The emergency physician can easily interpret an electrocardiogram result, the radiologist can analyse a magnetic resonance imaging scan with precision, the neurologist can accurately trace the underlying cause behind a symptom, and the coroner can confidently determine the cause of death. However, these physicians – and others – may face difficulty in diagnosing patients when they complain by only saying “I am exhausted’’. The physician’s starting point in diagnosing an illness is the objective characteristics of the complaint, not the complaint itself. Saying “I am exhausted” stems from the subjective experience of the patient’s suffering, giving it a secondary value to the objective medical diagnosis. The physicians seek information that can be observed, detailed, traced, and identified in the patient, in other words, they look for the subjects (symptoms and signs) that enable them to use their clinical skills. Here, we can see the dilemma that arises when the physician is confronted with the patient’s subjective experience, leaving them no choice but to break the symptoms down and reduce it to diagnosable subjects. At that point, we raise our question: How does the reduction of medical practice affect the patient’s recovery?
But before we answer that, we must talk first about the philosophy of the ailing body, as the medium through which suffering is objectified.
Different dimensions of the body
The French philosopher, Maurice Merleau-Ponty, tells us that the body is our means of being in the world. It is the embodiment of consciousness, experience, and vulnerability. In a philosophical sense, we say it is me, I am my body. When I complain “I am in pain’’, it means “my body is in pain’’. But the first sentence has a subjective connotation, while the second has an objective connotation. Here, Merleau-Ponty distinguishes between the subjective body and the objective body. They are different dimensions of one body, since the body is a subject and an object at the same time, and it is a unit that brings the soul and the body together, and it is also what makes existence possible in the world. Returning to the complaint of pain, the subjective body is the one that carries the subjective experience of suffering, because it represents the subjective and invisible dimension of my body. It’s what I mean by “I’’ when I say, “I am in pain’’. On the other hand, the objective body is the visible mass of flesh and bone in which the symptoms of suffering appear (heart palpitations, muscle contractions, shortness of breath, etc.) and its signs (such as an increase or decrease in vital indicators). Pathological suffering is not just a manifestation of symptoms and signs, but rather what I feel in my conscience as well. I am the subject and the object, and I do not accept reduction. I am the sum of them without increase or decrease.
After explaining these philosophical concepts, the idea of body dimensions may seem so intuitive to an extent that surprises us! How can such an idea be absent from our embodied awareness in our daily experiences?
The absence and the ailing presence of the body
When we walk, our bodies move unconsciously in harmony. Nobody thinks, “Now I am putting my feet up, I am putting my feet down’’. We perform these movements without occupying our consciousness with their details, because it is a taken-for-granted bodily function, and the body does not need to be conscious while performing its usual functions. Nonetheless, what if the ankle is sprained and every movement causes pain in the entire leg? Then the body will declare its presence in consciousness as ailing and objectionable. This absent body in harmony, when it gets ill, shows its objections, drawing consciousness into an urgent thought that says, “There is something wrong!” The more severe the illness, the more the body is included as the means of being in the world. That is, the sprained ankle does not force me to focus only on my painful body, but rather it withdraws my focus from everything else, so my existence becomes centred around the illness and its symptoms. In other words, we say that the ailing body imposes on itself a different existence in which it alienates the world and others, and in which it may alienate itself. Because suffering is an alienating process, in which the push-and-pull dynamics separate the self from its subject and isolate it from the subjects of the world.
Now, let’s delve deeper into the concept of suffering and ask: How does the ailing body affect our experiences and existence in the world?
The ailing body and its restricted presence
We find the answer again in Merleau-Ponty, who analysed in his book, The Phenomenology of Perception, several pathological cases whose ailing bodies affected their experiences and existence in the world. We start from his concept of perception, as it is “knowledge of the world and openness to it, as it is a joint relationship that exists between the perceiving self and the perceived world, and this process takes place through the body because it is the basis of the theory of perception…”. Consequently, we can conclude that “the perceived world is not what I think about, but what I live’’. Here, it becomes evident to us that “the body is the only way of being-in-the-world, and that the movement of consciousness to the world and from the world to consciousness, passes through the body”, as the bearer of our senses and selves. That is, the body’s state of health directly affects its presence in the world. This leads us to say that the ailing body has a restricted presence equivalent to the extent of its ailing.
