Men die in despair, while spirits die in ecstasy. —Balzac

Happiness has been deemed so important as to feature as an unalienable human right in the United States Declaration of Independence. It is, however, a fuzzy concept that means different things to different people. On one level, it can be amalgamated with a range of positive or pleasant emotions such as acceptance, contentment, gratitude, gratification, pride, excitement, amusement, and joy. On another level, it can be thought of in terms of human flourishing or the good life. I have discussed happiness at some length in my book The Art of Failure, and I do not intend to revisit the topic here. Instead, I propose to concentrate on euphoria and, in particular, on ecstasy.

Euphoria derives from the Greek eu- (“good”) and pherein (“to bear”), and literally means “to bear well.” The term has come to refer to any form of intense elation or positive feeling, especially that with an abstract or expansive quality. Such intense elation is uncommon in the normal course of human experience but can be sparked by certain substances and experiences, for example, beauty, art, music, love, orgasm, exercise, and triumph. It can also stem from a number of psychiatric and neurological disorders, in particular bipolar affective disorder and cyclothymia.

The pinnacle of euphoria is ecstasy, which literally means “to be or stand outside oneself.” Ecstasy is a trance-like state in which consciousness of an object, or objects, is so heightened that the subject dissolves or merges into the object. Einstein called this the “mystic emotion,” and spoke of it as “the finest emotion of which we are capable,” “the germ of all art and all true science,” and “the core of the true religious sentiment.”

Like it or not, man is by nature a religious animal, and most, if not all, cultures have interpreted ecstasy in terms of divine possession or revelation, or union with the divine. Many traditions seek to induce religious ecstasy or “enlightenment” by one or several methods, often meditation, intoxication, or ritual dancing. Yet, it is also possible for atheists and agnostics to experience ecstasy “by accident” and to interpret it in other terms, thereby experiencing the deepest religion without getting caught in the trivia and trappings of any one particular religion.

Ecstasy is difficult to describe, in part because its expression is culture-bound. Unless it is induced, it is more likely to supervene in a period of inactivity, particularly a non-routine period of inactivity, or in a novel, unfamiliar, or unusual setting or set of circumstances. The person enters into a trans-like state that typically lasts from minutes to hours, although subjective perception of time and space may be highly distorted. He or she feels a great sense of calm and quiescence and may become tearful and unresponsive up to the point of unconsciousness. The experience is typically described as delightful beyond expression and the first episode as life changing.

One of my friends explained it thus: “It felt like the fulfillment of my life, but, more than that, the fulfillment of all life, of life itself. It put everything into perspective and gave it all unity, purpose, and nobility. It’s completely changed me. Still today, everything that I do—and, perhaps more importantly, do not do—is grounded in that vision, grounded in that reality… It’s as if it’s opened up a channel in my mind. I feel more alert and alive, and often experience small aftershocks of the original experience. These aftershocks can be triggered by the smallest things: the song of a bird, the sun playing into a room, the fleeting expression on the face of a friend, or anything that is slightly heightened or unordinary and in some sense a reminder of the eternal and infinite.”

The friend in question also confided that he had torn up his CV (resume) after realizing that nothing that a CV could get him could be worth having. Ecstasy can lead to one or several such epiphanies. An epiphany, or “eureka moment,” can be defined as the experience of a sudden and striking realization, especially one that is both profound and against the grain (although the term is also used to refer to the manifestation of a divine or supernatural being, and, more specifically, to the revelation of the incarnation of the infant Christ to the Gentiles in the form of the Three Kings). In Sanskrit, “epiphany” is rendered as bodhodaya, which derives from bodha (“wisdom”) and udaya (“rising”), and literally means “a rising of wisdom.”

One of the cardinal features of ecstasy is the dissolution of boundaries, with the individual ego merging into all being. More than at any other time in human history, our society emphasizes the sovereign independence and supremacy of the ego, and the ultimate loneliness and responsibility of each and every individual. From a young age, we are taught to uphold and control the ego, so much so that we have lost the art of letting go. Indeed, we no longer even recognize the possibility of letting go, leading to a poverty or monotony of conscious experience. Today, if anyone cannot or will not remain in tight control of his or her ego, the consequences can be utterly devastating. Yet, letting go can free us from our modern narrowness and neediness, returning us to a primordial Eden. Little children have a quiescent or merged ego, which is why they are brimming with joy and wonder. Ecstasy can make us once again into a little child.


