The Ethics of Powerlessness: The Theological Virtues Today.

Our aim is to articulate an ethics of powerlessness, that is, an ethical framework for understanding and responding to circumstances of profoundly diminished agency from the perspective of both the affected individuals and those who care for them. We draw on the resources of phenomenology to make clear the underlying structure of experiences of powerlessness. We further draw on a neglected source in the history of Christian ethics in order to recover an understanding of what Thomas Aquinas described as the theological virtues: faith, hope and love (or charity - caritas). Our hypothesis is that a suitably adapted understanding of the theological virtues can provide the core of an ethics of powerlessness that can in turn provide guidance in navigating the challenges of diminished agency - even for those who do not share Aquinas' specifically Christian faith. We apply the results of our investigation to the contemporary public policy crisis concerning ethical care for aged or terminally ill patients in NHS settings.

Standard systems of ethics are united by a common structural feature: they are characteristically addressed to agents who are empowered to act in response to the demands of their situation. These standard ethical theories then teach the empowered agent something about how to exercise their power and agency. But human lives are often visited by circumstances where the power to act is profoundly diminished. Such circumstances include serious illness, depression, addiction and aging. They also include situations in which carers find themselves powerless to improve the circumstances of those for whom they care. In all these cases, we find ourselves beset by acute feelings of powerlessness. The standard ethical theories are ill-equipped to address these challenges. How do I act ethically when there is little or nothing that I can do to change my circumstances, or those of someone for whom I care, and yet feel there must be something I can and should do? Does ethics have anything to say to persons who find themselves in these situations?

The need for an ethics of powerlessness has been set in sharp relief by recent crises of public policy and public trust, particularly in connection with care for the aged and the terminally ill. Until 2012, the so-called "Liverpool Care Pathway" (LCP) provided guidance to doctors and other carers regarding ethical treatment at the end of life. Following several months of public controversy, the Department of Health confirmed in July 2013 that the LCP will be phased out over the next twelve months. To date no successor framework has been endorsed. Scandals such as the Mid-Staffordshire NHS Trust crisis have highlighted the ethical dangers in this area; but what would it be to get things right? From the perspective of the patient, standard injunctions to self-reliance, self-control and will-power are often counter-productive because they presuppose exactly the sort of robust agency that has been lost. From the perspective of carers, emphasis on such terms as 'compassion', 'vulnerability', 'empowerment' and 'spiritual care', which feature prominently in the relevant guidelines and policy documents, is often insufficient because these concepts are difficult to pin down. We need a fresh approach.

Benefits of the research include:

. An account of diminished agency - in general and with reference to palliative care.
. An account of faith, hope and love as contemporary virtues of powerlessness across religious and secular contexts.
. Improved public policy and care delivery in end-of-life contexts by fostering better understanding of powerlessness, the ethical challenges it raises, and the key terms in which policy documents and practice guidelines conceptualise the issues - such as 'vulnerability', 'empowerment', 'compassion', 'care for the whole person' or 'spiritual care'.
. Advances in on-going debates in virtue theory, virtue epistemology and the philosophy of agency.

Our Ethics of Powerlessness project will apply resources from the humanities to a pressing challenge in ethics and public policy. It directly answers recent calls for fundamental research into the experience of dying and the ethics of palliative care. The events organised by the project and the research outputs themselves will directly inform the on-going review of the practices of care at the end of life.

In July 2013 the Department of Health published the so-called Neuberger Report (NR): More Care, Less Pathway: Review of the Liverpool Care Pathway. The NR called for the phasing out of the Liverpool Care Pathway (LCP), which since 2003 had provided care-guidelines for patients deemed to be dying. The Report also highlighted the lack of specific guidance for nurses caring for patients at the end of life and the need for the Nursing and Midwifery Council to provide such guidance as a matter of urgency. Accordingly, the NR issued an urgent call for research: in particular, it recommends a) that the government fund research, not just into the 'biology of dying' but 'into the experience of dying, because there are critical and legitimate social and health objectives and benefits that must be understood in how patients, their relatives or carers experience care at the end of life' (1.26); and b) a 'collective commitment and plan of action for the whole health and care system to put greater emphasis on caring and compassion' (3.10).

The Ethics of Powerlessness project directly takes up these challenges. It draws on the resources of phenomenology in order to advance understanding of the experiences of terminally ill patients; and it recovers neglected resources from the history of Christian ethics in looking for ethical guidance for care. A fundamental aim of the research is to gain clarity about the "theological virtues": faith, hope and love (or charity - caritas). These virtues are often invoked in the charters of Christian hospices, but it is has been unclear how they can be applied in guiding concrete practices of care. Some healthcare professionals also express unease about applying these Christian ideas in our multicultural society. This makes our inquiry into the conditions under which faith, hope and love can be construed as secular virtues all the more important to help policy-makers in the face of the pressing demand for improved end-of-life care.

The main beneficiaries would be:

. Policy-makers in the field of palliative care, through better understanding of the ethical challenges associated with powerlessness at the end of life, together with an improved understanding of ethical responses to those challenges.
. Patients in end-of-life situations, through improved self-understanding and empowerment in the difficult palliative care decision-making process.
. Their relatives and carers: through improved understanding of profoundly diminished agency and of the potential for faith, hope and love as virtues of powerlessness.
. Medical staff: as stated by the NR, 'care of the dying requires not only substantial technical knowledge and clinical skill but above all it needs excellent communication skills' (p. 10). Improved understanding of experiences of powerlessness will enable health care professionals to communicate sensitively with patients and their relatives.

Benefits will be delivered by means of:

. Consultations with our network of patients, health-care professionals and policy-makers
. Liaising with hospice networks and workforce training
. A series of six public workshops and round tables held at Essex
. Three end-of-year conferences held in London
. Green papers presenting digests of the research and analysing changes in palliative care policies and guidelines
. A website publicizing research material and results, with pod casts of the various events
. Media exposure, including radio broadcasting