Ressentiment often arises from the feeling, in the aftermath, of not having been treated according to our true worth, of not having been put in the place to which we had a right, of not having heard the words we were legitimately awaiting, of not having seen our rights acknowledged. In ressentiment there is certainly anger, but also a disappointed desire for recognition. Yet it takes a certain time to set in — the time of rumination rather than that of reflection on the origin of the possible misunderstanding. It springs from a feeling of failure and helplessness in the relation to the other.
Many elements of varying importance — conscious or unconscious, hidden or visible, quick to form or slow to take shape — contribute to this feeling, which every child has experienced toward its parents at one moment or another of its development. But to be able to look at them with a clear gaze, freed of the idealization and the mythical images in which the child long clothed them — a gaze both critical and affectionate — to stop resenting them for their shortcomings and their mistakes, and to stop suffering from them, is certainly an important moment in the process of maturing toward adulthood. But this overcoming also entails being able to turn the same gaze upon oneself, and recognizing that rights and duties are not distributed in caricatured fashion between each of the actors in the relationship: all the duties for the parents, all the rights for the child.
Ressentiment rests on the feeling of an unjust inequality. Acknowledging one’s duties as much as one’s rights, one’s own as much as those of the other, is the necessary condition for moving toward a relationship of equality and reciprocal respect.
When ressentiment becomes a social bond between individuals and a collective phenomenon, it can be the cement of groups or political movements that privilege emotion and the demand for reparation over information, analysis, and reflection.
To better understand the elements on which ressentiment rests and the mechanisms by which it forms — and thus the means that allow one to prevent its onset or to overcome it once it has set in — I shall draw on the doctor-patient relationship.1
The reasons for choosing such an example are simple: I know these situations well, from professional experience; they concern a large number of individuals in our society — all of us, in fact — and present-day medicine, along with the social and ethical questions it raises, occupies an ever-growing place within them. More and more, the physician feels poorly recognized in his worth and his place, by the patient as much as by society, and the patient feels scorned by the physician and by medicine. I shall put forward the hypothesis that, at the root of these misunderstandings, these conflicts, and the suffering and the ressentiment that flow from them, there often lies the expectation of an ideal relationship of equality between them.
I hope the reader will be able, without too much difficulty, to adapt these reflections — drawn from the field of serious illness — to other situations, such as those that exist between minorities and majorities, old residents and newcomers, the powerful and the powerless, or again between countries and between peoples.
The constitutive elements of inequality and of the feeling of inequality.
They may be structural or contingent, objective or subjective.
It is the patient who suffers and who may die of the illness, not the physician, even if the latter is mortal too. It is easier for the physician to keep his composure than for the patient, whose distress — even when controlled — must not be underestimated when a serious illness is at stake. The physician must take this emotional difference between them into account, and accept a portion of the patient’s reactions, waiting for this distress to subside so that a more rational discussion can begin and develop between them. The arguments — or sometimes the balance of power — are not the same at different moments, for instance at the very beginning of treatment or when the treatment has settled into its cruising rhythm and no longer represents the frightening unknown for the patient.
But the patient must not resent the physician for his relative coldness and take it for indifference to his situation, his suffering, and the dangers that threaten him. If the physician feels too much emotion toward the patient, because the latter is, or appears to him, too close to himself, the rigor of his reasoning is liable to suffer for it. If he is too distant, he risks missing the small signs that, within the relation of empathy, the patient’s body and words address to him, and the patient may rightly complain of the distance that separates them, of being for the physician nothing but a body or an organ to be cured, an illness to be fought.
But the patient can be helped to understand the difference between his goal of being cured and his more or less conscious demand to be emotionally supported, esteemed, pitied, or loved by the physician, and the hierarchy he establishes between these two expectations. Likewise, the physician can be helped to find the right balance between excessive coldness and excessive emotion, the right distance between the patient and himself. But neither one nor the other can occupy all the places, play all the roles in the medical situation, or remain enclosed within the sealed vessel of their impassioned relationship. If the patient is too anxious and troubled by his illness, he can delegate to a third party (a relative, a friend, a person he trusts) a part of the rational dialogue with the physician. And likewise, the physician can be seconded or relieved by others who provide information and advice to help the patient better confront all the consequences of the illness in his daily life.
