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Keywords:

  • Osteoarthritis;
  • Virtue theory;
  • Chronic illness

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Objective

Virtues and vices possessed by patients may affect their quality of life and how well they cope with disease. The objective of this study is to assess the relevance of the concept of virtue and vice to patients with chronic arthritis.

Methods

Aristotle's theory of virtue and vice was used to construct a guide for in-depth interviews, carried out with 5 patients with chronic osteoarthritis. Interviews were tape recorded, transcribed, and analyzed (using Interpretative Phenomenological Analysis) for information on personal qualities or intellectual approaches that participants thought necessary to thrive in the face of chronic disease.

Results

Five main themes emerged: strength, prudence, gratitude, self-worth, and insight into flourishing. The data on each of these is compared with Aristotle's definitions of virtues and vices.

Conclusions

Aristotle's virtue theory can be applied to the narratives of these patients with chronic osteoarthritis, and may help in understanding their coping strategies and quality of life.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

This study is part of a program of research investigating the relevance of a particular type of philosophical theory, virtue theory, to the experiences of patients with chronic illness. Virtue theory is being explored as an alternative to modern psychological explanations of the role of character in chronic illness, and as a possible explanation of people's choice of coping strategies and of variations in their quality of life.

Virtue theory is a philosophical theory of human character. It states that there are specific human excellences of character or intellect to which individuals should aspire: these are the virtues. In contrast, there exist undesirable personal qualities, which should be avoided, and these are vices. It is argued that virtues are acquired, not inherited, characteristics (1). They can be acquired through education and habituation. Character, according to virtue theory, is therefore malleable. Virtue theory is derived to a large extent from Aristotle's Nichomachean Ethics (1), written circa 400 BC. Modern revival of interest in virtue and vice has been attributed to Elizabeth Anscombe's 1958 paper, “Modern Moral Philosophy” (2), and more recently to Alasdair MacIntyre's After Virtue (3). This article draws on the work of Aristotle to interpret arthritis patients' experiences. Aristotle defined a virtue as a “state of character,” displayed in the right situation to the right degree. For him, a virtue lies in a mean, between a vice of excess and a vice of deficiency. For example, the virtue of courage lies in a mean between the vices of cowardice and rashness. Aristotle described 2 types of virtue. Courage is a moral virtue. However, knowing what behavior constitutes courage, and knowing when and in what circumstances to exhibit that behavior, is also an intellectual operation and requires the possession of intellectual virtues, such as practical wisdom, goodness in deliberation, understanding, and judgment.

Why apply virtue theory to arthritis? Virtue theory in the context of health care has traditionally focused on the character of the health professional (4–11); however, it can also focus on the character of patients. Virtue theory is particularly relevant to the hardship of chronic disease if we agree that virtues include “specific strengths that partly grow out of adversity and sustain us in the midst of it,” as May believes (12). Shelp (13) presents courage as an important moral virtue for patients and practitioners alike. To this, he adds the desirability of the patient-specific excellences of compliance and gratitude. Lebacqz (14) defines the virtues of the patient as “qualities of excellence in response to the stresses of pain, discomfort, physical limitation, loss of autonomy, violation of privacy, vulnerability, and loss of self.” She goes on to identify 3 virtues—fortitude, prudence, and hope—as central to the task of being a patient. However, there has been no empirical research so far into patient virtues as viewed from the patient's perspective. This study attempts to rectify this omission by exploring the issue of character with patients themselves.

Why might possessing virtues help patients? The response to chronic arthritis and resulting quality of life varies among patients. Current exploration of this variation has concentrated on psychological concepts, such as coping theories (15–24) and the nature and determinants of quality of life (25–34). However, virtues and vices, whether preexisting or developed as part of the response to chronic disease, may affect both ability to cope and quality of life. For example, a virtuous person may select an appropriate coping strategy, e.g., seeking information and support, while a “vic-ious” person (a person possessing vices) may select an inappropriate one, e.g., turning to alcohol. The possession of virtues is important to quality of life, according to Aristotle, because only the virtuous person can achieve true human flourishing. Many factors impinge on quality of life in illness; however, in an era in which the patients are seeking to take a more active role in their illness management and are being portrayed as experts on their condition (35), their character and intellectual approach to illness are of relevance and deserve investigation.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

