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Objective Suffering: What is it? What Could it be?

Published online by Cambridge University Press:  06 February 2025

Tyler Tate
Tyler Tate*
Affiliation:
Stanford University School of Medicine, Department of Pediatrics, Stanford, CA, USA
*
Email: [email protected]
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Abstract

There is an ongoing debate in bioethics regarding the nature of suffering. This conversation revolves around the following question: What kind of thing, exactly, is suffering? Specifically, is suffering a subjective phenomenon—intrinsically linked to personhood, personal values, feelings, and lived experience—or an objective affair, amenable to impersonal criteria and existing as an independent feature of the natural world? Notably, the implications of this determination are politically and ethically significant. This essay attempts to bring clarity to the subjective versus objective debate in suffering scholarship by examining the history of the concept of “objectivity,” and putting that history in conversation with physician Eric Cassell’s famous theory of suffering. It concludes with a novel, albeit tentative, definition of suffering: suffering is the experience of a gap between how things are and how things ought to be.

Keywords

Eric CassellHistory of Scienceobjectivityphenomenologysuffering
Type
Research Article
Information
Cambridge Quarterly of Healthcare Ethics , First View , pp. 1 - 9
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2025. Published by Cambridge University Press

[A]t the most primitive level of our grasp of things, there is a contact which straddles the gap between “subject” and “object,” and which shows these terms to be ultimately out of place. Footnote 1

Introduction

There is an ongoing conversation in bioethics regarding the nature of suffering. This conversation revolves around the following question: what kind of thing, exactly, is suffering? Specifically, is suffering a subjective phenomenon—intrinsically linked to personhood, personal values, feelings, and lived experience—or an objective affair, amenable to impersonal criteria and existing as an independent feature of the natural world? Notably, the implications of this determination are significant. If suffering is subjective, and therefore defined as an agent-dependent, first-person experience (potentially comparable to experiences like guilt or humiliation, which have both affective and cognitive dimensions) the kinds of creatures who can suffer are delimited. For example, worms probably cannot suffer, and neither can people who are sedated or in a coma. In addition, if suffering is subjective, no one can tell a person that they are suffering, or have special knowledge about the suffering of another individual. Indeed, within the subjective frame, challenges to first-person reports of suffering do not make sense, since the buck of suffering stops with the experience of suffering (and attendant claims) itself. However, if suffering is an objective reality, and therefore not essentially tied to first-person experience or feelings, it changes the dynamic. If suffering is objective, then individuals can be deceived about their own suffering, just like someone can be deceived that they have a serious illness, are being slighted by a friend, or are the best painter in the art school. In addition, if suffering is objective, the proper modes of measurement and response to suffering change. If objective, suffering does not “resist articulation” as Arthur Frank has claimed.Footnote 2 In the objective frame, suffering is out “in the world.” Hence, objective suffering could, ostensibly, be studied empirically and addressed directly in the same way that a broken bone can be directly examined and fixed, a starving animal directly fed, or an unjust housing policy directly studied and remediated.Footnote 3

In what follows I will begin to outline a method for constructing a holistic theory of suffering, a theory that harmonizes the objective and subjective dimensions of human life. Along the way, I will review the complicated history of the concept of “objectivity,” and discuss why the idea of pure subjective suffering is, I believe, fundamentally incoherent (and highlight other sources that argue this point at length). Then, I will attempt to show why any viable theory of suffering must move beyond the confining dichotomy of objectivity and subjectivity. This dichotomy is confining insofar as it perpetuates a form of alienation between people who are suffering and the world in which sufferers live, breathe, and have their being. In addition, it builds a problematic mind–body and mind-world dualism into any theory of suffering.Footnote 4 This problem is revealed—as I will explore—in Eric Cassell’s dominant theory of suffering, a theory that has consumed nearly all discussions of suffering in Western medicine and bioethics for the past 40 years.Footnote 5

Objectivity and self-effacement

In the historians of science Lorraine Daston’s and Peter Galisons’ remarkable tome Objectivity, the authors make a series of startling claims: objectivity has a history, there have been numerous forms of objectivity since the 17th century, and the current scientific-cultural understanding of objectivity is relative to a particularly modern view of what a self is and what a self can confidently know about the world.Footnote 6 These insights bear on the construction of a theory of objective suffering.

