Philosophy, Psychiatry, & Psychology

Hillel Braude offers a thoughtful paper that explores the nature of suffering, with particular relation to—and distinction from—pain, as regards the work of Eric Cassell, and in reflection of the perspectives of Karl Jaspers and Emmanuel Levinas. To be sure, establishing distinction(s) between pain and suffering is not an easy task. As Yuri Maricich and I have noted, pain and suffering are often used synonymously, even in medical conversation(s). Yet, we have urged that such colloquialisms should be rectified, particularly in clinical contexts, because they can, and often do, foster ambiguities regarding the nature of these experiences, meanings to patient and clinician, and attendant trajectories and responsibilities for care (Maricich and Giordano 2009). Toward such a goal, one might seek to employ a number of viable definitions and discriminations of pain and suffering that have appeared in the literature. As Braude recognizes, Peter Moskovitz has recently provided a conceptual and neurobiological approach that seeks to explicate the activities of various somato-central (i.e., ‘bottom-up’) and centro-somatic (i.e., ‘top-down’) neural networks, describe the ‘states’ of pain and suffering and thereby frame the relation(s) and distinction(s) of these concepts (Moskovitz 2006, 2010). Pain can be a symptom of some insult or trauma, a disorder in and of itself (e.g., neuropathic pain), and manifest illness (i.e., maldynia). Each and all of these can evoke suffering.

Braude provides a perspective on Cassell’s characterization of suffering as “a state of severe distress associated with events that threaten the intactness of the person” (Cassell 1991, 33), and relates this to distinctions between disease and illness (ibid), such that disease is viewed as a pathologic process of cells and the physical body, while illness is a phenomenal experience of the being who is the patient. In many ways, these distinctions reflect Lynn Jansen and Daniel Sulmasy’s (2002) definitions of neurocognitive and agent-narrative forms of suffering in that the former refers to physiologic and causal mechanisms, while the latter is belief and value dependent. As well, Cassell’s, and Jansen and Sulmasy’s conceptualizations, when taken together, create a richer, and at the same time more finely-grained construct of the possible relationship of pain and suffering. As Braude (2012, 268) notes, “the subjective dimension of pain means that the simplistic dichotomy between pain and suffering [End Page 279] does not hold.” Indeed, Braude’s point speaks to the proverbial ‘problem of pain’: it is both the activation of certain peripheral and/or central neural mechanisms, pathways, and networks (that are objectively definable and describable as such) and the phenomenal experience of such activity as noxious that is contextualized and given meaning by the being in pain. Pain, qua pain, is an event of consciousness, and as such it is wholly subjective, transparent only in the first person, and intentional (Giordano 2009). Suffering, too, is a phenomenon of consciousness, and although some aspects remain at the limit of explicit cognition or language, it is important to bear in mind that the intentionality of consciousness fosters a referential quality to cognition, suffering and pain. In other words, we think ‘about something,’ and cognitively construct that we hurt and/or suffer ‘because of’ something. Thus, although pain does not always evoke suffering, it certainly can, and it is this situation of ‘suffering because of pain’ that is important to pain treatment and management.

The inextricability of the physiological and phenomenological aspects of pain reveals both its multi-componentiality, and the integrative aspects of neural systems as embodied and embedded within the spatial and temporal dimensions of internal and external environments. Thus, pain—like the being in which it occurs—is biopsy-chosocial: a happening not merely of the physical body (what in German is termed Körper), but of the dyad of objective corporeality and subjective understanding of this embodiment that is the lived-body (in German, Leib) that affects and reflects the patient’s life world and its circumstances (Giordano 2007; Leder 1990). In this way, pain— and suffering—gives rise to...