Three perspectives on suffering

Perspective 1: The Buddha's 

M. Scott Peck's renowned book, The Road Less Traveled, begins with the hauntingly simple sentence, “Life is difficult.” Peck then remarks on how every significant world religion has not only recognized that fact but has constructed its belief system around it.

Buddhism is perhaps the prime example. The Buddha's first noble truth emphasizes the role of humility as a response to life's fragility and unpredictability and the inevitability of suffering. One of the Buddha's central insights is his calling attention to the human propensity to deny the reality and inevitability of suffering. “Life is suffering,” the Buddha taught, and to understand that in the way intended is to become liberated from two of the most prominent misbeliefs of humankind—that “I” am something that can be made complete, perfect, secure, and eternally happy, and that there are “objects” out there in the world that, if I can acquire them, can help me acquire the pleasure and security I crave. Both beliefs, according to Buddhism, are false.

Buddhists spend much of their lives in meditation trying to overcome their “selves,” the natural human propensity toward self-preoccupation, self-interest, self-aggrandizement, and self-love. Also, we typically look to make ourselves happy by thinking that a new relationship, possession, or experience will allow us to “have it all.” At bottom, these are narcissistically based beliefs, and they seem particularly prevalent in the United States.

Reality gets in the way, of course. We can never sustain those fleeting moments of complete happiness because we are inherently fragile, subject to deterioration and finally death. And the objects that we believe will make us ecstatic and complete never ultimately deliver. Over time, the perfect partner ceases to be perfect. The job, object, or experience we passionately pursued and finally acquired becomes humdrum and routine, maybe even boring.

To Buddhists, it is this sense of chronic dissatisfaction—the fact that, try as I might, I will never be really happy by pursuing acquisition and great accomplishment—that constitutes suffering. Release from suffering results from the practices of meditation and compassion so that we overcome the cravings for the perfect life along with the belief that my individual happiness and security are attainable. The ultimate goal is to give up my interest in my “self” because, according to the Buddha, there isn't one. There is just the living of and responding to life, its joys, its tedium, and its challenges. The self is an illusion, so to try to make “it” happy and safe is a project doomed to frustration and disappointment.

This is a hard concept to grasp because it is so contrary to the way Westerners understand success. It runs counter to the “It's all about me” philosophy that many in our culture pursue. But to the extent that I persist in the belief that I can effectively fend off suffering or misfortune, I am in a poor position to respond to it when it happens to me or to someone I love. The Buddha's prescription for managing suffering is that by acknowledging it and extinguishing the urge to defend against or distance myself from suffering we will experience suffering differently. It will no longer be embarrassing or humiliating or a painful manifestation of existential defeat. Instead, by accepting the ubiquity of suffering as nature's way, I become more real, more human, and in a better position to help myself and others when real suffering occurs.

Unfortunately, we can acknowledge the existence of suffering without responding to it in a psychologically healthy fashion. Let me offer two examples.

Perspective 2: A cultural perspective 

I was born and raised in the anthracite coal-mining region of northeastern Pennsylvania (ie, Hazleton, Scranton, Wilkes-Barre), where there was a great deal of suffering. When I was growing up in the 1950s and 1960s, much of the population were first- and second-generation Americans born from immigrants who migrated to the area from eastern Europe around the turn of the century. I can only imagine how hard the lives of my parents' and grandparents' generations were: women raising large families during the Depression, men frequently out of work, lots of alcoholism, high rates of infant mortality, too many deaths before the age of 50, and low levels of education. Of course, all the men smoked and the typical diet was loaded with starches and fats. More than anything, though, the coal mines took their toll, especially with black lung disease and disabling injury (eg, my maternal grandfather was killed in the mines when a beam collapsed and buried him under the rock—all before workers' compensation, incidentally).

Unfortunately, a common cultural reaction to this kind of unending hardship was to evolve an understanding of suffering as a point of honor, as in, “Oh, you think that was bad? Just listen to what happened to me last week.” If you had no suffering to complain about, you weren't anybody. The few people who had some wealth and vitality stood out like sore thumbs. Although they may have been respected or envied (sometimes almost viciously), they didn't quite fit in.

What was particularly sad was how self-pity became a way of life for so many of the people of my parents' generation. (I can recall certain relatives who evolved it into a high art form, but they were hardly the only ones.) It would have made the Buddha wince because although it was a vivid, unending acknowledging of suffering, it had a remarkably unhealthy, attention-getting “Don't you feel terribly sorry for me?” twist. It was especially apparent among women, who did not have taverns, sports, antidepressants, or therapists. All they had was one another to complain to and gain sympathy from, given the endlessly depressing and trapped situation in which they found themselves.

Not surprisingly, many from my generation moved away in the hopes of attaining something better. A few years ago, I returned to visit relatives. As I was getting out of my car, a neighbor of my dad's whom I didn't know but who obviously knew me, asked me—in a remarkably melancholy tone of voice, which is what makes this experience stick in my mind—“How's Georgia?”

I replied, “It's absolutely fabulous. The weather is great. The economy is good. It's a great place to live.”