What does it mean to say that suffering is objective? To answer this question, a prior question must first be answered: what does it mean for a phenomenon to be objective at all? According to Daston’s and Galison’s (D&G) analysis, the answer to this question is not straightforward. Objectivity has evolved. Indeed, prior to the 17th century, the meanings of “subjective” and “objective” were actually flipped, with the predicate “objective” referring to things as they are presented to consciousness, (i.e., in the mind’s eye), whereas “subjective” referred to things that existed “in themselves” out in the external world.Footnote 7 Clearly, this is a far cry from the modern sense of “objective reality” which denotes “anything that exists as it is independent of any conscious awareness of it (via perception, thought, etc.).”Footnote 8

As D&G read it, the history of the idea of objectivity, somewhat surprisingly, is not a chronicle of humankind’s ability to know the world as it really is (vs. how it appears to be). Nor is it a history of humanity’s belief in its ability to grasp the “real world” (e.g., through the methods of photography, pure mathematics, or random sampling). Rather, it is a history of the self. Or, put more accurately, it is a history of the scientific self, which is the view that any scientific culture has regarding the degree to which a subjective self contributes to scientific observation and experimentation. This revelation bears both on how suffering is conceptualized today in bioethics, as well as the attendant subjective-objective debate.

According to D&G, the story of the emergence and reification of objectivity is a story of how the modern age has understood and coped with, the 18th-century Kantian insight that the self shapes the world. In the wake of Kant, it became incontrovertible that the self (via the mind) contributes foundational structures to experience that no scientist can get “underneath” or “behind.”Footnote 9 Kant inserted a wedge between subject and object and fated humanity to understand its experience of reality as occurring through a glass darkly, never face to face. This realization created epistemic anxiety in the hearts of scientists and philosophers, an anxiety that was relieved by the novel, world-gripping concept of objectivity.Footnote 10 For D&G, objectivity represents, tout court, the evolving attempt to recognize and suppress the subjective contribution of the self to the known world, to the world as it is known.Footnote 11 It follows that objectivity is essentially about epistemology. It is in this context that the power of D&G’s radical claim becomes apparent: “[o]bjectivity and subjectivity are as inseparable as concave and convex; one defines the other.”Footnote 12

D&G’s argument is convincing. Through meticulous documentation and analysis of scientific atlas design and production across the 18th–21st centuries, D&G displays the range of meanings of “objective.” They also demonstrate how these meanings are linked to particular historically specific scientific practices, and how each set of practices aims to both account for and bridle the spurious effects of self. For example, they show how, due to the “discovery” of the power of the will to transform so-called neutral observations, the structure and purpose of the scientific lab journal were recast in the 19th century. Originally viewed as a creative space for synthesis, the lab journal became, normatively, a ledger of pure observations, since the job of the observing scientist was to “forget all reasoning and only register.”Footnote 13 A difficult task, to be certain.

So how do these reflections and insights bear on the problem of suffering? Do they help clarify if suffering is fundamentally subjective vs objective? The chief insight is, I believe, that to speak of suffering as specifically subjective or objective is to say very little about the phenomenon of suffering itself. Rather, in claiming that suffering is objective, we reveal more about ourselves and join the chorus of scientists aiming to be freed from distorting feelings and artifacts injected by the mind.Footnote 14 However, as with all human inquiry, there is no view from nowhere.Footnote 15 To speak about suffering is always to speak from a situated history and perspective (i.e., a subjectivity). And yet—the world still exists! Indeed, I believe that we all believe that (1) the world exerts some form of accountability on our speech and concepts and that (2) in conversation with others, we can wander closer to or further from the truth of things (whether regarding suffering, love, or justice, etc.) —otherwise, we would just stop talking.Footnote 16 Therefore, to articulate a coherent and viable theory of suffering, the subjectivity (self) and objectivity (external world) of suffering must be married. A holistic account of suffering is the goal. But is this possible? For the remainder of this paper, I will consider that question.

Subjective suffering and Eric Cassell

To begin, I will briefly examine subjective suffering. An examination of subjective suffering is helpful in that it can reveal the problems a holistic theory of suffering must solve. To that end, Eric Cassell’s theory provides an exemplary account.

