Introduction

This text on pain, suffering and existence is an approach to the subject of philosophical research on health-sickness from the perspective of existential philosophy, which I intend to make my doctoral thesis research. The main thread of the research has been to reveal how pain and suffering, as fundamental mood swings, are themselves existential phenomena. Throughout the development of the study, and in this article as well, I seek to contrast the clinical conception that prevails in medicine with the existential analysis of Heideggerian hermeneutic phenomenology.

Pain and suffering are two phenomena whose appearance is almost universal in clinical medicine. Both are very frequent as symptoms and/or signs indicative of organic damage. In this sense, says Joan-Carlos Mèlich ⁽¹⁾, «it is not the good sense, or the reason, as Descartes thought, but the suffering what is better distributed in the world». For his part, Schopenhauer thinks that pain is consubstantial to life, and life is nothing but suffering ⁽²⁾. Nevertheless, the semiological analysis of each of these phenomena is very different; the clinic abounds in typifying descriptions of somatic pain: location, irradiation, typology, intensity and duration, and all this analysis has the purpose of conceiving pain as an objective phenomenon. On the other hand, there are no firm criteria for typifying clinical suffering, much less for an existential analysis.

Paul Ricoeur suggests that the clinic intersects with phenomenology in order to understand suffering, whose semiology points to «affections open to reflexivity, to language, to the relationship with oneself, to the relationship with others, to the relationship with meaning, to questioning» ⁽³⁾. Ricoeur proposes two axes of semiological analysis for suffering: the relationship between oneself and others and the making of suffering. In suffering, the self is increased by the annulment of representation, because in every attempt to think, suffering breaks through.

It is evident that medicine can give an account of pain quite precisely, at least in its physical manifestations. This is not the case with suffering, a phenomenon before which the clinic does not have a standard way of proceeding. In spite of this, the suffering of the other person appears before the patient, confronting him/ her with himself/herself and revealing his/her own existence. The hypothesis I put forward in this respect is that the doctor, faced with the suffering of the other, experiences an ethical conflict when confronting the difficulty of understanding the situation that the other is experiencing. Therefore, in this text I propose to consider how pain and suffering are linked to existence. How pain awakens fear in the middle of the night and the being trembles in a bath of anguish. How pain turns into suffering: that pain that brings the worst fears to life, and is a strange and always unexpected novelty that disturbs the everyday life. Pain that is its own event, whose meaning leads to a glimpse of existence.

It seems, then, that there is a two-way street to access understanding of pain and suffering. On the one hand, the attempt of medical science to establish pain and suffering as categories determined by physiological conditions. On the other hand, what is proposed by Heideggerian phenomenology to visualize these phenomena as existential. Both positions do not seem irreconcilable, but they do pose a methodological difficulty in the propaedeutic of clinical medicine. The clinic is a technique that protects the physician from involvement in the situation the patient is living, the existential analysis; instead, it exposes the physician to experience the existential «experience» of the other and of himself.

With respect to the ethical conflict, I think, with Maliandi, that the very nature of ethics is conflict ⁽⁴⁾. In this case, I am referring to the situation that the doctor faces the patient under the imperative to understand the suffering of another who is not me, starting from himself. I will designate conflict as the dilemma of understanding the other. The arguments of the dilemma are the following: it is imperative to understand the suffering of the patient in order to offer relief to the sufferer. I cannot offer relief if I have not understood the suffering. Offering relief without understanding means masking the suffering and losing the opportunity to act authentically.

Heidegger considers the being of man to be a being-in-the-world. This relationship determines responsibility, whether it is in one’s own world or in the world within. The essence of the being-there (dasein) is its existence. But existence implies the understanding of the world. Therefore, we assume that the other appears as another in the world and, consequently, that other sufferer is my responsibility, especially if I have his request for help. In this sense, the question that must be raised revolves around elucidating the conditions of possibility in which the understanding of the suffering of the other occurs.

