The Nature of Suffering and the Goals of Medicine
Author: Eric Cassell

Synopsis

Why is the medical profession failing in its fundamental goal and core duty, ‘the obligation to relieve the suffering caused by human sickness?’ (page 64). Why is the typical physician more interested in the diagnosis and treatment of disease than in the person suffering from the disease? (pages 4 and 64). Why does the prevailing scientific theory of medicine focus on understanding disease, but ‘says nothing about sick persons?’ (page 6). This book tackles these crucial questions, illustrating how physicians often underestimate the multifaceted causes of suffering on the false presumption that there is always a structural correlate for disease (page 7). The author’s key message, recurrent throughout the book, is that doctors should strive to know as much about the sick person in order to understand the cause of their suffering (page x).

The book defines suffering as ‘the state of severe distress associated with events that threaten the intactness of the person’ (page 33). It reviewed the diverse causes of suffering with emphasis on pain, fears of the future (page 37), reliving past injuries (page 39), perception of personal failure (page 41), loss of hope in a perceived future (page 43), and isolation (page 44). The author explored the disharmony, humiliation, embarrassment, and social failures which accompany suffering (pages 55-58). He sensitively describes the significant adjustments chronic sufferers have to make to deal with their disability, and these involve changes in their bodily functions and in their relationship to society. He however stressed that suffering is frequently not evident and ‘the only way to learn whether suffering is present is to ask the sufferer’ (page 44). The book explored the four strategies for relieving suffering, reflecting on effective measures such as encouraging patients ‘to root themselves in the absolute present‘ and ‘to be themselves to the fullest extent possible’ (pages 36-62). He stressed the importance of transcendence-giving suffering a meaning larger than the person-as ‘probably the most powerful way in which one is restored to wholeness after an injury to personhood’ (page 45).

At the core of the relief of suffering is the doctor-patient ‘healing relationship‘, and the book makes the crucial argument that this relationship relies more on the art than the science of medicine (pages 20 and 69). The book describes the skilful practitioner as one who ‘raises the relationship to an art‘, nurturing it to achieve the maximum therapeutic value for the patient (page 79). The author argues that successful doctors ‘have to know more about the sick person and the illness then just the name of the disease and its pathophysiology‘ (page 156). The book extensively reviews the role of the doctor in the treatment of chronic illness, urging practitioners to ‘focus primarily on the best interests of the sick person rather than treatment of the disease’ (page 241). He outlines the important goal of restoring ‘the intactness or integrity of the person’, but warns that ‘medical care… should not be so intrusive that a person is involved full time in following the doctors instructions’ (pages 124 and 246). He says the physician’s essential message to the patient should be ‘we are in this together‘ (page 239). In caring for people who are dying, the book encourages physicians to help them feel in control, and to ‘remain personally empowered until their death‘ (page 248).

The author related many interesting clinical anecdotes to illustrate the different facets of suffering. For example, he recounted the case of a sculptor with metastatic breast cancer whose suffering arose partly from her treatment. He used this case to demonstrate how ‘focusing entirely on the cure of bodily disease may lead physicians to ‘do things that cause the patient as a person to suffer’ (pages 30- 34). He also used the story of a man admitted with pneumonia but whose suffering was a result of wider social and health issues. The author here illustrated that the causes of illness are innumerable, and ‘illness cannot be viewed from the perspective of disease alone’ (page 109-111). He also narrated the story of the sales manager who developed chest pain following an argument with his wife. He used this tragedy to show that disease is context-specific, and depends on familial, ethnic, cultural, religious, political, and geographical factors (pages 159-161). The book explored several other relevant concepts such as resilience (page 44), lending strength (page 45), self-esteem (page 53), the placebo effect (page 119-120), treatment goals (page 123), prognosis (pages 128-137), rhetoric (page 147), illness narratives (page 166-168), the three goals that achieve relief from suffering (page 241), and the five faulty strategies of dealing with clinical uncertainty (page 230-231).

Opinion

This book is full of the wisdom that is essential to the healing art of medicine. The author addressed a variety of themes which are at the heart of the doctor-patient relationship. It is a sad commentary on the profession that such simple and basic themes are frequently deficient and need a book such as this to act as a reminder. The book is slightly marred by an excess of irrelevant academic musings on subjects such as the mind-body dichotomy, the concept of person, the theology of suffering, the nature of facts, and aesthetics. These sometimes threatened to distract from the key message the book wanted to project. The book could be shorter and more focused but it has thoroughly covered this neglected concept of medical practice.

Overall assessment

This is an excellent, even if slightly disjointed, account of the causes and remedies of suffering. It reveals the overarching importance of focusing on persons rather than diseases, and does so in a logical and profound way. The book is a guide and a reminder for physicians in an age when the science of medicine threatens to destroy its art. I highly recommend it to all doctors.

Book details

Publisher, Place, Year: Oxford University Press, New York, 1991
Number of Chapters: 12
Number of Pages: 254
ISBN: 9780195052220
Rating: 4 stars
Price: £23.32