The following articles, which deal directly with quantification in at least one significant passage, were identified as figuring on the website (www.panetics.info) of the International Society for Panetics on the 12th of February 2001. Panetometric comments, by Robert Daoust, and relevant excerpts (that can be seen by clicking on the titles) are given for each article. The present document is a part of an ongoing work that is described on the webpage entitled "Quantification Research about Suffering at the ISP".

Panetometric comments - Quantities in pain and suffering can be measured in function of external stimuli or events, and of internal modulations. Some such factors are mentioned. Pain can often be measured against a direct external referent, but suffering is too primarily a product of the central nervous system to permit such a direct correspondence. Besides, an observer is influenced by empathy or non-empathy when he or she measures a suffering.

Panetometric comments - Boulding proposes an analytic quantitative tool for decision-making that would include non monetary valuation elements, such as suffering, power, security, welfare… I propose to call it the "Boulding's cost-benefit analysis". The tool would work only if no value is considered to be "absolute", and if we formally address the question of "whose" costs and "whose" benefits are to be included in the calculations.

Panetometric comments - It is suggested that decision makers should have panetic estimates of alternative courses of action, i.e. "balance sheets" showing the relationship of financial costs to human suffering (cf. Boulding's cost-benefit analysis). At the time of the siege against the Davidians near Waco, an estimation of dukkhas and financial costs made by Davis showed prophetically, according to the editor's later addition to the Davis' article, that the decision to end the siege should have been taken as soon as negotiations were at a standstill, in order to minimize both cost and suffering.

Panetometric comments - In this example of panetometric analysis by Davis, the concurrent consideration of costs in dollars and in dukkhas brings us very close to a Boulding's analysis. The basis for the dukkhas calculation is intensity level 2, 16 hours per day, for each smoker. The rationale for this intensity and this duration is not clearly stated : we are left to think that level 2 multiplied by a daily duration of 16 hours constitutes a representative "average" of the suffering endured by smokers. I wonder if this kind of averaging should be generally adopted in order to bypass the impossible task of assessing all the variations of intensity and of duration in a given problematique. There would be at least one proviso : the assumptions and operations leading to the average should be clearly presented.

Panetometric comments - In this example of panetometric analysis by Davis, dukkhas (on the basis of intensity level 3, during 15 seconds, for each person exposed to one hi-noise aircraft takeoff) are used to quantify suffering within the framework of a policy-making issue. Costs could be weighed against suffering (cf. Boulding's cost-benefit analysis).

Panetometric comments - Philosophy (or epistemology or critical study) of panetometry should take note of the view that "objective quantification for the purpose of control" may be a source of problems rather than of solutions.

Panetometric comments - In the light of Widner's suggestions about methodology (4 conditions and 4 challenges), and with some references to Saunders' suggestions about connecting people to remote causes of their suffering, Fisher examines the relevance of "decisional panetometry" to the issue of food and drug safety. A good starting point would be to work out panetic tables that describe the complexities and trade-offs of this issue.

Panetometric comments - Galtung asserts that five constitutive principles can be found in the concept of the dukkha unit.
1- Humanism or personalism (Man, or sentience, is the measure of all things).
2- Subjectivism (I am the only judge of what is my situation with respect to suffering).
3- Egalitarism (all dukkhas are equal, there is no worthy or unworthy sufferer despite widespread tendencies to affirm the contrary).
4- Impossibility for dukkhas to be averaged with a supposedly positive counterpart like the measure of pleasure or happiness (people who have reasons for suffering do not suffer less because they may have reasons for being happy).
5- Independence from theories or ideologies (ideas about causes, kinds, or roles of suffering are not taken into consideration).
First applications of the dukkha could lack accuracy, but the measure would still be of immense value because of these principles. For a critique of Galtung's views, see Striner's Quantification and Values : Error or Confusion?

Panetometric comments - Inasmuch as the prevention and relief of suffering is a paramount goal for patients and health care workers, this goal should be a criterion for decision-making, and various tables that present quantitative data about suffering should be developed to allow more humanely cost-effective formulation, selection, and improvement of options for medical treatment and health care plans. Some illustrative panetometric tables for medical purposes are given (not available in the Web versions of the articles), showing the numbers of dukkhas, of cases (incidence), of dollars, and of days that can be related to certain illnesses or treatments. An interesting quotient is shown : the "econo-panetic efficiency" of a treatment or of a policy, expressed as dukkhas divided by costs. Another especially interesting number is the estimate of dukkhas typically attributed to an illness or to a treatment… Complete sets of such panetometric tables should be developed with data taken from existing medical literature, vital statistics, and public health statistics. Four sources are mentioned for assessing suffering intensity : sufferers, professional caretakers, instrumentation, and social indicators (incidentally, I note that pain is beginning to be considered as the fifth vital sign in medical practice, next to temperature, pulse, blood pressure, and respiration : we can already see bed charts that include inscriptions at regular time of pain intensities stated by patients, and eventually we should be able to draw new knowledge by compiling these charts). The authors add that medical dukkha tables could also includethe amount of suffering generated in others by a given illness : for example, the dukkhas flowing from the worries of the family members, the final burdens and associated sacrifices on the part of those who have to pay the bills, and the sadness and hardships of bereaved dependents. Let us note that the actual process of putting up these tables would teach us much on how to make them and on how to improve them.

It is proposed to measure suffering in dukkhas because of the following advantages :
1. The precision and accuracy is adequate for the purpose and context at hand.
2. The basic data is the direct personal estimates by the sufferer (how bad, how long, how frequent are your sufferings?).
3. The manipulation of the basic data to provide the final figure for quantity is logically sound.
4. The procedure is sufficiently simple, so that even laymen with minimal education are capable of using it to estimate their own amounts of suffering flowing from various sources and causes.
5. No special equipment is required other than paper and pencil.
6. The method is universally applicable for all individuals, institutions, governments, kinds of sufferings, conditions, and so on, so that comparative analyses, choices, and judgments can be made.
7. The ease and reliability of eliciting the necessary inputs to the calculations have been demonstrated in actual use for some time (see pain assessment in medical practice).

Panetometry introduces a new paradigm in science, with widespread consequences in medicine, government, business, social sciences, jurisprudence (for ex., increased uniformity and "fairness" in the award of damages for suffering in legal suits), insurance (for ex., higher predictability and confidence in the setting of related premiums), etc. I think that philosophy of panetometry would learn much, for the development of the discipline, from what Thomas S. Kuhn and other such thinkers have written on paradigmatic shifts.

Panetometric comments - One dukkha corresponds to the amount of suffering endured at intensity level one for one day by one person. This is a convenient magnitude for a unit of measure dealing with human suffering. I suggest that the usual or standard verbal description of the 9 degrees of intensity (1- Noticeable 2- Bothersome 3- Moderate 4- Considerable, seeking relief 5- Interfering with daily life 6- Quite A lot 7- Miserable, visiting physician 8- Excruciating 9- Unbearable) should definitely be improved : we can have recourse for that to the terminology of "pain questionnaires" that have been extensively studied in the field of pain research. I bring to attention that the 9-steps scale, which Siu favored because it has an easy-to-find middle point at 5, can actually be seen as a scale with 10 levels if we allow fractional degrees between 0 and 1 and between 9 and 10.

I suggest that panetics and panetometry should have more than one measure to deal with suffering : (1) the Siu's dukkha, (2) the neo-dukkha or NDK (see here above; the appellation NDK would also permit to avoid the impossibly awkward spelling of the word d-u-k-k-h-a), (3) the extra-dukkha or XDK (see here above), (4) the weighed dukkha or WDK (see comments on Striner's article), (5) the "case of excessive (or extra-aversive) suffering" (that would be a kind of epidemiological unit), (6) the "noxiousness" system of units (measuring the dukkhas-producing potential of various stressing conditions that can be inflicted to elicit suffering)…

Panetometric comments - An extensive literature can be found on the subject of pain or suffering measurement. It is panetometrists' responsibility to establish comprehensive bibliographies, and to review periodically what is published in the field.

Panetometric comments - Ten axioms and ten laws are very tentatively proposed as basic panetic principles. Some of them belong to the philosophy of panetometry, and some other could eventually be reformulated to become panetometric hypothesis to be tested within specific research projects.