My vulnerable, embodied nature, when it opens up to the world, places me on the ability spectrum between what I “can” and “can’t” do. That is, my vulnerability is what makes my body susceptible to illness, and my openness to the world enables this to happen.
I “can” now walk without thinking about the harmonious movements of my feet on the road. However, the vulnerability of my ankle remains the same, vulnerable to spraining at any moment. When this happens, I move my body to the opposite half of the ability spectrum. Then I say, “I cannot” walk, because my ability has temporarily disappeared. This absence of my ability is the restriction my ailing body imposes on my presence in the world. The spectrum has an important role in dividing ability into varying degrees, as the inability to walk is not the same for those injured. Someone who sprained his ankle is not in the same position as someone whose leg was amputated. Positioning on the spectrum is also highly dynamic, driven by many factors, the most important of which is medical interventions. The primary goal of all types of treatment (medical, surgical, psychological, and physical) is to return the patients to their baseline and improve their condition if possible. We can witness the medical miracles in the dramatic transformation of limbs when an artificial leg is fitted to someone whose leg was amputated, and thereby the ability to walk is restored with it.
Nevertheless, what about the experience of suffering? Does its subjective nature affect positioning and its dynamics among different people? In other words, can suffering vary in its effect on the ability spectrum while its cause remains constant? Simply put, yes. Because pathological experience is the result of the response of several biological (immune system) and psychological (psychological flexibility) factors to the cause of suffering (illness). This means that the same illness can produce different experiences on the number of ailing bodies, primarily, according to their vital and psychological differences. For example, an ankle sprain in three individuals (A, B, C) of different ages, weights, and health conditions will result in three varied subjective experiences across the ability spectrum.
Here we stress the importance of putting subjective experience in its correct context to empathize with patients. Patient A’s inability to walk does not make them weak compared to others, and Patient C’s tolerance of pain does not make their suffering easy. As many people have said, “I can,” while internally they are screaming in pain, and many have said, “I cannot” when they truly cannot.
After this lengthy conceptual foundation, it is time to extend the analysis beyond momentary physical pain and delve into the impact of chronic illness on the body and its presence in the world.
– Effect of chronic illness:
The journey of suffering from illness begins with the absence of patients’ subjective presence and ends with its emergence again after recovery. This journey may last for hours, days, or weeks, during which the patients’ presence is restricted because of their ailing bodies. After proper treatment, the body’s healing is complete and the restrictions on patients’ subjective presence are removed, allowing them to continue to live their lives normally. It is the moment you smell coffee after several days of a cold, and the moment when you hold a cup of coffee after several weeks of wearing a splint. But what if the illness is chronic? In that case, the body will reshape its world to align with its restricted existence; and when the self returns healthy to the world, it will find it different! A condition like the “phenomenological scar,” because it will remain within our experiences throughout our lives. If you suffer from a headache, even if it momentarily steals your existence and alienates you from the world, your world remains as you knew it, waiting for you to emerge from this ordeal. Except that chronic illness will change your experience and relationship with the world and others based on the suffering it causes, just as the scar does on the surface of the skin.
(Note that the examples mentioned are simplified for the purpose of illustrating the article’s ideas only and should not be taken as an attempt at health education.)
– Chronic illness and world objects:
Those who suffer from diabetes “cannot” eat candy or whatever increases the level of blood sugar, because their ailing body lost the ability to respond/secrete to insulin, which imposes a restricted presence in which their cognitive interaction with the world and its objects differs. That is, existence through the diabetic body reshaped the perceived world around them where objects of the world – food and sweets in particular – acquire a completely different meaning. This, in turn, is reflected in the subjective experience of the illness, which we previously said is invisible and unmeasurable. Physicians can measure the level of cumulative sugar in the blood and may admonish the patients when their results are high. However, they cannot measure the level of internal conflict that patients experience every time they see a piece of candy. Nor can they measure the level of the patients’ fears of losing their vision or foot, or that their condition deteriorates and affects their kidneys. These conflicts and fears are too important to be considered secondary values, as they are the cornerstone of the patients’ experiences of their suffering.