‘Patience’ (forbearing) derives from the Latin patientia, ‘patience, endurance, submission’, and, ultimately—like ‘passivity’ and ‘passion’—from patere, ‘to suffer’. It can be defined as the quality of endurance and equanimity in the face of adversity, from simple delay or provocation to grand-scale misfortune or calamity.

The Old Testament Book of Proverbs tells us that, ‘he that is slow to anger is better than the mighty; and he that ruleth his spirit than he that taketh a city’ (16:32, KJV), and also that, ‘by long forbearing is a prince persuaded, and a soft tongue breaketh the bone’ (25:15). According to Ecclesiastes, ‘better is the end of a thing than the beginning thereof: and the patient in spirit is better than the proud in spirit. Be not hasty in thy spirit to be angry: for anger resteth in the bosom of fools.’ In Buddhism, patience is named as one of the ‘perfections’ (paramitas), and, as in other religious traditions, extends to not returning harm. Thus, Paul’s First Epistle to the Thessalonians exhorts, ‘be patient toward all men. See that none render evil for evil unto any man; but ever follow that which is good, both among yourselves, and to all men’ (5:14-15).

Although patience is often spoken of as a virtue, it can also be construed as a complex of virtues such as self-control, humility, tolerance, generosity, and mercy. Patience also belies several other virtues, not least ambition, hope, faith, and love. If patience is a virtue, it is because it tends to be beneficial—and also very difficult. There are several types of patience, including patience in the face of irritation, patience in the face of boredom, patience in the face of vindication, patience in the face of misfortune, and, most difficult of all, patience in the face of suffering.

The opposite of patience is, of course, impatience, but also hastiness, impetuosity, and perhaps even cowardice, suggesting that patience may have a lot in common with courage. Impatience is the inability or disinclination to endure perceived imperfection. It amounts to a rejection of the present moment born out of an evaluation that it is marred and ought to be supplanted by a more ideal future. More than that, impatience can amount to a rejection of human finitude. Patience recognizes that life is a struggle for each and every one of us. Impatience on the other hand takes offence at things that are not intended to offend, betraying a certain disregard, even contempt, for others, and, by extension, the order of nature.

Impatience implies impotence, which in turn implies frustration, which is sterile and self-defeating in that it serves no purpose other than to make us miserable and turn others against us, rendering us even more impotent and frustrated. Indeed, ‘frustration’ derives from the Latin frustra, ‘in vain, in error’, and is related to fraus, ‘injury, harm’. More subtly, but also more perversely, impatience leads to procrastination, since to put off a difficult or boring task is also to put off the irritation and frustration to which it is bound to give rise.

Today more than ever, patience is a lost virtue. Our individualistic society values ambition and action (or at least activity) above all else, but unlike, say, glamorous courage, patience seems to involve a withdrawal and withholding of the self. Neither is technology helping. In a recent study of millions of internet users, researchers found that, within just 10 seconds, about half of users had abandoned videos that did not start playing. Moreover, users with a faster connection were quicker to click out, suggesting that the pace of technological progress is rapidly eroding our patience. Indeed, much of today’s economy is geared at making things faster and reducing waiting times to next to nothing. In my books The Art of Failure and Hide and Seek, I argue that our increasing impatience has much to do with the manic defence, the essence of which is to prevent feelings of helplessness and despair from entering the conscious mind by occupying it with opposite feelings of euphoria, purposeful activity, and omnipotent control.

Even in the most propitious of times, the so-called ‘egocentric predicament’ makes patience difficult to exercise. Simply put, because I have privileged access to my own thoughts and feelings, I magnify them out of all proportion. If I am impatient in the queue, it is ultimately because I am under the impression that my time is more valuable, and my purpose more worthwhile, than that of the mugs standing in front of me. Thinking that I could do a much better job of manning the till, I give dagger eyes to the cashier, failing to appreciate that she is coming at it from a different place and angle, and with different skills and abilities. An added source of impatience is with my impatience itself, as I vacillate between persisting in the queue and taking abortive action such as asking for another till to be opened, giving up on my shopping, or filing for divorce.