Panetometric comments - Poverty can cause suffering, wealth can alleviate it : is it possible to work out a dukkha-to-dollar scale that would express this axiom quantitatively? Langmuir tries and fails, but he admits that his starting assumptions are questionable. I think that one data he should have taken into account is the psychological surveys which show that as far as subjective well-being is concerned, money makes a difference only below one level of revenue : the one at which you have enough to live. Above that level, more or less money does not by itself make you more happy or unhappy. Seeking a conversion formula between dollars and dukkhas is natural, because we see that suffering and money are linked in many ways… However, I think that a dukkha-to-dollar scale would have to be worked out for every different problematique in which money and suffering are involved… A universal dukkha-dollar correlation is probably nonexistent.

Ten years after Ralph Siu asked the question : "Can we formulate a semi-quantitative unit of suffering for evaluative purposes?", Langmuir expresses doubts and asks : "What would panetics be without the dukkha?". One answer can be found in Striner's Toward a Values Based Methodology for Panetics. Another answer would be to furnish objective, repeatable evidence that the basic concept of the dukkha is valid and useful.

Panetometric comments - Bentham mentions seven circumstances that affect the value of a (actual or potential) pleasure or pain : 1- its intensity; 2- its duration; 3- its certainty or uncertainty (how sure are we of its existence?) ; 4- its propinquity (proximity) or remoteness (is it present or more or less future?); 5- its fecundity (how much sensations of the same kind does it necessarily brings about?); 6- its purity (how much sensations of the opposite kind does it necessarily brings about?); 7- its extent (how many people are affected by it?). Bentham's opinion is that quality of life can be expressed as a ratio of people's pleasures divided by their pains. I believe that panetics does not have to share this utilitarianism, because values cannot be reduced entirely to affectivity. Moreover, I think that pleasure and pain are two separate, independent phenomena that should not be considered as two opposites, except in a narrow "qualitative" sense. It is granted, however, that pleasure may be a value which has to be included, along with suffering and other affective or non affective values, in processes of panetic decision-making.

Panetometric comments - A quantitative measure of suffering could have many uses for humanitarian organizations, national governments, international agencies, the international community as a whole, and all those who have to deal with problems related to refugees and displaced persons. Limits of tolerance to suffering differ widely between individuals or cultures, but the "subjective discrepancies in direct and trans-personal appraisals of suffering lie well within quite technically manageable proportions". Social indicators that are already in used could be integrated with newly devised quantitative measurements of suffering to allow for a more comprehensive, thorough-going approach.

Panetometric comments - Michael worries about accuracy of dukkha measurement : well, a science become more valuable by becoming more accurate, and this comes with time and practice… Let us be optimistic for widespread acceptance of new measurements concerning suffering : in social sciences, it often happens that approximate judgmental indicators (e.g. the Consumer Price index, the poverty threshold) assume over the years the status of objective indicators.

Panetometric comments - In a lecture that is in part relevant to philosophy of panetometry, Saunders argues that, as far as policy-making is concerned, the challenge is not to quantify suffering but to give a new meaning to the concept of suffering in people's conceptual frameworks or mindsets. He suggests valuable ways to do that, but none seems really new or sufficient. Perhaps he has overlooked one thing : could quantification of suffering provide the needed new conceptual meaning? Introducing a measuring "lens" for suffering would surely "makes a big difference how issues are named and framed for deliberation". It could modify views not only in technical or objective dimensions of decision-making, but in deliberative or subjective dimensions as well. As for Saunders' question on what the connection is between citizens and distant suffering, I think it all depends on allegiances (or on what Bentham calls sympathetic bias) : from the self to the cosmos, and between the most far-off past or future, there are various groups or individuals for whom our compassion may be more or less excited, depending on how much our loyalty or devotion to them is a part of our mindset. Perhaps the "egalitarism" of the dukkha, or the "universalism" of quantitative numbers, would have a broadening effect on the citizens' conceptual frameworks! Another, more panetometric answer to Saunders' question could be that the more we let happen avoidable suffering in humans or animals, the more probable it is that we ourselves come to suffer monstrously! In any cases, when it is possible, we should take care to point to the connection between people and the remote causes of their suffering.

Panetometric comments - Siu here mentions some of his grand visions that are relevant to futurology in panetometry : gross national dukkha, gross global dukkha, overall equation of human well-being (into which is melt the generation and expenditures of dollars with the infliction and alleviation of dukkhas), unified mathematical theory of humane capitalism, international flow of dukkhas and antidukkhas… It may take 50 years before such things happen, he says, though many could also happen in a span of 6 years if political will was there. What can we do for now? Siu mentions a short-term possibility that is perhaps within our reach : "Any sophisticated polling body, like the Gallup organization and the New York Times-CBS News, can come up with a reasonably fair estimate of the running GND within a relatively short time." Such a service is unaffordable for us now, but national and international surveys have been made in the past about a lot of questions with which we are concerned, even about such things as people's happiness or unhappiness : our forthcoming Annual Handbook on Suffering could take advantage of those surveys, and for the future, we could perhaps get associated with pollers to suggest new contents and methods.

Panetometric comments - First, let us recapitulate Striner's position. Egalitarism is one of the constitutive principle of the dukkha unit, according to Galtung, but egalitarism cannot be accepted without restrictions under all conditions : equity, justice, or ethics often call for differentiation between less or more worthy sufferers. Errors in quantification may be allowed, because scientific progress is made through them, but confusion in values may not : since we measure suffering for lessening it, we should take into account not only intensity, duration, and the number of persons involved, but also values. But value-weights cannot be attributed in an objective, credible, impartial manner. Even with regards to value-free quantification, there can be no purely egalitarian measure of suffering : two measurements cannot be compared because there are differences between people, or between external events, or within the same person at different times. Moreover, in so far as suffering is a private emotional experience, the dukkha is perhaps as meaningless, as useless, and as misleading as would be a quantitative unit called the "christo" for measuring a Christian's level of faith! For all these reasons, the best that panetics can do is to develop, on one track, a credible (probably limited) source of quantitative data, capable of satisfying some aspects of a quantitative model, while on another track, since quantification is not the only way to develop a science, panetics should develop a methodology anchored in the use of a values-based model.

For the latter model, Striner suggests to resort to his decisioning analysis, a method that deals with the relationship between values, assumptions and policies in the decision-making process. We can make a connection, I believe, between Striner's decisioning and Boulding's cost-benefit analysis : Striner speaks of what is right for someone and of personal values systems, while Boulding speaks of one's best interest and of identifying what persons are considered when costs and benefits are calculated… Both authors suggest ways to assess suffering as a factor in a decision-making process. Could we make use of a Boulding-Striner analysis in panetics?

Striner's critique of the egalitarist dukkha seems beside the point as far as quantification is concerned : we have to know how much a person suffers, no matter how much worthy or unworthy he or she may be, and problems of individual or circumstantial differences can probably be attenuated by developing more finely tuned measurements or averagings… However, as far as values are concerned, suffering should be "weighed", but then it must be noted that a weighed dukkha constitutes a different unit than the Siu's dukkha, and it should have another name (the WDK?). A suffering is perhaps always more or less inherently negative, but it may be seen as more or less instrumentally positive or negative. The instrumental value of a suffering should be expressed by a weighed dukkha, the weight-value being dependent on the appraiser's preference. About qualitative, subjective, or private aspects of suffering, let us recall, as we do in comments about Whittemore's article, that the role of quantification is not at all to capture the "unsliceable wholeness of feeling and true knowledge" by a means similar to the "christo" unit. Panetometry is only a part of an integrated, evolving study which is dedicated to approach the subject of suffering in all its ramification. In any event, we should handle a gross national dukkha with as much discernment as a gross national product!

In relation with Striner's critique, I see some other problems related to the definition of the intensity component of the dukkha. On this matter, please refer to comments on ISP's document The Dukkha.

Panetometric comments - This article is partly different from Striner's Quantification and Values : Error or Confusion?, but passages relevant to quantification are the same.

