Peer-Reviewed Articles

Associations of Suffering with Facets of Well-Being Among Working Adults: Longitudinal Evidence from Two Samples, Cowden et al

Scientific Reports, Forthcoming

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.

Abstract: 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 I argue that Cassell’s distinction is philosophically untenable because he contrasts suffering with an outdated theory of pain.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.

Abstract: 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.

Abstract: 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.

Works in Progress

Pathologizing Pathos: Suffering, Civil Rights, and Malpractice Lawsuits in 20th-Century American Medicine

Article Under Review

This manuscript offers an intellectual and cultural history of the leading international theory of suffering in medicine, first introduced by American physician Eric Cassell (1928-2021) in the early 1980s. Beginning with his intellectual development in the 1960s and 1970s, this manuscript traces the origins of Cassell’s interest in suffering to his pioneering work in bioethics. Although closely aligned with philosophy, much of the institutional success of bioethics came from American law, a connection Cassell absorbed in his theorizing. Changes in medicine deepened this connection, as medicine witnessed an explosion of malpractice lawsuits during the time of Cassell’s writing which impacted his work in two ways. First, the medical establishment moved to contain physician liability through stricter consent legislation that required doctors to disclose bad news to patients. These disclosures supplanted a longstanding tradition of ‘benevolent deception’ aimed at protecting patients from the stress of a bad diagnosis. Forcing these difficult conversations to the fore raised concerns about doctors’ readiness to navigate this new terrain, a worry that motivated Cassell’s research. Second, a central feature of malpractice law was an award called ‘pain and suffering,’ which provided Cassell’s language and concepts as evidenced by analogues between his theory and legal terminology.

Fractures: A History and Philosophy of Suffering in 20th-Century American Medicine

Book Manuscript in Preparation

The Lot of Man: Suffering in Western Thought

Book Manuscript in Preparation

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