In a single day Laura's world fell apart. Until last week, life couldn't have been better. She was in the prime of her life, very happily married with two children aged six and two. The only warning she had was a slight visual disturbance. She thought she ought to ask her GP about it, but much to her surprise he sent her straight to our neurology department. She had a dense left hemianopia - unusual in someone who is only 34 years old. How should we have told her that her CT showed multiple cerebral metastases from malignant melanoma? How could we explain that the best treatment available would leave her nauseated, forgetful and bald, and would probably not lengthen her life at all? Was there any way to lessen the pain she felt when we told her that even though she felt perfectly well, she had months, probably only weeks left to live?

I have never felt so utterly helpless. What else could I have said? Was there any hope we could have offered her distraught husband? What would you have said to her?

Some things are clear. Suffering is real. It can strike anyone, and when it comes it can hurt deeply. But many things are not clear. Why do we face suffering? Why do I have to suffer? Why do some people seem to have far more than their fair share of life's pain? Suffering raises some of the most fundamental questions we can ask. It is important to ask them and to look for answers. It is vital for us as medics to think about these issues if we are to be of any help at all to our patients and to keep going ourselves without succumbing to the bleak cynicism of many of our colleagues.

Asking questions

The worldview a patient brings to their illness is critical to their response to suffering. At medical school we are taught to elicit a patient's ideas, concerns and expectations. In fact I found it quite hard to discuss things further with Laura, from inadequacy and lack of boldness, but I have often found it helpful to ask a question like, 'Do you have a faith that helps you at a time like this, or have you not thought much about these things?' It leads to some really interesting conversations. For example, Helen, another young mum in a very similar situation, told me she was a Buddhist.

Buddhism teaches that suffering is not real, but only an illusion. It occurs because we have the wrong desires; if we learn to master our wills and desire nothing we will be free from the sense of suffering. The problem for Helen was that she had discovered that suffering is real. And it was right for her to desire healing, to be alive for her husband and children. There is nothing in Buddhism that can help them. To watch Helen's family suffering without hope was a dreadful thing.

On my elective I met many patients who held Hindu beliefs. Suffering for them was a result of Karma, simply to be accepted. This leads to an incredible fatalism. I remember patients on the maternity wards whose children had died during delivery. They thought it was not right for them to mourn; they accepted it as justice, without a tear. But fatalism leads to great inaction. It is very hard to set up preventive health care if people accept ill health as Karma and there is no motivation to intervene in another's suffering.

As a student I met a man about my age who had failed in an attempt to kill himself. The psychiatrists were mystified because he was neither depressed nor psychotic. He was an atheist who had thought through the consequences of his beliefs. They concluded that this man's motivation for suicide was purely an outworking of his nihilistic beliefs (that life is without meaning and purpose). Because they shared his beliefs, they had no solution to offer him.

Though less extreme, many people we meet share his views. Society says there is no God, the universe we see is all there is, and life is merely the product of chance, time and evolution. According to Richard Dawkins:

In a universe of blind physical forces and genetic replication, some people are going to get hurt, other people are going to get lucky, and we won't find any rhyme or reason in it, nor any justice. The universe we observe has precisely the properties we should expect if there is at the bottom of it no design, no purpose, no evil, and no good; nothing but blind pitiless indifference. DNA neither knows nor cares. DNA just is, and we dance to its music.[1]

This raises several issues for medics. If life has no ultimate meaning, why should we dedicate our careers to fighting death? What is the point in palliative care if, after a week or two, the patient will cease to exist and will neither know nor care what happened during their life?

In the context of suffering, the atheist worldview is simply unliveable. When suffering comes, there is no explanation for it. It is cruel and fundamentally meaningless. In the face of death life becomes worthless. Just weeks before his death the actor Sir Michael Hordern wrote, 'I am sorry, but I see at the end of mine, no meaning to life but to fade into the light of common day.'

A Christian response

Do Christians have any answers to these great questions? I am convinced we do, but first some cautions. We do not have all the answers. Suffering is a vast and complex issue that cannot be wrapped up in a few glib words. As we will see, in a different way suffering is actually just as much a problem for those who believe in a living God. Moreover, there are some things that can only be learnt by personal experience. None of us want to endure suffering, but God in his wisdom will put many of us through it as it is the only way to learn and understand some of the answers to these questions. And the suffering we endure can strengthen our faith[2] and soften us so that we can be of use to others who suffer.[3]

Though the Bible has much to say about suffering, it remains silent on many things. Moses said, 'The secret things belong to the Lord our God, but the things revealed belong to us and to our children forever, that we may follow all the words of this law.'[4] God will not answer all our questions. There are simply some things that, in his wisdom, he chooses to keep secret from us. Instead he tells us only what we need to know to address the issues we will face. But he has given us some answers, and these are found in the Bible. They are for God's people forever, and we are to follow what we learn.

