in human existence; since catharsis every illegitimate display of pity and fear’’ (Bernays and its related forms are used by Plato, , (1857/1979, p. 155). Halliwell, on his part, finds that Philodemus, and other writers in the sense of Lessing’s interpretation is ‘‘close to the truth’’, based intellectual clarification, there is full justification as it is on a recognition of the role of emotions in for rendering this term in Chapter 6 (49b28) Aristotle’s moral theory (Halliwell, 1986/2000, p. 313). with the intellectual signification that makes it an For any reader of the Nicomachean Ethics it is integral part of the general argument of the evident that its author attributed the emotions with Poetics’ (Golden, 1973a, p. 45).7 a particularly important role in moral education and building of good . In Nicomachean One observation made in relation to Golden’s Ethics III.7, for example, Aristotle argues that man interpretation which I believe is worth taking into may learn to take correct decisions and become consideration, whatever one thinks of catharsis as good by developing the ability or disposition to face intellectual clarification, is what Keesey calls the situations with the appropriate emotional response, ‘‘shiftiness’’ and ‘‘fruitful ambiguity’’ of the word: which according to Aristotle always represents the ‘‘It won’t stay put’’; in the sense that it seems to be reaction situated in the middle between two operative on several levels and in relation to extremes. A man who learns this may thus use his different instances (Keesey 1979, p. 201-202). In emotional responses to situations that occur as the last paragraph of this section I shall come back guidance in arriving at the good and right decisions. to this observation. Thereby, he brings himself ‘‘nearer to the mean, where virtue lies’’, and by so doing, he becomes Educative and moral interpretations of ‘tragic ‘‘virtuous in character’’ (Janko, 1987, p. xviii). catharsis’ A common view among representatives of a moral interpretation of tragic catharsis is that Since the age of neo-classicism educative and moral Aristotle considered tragedy to be particularly well interpretations of catharsis have played a central suited for educating the emotions and for building role in the debate on Aristotle’s definition of character; for it offers a way we can learn to know tragedy. A very influential, but somewhat crude and develop the appropriate emotional responses variant of this view, neatly paraphrased by Halli- without having to undergo ourselves in reality the well, insists on a direct link between tragic catharsis dramatic situations represented in a play. How and ethical teaching: should one then conceive of the function and role CATHARSIS AND MORAL THERAPY II 145 of tragic catharsis in its character-building process? any further substantiation of its content. In fact, he One explanation of how tragic catharsis works, restricts himself to briefly mentioning certain reads as follows (Janko, 1987, p. xx): ‘‘consolations’’ inherently operative in Aristotle’s conception of tragedy, such as the rationality of the By representing pitiable, terrifying and other world of tragic events, the plausibility of its events painful events, tragedy arouses pity, terror and and the presence of a certain form of error or other painful emotions in the audience, for each mistake (hamartia) that makes the fall or misfor- according to his own emotional capacity, and so tune of the intelligible (Lear, 1992, p. stimulates these emotions as to relieve them by 334–335). In the last part of this section I shall giving them moderate and harmless exercise, return to the notion of hamartia and its possible thereby bringing the audience nearer to the mean role in enlightening the enigma of tragic catharsis. in their emotional responses, and so nearer to vir- tue in their characters; and with this relief comes Aesthetic, dramatic and structural interpretations of pleasure. tragic catharsis This interpretation represents one prominent ver- The present group of interpretations differs from sion of the view that tragic catharsis provides the previous ones in that the notion of tragic moral training through an education of the emo- catharsis does not primarily relate to the audi- tions. As observed by Lear, the strength of this and ence of a play, but to the poetic work itself. In cognate interpretations advanced (House, 1956; other words, tragic catharsis represents a kind of Nussbaum, 1986 and Halliwell, 1986/2000), is due, aesthetic ordering of the pitiable and terrible partly, to their neat compatibility with Aristotle’s material in the play so that it complies with the theory of emotions, and partly to their ability to end or form of the play (Goldstein, 1966, p. 574). account for the ‘‘peculiar pleasure we derive from a Consequently, the kind of pleasure generated performance of tragedy’’ (Lear, 1992, p. 318–319). from the play is aesthetic pleasure (Keesey, 1979, p. 200). The most prominent representative of this line of interpretation, labelled by Halliwell Tragic catharsis as emotional relief ‘dramatic’ or ‘structural’ instead of ‘aesthetic’ (Halliwell, 1986/2000, p. 356), is G.F. Else. He Yet, in of the ‘‘overwhelming advantages’’ of conceives of catharsis as a kind of purification of the above mentioned interpretations, Lear finds the tragic , ‘‘by the demonstration that its that no version of the ‘‘education-interpretation’’ motive was not miaron [i.e. morally repellent]’’ stands the test. He also rejects Bernays’ medical (Else 1957, p. 439). And this sort of catharsis, interpretation and other cognate interpretations. Else continues, is accomplished ‘‘by the whole Lear’s own suggestion as to how tragic catharsis structure of the , but above all by the should be interpreted is that Aristotle had in mind recognition’’ (p. 439). In this way, it becomes the special kind of relief a spectator of a play clear that it is recognition (anagnoˆreˆsis)asa experiences when releasing tragic emotions in a structural device ‘‘which makes it possible for the safe environment, i.e. of being given the possibility hero to prove that he did indeed act di’ hamar- of emotionally experiencing how it is to live tian tina (through some error) and so deserves through the worst of life situations with intact our pity’’ (Keesey, 1979, p. 200). As observed by dignity: Halliwell (1986/2000, p. 356) this shows that even It is this experience of the tragic emotions in an in Else’s theory affective implications cannot be appropriately inappropriate environment which, I avoided. think, helps to explain our experience of relief in the theater. We imaginatively live life to the full, Complex or ‘holistic’ interpretations of catharsis but we risk nothing. The relief is thus not that of ‘releasing pent-up emotions’ per se, it is the relief Although Keesey draws attention to the ‘‘fruitful of ‘realising’ these emotions in a safe environment ambuigity’’ and ‘‘shiftiness’’ of the word catharsis (Lear, 1992, p. 334). in Aristotle’s definition of tragedy (Keesey 1979, Lear admits, however, that to put the label of p. 201–202), Laı´ n Entralgo is the only scholar, to ‘catharsis’ on the kind of relief here experienced my notice, who has advocated a complex or does not represent a content-full characterisation holistic interpretation of tragic catharsis. He oper- of it, and he remains fairly vague when it comes to ates with a four-layered structure of tragic 146 JAN HELGE SOLBAKK catharsis and attempts accordingly to distinguish and promoted passions; insofar as they were between four different stages of the state of mind of expressive of a terrible, threatening, and surpris- the tragic spectator. For a first, a religious-moral ing fate, the well-composed of those words layer and state of mind: ‘‘The interpretation of made the emotional tension extremely great; inso- Aristotelian catharsis must have as its point of far as they determined an enlightening knowl- departure a fundamental fact: the essentially reli- edge, they swept out of the soul and gious character of from Thespis to induced catharsis. Not only in philosophy; in the creations of the last tragic writers’’ (Laı´ n tragedy as well the logos is superior to eˆ thos and Entralgo 1970, p. 204). Consequently, the tragic (Laı´ n Entralgo, 1970, p. 234). situation around which a play is dramatically Laı´ n Entralgo labels the fourth and final distinc- organized makes that the spectator is faced with tion necessary to make in the state of mind of the a conflict which is not only wrapped in religious tragic spectator the ‘‘somatic or medicinal point of drapery evoking religious emotions and memories tragic catharsis’’. A play does not only make its in the spectator; it also originates from a conflict impression on a spectator’s mind and soul; it which is basically religious: the conflict between affects his hair and humors as well, in the sense that faithfulness and obedience to the gods and the ‘‘the agent of tragic catharsis’’ – i.e. the word – hero’s search for and will to self-determination. returns ‘‘the crasis [admixture or composition] of ‘‘And thus’’, Laı´ n Entralgo argues, ‘‘not only in the the spectator to a more balanced and natural, tragic emotion of the spectator, in his fear and in hence more healthy and pleasurable, humoral and his pity, is there an essential religious and moral thermal state than the one immediately preceding moment, it is also present in the catharsis of those the cathartic process’’ (Laı´ n Entralgo, 1970, passions and in the pleasure that necessarily p. 235). Thus, it becomes obvious that the sort of accompanies the latter. The fatal or fortunate cleaning or clearing up that tragic catharsis outcome of tragedy reorders existence with respect imparts, brings order and enlightenment, and to what is most central and decisive in its structure, thereby pleasure, to the whole of one’s nature namely its relation to divinity’’ (Laı´ n Entralgo, (Ibid., p. 236). And this well-ordered and enlight- 1970, p. 231–232). ened state of mind produced by tragic catharsis, To the state of mind of the tragic spectator Lain Entralgo inquiringly remarks, is it not exactly belongs for a second the dianoetic or logical stage, what tried to engender in the soul of the i.e. the stage that gives voice to the spectator’s young Charmides by his moral regimen, ‘‘and to knowledge of what is taking place in the play and which Plato wished to give the already illustrious at the same time in himself: ‘‘Through the ana- name of soˆphrosyneˆ (Ibid., p. 237)? gnoˆreˆsis [recognition] the spectator learns to express in an orderly and satisfactory way what is Tragic catharsis: shiftiness within a fallible context happening on the stage and what is happening in his soul; he passes therefore from inarticulate Before I wind up the analytical part of this