An Ethical-Relational Algorithm to Map Human Suffering

doi:10.21203/rs.3.rs-7058244/v1

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An Ethical-Relational Algorithm to Map Human Suffering

https://doi.org/10.21203/rs.3.rs-7058244/v1

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Background. Suffering at the end of life is a multidimensional experience that encompasses physical, psychological, social, and spiritual dimensions. Conventional clinical models often reduce suffering to physical symptoms, leading to fragmented care and ethical oversights. This issue is particularly pronounced in Latin American contexts, where structural inequalities and cultural complexities further limit holistic and compassionate care. There is a clear need for context-sensitive, ethical, and operational tools that guide healthcare professionals in addressing suffering in all its dimensions.

Methods. We developed the Dynamic Algorithm of Suffering (DAS) through a multi-phase methodology. First, a narrative and thematic review of theoretical, clinical, and ethical literature was conducted to identify key dimensions and gaps in existing models. Then, a comparative matrix of validated tools for symptom and suffering assessment was created. Finally, a Delphi consensus process was carried out with 14 experts from five Latin American countries to construct and refine the DAS. Qualitative data were analyzed manually and supported by ATLAS.ti software. The resulting model was illustrated and operationalized for clinical application in palliative care.

Results. The DAS integrates four dimensions of human suffering—physical, psychological, social, and spiritual—organized into a dynamic matrix of internal and external factors. These dimensions are continuously reassessed to guide proportionate, patient-centered, and ethically grounded decisions. The model synthesizes validated instruments (e.g., ESAS-R, HADS, FACIT-Sp) within an adaptive framework that supports interdisciplinary teams. Consensus was achieved on 85% of the indicators proposed. Clinical vignettes demonstrated the model’s capacity to prevent unnecessary interventions, reduce spiritual and social distress, and enhance decision-making in complex end-of-life scenarios.

Conclusions. The Dynamic Algorithm of Suffering (DAS) represents an innovative ethical-operational model for addressing multidimensional suffering in palliative care. Its context-sensitive design makes it particularly relevant for under-resourced healthcare settings, especially in Latin America. By incorporating ethical principles, relational values, and narrative approaches, the DAS enhances clinical decision-making, promotes humanized care, and responds to the moral imperative of relieving suffering in all its forms. Further validation and implementation studies are warranted to expand its use in diverse care environments

Nursing

Oncology

Anesthesiology & Pain Medicine

Medical Ethics

Suffering

Palliative Care

Decision Making

Bioethics

Quality of Life

Patient-Centered Care

Terminally Ill

Health Evaluation

Spirituality

Theoretical Models

Suffering in the context of palliative care goes beyond physical pain; it encompasses psychological, social, and spiritual dimensions. This holistic perspective, initially proposed by Dame Cicely Saunders through the concept of "total pain," marked a paradigm shift in the understanding of end-of-life care by incorporating existential factors that directly influence the patient’s sense of well-being and dignity (1). However, the persistence of a disease-centered clinical model has led to what some authors call an "ethical blindness" toward subjective suffering, reducing the human being to an object of biomedical intervention (2, 3).

From a bioethical perspective, the failure to address suffering in all its dimensions constitutes a transgression of core ethical principles such as beneficence, justice, and respect for autonomy. Although the multidimensional nature of suffering is widely acknowledged in the scientific literature, there remains a marked asymmetry in how its various components are addressed (4, 5).

This imbalance has resulted in fragmented care practices, where immediate symptoms are addressed without considering the relational, communal, or existential determinants that deepen the experience of suffering. Moreover, evaluation is often conducted using unidimensional tools that fail to capture the real complexity of the process. Although validated instruments exist to assess specific dimensions—such as the FACIT-Sp for spirituality and FACIT-Pal for comprehensive palliative care—their systematic integration into clinical practice remains limited (6–8)

The ethical consequences of this gap are significant: clinical decisions are made with incomplete information, risking moral iatrogenesis and the dehumanization of care. As Balboni et al. (2010) have pointed out, spirituality, when neglected, becomes a factor that exacerbates the patient's suffering—even when physical symptoms are controlled (9). The situation is further compounded by a notable lack of validated integrative models. This reveals a serious methodological gap, particularly given that interdisciplinary teams require clear algorithms for the holistic management of suffering (5, 10, 11).