He gave me a totally blank look, as though I had just spoken in a foreign language, and then he walked slowly away. Now, maybe he just needed to go to the bathroom or maybe I reminded him of a loved one of his own who had moved away and for whom he longs. But I can't help but interpret his befuddlement this way: I had not related a tale of woe, so he was at a loss. As a stranger, I didn't given him the one thing he could really relate to—a sad story. My upbeat description of life in Georgia and I might as well have been from Mars.

Perspective 3: The nonempathic health professional 

Another story: A physician friend, whom I'll call Dr. Allen, recently told me about paying a hospital visit to a longtime friend who was in the terminal stages of liver cancer. When Dr. Allen entered his friend's room, his worst fears were confirmed. The patient, who I'll call Mr. Coyle, had developed a huge, ascitic belly out of which his legs protruded like matchsticks. He looked haggard, and he could move about in bed only with great difficulty.

Dr. Allen went on to tell me that the patient's wife and a physician assistant (PA) were already in the room. The PA was in the midst of describing how Mr. Coyle would have a feeding tube placed on the following day, apparently at the request of Helen, Mr. Coyle's stoical and ever hopeful wife. What struck Dr. Allen, however, was the PA's very upbeat delivery of all this information. She seemed very young, perky, and vigorous. Her communicational style alternated between rapid-fire, matter-of-fact information and a kind of “happy talk,” suggesting that the operation was a minor one, that Mr. Coyle would be greatly benefited, that everything should go extremely well and, ultimately, “be fine.”

When she finished, Mr. Coyle asked the PA and his wife if he could speak privately to Dr. Allen. As soon as they stepped outside, Mr. Coyle looked at Dr. Allen and said, “I don't want that tube. Help Helen to understand that. I don't want to keep living like this. It's time for me to go. I'm ready. I've been ready for weeks. Just tell them to keep me comfortable and let me die in peace.” Dr. Allen proceeded to tell Helen about her husband's wishes, which she accepted. The feeding tube was not inserted, and Mr. Coyle died peacefully 3 weeks later.

The point of my story is to reflect on the PA's behavior and clinical demeanor: how her tone or communicational affect was remarkably incongruent with Mr. Coyle's suffering. In a way, which no doubt was entirely unintentional, it seemed dismissive of or indifferent to his situation. He was dying, but the PA's body language and conversational style exuded something verging on delight and exhilaration. Her communication with Mr. Coyle was more about her and what she represented—namely, the insertion of the feeding tube—than it was about him. He became a means to an end, namely, the procedure.

Perhaps the PA might have begun her conversation with Mr. and Mrs. Coyle by saying in a quiet, serious, and respectful tone, “Mr. Coyle, I'm here to chat with you about the feeding tube that you're scheduled to receive tomorrow. I wonder what you've been told about it or what you know about it.” Perhaps Mr. Coyle might have taken that as an opportunity to register his ambivalence, but maybe not. If he had just shrugged, the PA might have continued with, “I wonder if you're interested in knowing about the procedure.” And if Mr. Coyle had said, “Sure, go ahead,” the PA might have gone slowly in her description and at the first significant sign of disinterest or consternation, she might have stopped for a few seconds and then said, “You look a bit thoughtful (or hesitant, bewildered, etc) about this, Mr. Coyle. I wonder what you're thinking about or feeling right now.”

Notice that these are not sophisticated psychotherapeutic maneuvers. Any health professional should appreciate their value, just as any health professional should appreciate the fact that Mr. Coyle has a short time to live and that he might have mixed feelings about an intervention that might present certain burdens as well as certain benefits.

Perhaps I'm being too hard on the PA. I seem to be criticizing her for not being clairvoyant, for not scrutinizing the depths of Mr. Coyle's soul and discerning his antipathy to the feeding tube. She's young, after all, and despite her training and work, she might not have reflected deeply on the significance of suffering among the patients she treats. Maybe her doing so, which would require her to practice deep empathy, would be too uncomfortable. Nevertheless, she exemplified a character fault similar to the one I discerned among so many people who lived in my childhood community: the way suffering arouses an unhealthy self-referentiality. Whether we use suffering as a means of one-upmanship, to attract attention, or to accommodate our need to feel helpful, suffering should not and does not exist to make us feel unique or important.

We take on a healthier attitude toward suffering when we allow its lessons to affect our lives when we are feeling well. The reason is that it is immensely tempting, as the Buddha would teach, to think that one can always be well and vigorous and that suffering is something that can be banished. Such beliefs, however, are not realistic, which explains why the PA's “therapeutic” presence wasn't realistic either.

People who have the opportunity to teach and affect future health professionals need to impress upon them the importance of being tuned into their patients' suffering without becoming overwhelmed and shattered by it. The PA hasn't learned this yet, but one hopes that she will. Currently, her patients' suffering is primarily about her by way of what she can do. But for Mr. Coyle, that was a tube he didn't want. Ideally, the PA will learn as the years go by how she can bring a mature professional self to the suffering she witnesses, how her discernment can “listen” to that suffering, and how she can use her developing wisdom to do what the suffering and the sufferer require.