PUBLICATIONS

Within the paradigm of existential positive psychology, suffering has the potential to be transformed into a source of strength, an opportunity to experience deeper meaning, and a possible gateway to reaching a higher state of self-transcendence, connectedness, and empowerment. Drawing on prior work involving implicit theories, this chapter introduces the notion of suffering mindsets to explore the role that fundamental beliefs about suffering might have in shaping experiences of suffering, influencing responses to suffering, and modifying the effects of suffering on well-being. We describe the process by which we developed the Suffering Mindset Scale, a brief but efficient tool that researchers and practitioners can employ in a variety of contexts to assess the central features of a person’s mindset about the consequences of suffering. We conclude by discussing some potential implications of suffering mindsets for theory, research, and practice. 

We propose new definitions for moral injury and moral distress, encompassing many prior definitions, but broadening moral injury to more general classes of victims, in addition to perpetrators and witnesses, and broadening moral distress to include settings not involving institutional constraints. We relate these notions of moral distress and moral injury to each other, and locate them on a “moral trauma spectrum” that includes considerations of both persistence and severity. Instances in which moral distress is particularly severe and persistent, and extends beyond cultural and religious norms, might be considered to constitute “moral injury disorder.” We propose a general assessment to evaluate various aspects of this proposed moral trauma spectrum, and one that can be used both within and outside of military contexts, and for perpetrators, witnesses, victims, or more generally. 

We put forward conceptual distinctions that can be drawn between pain and suffering as used in ordinary language. We propose that slight variations on the definition of pain used by the International Association for the Study of Pain (IASP) correspond respectively to ordinary language usage of “pain” and of “suffering.” We discuss the relevance of ordinary language usage of “pain” and “suffering” in clinical practice and suggest that greater attention to these nuances would provide greater opportunity for more holistic person-centered care. 

This commentary responds to the systematic review by Noe-Steinmüller et al (2022) entitled “Defining Suffering in Pain: A Systematic Review on Pain-Related Suffering Using Natural Language Processing.” While I celebrate the author’s creative methodology and rich discoveries, I also raise two concerns about their findings, which together underscore the importance of combining digital technologies with the humanities when conducting reviews. My first concern raises philosophical worries about the accuracy of the phrase ‘pain-related suffering’ in light of the scholarship on which the authors focus. My second concern looks to recent historical research on the literature reviewed to foreground conceptually significant historical insights, which cast doubt on the accuracy of pain descriptions that serve as the basis for the authors’ consensus definition. I suggest how these concerns could have been avoided by improving the review’s inclusion criteria, use of ‘pain-related suffering' terminology, and incorporation of knowledge from the humanities.

This extended essay tracks the development of Eric Cassell's theory of suffering and its global success in transforming tragic medical experiences into diagnosable clinical entities. Beginning with his intellectual development in the 1960s, this article traces Cassell’s initial interest in suffering first to his early research on truth-telling and autonomy, followed by his pioneering work in bioethics. Although closely aligned with philosophy, much of the institutional success of bioethics came from American law, which impacted Cassell’s theorizing. At the same time, doctors like him experienced a growth in medical malpractice lawsuits, driven in large part by costly ‘pain and suffering’ awards, which the medical community sought to curb by encouraging legislatures to codify informed consent. The success of these efforts mandated that doctors disclose previously withheld bad news capable of causing suffering. The cultural changes that followed these disclosures became Cassell's impetus, while legal pain and suffering supplied much of his theory's language and concepts.

In this extended essay, I make the following two claims. The first defends a recent critique of the leading medical theory of suffering, which alleges too narrow a focus on violent experiences of suffering. Although sympathetic to this critique, I claim that it lacks a counterexample of the kinds of experiences the leading theory is said to neglect. Drawing on recent clinical cases and the longer intellectual history of suffering, my paper provides this missing counterexample. I then answer some possible objections to my defense, before turning to my second aim: an expansion of my counterexample into a spectrum of suffering that varies according to the selves and purposes that suffering affects. Next, I connect this spectrum to the tolerability of suffering, which I distinguish from its affective intensity. I conclude by outlining some applications of this distinction for the psychometric reliability of assessment instruments that measure suffering in clinical contexts.

