Is Suffering the Enemy?

40 H A S T I N G S C E N T E R R E P O R T March-April 2002

In sorrow shall you bring forth children.—Genesis 3.16

Pain is ubiquitous in medical practice. In ambu-latory medicine, headache and backache aretwo of the most frequent presenting com-

plaints. Confronting pain, contemporary physicianswield a vast armamentarium by which to provide re-lief, from over-the-counter pain relievers to intra-venously administered opiate-receptor agonists thatmimic the brain’s endogenous painkillers.

Despite our burgeoning understanding of thephysiology and pharmacology of pain, however, wephysicians are routinely chided for our failure to pro-vide adequate pain relief. Undertreatment of pain,presumably grounded in ignorance and a fear of ad-diction to controlled substances, haunts manychronic pain patients and poses a vexing problem in

the care of the terminally ill. It is not so much dyingthat many of these patients fear, but dying in pain.

Anyone who has ever suffered from a naggingtoothache, menstrual cramps, migraine headache, orpainful spasms in the lower back—let alone the painof skeletal metastases or myocardial infarction—knows the havoc pain can wreak on the human psy-che. In the space of mere seconds, pain can so quick-ly invade and dominate the psychic landscape thatno room is left to attend to anything else. It can beextremely gratifying to provide symptomatic relieffor such a patient. Among the most frustrating casesin medicine are those in which pain is wrecking a pa-tient’s life but adequate relief cannot be provided, inpart because no anatomic explanation for the pain isapparent.

Yet should we regard pain always as an unadulter-ated evil, to be avoided and relieved wherever possi-ble? I recently spoke with a group of precocious fifthgraders about the development of anesthesia and theconquest of surgical pain. The fifth graders began topose some rather probing questions. First they want-ed to know what causes pain. We quickly produced a

The relief of suffering is the great goal of medicine. That physicians give up on suffering when they

can do nothing about the underlying condition is one of the contemporary criticisms of medicine. Yet even in

irremediable suffering there is something noble, to which physicians should attend.

Is Suffering the Enemy?

b y R I C H A R D B . G U N D E R M A N

Richard B. Gunderman, “Is Suffering the Enemy?,” Hastings CenterReport 32, no. 2 (2002): 40-44.

list of things that can be painful. Wenoticed that sometimes the source ofthe pain comes from outside, such asa traumatic laceration, and sometimesthe source of pain lies within, such asan infected tooth. Next they wantedto know why we feel pain. This pre-cipitated a brief discussion of the neu-rology of pain.

“But why do we feel pain?” the stu-dents insisted. It soon became appar-ent that they were posing a muchdeeper question. Taking into accounthow disturbing and even destructivepain can be, they wanted to knowwhy we even possess the capacity toexperience pain in the first place.“Wouldn’t the world be a better placeif there were no pain?” they asked.

I described to the students a fewcases I had encountered during mycareer of a remarkable conditioncalled congenital insensitivity to pain.Patients with this condition do notsense pain, or at least manifest a re-markable indifference to it. “What doyou suppose happened to these peo-ple?” I asked the students. “For exam-ple, what would happen to such achild if he broke his toe playing bas-ketball?” They pointed out that, de-spite the fact that you could amazeyour friends by sticking pins throughyour arms and the like, being pain-proof wouldn’t necessarily be a goodthing. I described the permanentskeletal deformities that often resultin such patients because of their ten-dency to ignore injuries that wouldimmediately stop the rest of us fromusing the wounded part.

Then some of the students men-tioned the importance of feelings ofprivation, such as hunger and thirst,which, though not the same as pain,seem to be closely related. If peoplewere undisturbed by the fact that theyhadn’t eaten in a very long time, orthat they were becoming severely de-hydrated, they probably wouldn’t sur-vive for very long. Soon we came tothe conclusion that, while it is unfor-tunate that any patient should suffer,and doctors and nurses should con-tinue to try to relieve suffering, wewouldn’t want to do away altogether

with the human liability to pain. As Igathered my slides to go, one of thestudents captured it nicely: “Withoutpain, we wouldn’t be able to live.”

Reflecting on this remarkable dis-cussion over the ensuing weeks, I real-ized that the fifth graders had taughtme something unexpected. My knee-jerk medical response to suffering—namely, to identify its source and at-tempt to remove or suppress it—was-n’t always on the mark. The discus-sion reminded me of the nineteenth-century controversy surrounding theintroduction of inhalation anesthesiain childbirth. Struck by the “unnatu-ralness” of painless childbirth, criticsof anesthesia pointed to the Biblicalcurse leveled at Eve on her expulsion

from the Garden of Eden: “In sorrowshall you bring forth children.” Thesedivine words, they argued, provided aclear indication that childbirth wasintended to be painful, and that ef-forts to provide artificial relief were anoffense against the express will ofGod. To this the great British physi-cian James Simpson, who knew hisBible perhaps even better than his op-ponents, retorted that God clearly en-dorsed anesthesia. After all, before heremoved from Adam the rib fromwhich he fashioned Eve, he put hispatient to sleep. Far from forbiddingpain relief, God himself had served asthe world’s first anesthetist.