Patience can be looked upon as a decision-making problem: eat up all the grain today or plant it in the ground and wait for it to multiply. Unfortunately, man evolved as a hunter-gatherer, not as a farmer. Our ancestral shortsightedness, manifest in our strong tendency to discount long-term rewards, is borne out by the Stanford marshmallow experiment, a series of studies on delayed gratification led by Walter Mischel in the late 1960s and early 1970s. These studies, conducted on hundreds of mostly four- and five-year-old children, involved a simple choice: either eat this marshmallow now or within the next 15 minutes, or hold back for 15 minutes and be given another one. Having explained this choice to a child, the experimenter left the child alone with the marshmallow, only to return after the 15 minutes had elapsed. Follow-up studies carried out over 40 years found that the minority of children who had been able to hold back for a second marshmallow enjoyed significantly better life outcomes, including higher SAT scores, less substance misuse, and better social skills.

Even so, patience is more than the mere ability to await some future gain. Exercising patience  (note the verb ‘to exercise’) is just like dieting or growing a garden: of course waiting is involved, but it is not just about waiting: there also needs to be a plan in place, and that plan needs to be worked at. When it comes to others, patience does not amount to mere toleration, but to a complicit engagement in their struggle and welfare, often at the expense of our own short-term welfare. In that much, patience is a form of compassion, which, instead of alienating people, turns them into friends and allies.

Rather than enfeeble us, patience frees us from frustration and its ills, delivers us to the present moment, and affords us the time and perspective to think, do, and say the right things—which is why, in psychotherapy, both patient and therapist can require several years together. Last but not least, patience enables us to achieve the greatest things. Being patient does not mean never complaining or giving up, but doing so in a considered fashion, never pettily or pointlessly, and never from an angry place. Neither does it mean withholding, just like ageing a case of fine wine for 10 years does not mean withholding from wine during all that time (God forbid). Life is too short to wait, but it is not too short for patience.

It is much easier to be patient if one can understand that patience can and does secure much better outcomes, not just for others but also and above all for ourselves. In 2012, researchers at the University of Rochester decided to replicate the marshmallow experiment. However, before doing so, they split the children into two groups, exposing a first group to unreliable experiences (broken promises) and a second group to reliable experiences (honoured promises). They found that the children exposed to honoured promises waited an average of four times longer than the children exposed to broken promises. In other words, patience is largely a matter of confidence, or trust, or faith.


1. Krishnan and Sitaraman (2012). Video Stream Quality Impacts Viewer Behavior. ACM Internet Measurement Conference, Nov 2012.

2. Mischel et al. (1972). Cognitive and attentional mechanisms in delay of gratification. Journal of Personality and Social Psychology 21 (2): 204-218.

3. Kidd et al. (2013). Rational snacking: Young children’s decision-making on the marshmallow task is moderated by beliefs about environmental reliability. Cognition 126 (1): 109-114.

This article, which I co-wrote with Abigail Taylor, a 5th year medical student at Oxford, is intended for healthcare professionals.

It guides the reader through the Mental Capacity Act 2005 (MCA) with the aim of clearing up several areas of lasting confusion, particularly in relation to the MCA Deprivation of Liberty Safeguards (DoLS) and its apparent overlap with the Mental Health Act.

The Mental Capacity Act

The Mental Capacity Act 2005 is a piece of legislation intended to protect people who lack the ability to make decisions about their health, welfare, and finances. It replaces Part 7 of the Mental Health Act 1983 and the Enduring Powers of Attorney Act 1985, and was introduced to clarify legal uncertainties around decision-making on behalf of adults with mental incapacity, and to create new safeguards.

Main Principles

  1. Presumption of capacity: a person is presumed to have capacity to make a decision unless it is established otherwise.
  2. Maximising capacity: before a person is deemed to lack capacity, all practicable steps must have been taken to help that person make his own decisions.
  3. Right to make unwise decisions: a person must not be treated as unable to make a decision merely because the decision appears unwise to others.
  4. Best interests: decisions made on behalf of a person who lacks capacity must be made in their best interests.
  5. Least restrictive option: those courses of action that are less restrictive to the person’s rights and freedom must be considered first.

Definition of capacity

Section 2 of the MCA defines capacity as follows:

‘a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.’

Capacity v. competence

  • Competence is the legal right to have one’s decision regarding treatment respected. It is a binary concept: a person is either ‘competent’ or not.
  • Capacity refers to the natural ability to make decisions: a person has a certain degree of capacity in relation to a particular decision at a particular time.
  • Competence is informed by capacity: if capacity is beyond a certain threshold, the person is deemed ‘competent’ to make a decision. This threshold varies according to the seriousness of the decision at hand.

