Copyright
by
Daniel S. Goldberg
2009
i
The Dissertation Committee for Daniel S. Goldberg Certifies that this is the
approved version of the following dissertation:
BEYOND OPIOID REGULATION: WHY A SOCIAL AND
CULTURAL ANALYSIS OF PAIN IN AMERICA IS A
PREREQUISITE FOR ETHICAL EVIDENCE-BASED PAIN POLICY
Committee:
William J. Winslade, J.D., Ph.D
Supervisor
Ben A. Rich, J.D., Ph.D
Howard A. Brody, M.D.,
Ph.D
Melvyn Schreiber, M.D.
Michele A. Carter, Ph.D
Jason E. Glenn, Ph.D
__________________
Dean, Graduate School
ii
BEYOND OPIOID REGULATION: WHY A SOCIAL AND
CULTURAL ANALYSIS OF PAIN IN AMERICA IS A
PREREQUISITE FOR ETHICAL EVIDENCE-BASED PAIN POLICY
by
Daniel S. Goldberg, J.D.
Dissertation
Presented to the Faculty of the Graduate School of
The University of Texas Medical Branch
in Partial Fulfillment
of the Requirements
for the Degree of
Doctor of Philosophy
The University of Texas Medical Branch
August, 2009
iii
Acknowledgments
This dissertation could not have been completed without the patience, guidance,
and understanding of a great many people. I would like to thank all of my professors and
colleagues in the Institute of Medical Humanities for creating an educational experience
that has forever changed me. In particular, I’d like to thank the members of my
dissertation committee: Dr. Brody, Dr. Schreiber, Dr. Carter, Dr. Glenn, and Dr. Rich for
continually challenging me. Dr. Winslade has been my mentor, advisor, and confidant
for a decade. I cannot thank him enough, nor heap enough credit upon him for whatever
I have managed to accomplish. I must thank my family of origin – Mom, Dad, Josh,
Seth, and Zeide – for the honey on the pages of my books. Finally, to my wife Yuko
Kishimoto, Ph.D, no words of gratitude are sufficient, only a life spent building a
building.
iv
Beyond Opioid Regulation: Why A Social and Cultural Analysis of Pain
in America is a Prerequisite to Ethical Evidence-Based Pain Policy
Publication No._____________
Daniel S. Goldberg, Ph.D
The University of Texas Medical Branch, 2009
Supervisor: William J. Winslade
v
Abstract: This dissertation analyzes the social, cultural, legal, and political
reasons for the widespread undertreatment of pain in the U.S. and prescribes evidencebased policy recommendations for improving culture and practice as to the treatment of
pain. Though the American problems in treating pain have, over the last three decades,
produced an abundance of scholarship, practical guides, and policy analyses, relatively
little progress has been made. To the contrary, there is evidence that problems in treating
pain have worsened, particularly as to disparities in treating pain effectively. Utilizing
methods derived principally from ethics, policy, and the history of medicine, I have
provided an interdisciplinary analysis of the undertreatment of pain in the U.S. This
analysis centers on the role and significance that material, visible pathology plays as to
pain within the American cultures of biomedicine and science. Because the phenomenon
of pain cannot be seen via objective instrumentation, it cannot be reified through the tools
of medicine and science. This results in widespread invalidation and stigma of the pain
sufferer, not just from health-care providers, but from caregivers and even from pain
sufferers themselves. Because this emphasis on the visible pathology decenters the pain
sufferer in favor of the discrete pathologies presumed to cause the pain, I adopt a
phenomenologic approach with the aim of privileging the pain sufferer’s lived
experiences. I translate this approach into three policy recommendations which, if
implemented by the appropriate stakeholders, may ameliorate the undertreatment of pain
in the U.S. These recommendations target federal reimbursement policy, education for
junior and senior professional healers, and education of pain sufferers and caregivers.
vi
Table of Contents
List of Figures ........................................................................................................ xi
List of Illustrations ................................................................................................ xii
Preface......................................................................................................................1
The Definition of Pain ....................................................................................2
Which Pain? ....................................................................................................4
The Redemptive Possibilities of Pain .............................................................6
Pain and Suffering...........................................................................................9
Terminology..................................................................................................11
Introduction: The Power of the Visible .................................................................13
The Undertreatment of Pain in the United States and the Dominant Policy
Response ..............................................................................................16
Section I: The Lived Experience of Pain ......................................................21
Section II: History, The Power of the Visible, and Pain ...............................23
Section III: Ethics, Subjectivity, and Pain ....................................................28
Section IV: Towards Ethical, Evidence-Based Pain Policy..........................30
SECTION I: The Lived Experience of Pain
36
Chapter 1: The Current State of Pain Treatment in the United States ...................36
The Prevalence and Scope of Pain in American society...............................36
Disparities In Pain Prevalence and TreatmentError! Bookmark not defined.
Prevalence vs. Undertreatment of pain .........................................................48
Chapter 2: The Lived Experience of Pain ..............................................................53
Introduction ...................................................................................................53
Phenomenology and Illness ..........................................................................55
The Phenomenology of Pain .........................................................................60
vii
SECTION II:
The Social and Cultural Power of the Visible in the Culture of
Biomedicine
74
Chapter 3: The Power of the Visible Prior to the Nineteenth Century ..................78
Objectivity, Subjectivity, and the Power of the Visible................................78
The Perils of ‘Seeing’ During the Middle Ages and the Renaissance ..........80
The Role of Anatomy in Constructing the Power of the Visible (Body)......83
Vesalius and the Power of The Visible in Anatomy .....................................88
Seeing Inside the Brain .................................................................................90
The Importance of Signs in the Early Modern Period ..................................94
Conclusion ..................................................................................................101
Chapter 4: The History of Pain Without Lesion in Nineteenth Century America102
Introduction .................................................................................................102
Pathological Anatomy & the Birth of the Clinic ........................................103
Nineteenth Century Theories of Disease: From Horse & Buggy Medicine to the
Birth of the Clinic ..............................................................................109
Humoralism and the Illness Sufferer’s Lifeworld .............................109
Pain and the Humoral Theory ............................................................112
The Birth of the Clinic .......................................................................115
The Clinical Gaze & Pain Without Lesion in Nineteenth Century America120
The Significance of Localization For Pain Among Late Nineteenth Century
American Physicians ..........................................................................127
Late Nineteenth Century American Physicians & Pain without Lesion .....130
Conclusion ..................................................................................................149
Chapter 5: The Role of the Clinical Gaze in Contemporary Biomedical
Understandings of Pain ...............................................................................151
Objectivity, Objectification, and the Clinical Gaze ....................................151
Particulars and Universals..................................................................153
The Role of the Clinical Gaze in Contemporary Understandings of Pain Within
the Culture of Biomedicine ................................................................158
The Power of Visible, Material Pathology in Shaping Mind-Body Dualism as to
Pain ....................................................................................................167
viii
SECTION III: Ethics, Subjectivity, and Pain
170
Chapter 6: Mind-Body Dualism, Subjectivity, and Consciousness .....................170
Introduction .................................................................................................170
Searle’s Account of the Role of Subjectivity in Consciousness .................173
Objectivity, Consciousness, and Reductionism .................................182
Pain, Subjectivity, and Neuroreductionism .......................................185
Pain Sufferers, Mind-Body Dualism, and the Power of Imaging ......188
Conclusion ..................................................................................................195
Chapter 7: Pain, Objectivity, and Bioethics .........................................................197
Introduction .................................................................................................197
The Role of Principlism In Bioethics..........................................................199
Criticisms of Moral Principlism..................................................................205
The Ethical Implications of The Phenomenology of Pain ..........................210
Dancy’s Moral Particularism ......................................................................215
Holism in Reasons .............................................................................217
From Holism in Reasons to Particularism .........................................219
Practical Reasoning for the Moral Particularist .................................223
Moral Thickness.................................................................................227
Implications for Pain ..........................................................................230
Conclusion ..................................................................................................234
SECTION IV: Towards Ethical, Evidence-Based Pain Policy
236
Chapter 8: Opioids & Pain Policy........................................................................239
Introduction .................................................................................................239
The Dominant Policy Approach to Pain: Balance in Opioid Regulations ..241
Evidence Related to the Use of Opioids in Treating Pain .................244
Opioids and the Meaning of Addiction in American Society .....................249
Criminal Prosecution for Opioids ......................................................250
The Meaning of Opioids ....................................................................256
ix
Chapter 9: Evidence-Based Pain Policy Recommendations ................................262
Introduction .................................................................................................262
Pain and the Policy Process ........................................................................265
Question #1: What is the problem? How does it manifest? ...............265
Question # 2: What would success look like? (Goal) .......................266
Question #3: Whose behavior needs to change in order to achieve the
goal? (Target Audience) ..........................................................267
Question # 4a: Who has the ability to change the behavior of the target
audience? (Political Actor) ......................................................269
Question # 5a: What policy is recommended to achieve the behavior
change in the target audience? (Ignore perceived limitations) 271
Question # 4b: Who has the ability to change the behavior of the target
audience? (Political Actor) ......................................................287
Question # 5b: What policy is recommended to achieve the behavior
change in the target audience? ..................................................289
Conclusion: Raison d’Être ...................................................................................298
Bibliography ........................................................................................................303
Vita .....................................................................................................................334
x
List of Figures
Figure 1:
Pain prevalence in the past month among adults 20+, 1999-2002 ...38
Figure 2:
Estimated incidence of pain relative to incidence of diabetes, coronary
heart disease, and cancer ...................................................................39
Figure 3:
Pain duration, 1999-2002 ..................................................................40
Figure 4
Low back, neck, migraine, and face pain in past 3 months (2004)...43
Figure 5
Health status measures for adults with/without recent low back pain,
2004...................................................................................................44
Figure 6
Low back pain in last 3 months, 2004 ..............................................47
Figure 7
Estimated Number of Fixed Computed Tomography and Magnetic
Resonance Imaging Units, U.S., Selected years 1995-2004 ...........294
Figure 8
Number of Computed Tomography and Magnetic Resonance Imaging
Procedures Per Thousand Traditiona Medicare Beneficiaries, 1985-2005
.........................................................................................................295
xi
List of Illustrations
Illustration1:
Vesalius’s assimilation of the Galenic scheme of “one natural and
four unnatural shapes" ................................................................92
Illustration 2:
Walter Charleton’s 1680 paean to anatomy ................................95
Illustration 3
The 1612 edition of John Cotta’s treatise on appropriate practices of
physick ........................................................................................99
Illustration 4
Thomas Willis’s landmark Cerebri Anatome was published in 1664
...................................................................................................102
xii
Preface
If knowledge is a seamless web, it is necessary to delineate the scope of
the particular inquiry at issue. It is both conventional and justifiable in any piece
of scholarship to indicate what is and what is not to be covered, though, of course,
there is often significant debate regarding which aspects of a given phenomenon
require detailed exposition and which do not.
While I have virtually always managed to define the scope of the project
along the way, such method seems to me to be impossible with regards to a
concept as multivalent, as ambiguous, and as complex as pain. Insofar as the task
I set for myself is a social and cultural analysis of the meaning of pain in
American society, a number of questions immediately present themselves:

Under what definition of pain am I operating?

If different kinds of pain produce different experiences and different levels
of treatment, which kinds of pain will I assess?

How do the redemptive possibilities of pain factor into an assessment of
its meaning?

What is the relationship between pain and suffering?
Sketching out some responses to these questions will hopefully elucidate
the limits and scope of the approach I am taking to the meaning of pain in
American society.
1
THE DEFINITION OF PAIN
The most widely utilized definition of pain is the one provided by the
International Association for the Study of Pain (IASP): “An unpleasant sensory
and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage.”1 Yet, as numerous commentators note, such
a proposition seems to suffice only as a starting point. That pain can exist in the
absence of tissue damage is undeniable as an empirical matter; yet the obvious
question left unanswered is why so many experiences that the sufferer identifies
as painful are, in the absence of visible lesions, questioned, delegitimized, or
rejected outright. Moreover, such a definition leaves unresolved the complicated
relationship between pain and suffering. Does, for example, depression qualify as
pain under the IASP definition? Is the grief experienced at the death of a child
pain?
In her masterful 2005 essay on stigma and chronic pain, Jean E. Jackson
quotes no less than fifteen different definitions of chronic pain from the applicable
literature. She reasons that “the highly contested definition of pain itself is a
major reason why defining chronic pain as symptoms that persist beyond
expected healing time, although true, does not take one very far.”2
In addition to this contest, pain is obviously not a unitary phenomenon.
Different kinds of pain are qualitatively different in important ways, and produce
different experiences for the pain sufferer, as well as different levels of treatment,
1
International Association for the Study of Pain, Pain Definitions: Pain, http://www.iasppain.org/AM/Template.cfm?Section=General_Resource_Links&Template=/CM/HTMLDisplay.cf
m&ContentID=3058#Pain (accessed March 16, 2008).
2
Jean E. Jackson, “Stigma, Liminality, and Chronic Pain: Mind-Body Borderlands,”
American Ethnologist 32, no. 3 (August 2005): 335.
2
stigma, and care. It is plausible to suggest that there is no phenomenology of
pain, but only phenomenologies of pain. These issues raise the question of
whether a single definition of pain is coherent at all. If not, how is it even
possible to meaningfully assess pain?
In prior work, I have adopted a nonessentialist approach to various
questions and problems related to health and illness in society.3 Drawing largely
on the work of the later Wittgenstein and the relevant secondary literature, I have
argued that epistemic agents do not require an analytic definition of a word or a
concept in order to use it meaningfully in practice. Though many aspects of
Wittgenstein’s thought prompt vigorous debate, there is remarkable agreement
that Wittgenstein’s conception of meaning rejects the need–if not the existence–
for necessary and sufficient criteria of words and concepts to ground those words
and concepts’ meaning.4
Giving full account of this approach is an entirely separate project, one
which ranges too far afield of my practical objectives in thinking about the
undertreatment of pain to permit its undertaking here. Nevertheless, I will
conceptualize pain from just such a nonessentialist vantage point, and thus I
intentionally do not proffer a discussion on the appropriate definition of pain.
While I maintain that the lack of such a definition does not preclude a
meaningful discussion of pain in American society, I do not wish to excuse
imprecision. Nothing in Wittgenstein’s account implies that precision in analysis
3
Daniel S. Goldberg, “Religion, the Culture of Biomedicine, and the Tremendum:
Towards a Non-Essentialist Analysis of Interconnection,” Journal of Religion and Health 46, no.
1 (March 2007): 99-108.
4
Sorin Bangu, “Later Wittgenstein on Essentialism, Family Resemblance and
Philosophical Method,” Metaphysica 6, no. 2 (2005): 53-73; and Marie McGinn, Wittgenstein and
the Philosophical Investigations (London, UK: Routledge Press, 1997).
3
is either impossible or undesirable; rather, the point is that the kind of precision I
can and should strive for cannot rise to the level of analyticity.5 Moreover, it is
precisely because pain is multivalent that it is important to specify the kinds of
pain that are being discussed at any particular level of analysis.
WHICH PAIN?
If I purposefully eschew the task of producing a definition of pain,
because I reject both its necessity and its utility, that only augments the
importance of carefully delineating the kinds of pain I will discuss. Clinical pain
is artificially designated as acute or chronic, though there are obviously many
more categories applicable to different pain experiences. However, the idea that
most kinds of pain are treated well–aside from many “problematic” kinds of
chronic pain–is unsupportable based on the best evidence. For example, as will
be documented in chapter 1, despite decades of efforts and the increasing
visibility and availability of a clinical subspecialty devoted entirely to palliation,
there is good evidence that persons suffering from acute pain secondary to
terminal illness continue to receive inadequate treatment for their pain. (Other
examples will be detailed in chapter 1.) Even acknowledging that many kinds of
chronic pain present the most serious difficulties in clinical practice, ethics, and
policy does not justify ignoring the evidence that many different kinds of pain
sufferers do not receive sufficient treatment for their pain, even while in the vast
majority of cases efficacious modalities exist for treating pain.
5
Quine is obviously also a relevant source on the problems of relying on analytic a priori
concepts in thinking about meaning. Willard von Orman Quine, “Meaning and Translation” and
“Two Dogmas of Empiricism,” in Challenges to Empiricism, ed. Harold Morick (Indianapolis, IN:
Hackett Publishing Company, 1980), 46-69, 70-94.
4
As such, the effort to remain focused on the general undertreatment of
pain in the United States seems to undermine any effort to focus the analysis
specifically on, for example, acute pain secondary to mechanical trauma, or low
back pain, or phantom limb pain, and so forth. In addition, leaving pain as
ambiguous and multifaceted as it seems to exist in people’s actual experiences is
consistent with a phenomenological approach. Pain as a lived experience defies
categories, straddles boundaries, and obliterates definitions. Demarcations
between different kinds of pain are at best useful heuristics, but are unavoidably
crude and inevitably fall far short of capturing the lived experiences of pain.
Where exists a number of interventions, pharmacologic and nonpharmacologic,
for which solid evidence indicates analgesic efficacy, it is difficult to perceive any
meaningful ethical distinction that turns on whether the pain identified is chronic
low back pain or acute pain secondary to mechanical trauma.6
Ultimately, even acknowledging the different experiences produced by
different kinds of pain, I do not see any reason to strain to disentangle pain
sufferers’ narratives of illness and impairment. Though this choice undoubtedly
introduces complexity into the analysis, I will argue that an interdisciplinary
medical humanities approach is particularly well-suited to making sense of such
complexity.7 I will also claim that the atomizing of variables that interact with
each other to produce system behavior is itself a problem in the vast majority of
attempts to produce knowledge on the meaning of pain in society. In contrast, an
6
However, this is not to claim that there are no meaningful distinctions between different
kinds of pain. As I have expressly argued, different kinds of pain produce different
phenomenologies of pain. The argument here is that the ethics of the body in pain do not turn on a
precise demarcation between types of pain.
7
William H. Newell, “A Theory of Interdisciplinary Studies,” Issues in Integrative
Studies 19 (2001): 1-25.
5
approach that begins by acknowledging the interactions, complexities, and
ambiguities of the phenomena of pain in society is, I submit, more promising as a
means of making sense of the undertreatment of pain.
That said, as indicated above, precision is important, and if there is
anything a medical humanities student should learn, it is that rhetoric matters. If I
choose not to expressly focus on any particular kind of pain, it is incumbent upon
me to specify wherever appropriate which specific type of pain is relevant to any
specific facet of the analysis. There are reasons why chronic pain sufferers
generally fare worse in seeking treatment than acute pain sufferers, and these
reasons are crucial in producing evidence that can be used to synthesize policies
that justify hope in ameliorating pain. Some aspects of my analysis will be more
applicable to some kinds of pain than others, and where this is so, I will endeavor
to specify as such and explain why it is so.
THE REDEMPTIVE POSSIBILITIES OF PAIN
One of the most intriguing questions about pain is whether it is, as some
have suggested, “the worst of all evils,”8 or whether the possibility of redemption
through pain opens up space to assess the merits of pain as a good of some sort.
The literature on this question alone is immense and is a particularly rich vein of
inquiry for all manner of social and cultural studies. The bulk of the contributions
to the lone expressly interdisciplinary approach to pain in culture take up this
question in earnest.9
8
Thomas H. Dormandy, The Worst of Evils: The Fight against Pain (New Haven, CT:
Yale University Press, 2006).
9
Sarah Coakley and Kay Kaufman Shelemay, eds., Pain and Its Transformations: The
Interface of Biology and Culture (Cambridge, MA: Harvard University Press, 2007).
6
I do not discount the potential or the power of the narrative of redemption
in giving meaning to experiences of pain; such a story has roots in the JudeoChristian tradition as old as the Book of Job and is told and retold in myriad ways
in many other traditions.10 However, the possibilities of redemption in pain are
not my subject here. If a narrative of redemption aids illness sufferers in making
meaning of their pain, that is all to the good. But there is an unavoidably
pragmatic element to my project: there is general consensus that millions of
Americans experience intense, sometimes incapacitating pain that may last for
days and recur for years, and that many of these people do not receive available
treatment that could significantly remedy their suffering. I do not doubt that some
of these sufferers’ broken stories could be and are fixed through a narrative of
redemption.11 However, I deem it safe to suggest that whatever the power of such
a narrative, it neither explains why so many experience pain when effective
treatments exist nor necessarily offers succor and relief to any particular pain
sufferer.12
10
Luis O. Gomez, “Pain and the Suffering Consciousness: The Alleviation of Suffering
in Buddhist Discourse,” in Pain and Its Transformations: The Interface of Biology and Culture,
ed. Sarah Coakley and Kay Kaufman Shelemay (Cambridge, MA: Harvard University Press,
2007), 101-121; Elizabeth Tolbert, “Voice, Metaphysics, and Community: Pain and
Transformation in the Finnish-Karelian Ritual Lament,” in Pain and Its Transformations: The
Interface of Biology and Culture, ed. Sarah Coakley and Kay Kaufman Shelemay (Cambridge,
MA: Harvard University Press, 2007), 147-165; and Martha Ann Selby, “The Poetics of
Anesthesia: Representations of Pain in the Literatures of Classical India,” in Pain and Its
Transformations: The Interface of Biology and Culture, ed. Sarah Coakley and Kay Kaufman
Shelemay (Cambridge, MA: Harvard University Press, 2007), 317-330.
11
Howard A. Brody, Stories of Sickness (New Haven, CT: Yale University Press, 1987).
12
Jean E. Jackson, “How to Narrate Pain? The Politics of Representation,” in Narrative,
Pain, and Suffering, ed. Daniel B. Carr, John David Loeser, and David B. Morris (Seattle, WA:
IASP Press, 2003), 230-242.
7
In her comments responding to several essays in the aforementioned
interdisciplinary anthology on pain, Elaine Scarry, whose work has inspired a
generation of pain scholars, notes her concern regarding
a view that might seem to license the infliction of pain . . . On the
one hand, we have to remember how a shaman can willfully take
on pain and actually bring about amazing world-transforming
effects through his own meditation on it. On the other hand, there
is the kind of pain that a person has no say over, did not authorize,
and does not have the option of expressing in . . . beautiful
language.13
Moreover, she observes, even acknowledging the “vast tonal and thematic
differences,” talk of the redemptive possibilities of pain “from the medical world”
could be perceived by the sufferer as “a horribly crude way of saying: ‘It’s okay
that you’re in pain. There is great meaning to be built from this, so live with
it.’”14
Similarly, ethnographies of pain sufferers, which I will address in chapters
2, 7, and 9, make clear that among at least some of their voices, narratives of
redemption are either absent or inadequate as a means of making meaning of the
sufferers’ pain. Not all pain sufferers are optimistic and hopeful; some are
embittered and broken.15 In my view, not even the most ardent proponent of the
redemptive qualities of pain is justified in suggesting that such qualities are a
13
Elaine Scarry and Arthur Kleinman, “Reductionism and the Separation of ‘Suffering’
and ‘Pain,’” in Pain and Its Transformations: The Interface of Biology and Culture, ed. Sarah
Coakley and Kay Kaufman Shelemay (Cambridge, MA: Harvard University Press, 2007), 139.
14
Ibid.
15
Sandra P. Thomas and Mary Johnson, “A Phenomenologic Study of Chronic Pain,”
Western Journal of Nursing Research 22, no. 6 (October 2000): 683-705.
8
sufficient answer to the questions of why so many Americans suffer so much
pain, and what can be done to ameliorate the undertreatment of that pain.
