Philosophy as a way of life, spiritual exercises, and palliative care

This paper proposes that resources from philosophy as a way of life (PWL), in particular the prescription of targeted ‘ spiritual exercises ’ (Hadot) can be used in palliative counselling, addressing Alexandrova's critique that philosophy as ‘ big picture ’ theories alone are insufficient. Part I shows how the disciplines of philosophy and medicine for a long time intersected, in particular in competing prescriptive notions of ‘ regimen ’ or ‘ way of life ’ ( diaitês ) in the ancient world, in which philosophy was considered widely as PWL. Part II applies PWL work on the ancient philosophical spiritual exercises to contemporary clinical settings. We show how six ancient spiritual exercises respond to patients' needs as persons, whose quality of life is importantly shaped by their beliefs and sense ‐ making, as they face profound existential or spiritual challenges, as well as forms of physical disability and diminished capabilities which they may never have previously countenanced.

pp.658-861)Recent criticisms of theoretical and applied efforts to promote patient well-being in medicine have questioned the utility of general, normative theories, calling instead for mid-range theories that respond to a particular cohorts' needs and concerns as these are expressed in daily life events 11 or even 'theories-without-theories'. 2om the side of philosophy, scholarship over the last decades has revisited Burnet's 1930 insight that 'it is impossible to understand the history of philosophy… without keeping the history of medicine constantly in view'. 12This work has been spearheaded by the dedicated Brill series, 'Studies in Ancient Medicine' and includes important monographs by van der Eijk, 13 Bartos, 14 and others, as well as collections reconsidering the philosophical bases of ancient conceptions of mental and psychosomatic illnesses. 15,16p.70The reconsideration of the philosophical dimensions to human experience, Miranda proposes, can 'expand our understanding of what it means to treat patients, and professionals, "as persons"' in medical settings, and "clarify the role of dialogue in diagnosis and care, as well as the relationship between science, value, virtue and philosophical sense in health and social care". 180][21][22] This work recognizes how ancient Greek and Roman philosophies, led by Stoicism and Epicureanism, were not pursued as solely abstract, cognitive, theoretical endeavors, aiming at esoteric theory-construction.They were practical philosophies aiming to engender well-being in practitioners, positioning the philosopher as 'spiritual directors' to students, 21

including prescribing regimens of what Hadot called
'spiritual exercises' to improve well-being. 19,20is paper will contend that the Hadotian reconception of philosophy as PWL makes a unique contribution to contemporary reconsiderations of philosophy in healthcare, 23,24 for two reasons.First, existing literature considering this intersection focuses on competing, 'big picture' philosophical theories, and whether these can facilitate 'a deeper understanding of what happiness, suffering, and evaluative engagement really are, and why they matter' 2,p.669 for clinical decision-making by the physician and patients.Hadot's work asks us to reconceive philosophy, moving away from the big picture model which is presupposed here, towards philosophy as an activity which involves both theory-formation and hands-on 'spiritual exercises'.These are forms of cognitive, dialogic, meditative and contemplative practices that philosophers would prescribe to their pupils as a means to ethical improvement and enhanced well-being (eudaimonia, euthymia, tranquilitas and serenitas).*Decisively, almost all of these exercises were recommended across dogmatic divides: that is, independently of students' needing to adhere to a 'big picture' theory of human nature or well-being, of the kind whose place witihin medical practice is today being questioned. 2,11cond, the independence of philosophical spiritual exercises from big picture dogmatic theories reflects their therapeutic aimthat of addressing the cognitive, habitual and physiological bases of forms of avoidable distress people typically experience in response to the existential realities medical practitioners face every day: those of adversity, accident, illness, pain, aging and mortality.The potential efficacy of undertaking the spiritual exercises that PWL research has identified in decreasing avoidable mental suffering does not depend on whether the patient is a convinced Platonist, hedonist, Stoic and so forth.Instead, these ancient philosophical exercises could be included in palliative regimens, as in the care of patients facing the end of life, as a means for patients to reflect upon their core beliefs, values and priorities, reduce avoidable distress, and foster an increased sense of psychosocial and psychological well-being.
Part I shows how the disciplines of philosophy and medicine for a long time intersected in Greco-Roman culture.In particular, we will highlight how the ancient philosophers led by the Stoics and Epicureans conceived of their goal as transforming the mental and wider habits of pupils to reduce avoidable forms of mental distress, anxiety, fear and dissatisfaction, in ways directly conversant with, and often described in terms of, the medical notion of 'regimen' or 'way of life' (diaitês).This metaphilosophical work enables us in Part II to show how philosophical 'spiritual exercises' which formed the heart of the ancient PWL conceptions of regimen and therapy examined in Part I can be applied to contemporary clinical settings.This ancient practice parallels what Alexandrova has called for as 'mid-level theories'.We show how six ancient spiritual exercises respond to patients' needs as persons, whose quality of life is importantly shaped by the profound existential or spiritual challenges that they are facing, as well as forms of physical disability and diminished capabilities which they may never have previously countenanced.

