Pain and suffering are some of the most common reasons patients seek out doctors. These patients seek answers about the causes of pain and they seek relief. Pain and suffering are not only unpleasant experiences that compromise our well-being. They threaten the sense we make of the world. Pain makes each of us ask: Why me? Why now?
While pain and suffering have always been a problem for humans, they have not been the same kind of problem. Medieval Europe understood pain as a religious problem because the pain and suffering of innocent people seemed incompatible with an all-powerful and merciful God. Enlightenment theorists rejected the view that pain was necessary to atone for sin and allow persons to join God in Heaven. They framed pain as a social problem that threatened the fabric of secular society and sought to minimize pain through social policy.
Pain as a Medical Problem
Over the past 200 years, we have come to see pain as a medical problem, with medical causes and medical remedies. By the 20th Century, this unidirectional medical model becomes dominant: Disease causes pain, which causes suffering. Pain has been separated from suffering as its medical component and is seen as the most important cause of suffering in the hospital.
Since 1800, the medical problem of pain has been addressed through the diagnosis and treatment of disease. But, beginning in 1953, John Bonica argued that controlling disease was not adequate to control pain, especially labor pain, cancer pain, post-operative pain, and chronic non-cancer pain. In 1973, Bonica started the discipline of Pain Medicine, which has made the causation and treatment of pain a separate focus for medical research and clinical care.
Suffering Beyond Pain
In the 1980s, Cicely Saunders in the UK and Eric Cassell in the US argued that pain control was not enough to relieve the suffering of patients, especially dying patients. Saunders argued that doctors needed to address not just pain from disease, but “total pain” that encompassed all of a person’s physical, psychological, social, spiritual, and practical struggles. Cassell argued that suffering arises from threats to the person that go beyond threats to the body: “Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain, but is by no means limited to it. The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick.”
Cassell strongly distinguished pain from suffering. He made pain separate and before suffering, although he sees pain as a product of both disease or damage and meaning. While persons attribute meaning to pain through interpretation, pain remains anchored in the perception of tissue damage (i.e., nociception) for Cassell: “Although bodies may experience nociception, bodies do not suffer. Only persons suffer.”
In general, Cassell both opposed the Cartesian dualism of mind and body and fell back into a dualism of person and body. While he allowed pain produced by the body to be affected by personal meanings, this meaning was never integrated into the pain mechanisms of the body. His sense of the body as a mechanism did not incorporate the pain neuroscience of the past 50 years. It specifically did not see pain as the product of a “multisensory salience detection system” that integrates signals of danger from outside the somatosensory system into the pain experience. He still understood our pain system as a “damage-detection system” rather than a “danger-detection system” that integrates multisensory cues (visual, auditory, olfactory) of danger into our pain experience. As I often tell my own patients, “Your pain system is smarter than you think it is. It is better at detecting threats to your integrity and protecting you from harm than a simple damage detection system.”
Perhaps the most clinically significant omission from Cassell’s theory of suffering is his focus on suffering as a consequence of pain without discussion of suffering as a cause of pain. There is a vast research literature documenting high rates of pain in patients with depressive and anxiety disorders, in patients with PTSD (Post-Traumatic Stress Disorder) and/or adverse childhood experiences, and in patients with prolonged grief. Analysis of data from the 2019 US National Health Interview Survey showed that 5% of the adult population have co-occurring chronic pain and anxiety/depression symptoms. Significant anxiety/depression symptoms were found in 24% of US adults with chronic pain, compared with 5% among those without chronic pain. Among those US adults with significant anxiety/depressive symptoms, chronic pain was present in a majority (56%), compared with a chronic pain prevalence of 17% among those without significant anxiety/depressive symptoms. Pain and suffering live together.
The Reciprocal Relationship Between Pain and Suffering
If the relationship between pain and suffering is reciprocal rather than linear, we need to radically rethink our clinical approach to chronic pain. We must move beyond conceiving pain as a product of the mechanical body and suffering as a product of the meaningful person. Experienced pain is shaped by anticipation of the future and thus is not a simple mechanical product of the past. Because pain is partially driven by our purposes, actions, and meanings, it includes elements of suffering. Suffering is an important cause of pain.
Chronic Pain Essential Reads
Cassell may be correct in asserting that it is the person who suffers, but this person is not only a biological individual. This person mediates between body and society: discerning safety vs. danger, negotiating identity and roles, confronting meaning and mortality. We need an anthropology of pain to investigate and describe the diversity of possible forms of pain and suffering across cultures. Therein lies the possibility of a non-reductive science and treatment of suffering persons in their social context.