PAIN AND SUFFERING
Most pain scholars agree that pain and suffering are distinguishable. Such
a belief commits one to the idea that it is phenomenologically possible to suffer
without pain, or to experience pain without suffering. Even assuming such a
distinction is coherent, disentangling the metaphysics of pain from the
metaphysics of suffering is an enormous conceptual task. To return to an earlier
example, it seems difficult to deny that depression produces suffering in some
sense, but it does not necessarily follow that depression produces pain. To
attempt to divide the question by resolving that depression causes mental but not
physical pain is obviously tautological and sheds no light on the issue of what, if
anything, distinguishes physical from mental pain. Such a response also seems to
assume the coherence of some kind of mind-body duality, which is problematic in
itself and which, I shall argue in chapter 6, is a primary factor in animating the
undertreatment of pain in the United States
Of course, it seems obvious that in many pain experiences of whatever
kind, the subject suffers. Bearing witness to the narratives of persons who
experience pain, whether in literature or in ethnography, confirms almost beyond
any doubt that many kinds of pain produce suffering. Some scholars have argued
that a basic means of drawing some kind of meaningful distinction (in practice,
but not an essential distinction) between kinds of pain centers on the purpose of
the pain. That is, some kinds of pain “serve an important biological (or
evolutionary) function in that it warns the organism of impending danger, informs
9
the organism of tissue damage or injury, or deters the organism from interfering
with healing or causing further tissue damage.”16 Support for this idea is evident
in the fact that an entirely painless existence is not conducive with human
flourishing. Known as congenital analgesia, individuals who have this rare
genetic disorder often suffer repeated injury, including broken bones, lacerated
skin, and damage to internal body tissues, and they have significantly shortened
life expectancy.17
Other kinds of pain, such as chronic pain that persists for years without
relief or explanation, seem to serve no identifiable “biological” purpose, and
hence may be more likely to cause phenomenologically distinct kinds of
suffering. Of course, even “useful” pain may cause suffering, but it may in truth
be easier to make meaning out of “useful” pain than pain which seems
“purposeless.”
In any case, I cannot hope to disentangle the complex meanings and
metaphysics of pain from the metaphysics of suffering in this dissertation. With
good evidentiary support, I take it as a given that many kinds of pain experiences
produce kinds of suffering, even acknowledging that different pain experiences
likely produce different kinds and intensities of suffering. Like many of the other
choices made in conceptualizing the undertreatment of pain, I submit that leaving
the relationship between pain and suffering as ambiguous, as complicated, and as
16
David B. Resnik, Marsha Rehm, and Raymond B. Minard, “The Undertreatment of
Pain: Scientific, Clinical, Cultural, and Philosophical Factors,” Medicine, Health Care and
Philosophy 4, no. 3 (October 2001): 280.
17
Niranjan Biswal, Murali Sundaram, Betsy Mathai, and Sijay Balasubramanian,
“Congenital Indifference to Pain,” Indian Journal of Pediatrics 65, no. 5 (September 1998):755769; Eric Hirsch, Danny Moye, and Joseph H. Dimon III, “Congenital Indifference to Pain: Longterm Follow-up of Two Cases,” Southern Medical Journal 88, no. 8 (August 1995): 851-857.
10
multivalent as it seems to be in people’s lived experiences is entirely consistent
with a phenomenologic approach to pain. Moreover, because of the
nonessentialist approach I take to pain, I maintain that such ambiguity does not
preclude meaningful thought about pain and suffering, nor does it undermine the
irreducibly pragmatic goal of my dissertation: producing policies that justify the
hope that the undertreatment of pain in the United States will be ameliorated.
TERMINOLOGY
Finally, I offer here an explanation of the term I will use to refer to the
subject in pain, the pain sufferer. This locution is simply a variant of the phrase
illness sufferer, which is widely used within and across medical humanities
scholarship. The notion of an illness sufferer is both broader and more accurate
than the clinical term patient, because while illness sufferers may often be
patients over the duration of any given illness experience, there are also likely to
be many moments during the course where they are not actively patients. That is,
a person can be undergoing an illness experience without undergoing that
experience as a patient. Nevertheless, the able reader may be wondering whether
terming the subject in pain a pain sufferer begs the crucial question regarding the
connection between pain and suffering. As noted above, I am content to leave the
relationship complex and ambiguous and do not, by referring to the subject in
pain as a pain sufferer mean to convey any commitment to the nature and
character of the interplay between pain and suffering.
It is a basic precept of the medical humanities that the human experiences
of illness and pain are limited only by the boundless capacity of the human search
for meaning in the face of illness. Just as referring to the person undergoing an
11
illness experience as the illness sufferer does not negate extreme heterogeneity
regarding the extent and even the existence of suffering in the face of illness, so
too does speaking of the subject in pain as the pain sufferer commit me to no firm
position on the extent, if any, to which the person in pain suffers. Given how vast
and deep the undertreatment of pain goes in the United States (documented in
section I), it seems safe to suggest that large numbers of persons in pain do in fact
suffer.
12
Introduction: The Power of the Visible
“That which is not on the scale of the gaze falls outside the domain of
possible knowledge.”18
Michel Foucault, The Birth of the Clinic
In early November, 1896, Walter James Dodd, a physician at
Massachusetts General Hospital, began to suffer from severe dermatitis in his
hands.19 Five months later, the itching had progressed to intense pain,
accompanied by visible changes in his hands and his face, both of which began to
appear scalded. In July 1897, Charles Allen Porter, his friend and surgeon,
performed on Dodd the first in a series of skin grafts.20
By 1902, cancer had spread into Dodd’s fingers. Porter and Dodd together
worked meticulously to preserve as much of Dodd’s hands as possible, basing
their surgical decisions “on the finger’s relative usefulness.”21 Dodd endured over
18
Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans.
Alan M. Sheridan Smith (New York: NY, Vintage Books, 1994), 166.
19
Rebecca Herzig, “In the Name of Science: Suffering, Sacrifice, and the Formation of
American Roentgenology,” American Quarterly 53, no. 4 (December 2001): 563-589.
Unfortunately, I have been unable to locate Walter James Dodd’s personal papers from any
available repository, including but not limited to the Countway Medical Library, Massachusetts
General Hospital, Radiological Society of North America, Massachusetts Medical Society, and the
American College of Radiology. Some correspondence with colleagues such as Maurice Howe
Richardson at Massachusetts General Hospital is extant, but these letters are fairly perfunctory and
say nothing of Dodd’s work with X-rays or his health problems.
20
Ibid.
21
Ibid., 576.
13
fifty separate operations, in which only the most severely affected portions of his
digits and hands were removed.22
Dodd even left raw nerve endings exposed in a finger, refusing to permit
amputation for months on end because he feared that the procedure would
preclude him from continuing his work.23 The pain must have been
unimaginable. Yet Dodd “embrace[d]” the pain, refusing treatment with opioids
and returning to his work almost immediately after awakening from the anesthesia
of his various operations.24
The instrumentality of Dodd’s suffering was the X-ray, with which Dodd
began experimenting mere months after European newspapers reported on
Roentgen’s discovery in December 1895. Dodd was one of the pioneers of
roentgenology in the United States, and thus his work as a roentgenologist was, as
Herzig puts it, quite literally the “agent of his destruction.”25 Nor was Dodd the
only early roentgenologist to suffer and die prematurely due to radiation-induced
cancer. Dozens of scientists and physicians endured multiple amputations in
unsuccessful attempts to halt the cancer that would spread to their internal organs
and frequently take their lives. Moreover, there is excellent evidence that the
scientific community in general, like Dodd, understood full well the danger of Xrays, even if the precise mechanism of the harm was unclear.
Thus, several questions immediately present themselves: why would these
healers and scientists willingly, proudly seek out the very activity that caused
22
Ibid.
23
Ibid.
24
Ibid., 577.
25
Ibid.
14
them indescribable pain and suffering? More so, why would many of these
professionals, like Dodd, endure even greater agony in delaying needed
amputations for the sake of operating the X-ray controls?
Though I answer these questions in detail in separate work, the short
answer is that, at least in part, these roentgenologists were willing to suffer and
die for the power of sight, for the capacity to see inside the body. Though this
dissertation is an attempt to evaluate the ways in which social and cultural beliefs,
practices, and attitudes about pain impede its treatment, one of my core claims is
that any such analysis is deficient without understanding the importance of the
visible in the American culture of biomedicine. In some sense, then, this
dissertation about the undertreatment of pain is an account of the social and
cultural significance of the visible in scientific and medical culture.
Positing the significance of seeing inside the previously opaque body as an
explanation for Dodd’s willingness to suffer leaves unresolved the essential
question: why was seeing inside the body worth suffering and dying for? What
specifically was at stake socially, culturally, and spiritually? What made this form
of observation valuable enough that Dodd and like-minded colleagues were
willing to endure unspeakable agonies en route to a premature death?
These questions revolve around the meaning of scientific and clinical
observation. While many nineteenth-century scientists and physicians had great
respect for the intricate botanical and anatomical illustrations of the modern era,26
the images produced through the X-ray belonged to a different paradigm.27 These
26
Lorraine Daston and Peter Galison, Objectivity (Brooklyn, NY: Zone Books, 2007).
27
Herzig, “American Roentgenology;” Tal Golan, “The Emergence of the Silent Witness:
The Legal and Medical Reception of X-Rays in the United States,” Social Studies of Science 34,
15
images were deemed to be produced by the operation of a machine, rather than by
subjective observation and subsequent representation. Indeed, the X-ray operator
was standing in a totally different place than the anatomist–he/she was not gazing
directly into the interior of the body. To oversimplify, anatomical and scientific
drawings, as much skill as they reflected, were subjective, while X-rays were
objective. The information produced via X-ray was literally an object that could
be perceived by external observers, one that was deemed by many proponents of
X-rays to reflect a fundamental correspondence with reality. X-ray images were,
to many, so unprecedented, so powerful, and so valuable precisely because they
were untainted by subjective interpretation.28
What does the power of the visible in the culture of biomedicine have to
do with the undertreatment of pain in the United States? Everything. To
understand why, it is necessary to examine more of the context surrounding pain
and pain policy in the United States.
THE UNDERTREATMENT OF PAIN IN THE UNITED STATES AND THE DOMINANT
POLICY RESPONSE
Two questions animate this project:
no. 4 (September 2004): 469-499. This is not necessarily to suggest the X-ray represented a
Kuhnian paradigm shift.
28
This is something of an oversimplification, because as Daston and Galison point out,
many scientists were well aware, for example, that photographic images did not perfectly
correspond to reality, and in fact depended greatly on the technique of the photographer.
Nevertheless, even their analysis shows that a dominant theme within nineteenth-century science
was the focus on what they term “mechanical objectivity,” or the hope that scientific imaging
techniques would eliminate as much subjective influence as possible in the production of
knowledge. I will return to these issues again in chapters 3-5.
16
1. Given that the vast majority of pain experiences can be adequately
managed using available treatment modalities, why does pain remain so
poorly treated in the United States?
2. Given the immense and crossdisciplinary scholarship, advocacy, and
policy attention to the undertreatment of pain in the United States, why
does pain remain so poorly treated in the United States?
As to the first question, the failure to treat pain adequately in the United
States is not a function of a dearth of efficacious treatment modalities. An
overwhelming majority of pain experiences can be alleviated using currently
available interventions, which include but are not limited to opioid analgesics.29
This fact suggests that the reasons for the undertreatment of pain go far beyond
any analysis of the clinical efficacies of various pharmacologic and
nonpharmacologic interventions. By this argument I do not mean to suggest that
such interventions are unimportant; attitudes and beliefs towards, for example,
opioid analgesics and addiction are relevant to the undertreatment of pain in the
United States. However, these attitudes and beliefs cannot be separated from an
analysis of how individuals and communities conceive of the phenomenon of pain
itself. Medicines, as a number of scholars point out, are social “objects” in the
sense that their meaning is necessarily shaped by social, cultural, and contextual
29
Noting that the majority of pain experiences can be ameliorated is an
oversimplification, of course, because different pain experiences are more or less susceptible to
different interventions. I will address this issue in more detail in chapter 1 and chapter 8.
17
factors.30 There is no reason to think opioids are exceptions to this
interpretation.31
As to the second question, the failure to treat pain adequately has not gone
unnoticed in the United States. There is an immense literature on the
undertreatment of pain across and beyond medicine and clinical practice to
biomedical research, ethics, health policy, sociology, anthropology, history,
public health, nursing, disability studies, literature, psychology, communications,
and so forth. The problem has sparked a veritable storm of scholarly and
professional attention, with scores of articles, books, and policy analyses
available, funding opportunities across public, private, and nonprofit sectors,
focus from multiple professional societies (such as the American Pain Society, the
American Academy of Pain Management, the IASP), and the focus of numerous
community-based organizations and advocacy efforts related to pain (such as the
American Pain Foundation, the Pain Relief Network, the American Chronic Pain
Association).
Despite nearly three decades of such attention, there is little evidence that
pain is generally being treated better, and even less evidence of improvement in
30
Joseph Gabriel, “Gods and Monsters: Drugs, Addiction, and the Origins of Narcotic
Control in the 19th Century Urban North,” (PhD dissertation, Rutgers University, 2006); Susan
Reynolds Whyte, Sjakk van der Geest, and Anita Hardon, The Social Lives of Medicines
(Cambridge, UK: Cambridge University Press, 2002); and Bruno Latour, We Have Never Been
Modern (Cambridge, MA: Harvard University Press, 1993).
31
Gabriel, “Gods and Monsters”; Caroline Jean Acker, Creating the American Junkie:
Addiction Research in the Classic Era of Narcotic Control (Baltimore, MD: Johns Hopkins
University Press, 2002); Caroline Jean Acker, “From All Purposes Anodyne to Marker of
Deviance: Physicians’ Attitudes towards Opioids in the US from 1890 to 1940,” in Drugs and
Narcotics in History, ed. Roy Porter and Mikulas Teich (Cambridge, UK: Cambridge University
Press, 1995), 114-132.
18
treating chronic pain.32 Moreover, as the number of chronically ill and disabled
persons increases,33 there is every reason to suspect that the prevalence and
incidence of pain will also increase. In addition, health disparities in general and
disparities as to the diagnosis and treatment of pain in particular, are widening.34
If the undertreatment of pain has been relatively common knowledge for
decades and if the problem has enjoyed no shortage of scholarly and practical
attention, why is it that pain remains so poorly treated in the United States? This
is one problem my research is intended to address. An additional, tacit question is
what are the limitations of current ethical and policy approaches to the
undertreatment of pain? Ultimately, if the ethical imperative to treat pain
adequately has meaning, it behooves participants in the relevant discourse to
ascertain exactly why past and currently prevailing approaches do not seem to be
effective in improving the treatment of pain.
My research has several objectives: First, I will explain why a social and
cultural analysis of the notion of pain in the United States is a prerequisite to
understanding the undertreatment of pain and to proposing workable solutions.
32
Noémi R. Tousignant, “Pain and the Pursuit of Objectivity: Pain-Measuring
Technologies in the United States c. 1890-1975,” (PhD dissertation, McGill University, 2006). I
will address in detail the empirical evidence regarding the prevalence, incidence, and
undertreatment of pain in chapter 1.
33
Ross DeVol and Armen Bedroussian, An Unhealthy America: The Economic Burden of
Chronic Disease (Santa Monica, CA: Milken Institute, 2007).
34
See Lisa J. Staton, Mukta Panda, Ian Chen, Inginia Genao, James Kurz, Mark Pasanen,
Alex J. Mechaber, Madhusudan Menon, Jane O’Rorke, JoAnn Wood, Eric Rosenberg, Charles
Faeslis, Tim Carey, Diane Calleson, and Sam Cykert, “When Race Matters: Disagreement in Pain
Perception between Patients and Their Physicians in Primary Care,” Journal of the National
Medical Association 99, no. 5 (May 2007): 532-537; Carmen R. Green, Karen O. Anderson,
Tamara A. Baker, Lisa C. Campbell, Sheila Decker, Roger B. Fillingim, Donna A. Kaloukalani,
Kathyrn E. Lasch, Cynthia Myers, Raymond C. Tait, Knox H. Todd, and April H. Vallerand, “The
Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain,” Pain Medicine 4, no.
3 (September 2003): 277-294.
19
Second, I will aim to use this analysis to explain why prevailing approaches have
not alleviated the undertreatment of pain and are unlikely to do so. Third, I will
produce policy recommendations based on the social and cultural analysis of pain
in context of American society. These policy recommendations will reflect the
best evidence regarding the causes of the undertreatment of pain.
Committing this project to the production of evidence-based policy is a
choice made with full awareness of the ongoing debate over the validity and
legitimacy of the notions of evidence-based policy and evidence-based medicine.
A significant portion of the criticisms of evidence-based medicine assails the
cramped view of what qualifies as relevant evidence. Numerous commentators
have pointed out the problems of relying on the evidence produced from
randomized controlled trials (RCTs) as the so-called gold standard regardless of
the phenomenon under investigation.35 Noting the limitations of RCTs is not to
suggest that evidence produced through them is necessarily infirm or wanting;
depending on the subject of inquiry, it may well be the superior form of
knowledge production. However, there is reason to believe, as Jason Grossman
and Fiona MacKenzie point out, that other kinds of evidence and analytical
modalities may be vastly superior to the RCT, depending, again, on the nature of
the question to be answered.
35
Jason Grossman, “A Couple of the Nasties Lurking in Evidence-Based Medicine,”
Social Epistemology 22, no. 4 (October 2008): 333-352; Adam La Caze, “Evidence-Based
Medicine Can’t Be . . .,” Social Epistemology 22, no. 4 (October 2008): 353-370; Howard Brody,
Franklin G. Miller, and Elizabeth Bogdan-Lovis, “Evidence-Based Medicine: Watching out for Its
Friends,” Perspectives in Biology and Medicine 48, no. 4 (Autumn 2005): 570-584; Ross G.
Upshur, “Looking for Rules in a World of Exceptions: Reflections on Evidence-Based Practice,”
Perspectives on Biology and Medicine 48, no. 4 (Autumn 2005): 477-489.
20
For example, few would suggest that the best means of gaining insight
into what it feels like, in a phenomenologic sense, for a person to live with
chronic pain is via a RCT. As a form of knowledge production, the RCT aims to
strip away individual variations in the hopes of maintaining high internal validity.
Indeed, Noémi Tousignant documents this phenomenon in context of Henry
Beecher’s pioneering work on analgesic clinical trials, which showed that
clinically useful information about pain was best produced by aggregating
individual experiences into a larger distribution.36 In contrast, the entire point of
an inquiry into the lived experiences of the chronic pain sufferer is to learn
something about those individual experiences. Not coincidentally, the vast
majority of studies devoted to assessing the lived experiences of chronic pain
employ narrative, phenomenologic, and related qualitative approaches.37 These
approaches aim to center the subject in pain, which is the theme both of my entire
project and of the first of four sections that comprise this dissertation.
SECTION I: THE LIVED EXPERIENCE OF PAIN
Because centering the subject in pain is paramount, section I addresses the
lived experience of pain. The rationale for this will hopefully become quite clear
by the end of my analysis, but the basic idea is that the pain sufferer’s lived
36
Tousignant, “Pain and the Pursuit of Objectivity.”
37
See, e.g., Jackson, “Stigma, Liminality, and Chronic Pain”; Jean E. Jackson, Camp
Pain: Talking with Chronic Pain Patients (Philadelphia, PA: University of Pennsylvania Press,
2000); Jean E. Jackson, “‘After a While No One Believes You’: Real and Unreal Pain,” in Pain as
Human Experience, ed. Paul E. Brodwin, Arthur Kleinman, Byron J. Good, and Mary-Jo
DelVecchio Good (Berkeley, CA: University of California Press), 138-168; Marja-Liisa
Honkasalo, “Chronic Pain as a Posture towards the World,” Scandanavian Journal of Psychology
41, no. 3 (September 2000): 197-208; Marja-Liisa Honkasalo, “What Is Chronic Is Ambiguity:
Encountering Biomedicine with Long-Lasting Pain,” Journal of the Finnish Anthropological
Society 24, no. 4 (1999): 75-92; Thomas and Johnson, “A Phenomenologic Study of Chronic
Pain.”
21
experiences are generally not centered in biomedical encounters in which relief
for pain is sought. Accordingly, in chapter 1, I survey the evidence relating to the
epidemiology of pain so as to provide a basic understanding of the prevalence and
distribution of pain within and between different populations and communities in
the United States. This approach contextualizes the subject of chapter 2, which
addresses the phenomenology of pain–that is, what it is like to be-in-the-world as
a pain sufferer.
My aim in section I is, through analysis of the epidemiology and
phenomenology of pain, to build a positive account of the pain sufferer’s
experiences, and to suggest that, sadly, these experiences are not central in either
American culture in general or in the American culture of biomedicine in
particular. Because the social and cultural factors that animate this de-emphasis
are just that–social and cultural–they affect all participants in the process,
including providers, caregivers, and pain sufferers themselves.38
However, because a significant portion of my analysis of these social and
cultural processes is historical in nature, beginning, as I do in section I, with
explication of the current meanings of pain in the United States requires
something of a reverse chronology. (Historical analyses, one might surmise, tend
to begin in the past rather than the present). The justification for a contrary
approach here is that beginning with the historical origins of our social and
38
The interplay between the population-based approach of chapter 1 and the
phenomenologic focus of chapter 2 itself characterizes some key aspects of the medical
humanities analysis I will use here. My general aim is to unpack some of the social and cultural
meanings of pain in the United States and then apply these understandings to assess and center the
lived subject in pain. This tacking back and forth between larger social representations and
narratives and the subject’s lived experiences of pain within their particular communities and
networks is part of what an interdisciplinary medical humanities approach can offer.
22
cultural attitudes towards the phenomenon of pain risks deflecting attention from
the contemporary pain sufferer. For reasons that I hope will become clear, the
possibility that the person in pain might disappear from the analysis at the outset
is an error that would substantially undermine my entire project. Therefore, the
choice to begin with the epidemiology and phenomenology of pain is intended to
reflect the ethical importance of centering the lived, subjective experiences of the
pain sufferer.
SECTION II: HISTORY, THE POWER OF THE VISIBLE, AND PAIN
Once I have articulated an account of the epidemiology and
phenomenology of pain in section I, I can move into section II of this thesis, in
which I will explain why the lived experiences of the pain sufferer are generally
not privileged. This explanation will focus on an account of how pain came to
mean what it has come to mean in American culture. My argument is that
because traditionally dominant policy approaches to improving the
undertreatment of pain have taken little account of either what pain currently
means or, perhaps more importantly, what social and cultural factors combined to
produce those meanings, they have not been and are unlikely to be successful in
reducing the needless suffering of millions of Americans. From section I’s focus
on the lived experience of pain, section II reaches back chronologically and
conceptually to assess the social and cultural power of the visible in biomedical
culture.
I began this project with a brief discussion of the early American
roentgenologists so as to highlight the importance of the visible in understanding
the American culture of biomedicine. I shall argue that the visible is particularly
23
relevant to thinking about pain because pain is generally taken to be an invisible,
subjective phenomenon. The idea here is that pain is problematic in American
culture because it cannot be seen in the body, and that this problem is a prime
factor in its undertreatment.