Additionally, a strong geographical bias in scientific production contributes to epistemic exclusion. More than 80% of the literature originates from North America and Europe, while less than 10% includes African, Asian, or Latin American contexts (12). This bias limits the applicability of existing models in cultures with different worldviews on spirituality, death, and community, and hinders the provision of culturally competent care.

In light of this landscape, there is a clear need to develop dynamic and validated models that enable personalized, holistic, and context-sensitive assessment and intervention. This critical review seeks to contribute to that need by systematizing the approaches, theories, and tools used in the evaluation of suffering, and by proposing the Dynamic Algorithm of Suffering (DAS)—a model built through comparative analysis and methodological consensus. Its purpose is to provide an ethical and operational guide for healthcare professionals caring for patients in conditions of high vulnerability and multidimensional suffering.

2.1. Suffering as an Ethical, Not Merely Clinical, Concern.

In bioethics, suffering is a central concern, not a peripheral or merely clinical phenomenon. The moral obligation to alleviate suffering from the Hippocratic tradition to contemporary principles of autonomy, beneficence, non-maleficence, and justice constitutes the normative core of ethical healthcare (13, 14). However, current biomedical frameworks tend to reduce suffering to physical or psychological expressions, neglecting its social (e.g., abandonment, exclusion, relational poverty) and spiritual (e.g., loss of meaning, existential void) dimensions (2, 3).

Cassell has argued that this omission can result in a form of moral iatrogenesis ethical harm arising from interpretative negligence of the deeper aspects of human experience (2). This concept calls for an expansion of the clinical paradigm toward an integral ethical perspective.

2.2. Structural Blindness and the Unjust Distribution of Relief.

Reducing suffering to what is measurable is not ethically neutral. It reflects a form of structural blindness, sustained by systems that prioritize the quantifiable, the standardized, and the protocolized over the spiritual, relational, and narrative (15). This type of exclusion perpetuates deep inequities. In distributive justice terms, as proposed by Norman Daniels, Balboni, and Martha Nussbaum, denying equitable access to comprehensive relief from suffering constitutes an ethical failure by restricting access to fundamental moral goods such as dignity, meaning, and personal agency (15–17).

Numerous studies show that unrecognized spiritual suffering is associated with poorer quality of life, increased prevalence of depression and anxiety, and, in some cases, radical clinical decisions such as euthanasia in the absence of severe physical pain (11, 18). These findings demand a reconsideration of intervention criteria grounded in a compassionate ethics of care.

2.3. Relational Epistemology and the Justice of Recognition.

From the perspective of critical theory, authors such as Axel Honneth and Nancy Fraser argue for a form of justice that includes not only distributive but also recognitional dimensions that is, justice that addresses marginalized voices and suppressed forms of knowledge (19, 20). Ignoring the spiritual dimension of suffering constitutes a form of epistemic injustice: the systematic denial of the cognitive value of certain human experiences (21).

Relational bioethics, as an emerging perspective, offers an integrated view that prioritizes relationships, context, and interdependence as the foundation of ethical care (22). From this standpoint, alleviating suffering is not merely about clinical intervention but about recognizing, validating, and accompanying the other’s narrative.

2.4. Toward an Ethical-Operational Model: The Value of the DAS.

In response to these gaps, the Dynamic Algorithm of Suffering (DAS) is proposed as an ethical, not merely technical, tool (Fig. 1). The DAS is not intended to replace clinical judgment but to render visible and integrate the multiple dimensions of human suffering: physical, psychological, social, and spiritual. Its development, based on a systematic review of existing theories and tools, was validated through Delphi consensus (Fig. 2), ensuring both conceptual rigor and clinical applicability ((3, 23, 24).

This model offers an ethical and operational guide for health professionals working with highly vulnerable populations. It facilitates context-sensitive evaluation, recognizing each patient's uniqueness and their right to be treated as a moral subject, not a pathological object (Figs. 1 & 2).

The Fig. 1 synthesizes the multidimensional architecture of the DAS, articulating the physical, psychological, social, and spiritual dimensions into a flexible ethical-operational guide that is sensitive to the Latin American context.

