Suffering the Enemy?
Caring for patients doesnt always mean relieving their suffering
by Dr. Richard Gunderman
Reprinted from the March/April 2002 issue of Hastings
Pain is ubiquitous in medical practice. In ambulatory medicine, headache
and backache are two of the most frequent presenting complaints. Confronting
pain, contemporary physicians wield a vast armamentarium by which to provide
relief, from over-the-counter pain relievers to intravenously administered
opiate-receptor agonists that mimic the brains endogenous painkillers.
Despite our burgeoning understanding of the physiology and pharmacology
of pain, however, we physicians are routinely chided for our failure to
provide adequate pain relief. Undertreatment of pain, presumably grounded
in ignorance and a fear of addiction to controlled substances, haunts
many chronic pain patients and poses a vexing problem in the care of the
terminally ill. It is not so much dying that many of these patients fear,
but dying in pain.
Anyone who has ever suffered from a nagging toothache, menstrual cramps,
migraine headache, or painful spasms in the lower backlet alone
the pain of skeletal metastases or myocardial infarctionknows the
havoc pain can wreak on the human psyche. In the space of mere seconds,
pain can so quickly invade and dominate the psychic landscape that no
room is left to attend to anything else. It can be extremely gratifying
to provide symptomatic relief for such a patient. Among the most frustrating
cases in medicine are those in which pain is wrecking a patients
life but adequate relief cannot be provided, in part because no anatomic
explanation for the pain is apparent.
Yet should we regard pain always as an unadulterated evil, to be avoided
and relieved wherever possible? I recently spoke with a group of precocious
fifth graders about the development of anesthesia and the conquest of
surgical pain. The fifth graders began to pose some rather probing questions.
First they wanted to know what causes pain. We quickly produced a list
of things that can be painful. We noticed that sometimes the source of
the pain comes from outside, such as a traumatic laceration, and sometimes
the source of pain lies within, such as an infected tooth. Next they wanted
to know why we feel pain. This precipitated a brief discussion of the
neurology of pain.
But why do we feel pain? the student insisted. It soon became
apparent they were posing a much deeper question. Taking into account
how disturbing and even destructive pain can be, they wanted to know why
we even possess the capacity to experience pain in the first place. Wouldnt
the world be a better place if there were not pain? they asked.
I described to the students a few cases I had encountered during my career
of a remarkable condition called congenital insensitivity to pain. Patients
with this condition do not sense pain, or at least manifest a remarkable
indifference to it. What do you suppose happened to these people?
I asked the students. For example, what would happen to such a child
if he broke his toe playing basketball? They pointed out that, despite
the fact that you could amaze your friends by sticking pins through your
arms and the like, being pain-proof wouldnt necessarily be a good
thing. I described the permanent skeletal deformities that often result
in such patients because of their tendency to ignore injuries that would
immediately stop the rest of us from using the wounded part.
Then some of the students mentioned the importance of feelings of privation,
such as hunger and thirst, which, though not the same as pain, seem to
be closely related. If people were undisturbed by the fact that they hadnt
eaten in a very long time, or that they were becoming severely dehydrated,
they probably wouldnt survive for very long. Soon we came to the
conclusion that, while it is unfortunate that any patient should suffer,
and doctors and nurses should continue to try to relieve suffering, we
wouldnt want to do away altogether with the human liability to pain.
As I gathered my slides to, one of the students captured it nicely: Without
pain, we wouldnt be able to live.
Reflecting on this remarkable discussion over the ensuing weeks, I realized
that the fifth graders had taught me something unexpected. My knee-jerk
medical response to sufferingnamely, to identify its source and
attempt to remove or suppress itwasnt always on the mark.
The discussion reminded me of the nineteenth-century controversy surrounding
the introduction of inhalation anesthesia in childbirth. Struck by the
unnaturalness of painless childbirth, critics of anesthesia
pointed to the Biblical curse leveled at Eve on her expulsion from the
Garden of Eden: In sorrow shall you bring forth children.
These divine words, they argued, provided a clear indication that childbirth
was intended to be painful, and that efforts to provide artificial relief
were an offense against the express will of God. To this the great British
physician James Simpson who knew his Bible perhaps even better than his
opponents, retorted that God clearly endorsed anesthesia. After all, before
he removed from Adam the rib from which he fashioned Eve, he put his patient
to sleep. Far from forbidding pain relief, God himself had served as the
worlds first anesthetist.
