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Nursing Ethics
http://nej.sagepub.com/content/16/2/173
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DOI: 10.1177/0969733008100076
2009 16: 173 Nurs Ethics
Franco A Carnevale
A Conceptual and Moral Analysis of Suffering

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What is This?

- Feb 23, 2009 Version of Record >>

by Alonso Pelayo on October 21, 2014 nej.sagepub.com Downloaded from by Alonso Pelayo on October 21, 2014 nej.sagepub.com Downloaded from
A Conceptual and Moral
Analysis of Suffering
Franco A Carnevale
Key words: emotions; empathy; epistemology; moral; pain; suffering
This analysis presents an epistemological and moral examination of suffering. It addresses
the specific questions: (1) What is suffering? (2) Can ones suffering be assessed by another?
and (3) What is the moral significance of suffering? The epistemological analysis is ori-
entated by Peter Hackers framework for the investigation of emotions, demonstrating that
suffering is an emotion. This leads to a discussion of whether suffering is a phenomenon that
can be evaluated objectively by another person who is not experiencing the suffering, ques-
tioning the validity of some decisional models for limiting life-sustaining therapies with
the aim of preventing suffering. This analysis highlights that understandings of suffering
are value laden. It is conventionally implied that suffering is bad and that it should be
eliminated. Suffering is commonly regarded as a moral wrong that needs to be made right
by health care. This article concludes with a recommendation for a paradigm shift in how
suffering can be better understood, through the practice of empathic attunement.
Introduction
In a recent study of the care of critically ill children in France and Quebec, one physician
reported:
Some children survive with the sole capacity of suffering pain and breathing. They have no
possibility of feeling pleasure or happiness. These children will be only a burden on their
families, doctors and nurses, and on society. We must absolutely prevent this (p. 129).
1
This quote highlights several common beliefs about suffering in modern medicine:
(1) suffering is often used interchangeably with pain; (2) a persons suffering can be
accurately assessed by another; and (3) the elimination of suffering should be a priority
for the health professions more important than preserving life. The term medicine is
used in this article to refer broadly to health phenomena and the health care professions;
it is not restricted to the practice of physicians. The article has a multidisciplinary
orientation.
Nursing Ethics 2009 16 (2) 2009 SAGE Publications 10.1177/0969733008100076
Address for correspondence: Franco A Carnevale, School of Nursing, Wilson Hall, Room 210,
McGill University, 3506 University Street, Montreal, Quebec, Canada H3A 2A7.
Tel: +1 514 398 1763; Fax: +1 514 398 8455; E-mail: franco.carnevale@mcgill.ca
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174 FA Carnevale
Nursing Ethics 2009 16 (2)
This analysis presents an epistemological and moral examination of suffering.
It addresses the specific questions: (1) What is suffering? (2) Can ones suffering be
assessed by another? and (3) What is the moral significance of suffering? For the pur-
poses of this analysis, epistemology refers to a conceptual analysis (i.e. a systematic
examination of the features of a concept, its elements, and how it resembles or differs
from related concepts).
The epistemological analysis is orientated by Peter Hackers
2
framework for the
investigation of emotions. Drawing on the dominant definitions of suffering in the
medical literature, I examine if suffering qualifies as an emotion or a related concept.
This requires a brief investigation not only of how the term is formally defined, but
also how it is used (e.g. the quotation above) to discern its operational meaning.
34
The
terms usage will help to identify its meaning in practice.
The analysis leads to a discussion of whether suffering is a phenomenon that can
be objectively evaluated by another who is not directly experiencing the suffering.
Another persons appraisal may more likely convey the others own emotional sympath-
etic experience. This raises questions about the validity of some decisional models for
high-risk procedures undertaken or withheld in health care, including the withdrawal
of life-sustaining therapies in the name of patient comfort, specifically, the prevention
of suffering.
