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Thursday Review: “Suffering and the Goals of Medicine”

We have a consciously dualistic view of ourselves. The mind and the body are separate things. One is subjective, the other is objective. One is a source of psychological “suffering” and the other is a source of biomedical “pain”.

If this is true, how can healthcare professionals—specifically those in medical fields—have any responsibility to their patients as human beings, and not just as complicated biomedical machinery?

In Medicine, Health Care and Philosophy, Stan van Hooft argues that suffering and pain are not separate things. Pain, van Hooft writes, is a specific kind of suffering.

This paper is deeply philosophical, but comes away with a concrete way to think about patients and their pain, suffering, and stories. Medical healthcare is only set up to treat physical and bodily pains and ailments. A malady, though, causes suffering in the whole person. Patients visit doctors’ offices with their whole suffering, not just the physical kind. Helping a patient transform an illness into a meaningful part of their own life story might be beyond the scope of medicine. Ignoring it, though, is only going to increase a patient’s suffering.

The article’s title is a reference to Eric Cassell’s book The Nature of Suffering and the Goals of Medicine.1 Cassell is cited throughout as an example of a medical humanist, although one who writes about the dualistic view of pain and suffering.

Like in the works of William J. Donnelly and W. T. Reich, pain is understood as a bodily sensation, and suffering is mental “anguish” or an “existential disruption”.

Van Hooft goes back to Aristotle’s four “parts of the soul” in The Nicomachean Ethics to challenge the mind/body, suffering/pain duality. Those parts of us are:

  1. the vegetative (biological functioning)
  2. the appetitive or conative (emotional and desiring functions)
  3. the deliberative (people’s practical and rational lives)
  4. the contemplative (people’s sense of the meaning of their existence)

The author conceives of each of these as affecting every other part. Each of these parts is teleological in the sense that they tend to their own distinctive fulfilment:

The fulfilment of the biological level of our being is the basis of health, while the fulfilment of the appetitive or conative part of us is a feeling of satisfaction, wellbeing, and zest for life. The deliberative or practical aspect of our lives is fulfilled when we perform our tasks as well as we are able (whether or not we are successful), while the fulfilment of the contemplative aspect of our being is our having a sense of the meaningfulness of life. The combination of all these levels of our existence is our wholeness and integration as persons.

Suffering, in van Hooft’s analysis, is anything which disrupts the fulfillment of one of these areas.

The author uses the term “malady” to refer to disease, as well as impairment, injury, and defect. This kind of suffering is primarily a “frustration” to our vegetative/biological level.

It doesn’t stay there, though. A malady frustrates our appetitive/desiring level: the things that we normally enjoy doing … lose their lustre when we are ill. At a deliberative/practical level, it places limitations on what we can and cannot do. Van Hooft calls this shift from our desired activities to caring for our illness the sick role. The “part of the soul” which healthcare is often least equipped to deal with is the contemplative/existential level, which is deeply connected with story:

If I cannot integrate my malady … into my existence by seeing it as part of a meaningful narrative of my life or by relating it to a reality greater than myself, then I will suffer from psychological distress.

If suffering is an unfulfiled aspect of our life, pain which disrupts that fulfillment is only one kind of suffering. Van Hooft sees bodily pain as primarily an appetitive/desiring frustration. Pain is always located in the body and is the opposite of sensual pleasure and should be analysed primarily as frustrations of our inherent desire for pleasure and comfort.

So pain—if it disrupts life—is suffering, but not all suffering is pain.

The author views “do no harm” as “cause no (further) suffering”. This is why being aware of a patient’s narrative is so important. A healthcare professional may not be able to change how a patient sees their illness as a part of their story. Ignoring that story, though, as part of the patient’s suffering that can’t be fixed can only do harm.

The doctor-patient relationship should be fully interpersonal and rich, rather than objectifying, routinised, and bureaucratised. All of the failings of the current biomedical regimen have the potential to add to the suffering of patients in the non-bodily dimensions of their being.


The article reviewed: van Hooft, Stan. “Suffering and the Goals of Medicine.” Medicine, Health Care, and Philosophy 1, no. 2 (1998): 125–31.

1 Cassell, Eric J. The Nature of Suffering and the Goals of Medicine. New York, NY: Oxford University Press, 1991.

Featured Image: cropped from “Arteries and Nerves of the Face and Neck”, from George Viner Ellis’s illustrations of dissections, shared by the University of Liverpool Faculty of Health & Life Sciences Flickr stream, used under a CC BY-SA 2.0 license.