I have divided the text into three segments. In the first I explore pain and suffering with respect to its ontic and categorical character, as studied by the science of medicine. This part seeks to highlight the objectivizing and objectifying intention of the other, as a suffering entity. In the second section, I orient the analysis to the consideration of the other in the doctor-patient relationship. This is a peculiar relationship, since it is always a predetermined encounter due to the demand for attention of the sufferer, before whom it is assumed that he or she has the duty to provide help. Many analyses have been made of this relationship and it has been said that it is based on the trust of one and the conscience of the other ⁽⁵⁾. In the third segment, I try to explore the ethical conflict of the physician in the first person. Although the conflict is always present, it is in the awareness of oneself that it manifests itself most clearly. Finally I draw some conclusions.

1. The intention to be objective

We can divide the experience of personal living into two moments. One, in which our life passes without pain and, another, where our existence is crossed by the uneasiness of suffering it. Here I refer to the pain perceived by the body as real. Pain situated in one’s own body or in the body of another who is not me. I speak of pain as an unpleasant sensory or emotional experience, associated or not with tissue damage ⁽⁶⁾. This classic conception of pain in medicine assumes that pain is associated with external stimuli that affect chemical receptors and mediators. This justifies the multitude of neurobiological researches in the clinical field, seeking to offer healing alternatives of pharmacological order.

Pain can be perceived from time to time and for short periods of time, but, sometimes, the pain settles down and persists for a long time; this condition is known as «chronic pain». Pain sensitivity is idiosyncratic, which means that there are individual degrees of tolerance. However, the biological nature of pain is characterized by the impossibility for the body to adapt to the stimuli. Therefore, chronic pain persists in living. Under these conditions, human life is lived in pain. In contrast, living without pain is the usual, everyday thing: that imperceptible and silent living that oscillates between pleasure and joy; that living in the realm of what we usually call health.

Neuroscience is clear that pain is caused by an injury or disease of the somatosensory system, whether central or peripheral to the body ⁽⁷⁾. There is precise knowledge about receptors, the biochemistry of neurotransmitters, nuclei and nerve pathways involved, and central nervous system centers that regulate the neuronal circuits. This knowledge is fundamental to establish a correlation between the injury and the pain ⁽⁸⁾.

On the other hand, there is clinical evidence of perceived pain, where tissue injury cannot be demonstrated. In this case we speak of psychological pain or pain constructed by the sufferer. A pain with a strong affective-emotional component, linked to dislike of living, frustrations, fears and various anxieties. We speak of idiopathic or psychosomatic pain, with which the doctor assumes that it is a non-existent pain, a hysterical or psychotic behavior. In this context, pain is suffering, whose existence is in the experience of the sufferer. Suffering goes far beyond pain; it involves emotional tremors such as fear, hopelessness, anxiety and frustration. Furthermore, suffering is far removed from clinical exploration insofar as it has as its topic the medicalized body. That is to say, suffering opens the world to the reflection of affections and the relationship that these have with oneself; likewise, suffering opens language and the search for meaning. All this escapes the clinic, it is judged subjective and is overlooked. The clinic is an objectivizing process that medicine never renounces.

Both pain and suffering evoke a living mettle of existence, a mettle that evokes the existence of oneself as another: I mourn, «I suffer, I am» ⁽³⁾. Immediacy seems irremediable, Ricoeur adds; it has no room for any Cartesian «methodical doubt». Reduced to the suf-fering self, I am wounded alive. In this context, existential analysis indicates the reduction of the representation of the world, which will accentuate the inhospitable nature of the world. Suffering, according to Ricoeur, implies the reduction of oneself as another: not being able to say, not being able to do, not being able to narrate oneself and not being able to estimate oneself. Nevertheless, Ricoeur conceives of man as an acting being, an agent and a sufferer. Therefore, suffering is a kind of endurance, a way of overcoming the experience of pain and suffering.