| ANCIENT MEDICINE, ANCIENT PHILOSOPHY, AND REGIMEN
To apply PWL research to contemporary palliative counselling, we need first to chart how in the ancient Greek period usually associated with the birth of rational medicine 25 no such sharp distinction yet existed.Indeed, as we will show, ancient philosophers often conceived of their task in explicitly therapeutic terms.p.14In later antiquity, the skeptical philosopher Sextus Empiricus was a medical doctor; on the other hand, the famous physician Galen was a recognized philosopher, as well as the author of a work arguing that the best doctor should also be a philosopher.13p.11So great was the influence of philosophical theorizing on ancient conceptions of medicine that, in the Hippocratic text known as On Ancient Medicine, the author feels the need to polemicize against this pernicious (as he sees it) influence.13p.19It is therefore anachronistic to suppose that the institutional and conceptual gulfs we know between medicine (iatrikê) and philosophy (philosophia) were stabilized at any period in Greco-Roman antiquity.
Writing in the first century CE, the Roman author Celsus would claim that the theoretical interest in health and disease emerged from within the studium sapientiae (philosophical studies) and that it was only with Hippocrates (c.p.10p.19Of greatest interest for us here is this idea of 'regimen' (diaitês).
In a study of the Hippocratic On Regimen, Bartos explains that, in the Hippocratic texts, a constellation of medical opinions solidified under this heading.This constellation took in, but extended beyond, what we would call a 'dietetic' concern with the forms of food and drink individuals consumed, reflecting the holistic, Hippocratic notion of the interconnection of body and mind.At issue was a much larger theory of health where it was viewed as follows: …a balanced mixture of opposing qualities, at the most general level hot, cold, dry, and wet.p.21,30,pp.374-375In different Hippocratic texts, we hence read recommendations for patients suffering from physical ailments, or indeed, people looking simply to preserve their good health, to undertake activities as diverse as wrestling, walks, running, bathing and massage.The text Airs, Waters, Places, includes a focus on the effects of climate and physical environment on the health of individuals.On the Nature of Men lists diagnostic considerations for the physician.These include prescribing 'regimens' to individuals according to their age, constitution, gender, diet, drinking and exercises, as well as the season of the year and specific nature of any disease they may be suffering.As