– Chronic illness and relationships with others:
Those who suffer from erectile dysfunction “cannot’’ engage in certain sexual practices, because their ailing bodies have lost the ability to do so for organic or psychological causes. This imposes a restricted presence in which their interaction with others as a partner (spouse) or potential partner (lover) differs. That is to say, existing through a body affected by erectile dysfunction reshapes their human relationships where seduction loses its meaning, and every sexual initiative turns into anxiety about failure to participate effectively and satisfy the desire of the other. Indeed, in our cultures that are affected by the phallus – the male organ in its erected state – as a symbol of power and authority, this illness reshapes the self’s relationship with its body based on a sense of helplessness; as if the self says to its body, “You’re not manly enough’’. This hellish experience of suffering, no matter how harsh it may seem to the patient, remains of secondary value to the physician!
So, what drives physicians to objectify patients’ suffering?
– The missing physician’s tool:
Treatment is an attempt to establish order out of chaos and to restore harmony to the body from the hardship of its illness. This requires a consistent methodology that is capable of describing and classifying the signs of the illness, then interpreting them causally, outlining diagnostic boundaries based on well-studied clinical criteria, and finally providing medical interventions with reliable results. In other words, objective medical practice favours the objective body because it speaks its language, obeys its tools, accepts its interpretations and heals with its interventions, in contrast to the subjective body that rejects and resists this. In addition, subjective experience is unstable, which makes it difficult to describe, classify, and explain. This removes it from its diagnostic value to the physician, who examines the complaint only to reduce it to its objective characteristics.
We can clearly see this reductionist process in the “pain assessment questions” taught in the clinical skills textbooks for all physicians and nurses who deal with patient complaints. These eight questions, known by the abbreviation (SOCRATES), are asked by the health practitioner to the patients when they come to the hospital with a pain complaint. They are as follows:
Site: Where do you feel pain?
Onset: Did you feel the pain suddenly or gradually?
Character: What is the nature of your pain sensation?
Radiation: Do you feel the pain shifting from one place to another?
Associations: Are there other symptoms associated with the pain?
Time Course: When did your pain start?
Exacerbation/Relieving Factors: Is there anything that reduces or increases the severity of the pain?
Severity: How do you rate the severity of the pain?
These questions seek to extract objective characteristics from the pain complaint in one way or another, ignoring the simpler question of the patient’s experience of suffering: the question of context and meaning.
Here, physicians may argue that this question has nothing to do with medical practice! Is this true?
– What physicians do not see:
This prevailing belief among physicians is the result of the academic medical mentality with its precise specializations that divide suffering among its branches. Since philosophy is far from medical specialities, it has become necessary to exclude it from the equation of the division of suffering, which through scientism processing has acquired a three-dimensional image (organic, psychological, social). Thus, everything about subjective suffering was eliminated from physicians’ mentality to the point where they looked at the patient and only saw the signs and symptoms of their illness. This is what happens in daily practice inside the hospitals, where the names of patients turn into the names of their cases. Someone’s name turns into “asthma patient” or “anaemia patient”, etc. It is a “radical split” as Professor Drew Leder describes it, between the two subjective and objective bodies under the physician’s examination.
The main problem here lies in dividing what cannot be divided. Given that suffering is not an independent condition with multiple aspects derived from disciplines isolated from each other. Rather, it is part of the fabric of life, consisting of the threads of the embodied experience of our vulnerable presence in the world. I am my body, and this means that the clinical examination that separates me from my body is flawed in its understanding of suffering. Which may lead to adverse effects that impact the patient’s overall health. After nearly 2,000 words of talking about the effect of an ailing body on its existence in the world, we can claim that there is “existential health” that ails and recovers. This is what the physicians cannot see.
– Protecting the patients from the effects of existential anxiety:
In his paper, Only Vulnerable Creatures Suffer, Professor Ola Sigurdson distinguishes between existential health as a comprehensive concept and the rest of the dimensions of health included in it: physical, psychological, and social. The first reflects the self-relationship with the existence formed through the ailing body with illnesses of other dimensions. Thus, existential wellness does not imply a state free of ailment, but rather a state of reconciliation with the restricted existence caused by the body’s ailments. For example, diabetic patients reconcile with their restricted existence in the world and achieve existential recovery despite their illness. In fact, there is an openness to life in this reconciliation with their ailing body.