These moments of living with pain and without it are similar to property and impropriety as fundamental modes of being, of dasein, exposed by Heidegger in the existential analysis of Being and Time ⁽¹⁰⁾. This similarity has given rise to interesting studies on the phenomenological conception of the disease ⁽¹¹⁾. The sustenance of supposing the disease as existential is provided by Heidegger himself, when in number 49, p. 270, he asks if this is possible in the following terms: «Should the disease and even death in general be conceived -also from the medical point of view- primarily as existential phenomena?» ⁽¹⁰⁾.

Sanz Peñuelas’ research abounds with suggestions showing how the pathological process produces mood swings linked to anguish in the face of death. In this same sense, I have centered my phenomenological research work on pain, assuming this event in itself, independently of the illness of which it may form part. That is, it is a symptom of illness, not the illness itself. In most medical treatises, the perception of pain is conceived as an indication of possible organic damage ⁽¹²⁾. Thus conceived, pain can be a bodily sensation with diverse modalities -lancinating, burning, and oppressive- or it can manifest itself as an unpleasant emotional reaction accompanied by fear, anguish and disgust.

All these data on pain that the clinic tries to show with objectivity are secondary to the original experience, as conceived by hermeneutic phenomenology in Heidegger ⁽¹³⁾. In its eagerness to be a positive science, clinical medicine has stopped paying attention to the original phenomena that are shown in the event of falling ill. What I want to emphasize here as the event of falling ill (ereignis) is not the illness that the doctor documents; it is not even what the patient «feels» or thinks he has. What comes is something more primary between the being and the entity: it is the apprehension of the difference between one and the other ⁽¹⁴⁾. The complexity of this event lies in its strictly ontological character. The origin of the event of pain is that, phenomenally, each time it shows itself as its own. That is, as my pain; as the pain of each one. This means that its significance is discovered from how it shows itself. The clinic, on the other hand, does not record the event, but only its appearance.

What happens in the patient is what is lived as experience. This experience that is experienced is nothing tangible; it is almost nothing, but something. It is this «something» that gives us a sense of courage, fear, threat, impotence, abandonment, resentment and despair. That something that is experienced as imprecise, ambiguous and full of uneasiness; as an anguish that senses the finitude of being. It can pass through a bad mood, a mere indisposition; as a kind of premonition. Perhaps as a warning, a warning; as something, in short, that symbolizes our fragility in the experience of daily life.

Do not think that we are talking about two types of pain. The pain that science objectifies and the pain that is lived in the original experience. The only difference, if there is one, is that the latter does not allow itself to be apprehended and tends to have its own existential «experience». Here the idea of factuality has vital importance, understood as «being in the world» ⁽¹⁵⁾, as «being the life that is lived» ⁽¹⁶⁾. This living is pre-reflective, and Heidegger refers to it as factual life, being-there, dasein or being-in-the-world. The factuality alludes to the convincing fact that we are entities and we are in the world as if we were thrown into it. The verb «arrojar» in Spanish indicates «to throw out» and connotes a certain violence. Therefore, it can also indicate to roll, to throw, and to push. In all cases, it seems that the entity is put out there; that is, existing in the world.

Now, lines above referred to the similarity between clinical pain versus existential pain and property and impropriety. To analyze this similarity it was necessary to digress into the factuality and the being-in-the-world. Now we can say that the being-there, as an entity, lives in a world of entities; it relates to them, it has them at hand, but this entity, which is us in each case, is different in that it has a world. The way it inhabits the world is different from the way a stone or an animal does. The fundamental way of being in the world, the being-there is to be possibility of being; that is, to choose oneself as possibility of being. And it is precisely the interpretation of these possibilities that gives meaning to the environment of your daily life.