We obtained local ethical committee approval to proceed. Five individuals with longstanding osteoarthritis (OA) took part in the study. All 5 participants were female, ranging from 63–89 years of age. Disease duration ranged from 2–16 years. The participants were a convenience sample recruited from a local specialist rheumatology service, a convenience sample being acceptable for such an exploratory study. Participants were approached in person at the hospital by a researcher, who was introduced by the patient's physician. They were given a patient information sheet relating to the study and invited to participate. Those willing to take part were asked for their name, address, and telephone number. They were subsequently contacted by the interviewer, and a convenient date, time, and location were arranged for interview. Each participant was interviewed separately. Prior to the start of each interview, written permission was obtained to tape record the interview. Interviews lasted between 1 and 2 hours. We designed an interview guide aimed at eliciting an open-ended conversation, covering any area of the participant's life with chronic arthritis. The focus of the interview was on aspects of the participant's character that they felt were relevant to how they coped with their illness, and their personal reflections on coping with their illness, including advice they would give to others about how to cope with it. The structure and focus of the interview thus provided a frame for the subsequent analysis (36). Interview recordings were transcribed and any identifiers in the transcripts were removed. The analysis method was Interpretative Phenomenological Analysis (37, 38).

Analysis.

In stage 1 of the analysis, the transcripts were explored for participants' talk of aspects of their character that had relevance to their illness, for example, “I suppose I'm emotionally strong.” This was done because, according to Aristotle, virtues and vices are acquirable states of character. In stage 2, transcripts were explored for what we term participant's intellectual approach: how and why they try to cope with the condition in a particular way, for example, “I think it's up to you to eat clean, healthy type food and behave yourself. … I've always tried to do that.” Such personal philosophies have a relationship to Aristotle's concept of intellectual virtue (or vice) because they are concerned with the attempt to develop and exercise good reason, judgment, and wisdom in relation to one's illness. Both analyses needed to be done because, to quote Aristotle, “good action and its opposite cannot exist without a combination of intellect and character.” The good action we were interested in during this research was “how to live well despite arthritis.”

This data was then combined and examined to see if there were any similarities between the interviews. Similarities are discussed in the results section.

In stage 3 of the analysis, we drew comparisons between the data we obtained and what Aristotle wrote about virtue and vice in Nichomachean Ethics (the location of each quote is identified in brackets, e.g., [III, 9] means Book III of Nichomachean Ethics, section 9). It should be noted that the analysis is drawn entirely from the participants' own opinions about their character and approach to arthritis; the authors are themselves not judging individual participants as virtuous or vic-ious.

No interrater reliability test was performed on the data, although findings were reviewed by 3 philosophers and 2 social scientists to determine the face validity of the data. These reviewers judged the analysis acceptable.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The main themes that emerged were courage, prudence, gratitude and goodwill, self-worth, and insight into flourishing.

Courage.

In 4 of the 5 interviews it was apparent that some kind of strength of mind or determination was required to persevere through the difficulties of life with a chronic condition. For example from interview 4, “I suppose you must have a certain—it sounds awful to say it but—a certain strength of character, I must have, otherwise I couldn't have coped with some of things that have happened in my life.”

One person indicated that strength was needed to overcome thoughts of suicide (from interview 4), “There are some times in the mornings when I get up and I haven't had the injections for 8 or 10 weeks and oh God, I really want out of it. I can't walk and it is so painful, it's horrible, and I think, ‘What am I living for? No, come on walk round, walk round, have a cup of coffee, do something.’”

Aristotle writes on courage, “It is for facing what is painful that men are called brave. Courage also involves pain and is justly praised; for it is harder to face what is painful than to abstain from what is pleasant,” [III, 9]. “It chooses or endures things because it is noble to do so…. The coward is a despairing person, for he fears everything…. Confidence is the mark of a hopeful disposition,” [III, 7]. Aristotle links hope to courage and despair to cowardice. We believe that participants in this study advocate the virtue of hope over despair when they offer advice such as, “Keep a positive mind, live on that day, and make the most of that day, ‘this is a lovely day I’ve got, I'm going to make the most of it,' I think it pulls you through. But I'd say to anyone, don't give in. Don't give in.”

Prudence.

Participants also advocated gaining a realistic picture of their condition and its treatment, including acceptance of the physical restrictions under which it places them, and maintenance of a sense of perspective. For example from interview 2, “I think what you've got to do is rest quite a bit. And pace yourself. I mean I go bull mad at things sometimes. It's like this lecture I went to on Monday evening. And I enjoyed it. But I realized I'd done too much the next day. But you've got to adjust your life to what you can do. I'm not saying it's easy to do.”