The patient may consider that the physician is jealous of his knowledge and of the power it confers, which may push him toward a disorderly search for information, a distrust of the physician, or a rivalry with him. In return, the physician may be anxious about the use the patient may make of the information he has gathered, particularly when the patient, relying on it, feels entitled to contest his therapeutic proposals or to seek to impose his own. To avoid the dangerous escalation of reciprocal ressentiment — the physician shutting himself up in the pride of his competence and his so hard-won knowledge, the patient in his distrust of the physician and his neophyte’s confidence in his newfound knowledge — both can be helped to understand that their respective bodies of knowledge do not have the same relevance or the same function. In particular, the physician’s knowledge is necessary for him to define the treatment, to carry it through to its conclusion, and to assume full responsibility for it; the patient’s knowledge helps him preserve his right of oversight over his own life, to maintain an active stance, to follow, understand, and better bear and accept the unfolding of the treatment and its possible difficulties, and to be able to speak of them to his loved ones.
The patient may know a great deal about the illness and about medicine, but the physician relies on a vaster knowledge that constitutes a body of knowledge — not merely a sum of partial pieces of knowledge — as well as on mechanisms of thought (lines of reasoning, causal links, etc.) and an experience that allow him to enrich but also to relativize his knowledge. He may thus be less alienated to that knowledge and less rigid in its use.
More and more patients wish to receive not only accurate and precise information about their illness and their treatment, but also about the way the physician constructs his therapeutic proposals, and more and more physicians look favorably on this and also contribute to the broader information of patients and their families. When the patient reproaches his physician for not telling him the whole truth, it is not always easy to distinguish what stems from the physician’s reluctance to convey the information, from his more or less accurate assessment of the patient’s capacity to bear hearing it, from the limits of his own competence in doing it well, or from the patient’s own limits in receiving and understanding this information.
The physician must certainly take into account the patient’s possible failures of understanding, owing to reasons of language, intellectual competence, or knowledge, but also to their cultural references or their modes of thought, sometimes very different from his own. These have their value within their habitual field of use and constitute important points of support for the patient, but at times they hinder, more or less strongly, the smooth course of the treatment, in particular when patients place them on the same plane as medical knowledge and its therapeutic consequences.
The physician may grow irritated at seeing the patient refuse the treatment he prescribes — a treatment that corresponds to current recommendations. If he knows and understands sufficiently the elements underlying the patient’s attitude, he is more at ease to assess them, to grasp their logic, and to find together with the patient compromises that place the latter in contradiction neither with his references, his bearings, and those around him, nor with the smooth course of the treatment. If such a compromise is not possible, for medical reasons, the patient is freer to make his decision, in full awareness of what he loses of his chances of recovery and of what he preserves of his sense of identity. Likewise, he will be less inclined to think that the physician refuses his demands out of personal antipathy, contempt, or social, ethnic, or religious racism.
But it is just as desirable and necessary that the patient make the effort to understand the logics of the treatment (not only its modalities) and the reasoning or the cultural bearings and references that lie at its origin. And he must also make the effort to explain to the physician his own lines of reasoning, which underlie his attitudes — whether these be passive and silent acceptance, active reluctance, or visible distress. In this way, the physician will not feel that his efforts to care for the patient run up against a wall of incomprehension, an irreducible difference, or an ingratitude that shakes his confidence in the professional choices he has made and in his ideals. Bitterness and disappointment, as well as the loss of ideals, prepare the ground for ressentiment against the other, accused of being responsible for it, and against all the others, accused of having done nothing to prevent it.
It is good for the physician to understand the patient’s modes of thought, and those of his loved ones, but also to help them understand his own. Yet his working time is not without limit, and the time he devotes to this task must not come at the expense of his other tasks and of his other patients — otherwise these latter might feel neglected and come to resent it.
The physician’s therapeutic capacity and the patient’s passivity.
When it comes to a serious and complex illness, it is the physician who possesses the capacity to cure, for self-medication is not possible here. The consequence is a position of relative passivity for the patient. Some bear it or are content with it, only to reproach themselves for it later and resent the physician; others rebel against it, sometimes excessively, at the risk of endangering the smooth course of the treatment. The reasons for these attitudes are often partly unconscious, and are to be sought as much in the elements of the present situation as in fantasies or in the patient’s and his family’s history, sometimes a distant one. It would be unreasonable for the physician to content himself with this passivity on the pretext that it relieves him of the inevitable complexity of the relationship with patients, or that his authority satisfies the tendencies toward alienation in some of them. Treating pain or depressive tendencies, preserving family, friendly, and social attachments, reflecting on the period after treatment and on readjustment to daily life — all these help to counter that passivity. Often, practical solutions to difficulties and to suffering soothe the conflicts and misunderstandings that prepare the ground for ressentiment.