By being in its world, the there being occupies itself and is absorbed in the world. This absorption in the world removes it from itself, loses it, and alienates it. Heidegger designates this condition as fall (verfallen) ⁽¹⁷⁾. To be fallen is a way of being, not a defect or a deficiency. It corresponds to the improper existence, and has the same rank as the own existence; but in the first one, the being-there is not himself, but «one with the other»; that is, a common and daily way of being with the others. «To be one with another» indicates to be occupied with others, under their lordship. «He is not himself; others have taken away his being» ⁽¹⁰⁾. In this way of being, the being-there «has grown: in him, with him and from him all genuine understanding, interpretation and communication, and all reappropriation takes place» ⁽¹⁸⁾. Furthermore, ownership and impropriety have a dynamic of temporariness, in such a way that the here-and-now can be in ownership and fall back into impropriety.

3. Self-pain

In so much experience of its own, pain comes before all wisdom. Before any joint of speech, pain is already there. Because pain is free at its appearance, it is not governed by anyone. Pain is master and lord: it decides when and how it appears. It does not matter if I have just been born or if I am on my last breath. Pain has no time, has no territory and has no limits. Pain just happens in the life of every one. It may not be active, but it is crouched out there waiting for the assault. To live is to expose oneself to sorrow: there is no living without sorrow.

When the time comes, you are already all pain. Like a thick fog invades everything within reach. Almost no territory can be saved. It irradiates and expands: it flows like a poison taking over body and spirit. It is a heart attack, you hear. It is a cancer, others say. What does it matter! One is a burning pain. A living ember. Living perception of impotence, fear and anguish. Where did it come from? Where is it going? What does it want from us? Nothing answers. Pain is mute, deaf and silent.

Pain has no present or future, only past. Everything I know about it is subsequent to its presence. It is, therefore, unpredictable. As an entity, it does not let itself be apprehended; it is ungraspable. I cannot keep it at hand. Although he is there, linked to my existence, I know nothing about him until he is gone. And when he returns, he surprises me again. He comes and goes through my body as if he were the owner. He gets into my guts and chokes them. I don’t know what to do with him. He is a despot and merciless tyrant. And everything I know about him is useless: it neither prevents nor avoids him. To know one’s own pain is useless.

I have meditated much on this painful experience. I have read treatises on physical pain: on its natural and divine nature; on its biology, physiology and biochemistry; on anthropology and sociology; in short, I have learnt about everything. Algologists know about the pain of others, but nothing about their own pain. They always speak in the third person. Because pain is non-transferable. It cannot be shared. There is no way to put oneself in the other’s shoes. The pain is always intimate and own.

Because of this property of being my own, it is the enemy of my self-esteem. It makes me lose my dignity, pride and decorum. My pain and my self-love are irreconcilable. Although they are similar, they are incompatible: both are invasive, jealous and totalizing. Deeply selfish, neither gives way to the other. Both make an experience of me: both take possession of me, they become present in my existence. The pain collapses me, exhausts my life and sinks me into despair. Love lifts me up, reaches me deep down and is a source of hope and faith. But pain cancels out, kills all hope.

Pain is mute. Dumb and jealous. When it happens it is silent pain. If pain speaks, it speaks as pain. It is jealous in thinking, jealous in memory. Pain is only pain. Even its name is not possible. It oppresses, presses, bites the flesh and martyrizes the soul. What would pain say if it could speak? Or perhaps it speaks? Perhaps it muses in the ear of the flesh. Perhaps it is inaudible when it screams inside the body. But none of that really happens. Pain is so proper, so unipersonal, that it is impossible to share it. Lonely pain in loneliness: painful loneliness.

In the face of an attack of pain, life seeks help. To flee, perhaps to forget. Nevertheless, the pain is there: joined to my existence, it is my most proper existence. Although I am mute, it points out and indicates meaning. Pain itself is a sign, a sign and a meaning. At first it is a cry, a whimper, a whimper. Nothing that gives peace of mind. The anguish that comes with fear and trembling. The flesh trembles with fear. It feels threatened, fragile, and finite. Alerts, warnings are fired. Something threatens to come and take existence by the neck. It is the tremor of being in the middle of nowhere ⁽²⁴⁾.