section, confusion to articulate knowledge’’ (Lain Entralgo it is necessary to pay a return visit to a couple of 1970, p. 233). observations made during the analysis: the obser- The third stage in the state of mind of the tragic vation about the shiftiness and fruitful ambiguity spectator, and notably the one attributed with of ‘tragic catharsis’ and the observation about the most prominence in Aristotle’s conception of role of hamartia in the shaping of tragic conflicts tragedy, is the pathetic or affective stage: and situations. My suggestion is to take a closer Tragic catharsis was no doubt the ‘purging’ or look at the idea underlying the notion of hamartia elimination of emotions that did not exist in the present in Poetics 53a13-179 and see whether it may soul before the viewing of tragedy, and it oc- help to make sense of the shiftiness and ambuiguity curred when the emotional tension reached its of ‘tragic catharsis’ and of the heterogeneity of peak. But the impulse unshackling the cathartic existing interpretations. The clause in the Poetics process did not come to the spectator ‘from be- involving the notion of hamartia insists that in the low’ – from his viscera and his humors I mean to ‘finest’ tragedy (the example here mentioned is say, even though the tragic state of mind might ’ play Oedipus Tyrannus), the fall of the both – but from ‘above’, from the dianoetic tragic agent into misfortune is not caused by enlightenment elicited by the logos of the poem. wickedness, but is due to a great hamartia on the The words of the tragic poem, insofar as they part of the agent himself. Since Aristotle wrote concerned the beliefs of the spectator, stirred up these lines the meaning of hamartia in relation to CATHARSIS AND MORAL THERAPY II 147

Greek tragedy10 has been subject of a controversy engages the whole of the soul – its rational parts as comparable in intensity and size perhaps only to well as its appetites, beliefs, emotions and . that of the catharsis clause in Poetics 49b23-31. In The uncovering of the broadness and variability of a recent article I have given a detailed account of meaning and applicability of the conception of this controversy and tried to show how the broad tragic catharsis makes it now possible to formulate variety of interpretations of the hamartia clause, a more differentiated and subtle answer to the ranging from purely epistemological forms of question what medical students actually experience fallibility such as ‘mistake of fact’, ‘ignorance of and learn when they attend classes of medical fact’, ‘error of judgement’, ‘error due to inadequate ethics. For a first, it paves the way for a psycho- knowledge of particular circumstances’ to full- somatic conception of moral enlightenment and fledged forms of moral failure such as ‘moral learning; as tragic plays affect the spectator’s mind error’, ‘moral defect’, ‘moral flaw’, ‘moral weak- and soul as well as his bodily hair and humors, so ness’, ‘defect of character’ and ‘tragic guilt’, mir- have tragic situations of medical decision-making rors the variety of tragic plots and plays Aristotle the potential to implicate students in their psycho- had at his disposal (Solbakk, 2004, pp. 105–112).11 somatic entirety in the learning situation. As This, I believe, indicates that Aristotle himself observed by Flashar, characteristic of the Aristote- imbued hamartia with a very broad meaning and lian account of tragic emotions is that they are applicability, so as to make his conception of always displayed as accompanied by a set of tragedy capable of covering the variety of individ- somatic symptoms: pity with weeping and tears in ual plots and plays he had at his disposal. Support the eyes, fear or terror with cold shiverings, for such a view may be adduced from the phrase in tremblings, quiverings of the heart and raising of Poetics 13 just preceding the hamartia clause the hair. In the introduction to this paper I made (53a10), where it is explicitly stated that what the claim that lecturers in medical ethics mainly Aristotle has in mind is not one specific kind of focus their attention on instrumental issues in their hamartia but ‘‘some sort of hamartia’’ (hamartian teaching, i.e. on conceptual clarifications and puri- tina).12 These observations about the broad mean- fications, on methodological case study analyses ing and varying applicability of hamartia I believe and on rational strategies and theories for resolving can now be used to make sense of the ambiguity moral dilemmas, while neglecting the cathartic role and shiftiness of ‘tragic catharsis’ and of the that pity and fear and other painful emotions, such heterogeneity of its interpretations. The inference as e.g. anger and embarrassment, may play in the I propose to draw is the following: If it is true that process of moral enlightenment and learning. Aristotle attempts to make his conception of In saying this, I do not deny the instrumental tragedy comply with the variety of tragic plots importance of such forms of analysis and clarifi- and plays he had at his disposal, a view which the cation; I believe, however, that students of medical analysis of the hamartia clause strongly suggests, ethics would be even better off if teachers of then it seems to follow that the catharsis clause medical ethics began to pay more serious and must be imbued with a corresponding broadness systematic attention to the cathartic role of