Are the professional descendants of James Simpson entirely on the mark?
On the one hand, the suffering of others is not a morally neutral matter.
To accept anothers suffering without concern is to be guilty of
indifference. To take delight in anothers suffering is to be guilty
of cruelty. Suffering is not something we can welcome, and we would probably
condemn anyone who sought to promote it. And yet can we really claim that
suffering is all bad? Would we condemn the tragedies of Sophocles and
Shakespeare, which invite us to share in suffering aplenty?
What of the patients and families who look back on periods of suffering
with a sense that they learned something through the course of their travails?
What of the countless people who have emerged from suffering with their
outlook on life transformedthe sense that, by virtue of having endured,
they are actually leading more meaningful lives? Is this merely the self-serving
reflex of the Pollyannas and Panglosses of this world, insistently finding
some silver lining in every cloud? Or is the larger truth to be found
in the words of Aeschylus: It is only through suffering that we
achieve wisdom (Agamemnon, II. 177 78)?
Far from condemning the likes of Sophocles and Shakespeare, it seems to
me, caregivers should seek them out.
The Nature of Suffering
Over the past century and a half, the vast territory of suffering has
undergone a series of conquests. The pain of the scalpel, for example,
has been largely subdued. But many aspects of suffering have proven more
resistant. Medications have not assuaged the helplessness and frustration
that accompany stroke and head trauma. Nor have they subdued the dementias,
most notably Alzheimers disease, which rob patients not only of
their intellectual and motor capabilities but of their very identities.
Pain is an abnormal presence, something that can be combated and suppressed.
With the absences of disability, however, there is not such external foe
to be reckoned with.
One of the most disturbing aspects of the loss of function is the assault
on the patients sense of personal integrity and independence. Patients
grappling with serious disabilities may cease to feel like actors in the
world and find themselves forced into the role of passive bystanders.
As they lose the ability to drive, walk, prepare their own meals, dress
themselves, handle their own toileting, feed themselves, and do the things
that have always provided them with sense of fulfillment, they may feel
that they are being reduced to a state of helplessness and humiliation.
It is bad enough to wear diapers, but it is ever so much worse when you
must rely on someone else to change them for you. Patients may fear that
they no longer appear themselves, or event that their condition has rendered
them repulsive to others.
Many patients stagger under other burdens as well. They may hold themselves
to blame for their afflictions. They may lash out in anger at others.
Most problematical, they may despair. We tend increasingly to regard depression
as a medical condition warranting antidepressant therapy, but in fact
despair may be a natural and even justifiable response to a bleak human
situation. This is not to suggest that we should simply accept it as though
there were nothing to be done. yet a failure to acknowledge and appreciate
the depth of a patients suffering may merely aggravate the situation.
Perhaps the most devastating aspect of despair is the inability to find
meaning. Human beings can endure great suffering if their struggle is
shaped by some sense of larger purpose. A cancer patient may tolerate
extraordinary insults and privations in pursuit of a cure. People may
be willing to place their health in jeopardy and even to sacrifice their
lives if they believe that their actions will help to secure the safety
and welfare of those they love. Conversely, less than heroic degrees of
suffering may prove intolerable if the patient regards them as essentially
meaningless. Job lost is possessions, his children, and his health, yet
the aspect of his suffering that tortured him most, leading him to rue
to the day he was born, was his inability to find any justification for
what befell him. In the contradiction between divine justice and his own
abject misery, he feels as though the fabric of the universe is being
rent apart. Through Job we learn that it is not suffering that destroys
people, but suffering without meaning.
The Medical Response
Contemporary medicines ability to "fix" certain types
of suffering has produced a gradual shift in caregivers attention
toward those types of suffering that are most fixable. Physicians tend
to feel most competent when addressing conditions that they can understand
anatomically, physiologically, and bio-chemicallythe conditions
for which pharmacological interventions are most readily available. Other
aspects of suffering, however, are not so easy to understand or treat
biologically, and many caregivers feel inept in dealing with them.