Ilsetraut Hadot comments of this branch of ancient medicine:
It is not content to formulate general directives for a healthy mode of life, but it goes much farther and takes in hand the whole of existence, the use of the time, alimentation, sleep.It determines the duration of nocturnal rest, the moment of waking, clothing, the composition of breakfast, the duration of physical exercise and its form, the hour of bathing, the moment and the menu of the lunchtime meal, the length of walk[s], the duration of conversation with friends, comportment at banquets, etc. 21,p.47-48In the context of ancient medical regimen, which intersects with what we call palliative counselling, the concerns of medical practitioners intersected especially directly with those of ancient philosophical ethicists, in particular, those of the Stoic and Epicurean schools, both of whom shared a holistic vision in which human suffering and wellbeing involved body as well as mind.The therapeutic relationship certainly aimed to reduce pain and suffering, but it also aimed to inform and educate the patient: …the subject of inquiry and discussion is simply and solely the suffering of these same ordinary folk when they are sick or in pain.Now to learn by themselves how their own sufferings come about and cease, and the reasons why they get worse or better, is not an easy task for ordinary folk; but when these things have been discovered and are set forth by another, it is simple. 31p.376Plato in his Republic is betraying an anxiety of influence when he takes the time to ridicule the dietetician, Herodicus, whom he accuses of asking people to spend their entire lives so preoccupied with preserving bodily health that this pursuit leaves no time to better their soul.p.110In this way, this Platonic dialogue denominates physiological preconditions for cultivating 'what is divine in us': the putatively immortal, asomatic soul whose perfection is the primary concern of the philosopher.The Timaeus itself indeed played a role in the history of medical regimen, for instance, in the work of Athenaeus of Attalia (first century CE), in whose prescriptions for physical health we find the recommendation of both mental or psychological activities such as studies (mathêmata), and physical activities: 'one must not overlook any lack of training p.110Within the division of regimen, ancient medicine reached upwards to take in concerns we would usually understand as philosophical.This understanding of medical regimen also prepares us to understand how, once again in Ilsetraut Hadot's words: When philosophy undertakes … to oppose a scientificallyfounded ethics [to accepted opinion] … it is not by chance that it compares its task with that of the doctor: the ethically faulty comportment then becomes a sickness of soul that an accurate discernment can cure.Philosophy becomes the knowledge which takes upon itself to cure the maladies of the soul in the same way that medicine is the knowledge which cures the body.21p.49In recent decades, both within and outside of work on PWL, this analogy between philosophy and medicine has become relatively wellknown.In English, Martha Nussbaum devoted an extended study to it, 33 and in French, a study from the same year (1993) appeared by André-Jean Voelke, La Philosophie comme thérapie de l'âme. 34p.320Arguably the locus classicus is from Cicero's Tusculan Disputations: What reason shall I assign, O Brutus, why, as we consist of mind and body, the art of curing and preserving the body 34 should be so much sought after, and the invention of it, as being so useful, should be ascribed to the immortal Gods; but the medicine of the mind should not have been so much the object of inquiry …? … Philosophy is certainly the medicine of the soul [medicina animi], whose assistance we do not seek from abroad, as in bodily disorders, but we ourselves are bound to exert our utmost energy and power to effect our cure. 36is ancient medical analogy for philosophical activity turns upon a 'cognitivist' conception of human agency and identity: that is, one which sees our bodily experiences, and even our desires, fears, and emotions, as interconnected with, and deeply shaped by, our beliefs about the world.For the Epicureans, humans become unhappy, as if they had contracted a disease, by conceiving empty beliefs (kenodoxia) about what they should desire and fear; and they will even describe the reign of such beliefs over entire societies as like an epidemic or plague. 37For the Stoics, comparably, distressing emotions like anger, and the behavioural response to these emotions, involve contestable beliefs about events in the world (that they are harmful).In this way, the defining philosophical concerns we still recognize-to identify the true, against the false, and come to knowledge, as opposed to ignorance-came in ancient philosophical literature to be tied to a medical vocabulary, as well as concerns for cultivating virtues, as against the vices.56,73 or the dietetician's replacing of unhealthy physical or wider behaviors with a regimen more conducive to physiological or wider balance (summetria) and health (hygeia).Philosophical reflection was viewed as providing medicine for the soul because it was presented as a dialogic practice that could help individuals to identify and replace false beliefs with those that are true, whether these concerned beliefs about the world, or what one needs to have and to avoid to be happy.
p.339p.349Gill also offers the comment that 'there is a much closer, and nonmetaphorical, relationship between regimen and philosophical discourse' which these texts make especially clear: This is particularly true if we do not just focus on the 'therapy' dimension of philosophical discourse but consider the overall aims of this kind of practice, integrating protreptic, therapy, and advice.p.347The above evidence is consistent with the view that philosophy was conceived as a medicine for the soul and that it was administered through a prescribed regimen in a manner that was similar to the practice of Hippocratic physicians.It is this regimen which Pierre Hadot identifies in his analyses of the ancient philosophies as different ways of life (tropoi tou biou) involving forms of spiritual exercises, and which we propose also has applications in contemporary forms of palliative care.

