Summary

I think extreme suffering is more serious than is commonly realized. My drive to prevent suffering is very strong, and I would feel I was failing my values if I took a more relaxed stance on the matter.

Translations: French

Two examples

There are many occasions when I've felt overwhelmed by the horror of suffering in the world. Following are just two of many examples.

On one afternoon, while walking outside, I saw many winged ants on the sidewalk, some of which had been stepped on. I wondered whether I should try to move them out of the way of pedestrians, but there were too many. The sheer number of ants was such that I felt awful thinking about the pain of each of their deaths, multiplied by how many there were. Of course, this is a drop in the bucket relative to nature as a whole, but seeing it up close made the horror sink in.

Soon thereafter, I read about patients being conscious and screaming during surgery. Apparently 0.01% of the US population wakes up during surgery every year:

Some just have fleeting memories of things they heard, but others describe "white-hot pain" and terror, triggering long-term emotional problems. Carol Weihrer of Reston, Va., said that 11 years after awakening during surgery to remove a diseased eye that caused severe pain, she still has post-traumatic stress disorder, can sleep for just short periods and suffers mood swings and panic attacks. Weihrer, who founded the group Anesthesia Awareness Campaign Inc., said she heard the doctor give instructions: "Cut deeper, pull harder." "I actually saw them cut the optic nerve when everything went black," she said. "While you're laying there on the table," she recalled, "you are thinking, praying, cursing, plotting, pleading, trying to crawl off the gurney, trying to kick, scream, move any part of your body to let them know you're awake. In effect, you are entombed in a corpse."

Even the routine preventive procedure of colonoscopy can be agonizing for some patients. Colonoscopies are recommended for all adults every 10 years starting at age 50. Alarmingly, patients may not realize how painful the procedure was because amnesic drugs like Versed prevent memories from being retained. The paper "Midazolam-pain, but one cannot remember it: a survey among Southern German endoscopists" discusses endoscopy, but similar findings may apply for colonoscopy:

Ninety-eight percent of the questioned physicians felt that patients have pain during endoscopy with midazolam+/-opioid, but do not remember later. Ninety-two percent reported that it happens that patients moan aloud because of pain and almost half of the endoscopists (48%) reported of screaming. The majority of the endoscopists (91%) reported fierce defense movements with midazolam or the need to hold the patient down on the examination couch because of fierce movements, respectively (75%). Seventy percent of the endoscopists wished to have the rooms for endoscopy preferably soundproof away from the waiting room [...].

Here's the account of one particular colonoscopy patient:

When I awoke, I was back in the curtained room and my boyfriend was there waiting for me. I felt exhausted and numb. I really didn't remember the things that happened to me, and wasn't really aware of my surroundings for quite some time. My limited speech was slurred. I was told that my examination was fine, but apparently kept asking over and over. Eventually, the drugs wore off completely, I dressed and went to lunch before returning home. It was a good result, and that's what mattered, right? Maybe. Here's what really happened. When I was wheeled into the nearby procedure room, my boyfriend was not allowed to stay in the empty curtained room; he inexplicably had to return to the reception area. When he asked the nurse why he had to move, the nurse would only say that, "Well, when the patients have the procedure, they are sometimes, well......ya know." He didn't question the "ya know," and went to the reception area. But after 35 minutes, he became anxious and walked back to the curtained room. I wasn't there, but he thought he could hear my panicked voice coming from the procedure room. The nurse immediately rushed over to him and told him the colonoscopy was still in progress. He was immediately asked to leave and he did so reluctantly. Unlike I remember it, my boyfriend was brought to the room after I was already there. He said I looked stunned, and that it appeared I had been crying—basically, my eyes and nose were red and watery. The nurse anesthetist was there (again, I don't remember anyone there but my boyfriend), and told him that I was quite groggy because I had "a little difficulty" with the procedure and required more drugs. He was assured I would come out of it soon. He told me I had trouble talking coherently, and that he couldn't understand what I was saying. The nurse told both of us that the procedure "was fine - nothing was wrong," but I don't remember it, and asked about twice later. [...] I now remember waking up and being in great pain. I remember screaming for them to stop, to take it out. I remember being told it was almost over, but screaming that it hurt too much. I am guessing at that point I got more drugs, because I don't recall the end of the procedure—just waking up in the curtained room. [...] I have given birth to two children, so I am no stranger to pain. For me to have cried or screamed means that it was excruciating.

