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Moral Burnout

photograph of surgeon crying in hospital hallway

Many workers are moving towards a practice of “quiet quitting,” which, though somewhat misleadingly named, involves setting firm boundaries around work and resolving to meet expectations rather than exceed them. But not everyone enjoys that luxury. Doctors, teachers, and other caregivers may find that it is much harder to avoid going above and beyond when there are patients, students, or family members in need.

What happens when you can’t easily scale back from a state of overwork because of the moral demands of your job? It might lead to a specific kind of burnout: moral burnout. Like other varieties of burnout, moral burnout can leave you feeling mentally and physically exhausted, disillusioned with your work, and weakened by a host of other symptoms. Unlike other varieties of burnout, moral burnout involves losing sight of the basic point or meaning of morality itself.

How could this happen? Many people enter caregiving professions out of a desire to help people and do the right thing — out of a deep commitment to morality itself. When people in these professions find that, despite their best efforts, they cannot meet the needs around them, it can be easy to feel defeated.

Over time, the meaning of those moral commitments can become eroded to where all that is left is a sense of obligation or burden without any joy attached to it. The letter of the moral law has survived, but not its spirit.

Moral philosophers often try to defend morality to the immoralist who only cares about themselves and maybe the people around them. But it seems to me that there might be an equally strong challenge from the other side: the hypermoralist who tries to follow morality’s demands as best they can but who is left cold and exhausted, no longer seeing the point of morality though still feeling bound to its dictates. What might the moral philosopher say in defense to this kind of case? It seems that it depends on diagnosing what exactly has gone wrong.

So, what has gone wrong when “moral burnout” appears? First, it seems that, like in normal cases of burnout, the person is not receiving enough support or care themselves. This might be from a systematic failure, such as doctors being unable to get their patients the care they need due to injustices in the healthcare system. It could be from an interpersonal failure, where friends and family members in that person’s life fail to see their needs or adequately support them. Or perhaps it is from an individual failure, such as the person failing to reach out for or accept help.

The main problem is that there is a significant mismatch between the amount of morally significant labor that the person gives and the amount of support and recognition they receive.

This mismatch alone, however, is not enough to explain why the hypermoralist is left cold by morality. Sure, they may feel exhausted and disillusioned with their job or the people around them, but they might say something like “morality is still worthwhile; it’s just that other people aren’t holding up their end of the deal with me.”

What else is required to become disillusioned with morality itself? Especially for those who were raised to take all the responsibility on themselves, it’s easy to misunderstand morality as having to do only with duties to others and not at all with duties to oneself. In this case, the person can fail to properly value or take care of themselves, and lose sight of an important part of morality – self-respect. It is no surprise that this kind of person would become disillusioned.

Even for those who understand the importance of duties to oneself, it can be easy to fall into a similar trap of self-sacrifice if no one else will take responsibility for a clear and present need.

Another possibility is that, even though the person recognizes and works to fulfill duties of self-respect and self-care, they may find themselves caught up in a kind of rule fetishism, where morality becomes merely a list of moral tasks to complete. Self-care becomes another obligation to fulfill, rather than a chance to rest and recuperate. In this state, morality can seem to be a matter solely of burdens and obligations that must be completed, without the sense of meaning that one would normally get from saying a kind word, helping someone else, or standing up for oneself. Perhaps the hypermoralist has lost sight of the possibility of healthier relationships with others, or is unable to set healthy boundaries within their relationships or accept friendship and help from others.

Like friendship, morality is not transactional – it isn’t simply a set of tasks to complete. Morality is essentially relational.

Though praising and blaming ourselves and others for the actions we perform is a core part of our moral practices, these norms allow us to analyze whether we stand in the right relation with ourselves and with others. It is no surprise, then, that the hypermoralist has lost the meaning of morality if they have substituted its relational core of love for self and love for others with a list of tasks and obligations that lack relational context.

So, what can the hypermoralist do to regain a sense of moral meaning? The answer to that question depends on a host of considerations that will vary based on the individual in question. The basic gist, however, is that it’s vital to seek meaningful and healthy relationships and advocate for support when it’s needed. For example, a doctor in an unjust working environment might protest the indifference and profit-motivation of insurance companies who stand in the way of their patients getting the care they need. Ideally, this would not be another task that the doctor takes up alone but one that allows them to be in solidarity with others in their position — meeting people they can trust and rely upon along the way. Seeking out those meaningful and healthy relationships (moral and otherwise) can be tricky. But I hope for all of us that we can find good friends.

