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Research
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Published: 29 September 2017
Conceptualizing suffering and pain
Noelia Bueno-Gómez
Philosophy, Ethics, and Humanities in Medicine volume 12, Article number: 7 (2017) Cite this article
61k Accesses
32 Citations
31 Altmetric
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Abstract
Background
This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Contributions of classical evidence-based medicine, the humanistic turn in medicine, as well as the phenomenology and narrative theories of suffering and pain, together with certain conceptions of the person beyond them (the mind-body dichotomy, Cassel’s idea of persons as “intact beings”) are critically discussed with such purpose.
Methods
A philosophical methodology is used, based on the review of existent literature on the topic and the argumentation in favor of what are found as better definitions of suffering and pain.
Results
Pain can be described in neurological terms but cognitive awareness, interpretation, behavioral dispositions, as well as cultural and educational factors have a decisive influence on pain perception. Suffering is proposed to be defined as an unpleasant or even anguishing experience, severely affecting a person at a psychophysical and existential level. Pain and suffering are considered unpleasant. However, the provided definitions neither include the idea that pain and suffering can attack and even destroy the self nor the idea that they can constructively expand the self; both perspectives can b e equally useful for managing pain and suffering, but they are not defining features of the same. Including the existential dimension in the definition of suffering highlights the relevance of suffering in life and its effect on one’s own attachment to the world (including personal management, or the cultural and social influences which shape it). An understanding of pain and suffering life experiences is proposed, meaning that they are considered aspects of a person’s life, and the self is the ever-changing sum of these (and other) experiences.Download PDF
Download PDF
Research
Open Access
Published: 29 September 2017
Conceptualizing suffering and pain
Noelia Bueno-Gómez
Philosophy, Ethics, and Humanities in Medicine volume 12, Article number: 7 (2017) Cite this article
61k Accesses
32 Citations
31 Altmetric
Metricsdetails
Abstract
Background
This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Contributions of classical evidence-based medicine, the humanistic turn in medicine, as well as the phenomenology and narrative theories of suffering and pain, together with certain conceptions of the person beyond them (the mind-body dichotomy, Cassel’s idea of persons as “intact beings”) are critically discussed with such purpose.
Methods
A philosophical methodology is used, based on the review of existent literature on the topic and the argumentation in favor of what are found as better definitions of suffering and pain.
Results
Pain can be described in neurological terms but cognitive awareness, interpretation, behavioral dispositions, as well as cultural and educational factors have a decisive influence on pain perception. Suffering is proposed to be defined as an unpleasant or even anguishing experience, severely affecting a person at a psychophysical and existential level. Pain and suffering are considered unpleasant. However, the provided definitions neither include the idea that pain and suffering can attack and even destroy the self nor the idea that they can constructively expand the self; both perspectives can b e equally useful for managing pain and suffering, but they are not defining features of the same. Including the existential dimension in the definition of suffering highlights the relevance of suffering in life and its effect on one’s own attachment to the world (including personal management, or the cultural and social influences which shape it). An understanding of pain and suffering life experiences is proposed, meaning that they are considered aspects of a person’s life, and the self is the ever-changing sum of these (and other) experiences.
Conclusions
The provided definitions will be useful to the identification of pain and suffering, to the discussion of how to relieve them, and to a better understanding of how they are expressed and experienced. They lay the groundwork for further research in all these areas, with the twofold aim of a) avoiding epistemological mistakes and moral injustices, and b) highlighting the limitations of medicine in the treatment of suffering and pain.
Introduction
This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Such definitions will be useful to the identification of pain and suffering, to the discussion of how to relieve them, and to a better understanding of how they are expressed and experienced. The provided definitions lay the groundwork for further research in all these areas, with the aim of avoiding epistemological mistakes and moral injustices such as the exclusion of certain experiences from the definition of suffering. Definitions are not inconsequential, since the way in which we define concepts has epistemological, ontological and practical dimensions.
Classical evidence-based medicine understands pain from a naturalistic point of view, and persons as beings are divided into two different entities: the body and the mind. Even if this perspective has led to great success in the relief of pain, certain problems have remained partially or entirely unresolved and/or unexplained, for instance the placebo effect, chronic pain and non-somatic pain. Moreover, classical evidence-based medicine has been increasingly criticized from the second half of the twentieth century onwards. This paper will begin by explaining the conceptions of pain and person used by evidence-based classical medicine and their Cartesian roots, followed by a critical discussion of the contributions made by the humanistic turn (represented by Cassell), and finally, the phenomenology and narrative conceptions of the self and the person.
