Human suffering constitutes one of the greatest challenges facing contemporary medicine and bioethics. Unlike pain, it cannot be reduced to biological parameters or measured by diagnostic tests, as it affects the person in all their dimensions: physical, emotional, relational, social, and spiritual. This reality takes on particular relevance in the face of issues such as euthanasia, suicide, and end-of-life care. Can suffering that is essentially subjective and that can be modified through care, support, and palliative care be considered irreversible? Addressing these questions requires recognizing the limitations of technology and reclaiming a medicine capable of attending not only to the disease, but also to the person who suffers.

Introduction: The epistemological status of suffering in modernity

Few human experiences possess such a universal and constant presence as suffering. It accompanies human beings from the beginning to the  end of life  and transcends all eras, cultures, and social conditions. Illness, loss, poverty, exclusion, war,  disability , loneliness, and the approach of  death  are some of its many expressions. Paradoxically, despite its omnipresence,  suffering has long occupied a secondary place in the reflections of mainstream medical science, which has focused primarily on the measurable aspects of the biological organism.

The history of medicine over the last two centuries can be interpreted as an extraordinary story of scientific success. Microbiological discoveries, the development of modern pharmacology, the diagnostic revolution driven by imaging technologies, and the remarkable progress of surgery have radically transformed therapeutic possibilities. However, this very success has fostered a progressive concentration of medical attention on what can be observed, measured, and quantified through the conventional clinical method. The dominant biomedical paradigm has historically given preference to objective parameters over subjective experiences.

As a direct consequence, laboratory tests, imaging studies, and physiological variables occupy an undeniably central place in everyday clinical practice. Conversely, complex and intangible aspects such as suffering, existential anguish, loss of meaning, and radical vulnerability have been relegated to a lower level of educational and methodological attention. For decades, medical education has trained students and professionals to recognize diseases with technical precision, neglecting instruction in the recognition and comprehensive management of human suffering. This troubling dichotomy does not stem from an intrinsic lack of moral sensitivity on the part of healthcare professionals, but rather from the epistemic limitations of a scientific model that is extremely effective at studying biological phenomena, yet insufficiently prepared to address complex existential experiences.

In this context,  contemporary palliative medicine  and clinical bioethics have emerged to remind us of a fundamental truth: the patient is not merely a biological organism altered by a pathology, but a specific person with a unique life story, stable emotional bonds, personal beliefs, life plans, and a particular understanding of themselves. The question of and approach to suffering are therefore not merely a supplementary problem in clinical practice, but a fundamental question concerning the status of the person in the medical act.

The ontological distinction between pain and suffering: Eric Cassell’s contribution

In routine clinical practice and everyday language, pain and suffering are frequently confused, treated as if they were equivalent or synonymous terms. However, contemporary clinical bioethics establishes a crucial ontological and operational distinction between these two concepts. One of the foundational milestones in this conceptual delimitation lies in the influential contributions of the American physician Eric J. Cassell, who, in his landmark 1982 essay,  “The Nature of Suffering and the Goals of Medicine ,” proposed a transformative maxim for contemporary clinical practice: bodies feel pain; people suffer.

According to Cassell, pain has a fundamentally neurophysiological dimension, with known and clearly identifiable anatomical transmission pathways and biological mechanisms. Pain can be localized, described in qualitative and quantitative terms, and is treatable through specific pharmacological or surgical interventions aimed at interrupting or modulating these nociceptive pathways. In contrast, suffering constitutes an existential and subjective experience of a radically different nature. Suffering formally emerges when the individual perceives a serious and destructive threat to their integrity and wholeness as a human being.

According to this anthropological framework, a person’s integrity is not limited to their anatomical or functional constitution. It is comprised of their biographical identity, moral autonomy, independence, body image, close emotional bonds, family and social roles, ethical and spiritual convictions, and the meaning they give to their own life. Consequently, suffering arises when any of these structural and identity-related pillars of a person is severely threatened or compromised by illness or other traumatic life events.

This distinction explains several common clinical phenomena. On the one hand, two patients subjected to a nociceptive stimulus of identical physical intensity may experience qualitatively and quantitatively disparate levels of suffering depending on the meaning they attribute to that pain. On the other hand, a person may suffer profoundly debilitating pain without experiencing any significant physical pain (as occurs in grief, a drastic loss of autonomy, or existential hopelessness), just as intense physical pain may be tolerated with minimal suffering if the patient understands that it has a curative purpose or a transcendent meaning. The practice of humanized medicine, therefore, requires that the clinician not only ask “what hurts the patient,” but fundamentally “what does what is happening to them mean?”