This analysis also examines the moral significations that underlie suffering. The con-
cept is not used in a neutral manner; it is value laden. In modernity, it is commonly
implied that suffering is bad and that it should be eliminated. Following the work of
Taylor
5
and Vergely,
6
this can be traced to modern western secularization, where the
good life has been construed in terms of the individual pursuit of happiness, with a
corresponding view of all phenomena as objects that can and should be manipulated to
serve the happiness interests of humans. An ethical problem that can result from such
usages of suffering is that socially-sanctioned medical measures are mistakenly turned
toward solving complex moral problems because of (as I will question) whether ones
suffering, first, can be objectively assessed by another and, second, is necessarily a
moral wrong that needs to be made right by medicine.
What is suffering?
Suffering is not pain
The first definition of suffering provided by the Merriam-Webster Online Dictionary is:
to endure death, pain, or distress. Pain is quite commonly regarded as synonymous
with suffering.
7
The greater the pain, the more it is believed to cause suffering
(p. 35).
8
Indeed, attempts to define suffering frequently involve delineations of how it
may differ from pain.
7
The most widely recognized conception of suffering in medicine has been advanced
by Cassell,
8
for whom suffering can be defined as the state of severe distress associated
with events that threaten the intactness of the person (p. 33).
8
As highlighted by
Edwards,
9
Cassell construes suffering with two defining features. First, suffering has
a phenomenological dimension in that it can be properly understood only in terms of
how it is subjectively experienced by the person who is suffering. The magnitude of
the suffering cannot be correlated with the severity of externally observable injuries or
afflictions because these will be experienced differentially by different people.
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An analysis of suffering 175
Nursing Ethics 2009 16 (2)
Second, the intactness of the person must be threatened. The problems confronted by
the person must be perceived as actually or potentially compromising his or her personal
integrity by limiting significant aspects of his or her life. This criterion helps to clarify
how Cassell distinguishes suffering from pain. Pain relates to the neurophysiological
process referred to as nociception. The pain of childbirth can be tremendously severe,
such that it can cause extreme distress. However, Cassell asserts that this experience
is not commonly referred to as suffering. This is because childbirth not only does not
threaten the womans personhood, but often contributes to it. However, if the woman
is notified that her in utero baby has died and labor is induced to remove the dead fetus,
this experience would likely be felt as suffering. Recurring, inescapable cancer pain can
contribute to suffering because it may signal the uncontrollability of the disease and its
potentially imminent threat to the persons life.
One may suffer without any pain. For example, one may feel severely distressed
about the persistent hopelessness of ones life in the context of depression, resulting
in suffering. Thus, although pain and suffering are frequently inter-related, pain is
neither a necessary nor sufficient condition for suffering.
What kind of a thing is suffering? A conceptual analysis
Cassell has made an important contribution towards recognizing the complexity of
suffering in medicine by distinguishing it from pain and by articulating an insightful
construal of this complex concept. However, the epistemology of suffering has not
been systematically examined. The concept has been defined and distinguished from
pain, yet little attention has been devoted towards determining what kind of a con-
cept suffering is (Edwards succinct critique of Cassell and van Hooft is a notable
exception
9
).
The analysis undertaken here is situated within a field of inquiry that can be referred
to as the philosophy of emotions. Specifically, suffering is examined in the light of
Hackers framework for the investigation of emotions.
2
Hackers work on emotions traces a significant conceptualization shift from the
dominant views of Damasio,
10
who largely builds on the work of James, for whom:
Our natural way of thinking about these standard emotions is that the mental perception
of some fact excites the mental affection called the emotion, and that this latter state of
mind gives rise to the bodily expression. My thesis on the contrary is that the bodily changes
follow directly the PERCEPTION of the exciting fact, and that our feeling of the same changes as
they occur IS the emotion (original italics and capitals) (p. 190).
11
For Damasio,
10
whereas a feeling is a mental perception of body state, an emotion is
the bodily reaction to this perception, including automatic behavioral responses.