But patients must also free themselves of the image of all-powerful physicians (an image that physicians may share), for if medical advances bring them far more powerful means than before, they at the same time impose on them growing constraints which, added to those that flow from the country’s laws, health policies, and economy, limit their freedom of action.
The risk of ressentiment diminishes when individuals or groups assess their situation in relation to present reality and not in relation to outdated or excessive images of themselves or of others.
Physicians were traditionally reproached for their paternalistic stance (“I know, I decide”). This stance is no longer defended by the medical societies and tends to disappear in practice.2 But it would be a pity if it were replaced by the contractual relationship (“the patient signed or clearly stated his position; he takes responsibility for it”).3 The laws and recommendations of the learned societies do not settle all the difficulties of so complex a relationship between human beings: it remains for each of the actors to invent this relationship, in the informed respect of the rules or in their knowing transgression. He who has done nothing but respect the rules tends, in case of failure, to turn his feeling of anger or guilt against others; he who has been responsible for his decisions, in such a case, may certainly reproach himself for his poor choices or turn his anger against others, but he will be less inclined to unload onto others the responsibility for this unfavorable outcome and to feel ressentiment toward them.
The individual and the group. In the eyes of certain patients, the physician belongs to a powerful group, faced with which they are merely individuals in a position of weakness. It is true that present-day medicine, by reason of its complexity, can no longer be practiced in solitary fashion, and the physician is part of a team or a care network, and often of a learned society. But these groups are more places of stimulating constraints (accounting for one’s work to one’s peers, submitting one’s innovations to them, accepting the recommendations that issue from collective experience) than corporatist structures of defense.
The patient, for his part, may be part of a patients’ association that defends his specific demands, expresses his expectations, his criticisms, his proposals, as much as it contributes to the financing of research and to the improvement of treatment conditions. It is understandable and legitimate that associations — of physicians or of patients — defend their specific interests, but these are not a priori or systematically opposed; they may go in the same direction. Inappropriate confrontations for the sake of prestige or of mistaken principles wear down those who let themselves be ensnared by them, for they leave behind the bitter feeling of time lost and of opportunities wasted. The participation of representatives of patients’ associations in the activities of certain medical societies, and the presence of patient committees in many hospitals, help to attenuate reciprocal distrust and ignorance and to develop a responsible solidarity.
In recent years, numerous legislative measures have been implemented to grant rights to patients with a view to reducing this inequality — on therapeutic trials, the right to information and the right of refusal, on no-fault medical liability, on direct access to one’s medical file, and so on.4 At the same time, other decisions showed the will of the public authorities (with the aim, above all, of economy) to set a limit to certain demands of patients, such as the coordinated care pathway or the limitation of reimbursement for certain medications. It remains to assess their effects, positive and negative, including on the perception of medicine by patients (some behave as consumers of care, or think first of asserting their rights) and by physicians (some feel made vulnerable in the face of patients and think first of protecting themselves from the risk of litigation).
The ideal conditions of an egalitarian relationship, of solidarity and reciprocal respect.
A sufficient reciprocal knowledge and trust.
Misunderstandings may also arise from the difference — not always easy to perceive — between the specific objectives that the physician and the patient have, behind the great common objectives such as curing, prolonging life, treating pain, preserving one’s dignity and one’s identity, and so on.5 6 Thus, the patient may consider that the drawbacks, whatever they may be, of the treatment are excessive in relation to the benefits he believes, rightly or wrongly, he can derive from it, particularly when the prognosis is severe and the chances of recovery slim.
For both alike, behind the principal and conscious objective of recovery, there exist several secondary objectives whose importance may reveal itself at a later stage: the physician, for instance, may want to cure the patient at all costs because the latter reminds him of his father, or in order to demonstrate the value of his innovative treatment; the patient may want to give up the treatment so as not to be an excessive emotional and financial burden on his family, or, on the contrary, may want to live until the birth of his first grandchild. To perceive these secondary aims sufficiently averts the misunderstandings that prepare the ground for conflicts, and the feeling of having been misunderstood that prepares the ground for ressentiment.