Panetometric comments - Bentham's utilitarianism is a relativism because it opposes pain and pleasure, while Siu's negative utilitarianism (least suffering for the least number of people) would be an absolutism, as is the ideology of human rights in the opinion of Hannah Arendt for example, because it favors only one paramount value. I don't think that panetics has to be utilitarian. Values cannot be totally reduced to affectivity like Bentham does, and they do not even have to be arranged in a hierarchy of superiority-inferiority : they can be envisioned as forming an ecological web in which each has its own interdependent function. Moreover, if any (anti)suffering is an absolute value, no "Boulding's cost-benefit analysis" is possible.

Whittemore seems anxious about quantifiers' mischiefs. We can agree with him that we are in many ways victims of greedy, power-hungry, quantitatively oriented perception manipulators. But as scientists, we must share our belief that quantification is indispensable for modernity and progress. Panetics is precisely a quest against the wrongdoers, including ourselves... Whittemore also questions the validity of quantification for suffering, saying that it cannot capture the "unsliceable wholeness of feeling and true knowledge". Let us recall that quantification is only a part of an integrated, evolving study that is dedicated to approach in all its ramification the subject of suffering.

Panetometric comments - Widner's experiment in Georgia is certainly, to this day, the most extensive exercise in panetic quantification. The author, who admittedly used incomplete data based on a few surveys and on casual conversations with Georgians, comes to the hypothetical number of 17,510.9 megadukkhas of suffering inflicted yearly by acts of corruptions in that country. This number of dukkhas is the sum total of estimates made under 21 categories covering the scope of the problem (as a result of a detailed panetic analysis). Of course, our new panetometric methods used to quantify suffering presents several anomalies. For example, Widner acknowledges that because our efforts to alleviate suffering should always focus on those people who suffer most intensely, panetics must develop a means to take this into account in its weighting and calculation of intensities. Another anomaly that I personally find conspicuous is the overestimation of the number of dukkhas when it is assumed that people are suffering from a certain cause 24 hours a day, 365 days a year, at a given average intensity : duration and/or average intensity should be very much lower. Except for such anomalies, Widner's attempt to assess suffering caused by corruption in Georgia seems to be exemplar in its simplicity, even if the author notes that in such a complex situation, panetic quantification would call for "capabilities rivaling those necessary to create a highly sophisticated econometric model". Strangely, the author argues that in a context of emergency such as the one in Georgia, and in the present stage of panetic development, it might prove more efficacious to report the result of a panetic analysis of corruption in economic terms rather than in terms of suffering and dukkhas, because economic data are available more readily, are understood best by the users and audience, and are an adequate index of well-being. I am skeptical! While a novelty like panetics can perhaps profit from being associated with an older approach, I wonder if economic or social units of measure can convey the new specific understanding that panetics is proposing for the betterment of people's fate... If they can, why don't we do social economic analysis rather than panetic analysis? If they cannot, why should we put in the foreground socio-econometric data rather than panetometric data?

Panetometric comments - The principal objective of Panetics is to develop and see applied quantitative measures of human suffering that help guide decision-making toward alleviation of that suffering, says Widner. Most conditions (opinion trends, familiarity with social indicators, institutional capacity and purpose) are in place for the use of applied panetics in collective governance. What is still lacking is a method for values-based decision making. This has been evoked in my comments on Boulding's and Striner's articles : weighed dukkhas are needed to decide about trade-offs between suffering and other values, and the chosen weight-values cannot be universal, they depend on different appraisers' preferences. Each context may require its own set of weight-values, not only for suffering but also for other interests involved. In that respect, Warfield's process and systems for taking into account diverse values and expectations can probably be usefully (a Boulding-Striner-Warfield analysis?). What is also lacking for the implementation of applied panetics is an extended set of panetometric tables, like the medical tables presented in Geelhoed and Siu's article. Such quantitative data lists should be developed for spheres other than the medical sphere, like justice, security, foreign policy, education, social services… In addition, regularly-employed social or economic indicators should be integrated into the panetometric toolbox, and this is what we are beginning to do in our forthcoming Handbook on Suffering. Eventually, development of applied panetometry will have to be carried on by universities and governments.

Panetometric comments - This article is partly the same as Widner's Four Big Methodological Challenge.

Panetometric comments - This article is essentially the same as Widner's Application of Panetics to Government Decision Making.

Panetometric comments - Decisional (or normative) panetometry : this is how I suggest to call the study of panetic decision making when quantification is involved. I suppose that in order to develop decisional panetometry we could resort to plenty of works dealing with the use of mathematics in decisions, especially in ethical decisions. A bibliographical research would be helpful. I have a feeling that the field of calculation with qualitative values is still deficient, but that panetics may pretend to an original contribution in the qualitative as well as quantitative mathematical handling of suffering. Though It is clear that decisions will remain made by human beings who cannot be reformed by any means in our possession now, bringing better quantitative and qualitative data on suffering would represent a concrete progress which can lead to at least some ideological changes.

The present Widner's article is akin to Widner's Application of Panetics to Government Decision Making, but it adds new details that are relevant to decisional panetometry. To address the challenge of complexity and trade-offs, it proposes to develop graphical and analytical conventions in the line of those offered by Siu (flow of dukkhas and antidukkhas between entities) and by Langmuir (system of dukkhas aggregation, and curve of concern). For the challenge of foreseeability, it proposes to develop procedures for anticipating and monitoring panetic consequences, and for adjusting decisions. For the challenge of time limits, it proposes to prepare in advance "panetic contingency tables" in much the way military, foreign policy, or natural disaster contingency plans are prepared by policy-planners. For the challenge of conflicting perceptions and values, it proposes to adapt John Warfield's procedures for facilitated "Interactive Management", so as to help individuals of very divergent views to come together, agree on a definition of the problem, evaluate intensities of suffering, rank consequences of inflictions or alleviations, establish a sufficient level of trust to reach consensus on what strategies are likely to ameliorate the problem, decide on trade-offs, settle on a decision, and agree on who has responsibility for implementation.

Panetometric comments - Social indicators, such as the ones presented by the Miringoffs in their book The Social Health of the Nation, are definitely an important tool for the measurement of suffering and for "decisional" panetometry. The use of indicators in the forthcoming ISP's handbook on suffering will be a first step toward developing a collaboration between us and people interested in social indicators.

It is essential that we keep in mind the distinction between pain and suffering.

Both are certainly influenced by subjective factors--compare the apparent experience of the religious martyr being burned at the stake with that of the individual trapped in a burning vehicle.

Pain, however, as customarily defined, is a result to stimulation of pain receptors located throughout the body (except in the case of central nervous system disease such as tumors, affecting the central pain centers). As such, the experience of pain can be measured against a standard stimulus to a group of those peripheral nociceptors, as, for example, in the application of a known amount of heat energy to a measured area of skin, or in the restriction of circulation--and consequently oxygen--to the arm, both for a determined period of time. Identical stimuli will not be similarly perceived by different people--or even by the same person at different times--because of the multiple synaptic steps between the stimulation of the pain receptor and the conscious perception of the pain, or even a reflexive response to the stimulus, such as withdrawal of a pain-stimulated extremity; a "gating" system, largely controlled by higher centers in the brain, has been identified within the spinal cord itself that controls the progress of the pain impulse, and while not as well defined, similar modulators doubtless exist within the brain.

Suffering, in contrast, is purely a mental phenomenon, a product of activity within the central nervous system. I know of no way to determine an external referent for it. (…) In medical/psychological terms, suffering is a consequence of injury to the ego, a result of an event that is unexpected and felt to be undeserved. It ranges from being treated badly-disrespectfully--in an encounter with another, to something untoward happening, whether it be illness or economic deprivation. Individual expectations, largely based on life experience, obviously play a key role here, from how one thinks one "ought" to be treated, to notions of personal invincibility/immortality, to concepts of opportunity and entitlement in a just society. (…)

As humans, we seem to be "hardwired" to compassionately respond to the image of a suffering human--something that both confidence men and public relations people recognized long before it was scientifically confirmed by the sociologists. This has been attributed to a "sympathetic identification" with the sufferer, a "like me", and "There, but for the grace of God..." reaction. Yet not all respond compassionately. The role of personal experience in influencing this response to suffering is complex and difficult to define. (…)

As an economist, I would have to say that Panetics has to come to grips somewhere along the line with cost-benefit analysis.

(…) Cost-benefit analysis is a kind of balance sheet which comes up with a "bottom line" of net worth. I have argued that we should perhaps expand this to "net worthiness" to include valuation elements that cannot be reduced to monetary measurement.

