Natural death and the work of perfection.

The historic or traditional Christian view of pain (suffering) and death, especially as preserved by the Christians East (i.e., the Orthodox), is radically opposed to the modern secular obsession with avoidance of pain. Everything about this life has its goal or aim in a mystical reality, the Kingdom of Heaven, for which earthly life is a preparation. While neither illness nor health are seen as ends in themselves, both are viewed as proceeding from the will of God for our benefit and have no ultimate meaning or purpose outside of eternal life. Death may be a relief or an ending of suffering, but in itself it is not "good" but evil. Because they are the embodiment of lived theology, saints' lives can be a sure guide to understanding how to die as a traditional Christian. To illustrate this, I have chosen some examples from the lives of relatively recent saints. I myself am from the Russian Orthodox spiritual tradition, so all but one of my examples come from pre-Revolutionary Russia. The question is not so much whether or not a traditional Christian can countenance physician-assisted suicide, but rather, what is the meaning or purpose of pain and suffering in general. Is it part of the "work of perfection" required of those who wish to enter the Kingdom of Heaven and therefore not to be completely denied?     

Why we need a theory of suffering, and lots of other theories as well: commentary

In the first section of his article, "The Role of Suffering and Community in Clinical Ethics," Erich Loewy sketches a theory of suffering. His conviction is that clinical medical ethics is not clearly rooted in theory and is inadequately grounded because of this. While acknowledging the merits of virtue ethics and casuistry, Loewy quickly dispenses with them, as contenders for this theoretical basis. Kantianism and utilitarianism are likewise rejected as "a universally acceptable grounding for ethics." In their place, Loewy proposes that "a deeper and more universal grounding can be found in the capacity of sentient beings to suffer." It is on this capacity to suffer that he builds his hierarchies of moral value, including primary, secondary, and symbolic worth. This theory of suffering should be welcomed. It promises to expand our awareness of clinical experience, and moral life generally, away from autonomy, utility, or virtue orientations toward attention to suffering and our response to it. Such a theory can give us a revitalized language to probe the issues of medical ethics. This should lead us to a careful reading of Loewy's larger work on which this article is based. Yet my enthusiasm is tempered by Loewy's noncritical acceptance of a peculiar, yet pervasive, understanding of the role and use of theory in ethics....     

Pain as purgation: The role of pathologizing in the life of the mystic

Since Descartes, man has been defined in terms of body and spirit only. Yet there is a third term that is of crucial importance for the founding of a psychology of suffering. The realm of psyche, or soul, is a middle ground between the spirit and the body in which the psychological forces of one's life find expression. A psychological approach to the anguish of the suffering soul can be found within the writings of the early desert fathers as well as in the paintings of Hieronymus Bosch. The penitent must learn patience in the face of his suffering, before he can experience the joy of spiritual maturity.A famous anchorite came to take counsel on high things with the abbot Pastor, but the old man turned away his head, and the anchorite went away aggrieved. His disciple asked Pastor why he had refused to talk with a man so great and of such reputation in his own country, and the old man said that his visitor could speak of heavenly things, but that he himself was of earth. If he had spoken to me of the passions of the soul I could have answered him: but of the things of the spirit I am ignorant.Mr. Fischer is a member of the Psychology Department, University of Dallas, Irving, Texas 75060.     

Conceptualizing suffering and pain

Background

This article aims to contribute to a better conceptualization of pain and suffering by providing non-essential and non-naturalistic definitions of both phenomena. Contributions of classical evidence-based medicine, the humanistic turn in medicine, as well as the phenomenology and narrative theories of suffering and pain, together with certain conceptions of the person beyond them (the mind-body dichotomy, Cassel’s idea of persons as “intact beings”) are critically discussed with such purpose.

Methods

A philosophical methodology is used, based on the review of existent literature on the topic and the argumentation in favor of what are found as better definitions of suffering and pain.

