The dual structure of ‘total pain’: multidimensionality and holism in the foundational concept of palliative care
Year: 2026
Type: review
Abstract: The concept of 'total pain', introduced by Cicely Saunders, is often treated as a historical milestone of the hospice movement rather than as a live theoretical resource. I argue instead that it is a concept with a definite architecture that remains operative as an implicit theory of suffering in contemporary palliative care. This architecture takes the form of two theses: an etiological thesis of multidimensionality, on which suffering arises from impairments across multiple dimensions of the person (physical, psychological, social, spiritual, among others), and an experiential thesis of holism, on which suffering is lived as affecting the person as a whole rather than a sum of discrete problems. I show that this dual structure is legible across the WHO definition of palliative care, the field's consensus definition, its validated measurement instruments, and the Lancet Commission's concept of serious health-related suffering. Each thesis plays a distinct role: multidimensionality supports a multidisciplinary approach to suffering, while holism supports respect for patient autonomy by giving due weight to the patient's perspective. I then ask whether two alternative conceptions-the objective, flourishing-based view and the thin phenomenological view-could perform the same work, and argue that the former secures clinical tractability at the cost of autonomy, while the latter centers the patient's experience without securing its link to symptoms. Finally, I address the objection that the dual structure cannot explain how distributed impairments become a unified experience, drawing on recent models in the philosophy of mind to show that it can. 'Total pain', then, is a conceptual compromise enabling care that is at once clinically effective and ethically person-centered.
Source: Frontiers in Sociology
Author: David Fajardo-Chica
Institution: Universidad Nacional Autónoma de México
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $1,418
OpenAlex ID: W7222575920