pity and variability of meaning and applicability. In and fear in this learning process. The Aristotelian other words, as the meaning of hamartia may differ notion of tragic catharsis proves here to be greatly from play to play, the kind of tragic particularly helpful, because it provides us with a catharsis evoked by different plays has to differ way of dealing didactically with these emotions accordingly. and their relation to the most sensitive and perhaps fragile parts of our moral make ups and capabil- ities. That is, by exposing medical students to The didactic potentials of tragic catharsis tragic stories of sickness – to narrated or repre- sented medical situations of pity and fear – they It is now due time to see whether the didactic will learn to experience, in a safe environment, how implications of Plato’s conception of cathartic it is to live through situations of medical decision- treatment and holistic cure researched in the making that are under a double constraint: the previous article may be broadened through the necessity to decide, amidst the absence of the hermeneutics of the Aristotelian notion of tragic possibility of making a decision not contaminated catharsis. The didactic implications drawn from with some sort of error or guilt (hamartia). Plato’s cathartic regimen was that the process of Thereby, they will also learn to acknowledge that moral learning is not confined to a cleaning or such is the nature of tragic choice; when the clearing up of the rational parts of the soul; it decision is taken, moral ambiguity and twilight will 148 JAN HELGE SOLBAKK still remain (Østerud, 1976, pp. 75–76). Finally, by story of sickness reported on June 16th, 2004 in the giving themselves over to the treatment of tragic Guardian (UK): catharsis and enlightenment students will also become aware of the limits of their moral compe- Ciaran was born at just 25 weeks. From the mo- tence and capability, as well as of that of their ment of his birth, his parents, Chris Kane and teachers. Hopefully, modesty and ethical wisdom Charlotte Lamb, spent almost all their time at the may also grow from this. hospital. They stood vigil at their tiny son’s cot, trying to grow their baby, who couldn’t metabolise milk, with instead. Three months later, Chris The making and -gogics of tragic stories of and Charlotte were being asked to make the sickness hardest decision of their lives. Ciaran’s consultants were talking about withdrawing intensive care The uncovering of the broadness and variability of treatment and taking him off the ventilator. the Aristotelian notions of hamartia and tragic Twice before, his condition had been critical, and catharsis makes it now possible to give a more twice before he had pulled through. His parents systematic and differentiated account of what sort hoped he could do it again. But what if he of of medical decision-making could couldn’t? Chris paced the empty hospital corridors qualify as ‘tragic stories of sickness’. This, I in the early hours of the morning. Charlotte stared propose to do, by exploiting Aristotle’s differenti- at the walls of their tiny parents’ room. Both of ation in Poetics 51a37-b33 of tragedy from history. them willed Ciaran to defy the doctors, and start to The first of their distinguishing traits is that history improve ... narrates things that have happened, while tragedy ... relates to events or incidents that may happen. This With Ciaran’s condition slowly worsening, Dr. is the reason why poetry, in particular tragic Wilf Kelsal, the consultant in charge of Addenb- poetry, is more philosophical than history; it speaks rookes neonatal unit that week, called a meeting of universals, while history is an account of with the family to explain how ill Ciaran was. ‘You particulars. ‘‘A universal’’, says Aristotle, ‘‘is the reach a point where you’ve tried everything, every sort of thing that a certain kind of person may well drug, every procedure, and the baby is not making say or do in accordance with probability or progress’, he says, ‘and instead is effectively deteri- necessity – this is what poetry aims at, although orating. This is very hard for parents to hear. And it assigns names [to people]. A particular is what it’s a huge turnaround for us to change a course of did or what he suffered’’ (Poetics 51b8- treatment when we have fought for weeks and 12). The remark about the use of historical names weeks to keep a baby alive’... in , and thereby about the representation ... of events that have actually taken place, is impor- Dr. Kelsall is everything you might hope for in a tant, because it informs us that not everything in a neonatologist. Intensely humane, he is also lively tragedy is made up. More important, however, is and occasionally self-mocking. After nearly the explanation Aristotle gives for the poet’s use of 20 years in paediatrics, he is the first to admit historical material. For tragic accounts to be that the technical abilities of his profession can trustworthy, they must be possible, and things produce uncomfortable dilemmas. ‘We can per- which have happened, says Aristotle, are obviously form heroic medical interventions, and sustain life possible. Consequently, by using events, names or in the smallest and sickest babies, but by far the things that have actually existed or taken place, as hardest part of our work is knowing when to templates for giving shape to a tragic , the poet