When does suffering become unbearable?

When does suffering become unbearable? This medical and ethical question presents a particular challenge for treatment teams working in palliative care. Dr. Claudia Bozzaro of the Institute of Ethics and History of Medicine at the University of Freiburg and Professor Dr. Jan Schildmann, Director of the Institute of the History and Ethics of Medicine at the University of Halle-Wittenberg, investigated problems faced by medical practitioners when it comes to the idea of suffering. Initial results of the interdisciplinary study have been published in the “Journal of Pain and Symptom Management” (JPSM).

“The very concept of suffering is barely explored; this often leads to problems and uncertainty regarding treatment in the practice of palliative sedation,” Bozzaro says. Many discussions about the suitability of a sedation at the end of patients’ lives are based on unclarified ideas about the qualities of suffering, she says.

Bozzaro and Schildmann examined two different concepts of suffering, one subjective and one objective, and their significance for the decision-making process in clinical practice. They showed that for instance the question of who should decide on a sedation can turn out very differently - depending on which concept you apply: In the subjective view of suffering, the decision is with the patient who can thereby call for the use of a medical measure. If you go with the objective notion of suffering, the decision would be for the medical team to make. The latter carries the danger of deciding what is best for people without letting them decide for themselves. Should phenomena such as psycho-existential or spiritual suffering be treated medically like physical suffering like pain and shortness of breath? This question too turns out differently depending on which concept of suffering you apply: According to the subjective view, all suffering must be seen equally as an object of medical indication; while the objective view provides the basis for a differentiation between various experiences of suffering.

Bozzaro has spent a long time working on this problematic issue in medical ethics. Schildmann, with whom she examined varying concepts of suffering and the resulting problems for day-to-day work in the clinic, supported her with his practical experience. Both agree that the study leaves open several questions which require further theoretical and empirical investigation. The goal is to find a definition of suffering which can solve the difficulties shown by the study, thereby providing a reliable guide in cases of uncertainty for medical practitioners. The researchers’ work also highlights that many questions can only be answered in a dialogue between theory and practise. In 2017 Bozzaro received the Albert Bürklin Prize from the Wissenschaftliche Gesellschaft Freiburg for her research into concepts of suffering and pain.

Publication:
Bozzaro, C./Schildmann, J. (2018): „Suffering“ in Palliative Sedation: Conceptual Analysis and Implications for Decision Making in Clinical Practice. In: Journal of Pain and Symptom Management 56/2, S. 288-294. https://doi.org/10.1016/j.jpainsymman.2018.04.003