If suffering is seen as a cost, then if the overall value of the benefits resulting is larger, then suffering is justified in terms of "net worthiness". Then a very important research question arises: what are the circumstances under which decisions are made which, in terms of some overall system of valuation, imposes costs which are less than the benefits?

Here we face some very tricky problems in the study of decision. Economists, of course, are rather obsessed with the principle of maximizing behavior, but the principle that people do what they think is best at the time, which underlies the mathematics of maximizing behavior, seems to me one of these things that might be called a "near identity," something that almost has to be true. Then the question arises, of course, as to whose costs and whose benefits are included in these calculations. The torturer inflicts pains, perhaps in part because he is a sadist, in part if he doesn't he will lose his job. This is a very narrow view of what is "best at the time." The person who orders the torturer, who pays the torturer, does so because he thinks the example of carrying out a threat for the information obtained or something is worth the increase in power or security which he believes, perhaps wrongly, that it gives. When Truman decided to drop the bomb on Hiroshima and Nagasaki, he no doubt thought that the suffering involved would be less than would be involved in an invasion of Japan.

The question is therefore, what kind of social institutions and structures diminish the probability of "bad decisions," those in which the net benefit, that is, benefit minus cost, is negative, or at least less than it might be if other decisions had been made in terms of what might be called "mature" structure of valuations?

This perhaps breaks down into two further questions: what are the learning processes by which people improve their estimates of costs and benefit? And what are the processes which make it more probable that people in positions of power will have both more accurate estimates of future costs and benefits and a mature value system that covers not only their own power and welfare but the whole state of the world? Under all this perhaps lies the question of what are the learning processes in the world and the institutions which promote these learning processes which are most likely to improve net benefits?

We also have to recognize that over against cost-benefit analysis, even in its more refined form, there may be an ethic of absolute values. (…)

(…)

Assume that there were 81 colony people and 300 government personnel involved. Assume that 16 government personnel were wounded, spent 2 weeks in the hospital and 5 weeks with outpatient care. Assume that 8 colony people were wounded, without hospital care for 51 days.

Calculations appear as follows:

Govt.: Wounded--16; in hospital 14 days at intensity 7 suffering = 1568 dukkhas. On outpatient basis, at intensity 5 suffering x 35 days x 16 = 2800 dukkhas.

Within the colony: Wounded--8, with crude medical care; 51 days x 8 persons x intensity 8suffering = 3264 dukkhas.

Colony under siege: limited food, watch hours kept, sound disturbance, siege conditions: 81persons x 51 days x intensity 4 suffering = 16,524 excess dukkhas.

Govt. personnel: 300 mounting 24hour watch, tent living, food, maneuvers, exposure to cold: 300persons x 51 days x intensity 3 suffering = 45,900 excess dukkhas.

Total increase in pain and suffering: 65,880 dukkhas. (Suffering of 1 person with mild toothachefor 8 hours equals one dukkha.)

Govt.: cost $51 million through 51 days of siege.

Looking at future:

Every additional day of siege generates 1288 dukkhas of added suffering and costs $1 million. In other words, $7813 generates or sustains or is accompanied by one dukkha of suffering. Government spending is thus connected to suffering at Waco. A continued standoff creates additional pain and suffering.

Siege has reached a steady-state condition. Both sides appear to have talked themselves out. N results from this effort. Only visible future milestone is an exhausted food supply in one year.

Negotiations essentially exhausted.

To continue siege up to one year: over 400,000 dukkhas of suffering imposed; $314 million would be the estimated government cost.

(Note by Robert Daoust : the following sequel has been added by the editor in 1993, within the original article, but after the end of the siege)

Worst case scenario (actually happened): 80 persons die. Average economic worth of person =$3501000 Loss: 80 x $350,000 = $28,000,000 lost economic value to society.

Cost to taxpayers (society) on 51st day: already about twice this 'value' of deceased commune people lost to society. This "value' will be exceeded each 30 days of additional siege. Yet we cannot expect a smart political leader to follow these numbers directly in his reasoning. He could not have predicted the loss of life without access to kinds of information apparently not available to him. Nor does he place a dollar 'value' on human life, yet he will assess in his mind the fact that the commune people are zealots; have isolated themselves from American social life; probably pay no income tax; produce little if any jobs, productivity, or cultural contributions to society. They have withdrawn and isolated themselves as a matter of choice. He will also assess the burden of $1million per day, the energetic scrutiny of the media people into every aspect of the Waco standoff and the embarrassment, of government at having failed on the initial approach. Covering these grim considerations is the heavy overlay of emotional arguments and rhetoric which are brought to bear on the decision making.

The panetic analysis would indicate that government should take steps to conclude the siege even earlier than 51 days. Once again, most errors throughout this episode have been in the execution of plans: failure to avoid swat team operations on an armed colony previously alerted and failure to understand cultism, when a colony with a fanatical leader is under siege and with murder charges hanging over its leaders.

In all probability, first things were not done first. Ideally a thorough assessment of cult behavior–with projected reactions–would have been first. It is an assessment as to whether BATF cadres were trained and equipped to deal with a heavy armed cult group. As a wild conjecture, it could be that a group of Seventh Day Adventist preachers would have been the best group of initial negotiators! Probably, the BATF field troops with flak jackets and automatic weapons were not trained properly to deal with cultists made desperate by a confrontation. Interesting, no one has said much about why the Waco Davidian group acquired such a big armory, and what they felt the threats were, from which they needed protection.

The decision to end the siege should have been taken as soon as negotiations were at a standstill, in order to minimize both cost and pain and anguish. Instead, lacking a panetic analysis, apparently the top leaders waited until the field forces got tired of the siege inactivity, and a tricky way to inject tear gas, etc. into the compound was devised and presented as a logical next step.

When the Attorney General, or other leaders, ask, "What are the options?" or "What are the alternatives?" they should have available such panetic estimates of alternative courses of action.

(…) The decision-maker should have in hand at least a close estimate relating tobacco tax revenue dollars with lives lost and suffering caused by nation-wide smoking under (1) present conditions, (2) after imposing a 50 cent added tax per pack, and (3) after imposing a $1.25 added-tax per pack. (…)

An estimate of the annual direct pain and suffering caused by smoking over that experienced by the remaining population would be 46 million smokers times an intensity level of 2 times (allowing 8-hours sleep per day) 365 days per year, or 32.6 billion dukkhas or: (46,000,000) x (2) x (365) x (0.67) = 32.6 billion dukkhas/yr. The intensity level of two is on a scale of 1 to 9. A level of two is 'bothersome' discomfort. The dukkha is found by multiplying the intensity level times the number of days it is experienced. The intensity level of 2 is estimated for this large population to recognize, beyond nonsmokers, the increase in coughing, colds, sinusitis, headaches, digestive problems, etc., accentuated by smoking. It also includes high intensity suffering leading to the annual 390,000 deaths due to smoking. (…)

In the case of a 50 cent tax 2.5 million smokers will quit. These millions would experience a reduction in pain and suffering due to less frequent colds, headaches, aches and pains in the joints and to the extreme distress of emphysema, fright and pain of heart attacks,, the extreme pain associated with lung cancer, surgery, chemotherapy treatments and, in many cases, terminal illness. Most of the expected 21,000 annual early deaths due to smoking in this group will be avoided. Estimating across this spectrum one might conclude that two dukkhas times 365 days times 2.5 million new nonsmokers, allowing eight hours of sleep, might encompass the reduced pain and suffering by 1.25 billion dukkhas. Of these 2.5 million new non-smokers, avoidance of early death by 21,000 per year at an average cost to society of $650,000 each would save $12.7 billion. (Avoided losses per person include average wages of $30,000/yr. and taxes for average of 20 years.) Additionally, health service costs would be reduced (based on experience of the Maryland Dept. of Health) by about $1.35 billion per year gradually toward zero dollars over the following 5 years. Absenteeism costs caused by smoking would be saved: calculated as 15 days/year at an average salary of $30,000 for 2.5 million smokers equals $5.0 billion/yr.

