Commentary by Dr. Katherine R. Peeler, Pediatrics, Global Health and Social Medicine, Center for Bioethics, Harvard Medical School; Division of Medical Critical Care, Boston Children’s Hospital
Feature Articles: Tate, T. (2020). Pediatric Suffering and the Burden of Proof. Pediatrics, 146(Suppl 1), S70-s74.
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Tyler Tate’s article “Pediatric Suffering and the Burden of Proof” in the August supplement of Pediatrics is a thought-provoking read. In it, he argues that traditional adult definitions of suffering (namely citing those of Eric Cassell) are insufficient and inappropriate to extrapolate to pediatric patients, particularly those who are unable to speak for themselves – infants and children with cognitive impairments. Specifically, Tate takes issue with Cassell’s definition of suffering as “the state of severe distress associated with events that threaten the intactness of the person,” as expressed as a [Tate’s words] “subjective, personal, and individualized phenomenon.” Cassell argues that children cannot suffer because they do not have a sense of self and cannot reflect on their suffering. Rather what they experience is [Tate’s words] “merely pain or some other basic emotional response to its environment.” What is not clear to me, however, is what exactly Tate takes issue with – does he believe that pain is equivalent with suffering in a infant and so Cassell’s definition is inadequate because the ability to reflect and understand one’s personhood should not be part of the definition of pediatric suffering? Or does Tate believe that even infants can think and reflect and therefore “suffer” in the more profound sense of something that is more than “merely pain?” Unfortunately, Tate cites many articles that support the idea of pediatric suffering, but he never comes out and says what he believes to encompass suffering in children.
Later in his piece, Tate compares pediatric suffering to beauty in art: the truth (of suffering vs not; beautiful vs not) is in the eye of the beholder. But I would disagree with this. Art is inanimate. There is literally no answer to the question of whether or not a given piece of art is beautiful. It is unknowable to everyone – both observers and the piece of art itself. There is, however, an answer to whether a child is suffering. The problem though is that the child knows and no one else can truly know. I was also unclear on Tate’s take on the “accessible subjective experience of the child’s caretakers (parent, nurse, therapist, or physician).” He states, “when the (1) subjective discomfort or (2) subjective hope experienced by a caretaker is projected onto the child, it becomes either the (1) presence or (2) absence of suffering.” Is he stating that this is how we should be framing our view of pediatric suffering, or is he simply stating that this is the current state of affairs vis-à-vis how pediatric suffering is assessed? If the latter, I would agree. If the former, I would disagree and state that the accessible subjective experience represents only the experience of that particular person and his/her suffering in caring for a child in pain, discomfort, etc.
Finally, Tate poses the question of who is to judge and deem a child as suffering or not. He calls for “a more objective theory of pediatric suffering.” I think before a theory of knowledge and assessment can occur, there must be a definition, and this is what I feel Tate’s article lacks. As I wrote in the beginning, I would have liked a bit more of a dissection of Cassell’s definition and where Tate felt it broke down. As someone who cares for critically ill children of all types – infants, cognitively delayed, and fully cognitively intact older children – I don’t have answers to these questions myself and appreciate Tate’s article for pushing me to think deeply about this.