The multidimensional architecture of the experience of suffering

Given that the person constitutes a complex reality in which multiple dimensions converge in an integrated way, suffering shares this same multidimensional nature. To avoid the clinical temptation of reducing suffering to its most visible components, an operational classification framework of its main constitutive dimensions is proposed:

• Organic Dimension:  This dimension derives directly from the measurable physical and pathophysiological alterations of the disease, such as nociceptive or neuropathic pain, dyspnea (shortness of breath), chronic fatigue, and cachexia, among other debilitating symptoms. Although it has an undeniable biological basis and constitutes the primary focus of conventional therapy, the correspondence between the physical injury and the intensity of the experience of suffering is not linear, always requiring the patient’s interpretive mediation.
• Emotional and Psychopathological Dimension:  This dimension is closely linked to complex affective states such as anxiety, fear of pain or death, clinical depression, guilt, and existential uncertainty. It constantly interacts with the individual’s pre-existing personality, character, and resilience mechanisms. Illness is never confronted from a blank slate, but rather from the personal and historical structure that defines each individual’s capacity for adaptation and coping.
• Existential or Spiritual Dimension:  This corresponds to the painful perception of a loss of meaning in life, the breakdown of one’s identity, or a perceived breach of personal dignity. It appears paradigmatically in the face of advanced illnesses, states of absolute dependence, and situations of extreme vulnerability. This dimension evokes the anthropological concept of Homo patiens, the suffering human being who seeks meaning in their pain. Clinically, it manifests through the fundamental existential question: “Who am I now that I can no longer do what once defined me?”

These three core dimensions are inextricably linked to the biographical and memory dimension (where past traumas or losses act as an interpretive filter for current reality), and the relational or familial dimension. Human beings are inherently relational, so the disruption of bonds, the interruption of social roles, or the profound fear of becoming a physical or financial burden on loved ones are preeminent sources of existential anguish. Finally, cultural frameworks and collective beliefs dictate the limits of acceptability and the legitimate ways of expressing and coping with grief and death.

Structural suffering and its social determinants

Although the analysis of suffering tends to focus on the individual and internal experience of the patient, contemporary bioethics insists on making visible what is known as social suffering. This is suffering systematically generated by unjust political, economic, and social structures that expose large groups of people to situations of extreme vulnerability.

Phenomena such as extreme poverty, chronic social exclusion, lack of equitable access to quality healthcare, absence of social support networks, persistent unemployment, and job insecurity constitute genuine social determinants of suffering. From the perspective of global bioethics, it is insufficient to resolve ethical dilemmas confined to the interpersonal clinical relationship. Distributive justice emerges as an unavoidable ethical category: a society that tolerates or promotes severe structural inequalities is co-responsible for the production of human suffering that is, by definition, avoidable.

Suffering in ethical-legal dilemmas: Euthanasia and suicide in Spain

The enactment of Organic Law 3/2021 regulating euthanasia in Spain has placed the concept of suffering at the center of contemporary clinical, ethical, and legal debate. The law explicitly introduces the criterion of “constant and intolerable physical or psychological suffering” as one of the essential requirements for accessing assisted dying services.

This legislative formalization gives suffering an unprecedented triple dimension, simultaneously transforming it into a medical, moral, and legal category. However, this circumstance raises epistemological questions of extraordinary clinical complexity and difficult practical resolution:

First, there is the acute problem of quantification and objectification. Since suffering is a radically subjective and intimate experience, it lacks any direct clinical parameter that would allow for its objective measurement (such as a laboratory test or a neuroimaging study). The intensity of suffering can only be truly known and expressed by the person experiencing it, forcing healthcare professionals and evaluation committees to make indirect assessments, necessarily based on interpretation, empathy, and trust in the patient’s testimony.

Secondly, the complex clinical distinction between treatability and irreversibility is presented. While in the organic sphere irreversibility is usually unequivocally linked to the pathophysiological progression of an incurable disease in the absence of effective curative options, in the psychological, emotional, and existential dimensions this category is profoundly uncertain. Evidence from clinical history solidly demonstrates that experiences of psychic or existential suffering considered unbearable by the patient can undergo substantial modifications over time if quality human support, specialized psychotherapy, adequate social support, rigorous symptom control, or timely spiritual care are introduced.