From an applied bioethics perspective, the DAS represents a normative innovation that transforms suffering into a moral imperative for action, structuring clinical decision-making through informed compassion, the justice of recognition, and respect for the patient’s narrative integrity.

The Dynamic Algorithm of Suffering (DAS) emerges as an ethical, adaptive, and context-aware tool specifically designed to address the challenges of multidimensional suffering in Latin America. Its development acknowledges the region's cultural, social, and spiritual particularities and proposes an operational structure that coherently integrates the physical, psychological, social, and spiritual spheres of human suffering (Fig. 1). Unlike traditional clinical models focused on symptomatology, the DAS operates as a situated ethical guide oriented toward compassionate deliberation, the justice of recognition, and respect for the patient's narrative.

3.1. Origins and the Need for an Innovative Approach.

In Latin American clinical settings, marked by structural inequalities, complex family networks, and deep-rooted spiritual worldviews, addressing suffering requires a model that transcends traditional biomedical categories. The DAS responds to this need by integrating physical, psychological, social, and spiritual dimensions within a flexible, ethically operational, and culturally relevant system (Fig. 1).

Unlike rigid scales centered on symptom evaluation, the DAS serves as a dynamic guide for ethical clinical reasoning, enabling healthcare professionals to map the multiple sources of suffering that affect each patient in their uniqueness and co-construct an integral care plan together with the patient and their family (27–30)

3.2. Core Principles of the Dynamic Algorithm of Suffering (DAS).

The development of the DAS is grounded in five principles derived from contemporary bioethics, clinical psychology, and cross-cultural studies:

Integrated Multidimensionality, based on the concept of "total pain" proposed by Saunders (1).
Dynamism, following models of continuous reassessment of suffering as described by Breitbart (31, 32).
Person- and Family-Centered Care, aligned with person-centered medicine, in which the DAS incorporates the patient’s and family’s narratives as legitimate sources of clinical truth (33).
Intercultural Sensitivity, which considers factors such as religious beliefs, extended family traditions, and community practices specific to the Global South (29, 30, 34, 35).
Ethical-Operational Applicability, enabling ethically sound clinical decision-making without requiring complex resources, essential in Latin American contexts (36, 37).

3.3. Internal and External Factors of Suffering in the DAS.

The DAS distinguishes between internal factors (related to the patient) and external factors (related to the patient’s context), allowing for a relational and adaptive understanding of suffering.

A. Internal factors:

Physical pain and refractory symptoms (38)
Mood disorders, anxiety, hopelessness (39)
Unresolved personal conflicts, including guilt, trauma, existential ambivalence (40)
Spiritual crisis: loss of meaning, rupture with religious or spiritual worldview (41)

B. External factors:

Dysfunctional family dynamics or lack of support (42)
Conditions of poverty and limited access to care (43)
Stigma, discrimination, or institutional abandonment (19, 44)
Imposed medical decisions without the patient’s or family’s active participation (45–47)

These factors are organized into a two-axis matrix that evaluates their intensity and interaction. This matrix is continuously updated throughout the care process, allowing ethical and personalized monitoring of suffering.

3.4. Adaptability to the Latin American Context.

The DAS is designed with an intercultural logic, reflecting the sociocultural realities of countries like Colombia, Mexico, Peru, and Brazil. In these settings, popular religiosity, community solidarity, and extended family structures are essential for understanding the lived experience of suffering (48, 49).

The model also recognizes recurring structural limitations in regional healthcare systems (6, 21, 45, 50):

Scarcity of palliative care specialists
Extended hospitalizations without family or community support
Fragmentation between biomedical and spiritual care
Lack of culturally validated assessment tools

Rather than proposing a single protocol, the DAS presents a flexible architecture usable by general practitioners, nurses, psychologists, social workers, and community leaders. This approach fosters transdisciplinary intervention and the humanization of care.

3.5. Clinical Application and Ethical Decision-Making.

The DAS is conceived as a support tool for ethical decision-making in complex clinical scenarios. Rather than functioning as a closed scale, it serves as a moral compass that helps the healthcare team formulate critical questions:

Which dimension of suffering is predominant in the patient?
What are the internal and external causes aggravating it?
Have spiritual and social needs been adequately explored?
How actively is the patient's voice present in the decision-making process?