stop intervening, when to help parents accept that is free to ‘‘invent for himself’’ a whole that may further treatment is futile. Sometimes it’s easier have taken place (Poetics 53b23-27). Thereby, out for us, as professionals, to just carry on, regard- of the creative reconfiguration of the historical and less of the toll the treatment is taking on the particular, emerge neither imaginary accounts nor baby and the family’... wild thought experiments but accounts that are ... possible and at the same time of universal rele- Though he has been party to such discussions on vance and value.13 a number of occasions, Dr. Kelsall admits that To illustrate the medical relevance of this they never get any easier. ‘Sometimes you go on distinction between history and tragedy and of duty with a heavy heart when you have a baby the criteria identified for making such a distinction, on the unit who is sick and unlikely to get any I propose to take a closer look at the following better. You feel pretty wrecked at the end of a CATHARSIS AND MORAL THERAPY II 149

week on service if you’ve had that situation to that the tragic hero should possess great reputation deal with’. and fortune (Poetics 53a11-12). A re-reading of the reported story makes it clear that the description of For Chris and Charlotte, there is consolation in the neonatal consultant in charge of Ciaran neatly the knowledge that they made their decision out complies with all four criteria. Besides, he is of overwhelming parental love. As Chris puts it: displayed as a character with a good and long ‘‘It isn’t easy to understand. We loved him so professional reputation. much that we didn’t want to lose him – but we From the selection of the physician in charge as loved him too much to keep him as the main character around who a tragic story of well. We did what we thought was best for him’’. sickness is to be crafted, we now have to search for No doubt this is a sad story about a tiny child’s suitable actions, events or incidents in the real futile fight for life. At the same time it is a story, which may serve as a basis or template for dramatic narrative of what takes place emotion- inventing the tragic incident. According to Aris- ally when loving parents and compassionate totle (Poetics 53b14-38), there are four possible consultants are faced with the technological and sorts of actions or incidents that may arouse fear or moral limits of neonatal medicine. Third, it is a terror and pity in us, and thus qualify as tragic moving account of what actually happened with actions or incidents: the premature child, the consultants and the incidents where one acts in full knowledge,asis parents after the decision not to forgo treatment  the case when Medea in Euripedes’ homonymous had been made: death of the child, relief and self- play kills her children; consolation on the part of the loving parents and incidents where one may be going to act, in full compassionate consultants. Yet, and in spite of all  knowledge, but abstains from performing the act; this, this story does not qualify as a tragic story of incidents where one acts, but performs the dread- sickness.  ful deed in ignorance, and recognizes afterwards To make a tragic narrative of sickness out of what has taken place, as is the case in Sophocles’ this real life story, the medical ethics teacher play Oedipus Tyrannus; and finally, would need to introduce several changes taking incidents where one is about to act, in ignorance, his cue from the Aristotelian account and qual-  but then recognizes it before doing so. ifications of tragedy. It is the possibility of such a refashioning to which I shall now turn my Among these four possible sorts of tragic attention. actions or incidents, Aristotle qualifies the two last This brings me first to the requirements of tragic ones involving ignorance as the best options, character and the attempt to remake one of the number four as the very best, while as the worst characters of the reported story of sickness so as to one he stigmatizes the second type of incident fit with Aristotle’s requirements. Then, in the (Poetics 53b39-1454a9). In the following I propose context of reconfiguration, Aristotle’s discussion to redraft the incidents at our disposal so as to fit of the best type of tragic actions, events or with the characteristics of the third form of tragic incidents will be consulted. Finally, his suggestions action; i.e. an act done in ignorance followed by for what qualifies as tragic fortune will be applied subsequent recognition of its dreadful effects. One to the story of little Ciaran. way of remaking the reported story so as to comply According to the Aristotelian account of tragic with these requirements, is to focus the attention character, there are four things at which the on the second time little Ciaran’s condition became composer of tragedy should aim: critical. As the symptoms were only slightly different from the first critical instance, the con-  the characters should be good, in the sense that sultant in charge, i.e. our tragic agent, decided to they should neither be morally superior nor infe- follow the same treatment procedure as during the rior to ourselves; second, previous occasion. The only modification he had to  they should be appropriate; third, make was in relation to the dosage of one of the  they should be life-like; and fourth, and last, but drugs employed. The appropriate