Suffering is not just an intellectual game

In general, the prospective horror of suffering toward the end of life due to any number of medical complications, culminating in the process of dying, has haunted me ever since I watched videos about it in high school, though usually I put it at the back of my mind. Unlike more speculative fears, pain near the end of life has probability near 1, so I can't just brush it off as irrational.

When I get older, I plan to research how to minimize pain during surgery, what options for euthanasia I can pursue, and so, but there's also the unavoidable risk of some accident or illness happening in the near term, putting me in a situation of immense pain and needing to make medical choices before I've done my homework. Or, worse, being incapacitated and unable to make such choices—and given the pro-life and suffering-isn't-so-bad impulses of most people, this possibility is truly frightening.

Most people ignore worries about medical pain because it's far away. Several of my friends think I'm weird to be so parochial about reducing suffering and not take a more far-sighted view of my idealized moral values. They tend to shrug off pain, saying it's not so bad. They think it's extremely peculiar that I don't want to be open to changing my moral perspective and coming to realize that suffering isn't so important and that other things matter comparably.

Perhaps others don't understand what it's like to be me. Morality is not an abstract, intellectual game, where I pick a viewpoint that seems comely and elegant to my sensibilities. Morality for me is about crying out at the horrors of the universe and pleading for them to stop. Sure, I enjoy intellectual debates, interesting ideas, and harmonious resolutions of conflicting intuitions, and I realize that if you're serious about reducing suffering, you do need to get into a lot of deep, recondite topics. But fundamentally it has to come back to suffering or else it's just brain masturbation while others are being tortured. Of course, I'm guilty of plenty of that, and to some extent it's necessary for sustainability. (Rob Wiblin said something like, "Altruism is a marathon, not a sprint.") But basing your whole moral outlook on pleasant abstractions does not seem tenable to a brain wired the way mine is.

In a Facebook comment, I said:

I take a hard line because concern for suffering is just one of many causes a person can be entrained by. It's easy for organisms to let their value systems shift around until what was yesterday's overriding principle is today's lost cause. Consider an example that was floated around recently—live sushi in Japan. That people can take delight in a dining fad without giving a second thought to the (potential) massive suffering they're causing illustrates the wide range of potential human motivational impulses. It's easy for us, in our comfortable houses and with full stomachs, to muse about various moral abstractions that catch our interest. I say no. When you let other things displace the importance of suffering, that's not an improvement but a failure of goal preservation. That future self would be failing to live up to what I care about now, and I don't want that to happen. It's the feeling other altruists would have if they started using all their money to buy expensive cars and mansions. Now, there are plenty of fuzzy moral sub-questions when defining what "reducing as much expected suffering as possible" looks like: What computations are conscious? Do you weight by brain size? How do you handle infinities? Etc. These questions have to be answered to make the suffering-reduction program specific. But they don't involve trading suffering reduction against some other value that tempts euthymic minds, like complexity or knowledge or life or whatever else.

Matt Ball is someone else who understands my perspective:

The single most important lesson I've learned in the past 20 years is that the irreducible heart of what matters is suffering. Back then, although I was sure I knew everything, I really didn't know anything about suffering. Since then, though, I've developed a chronic disease, and experienced times when I thought I was going to die, times when I wished I would die. Back then, I worried about abstractions and words and principles; I argued about exploitation, oppression, liberation, etc. I didn't take suffering seriously. Now, knowing what suffering really is, and knowing how much there is in the world, all my previous concerns seem -well, to put it kindly, ridiculous.

One person suggests that past experience with suffering is "a reason to avoid fighting suffering. Your own experiences have biased you about how bad suffering is. It’s like someone who keeps a year of food in his basement because he had to go without food at times when he was a kid, or checking where your keys are 20 times a day because you once forgot your keys." I replied: "Some of the life experiences that make us unique we choose to keep as intrinsic moral values, while others we disregard. If we didn’t keep any of the 'biases' that our development instilled in us, we might be paperclip maximizers instead. My moral biases are what make me me."

