The Nature of Suffering and the Goals of Medicine By Eric Cassell (review)

BOOK REVIEW The Nature of Suffering and the Goals of Medicine. By Eric Cassell. New York: Oxford Univ. Press, 1991. Pp. 254. $24.95. Eric Cassell has written an important book that deserves the attention of our profession. In The Nature of Suffering and the Goah ofMedicine, Cassell, an internist and clinical professor of Public Health at Cornell University Medical College , makes the now familiar critique that modern medicine suffers from a confusion of purpose. Though he echoes the pleas of others for a renewed respect for genuine conversation in medicine, he adds the provocative insight that our confusion may stem from a flawed understanding of the nature of disease. Cassell sees that most of medical education and practice focus on the idea of a disease with a fixed nature that is separate and abstracted from the particular individuals who may harbor it. Pneumonia, in one example that he cites, is commonly defined as an inflammation of the alveoli. Knowledge of the person with the pneumonia is seen as irrelevant to our understanding of what the disease is or how to treat it. To Cassell, this abstract understanding of disease is a fiction, perhaps useful at one stage in medicine's development as a science, but now increasingly unhelpful in addressing the real issues that confront doctor and patient. He argues that it is counterproductive to speak of a disease independent of the person with the disease. "The uncomfortable fact remains," he asserts, "that doctors cannot get at disease without dealing with patients." In an elderly man with pneumococcal pneumonia, for instance, is the "cause" of his illness the pneumococcus , or is it his isolation on the fifth floor of a walk-up and the osteoarthritis that kept him from going out to buy food? By focusing on the bacterium, notes Cassell, we leave the underlying problems unaddressed, and the patient is likely to return shortly. Cassell's person-centered understanding of disease leads to his analysis of suffering, the relief of which he sees as the central purpose of medicine. Suffering , to Cassell, is both a physical and a spiritual condition. "Suffering occurs when an impending destruction of the person is perceived . . . Most generally, suffering can be defined as the state of severe distress associated with events that threaten the intactness of the person," he writes. In order to assist the suffering person, the physician must try to learn the patient's identity, past, concerns, fears, wishes, and values. Cassell perceptively argues that some persons may suffer with seemingly minimal degrees of pain, Permission to reprint a book review printed in this section may be obtained only from the author. 150 Book Reviews while others with greater physical pain may not suffer. "Suffering can be relieved in the presence of pain by making the source of the pain known, changing its meaning, and demonstrating that it can be controlled and that an end is in sight." This is not to diminish the need to treat physical symptoms but to emphasize that attempts to control those symptoms without addressing the suffering person are likely to fail. Cassell thinks that most people understand the relief of suffering to be one of the primary ends of medicine, but that our profession has chosen to concentrate almost exclusively on the cure of disease. This conflict in perspective may contribute to the mutual alienation of doctor and patient and to those paradoxical outcomes of high-tech medicine in which physicians cause rather than relieve suffering. I particularly appreciated his discussion of the central therapeutic role of the doctor-patient relationship. That the physician as person can play a healing or a harmful role has been well documented in, say, studies of the placebo effect. Yet, as Howard Spiro and others have argued, the potential of physician as person is often downplayed by a medicine that aspires to be neutral science. Cassell understands that there is a craft of healing physicianship with virtues that can be defined and taught. He sees trustworthiness, self-discipline, and self-knowledge as essential; and the distinction between technical competence and humane practice as artificial. "A doctor without technical competence would be inadequate and unworthy of trust," he writes. "Knowledge...