For instance, in the case of a palliative sedation request, the algorithm enables verification of whether the suffering is truly refractory or if unaddressed factors (e.g., spiritual despair or family conflict) are influencing the request. This prevents rushed decisions and promotes proportionality and patient participation.

The development of the Dynamic Algorithm of Suffering (DAS) was grounded in a comparative systematization and participatory methodological construction approach, aiming to design an ethical and clinically useful tool to address multidimensional suffering in palliative care settings.

4.1. Theoretical and Analytical Review.

A narrative and thematic analysis of the specialized literature was conducted, encompassing philosophical, bioethical, anthropological, and clinical approaches to human suffering. Classical contributions, were included, along with contemporary developments in relational bioethics, the justice of recognition, and narrative medicine (5,11,13,27,27,33,35,51–53).

This process allowed the identification of four fundamental dimensions of suffering (physical, psychological, social, and spiritual), as well as the primary reductionist biases present in traditional clinical models (2,3,23).

4.2. Categorization of Existing Model.

A comparative table of tools used to assess suffering was developed, distinguishing those based on clinical foundations (FACIT-Sp, ESAS, SPIKES) from those incorporating spiritual or existential dimensions (Table 1).

Instruments were analyzed from three perspectives:

· Dimensional focus (number and type of dimensions evaluated)

· Cultural scope (applicability in Latin American contexts)

· Normative framework (explicit presence of ethical values, justice, autonomy, etc.)

The table 1 below summarizes representative instruments by dimension, including domains, validation background, and clinical utility:

Dimension	Instrument	Domain(s) Covered	Validity and Use
Physical	ESAS-R, VAS	Symptom intensity	Widely used in palliative care; assesses pain, fatigue, nausea, etc.
Psychological	HADS, Mini-MAC	Anxiety, depression, coping	High reliability; Mini-MAC validated in oncology; explores coping styles.
Social	IPOS (social), SSQ	Social support, social burden	Evaluates support networks; IPOS covers holistic needs.
Spiritual	FACIT-Sp, Brief RCOPE, FICA	Meaning, peace, faith, distress	Validated tools assessing spiritual distress and coping; applicable in cross-cultural settings.
Communication	SPIKES protocol	Clinical communication	Used for delivering bad news; promotes shared decision-making.

4.3. Construction of the DAS Model: Delphi Technique.

Based on the initial categorization, the DAS model was developed using the Delphi technique, a structured qualitative methodology for achieving expert consensus (34).

Fourteen experts from five Latin American countries (Colombia, Mexico, Peru, Argentina, and Chile) participated, with backgrounds in clinical bioethics, palliative medicine, existential psychology, and health-related spirituality. The process involved three rounds:

1) First round

a) Open exploration of essential components for an integral suffering model.

2) Second round

a) Consolidation of key dimensions and validation of the physical, psychological, social, and spiritual axes.

3) Third round

a) Evaluation of the graphic algorithm prototype and the operational guidelines for implementation in clinical contexts. A detailed outline of these operational guidelines is provided in Annex 1, offering step-by-step recommendations for clinical teams implementing the DAS model.

Consensus was established at an 85% agreement threshold for the inclusion of categories and operational criteria. Content analysis was conducted manually and supported by ATLAS.ti software.

4.4. Preliminary Operational Validation.

Although the DAS has not yet undergone quantitative validation, its formulation was qualitatively contrasted with documented clinical experiences in Latin America (54), particularly in rural areas and among populations facing structural access (49).

The construction process of the Dynamic Algorithm of Suffering (DAS) was carried out through a mixed methodology involving documentary analysis, theoretical systematization, and expert consensus using the Delphi technique. The most relevant results of this process are presented below.

5.1. Systematization of Approaches and Dimensions of Suffering.

The Table 2 presents an integration of conceptual approaches and dimensions of suffering based on the main theoretical currents identified in the reviewed literature. Four central dimensions were recognized: physical, psychological, social, and spiritual, each with specific manifestations and sources of suffering, as reflected in the categories organized in the table. This analysis enabled the development of a theoretical matrix that served as the basis for constructing the algorithm’s indicators.

