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 wouldn’t 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 wouldn’t be able to live.”

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 patient’s suffering may merely aggravate the situation.

Confronted with suffering, the caregiver’s goal is not merely to deaden pain. Too often, efforts to deaden pain end up in deadening awareness as well.



































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.




































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.










































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.

Magazine
Summer/Fall 2002

Is Suffering the Enemy?
Caring for patients doesn’t always mean relieving their suffering…


by Dr. Richard Gunderman ’83
Reprinted from the March/April 2002 issue of Hastings Center Report

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 brain’s 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 back—let alone the pain of skeletal metastases or myocardial infarction—knows 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 patient’s 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. “Wouldn’t 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 wouldn’t 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 hadn’t eaten in a very long time, or that they were becoming severely dehydrated, they probably wouldn’t 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 wouldn’t 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 wouldn’t 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 suffering—namely, to identify its source and attempt to remove or suppress it—wasn’t 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 world’s 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 another’s suffering without concern is to be guilty of indifference. To take delight in another’s 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 transformed—the 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 Alzheimer’s 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 patient’s 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 patient’s 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 medicine’s ability to "fix" certain types of suffering has produced a gradual shift in caregiver’s 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-chemically—the 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 suffering—dependency, guilt, anger, isolation, the loss of pleasures and fulfillment that make life worth living—are regarded by many physicians as outside medicine’s 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 caregiver’s 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 doesn’t always mean relieving their suffering; sometimes it means sharing their suffering, helping them to shoulder the burden.

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 Homer’s 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. Homer’s 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, Gloucester’s son, Edgar, is transformed from naïve victim into the drama’s 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 death—these 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 one’s happiness with that of the beloved, one compounds one’s 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 Tolstroy’s 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 person’s 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 life’s 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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