Volume 3, Issue 02 - April 2000

Spirituality and Ethical Issues Related to Pain and Suffering

Guest Writer Profile:
Philip Behman

Philip Behman This month we are very pleased to have as our guest writer, Philip Behman, PhD.

Philip is currently the Co-ordinator of Spiritual Care at the Alberta Children's Hospital in Calgary. He is a Teaching Supervisor of Clinical Pastoral Education and is part of a teaching team that trains Chaplains in the Calgary Regional Health Authority.

Philip recently completed his Doctoral studies in the area of palliative care and ethics through St. Stephen's College, Edmonton. He is also the current Chair of the Alberta Children's Hospital Ethics Committee.

Philip is married and has three school-aged children.

"If our duty is to reduce suffering, then we cannot ignore the spiritual factors related to suffering."

Pain & Suffering

Pain and suffering are closely related phenomena that greatly influence medical treatment decisions. Many of these decisions have ethical import. Suffering is clearly a universal condition of humankind, a condition that goes beyond the experience of physical pain. Suffering is also a psychological, social, and ultimately a spiritual issue that touches the very heart of what it means for persons to be human. Cassell defines suffering as follows:

"Suffering is...induced by the loss of intactness of a person or by a threat that the person believes will result in the loss of his/her intactness..."1

Thus, persons suffer because the very essence of who they are is threatened. And this suffering is not determined by physical pain alone. Psychic or "soul" pain is recognized as equally threatening to one's sense of intactness.2 Grief due to personal loss, the witnessing of traumatic events, and fear of death are examples of potentially painful experiences that are not directly associated with physical calamity. This is not to say that physical pain does not have its effect on the psyche or vice versa, but suggests that the relationship between pain and suffering and the individual is complex and uniquely experienced.

Spirituality

Spirituality as a modern concept has come to refer to a person's life and activity in relationship to oneself, other people, and to a Divine being. There are a plethora of definitions of spirituality, most suggesting both ontological (who I am at the core) as well as a teleological (becoming who I am meant to be) elements to the human expression of life. Simply put, every person possesses a unique spirituality that begins at the centre of one's person-hood and works itself outward as it expresses itself in the social context. It could even be said that "soul" refers to the inner essence of persons whereas the "spirit" is the active force recognized in the world through action. Spirituality, then, is about one's soul at the core of one's self, and one's spirit as the self is manifest in action.

Spirituality & Suffering

Spirituality and human experience of suffering are intimately related because anything that affects the "intactness" of a person will have deep effect on his/her inner life. The strength and resiliency of one's spiritual life will no doubt have a great influence on how pain and suffering are experienced.

"Resiliency" is a term that relates to how an individual finds ways to cope with significant adversity and stress.3 Spiritual resources, often defined by religious practices such as prayer and liturgical rites, can create meaning out of any experience, be it the experience of pain, suffering, joy, or happiness. The capacity of an individual to create meaning, as determined by any number of spiritual practices, plays an important part in leading to a more 'resilient' life.4 And the greater one's resiliency, the greater one's ability to deal with suffering.

But the development of a mature spirituality does not come by way of chance. It has to be worked at. Bill Schmidt divides the work of the spiritual journey into two qualitatively distinct practices termed 'spirit work' and 'soul work.'5

Soul Work & Spirit Work

I would argue that both 'soul work' and 'spirit work' are essential activities of the human condition that attempt to make sense out of the lived experience of suffering.

'Soul work' describes any practice, religious or otherwise, that leads to a strengthening of inner processes of identity formation in relation to others and Otherness (God). In other words 'soul' is concerned with the 'unfolding' of human identity. There is an inner directedness to soul work that cultivates qualities such as stillness, receptivity, openness, vulnerability, incubation, and love. 'Spirit work' on the other hand, speaks to the active expression of the inner life as informed by Otherness (God). Different than 'soul', which is passive, 'spirit' is active and other-directed. 'Spirit work' manifests the qualities of seeking, searching, challenging, differentiating, acquiring, letting-go, and loving, to name a few.

Like the exercising of a muscle to make it strong, the practice of such spiritual disciplines help to strengthen the capacity of the inner life to deal with complex and difficult life situations. Intuition and my own experience tells me that the spiritually mature individual will do better when faced with suffering either within themselves or when called upon to act in the best interests of others who suffer.