Should I Stay, or Should I Go: Holidays in the Age of Coronavirus

photograph of "Stay Safe" message among pumpkins and thanksgiving background

Some of the busiest holidays in America Thanksgiving, Christmas, and New Years bring floods of people into airports, who are all looking to travel across the country to see family that they might not have seen all year. Normally, the last few months of the year bring plenty of opportunity for those families to meet each other over pounds of food and gift exchanges. The year of 2020, however, is anything but normal. The coronavirus has put a halt to any and all ideas of what was once considered typical. This virus has been ravaging the world for almost a year now, and the country has managed to still celebrate some holidays, such as the Fourth of July, as summer weather allowed for outdoor gatherings where it was easy to social distance, and harder for the virus to spread. Now that winter is coming on, however, these get-togethers will have to be inside the homes of Americans, with far more risk of transmission. As cases climb and hospitals fill, one has to ask what the appropriate course of action is for Americans who want (understandably) to visit family during the holidays, while this pandemic is surging forward with little end in sight.

As scientists have been concerned about since the beginning of this pandemic, the world appears to be entering a second wave of coronavirus cases. After opening up during the summer months, Europe is introducing new restrictions limiting which businesses can open, as well as night curfews for citizens, as they see cases beginning to surge across the continent. Due to far less restrictions than Europe, and the lack of a cohesive federal response to COVID, America never really cleared the first wave of the virus. While the summer months saw a decline in cases, recently the country set a new record of 90,000 cases in a single day, bringing the total cases to nearly 9 million just in the U.S. As cases rise, hospitals are quickly beginning to fill up, which when this virus first hit led to people dying in hallways of hospitals, mass burials, and hospital workers not having proper equipment to protect themselves from the virus. While in the summer it appeared as if the country was past those horrible conditions, the colder months have brought a reminder of the fact that the world is still very much in the midst of this pandemic.

As the temperature grows colder people are coming in contact more often in enclosed spaces, which increases the spread of the virus. But there is also the issue of pandemic fatigue. This virus has taken over every aspect of life, putting extra stress on everyone’s lives. People have had to create new routines and question behaviors that they once thought completely normal, like hugging grandma. People are growing weary of the fact that life is not what it once was, and that there is an ever-present threat that continues to loom over the entire globe. This exhaustion can lead to an increase in cases as people begin to exercise more risky behavior, like dining inside or going to large events, as if we’ve beaten the virus. As we head into the holidays it makes sense that people want to spend time with their loved ones, especially ones that they haven’t seen for months. The winter months already see a combination of seasonal depression with regular depression among people, and COVID certainly led to a decline of mental health among Americans. The rates of both suicides and opioid overdoses have become very concerning for public health experts who warn of an underlying mental health crisis as a result of the stress and anxiety surrounding the coronavirus. People have been isolated from their families and friends for months because of travel restrictions, and now is the time when people most often travel to see their loved ones. It makes perfect sense that people would want to gather for comfort and strength in these very uncertain and stressful times. Many families have lost loved ones — there are over 230,00 deaths in the U.S. currently — and this is the first time that they will have to experience these holidays without those people present. Grief is a powerful emotion, and mixed with pandemic fatigue, this may lead to people willing to take more risks in order to seek comfort in their families.

The winter holidays are most definitely some of the busiest days of the years for travel, either by car, plane, or other transport. This creates a big risk for people who want to visit their families, but need to visit airports to make it home. Just last year over 45 million people traveled on American airlines throughout the globe over this time period. Considering the fact that many countries have restrictions on who can come in, and America is often on the list of those nationalities who are not allowed in, that number will most definitely be lower. Masks are required throughout the airports and during the flight, which would make it seem as if these flights were quite safe. A new study even came out recently which concluded air travel was safer than eating at a restaurant, albeit this study was sponsored by the air industry, which is desperate for flyers due to the loss of revenue from air travel being restricted throughout the entire globe. A recent long distance flight to Ireland, however, questions the validity of this study as 13 passengers tested positive for the coronavirus on the flight, and then passed it on to people in Ireland, for a total of 59 cases all linked to this flight. Throughout the pandemic, the coronavirus has shown how little we actually know about the virus, as even mask wearing was once deemed not important by health officials. But now calls for a national mask mandate have been amplifying, as they have proven to be extremely effective in stopping transmission of the virus. So the question of risk regarding air travel remains up in the air.