Pierre Hadot's claim that ancient philosophy involves what he terms
'spiritual exercises' has attracted criticism, for collapsing philosophy into religion. 39pp.79-82In a recent synoptic study, Sharpe and Ure 22,pp.5-7identify some 12 species of these exercises, only three of which are solely cognitive (reading, writing, and dialogic exercises).Notably, one branch of exercises (and ancient texts) aimed at the therapy of the passions.Others were intended to transform students' perception of things and the world, or to cultivate specific forms of meditative or contemplative attention by engaging memory, imagination, and wider sensibility; others involve forms of physical activity or abstinence to build endurance.It is the presence of these exercises, being practiced in a text like Marcus Aurelius' Meditations, or being prescribed in texts like Epictetus' Manual, that for Hadot gives force to the idea of ancient PWL.As he writes: In [the ancients'] view, philosophy did not consist in teaching an abstract theory, much less in the exegesis of texts-but rather in the art of living.It is a concrete attitude and determinate lifestyle, which engages the whole of existence.p.83p.309Nevertheless, as we indicated above, Hadot also maintained that spiritual exercises were relatively independent from the big picture theories of nature and human nature developed within the competing schools, for example, Epicurean ataraxia, the Hippocratic optimal balance of bodily humors, or Stoic smooth flow of life [euroia biou]).Indeed, Hadot claims that the contemporary reactivation of ancient spiritual exercises 19,p.280p.330We contend that the meta-philosophical approach of PWL, as developed by Hadot, is consistent with current efforts to re-establish an effective dialogue between the science and philosophy of wellbeing. 11,41Alexandrova 11 has articulated the challenge for achieving this goal.Namely, well-being and HRQL have been historically defined by high-level normative theories such as eudaimonism, hedonism, object list theories, or desire satisfaction theory.These are crafted to apply to humans in general.As such, they fail to capture the complexity of how an individual might apply the 'big picture' within the psychosocial context that frames their particular lived experience.PWL we believe can make a distinct contribution here.
For it situates philosophical activity as operating in between highlevel theories of well-being and individual experience.It does so not by positing 'mid-level theories', but by pointing to therapeutic processes or activities through which high-level visions of the good life and well-being are activated (or 'relativized') by a given individual within the parameters (psychosocial demands and resources) of their situational context. 11,42om a clinically applied perspective, PWL is a procedure that identifies structured activities, the spiritual exercises, that promote a process of transformation for an individual, as they aspire to promote well-being and HRQL in their life.These exercises provide an opportunity for the individual to gain improved insight and efficacy as they obtain performance-based feedback that reinforces their motivation and ability to optimize well-being and HRQL (cf.self-efficacy theory 43 ).† To give a preliminary guide to how we believe PWL can be applied by contemporary counsellors, we consider here six such philosophical exercises and their application to the situation of patients facing chronic illness or end-of-life: exercises to distinguish between what the individual can and cannot control (i), to prepare for future adversities (ii), to come to terms with distressing emotions (iii), address the fear of death (iv), undertake nightly self-examination (v) and foster a global 'view from above' on one's life.These activities exemplify therapeutic practices that were promoted in Stoic and Epicurean schools of philosophy as a 'medicine for the soul', as detailed above.Our discussion of the spiritual exercises will illustrate the therapeutic objective of PWL, which is to provide a meta-philosophical perspective on health-related constructs, such as HRQL and well-being, by focusing on structured activities or procedures that address the student/patient's intrinsic life goals and values-for example, to experience personal affiliation or intimacy with significant others (spouse, family and friends), to fulfill social roles or responsibilities that one values and that are valued by others, to engage in activities that promote self-expression and personal mastery, or to engage in self-affirming activities that express or strengthen one's sense of personal agency by feeling connected with a greater purpose, or by optimizing one's sense of health and well-being-whether this is in response to events that are not stressful, or those that evoke physical or emotional distress, pain or suffering. 8,44,‡ † Nolan and Sharpe recently addressed this core feature of PWL by identifying how spiritual exercises from Stoic and Epicurean philosophy addressed goals for living well that overlapped with life aspirations or features of personal loss that were documented among individuals with chronic heart failure, which is a progressive medical condition associated with premature death (Nolan & Sharpe, In Press).‡ These activities are goal-directed and self-reinforcing insofar as the activity provides a means of engaging life goals that reflect an intrinsic value or salient meaning for the individual.For example, connecting with a greater purpose or spending time with a significant other can be perceived as a valued end in itself.This is distinct from instrumental activities that may be valued by an individual solely because of their association with an external value-for example, paying taxes solely to avoid a financial penalty.divide what is and is not in our control. 45This exercise responds to the habit of generating worried thoughts about events that we cannot change, which promotes avoidable forms of inner distress.
The therapeutic strategy of this exercise is to accept what is past and to plan for what may come.In the case of patients facing chronic or end-of-life conditions, this exercise might be especially efficacious as a guide to redirect thoughts back to what they can presently change, which would reduce rumination and anxiety while fostering greater acceptance of the things we cannot change.In the context of managing emotional distress, trauma, or modifying lifestyle to sustain health, the act of identifying change goals that are personally meaningful and within one's control is central to diverse models of psychotherapy, including cognitive-behavioural therapy, 23 motivational interviewing, 46 or social-cognitive interventions. 43Epictetus suggests dedicated times to practice this exercise with regard to all objects and others a person encounters in the morning.