Results

Pain can be described in neurological terms but cognitive awareness, interpretation, behavioral dispositions, as well as cultural and educational factors have a decisive influence on pain perception. Suffering is proposed to be defined as an unpleasant or even anguishing experience, severely affecting a person at a psychophysical and existential level. Pain and suffering are considered unpleasant. However, the provided definitions neither include the idea that pain and suffering can attack and even destroy the self nor the idea that they can constructively expand the self; both perspectives can b e equally useful for managing pain and suffering, but they are not defining features of the same. Including the existential dimension in the definition of suffering highlights the relevance of suffering in life and its effect on one’s own attachment to the world (including personal management, or the cultural and social influences which shape it). An understanding of pain and suffering life experiences is proposed, meaning that they are considered aspects of a person’s life, and the self is the ever-changing sum of these (and other) experiences.

Conclusions

The provided definitions will be useful to the identification of pain and suffering, to the discussion of how to relieve them, and to a better understanding of how they are expressed and experienced. They lay the groundwork for further research in all these areas, with the twofold aim of a) avoiding epistemological mistakes and moral injustices, and b) highlighting the limitations of medicine in the treatment of suffering and pain.

     

Equality in health care: Christian engagement with a secular obsession.

A frenetic search for equality lies at the center of much secular and even "Christian" bioethics. In a secular world, if one does not believe in God, if this life is one's whole existence, it would seem that one could not settle for less than equal approbation, especially equality before the risks of suffering and death, which medicine promises to ameliorate. Yet, the concern for equality in health care is puzzling. After a modest level of access to health care there is little difference in average life expectancy. Are concerns for equality in health care even vaguely Christian? The pursuit of Christian perfection has never been correctly equated with state-imposed egalitarianism. Furthermore, an all-encompassing, secular, egalitarian health care system may provide equal access to significantly immoral medical treatments. In contrast to secular thought, the call of Christianity is a call to holiness, not a call to an egalitarianism that superficially resonates with certain elements of Christian thought.     

Two observations about human reason

The first observation is that existential reason has two principal strata. While the function of lower reason is primarily reasoning or logic, upper reason ponders emotions, the meaning of existence, the transcendent. Those whose understanding of reason is confined to lower reason are handicapped in coping with emotional and spiritual suffering. Upper reason is a necessary intellectual facility in the resolution of such suffering. The second observation is of thedialectical nature of reason, with which clinicians and theologians trade when pondering reality and in dealing with those they counsel. Yet, many people, especially Americans, are oblivious to the “both-and” reality of existence. Consequently they are not realistic about life nor are they skillful in dealing with their resulting existential conflicts. They are lost when psychological problems cannot be satisfactorily resolved by lower reason; for only upper reason can perceive and creatively integrate the dialectical tensions of existential problems.     

A Quality Life in the Shadow of Terrorism

After the demise of the Soviet Union, many individuals felt a sigh of relief as fear was leaving them. Yet, over the years, counselors have seen a new fear—terrorism—demonstrated in drive-by shootings, hate crimes, and now, weapons of mass destruction. In helping clients deal with this all-too-real phenomenon, a reframing process is in order, one that views our lives not in permanence, but as constant change. Much needless suffering is due to clinging to permanent belief systems, which, in reality, are impermanent. Many clients I have worked with have found effective ways not only to deal with, but to flourish in whatever life brings, via a self-Being relationship.     

A life not worth living?

The work of Dan Brock and Helga Kuhse is typical of the current stream of thought rejecting the validity of sanctity of life appeals to instill objective inviolable worth in human life regardless of the quality of life of the patient. The context of a person's life is supremely important. In their systems life can have high value, yet the value of life can be outweighed by the force of other disvalues. The notion of quality of life has increasingly come to signify the measurement of the worth of a person's life itself. Having a life equals a personal life. Any objectivity to life resides in 'personal', 'biographical', or 'creative' life, not mere biological life. Personal life represents the minimal threshold for any objective worth. In responding to this challenge, John Finnis has argued extensively that life is an intrinsic good--a basic human good. Following from our grasp of human life as a basic incommensurable good, it cannot be practically reasonable both to affirm that (a) 'human life is a basic human good', and (b) that 'human life qua human life can be intentionally acted against to its destruction'. Yet, if the good of human life can be considered self-evident, the self-evidence of the basic human good qua good does not mean that dialectical reasoning cannot be engaged in to indirectly support the practical reasonableness of respecting the good of human life in the deliberative choices that persons make concerning their actions. It is to the use of such dialectical reasoning, supportive of the status of human life as such a basic human good, that the article is primarily concerned to draw out and articulate.     