level of dosage, not the least, however, he had to check. Unfortunately, due to  they should be consistent (Poetics 54a16-30). grief and distress caused by the sudden and unexpected death of another child in the unit just In the attempt at applying these requirements to hours before, our agent had misplaced his treat- the story of little Ciaran, we may also profit from ment manual where he used to keep small notes Aristotle’s suggestion, a little earlier in the Poetics, with specifications of drug dosages for treatment 150 JAN HELGE SOLBAKK situations at odds with standard procedures. Time led him to overlook the dislocation of the was too short to try to trace the manual, because endotracheal tube as already accounted for, he felt Ciaran was in a critical condition. Immediate pretty wrecked after the sudden and unexpected intervention was therefore necessary. Conse- death of another child in the unit just hours before quently, our agent was under a double constraint; the incident of Ciaran. In a way, therefore, pity, he had no time to trace the manual containing his distress and grief were involved in this unfortunate notes, and yet he could not abstain from trying to incidence from the start. Furthermore, it appears save the child’s life. embarrassed about the that it was this experience that made our agent the loss of his manual he did not inform the rest of the victim of the first sort of hamartia; the misplace- team about the incidence and pretended to be in ment of his treatment manual. I suggest to label full control of the situation. Treatment was admin- this failure an epistemological failure although, as istered, and to our agent’s great relief, the child observed, its origin seems to be emotional. His seemed once again to pull through. Even greater second failure, on the other hand, i.e. his absten- relief he felt when he shortly afterwards retraced tion – out of embarrassment and – from his manual and found out that he had provided informing the rest of the team about the misplace- Ciaran with the appropriate dosage of the drug in ment of the treatment manual, is clearly a moral question. failure. What then about his third failure, i.e. the Twenty minutes later, however, Ciaran’s condi- failure directly related to the deterioration of tion started to deteriorate. At first, no explanation Ciaran’s condition? Was that an epistemological as to the possible cause of the deterioration was form of failure or a moral failure? Or was it a found. Then, to his terrible horror, our agent composite failure, i.e. a failure due to emotional, discovered that the temporary obfuscation of his epistemological as well as moral forms of hamar- attention triggered by the loss of his manual had tia? Suppose our agent had had the to act made him overlook a dislocation of the endotra- differently in the first place; suppose that, instead cheal tube. The probable cause of the child’s of keeping silent, he had informed his colleagues deterioration was irreversible damage to his brain about the misplacement of the treatment manual. due to inadequate ventilation. Without revealing Suppose the disclosure of this secret had made the secret of his mistakes our agent consulted the both him and his colleagues more attentive in the rest of the team about Ciaran’s condition and actual treatment situation, so that he (they) had decided to call a meeting with the family. not failed to notice the dislocation of the endo- To proceed further in the remaking of the real- tracheal tube. There are good reasons to believe life story, I shall now try to apply Aristotle’ that the situation for himself and the team as well qualifications of ‘tragic fortune’ to the situation of as for the child would have been vitally different, our agent. According to Aristotle (Poetics 52b32- had our agent acted otherwise at the moment he 53a17), the following three situations disqualify as discovered the first incidence of hamartia. terrifying and pitiable events: To finish the remaking of the reported story, and illustrate the function and role of tragic  a virtuous person undergoing a change from catharsis, we shall now finally move to the meeting good fortune to misfortune; such a change is only our agent decided to have with his team and shocking; Ciaran’s parents to explain the situation. How  a wicked person passing from misfortune to good should he behave and what should he tell his fortune; according to Aristotle the most untragic colleagues and the parents if the refashioned story of all changes; is to comply with the requirements of a tragic story  a thoroughly villainous person passing from good of sickness? I will here put forward a way of fortune to misfortune; ‘‘such a structure’’, says breaking the bad news, that I believe, complies Aristotle, ‘‘can contain moral satisfaction, but with the Aristotelian requirements. Our agent not pity or terror... (Poetics XIII. 1453a3-5). should start by conveying the sad news about It remains then only the situation where a Ciaran’s deteriorating condition and bleak prog- person not superior to us in virtue and with a good nosis. Second, he should communicate to them the reputation falls into misfortune not because of vice discussions he has had with his colleagues about and wickedness, but because of some sort of withdrawing intensive care treatment and taking hamartia. him off the ventilator. Most important, however, In order to qualify the kind