Accepted Manuscript

Isolation and Suffering Related to Serious and Terminal Illness: Metaphors and
Lessons from Albert Camus’ Novel, The Plague

Akosua N. Tuffuor, B.A., Richard Payne, M.D.

PII: S0885-3924(17)30315-9
DOI: 10.1016/j.jpainsymman.2017.07.046
Reference: JPS 9477

To appear in: Journal of Pain and Symptom Management

Received Date: 25 July 2017

Revised Date: 0885-3924 0885-3924
Accepted Date: 27 July 2017

Please cite this article as: Tuffuor AN, Payne R, Isolation and Suffering Related to Serious and Terminal
Illness: Metaphors and Lessons from Albert Camus’ Novel, The Plague, Journal of Pain and Symptom
Management (2017), doi: 10.1016/j.jpainsymman.2017.07.046.

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Isolation and Suffering Related to Serious and Terminal Illness:

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Metaphors and Lessons from Albert Camus’ Novel, The Plague

Akosua N. Tuffuor, B.A.

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Richard Payne, M.D.

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Running Title: Isolation and Suffering: Lessons from The Plague

Keywords: suffering, spiritual distress, burnout, doctor-patient relationship

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Word Count: 2,413 words

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Corresponding Author:
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Richard Payne, M.D.

Duke University
The Divinity School
Box 90968
Durham, NC 27708
Office (919) 812-4594
Fax (919) 660-3544
Email rpayne@div.duke.edu
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Abstract

Health care providers have much to learn from Albert Camus’ great novel, The Plague .

The Plague tells the story of a bubonic plague epidemic through the lens of doctor-narrator

Rieux. In addition to Rieux, this essay also focuses on the perspective of Father Paneloux, a

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Jesuit priest who provides important religious commentary on the epidemic, before falling victim

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to it and dying. Camus’ masterful engagement of the metaphor of isolation and its profound

impact on suffering emphasizes the important role of community and spiritual perspectives of

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patients and providers in coping with serious illness, death, and dying. The Plague is relevant

today, particularly given the challenges of distancing, alienation and isolation imposed by not

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only disease, but also by technology, and clinical and administrative practices that have
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unintended consequences of incentivizing separation between patient and healer, thus
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engendering greater stress and suffering in both.

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Introduction

Recognizing and responding to the existential and physical distress that causes suffering

during the course of a serious medical illness are the sine qua non of palliative care.1 To

maintain a clear vision of the sources of suffering in our patients, we can reflect on literature and

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the visual arts whose content addresses suffering. Albert Camus’ masterpiece , The Plague

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demonstrates how literature can provide insight into the multidimensional experience of

suffering and its impact on the patient as well as the caregiver. 2 Set in the northern African city

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of Oran in the mid-twentieth century, The Plague tells the story of a bubonic plague epidemic

through the lens of Rieux, a medical doctor. By addressing the struggle of an ailing community

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from Rieux’s perspective, Camus allows us to not only feel the internal struggles of the patients,
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but also the emotional effects of illness on the patients’ caregivers as well as the collapse and

revival of a community. Through the dialogue of several characters, particularly Dr. Rieux and
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Father Paneloux, Camus provides important commentary on the role of caregivers for the
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seriously ill, and the role of religion and spirituality in healing the dying. Dr. Rieux’ journey
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exemplifies the complexities of doctoring in desperate circumstances; he demonstrates important

aspects of professionalism, compassionate caring, and later, emotional burnout. Father Paneloux,
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a Jesuit priest, provides critically important religious perspectives on illness, suffering, death,

and dying during the epidemic; his religiosity serves as a foil to Rieux’s atheism.
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Isolation, Alienation and Suffering

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Palliative care practitioners must address psychological and spiritual distress in their

patients in ways that do not reduce it to merely another medical symptom. As chronic illness

compromises the integrity of the body, patients experience suffering that extends beyond

physical causes. Alienation from self, family, community, and even from one’s own God
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exacerbates suffering. Humans depend on social context to provide meaning to their existence.

Ironically, even hospice and palliative care programs may contribute to the isolation of patients

when they take on the reductionist culture of traditional medical environments, by approaching

suffering as a medical symptom, and making it difficult for their patients to maintain healthy

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connections to family and loved ones. As the late theologian Allen Verhey has noted,

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paradoxically the success of the palliative care movement in recent years may actually contribute

to isolation and alienation of patients. He said:3

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“The great advance of the inclusion of hospice care with health care coverage has risked
subsuming hospice care under health care…rendering death and dying medical events rather than human
events. The growing professionalism of palliative care…has been attended by the risk of breaking

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community with the dying. The expertise…can form relations of ’expert’ and ‘needy’ beneficiaries.
Worse, those of us who are not ‘expert’ and have ‘compassion’ may exercise it by sending the one
suffering or dying away, surrendering their care into the hands of the expert stranger.”
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As Verhey implies, the risk of sending sick people to palliative care experts ironically
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might exacerbate suffering by isolating the patients from a community of loved ones. Camus

illustrates the relationship between isolation and suffering when he compares the plight of the
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patient to imprisonment. Camus notes that many of the Oranians felt that “they had been
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sentenced, for an unknown crime, to an indeterminate period of punishment”.2 Camus’ use of the
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analogy to imprisonment captures the ethos of many patients undergoing palliative and end of

life care today. In order to combat a patient’s sense of “imprisonment”, the healing process must
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involve affirming the patient’s identity by restoring their social connections.