What does God reveal to us? John chapter 11 is a very helpful place to start; it records Jesus' own response to suffering when one of his close friends, Lazarus, died. The account gives us a framework to approach these questions, and teaches us to think with a right perspective. Four key truths stand out.

1) God is loving

How often are we told we mustn't become too involved in our patients' problems? We are told to keep a distance, to protect ourselves and learn to switch off from situations. What would Jesus say to that?

Jesus cared deeply about this family and was profoundly involved in their suffering. Lazarus was described as 'the one you love'. People who knew Jesus had all seen in his actions how much he cared for Lazarus and his whole family (vv3,5).

It's essential that we understand Jesus' love. This is the first thing that John wants us to know about his response to suffering. When a believer experiences real suffering they can rapidly come to question God. If he really loved us, surely he wouldn't let us suffer? Suffering is so awful that no good God would allow it. If he could stop it, surely he would? C S Lewis called this 'the problem of pain'. If God is all powerful and all loving, how can he allow suffering? Either God isn't loving or he isn't all powerful. If he isn't loving, then we are better off without him. And if he isn't all powerful, we are just a whisper from saying, 'maybe he isn't there at all?'[5]

This is the same question the crowds asked too. 'Some of them said, 'Could not he who opened the eyes of the blind man have kept this man from dying?''(v37). From their own experience they knew that Jesus was powerful, so they couldn't understand why he allowed his friend to suffer. Maybe he wasn't loving?

But soon we see the extent of Jesus' love for suffering people; he chose to be involved personally when he travelled to the town where Lazarus was, despite considerable risk to his own physical safety (vv7-11). John's account (vv32,33) is remarkable:

When Mary reached the place where Jesus was and saw him, she fell at his feet and said, 'Lord, if you had been here, my brother would not have died.' When Jesus saw her weeping, and the Jews who had come along with her also weeping, he was deeply moved in spirit and troubled.

Jesus was deeply moved by human suffering. It troubled him. Suffering is not a good thing, and he longed to help. We know the end of the story, but Jesus didn't just put things right straight away. Verse 35 is the shortest verse in the Bible, and one of the most amazing: 'Jesus wept'.

When Jesus looks at the suffering in our world he weeps. This is a God who really cares, and those watching him could see that. But what about the second possibility? Maybe God loves, but he is not all powerful.

2) God is in control

This passage also shows us that God is certainly not powerless. He is in complete control, and perfectly able to end suffering if he chooses. From their own experience Jesus' friends knew his power, which was why they sent for him, but what is striking is that his response was not to rush to the scene immediately (v6). Jesus knew that his delay would allow Lazarus' death, but there was no hurry - he was in control, and had wiser plans.

Imagine responding like that as a doctor. You hear your emergency bleep: 'Cardiac arrest Ward 6D'. You can help, but instead of going immediately you stay where you are and only start trying to resuscitate the patient once they've been in the mortuary for four days. Jesus had absolute confidence in his power.

There's no doubt that Lazarus really had died. There were hundreds of witnesses in the funeral crowd, and his tomb was beginning to smell. So picture the scene when Jesus turned up late for the funeral. The family and friends were all still mourning, but there was no apology for being late. Instead he said the most outrageous thing possible. Jesus stood at the grave and shouted, 'Lazarus, come out!' (v43).

Jesus is not like us. He claimed to be God made man, and what is recorded here is just one of many pieces of evidence. God can stop suffering if he chooses. He is not powerless. Certainly John, who wrote this account, was convinced of this.

Job was also convinced. If we are struggling with questions about suffering this is a wonderful book to read. Job was a good man whose untroubled life was turned upside down by immense suffering. First he lost his house and his business collapsed. Then his entire family was killed. He knew what suffering was. But how did he respond? He turned to God in prayer and acknowledged his sovereign power.[6] He knew that the Lord God is powerful, and that truth made him praise God. When we are suffering, we too can depend on that truth.

But this leaves a big question. Why is Lazarus' healing the exception, not the rule? Why does God still let countless people suffer in many ways?