This sense of incompetence can breed avoidance, and physicians soon find
themselves referring patients whose suffering cannot be managed biologically
to psychologists, social workers, and chaplains. Larger issues of human
sufferingdependency, guilt, anger, isolation, the loss of pleasures
and fulfillment that make life worth livingare regarded by many
physicians as outside medicines core competency. Patients who cry
out for help and support in dealing with such difficulties may find that
their entreaties fall on deaf ears.
The fact that an injury is unfixable does not necessarily give us license
to give up on it. We need to expand our cognitive range. Human experience
is an intricate phenomenon, and its myriad facets cannot be adequately
comprehended from any single vantage point. Molecular biology cannot represent
the only relevant form of human discourse, for it is impossible to render
all that physicians know in molecular terms. Likewise, the contemporary
pharmacopoeia does not contain every response to suffering that physicians
need to be capable of offering their patients.
Confronted with suffering, the caregivers goal is not merely to
deaden pain. Too often, efforts to deaden pain end up in deadening awareness
as well. I can recall a number of patients who, much to the surprise of
their health care team, requested a reduction in the dosage of their painkillers
because the drugs were making them feel groggy or slow or "just plain
stupid." Most patients want relief from pain, but they also want
to remain themselves.
The effort to excise suffering pharmacologically sometimes denigrates
the whole experience. "Oh, your spouse just died?" we seem to
say, "Let me give you a pill for that." Signal life events such
as serious illness or the death of a loved one are part of the human condition
and should be treated more as burden to bear and struggle with than as
irritations to be cast off and ignored. To attempt to make them simply
go away is to imply that the person confronting them might as well go
away. Caring for patients doesnt always mean relieving their suffering;
sometimes it means sharing their suffering, helping them to shoulder the
Is Suffering the Enemy?
Have you ever watched television in an intensive care unit? Confronting
the travails of serious illness, one can suddenly see the products advertised
for the distractions they really are. There are far more meaningful goods
to be found. Given the chance, patients and families confronting impending
death talk not about their automobiles, their houses, or their bank accounts,
but about their friends and family, and the times they have shared together.
They dwell not on what they have coveted, but on what they have loved.
Suffering reminds us of the fragility of our mortal coil. We have an insatiable
appetite for tidbits of health information that we hope will enable us
to live longer and healthier lives. By eating right, exercising, avoiding
tobacco and the immoderate consumption of alcohol, taking the right nutritional
supplements, and so on, we week to insulate ourselves against the vicissitudes
of our corporeal condition. In fact, however, all of us are going to die,
and most of us will suffer one or more bouts of serious illness before
we do. The idols of youth and fitness will eventually let each of us down:
our skin will sag, our hair will turn gray and thin, our hearing harden,
our vision dim, our step slow, our spines shorten, our joints stiffen,
our sexual powers flag, our powers of computation and recall fail. In
general our vital capacity will inexorably decline. Aging and death are
not avoidable misfortunes, but ineluctable stages of human life, without
which life itself would not be complete. To play the role of immortals
is not in our script.
The illusion that life will somehow go on interminably, that there is
no urgency about seizing today, for tomorrow will always come, is one
of the most enervating fallacies to which we can succumb. The invulnerable
immortals of Homers Iliad lead lives of unsurpassed vanity and triviality.
they feel no sense of urgency about living, and as a result they fritter
away their lives in idle distractions. Homers mortal heroes face
up to the fact that they will not live forever, and in so doing embody
a shining nobility of spirit. It is their consciousness of their own finitude
that enables them to look beyond the comfort and convenience of the moment
and devote their lives to a higher purpose. Their suffering is terrible,
yet through it they come to realize what life can truly amount to. They
cease to live for living, merely for the sake of remaining alive and comfortable,
and self-consciously pursue something beyond narrow self-interest. Suffering
reminds us that our health is not a precious jewel to be hidden away for
fear that it might be damaged, but a time-limited opportunity that should
be seized and exploited, even to the point of wearing it out. The preciousness
of life is found not in the saving but in the expending of it.