For Cassell, suffering is the “severe distress induced by the loss of integrity, intactness, cohesiveness, or wholeness of the person, or by a threat that the person believes will result in the dissolution of his or her integrity.”Footnote 17 The Cassellian concepts of distress, intactness, and personhood are complex, but what weaves them together into a form of subjectivity is their dependence on interpretation and meaning. Indeed, for Cassell, meaning (which is a function of the mind) is the crux of suffering, and the attribution of meaning to things is a function of persons.Footnote 18 Persons have minds, durable identities, a central purpose, and a coherent sense of self. Persons are not bodies, not Turing meat machines. Persons are non-fungible and therefore suffering is non-fungible.

It follows that suffering is never meaningless, and any creature incapable of recognizing and reflecting on its distress cannot actually suffer: it merely feels pain (or some other basic emotion) in response to its environment.Footnote 19 Notably, this framing excludes the possibility of personhood, and therefore of suffering, for many children, as well as anyone with serious intellectual disability, dementia, or altered levels of consciousness.

And what of this framing? When considering Cassell’s agenda-setting influence on the conceptualization of suffering in medicine and bioethics, I am reminded of Ludwig Wittgenstein’s remark about representational epistemology that “A picture held us captive, and we could not get outside it, for it lay in our language and language seemed to repeat it to us inexorably.”Footnote 20 Cassell’s subjectivism links suffering directly, and exhaustively, to identity and meaning. The Cassellian picture imagines that all suffering experiences must be felt and experienced by and in the mind, as the mind is the location of meaning.Footnote 21 Suffering is never experienced non-mentally as “merely” an affliction, process, or cross to bear.Footnote 22 But this view has implications. By subjectivizing suffering, Cassell dislocates suffering from its traditional connections to injustice and structural inequality and thereby delegitimizes the important category of social suffering (by pitching suffering as something that is “principally psychological or medical and, therefore, individual.”)Footnote 23 The lamination of suffering to meanings and central purpose (which Cassell sees as the unique essence of a self) also prevents suffering from being viewed as an opportunity for personal growth and change (an either/or kind of perspective) and fails to account for human self-deception and lack of insight.Footnote 24 Finally, Cassellian suffering flouts ordinary language and is therefore oddly incapable of characterizing the suffering of most animals or any human lacking a durable sense of identity and self.Footnote 25

Taken all together, I am convinced that if suffering is not held accountable to some form of natural, observable, and public criteria—for instance oppression, severe bodily impairment, or the absence of well-being—it inevitably becomes thin and idiosyncratic, or indistinguishable from emotions or mood disorders like anxiety or depression.Footnote 26 A better theory of suffering must be formulated.

Suffering and the world at large

Brent Kious has noted the possibility that suffering is inherently pluralistic.Footnote 27 There is wisdom in this claim. However, I am unwilling to give up on the idea that there are ties that bind the various meanings of suffering together, a union of subjectivity and objectivity into a singular theory of human suffering.

But what could such a theory look like? My hypothesis is that suffering emerges as a name given to an act of coproduction between intentional subject and world.Footnote 28 So framed, suffering necessarily involves both nature and culture, since subjects only know the world as it is mediated to them (for example, as children learning a language and adapting moral notions and norms) through a culture. Suffering, like all concepts (e.g., love and justice), is not an idea that people concoct on their own in isolation. It is not a meaning in the mind which may or may not coincide with a distant cause.Footnote 29 Rather, at the highest level, it is something co-produced by the subject and world, a type or form of reality generated through the interaction between the two. As a joint production, any description of suffering is fundamentally structured (like a hand in glove) by contact between the embodied mind and the world; taken further, an accurate grasp of suffering is determined by contact as well as interaction, an interaction that quite literally cannot be described (i.e., it becomes nonsense) while just talking about agents in isolation.Footnote 30

Human beings are material things. They are part of nature, parts of the cosmos, like graphite and magnolia trees, like candle wax or sewing machines. However, because they are alive and have language they can know and articulate aspects of their world in a way that exceeds other material things.Footnote 31 Yet these articulations are not limitless but rather are constrained by both historical and cultural parameters, and natural features of their bodies and environments (humans can think and believe a lot of things, but they cannot think and believe anything, at least not in good faith and without flouting basic requirements of reason).Footnote 32 Suffering is one such articulation. Like justice, or love properly understood, human suffering is a real feature of the human world, an objective (in an interpretive, holistic sense) description of how individuals, communities, or populations are configured in relation to themselves, to others, and to the world.Footnote 33 And what of this view? If a holistic position is correct, I believe, suffering studies has barely begun.Footnote 34 To understand the how and why of human suffering, an interlocking theory of (1) human (bio-psycho-spiritual) nature, (2) human culture, and (3) the process by which culture interprets nature (i.e., presses upon nature certain forms, fears, aspirations, and norms) to beget a believable suffering claim, must be generated.Footnote 35 Without such a theory of suffering, I suspect, a fragmentary pluralism is as good as it gets.Footnote 36

References

Notes

1. Dreyfus, H, Taylor, C. Retrieving Realism. Cambridge, MA: Harvard University Press; 2015, at 94 CrossRefGoogle Scholar.