of hamartia he should no longer try to alleviate his own committed by our agent it is important first to emotional suffering by rational forms of self- trace the emotional origin of the causal chain that deception (keeping silent, pretending to be in full CATHARSIS AND MORAL THERAPY II 151 control of the situation) or by claiming himself the that led to Ciaran’s premature death, and with- innocent victim of misfortune (misplacement of the drew his medical license for six months. treatment manual because of emotional distress and grief); instead he should demonstrate the moral courage to apologize for his behaviour to Concluding remarks his colleagues. Third, he should communicate directly to the parents his distress and grief of In this paper Aristotle’s poetic conception of discovering that the deterioration of their child catharsis has been the subject of investigation. probably originates from a chain of mistakes in The aim has been to demonstrate that ‘tragic which he himself has been the main actor: catharsis’ may be used to enlighten the particular I know there is nothing I can do which will make didactic challenges involved when training medical Ciaran better, nothing that I can say to console students to cope morally with complex or tragic you. Out of pity and grief from losing another situations of medical decision-making. A further child, out of forgetfulness thereafter, I lost focus aim has been to show that Aristotle’s criteria for in my medical care of Ciaran. Out of embarrass- distinguishing between history and tragedy can be ment and pride, I tried to hide my forgetfulness employed to reshape authentic stories of sickness from my colleagues. Out of my silence emerged into tragic stories of sickness. Furthermore, the the error that I believe finally made Ciaran’s didactic potential of such a reconfiguration has health deteriorate. I am so sorry. I am so terribly been tried out. Besides providing material to sorry. address these issues, the analysis to have made clear why tragic stories of sickness should be In the eyes of the colleagues of our agent and in the considered the most prominent teachers and eyes of the parents of little Ciaran, and notably sources of medical ethical wisdom. Finally, also, in the eyes of the agent himself, it probably through the hermeneutics of the Aristotelian con- matters a lot that he finally demonstrates the ception of tragic catharsis the possibilities demon- emotional and moral courage to openly admit his strated in the previous article of developing a fallibility; because this gives the parties involved the therapeutic conception of medical ethics has also possibility of recognizing the true dimensions of the been strengthened. incident and of reacting to it not only as compas- sionate consultants or parents in grief, but as victims implicated in a tragic story of sickness. Thus it also becomes clear that in spite of the occurrence Acknowledgements of avoidable forms and situations of medical hamartia, it remains within the culpable agent’s This paper has benefited a lot from advice and moral power to try to heal some of the emotional suggestions made by Ronald Polansky, Anastasia and moral wounds inflicted by his fallibility. There- Maravela-Solbakk, Petter Andreas Steen, Ola by the particular kind of cathartic effect a tragic Didrik Saugstad and colleagues at Section for story of sickness is able to convey has also been Medical Ethics. demonstrated; an effect which, in Kitto’s wording reads as follows: ‘‘The catharsis that we are looking for is the ultimate illumination which shall turn a Notes painful story into a profound and moving experi- ence’’ (Kitto, 1939/1995, p. 142). 1. All the translations from the Poetics are from Janko, 1987. Most of those present at the meeting were visibly 2. For a further qualification of the notion of ‘tragic’ in moved by the chief consultant’s sobbing confes- relation to moral conflicts within a medical context, sion. At the end of the meeting, Ciaran’s parents see Solbakk, 2004, pp. 105–112. went up to the culpable physician and embraced 3. Aristotle, Poetics 49b23-31. him, and they all broke down in tears. Two days 4. Aristotle, Politics VIII 7.1341-1342a18 (quoted from after the meeting the parents told the hospital Janko 1987, p. 59): ‘‘We accept the division of songs authorities: ‘‘We know he cannot undo what he proposed by some people engaged in philosophy into has done to Ciaran. We all agree he made several songs relating to (a) character, (b) action and (c) ec- mistakes. And yet, we forgive him’’.14 stasy, as well as their proposal that the nature of the melodies particular to each of these varies according to One year later the court found the chief consul- the type [of song] involved. We can therefore state that tant guilty of having implicated the deteriorations the art of music should be used not for a single benefi- 152 JAN HELGE SOLBAKK

