Summary
Suffering is the experience of a person who perceives a threat to their integrity — to their continued existence as a coherent self. It is not the same as pain, though pain can cause it. It is not the same as disease, though disease can produce it. And it is not addressed by the same means that treat disease, which is why modern medicine has struggled to see suffering as part of its proper domain. Eric Cassell’s The Nature of Suffering and the Goals of Medicine (1991) mounted the most systematic argument that suffering belongs at the center of medical concern, and Arthur Kleinman’s The Illness Narratives (1988) demonstrated how the biomedical encounter systematically strips away the dimensions of experience where suffering lives. Together, these works established that medicine’s failure to address suffering is a structural consequence of how the profession understands its purpose.
Cassell’s Definition
Cassell defined suffering as severe distress associated with events that threaten the intactness of the person. Suffering occurs when an impending destruction of the person is perceived, and it continues until the threat of disintegration has passed or the integrity of the person can be restored (Cassell, 1991). The definition is precise: suffering is about persons, not bodies, and its trigger is a perceived threat to intactness, not necessarily a physical lesion.
This yields the central distinction of Cassell’s work: pain and suffering are phenomenologically distinct. Patients can have severe pain without suffering — when the source is known and controllable, as in childbirth or athletic exertion — and can suffer without significant pain — when the meaning of symptoms is dire or the future threatening (Cassell, 1991). The distinction is not merely philosophical. It has direct clinical consequences: treating the pain may not relieve the suffering, and addressing the suffering may not require treating the pain. Toombs reinforces this point from a Husserlian direction: suffering occurs at the reflective level and is intimately related to the meaning and significances the patient assigns to pre-reflective sensory experience — it is experienced by persons, not merely by bodies (Toombs, 1992).
The Topology of the Person
Cassell argued that understanding suffering requires a topology of the person. Persons have personality, character, a lived past, a family, cultural background, roles, associations, a political dimension, daily behaviors, an existence below awareness, a body, a secret life, a believed-in future, and a transcendent dimension (Cassell, 1991). Suffering can originate in damage to any of these dimensions. A person who loses a limb suffers not merely the physical loss but the disruption of self-image, role, daily function, and projected future. A person told they have a terminal diagnosis suffers the destruction of their believed-in future before any physical deterioration occurs.
Personal meaning — encompassing cognitive, affective, bodily, and transcendent dimensions simultaneously — is a fundamental aspect of person that cannot be divorced from illness or suffering (Cassell, 1991). The same word can elicit contradictory meanings at different levels of the person, which is why suffering is so difficult to standardize or measure.
The Temporal Dimension
Suffering has an essential temporal element. It always involves the person’s perception of future events, requiring a projected future in which things are worse (Cassell, 1991). A person in pain who knows the pain will end in ten minutes does not suffer in the way a person does who fears the pain will be permanent. Suffering can be relieved by rooting the person in the absolute present — a fact exploited by contemplative traditions but rarely by clinical medicine.
Medicine’s Structural Blindness
The Cartesian mind-body split, Cassell argued, has given medicine too narrow a conception of its domain, effectively excluding the person from medical concern and making suffering either “unreal” (subjective) or identified exclusively with bodily pain (Cassell, 1991). Modern medicine can do remarkable things for diseased organs and pathological processes, but its conceptual framework contains no category for the suffering of persons. Even in the best clinical settings with the most competent physicians, patients may suffer both from their disease and from its treatment, because medicine’s concern primarily with the body and physical disease leaves the suffering person unaddressed (Cassell, 1991).
When physicians fail to validate a patient’s pain — suggesting it is imaginary or “psychological” — this invalidation itself becomes a source of suffering by causing the patient to distrust their own perceptions of self (Cassell, 1991). The iatrogenic production of suffering through delegitimation is one of the most common and least recognized failures of clinical practice.
Medicine’s wholesale embrace of science created a fundamental tension: science is value-free and deals with generalities, while medicine must deal with value-laden, individual persons (Cassell, 1991). The promise of scientific medicine — that knowing the disease and its treatment is equivalent to knowing the illness and how to treat the ill person — is the fundamental error driving the neglect of suffering (Cassell, 1991).
Chronic Illness and Suffering
Chronic illness sharpens every dimension of the problem. Chronic illness and chronic disease are distinct: diseases are specific entities characterized by disturbances in structure or function, while illnesses afflict whole persons and include all the disordered functions and feelings by which persons know themselves to be unwell (Cassell, 1991). The degree to which a chronically ill person believes themselves disabled is often poorly predicted by knowledge of their disease — severity of illness and severity of disease are regularly dissociated (Cassell, 1991).