Rights and duties of equivalent level
Competence is a duty, and the physician as much as the patient must be equal to the tasks they have to accomplish. It is relatively easy to define the criteria of the physician’s competence. But the patient? Must he know his illness and its treatments sufficiently to preserve his legitimate right of oversight over what is done to him? Must he also strive to preserve his social and family place, his identity-bearing references, in order to remain himself, not to be merely a “patient”? The feeling of having lost what made his worth and his identity, in his own eyes and in those of others, also prepares the ground for ressentiment.
An equivalent level of power.
The physician can state the diagnosis, define the treatment, and bring it about. The patient can choose his physician, have access to his medical file, refuse the treatment. But in this last case, the physician may consider, beyond certain demands of the patient, that he is no longer in a position to guarantee the proper conduct of the treatment.
An equivalent level of responsibility.
The necessary co-responsibility does not necessarily entail the co-decision that some propose and that others criticize, for in the face of his death the patient might reproach himself for being responsible for it on account of the bad decision he made. It is preferable that he address his doubts, his reproaches, his anger to the physician. He may certainly reproach himself for having chosen the wrong physician, for having trusted him too much, but the latter can, in dialogue, accept his criticisms or justify his therapeutic choices.
The physician has responsibilities toward the patient. He must care for him in the most effective way possible, in accordance with current knowledge and experience, national and international, in respect of medical ethics. This ethics entails thinking first of the patient’s good, ensuring that the benefits of the treatment are as far as possible greatly superior to its drawbacks or to the risks it involves (physical, psychic, social), in the short and longer term; doing nothing that would make him lose his dignity; not disadvantaging him in relation to other patients; preserving his autonomy.7
The patient has responsibilities toward the physician. He must preserve normal civil relations: illness, pain, and the risk of death do not excuse aggressive behavior; the medical field is not an extraterritorial zone of society. Likewise running counter to an egalitarian relationship are: the use of the physician solely as a technical instrument of cure, contempt, distrust a priori, systematic checking and incessant criticism, the abusive monopolizing of his time through limitless demands, well beyond the legitimate and necessary exercise of one’s right of oversight and criticism. Such behaviors contribute to the wearing-down of the physician and of care teams. The patient has to find the middle ground between expecting everything of the physician or expecting nothing of him but care, in the posture of a consumer demanding a guarantee of success.
The physician has responsibilities toward others. His investment in one patient must not come at the expense of the others: his time, his human, material, and financial means are not unlimited. Attitudes contrary to good practice and to ethics discredit a department or a hospital. They may result in a reluctance to consult or to seek care, and thus contribute to hindering free access to care. Likewise, the reluctance, for example, to propose to patients that they be included in therapeutic trials has the consequence of slowing the medical advances that everyone wishes for. But unethical practices in medical research, which undermine society’s confidence in medicine, produce the same effect.
Likewise the patient, for example: his demand for costly treatments judged useless by the physician, were it accepted, would come at the expense of the limited resources at the physician’s disposal for all patients; his refusal to take part in therapeutic trials could slow the therapeutic advances that, moreover, he calls for.
The physician has responsibilities toward society. Physicians must make good use of the money and the means entrusted to them. Likewise, they must be equal to the values they embody — values sometimes contradictory with the demands of patients and of society — and not misuse the trust placed in them, not disappoint it.
Likewise the patient. No more than the physician does he have to accept unacceptable practices. He contributes, through his vigilance, his criticisms, and his proposals, individual or collective, to making the physician and medicine evolve positively. But to discredit them unjustly would contribute to the wearing-down of caregivers, to the feeling of insecurity of other patients, as well as to the more general loss of confidence in the values of a society that would accept such practices without reacting.
