Friday, January 19, 2007

Suffering according to Cassell, Murray, and as far as yours truly is concerned

“Most generally, suffering can be defined as the state of severe distress associated with events that threaten the intactness of person.” Eric J Cassell, The Nature of Suffering and the Goals of Medicine, 1991.

Suffering can be defined in many ways. Cassell wants to restrict its meaning to the severe, the mental, and the personal whole intactness. His redefinition is certainly good for certain purposes, but I think it has done inadvertently a disservice to the study and management of pain and suffering. Instead of the word suffering, I suggest that we should use for what he means the expression ‘integrity suffering’ (or something like that).

Few words in English are more ambiguously entangled than pain and suffering. As a solution, here is what I wrote at the beginning of Wikipedia article on suffering. Suffering is usually described as a negative basic feeling or emotion that involves a subjective character of unpleasantness, aversion, harm or threat of harm. Suffering may be said physical or mental, depending whether it refers to a feeling or emotion that is linked primarily to the body or to the mind. Examples of physical suffering are pain, nausea, breathlessness, itching[1]. Examples of mental suffering are anxiety, grief, hatred, boredom[2]. There is much ambiguity in the use of the words pain and suffering. Sometimes they are synonyms and interchangeable. Sometimes they are used in contradistinction to one another: e.g. "pain is inevitable, suffering is optional", "pain is physical, suffering is mental". Sometimes yet, like in the previous paragraph, they are defined in another way.

Jock Murray, in his 1995 report entitled Chronic Pain, has a section on suffering, page 51-53. Here is what I retained from it. All along, and to the end of this post, I will be citing his text, and will put between brackets and in italics my own contribution.

[Murray begins by putting a quotation from Cassell as an epigraph] “[…] Attempting to understand what suffering is and how physicians might truly be devoted to its relief will require that medicine and its critics overcome the dichotomy between mind and body and the associated dichotomies between subjective and objective and between person and object.” [Unfortunately those dichotomies are perpetuated in Cassell’s and Murray’s ‘phenomenological’ distinction between pain and suffering, as we will see]

[Murrays goes on…] Although the title of this report is related to "Pain", I suspect that we would understand the situation and the patients much better if we concentrated more on the concept and meaning of "suffering" [indeed!!!]. This would help us understand what is occurring to the people, their families, their therapists and all the others who relate to them.

The aim of the medical profession is to relieve suffering [false, it is to treat mind and body dysfunctions and further health: a lot of professions claim that relieving suffering is a concern to them, but for none this is THE aim]. Cassell (1982) reminds us, however, that this may be naive. He states that the public, and patients, feel that the aim of the medical profession is the relief of suffering, but apparently the profession doesn't. Doctors tend to separate the physical and the non-physical aspects of suffering. Medicine's traditional concern for the body and physical disease, and the widespread belief in the mind-body dichotomy in medical theory and practice, resolves to the paradoxical situation in which physicians may even create [alas! a lot of undue] suffering in the course of their treatment of the sick.

Cassell makes three major points. First, suffering [as well as pain, I must add in this context] is experienced by persons [or individuals I’d say without ‘speciesism’]. […] Second, suffering occurs when an impending destruction of the person is perceived, as from any event that threaten the intactness of the person [Cassell says that because he restricts the definition of suffering in a very particular way]. The third point, and one that I think is often missed [by physicians who are busy with other things, I presume], is that suffering can occur in relation to any aspect of the person, whether it is in social role, group identification, the relation with self, body, family, or the relation with a trans-personal transcendent source of meaning. Suffering is ultimately a very personal matter. Patients may report suffering when one does not expect it, or do not report suffering when one expects they would.

As Fordyce (1988) comments, “One of the greatest problems in clinical pain, particularly chronic pain, is the confounding of pain with suffering, both by the patient and by the professional.”[indeed!!!] […]

In overcoming the weight and impact of suffering [in other words in taking care and in suffering less because they take care], people can begin to find meaning in their experience [to suffer is to find meaninglessness], or achieve transcendence over the experience [to suffer is to achieve immanence]. In many cultures, suffering is seen as a way of bringing one closer to God [an artifact invented against, very closely against suffering]. Frankl (1984) found that overcoming adversity and suffering was one way that people found meaning in their life [stubbing one’s toe requires instantly to reinterpret one’s position in life]. As Cassell says, “This ‘function’ of suffering [i.e. to react against suffering by appealing to our highest means] is at once its glorification and its relief. If, through great pain and deprivation, someone is brought closer to a cherished goal, that person may have no sense of having suffered but may instead feel enormous triumph.”