An alternative to the mind/body dichotomy is assumed, consisting of an understanding of persons as psychophysical, socioculturally situated beings. Both pain and suffering have bodily, psychological and sociocultural dimensions. Pain (like pleasure) has been defined as a process resulting from a somatosensory perception, subsequently present in the brain as a mental image and followed by an unpleasant emotion as well as changes in the body [1], but such a process cannot be described exclusively in these neurological terms. Cognitive awareness [2], interpretation [3], behavioral dispositions [1], cultural [4] and educational factors [1] influence the perception of pain – for example, pain tolerance or the pain threshold.Footnote1 Suffering is proposed to be defined as an unpleasant or even anguishing experience which severely affects a person at a psychophysical and an existential level. Even when suffering is not caused by biological or observable circumstances (like the pain associated with tissue damage), it is an embodied experience which we cannot but feel in the rhythm of our hearts, the clenching of our stomachs, the sweat on our hands, our (in)ability to sleep, or the position of our shoulders, just to provide a few examples. Even if suffering does not originate from illness or pain, it can make us feel ill and can even cause us to develop various ailments. Pain can be a source of suffering, but it is not the only one. Social problems like poverty, social exclusion, forceful social inclusion (like peer pressure), forced displacement and uprooting; existential and personal problems like grief and stress; conditions like nausea, paresthesia, a non-painful illness, anxiety or fear can likewise be a cause of suffering. Although pain and suffering are unpleasant, they are not per se either destructive or constructive forces which tear down or build up the self. Rather, they are part of a person’s life, and the self is the result of various experiences includingDownload PDF
Download PDF
Research
Open Access
Published: 29 September 2017
Conceptualizing suffering and pain
Noelia Bueno-Gómez
Philosophy, Ethics, and Humanities in Medicine volume 12, Article number: 7 (2017) Cite this article
61k Accesses
32 Citations
31 Altmetric
Metricsdetails
Abstract
Background
This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Contributions of classical evidence-based medicine, the humanistic turn in medicine, as well as the phenomenology and narrative theories of suffering and pain, together with certain conceptions of the person beyond them (the mind-body dichotomy, Cassel’s idea of persons as “intact beings”) are critically discussed with such purpose.
Methods
A philosophical methodology is used, based on the review of existent literature on the topic and the argumentation in favor of what are found as better definitions of suffering and pain.
Results
Pain can be described in neurological terms but cognitive awareness, interpretation, behavioral dispositions, as well as cultural and educational factors have a decisive influence on pain perception. Suffering is proposed to be defined as an unpleasant or even anguishing experience, severely affecting a person at a psychophysical and existential level. Pain and suffering are considered unpleasant. However, the provided definitions neither include the idea that pain and suffering can attack and even destroy the self nor the idea that they can constructively expand the self; both perspectives can b e equally useful for managing pain and suffering, but they are not defining features of the same. Including the existential dimension in the definition of suffering highlights the relevance of suffering in life and its effect on one’s own attachment to the world (including personal management, or the cultural and social influences which shape it). An understanding of pain and suffering life experiences is proposed, meaning that they are considered aspects of a person’s life, and the self is the ever-changing sum of these (and other) experiences.
Conclusions
The provided definitions will be useful to the identification of pain and suffering, to the discussion of how to relieve them, and to a better understanding of how they are expressed and experienced. They lay the groundwork for further research in all these areas, with the twofold aim of a) avoiding epistemological mistakes and moral injustices, and b) highlighting the limitations of medicine in the treatment of suffering and pain.
Introduction
This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Such definitions will be useful to the identification of pain and suffering, to the discussion of how to relieve them, and to a better understanding of how they are expressed and experienced. The provided definitions lay the groundwork for further research in all these areas, with the aim of avoiding epistemological mistakes and moral injustices such as the exclusion of certain experiences from the definition of suffering. Definitions are not inconsequential, since the way in which we define concepts has epistemological, ontological and practical dimensions.