The role of the visible in conceptualizing illness, pain, and the body is an
extraordinarily rich and layered topic, and doing it any justice requires the
assimilation of a variety of historical evidence and themes. While I do endorse
the notion, held by myriad historians of medicine, that the nineteenth century is of
particular importance in understanding contemporary American healing practices
and beliefs, limiting the analysis exclusively to the nineteenth century runs too
great a risk of periodicity (an insufficient understanding of the influence that older
ideas, events, and conditions exert on later practices). Accordingly, chapter 3 sets
needed context for the crucial changes that occurred in the nineteenth century by
addressing the power–and the peril–of the visible inner body in Western culture
from the Middle Ages to 1800. Of course, attempting precise historical
scholarship of a 700-year period across multiple regions, societies, and
communities in a single chapter is a fool’s errand, and chapter 3 therefore
concerns itself merely with identifying broad strokes and patterns that would
come to shape early modern and modern practices regarding the power of the
visible.
Chapter 4 picks up the narrative in the nineteenth century and introduces
one of the major theoretical frameworks upon which this project rests: Michel
Foucault’s analysis of the genesis of the “clinical gaze.” Medical perception is
front and center in Foucault’s analysis of the rise of contemporary Western
24
clinical medicine.39 As such, a Foucauldian frame is especially well-suited for a
project devoted to tracing the impact of the visible in American culture in general,
and in American cultures of biomedicine and science in particular.
In chapter 4, I bring this lens to bear on the problem of pain without lesion
in mid-to-late nineteenth-century America. The central question here is as the
anatomoclinical method and the clinical gaze took hold during the nineteenth
century, how did physicians account for pain that could not be connected with any
material pathology or lesion inside the body? Answering this question is integral
to comprehending the role visible pathology plays in the contemporary
undertreatment of pain, and therefore chapter 4 utilizes a number of neurological
and medical primary sources to ground an argument that pain without lesion was
not tenable to leading lights of American medicine.
Foucault did not expressly connect his work on medical perception to the
contemporary treatment of pain. David B. Morris, however, has picked up the
theme and in a 1991 book and a 1998 essay, argues that a Foucauldian analysis
can explain how it is that pain came to be seen as “invisible” in the West during
the nineteenth century (presumably both in Europe and in the United States).40
While I enthusiastically endorse Morris’s conclusions, his arguments have come
under fire from several notable sources on the history of pain. Marcia L.
Meldrum and Noémi Tousignant have both criticized Morris for overreaching,41
39
Indeed, it is the subtitle of Foucault’s main work on the subject: The Birth of the
Clinic: An Archaeology of Medical Perception.
40
David B. Morris, “An Invisible History of Pain: Early 19th-Century Britain and
America,” Clinical Journal of Pain 14, no. 3 (September 1998): 191-196; and David B. Morris,
The Culture of Pain (Berkeley, CA: University of California Press, 1991).
41
Marcia L. Meldrum, “A Capsule History of Pain Management,” Journal of the
American Medical Association 290, no. 18 (November 12, 2003): 2470-2475; and Tousignant,
“Pain and the Pursuit of Objectivity,” 53.
25
and Andrew Hodgkiss devoted an entire monograph to repudiating Morris’s
claims.42 Part of the problem is that, as I shall show in chapter 4, Morris makes
bold claims regarding pain during the nineteenth century, and does so with little
reference to primary sources. The breadth of Morris’s arguments, combined with
the relative paucity of close historical analysis of primary sources, makes his
contentions centering on Foucault, the nineteenth century, and the invisibility of
pain ripe for criticism, and, as I aim to show, for misinterpretation as well.
Accordingly, a key objective for my project is to pick up Morris’s analysis
and supply some of the evidentiary gaps in his argument. But more than simply
filling gaps, I will argue that many of the criticisms of Morris’s argument are
based on a misinterpretation, namely, that he argues that pain became invisible in
the sense that nineteenth-century physicians ignored or trivialized their patients’
pain. As I will show in chapters 4 and 5, Meldrum, Tousignant, and Hodgkiss are
quite right to suggest that the historical record does not support such a claim.43 I
will argue, however, that a more subtle interpretation of Morris’s argument is both
more charitable and more persuasive: it is not that nineteenth-century physicians
ignored or trivialized their patients’ pain, but rather that pain in the absence of
visible, material pathology vanished from medical (and cultural) perception. This
is the thesis I will defend in this project, and I will link it to the contemporary
undertreatment of pain.
42
Andrew Hodgkiss, From Lesion to Metaphor: Chronic Pain in British, French, and
German Medical Writings 1800-1914 (Amsterdam, Netherlands: Rodopi Press, 2000).
43
There is, in my view, similarly little justification for suggesting that twenty-firstcentury health providers ignore or trivialize their patients’ pain, nor that they undertreat pain
because the providers are genuinely unconcerned with human suffering. Asserting that the
undertreatment of pain is equivalent to wanton cruelty or negligence is either question-begging or
is based on extremely weak empirical evidence (i.e., that health-care providers are any more
disposed to wanton cruelty than a suitable control group).
26
Chapter 5 occupies functional space similar to chapter 2. Chapter 2 brings
the population-level evidence surveyed in chapter 1 to the pain sufferer, while
chapter 5 links the historical evidence marshaled in chapters 3 and 4 to the
contemporary problems in treating pain in the United States. Chapter 5 also picks
up the evidence surveyed in chapters 3 and 4 suggesting that conceptions of the
relationship between mind and body play a crucial role in shaping and informing
the meaning of pain in American culture.
Part of the problem in the oft-utilized distinction between “mental” and
“physical” pain is a ubiquitous but erroneous mind-body dualism that pervades
both lay and scholarly conceptions of mind, consciousness, and pain.44 There is
excellent reason to believe that adherence to mind-body dualism animates some
of our problems in treating chronic pain in particular, and plays a significant role
in producing the stigma that chronic pain sufferers so frequently endure.45
Chapter 6 connects this adherence to the power of the visible in context of
pain via analysis of functional magnetic resonance imaging (fMRI) techniques.
By measuring blood oxygenation levels in precise areas of the brain that are
known to be associated with certain functions, fMRI techniques have enabled
investigators to identify neural correlates.46 My particular interest is the fMRI
studies identifying neural correlates of pain. Many of these studies have either
implied or stated that fMRI techniques have finally provided objective evidence
44
Jackson, “Stigma, Liminality, and Chronic Pain”; and John Searle, The Rediscovery of
Mind (Cambridge, MA: The MIT Press, 1992).
45
Jackson, “Stigma, Liminality, and Chronic Pain”; and Jackson, Camp Pain.
46
The term correlate is important and has been the source of much confusion, which I
will address in chapter 5.
27
of pain.47 There is, however, evidence both that scientists and scholars may
overstate the meaning and significance of fMRI studies,48 and that media accounts
frequently misinterpret the inferences that can legitimately be drawn from finding
neural correlates of a mental phenomenon.49
Although evaluating the claims of fMRI proponents as to pain is
important, more interesting is the question posed earlier in context of
contemporary neuroimagers’ roentgenological predecessors: What is at stake in
asserting that such imaging techniques produce objective evidence of pain? Why
are these claims socially, culturally, and clinically significant? Accordingly, in
chapter 6, which marks the beginning of section III, I will answer these questions
by analyzing some of the philosophical and neuroscientific debates over the role
subjectivity plays in the conception of consciousness.
SECTION III: ETHICS, SUBJECTIVITY, AND PAIN
While this dissertation is in no way an account of consciousness, it is, I
suggest, no accident that philosophers and neuroscientists alike frequently refer to
47
Thorsten Giesecke, Richard H. Gracely, Masilo A. B. Grant, Alf Nachemson, Frank
Petzke, David A. Williams, and Daniel J. Clauw, “Evidence of Augmented Central Pain
Processing in Idiopathic Chronic Low Back Pain,” Arthritis & Rheumatism 50, no. 2 (February
2004): 613-623; and Robert C. Coghill, John G. McHaffie, and Ye-Fen Yen, “Neural Correlates of
Interindividual Differences in the Subjective Experience of Pain,” Proceedings in the National
Academy of Sciences 100, no. 14 (July 8, 2003): 8538-8542
48
Edward Vul, Christine Harris, Piotr Winkielman, and Harold Pashler, “Puzzlingly High
Correlations in fMRI Studies of Emotion, Personality, and Social Cognition,” Perspectives in
Psychological Science 4, no. 3 (April 2009): 274-290; Michael S. Pardo and Dennis Patterson,
“Philosophical Foundations of Law and Neuroscience,” University of Alabama Public Law
Research Paper No. 1338763, http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1338763
accessed July 2, 2009); and Amanda Pustilnik, “Violence on the Brain: A Critique of
Neuroscience in Criminal Law,” Harvard Law School Faculty Scholarship Series, Paper 14,
http://lsr.nellco.org/harvard/faculty/papers/14/ (accessed June 5, 2009).
49
See, e.g., Jane Elliott, “Studying the Brain to Relieve Pain,” BBC News, February 5,
2006, http://news.bbc.co.uk/1/hi/health/4674136.stm (accessed May 31, 2009).
28
pain in their discourses on consciousness: pain is a paradigm case of
consciousness. Insofar as the role of subjectivity in consciousness has important
implications for the ways pain and the relation between the mind and the body is
conceived in American culture, any account of social and cultural beliefs and
practices about pain must assess cultural narratives and perspectives on
consciousness, subjectivity, and pain. These meanings overlap in substantial
ways with the meaning of fMRI studies of pain. Chapter 6 assesses these issues
in context of ethics, subjectivity, and pain.
However, were the analysis to focus narrowly on scientific and biomedical
culture, it would be thin indeed, because philosophers of science like Thomas S.
Kuhn, Paul Feyerabend, and Evelyn Fox Keller have long noted that scientific
practices are profoundly shaped by the larger cultures in which they are situated.50
Thus, an account of the role of the visible in biomedical culture requires analysis
of the significance of the visible as to health and illness in American culture in
general, and of the interactions between these cultures. Keller highlights this
dynamic as the discursive nature of culture and scientific practice; each is in an
important sense constitutive of the other.51
This cultural feedback loop is a key part of my analysis.52 Given the close
connection between Western philosophy and natural science since the early
50
Evelyn Fox Keller, Making Sense of Life: Explaining Biological Development with
Models, Machines, and Metaphors (Cambridge, MA: Harvard University Press, 2002); Evelyn
Fox Keller, Refiguring Life (New York, NY: Columbia University Press, 1995); Paul Feyerabend,
Farewell to Reason (New York, NY: Verso Books, 1987); Paul Feyerabend, “How to Be a Good
Empiricist - A Plea for Tolerance in Matters Epistemological,” in Challenges to Empiricism, ed.
Harold Morick (Indianapolis, IN: Hackett Publishing Company, 1980), 164-193; and Thomas S.
Kuhn, The Structure of Scientific Revolutions , 3d ed. (Chicago, IL: University of Chicago Press,
1996).
51
Keller, Refiguring Life.
52
Ibid.
29
modern era, it is unsurprising that the interplay between scientific practices and
culture is evident in contemporary Western philosophy.53 For similar reasons,
the emphasis on an abstract, objectivist school of thought within current bioethics
discourse is equally unsurprising. This latter emphasis is the subject of chapter 7.
In chapter 7, I continue the analysis developed in section II and chapter 6
related to the general cultural distaste for subjective ways of knowing in context
of health, illness, and pain, and I examine the effect this distaste has in bioethics.
I survey the conceptual work that moral objectivism does in its most dominant
form within bioethics discourse–principlism–and explain why principlism in its
prevailing forms is insufficient to account for the lived experiences of pain and,
hence, is wholly inadequate for a rich and informed notion of the ethics of pain.
In its place, I extend the discussion in chapter 2 centered on the phenomenology
of pain and address its ethical implications. I supplement this approach with an
account of moral particularism and explain how a particularist approach is
preferable for unpacking the ethics of pain and, unlike principlism, is well-suited
to supporting evidence-based pain policies.
SECTION IV: TOWARDS ETHICAL, EVIDENCE-BASED PAIN POLICY
The move to ethical, evidence-based pain policies is the subject of section
IV, which is comprised of the final two chapters in my dissertation. For many
reasons, some of which I have already touched on, I eschew an approach that
tracks the general emphasis within pain policy and ethics discourse on opioids and
the opioid regulatory scheme.
53
See Robert L. Martensen, The Brain Takes Shape: An Early History (New York, NY:
Oxford University Press, 2004).
30
Though I will address this in detail in section IV, the currently prevailing
approach to the undertreatment of pain focuses on the need for balance in pain
policy.54 Balance is sought between the need to prevent diversion of opioid
analgesics for illegal purposes and the need to use such analgesics in treating pain
sufferers. There is, of course, nothing inherently wrong with the goal of balance
in pain policy; indeed, who would endorse unbalanced policy of any kind?
The flaw in this approach, however, is that regulatory schemes are
themselves discursive products that are animated by a host of political, social, and
cultural beliefs, attitudes, and practices.55 As such, simply tweaking the
regulatory scheme, however well-intentioned, sheds no light on why the scheme
is unbalanced to begin with. If the goal is to create policy that encourages the
proper use of appropriate medications for the treatment of pain, it is desirable, if
not necessary, to tailor that policy to address the root social causes that drive
unbalanced pain policy.
Moreover, focusing almost exclusively on opioid regulation leaves
obscure the effect of social and cultural beliefs and attitudes towards the
phenomenon of pain itself. There is little doubt that these beliefs and attitudes
influence the treatment of pain. To take just one example, there is good evidence
that elderly populations significantly underreport their pain.56 Given that the
54
Aaron M. Gilson, David E. Joranson, Karen M. Ryan, Martha A. Maurer, Jody P.
Moen, and Janet F. Kline, Achieving Balance in Federal and State Pain Policy (Madison, WI:
Pain & Policy Studies Group, University of Wisconsin Paul B. Carbone Comprehensive Cancer
Center, 2008), http://www.painpolicy.wisc.edu/Achieving_Balance/index.html (accessed June 3,
2009).
55
Shai Joshua Lavi, The Modern Art of Dying: Euthanasia in the United States
(Princeton, NJ: Princeton University Press, 2006).
56
Daniel S. Goldberg, “The Sole Indexicality of Pain: How Attitudes towards the Elderly
Erect Barriers to Pain Management,” Michigan State University Journal of Medicine & Law 12,
no. 3 (2008): 51-72.
31
health-care provider’s primary means of assessing pain is through the patient’s
self-report, a patient’s unwillingness to report his/her own pain is a significant
impediment to effective treatment of pain. Yet it is unclear how addressing the
regulatory scheme for opioid distribution will do anything to ameliorate this
problem; indeed, it is not apparent how the prevailing policy approach even
accounts for such a problem.
Nevertheless, while I do not share the apparent conviction that
ameliorating the excesses of the opioid regulatory scheme is likely to substantially
improve the undertreatment of pain in the United States, I do agree that opioid
policy is at least relevant to the problem. Therefore, in chapter 8, I touch on some
of the debate over opioids, both to explain what I do (and do not) think is
important about that discourse and to justify an approach that does not dwell on
such interventions.
Tracking my approach that deemphasizes the significance for opioid
policy in thinking about the undertreatment of pain in the United States, for the
most part, I will similarly avoid focusing on the connection between fears of
addiction and the undertreatment of pain. This is not, of course, because I deny
the existence of such a connection. However, as I am expressly arguing that the
undue focus on opioids has not improved and is unlikely to substantially improve
the undertreatment of pain, it follows that a similar focus on alleviating the fears
of addiction to opioids is also unlikely to result in significant improvement. As
with opioids in general, I do agree that the issue of addiction is relevant, and I will
mention it in chapter 8. Nevertheless, it is not a focus of my work here, and while
it certainly merits deep analysis on its own terms, I do not think it is of central
importance in explaining the undertreatment of pain.
32
The obvious objection here is that, even assuming the criticisms of the
general focus on opioids within pain policy and ethics discourse has merit, it
remains unclear why and how a medical humanities approach promises to
improve on currently dominant approaches. The short answer is that enhanced
understanding of the social and cultural roots of our practices and attitudes
towards pain will facilitate the creation of policy recommendations that may
justify some measure of confidence in their capacity for improving both the
culture and the practice of treating pain.
A slightly longer answer requires reference to the medieval and
Renaissance humanists from whom we derive the educational program known as
the humanities.57 One of the key tenets of the humanist ethos was an emphasis on
practical engagement. That is, the Renaissance humanists expressly rejected the
earlier Scholastic tendency to bandy abstractions that had little relevance for
people’s daily lives and that did even less to encourage virtue.58 They stressed
that the virtuous scholar lived a life of practical engagement with the world.
Utilizing scholarship as a means of producing knowledge that is informed
by and relevant to our actual practices is a core precept of the humanities.
Therefore, in an important sense, the humanists were early translational
researchers. While a social and cultural analysis of the meaning of pain in
American society is hopefully a worthy contribution in its own right, if such an
analysis is unmoored from an attempt to translate such theory into practice, it is
57
The humanists themselves referred to the program as the studia humanitatis, which
consisted largely of the seven liberal arts, made up of the quadrivium (arithmetic, astronomy,
geometry, and music) and the trivium (logic, rhetoric, and grammar).
58
See, e.g., Charles G. Nauert, Humanism and the Culture of Renaissance Europe, 2d
ed., (Cambridge, UK: Cambridge University Press, 2006); and William J. Bouwsma, “The Culture
of Renaissance Humanism,” American Historical Association Pamphlet (1973), 1-26.
33
arguably inconsistent with the ethos of the humanists. A project more faithful to
the lessons of the humanists ought to endeavor to translate its social and cultural
“evidence” into policy recommendations intended to produce practical changes in
relevant actors’ actual practices. While the intention behind such policy
recommendations is important, arguably more important is whether the belief in
their ability to affect practices is justified based on the available evidence.
Chapter 9 embodies a medical humanities approach to the problem of pain
by assimilating all of the arguments and analyses developed in the first eight
chapters into three separate policies intended to address the undertreatment of
pain in the United States. These policies attend to the deeply rooted social and
cultural forces and pathways that shape the meaning of pain in American society,
and then bring this attention to the level of the pain sufferer him-or-herself, who is
thereby centered in the analysis. Because these pain policies are built upon
evidence regarding the power of the visible and its role in the culture of pain,
there is, I submit, reason to hope that if such policies or related approaches were
implemented, the pervasive undertreatment of pain in the United States could be
ameliorated. The recommended pain policies are specifically directed to the
actors who enjoy the capacity to change the relevant behaviors. The intended
policy audiences include federal and state regulators, professional health
administrators, professional health educators, pain policy scholars, as well as pain
advocates, caregivers, and pain sufferers themselves.
As suggested above, constructing a useful notion of evidence-based policy
requires an understanding of the evidence as to pain that is both deeper and
broader than is generally conceived of and utilized in both evidence-based
medicine and evidence-based policy. Though nothing adduced herein qualifies as
34
evidence in the crabbed sense of the term, I submit that the bulk of it is devoted to
the production and synthesis of evidence in the larger sense of the term, evidence
that includes analysis of the social and cultural beliefs, attitudes, and practices
regarding the meaning of pain. These “variables” are prime determinants in the
undertreatment of pain. This sociocultural evidence base is incorporated in the
policy recommendations detailed in chapter 9, which is why I term them
“evidence-based policy recommendations.”
The tension between the broader and narrower senses of the evidence base
that ought to be used in constructing pain policies is not mere semantics. The
statistics regarding the prevalence of pain and the failures in treating it are
staggering, as chapter 1 will document. If policies intended to improve these
problems are unlikely to be successful because they fail to consider the social and
cultural factors that animate the undertreatment of pain, then opportunities to
reduce the suffering of millions of people may be lost or undermined.
In part, my argument is that a thorough comprehension of the myriad ways
in which attitudes and beliefs about pain shape the treatment of pain may dispel
the notion that focusing simply on opioid regulation is sufficient to alleviate the
suffering of the millions of Americans who endure pain without adequate
treatment. I turn now to chapter 1 in the hopes of documenting the scope of their
suffering.
35
SECTION I: The Lived Experience of Pain
Chapter 1: The Current State of Pain Treatment in the United
States
In prior work, I have noted that two extremely broad premises are needed
to begin discussion on pain in American society: (1) pain ought to be adequately
treated; and (2) pain is not adequately treated.59 The first premise is normative,
and a significant portion of this dissertation is devoted to discussing the ethical
implications a moral agent faces when encountering the person in pain. This
chapter addresses the second premise above, which is, of course, an empirical
claim.
THE PREVALENCE AND SCOPE OF PAIN IN AMERICAN SOCIETY
The National Center for Health Statistics (NCHS), operated under the
auspices of the Centers for Disease Control (CDC), focused on pain in the 2006
installment of its annual analysis on U.S. health. Why pain? The lead study
author noted in the press release accompanying Health United States 2006 that
[w]e chose to focus on pain in this report because it is rarely
discussed as a condition in and of itself–it is mostly viewed as a
byproduct of another condition . . . We also chose this topic
because the associated costs of pain are posing a great burden on
the health care system, and because there are great disparities
59
Goldberg, “The Sole Indexicality of Pain.”
36
among different population groups in terms of who suffer from
pain.60
The statistics collated by NCHS in the 2006 report are sobering, to put it mildly.
According to data taken from the 1999-2002 National Health and Nutrition
Examination Survey, over one-quarter of Americans (26 percent) aged twenty
years and older reported a problem with pain of any kind that lasted more than
twenty-four hours in the month prior to the interview (Figure 1).
As the American Pain Foundation notes, the fact that 26 percent of
Americans report pain means the incidence of pain is greater than that of diabetes,
heart disease, and cancer combined (Figure 2).61
And, as mentioned in the Introduction, elderly persons were least likely to
report pain (21 percent), which is especially troubling given the estimates of high
pain prevalence among such populations.62 The NCHS 2006 report notes
although elderly populations report pain less frequently than other classes of
adults, “57 percent of older adults who reported pain indicated that the pain lasted
for more than 1 year compared with 37 percent of adults 20–44 years of age who
reported pain” (Figure 3).63
60
National Center for Health Statistics, Health United States 2006,
http://www.cdc.gov/nchs/pressroom/06facts/hus06.htm (accessed June 5, 2009).
61
American Pain Foundation, Pain Facts and Figures,
http://www.painfoundation.org/page.asp?file=Newsroom/PainFacts.htm (accessed June 5, 2009).
62
Aida B. Won, Kate L. Lapane, Sue Vallow, Jeff Schein, John N. Morris, Lewis A.
Lipsitz, “Persistent Nonmalignant Pain and Analgesic Prescribing Patterns in Elderly Nursing
Home Residents,” Journal of the American Geriatrics Society 52, no. 6 (June 2004): 867-874;
Joan M. Teno, Sherry Weitzen, Terrie Wetle, and Vincent Mor, “Persistent Pain in Nursing Home
Residents,” Journal of the American Medical Association 285, no. 16 (April 25, 2001): 2081;
Bruce A. Ferrell, Betty R. Ferrell, and Lynne Rivera, “Pain in Cognitively Impaired Nursing
Home Patients,” Journal of Pain and Symptom Management 10, no. 8 (November 1995): 591-598.
63
National Center for Health Statistics, Health United States 2006, 70.
37
Figure 1:
Pain prevalence in the past month among adults 20+, 1999-2002
Figure 2:
Estimated incidence of pain relative to incidence of diabetes,
coronary heart disease, and cancer64
64
Ibid.