2. Frank, AW. Can we research suffering? Qualitative Health Research 2001;11(3):353–62, at 353. doi:10.1177/104973201129119154 CrossRefGoogle ScholarPubMed

3. For further discussion of the objective-subjective distinction (including but not limited to an ongoing friendly debate between me and Brent Kious) see: Tate, T, Pearlman, R. What we mean when we talk about suffering-and why Eric Cassell should not have the last word. Perspectives in Biology and Medicine 2019;62(1):95–110. doi:10.1353/pbm.2019.0005 CrossRefGoogle Scholar ; Tate, T. What we talk about when we talk about pediatric suffering. Theoretical Medicine and Bioethics 2020;41(4):143–63. doi:10.1007/s11017-020-09535-8 CrossRefGoogle ScholarPubMed; Kious, BM. Suffering and the dilemmas of pediatric care: A response to Tyler Tate. Theoretical Medicine and Bioethics 2023;44(3):249–58. doi:10.1007/s11017-023-09615-5 CrossRefGoogle ScholarPubMed; Kious, BM. Three kinds of suffering and their relative moral significance. Bioethics 2022;36(6):621–27. doi:10.1111/bioe.13021 CrossRefGoogle ScholarPubMed; Nelson, RH, Kious, B, Largent, E, Moore, B, Blumenthal-Barby, J. Is suffering a useless concept?. American Journal of Bioethics Published online June 6, 2024. doi:10.1080/15265161.2024.2353799 CrossRefGoogle ScholarPubMed. Notably, I view both “value-based” like Eric Cassell’s and “sensation-based” theories of suffering (as discussed in Kious 2022 and Nelson et al. 2024) as examples of subjective theories of suffering, due to their shared reliance on personal (that is creature/agent-defined) conscious experience.

4. My thinking on suffering and dualism has been influenced by Stan Van Hooft, one of the few writers in bioethics who advances a fully non-subjectivistic/non-mentalistic view of suffering. See: van Hooft, S. Suffering and the goals of medicine. Medicine, Health Care and Philosophy 1998;1(2):125–31. doi:10.1023/a:1009923104175 CrossRefGoogle ScholarPubMed and van Hooft, S. The suffering body. Health 2000;4(2):179–95. doi:10.1177/136345930000400203 CrossRefGoogle Scholar.

5. For the arc of Cassell’s writing on suffering, see: Cassel, EJ. The nature of suffering and the goals of medicine. New England Journal of Medicine 1982;306(11):639–45. doi:10.1056/NEJM198203183061104 CrossRefGoogle ScholarPubMed, Cassell, EJ. The Nature of Suffering and the Goals of Medicine. 2nd ed. New York: Oxford University Press; 2004 CrossRefGoogle Scholar, and Cassell, EJ. The Nature of Healing: The Modern Practice of Medicine. New York: Oxford University Press; 2012 CrossRefGoogle Scholar. For an engaging historical-critical analysis of Cassell on suffering see: Duffee, C. An intellectual history of suffering in the encyclopedia of bioethics, 1978–2014. Medical Humanities 2021;47(3):274–82. doi:10.1136/medhum-2019-011800 CrossRefGoogle ScholarPubMed.

6. Daston, L, Galison, P. Objectivity. Brooklyn, NY: Zone Books; 2007 Google Scholar.

7. See note 2, Daston and Galison 2007, at 29–35. As they discuss, this original subjective-objective distinction was linked to knotty scholastic and Early Modern debates around nominalism versus realism regarding the existence of universals, primary and secondary qualities, substance and accident, etc.

8. Mulder DH. Objectivity. Internet Encyclopedia of Philosophy; available at https://iep.utm.edu/objectiv/ (last accessed 24 August 2024).