This data bears a relationship to Aristotle's view of the virtuous person as someone who perceives what is good or fine or right to do in any given situation. It also has something in common with the specific intellectual virtue of prudence, or practical wisdom, which is “knowledge of how to secure the ends of human life,” [VI, 5]. For Aristotle, possessing the intellectual virtue of practical wisdom is necessary to know what actions to take to achieve the good life. For the chronically ill, there may be several possible ways of coping, but one may need to develop knowledge and apply wisdom to know which path to take and why.

Gratitude and goodwill.

Gratitude, or at least goodwill, featured in the narrative of all participants: they expressed thankfulness for what they saw as their relative good fortune in comparison with the experiences of others. They advocated thankfulness as an appropriate feeling in certain circumstances, for example from interview 4, “I was staggering around and a member of staff came up to me and said, ‘Would you like some help?’ They brought me a chair, they brought me my plastic card, the things to sign, I didn't have to do a thing, they were lovely…. I have to walk with a stick when these injections are wearing off and they invariably come and offer to help, it's amazing. But I found that quite hard to start with because I've always been terribly independent, I've coped with everything, and I thought, ‘Good God, I can’t even do the shopping,' but then I thought, ‘Take it easy old girl, be thankful someone will do it for you and help you.’ ”

They also expressed gratitude or goodwill toward valued actions or attitudes of others, such as family, friends, and health care professionals. For example from interview 5, “I don't think I would have had the will like I've got now had it not been for [the hospital staff]. And I've always said that. I could never pay them back for what they have done for me.”

Aristotle writes, “The man who has received a benefit bestows goodwill in return for what has been done to him, but in doing so is only doing what is just.” St. Thomas Aquinas (39), who wrote on virtue in the Middle Ages within a Christian framework and built upon the work of Aristotle to provide extremely detailed definitions of numerous virtues, writes that gratitude first admits a favor was done to us, secondly it praises it and expresses thanks, and thirdly it repays it in the proper circumstances and according to our means. If one accepts this definition, it is clear in the narratives that gratitude is present: participants admit and describe favors that have been done, they express their thanks for them, and 2 participants specifically mention ability or inability to repay such acts.

Self-worth.

One participant (interview 1) believed that it was important to respect one's body and look after it. This participant, whose medication had given her urinary problems, was left feeling upset and disgusted with herself, and she stated, “… especially when I got onto these tablets that got into my kidneys, that was since I've been here. I was absolutely disgusted. I felt dirty … I felt I'd let myself down somehow.”

Another participant (interview 2) indicated that her feelings of self-worth were undermined by the attitudes of friends and strangers towards her, “If a person's nice, or affable or is friendly, it enhances your feeling self-worth. Whereas if they let the door swing in your face, you think—it makes you feel like something the dog dragged in, it gives you a feeling of inadequacy.”

Aristotle thought that a proper appreciation of one's worth was an essential dimension of the truly virtuous person. The individual with the virtue of “megalopsuchia” or “proper pride” has found a mean between the vices of vanity and undue humility. Aristotle writes that the proud person “claims what is in accordance with his merits … it is honour that they chiefly claim, but in accordance with their deserts,” [IV, 3]. He also writes, “The good man should be a lover of self (for he will both himself profit by doing noble acts, and will benefit his fellows),” [IX, 9]. He also writes of the “quasi-virtue” of shame that (incompletely) virtuous people feel when they have done something wrong.

An additional point related to self-worth was present in 2 interviews, in which participants revealed concerns about the negative opinions they felt others held of them. One person thought her inability to stand and chat at social functions could be interpreted as unfriendliness. Friendliness, according to Aristotle, is a virtue lying in a mean between the vices of obsequiousness and surliness. The friendly person “will associate with people in the right way,” [IV, 6]. Another participant stated from interview 1, “What's worried me most of all was that people thought I was not telling the truth. I felt people thought I was exaggerating and thought I was making a fuss about, well not nothing exactly, but making a lot of fuss.”