38
Figure 3:
Pain duration, 1999-2002
A recent study, however, found lower prevalence of chronic pain than was
reported in the 2006 NCHS Report. In this study, based on a representative
sample, prevalence of chronic pain in the United States was estimated at 10.1
percent for back pain, 7.1 percent for pain in the legs/feet, 4.1 percent for pain in
the arms/hands, and 3.5 percent for headache.65 Chronic regional pain was
reported by 11 percent of subjects, with chronic widespread pain being reported
by 3.6 percent of subjects. However, the data used in this study was obtained
entirely by personal interview, which the authors admit differs from the methods
used in other epidemiologic studies of chronic pain. Moreover, the authors noted
that “some individuals with recurrent chronic pain, such as migraine headaches,
65
Jochen Hardt, Clemma Jacobsen, Jack Goldberg, Ralf Nickel, and Dedra Buchwald,
“Prevalence of Chronic Pain in a Representative Sample in the United States,” Pain Medicine 9,
no. 7 (October 2008): 803-812.
39
were likely not detected by the definition of chronic pain used.”66 The authors
admit that their findings as to prevalence were lower than many international
studies, many American studies, and reports from previous iterations of the same
survey (the National Health and Nutrition Survey). They expressly note that “the
confidence intervals around our estimates do not explicitly rule out rates that
correspond to the range of values observed in these other studies.”67
Like the 2008 study, the 2006 NCHS Report breaks down pain prevalence
by the type of pain. This breakdown is important because different kinds of pain
seem to correlate with a better likelihood of receiving adequate treatment. For
reasons that will be discussed in detail, there is good evidence that a person
presenting, for example, with acute pain secondary to organic insult (such as from
a car accident) stands a better chance of receiving adequate treatment for his/her
pain than a person presenting in the same health care setting with, for example,
chronic pain.68
Accordingly, as virtually all pain scholars note, pain is not monolithic.
Different kinds of pain produce vastly different experiences for the pain sufferer
in phenomenologic terms, in terms of pain sensation (for example, burning,
crushing, piercing), duration, prevalence, treatment, and stigma, to name but a
few. Thus, examining closely the different pain experiences of the illness sufferer
is crucial in unpacking the various meanings of pain in American society.69
66
Ibid., 809.
67
Ibid., 806.
68
Jackson, “Stigma, Liminality, and Chronic Pain.”
69
The implications of this idea for my approach are discussed in my Preface.
40
Of the four types of pain (low back pain, migraine/severe headache, neck
pain, and/or face pain) assessed in the 2006 NCHS Report, low back pain was the
most prevalent overall and within each age group (Figure 4). This typology is
significant for a number of reasons related to the visibility of pain experiences, as
there is good evidence that low back pain is a particularly challenging (chronic)
pain experience for providers, caregivers, and sufferers alike.70 Some of the
implications of this will be addressed in chapter 5. In addition, adults who
reported low back pain lasting more than three months in 2004 reported worse
health status via a number of indicia than those who did not report such pain,
regardless of age (Figure 5).
Migraine/severe headache occurred in 15 percent of the adults (Figure 4),
but was particularly prevalent among women in their reproductive years, with
roughly 25 percent of women aged eighteen-forty-four years reporting
migraine/severe headache between 1997 and 2003.
70
Lorna A. Rhodes, Carol A. McPhillips-Tangum, Christine Markham, and Rebecca
Klenk, “The Power of the Visible: The Meaning of Diagnostic Tests in Chronic Back Pain,”
Social Science & Medicine 48, no. 9 (May 1999): 1189-1203.
41
Figure 4:
Low back, neck, migraine, and face pain in past 3 months
(2004)
42
Figure 5: Health status measures for adults with/without recent low back pain,
2004
Thus, what the empirical evidence suggests about pain is not merely its
prevalence, but how that prevalence stratifies across different communities, each
of which has social worlds, histories, and practices of its own that are important in
unpacking what pain experiences mean. Obviously relevant to that stratification
is the recent explosion of literature demonstrating disparities in and across
multiple dimensions of health and health care in the United States. Pain is no
exception to these general trends; not only do women suffer migraine/severe
headache more frequently than men, but the 2006 NCHS Report found gender
differences in low back pain as well, and further found differences along age and
racial/ethnic lines:
43

older women reported more low back pain than older men (Figure 4);

non-Hispanic black women reported low back pain 30 percent more often
than non-Hispanic black men (Figure 4); and

Hispanic women reported low back pain 40 percent more often than
Hispanic men (Figure 4).
In addition, given the robust literature linking income and health,71 it should be
unsurprising that women of lower income levels were more likely to report pain
(Figure 6).
Moreover, ample evidence supports the findings of the 2006 NCHS
Report.72 These disparities began to attract significant attention in the early
71
See, e.g., Daniel S. Goldberg, “In Support of a Broad Model of Public Health:
Disparities, Social Epidemiology and Public Health Causation,” Public Health Ethics 2, no. 1
(April 2009): 70-83.
72
Staton, Panda, Chen, Genao, Kurz, Pasanen, Mechaber, Menon, O’Rorke, Wood,
Rosenberg, Faeslis, Carey, Calleson, and Cykert “When Race Matters”; Janet Kaye Heins, Alan
Heins, Marianthe Grammas, Melissa Costello, Kun Huang, and Satya Mishra, “Disparities in
Analgesia and Opioid Prescribing Practices for Patients with Musculoskeletal Pain in the
Emergency Department,” Journal of Emergency Nursing 32, no. 3 (June 2006): 219-224; Ian
Chen, James Kurz, Mark Pasanen, Charles Faselis, Mukta Panda, Lisa J. Staton, Jane O’Rorke,
Madhusudan Menon, Inginia Genao, JoAnn Wood, Alex J. Mechaber, Eric Rosenberg, Tim Carey,
Diane Calleson, and Sam Cyker, “Racial Differences in Opioid Use for Chronic Nonmalignant
Pain,” Journal of General Internal Medicine 20, no. 7 (July 2005): 593-598; Louis D. Sullivan and
Barry A. Eagel, “Leveling the Playing Field: Recognizing and Rectifying Disparities in
Management of Pain,” Pain Medicine 6, no. 1 (January 2005): 5-10; George Rust, Wendy N.
Nembhard, Michelle Nichols, Folashade Omole, Patrick Minor, Gerrie Barosso, and Robert
Mayberry, “Racial and Ethnic Disparities in the Provision of Epidural Analgesia to Georgia
Medicaid Beneficiaries during Labor and Delivery,” American Journal of Obstetrics and
Gynecology 191, no. 2 (August 2004): 456-462; Carmen R. Green, Karen O. Anderson, Tamara A.
Baker, Lisa C. Campbell, Sheila Decker, Roger B. Fillingim, Donna A. Kaloukalani, Kathyrn E.
Lasch, Cynthia Myers, Raymond C. Tait, Knox H. Todd, and April H. Vallerand, “The Unequal
Burden of Pain: Confronting Racial and Ethnic Disparities in Pain,” Pain Medicine 4, no. 3
(September 2003): 277-294; Vence L. Bonham, “Race, Ethnicity, and Pain Treatment: Striving to
Understand the Causes and Solutions to the Disparities in Pain Treatment,” Journal of Law,
Medicine & Ethics 28, no. s4 (March 2001): 52-68.
44
1990s, prompting the Joint Commission to include pain guidelines in its
accreditation requirements, and the Veterans Health Administration to introduce
its own set of guidelines for the treatment of pain.73 Yet, consistent with the
trajectory of pain policy over the last twenty-five years, there is little indication
that these efforts–among many others–have alleviated disparities in pain. Three
studies all published within the last two years of this writing, document
significant pain disparities in different settings: (1) In a study of women with
metastatic disease resultant to breast cancer, race was found to be a significant
risk factor for severe pain (for example, non-Caucasian women were significantly
more likely to suffer severe pain);74 (2) in a review of the literature regarding the
quality of cancer pain management in vulnerable populations, the authors found
significant disparities in the treatment of such pain among such populations
(including racial/ethnic minorities, persons of low socioeconomic status, and the
elderly);75 and (3) in a study of patients presenting to emergency departments, the
authors found that national quality improvement initiatives had increased access
to opioids for patients making a pain-related visit, but that disparities in opioid
prescribing by race/ethnicity had not diminished.76
73
Kathryn Senior, “Racial Disparities in Pain Management in the USA,” Lancet
Oncology 9, no. 2 (February 2008): 96.
74
Liana D. Castel, Benjamin R. Saville, Venita DePuy, Paul A. Godley, Katherine E.
Hartmann, and Amy P. Abernethy, “Racial Differences in Pain during 1 year among Women with
Metastatic Breast Cancer,” Cancer 112, no. 1 (January 1, 2008): 162-170.
75
Jeanette A. McNeill, Janice Reynolds, and Margaret L. Ney, “Unequal Quality of
Cancer Pain Management: Disparity in Perceived Control and Proposed Solutions,” Oncology
Nursing Forum 34, no. 6 (November 2007): 1121-1128.
76
Mark J. Pletcher, Stefan G. Kertesz, Michael A. Kohn, and Ralph Gonzales, “Trends in
Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments,”
Journal of the American Medical Association 299, no. 1 (January 2, 2008): 70-78.
45
Figure 6:
Low back pain in last 3 months, 2004
In addition, reports of pain prevalence and treatment in certain populations
particularly likely to experience pain (such as the elderly and veterans) paint an
even more disturbing picture. A 2004 study in the Journal of the American
Geriatrics Society reported that persistent nonmalignant pain among nursing
home residents in the United States was reliably estimated at a prevalence of 4984 percent,77 which is consistent with other studies.78 As to veterans, there is a
77
Won, Lapane, Vallow, Schein, Morris, and Lipsitz, “Persistent Nonmalignant Pain and
Analgesic Prescribing Patterns in Elderly Nursing Home Residents.”
78
Ibid.; Teno, Weitzen, Wetle, and Mor, “Persistent Pain in Nursing Home Residents”;
and Ferrell, Ferrell, and Rivera, “Pain in Cognitively Impaired Nursing Home Patients.”
46
paucity of systematic data, and estimates of pain prevalence vary depending on
the particular population under investigation, but several small studies report
prevalence of 50 percent;79 47 percent;80 and 78 percent in a study of women
veterans.81
In a news article reporting on some of the more the recent findings, Sean
Morrison, one of the most recognizable palliative care physicians in the United
States, was quoted as stating that “‘These studies are particularly distressing as
they indicate that so little progress has been made in the last decade in spite of
substantial efforts to redress this situation.’”82 Again, shedding some light on the
social and cultural reasons for this lack of success is a central objective of this
project.
Of course, the bulk of the data on pain prevalence addresses the reporting
of pain, which is not in and of itself equivalent to the experience of pain. This
distinction exists at least in part because, as mentioned in the Introduction,
members of certain populations are significantly less likely to report pain even if
they experience it. For my purposes, however, this fact actually strengthens the
analysis, because the reasons why some communities might underreport their pain
experiences are a key feature of the social and cultural discourses that shape and
79
J. David Clark, “Chronic Pain Prevalence and Analgesic Prescribing in a General
Medical Population,” Journal of Pain and Symptom Management 23, no. 2 (February 2000): 131137.
80
Ronald J. Gironda, Michael E. Clark, Jill P. Massengale, and Robyn L. Walker, “Pain
among Veterans of Operations Enduring Freedom and Iraqi Freedom,” Pain Medicine 7, no. 4
(July/August 2006): 339-343.
81
Sally G. Haskell, Alicia Heapy, M. Carrington Reid, Rebecca K. Papas, Robert D.
Kerns, “The Prevalence and Age-Related Characteristics of Pain in a Sample of Women Veterans
Receiving Primary Care,” Journal of Women's Health 15, no. 7 (September 2006): 862-869.
82
Sean Morrison, quoted in Senior, “Racial Disparities in Pain Management,” 96.
47
inform beliefs, attitudes, and practices towards such pain. To understand why
elderly populations tend to underreport their pain requires some analysis of the
meaning of pain in and among elderly populations.83 My thesis here is that
producing evidence-based pain policies that justify a hope that the undertreatment
of pain can be ameliorated requires consideration of such social and cultural
factors.
PREVALENCE VS. UNDERTREATMENT OF PAIN
Thus far, the evidence discussed in this chapter documents the high rates
of pain prevalence and of disparities in pain. To what extent does the high
prevalence of pain in general and chronic pain in particular suggest failures in
treating that pain?
Chronic pain is by definition persistent or recurring. Therefore, high
prevalence of chronic pain by itself suggests that such pain is not being alleviated,
although it does not necessarily follow that such pain results from undertreatment.
Nevertheless, the evidence of undertreatment of pain is overwhelming.
Consider, for example, the opening sentences in Resnik, Rehm, and
Minard’s 2001 article on the undertreatment of pain:
Pain is the principal reason why patients see physicians but it is
routinely undertreated in health care. Many recent studies have
demonstrated inadequate pain management in many different
circumstances, including pain in terminal illness . . . pain in
elderly populations . . . cancer pain . . . chronic pain . . . pain in
emergency care . . . and post-operative pain . . .84
83
Goldberg, “The Sole Indexicality of Pain.”
84
Resnik, Rehm, and Minard, “The Undertreatment of Pain,” 277 (citations omitted).
48
Also in 2001, Barry Furrow noted that “[p] ain is undertreated in the American
health-care system at all levels: physician offices, hospitals, long-term care
facilities.”85 C. Stratton Hill, Jr., a Texas-based pain physician who has devoted
much of the last three decades to advocating locally, regionally, and nationally for
improved treatment of pain, noted in 1995 that inadequate treatment for pain is
the norm.86 David Morris, whose work on pain is the chief inspiration for the
approach employed in this project, observed in 1998 that “[f]or years, reliable
studies have estimated the undertreatment for cancer pain at 50 percent of
patients.”87 And a very recent study examined the adequacy of pain management
practices between 1999 and 2006 in patients with bone metastases arising from
terminal cancer, which are particularly painful. The authors concluded that,
despite significant investment in and attention to cancer pain management, “there
was no significant and perpetual decrease in the proportion of undermedicated
patients over the seven-year study period . . . .”88
As I will discuss in chapter 6, there is reason to believe that pain resultant
to visible lesions is likely to be treated better than pain that occurs in the absence
of such perceptible pathologies (such as chronic pain). Given this, the fact that so
85
Barry R. Furrow, “Pain Management and Provider Liability: No More Excuses,”
Journal of Law, Medicine & Ethics 28, no. s4 (March 2001): 28.
86
C. Stratton Hill, Jr., “When Will Adequate Pain Management be the Norm?” Journal of
the American Medical Association 274, no. 23 (December 20, 1995): 1881-1882. This project
benefits from the experience, counsel and suggestions of Dr. Hill, to whom I am greatly indebted.
87
David B. Morris, Illness and Culture in the Postmodern Age (Berkeley, CA: University
of California Press, 1998), 195.
88
Andrea M. Kirou-Mauro, Amanda Hird, Jennifer Wong, Emily Sinclair, Elizabeth A.
Barnes, May Tsao, Cyril Danjoux, and Edward Chow, “Has Pain Management in Cancer Patients
with Bone Metastases Improved? A Seven-Year Review at An Outpatient Palliative Radiotherapy
Clinic,” Journal of Pain and Symptom Management 37, no. 1 (January 2009): 82.
49
many cancer patients suffer significant pain suggests that the undertreatment of
chronic pain may be far worse.
Interestingly, precise data on the undertreatment of chronic pain is
difficult to unearth. This is surprising until one apprehends that virtually
everything about chronic pain, both as a concept and as a lived experience, is
contested, regardless of whose perspective is assessed (illness sufferer, provider,
caregiver, policymaker, etc.).89 Why chronic pain is subject to such intense
contest is a central theme of this dissertation. But given that even the very
concept itself–what qualifies as chronic pain–promotes widespread disagreement,
it is less surprising that there exists a paucity of precise data on the undertreatment
of chronic pain. Nevertheless, Ann M. Martino notes
a widely shared and growing consensus in the medical and
scientific communities . . . the law, social sciences, and humanities
. . . and the popular press . . . that inadequate treatment of chronic
pain is the rule in the United States and most developed nations.90
Indeed, there is no serious suggestion in the relevant scholarship since
Martino’s article that undertreatment of chronic pain is no longer the problem it
once was. Moreover, given the upward trends in chronic disease in general,91
there is reason to suspect that prevalence of chronic pain will increase in the
foreseeable future, with little obvious reason to suspect dramatic advances in
ameliorating the undertreatment of pain.
89
Jackson, “Stigma. Liminality and Chronic Pain.”
90
Ann M. Martino, “In Search of a New Ethic for Treating Patients with Chronic Pain:
What Can Medical Boards Do?” Journal of Law, Medicine & Ethics 26, no. 4 (December 1998):
333 (citations omitted).
91
Ross DeVol and Armen Bedroussian, An Unhealthy America: The Economic Burden of
Chronic Disease (Santa Monica, CA: Milken Institute, 2007).
50
One rejoinder to this latter surmise is that there exists a large and diverse
community currently converging on the goal of ameliorating the undertreatment
of pain. Thus, there may well be reason for optimism. This perspective,
however, is unconvincing, given that such forces have converged on the issue for
at least a quarter of a century, with little indication that the problems in treating
pain in the United States have improved significantly.92 Resnik, Rehm, and
Minard observe that the undertreatment of pain
is by no means a new problem in health care: for more than 25
years researchers have documented the undertreatment of pain . . .
In the last decade, many health care professionals (HCPs),
professional organizations, and scholars have decried this problem
and have championed the cause of better pain control . . .93
As mentioned in the Introduction, this obviously well-intentioned and
immense social and cultural undertaking involving extremely diverse actors
exchanging material, social, and technical resources, drawing the attention of
some of the most wealthy and powerful organizations and institutions in the world
(such as the U.S. government94 and the pharmaceutical industry95) has seemingly
made little progress in improving one’s chances of receiving adequate treatment
for pain in the United States.
92
Tousignant, “Pain and the Pursuit of Objectivity.”
93
Resnik, Rehm, and Minard, “The Undertreatment of Pain,” 276.
94
The NIH has evidenced particular interest in pain, establishing the NIH Pain
Consortium in 1998, which is devoted to promoting collaboration in determining the optimal pain
research agenda.
95
For example, Purdue Pharma and Endo Pharmaceuticals are two particularly visible
and active supporters of improved pain management practices. The motivation for such support,
of course, is another matter entirely, but the point is that significant private sector resources have
been and continue to be marshaled in support of the treatment of pain.
51
Chapter 2 begins the task of explaining how and why this is so.
52
Chapter 2: The Lived Experience of Pain
INTRODUCTION
Pain is fundamental to our lived experiences as human beings. A painless
existence, as it turns out, is not conducive to human flourishing. Known as
congenital analgesia, individuals who have this rare genetic disorder often suffer
repeated injury, including broken bones, lacerated skin, damage to internal body
tissues, and have significantly shortened life expectancy.96 Some kinds of pain
“serve an important biological (or evolutionary) function in that it warns the
organism of impending danger, informs the organism of tissue damage or injury,
or deters the organism from interfering with healing or causing further tissue
damage.”97 Many other pain experiences, typically identified as “pathological,”
seem to serve no such purpose, and simply persist, unrelenting, for long periods of
time.98
The point is that in whatever manifestation, pain is a fundamental part of
human life. This is in part why a phenomenological approach to thinking about
pain and the ethics of pain is so important. As I will argue, a phenomenologic
approach expressly begins by refusing to abstract the phenomenon under
consideration from its context in the flow of lived experiences. In contrast, there
96
Hirsch, Moye, and Dimon, “Congenital Indifference to Pain”.
97
Resnik, Rehm, and Minard, “The Undertreatment of Pain,” 280.
98
Ibid. One of the critical changes in pain medicine over the last fifty years is the change
between the view of pain as a mere symptom and the recognition that some kinds of
“pathological” pain are illness experiences deserving of treatment in and of themselves. Isabelle
Bazsanger, Inventing Pain Medicine: From the Laboratory to the Clinic (New Brunswick, NJ:
Rutgers University Press, 1998).
53
is no shortage of analytic philosophical treatments of pain.99 Whatever their
merits, however, I deem such analyses of limited practical use in attempting either
to understand why pain is so consistently undertreated in the United States or to
improve the situation.100
In contrast, I maintain that a phenomenology of pain is crucial to both of
these objectives. The reason for this in many ways encapsulates the central
argument of my thesis: improving the undertreatment of pain through policy is
either impossible or at least unlikely without a detailed understanding of the
meaning of pain in American society. In large part, the evidence base that has
been sorely lacking from dominant approaches to the ethics and policy of pain is a
thorough accounting of what pain means in the United States and why it takes on
that particular constellation of meanings. A phenomenologic approach is crucial
because it is expressly directed towards the aim of meaning, and towards the goal
of unpacking what the lived experience of pain is like for the sufferer, the
caregiver, the provider, and other relevant stakeholders.
99
Murat Aydede, “Introduction: A Critical and Quasi-Historical Work on Theories of
Pain,” in Pain: New Essays on Its Nature and the Methodology of the Study, ed. Murat Aydede
(Cambridge, MA: MIT Press, 2005), 1-58; Christopher S. Hill, “Ouch! An Essay on Pain,” in
Higher Order Theories of Consciousness, ed. Rocco J. Gennaro, (Amsterdam, Netherlands: Johns
Benjamins Publishing Company, 2004), 339-362; Michael Tye, “On the Location of a Pain,”
Analysis 62, no. 274 (April 2002): 150-153; Murat Aydede and Güven Güzeldere, “Some
Foundational Problems in the Scientific Study of Pain,” Philosophy of Science 69, no. S3
(September 2002): S265-S283; and Grant R. Gillett, “The Neurophilosophy of Pain,” Philosophy
66, no. 256 (April 1991): 191-206.
100
This is not to suggest that the philosophical study of pain is unimportant. But, as I
will suggest in chapter 7, a medical humanities approach requires that scholarship be deployed
with an aim to facilitating the conditions for flourishing in human beings’ daily moments and
lives. It may be my own failure of imagination, but as important as the philosophy of pain may
be, I do not see a robust connection between this practice and improvement in the treatment of
pain in the United States. This again demonstrates a difference between a philosophy dissertation,
which obviously has its place, and a medical humanities dissertation, which may utilize
philosophical approaches but is not reducible to philosophical method.
54
PHENOMENOLOGY & ILLNESS
First, a brief account of the phenomenology of illness itself is needed. I
am not expressly claiming that the phenomenology of pain is entirely
distinguishable from a general phenomenology of illness, though there may in fact
be some aspects of the experience of pain that are peculiar to it.101 This in itself
should be uncontroversial, as there are presumably experiences specific to any
given illness that may not be generalizable to other types of illness experiences
(such that the phenomenology of ovarian cancer may be qualitatively different in
some ways from the phenomenology of type II diabetes). Nevertheless, there are,
I submit, important insights into the experience of pain available in assessments
of the general phenomenology of illness.