Hacker argues that this received view has insufficiently examined the complex
conceptual aspects of emotions by systematically investigating how emotions can be
understood in relation to a myriad of related concepts. Hackers framework regards
feelings as an overarching concept. There can be four types of feelings: (1) tactile per-
ceptions (e.g. heat, solidity); (2) sensations, which can be localized (e.g. pain) or of
ones overall bodily condition (e.g. weariness); (3) natural appetites (e.g. hunger, thirst,
sexual) or non-natural appetites (e.g. addictions); and (4) affections, which can be
further divided into agitations, moods, and emotions. It should be noted that the brief
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Nursing Ethics 2009 16 (2)
overview presented here is not a substitute for the complex detail provided in Hackers
original source.
Agitations refer to short-term affective disturbances, usually caused by something
unexpected, such as feeling excited, amazed, surprised, or revolted. Moods are longer-
term dispositional states of mind such as feeling cheerful, irritable, or depressed.
Finally, emotions refer to feeling things, such as love, hate, hope, fear, pride, regret,
guilt, grief, or compassion. These consist of emotional perturbations and emotional
attitudes. The former resemble agitations. Some emotional perturbations have associ-
ated somatic features such as measurable physiological reactions, while some may not,
such as humility or compassion. They are manifested in expressive behavior, which can
include changes in facial skin like blushing or pallor. This behavior can be voluntary
(e.g. reflected in verbal statements), partly voluntary (e.g. change in vocal tone), or in-
voluntary (e.g. cry of terror).
A chief distinction that Hacker makes from the work of Damasio is the differences
he draws between emotional perturbations and attitudes. An emotional attitude
involves a lasting regard for the object of the emotion, and standing motives, desires,
and thoughts that correspond with the emotion.
One cannot measure a persons emotion simply by the frequency or intensity of the
emotional perturbations he feels ... Rather, its strength is evaluated by the extent to
which the emotion determines behavior over time and the kind of behavior it determines
(p. 203).
2
Emotional perturbations and attitudes share some common features, such as causes,
objects, and agential reasons for the feelings and for their constitutive beliefs, reasons
for acting, appraisal and evaluation (p. 203).
2
Hacker outlines six specific features of emotions. First, emotions are not necessarily
tied to localized sensations in the way that appetites are. Second, emotions have
formal objects, referring to a general sense of what the emotion is aimed toward, as
well as specific objects such as feeling remorse for a specific action. Third, the intensity
of emotions does not proportionately correspond to the intensity of felt sensations.
Fourth, emotions are not based physiologically in the way that appetites are, so they do
not have a consistent pattern of occurrence, satiation, and recurrence. Fifth, emotions
have a cognitive dimension. They relate to things that the person knows something
about. Finally, many emotions are exhibited by characteristic facial expressions and
tones of voice.
Referring to the clinical characterizations of pain and suffering mentioned above,
pain is a localized sensation while suffering is an emotion. Suffering can involve
emo tional perturbations and attitudes. These perturbations may have associated
somatic features such as inescapable severe pain and exhaustion. They can also
involve expressive behavior that can be voluntary (e.g. calling out for comfort), partly
voluntary (e.g. change in vocal tone), or involuntary (e.g. facial grimacing, moaning,
lamenting). Suffering also involves attitudes. That is, the persons suffering entails
a lasting regard for the object of the suffering and corresponding standing motives,
desires and thoughts. For example, the person can have ongoing concern about cancer
pain, motivation to seek relief, a desire to be cured and fearful thoughts of an impending
tormented death.
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Nursing Ethics 2009 16 (2)
Suffering perturbations and attitudes relate to causes, objects, and agential reasons
for the feelings. That is, suffering can link severe symptoms (cause) with the disease
(object) for which the symptoms serve as a constant marker, threatening the agents
interests to live a long, comfortable, and happy life.
Suffering has the six specific features of emotions described by Hacker. First, suffer-
ing is not necessarily tied to localized sensations in the way that pain may be. For
example, suffering can be associated with prolonged demoralization or depression.