Table 2
Systematization of dimensions of suffering and associated theoretical frameworks
Dimension	Manifestations
Physical	Pain, fatigue, dyspnea, insomnia
Psychological	Anxiety, depression, fear, hopelessness
Social	Isolation, abandonment, family burden
Spiritual	Loss of meaning, guilt, moral distress

5.2. Consensus Evaluation Using the Delphi Method.

Table 3 shows the levels of consensus reached by experts during the Delphi rounds regarding the proposed indicators for each dimension of suffering. It was observed that over 85% of the items reached a consensus level ≥ 80%, considered acceptable for inclusion in the final model.

Table 3
Consensus levels achieved for indicators in each dimension of suffering
Dimension	Items Evaluated	Average Consensus (%)
Physical	10	93%
Psychological	8	91%
Social	6	86%
Spiritual	7	83%

5.3. Prioritization of Existing Clinical Tools.

Table 4 shows the prioritization of tools used in clinical practice for the evaluation of each dimension of suffering. Among these, the use of the FACIT-Sp scale for spiritual suffering, HADS for anxiety and depression, and ESAS-R for physical pain stands out.

Table 4
Validated instruments by dimension and their clinical applicability according to experts
Dimension	Instrument	Clinical Applicability
Physical	ESAS-R	Monitoring of physical symptoms in palliative care
Psychological	HADS	Evaluation of anxiety and depression
Social	Family Support Index	Assessment of social support and family burden
Spiritual	FACIT-Sp	Measurement of spiritual well-being in chronic illness

The DAS algorithm integrates these instruments within a dynamic evaluation system, allowing for synergistic articulation in diverse clinical contexts, especially in highly vulnerable settings in Latin America (Figure. 2).

The visual representations developed from the DAS model illustrate both the conceptual structure of suffering and its clinical functionality. Figure 1, presented as an axial mandala, depicts a static integral model that is useful for the initial identification and classification of suffering factors across the four core dimensions: physical, psychological, social, and spiritual. In contrast, Fig. 2 illustrates the dynamic process of the DAS, highlighting its adaptive, ethical, and evolving nature through feedback loops and ongoing evaluation.

These figures are not mutually exclusive but complementary. Figure 1 supports a relational understanding of human suffering and its origins (Gijsberts et al., 2019; Breitbart & Poppito, 2014), whereas Fig. 2 enables clinical decision-making structured by principles of proportionality, relational autonomy, and recognition justice (27, 45, 46).

The Dynamic Algorithm of Suffering (DAS) represents a conceptual and methodological innovation in addressing multidimensional suffering, particularly in the context of palliative care in Latin America. Unlike scales such as the FACIT-Sp or the Edmonton Symptom Assessment System (ESAS), which focus on measuring specific symptoms, the DAS proposes a comprehensive ethical-operational model designed not only to quantify but also to ethically interpret and respond to human suffering across its physical, psychological, social, and spiritual dimensions (23, 25, 27, 28).

The DAS is not limited to evaluating isolated clinical indicators; rather, it offers a dynamic and relational framework in which suffering is understood as a moral experience, beyond a mere clinical category. It goes beyond symptom-based assessment by integrating qualitative indicators, validated tools, and deliberative frameworks for bioethical analysis. Unlike other instruments focused solely on spiritual well-being or physical symptoms, the DAS brings these components together under a coherent ethical-operational logic. This enables support for complex clinical and ethical decision-making processes, particularly in contexts of high vulnerability in Latin America.

The Latin American perspective of the DAS lies in its cultural, sociopolitical, and spiritual sensitivity, reflecting the region’s structural and symbolic conditions. This model is built from realities characterized by inequity, poverty, religious syncretism, and the extended role of families in caregiving (12, 50, 55, 56). Therefore, the DAS does not seek to export models from the Global North but to create ethical and operational responses from and for Latin America, incorporating practices of spiritual accompaniment, narratives of suffering, and contextual normative frameworks (20, 49).

The DAS makes a substantive contribution to current bioethical debates, such as:

The visibility of spiritual and existential suffering, still marginal in many health systems (9, 16).
The incorporation of relational autonomy as a response to critiques of imposing individualistic decision-making models (57).
The integration of recognition ethics and narrative ethics, enabling the construction of compassionate medicine centered on the meaning of the patient’s experience (19, 51).

