A Simplified Description of the Person
The Nature of Suffering
And The Goals of Medicine

by Eric J. Cassell
Oxford University Press

Unlike other objects of science, persons cannot be reduced to their parts in order to better understand them. But a simple topology of person may be useful in understanding the relation between suffering and the goals of medicine. The features identified should also apply to ourselves and thus be confirmable on the basis of our own life experiences. They should also point the way to further study and to the possibility of specific action by individual physicians. Persons have personality and character. All parents know that personality traits appear within the first few weeks to months of life and are remarkably durable over time. Some personalities handle some illnesses better than others. What may be destructive for one person is easily tolerated by another, but some stresses that may accompany illness, such as loss of control, are universally difficult to bear. Individuals vary in character as well as personality. During the heyday of psychoanalysis in the 1950s, all behavior was attributed to unconscious determinants laid down early in life. No one was bad or good; they were merely sick or well. Fortunately, such a simplistic view of human character is passing from popularity. Some people do, in fact, have "stronger" character than others and bear adversity better. Some are good, kind, and tolerant under the stress of terminal illness, while others become mean and strike out when even mildly ill.

A person has a past. Things done and places visited. Accomplishments and failures. The lived past is a story that has taken place over time, in many places, and involving countless others. The experiences gathered during living one's life are part of today as well as yesterday. Events of the present can be checked against the past, and events of the past contribute to the meanings assigned to present happenings. It would be an error to think that the past is simply memories stored in some old mental filing cabinet. Rather, the constant flow of happenings reinforces some past experiences and dilutes others. Memory exists in the nostrils and the hands as well as in other body parts. A fragrance drifts by and an old memory is evoked. My feet have not forgotten how to roller skate and my hands remember skills I was hardly aware I had learned. When these memories and past experiences involve sickness and medical care. They can stimulate fear or confidence, bodily symptoms, and even anguish. It damages people to rob them of their past, deny the truth of their memories, or mock their fears and worries. A person without a past is incomplete.

Life experiences-- previous illness, experiences with doctors, hospitals, medications, deformities and disabilities, pleasures and successes, or miseries and failures-- form the background for illness. The personal meaning of the disease and its treatment arise from the past as well as the present. If cancer occurs in a patient with self-confidence resulting from many past achievements, it may give rise to optimism and a resurgence of strength. Even if fatal, the disease may produce not the destruction of the person, but rather reaffirm his or her indomitability. The outcome would be different in a person for whom life had been a succession of failures. Some time ago I reviewed an examination meant to test the interpersonal skills of medical students by having them interview an actress playing the part of a patient. The "patient" was a woman who had just discovered a lump in her breast. Her past history is given. Her father died when she was very young and her mother was an alcoholic. The patient's first marriage ended in disaster, leaving her with a brain-damaged child. She has been unable to hold a job. She has finally made a liaison with a man and is about to go off with him when she discovers the breast mass. The student's job is to convince her of the need for surgery. The examination sheet that provides this history ends with, "The patient was very optimistic about her future." That is not true to life-- nobody with her history could be optimistic. She "knows" that the mass will be cancer, and it does not matter whether it is or not. Nothing good has ever happened to her, and this tumor is just another piece of her that is rotten. Her suffering, one might postulate, would start before her operation, when she became aware again of how much less whole she is than other people. Like an old wound that aches when it rains, one can suffer again the injuries of yesterday. The lived past provides other occasions for suffering. It may simply be lost, as in the case of amnesia, leaving the person less whole. Or its truth may be denied by the events of today, as in "All my life I believed in..., and now, when it is too late to change, it turns out not to be true."

A person has a family. The intensity of family ties cannot be overemphasized; people frequently behave as though they were physical extensions of their parents. Things that might cause suffering in others may be borne without complaint by someone who believes that the disease is part of the family identity and thus inevitable. I remember a man with polycystic kidney disease who was quite proud of his ultimately fatal disease because he was finally "one of them," like his mother and sister. Many diseases where no heritable basis is known are also acceptable to an individual because others in the family have been similarly afflicted. What seems to count is the connection of the individual to the family. One of my patients, dying of cancer of the lung, literally shrugged his shoulders over his impending death from the disease that killed his father and two brothers. His children suffered at his bedside. He was fulfilling his destiny, while they were losing a father. Just as a person's past experiences give meaning to the present, so do the past experiences of the person's family. They are part of the person.


© Copyright Oxford University Press, 1991. All Rights Reserved. No portion of this work may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system now or hereafter invented, without permission in writing from the Publisher. The names of patients described in this excerpt are fictions. It is purely coincidental if they resemble the names of persons living or dead.