| EXERCISES TO PREPARE FOR FUTURE ADVERSITIES
Patients with chronic conditions have typically had their old way of life disrupted.They may face uncertain prognoses about the future quality of their life, or their possible mortality (see Section 4).The ancient Stoics observed that anxiety is fed by uncertainty and anticipation that the worst things we fear might happen.To reduce anxiety, they therefore counselled the exercise of premeditating the worst adversities a person may have to face, in advance, coupled with the directive to also then visualise how they would constructively respond to that situation ('negative visualization').Premeditation of the worst that could happen has the potential to forearm a person with adaptive (problem-focused) coping skills as they prepare how to best respond to whatever may come, while providing reassurance of how they can maintain their agency and dignity.There is indeed a strong evidence base that supports the efficacy of this cognitive strategy, which is commonly utilized as covert modelling in stress inoculation training, 47 or as anticipatory coping for individuals who must learn to manage life challenges such as being diagnosed with a chronic progressive medical condition. 48This exercise can be practiced as a form of meditation, active imagination, or with the guidance of a counsellor.about their situation can be changed, and to prepare for events or processes that are inevitable, in this way minimising ongoing sources of avoidable psychological burden.The process of learning how to regulate distressing emotions is taught in cognitive-behavioral therapy as active emotion-focused coping, which includes strategies such as acceptance, or alternatively, emotional buffering (with humor, or cognitive reframing of the meaning of the stressor) to decrease the perceived burden of a stressor on one's life.Interestingly, active emotion-focused coping has been shown to complement the use of problem-focused coping (i.e., using cognitive restructuring to reduce stress) in predicting improved HRQL outcomes among individuals diagnosed with heart failure. 49

