PAIN AND SUFFERING

Suffering demands explanation and relief. Some appear to suffer in excess of their actions, the innocent suffer as the evil do, and the best suffer with the worst. Theologies and theodicies attempt to cope with the paradox of a holy, omnipotent, omniscient, just god and the presence of suffering. Healers and systems of medicine arise in every culture in response to suffering. Yet what suffering is, where in the human condition it originates, and in what direction its solution is, remain poorly understood.

Pain is the most commonly considered source of suffering, so much so that the two terms are commonly linked—as in "pain and suffering." They are, however, distinctly different forms of distress. Understanding what pain is, and how it is related to but different from suffering, provides an introduction to the topic.

How the Nervous System is Involved in Pain: The Nociceptive Apparatus

The nervous system pathways—the nociceptive apparatus— involved in the transmission of noxious stimuli do not simply transfer information from an injured part to the central nervous system. They are part of a system in which the information can be either enhanced, diminished, or suppressed. The modulation of the noxious sensation occurs as part of the process of perception where meaning influences the original message.

Skin, muscles, and internal organs are supplied with nerve endings that come from several types of nerve fibers. Some are specifically responsive to mechanical, thermal, and chemical stimuli that give rise to the noxious physical sensation called nociception. These nociceptive nerve fibers enter the spinal cord and make complex connections with the spinal nerves that ascend to the thalamus and from there to areas of the cortex of the brain. Neural pathways from the higher centers, in what is called the endogenous pain control system, descend to make connections in the dorsal horn of the spinal cord in the area where the pain fibers make their initial central connections. These descending tracts are able to modulate the nociceptive signal by exerting an inhibitory effect specifically on pain-transmission neurons.

In addition to neural pathways, which do not merely transmit noxious sensations but change their character, chemical messengers and their receptors within the nervous system also have an influence on the message. Naturally occurring brain peptides such as enkephalin and beta-endorphin, collectively known as endorphins, exert analgesic effects in different areas of the nervous system by binding to specialized receptors. These same receptors also bind drugs such as morphine or meperidine, allowing them to provide pain relief. Other neurotransmitters, such as serotonin and dopamine, also have effects that temper the transmission of nociceptive messages.

Pain as Perception

Historically, knowledge about nociception as neural transmission of noxious stimuli predated knowledge about the modulation of the nociceptive process. This simplified view of nociception fits the mechanical understanding of the nervous system that has held until recent times. This view accounts for the fact that the noxious sensation that is nociception is so commonly confused with pain and that the two terms, although distinct, are often used interchangeably. Nociception provides the noxious sensation resulting from extremes of mechanical pressure or temperature that is interpreted by the organism as pain.

Because pain is a perception based on sensory information from the nociceptive apparatus—just as seeing something is a perception based on information from the visual apparatus—it involves a cognitive effort that requires judgment. The place of cognition in the process may be questioned in acute, severe, or momentary pain, but most pain is longer lasting and more ambiguous in source and meaning.

Nociception is usually followed by aversive action. The reflexive withdrawal of a burned hand, however, has little applicability to understanding human pain. The actions of humans in response to pain generally take into account the location, severity, cause, and anticipated course of the pain. Knowledge and judgment are required. Reactions to pain range from the momentary to well-laid future plans. While the former may depend on reflexes, the latter do not. Pain is the entire process of sensing, interpreting, and modulating the nociceptive process, assigning cause, anticipating course, and determining response. As a consequence, it is obvious why it is a source of confusion that human pain does not exist without sentience. Unconscious or comatose persons may demonstrate nociceptive reactions such as reflex withdrawal from noxious stimuli or elevations in pulse and blood pressure. Consciousness, however, is required for the full experience of pain. This is why a useful working definition of pain is experience reported in the statement "it hurts."

Attempts to refute the subjective nature of pain may take the form of statements that pain is usually accompanied by physiologic changes in, for example, pulse and blood pressure, but the body and its physiology are part of the person and nothing happens to one part that does not happen to all. Confusions such as this are residua of the mind–body dichotomy that has ruled medical science for centuries and still disorders understanding. The fact that pain cannot be measured has been a source of great frustration to investigators. Noxious stimuli and nociceptive responses can be quantified, but pain cannot. The difficulty of understanding pain is part of the age-old conundrum of how a physiological event becomes a feeling or a thought and how thoughts and feelings are translated into physiology.