This last year has probably been one of the most stressful, if not the most stressful, period of most people’s lives around the world. This virus is something that none of us can ignore because it affects everyone. If it takes the whole world to spread the virus, it seems it is going to take the whole world working together in order to stop it. This end appears to still be quite a ways off, however, and people are still left with a feeling of inevitableness of this eternal feeling of waiting. Understandably, the first instinct for a lot of people might be to reach out to those closest to them. Some might want to continue decades-long traditions that their families have carried on in an attempt to find a sense of normalcy in these strange times. The Centers for Disease Control (CDC) has information on their website to help people make responsible decisions if they decide to have some sort of celebration for the holidays. But, one must remember that these are strange times, and any contact with people outside those you live with carries some level of risks. As with most things during this pandemic, people will have to consider the risks of celebrating the holidays this year with those they hold most dear.

The Politics of Depression

blurred photograph of crowd on busy street at night

In contrast to the exuberant energy of the 2016 presidential election (for better or for worse), the 2020 election has been characterized by fatigue, anxiety, and even depression. Regardless of which candidate triumphs in the presidential election, many voters on both sides can’t help feeling daunted by the government’s inability to meet the needs of its citizens.

The language of illness has always been a useful lexicon for politics; the metaphor of the “body politic” informed statecraft in Europe for centuries, and enemies of the state have always been described as a disease eating away at that body. But for those members of the body politic struggling with mental illness, the question is how to remain politically active while battling depression, especially when the stakes are so high.

Depression may be the mental illness par excellence for political discourse under capitalism. While capitalism has been linked to schizophrenia (we are expected to be sober workers by day and hedonists by night, as sociologist Daniel Bell points out, which ultimately creates a fractured psyche), Mark Fisher draws comparisons between his experiences with depression and the mindset induced by capitalism. In his 2009 book Capitalist Realism, he writes that “while sadness apprehends itself as a contingent and temporary state of affairs, depression presents itself as necessary and interminable: the glacial surfaces of the depressive’s world extend to every conceivable horizon.” He sees a parallel between the “the seeming ‘realism’ of the depressive, with its radically lowered expectations, and capitalist realism.” As Fisher understands, enacting political change and fighting depression are struggles against a similar opponent.

Depression itself is becoming increasingly political, both in terms of how we conceptualize it and how we attempt to cure it. Danish literary critic Mikkel Krause Frantzen proclaims in an incendiary essay for the LA Review of Books that “any cure to the problem of depression must take a collective, political form; instead of individualizing the problem of mental illness, it is imperative to start problematizing the individualization of mental illness.” He asserts that “Dealing with depression—and other forms of psychopathology—is not only part of, but a condition of possibility for an emancipatory project today. Before we can throw bricks through windows, we need to be able to get out of bed.” This political approach to illness is rooted in a wider politicization of illness. For example, Anne Boyer writes in her recently published memoir about cancer, The Undying, that “Disease is never neutral. Treatment never not ideological. Mortality never without its politics.” Boyer rejects apolitical cancer treatment, noting that “Our genes are tested, our drinking water is not. Our body is scanned, but not our air . . . The news of cancer comes to us on the same sort of screens as the news about elections.” Like cancer, depression is often viewed as purely somatic, not as a condition with a basis in the material reality of the afflicted.

When we acknowledge that material reality, we create the potential to radicalize those with mental illness. However, the fatalistic mindset of depression often discourages political engagement. One study conducted by researchers at Pennsylvania State University, which argues that “that depression is a political phenomenon insofar as it has political sources and consequences,” found that mental illness “consistently and negatively affects voting and political participation.” Furthermore, “depression also has developmental consequences for political behavior. Adolescent depression has the potential to set individuals on a trajectory of political disengagement in adulthood.” The study paints this as a vicious cycle; without adequate mental health care, we become depressed, and then depression inhibits political engagement, which prevents healthcare policies from ever changing. The study concludes that though research into the neurological aspect of depression is extremely important, it is also,

“worthwhile to theorize about depression in terms of the social model, especially because the experience of a mood disorder such as depression is largely rooted in social circumstances. Depression is socially-situated in so far as it is not something that simply ‘happens’ to someone but arises out of the circumstances of life. This is compounded by the fact that traditionally disadvantaged groups disproportionately experience depression.”