The physician has responsibilities toward himself. He must remain equal to his vocation, his ideals, his ethical references. The feeling of failure, of shame, of having been mistaken or of having been deceived, heightens the wearing-down, especially if economic difficulties are added to it. And this makes the young hesitate to follow the path of their elders.8 To resist the risk of wearing-down, of regret, and of ressentiment, it is important that the physician, like the patient, be at ease with himself in his situation and in his tasks, in the gaze he turns upon the life choices he has made, that he have a clear gaze on his faults and his limits and a sufficient confidence in his qualities and in the place he occupies in his family and in society.9
The same is true for the patient. He is more at ease when he understands his illness and his treatment, and when these do not represent a financial cost or constraints such as would make him hesitate to accept the treatment. The experience of serious illness is a trial of truth: it awakens emotions and memories, sometimes old ones, gives rise to troubling thoughts, reveals qualities and faults that at times he was unaware of or did not want to see; it prompts him to turn a gaze upon his life, upon his past and present choices, upon his marriage, his relationship to his children, to his friends, as well as upon his ideological, moral, or religious references. It is important that he remain himself while accepting the changes introduced and imposed by the illness and the treatments, and that he not systematically and a priori seek out culprits for his misfortune. It is legitimate for him to expect much of physicians, but no more than what present-day medicine can reasonably offer. Such a balance is certainly difficult to find and to preserve, but it helps him keep an egalitarian relationship with the physician, and to limit the present and future destabilizations that the illness can provoke. These destabilizations may express themselves through aggressiveness, egoism, violence, excessive and inappropriate demands, depression, the posture of victim or of a dependent person to whom everything is owed, ressentiment.
Equality is inseparable from freedom, from dignity, from responsibility.
An equivalent freedom of thought and action is necessary to an egalitarian relationship. This freedom is impeded by the refusal or the incapacity to take reality into account, along with its limits and its constraints. To take them into account does not imply accepting them all, submitting to them passively, or renouncing one’s ideals. This applies to physicians as much as to patients. Their freedom may also be limited by their passions (to cure, to succeed, to be loved or admired, etc.), which influence their decisions excessively, as much as by incompetence, ignorance, misunderstanding. They may likewise be influenced by their loved ones, their community, the ideology of society and public opinion, the media, which may invest in these situations their expectations, their fears, their battles.
Automatism is contradictory with ethics and with freedom. The patient may fear that the physician will mechanically apply treatment protocols. Automatism may come from the inherent logic of the illness, which sometimes imposes its ineluctable evolution. The automatism of the relationship may stem from the similar personality of physician and patient, both prisoners of the same certainty of being right, of the same passion.
Dignity. It is preserved when the patient has the feeling of having, in spite of everything, remained the same, recognized in his fundamental characteristics, still loved and esteemed, and that his life was worth living, in his own eyes and in those of others. The same is true when the physician, tested by the duration and the harshness of his profession, keeps his vocation and his ideals, even if they have evolved.
Responsibility. The physician alone is responsible for his decisions and his acts, even within the framework of present-day collective medicine. The patient, who certainly did not choose to be ill, is responsible for his ways of being ill and of integrating this reality into his life, his identity, his relation to others.
Ethical reflection is mobilized when the advantages and the drawbacks of the decisions to be taken appear equal and their consequences serious in all cases; when the interest of one patient appears contradictory with that of others; when the ways of thinking, the behaviors, and the decisions of the other seem incomprehensible; when there arises the feeling of being alone, not free to decide, of losing one’s dignity, one’s ideals, what made one’s identity. The preservation of a relationship of equality between the actors in these difficult, complex, and trying situations is an indispensable condition for their possible resolution. The necessary respect for oneself and for the other is bound up with it; failing which it is ressentiment — against the other, sometimes the closest one, or against oneself — that triumphs.
Conclusions
The search for equality in these difficult situations demands of each person the effort to preserve, with the same level of exigency, what constitutes his major ethical references: his freedom of thought and action (which may be limited or impeded by elements of reality or by psychic processes), his autonomy and his refusal of alienation, his ideals and his values, his dignity, his responsibility with regard to the tasks that are his own, as well as his respect for himself, for the other, for others.
This equality also demands the recognition of one’s responsibility toward the rights and duties of each — one’s own as much as those of the other. The role of laws or of the constraints exercised by others is certainly important for moving toward a greater relationship of equality, but their effects may be contradictory with their objectives when they are understood as granting rights to one and duties to the other, rather than rights and duties to one and to the other. Good material and social conditions also contribute to a greater equality.
In these situations, the irrational and unconscious thoughts and feelings of the physician and the patient may be strongly mobilized. Likewise, old situations, or their memory, may be reactivated and constitute a distorting filter through which they perceive and understand the present situation. These elements may explain certain inadequate or paradoxical decisions or behaviors. To understand their origin averts the development of misunderstandings and conflicts, and helps one recover the freedom of thought, decision, and action that is necessary to the egalitarian relationship and to the prevention of ressentiment.
Notes
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