In the case of a $1.25 tax , we might expect a reduction of smokers by 5.4 million using the same method of calculation as shown above. With respect to pain and suffering, these 5.4 million would be spared an estimated 2.65 billion dukkhas per year induced by smoking. This reduction in pain and suffering is so large it cannot be ignored as a major factor in the minds of political and government officials. About $30.4 billion will be saved by avoidance of death by 46,800 of this group, and about $3.0 billion in health costs would be saved. The cost of absenteeism due to smoking would be saved: $12.9 billion. (These savings are to society. Partly they will be lost wages saved and partly costs to industry saved by avoidance of lowered efficiency and salaries paid in absentia. Both should be very important to the decision maker.)

(…)Number of people in flight path affected by aircraft takeoff noise (1000). Each takeoff affects 1000 people in the 5-10 mile by I mile takeoff path for 15 seconds. Number of takeoffs per aircraft/year (750). (…) Initial Conditions (before Legislation) 2000 hi-noise aircraft for 10 years. Aircraft takeoffs = 750/yr per aircraft or 7500/decade. Fleet (2000) takeoffs 15,000,000/decade. Average discomfort level during one takeoff is 3. Duration is 15 seconds for 1000 people. Then 1000 x 15seconds x intensity 3 divided by 24 hours x 3600 seconds/hr equals 0.52 dukkhas per takeoff. Under these initial conditions, therefore: 15,000,000 x 0.52 7,800,000 dukkhas during the 10 years.

The original FAA regulations called for a linear phase out of hi-noise aircraft in 10 years. Based on the above assumptions, only half as many takeoffs will occur and 3,900,000 dukkhas would be produced in the 10-year period.

Final Quayle Stretch. This plan as imposed is assumed to have extended the replacement years from 10 to 15 years. This is an increase of 50% on the excessive noise experience over the FAA plan, or 5,850,000 dukkhas of discomfort and suffering.

Conclusion. 5,850,000 minus 3,900,000 equals 1,950,000 dukkhas added by the Quayle plan over the FAA plan.

Observations. Beyond the scope of this calculation, a cost estimate could be made of the Quayle plan if more was known about the phase out rate, the cost of money needed to buy new aircraft, etc. Then policy makers could properly weigh cost versus suffering.

(…) my studies of capitalism and of exchange societies are leading me to the conclusion that, if our present situation is not an aberration, then it was the analysis (objective quantification for the purpose of control) that put us here. Continuing to seek solution to problems created by this analysis that put us in our present situation is likely to lead to our peril. I hope to be wrong. Panetics, to the extent that it does not attempt to supersede the analysis of capitalism, is limited by its terms.

(…)

I suggest that the thinking of Lovelock ("GAIA: A New Look at Life on Earth") and Schumacher ("SmalI Is Beautiful") are among the best, well organized, and defensible thinking that addresses the issue of pain. Both propose concrete analyses that advance balance in the relationships between humans and between humans and other creatures. These analyses proceed from fundamentally different assumptions about how the world works, yet are coherent and workable.... (…)

(…) But what is the harm in marketing a product that is probably safe but has little or no benefit? Is this a panetic question? Who gets hurt if they consume a food with empty calories or a drug that is ineffective? Where is the suffering except in the pocketbook? Is this issue ripe for analysis? Is the topic of food and drug safety decision-making a subject worthy of inclusion in the interdisciplinary, inter-professional research effort concerning the infliction and alleviation of suffering? It certainly fits the model as a very complex issue with layers of trade-offs. Thus I’d like to explore this issue and elicit some spirited discussion.

As Ralph Widner pointed out, even while producing considerable suffering on my part when he asked me to speak on this subject, many political decisions involve the imposition of some degree of suffering on one group in order to benefit another. Ralph’s thesis is derived from the powerful book by Harold Lasswell who characterized politics as the art of deciding "who gets what, when, and how".

Applied to the issue of food and drug safety, if we determine by some means that something is safe and something else is not safe, who is going to benefit and who is going to suffer? If those who benefit are not satisfied with the benefit, what will they do that may heighten further suffering? If those who suffer are sufficiently distressed, what further suffering might they induce?

(…)

My point should be clear. What should be a common sense decision or one based on scientific knowledge by informed and educated citizens has increasingly moved into the judicial system where the decision may be based more on legal precedents rather than common sense or weight of scientific evidence. In such situations, where an either/or decision is made by an institutionalized entity that is not directly affected either way, someone wins and someone loses; someone has less suffering and others end up with more suffering. But Harold Saunders offered a slightly different perspective in his concept of "connection". What was a personal or family, or village decision about what foods are safe evolved into a decision made on the basis of science, one step removed. Now we see a second step of removal, science is not enough and we need the courts to decide. The connection to the citizens becomes more and more tenuous. Perhaps the more logical approach of paneticists should be to alert citizens to the complexities and trade-offs in any food safety disagreements.

(…)

First, the guiding principle of safety decisions related to foods and substances added to foods is the regulatory concept of "ordinarily not injurious to health" and "reasonable certainty of no harm". As senior or aspiring paneticists, I would ask you to consider: 1. What is ordinarily? 2. What is injurious to health? 3. What is reasonable certainty? 4. How do you define "no harm"?

(…)

My point is that panetic analysis of issues in public health and safety are indeed complex and application of such analysis is not so straightforward. Thus Dr. Saunders’ idea of less emphasis on quantification and more effort to make connections that provide a basis for the body politic to buy in may have merit here, and in other similar circumstances too.

So where are we? Is the issue of food and possibly drug safety amenable to panetic analysis? The picture is not as bleak as I have painted it. Perhaps I have been too eager to identify complexities and their inherent result, trade-offs. Certainly, development of panetic tables which include both direct and indirect consequences of decisions in the arena of food safety decision-making would be a good place to start. Perhaps this effort could be a way to raise the awareness of the body politic.

Could we do this on an international basis? Probably, its a bit early to try as the climate, even in this country, has not yet reached the point where the public realizes that the food supplies of the world are very complex and interdependent -- on weather, political, economic, and cultural aspects of most of the world’s food producing regions. Education of the US public is a worthy goal.

In the area of food safety, as in other issues of common welfare, governments are perhaps a major barrier to alleviation of suffering that is due to an unsafe food supply. Right now, the purpose within our own government is lacking, but our system of government does have the necessary capacity to undertake such panetic analyses. In the near future, it should be our responsibility to make both citizens and decision-makers more familiar with the methodology of panetic analysis. What better way than to dissect the complexities of food safety and develop sound panetic tables for analysis along with efforts to make the public recognize the connections with their best interests. If these were done on the same or similar topics for several countries, a comparative basis for further work would be established.

The trick of course, will be to pick topics that would arouse the interest and understanding of citizens in several countries, and, at the same time, be amenable to comparative analysis. Perhaps, we can start the discussion with this aspect of furthering the application and utility of panetics in understanding and alleviating human suffering that is a component of the world’s ability to provide a safe and adequate food supply for the population of the world.

(…) we can measure dukkha on a 9-point dukkha scale from "1", the "barely noticeable", to "9", the "unbearable, wanting to die"; the unit, one dukkha, being defined as one person suffering level "1" for one day ("0" means no suffering). This permits us to make comparisons across time and space for any set of humans from the individual via the couple/family and the country to the globe, for any length of time, measuring the level of suffering as: Average level of dukkha x No. of persons involved x No. of days.

Let us deconstruct, to understand the underlying message.

First, the measure is in the homo mensura tradition of Protagoras, "Man is the measure of all things". In a community, a country, you may have the most glittering buildings or other material achievements, you may be politically/ideologically correct, being based on the purest implementation of the single true teaching of whatever kind. This measure makes us focus on the reality of the human experience. If people, persons, humans, in fact suffer, then what is so great about it?

Second, the measure is subjective. The single person is the only judge of his/her situation. My suffering is mine. Nobody is going to tell me I am not suffering when in fact I am; nor that the suffering is good for me, I have already considered that. Nor is anybody going to tell me I am suffering when in fact I am not; because according to them the objective circumstances should make me suffer. I decide that. I alone.

Third, the measure is profoundly egalitarian. Each person's suffering is given the same weight in the terse, mathematical, "No. of persons involved". Sounds trivial, and yet filled with dramatic implications. We humans suffer from serious fault-lines in our social constructions, between us and other forms of life, between genders, generations and races, between classes, nations and states. Genocide is massive violence across such fault-lines, direct or structural. Yet we protect ourselves against taking in the suffering on the other side, drawing clear lines between worthy and unworthy sufferers, like we do these days in Yugoslavia. The suffering of dehumanized, even demonized persons does not count. This measure makes us all equal before the suffering, like before the law. My enemy counts like myself.