Decisions at the end of life: Catholic tradition.

Medical decisions regarding end-of-life care have undergone significant changes in recent decades, driven by changes in both medicine and society. Catholic tradition in medical ethics offers clear guidance in many issues, and a moral framework accessible to those who do not share the same faith as well as to members of its faith community. In some areas, a Catholic perspective can be seen clearly and confidently, such as in teachings on the permissibility of suicide and euthanasia. In others, such as withdrawal of nutrition and hydration, the Church does not yet speak with one voice and has not closed out the discussion. Yet, it is not in the teaching on individual issues that a Catholic moral tradition offers the most help and comfort, but in its account of what it means to lead a life in Christ, and to prepare for a Christian death. As in the problem of pain and suffering, it is the spiritual support more than the ethical guidance that helps both patients and physicians bear the unbearable and fathom the unfathomable.     

Suffering–At the Bedside of the Dying

SUMMARY

Care of people at the end of life is a challenge for the person with a life-limiting illness, their family and friends, and their professional carers. Clinicians, including pastoral care workers, nurses, doctors, and allied health professionals, find themselves at the bedside of the dying. At times, the professional's sense of self is challenged both by the suffering that they witness (physical, emotional, existential, social, sexual, or financial) and a sense of helplessness to relieve not only the patient's suffering but also that of the people to whom the dying person is close. What framework can help us to deal with the suffering that we cannot help but encounter? Ultimately people connecting in a real and meaningful way with other people is probably the only way that each of us can confront suffering and not have it destroy us. Creating an environment where people can begin to, or continue to connect with others at a level that is meaningful for all concerned is a pivotal starting point in dealing with suffering in any encounter with people at the bedside.     

Influence of Religiosity on the Quality of Life and on Pain Intensity in Chronic Pancreatitis Patients After Neurolytic Celiac Plexus Block: Case-Controlled Study

The quality of life in patients with chronic pancreatitis (CP) is reduced due to their suffering of high levels of pain. It has been presented that quality of life can also be linked to religiosity and/or spirituality. The aim of this study is to assess the influence of religious practices on the quality of life and on the subjective level of pain in CP patients. Ninety-two patients (37 women and 55 men) with chronic pancreatitis were treated invasively for pain with neurolytic celiac plexus block (NCPB). The religiosity of the patients was recorded and served as a dichotomizer. Group 1 was for patients who claimed to have no contact with the church or to have very sporadic contact (N = 35 patients). Group 2 was for patients who claimed to have deep faith and were regular participants at church activities (N = 57 patients). Visual analogue scale was used to assess pain, while the quality of life was measured by using QLQ C-30 questionnaire adapted for chronic pancreatitis patients in Polish population. The patients were assessed prior to the pain-relieving intervention and subsequently 2 and 8 weeks after it. The intensity of pain was reduced in both groups significantly after performing the NCPB. Patients who declared a deep faith reported higher level of pain on the VAS scale prior to intervention than non-religious patients. Quality of life in both groups of patients significantly improved after NCPB. Following NCPB, global quality of life in patients who declared higher religiosity/church attendance was significantly higher (79.88) than for those patients who have no contact or sporadic contact with the church (44.21, P < 0.05). NCPB resulted in significant reduction of pain and increase in quality of life in both groups of patients with CP. Nevertheless, in the group declaring higher religiosity/church attendance, reported pain was higher, but, despite that, quality of life better. It may be concluded that religious practices might serve as an additional factor improving quality of life and coping in patients suffering from chronic pancreatitis.     