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Falling Into the Ditch-Emotional Burnout of Caregivers

Patients are not the only victims of the exhaustion, depression, and suffering associated

with the isolating effects of illness. Many palliative and hospice care professionals experience

compassion fatigue, a kind of emotional burnout that stems from constantly attending to patients

who face particularly gloomy prognoses.4 Dr. Rieux demonstrates signs of compassion fatigue
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as he cares for those dying from bubonic plague. While tending to patients, Dr. Rieux noticed

that, “[his sensibility] seemed to snap completely now and then, leaving him the prey of his

emotions. No resource was left but to tighten the stranglehold on his feelings and harden his

heart protectively”. 2 The intimate nature of healing people can often obfuscate the boundaries

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between a provider’s professional work and personal care work.4 Healing takes such a toll on

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Rieux’s spirit that he emotionally withdraws and sinks reflexively into a state of hopelessness

and personal defeat. For Dr. Rieux, like many of our contemporary non-fictional colleagues, this

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withdrawal serves as a putatively “protective” mechanism. Dr. Rieux understood that during the

plague “...a period whose end he could not glimpse, his task was no longer to cure but to

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diagnose. To detect, to see, to describe, to register. And then condemn (emphasis ours)--that was
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his present function”.2 Although the endless dying associated with the bubonic plague causes

Rieux to emotionally withdraw to avoid a profound sense of professional and personal failure, it
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also forces him eventually to reflect on his understanding of the difference between a failure to
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cure and a failure to heal.

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-insert Fig. 1 about here-

The artist Vincent van Gogh’s painting “Portrait of Dr. Gachet” captures the emotional
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weariness associated with depression similar to that of Dr. Rieux. One can sense Dr. Gachet’s

distress through observing his weary expression and his distant gaze that indicates his
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resignation. Of note, Van Gogh’s relationship with the real Dr. Gachet intensified in the artist’s
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later years when his health declined. In fact, both van Gogh and Gachet experienced periods of

deep depression. This underscores the unfortunate truth that doctors’ state of health can mirror

that of their patients—especially in the context of prolonged and intense interactions

characterized by death and dying. In fact van Gogh wrote a letter to his brother Theo in which
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he writes, “I think that we must not count on Dr. Gachet at all. First of all, he is sicker than I am,

I think, or shall we say just as much, so that's that. Now when one blind man leads another blind

man, don't they both fall into the ditch?”5

Religion-a balm to relieve, or a sword to exacerbate suffering?

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Spiritual and religious beliefs can either serve as a source of support in times of stress or

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can compound anxiety, depression and gloom. Father Paneloux experiences the latter as he

witnesses the death of others and eventually succumbs to the plague himself. Father Paneloux

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demonstrates how religious fervor can mask one’s complicity in human despair. The Jesuit priest

first preached a view of theodicy that required wholehearted acceptance of the suffering of

innocent people as a part of God’s divine plan.

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This authoritarian outlook on faith leaves little room to engage with the complexities of

death and dying, and provides no space for accommodating the very human need to lament the
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evil and suffering in the world. During one of his sermons Paneloux proclaims that, “the love of
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God is a hard love. It demands total self-surrender, disdain of our human personality. And yet it
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alone can reconcile us to suffering and the deaths of children, it alone can justify them, since we

cannot understand them, and we can only make God's will ours...That is the faith, cruel in men's
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eyes, and crucial in God's.2 However, following this dangerous advice would stifle palliative

care clinicans’ ability to connect to their patients through a bond of a common humanity that
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encompasses the need to question suffering. Paneloux’s beliefs do not encourage faith, but rather
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encourage an ultimately self-defeating sense of human resignation. In the end, Father Paneloux’s

own death reiterates how his authoritarian view of God’s will failed to grant him peace. When

Dr. Rieux offered to stay with Paneloux in his last moments of life, “...speaking with such

difficulty that it was impossible to tell if there was sadness in his voice, [Paneloux] said:
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"Thanks. But priests can have no friends. They have given their all to God.”2 Paneloux’s

rejection of Rieux’s offer to keep him company severs a tie to a human connection that could

have celebrated his individuality and role in the community. In other words, Paneloux rejected a

potential way to alleviate his existential isolation and distress. In the end, his inability to question

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the “hard love” of God proves to be its own source of suffering.