Fourth, the measure does not include sukha, bliss, happiness. We might argue that there could be a separate sukha scale, and I would probably argue that. But the danger would be that some people's sukha is used to compensate, in an average way, for a lot of other people's dukkha the way economists construct their flawed measure of growth as per capita growth. This is both humanly, intellectually and politically impermissible, and panetics, the study of (inflicting) suffering, does not commit that elementary mistake. The dukkha is there, revealed by figures staring us in the eyes. Our task is to reflect it and reflect on it, not to reduce it through some averaging. Averages bring no comfort to the sufferer; reducing the infliction, alleviating the suffering does. Quite another matter is the dispersion, the distribution of suffering. Some groups, some persons, suffer more than others. There is a policy in that: give priority to those who suffer most.

Fifth, the measure is non-theoretical. All that is said is that concrete human beings report suffering, some more than others. The measure does not tell us why. Maybe this is an improvement on Lord Buddha's reductionist insistence on greed and craving as the prime cause. Maybe better trying to identify the causes for each concrete case? But there is also a deeper reason hidden behind this formula: the theory we have may itself cause immense suffering. A formula to obtain the good society is usually also a formula to reduce suffering, and that formula may close out the suffering that is not supposed to be. Fault-lines dehumanize the unworthy sufferers; theories make us see the suffering as transitory, as means hallowed by the ends -- you cannot make omelets without crushing some eggs.

(…)

P, the perpetrator, has made V, the victim, suffer through an act of crime: theft, violence, sexual violence. One way of handling this is through revenge: V inflicts suffering on P, or V's family on P's family, in a vendetta that lasts generations. But the (modern) state intervenes, deprivatizing the counter-violence, telling V "I'll do the infliction of violence on P for you, on the condition that you remain quiet". There is even a new terminology: violence from the state, from above, is not referred to as violence but as "justice", as when the head is severed from the body by the French guillotine and the henchman pronounces: "Au nom du peuple francais justice est faite." The panetics approach will now inform us of the following: we started with V's family suffering, now there are two families suffering. The point here is not that they can be compared, all sufferings can be, using the measure. The point is that in the Judeo-Christian legal tradition a mathematical theorem is invoked in such cases: the sum of two sufferings is zero. One suffering washes away the other: the victim feels fulfilled, reconciled to his/her fate, knowing that justice has been done. In the USA today V may even watch P being executed, presumably to speed up the process whereby one violence cancels the other. The panetics approach harbors no such theorem. The sum of two sufferings is two, not zero, sufferings. No stand is taken on crime and justice except one: try to minimize the infliction of suffering by preventing crime in the first run; do not believe that you reduce human suffering through punishment.

(…)

Multiply the military figures about casualties at least by a factor of 10 for the primary bereaved (near family and friends) and by a factor of 100 for the secondary bereaved (extended family, neighbors, colleagues). Panetics will show the madness of war much more clearly; our usual statistics conceal the suffering.

(…) Combine this with the image of the bereaved and traumatized and we sense the enormous suffering through the millennia. But we only sense this if we open our hearts and minds to the suffering of everybody, not privileging some suffering at the expense of others. As a matter of fact, probably one of the worst forms of dehumanization is to deny some categories their suffering, invoking theories like "they suffer less because they are so used to it". Deprive a human being of suffering and you deprive him/her of subjectivity, deprive him/her of subjectivity and you have constructed a non-human. The genius of Ralph Siu consists exactly in presenting us, in the double meaning of present, with an image so compelling that we can act upon it.

(…) In short, his image, expressed in megadukkhas, is of a society where crime may be an irritant but of very little significance relative to the suffering caused by Capital and State as expressed in unemployment and poverty. Even lawyers and church leaders get off the hook; their role is very minor.

(…) War and unfettered growth become like slavery and colonialism: labels for untold suffering. Due to Ralph's work the untold can now be told, if we sit down and to the job, trying to get some numerical estimates. As he says, they may be 100% off, yet the measure will tell us something of immense value. We may differ as to the good society, the good world and human happiness. But we might agree on something very basic: to reduce suffering, to stop inflicting suffering. So let us all do our best to translate these brilliant insights into tools of policy theory and practice, breaking the pattern of selecting some suffering and neglecting the other, and of aiming for the stars, oblivious of the suffering in our backyard.

and http://www.panetics.info/DisplayOneEvent.cfm?i=45 (Part Two)

Part I

Physicians and health care workers daily face the task of assessing suffering and the steps to be taken to relieve it for individual patients. And one of the most important and difficult of the ongoing tasks facing leaders in any country is to formulate a continually updated, humanely cost-effective health care plan for their people. A critical input is the comparative amounts of the associated suffering, potentially preventable and/or relievable, among the given arrays of available resources and feasible options. What follows may be one of the most direct, practical, simplest, tested, and accurate methods to quantify suffering for these purposes. We believe the occasion for their application may be propitious.

The description of a "dukkha-based" assessment of the suffering entailed in individual illness and medical treatment described below is the subject of Part I. Part II summarizes the products of intensity and duration of suffering, with and without treatment options for the national frequency of selected illnesses and treatments of concern to United States public health. Only after judging the burden of suffering of illness and that additional suffering both imposed and relieved by medical treatment will we factor in Part II quantitative cost, both for individual treatment options and for collective national health planning.

(…)

Health Care Reform and Reduction of Suffering

The discussion might not have to be couched in terms derived only from the "dismal science." Might it not be feasible to start with the professed fundamental goals of both the patient in seeking help from a health care provider and the professional in practice–to reduce suffering? If this suffering were quantifiable and various treatment options could be expected to accomplish a reduction in the suffering, a humane analysis of the optimum medical treatment options might be possible, and economic cost/benefit considerations would become derivative from it. If a certain reduction in suffering were predictable, resource allocations might be decided by what accomplishes this predetermined goal most efficiently--with some expeditious high-cost options quite probably winners.

There are no magic wands in health care–whether the treatment is a procedure, a drug, or reassurance. Not only is each intervention accompanied by cost but also hazard--and one real risk is that of the iatrogenic infliction of still more suffering. It is quite possible that health care contributes to the sum of human misery in some conditions, and how can that infliction be mitigated or such options be selected against?

There are some agreed upon benefits against trivial infliction–the immunization injection that brings tears to the eyes of a child and lowered risk of communicable disease, for example. There are some procedures for which the balance of inflicted suffering against predictable relief may prohibit the technique as therapy except in terms of Phase II development in clinical research–bone marrow transplantation following radical chemotherapy of metastatic cancer, for example. To analyze the relative success of any medical intervention, then, we would have to consider the sum balance of suffering relieved, and select against all treatments that would cause more suffering to be inflicted than they could reasonably be anticipate to be relieved.

It is particularly timely to redirect attention to first principles in view of the intense debate across the United States on a new trail-blazing national health care plan for the American people. Many options and variations are vigorously advanced. Beyond the humane analysis of a preferred medical treatment option for a given patient, what public good may result from optional health care plans?

It would appear that the version ultimately adopted by the federal government would address the following complex economic types of questions (among others) explicitly and head-on in as clear, direct and firmly grounded a manner as possible:

1. What national health care plan will potentially bring about the largest amount of medical suffering prevented and/or relieved for the population as a whole per million dollars expended?

2. What will be the likely family of curves of the amount of medical suffering sustained by the people at large plotted against time for the period concerned at various levels of funding?

3. What will be the likely corresponding families of curves for various categories of the citizenry calling for special consideration?

4. How about analogous curves for the various proposals regarding the distributions of resources among categories of illness for various overall levels of approximations?

To the degree that the best available tools for the quantitative estimation of suffering are used, to that degree will the answers to the above kinds of questions be more sharply focused and useful. We wish to bring the recently developed quantitative unit of the dukkha and medical dukkha tables to the attention of the responsible policy makers. They might be of some facilitating assistance.