The great tragedies also remind us that we do not exert complete control
over our lives. At times this reminder proves a terribly bitter pill to
swallow. In King Lear, the blinded Gloucester despairingly remarks, As
flies to wanton boys, are we to the gods; they kill us for their sport
(King Lear, IV.I364) Yet suffering need not produce despair. Through his
nearly unimaginable anguish, Gloucesters son, Edgar, is transformed
from naïve victim into the dramas noblest hero, the righter
of wrongs, and, humanly speaking, the rightful heir to the throne.
Similarly, suffering is pregnant with the insight that there are at work
in the world forces beyond even our ken. Reproduction and birth, growth
and development, sickness and deaththese are rhythms of life that
we should seek to listen for, learn from, and move to. By helping us to
see what we really are, suffering helps us to find our proper place in
the world. To seek to shield ourselves from all suffering would be a self
assertive act of lunatic proportion. By trying to remake reality as though
our safety and contentment were all that really mattered, we would devalue
both ourselves and the good in the world around us. We were made for greater
things: to explore, to illuminate, to enliven and enrich, to help complete
what nature herself is not able to bring to a finish. We are not gods,
creating light out of darkness, giving form to the void, bringing meaning
to nothingness, but finite creatures whose life task it is to find peace
and harmony with the larger reality of which we are but a part. We must
take care not to cast so long a shadow that our view of that larger reality
is obscured. Hence the words of the Delphic Oracle, Know thyself.
To know ourselves fully requires that we recognize our incompleteness.
Alone, we are not whole. yet with incompleteness comes vulnerability.
Life with vulnerability, devoid of the potential for suffering, entails
so great a withdrawal from everything vital that only isolation and sterility
can result. Conversely, to love is to open oneself up to the possibility
of suffering. By binding ones happiness with that of the beloved,
one compounds ones own liability to suffer with that of another.
Those who love, having expanded their sphere of concern and commitment
to encompass others, no longer mistakenly suppose that they can flourish
by tending only to themselves. Yet in spite of the enhanced vulnerability
that love requires, what person in is or her right mind would choose a
life devoid of love? It is precisely in loving that we achieve our highest
degree of human virtuosity, and it is only together in love that we grow
to be most fully alive. To cut oneself off from the possibility of suffering
is to cut oneself off from love, and to cut oneself off from love is to
cut oneself from life itself.
It can be tempting to ignore suffering, to try to take away some of its
edge by pretending that it does not exist. Yet to the patient, this well
intentioned pretense represents an insidious form of degradation, enmeshing
both caregiver and patient in a web of mutual deception. What torments
Tolstroys Ivan Ilych most is not the physical pain he suffers, but
the web of deception that ensnares him, his family, and his caregivers,
and from which he can find no means of escape. Wisdom is the profoundest
kind of truth, to which deception is utterly inimical. To deny suffering
is to trivialize another persons experience, to diminish its scope
and lessen its significance. It is to falsify and invalidate the other
person as a person. Such deception quickly infects and corrupts the entire
doctor-patient relationship, making it impossible for the caregiver to
discern what is truly best for the patient, and rendering the patient
unable truly to trust the caregiver. Each is holding back, each navigating
by a false map, each misapprehending where the other is coming from.
Attending to What We Cannot Correct
The fifth graders were on to something, a paradox of sorts. The relief
of suffering is one of lifes noblest callings, in which health professionals
are privileged to participate. In caring for the sick, we seek to lighten
their afflictions, and in so doing we labor on the side of the angels.
Yet it would be wrong to say that virtue consists in dodging suffering.
To be sure, there would be a certain artfulness in this dodging, but the
art of caring, which is the art of humaning, consists of something
more. Ironically, it is sometimes only in the midst of sorrow that we
bring forth the greatest and most inspired truth we have to share. Our
curse is, in a sense, also our birthright.
Just as it would be self-defeating to seek to craft for ourselves a life
devoid of all possibility of suffering, we should protect those for whom
we care from similar harm. The suffering that we cannot relieve may be
every bit as deserving of our attention, perhaps even more so, than the
suffering that our magic bullets can vanquish. To make suffering a purely
technical problem in order that we may abort it is, in effect, to deny
and trivialize life itself. Far from denying suffering by treating only
the pain, we should acknowledge it, and even, in a certain sense, embrace
it. To inflict suffering would be cruelty but to ignore or deny or trivialize
it is no less inhumane, for it blinds us to love, and stifles the human
calling to become wiser than we are.
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