Pathophysiology, despite superseding classical structural disease theory, cannot explain chronic illness because it extends only from the molecular to the organ level — it does not reach the social, psychological, and existential levels at which chronic illness operates (Cassell, 1991). In chronic illness, symptoms and compensatory mechanisms interact in a self-sustaining cycle: symptom avoidance produces further dysfunction, and attempts to maintain normalcy generate overuse injuries (Cassell, 1991).
Suffering in chronic illness arises primarily from internally generated conflict between different aspects of the same person: social standards and expectations (which are actually internalized, not merely external) demand what the sick body cannot provide (Cassell, 1991). Chronic illness creates a changed world perception: once diagnosed, the person perceives themselves as a “diseased person” and all subsequent sensations are interpreted through the history of the illness (Cassell, 1991).
Kleinman made a convergent argument: for the chronically ill, the quest for cure is a dangerous myth that distracts from the step-by-step behaviors that actually reduce suffering (Kleinman, 1988). Addressing that suffering requires the practitioner to map the patient’s life world in concrete terms: daily routines, social supports, economic constraints, family dynamics, and the specific ways illness disrupts each of these (Kleinman, 1988). Toombs echoes this: if cure of disease is taken as the overriding goal of the medical encounter, those with incurable illness are seen as beyond help and become living affronts to medicine — yet patients with chronic illness far outnumber those with curable disease (Toombs, 1992). Clinical and behavioral science research, he observed, has no category for suffering at all; symptom scales and outcome questionnaires quantify functional impairment but produce a “scientifically replicable but ontologically invalid” picture of patients (Kleinman, 1988).
Illness as Meaning
Kleinman described chronic illness as acting like a sponge — absorbing personal and social significance from the sick person’s life world (Kleinman, 1988). The central meaning for most chronically ill patients is loss: loss of body parts, physical function, body image, self-image, way of life (Kleinman, 1988). The illness narrative does not merely reflect this experience; it actively constitutes it: the patient’s account of origin, cause, and meaning contributes to the ongoing experience of symptoms and suffering.
Illness is polysemic: symptoms simultaneously radiate multiple meanings, and these meanings shift over the long course of chronic disorder as situations change (Kleinman, 1988). Cassell and Kleinman converge on the insight that suffering is a crisis of meaning — not in the abstract sense of existential philosophy but in the concrete sense that the person’s capacity to make sense of their own life has been damaged.
Compassion and the Response to Suffering
Pellegrino and Thomasma argued that compassion — etymologically com-pati, to suffer together — is a moral virtue necessary to the ends of medicine precisely because it is the disposition that allows the physician to perceive and respond to suffering (Pellegrino, 1993). The etymological derivation points to cosuffering as its character: a fellowship in the experience of illness, not merely sympathy from a distance (Pellegrino, 1993). Compassion has both a moral and intellectual component: the habitual disposition to comprehend the uniqueness of each patient’s predicament (Pellegrino, 1993). The ends of medicine include not only curing disease but caring for the patient living with residual suffering (Pellegrino, 1993).
This relational capacity is not merely a supplement to technical treatment but operates as a therapeutic factor in its own right, carrying healing power across cultures and traditions independently of specific medical or surgical interventions (Cassell, 1991). The art and science of medicine, Cassell argued, are not opposed but concerned with two different things: science is essential for treating disease processes; art is essential for treating sick persons as the persons they are (Cassell, 1991). Sick persons cannot be objects of science in the classical sense: they cannot be completely known or known apart from the knower, cannot be measured solely in objective terms, and are ultimately moral (Cassell, 1991).
See Also
- Eric Cassell
- Arthur Kleinman
- Chronic Illness
- Illness and Disease Distinction
- Physician-Patient Relationship
- Compassion
- Phenomenology of Illness
- Pain
- Autonomy
Sources
- Cassell, E. J. (1991). The Nature of Suffering and the Goals of Medicine. Oxford University Press. [cassell-nature-of-suffering-1991] — Lead authority
- Kleinman, A. (1988). The Illness Narratives: Suffering, Healing, and the Human Condition. Basic Books. [kleinman-illness-narratives-1988] — Lead authority
- Pellegrino, E. D. & Thomasma, D. C. (1993). The Virtues in Medical Practice. Oxford University Press. [pellegrino-thomasma-virtues-1993]
- Toombs, S. K. (1992). The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Kluwer. [toombs-meaning-of-illness-1992]