This reconciliation, as a subjective process, depends on rationalising the suffering and placing it in its larger context of the meaning of life, death and what is in between. Suffering is meaningless, challenging to rationalise, and difficult to reconcile with. Here comes the role of physicians to protect patients from the effects of existential anxiety and loss of meaning. We have previously stated that pathological suffering begins with an absence of subjective presence, where the patients are in a state of fragility that makes their alienated selves lose confidence in their bodies, the world, and others. At that moment, the physician has to start treating the two bodies together, the subjective body and the objective body, given that restoring confidence in the world and the rest of it begins in the clinic. This is achieved by being present with the patients and allowing space for the narrative of their suffering to unfold, considering it as a tool for diagnosis and treatment. Hence, we go back to SOCRATES questions and ignore the question of context and meaning, to see how this disregard affects the patient’s narrative, and therefore their existential health. A person or the self cannot come to terms with their suffering if the physician does not aid them to put the suffering in the right context so that the picture is complete, and the meaning is clear.
From this perspective, we can say that the subjective body – “I am in pain” – is important in treating existential suffering, just as the objective body – “My body is in pain” – is important in treating physical suffering. Since the dimensions of the body and suffering are indivisible – “I am my body” – we conclude the invalidity of the opposing attitude that rejects the adoption of philosophical tools in medical practice.
Rather, we go further and say that it is shameful for a physician to spend seven years studying in medical school without learning a single philosophical concept about the subjective experience of suffering! This leads us to the final aspect of this article.
– Criticizing medical practice does not mean demonizing the physicians:
I believe it is unfair to criticize medical practices without revealing the context of the reality of daily work in hospitals. The root of the problem lies in the bureaucratic structure and hierarchical systems of institutions, not the physicians, who have been its product since their student days. The process of receiving starts with studying, where the students memorize an enormous amount of information and concepts that shape their reductive medical viewpoint, until the logic of the SOCRATES questions and their disregard for meaning is firmly established in their minds. Then, they begin repeating them to every patient without stopping for a day and asking themselves, “What about the patient’s experience of his suffering? This is because the number of patients visiting clinics is too large for the physicians to give them room to elaborate on their narratives, which forces the patients to break down their narrative in an atomistic and decontextualized manner, so the physician’s visit turns into a silence session interspersed with some questions and answers. Thus, the result will be a patient who does not know his illness! Also, physicians who work for more than 24 hours can only think about their suffering! Physicians and patients are victims of the system itself.
– Note on existential suffering from my personal experience as a physician:
(We note here that the story below is real, but the details of the case do not match reality to protect the patient’s identity.)
When our medical team was called to examine a patient complaining of pain after taking the maximum dose of the prescribed painkiller, I witnessed the experience of suffering that the patient endured in their body and soul. The sound of his cries echoed through the corridor, making us doubt whether he had taken his medications. However, the nurse in charge assured us that he had. The patient cried out in pain despite all the painkillers flowing through his veins. Before entering the patient’s room, I paused at the nursing station and opened his medical file, only to find a young man no older than twenty diagnosed with AIDS. At that moment, I perceived his cries in a completely different view, it seemed to me understandable and rich in meaning, even if it was just primitive screaming. His pain was physical, psychological, and, more importantly, existential. No medication in the world could alleviate it. A young man at this age, with AIDS, does not see the world as we do. Undoubtedly, he does not live in it as we live. His relationship with others is tainted by judgments in all their religious, social, and moral forms. He struggles with the pain of his illness, the issues of the world, and the gazes of others. It is hell within hell and he needed help to get out of it. Dante needed Virgil, and all the patients suffering in the hellish pain on hospital beds need Virgil to lead them out of this suffering. If morphine, tramadol, and paracetamol alleviate the objective pain of the body, who will say to the subjective body, “Therefore, for your peace, I suggest that you follow me, and I will be your guide…’’? If not the physicians, then who?
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