Classical evidence-based medicine understands pain from a naturalistic point of view, and persons as beings are divided into two different entities: the body and the mind. Even if this perspective has led to great success in the relief of pain, certain problems have remained partially or entirely unresolved and/or unexplained, for instance the placebo effect, chronic pain and non-somatic pain. Moreover, classical evidence-based medicine has been increasingly criticized from the second half of the twentieth century onwards. This paper will begin by explaining the conceptions of pain and person used by evidence-based classical medicine and their Cartesian roots, followed by a critical discussion of the contributions made by the humanistic turn (represented by Cassell), and finally, the phenomenology and narrative conceptions of the self and the person.
An alternative to the mind/body dichotomy is assumed, consisting of an understanding of persons as psychophysical, socioculturally situated beings. Both pain and suffering have bodily, psychological and sociocultural dimensions. Pain (like pleasure) has been defined as a process resulting from a somatosensory perception, subsequently present in the brain as a mental image and followed by an unpleasant emotion as well as changes in the body [1], but such a process cannot be described exclusively in these neurological terms. Cognitive awareness [2], interpretation [3], behavioral dispositions [1], cultural [4] and educational factors [1] influence the perception of pain – for example, pain tolerance or the pain threshold.Footnote1 Suffering is proposed to be defined as an unpleasant or even anguishing experience which severely affects a person at a psychophysical and an existential level. Even when suffering is not caused by biological or observable circumstances (like the pain associated with tissue damage), it is an embodied experience which we cannot but feel in the rhythm of our hearts, the clenching of our stomachs, the sweat on our hands, our (in)ability to sleep, or the position of our shoulders, just to provide a few examples. Even if suffering does not originate from illness or pain, it can make us feel ill and can even cause us to develop various ailments. Pain can be a source of suffering, but it is not the only one. Social problems like poverty, social exclusion, forceful social inclusion (like peer pressure), forced displacement and uprooting; existential and personal problems like grief and stress; conditions like nausea, paresthesia, a non-painful illness, anxiety or fear can likewise be a cause of suffering. Although pain and suffering are unpleasant, they are not per se either destructive or constructive forces which tear down or build up the self. Rather, they are part of a person’s life, and the self is the result of various experiences including pain and suffering, which have an existential dimension inasmuch as they depend on the person’s attitude, resources for their management, as well as choices and commitments related to that person’s attachment to life and the world. Such personal options are influenced by social [5, 6] and cultural [7, 8] patterns.
Background
The mind/body dichotomy
Even if the “problem of consciousness” – “how consciousness arises from matter or, more cautiously, how it is related to matter” [9] – is far from a definitive solution, there is a generalized agreement in literature (particularly in sociology and the philosophy of medicine) regarding the need to question the traditional Cartesian distinction between the body and mind [1,2,3]. Kügler argues for the impossibility of conclusively solving the problem of consciousness, concluding that philosophy must continue working on this topic. However, such difficulties (or even impossibilities) may be due to the fact that we continue to use the classical concepts: We cannot resolve this dualism if we still think in dualistic terms. In order to reframe the mind/body problem, we need to think in terms of “embodying the mind” and “minding the body.”Footnote2
After questioning the mind/body dualism, the concepts of suffering and pain need to be reconsidered, even if a new conceptualization is indeed difficult [10, 11]. Simply put, it is no longer acceptable to consider pain only in physical and suffering only in psychological terms. The Cartesian distinction between res cogitans and res extensa is the driving force behind the whole structure of thinking in and the organization of medical sciences and psychology. Once we question this distinction, we need to reconsider this structure of thinking and organization, as well.
Questioning the distinction between the body and mind is not a new idea, despite its persistent prevalence in Western thought. The materialistic understanding of the mind (one of the alternatives to the mind/body dichotomy) can be traced as far back as the philosophy of Epicurus.Footnote3 In fact, there exists a whole alternative perspective, parallel to the Cartesian conception of the body and mind, developed by Spinoza and continued by Nietzsche and the American pragmatists (particularly William James), as pointed out by Johnson [10].