| EXERCISES TO LESSEN THE FEAR OF DEATH
Martha Nussbaum noted 33,p.**, that the ancient philosophies of Stoicism and Epicureanism pay a good deal of attention to addressing the human fear of death.Lucretius (first century BCE) proposed that this unaddressed fear lies at the root of lesser anxieties that are commonly experienced, but in patients facing chronic illness and endof-life conditions this fear has the potential to profoundly diminish HRQL.These philosophies proposed that if people reflect upon their mortality, fear of death can be reduced, and they can appreciate the life that remains to them more fully.For Epicureans, for example, the principal meditation asks us to recall that when death arrives, 'we' will not be present to experience any sensation, either of pleasure or pain.Therefore, like a dreamless sleep, there is (literally) nothing to be feared.The Epicureans also ask us to recall that being dead is most probably like how we 'were' before birth, yet we do not fear or lament this.Stoic forms of this memento mori also stress our mortality's naturalness: like birth, it is one moment in the larger life of the cosmos.They also include recollecting the possible immanence of death as a way to focus our attention on the lives we have, so that we don't waste the time that remains on idle concerns or avoidable, negative emotions.These spiritual exercises are extraordinarily challenging because they require one to learn how to accept oneself as being in a reality where they do not exist, which can feel fundamentally alien.Yet qualitative research has documented how individuals with a medical condition that involves premature death (e.g., heart failure) learn to accomplish this feat 50,51 by embracing other features that have intrinsic value or meaning, such as fulfilling their role as a spouse or parent who aspires to support the security and well-being of their family.Interestingly, acceptance of the finiteness of life appears to be liberating, as these individuals report an ability to appreciate the intrinsic value of 'the little things' that are found in daily life. 51

| NIGHTLY SELF-EXAMINATION EXERCISES
Mental health for patients suffering chronic or end-of-life conditions is processual: it tends to improve or deteriorate over time in response to ongoing changes in one's bio-psycho-social life domains.The ancient philosophers understood, like the Hippocratic doctors, the importance of habituation and repetition in shaping how we feel and what we do.For this reason, several ancient schools including the Stoics recommended nightly exercises of self-review or self-examination.In these exercises, the individual reviews what they have said or done over the course of the day, and assesses these behaviours against their core values: have they acted as they would have wished, or were there some actions which they are now critical of?Are there any things they would do differently?The aim of exercises of nightly self-examination is for a person to recall their core values, honestly assess how they have acted, and then commit (in cases where they have fallen short of what they had hoped) to doing better.Nightly self-examination fosters greater self-awareness and clarification of one's intrinsic values and life goals.The therapeutic benefit of this process is expressed most fully as it begins to include unconditional positive regard for oneself, which is foundational to several models of psychotherapy: cf.humanistic psychotherapy, 52 motivational interviewing, 46 self-determination theory, 6 and acceptance and commitment therapy. 53A self-awareness that includes self-acceptance (of both our virtues and limitations) fosters a constructive tension between the present moment and the valued self that one aspires to become more fully.This tension in turn becomes an intrinsic source of motivation for personal growth.Self-examination can be conducted as a self-guided exercise, or as a procedure with a skilled confidant or counsellor.

| EXERCISES TO FOSTER A 'VIEW FROM ABOVE' ON ONE'S LIFE
The human need to assign meaning to our current experiences is addressed in the ancient meditative practices of the 'view from above'.This exercise was recommended by philosophers of different orientations, asking individuals to imagine themselves looking down upon themselves from a great height.This serves to reframe people's challenges and worries, on one hand, reminding them of how small or temporary these are in the larger world, and in the full sweep of time, regardless of however enormous they may feel 'from the inside'.On the other hand, the exercise prompts practitioners to adopt a 'cosmic perspective', one in which they recontextualise their lives as part of the larger cycles and realities of the shared world.This exercise reflects a process that is described in the Transtheoretical Model of Change as self-re-evaluation, and it is considered to play a pivotal role in moving forward with overt changes in one's lifestyle. 54As with self-re-evaluation, the view from above can foster a renewed identity where one views their life as being part of a greater reality that includes the lives of loved ones, the local community, society at large, or the collective human drama that spans history.