Beneficence & Spirituality

It can be argued that the amelioration of pain and suffering is a prima facie duty generated by the ethical principle of beneficence (do good). This would certainly be true for the medical community and health care professionals in general who are also bound by the prima facie duty to "do no harm"; i.e. the principle of non-maleficence found in the Hippocratic oath. It could also be argued that all persons in society that respect the principles of beneficence and non-maleficence as moral directives must endeavor not only to resist acting in ways that cause persons to suffer but they are also called to reduce suffering where it is found.

One of the simplest and most efficient means to ameliorate pain and suffering is through the use of analgesics or pain medication. When a patient is struggling with physical malady as a result of treatment for illness or disease, medication may indeed be the best solution to relieve the problem of pain and thus reduce suffering. If "psychic pain", unrelated to disease or physical illness, is suspected, then the use of analgesics alone is morally suspect.

Eric Cassell6 proposes six ways by which caregivers can ameliorate suffering by reducing pain:

  1. Reduce the stimulus to reduce the pain ( example "take out the tumour")

  2. Reduce the sensation to reduce the pain ( example "give pain medication")

  3. Change the behaviours to reduce the pain ( example "exercise regularly")

  4. Alter the perception of the pain ( example "come to believe there is an end in sight")

  5. Change the meaning of the pain ( example "learn from the experience")

  6. Encourage a change in the person experiencing the pain (show how they can rise above it, how to restore intactness or find a different kind of intactness through self-transcendence and hope).

Three of these ways speak just to the physical condition of the sufferer and involve techniques are externally driven treatment possibilities. The other three suggestions speak to a more psychological/spiritual solution, reflecting the inner attitude of the individual.

I would claim that there is a spiritual quality to how a person perceives pain, finds meaning in pain and is able to transcend the suffering caused by pain. I would also suggest that most of our medical solutions attempting to ameliorate suffering (at least in acute care hospitals) focus on externally driven treatment solutions that give little consideration to the constitution of the human psyche. This factor plays a significant role in the quality of suffering experienced by an individual. If indeed our duty as caregivers is to reduce suffering where we find it, then we cannot ignore the spiritual factors related to suffering.

Implications

Attention to spiritual aspects of human experience as related to suffering and pertaining to moral discourse will require an attunement to relationally oriented frameworks for ethical decision making. The ethic of care7 is one such philosophy of caregiving that places quality of relationship at the centre of caregiving with a concomitant desire to seek connection with the inner life of the individual.

The relational context for this endeavor is community. For it is between individuals and among people, that understanding through compassion is found; it is through kindness that perceptions are altered; and it is by love that self-transcendence is effected. This is admittedly a tall order for anyone as many of us are already relationally stretched to the max. Nevertheless, we begin with the knowledge that we too carry a spiritual centre and that it is in community that we are collectively and morally compelled to reach out to assuage the suffering of others.


References:

  1. Cassell, Eric. 1993. Pain and Suffering. (Unpublished conference proceedings.)

  2. Kearney, Michael 1996. Mortally Wounded: Stories of Soul Pain, Death, and Healing. New York: Scribner.

  3. Mangham, Colin, Patrick MacGrath, Graham Reid, and Miriam Stewart. 1994. Resiliency: Relevance to Health Promotion. Atlantic Health Promotion Research Centre: Dalhousie University.

  4. Frankl, V. 1952. Man's Search for Meaning. Boston: Beacon Press.

  5. Bill Schmidt personal communication January 19, 2000.

  6. Ibid.

  7. Gadow, S. 1980. Existential Advocacy. Nursing: Images and Ideals. New York: Springer.

 

Upcoming Project to Watch For: Provincial Bioethics Week

Bioethics Week!


The PHEN staff is pleased to announce that it is preparing to launch Bioethics Week - the first annual provincially-coordinated celebration of health ethics issues.

Bioethics Week will be a provincially designated period, tentatively scheduled to take place in late 2000/early 2001, for Alberta health institutions to offer ethics-related events with support from Network staff.

Bioethics Week has been designed with several goals in mind:

  1. It will emphasize the importance of examining values underpinning the health system

  2. It will facilitate the health ethics education of various stakeholders in the system, from members of the community to institution staff

  3. It will provide an opportunity to improve the visibility of local bioethics committees

The Network staff are currently in the process of having such a week appointed, with the exact date to be determined shortly. A Bioethics Week resource manual is also being developed to assist institutions and ethics committees in developing and advertising programming that is appropriate for their respective constituencies.

Stay tuned for more information on this exciting program!

 

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.