So how can the mentally ill break out of that vicious cycle? There is no easy solution to this dilemma. Even recognizing that major changes that need to be enacted in order to create a liveable world isn’t always enough. As Frantzen says, “there is no reason to believe that abolishing private property ownership, or realizing a global and absolute cancellation of private debt, will relieve the suffering of depressed people with a single stroke, as if by magic.” For voters experiencing a sense of hopelessness at the polls, and who fear plunging to an even greater depth of hopelessness on election night, a radical kind of self-care is needed. Many have already pointed out the often vacant politics of “self-care,” which does not always promote social change as much as we’d like it to. But when self-care is able to foster “not competition among the sick, but alliances of care that will make people feel less alone and less morally responsible for their illness,” in Frantzen’s words, it is certainly a step in the right direction.

Depression, “Special K,” and the FDA

refracted rings of yellow light emanate from red core

Recently approved by the FDA is the newest groundbreaking antidepressant by the name of Esketamine. In the form of a nasal spray, the drug can treat symptoms of depression in a matter of hours. Esketamine is composed of the chemical ketamine and will be produced by the company Johnson & Johnson. This drug could offer relief to those who are suffering from Treatment Resistant Depression (TRD). TRD is when people have tried two or more antidepressants without success. Major depressive disorder effects 300 million people globally and approximately 1 in 3 people that suffer from depression would qualify for the treatment.

There are many positives that come from this new drug. Depression is still widely studied and is difficult to treat because everyone responds differently to antidepressants. Esketamine gives those who were once hopeless a new option for finding a successful treatment. Those who take the drug will no longer suffer from the very serious mood disorder that once hampered their daily lives.

In addition, this research has led to groundbreaking findings relating to the drug ketamine, the major component in esketamine. Ketamine is used as an anesthetic for “children or patients undergoing minor surgeries”and veterinary purposes. However another main use of ketamine was its infamous reputation as a party drug, called “special K.” Taken at high doses, ketamine can cause users to hallucinate and lose sense of time and reality. People “trip” on the drug in the same way they might trip on LSD and other hallucinogenic drugs. The drug became such a problem that in 1999 the federal government classified ketamine as a Schedule III controlled substance to make an effort in stopping its recreational use.

Patients who take esketamine can experience side effects from ketamine. Such side effects are serious and can lead to memory loss, hallucinations, and loss of body control. That’s why ketamine is unique in depression treatment as the drug cannot be brought home. Instead, the antidepressant is administered from a certified treatment center. Patients are required to return to the treatment centers once or twice a week.

One issue to consider with ketamine is its limited accessibility. Because the drug needs to be closely monitored, the only people able to receive the treatment are those with access to authorized treatment centers. In addition, the list price of the drug is currently set at $590 to $885 per treatment session depending on the dosage. For just the first month of treatment, the expected price range is between $4,720 and $6,785. This limits the usage of the drug to only those who can afford to take it.

While the FDA approved the treatment, it was given a “black box warning,” the most serious warning that can be issued. “It will caution users that they could experience sedation, problems with attention, judgement and thinking, and there’s a potential for suicidal and abusive thoughts,” explains the Washington Post. The FDA advisory committee approved the drug in a vote 14-2. The approval process differed from other approved antidepressants. TRD qualifies the drug for “fast track” approval because of the severity of the disorder and the need of the product. Instead of having two positive short-term trials of the drug, keramine only had one positive trial. It then had a second trial that was a withdrawal study.

Kim Witczak is a member of the advisory committee and a consumer representative that voted against the drug. Witczak wrote in a blog that she feared the limited case trials and the serious side effects that come with the drug outweighed the potential benefit the drug can bring. She said, “I cannot vote for something when the perceived benefits do not clearly and demonstrably outweigh the potential for known harms such as sedation, dissociation, and long-term cognitive or memory loss — this is especially so considering the extremely limited positive clinical trial results.” In her rebuttal, she criticized the ineffectiveness of other trials and how there was only one positive short-term trial. There were also participant suicides that occurred during the trials that were “glossed over and presented as unrelated.”