Her concern that they think she is not telling the truth is related to another virtue. Aristotle writes that truthfulness is a virtue, which lies in a mean between the vices of boastfulness and mock modesty. The truthful person “loves truth and is truthful where nothing is at stake; will still be more truthful where something is at stake; he will avoid falsehood as something base … and such a man is worthy of praise.” By not having her story believed, this participant feels she is not being accorded the respect she is due.

Insight into flourishing.

To explore Aristotle's notion of “eudaemonia” (flourishing), which is the end point of a virtuous life, participants were questioned directly about factors that they felt contributed to their happiness or gave their life meaning despite illness. Of most importance to them were maintaining relationships with others and maintaining interests and activities.

Participant 3 states, “Well as I was saying to the doctor, just having my granddaughter cheers me up. She is so, so funny, but how do I explain it, she just cheers you up. She just literally cheers you up.”

Participant 2 gives an example of maintaining interests and activities, “And when you read of course, you gather knowledge and all sorts of things and when you listen to quizzes you think ‘Oh I know that.’ Like ‘Fifteen to One’ or those tea-time quizzes, and you think, ‘I’m not so thick after all!' And it sort of keeps your mind active! My sister-in-law's 83 and does algebra every night! I believe in that. I don't do that sort of thing, but I do sew and knit and I find comfort in creating things like that. I knit clothes for the grandchildren or knit a doll or something.”

Participant 1 says on the subject, “Oh … it's little things. The beauty of the world. And animals, I love animals of course, but unfortunately I can't have them where I live. Yes, I think just the little things of life. Peoples' smiles. A good kind word. …”

Relationships and interests were a direct source of happiness or satisfaction, but they also served as a distraction from the pain and disability of OA. Participants expressed their awareness of the value of such things and felt that they “keep you going.” Aristotle writes “It is thought to be the mark of a man of practical wisdom to be able to deliberate well about what is good and expedient for himself … about what sorts of things conduce to the good life in general,” [VI, 5]. Aristotle also placed much importance on the virtue of friendship, and 2 chapters in Nichomachean Ethics are devoted to this subject. For example, he writes, “For without friends no one would choose to live, though he had all other goods. … And in poverty and in other misfortunes men think friends are the only refuge,” [VIII, 1].

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Using Aristotle's work on moral and intellectual virtue, we have demonstrated that the personal qualities and intellectual approaches that these patients feel are relevant to their condition and have a relationship to virtues. Further research is needed to establish whether the personal qualities mentioned here are relevant to other patients with arthritis.

But why call these personal qualities virtues? One might call such personal qualities by such relatively recent psychological names as “cognitions,” “attitudes,” or “personality,” but this research is about an ancient philosophical interpretation of the role of character in arthritis. Virtue theory is an alternative, an older theory of human character and behavior. However, unlike more value-neutral modern theories of character, it divides personal qualities into the desirable and the undesirable, and links these to the ability to live a flourishing life. This is a relevant concept in the area of chronic disease.

What about vices? Participants did also mention negative qualities they possessed, but each mentioned different qualities; thus they are not included as the main topics in the results section. For example, one participant felt she had become more angry and vindictive in the face of others' lack of understanding. Another participant mentioned her envy and resentment of others' abilities. Yet another participant mentioned her increased irritability when her arthritis was bad. The emergence of vices is therefore also a possibility in chronic illness and could be explored in more depth in a future study.

What is the practical significance of virtue theory for arthritis patients and professionals? If it can be established that particular personal characteristics and approaches to arthritis are relevant to outcome, patients at risk of lower quality of life may be identifiable. The personal development of people with arthritis who are coping well may provide a useful source of advice for such patients. Health care professionals may play a role by providing such information to new patients or those failing to cope well.

A couple of methodologic issues should be addressed. As previously mentioned, the data were not tested for interrater reliability, although findings were passed to a panel of philosophers and social scientists to review for face validity. Further research should be done to see if these findings could be independently replicated.

In the open-ended interviews, participants tended to go no deeper than discussion of functional ability and physical coping strategies until more structured questioning by the interviewer was undertaken. This would indicate that in future research semistructured interviews may be needed to engage people in the high levels of self-reflection required here.

The qualitative research method of semistructured interviews appears to be appropriate for undertaking this kind of inquiry. Virtue theory places an emphasis on the development of virtues throughout the course of a human life. It therefore seems an appropriate theory to investigate in relation to long-term illness. The range of responses to chronic illness is vast, and this variation in coping and outcomes may, in part, be explained using virtue theory, which deserves further investigation.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES