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Abstract

The topic of suffering encompasses an enormous range of issues. In this discussion the focus will be is on two key sets of questions: the nature and deﬁnition of suffering and the nature of the responses to suffering. At its broadest, suffering is taken to be identical with any negative or “unpleasant” experience, but such a conception suffering gives rise to several problems. On a more nuanced account, suffering is tied to a disruption or potential disruption to the integrity of the person. The differences between these two accounts are themselves tied to differences in responses to suffering and in approaches to the relief of suffering. As it is central to any attempt to understand human being in the world, the topic of suffering is central within bioethics but also a challenge to it.

Introduction

The topic of suffering is one of the most profound and far reaching. It brings to the fore a set of key issues concerning the character of human being, of the relations between human beings, and of the relation of human beings to the world (including the relation to other nonhuman beings). Two sets of questions come to the fore in most discussions of suffering within bioethics: ﬁrst, questions concerning the nature and deﬁnition of suffering, including the experience and signiﬁcance of suffering, and, second, questions concerning the nature of the response to suffering, including the imperative to relieve suffering and the implications of that imperative and the manner in which it is realized. These questions inevitably reach back to the fundamental issues concerning human being that are at stake here, while they also extend outward to encompass a range of further issues including the physiology and psychology that underpins suffering (often addressed in connection with the physiology and psychology of pain); inequalities in suffering across societal, cultural, and geographical divides; the appearance of new forms of suffering that may be consequent on social, technological, or political change; the interrelation between suffering and discrimination or between suffering, justice, and law; the cultural and historical context in which suffering is understood; and the portrayal of suffering in its personal, institutional, and historical dimensions. The extent of these questions is enormous, and the discussion in this chapter cannot do justice to all of them. Instead the aim here is to provide an analysis of the nature of suffering and of the response to suffering in terms of the core philosophical and conceptual issues at stake.

History And Background

The history of human attempts to express and articulate responses to the experience of suffering goes back to the very earliest forms of recorded human thought. Whether one looks to the Babylonian Epic of Gilgamesh, the Jewish Torah, the Iliad and Odyssey of Homer, the Analects of Confucius, or the Christian Gospels, suffering appears as a central and persistent theme. There is thus a history of thinking about suffering, including the relation between suffering and ethics, that long precedes contemporary bioethics (see Amato (1990) for an account of suffering in its broader historical and political context). Yet notwithstanding the history and importance of the topic, suffering has not always received as much attention within bioethics as have many others. This is undoubtedly a consequence of the very breadth and depth of the topic itself but also of the tendency for bioethics to focus on more speciﬁc and immediately contentious topics often directly related to speciﬁc problems of technology or practice. Moreover, traditional bioethical thinking has also been heavily inﬂuenced by models of analysis derived from a natural scientiﬁc model (not surprisingly given the dominance of such models within contemporary medicine) that have often seemed ill equipped to deal with the complex character of suffering and especially its embeddedness in the experiential and the “subjective.” The last 30 years or so have nevertheless seen increasing attention being given to the topic of suffering in the bioethical and biomedical literature. This has been due to a number of factors, including the rise of palliative medicine, of more patient-oriented approaches to pain, and the greater inﬂuence, within bioethics, of philosophical approaches from within the phenomenological, hermeneutic, psychoanalytic, and poststructuralist traditions.

The Nature Of Suffering

Suffering, Pain, And Distress

Etymologically, suffering comes from the Latin suffere, meaning to bear or undergo. In this respect, it is clearly related in meaning to the Greek pathe, meaning to be affected by, which is itself related to other Greek terms meaning suffering, pain, and grief, and also to the Latin passio, which itself means suffering and from which comes the English passion. In its simplest and most everyday usage, suffering is experiencing or being affected that is negative in character. Understood in this broad sense, suffering is indistinguishable from pain, whether occasioned by physical or mental hurt, and may be borne individually or collectively; in this sense, it encompasses all forms of hardship and distress.

It is something like this broad conception of suffering (though understood primarily in terms of the suffering of individuals) that Peter Singer argues is the basis for moral concern. To be a creature that has interests worthy of moral concern, claims Singer, is to be a creature that can experience suffering or, on the positive side, enjoyment (Singer 2011: 50). Given his utilitarian standpoint, Singer’s conception of suffering is one that allows suffering to be quantiﬁed: suffering is increased as the number of individuals who suffer increases, and, in some case, suffering increases according to the capacities of the individuals who suffer (whether because of greater physical vulnerability, sensory sensitivity, or capacity for emotional and cognitive response). Although Singer is an inﬂuential ﬁgure in contemporary bioethics, his account of suffering has not ﬁgured signiﬁcantly in the biomedical accounts of suffering. It nevertheless deserves notice not only because of Singer’s wider inﬂuence, but also because that account does indeed seem to ﬁt with the idea of suffering as broadly understood, and because it understands suffering as something felt rather than merely inﬂicted. Singer’s account of suffering, which is essentially an account of suffering as “negative experience,” echoes in the background of some other accounts, notably Jamie Mayerfeld’s deﬁnition of suffering as “disagreeable overall feeling” (Mayerfeld 2005: 14). Mayerfeld characterizes “suffering” as psychological distress and so, in his terms, as “subjective” rather than “objective.”

That suffering is indeed “subjective in the sense that it pertains to the subject’s experience of the world (rather than pertaining to the world as it might be construed apart from the subject’s experience of it) seems clear. That an individual suffers is thus a fact about their experience, rather than being determined by anything independent of that experience. The same can be said to be true of pain, and yet the tendency of broad accounts of suffering, including Singer’s, to treat suffering as more or less indistinguishable from pain gives rise to problems. One reason for this is that there are surely instances of pain that do not count as suffering. One might say this is true of momentary pain, and perhaps of most pain of relatively short duration, or of pain that is not severe but also of pain to which we stand in a particular cognitive or emotional relation. The pain one may feel in accomplishing something – say the pain of an athlete as she pushes her body in competition – is not, by the mere fact that it is pain, also to be counted as suffering. Equally, the pain one may feel when undergoing some medical procedure, assuming it is properly administered with a therapeutic intent, is not always taken to be an instance of suffering. There are clearly cases of what might colloquially be referred to as mental pain or discomfort – whether incurred in the process of completing some bureaucratic process or trying to think through a difﬁcult conceptual problem – that are not, in virtue of their being extremely discomforting or even, in some sense, “painful,” also cases of suffering.

On Singer’s account, pain can certainly be outweighed, in a utilitarian calculation, by an associated good – and these latter cases could be viewed in this way: the therapeutic goal being primary in the case of the medical procedure or the achievement, or hope of achievement, in the athletic case (and analogously so in the mental case). Yet precisely because Singer’s account is a quantitative and cumulative one, so it seems that the pain still remains as itself a form of suffering. Utilitarianism aside, one might acknowledge that to experience pain may well be to suffer, at least in some cases, but also claim that suffering is a matter of the overall experience of which pain may be but a part, as in Mayerfeld’s talk of “overall experience,” and not of any separate part of the experience (if we can indeed attach sense to this). Equally one might distinguish between different kinds, degrees, or levels of pain – only some of which, perhaps the most severe, count as suffering – and between different kinds, degrees, or levels of suffering also. Ronald Anderson argues that suffering subsumes pain or, at least, severe pain but also distinguishes between three different kinds of suffering, physical, mental, and social, with pain falling into the ﬁrst (Anderson 2014: 2–3).

Suffering And The Person

In allowing that there can be forms of suffering that go beyond pain alone, Anderson follows a tendency that has largely prevailed across the bioethical literature. This suffering has generally been seen as a form of severe and encompassing distress that is not simply reducible to pain and that may even be said to affect the very character of a life in its entirety. Such an encompassing conception is evident in the now-classic deﬁnition of suffering advanced by Eric Cassell, according to which suffering is a state of severe distress in which the integrity or intactness of the person is threatened (see Cassell 2004: Chap. 3). Although it implies a distinction between suffering and pain, as well as between suffering and distress (even though suffering may be said to be a form of distress, it cannot be said to be identical with distress), Cassell’s emphasis on suffering as pertaining to the person, and so to the “whole” (since the person is a whole), as well as his treatment of suffering as “subjective” (a state that is felt or experienced by the sufferer) can be seen as convergent with Mayerfeld’s emphasis on suffering as an “overall feeling.” Where Cassell’s deﬁnition differs most signiﬁcantly from Mayerfeld’s, however, is precisely in the way it draws upon the notion of personhood and so implies a degree of self-referentiality.

As Cassell emphasizes, what is threatened in suffering is indeed the intactness of the person as a person. Suffering is thus, on Cassell’s account, what one might call a self-reﬂexive or self-regarding concept – it is to have a sense of one’s own impending disintegration. Mayerfeld’s deﬁnition, like Singer’s use of the notion, requires no such sense of personhood or of self. One might argue that, in this respect, Cassell’s deﬁnition of suffering is too narrow since it appears to rule out suffering where there is no capacity for self-regard or self-reﬂection – where there is no sense of impending personal self-disintegration (as in the case of nonhuman animals or human infants). Rather than Cassell’s deﬁnition being too narrow, however, it should rather be understood as itself encapsulating the importance of the capacity for self-regard or self-reﬂection in making possible a distinction between pain or distress and suffering. It is not the case that those creatures that lack an ability to articulate a sense of self that is threatened in the experience of suffering do not suffer or that they suffer less, but rather that in such cases, the pain and distress at issue are identical with the suffering. Consequently, there is no need to choose between a narrow and broad sense of suffering – accepting one and rejecting the other. Instead, both senses can and should be acknowledged. Signiﬁcantly, the lack of a sense of self or personhood on the part of the creature that suffers does not itself imply any lessening in the ethical importance of the suffering at issue nor, taken on its own, does it justify any lessening in the consideration that it demands – indeed, one might argue that in some cases, it indicates the need for a greater degree of attentiveness and responsibility.

The Complexity Of Suffering

The way suffering, understood as distinct from pain and distress, is tied to the idea of impending personal disintegration is indicative of the complex nature of suffering (and the complexity of the pain and distress that may be associated with it), once suffering is indeed distinguished from pain or distress understood more broadly. Just as there is enormous variation between persons and between different persons’ experience of the world – differences that are underpinned by differences in cultural and social background, education and occupation, family, and character, to name but a few – so there is enormous variation between the suffering that persons undergo and between the personal circumstances that may give rise to suffering. The complexity of suffering thus reﬂects the complexity of “personal,” that is to say, of human life (where “human” is used to indicate not a biological category but an ontological or ethical one). The recognition of such complexity is evident at many places in the existing bioethical and biomedical literature.

The implication of the person and the self in suffering means that in the experience of suffering, one is brought face-to-face with one’s own being as a person. Existential and phenomenological analyses often tend to emphasize the importance of death, or the anticipation of death, as that which brings with it a sense of the personal character of existence – that is, it makes salient one’s being as one’s own – and so makes salient the way in which to exist is precisely for one’s being to be an issue for one. Yet it is perhaps the real experience of suffering that is actually the key here, since that suffering, understood as an experience of impending personal disintegration (which it may be argued is more profound than the mere intellectual anticipation of one’s own demise), is indeed that which brings our own personal being directly and unavoidably into view – that does indeed most directly and concretely make it into an issue for us. Like the anticipation of death, but again perhaps, more concretely, suffering also makes salient the essentially ﬁnite character of existence (and this may be the key to the character to existence as personal) – that is, its essential formation in relation to limit – and, on this basis, suffering must be understood as a necessary, and not merely contingent, feature of life and existence. The latter point is contested, however, by an abolitionist strain in contemporary thought, partly deriving from utilitarian thinking, and closely associated with transhumanism, which argues for the elimination of suffering by technological means as a necessary and achievable end. The abolitionist position aside, however, there is also a tradition of thought that takes the connection between suffering and limit to be indicative of the importance of suffering to the possibility of knowledge (where knowledge is itself knowledge of both limit and of self) and so as closely connected with the injunction “suffer and learn” (pathei mathos) that appears in Aeschylus’ Agamemnon (see Aeschylus 2009: line 177).

The personal character of suffering may suggest that suffering is always an experience that is deeply introverted – that it is an experience that turns back toward the self in which the sufferer loses sight of any connection to others or to the wider world. Yet although there is a sense in which suffering can be construed in this fashion (partly because suffering can itself undermine the usual sense of the distinction of self from world so all that exists is the “subjective” world that is one’s suffering), it cannot be taken as an adequate characterization of what occurs in suffering or in the experience of suffering. Central to Cassell’s deﬁnition of suffering, and one of its central insights, is a conception of the person as complex and essentially relational. The threat to the person that occurs in the experience of suffering is a breakdown in the relationality of the person – in the capacity to integrate the elements of the person. Although it always involves self-relationality (since the sense of impending breakdown itself involves a mode of self-reﬂexivity), such breakdown can arise with respect to any of the relations by which personhood is articulated and often encompasses many or all of them. Moreover, the self-relationality that is at issue here is not a relationality to a self that remains itself secure – suffering is precisely a state in which the self is under threat, in which we lose a sense of orientation to ourselves, to others, and to the world. It is thus that Elaine Scarry can indeed speak of the suffering that is felt in certain experiences of pain and especially of the extreme pain and cruelty evident in torture, as an “unmaking of the world” (see Scarry 1986).

If suffering forces us to a recognition of our own personal being, then it also has the potential to bring to light our own being with others – even if this is evident in its incipient breakdown. Certainly there is the potential for the sufferer to respond to suffering in anger or bitterness, withdrawing into their suffering in a way that severs them from themselves as well as from others, but suffering also carries within it the potential to open us up to others through the very relationality that it brings into focus – as Tolstoy might be taken to suggest in the conclusion to The death of Ivan Ilyich in which Ivan is opened to those around him and so released from his imprisonment in his own anger and hatred, in a way that also provides release from the suffering that he has endured (Tolstoy 1989 [1886]).

The capacity for suffering to open us to others, and to our relationship to others, is relevant, moreover, not only to those who suffer but also for those who are witness to suffering – at least if they allow themselves to be drawn into that suffering. What suffering has the potential to lay bare, then, is the character of human or “personal” being as not merely a being with oneself but always a being with others as well as within a world. It is not that being oneself comes ﬁrst, and that from there one moves out to others, but rather that being oneself is only possible in relation to being with others. Such a notion, though variously articulated, can be found in philosophical form in the work of such twentiethcentury thinkers as Max Scheler, Martin Buber, Hans-Georg Gadamer, and Emmanuel Levinas. In Levinas’ work, in particular, the idea of the interpersonal or “the interhuman” (to use Levinas’ term) is developed in explicit relation to the ethical demand placed upon us by the encounter with others and especially by the encounter with the other as one who suffers (Levinas 1998 [1982]).

Accounts that tie suffering to the idea of the person stand in sharp contrast to those, like Singer’s, that treat suffering as identical with pain or distress – as “negative experience” – and this contrast is not merely one of breadth or narrowness in deﬁnition. Understood as the experience of a threat to the very being of the person, there is an important sense in which suffering stands outside of any “calculation” and may even be said to resist the very possibility of rational interrogation. Suffering thus appears as a “singularity,” such that it may even be said that suffering reaches its absolute in any and every instance of an individual who suffers. Certainly, on such an account, suffering is not divisible, and the pain and distress that may be discerned in suffering are not separate instances of suffering, since suffering is an experience of the person, rather than of any “part” of the person. If, on the other hand, one takes suffering to be identical with pain or distress in general, then one is committed to the view that any discrete instance of pain or distress is also an instance of suffering, as well as to the possibility that suffering can be understood as com posed out of other instances of pain and distress – out of other instances of suffering. Suffering is then both potentially divisible and cumulative, and it is also potentially amenable to quantiﬁcation and calculation, whether for an individual who suffers or across many such individuals.

The latter conclusion is an obvious component in Singer’s approach – it is a fundamental element in his commitment to utilitarianism. Yet whether or not it is formulated in terms of an explicit utilitarian commitment, it is also a common element in much contemporary bioethical thinking for the simple reason that it does indeed enable suffering to be accommodated within a rational scheme – within a possible “economy” of suffering in which suffering can become the subject of assessment and calculation. The way in which it takes suffering to stand outside of any such “economy” is part of the genuine radicality of Cassell’s account of suffering, a radicality only partially realized in his own development of that account and often passing unremarked upon in the way that account is taken up. Genuinely taking account of the personal and singular character of suffering almost certainly implies a rethinking of many aspects of contemporary medical practice (including the intrusion into medicine of neoliberal models of management and decision-making) and even of current bioethical orthodoxy. It also makes the task of responding to suffering as complex as is the phenomenon of suffering itself.

Responses To Suffering

The relief of suffering has been at the heart of medical practice from the beginning, but one might also argue that it lies at the core of ethical conduct when understood in explicitly relational terms. One might even argue that suffering carries within it an ethical demand that is absent in the experience of happiness: there is an ethical demand to relieve suffering, but no analogous demand to increase happiness. Utilitarians would dispute the seeming asymmetry between suffering and happiness that appears to emerge here, but even if it is rejected, and suffering and happiness are seen as standing exactly counter to one another and of equal ethical weight, still the relief of suffering remains a powerful ethical imperative. For utilitarians, it is simply that suffering is not exclusive in this regard (although the “emotional” power of suffering could also be seen as potentially misleading and as tending precisely toward an overestimation of the ethical signiﬁcance of suffering in relation to happiness).

Suffering remains an important moral concern regardless of whether one takes a utilitarian or nonutilitarian approach. Nonetheless, exactly how one understands suffering may have important consequences for what one takes to be the best means of responding to suffering or to what one takes as the best means of achieving the relief of suffering. If suffering is understood, for instance, as identical with pain, then the relief of pain must constitute the relief of suffering, and if pain could be universally eliminated, then so too would suffering be universally eliminated along with it – a utopian ambition embraced by some, as noted above, but warned against by others. Yet if suffering is understood as distinct from pain, and instead as tied to the threatened disintegration of the person as in Cassell’s account, then the relief of pain alone may be insufﬁcient for the relief of suffering, and the capacity to relieve pain may also turn out to be limited in a way that parallels the character of suffering as itself a marker of the limitation or ﬁnitude that is itself a central feature of the existence of persons. Understood as a condition pertaining to the person, suffering can only be addressed by addressing the person and the overall conditions affecting the person. Moreover, not only does this require more than addressing pain alone, but because it requires attending to a holistic complex of elements, so it will never be amenable to any complete or determinate control. On this account, there can be no “technology” for the elimination of suffering, since there can be no “technology” of persons.

The emphasis here on the need, if one is properly to address suffering, to address the person “as a whole” and so to attend to the complexity of personal life and situation is itself captured in the emphasis on the character of suffering as involving a breakdown in the possibility of “meaning” or “signiﬁcance” (something already suggested by the idea of suffering as involving a “loss of orientation” of the self). The meaning or signiﬁcance at issue here is precisely the meaning or signiﬁcance associated with a sense of personal integration or identity, and this sort of meaning or signiﬁcance typically takes the form of a capacity to ﬁnd narrative structure in one’s experiences and in the events in which one is involved. There is considerable philosophical and psychological literature that takes the self to be constituted in such narrative terms, and similarly the bioethical literature contains many discussions of the importance of narrative in the response to suffering (see, e.g., Carr et al. 2005). Cassell notes that “assigning meaning to [an] injurious condition often reduces or even resolves the associated with it” (Cassell 2004: 43), and this is precisely what narrative enables. Cassell also notes that as it involves a sense of “impending” disintegration, so suffering has an essentially temporal dimension (see Cassell 2004: 35), and this directly implicates ideas of narrative as a projection of future possibility.

The way in which suffering seems to stand opposed to meaning is given a particularly powerful form in the seeming opposition, within many traditional religious contexts, between suffering and the idea of beneﬁcent divinity (whether understood in terms of a divine person or a divinity that attaches to the universe as a whole). Indeed, this opposition can almost take the form of a dilemma: on the one hand, the experience of suffering can impel us toward a notion of the divine as a means to uncover meaning (indeed, suffering plays a key role in religious thinking within bioethics as well as more broadly – see, e.g., Engelhardt 2000), while on the other hand, the very existence of suffering seems to be incompatible with the existence of the divine (or at least with the idea of divinity as beneﬁcent).

In Albert Camus’ novel The Plague, the priest Paneloux and the doctor Rieux both witness the suffering and death of a child. The priest’s response is that what they have witnessed is “beyond us,” but then he goes on to add that “perhaps we should love what we cannot understand.” The response of the doctor, Rieux, which undoubtedly coincides with Camus’ own, is quite contrary: “‘No, Father,’ he said. ‘I have a different notion of love; and to the day I die I shall refuse to love this creation in which children are tortured.’” (Camus 1971 [1947]: 178). The episode not only echoes an idea found elsewhere (most notably in Dostoyevsky 2002 [1880]: Chap. 5), but it also exempliﬁes Camus’ opposition of medicine, as that which ﬁghts against suffering, to the divine, as that which sanctions suffering (an opposition that derives less from Camus’ atheism as his profound “humanism”). Here what also comes into view (and is especially clear in Dostoevsky) is the question – a pressing one within medical practice itself and whose answer is once again dependent on how suffering is understood – as to whether and under what circumstances it can ever be acceptable to inﬂict suffering on another (Camus rejects, as does Dostoevsky, the idea of justifying the suffering of one by the welfare of others while remaining silent on the matter of suffering inﬂicted with the consent of the one who suffers). Camus’ position represents an extreme version of the traditional problem that suffering, as the paradigm case of evil, presents for theology, and to which theodicy is a response. Yet it also stands as another example of the centrality of suffering to any attempt to think about the world and human existence – suffering not only presents a problem for the idea of a beneﬁcent divinity (to which the idea of the divine may also appear as an answer) but for the very attempt to make sense of human being in a world so given to contingency and seeming senselessness.

Responding to suffering, whether in speciﬁc instances or more generally, requires that we ﬁnd ways to reconstitute the meaning that suffering seems to rend asunder, and it is here that narrative plays a central role. Yet narrative is also signiﬁcant as one of the means by which sufferers are able to give expression to their suffering. The very character of suffering as threatening both personal integration and the possibility of meaningfulness (which here amount to the same thing) is indicative of the way suffering can also threaten the very capacity for expression and communication, and the consequent isolation itself becomes an additional source of suffering. In Sophocles’ play, the Greek hero Philoctetes, stricken with a festering wound that leads his fellow Greeks to abandon him on a deserted island, is unable to speak his suffering other than through inarticulate cries (Sophocles 1994). In the worst throes of his suffering, Philoctetes’ exile from others is also a seeming exile from language. From a medical perspective, ﬁnding ways to enable a patient to express and communicate their suffering is surely a prerequisite for successful medical diagnosis and treatment, but more than this, it may be an essential component in the treatment itself.