Second, suffering will have both formal objects, such as a general interest in comfort
and delayed mortality, as well as specific objects, like dreading the return of inescapable
symptoms such as severe pain, nausea, and fatigue. Third, the intensity of suffering does
not proportionately correspond with the intensity of felt sensations such as pain. The
intensity of suffering can relate more directly to the grandeur of how it compromises
ones life, which may not be readily observable. Fourth, suffering does not have a
consistent pattern of occurrence, satiation, and recurrence, as do the appetites. Fifth,
suffering has a cognitive dimension, relating to the significance of the life limitations
that the person is confronting. Finally, suffering may be exhibited by characteristic
facial expressions, tones of voice, and other bodily expressions.
In short, the features of clinical suffering correspond directly with the characteristics
of emotions outlined by Hacker. Suffering should be regarded as an emotion.
Can ones suffering be assessed by another?
Although the objective measurement of suffering is recognized as problematic in health
care, it is still commonly assumed that others can validly assess a sufferers degree of
suffering.
Suffering is a subjective feeling that cannot be measured objectively, whether in adults
or in infants. We accept that adults can indicate when their suffering is unbearable.
Infants or older children and adults with severe brain injury usually cannot express their
feelings through speech, but it is widely held that they can do so through observable
parameters. For example, pain scales for newborns, based on changes in vital signs
(blood pressure, heart rate, and breathing pattern) and observed behavior are used to
determine their degree of discomfort and pain. Experienced caregivers and parents are
regarded as capable of evaluating the degree of suffering in a newborn baby, as well as
the degree of relief afforded by medication or other measures.
12
Having established the conceptual identity of suffering as an emotion, this has
implications for how we can know about anothers suffering. How can it be appraised
or evaluated?
Although suffering may have expressive features associated with it, such as facial,
vocal, and physiological manifestations, these do not directly correspond with the
intensity and agential significance of ones suffering. Suffering also involves cognitions
about its meaning for the agent. Suffering is an emotion that is subjectively particular;
it is most properly understood by the person who is suffering. Given its subjective pro-
perties, suffering cannot be objectified and validly assessed by another.
A similar analysis should be conducted regarding pain. It is widely held in medicine
that pain can be reliably and validly appraised by others through objective measures.
13

It is noteworthy that research evidence regarding the appraisal of pain in children has
demonstrated that parents tend to overestimate their childs pain, while clinicians
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Nursing Ethics 2009 16 (2)
underestimate pain when compared with the childs own assessment of his or her pain.
These appraisal variations may be related to the appraisers sympathetic responses to
the childs pain, along the lines of Smiths conception of sympathy discussed below.
A further issue arises in consideration of anothers appraisal of ones suffering.
Clinical discussions about the speculated suffering of particular patients disregard the
phenomenon of sympathy that is experienced in the face of anothers ill fortune. In
The theory of moral sentiments, Smith argued that all persons are inherently moved emo-
tionally by the experience of another.
14
However, what is sensed by the observer is an
imaginative reconstruction of the experience of the other, of how the observer would
feel if he or she was in the position of the other.
As we have no immediate experience of what other men feel, we can form no idea of the
manner in which they are affected, but by conceiving what we ourselves should feel in the
like situation. Though our brother is on the rack, as long as we ourselves are at our ease,
our senses will never inform us of what he suffers. They never did, and never can, carry us
beyond our own person, and it is by the imagination only that we can form any conception
of what are his sensations. Neither can that faculty help us to this any other way, than by
representing to us what would be our own, if we were in his case. It is the impressions of
our own senses only, not those of his, which our imaginations copy. By the imagination,
we place ourselves in his situation (p. 3).
14
If we accept Smiths argument that humans are inherently sympathetic, this brings
into question the scientific premise that the perspective of another can be objectively
appraised. Although a person may be genuinely orientated to the interests of another
and grasp their experience to some degree, this appraisal process necessarily implies
the appraisers own emotions, which significantly affect ones understanding of
anothers perspective.