Capacity is contextual and should not simply be inferred from the patient’s diagnosis or from previous assessments of his capacity.

According to Section 3 of the MCA, a person has capacity to make a particular decision if he:

  • Understands the information relevant to decision-making.
  • Retains the information for long enough to make a decision.
  • Weighs-up the information and understands the consequences of a decision.
  • Communicates this decision by whatever means necessary.

Assessment of capacity in adults

Stage 1: Diagnostic test

Assess whether there is a disturbance or impairment of the mind (e.g. intoxication, head injury, learning disabilities, or dementia) which may affect decision-making at this point in time. Your assessment must lean on standardised criteria such as the ICD-10 or DSM-V diagnostic criteria.

Stage 2: Functional test

Assess by the four criteria in Section 3 of the MCA whether this disturbance or impairment renders the person unable to make a decision about the matter in hand. Your assessment should be made on the ‘balance of the probabilities’, meaning that it is more likely than not that the person lacks capacity to make that decision.

Efforts to optimise capacity might include:

  • Making your explanations easier to understand e.g. by using diagrams.
  • Seeing the patient at his best time of day.
  • Seeing him with one of his friends or relatives.
  • Improving his environment e.g. finding a quiet side-room.
  • Adjusting his medication e.g. decreasing the dose of sedative drugs.

Remember to document your assessment and to outline your reasoning.

Assessment of capacity in children and adolescents

As far as possible, minors ought to be involved in decisions about their care, whether or not they are deemed competent.

  • Decisions on behalf of a minor can be made by a person with parental responsibility or by a High Court.
  • 16- and 17-year-olds are deemed competent by the same standards as adults (Family Law Reform Act 1969). However, they cannot refuse treatment if it has been agreed by a person with parental responsibility or the Court and it is in their best interests.
  • Under-16s may be deemed competent to accept an intervention if they are mature enough to fully understand what is proposed (‘Gillick competency’, after Gillick v. West Norfolk and Wisbech Area Health Authority, 1986). Much will depend on the relationship between the clinician and the child and the family, and also on what intervention is being proposed.
  • Ideally, the consent of a person with parental responsibility should also be sought. However, the decision of a competent minor to accept treatment cannot be overruled by a parent.
  • A court order may be obtained to overrule the decision of a competent minor or parent if it is considered in the best interests of the minor.

Deprivation of Liberty Safeguards

The Deprivation of Liberty Safeguards (DoLS) is an amendment to the MCA intended to protect vulnerable adults in care from arbitrary or excessive restrictions on their freedom, and also to give them the right to legally challenge their detention.

In practice, DoLS is pertinent to most mentally incapacitated adults living in care who, for the sake of their own welfare, are prevented from leaving. In such cases, the hospital or care home must apply for authorisation from a DoLS supervisory authority, whether or not the patient (who lacks capacity) is ‘agreeing’ to the arrangements.

DoLS is not applicable to people detained under the Mental Health Act (MHA).


The MHA applies to people with a mental disorder who need to be detained for assessment or treatment in the interests of their own health and safety or the safety of others (see Station X). DoLS is used for people with mental disorders such as dementia and learning disabilities who do not require assessment and for whom there is no medical treatment (for the mental disturbance), and who therefore do not meet the MHA criteria, but who nevertheless require deprivation of liberty for their wellbeing, including for the treatment of physical illness.


Advance decisions

Formerly known as advance directives or living wills, advance decisions enable a person to make decisions about their future care in the event that they come to lack the capacity to make these decisions. An advance decision can only be used to refuse, not to demand. It is valid if it is unambiguous, applicable to the circumstances, and written without coercion at a time when the person had an appropriate level of capacity. If related to life-sustaining treatments, it must also be dated and signed by an adult witness.

Lasting Power of Attorney (LPA)

An LPA is a legal document stating that one person has chosen another to make decisions about his welfare on his behalf, should he lose capacity. There are two types of LPA, personal welfare and property and affairs.

Court of Protection

The Court of Protection can rule upon whether a person has capacity, and, if not, appoint deputies (usually relatives or friends) to make decisions on his behalf. It usually has the final say in the event of a dispute about the best interests of the person who lacks capacity.

The full text of the MCA is available at