Of course, the literature on this is robust, so I can provide nothing more
than a brief overview here. Time and space preclude detailed analysis of the
imposing phenomenologic literature, but the most apposite primary sources for
the phenomenology of pain are Heidegger and Merleau-Ponty. While I will
highlight some of their central phenomenologic insights, Eric Matthews’ recent
account of the problems in conceptualizing mental illness provides an excellent
starting point in thinking through some aspects of the phenomenology of
illness.102
Matthews begins by explaining the materialist roots of the dominant
medical model in conceptualizing psychiatric illness. For example, he notes,
101
For support for the notion that chronic pain is phenomenologically unique, see Jane
Richardson, “Establishing the (Extra)ordinary in Chronic Widespread Pain,” Health 9, no. 1
(January 2005): 31-48. I will not here defend such a claim.
102
Eric Matthews, Body-Subjects and Disordered Minds (New York, NY: Oxford
University Press, 2007).
55
depression is psychiatry is frequently explained in terms of the accumulation of
serotonin levels in the brain.103 This frame is crucial to my analysis, because it
tends to categorize a subjective phenomenon (here depression) in terms of a
material, neurophysiological substrate. Similarly, in tracing the rise of the
importance of diagnosis in psychiatry, Charles Rosenberg explains that
[e]arlier interest in clinical description and postmortem pathology
had articulated and disseminated a lesion-based theory of disease,
but the late nineteenth century saw a hardening in this way of
thinking, reflecting the assimilation of germ theories of infectious
disease as well as a variety of findings from the laboratories of
physiologists and biochemists.104
The key, as Rosenberg notes, is the somatization of mental illness during
the nineteenth century: “social legitimacy presumed somatic identity . . . .”105 The
importance of this modality in understanding the meaning of pain can hardly be
overemphasized, and will be discussed in detail throughout my project. However,
from a phenomenologic perspective, Matthews contends that, even if correct, the
depression-serotonin explanation106 fails to “help us understand any better why
[the person] suffered from depression.”107 That is, even if we were certain that
serotonin levels cause depression, we would still need “to understand the
103
Ibid., 60-69.
104
Charles E. Rosenberg, “Contested Boundaries: Psychiatry, Disease, and Diagnosis,”
Perspectives in Biology and Medicine 49, no. 6 (Summer 2006): 413.
105
Ibid., 414.
106
As will be noted in chapter 3, the endurance of the chemical imbalance theory of
depression with little supporting evidence and significant contravening evidence makes for a
fascinating example of the ways in which our notions of disease causality reveal much of social
and cultural significance. I tend to agree with Arikha’s suggestion that the persistence of this
causal attribution may signal the continued influence of the humoral theory. Noga Arikha,
Passions & Tempers: A History of the Humours (New York, NY: Harper Perennial, 2007).
107
Matthews, “Body-Subjects,” 65.
56
connection between these communication problems in the brain and the feelings
of unworthiness intense enough to make one contemplate taking one’s own
life.”108
In place of, or at least in addition to the tendencies of the dominant
medical model to facilitate the reduction of symptoms (re: experiences) to
material, “biological” entities and pathways, Matthews offers an account of illness
that “relate[s] the meaning of concepts to its roots in the experience of subjects.
What, after all, could, say, ‘time’ mean except what we meant by it?”109 Such an
account constitutes a phenomenology: “A phenomenological investigation of the
meaning of concepts could not be separated from reflection on the consciousness
which gave them meaning.”110 Moreover, a phenomenological approach eschews
a focus on ontological questions of causation and materialism, not because such
inquiries are unimportant, but because they do not capture what it is like to
actually experience the phenomenon. Matthews’s point is to highlight the
absurdity of the idea that the depression-serotonin causal explanation is literally
equivalent to the subjective experience of depression. As Matthews puts it, the
phenomenologist “seeks to describe our experience just as we have it . . . .”111
108
Ibid. John Searle makes a similar argument in defending his account of
consciousness, which I will address in chapter 6. Moreover, this is to say nothing of the
omnipresence of the fallacy confusing correlation with causation in the chemical imbalance
theory, about which Jonathan Leo has written extensively. Jeffrey R. Lacasse and Jonathan Leo,
“The Media and the Chemical Imbalance Theory of Depression,” Society 45, no. 1 (February
2008): 35-45; Jeffrey R. Lacasse and Jonathan Leo, “Serotonin and Depression: A Disconnect
between the Advertisements and the Scientific Literature,” PLoS Medicine 2, no. 12 (2005): e392,
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020392 (accessed June 5,
2009); Jonathan Leo, “The Chemical Theory of Mental Illness,” Telos 122 (Winter 2002): 169177.
109
Matthews, “Body-Subjects,” 81.
110
Ibid.
111
Ibid., 82.
57
In Heidegger’s terms, we are unequivocally “beings-in-the-world:”
We should start, not from some ideal absolute, but from where we
actually are. Our experience of the world is that of beings who are
in the world, in some specific place and time, and for that very
reason, experience or consciousness is not a matter of pure
intellectual contemplation, but of active and emotional engagement
with the world in various ways.112
Similarly, our lived experiences, the phenomena of our lives, are
necessarily situated within social worlds and relationships; “[m]eanings are to be
found, not by looking inside our own heads, but by investigating what we share
with each other, in our common practical engagement with the world.”113 The
phenomenologist rejects as absurd the idea, not only that we can partition off our
own subjectivity from our lived experiences, but that, from the perspective of
knowledge production, we ought to do so. This is what it means to “be in the
world;” we are never outside of that world inasmuch as the world we are
concerned with is the world of our lived experiences. Matthews notes that
“[s]ubjectivity, or mind, is not something detached from the world, but part of the
world, interacting with objects rather than simply contemplating them.”114
Thus in Being and Time, Heidegger observes that our “dealings” as
beings-in-the-world are not “bare perceptual cognition, but rather that kind of
concern which manipulates things and puts them to use; and this has its own kind
of ‘knowledge.’”115 Heidegger emphasizes that as a discipline biology is not
concerned with the question of how the being-in-the-world makes meaning of its
112
Ibid., 85.
113
Ibid., 88.
114
Ibid.
115
Martin Heidegger, Being and Time, trans. John Macquarrie and Edward Robinson
(San Francisco, CA: Harper Books, 1962), 95.
58
lived experiences,116 but is rather, in Frederick Svenaeus’s language, “focused on
measuring the life-activities of objects in the world.”117 Heidegger observes the
significant value in such practices, but argues that any attempt to understand how
the subject makes meaning of their own lives and experiences in the world must
proceed via entirely different pathways.118 Similarly, Merleau-Ponty notes that
“when I say that I see the house with my own eyes . . . I do not mean that my
retina and crystalline lens, my eyes as material organs, go into action and cause
me to see it; with only myself to consult, I can know nothing about this.”119 It is
obviously not that the retina and material structures are irrelevant to vision, but
rather that the experience of seeing is simply not reducible to such structures.120
The subjectivity central to the phenomenology of Heidegger and MerleauPonty is also crucial to thinking phenomenologically about illness and pain.
Indeed, it is constitutive of it. It is impossible to assess the lived experience of
illness and pain without accounting for the subjective understandings, feelings,
and sensations that attend the illness or pain experience. The value of a
phenomenological account of illness is precisely that the subjective experiences
are the focus of the inquiry. A phenomenology of depression, for example, would
tend to avoid detailed analyses of the biochemical and neurophysiological
pathways (“causes”?) of depression, because, however relevant those pathways
116
Heidegger, Being and Time, 75.
117
Frederick Svenaeus, “The Body Uncanny-Further Steps Towards a Phenomenology of
Illness,” Medicine, Health Care and Philosophy 3, no. 2 (May 2000): 127.
118
Heidegger, Being and Time, 71-75.
119
Maurice Merleau-Ponty, Phenomenology of Perception, trans. Colin Smith (London,
UK: Routledge Press, 2002).
120
I will take up this argument again in earnest in chapter 6.
59
might be to understanding the causation and treatment of depression, they have
little to do with what it feels like to live with and experience depression.
So too does a phenomenology of pain attempt to account for the lifeworld
of the pain sufferer. What is it like to suffer from pain? How is one’s world
constructed or taken apart in the face of pain? And because a phenomenological
account understands ‘being-in-the-world’ in terms of our relationships with
others, questions pertaining to the pain sufferer’s social status and relationships
with intimates, professional healers, and even perfect strangers take center stage.
Ultimately, I want to suggest that thinking phenomenologically about the pain
sufferer has vital implications for the ethics of pain.
THE PHENOMENOLOGY OF PAIN
So, what is it like to suffer from pain? There are numerous sources upon
which to draw in answering this question, which is fortunate, for it signals that the
value of a phenomenological approach to pain is recognized in at least some
quarters. Perhaps the seminal work, though not expressly phenomenological, is
Elaine Scarry’s The Body in Pain.121 According to Scarry, pain silences. It
destroys language and communication. It does this in large part because of what
Scarry terms its “unsharability.”122 Pain is ‘unsharable’ because it is the
quintessential private, subjective phenomenon. My pain is qualitatively distinct
from your pain, even if our pain is caused by the same stimulus. As a corollary,
there is an important sense in which others lack access to the qualitative
121
Elaine Scarry, The Body In Pain: The Making and Unmaking of the World (New
York: Oxford University Press, 1985).
122
Ibid., 4.
60
experience of my pain. Scarry explains that “when one speaks about ‘one’s own
physical pain’ and about ‘another person’s physical pain,’ one might appear to be
talking about two wholly distinct orders of events.”123 She continues, “pain does
not simply resist language, but actively destroys it, bringing about an immediate
reversion to a state anterior to language, to the sounds and cries a human being
makes before language is learned.”124
It should be noted here that while her perspective remains influential for
pain scholars, not all commentators accept Scarry’s perspective on the private,
unsharable nature of pain. For example, Mark Sullivan, exploring Wittgenstein’s
perspective, argues that pain itself is inherently social, and, as such, exists neither
in minds or bodies but between them: “If pain acquires its meaning from use in
dialogue, it may be most intelligible from the interpersonal point of view.”125
This explains why “[w]e are constantly socially negotiating as to what pain is or
not.”126 Furthermore, Stan van Hooft notes that the mere fact that pain talk
frequently involves figurative language to describe its phenomenology does not
imply its unshareability: “That one needs metaphors here does not imply that the
123
Ibid.
124
Ibid.
125
Mark D Sullivan, “Finding Pain Between Minds and Bodies,” The Clinical Journal of
Pain 17, no. 2 (June 2001): 151. Though Wittgenstein’s work is not the subject of this project, the
philosophy, if it can be called such, of later Wittgenstein deeply influences all of my scholarship.
The fact that Wittgenstein was fascinated with and expressly wrote on pain makes him even more
relevant, and I hope to address his analysis in future work. The primary reason I have not
addressed Wittgenstein in detail here is because of the complexity involved in any attempt to
extricate Wittgenstein’s specific perspective, and because any analysis that mentions Wittgenstein
tends in due course to wholly become an analysis of Wittgenstein’s perspective. I enthusiastically
endorse the premise that his work virtually always deserves such attention, but that notion
suggests this project would quickly transform into a Wittgensteinian account were I to address his
writings on pain in any detail. In any case, Sullivan’s 2001 essay is an excellent introduction to
some of the implications of Wittgenstein’s writings on pain.
126
Ibid.
61
experience is radically private, incommunicable, or unshareable.”127
Nevertheless, neither denies from a phenomenologic perspective the silencing
qualities of pain, which are well-recognized in the phenomenologic literature.128
In addition, communication and relationships between pain patients and
their physicians are generally poor, with evidence of significant hostility between
patients and providers.129 Yet, given the soteriological importance of physicians–
their social role in saving the illness sufferer130–and the ubiquity of the rescue
fantasy,131 pain sufferers often maintain ambivalent feelings towards their
physicians. Sandra Thomas and Mary Johnson note that “the sufferer longs for a
physician rescuer. Physicians are both trusted and mistrusted, with the pendulum
swinging toward greater mistrust and alienation after repeated experiences of
being unheard and unhealed.”132
It is important to note that pain does not just promote silence between
patient and provider, but between pain sufferer and caregiver as well. In her
ethnography of chronic pain patients, Jean Jackson notes that one of the patients
remarked, “after a while, no one believes you. Even my wife.”133 The persistence
127
Stan van Hooft, “Pain and Communication,” Medicine, Health Care and Philosophy
6, no. 3 (October 2003): 257.
128
See Daniel S. Goldberg, “Exilic Effects of Illness and Pain in Solzhenitsyn's Cancer
Ward: How Sharpening the Moral Imagination Can Facilitate Repatriation,” Journal of Medical
Humanities 30, no. 1 (March 2009): 29-42; Goldberg, “The Sole Indexicality of Pain.”
129
Jackson, “Stigma, Liminality, and Chronic Pain;” Angela Byrne, Juliet Morton, and
Peter Salmon, “Defending Against Patients’ Pain: A Qualitative Analysis of Nurses’ Responses to
Children's Postoperative Pain,” Journal of Psychosomatic Research 50, no. 2 (February 2001): 6976.
130
See Goldberg, “Religion, the Culture of Biomedicine, and the Tremendum.”
131
Howard Brody, The Healer’s Power (New Haven, CT: Yale University Press), 137-
132
Thomas and Johnson, “A Phenomenologic Study of Chronic Pain.”
133
Jackson, “After a While No One Believes You,” 151.
156.
62
of pain for weeks, months, and years may lead to caregiver exhaustion, to a
scenario in which the caregiver’s capacity to hear and bear witness to the
sufferer’s pain erodes. Arthur Kleinman, Paul Brodwin, Byron Good, and MaryJo DelVecchio Good suggest that “[a]bsolute private certainty to the sufferer, pain
may become absolute public doubt to the observer. The upshot is often a
pervasive distrust that undermines family as well as clinical relationships.”134
Marja-Liisa Honkasalo observes that “[s]everal of my informants say that social
exclusion is the worst experience connected to chronic pain and that it is often felt
as a punishment–hey feel guilty for their condition and isolated from others.”135
Yet, given the hope the suffering patient tends to invest in their physician,
the alienation of the pain sufferer from their physician is in some sense even
crueler than the silence that arises between the pain sufferer and his/her loved
ones:
Clearly, the most prominent others in narratives of pain patients,
more significant than family members or friends, were physicians.
Despite repeated experiences with doctors who were impersonal,
unkind, or even cruel, participants [in the study] could not abandon
a fantasy that there was a caring doctor out there somewhere who
could provide relief for them.136
This assignment of hope is not particularly surprising given the social role
of the physician as the rescuer, which itself helps illuminate why the professional
134
Arthur Kleinman, Paul E. Brodwin, Byron J. Good, and Mary-Jo DelVecchio Good.
“Pain as Human Experience: An Introduction,” in Pain as Human Experience, ed. Paul E.
Brodwin, Arthur Kleinman, Byron J. Good, and Mary-Jo DelVecchio Good (Berkeley, CA:
University of California Press, 1992), 5.
135
Marja-Liisa Honkasalo, “What is Chronic is Ambiguity: Encountering Biomedicine
with Long-Lasting Pain,” Journal of the Finnish Anthropological Society 24, no. 4 (1999): 79.
136
Thomas and Johnson, “A Phenomenologic Study of Chronic Pain,” 692.
63
healer in many societies–including ancient Greece–is a shaman or a priest.137
Pain also encourages silence because of typical reactions to pain behavior, which
tend to stigmatize the pain sufferer. The pain sufferer’s experiences with and
fears of being stigmatized contributes to the silencing features of pain:
“Participants generally kept the secret of having a chronically painful condition
because they anticipated adverse outcomes if it were revealed. They perceived
other people to have pejorative views of pain patients. They expected skepticism
and disinterest rather than sympathy and support.”138
Imposed silence, of course, can be isolating, and perhaps above all
isolation and alienation characterize much of the lived experience of pain and of
chronic pain in particular.139 The discussion of the language-destroying
characteristics of pain is one component of this isolation, but the phenomenologic
importance of isolation for the pain sufferer goes beyond the ‘unsharability’ of
pain. Virtually every phenomenologic account of pain I have located, and most
general phenomenologies of illness as well,140 identify isolation as a powerful
component of the lived experience of pain and illness. van Hooft argues that it is
not by virtue of its subjectivity that pain is difficult to communicate, because “all
subjective states are like that.”141 I have articulated a similar point in context of
137
Goldberg, “Religion, the Culture of Biomedicine, and the Tremendum.”
138
Thomas and Johnson, “A Phenomenologic Study of Chronic Pain,” 691.
139
Daniel S. Goldberg, “Exilic Effects of Illness and Pain in Solzhenitsyn's Cancer Ward:
How Sharpening the Moral Imagination Can Facilitate Repatriation,” Journal of Medical
Humanities 30, no. 1 (March 2009): 29-42; Drew Leder, “The Experience of Pain and Its Clinical
Implications,” in The Ethics of Diagnosis, ed. Jose Luis Peset and Diego Gracia (Dordrecht,
Netherlands: Kluwer Academic Publishers, 1992), 95-106.
140
Sveneaus, “The Body Uncanny;” Drew Leder, The Absent Body (Chicago, IL:
University of Chicago Press, 1990).
141
van Hooft, “Pain and Communication,” 259.
64
indexicals. While the same sentence “I am in pain” means something different
depending on whether Paul or Jane is the speaker, so too does the sentence “I am
hungry.”142 What is unique about the phenomenology of pain is that can isolate
the pain sufferer in a “prison” of “their own suffering.”143
Pain isolates because it paradoxically connects the sufferer to his/her own
body at the same time it separates the sufferer from his/her own body. Outside of
pain and illness experiences, our bodies are generally absent from our attention.144
van Hooft observes that
[i]nternal organs like the heart, lungs, or lover do their lifepreserving work without calling attention to themselves in any
way. Similarly, those parts of our body which we regularly use
and can apprehend, such as our legs and hands, are absent from our
attention as we use them. Our agency flows through them, as it
were, and focuses upon the things in the world with which we are
dealing.145
Drew Leder summarizes: “In our daily life we simply are our body,
moving through the world as an integrated whole.”146 But pain disrupts this
integration, often in sudden and terrible ways: “The body that was once silent now
screams for attention. Where it once obeyed the least command, it now rebels
against our desires and undermines our projects.”147
142
Goldberg, “The Sole Indexicality of Pain,” 53-55.
143
van Hooft, “Pain and Communication,” 259.
144
Leder, The Absent Body.
145
van Hooft, “Pain and Communication,” 256.
146
Leder, “The Experience of Pain,” 98.
147
Ibid.
65
The body in pain, then, becomes something grotesque and foreign: “For
the painful body is already profoundly alien. Before coming to the doctor, the
patient has already begun to objectify her body, poke and prod it, wonder at and
resent its strange autonomy.”148 Leder notes the phenomenological paradox that
pain presents: “Pain recalls us to our finitude and dependency, dragging us back
into the mundane world. Yet this is a world in which we no longer feel at
home.”149 Accordingly, pain isolates the sufferer not just from their providers and
caregivers, but from themselves. “That to which we are most intimately
connected becomes that from which we are most estranged.”150 Thomas describes
much of the dialogue in her study as “between the study participants and their
nonhuman tormentor, the pain, more so than with other human beings.
Participants described their pain as imprisoning them.”151
Moreover, there is an aspect of this self-isolation that perpetuates a distinct
kind of suffering: the fact that it hinges on mind-body dualism.152 Chronic pain
patients often report a feeling of war or conflict with their own bodies. Milfrid
Raheim and Wenche Haland characterize the experience of one chronic pain
sufferer as “a feeling of being at the will of a treacherous body and left alone in
never-ending pain. The body feels impossible to control.”153 This sufferer’s
148
Ibid.
149
Ibid.
150
Ibid.
151
Thomas and Johnson, “A Phenomenologic Study of Chronic Pain,” 692.
152
The role of mind-body dualism in shaping the meaning of pain in the United States is
the primary subject of chapter 6.
153
Milfrid Raheim and Wenche Haland, “Lived Experience of Chronic Pain and
Fibromyalgia: Women’s Stories from Daily Life,” Qualitative Health Research 16, no. 6 (July
2006): 748.
66
“body is extremely objectified in her descriptions, experienced at a distance,
pointing to an extreme disintegration between body and self, body and the
practical world.”154 Svenaeus observes that “[i]n illness, the body is experienced
as alien, as a ‘broken tool’ which gives rise to helplessness, resistance, and lack of
control.”155
And Leder explains it thusly: “The mind thus experiences the
Otherness of the physical.”156
The phenomenologic account of (chronic) pain I have sketched here is, to
say the least, not cheery.157 The pain sufferer’s lifeworld is often characterized by
a variety of different kinds and sources of suffering. The pain sufferer may be
isolated, often from his/her own body, may be silenced, may experience a
profound rupture in their social and cultural worlds, and yet cannot escape the
reality of their own pain experiences. Pain simultaneously exiles and separates
the sufferer from their local worlds, but also swells to inhabit the geography of
that world. Raheim and Haland describe how, for ‘Maren,’ “pain preoccupies her,
disorganizing her world, leaving no place or time for relief. She describes an
internal relation paradoxical in character, extreme distance toward her body and
being totally absorbed by pain at the same time. Maren ‘is pain’ in radical
meaning.”158 van Hooft notes that “pain crowds out all other interests and
commitments. [Pain sufferers’] attention is focused upon themselves . . . There is
154
Ibid., 753.
155
Svenaeus, “The Body Uncanny,” 134.
156
Leder, “The Experience of Pain,” 92.
157
For reasons discussed in the Preface, I am less interested in the redemptive
possibilities of pain, though I do not deny the existence or the power of such a meaning-making
device.
158
Raheim and Haland, “Lived Experience of Chronic Pain,” 753.
67
no reality for them but their own suffering. There is no subjectivity present to
them but the nagging and searing insistence of their own tortured and isolated
subjectivity.”159
A phenomenology of pain is nevertheless crucial because only by
understanding the features of the pain sufferer’s lifeworld can ethical strategies be
developed for easing the existential suffering.160 These strategies should
themselves incorporate a phenomenologic understanding of the crucial role of
community in shaping lived experiences, including experiences of pain.
Kleinman, Brodwin, Good, and Good argue that “[t]o regard pain as the
experience of an individual, as it is regarded in standard biomedical practice, is so
inadequate as to virtually assure inaccurate diagnosis and unsuccessful
treatment.”161
Indeed, exactly what the phenomenology of illness suggests is most
absurd about dominant Western medical models–the attempt to carve out, excise,
or simply minimize the role of subjectivity in the experience itself–is a prime
characteristic of contemporary attitudes, beliefs, and practices towards pain, from
providers, caregivers, and even pain sufferers themselves.
Accordingly, Isabelle Baszanger notes that
[t]he development of anesthesia and the control of surgical pain it
allowed, along with the emergence of effective therapeutic means,
whether chemical or surgical . . . combined with the undeniable
progress of anatomical, histological, and neurophysiological
159
van Hooft, “Pain and Communication,” 259.
160
I will detail these strategies in chapter 9, in which I discuss my recommendations for
ethical, evidence-based pain policy.
161
Kleinman, Brodwin, Good, and Good. “Pain as Human Experience: An Introduction,”
9.
68
knowledge, reinforced the vision of pain as a signal or sympton
that could reasonably be combated through the cause it indicated
rather than for itself. In a sense, the approach to pain was confined
to diagnosis and its difficult, more subjective aspects were
excluded.162
It is the objects that cause pain, objects which facilitate diagnosis and causal
attribution, that takes priority in most clinical encounters related to pain.
Similarly, in his analysis of “pain talk” in the medical encounter, Christian Heath
observes that
[t]he cry of pain does not occasion sympathy or appreciation from
the practitioner, nor is the actual experience of suffering by the
patient addressed as a topic in its own right. Rather the pain is
managed within the framework of the diagnostic activity in which
the doctor is engaged. The cry is treated as the basis for
subsequent enquiries . . . The practitioner maintains an analytic
stance towards the suffering of the patient, a stance which arises
from the necessity to make further enquiries in order to arrive at a
diagnosis of the complaint.163
This is not to imply that the doctor in this encounter is callous or unsympathetic,
but rather than the phenomenon of the patient’s pain is important only insofar as it
contributes to the reading of the signs, a reading which typically relies heavily on
anatomical correlation.164 Using a social psychological frame, Heath documents
how the physician’s body language and verbal cues permit the physician to
“delicately sidestep . . . appreciation of the suffering and discourage . . . further
cries of pain from the patient. In this way he is able to pursue the diagnostic
162
Bazsanger, Inventing Pain Medicine, 29.
163
Christian Heath, “Pain Talk: The Expression of Suffering in the Medical
Consultation,” Social Psychology Quarterly 52, no. 2 (June 1989): 115-16.
164
The role of anatomy in shaping the meaning of pain is paramount, and will be
addressed in detail in chapters 3, 4, and 5.
69
enquiries at hand.”165 Similarly, Kleinman, Brodwin, Good, and Good observe
that “[n]either in the biomedical research literature nor in the pain clinic does the
suffering of pain patients and their intimate social circles receive much attention
as such, that is, as a moral burden or a defining existential experience.”166
Heath also explains that this dynamic does not implicate providers alone,
but is a key device pain sufferers use in conceptualizing and understanding their
pain. Thus, it is not simply that the physician alone sidesteps the sufferer’s pain
in the interests of making a diagnosis; the patient collaborates in this endeavor:
“[T]he patient produces no further cries of pain. She withholds expression of her
suffering and adopts an analytic or objective stance towards her own subjective
experience . . . the patient is drawn into a particular framework of
participation.”167 Honkasalo concurs, stating that the process of “diagnosis is
morally crucial for the sufferers . . . Patients are diligent pupils of learning
biomedical language.”168 The importance of this point, that pain sufferers too
participate in particular, acculturated discourses about pain, cannot be
overemphasized, and will be a recurring theme through my analysis.
Furthermore, the operation of pain in the clinical encounter is a function of
its localizability:
The actual expression of pain in the consultation . . . is in large part
limited to certain relatively circumscribed diagnostic activities and
165
Ibid., 116.
166
Kleinman, Brodwin, Good, and Good, “Pain as Human Experience,” 14 (emphasis in
original).
167
Heath, “Pain Talk,” 116.
168
Marja-Liisa Honkasalo, “Chronic Pain as a Posture Towards the World,”
Scandanavian Journal of Psychology 41, no. 3 (September 2000): 204.
70
in particular to occasions on [sic] which the practitioner is
systematically attempting to identify the locale and thereby the
nature of the patient’s pain or suffering. Within the framework of
these specific diagnostic activities, we can begin to discern the
ways in which the revelation of pain is ‘locally’ organized . . . .169
In Honkasalo’s ethnographic research, “people spoke about body parts that were
hurting and they searched for permanent localizations, names, and thus for moral
relief from their situation.”170 Moreover, she observes, localization, or
“attempt[s] to visualize and localize pain,” is a feature of “medical diagnostics,”
and also “echoes patients’ experiences.”171 The localizability of pain is a key
aspect of the efforts to materialize pain, to carve out the lived experiences of pain,
and hence the rise of localization in the nineteenth century is a vital part of the
story I am trying to tell (and is a central subject of chapters 4 and 5).
Honkasalo observes that because knowledge of chronic pain cannot be
separated from subjective experience in a phenomenologic sense, “clinicians often
fail to take chronic pain seriously.”172 This follows, for Honkasalo, because
communication about illness in the clinical encounter “is based on the visibility of
causal connections and location . . . if [those parameters] fail, as in chronic pain,
people’s intensive experiences are not taken seriously.”173 Jackson notes that “the
clinical perspective is the most authoritative discourse we have, so much so that
other ways of talking about pain are automatically considered secondary or even
suspect.”174 Even in context of providers, the attempt to excise the subjective
169
Heath, “Pain Talk,” 122.
170
Honkasalo, “Chronic Pain as a Posture,” 204.
171
Honkasalo, “What is Chronic is Ambiguity,” 80.
172
Honkasalo, “Chronic Pain as a Posture,” 198.
173
Honkasalo, “What is Chronic is Ambiguity,” 40.
174
Jackson, “Stigma. Liminality, and Chronic Pain,” 15.
71
experience of pain is not limited to physicians; Carson and Mitchell observe that
“[n]urses have been directed to try to manage pain as a problem instead of
attending to the person who is living with the experience as the leader and teacher
about how to live with pain when it is a persistent presence.”175
Thus, if due attention to the phenomenology of pain is often missing in the
clinical pain encounter, there exists for all stakeholders–including the pain
sufferer him or herself–an opportunity to attend to the pain sufferer’s lived
experiences. This attention has ethical significance, as Carson and Mitchell
suggest: “[U]nderstanding another’s lived experience, especially the experience of
a person in pain, is essential to any helping relationship.”176
While I will address in detail the ethical implications of the
phenomenology of pain in chapter 7, the key points here are (1) the ethical
importance of the phenomenology of pain, of the attempt to understand what it is
like to suffer pain; and (2) the unfortunate fact that these lived experiences of pain
are not central in American biomedical encounters in which relief for pain is
sought. Rather, as Heath documents, what takes priority in most of these
encounters is the search for visible, material pathologies which are causing the
sufferer’s pain. Why? Certainly, I am in no way asserting or implying that the
pain sufferer’s subjective experiences are minimized because the provider is
callous or uncaring. As demonstrated in this chapter, even the pain sufferers
themselves participate in the dynamic which tends to minimize their own
175
M. Gail Carson and Gail J. Mitchell, “The Experience of Living with Persistent Pain,”
Journal of Advanced Nursing 28, no. 6 (December 1998): 1243.
176
Ibid.
72
suffering and render its relevance a function of its utility in driving the diagnosis,
the search for visible, material pathologies.
Indeed, one of my central claims is that an explanation of why the
subjective experiences of pain are often missing or diminished in clinical
encounters is vastly more complicated than a brute dichotomy between “good”
and “bad” providers. Unpacking this complexity is the subject of Section II, to
which I turn now.
73
SECTION II:
The Social and Cultural Power of the
Visible in the Culture of Biomedicine
The reader interested in pain policy c. 2009 may fairly be concerned how
the subject matter of chapters 3 and 4–the history of the visible–relates. After all,
one might surmise that in a dissertation ostensibly addressing pain policy, the vast
majority of the discussion should necessarily focus in on that policy. If so, it is
unclear why several chapters worth of discussion on the history of the visible in
Western and American culture, stretching from the Middle Ages to the nineteenth
century, is helpful.177
The answer to this admittedly legitimate concern, which I have tried to
make plain thus far, is that the undue focus on the intricacies of the opioid
regulatory regime (which is what comprises the overwhelming majority of policy
discourse on pain in the United States) is not the best means of improving the
undertreatment of pain. Indeed, such a focus has apparently had little measurable
effect on the undertreatment of pain in the United States. While the idea that
diverting attention, at least momentarily, from the bowels of pain policy is an
avenue to improving pain policy may be counterintuitive, it is not paradoxical.
My argument is precisely that to understand the deficiencies in the
conventional policy approaches to pain, one must conceptualize policy as a
discursive product, one which is profoundly shaped by larger, often less
177
I discuss these connections in detail in chapter 5, but felt it important to lay the
groundwork now, to explain in advance why some of section II addresses the history of the visible
in Western culture, rather than pain policy.
74
perceptible social and cultural structures. A narrow focus strictly on policy
schemes and frameworks is likely to miss some of these larger, and, I submit,
more powerful determinants of behavior, practice, and attitudes towards pain in
the United States. I will endeavor to demonstrate in section II that the visible in
American culture in general, in the American cultures of biomedicine and science
in particular, is just such a determinant.
The study of history is not simply worthwhile as an artifact, as an
examination of the ‘way we were.’ Public health policy disconnected from the
study of history risks ineffectiveness at best; in contrast, as Alison Bashford and
Carolyn Strange observe, “thinking historically about public health and its
management across time and cultures greatly enriches our analytical capacity.”178
The express argument of my approach is that an informed historical analysis is
integral to comprehending the meaning of pain in contemporary American
society, and is a prerequisite for evidence-based pain policies that justify hope in
improving the undertreatment of pain. Historian of pain Roselyne Ray concurs,
noting that “the past is useful, not for its curiosity value but for its contribution to
the understanding of present-day behaviour vis-à-vis pain since it is a possible
means of putting our preconceptions and the fundamental basis of our
understanding of pain into context.”179
As such, understanding precisely why and how the power of the visible
came to exert such profound effects on our understanding of illness, the body, and
pain is integral. In turn, there is no real way to assess the power of the visible in
178
Alison Bashford and Carolyn Strange, “Thinking Historically About Public Health,”
Medical Humanities 33, no. 2 (December 2007): 87-92 (emphasis in original).
179
Roselyne Ray, The History of Pain (Cambridge, MA: Harvard University Press,
1993), 10.
75
American culture without attending to its development along historical pathways.
This comprises a dialectic model of history, in which past ideas, events, and
conditions continue to exert an often powerful effect on contemporary attitudes,
practices, and beliefs. An analogy I frequently return to in explaining this idea is
the notion that these older social and cultural components of U.S. and Western
history are ‘contained’ in contemporary society just as surely as flour is
‘contained’ in finished cake.180
Modernity, as Charles Taylor points out, cannot fruitfully be understood
ahistorically.181 Nor, I submit, can the undertreatment of pain. Therefore, while I
am sympathetic to the reader who doubts the connections between the history of
the visible stretching back to the Middle Ages and the contemporary
undertreatment of pain, I do not ultimately share such doubts. Vesalius, as we
shall see, is not important simply because he was the father of modern anatomy.
Rather, as the forerunner of the practice of pathological anatomy that arose in the
nineteenth century, Vesalius is crucial to comprehending the power of the visible
in contemporary times, and hence wholly relevant to understanding the meaning
of pain and its concomitant undertreatment.182
180
Goldberg, “The Sole Indexicality of Pain.”
181
Charles Taylor, “Two Theories of Modernity,” Hastings Center Report 25, no. 2
(March/Aril 1995): 24-33.
182
These considerations also demonstrate a crucial difference between a medical
humanities analysis and a more traditional law or policy assay; for the former, tacking back and
forth between larger social and cultural structures and contemporary practices is entirely
appropriate. Part of my project here is to indicate how and why such an approach is not only
appropriate, but is in some ways preferable, especially insofar as a medical humanities approach
embodies a refusal to distill complex, nonlinear social phenomena to discrete, individual
components (i.e.,“a law,” or “a policy”). This is arguably a key advantage to an interdisciplinary
approach in general.
76
Of course, the inferences between these premises must be supplied, which
is the central aim of chapters 3 and 4. Chapter 5 summarizes the links adduced in
in chapters 3 and 4.
77
Chapter 3: The Power of the Visible Prior to the Nineteenth
Century
OBJECTIVITY, SUBJECTIVITY, AND THE POWER OF THE VISIBLE
It is axiomatic that part of what makes the treatment of pain difficult is its
subjective nature. But this, I want to suggest, is a set of questions masquerading
as an answer. What does it mean to say that pain, as opposed to, for example,
tachycardia or neutropenia, is a subjective phenomenon? What is it about the
subjectivity of pain that makes its treatment difficult? If answering these
questions is relevant to promulgating effective pain policy there is no legitimate
way to avoid assessing the meaning of subjectivity and objectivity in American
(biomedical and scientific) culture. Fortunately, the history of objectivity in
Western culture has received much attention among historians of science in
particular, and there is accordingly a rich literature to draw on in sketching the
development of objectivity as a concept and its implications for conceptualizing
the power that the empirical Eye can bestow.
The history of objectivity in Western culture is a central theme in this
chapter in no small part because this history overlaps in crucial ways with the
history and power of the visible. It is therefore vital to understand that the
concept of objectivity itself has a history; it did not simply appear in
contemporary clothing in the twentieth century. Indeed, the notion of objectivity
has undergone profound conceptual changes in the modern era.183
183
Daston and Galison, Objectivity; Alberto Cambrosio, Peter Keating, Thomas Schlich,
and George Weisz, “Regulatory Objectivity and the Generation and Management of Evidence in
Medicine,” Social Science & Medicine 63, no. 1 (July 2006): 189-99.
78
Properly historicizing the rise of scientific objectivity in the West is
important for a variety of reasons related to the medical humanities in general and
the study of pain in particular. Without an informed understanding of how the
reliance on objectivity and objectification came to rest at the very core of what it
means to practice clinical medicine, any social and cultural analysis of that
practice is limited. In turn, because understanding the effects of objectivity in
clinical medicine is, as most scholars agree, fundamental to assessing both the
meaning of pain and the problems in treating it, this history is a prerequisite to
unpacking contemporary problems in treating pain adequately.
This chapter therefore summarizes the pathways along which the emphasis
on the visible object became an important part of Western scientific and
biomedical culture. Because there is ample scholarship and historiography on the
subject, my principal task here will be to summarize the evidence so as to
contextualize the crucial changes in Western medicine during the nineteenth
century. These changes are inextricably intertwined to the increasing status and
role for pathological anatomy during the nineteenth century, thereby suggesting
that analysis of anatomy is in many ways coextensive with analysis of the power
of the visible in Western culture.
As the practice of anatomy naturally fuses the social worth of the visible
with medicine and science, it is the focus of this chapter. I begin with a brief
discussion of the power and the peril of anatomical practice during the Middle
Ages.184 This summary contextualizes the analysis of anatomy during the
184
Of course, anatomy is ancient, but one has to begin and end somewhere, and ancient
anatomical practices were modulated in crucial ways in the late Middle Ages. These modulations
would come to have pronounced effects on the practice of anatomy during the nineteenth century,
and resonate in the present.
79
Renaissance and the early modern era, which appropriately centers on Vesalius.
Vesalius is integral not simply because of his stature as the father of modern
anatomy, but because he exemplifies the increasing value that attended seeing
inside the body, and connecting the objects of inquiry with illness and health.
Chapter 3 concludes by linking this Vesalian emphasis on the power of
anatomical sight to early modern attitudes and beliefs regarding the power of the
visible, the latter of which is exemplified in the increasing early modern focus on
medical signs.
THE PERILS OF ‘SEEING’ DURING THE MIDDLE AGES AND THE RENAISSANCE
A central theme of a distinctly medieval ethos was that of order, such that
every natural phenomenon–people, planets, animals, etc.–had a specified station,
a place which constituted their self and defined their purpose.185 Deeply
influenced by the teleological nature of Aristotelian naturalism,186 any social
movement or perspective which challenged the assignment of these stations risked
being seen as unnatural and heretical.187
Similarly, medieval ethos encouraged reliance on authority, such that
challenging the wisdom of the recognized authorities constituted an affront to the
natural order as ordained by God and identified by, for example, Aristotle,
Augustine, and Thomas Aquinas.188 The dialectic clash between what authority
185
Colin Morris, The Discovery of the Individual 1050-1200 (New York, NY: Harper
Torchbooks, 1972).
186
Cary J Nederman, “The Meaning of ‘Aristotelianism’ in Medieval Moral and Political
Thought,” Journal of the History of Ideas 57, no. 4 (October 1996): 563-585.
187
Edward J. Peters, Heresy and Authority in Medieval Europe (Philadelphia, PA:
University of Pennsylvania Press, 1980).
188
Ibid.
80
dictated and what the Eye perceived can be seen across the Late Middle Ages, the
Renaissance, and into the early modern era. A. Richard Turner expressly
connects the significance of the investigating Eye to the expression of the
individual ‘I’ that many scholars have taken as characteristic of Renaissance
thought. Thus, in conceptualizing the world in which Leonardo lived and worked,
Turner frequently refers to the Eye/I:
The triumph of Eye/I in Leonardo’s day was based on a solid
assumption and two emerging notions. The assumption was that
an autonomous individual, through the exercise of virtu (masterful
excellence), could state an idea, perform a deed, or create an object
whose intention and character were manifest to his audience. The
first notion was that knowledge, beyond being the fuel to nurture
understanding was power in the hands of the person who used it.189
Turner’s point is that the the image of the autonomous self acts as a mirror for the
eye that embodies observation of the natural world (the “Eye/I”).
As to the tension–and the connection–between the Eye/I, Anthony Grafton
notes that the humanist “modernization took the form of an increasing attention to
material objects, both as found in nature and as reworked by man. This interest
grew in part from classical texts.”190 Allan Debus observes that “[t]he new love
of nature expressed by Petrarch . . . was instrumental in the rise of a new
observational study of natural phenomena . . . .”191 Pliny’s natural history,
189
A. Richard Turner, Inventing Leonardo (Berkeley, CA: University of California Press,
1992), 172.
190
Anthony Grafton, “The New Science and the Traditions of Humanism,” in The
Cambridge Companion to Renaissance Humanism, ed. Jill Kraye (Cambridge, UK: Cambridge
University Press, 2004), 214.
191
Allen G. Debus, Man and Nature in the Renaissance (Cambridge, UK: Cambridge
University Press, 1978), 5.
81
Aristotle’s works on animals, and Theophrastus’s compendium of plants were all
translated into Latin during the fifteenth century, and the humanist translators
“complemented it with further material, much of it derived from direct inspection
of the natural world.”192 Nancy Sirasi notes that “[c]ertainly the activities and
statements of sixteenth-century anatomists, botanists, zoologists and so on appear
to reflect their unanimous conviction that empirical knowledge (whether first
hand or reported) and descriptive procedures, both verbal and visual, had a valid
place in natural philosophy.”193 Moreover, the Renaissance emphasis on
naturalism and perspective combined with the invention of the printing press
changed “the possibilities for transmitting pictorial representations.”194
In the early modern era, the Eye/I tension is particularly obvious in the
Church’s reaction to Galileo’s telescopic observations. It is, I suggest, no
accident that the powerful and dangerous Eye is a recurring motif in Bertolt
Brecht’s eponymous drama about Galileo. Galileo tells Sagredo that “[t]he
evidence of your own eyes is a very seductive thing.”195 Indeed, Galileo goes so
far as to elevate the investigating Eye over classical knowledge itself: “The
question is whether these gentlemen here want to be found out as fools by men
who have not had the advantages of a classical education but who are not afraid to
use their eyes.”196 Such a rejection of classical authority in favor of the
192
Grafton, “New Science,” 214.
193
Nancy G. Siraisi, “Vesalius and Human Diversity in De humani corporis fabrica,”
Journal of the Warburg and Courtauld Industries 57 (1994): 67.
194
Mary G. Winkler, and Albert Van Helden, “Representing the Heavens: Galileo and
Visual Astronomy,” Isis 83, no. 2 (June 1992): 200.
195
Bertolt Brecht, Galileo, ed. Eric Bentley, trans. Charles Laughton (New York, NY:
Grove Press, 1994), 63.
196
Ibid., 69.
82
investigating Eye would almost certainly have been viewed by many authorities
of the time as dangerous, if not outright seditious.
Perhaps most interesting is that Brecht expressly connects the Eye/I
tension to anatomy, which, for my purposes, is above all practices in the early
modern era in terms of its importance to understanding the power of the visible.
In the drama, Matti warns Galileo that “[t]he same circles that are hampering you
now will forbid the physicians at Bologna to cut up corpses for research.”197
THE ROLE OF ANATOMY IN CONSTRUCTING THE POWER OF THE VISIBLE
(BODY)
Turner notes that anatomy in the Middle Ages, at least prior to the
Renaissance, reflected the medieval emphasis on authority and station: “Cutting
open a body was something to be done under the most controlled of
circumstances, and only then to confirm tradition rather than to advance
knowledge.”198 Even in Renaissance Italy, Katharine Park observes that
dissections functioned rather like an extension of anatomical
illustration. Their goal was not to add to the existing body of
knowledge concerning human anatomy and physiology but to help
students and doctors understand and remember the texts in which
that knowledge was enclosed.199
These texts, of course, were the repositories of authority and knowledge, and
hence the entire purpose of anatomical dissection was to reinforce the legitimacy
197
Ibid., 105.
198
Turner, Inventing Leonardo, 197.
199
Katharine Park, “The Criminal and the Saintly Body: Autopsy and Dissection in
Renaissance Italy,” Renaissance Quarterly 47, no. 1 (Spring 1994): 14.
83
of that knowledge. As we shall see, when one assesses what Vesalius considers to
be the main purpose of dissections roughly a century later, the contrast is stark.
While there is debate over the extent of opposition to anatomical
dissections in the Late Middle Ages and the Renaissance, the general consensus
remains that anatomy was socially, culturally, and spiritually tenuous for a variety
of reasons. First, Turner notes that because the medieval body was perceived as a
sacred gift from God, delving into the inner sanctum of that space risked
profaning the divine.200 Second, as Brecht hints, and as Vesalius, Harvey, and
Willis among many others would demonstrate, anatomy could provide a basis for
challenging medical and anatomical authorities like Aristotle and Galen. Third,
anatomy was perilous because criminals often supplied the corpse, and were
subjected to public dissection. However, Park notes that the stigma of the latter
did not, at least in Italy, stem from the fact that the body was opened up for
dissection, but was rooted “in the dramatic violation of personal and family honor
involved in public dissection.”201
Moreover, the traditional narrative that anatomy violated generalized
taboos across Europe is too sweeping, and is unsupported in the historiography.
Park argues that while bodily integrity was of great weight in problematizing
anatomical dissections in England and in Northern Europe, in Italy, postmortems
sponsored by patrician families were not uncommon, and there was general
tolerance for anatomy and dissection.202 Some of these differences turned on
200
Turner, “Inventing Leonardo,” 195-200.
201
Park, “The Criminal and the Saintly Body,” 12 (emphasis added).
202
Katharine Park, “The Life of the Corpse: Division and Dissection in Late Medieval
Europe,” Journal of the History of Medicine and the Allied Sciences 50, no. 1 (1995):111-132; and
Park, “The Criminal and the Saintly Body.”
84
geographically divergent beliefs and attitudes about the status of the corpse. In
northern Europe of the Late Middle Ages, the corpse remained a “magical and
semi-animate object” for as long as a year after death, while in Italy “the corpse
was only a corpse, a castoff of a self now definitively elsewhere . . . .”203
Northern European beliefs even encouraged division of the corpse–in which
different parts of the corpse would be sent to different areas for burial–because
these parts of the body were deemed to carry spiritual and magical properties.204
Thus the issue was not equally charged in all societies across Europe during the
Renaissance and early modern era.205
Park also mentions the notorious bull Detestande feritatis, issued by Pope
Boniface VII in 1299, which prohibited persons from separating the flesh from
the bones of dead crusaders by boiling the dead bodies (in order to carry the flesh
home for burial).206 While this bull was widely misinterpreted as a general ban on
anatomical dissection, the very fact that the misconstrual was so ubiquitous and
continued to be propagated well into the following centuries testifies to the
enduring nature of the concern regarding the legitimacy of dissection.