9. See note 2, Daston and Galison 2007, at 30–3.

10. See note 2, Daston and Galison 2007, at 258–83.

11. Notably, it is a bit more complicated than this. Once recognized, the contribution of self was not always resisted. Rather, the response to the self in science occasionally fluctuated among control, understanding, suppression, or management. At times the response was even to cultivate the wise and intuitive self, as with the idealizing classification of fluid droplets by British physicist Arthur Worthington. Relying on a kind of gestalt, Worthington prioritized symmetry, and jettisoned disorder from his atlas images, to capture the “essence” of fluid movement beneath the chaos of appearances. See note 2, Daston and Galison 2007, at 11–6. However, the overarching response (to the contribution of self to the scientific program of knowing the world as it really is) has been suppression.

12. See note 2, Daston and Galison 2007, at 197.

13. See note 2, Daston and Galison 2007, at 243.

14. This is not to suggest that the project of gaining freedom from self-deceptions or self-projecting fantasies is bad. Rather, it is to suggest a wariness toward claims that complex phenomenon like suffering, the self, forgiveness, love, justice, or religion, can be fully laid bare or understood via purely objective/scientific measurements and methods.

15. Nagel T. The View from Nowhere. New York: Oxford University Press; 1986, at 13–27. Nagel anticipates L&D’s conclusion regarding the desire for objectivity: “It is natural to want to bring our capacity for detached, objective understanding as much into alignment with reality as we can, but it should not surprise us if objectivity is essentially incomplete” Nagel 1986, at 18.

16. For a related discussions see: Williams, R. The Edge of Words: God and the Habits of Language. London: Bloomsbury; 2014, at 41 Google Scholar.

17. Cassell, EJ. Pain and suffering. In: Post, SG, ed. Encyclopedia of Bioethics. 3rd ed. New York: Macmillan Reference USA; 2004:1961–68, at 1964Google Scholar.

18. See note 5, Cassell EJ 1982, at 641.

19. See note 16, Cassell EJ 2004, at 1966.

20. Wittgenstein, L. Philosophical Investigations. Trans. GEM, Anscombe. 3rd addition. Malden, MA: Blackwell Publishing; 2001, at 41 Google Scholar.

21. Jeffery Bishop describes Cassell’s inadvertent dualism: “Cassell, who castigates the West for its mind/body dualism, claims in an oddly dualistic move that ‘bodies do not suffer, persons suffer.’ Although he might be horrified at such a charge, a subtle dualism also lurks in his sentiment that ‘[e]very person has a body’” ( Bishop, JP. The Anticipatory Corpse: Medicine, Power, and the Care of the Dying. Notre Dame, IN: University of Notre Dame Press; 2011, at 295 CrossRefGoogle Scholar.

22. Here the word ‘experience’ is polysemous and is not identical with ‘felt.’ A failure to distinguish these two meanings has led to much confusion and a false sense of agreement and understanding across conversations about suffering. For example, the sentence “I experience pain, joy, anxiety and suffering” makes it appear that suffering has a specific raw feel like these other sensations. However, when pressed we find that it does not. There is no raw feel or qualia that defines suffering qua suffering. Rather, there is always something else that makes us count an experience (of either semantic variety) as suffering. Indeed, this was the insight (specifically re: the ethical value of autonomy) that led Cassell to develop his “value-based” theory involving personal integrity and meaning, and distance himself from pure feeling-based theories of suffering like that of Jamie Mayerfeld (though by making despair a necessary condition for suffering he did maintain a required type of feeling). On the evolution of Cassell’s theory see: Duffee, C. An intellectual history of suffering in the Encyclopedia of Bioethics, 1978–2014. Medical Humanities 2021;47(3):274–82. doi:10.1136/medhum-2019-011800 CrossRefGoogle ScholarPubMed and Duffee C. Pathologizing pathos: Suffering, technocentrism, and law in twentieth-century American medicine. Journal of the History of Medicine and Allied Sciences 2023; jrad067; available at https://doi.org/10.1093/jhmas/jrad067. (last accessed 5 January 2025) For Mayerfeld see: Mayerfeld, J. Suffering and Moral Responsibility. New York, NY: Oxford University Press; 1999 CrossRefGoogle Scholar. On the vexed nature of Cassell’s concept of distress see: Duffee, C. What really is the nature of suffering? Three problems with Eric Cassell’s concept of distress. Bioethics 2020;34(7):695–702. doi:10.1111/bioe.12748 CrossRefGoogle Scholar.