For Descartes, the body and mind are two different substances with a different ontological status: The body is like a mechanism that exists in time and space, it can be measured and so can its reactions and processes; however the mind lacks these spatial and temporal dimensions and can exist without a corresponding body. Accordingly, pain is something which occurs in the body and which can be described in terms of visible, physical, measurable damage (for example, tissue damage). In a period of increasing importance of the natural sciences, the Cartesian conceptualization of the res extensa presupposes a knowable world, organized according to certain natural laws [12]. It assumes that it is possible and desirable to intervene in the world scientifically to further the progress of humanity, which includes medicine, in particular. By using scientific methodology, it is considered possible to repair a body in the same way in which we can repair a machine (or an animal, inasmuch as Descartes considers animals part of the res extensa). Descartes himself is engaged in the enterprise of knowing the world in order to turn humans into “maîtres et possesseurs de la nature” (“masters and possessors of nature”) [12], proposing a scientific method and using it to improve living conditions. He trusts in human reasonto the point of believing that progress in medicine will be able to relieve us of illness and even the weakness associated with old age, thus showing the first signs of an attitude which reaches its peak during the Enlightenment and declines (in a certain sense) in twentieth century, when the risks of scientific and technological intervention started to become apparent. The Cartesian perspective drove the development of clinical medicine as an empirical science based on evidence.
However, for Descartes, it was clear that our states of mind (“esprits” in the original French) depend on the “disposition of the organs of our body” [12]. Hence, medicine should contribute not only to the physical, but also to the spiritual and mental wellbeing, and ultimately result in “wiser” humans, both because medicine is able to provide scientific knowledge about human body (which constitutes a contribution to wisdom), and because medicine provides useful knowledge about the body which might allow humans to be free of illness and weakness, thus enabling them to develop and apply their intelligence to increase the knowledge of humanity. In short, it is not true that the body does not matter to Descartes, who was a rationalist but not an idealist, in the sense that he was not willing to risk his “corporeal” existence in order to defend his ideas (he preferred to accept rules and laws of his time that were incompatible with his own ideas in order to avoid imprisonment and other legal consequences, even though he supported the autonomy of reason). In this sense Cartesian dualism does not imply a dismissal of the body. Still, Descartes argues for the existence of an immortal soul which can stand on its own, without a body. Herein Damasio sees Descartes’ “mistake”: in the idea that the mind can exist or even operate independently of the body [1].
The conceptualization of pain and suffering in classical evidence-based medicine
Pain and suffering cannot be treated exclusively in naturalistic, scientific terms, at least under a certain view of what science is. Medicine became a science at the end of the eighteenth century with the emergence of clinical, evidence-based medicine. In the context of such medicine, suffering and pain were dissociated from the context of a theodicy [13] and to be treated scientifically. Medicine started to be systematically organized in clinical environments, where patients could be observed and the symptoms and diseases compared and described as neutrally as possible: As explained by Foucault, the physician must distance himself from the diseased in order to learn the truth of the pathological fact [14]. Disease and pain started to be considered as being situated in bodies, since bodies and their processes came to be viewed in standardized, universalizeable terms. Knowing the medical, scientific truth about pain required both abstracting the body from the person, and the pathological fact from all normal bodily functions. These developments gave rise to the modern problematic approach to dealing with pain and suffering. According to Rey,
“At the dawn of the 19th century, physicians were looking for a pure sign which would remove the ambiguities inherent in symptoms. They wished to find a sign, the meaning of which would be as certain as that provided by the lesion found at dissection. However, they were to be confronted not only with the multiple signs fundamental to pain, but also by that special exchange between physician and patient in which, whether consciously or not, the latter adopts a distinctive attitude in relating the details of his painful symptoms” [4].
The challenge of medicine based on observation, objective description of symptoms and diseasesFootnote4 and experimentally proven treatments is dealing with a phenomenon like pain, which may or may not correlate to physical symptoms, whose relief may or may not be affected by the administration of certain drugs, but not always and not to the same degree, and which is definitely modulated by circumstances which are difficult or impossible to measure scientifically, like educational factors moral or religious beliefs, or personal attitudes. Pain is not a kind of spring, and bodies are much more than mere mechanisms, as phenomenologists have striven to show in the 20th century. Abstracting the “pathological fact” from the body and the body from the person facilitated a number of impressive results, treatments and medical progress. However, it proved to have its limitations too.