From a clinical perspective, the DAS offers multiple benefits:

It highlights non-physical suffering, especially spiritual and social (9, 16).

It facilitates shared decision-making by integrating the voices of patients and families (33).

It serves as a pedagogical tool for teaching clinical ethics from a holistic perspective (3).

It is applicable in low-complexity settings, adaptable to rural or marginalized regions (55)

It enables an evolving evaluation, tailored to changes in the disease process (58).

While pragmatic (time and resource use), epistemological (spiritual measurement), and ethical (intrusion into personal spheres) objections have been raised, the DAS offers robust responses grounded in deliberative frameworks, relational autonomy, and narrative interviews (41)

Moreover, the model requires empirical validation and institutional sustainability. The following are recommended:

Pilot studies in palliative care units.
Cross-cultural adaptations.
Interprofessional training sensitive to the ethics of care.

The DAS is not just another scale—it is an ethical compass for humanizing end-of-life care. It is a tool that recognizes unaddressed suffering as a moral failure of the health system. Its implementation can contribute to a Latin American bioethical reform centered on the patient’s relational dignity and the collective duty to accompany suffering with compassion. The algorithm advocates for a situated, flexible, and context-sensitive ethics based on the conviction that every unheard suffering constitutes a moral failure—and that only by listening deeply can truly compassionate medicine be achieved.

When suffering is reduced to a clinical or symptomatic category, it ceases to be a lived reality and becomes a statistical variable. This shift carries deep ethical implications, as it depersonalizes care, silences patients' voices, and hinders the possibility of truly compassionate care.

The Dynamic Algorithm of Suffering (DAS) proposed in this article aims precisely to counter this trend. It is not merely another technical tool, but rather an ethical and contextual compass, designed to support clinical decision-making through listening, relational engagement, and complexity. Its strength lies in its ability to articulate frequently overlooked dimensions—such as the spiritual and the social—with the operational demands of clinical practice.

Moreover, the DAS emerges in and for contexts such as Latin America, where suffering cannot be understood without accounting for its historical, cultural, structural, and spiritual determinants. This model not only provides a new tool for healthcare teams, but also challenges the dominant biomedical paradigm with a normative proposal grounded in recognition, narrative ethics, and relational dignity.

Funding

The author declares that no funding was received for the development of this manuscript.

Human Ethics and Consent to Participate Statement

This study was reviewed and approved by the Ethics and Research Committee of the Organización Clínica General del Norte (Barranquilla, Colombia). Individual consent was not required as no patients or identifiable personal data were directly involved..

Human ethics declarations and consent to participate

Not applicable.

Clinical trial registration number.

Not applicable.

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The authors declare no competing interests.

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Annex 1. Operational Guidelines for the Application of the Dynamic Algorithm of Suffering (DAS)

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An Ethical-Relational Algorithm to Map Human Suffering

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Abstract

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1. Introduction

2. Normative Foundation: Why It Is Ethically Imperative to Integrate Multidimensional Suffering

2.1. Suffering as an Ethical, Not Merely Clinical, Concern.

2.2. Structural Blindness and the Unjust Distribution of Relief.

2.3. Relational Epistemology and the Justice of Recognition.

2.4. Toward an Ethical-Operational Model: The Value of the DAS.

3. The Dynamic Algorithm of Suffering (DAS)

3.1. Origins and the Need for an Innovative Approach.

3.2. Core Principles of the Dynamic Algorithm of Suffering (DAS).

3.3. Internal and External Factors of Suffering in the DAS.

3.4. Adaptability to the Latin American Context.

3.5. Clinical Application and Ethical Decision-Making.

4. Methodology

4.1. Theoretical and Analytical Review.

4.2. Categorization of Existing Model.

4.3. Construction of the DAS Model: Delphi Technique.

5. Results

5.1. Systematization of Approaches and Dimensions of Suffering.

5.2. Consensus Evaluation Using the Delphi Method.

5.3. Prioritization of Existing Clinical Tools.

6. Discussion

7. Conclusions

Declarations

References

Additional Declarations

Supplementary Files

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