How can such a gauge of suffering be derived? By doing what all clinicians have always done--ask the patient. Describe the pain to me–how bad is it? For how long have you had it? Does it come and go? What seems to make it better? What exacerbates it?" Pain is the experience of the sufferer, but the intensity, duration, and characterization are judged by the clinician, who is always at least ranking it.

lf prevention and reduction of suffering is a fundamental principle in health care, can a new paradigm be constructed using the first principle for decision making among treatment options and national plans?

Quantification of Suffering

The direct quantitative measure of suffering, called the dukkha, is a slight adaptation of the routine intuitive practice followed by physicians and laymen alike for millennia. Among the first questions asked the patient by the doctor is: "How badly do you feel on a scale of ten--ten being the worst possible." And the second is: "For how long have you been feeling so badly?" The dukkha is determined by the standardization of the two steps and a multiplication of the two answers to provide the quantity of suffering.

The first factor regarding the intensity of suffering is set as an odd-number nine-step range, in order to make it easier for the respondent to find the midpoint of five. The intensity scale in approximately equally spaced ascending de descriptive terms is as follows: 1, noticeable; 2, bothersome; 3, moderate; 4, considerable, seeking relief; 5, midpoint, interfering with daily life; 6, quite a lot; 7, miserable, visiting physician or other healer; 8, excruciating; and 9, unbearable, wanting to die.

The second factor of duration is given in days. Thus the number of dukkhas experienced is (number of persons) x (average intensity of suffering on a 9-step scale) x (duration in days). One dukkha is the suffering borne by one person experiencing an intensity level of one unit for one day.

A person with a moderate toothache for eight hours, for example, endures one dukkha of pain, i. e., (1 person) x (intensity 3) x (8/24 day). A thousand persons with flaring peptic ulcers without medication for a year is estimated as having collectively endured approximately a million dukkhas, i. e., (1,000 persons) x (average intensity 6.5) x (10 hours of pain/24 hour day) x (365 days).

At lower levels of suffering, sleep is a possible source of relief with or without hypnotic or sedative agents. At higher levels of suffering, sleep is impossible sometimes even despite analgesics. So, for example, at levels of intensities at 1-3 steps, it is assumed that eight hours of suffering-free sleep may be possible and the average intensity of suffering per day is reduced by a third within a 24hour interval. At the higher levels of intensity of 7-9, sleep is precluded, so no such reduction is made in the estimate of sleepless suffering.

The dukkha is fit to meet the following specifications, which have been advanced for a direct and practical quantitative measure of suffering for- everyday social usage by laymen:

1. The precision and accuracy should be adequate for the purpose and context at hand.

2. The basic data should be the direct personal estimates by the sufferer. This requirement stems from the very definition of suffering itself as being subjective.

3. The manipulation of the basic data to provide the final figure for quantity should be logically sound.

4. The procedure should be sufficiently simple, so that even laymen with minimal education would be capable of using it to estimate their own amounts of suffering flowing from various sources and causes.

5. No special equipment should be required other than paper and pencil.

6. The method should be universally applicable for all individuals, institutions, governments, kinds of sufferings, conditions, and so on, so that comparative analyses, choices, and judgments can be made.

7. The ease and reliability of eliciting the necessary inputs to the calculations should have been demonstrated in actual use for some time.

The key new input required for the generation of dukkha tables to serve as a useful addition to public health statistics is reliable estimates of the intensities of suffering. The rest of the data arc readily available from existing vital statistics and the medical literature.

Four avenues are at hand for obtaining estimates of the intensities of suffering. The direct method is a statement by the sufferer himself/herself. By the very definition of suffering, this is thc unarguable estimate. The indirect methods derive their validity from an invariable correlation with this subjective reference.

Where direct methods are impractical at the moment, recourse must be made to indirect approximations. Reasonably reliable figures may be forthcoming from attending medical personnel familiar with a large body of cases. This would hold especially if the non-sufferer's estimates had been demonstrated to be highly correlated with the sufferer's statements in other instances.

Another indirect method involves physical instrumentation. Here again, its utility depends on the correlation with the patient's estimates. We do not foresee the time when sufficient correlations can be worked out for even a small fraction of the purely physical suffering, not to mention mental ones.

The fourth approach involves social indicators, such as lost labor hours, freedom, and income. These are too gross, indirect, both overlapping and incomplete at the same time, and disparate for logical combination. In the absence of a direct quantitative measure of suffering, they have been the most expedient under the circumstances. But this no longer is the situation.

We are thus practically left with the first two avenues. While awaiting the day when the ultimately standardized medical dukkha tables would be largely based on direct estimates from the sufferers themselves, we have relied on indirect estimates by a limited number of physicians for the construction of the present illustrative prototype table.

Illustrative Prototype Medical Dukkha Table

A complete table of the number of dukkhas suffered by the average patient stricken with various illnesses, the probability of prevention and cure with respective costs in dollars and time for the optional treatment regimes now available, and the numbers of patients so afflicted would appear to be necessary as a minimum for a rigorous basis of comparative evaluation of health-care system options. The core information is the number of dukkhas suffered by patients in each case of illness, with and without medical treatments. An illustrative prototype medical dukkha table of this nature is presented below.

The core array can then be amplified with additional relevant columns. Typical would be the number of cases in the United States per year with and without medical treatment, thereby providing the total number of dukkhas of suffering endured by the American people as a whole for thc particular illness (Part II to follow). Econo-panetic information may also be incorporated, such as the cost of treatment, thereby providing estimates of the number of dukkhas relieved per million dollars for the country as a whole for various combinations and permutations of plans, resources, categories of people, and systems of treatment.

Other representative tables for finer-grained analysis might include the following: (1) Dukkha tables for the twenty illnesses engendering the greatest amount of suffering for individuals per case, (2) Dukkha tables for the twenty illnesses engendering the greatest amount of suffering for individuals at intensities 8 to 9, (3) Dukkha tables for the twenty illnesses engendering the greatest amount of suffering for the population of the country as a whole, (4) Dukkha tables for the twenty illnesses engendering the greatest amount of suffering at intensities 8 to 9 for the population as a whole, (5) Dukkha tables for the twenty illnesses costing the most for medical treatment per case, (6) Dukkha tables for the twenty illnesses costing the most for the population as a whole, and (7) Dukkha tables for illnesses without known medical treatment.

 Part II.

Proper health care for all the citizenry has increasingly become a concern for all national governments in recent decades. The ongoing process of health care reforms in the United Sates has reached an intensive phase with the first years of a new administration pledged to make health security a centerpiece of domestic policy.

Part I of this two-part article described a missing critical component of the voluminous demographic and cost data, which are presently available to decision-makers and the public. Without this humane component of health care's objectives and limits, a clear-headed formulation of health plans and a prudent and humane selection of the optimum for the country as a whole and for individuals in special circumstances is severely handicapped.

Because the health care system is a very complex and specialized entity, one component that can be measured by a universally comprehensible metric is cost -and that has been the primary focus of most analyses of health care options. We have chosen to begin with a more fundamental measure of health care's humane effectiveness, and have offered for initial consideration a measure of human suffering and its relief.

As explained in Part I, the dukkha is a direct quantitative unit of suffering, applicable to the determination of the amount of suffering of all kinds across the board, as experienced and quantified by the sufferer. The number of dukkhas endured by a group of individuals is the product of (number of persons) x (average intensity of suffering on a scale of nine) x (duration in days).

Previously, not a single figure for any illness has been published; nor has there been an attempt to rigorously measure and sum suffering for patients and populations. By way of illustration, a set of suffering values for ten illnesses was presented in Part I. An abbreviated extension for six illnesses and eight medical treatments is given in Table 1 below.

These dukkha data can then be coupled with illness incidence, cost, medical, and social information to provide side by side comparisons of the emerging alternative health care proposals.

This Part II exemplifies the use of this dukkha information with the associated incidence and cost. The resulting econo-panetic implications are consolidated in Table 2.

We believe that attempts at this knowledge of health "numerator" data would be of considerable value in the understanding of, and decision-making for key public health issues. In addition to the discussion in Part I, the following are several more topics that can be extrapolated from having both humane numerator and cost denominator quantifications before policy decisions.