与彼得·辛格的对话

对话的主题涉及辛格对马克思、全球伦理、道德责任、动物解放、伦理思维中的直觉层次与批判层次以及伦理的客观性问题。辛格哲学的特点不仅在于他始终不懈地将伦理的思维与减少痛苦与苦难的价值付诸行动,而且也在于他拓宽伦理思维的能力。辛格博采生物学、历史学、人类学、经济学以及博弈论研究成果,丰富并阐明了伦理理论与实践何以可以被现实赋予活力。当我们转向辛格的哲学时,我们会发现一种伦理的生活方式:不仅仅为此刻活着,也不仅仅根据个人喜好活着,而是去过一种具有更广意义的生活,它要求献身于所有有感受能力的生命的福祉和环境保护之中。     

关于高龄恶性肿瘤与人类自然死亡

“天寿癌”指的是高寿者经历漫长和满足的生命历程后平和地几乎没有痛苦地死于恶性肿瘤。癌症在高龄人群中十分常见,故高龄者死于癌症亦可被认为是一种形式的生命自然终结过程。因此,“天寿癌”的提出可能有助于老年人较实际地面对致死性肿瘤性疾病。对“天寿癌”的概念、诊断、治疗及其医学伦理学的问题进行简要的讨论。     

Skepticism and faith in Shestov’s early critique of rationalism

Shestov’s work can be summed up under six headings. Three are sharp contrasts, three are paradoxes. (1) First there is the contrast between Shestov the person, who was moderate, competent, and calm, and Shestov the thinker, who was extreme, incandescent, and impassioned. (2) Then there is the contrast between his critique of reason, his acceptance of irrationalism, and the means by which he attacks the former and defends the latter: namely, careful rational argument. Sometimes he argues like a lawyer (after all, he had a law degree from Moscow University). (3) Shestov speaks repeatedly of the “horrors and atrocities of human existence.” But his examples are always drawn from history or literature, never from his own life, although we know that he experienced much horror. (4) Nietzsche is the thinker whom he invokes most frequently, and most warmly. Yet, paradoxically, Shestov completely ignores most of Nietzsche’s central themes. (5) Shestov’s skeptical doubts are mostly directed at rationalism; he is not skeptical about the existence or benevolence of God. Yet he is explicitly skeptical about divine omniscience and implicitly skeptical about divine omnipotence in a metaphysical sense, though not in its ethical application. (6) Shestov has a deep faith that God can undo all the horrors of life, putting an end to all suffering. At the same time he knows that this will not, and cannot, happen, since the very idea of undoing the past, erasing its horrors, is conceptually incoherent.     

Anticruelty care: commentary

The anticruelty policy is a best-interests test for treatment plans including decisions to forgo life-sustaining therapy for certain incompetent patients. In connection with specific proposed therapy, the policy requires no reference to the patient's unknowable values, subjective experiences, or quality of life. The decision to undertake a treatment plan derives from the caregiver's knowledge of burdens and benefits of that treatment when used in caring for the competent or for those incompetents capable of growth or repair. The caregiver should weigh the potentially cruel effects of treatment against the likelihood of reducing suffering or encumbrance with the treatment. The terms "burden" and "benefit," in fact, are replaced by the terms "cruelty" and "beneficence," as the relevant opposing outcomes that must be weighed. Thus, the anticruelty policy shifts our scrutiny from experiences of the patient that we cannot evaluate to the proposed actions of the competent decision makers and caregivers. Notably, it is a protreatment policy when the goals of medicine are attainable; and it is an anticruelty policy when they are not. The policy does evaluate the world of the patient to the extent that it requires a judgment based upon external appearances about patient pleasure or happiness in living. It presumes to universalize larger societal values about cruelty, beneficence, compassionate concern for the helpless, and certain rights of individuals. And it presumes to universalize on the patient's behalf specific medical values about hopeless injury, timely death, the goals of medicine, and cruelty, which should remain open to societal discussion and revision. The presented definition of hopeless injury does not require brain death, coma, or persistent vegetative state. Specifically, the policy holds that death is timely for a patient with hopeless injury, and that prevention of death for such patients is not a goal of medicine but a cruelty.     