Chronic Pain

Chronic pain—by definition, pain lasting more than six months—represents a greater challenge to understanding than acute pain. What is known about the nociceptive system does not explain the phenomenon of chronic pain. There is evidence that the reparative response that occurs after damage to peripheral nerves may alter their function in a manner that perpetuates or exaggerates their response to noxious stimuli. Similar modifications of the whole nociceptive apparatus, including the function of its neuroendocrine component (for example, endorphins), may provide some basis for pain that continues after the initial stage of tissue damage. Nonetheless, paucity of solid evidence to resolve the enigma of chronic pain has led to speculation and hypothesis based more on belief than on knowledge. For example, various schemata have been developed that explain chronic pain in many ways: as a result of continued tissue damage (e.g., rheumatoid arthritis); because of psychic perpetuation of organic pain (e.g., phantom limb pain); or from emotional factors believed to precipitate the organic (e.g., duodenal ulcer); as well as to hypothesized states of psychogenic pain arising from psychic conflicts experienced in a somatic manner (Whitehead and Kuhn).

The problem has also been framed as a conflict between peripheralists and centralists. The peripheralist believes that there must be continued nociceptive input and that treatment should be directed toward blocking the presumed nociceptive process with analgesics or nerve blocks and by other means. Centralists believe that although some peripheral pathology with nociceptive consequences initiated the pain, under some circumstances it can be continued "as a self-perpetuating physiological generator mechanism within the central nervous system" (Crue).

The Role of Meaning

Human pain, acute or chronic, involves the constant and interactive contribution of both psychic and physical determinants. The most important psychological component of pain is its meaning, that is, its significance and its importance. Significance denotes the event as a this or a that: "Chest pain (of this type) signifies a heart attack." Importance evaluates the event: "A heart attack will be the end of my active life." These two functions of meaning are always intertwined and arise from the concepts (e.g., heart attacks) to which they refer. The interpretation of a pain as arising from, for example, cancer, contains within it ideas of process: "Cancer comes from … and goes on to become …" as well as to ideas of the impact on the person: "Cancer pain is terrible and heralds death." Things have affective, physical, and spiritual as well as cognitive meanings. People act on their interpretation of the consequences of the distress, doing what is necessary on their part for it to improve. For example, a person who develops unexpected chest pain while walking may stop because it is impossible to continue. But the person may also walk more slowly in the future, deny the pain's significance, go to an emergency room, worry, panic, take nitroglycerin, or any of a variety of actions, in response to what the person believes the symptom means.

The Distinction between Pain and Suffering

Suffering is closely related to pain because pain is a common cause of suffering, but they are distinct forms of distress. People may report suffering when a pain, such as that caused by a dissecting aortic aneurysm, is overwhelming. Or they may tolerate even extremely severe pain if they know what it is, know that it can be relieved, or know that it will soon end. Less intense pain may be a source of suffering if the person does not know its source or believes that it has a dire cause(e.g., cancer), cannot be controlled, or will be "neverending." Suffering can sometimes be controlled merely by changing the meaning of the pain. Clinicians working with terminally ill patients frequently see suffering patients grunting with pain who cannot be comforted. When their pain has been adequately relieved and it has been demonstrated that such relief will be forthcoming if the pain should return, they will frequently tolerate the same level of pain (by their report) without requesting medication. Once assured that relief is possible, suffering often subsides although the pain remains. It is difficult to relieve the suffering of patients who are frightened without also relieving their fear.

People may suffer from pain even when the pain is not present. Some who have had severe pain will suffer from the fear of the pain's return even when they are pain-free. People with severe and frequent migraine may suffer from their fear of a return of the headache. These headaches have repeatedly ruined what would otherwise have been pleasurable or important experiences: Family relationships, jobs, sports, and virtually everything that is dear to the person may have been negatively influenced by the headaches. Not surprisingly, such patients may be obsessed with their headaches and their attempts at relief virtually to the exclusion of other aspects of life. They suffer when they do have the actual pain and also when they do not.

The distinction between pain and suffering is clarified by the case of the pain of childbirth. Different kinds of pain relief, some more effective than others, are popular in different parts of the United States. The more important issue seems to be the degree to which the woman is in control of her own labor and delivery, rather than the absolute control of pain. Control of the process of childbirth does not relieve pain, but appears to prevent suffering. In other cases, symptoms such as dyspnea (labored respiration), choking, or even diarrhea may be sources not of pain but of suffering if they are sufficiently severe. In fact, suffering may be present in the absence of any symptoms. Parents, particularly if they are helpless in the situation, commonly suffer at the sight of their children in pain. Grinding poverty may be a source of suffering, as well as betrayal or the loss of one's life work.

The Role of the Future

The role of the future in these situations of suffering is crucial. In cases of overwhelming pain, in long-continued ("never-ending") pain accompanied by fear of the inability to continue to "take it," and in the situation where the pain is suspected of having terrible meaning, a sense of future is necessary in order to suffer. In each of these instances— when at the moment the pain is not overwhelming, the person is "taking it," and the fact of a dreadful disease does not yet exist—the body cannot worry; it knows no future. The body cannot supply information about the future because at any moment, for the body, the future does not yet exist. Only imagination, beliefs, memories, or ideas can supply the information necessary to provide a "future." In other words, in order to suffer, there must be a source of thoughts about possible futures.

To summarize thus far: Although suffering may attend pain, they are distinct. There may be pain without suffering. There may be suffering without pain. There seems to be no suffering without an idea of the future. Bodies do not have the beliefs, concepts, ideas, or fantasies necessary to create a future—only persons do. One can conclude that although bodies may experience nociception, bodies do not suffer. Only persons suffer.

Suffering Defined

Suffering is a specific state of severe distress induced by the loss of integrity, intactness, cohesiveness, or wholeness of the person, or by a threat that the person believes will result in the dissolution of his or her integrity. Suffering continues until integrity is restored or the threat is gone. The whole person does not mean solely the whole biological organism or the solid-bounded object, although it may be the object of the threat. Persons, while they may be identified with their bodies, cannot be whole in body alone. Nor should the threat to the whole person be understood as solely a quantitative matter (i.e., that persons subjected to more than X amount of pain or Y amount of tissue destruction suffer, even if this amount of pain or tissue destruction may virtually always cause suffering), since one individual may suffer from pain considered unimportant by another. Suffering may occur in relationship to any part of a person.

Wholeness, Self, and Person Defined

Suffering helps define the concept of person. Person is not mind, body, or self, although persons have all of these things. The word self, as employed here, denotes that aspect of the person that is an object of the consciousness of a person— the person's own consciousness or that of another. It has cohesive characteristics and it exists over time. Persons cannot be known in their entirety and they cannot be known by reducing them to their parts. As one does that, the person disappears. A topography, however, is possible. A person is the composite entity made up of its body, its selves, its history, its collected beliefs, its believed-in future, unconscious, incorporated society and culture, associations with others including the family, the family's history, its political dimension, secret life, and transcendent dimension.

Persons are also constructed by their ideas and beliefs, by the past, the present, and a sense of the future, as well as by a sense of some level of stability in the environment. Suffering may thus be initiated by profound changes in the person's physical, political, or social world. Clinical observation suggests that the suffering of some patients is initiated by their inability to explain what has happened to them. "What did I do that made this happen to me?" is not merely a question but a metaphysical statement about how the world works. If the person's beliefs and demand for explanations are too rigid and the person cannot accept fate or uncertainty, then the integrity of the person is violated by the unexplained injury.

If physicians focus on the sick person, as necessitated by suffering, they will require knowledge of persons in the way that they presently have knowledge of the body. Persons, however, are different from other objects of science and so they pose difficulties for twentieth-century understanding. Considering persons as ahistorical, atomistic individuals, in which the body is separate from the mind—largely the stance of the sciences, the law, and some schools of philosophy—is not supported by a knowledge of suffering. The sciences of humankind, including psychology and the social sciences, have followed the lead of the physical sciences in employing reductive methodologies, but these lead to a distorted understanding. Similarly, division of the sciences of humankind into the physical, psychological, and social leads away from an understanding of persons and therefore of suffering. Virtually everything that is social is also ultimately physical and psychological. A person is not an object with physical or temporal boundaries, but rather he or she is a process in a trajectory through time. The challenge to a scientific understanding of persons lies in accepting these characteristics.

Suffering is Unique and Individual

Suffering is always individual because it can arise in relation to any aspect of a person, and persons are necessarily unique and particular. If the suffering of two people is initiated by an identical physical insult (e.g., the same kind of severe burn or similar overwhelming pain), the suffering of each will be unique and particular because it becomes suffering by virtue of its effect on a particular dimension or characteristic of the suffering person. No one can know with certainty why another person suffers. One can know that someone is suffering, but not what it is about this specific person that leads to the suffering. Sufferers themselves may not know. What threatens the loss of wholeness of one person is not necessarily the same as that which jeopardizes another. In chronic illness this distinctiveness is more easily seen. Here, suffering can arise because the sick person may not be accepted by, feel at home in, or be able to meet the expectations of others. The way these feelings affect the person will be unique to that person. These difficulties may evoke loneliness, anger, or feelings of unfairness, abandonment, or hurt. The suffering person will be focused on the feeling and the external source that is seen as its cause, not on suffering per se. This is because the same feelings may cause suffering in one person but not in another, and the suffering itself is the result of the disruption of the person arising from the discomfort. Even when suffering is caused by physical pain, the person feels pain, not suffering.

Purpose

To be whole and able to suffer is to have aims or purposes. One of these purposes, central purpose, is the preservation and continued evolution of myself as I know myself. Purposes entail actions. When suffering exists, the identity that the sufferer fears will disintegrate is an identity expressed in purposeful action—legs walk, hands grasp, eyes see, minds have ideas. Purposes and their enabling actions may not require anything from consciousness, but they are nonetheless self-defining. Illness and other sources of suffering interfere with actions that may be conscious, below awareness, or habitual, and thus contribute to damaging the integrity of the person and lead to suffering.

The suffering of the chronically ill may start with the inability to accomplish their previously important purposes. It may actually begin when it finally dawns on the chronically ill person that the life of illness that has been held off for so long and with such effort and determination is now truly imminent. Again, notice that suffering begins not merely when persons cannot do something but when they become aware of what the future holds, even though at the time of recognition their function has not yet worsened. The task of the person, of identity, indeed of wholeness, is the centralization of purpose, while disease, pain, and suffering may contribute to the defeat of such purpose. Pain or other symptoms may focus the person's attention on the distressed body part so completely that central purpose is lost (Bakan). This is probably always true of suffering, which arises with the loss of the ability to pursue purpose and also defeats purpose. It is one of the wonders of humanity, on the other hand, to see how a central purpose, exemplified in the biblical story of Job, may overcome suffering as well as disease and pain.

Suffering Always Involves Self-conflict

The source of suffering is usually seen as outside the sufferer. What is usually identified as the origin of the suffering is the thing that causes the pain, or the pain itself, the life circumstances, or the stroke of fate. In fact, however, suffering always involves self-conflict. Thinking about acute pain, one wonders how this can be. The clue lies in the fact that meaning is essential to suffering. The threat to the person's intactness or integrity resides in the meaning of the pain or beliefs about its consequences. The book of Job provides an illustration of the place of self-conflict in suffering. That there is a God and that God is just are not merely facts for Job; they are part of his self-understanding. Job is a righteous man, but his friends taunt him: If Job is righteous as he says, God would not punish him. Job responds, "Yet does not God see my ways and count my every step?" (31: 4). On the other hand, he wants to defend himself before God: "I would plead the whole record of my life and present that in court as my defense" (31: 37). If God knows his every step and God is just, why would he have to defend himself? The suffering of Job, generally identified with the awful things that happen to him, has as its deeper source the conflict between that part of him that knows that God is aware of his every step and is a just God, and that part of him that believes (with his friends) that only the wicked are punished. Either he is wicked when he knows he is not, or God is not just.

The saints offer a contrary example. Reaching toward Christ by sharing the bodily suffering of others or through punishments imposed on the body are familiar aspects of early Christianity. Denial of bodily needs, tolerance of awful afflictions, and self-inflicted torture are commonplace in the histories of the saints. Adversities and pains are seen as allowing the holy person to identify with the suffering of Christ. Conflict with the body and the tolerance of the pain do not cause conflict within the person because they permit reaching a desired goal. If there were no Christ with whom to identify, then suffering would follow.

The sick, especially the chronically ill, are often unable to do what they need to do to ensure their self-esteem and their ability to be like others and be admired by others, to excel. But they do not stop wanting to meet these standards, which they usually picture as existing outside of themselves. The resulting internalized conflict of the sick person with the external world becomes self-conflict.

Confrontations between the person and his or her body, as well as dissension within the various aspects of the individual, can threaten to destroy the integrity of the person. This is most easily seen when the demands of the body conflict with the needs of the person. Pain or other symptoms, disabilities, medical care, or other needs may require attention to the body that deters the person from pursuits or purposes considered vital, or they may require attention to the body that the person finds extremely onerous. The body may become an untrustworthy "other" that fails the sick person when it is most needed. It may be a source of humiliation because of, for example, loss of bowel or bladder control. The body's needs, sexual or otherwise, may force the person to engage in behaviors that lead to social failures. Conflicts between the person and the body may cause suffering when no illness is present. The internal struggle that may occur in regard to sexual desire is notorious. Even in acute pain, self-conflict is present. If the person did not care about the pain or its consequences, did not resist its overwhelming force, and instead became completely passive or resigned to the injury, suffering would not occur. This represents extreme self-discipline. People want to live, to resist the pain, to fight back, and therein is the genesis of the suffering.

Suffering is a Lonely State

Because the individual is ultimately unknowable and suffering is unique and individual, involving a withdrawal of purpose from the social world and marked by self-conflict, suffering is inevitably a lonely condition. The inability to know with certainty why someone is suffering, and thus to identify truly with the sufferer, creates difficulties for its treatment. The treatment and relief of suffering, even when pain cannot be relieved, is often best accomplished by attempting to overcome its loneliness. This is illustrated in Tolstoy's superb story about sickness and suffering, The Death of Ivan Ilych. Virtually the only relief from his suffering that Ilych experiences late in his illness is the constancy and compassion of the servant, Gerasim, who stays with him when all others have effectively abandoned him (Reich).

Persons are communal in origin and by nature. They cannot be known or understood apart from their social being. As a consequence, the sufferer's inherent loneliness furthers the suffering. Because the sufferer's loss of connection with the group is one of the most important aspects of suffering both from the standpoint of its origins and its opportunities for relief, the loneliness of the sufferer is not only the feeling of being alone but an absence from the general "we-ness" of the world, from a shared participation in spirit. The idea of spirit reaches back into the history of both philosophy and religion. The word has many meanings in different traditions, but fundamentally, spirit has to do with the relationship of individuals to the group and to an overriding belief in the existence of God, Nature, or other transcendency. For the purposes of understanding suffering, spirit in a Hegelian sense is useful: some sort of general consciousness that unites all persons (Solomon).

Pain or Suffering in Special Groups

Until recently, minor surgical procedures were performed on newborns and very young infants without anesthesia in the belief that they did not feel pain. Whether their perception is of pain in the manner of fully functioning adults, where other psychological factors such as meaning play a part, is not as important as the understanding that newborns and very young infants (as known from neuroanatomic criteria, psychophysiologic measures, and their behaviors) experience nociception and resulting sensory pain and thus require anesthesia and analgesia. The situation is not as clear for fetuses, but they also exhibit aversive responses to nociceptive stimuli, suggesting the need for analgesia (Anand and Carr).

Depending on the depth of coma, patients in coma may or may not experience nociception as shown by whether they react to nociceptive stimuli. Reaction to painful stimuli is employed as a measure of the depth of coma and is often the first sign of recovery of central nervous system function. Nociception does not appear to be present in persons in a persistent vegetative state (Katayama et al.).

By definition, comatose patients and patients in a persistent vegetative state cannot suffer. Since suffering involves persons and their appreciation of their own intactness or threats to it, and requires a sense of identity, of the past, and of the future, these features must be present for suffering to occur. The applicability of these criteria to fetuses and neonates is unknown, but young children have the capacity to suffer.

Philosophical Issues

The history of medicine, like much of philosophy, has been marked by the dichotomy between empiricism and rationalism. In medicine, empiricism has also been identified with vitalism, the belief that there exist forces for health within the patient—the physis of the Hippocratics. For more than 150 years, medicine has been dominated by rationalist thought that has focused on disease as known by the objective criteria of pathoanatomic or pathophysiologic alterations. Diagnostic and therapeutic interventions and the actions of physicians have been based on the science of medicine and its conviction that all illness and pathophysiology would be explained by the laws of physics and chemistry. Symptoms and the reactions of sick persons to their diseases have been treated as epiphenomena, matters of less importance than science, and given over to the art of medicine, which was ranked lower than that of science.

In recent decades, however, the sick person has become more important. This is largely the result of vitalist-empiricist beliefs expressing themselves as a desire for a more "holistic" medicine, as well as changes in the social context of medicine since the 1960s. During the period of the civil-rights movement and the women's movement in the United States, patients (and more recently persons with disabilities) have achieved the social status of full personhood. The rise of bioethics in the United States during this period has played an important part in this social transformation. Recent interest in pain and suffering can be attributed both to the fact that they defy explanation on purely physicochemical grounds and to the increased attention being given to the experience of the sick person.

The concept of patient autonomy has been of central importance in bioethics, but suffering can put the sufferer's autonomy in question, creating ethical dilemmas. Autonomy implies a self-directed individual with consistent goals and intentions springing from a rational evaluation of situations and norms. Reasoning about choices is coupled here with coherence of purpose—central purpose. The ability to remain autonomous requires that things over which one has no control do not remove all of one's choices or the ability to choose. For the suffering person, autonomy is removed when purposes are directed by the immediate needs of the sick body or by the compulsion to address what is perceived to be the source of suffering. This creates difficulties for an ethics that relies heavily on the principle of autonomy. The exercise of authentic choice in this circumstance requires the help of others, individuals who can represent suffering persons to others and, perhaps, to themselves. The difficult task in these situations is to help the sufferer make choices and act as if suffering were absent. But suffering is marked by loneliness that can deny the help of others. The loss of autonomy following severe illness is usually obvious, while the fact that autonomy is no longer present because of suffering may not be apparent. Actions that are beneficent or even nonmaleficent in relation to the suffering person, in contrast to the ill person, may not be obvious. Thus, what is known about suffering casts doubt on the usefulness of an ethics of principle such as that advocated by Tom Beauchamp and James Childress. In contrast, the nature of suffering suggests the importance of a communitarian view of ethics where the relations of individuals to each other as members of a community guide notions of the right and the good. Stanley Hauerwas has raised questions about the obligations of physicians to relieve suffering—if, in fact, medicine could remove all suffering—in view of the importance often placed on the benefit of suffering. Rather, the duty to alleviate suffering highlights the physician's classical responsibility to have compassion for the suffering person, as in the story of the Good Samaritan, even in the absence of the ability to lift the burden of the sufferer (Hauerwas).

Theological Perspectives on Suffering

SUFFERING AS A RESULT OF HUMAN SIN. A commonly employed explanation of suffering is to see it as the fault of human beings, as punishment or retribution for individual or group actions or sins. The idea that God keeps tabs on individual actions and punishes sinners is widespread. This corresponds to the conviction of one of Job's friends: "As I have seen, those who plow iniquity and sow trouble reap the same" (Job 4: 8). Yet, it is obvious that the innocent as well as the evil are made to suffer. In the New Testament (Luke 13: 1 and John 9), Jesus indicates the mistake of interpreting each evidence of suffering as the consequence of someone's sins. A recent Apostolic Letter of Pope John Paul II (1984) on the Christian meaning of suffering acknowledges the Old Testament writings that show suffering as punishment inflicted by God for human sins, but goes on to disavow such a simple understanding.

SUFFERING AS EDUCATIONAL AND EVIDENTIARY. Where would we be without suffering to tell us what is important, make us better, to lead us back into the paths of righteousness? Suffering, in this view, offers the opportunity to learn humility.

My son, do not spurn the Lord's correction or take offence at his reproof; For those whom he loves the Lord reproves, and he punishes a favorite son. (Proverbs 3: 11, 12)

But it could not provide such opportunities in the absence of a God of grace and love. The prophets provide many examples of this view of the importance of human suffering. But suffering also reveals to the sufferer a greater depth of human experience and meaning. After the experience of suffering, the person is led to a richer understanding of the meaning of being human, a greater concern for the suffering of others, and away from the superficialities that too often characterize daily existence.

SUFFERING AS SACRIFICIAL AND LEADING TO SOME GREATER GOOD. Both on a religious and a secular basis, it is not unusual for suffering persons to believe that their suffering is a form of selfless service to others. Through the acquisition of meaning in this fashion, the suffering is alleviated. It should be remembered that suffering occurs when the intactness or integrity of the person is threatened or disrupted, and it can be relieved when the person is reconstituted even if the agency of its occurrence continues. Giving meaning to the distress, which is what occurs in sacrificial suffering, is one way the person can be made whole again. The suffering of one may benefit many. The suffering of the prophets in the service of Israel is such an example. Another is the crucifixion of Jesus, an evil done by others, turned by God into Christianity's central saving act and a demonstration of the power of love over suffering.