This conclusion is particularly significant in the context of persons who are incap-
able of explicitly expressing their state of suffering, such as young children and persons
with some form of mental impairment. This raises additional questions about the kind
of suffering (and other emotions) that mentally impaired persons may experience,
which Damasio
10
has examined in his study of stroke victims. An examination would be
needed of the suffering that can be experienced by children at different developmental
levels. Does the feeling of suffering necessitate a specific level of neurological and
cognitive development and functioning? Given their limited cognitive functioning, are
persons in a persistent vegetative state capable of suffering? It is frequently argued
that life in persistent vegetative state is not worth living because it entails excessive
suffering. This assertion remains an unsettled speculation.
Recognizing that a persons suffering cannot be objectively assessed by another has
significant implications for clinical practice. For patients unable to represent verbally
their suffering experience explicitly (such as children), it is commonplace for inter-
ested adults (e.g. family members, health care professionals) to assess these patients
perspective in order to judge the latters best interests. The dominant standard for
clinical decision making for patients unable competently to express their wishes is
for designated decision makers to assess the benefits and burdens associated with each
possible course of therapy and identify the one in which the benefits are proportionately
greatest in relation to the corresponding burdens. This analysis helps to determine
patients best interests.
15,16
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Nursing Ethics 2009 16 (2)
For patients who were previously competent, the surrogate decision maker should
try to judge these benefits and burdens as the patient himself or herself would have
done; this is the substituted judgment standard.
15,16
These legal standards are designed
specifically to require the decision maker to act with regard for the patients preferences,
and not his or her own.
Suffering is commonly a central consideration in such appraisals of patients interests.
Decision makers evaluate the potential merits of a course of therapy in relation to the
present or future suffering that this will imply for the patient. For example, in the
context of metastasized incurable cancer, where experimental chemotherapy could pro-
long life for two to four weeks, physicians may advise against it because they judge
that the (suffering) discomforts associated with the therapy will clearly outweigh the
limited benefits.
If suffering is by definition a subjectively particular phenomenon that cannot be
objectively assessed by another, except in terms of ones own sympathetic response,
then the conceptual soundness of the weighing of benefits and burdens for patients by
surrogate decision makers may be highly contestable.
Particularly worrisome are surrogate decisions for determining whether life-
sustaining therapies should be maintained or not. Decisions to withdraw life supports
or withhold cardiopulmonary resuscitation from incompetent or minor patients are
based on decision makers appraisal of the kind of life that the person would live,
typically considering the amount of suffering that would be implied. Decision makers
assess what it would be like for the patient to survive with disability or other limitations,
with a common presumption that these contribute to suffering. However, drawing on
Smith,
14
this appraisal process more likely involves an expression of ones sympathy
towards the ill fortune of the patient and how he or she would like to be cared for in
that position. These appraisals can be questionable assessments of the patients best
interests, but more likely inescapable expressions of the appraisers projected self-
interests.
What is the moral significance of suffering?
Nussbaum has demonstrated that emotions involve judgments about value.
17,18
Contest-
ing the Jamesian tradition of regarding emotions as bodily changes, she argues that
emotions require mindful appraisals of the things that matter to the person. Nussbaums
position also contests the modern western conception of detached instrumental reason;
one cannot think heartlessly. This work further challenges the presumption that a
patients emotions (such as suffering) can be assessed through rational objectivity: to
represent certain forms of truths, one must represent emotions.
Taylor argues that attunement to emotions captures the way in which something
can be relevant or of importance to the desires or purposes or aspirations or feelings
of a subject; or otherwise put, a property of something whereby it is a matter of non-
indifference to a subject (p. 48).
19
The sensation of suffering relates to the sufferers
values; it has a bearing on the things that matter to the person. This bearing will vary
across persons and contexts.
How ones suffering matters can be fully grasped only by the sufferer. It does not
vary in degree along a fixed quantitative continuum, relating to qualitatively diverse
dimensions of life in differing ways.
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Nursing Ethics 2009 16 (2)
However, there is a common view within medicine that suffering should be eliminated
and its elimination (or minimization at least) is a primary obligation of medicine.