Antihypertensive treatment,compliance, and quality of life: Review of a little-understood relation

If patients notoriously violate treatment regimens known to effectively control hypertension, then there must be some subjective costs associated with adherence to these regimens. Generally speaking, there must be some reduction in quality of life associated with antihypertensive medication. Unfortunately the concept of quality of life, due to its lack of specificity, is of little help in further investigating the nature of these subjective costs. We developed a simple neuropsychophysiological model based on fundamental psychological and physiological processes: corticoinhibitory effects of phasic blood pressure elevation reduce the aversive or painful qualities of many stressors. This negative reinforcement increases the rate of the reinforced physiological behavior, i.e., phasic analgesic blood pressure increases. Such negatively reinforced operant behavior is known to be extremely resistant to extinction. Counter actions such as taking antihypertensive medication not only lead to reduced quality of life due to their cancellation of the analgesic effect of conditioned blood pressure increase, but also lead to some form of reluctance to comply with treatment. The model not only provides an innovative etiological path to the emergence of neurogenic essential hypertension, but also yields a highly specific and lean concept of quality of life. Furthermore, it supplies the health care community with a concise explanation for the well-known low compliance of patients with their antihypertensive regimens. In addition to its parsimony, the model fits well with various experimental findings and has been operationalized and tested empirically. Specific therapeutic implications can be derived.     

Quality of Life of the Hidden Youth in Hong Kong

Hidden youth was a phenomenon which originated in Japan and later spread to Hong Kong. The youth were described as being in a state of social isolation, marginalization, and prone to emotional disturbances. This may imply that they were suffering from a poor quality of life. However, direct contact with the hidden youth found that some of them are satisfied with their lives. The present study aims to investigate the relationship between the hidden youth’s quality of life and their period and level of social withdrawal. A total of 588 of the hidden youth took part in the study. With the use of mean plots in ANOVA, correlation analysis, regression analysis, and mediation analysis, it was found that the longer the period of social withdrawal, the better the quality of life. The positive correlation between the two variables was mediated by positive emotions derived from social support. On the other hand, as the level of social withdrawal increased, the quality of life decreased. The negative association between the two variables was mediated by negative emotions caused by low levels of social support and a high sense of loneliness. These findings suggest that being “hidden” is the preferred lifestyle of young people and it should not be regarded as a problem that undermines their quality of life.     

Issues of ethics and identity in diagnosis of late life depression

Depression is often diagnosed in patients nearing the end of their lives and medication or psychotherapy is prescribed. In many cases this is appropriate. However, it is widely agreed that a health care professional should treat sick persons so as to improve their condition as they define improvement. This raises questions about the contexts in which treatment of depression in late life is appropriate. This article reviews a problematic case concerning the appropriateness of treatment in light of the literature in bioethics. Specific attention is paid to the concept of authenticity and the role of suffering. Suffering is often the result of a situation in which one's self is damaged. In some circumstances, this suffering should not be seen as a symptom of illness, but as a reflection, in a difficult life context, of the individual's authentic nature. Assessment of depression in the elderly must go beyond a symptom list and must consider both the context of the individual's situation and his or her authentic self. When the symptoms reflect the individual's assessment of the situation in the context of the authentic self, they may be "appropriate." However, even when the symptoms are appropriate, if they interfere with life assessment and adjustment, treatment should be considered.     

Different Ways to Hurt: An Elderly Woman's Narrative of Suffering

This article presents and interprets the case study of an elderly woman's story of suffering. It results from interviews conducted with African-American and Caucasian men and women, aged 70 and above, concerning their personal definitions, attributions, and theories about suffering. Elders' experiences of suffering were examined under the rubrics of gerontology, narrative, and religious studies. Key themes offered in this case study are: (a) How the life course unfolds because of or despite suffering, (b) what moral status an elder confers on past or present suffering, (c) how a personal sense of the sacred accommodates suffering, (d) how this particular respondent alters her identity based on assimilating the new information of suffering, and (e) how the story of suffering stands out against or blends in with the backdrop of the life story. The uniqueness of this case study also mirrors commonalities of elders' narratives of suffering, particularly those of women. This elder's story demonstrates that smaller individual suffering is rooted in the frame of the larger public world. It also illustrates that the language women use to attribute, define, and theorize suffering is embedded in relationships.