“Pain and suffering” are often identified as similar in medical literature but they are phenomenologically distinct [phenomenologically here means subjectively; we will be told next that pain, even extreme or excruciating, can occur without suffering; I object and prefer to say that there is some suffering in the slightest pain, because thus I preserve the common use of a common language word (suffering) for referring to one of the most basic categories of the objective-subjective world reality, that is our sensibility to the unpleasantness that there is both in pain (physical suffering) and in suffering (i.e. mental suffering)]. Women undergo extreme pain in childbirth, but regard childbirth as joyous and rewarding. I have a friend who has repeated kidney stones which cause excruciating pain, but he knows what it is, understands it and endures it like one of those irritating problems of life like a flat tire or a broken window pane. Patients suffer when [here the author means ‘only when’ where I’d rather say ‘when for instance’] they perceive that there is some threat to their person, they have no control and the pain may not pass. When patients feel that their problem can be managed, and that their pain and distress can be controlled, their suffering is remarkably reduced [simply because pain and distress ARE suffering]. A loss of control is an important component of suffering. Cassell concludes that people in pain report suffering [of course, they would not report it to a doctor at other times when it is in control, slight, etc.] when they feel it is out of control, when the pain is overwhelming, when its source is unknown, when the meaning of the pain is dire, or when the pain is chronic. Thus, they perceive pain as a threat to their continued existence, not merely to their lives, but to their integrity as persons. There is some hope in this concept [the concept that the suffering of pain is worst when pain is a threat to the person, I guess], as we may be able to relieve suffering if we can make the source of the pain known, or change its meaning, or demonstrate that it can be controlled, or that an end is in sight [of course… but couldn’t we make it all clear if all those who are deeply concerned would meet and discuss at last the question of defining suffering usefully?].

Thursday, January 11, 2007

On Scarry's "The Body in Pain"

“Directed against the isolating aversiveness of pain,
mental and material culture assumes the sharability of sentience.” (page 326)
The often cited Elaine Scarry’s 1985 book “The Body in Pain – The Making and Unmaking of the World” ought to be considered among groundwork classics for algoscience, the field of studies on suffering that I advocate to create. Well, of course Scarry proposes a new science of creation (p. 280), not of suffering, but such a displacement illustrates by itself the difficulty of focusing on suffering that is so typical in the whole history of human concern with that subject. Her book is an instance of what it talks about, a human creation, brought about like every creation, in final analysis, by the need and purpose to relieve suffering. At the same time, it is an instance of the difficulty about which it speaks, the difficulty to speak about suffering: “(…) the sentient fact of physical pain is (…) so flatly invisible (…) that almost any other phenomenon occupying the same environment will distract attention from it.” (page 12), and “(…) as physical pain destroys the mental content and language of the person in pain, so it also tends to appropriate and destroy the conceptualization abilities and language of persons who only observe the pain.” (page 279)

Her book is a success because it goes beyond that difficulty in an unprecedented manner. Not so much because the unbearable depiction of pain in torture is flatly put in words on the pages, but because the reality of suffering is presented at length as the most salient and the most reality-conferring feature of the most real of all phenomenon, the one which for us gives reality to every thing in the world, our sentience.

It is high time, I suggest, that we accord to the sentient group of things its due place among our main objects of concern, among our deepest motives of common allegiance, among our most dear and sacred but hopefully never absolute terms of personal identification like our nation, religion, ideology, profession, family, species, etc.

I advocate the creation of algonomy, a whole new domain for dealing with the knowledge and management of suffering, because it appears to me, based on millions of utterances among which Scarry’s book is one of the most knowledgeably heartfelt, that the management of suffering is the activity that will decide, at this time in our planet history, whether our humanly made world will be unmade into a hellish desert or made into a more inhabitable world for all sentient beings.

But where shall we find a place to meet for studying suffering, in particular Scarry’s insights on the crucial role of that monstrous feeling in human creation? Do we first have to find money for that? If yes, who will validate our claim for subvention? If no, as I believe, can you help, at least by circulating this call toward those who might be interested in meeting for the sake of sentience rather than money?
“The problem of economic distribution (…) is the problem of distributing the
power of artifacts to remake sentience.” (page 263)