Suffering is an experiential state that every person encounters at one time or another, yet little is known about suffering and its consequences for the well-being of nonclinical adult populations. In a pair of longitudinal studies, we used two waves of data from garment factory workers (Study 1 [T1: 2017, T2: 2019]: n = 344) and flight attendant workers (Study 2 [T1: 2017/2018, T2: 2020]: n = 1,402) to examine the prospective associations of suffering with 16 outcomes across different domains of health and well-being: physical health, health behavior, mental health, psychological well-being, character strengths, and social well-being. The primary analysis involved a series of regression analyses in which each T2 outcome was regressed on overall suffering assessed in T1, adjusting for relevant sociodemographic characteristics and the baseline value (or close proxy) of the outcome assessed in T1. In Study 1, associations of overall suffering with worse subsequent health and well-being were limited to a single outcome on each of the domains of physical health and mental health. Overall suffering was more consistently related to worse subsequent health and well-being in Study 2, with associations emerging for all but two outcomes. The pattern of findings for each study was largely similar when aspects of suffering were modeled individually, although associations for some aspects of suffering differed from those that emerged for overall suffering. Our findings suggest that suffering may have important implications for the well-being of worker populations and can be used by employers and practitioners to promote employee health.

My paper challenges an influential distinction between pain and suffering put forward by physician-ethicist, Eric Cassell. I argue that Cassell’s distinction is philosophically untenable because he contrasts suffering with an outdated theory of pain. In particular, Cassell focuses on one type of pain, the interpretation of nociception induced by noxious stimuli such as heat or sharp objects; yet since the late 1970s, pain scientists have rendered both nociception and noxious stimuli unnecessary for pain. I argue that this discrepancy between Cassell’s distinction and pain science produces three philosophical problems for his distinction: first, he frames his distinction too generally, concentrating on only one type of pain (interpreted nociception) to the neglect of others, such as neuropathy; second, it is possible that Cassell’s understanding of pain may include suffering; and third, Cassell gives examples of pain and suffering manifesting independently of each other, but it is possible that these cases may instead exemplify differences between nociceptive and non-nociceptive types of pain. Due to these problems, I conclude that Cassell’s distinction currently lacks a difference. I call for new efforts to articulate the differences, if any, between pain and suffering. 

Suffering is an important theme in many bioethical debates, yet little historical research is available to contextualize ideas about it. My article proposes a preliminary intellectual history of suffering in bioethics using the field’s most trusted tertiary work, the four editions of the Encyclopedia of Bioethics (1978-2004), later renamed Bioethics (2014). In the first edition, I find suffering roughly conceptualized as either the negation of a good or as a pain. The former acquired a technical connotation beginning in the second edition, when physician Eric Cassell refined the negative aspects of suffering into a full-fledged theory. Now, suffering no longer marked the loss of just any good but instead threatened one’s purpose in relation to that good. Cassell also strongly distinguished suffering from pain which, when combined with his theory of suffering, hardened earlier distinctions between pain and suffering that were present but weak in the first encyclopedia. Both Cassell’s theory and his strong distinction impacted how other contributors moralized suffering in the later encyclopedias, although his influence was not total: utilitarians continued to moralize suffering in ways that still roughly construed it as pain. Consequently, Cassell and the utilitarians conflicted conceptually. Nevertheless, this tension went unfelt in the encyclopedias for reasons I describe. I close by suggesting areas for further historical research and argue for their relevance to bioethical inquiries into suffering.

Eric Cassell famously defined suffering as a person’s severe distress at a threat to their personal integrity. This article draws attention to some problems with the concept of distress in this theory. In particular, I argue that Cassell’s theory turns on distress but does not define it which, in light of the complexity of distress, problematizes suffering in three ways: first, suffering becomes too equivocal to apply in at least some cases that Cassell nevertheless identifies as suffering; second, Cassell’s account does not explain what sort of experience suffering is, resulting in theoretical and practical difficulties in distinguishing it from other medical conditions; third, there is good reason to believe that in medical contexts, ‘distress’ just means ‘suffering’ or some cognate concept not yet distinguished from it, rendering Cassell’s theory circular. I consider a rebuttal to my objections and reply, concluding that Cassell’s theory of suffering needs a definition of distress to settle what the nature of suffering really is. 

In the extensive conceptual, bioethical, and empirical literature on suffering, a growing number of ethical objections to its measurement have emerged, including concerns about iatrogenically causing or worsening suffering, which have gone largely unaddressed by empirical researchers. This paper resolves these challenges by reframing them not as intractable ethical divergences, but as resolvable methodological differences concerning validity and data scope in philosophy and empirical research. Furthermore, the implications of this resolution may also apply beyond suffering to empirical research on similarly subjective topics, such as moral injury.

What we think the good life is often comes out most clearly when times are bad: much can be learned about a morality by what it offers as its best responses to the worst misfortunes. My project is a historical study in these best responses, with a view to better understanding how we in the West have organized our moralities. 

This project uses digital humanities tools to scope an intellectual history of suffering over the longue durée. With the help of HathiTrust tools for text analysis, I track semantic associations with suffering (such as word prevalence and co-occurrence) across different compilations of the Western canon. I use these associations as a framework for a multi-disciplinary narrative.