The Nature of Suffering and the Goals of Medicine

The question of suffering and its relation Suffering can include physical pain but is by to organic illness has rarely been addressed in the no means limited to it. The relief of suffering and medical literature. This article offers a description the cure of disease must be seen as twin obligeof the nature and causes of suffering in patients tions of a medical profession that is truly dedicated undergoing medical treatment. A distinction based to the care of the sick. Physicians' failure to underon clinical observations is made between suffering stand the nature of suffering can result in medical and physical distress. Suffering is experienced by intervention that (though technically adequate) not persons, not merely by bodies, and has its source only fails to relieve suffering but becomes a source in challenges that threaten the intactness of the perof suffering itself. (N Engl J Med. 1982; 306:639son as a complex social and psychological entity45.) The obligation of physicians to relieve human suffering stretches back into antiquity. Despite this fact, little attention is explicitly given to the problem of suffering in medical education, research, or practice. I will begin by focusing on a modern paradox: Even in the best settings and with the best physicians, it is not uncommon for suffering to occur not only during the course of a disease but also as a result of its treatment. To understand this paradox and its resolution requires an understanding of what suffering is and how it relates to medical care. Consider this case: A 35-year-old sculptor with metastatic disease of the breast was treated by competent physicians employing advanced knowledge and technology and acting out of kindness and true concern. At every stage, the treatment as well as the disease was a source of suffering to her. She was uncertain and frightened about her future, but she could get little information from her physicians, and what she was told was not always the truth. She had been unaware, for example, that the irradiated breast would be so disfigured.' After an oophorectomy and a regimen of medications, she became hirsute, obese, and devoid in the hand that she had used in sculpturing, and she became profoundly depressed. From the Department of Public Health, Cornell University Medical College, New York. Address reprint requests to 411 E. 69th St., New York, NY 10021. Supported in part by a Sustained Development Award for Ethics and Values in Science and Technology (NSF OSS 80-18086) from the National Science Foundation and the National Endowment for the Humanities. She had a pathologic fracture of the femur, and treatment was delayed while her physicians openly disagreed about pinning her hip. Each time her disease responded to therapy and her hope was rekindled, a new manifestation would appear. Thus, when a new course of chemotherapy was started, she was torn between a desire to live and the fear that allowing hope to emerge again would merely expose her to misery if the treatment failed. The nausea and vomiting from the chemotherapy were distressing, but no more so than the anticipation of hair loss. She feared the future. Each tomorrow was seen as heralding increased sickness, pain, or disability, never as the beginning of better times. She felt isolated because she was no longer like other people and could not do what other people did. She feared that her friends would stop visiting her. She was sure that she would die. This young woman had severe pain and other physical symptoms that caused her suffering. But she also suffered from some threats that were social and from others that were personal and private. She suffered from the effects of the disease and its treatment on her appearance and abilities. She also suffered unremittingly from her perception of the future. What can this case tell us about the ends of medicine and the relief of suffering? Three facts stand out: The first is that this woman's suffering was not confined to her physical symptoms. The second is that she suffered not only from her disease but also from its treatment. The third is that one could not anticipate what she would describe as a source of suffering; like; other patients, she had to be asked. Some features of her condition she would call painful, upsetting, uncomfortable, and distressing, but not a source of suffering. In these characteristics her case was ordinary. In discussing the matter of suffering with lay persons, I learned that they were shocked to discover that the problem of suffering was not directly addressed in medical education. My colleagues of a contemplative nature were surprised at how little they knew of the problem arid how little thought they had given it, whereas medical students tended to be unsure of the relevance of the issue to their work. The relief of suffering, it would appear, is considered one of the primary ends of medicine by patients and lay persons, but not by the medical profession. As in the care of the dying, patients and their friends and families do not make a distinction between physical and nonphysical sources of suffering in the same way that doctors do. A search of the medical and social-science literature did not help me in understanding what suffering is; the word "suffering" was most often coupled with the word "pain," as in "pain and suffering." (The data bases used were Psychological Abstracts, the Citation Index, and the Index