David Fajardo-Chica, a researcher at the Institute for Philosophical Research at the National Autonomous University of Mexico, reconstructs that architecture in the form of two theses operating at different levels. The first is etiological: suffering arises from impairments across multiple dimensions of the person, paradigmatically the physical, psychological, social, and spiritual. He calls this the thesis of multidimensionality. The second is experiential: suffering is lived not as a collection of isolated problems but as something that affects the person as a whole. He calls this the thesis of holism. ‘Total pain’ is the conjunction of both. Multidimensionality makes suffering tractable for clinical intervention, while holism keeps care anchored in the lived experience of the person. Neither thesis can do the concept’s work alone, and the article takes care to guard each against a characteristic distortion.

Two clarifications are central to the reconstruction. First, ‘total pain’ does not claim that suffering requires impairments in multiple personal dimensions. A serious impairment in a single domain, such as severe pain, profound grief, or social isolation, may suffice. The relevant criterion is whether the person experiences the disturbance as affecting them as a whole. Multidimensionality describes a common etiological pattern, but suffering derives its unity from its impact on the person. Second, the concept does not hold that any set of minor impairments across several domains amounts to suffering. A stiff joint, thinning hair, or reduced stamina may involve multiple dimensions, but unless they are perceived as bearing on the person as a whole, they do not constitute suffering. Holism supplies the condition that etiology alone cannot, which is why the two theses are intelligible only in relation to one another.

The most influential systematization of the holistic thesis, the article notes, is Eric Cassell’s theory of suffering as a threat to the person, first published in the New England Journal of Medicine in 1982. On Cassell’s account, suffering occurs when a person perceives a threat to their sense of personhood; it is the person, not just the body, who suffers. What can be threatened spans far more than the body: character, history, the meanings attached to illness, family bonds, cultural belonging, social roles, emotions, a private inner self, and a projection toward the future that many would call transcendent. Cassell’s theory articulates, with a philosophical vocabulary of personhood, the same dual structure Saunders had already built into ‘total pain’. There is, however, a difference in role. In Cassell, the dimensions are aspects of the person that can be threatened; in ‘total pain’, they are also causal fronts of clinical intervention, each answerable to a distinct form of care. Despite the frequent identification of Cassell’s view as the dominant theory of suffering in the field, its underlying architecture, the article argues, is Saundersian.

What makes the argument striking is the evidence that this dual structure remains operative wherever the contemporary field defines, measures, or globally assesses suffering. The World Health Organization defines palliative care as an approach that improves quality of life through the prevention and relief of suffering by identifying, assessing, and treating pain and other problems, physical, psychosocial, and spiritual. The more recent consensus-based definition characterizes palliative care as the active holistic care of persons with serious health-related suffering across those same dimensions. The field’s measurement practices exhibit a consistent pattern as well. Internationally validated instruments typically decompose suffering into discrete symptoms, assessing physical impairments such as pain, dyspnea, and constipation alongside psychological distress, social difficulties, and spiritual suffering. At the same time, other instruments capture the global, integrated character of the experience. The SOS-V explicitly distinguishes the intensity of individual symptoms from the overall unbearability of suffering, which need not track any single symptom. The PRISM goes further: a nonverbal instrument on which the patient represents the distance between the self and the illness, it measures suffering not as a profile of impairments but as the global encroachment of illness upon the person. That the field has found both registers indispensable is consistent with the dual structure of the concept.

In global health, the same structure appears in the Lancet Commission on Palliative Care and Pain Relief’s concept of serious health-related suffering, introduced to establish a proxy for palliative need and to measure the state of palliative care across world regions. Suffering becomes serious when it cannot be relieved without professional intervention and when it compromises physical, social, spiritual, or emotional functioning. The Commission’s methodology identified common diseases and their usual symptoms, producing a list of eleven physical and four psychological symptoms through which the assessment proceeds, while the very notion of suffering these symptoms are meant to capture retains the holistic orientation of ‘total pain’, in which it is the person whose functioning is compromised. The concept continues to generate theoretical and empirical work as it is extended to new populations and contexts, including dementia, cancer survivorship, social suffering among marginalized groups, and even the indirect victims of enforced disappearance.

Each of the two theses grounds a distinct normative commitment, and the article shows why these roles are not interchangeable. Multidimensionality supports a diagnostic and pragmatic stance toward suffering. It allows clinicians to map the domains in which impairments arise and to address each through appropriate expertise. Crucially, these domains are qualitatively heterogeneous: relieving physical pain, addressing social isolation, and treating psychological distress require different forms of expertise, including pharmacology, social intervention, and psychotherapy. Because the sources of suffering belong to different orders, no single expertise can reach them all. This is what grounds the multidisciplinary model of palliative care, which deploys not only physicians and nurses but also psychologists, social workers, and spiritual care providers. Historically, this was precisely the innovation of Saunders’s concept: it authorized the clinic to treat as pain, and therefore as its proper object, what the biomedical model had classified as extraneous to it, validating forms of distress with no obvious somatic correlate, such as feelings of abandonment, loss of meaning, and isolation.

Holism, by contrast, grounds an ethical demand centered on the person as a whole. It frames the patient not as a bearer of symptoms but as a person whose capacity for coherence is at stake, and it connects the experience of suffering to respect for autonomy in specific ways. The article distinguishes three claims. First, the sufferer has privileged epistemic authority over what their suffering is, because its full significance is accessible only from the perspective of the person who experiences it. Second, the sufferer’s values and perspective carry particular weight in determining what would count as relief, which becomes relevant to care planning, informed consent, withdrawal of life-sustaining treatment, and palliative sedation. Third, the sufferer has decisional authority over what should be done, and this claim, the article argues, is not supported by the holism thesis itself. Respect for autonomy ordinarily requires that the patient’s preferences guide care, but professional judgement may legitimately depart from them when decision-making capacity is impaired, preferences are unstable, or other ethically relevant considerations apply, as in situations common in palliative settings such as delirium and acute psychological distress. Holism therefore does not grant the patient a veto; instead, it requires professionals to justify departures from the patient’s perspective.