The most tragic and extreme manifestation of suffering that exceeds an individual’s adaptive resources is found in the phenomenon of suicide. According to official registry data in Spain, 3,953 deaths from this cause were documented in 2024. This dramatic statistic reveals that profound suffering, particularly of a psychological and existential nature, constitutes a socio-health reality of colossal dimensions that frequently remains invisible, stigmatized, and neglected in the general public and clinical debate. Suicide represents the ultimate conviction of the individual that the intensity of their suffering is unbearable and cannot be changed with the resources available to them in their environment.

Palliative medicine as an integrative response and the value of dignity

Faced with the complexity of intractable suffering, palliative medicine represents the most robust and ethical response developed by contemporary medical science. Its primary objective goes beyond the mere pharmacological suppression of physical symptoms, focusing instead on a model of comprehensive and holistic care for the patient and their family.

The palliative care approach begins with the explicit recognition of the multidimensional nature of the patient, implementing diagnostic and therapeutic tools of a relational nature: active listening, compassionate and honest communication, continuous emotional support, family accompaniment in the dying process, and respectful care of the individual’s spiritual and existential dimensions. Through this model, a fundamental bioethical truth is operationalized: the inherent dignity of the human person remains ontologically intact and unaltered, even in conditions of extreme frailty, physical dependence, or bodily dysfunction.

When curative therapies have exhausted their biological possibilities for success, the task of medicine does not end at all, but rather transforms and intensifies. The dignity of the sick person demands a commitment to not abandoning them. Professional excellence is redefined in these clinical settings as the act of remaining with the one who suffers, validating their experience and offering a space of safety, relief, and humanity.

Conclusions: The limits of technique and the humanity of the clinician

Human suffering is a complex and irreducible reality that challenges the assumptions of the traditional biomedical model focused on quantification. The distinction established by Cassell and further developed by contemporary bioethics is essential to guide clinical practice: diseases affect the biology of bodies, but suffering disrupts the whole person.

The treatment and understanding of suffering require medical professionals to broaden their epistemic and clinical perspectives. They must be able to harmoniously integrate the highest technical and scientific excellence with profound ethical and human sensitivity to decipher the complexity of the patient’s biographical history, family environment, culture, and existential needs. Likewise, legislators and clinicians must proceed with extreme caution and epistemological humility when using intolerable suffering as a determining ethical and legal criterion, acknowledging the intrinsic limitations of its objectification and recognizing the dynamic and modifiable nature of crises of meaning through accompaniment.

Contemporary medicine does not have the power to completely eradicate human suffering, as it is intimately linked to our inherent finitude and vulnerability. However, science and medical ethics do have the absolute imperative to avoid one of the most painful and destructive expressions of human suffering: that which occurs when the patient, in their extreme fragility, is reduced to a mere biological diagnosis, their subjectivity ignored, or abandoned to the solitude of their vulnerability. The ultimate lesson of humanistic medicine lies in understanding that when technology reaches its insurmountable limits, the presence, compassion, and humanity of the clinician remain an irreplaceable therapeutic and integrative tool.

Bibliographic References

Domínguez-Roldán, JM (2026). Human suffering: an irreducible reality for medicine and bioethics. Bioethics and Health Sciences, 14(2). doi:10.69105/BYCS.2026.14.2.1.3

Domínguez-Roldán, JM (2026). Human suffering. Can it be measured? Bioethics Observatory, Institute of Life Sciences, Catholic University of Valencia. Originally published in The Conversation.

Cassell, E. J. (1982). The nature of suffering and the goals of medicine. New England Journal of Medicine, 306(11), 639-645.

Frankl, VE (2014). Man’s Search for Meaning. Boston: Beacon Press / Barcelona: Herder.

Bayés, R. (2001). Psychology of suffering and death. Barcelona: Martínez Roca.

Pellegrino, E.D., & Thomasma, D.C. (1988). For the patient’s good: the restoration of beneficence in health care. New York: Oxford University Press.

Sulmasy, D. P. (2002). A biopsychosocial-spiritual model for the care of patients at the end of life. Gerontologist, 42(Spec No 3), 24-33.

Spain. (2021). Organic Law 3/2021 regulating euthanasia. Official State Gazette, March 25, 2021, (72), 34037-34049.

Chochinov, H. M. (2026). Twenty Years of Dignity Therapy: Evidence, Challenges, and Implications for Person-Centered Care. Journal of Palliative Medicine.

Article written based on the articles  “Human suffering: an irreducible reality for medicine and bioethics”  and  “Can human suffering be measured? An uncomfortable question for medicine ”, by Dr. José-María Domínguez-Roldán