October 24, 2019

The goals of medicine and the nature of suffering

by francesco in Uncategorized

The relief of suffering has always been one of the main drives in those who pursue a career in health care. As pointed out by EJ Cassel in a cornerstone article published in 1982 on the New England Journal of Medicine:

Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.

During their Summer Shadowing Program in Rome, our fellows Catherine, Peter, and Michael had a chance to encounter and see first-hand what suffering means to patients and doctors. The Fellowship Program gave them a chance to do more than just discover Italian culture, immerse themselves in the beauty of a different country and learn some Italian: it was an occasion to delve into the reality of a physician’s life and discover the effect that pain and suffering have on their job. Here are some of their reflections, based on the analysis of the 1982 article written by EJ Cassel and their own observations of patients in the hospital wards and in outpatient settings.

Catherine Steffens ’20
Gettysburg College

“Many times physicians can forget that a treatment may resolve the medical issue of the patient, but if it gets in the way of the patient’s way of life, it is not the correct treatment. For example, a vocalist cannot take medication if some of the primary side effects are dry mouth and trouble taking deep breaths without suffering because the treatment impedes their livelihood. It is crucial as physicians to take into account the intersections of a patient’s life in order to give the best medical care. As developed in this article, a loss from what makes someone human can lead to suffering. The patient mentioned in the article had become depressed due to her suffering from the loss of her ability to sculpt as well as her physical features being altered, unable to have the confidence from before the treatment. Although it would have been much more difficult for the doctors to find a treatment that would have avoided these issues, the patient would have most likely suffered less. The phrase “quality of life” should always be in the heads of physicians for their patients; the definition of “quality of life” changing for each patient as each life is different. Being able to have conversations with patients about options for their treatment based on how the therapy will affect the patients’ lives is beneficial for the patients and helps them feel in control of their own lives. Doctors do have the responsibility of caring for the health and wellness of others, but what is often left out from this care is the presence of suffering from the loss of what makes a patient’s life whole. By incorporating all dimensions and intersections of the patient’s life, this will aid in the overall “quality of life” for a recovering patient”.



Peter Stubin ’19
University of Maryland

“Recently I had the chance to reread my first reflection on Dr. Eric J Cassel’s special article “The Nature of Suffering and the Goals of Medicine,” and immediately I knew I had to write a new reflection. With a fresh set of eyes and new experiences, I realized that my first reflection had missed the mark and didn’t highlight the importance of Dr. Eric J Cassel’s message to the medical community.

While rereading the article, I found myself much more emotionally affected by the story of the 35-year-old sculptor that Dr. Cassel writes about. The sculptor had hopes of returning to doing what she loved, of being connected with her friends, and being able to feel like herself again, but her medical treatment pulled her further away from believing that these things could happen. She was housebound and bed-bound, her breast was disfigured, her face was changed by steroids, she was masculinized by her treatment, and she lost almost all of her hair. With such drastic physical changes, one could only imagine how much suffering she went through. Yet, as Dr. Cassel emphasizes, the suffering a patient experiences doesn’t just stop at the physical level – it encompasses a much more vast and complex realm.

Dr. Cassel explains that medicine is highly involved in the physical realm, but falls short when it comes to the mental realm – or really any realm that is not the physical realm. Dr. Cassel vividly describes all the pieces that make up a person, which extend well beyond just a person’s body. People have dreams and aspirations, people have roles in their families and in their communities, people are spiritual, people have previous experiences – essentially people are much more complex than what lies in the physical realm. A problem with their bodies can affect many of these other realms, which aren’t obvious unless one gets to know them well. By no means is Dr. Cassel looking to shame the medical community. In fact, he admits that most doctors have good intentions and want to be compassionate and helpful. He states that the doctors responsible for the treatment of the 35-year-old sculptor were competent and were acting out of genuine kindness and concern.

The purpose behind Dr. Cassel’s article is to inspire medical professionals to consider the complexity of their patients and to look beyond just treating physical symptoms to make their patients feel better. He states that the traditional theory of the mind-body duality that historically has had a strong influence on medicine is being questioned (his article came out in 1982, so he was speaking to the situation in the 80’s), as a result of patient demands and new technologies. In addition, he implies that medical school curricula aren’t sufficiently preparing doctors to be able to relieve suffering in their patients. In conversations with colleagues, he learns that few had thought about considering patient suffering in the terms he describes them in. Even myself, I hadn’t conceived the notion of teaching doctors to look beyond pain to relieve a patient’s suffering until I read Dr. Cassel’s article!

After reading the article for the first time, I thought it would be too difficult for doctors to relieve suffering in the way Dr. Cassel describes it in his article. However, after reading the article this second time, I now feel that it is possible, and I draw my inspiration from his last paragraph: “Attempts to understand all the known dimensions of personhood and their relations to illness and suffering present problems of staggering complexity. The problems are no greater, however, than those initially posed by the question of how the body works – a question that we have managed to answer in extraordinary detail.” Who would have thought that we would know everything we know about the human body now? In the same way, I imagine that if we look to address the problem of suffering and its complexities with the same motivation we had to learn about the human body, we’ll be astounded by what we can accomplish.”


Michael Carinha ’20
Ithaca College


“Pain is much more than suffering from a physical source like a chemotherapy treatment or pain
post-operation, which is why a patient must be treated as a whole. Suffering can be physical,
mental, and spiritual where those not directly affected by the pain can still suffer. A parent of a patient can suffer tremendously, which can then, in turn, make the patient suffer more because they know that their pain is hurting others. Suffering can also occur from things besides physical pain like if they know that if a bad consequence or severe pain is coming, but not currently present.

People are very complex, and have multiple ways of identifying whether it be a group identity, personal identity, a relationship with friends and family, or a social role in their lives and suffering can affect anyone of these aspects of the person. Not being able to fulfill the role of being a mom when sick and be able to take care of their children is just one example of the suffering an illness can cause a patient. Again, this is why the patient must be treated as a whole person when being treated so that it may be possible to avoid any type of suffering. A person’s cultural background can also shape the perception of pain, like being super masculine affects people so that they may not feel like they’re suffering from something because their cultural identity alters their perception. The treatment itself can also affect suffering. If a female is taking medication that destroys her hair, breasts, and femininity, she’ll most likely experience more suffering due to a loss of identity. A person’s perception of what’s causing the pain determines the amount of suffering. For example, if a patient thinks they have some kind of shoulder tendonitis, they use a small dose of a pain killer. When they find out it’s a malignant disease, they use a larger dose to cope with the pain. It’s very clear that pain and suffering have multiple layers and can affect many different things, which is why people must be treated as a whole when they become patients; humans are extremely complex creatures and must be treated with careful consideration of every aspect of their being.”