Pain has not been at the center of medical interest for the whole history of medicine. Of course, pain, like suffering, has always concerned medicine, but treating diseases in the search for healing and accumulating the necessary knowledge and expertise to do so more effectively in the future may be a better definition of the general goal of medicine in all times [4]. The Hippocratic moral maxim of “primum non nocere” has frequently been interpreted in this sense: To inflict pain (iatrogenic pain) can be considered “non nocere”, that is, not harmful, if it is done for the ultimate goal of curing the patient. In fact, the idea that greater pain can erase lesser pain is also of Hippocratic origin. This principle was particularly used during the nineteenth century by physicians who believed that pain can be useful for the purpose of healing [15]: The “moxa” procedure (direct moxibustion) consisted of placing a burning cone on the skin of a patient suffering from an ailment in order to infuse the body with external energy and stimulate the healing process. The pain resulting from the burn sore was seen as essential in swaying the body to combat the illness or pain the patient was suffering from in the first place [4]. We are usually willing to accept certain nuisances or evenstrong, painful secondary effects of medical treatments if we take them to enhance the recovery process or our quality of life. More questionable is the damage inflicted in order to prevent a more or less probable future disease, and an entirely different discussion concerns the damage inflicted in order to improve the knowledge of the discipline. In any case, the fact of the matter is that medical treatments and healing can – and usually do have – painful consequences, and they can cause suffering.
The attitude of trying to view the ills in the abstract in order to know the scientific “truth” of the pathological fact, and the empirical methodology, combined with the idea that healing is the ultimate goal of medicine, were precisely the focus of the criticism leveled against medicine, the new demands of patient and professional organizations, as well as the discipline of bioethics beginning in the 1960s. All these demands for a “more human” form of medicine were developed in a social context of alarm about the risks of techno-scientific progress and the general questioning of authority on many fronts [16, 17]. This criticism came to be known as the “humanistic turn” and it emerged from different fronts: the hospice movement [18], women’s rights movements which advocated a more active role of women in childbirth [19], Christian humanistic criticism against medicalization [20], bioethics and its criticism of medical paternalism [21], postmodern criticism of medicine [22], theDownload PDF
Download PDF
Research
Open Access
Published: 29 September 2017
Conceptualizing suffering and pain
Noelia Bueno-Gómez
Philosophy, Ethics, and Humanities in Medicine volume 12, Article number: 7 (2017) Cite this article
61k Accesses
32 Citations
31 Altmetric
Metricsdetails
Abstract
Background
This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Contributions of classical evidence-based medicine, the humanistic turn in medicine, as well as the phenomenology and narrative theories of suffering and pain, together with certain conceptions of the person beyond them (the mind-body dichotomy, Cassel’s idea of persons as “intact beings”) are critically discussed with such purpose.
Methods
A philosophical methodology is used, based on the review of existent literature on the topic and the argumentation in favor of what are found as better definitions of suffering and pain.
Results
Pain can be described in neurological terms but cognitive awareness, interpretation, behavioral dispositions, as well as cultural and educational factors have a decisive influence on pain perception. Suffering is proposed to be defined as an unpleasant or even anguishing experience, severely affecting a person at a psychophysical and existential level. Pain and suffering are considered unpleasant. However, the provided definitions neither include the idea that pain and suffering can attack and even destroy the self nor the idea that they can constructively expand the self; both perspectives can b e equally useful for managing pain and suffering, but they are not defining features of the same. Including the existential dimension in the definition of suffering highlights the relevance of suffering in life and its effect on one’s own attachment to the world (including personal management, or the cultural and social influences which shape it). An understanding of pain and suffering life experiences is proposed, meaning that they are considered aspects of a person’s life, and the self is the ever-changing sum of these (and other) experiences.
Conclusions
The provided definitions will be useful to the identification of pain and suffering, to the discussion of how to relieve them, and to a better understanding of how they are expressed and experienced. They lay the groundwork for further research in all these areas, with the twofold aim of a) avoiding epistemological mistakes and moral injustices, and b) highlighting the limitations of medicine in the treatment of suffering and pain.
Introduction
This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Such definitions will be useful to the identification of pain and suffering, to the discussion of how to relieve them, and to a better understanding of how they are expressed and experienced. The provided definitions lay the groundwork for further research in all these areas, with the aim of avoiding epistemological mistakes and moral injustices such as the exclusion of certain experiences from the definition of suffering. Definitions are not inconsequential, since the way in which we define concepts has epistemological, ontological and practical dimensions.