Emotions as incomparable

In 2006, I discussed the problem of trading off suffering against other emotions with a friend. He said that in his experience, different emotions can be not just strong or weak but even "incomparable" with one another; certain emotional states can seem incompatible with memories of other emotional states. I replied that we're forced to compare them, and whatever tradeoffs we make in our decisions imply some exchange rates among emotions. While this is true, I still find a certain wisdom in the view that my friend expressed.

Organisms routinely make welfare tradeoffs—e.g., enduring the cold outside your cave to find food. Being able to make these tradeoffs is even used as an indicator of non-reflex cognition in animals, such as when shocked crabs are more reluctant to give up higher-quality shells. But I think there's some point at which the brain's ability to make these tradeoffs caps out. If an emotion exceeds that threshold, all the organism's resources are channeled toward responding to the emotion. This is particularly true with pain. At some level of agony, there's no benefit that can outweigh the suffering an organism is enduring, and every fiber of its being tries to escape.

O'Brien said it well in 1984 (Part 3, Chapter 5):

But for everyone there is something unendurable—something that cannot be contemplated. Courage and cowardice are not involved. If you are falling from a height it is not cowardly to clutch at a rope. If you have come up from deep water it is not cowardly to fill your lungs with air. It is merely an instinct which cannot be destroyed. It is the same with the rats. For you, they are unendurable. They are a form of pressure that you cannot withstand, even if you wished to. You will do what is required of you.

For an organism in the moment of such an experience, it is literally true that its suffering is worse than all the possible future pleasures in the universe. Call it irrational or scope-insensitive if you like, but there's an empathy gap between you and that organism. You and I right now do not realize how bad it feels, and we cannot internalize it without experiencing it.

For example:

Erich “Mancow” Muller, a Chicago-based conservative radio host, recently decided to silence critics of waterboarding once and for all. He would undergo the procedure himself, and then he would be able to confidently convince others that it is not, in fact, torture. Or so he thought. Instead, Muller came out convinced. “It is way worse than I thought it would be, and that’s no joke,” Mancow said.

Susan Sontag writes about those who have endured war:

“We”—this “we” is everyone who has never experienced anything like what [people in war] went through—don’t understand. We don’t get it. We truly can’t imagine what it was like. We can’t imagine how dreadful, how terrifying war is—and how normal it becomes. Can’t understand, can’t imagine.

It's important to remember this when we try to brush off extreme suffering as "an acceptable casualty when promoting greater happiness."

Of course, suffering reducers should remain practical and conciliatory. We need to compromise with those who feel differently rather than trying to push for radical changes that will almost certainly fail and may tarnish our cause. Rather, my aim with this essay was to explain where I'm coming from and encourage others to better appreciate why some people feel so passionately about this issue.

Epistemic modesty

From my perspective it seems obvious that reducing suffering is the highest priority. I think many people agree that this goal is really important, especially in the abstract, even if they don't have the physical or emotional resources directly to invest in it much themselves. I also think that people in comfortable conditions who do have the resources to work toward reducing suffering can become caught up in entertaining distractions, and because they don't feel the extent of suffering in the world on a daily basis, they assume it has lower priority than they would if they had more direct access to it.

Even though I disagree with others to some extent on these issues, I agree there remains a place for epistemic modesty when assessing ethical tradeoffs, that is, giving weight to the views of others rather than relying solely on my own judgment calls. We can categorize the motivations for ethical epistemic modesty into three, ascending levels of breadth, discussed in the following subsections.

Level 1: How bad are various kinds of suffering?

This level seems important even to the most parochial suffering reducer. His own experiences of suffering do not capture all kinds of suffering experienced by all kinds of people and animals. For instance, even if he thinks an hour of enduring upset stomach is less bad than vomiting and feeling better afterward, it may not be appropriate to impose the same comparison on others. Some prefer to vomit and be done than endure prolonged nausea. There are many more tradeoffs of this type among more diverse forms of suffering. Of course, we shouldn't blindly assume that whatever choice a person makes encapsulates his idealized tradeoff. The pain of avoiding sex when you don't have a condom on hand is less than the expected pain of contracting an STI, but people sometimes have risky unprotected sex anyway.

Level 2: How much does suffering matter compared with other experiences?