23. Quotation from Kleinman, A, , V, Lock, MM Introduction. In: Kleinman, A, Das, V, Lock, MM, eds. Ering. Berkeley, CA: University of California Press; 1997:ix–xxvii, at ixGoogle Scholar. For these authors, social suffering (as one type of suffering) is an interpersonal social experience that can occur in the absence of the high bar of injuries or threats to personal integrity or personhood. Rather, social suffering indicates a kind of societal affliction (that can be equated to material afflictions like poverty) or social illness (like oppression or exploitation). Notably, at the end of the day, Cassell believes this is a false category of suffering. For instance, he says “[S]uffering is ineluctably subjective…suffering is subjective and cannot be made objective (Cassell EJ. Suffering and human dignity. In: Green RM, Palpant NJ, eds. Suffering and Bioethics. Oxford University Press; 2014:15–30, at 17). Furthermore, because Cassell’s suffering is narrowly defined as a monolithic problem of consciousness and subjectivity, he must reject any pluralistic account or typology of suffering (e.g. physical, social, existential). On this point he is explicit: “Suffering is suffering. There may be different causes of suffering, but not different kinds. Suffering is suffering” in Cassell, EJ. The Nature of Healing: The Modern Practice of Medicine. New York: Oxford University Press; 2013, at 219 Google Scholar. A brute assertion, to be sure. For more on suffering and its necessary connections to injustice and structural inequality see: Hooft, SV. The meanings of suffering. Hastings Center Report 1998;28(5):13. doi:10.2307/3528226 CrossRefGoogle Scholar and Griffin, M, Block, JW, eds. In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutiérrez. Maryknoll, NY: Orbis Books; 2013 Google Scholar. For more on social suffering see: Benatar, SR. Social suffering: relevance for doctors. British Medical Journal. 1997;315(7123):1634–5. doi:10.1136/bmj.315.7123.1634 CrossRefGoogle ScholarPubMed and Wilkinson, I, Kleinman, A. A Passion for Society: How We Think about Human Suffering. Berkeley, CA: University of California Press; 2016 CrossRefGoogle Scholar.

24. Cassell calls a person’s “central purpose” the very “being of oneself.” See note 22, Cassell EJ 2014, at 15. For critiques of Cassell’s idea that human beings have a core, singular, and abiding central purpose that defines the self and therefore suffering (when the central purpose, that is integrity, is threatened or injured), see Bueno-Gómez, N. Conceptualizing suffering and pain. Philosophy, Ethics, and Humanities in Medicine 2017;12 (7): 1–11 CrossRefGoogle ScholarPubMed and Duffee C. Existential spectrum of suffering: Concepts and moral valuations for assessing intensity and tolerability. Journal of Medical Ethics Published online July 20, 2023. doi:10.1136/jme-2023-109183. On suffering as an important opportunity for personal growth and change (which Cassell denies) see: Davies, J. The Importance of Suffering: The Value and Meaning of Emotional Discontent. Hove, UK: Routledge; 2012 CrossRefGoogle Scholar and Wong, PTP, Ho, LS, Mayer, CH, Yang, F, Cowden, RG. Editorial: A new science of suffering, the wisdom of the soul, and the new behavioral economics of happiness: towards a general theory of well-being. Frontiers in Psychology 2023;14:1280613 CrossRefGoogle Scholar. Published 2023 Sep 21. doi:10.3389/fpsyg.2023.1280613. On self-deception see: Funkhouser E. Self-Deception. Abingdon, UK: Routledge; 2019. Or as Harry Frankfurt, in what feels like could be a critical response to Cassell’s meaning and value-based theory of suffering, puts it: “The inner lives of human being are obscure, not only to others but to themselves as well. People are elusive. We tend to be rather poorly informed about our own attitudes and desires, and about where our commitments truly lie. It is useful to keep in mind, then, that a person may care about something a great deal without realizing that he cares about it. It is also possible that someone really does not care in the slightest about certain things, even though he sincerely believes that he considers those things to be extremely important to him” ( Frankfurt, H. The Reasons of Love. Princeton, NJ: Princeton University Press; 2004, at 21 Google Scholar.