Classical evidence-based medicine understands pain from a naturalistic point of view, and persons as beings are divided into two different entities: the body and the mind. Even if this perspective has led to great success in the relief of pain, certain problems have remained partially or entirely unresolved and/or unexplained, for instance the placebo effect, chronic pain and non-somatic pain. Moreover, classical evidence-based medicine has been increasingly criticized from the second half of the twentieth century onwards. This paper will begin by explaining the conceptions of pain and person used by evidence-based classical medicine and their Cartesian roots, followed by a critical discussion of the contributions made by the humanistic turn (represented by Cassell), and finally, the phenomenology and narrative conceptions of the self and the person.
An alternative to the mind/body dichotomy is assumed, consisting of an understanding of persons as psychophysical, socioculturally situated beings. Both pain and suffering have bodily, psychological and sociocultural dimensions. Pain (like pleasure) has been defined as a process resulting from a somatosensory perception, subsequently present in the brain as a mental image and followed by an unpleasant emotion as well as changes in the body [1], but such a process cannot be described exclusively in these neurological terms. Cognitive awareness [2], interpretation [3], behavioral dispositions [1], cultural [4] and educational factors [1] influence the perception of pain – for example, pain tolerance or the pain threshold.Footnote1 Suffering is proposed to be defined as an unpleasant or even anguishing experience which severely affects a person at a psychophysical and an existential level. Even when suffering is not caused by biological or observable circumstances (like the pain associated with tissue damage), it is an embodied experience which we cannot but feel in the rhythm of our hearts, the clenching of our stomachs, the sweat on our hands, our (in)ability to sleep, or the position of our shoulders, just to provide a few examples. Even if suffering does not originate from illness or pain, it can make us feel ill and can even cause us to develop various ailments. Pain can be a source of suffering, but it is not the only one. Social problems like poverty, social exclusion, forceful social inclusion (like peer pressure), forced displacement and uprooting; existential and personal problems like grief and stress; conditions like nausea, paresthesia, a non-painful illness, anxiety or fear can likewise be a cause of suffering. Although pain and suffering are unpleasant, they are not per se either destructive or constructive forces which tear down or build up the self. Rather, they are part of a person’s life, and the self is the result of various experiences including pain and suffering, which have an existential dimension inasmuch as they depend on the person’s attitude, resources for their management, as well as choices and commitments related to that person’s attachment to life and the world. Such personal options are influenced by social [5, 6] and cultural [7, 8] patterns.
Background
The mind/body dichotomy
Even if the “problem of consciousness” – “how consciousness arises from matter or, more cautiously, how it is related to matter” [9] – is far from a definitive solution, there is a generalized agreement in literature (particularly in sociology and the philosophy of medicine) regarding the need to question the traditional Cartesian distinction between the body and mind [1,2,3]. Kügler argues for the impossibility of conclusively solving the problem of consciousness, concluding that philosophy must continue working on this topic. However, such difficulties (or even impossibilities) may be due to the fact that we continue to use the classical concepts: We cannot resolve this dualism if we still think in dualistic terms. In order to reframe the mind/body problem, we need to think in terms of “embodying the mind” and “minding the body.”Footnote2
After questioning the mind/body dualism, the concepts of suffering and pain need to be reconsidered, even if a new conceptualization is indeed difficult [10, 11]. Simply put, it is no longer acceptable to consider pain only in physical and suffering only in psychological terms. The Cartesian distinction between res cogitans and res extensa is the driving force behind the whole structure of thinking in and the organization of medical sciences and psychology. Once we question this distinction, we need to reconsider this structure of thinking and organization, as well.
Questioning the distinction between the body and mind is not a new idea, despite its persistent prevalence in Western thought. The materialistic understanding of the mind (one of the alternatives to the mind/body dichotomy) can be traced as far back as the philosophy of Epicurus.Footnote3 In fact, there exists a whole alternative perspective, parallel to the Cartesian conception of the body and mind, developed by Spinoza and continued by Nietzsche and the American pragmatists (particularly William James), as pointed out by Johnson [10].