Anatomical dissection was quite literally visceral:
203
Park, “The Life of the Corpse,” 126; accord Elizabeth T. Hurren, “Whose Body Is It
Anyway? Trading the Dead Poor, Coroner’s Disputes, and the Business of Anatomy at Oxford
University,” Bulletin of the History of Medicine 82, no. 4 (Winter 2008): 775-819; and Helen
MacDonald, Human Remains, Dissection, and its Histories (New Haven, CT: Yale University
Press, 2005).
204
Park, “The Life of the Corpse.”
205
Robert L. Martensen, The Brain Takes Shape: An Early History (New York, NY:
Oxford University Press, 2006).
206
Park, “The Life of the Corpse;” Park, “The Criminal and the Saintly Body”; and
Elizabeth Brown, “Authority, the Family, and the Dead in Late Medieval France,” French
Historical Studies 16, no. 4 (Autumn 1990): 803-832.
85
The idea that the body is the cosmos in miniature carried with it
the possibility that intervention in the body could constitute
interference in the perfect workings of God’s creation. The body
was under the rule of the planets, and such medical treatment as
existed was subject to favorable or unfavorable celestial
configurations. To cut open the body was to draw blood both
sacred and profane–the blood of Christ, but also the blood of
menstrual flow.207
As Turner puts it, it is “no wonder that among the anathematized were
executioners, butchers, and surgeons.”208 Even as a rhetorical device anatomy
could be risky: Robert Burton notes in the Anatomy of Melancholy that in
pondering what causes men to pursue their own unhappiness, “I do anatomise and
cut up these poor beasts, to see these distempers, vanities, and follies, yet such
proof were better made upon man’s body . . .”209 Mary Winkler suggests that the
frontispieces and illustrations that accompanied early modern anatomical texts
may be viewed with pleasure by contemporary observers precisely because
“artists and anatomist collaborated in creating an image of dissection that
subsumes any horror of desecration in the drive for ever-increasing knowledge of
human nature and human potential.”210
Even Park, who set out in a 1994 article to disprove what she terms the
“myth” of a generalized taboo against dissection across Europe, notes that despite
the northern European proclivity for division of the corpse, attitudes towards
anatomical dissections were an entirely different story: “[T]o open or dismember
207
Turner, Inventing Leonardo, 199.
208
Ibid., 197.
209
Robert Burton, The Anatomy of Melancholy (1652),
http://www.gutenberg.org/files/10800/10800-h/10800-h.htm (accessed June 15, 2009).
210
Mary G. Winkler, “The Anatomical Theater,” Literature and Medicine 12, no. 1
(Spring 1993): 66.
86
the body for doctors to inspect–an act of no conceivable unity to the deceased,
now beyond all medical aid–was an act of objectification and a violation of
personal honor.”211 And Renaissance Italians, who generally tolerated anatomy
and dissection, were afraid of vivisection.212
Ultimately, despite the complexity of Renaissance and early modern
attitudes towards anatomy and dissection, Mark Jenner’s assessment seems
accurate: “Most would . . . agree that the practice of anatomy was not
foregrounded when an early modern doctor sought to present himself in polite and
civil company.”213 Similarly, Siraisi notes that “[o]pening the body did not
violate any specific religious taboos, but scientific and social rituals were
evidently needed to mitigate discomfort.”214 Though the story is likely a
fabrication, longstanding legend had it that Vesalius had incurred the wrath of the
Spanish Inquisition by carrying out an autopsy on a patient that was still alive.215
Akin to the effect of Detestande feritatis, the very fact that the rumor had
currency is evidence of the danger and peril of anatomical studies.
The enduring nature of the legend regarding Vesalius and vivisection hints
at his importance. Indeed, any discussion of anatomy during the Renaissance and
the early modern period begins and ends with Vesalius. Vesalius is not simply
the father of modern anatomy and a still-towering figure in medicine and science,
211
Park, “The Life of the Corpse,” 126.
212
Park, “The Criminal and the Saintly Body.”
213
Mark S. Jenner, Body, Image, Text in Early Modern Europe. Social History of
Medicine 12, no. 1 (1999): 145.
214
Nancy G. Siraisi, “Vesalius and the Reading of Galen’s Teleology,” Renaissance
Quarterly 50, no. 1 (Spring 1997): 23.
215
Park, “The Criminal and the Saintly Body.”
87
he was also a product of the studia humanitatis, the humanist educational
program, and is therefore of unparalleled importance to the medical humanities.
Moreover, the dialectical clash between the medieval respect for place and
authority and the power of the Eye/I is readily apparent in Vesalius’s work.
VESALIUS AND THE POWER OF THE VISIBLE IN ANATOMY
The Belgian humanist Andreas Vesalius did not mince words when it
came to his views on prevailing traditions of anatomy. He ridiculed the
anatomists of his day, who did little dissection and empirical examination of their
own, but instead relied almost exclusively on Galenic models of anatomy.216 In
spite of Vesalius’s vituperative criticisms of those who trusted to anatomical
authority rather than the investigations of their hands and eyes, the Eye/I tension
is demonstrated in Vesalius’s reluctance to sharply criticize or depart from
Galenic dicta. It was, of course, well-known in Vesalius’s time that Galen
himself participated in few human dissections, confining his observations to the
examination of gladiator’s wounds and the dissection of various animals (pigs,
oxen, the Barbary ape, etc.). Nevertheless, Vesalius lauds Galen for his hands-on
care of the gladiators, and notes that “even as his age increased was unwilling to
have apes skinned for him by slaves prior to dissection.”217 There is, therefore,
little doubt that the Galenic anatomical corpus was central to Vesalius’s work.218
216
See Siraisi, “Vesalius and the Reading of Galen’s Teleology”; Nancy G. Siraisi,
“Vesalius and Human Diversity”; Debus, Man and Nature in Renaissance; and Martin Kemp,
“Dissection and Divinity in Leonardo’s Late Anatomies,” Journal of the Warburg and Courtauld
Institutes 35 (1972): 200-225.
217
Andreas Vesalius, De humani corporis fabrica, ed. and trans. William Frank
Richardson and John Burd Carman (New York, NY: Norman Publishing 2009), 2r.
218
Siraisi, “Vesalius and the Reading of Galen’s Technology”; and Kemp, “Dissection
and Divinity.”
88
Despite the honor and authority which Vesalius accorded Galen’s
teachings, the imperative to use one’s own hands to see inside the body did not
entirely spare Galenic models from Vesalius’s critical gaze. Siraisi suggests, in
an excellent example of the Eye/I dialectic, that the Fabrica “is in general Galenic
[and] is combined with numerous and forceful criticisms of Galen’s teachings on
specific points.”219 Elsewhere she observes that Galen’s work “was at once the
object of some of Vesalius’s sharpest criticisms and a source from which he freely
drew.”220
Vesalius’s reluctance to depart from Galenic conception is most evident in
his struggle to reconcile with his own observations the key element of the Galenic
conception of the heart: the presence of interventricular pores.221 Even while his
dissections repeatedly confirmed the absence of the pores, it took Vesalius over a
decade to pronounce the Galenic conception mistaken.222 By 1555, the year in
which Vesalius published a revised edition of the Fabrica, Vesalius’s exclamation
that appeared in the 1543 edition, on the industry of the Creator who created the
mechanism of the pores had disappeared: “[H]aving become even more doubtful
of the existence of such pores, he omitted the remark.”223 For Vesalius, the
investigating Eye/I took primacy over received wisdom, but not without
219
Siraisi, “Vesalius and Human Diversity,” 65.
220
Siraisi, “Vesalius and the Reading of Galen’s Technology,” 4.
221
Debus, Man and Nature, 59-66.
222
Ibid. An earlier example of the same dynamic is the fact that Leonardo, despite his
rigorous and detailed anatomical observations, drew the human heart entirely consistent with
Galenic anatomical conception. Mirko D. Grmek, “A Plea for Freeing the History of Scientific
Discoveries from Myth,” in On Scientific Discovery: The Erice Lectures 1977, ed. Mirko D.
Grmek, Robert S. Cohen, and Guido Cimino (Dordrecht, Netherlands: Reidel Press, 1981), 9-42.
223
Siraisi, “Vesalius and the Reading of Galen’s Technology,” 18.
89
significant resistance, even while he publicly ridiculed his contemporaries for
trusting to Galenic authority over their own observations.
SEEING INSIDE THE BRAIN
Because the role that the visible pathology plays in the undertreatment of
pain is mediated in critical ways by conceptions of the brain, it is worth pausing to
note that Vesalius was also particularly interested in the anatomy of the head, and
for what it symbolized in the early modern discourse regarding particulars and
universals. Of this distinction I shall have more to say in chapters 5 and 6, but for
now, it is sufficient to note that the discussion of the human head occupies a
significant portion of the early chapters of Fabrica.224 Indeed, some of the
earliest Western attempts to localize brain function to head shape occur in the
Galenic Ars medica, and the significance of head shape in producing human
variation was not lost on Vesalius (Illustration 1).225
224
Siraisi, “Vesalius and Human Diversity.”
225
The history of localization plays a crucial role in the conceptualization of pain during
the nineteenth century, as I will demonstrate in the next chapter. The fact that such a concept
dates to Galenic texts and were relevant for Vesalius again demonstrates the necessity of properly
contextualizing the changes that would occur in the nineteenth century regarding the power of
seeing not just inside the body, but of seeing inside the brain and nervous system. These themes
also link up in significant ways with the fMRI studies on pain insofar as localization is a key
aspect of the conceptual base of fMRI. See Pustilnik, “Violence on the Brain.”
90
Illustration 1: Vesalius’s assimilation of the Galenic scheme of “one natural and
four unnatural shapes.”226
The history of localization plays a crucial role in the conceptualization of
pain during the nineteenth century, as I will demonstrate in the next chapter. The
fact that such a concept dates to Galenic texts and were relevant for Vesalius
again demonstrates the necessity of properly contextualizing the changes that
would occur in the nineteenth century regarding the power of seeing not just
inside the body, but of seeing inside the brain and nervous system. These themes
226
Siraisi, “Vesalius and Human Diversity,” 81.
91
also link up in significant ways with the fMRI studies on pain insofar as
localization is a key aspect of the conceptual base of fMRI.227
The Preface to Walter Charleton’s 1680 treatise Enquiries into Human
Nature: Anatomic Praelections in the New Theatre of the Royal Colledge of
Physicians in London (Illustration 2) demonstrates the spiritual aspects of
anatomical practice, and in particular anatomy of the brain:
Who can look into the Sanctum Sanctorum of this Temple, the
Brain, and therein contemplate the pillars that support it, the arch'd
roof that covers and defends it, the fret-work of the Ceiling, the
double membrane that invests it, the resplendent partition that
divides it, the four vaulted cells that drain away impurities, the
intricate labyrinths of arteries that bring in from the heart rivulets
of vital blood to heat and invigorate it, the Meanders of veins to
export the same blood, the Aqueducts that preserve it from
inundation, the infinite multitude of slender and scarce perceptible
filaments that compose it, the delicate nerves or chords spun from
those threds, the original of that silver chord (as Ecclesiastes calls
it) or Spinal marrow, upon which the strength of back and limbs
chiefly depends; and many other parts of the wonderful Engine:
and not discern an infinite Wisdom in the design and construction
of them?228
The power of seeing inside the body and the brain was such that it could best
described in religious and spiritual language, a metaphor that will be relied upon
time and again during the nineteenth century, and in the narratives of the
American roentgenologists.229 Charleton expressly notes that “we may safely
conclude that to study Anatomy diligently and reverently, is to learn to know
227
Pustilnik, “Violence on the Brain.”
228
Walter Charleton, Enquiries into Human Nature: Anatomic Praelections in the New
Theatre of the Royal Colledge of Physicians in London (London, UK: Turks Head in Cornhill,
1680), Preface.
229
Herzig, “American Roentgenology.”
92
God, and consequently to venerate Him; Deum enim colit, qui novit,” and “that if
I knew an Atheist (if there can be such a Beast in the world) I would do my best
to bring him into this Theatre, here to be sensibly convinced of his madness.”230
The importance of claiming that anatomy is sacred practice is evident when one
considers the previously discussed perception that anatomy profaned the temple
of the body.
Illustration 2: Walter Charleton’s 1680 paean to anatomy. Courtesy of Cambridge
University Library, all rights reserved.
Even giants of early modern thought were not immune from the
evidentiary challenges posed by the new empiricism: In 1669, Nicolaus Steno
230
Charleton, Enquiries into Human Nature, Preface.
93
“patiently showed how a correct analysis of a correctly performed brain dissection
proved that the pineal gland could not possibly function in the way Descartes
imagined”231 Steno followed Vesalius in his disdain for the typical anatomist
practice of theorizing without focus on seeing the body via dissection.
He conceived of the brain as a machine, and like any machine, believed
that it could be understood if it could be deconstructed and its pieces examined.232
Evelyn Fox Keller’s examination of the role of the computer metaphor in
cognitive science233 demonstrates the enduring influence of the brain-as-machine
image, and the concomitant focus on seeing the parts of the brain as a cipher for
function. Steno’s rigorous insistence on dissection as the only adequate means for
discerning neural function shows the importance of empiricism in the early
modern era.234 It is what can be seen, what is visible to the Eye/I, that is most
significant.
THE IMPORTANCE OF SIGNS IN THE EARLY MODERN PERIOD
Ultimately, in spite of the tension between natural observation and the
medieval focus on authority and order (which implied that the habit of looking
beyond authoritative sources was dangerous), it is difficult to contest the notion
231
Noga Arikha, “Form and Function in the Early Enlightenment,” Perspectives in
Science 14, no. 2 (Summer 2006): 159.
232
Ibid. The body as machine metaphor also figured prominently in Leonardo’s work.
Turner, Inventing Leonardo; and Kemp, “Dissection and Divinity.”
233
Keller, “Refiguring Life,” 79-118.
234
As I will argue in more detail in chapter 5, imaging the brain–whether through the
anatomical drawings of the humanists and the early moderns or through modern imaging
techniques–are a key to its reification. Imaging therefore operates as a tool for translating brain
function (and thereby unlocking the brain’s secrets), and this was as true of the imaging performed
in early modern times as it is today for fMRI.
94
that, by the early modern era, the concept of physical signs was of great
importance in the social conception of disease. In this context, it is perhaps
unsurprising that medical semiotics takes on new, or at least renewed, importance
in the early modern period. Hess notes that eighteenth century pathology
continued the body-as-machine metaphor and connected the visible illness to a
disordered interior, a schema that harkens back at least as far as Galen: “Visible
perception corresponded to the invisible inner disorder of the body machine . . .
The hidden disorder, interruption, obstruction, or transformation in the fluid or
solid parts was considered as the essential ‘nature’ of the disease or as the disease
in a pathological sense.”235 And Ian MacLean, in his account of the role of
semiotics in Renaissance medicine, notes that the most sophisticated physicians
adopted a precise method intended to permit apprehension of the relationship
between inner states and external signs.236 According to Sanctorius, “[r]ational
doctors . . . begin with convertible signs . . . move from the universal to the
particular, and proceed by way of symptoms of causes, to the symptoms of the
affected parts and the affected virtues or faculties.”237
Accordingly, John Cotta observed in 1612 that “[i]t is a chiefe point in all
learnings truly to diſcerne betweene differing ſimilitudes and like differences.”238
Cotta details the importance of medical semiotics in his treatise entitled A Short
235
Volker Hess, “Medical Semiotics in the 18th Century: A Theory of Practice,”
Theoretical Medicine and Bioethics 19, no. 3 (June 1998): 207.
236
Ian MacLean, Logic, Signs, and Nature in Renaissance Medicine (Cambridge, UK:
Cambridge University Press, 2002).
237
Ibid., 296.
238
John Cotta, A Short Discoverie of the Unobserved Dangers of Severall Sorts of
Ignorant and Unconsiderate Practicers of Physicke in England (London, UK: 1612), 17.
95
Discoverie of the Unobserved Dangers of Severall Sorts of Ignorant and
Unconsiderate Practicers of Physicke in England (Illustration 3):
Contraries haue oft in many things likeneſſe, and likeneſſe
contrarieities eaſilie deceiuing the vnwotting and vnlearned. It is
therefore of no ſmall moment or conſequence for a Phyſition truly
by a diſcerning eye to put iuſt difference.239
Cotta argues that even the apparent antipodes of life and death can present similar
signs to the physician, whose learning and experience is therefore crucial in
determining appropriate practices.240 Thomas Willis, in his 1667 treatise on the
pathology of the brain, acknowledges that his forebears could not be blamed for
thinking demons to be the cause of epileptic fits, as no essence of inner disease
had been found:
In truth, in this Distemper, no marks at all, of the morbifick matter
appears, or are so very obscure, that we may have deservedly
suspected it, to be an inspiration of an evill Spirit, at least it is
probably, that as often as the Devill is permitted to afflict
miserable Mortals, with his delusions, he is not able to draw more
Cruel Arrows, from any other quiver, or to shew miracles by any
better witch, than by the assaults of this monstrous Disease.241
239
Ibid.
240
Ibid.
241
Thomas Willis, Essay on the Pathology of the Brain and Nervous Stock: In Which
Convulsive Disease are Treated Of, trans. Samuel Pordage (London, UK: Harrow at ChanceryLane-End, 1681), 12.
96
Illustration 3: The 1612 edition of John Cotta’s treatise on appropriate practices of
physick. Picture courtesy of the British Library, all rights reserved.
Charleton is even more explicit regarding the necessity of signs in
diagnosis and treatment of disease, and he connects knowledge of such signs to
anatomy:
no good judgment can be made of the nature and kind of any
disease, unless it be first known, what part of the body is thereby
chiefly affected; and the most certain indieia or distinctive signs of
the part affected, are taken principally from the situation of the
part, and from the action of it hurt. For instance, he that knows the
Liver to be naturally seated in the right Hypochondrium, if in that
place pain be felt, or swelling appear from a Tumor within, will
easily thence collect, that the Liver is the part then affected: and he
that knows, that the principal action of the Stomach is Concoction,
will soon know, if Concoction be hurt, that the Stomach is
misaffected. But both the places and actions of the parts are learn'd
only from Anatomy: and therefore whoever is ignorant of
97
Anatomy, can have no certain knowledge of either those, or
these.242
Claudia Stein argues for a similar significance of physical signs in her
exploration of French smallpox in early modern Augsburg. Certain physical
requirements were the key to admission to an Augsburg hospital as early as the
mid 1530s.243 The putative patient would be examined by “a barber-surgeon and
a university-trained physician” to assess whether the patient displayed the
physical signs necessary for admission.244 Interestingly, the division of labor
between the barber-surgeon and the physician in Augsburg during this time
demonstrates the importance of discerning the “invisible realm of physical signs
that was considered crucial for the understanding of their relationship to
disease.”245 Although the barber-surgeon treated the patient’s external symptoms,
“the higher salary and greater responsibility of the academic physician suggest
that it was the investigation of the invisible realm of physical signs that was
considered crucial for the understanding of their relationship to disease.”246 The
invisible was a “powerful organizational force” in the Augsburg hospital that
“structured not only the healers’ authority over the human body and the
professional hierarchy, but also the entire institutional space.”247
242
Charleton, Enquiries into Human Nature, Preface.
243
Claudia Stein, “The Meaning of Signs: Diagnosing the French Pox in Early Modern
Augsburg,” Bulletin of the History of Medicine 80, no. 4 (Winter 2006): 617-648.
244
Ibid., 618.
245
Ibid., 625.
246
Ibid.
247
Ibid.
98
As Stein’s analysis suggests, the inner-outer distinction was crucial in
early modern medical semiotics, but had a long and vibrant history248 as “a major
symbolic opposition in Western medicine from its first formulation in the ancient
Greek Hippocratic treatises.”249 The inner body was “a place of hidden
activities,”250 which again underscores the danger of dissection studies in
medieval, Renaissance, and early modern thought.251 The inner space of the
body, including the brain, was sacred space; knowledge of it was literally
revelatory. Thomas Willis was careful to note in his Cerebri Anatome (1664)
(Illustration 4) that his work was intended to “unlock the secret places of Mans
Mind and breathing chapels of the Deity.252
Yet it was “only through the
248
See MacLean, Logic, Signs, and Nature.
249
Stein, “The Meaning of Signs,” 630.
250
Richard Selzer, Mortal Lessons: Notes on the Art of Surgery (New York, NY: Simon
& Schuster, 1979), 24.
251
Again, this is not to posit any false equivalence in beliefs and attitudes towards
anatomy and dissection across Europe over the span of several centuries. Park’s analysis
demonstrates important differences in such attitudes in different societies of the same time, which
implies even greater differences in various societies’ beliefs and customs regarding the integrity of
a corpse across the centuries spanning the medieval to early modern periods. Nevertheless, I
suspect there is enough continuity of some rough sort to suggest, as I have here, that anatomy and
dissection were problematic at various times and in various cultures during these periods.
Moreover, as Tatjana Buklijas recently demonstrated, nineteenth century attitudes towards
anatomy and dissection in Vienna (a world center for anatomical science at the time) show
remarkably similar attitudes and beliefs towards the risks and offenses that attended anatomy.
Tatjana Buklijas, “Cultures of Death and Politics of Corpse Supply: Anatomy in Vienna, 18481914,” Bulletin of the History of Medicine 82, no. 3 (Fall 2008): 570-607. Similarly, Elizabeth
Hurren’s recent analysis of the economy of anatomical supply at Oxford during the nineteenth
century demonstrates both hesitation to countenance anatomy, and the Oxford anatomists’ strong
desire to keep their efforts at acquisition clandestine. Hurren, “Whose Body Is It Anyway?”
Hurren specifically notes that “local attitudes to dissection stressing the sanctity of the human
body had been unchanged since the eighteenth century.” Ibid., 778. This obviously testifies to the
enduring nature of the perceived risks of peering inside the body within a scientific and
biomedical context.
252
Thomas Willis, The Anatomy of the Brain and Nerves, ed. William Freindel (Ann
Arbor, MI: Classics of Medicine Library, 1978), 69.
99
physical sign on the surface of the skin could a patient and his or her healers
speculate about the secrets inside.”253
Illustration 4: Thomas Willis’s landmark Cerebri Anatome was published in
1664.
Stein’s specific focus on smallpox is not my project here, but the key
insight for my purposes is the significance of the invisible forces that inhabited
the body for the outer symptoms of disease. “Proper knowledge and diagnosis of
the pox in Augsburg’s French-disease hospital was gained not by the mere act of
‘seeing’ the physical sign, but only by decoding its invisible meaning.”254 But
what if the invisible could be made visible? If what was unseen could become
253
Stein, “The Meaning of Signs,” 630.
254
Stein, “The Meaning of Signs,” 646.
100
seen? As we shall see in chapter 4, the significance of these questions hardly
dissipated between the early moderns and the nineteenth century; if anything, it
took on even greater importance in Western scientific and biomedical culture by
the nineteenth century.
CONCLUSION
After years and much reluctance, Vesalius eventually acknowledged the
power of the Eye/I in undermining even as revered a medical authority as Galen
himself. A half-century later, in 1628, Harvey repudiated the Galenic model of
circulation. Yet some kind of Galenic model held sway in the West for nearly
two centuries after Harvey’s discovery.
The social, cultural, and intellectual currents that would eventually result
in the apparent ‘downfall’ of the Galenic model255 can be traced to a specific date:
1800, the dawn of the nineteenth century. Here, according to Foucault, the clinic
is born. And with an understanding of the increasing importance of the visible in
Western, scientific, and biomedical culture, it is here that I may directly pick up
the story of pain once again.