3) Suffering is part of a broken world

Suffering is not a good thing, but the Bible teaches us that God allows it. Genesis gives a wonderful picture of God creating the world and creating men to live in it, in perfect relationship with him. There was no sin and no suffering. But then man chose to ignore God's rule over his life by disobeying God. And as warned, death and suffering came as the inevitable consequences.[7]

We all know that some suffering is a direct result of man's sin; we need only think of the victims of crime, drugs or warfare. But other suffering, especially that caused by disease, is less obviously linked with wrongdoing. God allows this suffering as part of his judgment on man's rebellion.[8] We live in a fallen world: a world affected by the consequences of mankind's sin, and suffering in our lives is a constant reminder that the world is not the way it was meant to be.

We must be careful how we think though: some people suffer more than others but it is not usually a sign that they are more sinful. Job is a good example. He suffered more than most people ever will, but the first thing we are told about him was that he was blameless and upright; he feared God and shunned evil.[9] We must never judge someone, or feel they have deserved their suffering more than we might have.

4) God can be glorified through suffering

Before Lazarus died, Jesus said, 'This sickness will not end in death. No, it is for God's glory so that God's Son may be glorified through it' (v4). Somehow suffering can bring glory to God. How can this be?

Firstly, believers can witness through their response to suffering. The way Job bore his suffering so well brought great glory to God. The same happened in the account of Lazarus: both his sisters continued to trust in Jesus' power and goodness.

Secondly, suffering allows God to demonstrate his nature. In the story of Lazarus Jesus' love and sovereign power were amply demonstrated through suffering.

Most of all, suffering can lead people to faith in Jesus. C S Lewis said, 'God whispers to us in our pleasures, speaks in our conscience, but shouts in our pains. They are his megaphone to rouse a deaf world.'[10]

Looking back to John 11:25,26, Jesus said to Martha, 'I am the resurrection and the life. He who believes in me will live, even though he dies; and whoever lives and believes in me will never die. Do you believe this?' She was faced with three options: maybe Jesus was completely mad and deluded, or maybe he was knowingly a blasphemous, heretical liar. As someone who knew Jesus personally, Martha couldn't accept these possibilities. She chose the only remaining option, to take his claim at face value (v27): ''Yes, Lord,' she told him, 'I believe that you are the Christ, the Son of God, who was to come into the world.'' Now this was an amazing claim. Where was the evidence? Jesus clearly said that Lazarus' resurrection, and later his own rising from the dead were the evidence they needed. In verse 45 we see that a crowd of sceptical Jews were certainly convinced. What about us? What do we make of Jesus' claim?

So what can we say?

We cannot answer all our patients' questions on suffering and we are to be honest about this, rather than pretending that Christians have all the answers. Likewise there is never an excuse for lying to try and protect patients from painful information. However, that doesn't necessarily mean that we are to tell them everything we know about their future: sometimes pacing the flow of information is important, and some may wisely choose not to seek all the details of their prognosis.

But the Bible provides a framework for sharing some crucial truths with people. Pray for opportunities to talk with patients about spiritual issues. Like Jesus, try asking questions; they provide a gentle way into a conversation and demonstrate that we are interested in their understanding.

When talking to a Christian we can remind them that Jesus has been there already. He didn't refuse to get involved but joined in our suffering to save us from our sin and its awful consequences.[11] He knows what we're going through. The Christian also has unique hope in suffering. We have the privilege of knowing that God is working in all things, good or bad, to accomplish his best purposes for those he loves.[12] James teaches us too that part of the purpose of suffering for a believer is to develop maturity and strengthen our faith.[13] And, most wonderfully of all, there is the ultimate assurance for the believer that Jesus will one day return and end all suffering: on that day there will be no more death or mourning, crying or pain, and he will wipe every tear from our eyes.[14]

But what can we say to the non-Christian? The assurances we can offer to the believer simply do not apply to those who persist in rejecting Jesus. Suffering makes no sense so we cannot offer them platitudes. The Bible offers absolutely no hope to those who refuse to repent so we must be very compassionate, as suffering is just the beginning of God's eternal judgment. Jesus was clear about this.[15] He used suffering as an opportunity to call people to repent.[16] We must therefore pray for our patients to turn to Jesus. Then they will be able to affirm his words to Martha: 'I am the resurrection and the life. He who believes in me will live, even though he dies; and whoever lives and believes in me will never die. Do you believe this?'[17]