Introduction

Alleviating suffering is generally accepted as one of the fundamental endeavors of medicine (Jansen and Sumasy 2002) however what this means and entails remains unclear. In principle suffering is distinct from pain and ultimately a deeply personal and subjective matter.Therefore, to appropriately value and engage with the phenomenological experience of a patient’s suffering, physicians and bioethicists must acknowledge the subjective dimension of suffering. However, as Cassel (1991) outlines, this poses a dilemma to contemporary medicine because of its association with science and standards like objectivity and generalizability.  Cassel offers two alternatives for medicine : A) retain its alignment with science thus renounce/ignore reality of suffering; or B) acknowledge the reality of suffering thereby jeopardize the scientific status of medicine.

Whether Cassel’s dilemma is a false dichotomy remains open for discussion. Nevertheless, in medicine an appropriate understanding and response to suffering remains essential to understanding the ‘whole person’ and counsel patients faced with difficult situations such as palliative care, end of life decisions, and medical aid in dying.

*see the seminar series tab on medical aid in dying for more information on this topic*

Assigned Readings

The following papers were used to inform and ground the discussion:

Edwards S. D. (2003). Three concepts of suffering. Medicine, health care, and philosophy6(1), 59–66. https://doi.org/10.1023/a:1022537117643

Thesis: Edwards provides a critical assessment of suffering models and sketch a more plausible concept using intuitive method from Wittgeinsteinian linguistics ie reveal and determine meaning by use of language

Jansen, L. A., & Sulmasy, D. P. (2002). Proportionality, terminal suffering and the restorative goals of medicine. Theoretical medicine and bioethics23(4-5), 321–337. https://doi.org/10.1023/a:1021209706566

Thesis: Jansen and Sulmasy call for a reformulation of the proportionality principle in medical decision making and the need to embrace a biopsychosocial model to distinguish between types of suffering and respond to them adequately.

Discussion Questions

The following questions were considered by seminar participants prior to the discussion.

  1. Name a few of the problems for both Cassell’s and van Hooft’s theories of suffering, as articulated by Edwards.
  2. Explain Edwards’s Wittgenstein-inspired ordinary usage theory of suffering. What are its strengths and weaknesses? 
  3. Explain Jansen and Sulmasy’s distinction between neuro-cognitive suffering vs. agent narrative suffering. 
  4. Reconstruct Jansen and Sulmasy’s main argument and evaluate (e.g., do the conclusions follow from the premises, are there hidden assumptions/premises, are the premises true)?

Reflection Points

In discussion, seminar participants reflected on the following points.

  1. One’s integrity can be threatened by pain.
  2. Physicalist view of mental states rejects the distinction between neurocognitive suffering and agent-narrative suffering.
  3. Stipulating definitions of suffering often creates a gap between technical language and moral/conceptual significance.
  4. In cases of suffering motivations for medical aid in dying we should cover our bases epistemically and follow validated treatment algorithms, before we conclude that further intervention would not be beneficial.
  5. Restoration is a foundational goal of medicine.
  6. Restoration may be one of the goals of medicine only insofar as it alleviates/prevents suffering.

References and Additional Resources

Tate, T., & Pearlman, R. (2019). What We Mean When We Talk About Suffering—and Why Eric Cassell Should Not Have the Last Word. Perspectives in Biology and Medicine 62(1), 95-110. doi:10.1353/pbm.2019.0005.

Svenaeus, F. (2014). The phenomenology of suffering in medicine and bioethics. Theor Med Bioeth 35, 407–420. https://doi.org/10.1007/s11017-014-9315-3

Frank, A.W. (2019). Suffering, Medicine, and What Is Pointless. Perspectives in Biology and Medicine 62(2), 352-365. doi:10.1353/pbm.2019.0019.

Connelly, J. E. (2009). The Avoidance of Human Suffering. Perspectives in Biology and Medicine, 52(3), 381-91. https://www.proquest.com/scholarly-journals/avoidance-human-suffering/docview/233166354/se-2?accountid=11862

Edwards, S.D. (2003). Three concepts of suffering. Med Health Care Philos, 6(1):59-66. doi: 10.1023/a:1022537117643. PMID: 12710565.

Jansen, L.A. & Sulmasy, D.P. (2002). Proportionality, terminal suffering and the restorative goals of medicine. Theor Med Bioeth 23(4-5):321-37. doi: 10.1023/a:1021209706566. PMID: 12516836.