SUFFERING RESULTING FROM THE FORCES OF EVIL OR CHAOS. This view suggests that God is not the only super-natural force and that there exist powers that are specifically evil. Satan is such an example, although he is specifically mentioned only three times in the Old Testament; the best known of these mentions appears in Job. In the New Testament, the Devil, Satan, demons, or evil spirits are frequently mentioned as sources of suffering. Modern peoples are frequently uncomfortable with such images, yet suffering on a huge scale has occurred so often in recent times that it seems necessary to draw on some other source of evil while keeping God a positive, loving, and just force. Another variant, nondemoniac, implies that there is a limit to the power of God and that he is just one force in the universe. God, in this view, should be called on for what he can do, but one should realize his limitations. A popular book employs this explanation for the problem raised in its title, When Bad Things Happen to Good People (Kushner). The mystical tradition of Judaism denies these limitations, insisting that to speak of God as one ("Hear, O Israel, the Lord is God, the Lord is One" [Deut. 6: 4]) is to speak of the unity of all. Everything is God, good and evil, joy and suffering. "And know today and bring it home to your heart that the Lord, He is God, in the heavens above and on the earth below—there is none other" (Deut. 4: 39) (Luzzatto).

SUFFERING AS MYSTERIOUS OR MEANINGLESS. For the classical Greeks, fate and the actions of the gods are indifferent to humankind's ideas of good or justice. Unconcerned fate has, however, a beginning, a middle, and an end and what starts must ultimately be realized. In the Greek tragedies, the terrible end is foretold in the beginning, the middle is the attempt of the hero to live the heroic existence, while in the end the suffering and tragedy that had been foretold must necessarily occur. Suffering and tragedy, then, have their origins in meaningless fate, but they follow from initial actions of humans. A somewhat similar conclusion is reached in the reincarnation religions such as Buddhism and Hinduism: Suffering in this life is inherent in existence, following, in part, from desire in a previous existence that determines the current behavior that leads to suffering. Since one cannot know what transpired in the previous animation, suffering in this life appears to be the result of capricious fate. Deliverance can only come by escape from individual personality, and ultimately, by giving up desire.

The Old Testament, particularly in Job and Ecclesiastes, explores the problem of suffering in depth, ultimately concluding that it is beyond the ability of ordinary mortals to explain. Explanation itself, and the reasoning on which it is based, may be the problem. In their early speeches, Job's counselors know that he must have transgressed, otherwise he would not be punished. Simple explanation—the connection of logically related, but largely unexamined, premises leading to a conclusion—particularly of the facile type presented by Job's counselors, prevents any deeper understanding. If, for example, Job's privations are not punishment directed at him, but occur as part of the natural order of God's universe, then the search for the explanation itself prevents an acceptance of the mystery. Yet the acceptance of mystery, of the fundamentally unsolvable, points the way to changes in fundamental presuppositions and to the relief of suffering. Religion for the Preacher of Ecclesiastes and for Job represents the general, not simple, truths, including the goodness of God, that have the capacity for transforming character and relieving suffering when they are sincerely held and vividly apprehended, even in the painful void of evidence for their truth. It belongs to the depth of religious spirit to have felt forsaken by God (Whitehead).

A consideration of the nature of suffering opens possibilities for reflection and study about the nature of persons, the relation of persons to their bodies, the goals of medicine, relationships between persons and within communities, and the place of spirit in the lives of individuals. It is little wonder that consideration of suffering and its place in the human condition and in the relationship of God to humankind has occupied human thought throughout the ages—and still the questions remain.

eric j. cassell (1995)

SEE ALSO: Authority in Religious Traditions; Autonomy; Chronic Illness and Chronic Care; Care; Compassionate Love; Health and Disease: The Experience of Health and Illness; Life, Quality of; Life Sustaining Treatment and Euthanasia; Medicine, Anthropology of; Palliative Care and Hospice; Pastoral Care and Healthcare Chaplaincy; Rehabilitative Medicine; Suicide

BIBLIOGRAPHY

Anand, K. J. S., and Carr, D. B. 1989. "The Neuroanatomy, Neurophysiology, and Neurochemistry of Pain, Stress, and Analgesia in Newborns and Children." Pediatric Clinics of North America 36(4): 795–822.

Bakan, David. 1968. Disease, Pain, and Sacrifice: Toward a Psychology of Suffering. Chicago: University of Chicago Press.

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