Because, indeed, there seems to be nothing but pain. Pain is nothing. Pain is pain. So there is something and not nothing. The pain is there, I can locate it, refer it to a bodily territory. It is somewhere in my body: it is myself. There is a spaced out and temporary body. The night is passing. The light of dawn draws the horizon. It is my body that hurts. There is a painful interior; something inside must be rotting. Now I can see the geography of the body. An illumination comes to give it meaning: it was nothing more than a pain, a pain that has not gone away but that now means to be painful: to know about possibilities.

Existing with pain is not the same as the pain of existing. I don’t know if existence hurts. It hurts me to exist in pain. I know of other sufferers that it hurts them to exist, but I have not felt their pain. Do they live my painful existence? Can they put themselves in my place? Can I for an instant replace them in their pain? Can I be those? The melancholic, the depressed, the empty of enthusiasm and full of guilt. It is not my case and I cannot be them. Pain enlightens me, opens the way to the meaning of life. It illuminates life itself. They with their pain, I with mine. At last the curtain of opacity has been drawn and it has made clear the existence. Pain is pain to live; it is life that vibrates and shakes. Own life, true life; finally, life that you can grasp in order to live.

What does this knowledge know about existing with pain? Does it know something? It knows nothing. It only knows that pain hurts. It knows that hurting hurts to exist. Existing -ex stare- is an intent, a voice that encourages the consciousness to rise, to make an effort and to see what is there. What am I? This suffering body. This martyred flesh. This limbic existence. This suffering, finite, mortal finitude. But this is what it is. It is so or it is not. And if it must be so, let it be so.

To accept this condition of being situated, implies what Heidegger calls the «factual living» ⁽²⁵⁾. Not living as an isolated entity, but in a surrounding world. Nor to remain static, undaunted: blinded by the light of the clearing. In his quest to clarify the concept of factuality, Heidegger uses diverse expressions that we now assume to be equivalent. Thus, according to Paloma Martínez, Heidegger speaks of: «living the world-environment» (umwelterlebnis), later substituted by the formula «factual experience of living» (faktische Lebenserfahrung), later called «factual living» (faktisches leben) and finally «being-there» (dasein) ⁽²⁶⁾.

«Factual living experience» refers more clearly to how we experience living in the most absolute concreteness, without previous theorizing or reflection. The factuality (factum) of life is what it is: what is real, what is done; what is done or realized de facto in living. Therefore, the painful experience is a factum: a painful living that is realized prior to all knowledge. Only in these conditions does pain have an ontological character and, therefore, can it be an existential one; that is, a way of being of the being-in-the-world.

The world appears before the eyes not immediately, but by painful experience. The world is the environment, the history and the future. But pain does not come and go into the world. Pain is not out there like anything else. The world has no pain. Intramundane things do not hurt for anyone. Only the entity, in whose being your being goes, is a suffering entity. And there is only one pain, a pure, genuine and original pain; the pain of every one, that which digs its teeth into the heart attack; in cancer; that which bites its own flesh in the unexpected night of anguish. That which paralyzes with terror; that which announces possible death and the end of existence. This is my pain. That is also your pain. But, what about these two suffering beings? Can they be one by understanding each other? Can they be one for the other? Can they, in short, put one in place of the other? That would be understanding.

Pain is urgency, haste. Its abrupt appearance is disruptive to daily living. Painless life flows anonymously, improperly and unrelated to itself. It is the way to live amidst indolent ordinariness. Living goes that way. It goes more or less: sometimes tedium and boredom dominate; other times, mediocre joy. This way of living does not live itself, does not take itself seriously. It goes from here to there, is distracted by the words of others and gets lost to itself. In the post-truth era, the factuality of life is wrapped up in «social networks», where everything is triviality, banality of «information», «tendencies of opinion makers» interested in distracting that factual life, which is also banal and meaningless.