9,20,21
Suffering has a moral designation: it is regarded as bad and its relief as good. Medicine
that eliminates suffering is good medicine (or good nursing); medicine that fails to
eliminate it, or in fact causes and prolongs suffering is bad medicine (or bad nursing).
The opening quote by a physician regarding a critically ill child implies that medicine
should prevent survival with the sole capacity of suffering pain and breathing.
In practice, this medical imperative to eliminate suffering helps to justify the ac-
cepted limitation of life-sustaining therapies (as described above) and the practice of
assisted suicide or euthanasia where it is legally permitted. In the Netherlands The
Groningen protocol allows for the euthanasia of severely ill newborns with a hopeless
prognosis and unbearable suffering (p. 157).
22
Verhagen and Sauer examined the considerations used to support the decision to
end the life of a newborn baby in a review of 22 cases in the Netherlands (infant eutha-
nasia has recently been legalized in the Netherlands).
12
Suffering was reported as a
consideration in all of the cases. It is interesting to see how suffering was construed.
The infant was considered better off dead than alive with suffering, which is conceived
in terms of functional disability, pain, discomfort, poor prognosis, and hopelessness.
The latter were evaluated by the infants surrogate decision makers.
Suffering has been attributed an extraordinary moral value. The elimination of
suffering holds a greater value than the preservation of life. How has this come to be?
This moral signification of suffering can be understood against the moral horizon
that serves as a background in the modern West. The decline of religiously-orientated
meaning systems paved the way for the rise of utilitarian moral viewpoints.
5,23
Without
a commitment to an ultimate good beyond humanity, self-fulfillment and the pursuit
of happiness emerged as dominant moral values. Suffering had become meaningless,
and its relief is regarded as meaningful and good.
6
This background horizon has become centered on: (1) individualism as an end in
itself, not as a means to a higher order as Augustine had originally conceived;
5
and
(2) instrumental reason, the view that individual interests can be attained through
calculative objectivism.
23
The rise of instrumental reason is consistent with the turn to medicine and science
by modern societies to ensure the maximization of happiness and the minimization of
suffering. Increasingly, the latter seems to have trumped medicines earlier mandate
to save life. Saving life remains important, but lifes value has become relative to the
quality of that life, and medicine has become morally responsible for the management
of happiness and suffering.
24
Medicine is commonly involved in attempting to boost happiness and eliminate
suffering. It has constructed therapies for: (1) prolonged sadness; (2) the reconstruc-
tion of physical features that are not consistent with contemporary ideal body types;
(3) modifying personal dispositions that do not fit with societal ideal personality types
through medications such as Prozac; (4) pharmacologically improving the academic
performance of children who are already performing well; and (5) ensuring a good
death by invoking the principle of double effect to justify the administration of high-
dose opioids or withholding nutrition and hydration from severely ill patients with an
understanding that this will hasten death, or performing assisted suicide or euthanasia
where legally permitted.
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Recognizing suffering as a Hackerian emotion
If we accept that suffering is an emotion with corresponding moral significance, and
that it can be genuinely understood only by the sufferer, what does this imply for
clinical practice? This conceptual retrieval of suffering in medicine calls for a rethinking
of the dominant instrumental reason paradigm among the health professions. Aims
towards the objective assessment of suffering are conceptually problematic and poten-
tially dismissive of the implied moral dimensions.
A conceptually sound recognition of suffering requires a paradigm shift in medical
discourse. There has been some discussion of possible directions for such a shift in the
nursing literature regarding emotions, which can be related to suffering.
25,26
Attending to suffering in particular calls for a turn towards attending to emotions
in general. This requires an understanding that clinical practice is not merely a (dis-
engaged) rational activity. It involves a practice that relates to people who feel people
who emote people who suffer.
Grasping the (emotional) suffering experience of another is inherently limited. Yet,
it would appear warranted to seek ways to promote emotional and moral sensitivity in
the health professions. These can enhance clinicians understanding of the emotional
and moral lives of patients.