25. I have discussed Cassell’s problem of language flouting in reference to pediatric medicine in: Tate, T. Pediatric suffering and the burden of proof. Pediatrics. 2020;146(Suppl 1):S70–S74. doi:10.1542/peds.2020-0818 NCrossRefGoogle ScholarPubMed. On the reality of the suffering of non-human animals see: DeGrazia, D. What is suffering and what sorts of beings can suffer? In: Green, RM, Palpant, NJ, eds. Suffering and Bioethics. New York, NY: Oxford University Press; 2014:134–56CrossRefGoogle Scholar and Wendler, D. Suffering in animal research: The need for limits and the possibility of compensation. Kennedy Institute of Ethics Journal 2022;32(3):297–311. doi:10.1353/ken.2022.0019 CrossRefGoogle ScholarPubMed. DeGrazia explicitly discusses the chauvinism of Cassell’s theory.

26. I discuss the relationship among suffering, well-being, and flourishing in: Tate, T. From sickness unto life: How community and belonging can bolster wellbeing during serious illness and end-of-life care. In: Phillips, T, Araujo, N, Jones, T, Taylor, J, eds. Narratives of Wellbeing. Cham, Switzerland: Palgrave MacMillan; 2024: 127–41CrossRefGoogle Scholar. Importantly, regarding emotion, there are multiple competing views on what an emotion is, and the view I refer to here (into which purely subjectivistic theories of suffering are at risk of collapsing) is the “feeling” view associated with William James in which an emotion is completely reducible to bodily feelings (see: Brady, MS. Emotion: The Basics. Abingdon, UK: Routledge, at 16–19 Google Scholar). Regarding suffering, what I fundamentally reject about Cassell’s view is twofold. First, I reject the idea that suffering is a personal phenomenon that is defined by how an individual feels and the personal meanings they attach to events, a view which implies that individuals cannot be self-deceived about their own suffering—or as Cassell puts it, “The only way to learn…whether suffering is present, is to ask the sufferer” (see note 5, Cassell 1982, at 139). I elaborate on this critique, with counter-examples that highlight both the thinness and idiosyncrasy of purely subjective suffering, as well as several situations where it appears self-evident that we can be mistaken about the presence or absence of our own suffering in: note 3, Tate, Pearlman 2019, at 97–9, and Tate 2020, at 153–4. Notably, my view here on self-deception is influenced by Elenore Stump. Stump argues that just because someone (e.g. the Nazi Herman Goering) does not feel bad (and may even experience great satisfaction and joy), or experience a threat to their integrity as a self, upon dedicating their life to evil acts, it does not mean that they are not suffering (e.g. experiencing the privation of something good), as evidenced by the fact that we would not want to switch places with them (even if our own life is going quite poorly); for Stump, we do not want to switch places with them because our intuition tells us that they are suffering insofar as there is something bad about their life ( Stump, E. Wandering in Darkness: Narrative and the Problem of Suffering. Oxford: Oxford University Press; 2010, at 4 CrossRefGoogle Scholar). Notably, I believe that, despite Cassell’s scattered talk of “causes” and the importance of social structures or shared cultural norms in understanding suffering, his theory must ultimately jettison the idea that the world (i.e. that which is not the self) is necessary for suffering or that the world or nature determine facts about human life which may be relevant to human suffering (for instance how humans ought to live or how they ought to understand the contours of a good life), as the quotes from note 22 demonstrate. Basically, regarding the value of the “world” to suffering, in the final analysis of his work, despite an ocean of case descriptions and assertions and pages of conceptual gymnastics, given his central commitments and overarching picture of personhood, Cassell cannot, logically, have his cake and eat it too). I discuss this problem in Cassell’s work further in: Tate, Pearlman 2019, at 99. Second, I reject the idea that suffering is limited to creatures with consciousness and a sense of self. For instance, in both pediatric and adult medicine, surrogate decision makers frequently attribute suffering to their unconscious and/or sedated loved ones (for examples see: Blume, ED, Balkin, EM, Aiyagari, R, Ziniel, S, Beke, DM, Thiagarajan, R, et al. Parental perspectives on suffering and quality of life at end-of-life in children with advanced heart disease: An exploratory study*. Pediatric Critical Care Medicine 2014;15(4):336–42CrossRefGoogle ScholarPubMed and Kious, BM, Vick, JB, Ubel, PA, Sutton, O, Blumenthal-Barby, J, Cox, CE, et al. Talking about suffering in the intensive care unit. American Journal of Bioethics Empirical Bioethics. Published online September 9, 2024. doi:10.1080/23294515.2024.2399534 Google ScholarPubMed). Indeed, human beings talk endlessly about the suffering of other kinds of creatures (e.g. see note 25, Tate 2024, at 128–30) and this talk must be accounted for. An explanatory theory cannot reject massive swaths of ordinary language if it is to have traction in a culture’s language and in people’s lives, and, I would argue but cannot defend here, arc toward truthfulness (I discuss this further in: note 3, Tate 2020, 147–8). Suffering is more than simply existential suffering, which is what Cassell’s suffering most closely resembles (this can be seen in Kissane, DW. The relief of existential suffering. Archives of Internal Medicine. 2012;172(19):1501–5 at 1501–2CrossRefGoogle ScholarPubMed). I believe, but have yet to fully articulate, that suffering is linked to different dimensions of what different creatures are and can be, as well as the different kinds of challenging experiences different creatures undergo, or by which they can be afflicted. Here I find my own view much in line with a view found in Thomas Aquinas (see: Miner, R. Thomas Aquinas on the Passions: A Study of Summa Theologiae, 1a2ae 22–48. Cambridge: Cambridge University Press; 2009 CrossRefGoogle Scholar). Thank you to an anonymous reviewer for pointing me to Aquinas’s insightful work on suffering and to this book, and for forcing me to clarify how my own view differs from Cassell’s.