Although Witczak is just one opinion on the FDA advisory board, it is still important to consider her objections. In particular, Witczak notes the conflicts at the heart of FDA drug approval. Should we “fast track” drugs that have an urgent demand? Should we scale down the process to help more people quicker?

The hope is that Esketamine is just the start of treatments that more effectively treat depression. Although it is called groundbreaking today, we could also consider other drugs that were groundbreaking at the time. Prozac was the game changer antidepressant in the 1980s and it was only after this that people discovered the true inadequacy of antidepressants and the dangers associated with them including suicide and withdrawal. With a drug with so many risks like ketamine it is intriguing to think of the impact it will make in the long run.

Sparking Joy: The Ethics of Medically-Induced Happiness

Photograph of a sunflower in sunshine with blue sky behind

Happiness is often viewed as an ephemeral thing. Finding happiness is an individual and ever-developing process. Biologically speaking, however, all emotions are the simple result of hormones and electrical impulses. In a recent medical breakthrough, a team of scientists has found a way to tap in to these electrical impulses and induce joy directly in the brain. This kind of procedure has long been the stuff of speculation, but now it has become a reality. While the technique shows a good deal of promise in treating disorders such as depression and post-traumatic stress, it also presents an ethical conundrum worth considering.

On initial examination, it is difficult to point out anything particularly wrong with causing “artificial” joy. Ethical hedonism would prioritize happiness over all other values, regardless of the manner in which happiness is arrived at. However, many people would experience a knee-jerk rejection to the procedure. It bears some similarity to drug-induced euphoria, but unlike illicit drugs, this electrical procedure seems to have no harmful side effects, according to the published study. Of course, with a small sample size and a relatively short-term trial, addiction and other harmful aspects of the procedure may be yet undiscovered. If, as this initial study suggests, the procedure is risk-free, should it be ethically accepted? Or is there cause for hesitation beyond what is overtly harmful?

The possibility of instantaneous, over-the-counter happiness has been a frequent subject of science-fiction. Notable examples include Aldous Huxley’s Brave New World, which featured a happiness-inducing drug called “soma”; and Philip K. Dick’s Do Androids Dream of Electric Sheep? (later adapted into the film Blade Runner), which included a mood-altering device called a “mood organ.” Both novels treat these inventions as key elements in a dystopian future. Because the emotions produced by these devices are “false”—the direct result of chemical alteration, rather than a “natural” response to external conditions—the society which revolves around them is empty and void of meaning. What is the validity of this viewpoint? Our bias towards what we perceive as “natural” may be simply a matter of maintaining the status quo–we’re more comfortable with whatever we’re used to. This is similar to the preference for foods containing “natural” over “artificial” flavoring despite nearly identical chemical compositions. While we are instinctively wary of the “artificial” emotions, there may be no substantive difference to the unbiased feeler.

Of course, emotions exist for more than just the experience of feeling. The connection between emotions and the outside world was addressed by Kelly Bijanki, one of the scientists involved in the electrically-induced happiness study, in her interview with Discover Magazine: “Our emotions exist for a very specific purpose, to help us understand our world, and they’ve evolved to help us have a cognitive shortcut for what’s good for us and what’s bad for us.” Just as pain helps us avoid dangerous hazards and our ability to taste bitterness helps us avoid poisonous things, negative emotions help drive us away from harmful situations and towards beneficial ones. However, living in a modern society to which the human body is not biologically adapted, our normally helpful sensory responses like pain and fear can sometimes backfire. Some people experience chronic pain connected to a bodily condition that cannot be immediately resolved; in these cases, the pain itself becomes the problem, rather than a useful signal. As such, we seek medical solutions to the pain itself. Chronic unhappiness, such as in cases of anxiety and depression, could be considered the same way: as a normally useful sensory feedback which has “gone wrong” and itself become a problem requiring medical treatment.