This can be fostered, in part, through the cultivation of empathic attunement. I am
adapting this term for this discussion. Empathy implies an attempt to understand an
experience from the perspective of the other,
27
which has already been acknowledged
as problematic with regard to suffering and other emotions. By empathic attunement
I am not implying the conventional meaning of empathy. Rather, I construe empathy
as a speculative, provisional, and quite fallible attempt to grasp a sense of the felt
emotion of the other.
27
This view of empathy is based on a hermeneutic conception
of understanding rather than a positivist notion of objective assessment.
28
Taylor
has articulated how understanding human phenomena (e.g. suffering) involves an
on going interpretive process, continually attempting to grasp the significance of the
experi ence for the person, from his or her own system of meanings.
28
Emotions relate
to background horizons of significance that shape how things matter to a person in a
particular sociocultural context. Understanding anothers emotions therefore requires
an attentive engagement with his or her phenomenal world, to attempt to sense the
meanings he or she associates with a particular emotion, such as suffering.
An a priori position of humility towards the unique particularity of a persons
sub jective experience can help to bracket the clinicians pre-understandings of the
patients perspective. In turn, the clinician can practice a form of engaged attunement
to the perspective of the other, where he or she can arrive at as good an understanding
as possible through a process of personal transformation described by Gadamer as
a fusion of horizons.
29
Through empathic attunement ones pre-understandings are
changed in response to a proximate experience of the perspective of the other. This
form of engagement recognizes the patient as a person who feels, while recognizing
the clinician as a feeling person as well.
27
This process will awaken sympathetic emotions within the clinician that are his or
her own by fostering clinician self-reflection, and should not be confused with those
of the patient. For example, it can be distressing to engage empathically with a person
who has become quadriplegic and ventilator dependent. This process will uncover
the clinicians own related emotions and values, yet does not necessarily correspond
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Nursing Ethics 2009 16 (2)
directly with those of the patient. The clinicians potential felt sense that this would not
be a life worth living would not necessarily accurately reflect the patients sense. Many
persons live with profound disabilities but they do not all commit suicide or become
permanently depressed.
An authentic recognition of the perspective of the patient, faced doubly with his or
her own disability or mortality, is typically beyond the ordinary grasp of clinicians.
24

Significant shifts in the educational preparation of health care professionals are needed
to enable them to recognize the complexity of patients emotional and suffering experi-
ences. This will help them to become more attentive towards understanding patients
perspectives. Although empathic attunement is inherently limited, given that the
patients subjective experiences are largely beyond the grasp of others, clinicians will
derive some sense of the patients viewpoint, while conveying a form of regard for
the patient by recognizing his or her perspective as unique. Taylor has argued for a
politics of recognition for differing perspectives within political discourse. Such a pro-
cess of recognition would also appear relevant for bridging the diverse perspectives of
patients and clinicians.
30,31
Some may argue that, although such empathic attunement may be arguably bene-
ficial for the treatment of patients, this would involve an excessive emotional demand
on clinicians. It is conventionally held that clinicians need to maintain a professional
distance in order to protect themselves emotionally from problems such as burnout.
32

Some would also argue that professional distance is important for ensuring clinical
objectivity, which is a view that I have already contested above with regard to patient
suffering.
27
However, if Smith
14
is right in arguing that humans are inherently sympathetic,
moved by the perspective (good or bad fortune) of others, then distance would appear
counterintuitive. Rather, personal engagement that can help the clinician to attend in
an optimal way to the suffering of the patient may ultimately enable him or her to
derive a greater satisfaction from professional practice.
27
Clinical practice requires a recognition of the conceptual and moral significance of
suffering for patients, families and health care professionals. Clinical practice is inescap-
ably an emotional undertaking involving the emotions (including suffering) of patients
and those of clinicians.
Acknowledgement
I would like to thank Professor Andr Duhamel (Universit de Sherbrooke) for helping
me understand many of the ideas I have adapted in this article.
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