Between 1958 and 1967 at St Joseph’s Hospice and from 1967 at St Christopher’s Hospice (London), Cicely Saunders developed a concept that founded modern palliative medicine and hospice care: total pain — the all-encompassing suffering in dying.
According to Saunders, the suffering of a dying human being is not an aggregate of single forms of pain. It is an indivisible whole with four mutually interacting dimensions:
The four dimensions
Physical dimension — somatic pain: tumor, nerve, bone, wound and treatment pain. The standard target of pharmacological pain therapy.
Psychological dimension — anxiety, depression, despair, anger, loss of hope. It is intensified by untreated physical pain and in turn intensifies it.
Social dimension — worry about those left behind, unresolved conflicts, loneliness, loss of one’s role in family and community, financial worries. It testifies to the personal embeddedness of the person even in dying.
Spiritual dimension — crises of meaning, doubts of faith, feelings of guilt, the question of the worth of the life lived, the question of what comes after death. Whoever treats only the other three dimensions and passes over the spiritual one does not treat the person as a whole.
Structural parallel to personal ontology
The four dimensions of total pain stand in a striking structural parallel to the anthropology of this book: the person, as a bodily-spiritual unity, is not an aggregate of pain types but a sufferer whose suffering has personal depth.
Somatic pain is not “the real” pain to which psychological, social and spiritual aspects are then secondarily attached. Rather, each dimension reaches into all the others. Loss of hope can have a spiritual, existential and psychological dimension that intensifies the physical intensity of pain; physical pain can sharpen social and psychological pain arising from a felt abandonment.
Consequence for practice
From the total-pain concept follows a central practical demand: no single profession and no single discipline can treat total pain alone. Interdisciplinary teams — physician, nurse, social worker, chaplain, psychologist — are the institutional answer to the four-dimensionality of suffering.
The hospice movement is the structural embodiment of this demand. It is the answer to a medicine that decomposes the person into her single dimensions and treats only the somatic one.
Counter-model: somatic reduction
Whoever treats only the physical dimension in dying advocates — consciously or unconsciously — a somatic reduction of the person. That is a form of practical oblivion of the person: the person is reduced to her body, her personal suffering is overlooked.
Advocacy of euthanasia frequently follows a similar logic: because the somatic suffering is “no longer treatable,” death is said to be the only answer. Total pain shows: the question is wrongly posed. What can always be treated is total pain — and it is treatable.
Ontological classification
Superordinate concepts: State of affairs (all-encompassing suffering in dying)
Four subdimensions: physical, psychological, social, spiritual — all interact with one another.
Ontological relations:
- grounds the practice of: hospice, palliative care
- structural parallel to: the bodily-spiritual unity of the person, the three dimensions of personhood
- argumentative counter-model to: euthanasia (somatic reduction)
- holds in every phase: prefinal, terminal, dying
Chapter assignment: Chapter 4: What Is Human Personhood? (German), Chapter 5: Oblivion of the Person (German)
Saunders’ motto
“You matter because you are you, and you matter to the end of your life.” — Cicely Saunders
Translated into personal ontology: personhood is inalienable; the dignity of the person lasts until the last breath. Total-pain treatment is the practical consequence of this sentence.
Sources: Generated by querying the Personhood ontology.
Further sources:
- Saunders, Cicely (1958): Dying of cancer. St Thomas’s Hospital Gazette 56(2): 37—47. An early account of the multidimensional reality of pain.
- Saunders, Cicely (1964): The need for institutional care for the patient with advanced cancer. In: Anniversary Volume, Madras: Cancer Institute, pp. 1—8.
- Saunders, Cicely (1964): The symptomatic treatment of incurable malignant disease. Prescribers’ Journal 4(4): 68—73. The first systematic presentation of the four dimensions of pain.
- Saunders, Cicely (1967): The management of terminal illness. London: Hospital Medicine Publications. The concept for practice at St Christopher’s Hospice.
- Clark, David (1999): “Total pain”, disciplinary power and the body in the work of Cicely Saunders, 1958—1967. Social Science & Medicine 49(6): 727—736. Historical and theoretical reconstruction of the concept’s development.
- Mehta, Anita; Chan, Lisa S. (2008): Understanding of the concept of “total pain”: A prerequisite for pain control. Journal of Hospice and Palliative Nursing 10(1): 26—32.
- Wood, Joe (2022): Cicely Saunders, “Total Pain” and emotional evidence at the end of life. Medical Humanities 48(4): 411—420.
- Ong, C. K.; Forbes, Duncan (2005): Embracing Cicely Saunders’s concept of total pain. BMJ 331(7516): 576. https://pmc.ncbi.nlm.nih.gov/articles/PMC1200625/
- Palliative Care Network of Wisconsin — Fast Fact #417: Total Pain. https://www.mypcnow.org/fast-fact/total-pain/
- VUMC Palliative Medicine: Fast Facts and Concepts #417 Total Pain (PDF). https://medicine.vumc.org/sites/default/files/2025-11/11-25—ff-417-total-pain-2025-11-04-104126.pdf
- Bexten, Raphael E. (2017): Was ist menschliches Personsein?. Eichstätt-Ingolstadt, Diss. — On the bodily-spiritual unity of the person and the differentiation of the First, Second and Third Dimension.