cial purpose only, but for several. In fact it should be tioned, or by a better person rather than a worse used (a) for education and (b) for catharsis (what we one’’. mean by catharsis, we shall state simply now, but more 10. By ‘Greek tragedy’ are here meant the 33 plays of tra- clearly in the Poetics), and thirdly (c) for entertain- gic theatre that have been preserved from Greek antiq- ment, for both rest and from tension. uity. Of (525/4-465/5 B.C) seven plays have It is therefore obvious that one must use all the survived: Suppliants, Persians, Seven against Thebes, [kinds of] melodies, but not use them all in the same Prometheus Bound, Agamemnon, Libation-Bearers and way. (a) Those most related to character must be used Eumenides; Of Sophocles (495-406 B.C) another seven for education, but (b) those related to action and to ec- plays have come down to us: Ajax, Antigone, Oedipus stasy must be used for listening to while others play Tyrannus, The Women of Trachis, Electra, Philoctetes them. For the emotion that arises violently in some and Oedipus at Colonus; finally of (480-407 souls exists in all but differs in its degree, e.g. pity and B.C) 18 plays have been preserved: Alcestis, Medea, terror, as well as ecstasy. Some people tend to be taken Hippolytus, Heracleidae, Andromache, Hecuba, Hera- over by this agitation [of the soul], but we can see that, cles, Suppliants, Ion, Trojan Women, Electra, Iphigenia as a result of the holy songs they use to rouse the soul in Tauris, Helen, Phoenissae, Orestes, Bacchae, Iphige- to a frenzy, they settle down as if they have attained nia at Aulis and Rhesus. Several other tragic poets from healing, i.e. catharsis. It follows that this very same the same period are attested by name, but only frag- thing happens to people who are prone to [an excess ments of their works have survived. of] pity, terror and emotion in general, and to the rest 11. There are good reasons to believe that Aristotle was [of us] to the degree that each participates in such familiar with a far greater number of tragedies than [emotions], and a sort of catharsis and relief, accompa- the 33 plays known to us today. For this, see Easter- nied by pleasure, comes about for everyone. Likewise ling and Kenney, 1985, pp. 258–345. cathartic songs too afford people harmless delight. For 12. This observation about the phrase in Poetics 13, I this reason, those perfomers who are concerned with owe to Halliwell (1986/2000, p. 221): ‘‘…that the music for the theatre must be allowed to use such mel- hamartia of ch. 13 is not meant to be tied to one spe- odies and songs’’. cific kind of fault or error is strongly suggested by the 5. For further critique of a medical interpretation of tra- phrase ‘some sort of hamartia’(hamartian tina)at gic catharsis, see Janko 1987, p. xvi–xvii and Halli- 53a10). Halliwell (ibid., p. 221) also draws support well 1986/2000, p. 353–354. for a broad interpretation of hamartia from Nico- 6. For the use of catharsis to describe menstrual dis- machean Ethics II. 6. 1106b, where Aristotle states charge, Lear refers to Generation of Animals I. 20, that it is possible to fail in many ways so as to gener- 728b3, 14; IV. 5,773b1; IV. 6,775b5; History of Ani- ate evil results. mals VI. 18,573a2, a7; VI. 28,578b18; VII. 2, 582b7; 13. For a critical assessment of the use and abuse of 30; VII. 4,5848a8; VIII. 11, 587b2,b30-33, 588a1, for imaginary stories and thought experiments in medical seminal discharge, he refers to Generation of Animals ethics literature, see Solbakk, 2005. II. 7, 747a19; and for the discharge of urine he refers 14. These two last parts of our refashioned story is based to History of Animals VI. 18,573a23; for birth on a real-life story of medical fallibility, reported by Daily Telegraph discharge, History of Animals VI. 20, 574b4. S. Pook in the on April 12th 2002. 7. For Golden, see also: Golden, 1962, 51–60; Golden and Hardison, 1968; 1969, 145–153; 1973b, 473–479; 1976a, 21–33 and 1976b, 75–85. For a similar line of References interpretation, see Nicev, 1982. 8. Here quoted in English from Bernays 1857/1979, Bernays, J.: 1857, Grundzu¨ge der verlorenen Abhandlung des p. 155. In original this quote reads as follows: (Les- Aristoteles u¨ber Wirkung der Trago¨die. Breslau: E. Tre- sing, 1767–8/1978, p. 380: ‘‘Da na¨ mlich, es kurz su wendt. sagen, diese Reinigung in nichts anders beruhet als in Bernays, J.: 1979, ‘Aristotle on the Effect of Tragedy’, in: der Verwandlung der Leidenschaften in tugendhafte J. Barnes, M. Schoefield, and R. Sorabji (eds.) ‘Articles Fertigkeiten, bei jeder Tugend aber, nach unserm Phi- on Aristotle, Vol. 4.’ Duckworth: London, pp. 154–165. losophen, sich diesseits und jenseits ein Extremum fin- Easterling, P.E. and E.J. Kenney: 1985, The Cambridge det, zwischen welchem sie innestehet, so muss die History of Classical Literature, Vol I, Greek Literature. Trago¨ die, wenn sie unser Mitleid in Tugend verwan- Cambridge etc: Cambridge University Press. deln soll, uns vomn beiden Extremis des Mitleids zu Else, G.F.: 1957, Aristotle’s Poetics: The Argument. Cam- reiningen vermo¨ gend sein; welches auch von der fur- bridge, Mass: Harvard University Press. cht zu verstehen’’. Flashar, H.: 1956, Ô‘Die Medizinischen Grundlagen der 9. Aristotle, Poetics 53a13-17: ‘‘Necessarily, then, a plot Lehre von der Wirkung der Dichtung in der Griechischen that is fine is single rather than (as some say) double, PoetikkÕ’, Hermes 84: 12–48. and involves a change not from misfortune to good Golden, L.: 1962, ÔCatharsisÕ, TAPA 93: 51–60. fortune, but conversely, from good fortune to misfor- Golden, L. and O.B. Hardison: 1968, Aristotle’s Poetics: A tune, not because of wickedness but because of a Translation and Commentary for Students of Literature. great error [hamartia] by a person like the one men- New York: Englewood Cliffs. CATHARSIS AND MORAL THERAPY II 153

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