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Chapter 1
Medicine, Suffering and Healing
CONTENTS
Introduction
Suffering and healing
Curing versus healing
Healers in society
Traditional healers
The modern doctor as healer
The ‘wounded’ healer
Tying it all together: Reflecting on healing
Conclusion
Introduction
The practice of medicine is usually quite straightforward: this or that abdominal pain may have a surgical cause; a broken leg can be set; diabetes can be managed. Routine practice, regardless of context, does not usually ask questions of meaning or professional identity. Yet now and again there is a sense that a straightforward approach is not enough. We encounter patients who challenge our ideas about medicine and what we hope to achieve: the more complex, even ‘difficult’ patients. Underlying issues now need to be addressed.
We start this chapter, then, with two questions: ‘Is medicine a healing profession?’ and ‘Are doctors healers?’ While these questions are challenging and provocative, they are a useful start for thinking about the aims of clinical practice. If doctors are not involved in healing, regardless of specialty, then what is their purpose?
We will explore suffering and healing as separate from cure, as well as the concept of doctors as healers. We will then draw these ideas together, identifying an apparent contradiction as doctors learn to use themselves as the healing agent.
While our observations of clinical practice are located in primary care, these ideas about doctoring are generic and apply to doctors in all specialties. Making the transition from hospital to general practice can simply make these issues more apparent.
We start with a short vignette about a patient with an acute illness. While the setting is the emergency department, this patient might just as easily present herself in general practice or be referred to a gastroenterology clinic for review. The vignette illustrates some of the major themes in this chapter. The doctor’s perspective will be discussed later.
VIGNETTE 1.1 HOLDING IT ALL IN
A 20-year-old woman came to the emergency department with four hours of severe dry-retching every 10 to 15 minutes. This had happened a few times previously and she usually required an injection for the bouts to stop. She initially attributed this episode to last night’s meal of chicken, although others who ate a similar meal were unaffected. She looked anxious, but her examination was unremarkable. BP and pulse were normal, no evidence of dehydration, abdomen soft. She had a friend with her.
Over the next two hours she had two anti-emetic injections that made no difference at all.
A second doctor came on duty and was asked to take over this patient’s care. He took the history a little further. She outlined a story of previous bouts of such vomiting over the past seven years, occurring about once per year. Exploration of her family history revealed that her mother had problems with undiagnosed headaches and that her father was physically well. Her only sibling, an older sister, had died some years before in a tragic accident. She said this was an ongoing issue for her, although she had a reputation of ‘coping well’.
On further enquiry about her life, she said she was studying for a degree but had yet to apply for the one she really wanted. She was also ambivalent about whether or not to hold her 21st birthday party in the next few months, aware that her father’s life plans had changed dramatically since the death of her sibling. She was fearful that a 21st celebration would cause her family even more pain. The change in family dynamics after her sister’s death had been very difficult. She had not really discussed these issues with anyone (including her friend who was present), as they might see her as not coping so well.
This second consultation took about 15 minutes. At this stage, she appeared calm and relaxed, and the dry retching had completely stopped. She thanked the doctor and made arrangements to leave.
What was going on here? Why did the patient suddenly improve? What did the doctor actually achieve, and how?
Rather than presenting this vignette as a ‘diagnostic puzzle’ to be solved, the story is intended to stimulate thought about possible links between acute illness and suffering, and how we might consider the doctor’s role. First, though, we will consider the central concept of ‘suffering’. What is it, and how does it relate to our work as doctors?
Suffering and healing
Dr Eric Cassell is a physician from New York who has written extensively on suffering. His 1982 article ‘The nature of suffering and the goals of medicine’, in the New England Journal of Medicine, has been widely quoted,(1) and his later book of the same title is one of the classic modern texts on this subject.(2)
Cassell helpfully distinguishes between pain and suffering. Patients with their first bout of renal colic, for example, may be scared and apprehensive about what is causing the pain, but once they know and understand the diagnosis they can cope reasonably well, knowing that it will soon pass. On the other hand, back pain that might mean the recurrence of cancer is much less bearable. The uncertainty of the pain and its implications can be profound for that person’s future.
Suffering, then, is less about pain and more about the meaning or implications of the symptom or illness. It usually involves a feeling of helplessness in the face of a threat to their idea of themselves and/or their world. As Cassell puts it, ‘Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity’(our italics).(2)
In a similar way, parents suffer greatly from the illnesses of their children, especially long-term illnesses such as cancer or congenital disease. It is also hard to sit by and observe the pain and distress of parents or loved ones, especially in terminal illness. Suffering is felt by the whole family, not just the person who is ill. The powerlessness of being unable to relieve the pain or discomfort of others can cause tremendous suffering.
Cassell outlines a comprehensive typology of persons that we will return to in Chapter 2. Disturbance in any aspect of personhood can cause suffering. Doctors need to be curious about patients as persons, in order to identify the meaning of their particular suffering.
On the other hand, healing involves the amelioration of suffering. Suffering is resolved if the threat to personal integrity is removed. Following on from Cassell, Egnew helpfully proposes a definition of healing as ‘the personal experience of the transcendence of suffering’.(3) Suffering can be transcended through acceptance of the situation or by finding meaning in the experience of suffering. This can happen regardless of whether or not the patient is actually cured or restored to health, and even when the patient knows their illness is terminal.