Are the professional descendants ofJames Simpson entirely on the mark?On the one hand, the suffering ofothers is not a morally neutral matter.To accept another’s suffering withoutconcern is to be guilty of indifference.To take delight in another’s sufferingis to be guilty of cruelty. Suffering isnot something we can welcome, andwe would probably condemn anyonewho sought to promote it. And yetcan we really claim that suffering is allbad? Would we condemn the

tragedies of Sophocles and Shake-speare, which invite us to share in suf-fering aplenty?

What of the patients and familieswho look back on periods of sufferingwith a sense that they learned some-thing through the course of their tra-vails? What of the countless peoplewho have emerged from sufferingwith their outlook on life trans-formed—the sense that, by virtue ofhaving endured, they are actuallyleading more meaningful lives? Is thismerely the self-serving reflex of thePollyannas and Panglosses of thisworld, insistently finding some silverlining in every cloud? Or is the largertruth to be found in the words ofAeschylus: “It is only through suffer-

ing that we achieve wisdom”(Agamemnon, ll. 177-78)?

Far from condemning the likes ofSophocles and Shakespeare, it seemsto me, caregivers should seek themout.

The Nature of Suffering

Over the past century and a half,the vast territory of suffering has

undergone a series of conquests. Thepain of the scalpel, for example, hasbeen largely subdued. But many as-pects of suffering have proven moreresistant. Medications have not as-suaged the helplessness and frustra-tion that accompany stroke and headtrauma. Nor have they subdued thedementias, most notably Alzheimer’sdisease, which rob patients not onlyof their intellectual and motor capa-bilities but of their very identities.Pain is an abnormal presence, some-thing that can be combated and sup-pressed. With the absences of disabili-ty, however, there is no such externalfoe to be reckoned with.

One of the most disturbing aspectsof the loss of function is the assault on

H A S T I N G S C E N T E R R E P O R T 41March-April 2002

Is the larger truth to be found in the words of

Aeschylus: “It is only through suffering

that we achieve wisdom”?

the patient’s sense of personal integri-ty and independence. Patients grap-pling with serious disabilities maycease to feel like actors in the worldand find themselves forced into therole of passive bystanders. As they losethe ability to drive, walk, preparetheir own meals, dress themselves,handle their own toileting, feedthemselves, and do the things thathave always provided them with asense of fulfillment, they may feel thatthey are being reduced to a state ofhelplessness and humiliation. It is badenough to wear diapers, but it is everso much worse when you must relyon someone else to change them foryou. Patients may fear that they nolonger appear themselves, or even thattheir condition has rendered them re-pulsive to others.

Many patients stagger under otherburdens as well. They may holdthemselves to blame for their afflic-tions. They may lash out in anger atothers. Most problematically, theymay despair. We tend increasingly toregard “depression” as a medical con-dition warranting antidepressanttherapy, but in fact despair may be anatural and even justifiable responseto a bleak human situation. This isnot to suggest that we should simplyaccept it as though there were noth-ing to be done. Yet a failure to ac-knowledge and appreciate the depthof a patient’s suffering may merely ag-gravate the situation.

Perhaps the most devastating as-pect of despair is the inability to findmeaning. Human beings can enduregreat suffering if their struggle isshaped by some sense of larger pur-pose. A cancer patient may tolerateextraordinary insults and privationsin pursuit of a cure. People may bewilling to place their health in jeop-ardy and even to sacrifice their lives ifthey believe that their actions willhelp to secure the safety and welfareof those they love. Conversely, lessthan heroic degrees of suffering mayprove intolerable if the patient regardsthem as essentially meaningless. Joblost his possessions, his children, andhis health, yet the aspect of his suffer-

ing that tortured him most, leadinghim to rue the day he was born, washis inability to find any justificationfor what befell him. In the contradic-tion between divine justice and hisown abject misery, he feels as thoughthe fabric of the universe is being rentapart. Through Job we learn that it isnot suffering that destroys people, butsuffering without meaning.