| CONCLUSION
This paper has shown how, in Greco-Roman antiquity, the separation of medicine and philosophy was not established.As PWL research has highlighted, the two intersected from a therapeutic perspective around the importance of regimen, and the notion that well-being involves an active process or 'way of life' (Part 1).We have contended that ancient philosophies' prescriptions of personal reflection/meditation and other 'spiritual exercises' do not presuppose strong commitments to any one 'big theory' of human nature or well-being.They respond to beliefs about ourselves and the world that regulate our emotional condition, and which can be challenged or transformed to minimise avoidable distress.In Part 2, we discussed six philosophical exercises which we contend could be included in palliative counselling for patients with chronic illnesses or who are facing the end-of-life: dichotomy of control, premeditation of adversities, examination of emotional beliefs, premeditation of mortality, nightly self-examination, and the view from above.
It is important to stress that these six exercises are offered here as an illustrative sample of the way PWL practices can inform palliative counselling, to minimise patient anxiety (i, ii), fear (iv), disorientation, shame or guilt (v), sadness or other distress (iii), and to foster a sense of wider meaning (v, vi).In proffering this illustrative 'regimen', it is important to stress that Hippocratic principles of tailoring care to individuals, their situation, aptitudes and concerns apply.We acknowledge that a select exercise may assume more therapeutic relevance for an individual patient, while for others, additional exercises, beyond the six illustrated here, might prove to be more helpful.It is also important to stress that individuals must voluntarily undertake these activities to ensure that the process and outcome is personally meaningful and valued.
As philosophical exercises, they are shaped by ideas broadly shared between the philosophical schools.Most importantly, the therapeutic value of these exercises is influenced by how they are taught or administered, which should reflect unconditional regard for patients as reflective, thinking agents whose embodied experience of the world is mediated by what they freely hold to be true and right, and who are capable of thinking for themselves to assign meaning to their experiences.
through promoting a new, philosophically-shaped way of life, including regimens of what Hadot calls 'spiritual practices'.The earliest Greek attempts to account for forms of mental and somatic illnesses, without recourse to theological hypotheses (illnesses as forms of divine judgment or punishment) developed out of forms of Greek natural philosophy, and in connection with Pythagoreanism.Many figures we think of as preSocratic natural philosophers (physikoi), such as Empedocles, undertook what we would classify as medical research, and the philosopher Democritus authored at least four works on medical topics, including Prognôsis, Peri diaitês ê diaitêtikon, Hê iatrikê gnômê and Aitiai periakairiôn kai epikairiôn.26p.5In his Symposium, Plato includes a long speech on Erôs by a medical doctor, Erixymachus, and

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Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jep.13902by Australian Catholic University Library -Electronic Resources, Wiley Online Library on [14/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4 | EXERCISES TO DISTINGUISH BETWEEN WHAT THE INDIVIDUAL CAN AND CANNOT CONTROL Ancient philosophers observed that negative affects like regret and shame concern past things we cannot change, fear and anxiety concern future things we cannot control, and envy and jealousy concern others' possessions of things also not under our volitional command.Patients facing chronic health conditions may feel a profile of such affects, as they try to come to terms with what has happened to them, and their diminished life prospects.The Stoic 'dichotomy of control', most famously stated in Epictetus' Encheiridion 1, asks us to

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EXERCISES TO COME TO TERMS WITH DISTRESSING EMOTIONS Patients facing chronic or end-of-life diagnoses will typically experience a range of negative emotions surrounding what has and may yet occur.Philosophical practices of examining one's beliefs about the world and the situation which underlies the associated affects, in writing or in dialogue with a palliative counsellor may, first, draw out and address any unstated worries that they may be carrying.This process may also help individuals to develop a new perspective that enables them to consider their fears, anxieties, and grief with a new measure of inner distance.Second, making underlying beliefs explicit enables an individual to identify, examine, and potentially cast aside irrational beliefs that do not reflect the realities of the situation, or what they can do about it.Third, this exercise enables patients to formulate action plans to address what

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Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jep.13902by Australian Catholic University Library -Electronic Resources, Wiley Online Library on [14/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License