• Total amount of medical suffering potentially prevented and/or relieved in the national population by each of the proposed health care plans per million dollars appropriated;

• Total amount of medical suffering remaining unrelieved by each of the proposed health care plans at various levels of overall appropriation;

• Amounts of medical suffering potentially relieved and unrelieved within various subclassifications of people by each of the proposed health care plans at various levels of overall appropriation.

A reasonably reliable comparative analysis of this sort will facilitate the process of arriving at a prudent formulation, selection, and progressive improvement of national health care plans and humanely cost-effec¹ive programs.

Discussion

The common availability of data of the type illustrated in the tables in this article and in preceding Part I would be most helpful in addressing the inescapable questions perennially confronting government officials, community leaders, and others concerned with public health. Typical of the critical issues are the following:

• What fraction of the overall budget should be allocated to health care? One of the significant criteria has to be the comparative amounts of net suffering among the respective budgetary components thereby burdened on the citizenry.

• Given a limit for total health care expenditures, how should the resources be distributed among the various illnesses, regions of the country, and categories of people?

• How should the funds available for medical research be divided among the various illnesses without effec¹ive palliation and remedy? A comprehensive, standardized, and internationally accepted set of continually updated medical dukkha and econo-panetic tables would also contribute to decision making in areas far beyond the immediate setting of individual illness. Several examples are sufficient to make the point.

• In jurisprudence: increased uniformity and "fairness" in the award of damages for suffering in legal suits.

• In insurance: higher predictability and confidence in the setting of related premiums.

• In the transition zone of public health and communal well-being: extension of the medical dukkha table can aid health policy decisions that include higher order panetic ramifications. What would be the amount of suffering generated in others by a given illness? For example, the dukkhas flowing from the worries of the family members, the financial burdens and associated sacrifices on the part of those who have to pay the bills, and the sadness and hardships of bereaved dependents? How far should the concerns of physicians and other public health professionals be stretched into the domain of societal wellbeing from the narrow confines of medical suffering of the patient alone to the associated distresses of related others? In particular, how do the econo-panetic efficiencies of the various mixes of preventive and remedial measures compare? How should public policy go about taking this factor into explicit account?

• In the implications of panetic responsibility in personal and social ethics: the enormity of breaches in ethics takes on a new dimension of astareness when the amount of suffering engendered by the causing or passing on of various illnesses is dearly laid out and appreciated.

Conclusion

Sound medical dukkha tables and econo-panetic analyses can play critical roles in the prudent formulation, selection, and continuing improvement of national health care plans and medical treatment options. Their usefulness can also be extended far into the realms of other human concerns, such as business, law, ethics, and panetitude. The institution in the best position to compile authoritative arrays of these kinds appears to be the national government. A comprehensive and provisionally usable set can be developed by American public health agencies within a relatively short time. We urge that serious consideration of their development be given by the responsible public health leaders. This will refocus the crux of the debate on suffering and its reduction instead of dollars, sources of revenues, and managerial procedures and prerogatives.

What is essential at this point in time is not wishful debates over the speed of progress in the research on and compilation of the pertinent figures. What really matters is that the arduous task be begun at the earliest date by sufficient numbers of talented persons in or out of government. The present and continuing requirement for the enhancement of basic human well-being everywhere is obvious.

The dukkha is a quantitative unit proposed by Ralph G.H. Siu to measure suffering. The term is based on "dukkha", meaning "suffering" in Pali, the ancient language of the Buddha.

Siu developed a 9-step intensity scale to quantify the infliction of suffering. In step 1 suffering is "noticeable"; by step 9 suffering is so intense that "one would rather die". A rough description of the respective intensities is given in Table 1.

Table 1. Intensity scale of suffering

1- Noticeable 2- Bothersome 3- Moderate 4- Considerable, seeking relief 5- Interfering with daily life 6- Quite A lot 7- Miserable, visiting physician 8- Excruciating 9- Unbearable, wanting to die The quantity of suffering borne by a person is calculated by multiplying the intensity of suffering by the duration in days. Thus, one dukkha expresses the amount of suffering endured by one person at intensity level one for one day. It is roughly equivalent to that felt by one person with a moderate toothache for eight hours, i.e. (1 person) x (intensity 3) x (8 hours / 24 hours in a day).

A million dukkhas, or a megadukkha, represent the order of magnitude of suffering sustained for about 10 hours a day collectively by 1,000 persons with severe stomach ulcers without medication for a year, i.e., about (1,000 persons) x (intensity 6.5) x (10 hours / 24 hours in a day) x (365 days).

To summarize, the dukkha is calculated by multiplying the number of persons by the intensity level by the number of days: persons x intensity level (1-9) x days.

Those who are skeptical about the practicality of Ralph Siu’s proposed Dukkha Scale to measure the intensity of human suffering might be interested in several press accounts of similar scales applied in medicine.

On September 14, 1999, the New York Times reported guidelines of a pain management regimen for patients with sickle cell anemia. "Drafted by an expert panel sponsored by the American Pain Society...the guidelines are the first in a series of research-based recommendations for treating pain in several diseases, including arthritis and cancer," reporter Warren E. Leary writes. Since Sickle Cell Anemia is a life-long affliction, a scale of pain intensity was developed for use in treating pain in children. This "Oucher Scale" grades upward from zero to 100. Each level in the scale is accompanied by a child’s face showing rising levels of anguish. A child can point to the face that reflects the pain he or she is having. The report continues: "Dr. Lennette J. Benjamin, clinical director of the Comprehensive Sickle Cell Center at Montefiore Medical Center in the Bronx, a member of the drafting panel, said: ‘I see patients every day who have suffered a lifetime of needless pain simply because their doctors and others treating them don’t understand or practice the principles of good pain management...Unrelieved pain leads to longer hospitalizations, greater suffering and complications and more deaths’."

On February 27, 2000, the New York Times reported still another effort to gauge the severity of pain and suffering by Dr. A Vania Apkarian at the State University of New York's Upstate Medical University in Syracuse and Dr. Nikolaus Szeverenyl, a radiological physician in Albany. The Times reported that: "Volunteers in their studies are subjected to varying degrees of discomfort and their brains' responses are recorded in an electroencephalogram or imaged by a C. T. scan or M.R.I. But even with such a complex assortment of electronic gadgetry, results depend ultimately on the subjects' description of the degree of pain they feel, which is signaled by how far they separate their opposed thumb and forefinger" on a scale of 1 to 10. In this way, the two physicians hope that they can create a "quantitative analysis to characterize the brain's representation of pain." The Times account goes on to report that measuring the many manifestations of pain, objective and subjective, has proven so complex that an International Association for the Study of Pain has been organized. Pain, the article points out, is both a sensation and an emotional experience influenced to a significant degree by the emotional predispositions of the sufferer.

A more tongue-in-cheek piece appeared in Men’s Health (www.menshealth.com) in November 1999. The reporter interviewed physicians using "a 2-inch strip of paper called the ‘visual analog scale’ or VAS. During a procedure, patients rate their pain by marking the strip close to the left (a pinch) or right (being burned alive, or listening to the music from Rent.)"Asked by the reporter to rank pain intensities on the scale, physicians provided the following analogs: VAS 1: Having a Mole Removed VAS 6: A spinal tap. VAS2: A digital rectal exam VAS 7: A penis catheter VAS 3: Five stitches VAS 8: A rabies shot. VAS 4: Removing wisdom teeth VAS 9: A barium enema. VAS 5: A colonoscopy VAS 10: Testicular torsion

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Provisional Axioms

The infliction of suffering is intrinsic to the processes of life and social operation. Every decision and action of a person or an institution has the potential, qualitatively or quantitatively, to modify the state of suffering in oneself or others, immediately or n-steps removed. Everybody inflicts suffering on others and everybody is inflicted upon. The threatened or actual infliction of suffering is the most powerful instrument of persuasion. Every human being is caught in a never-ending personal tug-of-war between the largely cultivated need to inflict suffering on others and the largely natural desire to reduce it. The victim's pain is a function of the infliction actually delivered and independent of the inflicter's awareness, intentionality, and justification. It is the situational context which usually opens the door to a given spectrum of panetic choices. Any significant change in a given social relationship among parties will eventually modify the distribution of suffering among them. The success of a government in reducing the suffering of its people and maintaining it at a practicably humane level is a direct function of its panetic knowledge and integrated management. Humaneness starts with stopping the inflicting.