The imperative to relieve suffering is frequently cited as a key consideration in the argument for euthanasia – or what is often termed “physician-assisted suicide” or (somewhat euphemistically) “physician-assisted dying.” Yet here too, much depends on how suffering is itself understood. It is sometimes claimed that the imperative to relieve suffering is incompatible with the medical imperative to do no harm or more speciﬁcally with the ethical prohibition against killing. But this assumes that the death of the one who suffers is indeed a relief of suffering rather than simply a cessation of suffering itself consequent on the cessation of the life of the one who suffers. If relief of suffering is more than the mere cessation of suffering (just as it is more than pain or distress), then the imperative to relieve suffering need never come into conﬂict with the imperative not to harm or not to kill. Moreover, the prohibition against killing might itself be particularly important in medicine given the enormous power of the medical practitioner as against the vulnerability of the patient and especially of the suffering patient (inasmuch as suffering threatens the integrity of the person, then so it also threatens the capacity of the person to maintain their own integrity, and that may well include the capacity for effective decision-making even in relation to their suffering). Where euthanasia is advanced as a remedy for suffering, then it is most persuasively advanced as a remedy in cases where patients are also at their most vulnerable and so in cases where the risks of increased harm or suffering are at their greatest – cases in which the exacerbation of patient vulnerability through suffering becomes itself a reason that counts against euthanasia and for a more cautious and careful approach.

Although the relief of suffering is often cited as a primary consideration in arguments for euthanasia, considerations concerning the nature of suffering and its relief, and the vulnerability of suffering patients, suggest that the argument is more plausibly (but, in some respects, perhaps less persuasively) founded in the assertion of individual autonomy in a way essentially independent of any question of suffering as such. Euthanasia is thus founded in the absolute right of the individual to dispose of their lives however they see ﬁt, but, in addition, it must also make a claim, whether explicitly or not, to a right to be supported in the exercise of that autonomy by others. There is some irony in this, not to say a fairly obvious problem, since it allows the assertion of autonomy to be used in a way that makes claims on others (whether on individuals or the state) in a way that potentially infringes on the autonomy of those others and is often effectively an attempt at the coercion of others to act in ways consistent with the wishes of the individual who makes the claim. Yet regardless of the internal consistency of the arguments used to advance euthanasia on the basis of autonomy, such strong assertions of autonomy seem to be incompatible with the sort of relational view of persons that underpins accounts of suffering such as Cassell’s. If persons are understood relationally (in terms both of self-relationality and relationality to others), then the autonomy that pertains to persons cannot be construed as absolute but must always be interpreted against the background of the relationality out of which it comes and so as constrained by that relationality.

One of the ways in which the relationality at issue here is evident in a particularly relevant and signiﬁcant fashion is in regard to the effect of patient suffering on the experience of the doctors and nurses who care for them. What, one may ask, is the appropriate comportment of medical practitioners to the suffering of their patients – should it be one of “objective” detachment or of compassionate solidarity? There is good reason for arguing that if one accepts that suffering involves the entire person and that the person is indeed a relational entity, then the second of these responses is the more appropriate (and may in one sense be seen as more rather than less objective precisely in allowing greater access to the reality of the patient’s experience). As the term itself suggests, however, compassion is itself a form of “suffering with,” and although this may be important in allowing medical practitioners better to understand their patients, and so to care more effectively for them, it surely also opens practitioners more directly to the patient’s own suffering, placing a burden on the practitioner that may not be so obviously present (although it may be argued that it is merely suppressed) in cases where a more “objective and detached” stance is adopted.

Conclusion

The nature of suffering and the responses to it constitute questions central to bioethics, as they are to ethics more generally (and to any genuine attempt to think the nature of the human or of human being the world). Yet how one responds to those questions also makes for radical differences in how bioethics is itself understood and in the manner of the thinking in which it is taken to consist. Moreover, what one takes as the evidence on which those questions are addressed and the sources of that evidence are also key issues – part of the implicit argument here is that not only clinical practice or philosophical analysis but also literary and artistic expression and exploration may be vital in any adequate thinking of suffering and its implications. The questions at issue in suffering not only constitute some of the most basic questions that bioethics must address, but they also present a challenge to bioethics as such (especially to bioethics in more technically oriented forms), since they bring into view what ought to be foundational to both bioethical thought and biomedical practice, as well as their very limits.

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