27. See note 3, Kious 2022, at 627.

28. Here I mean intentional (that is a human subject that intends) in the technical sense as it is used in the philosophical field of phenomenology. See; Sokolowski, R. Introduction to Phenomenology. New York, NY: Cambridge University Press; 2000, at 88–91 Google Scholar.

29. See note 1, Dreyfus and Taylor 2015, at 94.

30. See note 1, Dreyfus and Taylor 2015, at 94–5.

31. Here I am thinking of Charles Taylor’s understanding of the human power to articulate its world. See: Taylor, C. The Language Animal: The Full Shape of the Human Linguistic Capacity. Cambridge, MA; Harvard University Press, 2016, at 177–87CrossRefGoogle Scholar. Or as Aristotle famously puts it, human beings are rational animals.

32. On the constraints placed by bodies and environments on concepts see: Lakoff, G, Johnson, M. Metaphors We Live By. Chicago, IL: University of Chicago Press, 1990 Google Scholar.

33. On love “properly understood” (namely, as something much more than a mere feeling), see: hooks b. All About Love: New Visions. New York, NY: HarperCollins; 2001 and Jenson, R. Story and Promise: A Brief Theology of the Gospel About Jesus. Eugene, OR: Wipf and Stock; 1973 Google Scholar. Here, I think, Jensen gets it right: “Love points not so much to something inside each of us as to something between us: to a particular kind of network of communication, with all its words and acts; to a particular way of sharing a world…[love] cannot be an inward state. For love means that I emerge from the security of what I am in myself, and risk myself out there in the world that is neither my inner world nor your inner world, but precisely the world between us in which we can be together” (Jensen 1973, at 55–6).

34. Ultimately, I view holistic objectivity in the more Nagelian sense of being about how the world actually is, for us as humans, with every individual “person and his viewpoint included” (see note 3, Nagel 1986, at 3), not scientifically objective in the ideal or quasi-mathematical sense of being bleached of all particular perspectives, value judgments, or personal interests.

35. I believe that a bare-bones definition of suffering is finally in order. I offer: Suffering is the experience of a gap between how things are, and how things ought to be. Here I liberate ‘experience’ to take on either of its two senses since suffering can, of course, be something that individuals or groups undergo, and also something which may be perceived/sensed/experienced in a (for now, nondescript) first-personal way. Importantly, it is the gap that is perceived/sensed/experienced—emotions like fear or anxiety, though often a part of the experience of suffering are, as discussed in note 21, incidental. Notably, in this definition there are echoes of both Buddhist thought, and of Aquinas; compare to: “What produces sorrow [for Aquinas, who closely links sorrow to suffering] is our recognition of the gap between the condition we desire—to be in union with all other goods, insofar as they complete our natures—and the condition in which we actually find ourselves, described by terms like ‘fragmentation’ and ‘alienation’” (note 24, Miner R 2009, at 199).

36. And perhaps, pragmatically speaking, that is good enough.