In this case, a pure suffering reducer might disregard others' assessments, while someone taking a slightly broader view might indeed count them to a degree. If a person experiences a painful event and concludes, even during that event, that it was worth it for some greater good, it's plausible to agree with this person that it was net good to allow that suffering. I'm more skeptical when people

make these assessments in the abstract, without actually experiencing the events in question—e.g., blithely assuming "torture wouldn't be that bad" because "torture" is just a word they throw around rather than an experience they can recollect and whose seriousness they can internalize, or

make these assessments after the fact—for instance, "Yeah, that was awful, but it was worth it in the end because it paid off." It's easy enough to hold this view now that the pain is over and the fruits are being enjoyed, but your opinion during the agony might have been very different.

Example: Fear of death

One instance where I may need adjustment to my own subjective assessment of different values that people hold is trading off suffering vs. death. Personally I don't understand the drive to avoid death. To me death sounds like a peaceful conclusion to a fulfilling life, and I don't regret it. Of course, I have an obligation to stay alive as long as possible to do as much good for others as I can, but when the inevitable comes, so be it. I agree with the following quote, probably apocryphally attributed to Mark Twain: "I do not fear death. I had been dead for billions and billions of years before I was born, and had not suffered the slightest inconvenience from it."

Yet others seem to feel differently. Fear of death is a major component of religious, cultural, and personal life for many people across the globe. There's even a psychological theory based around the premise that people act in certain ways to cope with death anxiety. It's not just a religious thing; even many atheists I know are deathly afraid of mortality.

More generally, organisms seem to have a will to live even potentially in spite of hedonic self-interest. We see this in the case of terminally ill people who cling to life even when they're in extreme pain. My subjective sense of the value of suffering vs. the value of life is not calibrated to account for this. One approach is to say these people are irrational, but another possibility is that my personal psychology is peculiar, and I'm failing to recognize a genuine feeling that many other people would continue to hold even on reflection.

Level 3: How much weight should we place on a particular moral system rather than another?

This level of abstraction considers not just an organism's assessment of value to himself, for aggregation within a given consequentialist framework, but his assessment of the moral framework itself. Placing epistemic weight on the views of others here is quite controversial. For instance, are you willing to lend some weight to Hitler's moral system? In general, for almost any moral sentiment, one could potentially construct a mind that holds the opposite sentiment.

There are intrinsic, compromise-motivated reasons to place weight on the views of others, but even from an intrinsic perspective, I feel some motivation in this regard. If your moral views imply a conclusion that many other people would regard as atrocious, not just naively but even on reflection, this should at least give you pause. Certain psychopaths may do ghastly acts without seeing what the problem is. If we likewise find a certain moral perspective plausible, even though it strikes horror into the hearts of almost everyone else, aren't we in a potentially similar position?

Of course, there are exceptions. If you lived in a world full of passionate Nazis, your views would contradict those of almost everyone else. In our multiverse, worlds full of passionate Nazis do exist. But as a general principle, it seems that when you go up against overwhelming moral opposition that doesn't budge even after hearing your arguments, it's more likely that you're doing something wrong rather than the opposite.a (Here by "wrong" I'm speaking poetically, in the sense of "something that further reflection would plausibly motivate you not to do" rather than something literally wrong in a confused moral-realist sense.)

So I think suffering reducers should remain sane. They generally shouldn't advocate policies that most smart people continue to regard as evil even after thoroughly understanding the arguments. By all means we should push the envelope of exploration, like moral equivalents of Copernicus and Galileo. But on a practical level, when people fanatically fight for fringe views, they generally make things worse, and this same intuition should moderate our own feelings of the absolute rightness of our cause. (Thanks to Nick Beckstead and others for emphasizing this point.)

Of course, it's tough to make the assessment of when to push a new moral stance and when to defer to majority judgment. Fifty years ago, majority judgment would have asserted that gay marriage is wrong, and animal suffering doesn't matter. That doesn't mean people in the past should have remained content with the status quo. But we should challenge majority judgment first in the realm of ideas. Then if it gains traction, we can move to the realm of practice. In general, there are bad consequences when fringe groups take matters into their own hands; they should start by trying to win hearts and minds.

The moral urgency of suffering is widely recognized

Sometimes it's claimed that placing special weight on reducing suffering relative to other values is abnormal. I agree that in practice, most people's actions don't align with a foremost emphasis on suffering reduction. That said, there is a long history of ethical intuitions consistent with giving special priority to preventing suffering. For example:

The Foundational Research Institute has a more complete bibliography of works that defend various flavors of suffering-focused ethics.