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Dr. Rieux, on the other hand, rejects the rigid Christian doctrine espoused by Father

Paneloux. Instead, Rieux not only accepts atheism, but embraces his spiritual doubt in order to

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find purpose in his work. During a conversation with another character, Jean Tarrou, Dr. Rieux

says, “since the order of the world is shaped by death, mightn't it be better for God if we refuse

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to believe in Him and struggle with all our might against death, without raising our eyes toward
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the heaven where He sits in silence." Tarrou nodded. "Yes. But your victories will never be

lasting; that's all." Rieux's face darkened. "Yes, I know that. But it's no reason for giving up the
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struggle." 2 It seems that Rieux’s “struggle against death” provides a foundation of compassion,
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that is, the ability “suffer with” (the Latin root of compassion)6 and to be affected and moved to
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action by another’s distress 4.

Help out of “the ditch”

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Shortly before his death, Father Paneloux appears to have engaged in some introspection

about his absolutist view of God. His sermon described a more collective experience of spiritual
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suffering, thus reminding us that in a healthy and truly healing relationship, doctor and patient
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are united in a bond embedded in a social context. He acknowledged that “for many long months

the plague had been in our midst, and we now knew it better, after having seen it often seated at

our tables or at the bedsides of those we loved. We had seen it walking at our side…[we were]

better able to comprehend what it was telling us unceasingly; a message to which...we might not
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have listened in due heed”.2 By emphasizing the ubiquity of the effect of the plague, Paneloux

legitimizes the experience of people’s suffering. Furthermore, he seems to recognize that the

ability of a community to respond to and absorb suffering collectively is an important step

toward individual and communal healing.

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However, as an atheist, Rieux might underestimate the powerful role that ritual and

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spirituality can play in the alleviation of suffering. In many religious traditions, rituals such as

singing hymnals, reciting sacred texts, and performing tradition-specific rites, reinforce the idea

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of belonging to and sustaining a community that can endure the spiritual pain of its members.

Healing narratives and parables in sacred texts often provide inspiration and illumination to the

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religious believer. Had Dr. Rieux been able to call on personally meaningful rituals, one can only
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wonder if he would have been able to climb out of the “ditch” of his despair to better manage his

patients.
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The physician-author Abraham Verghese reminds us that an important ritual in medicine

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is that of systematic touching of doctor-to-patient in the form of the physical examination.7 He

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notes that even in this age of technologically advanced medical care, the physical examination

remains an important diagnostic tool.8 Perhaps of equal or greater importance is the idea that the
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routinized physical touching of patients in the examination signifies a human bond between a

patient and a doctor-healer and communicates to patients that their doctors will not abandon
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them during their journey through illness. Unfortunately, deadly infectious diseases further
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isolate the patient from caregivers because they make physical contact risky, even dangerous,

thereby promoting greater distancing and potential suffering.

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Conclusion

The Plague’s masterful engagement of the metaphor of isolation and its profound impact

on suffering emphasizes the important role of community and spiritual perspectives of patients

and providers in coping with serious illness, death, and dying. Study of this novel is perhaps ever

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more relevant for contemporary health care providers and patients dealing with challenges of

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distancing, alienation and isolation imposed by disease, technology, and clinical and

administrative practices that seem to perversely incentivize separation between patient and

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healer, thus engendering greater stress and suffering in both. Furthermore, reading of this novel

can open the imaginations of healthcare providers and broaden their perspectives and approaches

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to address the isolating effects of serious illness on their patients and themselves. Spiritual
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perspectives and needs of patients and caregivers alike require assessment and intervention to

effectively cope with illness, death and dying. Palliative care providers indeed can learn much
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from a careful reading of Camus’ classic narrative.

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Figure 1. The Portrait of Dr. Gachet. Vincent Van Gogh. Oil on Canvas. 1890. Musse d’Orsay.

Paris.

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References

1
WHO Definition of Palliative Care. http://www.who.int/cancer/palliative/definition/en/. Accessed May 3,
2017
2
Albert Camus. The Plague. London, Allen Lane, 2001 (translated by Robin Buss)

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3
Allen Verhey. Reading the Bible in the Strange World of Medicine. Wm.B. Eerdman’s Publishing, Grand
Rapids, MI, 2003, p. 63-64
4
Leadoux K. Understanding compassion fatigue: understating compassion. Journal of Advanced Nursing

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2015;71:2041-2050
5
Vincent van Gogh. Letter to Theo van Gogh. Written 10 July 1890 in Auvers-sur-Oise. Translated by
Robert Harrison, edited by Robert Harrison, number 648.

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http://webexhibits.org/vangogh/letter/21/648.htm. (Accessed May 3, 2017)
6
Online etymology dictionary. http://www.etymonline.com/index.php?term=compassion. (Accessed May
3, 2107)

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7
Verghese A. A Doctor’s Touch. TED Global, July, 2011.
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https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. (Accessed May 3, 2017)
8
Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis J. Inadequacies of physical examination as
a cause of medical errors and adverse events: a collection of vignettes. The American Journal of
Medicine 2015;128:1322-1324.
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