For Descartes, the body and mind are two different substances with a different ontological status: The body is like a mechanism that exists in time and space, it can be measured and so can its reactions and processes; however the mind lacks these spatial and temporal dimensions and can exist without a corresponding body. Accordingly, pain is something which occurs in the body and which can be described in terms of visible, physical, measurable damage (for example, tissue damage). In a period of increasing importance of the natural sciences, the Cartesian conceptualization of the res extensa presupposes a knowable world, organized according to certain natural laws [12]. It assumes that it is possible and desirable to intervene in the world scientifically to further the progress of humanity, which includes medicine, in particular. By using scientific methodology, it is considered possible to repair a body in the same way in which we can repair a machine (or an animal, inasmuch as Descartes considers animals part of the res extensa). Descartes himself is engaged in the enterprise of knowing the world in order to turn humans into “maîtres et possesseurs de la nature” (“masters and possessors of nature”) [12], proposing a scientific method and using it to improve living conditions. He trusts in human reason to the point of believing that progress in medicine will be able to relieve us of illness and even the weakness associated with old age, thus showing the first signs of an attitude which reaches its peak during the Enlightenment and declines (in a certain sense) in twentieth century, when the risks of scientific and technological intervention started to become apparent. The Cartesian perspective drove the development of clinical medicine as an empirical science based on evidence.
However, for Descartes, it was clear that our states of mind (“esprits” in the original French) depend on the “disposition of the organs of our body” [12]. Hence, medicine should contribute not only to the physical, but also to the spiritual and mental wellbeing, and ultimately result in “wiser” humans, both because medicine is able to provide scientific knowledge about human body (which constitutes a contribution to wisdom), and because medicine provides useful knowledge about the body which might allow humans to be free of illness and weakness, thus enabling them to develop and apply their intelligence to increase the knowledge of humanity. In short, it is not true that the body does not matter to Descartes, who was a rationalist but not an idealist, in the sense that he was not willing to risk his “corporeal” existence in order to defend his ideas (he preferred to accept rules and laws of his time that were incompatible with his own ideas in order to avoid imprisonment and other legal consequences, even though he supported the autonomy of reason). In this sense Cartesian dualism does not imply a dismissal of the body. Still, Descartes argues for the existence of an immortal soul which can stand on its own, without a body. Herein Damasio sees Descartes’ “mistake”: in the idea that the mind can exist or even operate independently of the body [1].
The conceptualization of pain and suffering in classical evidence-based medicine
Pain and suffering cannot be treated exclusively in naturalistic, scientific terms, at least under a certain view of what science is. Medicine became a science at the end of the eighteenth century with the emergence of clinical, evidence-based medicine. In the context of such medicine, suffering and pain were dissociated from the context of a theodicy [13] and to be treated scientifically. Medicine started to be systematically organized in clinical environments, where patients could be observed and the symptoms and diseases compared and described as neutrally as possible: As explained by Foucault, the physician must distance himself from the diseased in order to learn the truth of the pathological fact [14]. Disease and pain started to be considered as being situated in bodies, since bodies and their processes came to be viewed in standardized, universalizeable terms. Knowing the medical, scientific truth about pain required both abstracting the body from the person, and the pathological fact from all normal bodily functions. These developments gave rise to the modern problematic approach to dealing with pain and suffering. According to Rey,
“At the dawn of the 19th century, physicians were looking for a pure sign which would remove the ambiguities inherent in symptoms. They wished to find a sign, the meaning of which would be as certain as that provided by the lesion found at dissection. However, they were to be confronted not only with the multiple signs fundamental to pain, but also by that special exchange between physician and patient in which, whether consciously or not, the latter adopts a distinctive attitude in relating the details of his painful symptoms” [4].
The challenge of medicine based on observation, objective description of symptoms and diseasesFootnote4 and experimentally proven treatments is dealing with a phenomenon like pain, which may or may not correlate to physical symptoms, whose relief may or may not be affected by the administration of certain drugs, but not always and not to the same degree, and which is definitely modulated by circumstances which are difficult or impossible to measure scientifically, like educational factors moral or religious beliefs, or personal attitudes. Pain is not a kind of spring, and bodies are much more than mere mechanisms, as phenomenologists have striven to show in the 20th century. Abstracting the “pathological fact” from the body and the body from the person facilitated a number of impressive results, treatments and medical progress. However, it proved to have its limitations too.