The Medical Response

Contemporary medicine’s abilityto “fix” certain types of suffering

has produced a gradual shift in care-givers’ attention toward those types ofsuffering that are most fixable. Physi-cians tend to feel most competentwhen addressing conditions that theycan understand anatomically, physio-logically, and biochemically—theconditions for which pharmacologicalinterventions are most readily avail-able. Other aspects of suffering, how-ever, are not so easy to understand ortreat biologically, and as a result,many caregivers feel inept at dealingwith them. This sense of incompe-tence can breed avoidance, and physi-cians soon find themselves referringpatients whose suffering cannot bemanaged biologically to psycholo-gists, social workers, and chaplains.Larger issues of human suffering—dependency, guilt, anger, isolation,the loss of the pleasures and fulfill-ment that make life worth living—areregarded by many physicians as out-side medicine’s core competency. Pa-tients who cry out for help and sup-port in dealing with such difficultiesmay find that their entreaties fall ondeaf ears.

The fact that an injury is unfixabledoes not necessarily give us license togive up on it. We need to expand ourcognitive range. Human experience isan intricate phenomenon, and itsmyriad facets cannot be adequatelycomprehended from any single van-tage point. Molecular biology cannotrepresent the only relevant form ofhuman discourse, for it is impossibleto render all that physicians know orneed to know in molecular terms.

Likewise, the contemporary pharma-copeia does not contain every re-sponse to suffering that physiciansneed to be capable of offering theirpatients.

Confronted with suffering, thecaregiver’s goal is not merely to dead-en pain. Too often, efforts to deadenpain end up deadening awareness aswell. I can recall a number of termi-nally ill patients who, much to thesurprise of their health care team, re-quested a reduction in the dosage oftheir painkillers because the drugswere making them feel groggy or slowor just plain “stupid.” Most patientswant relief from pain, but they alsowant to remain themselves.

The effort to excise suffering phar-macologically sometimes denigratesthe whole experience. “Oh, yourspouse just died?” we seem to say.“Let me give you a pill for that.” Sig-nal life events such as serious illnessand the death of a loved one are partof the human condition and shouldbe treated more as burdens to bearand struggle with than as irritationsto be cast off and ignored. To attemptto make them simply go away is toimply that the person confrontingthem might as well go away. Caringfor patients doesn’t always mean re-lieving their suffering; sometimes itmeans sharing their suffering, helpingthem to shoulder the burden.

Is Suffering the Enemy?

Have you ever watched televisionin an intensive care unit? Con-

fronting the travails of serious illness,one can suddenly see the products ad-vertised for the distractions they real-ly are. There are far more meaningfulgoods to be found. Given the chance,patients and families confronting im-pending death talk not about theirautomobiles, their houses, or theirbank accounts, but about theirfriends and family, and the times theyhave shared together. They dwell noton what they have coveted, but onwhat they have loved.

Suffering reminds us of the fragili-ty of our mortal coil. We have an in-


H A S T I N G S C E N T E R R E P O R T 43March-April 2002

satiable appetite for tidbits of healthinformation that we hope will enableus to liver longer and healthier lives.By eating right, exercising, avoidingtobacco and the immoderate con-sumption of alcohol, taking the rightnutritional supplements, and so on,we seek to insulate ourselves againstthe vicissitudes of our corporeal con-dition. In fact, however, all of us aregoing to die, and most of us will suf-fer one or more bouts of serious ill-ness before we do. The idols of youthand fitness will eventually let each ofus down: our skin will sag, our hairturn gray and thin, our hearing hard-en, our vision dim, our step slow, ourspines shorten, our joints stiffen, oursexual powers flag, our powers ofcomputation and recall fail. In gener-al our vital capacity will inexorablydecline. Aging and death are notavoidable misfortunes, but in-eluctable stages of human life, with-out which life itself would not becomplete. To play the role of immor-tals is not in our script.

The illusion that life will somehowgo on interminably, that there is nourgency about seizing today, for to-morrow will always come, is one ofthe most enervating fallacies to whichwe can succumb. The invulnerableimmortals of Homer’s Iliad lead livesof unsurpassed vanity and triviality.They feel no sense of urgency aboutliving, and as a result they fritter awaytheir lives in idle distractions.Homer’s mortal heroes face up to thefact that they will not live forever, andin so doing embody a shining nobili-ty of spirit. It is their consciousness oftheir own finitude that enables themto look beyond the comfort and con-venience of the moment and devotetheir lives to a higher purpose. Theirsuffering is terrible, yet through itthey come to realize what life cantruly amount to. They cease to live forliving, merely for the sake of remain-ing alive and comfortable, and self-consciously pursue something beyondnarrow self-interest. Suffering re-minds us that our health is not a pre-cious jewel to be hidden away for fearthat it might be damaged, but a time-

limited opportunity that should beseized and exploited, even to thepoint of wearing it out. The precious-ness of life is found not in the savingbut in the expending of it.