In this respect, Heidegger speaks of the flight in the fall (verfallen); of escape or flight from one’s own being that trembles there at the bottom, of which one knows in some way. That is, the factual life always knows that it can be itself. Only it does not dare to face the anguish of being. Anxiety and pain are fearful existential. Neither one nor the other can be removed from life as one removes the old skin from the serpent. Anguished people, fleeing, try to distract themselves and to pass the time; but pain is more acute and persevering. Pain, as we said, catches us and knocks us down. But sorrow, like anguish, is a manifold revelation of the world.

That is why I insist that if in the fall, pain occurs, the factual living becomes astonishment. An «affective disposition» takes possession of us. Our life, which seemed alien, is not so alien, because we recognize ourselves as mourners. In the midst of this temperament that bathes the factual life, life finds itself. Life meets the overwhelming factum of being life itself. The meeting of factual life, the caring for, the preoccupation with, are existential or modes of being of the being-there. In all cases, it is the event of appropriation of oneself. That is, that the being of the entity takes the being in his hands.

It is I who mourn. Here, «I» is not yet consciousness. It is not psychic perception. I am the pain that hurts me. The pain is here in myself. So I can no longer run away; wherever I go I will go as a grieving entity. That is how it is. If it must be so, so be it. There is nowhere to go, you have to face the situation: face it. To face it is to come face to face with another. But here there is no other, but the «self as another» ⁽⁹⁾. To look at oneself there: thrown away, in pain, in anguish, it encourages one to decide, to resolve to face the pain; that is, to accept one’s own existential possibilities ⁽¹⁰⁾.

The «state of resolved», says Heidegger in number 74 of The Being and Time; the being-there goes back to itself, opens the factual possibilities of its own existence ⁽¹⁰⁾. These possibilities are options of being, ways of being in the world. In finding oneself, one finds one’s history in the form of cultural heritage. Traditions, ways of being. To resolve to be by one of these modes, understanding the meaning it has for one’s existence. Some of these possibilities may be ambiguous, confusing or inappropriate. Authenticity is not just about choice: the authentic being has a certain coherence with the world, because it is the world itself.

4. Conclusions

Thinking about pain, suffering and existence has ethical implications, insofar as these phenomena are inherent to being in the world. Not only in one’s own world, but in the world that includes others. Those others who often ask for help in relieving their pain and reducing their suffering. Although one’s pain isolates and alienates, being-there is being-in and being-with the world. When the pain is someone else’s and he asks me for help, I cannot ignore it. Because being in the world makes me responsible for the world. I live my sorrow, I experience it, but the sorrow of the other, even though it is not alien to me, I cannot understand it: he lives his sorrow and I cannot be through him, in him and with him. Even he cannot be me. This impossibility is an ethical dilemma for me.

In these reflections, one’s own experience is made manifest, trying to make a pre-reflective, and atheoretic experience, far from scientific conceptions. An attempt to make an experience-in-pain-of-being as a fallen being. An experience that is every day and trivial. Everyone who has pain does not stop existentially to make an experience. The painful one runs to seek relief. The improper form seeks to mask the anguish with the help of the other. Medicine, science and technology have their degree of impropriety. They are ways of masking the self. In the impropriety, the being-there lives the request: it seeks help.

We also try to find theoretical elements to confirm the validity of our own and others’ painful experience. To make an experience is to allow oneself to be assimilated by the experience. In this phenomenology the ontic-ontological character of pain and suffering is evident. Hermeneutic phenomenology offers the possibility of understanding one’s own experience and that of another. Heidegger is a widely studied philosopher. In itself, Heidegger’s thought is diverse, wide and complex. In this work I have limited myself to the most indispensable bibliographical references.

Here, the possibility that pain has an existential character has been explored. It is convenient to take into account that, for Heidegger, the existential ones are essential characters of the being-there evidenced by the analysis of the factuality. In the same way, it is necessary to take into consideration the distinction that Heidegger makes between categories and existentialist. It seems evident that there is a simile between anguish and pain as existentialist. What is relevant about this similarity is the emphasis on the existential character that pain has for the opening to the world.