Pain has not been at the center of medical interest for the whole history of medicine. Of course, pain, like suffering, has always concerned medicine, but treating diseases in the search for healing and accumulating the necessary knowledge and expertise to do so more effectively in the future may be a better definition of the general goal of medicine in all times [4]. The Hippocratic moral maxim of “primum non nocere” has frequently been interpreted in this sense: To inflict pain (iatrogenic pain) can be considered “non nocere”, that is, not harmful, if it is done for the ultimate goal of curing the patient. In fact, the idea that greater pain can erase lesser pain is also of Hippocratic origin. This principle was particularly used during the nineteenth century by physicians who believed that pain can be useful for the purpose of healing [15]: The “moxa” procedure (direct moxibustion) consisted of placing a burning cone on the skin of a patient suffering from an ailment in order to infuse the body with external energy and stimulate the healing process. The pain resulting from the burn sore was seen as essential in swaying the body to combat the illness or pain the patient was suffering from in the first place [4]. We are usually willing to accept certain nuisances or even strong, painful secondary effects of medical treatments if we take them to enhance the recovery process or our quality of life. More questionable is the damage inflicted in order to prevent a more or less probable future disease, and an entirely different discussion concerns the damage inflicted in order to improve the knowledge of the discipline. In any case, the fact of the matter is that medical treatments and healing can – and usually do have – painful consequences, and they can cause suffering.
The attitude of trying to view the ills in the abstract in order to know the scientific “truth” of the pathological fact, and the empirical methodology, combined with the idea that healing is the ultimate goal of medicine, were precisely the focus of the criticism leveled against medicine, the new demands of patient and professional organizations, as well as the discipline of bioethics beginning in the 1960s. All these demands for a “more human” form of medicine were developed in a social context of alarm about the risks of techno-scientific progress and the general questioning of authority on many fronts [16, 17]. This criticism came to be known as the “humanistic turn” and it emerged from different fronts: the hospice movement [18], women’s rights movements which advocated a more active role of women in childbirth [19], Christian humanistic criticism against medicalization [20], bioethics and its criticism of medical paternalism [21], postmodern criticism of medicine [22], the “medical humanism” exemplified by Cassell’s work [3], and phenomenological as well as narrative approaches to the practices of medicine and the experiences of the patients, not to mention the contributions of the history, philosophy and sociology of medicine, which placed an emphasis on its fallibility and limitations, its historical and sociological dimensions, and, last but not least, its ontological assumptions. Due to this intense, yet unfinished debate and criticism, clinical medicine has begun to change, incorporating more or less parsimoniously any of the required reforms, while simultaneously increasing its techno-scientific dimension [23].
These theoretical critical approaches and the parallel social activism challenged the methods, goals and consequences of medicine in different ways. For example, the hospice movement is particularly relevant concerning the aforementioned predominance of the “healing goal” instead of the “palliative goal” of medicine. Cicely Saunders and Elisabeth Kübler-Ross pioneered this movement by emphasizing the necessity of taking care of patients even if their diseases are incurable. Displacing the goal of healing and situating “care” in itself as a focus of healthcare assistance involved increasing interest in the phenomena of pain and suffering in all their dimensions, as well as the research dedicated to improving and implementing analgesia.
All these critical approaches coincide in a demand for the resituation of the ill person in medical contexts. The patient should not be considered a “patient” anymore – a passive being patiently waiting for treatments and medical examinations. The modern patient expects to negotiate the medical decisions concerning them, because medical decisions are never strictly “scientific”, but also moral and/or political. For example, the decision to accept or reject a medical treatment in order to prevent a possible disease cannot be taken “objectively” because this is not a purely objective decision; it involves issues like the evaluation of the secondary effects of the treatment, the personal values and priorities of the affected person, or his/her ability to assume the risk. The scientific dimension of the decision is certainly only one among many. So the challenge mentioned previously still persists, since the physician is now required not to make an abstraction of the ill person, not to look at the body as if it were a mere mechanism to repair, not to take into account only somatic pain, but also to consider non-somatic pain, secondary effects of treatments, personal circumstances, etc. This situation requires the reconceptualization of pain and suffering, and a serious debate about the goals of medicine and its role in society.