The great tragedies also remind usthat we do not exert complete controlover our lives. At times this reminderproves a terribly bitter pill to swallow.In King Lear, the blinded Gloucesterdespairingly remarks, “As flies to wan-ton boys, are we to the gods; they killus for their sport” (King Lear,IV.i.364) Yet suffering need not pro-duce despair. Through his nearly

unimaginable anguish, Gloucester’sson, Edgar, is transformed from naïvevictim into the drama’s noblest hero,the righter of wrongs, and, humanlyspeaking, the rightful heir to thethrone.

Similarly, suffering is pregnantwith the insight that there are at workin the world forces beyond even ourken. Reproduction and birth, growthand development, sickness anddeath—these are rhythms of life thatwe should seek to listen for, learnfrom, and move to. By helping us tosee what we really are, suffering helpsus to find our proper place in theworld. To seek to shield ourselvesfrom all suffering would be a self-as-sertive act of lunatic proportion. Bytrying to remake reality as though oursafety and contentment were all thatreally mattered, we would devalueboth ourselves and the good in theworld around us. We were made forgreater things: to explore, to illumi-nate, to enliven and enrich, to helpcomplete what nature herself is notable to bring to a finish. We are notgods, creating light out of darkness,giving form to the void, bringingmeaning to nothingness, but finitecreatures whose life task it is to findpeace and harmony with the larger re-ality of which we are but a part. Wemust take care not to cast so long a

shadow that our view of that larger re-ality is obscured. Hence the words ofthe Delphic oracle, “Know thyself.”

To know ourselves fully requiresthat we recognize our incompleteness.Alone, we are not whole. Yet with in-completeness comes vulnerability.Life without vulnerability, devoid ofthe potential for suffering, entails sogreat a withdrawal from everythingvital that only isolation and sterilitycan result. Conversely, to love is toopen oneself up to the possibility ofsuffering. By binding one’s happinesswith that of the beloved, one com-

pounds one’s own liability to sufferwith that of another. Those who love,having expanded their sphere of con-cern and commitment to encompassothers, no longer mistakenly supposethat they can flourish by tending onlyto themselves. Yet in spite of the en-hanced vulnerability that love re-quires, what person in his or her rightmind would choose a life devoid oflove? It is precisely in loving that weachieve our highest degree of humanvirtuosity, and it is only together inlove that we grow to be most fullyalive. To cut oneself off from the pos-sibility of suffering is to cut oneself offfrom love, and to cut oneself off fromlove is to cut oneself off from life it-self.

It can be tempting to ignore suffer-ing, to try to take away some of itsedge by pretending that it does notexist. Yet to the patient, this well-in-tentioned pretense represents an in-sidious form of degradation, enmesh-ing both caregiver and patient in aweb of mutual deception. What tor-ments Tolstoy’s Ivan Ilych most is notthe physical pain he suffers, but theweb of deception that ensnares him,his family, and his caregivers, andfrom which he can find no means ofescape. Wisdom is the profoundestkind of truth, to which deception isutterly inimical. To deny suffering is

It is not suffering that destroys people,

but suffering without meaning.


to trivialize another person’s experi-ence, to diminish its scope and lessenits significance. It is to falsify and in-validate the other person as a person.Such deception quickly infects andcorrupts the entire doctor-patient re-lationship, making it impossible forthe caregiver to discern what is trulybest for the patient, and renderingthe patient unable truly to trust thecaregiver. Each is holding back, eachnavigating by a false map, each mis-apprehending where the other iscoming from.

Attending to What We CannotCorrect

The fifth graders were on to some-thing, a paradox of sorts. The re-

lief of suffering is one of life’s noblest

callings, in which health professionalsare privileged to participate. In caringfor the sick, we seek to lighten theirafflictions, and in so doing we laboron the side of the angels. Yet it wouldbe wrong to say that virtue consists indodging suffering. To be sure, therewould be a certain artfulness in thisdodging, but the art of caring, whichis the art of “humaning,” consists ofsomething more. Ironically, it issometimes only in the midst of sor-row that we bring forth the greatestand most inspired truth we have toshare. Our curse is, in a sense, alsoour birthright.

Just as it would be self-defeating toseek to craft for ourselves a life devoidof all possibility of suffering, weshould protect those for whom wecare from similar harm. The suffering

that we cannot relieve may be everybit as deserving of our attention, per-haps even more so, than the sufferingthat our magic bullets can vanquish.To make suffering a purely technicalproblem in order that we may abort itis, in effect, to deny and trivialize lifeitself. Far from denying suffering bytreating only the pain, we should ac-knowledge it, and even, in a certainsense, embrace it. To inflict sufferingwould be cruelty, but to ignore ordeny or trivialize it is no less inhu-mane, for it blinds us to love, and sti-fles the human calling to becomewiser than we are.

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Is Suffering the Enemy?