The article then asks whether two rival conceptions of suffering could perform the same conceptual work. The objective, flourishing-based view, developed most prominently by van Hooft, defines suffering as the frustration of the tendency toward fulfillment of four levels of human functioning: the biological, the appetitive, the deliberative, and the contemplative. A person may suffer from conditions such as addiction, poor nutrition, or social deprivation even if they do not perceive these as threats, and in van Hooft’s strongest formulation, may suffer without any awareness of it at all. This view aligns with part of what the multidimensional thesis does, allowing identification of causal pathways to suffering that the individual does not directly perceive. But the resemblance is partial, and the detachment is precisely why the objective conception is ill suited to patient autonomy. Because suffering is fixed independently of the person’s own experience and values, it can be identified and acted upon without reference to the patient’s point of view. Van Hooft embraces this consequence, holding that there is no medical mission to confront the spiritual condition of the patient. Whatever its merits as a general theory, this is the opposite of what the holistic thesis secures, and the objective view can reproduce the paternalism that palliative care seeks to avoid.

The thin phenomenological conception, which identifies suffering with its felt quality, faces the mirror-image problem. It shares with ‘total pain’ the view that suffering is a first-person experience in which the patient’s perspective is central, the very feature the holistic thesis exploits in supporting autonomy. But it has two limitations. The first is epistemic: because suffering is identified with how it feels, one may judge objectively whether a person is undergoing a physical ordeal yet not thereby judge whether they are suffering, since such ordeals carry different significance for different people. The second is deeper: the phenomenological conception does not guarantee any relationship between suffering and symptoms. If suffering is primarily a feeling, nothing in the concept explains why particular impairments should give rise to it, whereas the multidimensional thesis establishes causal links between symptoms and suffering, which is what makes suffering tractable for intervention. Neither rival can perform both functions that ‘total pain’ performs at once.

A final objection invites the worry that the dual structure is incoherent: if suffering results from impairments in several distinct dimensions, how can it also be experienced as affecting the person as a single whole? The article frames the problem with a metaphor. A fragrance is composed of distinct notes, yet what one smells is not a list of ingredients but a single scent; no individual note captures it. But a perfume does not compose itself. What, in human experience, plays the role of the perfumer, the principle that binds distinct impairments into one experience of suffering? The closest answer lies in Cassell’s account: suffering occurs when a person perceives a threat to their integrity, and that perception transforms impairments arising in different dimensions into a single experience. Krikorian and Limonero extend this proposal by adding the notions of coping resources and their exhaustion, specifying a mechanism through which multidimensional impairments issue in a single holistic experience: it is the failure of integration under load, not the impairments alone, that constitutes suffering.

Recent work in the philosophy of mind offers independent models of how impairments across distinct domains can integrate into a global experience. McClelland’s disruption model makes the mechanism especially explicit: suffering is not the unpleasant mental state itself but the unpleasant disruption that state produces across a person’s mental life. Pain or grief is a state that conflicts with a person’s wider mental life, and suffering consists in the disruption caused by accommodating it. When suffering captures attention, ongoing projects are impeded, other experiences are affected, and the mind must reorganize around it. An unpleasant state that causes no such disruption would not amount to suffering; pain can, in principle, be experienced without disrupting mental life. The impairment is local, but its effects are global, and it is the global disruption that constitutes the suffering. Other models trace different routes to the same destination: a perceived threat to the self, an unmet desire for an unpleasant experience to end, a pervasive negative construal of one’s whole situation as calling for a change one is powerless to bring about, and, in Svenaeus’s rich phenomenological account, a suffering mood that alters the person’s being-in-the-world and generates a sense of alienation from the familiar world. Each makes distinct impairments into a single experience by having them register at a global level rather than as isolated complaints.

The upshot is that ‘total pain’ should be read not as a relic but as a conceptual compromise that enables care at once clinically effective and ethically person-centered. Holding both theses together is what lets the field attend to the identification and treatment of symptoms while remaining centered on the person, a dual capacity that neither the objective conception, which secures intervention at the cost of autonomy, nor the thin phenomenological conception, which centers experience without securing its link to the clinical, can match. Nor is the combination incoherent: the apparent tension between distributed causes and unified experience is not a conceptual defect but an explanatory question that recent models in the philosophy of mind show to be tractable. The article also points beyond the individual patient, noting that a fully holistic account implies family members and informal caregivers are not merely part of the patient’s environment but persons who suffer in their own right and whose interests warrant separate ethical consideration. More than sixty years after Saunders introduced it, the concept of ‘total pain’ continues to find expression across the field of palliative care, from clinical guidelines and validated measurement instruments to global health metrics, and its architecture now stands revealed as the field’s living, implicit theory of suffering.

Subject of Research: The dual structure of ‘total pain’: multidimensionality and holism in the foundational concept of palliative care

Article Title: The dual structure of ‘total pain’: multidimensionality and holism in the foundational concept of palliative care

Article References: The dual structure of ‘total pain’: multidimensionality and holism in the foundational concept of palliative care. (n.d.). https://doi.org/10.3389/fsoc.2026.1985788

Image Credits: AI Generated

DOI: 10.3389/fsoc.2026.1985788

Keywords: dual, structure, total, pain, multidimensionality, holism, foundational, concept, palliative, care, scientific research