Suffering is not defined by the diagnosis of a particular disease. Suffering is an experience that is peculiar and specific to each person. Healing must also be specific: whether a doctor can help or not will be specific to that person, the meaning of their illness, and the particulars of the doctor–patient interaction.
Fortunately, most disease does not cause much suffering, as the challenge to the patient’s integrity as a person is relatively minor. Patients quickly accommodate a short-term problem such as tonsillitis or a broken bone; they know they will recover their lives fully. As will be noted later, this is known as the ‘restitution narrative’: it is the common overall storyline in acute illness.
To a variable extent, patients will also resolve the impact of more serious disease on their lives and day-to-day aspirations. An injury causing paraplegia, however, will be a profound challenge to the perceived future of most people. Some patients accommodate such misfortune, reaching a new equilibrium within themselves, while others remain bitter and resentful about their bad luck.
Figure 1.1 illustrates how suffering and healing can be usefully identified as sitting at either end of a continuous scale.(4) For example, a person in major grief is clearly suffering; those around them attempt to facilitate their journey towards some equanimity and inner peace in relation to their loss. Similarly, patients are often quite anguished at the onset of major life-threatening disease such as cancer, stroke or heart attack. Their overall recovery will involve physical treatment but may also entail some revisions of who they are as a person.
FIGURE 1.1 WOUNDING AND HEALING
Total pain refers to the combination of physical, emotional and/or spiritual pain. Adapted from Hutchinson et al.(4)
By placing this continuum over time, it is possible to chart each patient’s potential journey towards wholeness and recovery. One of the doctor’s tasks is to be conscious of these dimensions and of what is helping or hindering the healing process. Clues to this often lie in aspects of personhood. Being curious and observant of the illness experience and becoming interested in how the patient is doing in relation to their disease is the first step.
VIGNETTE 1.2 GRIEF AND ILLNESS
An elderly woman suffers the loss of her husband of over 40 years. She starts to recover from acute grief but, as is quite common in such situations, develops an intercurrent illness (pneumonia). Her physical recovery from this is quite slow and she requires increased home care. Her daughter comes to stay, encouraging her to resume her previous employment in the local vicarage. This helps her to reconnect back to her original sense of self and identity and she is now able to make the transition to living on her own.
Figure 1.2 illustrates this case as just one example of many healing journeys.
FIGURE 1.2 DIMENSIONS OF HEALING JOURNEY
Adapted from Hutchinson et al.(4)
It is fascinating to see how some patients with advanced cancer manage to let go of the idea of cure entirely and embark on a personal journey of discovery about the meaning of their disease. In contrast to restitution, this is known as a ‘quest narrative’.(5) Here the action is one of letting go and personal growth. Surprisingly, many such patients comment that having cancer was the ‘best thing’ to happen to them, as their life was changed for the better.
Mount gives the meaning of healing as ‘a relational process involving movement towards an experience of integrity and wholeness, which may be facilitated by the caregiver’s interventions but is dependent on an innate potential within the patient’.(6) This useful definition is respectful of each person’s capacity for healing, and includes the potential role of the doctor, other health professionals, or family and friends. Before we explore this healing role further, we need to clarify the important distinction between curing and healing.
Curing versus healing
Over the last hundred or so years, the idea that the primary purpose of medicine is to ‘cure’ has become quite dominant. Historically, the emphasis on a ‘cure-based’ approach to medical practice is an outcome of the increasing effectiveness of a scientifically based medical practice. While being a powerful curer may be a motivating (if somewhat naïve) idea for early medical students, the reality of clinical practice is quite different. There are many patients who are not curable, many who are dying, and many in whom no disease is actually found. Even though there is much more acknowledgement now of the increasing burden of chronic (‘un-curable’) disease and the role of community-based health care, the tensions between a ‘cure’ and a ‘care’ orientation are still significant and current.
Dr Ellen Fox’s insightful and perceptive 1997 article on the ‘curative’ and the ‘palliative’ approaches to medical care remains one of the best reviews of this ongoing tension.(7) She asserts that while both models have their place, they are to some extent incompatible. She maintains that the continued, unexamined, and predominant emphasis on cure means that other goals are undervalued, such as ‘promoting health, preventing illness and injury, avoiding premature death, restoring functional capacity, relieving suffering, and caring for those who cannot be cured’.
By ‘cure’, she refers to the eradication of the cause of disease or reversal of the natural history of that disorder. Examples are the removal of an inflamed appendix, successful chemotherapy for leukaemia, or using antibiotics to treat meningitis. Here, the necessary, but exclusive, focus is on the disease of the organ rather than on the person. On the other hand, the palliative care approach, as defined by the World Health Organization, is the ‘active total care … of patients whose disease is not responsive to curative treatment’.(7) The attention is on the amelioration of symptoms even if their cause is obscure. The focus is on the whole patient, with their unique social concerns and issues. This approach requires humane qualities and interpersonal skills.
Doctors can be flexible enough to make judicious use of both models in certain circumstance...