What if the use of electrically-induced happiness extended beyond temporary medical treatments? Why shouldn’t we opt to live our lives in a state of perpetual euphoria, or at least have the option to control our emotions directly? As was previously mentioned, artificial happiness may be indistinguishable from the real thing, at least as far as our bodies are concerned. Human beings already use a wide variety of chemicals and actions to “induce” happiness–that is, to make ourselves happy. If eating chocolate or exercising are “natural” paths to happiness, why would an electrical jolt be “unnatural”? Of course, the question of meaning still bears on the issue. Robert Nozick argues that humans make a qualitative distinction between the experience of doing something and actually doing it. We want our happiness to be tied to real accomplishments; the emotion alone isn’t enough. More concretely, we would probably become desensitized to happiness if it were all we experienced. In the right doses, sadness helps us value happiness more; occasional pain makes our pleasure more precious.

If happiness in the absence of meaning is truly “empty,” our ethical outlook toward happiness should reflect this view. Rather than viewing pleasure or happiness itself as the ultimate good, we might instead see happiness as a component of a well-lived life. Whether something is good would depend not on whether it brings happiness, but whether it fulfills some wider sense of meaning. Of course, exactly what constitutes this wider meaning would continue to be the subject of endless philosophical debate.


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Why Act When It Doesn’t Make a Difference?

This post originally appeared on May 28, 2015.

I’ve got a friend who’s suffering from depression. He’s been holed up in his house for the last two years; living first on sick pay, then savings; venturing out only for fish and canned vegetables. (“They’re healthy.”) I visit him from time to time, which isn’t often enough, and I excuse the infrequency with a lame thought: it doesn’t matter whether I go.

The problem is not that I’m wrong. He doesn’t want visitors, we have the same conversation each time, and he isn’t getting any closer to the man he once was, all bright and bounding. If I’m showing up to make a difference, I’m probably wasting my time.

This defense of inaction is psychologically powerful. We know how the election will play out, so we don’t vote. We know that having tofu won’t save a cow from slaughter, so we have the burger. We know that Old Navy isn’t going to notice whether we shop elsewhere, so we may as well save some money. When we can’t make a difference, why bother?

Sometimes, because we’re wrong. It only seems like we can’t make a difference because so many people contribute to the effect. This tends to be the story in consumer ethics: industries don’t care about what any one person does, but they certainly care about what lots of people do, and “lots of people” don’t do anything if we don’t do something.

In other cases, we really can’t accomplish what we’d like—too few are willing to take up the cause—but we can do something else worthwhile. Consider, for example, participating in Adjunct Walkout Day. My university isn’t going to start paying adjuncts a living wage, so canceling class for their sake feels pointless. By joining in, though, we stand in solidarity with those who aren’t being treated fairly, insisting that wrongdoers be held accountable. That’s a far cry from achieving securing fair wages, but it still isn’t trivial to encourage and criticize, respectively, those who deserve encouragement and criticism.

All that said, my friend’s depression isn’t a collective action problem; it isn’t as though a few more supporters will tip the scales. Protest won’t help either: depression may be a thief, but it can’t be shamed. And we could conclude, on this basis, that my excuse is a good one. But I remain unsatisfied by it. When I drive the twenty-two miles to his door, I’m his friend. When I pick up a book instead, I’m not. And that choice isn’t trivial.

It might sound like I’ve just made this about me. “I can’t make a difference in my friend’s life, but I can make a difference in mine: I can choose what sort of person I’ll become, the ideals that I’ll embody.” And although those things are true, they’re beside the point.

Which is this: sometimes, difference-making doesn’t matter. If I’m going to be a friend, I’m going to sit with him in his depression. Not at the expense of everything else in my life—that’s martyrdom. But at real expense, since that’s what friendship involves. Likewise, if I’m a citizen, I vote; if I’m compassionate, I don’t want anything to do with factory farms. That’s what it is to be a friend, or a citizen, or compassionate. And that’s why we aren’t bad friends or citizens if we fail, or a little less compassionate when we keep eating animals. Rather, we are “friends” and “citizens” and “compassionate.” We have different versions of these relationships and roles and virtues—the paltry, calculating ones where “This is my country” isn’t argument enough for voting, and “That creature suffered needlessly” isn’t argument enough for abstaining. Not so with the versions worth having: they settle how we ought to proceed. (Indeed, that’s much of why they’re worth having.)

Why act when it doesn’t make a difference? In some cases, because it does—though only with some help, or not how we’d hoped. But often enough, this is the wrong sort of question to ask, and the right kind is much simpler:

Are we friends?