255
A dialectic conception of history would caution against hastily concluding that the
basic model of disease that held sway in Western minds for approximately 1800 years has been
wholly erased from the fabric of contemporary Western societies. Indeed, I have personally been
struck by the persistence of the ‘chemical imbalance’ theory of mental illness in spite of an
abundance of evidence suggesting its implausibility. For references on this subject, see note 110.
In any case, perhaps a Galenic model of disease, predicated on the notion of humoral imbalances,
is not quite as dead as it appears to be. Noga Arikha, in her recent history on the humors,
expressly argues that much biomedical discourse on disease conception remains fundamentally
Galenic. Arikha, Passions & Tempers.
101
Chapter 4: The History of Pain Without Lesion in Nineteenth
Century America
INTRODUCTION
Recall that two questions lie at the core of this thesis:
1. Given that the vast majority of pain experiences can be adequately
managed using available treatment modalities, why does pain remain so
poorly treated in the U.S.?
2. Given the immense and cross-disciplinary scholarship, advocacy, and
policy attention to the undertreatment of pain in the United States, why
does pain remain so poorly treated in the United States?
The argument I am developing posits that pain continues to be
significantly undertreated, and that the copious attention to the law, ethics, and
policy of pain treatment has had little salutary effect precisely because these
efforts have not been moored to a social and cultural analysis of the meaning of
pain in American society. In turn, understanding what the lived experience of
pain means in American society requires an understanding of the power of the
visible in Western scientific and biomedical culture. Finally, apprehension of the
power of the visible in Western culture is, I submit, impoverished without
examining how that power came to be conceptualized, understood, and harnessed
in the roots of the modern era.
Yet, as important as events and concepts of earlier eras may be to current
thinking about pain, this is not a project devoted to Renaissance or early modern
history. I have already committed myself to the notion that the nineteenth century
102
is of peculiar importance in understanding the meaning of pain in American
society. Thus, I turn now to an analysis of the changes in Western scientific and
biomedical culture during the nineteenth century. After explaining the general
frame I will utilize in thinking about these changes, I will assess the beliefs,
attitudes, and practices of leading nineteenth century U.S. healers and scientists
towards pain without lesion. This latter analysis is crucial for understanding the
role of the visible in structuring attitudes towards clinical phenomena that were
not susceptible to the methods of seeing pioneered during the nineteenth century.
PATHOLOGICAL ANATOMY & THE BIRTH OF THE CLINIC
As the power of the visible is a central theme for my project, it should
come as no surprise that Michel Foucault’s conception of the rise of clinical
medicine figures prominently in my analysis. Foucault’s most important text for
my purposes, The Birth of the Clinic, is subtitled An Archaeology of Medical
Perception. As always in a medical humanities analysis, rhetoric matters. The
term archaeology is crucial because it characterizes Foucault’s project in The
Birth of the Clinic: an attempt to excavate from the social and cultural fabric of
Western culture the genesis of a dramatically different understanding of the body,
of illness, and of therapeutic practices than what had been understood and
generally accepted–with obvious local and particular variation–for many centuries
prior in many different societies in the West.
In The Birth of the Clinic, Foucault argues that the clinic is born in the
West in 1800. How can he say this? What happened in and around 1800 that
103
enables him to make an argument that even his critics concede is generally
accurate?256
The short answer is that, at the turn of the nineteenth century, in one of the
centers of Western medicine (Paris), a group of scientists and physicians began to
formulate a model of health and disease that would come to be called, in
Foucault’s terms, the anatomoclinical method. Of course, given the enormity of
the change, pinning it to the narrow space of a year or even a few years is
untenable. The changes in medical perception during the nineteenth century took
place over decades, and, I will argue, are in some important sense still taking
place today. Accordingly, Foucault’s longer answer to the implicit question in the
title of his book (how was the clinic born?) is premised, like any sound historical
analysis, on an understanding of the ideas, conceptions, and conditions that
preceded it. To understand the nineteenth century changes in medical practice,
disease, health, and ultimately, in pain, it is necessary to apprehend some of the
competing conceptions of disease and the body that existed prior to the nineteenth
century.
To term these conceptions “competing” is to oversimplify, because culture
is dynamic, fluid, and multivalent, such that even ‘competing’ ideologies and
understandings of illness can coexist and amalgamate in important ways. Norman
D. Jewson notes that “bedside medicine” in the late eighteenth century “was
polycentric and polymorphous . . . medical knowledge consisted of a chaotic
diversity of schools of thought. The definition of the field was diffuse and
256
E.g., Hodgkiss, From Lesion to Metaphor.
104
problematic, disciplinary boundaries weak and amorphous.”257 Similarly, by the
nineteenth century, two of the most important theories of disease causality–
contagionism and anticontagionism–alloyed in significant ways, with adherents of
both camps adopting numerous precepts and practices of the other.258
Even allowing for such complexity, however, it is not impossible to
discern some important themes and patterns among competing medical
cosmologies.259 One axis for understanding these different theories of illness in
the nineteenth century is the practice of anatomy. Foucault observes that
[a]t a very early stage historians linked the new medical spirit with
the discovery of pathological anatomy, which seemed to define it
in its essentials, to bear it and overlap it, to form both its most vital
expression and its deepest reason; the methods of analysis, the
clinical examination, even the reorganization of the schools and
257
Norman D. Jewson, “The Disappearance of the Sick-Man from Medical Cosmology,
1770-1870,” Sociology 10, no. 2 (May 1976): 227. Rosenberg terms this essay an “influential, if
categorical” effort. Charles E. Rosenberg, “Disease and Social Order in America,” in Charles E.
Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge, UK:
Cambridge University Press, 1992), 267. Its influence was sufficient to spark several
commentaries and reflections on Jewson and the essay in a very recent issue of the International
Journal of Epidemiology. In particular, see John V. Pickstone, “From History of Medicine to a
General History of ‘Working Knowledges,’” International Journal of Epidemiology 38, no. 3
(June 2009): 646-649.
258
See Michael Brown, “From Foetid Air to Filth: The Cultural Transformation of British
Epidemiological Thought, ca. 1780–1848,” Bulletin of the History of Medicine 82, no. 3 (Autumn
2008): 515-544; Peter Vinten-Johansen, Howard Brody, Nigel Paneth, Stephen Rachman, Michael
Rip, and David Zuck, Cholera, Chloroform and the Science of Medicine: A Life of John Snow
(New York, NY: Oxford University Press, 2003); Martin S. Pernick, “Contagion and Culture,”
American Literary History 14, no. 4 (Winter 2002): 858-865; Christopher Hamlin, Public Health
and Social Justice in the Age of Chadwick (Cambridge, UK: Cambridge University Press, 1998);
Christopher Hamlin, “Predisposing Causes and Public Health in Early Nineteenth-Century
Medical Thought,” Social History of Medicine 5, no. 1 (1992): 43-70; Charles E. Rosenberg,
Explaining Epidemics and Other Studies in the History of Medicine (Cambridge, UK: Cambridge
University Press, 1992); and Margaret Pelling, Cholera, Fever and English Medicine, 1825-1865
(New York, NY: Oxford University Press, 1978). The seminal text on this issue, of course, is
Erwin H. Ackerknecht, “Anticontagionism Between 1821 and 1867,” Bulletin of the History of
Medicine 22 (October 1948): 562-93.
259
Jewson, “The Disappearance of the Sick Man.”
105
hospitals seemed to derive their significance from pathological
anatomy.260
This is in no small part why the bulk of chapter 3 focused on the significance of
anatomy in constructing the power of the visible. As mentioned above, Foucault
even terms the new method the “anatomoclinical” method, and his language has
generally stuck. The question here is why was anatomy so important to the new
method? Moreover, if, as I have argued, anatomical practice took on increasing
importance during the early modern period, how does the focus on anatomy in
nineteenth century medicine mark a break with what preceded it?
A classic and dangerously easy mistake to make in any social history is to
presume that the attitudes, beliefs, and practices of elites and historically
“important” figures illuminate the customs and conventions of non-elite
practitioners.261 The fact that anatomy was of increasing importance in academic
medicine during the modern era does not imply that anatomical dissection was a
key component of the healing practices during the period. Moreover, it is just as
dangerous to assume that the debates within the annals of early modern academic
medicine trickled down to illness sufferers themselves.262 Accordingly, I have not
argued that anatomy and dissection were particularly significant to everyday
260
Foucault, The Birth of the Clinic, 114-15.
261
See Miles Fairburn, Social History: Problems, Strategies, and Methods (New York,
NY: Palgrave Macmillan, 1999); and Mark Jenner, “Body, Image, Text in Early Modern Europe,”
Social History of Medicine 12, no. 1 (1999): 143-154.
262
See Fairburn, Social History. Though such caution is warranted from a general
methodological perspective, there is some evidence that there was greater sharing of medical
knowledge between professionals and laypersons during the early modern era than might generally
be presumed. Alisha Rankin, “Duchess, Heal Thyself: Elisabeth of Rochlitz and the Patient’s
Perspective in Early Modern Germany,” Bulletin of the History of Medicine 82, no. 1 (Spring
2008): 109-144; Martensen, The Brain Takes Shape, 95-116, 153-169.
106
physicians, midwives, herbalists, apothecaries, and/or other healers during the
Renaissance and early modern era, let alone to illness sufferers themselves.
While signs of illness were an essential part of the physician’s
interpretation of disease during the early modern era,263 there is little indication
herein that anatomy and dissection was a significant part of typical healing
practices during the early modern era. David Harley observes that while several
autopsies on highly visible royal figures and politicians helped ground the
legitimacy of anatomy in seventeenth-century England, English physicians
nevertheless generally turned over responsibility for the conduct of such autopsies
to surgeons.264 They apparently felt that anatomical practice was inconsistent
with the genteel professional image they wished to present.265
The importance of anatomy during the early modern period does not,
therefore, rest in any proliferation of its practice amongst physicians and healers,
but rather, reflects at a broad social and cultural level the increasing importance of
the visible, and the connections between the power of scientific observation and
263
Rankin, “Duchess, Heal Thyself;” Lisa Wynne Smith, “‘An Account of an
Unaccountable Distemper’: The Experience of Pain in Early Eighteenth-Century England and
France,” Eighteenth-Century Studies 41, no. 4 (Summer 2008): 459-480; Stein, “The Meaning of
Signs,” Martensen, The Brain Takes Shape; and Guido Ruggiero, “The Strange Death of
Margarita Marcellini: Male, Signs, and the Everyday World of Pre-Modern Medicine,” American
Historical Review 106 (2001): 1141-58,
http://www.historycooperative.org/journals/ahr/106.4/ah0401001141.html (accessed June 9,
2009).
264
David Harley, “Political Post-mortems and Morbid Anatomy in Seventeenth-century
England,” Social History of Medicine 7, no. 1 (1994): 1-28.
265
Ibid.; see also Steven Shapin, A Social History of Truth (Chicago, IL: University of
Chicago Press, 1994). Of course, English perspectives on anatomy were quite different from
many other European societies of the early modern era. Martensen, The Brain Takes Shape, 98102; Park, “The Life of the Corpse,” 125-17. Nevertheless, while anatomy certainly occupied a
more public space outside of England (quite literally, as cities like Amsterdam, Bologna, and
Padua maintained “communally financed anatomical theaters”), there is little evidence that it was
an important part of everyday medical practice of the time. Martensen, The Brain Takes Shape,
100.
107
inner disease states. The convergence between the increasing emphasis on the
autonomous self and the investigating empirical Eye, Vesalius’s intolerance for
those anatomists who refused to actually dissect, and the importance of signs in
early modern medical thought and practice all highlight the emerging power of
the visible body prior to the nineteenth century.
Nevertheless, it was not until the nineteenth century that anatomy would
begin to take on a central role in defining medical practice.266 Resolving why the
link between anatomy and medical practice did not connect in earnest until the
nineteenth century is an intriguing and difficult question to answer. Some of it
likely is rooted in traditional reluctance to countenance or participate in
anatomical dissections.267 However, such trepidation lasted well into the
nineteenth century,268 and certainly after the sea changes Foucault documents in
medicine and science had taken firm root. Indeed, if current debates over the
ethics of displaying plastinated bodies are any indication,269 the anxiety that
accompanies the opening and displaying of dead bodies is extant. In any case,
266
In England, the Medical Act of 1858 required two years of study in human anatomy as
a prerequisite for a license to practice either medicine or surgery. Hurren, “Whose Body is it
Anyway.” This was in contrast to the general requirements earlier in the nineteenth century,
pursuant to which anatomical training was the basis of surgical but not necessarily medical
education. Ibid.
267
E.g., Ibid.; Buklijas, “Cultures of Death and Politics of Supply;” Alan William Bates,
“‘Indecent and Demoralising Representations’: Public Anatomy Museums in mid-Victorian
England,” Medical History 52, no. 1 (January 2008): 1-22; Vanessa McMahon, “Reading the
Body: Dissection and the ‘Murder’ of Sarah Stout, Hertfordshire, 1699,” Social History of
Medicine 19, no. 1 (2006): 19-35; and Russell C. Maulitz, Morbid Appearances: The Anatomy of
Pathology in the Early Nineteenth Century (Cambridge, UK: Cambridge University Press, 1987).
268
Hurren, “Whose Body is it Anyway;” Buklijas, “Cultures of Death and Politics of
Supply;” Bates, “Indecent and Demoralising Representations.”
269
Dirk Preuß, “Body Worlds: Looking Back and Looking Ahead,” Annals of Anatomy
190, no. 1 (February 28, 2008): 23-32; Lawrence Burns, “Gunther von Hagens’ BODY
WORLDS: Selling Beautiful Education,” American Journal of Bioethics 7, no. 4 (April 2007): 1223; and Y. Michael Barilan, “Bodyworlds and the Ethics of Using Human Remains: A Preliminary
Discussion,” Bioethics 20, no. 5 (September 2006): 233-247.
108
while there is no shortage of historiography on the question, resolving it is not my
project here. For my purposes, two points are most pertinent: first, the
significance of anatomy during the period prior to the nineteenth century reflects
the increasing importance of the visible in scientific and biomedical culture; and
second, in spite of its social and cultural significance, anatomy did not occupy a
central place in medicine and healing practices in the West prior to the nineteenth
century.
NINETEENTH CENTURY THEORIES OF DISEASE: FROM HORSE & BUGGY
MEDICINE TO THE BIRTH OF THE CLINIC
Humoralism & the Illness Sufferer’s Lifeworld
To understand the nineteenth century changes, and why anatomical
practice became constitutive of the clinical method that began to be
conceptualized in and around 1800, some common themes and practices of
modern and early modern physicians and healers do require examination. The
dominant conception of disease prior to the nineteenth century remained
fundamentally Galenic, and was rooted in a conception of the humors.270 The
basic idea of the theory posits that disease is the result of an imbalance in the four
humors: blood, phlegm, black bile, and yellow bile. Each humor is closely
associated with a season, an element, a particular climate, and a temperament.
The latter is significant because it meant that a person’s character, habits, and
270
Arikha, Passions & Tempers; Martensen, The Brain Takes Shape; Owsei Temkin,
“Greek Medicine as Science and Craft,” in Owsei Temkin, The Double Face of Janus and Other
Essays in the History of Medicine, (Baltimore, MD: Johns Hopkins University Press, 1973), 137153.
109
personality were in an important sense a product of their own humoral state.271
By the eighteenth and nineteenth centuries, a complex conception of disease had
formed in the West–both across Europe and in the United States–which linked the
humoral theory of disease to a notion often termed the ‘predisposing causes’
theory of disease.272
Roughly speaking, the ‘predisposing causes theory’ attributes disease to
the confluence of distal and proximal factors. The distal factors predispose the
body to a state which renders one susceptible to the influence of a proximal,
“exciting” (or “accelerating”) cause which then acted to produce disease. The
distinction between these different kinds of causal factors was itself understood
well before the early modern era, but became central to understanding health and
illness during the early modern era and into the nineteenth century. Under the
predisposing causes theory, the roster of potential causes of disease was immense.
Any number of predisposing conditions, including but not limited to the
individual patient’s personality, social class, family ties, constitution, drinking
habits, education, and occupation could interact with countless exciting causes
such as topography, proximity to water, filth, climate, atmospheric conditions,
and so-called fomites or animalcules (the vectors by which infectious diseases
were thought to spread) to cause disease.
For purposes of understanding the nineteenth century changes, the key is
that because so many different factors could combine in distinct permutations to
produce illness in any given patient, the physician could not treat the patient
271
Baszanger documents that “temperament” plays a role in some of the cognitive
behavioral techniques utilized in contemporary pain medicine practice. Baszanger, Inventing Pain
Medicine.
272
Hamlin, Public Health and Social Justice; and Hamlin, “Predisposing Causes.”
110
without significant investment in the patient’s social world. A focus on
predisposing conditions required the professional healer to delve deeply into that
world, because conditions specific to that patient might well be a significant
(predisposing) cause of disease.273 The illness sufferer’s constitution was widely
held to be a particularly important predisposing condition, such that “all aspects
of emotional and spiritual life were deemed relevant to the understanding of the
functions of the constitution.”274 As late as 1890, the influential American
neurologist James Leonard Corning averred that “nervous headache” resulted
from the “predisposing element” of the neurotic and impressionable constitutions
of the patients, or their ancestry,” combined with the exciting causes of “worry,
disappointment, and pecuniary losses.”275
The point is that many of these predisposing causes are fundamentally part
of the patient’s lived experiences. How could a physician understand what
predisposed their patient to develop, for example, neuralgic pain, without
engaging that patient’s subjective experiences, and without exploring the features
of that patient’s lifeworld?276 A physician could not. Because “each individual
had his own unique pattern of bodily events which the practitioner had to discern
in each case . . . [t]he practitioner was expected to adopt an active therapeutic role
. . . .”277
273
Hamlin, “Predisposing Causes.”
274
Jewson, “The Disappearance of the Sick Man,” 229.
275
James Leonard Corning, A Treatise on Headache and Neuralgia, Including Spinal
Irritation and A Disquisition on Normal and Morbid Sleep, 2d ed. (New York, NY: E.B. Treat,
1890), 40.
276
For a general discussion of the phenomenology of illness, see chapter 2.
277
Jewson, “The Disappearance of the Sick Man,” 229.
111
Furthermore, it is well-settled that adherents of the humoral conception of
disease tended to eschew the importance of localization in thinking about illness.
The “morbid forces [that caused disease] were located within the context of the
total body system rather than any particular organ or tissue.”278 As we will begin
to see in this chapter, the role that localization plays in constructing the meaning
of pain can hardly be overstated. Thus, it is crucial to understand that prior to the
nineteenth century, changes in understandings of illness and the body, the
prevailing medical cosmology promoted a holistic conception, one predicated on
humoral balance rather than on local pathologies. Martensen notes that “[i]n a
humoral schema, none of the solid tissues of the body were as important as the
body’s hollow spaces. These spaces contained the humors and humors had
physiologic agency.”279
Pain & the Humoral Theory
The humoral emphasis on the illness sufferer’s lifeworld, on a holistic
notion of the interplay between subject and illness, is also evident in humoral
understandings of pain. Smith’s analysis of several sets of eighteenth century
medical consultations confirms the general medical cosmologies attributed here to
a humoral schema. The language of pain in these letters “was extraordinarily
descriptive and personal. Humoralism fundamentally shaped sufferers’
experience of their bodies, as revealed by descriptions of internal sensations and
mind/body overlap.”280 Specifically,
278
Ibid.
279
Martensen, The Brain Takes Shape, 13.
280
Smith, “‘An Account of an Unaccountable Distemper,’”463.
112
[s]uffering had a flexible vocabulary, concurrently describing
physical and emotional pains in ways that underscore the anxiety
surrounding illness. This emphasizes the extent to which body and
mind were inseparable in the early eighteenth century; pain
involved one’s whole being, both body and soul. Patients and their
doctors often referred to emotional states as symptoms.281
Thus one early modern physician linked his clinical diagnosis “with the patient’s
perceptions, which appear plainly–‘sinking at the heart.’ While it was a physical
problem, the term also indicated an emotion when alongside symptoms like
‘heavy disposition’ and ‘dejection of spirit.’”282
Given the dialectic nature of history, one should not be surprised that this
early modern linkage of body and soul in context of pain has older roots. Esther
Cohen observes that “[a]ll major late medieval discourses on pain–in theology,
medicine, and law–viewed ‘physical’ pain as a function of the soul.”283 Erected
primarily on Augustinian foundations, which even the Thomism and
Aristotelianism of the Middle Ages could not “cancel . . . out,”284 pain was
inextricably linked with guilt and fear.285 Augustine explained the marytrs’ lack
of pain on this basis; they, like the Virgin Mary herself, did not suffer pain
because they were free of guilt and fear.286 “The message was clear: pain lay in
281
Ibid.
282
Ibid.
283
Esther Cohen, “The Animated Pain of the Body,” American Historical Review 105,
no. 1, http://www.historycooperative.org/journals/ahr/105.1/ah000036.html (accessed June 6,
2009), 5.
284
Ibid., 6.
285
Ibid.; and Mitchell B. Merback, The Thief, the Cross, and the Wheel: Pain and the
Spectacle of Punishment in Medieval and Renaissance Europe (Chicago, IL: University of
Chicago Press, 1999).
286
Cohen, “The Animated Pain,” 6.
113
the soul; it resulted from the soul’s sin and guilt, and its awareness of that guilt, of
the ensuing retribution, and of the fear thereof.”287
The key point in the humoral conception of pain in the West was the
fundamental enmeshment of ‘physical’ and ‘emotional’ pain, of mind, body, and
soul. Consistent with humoral medical cosmologies, the subjectivity of the
patient’s lived experiences were inseparable from illness and pain experiences.
However, this is not to suggest that the concept of pain in humoral schemes was
unproblematic. The connection between expressions of pain and truth challenged
persons and communities from the Middle Ages to the early modern period, and
the best evidence of these challenges is in the practice of torture.288 Cohen
observes that “for the physician, expressions of pain led to the truth of illness, and
for the theologian, to the truth of sin and salvation.” “Torture was thought to
work because of the close relationship between body and soul; the truth of the
soul could be forced out through physical pain.”289 In her 2001 monograph on the
relationship between pain, torture, and truth in early modern France, Lisa
Silverman explains that
[t]ruth is lodged in the matter of the body; judges were required to
draw it out (tirer) or extract it (arracher) from thebody, just as
287
Ibid., 6-7. The connections between guilt, fear, and pain are complex and significant.
The analysis required to unpack these connections would stray too far from my focus on the power
of the visible pathology as a prime source of the meaning of pain in the United States. However, I
am actively working on the topic and expect that my future work in pain will involve just such an
analysis.
288
Smith, “‘An Account of an Unaccountable Distemper,’” Silvia de Renzi, “Witnesses
of the Body: Medico-Legal Cases in Seventeenth-Century Rome,” Studies in History and
Philosophy of Science 33, no. 2 (June 2002): 219-42; Cohen, “The Animated Pain of the Body;”
Lisa Silverman, Tortured Subjects: Pain, Truth, and the Body in Early Modern France (Chicago,
IL: University of Chicago Press, 2001); Merback, The Thief, the Cross, and the Wheel.
289
Smith, “‘An Account of an Unaccountable Distemper,’” 467.
114
tears and teeth are drawn. Truth resides in the flesh itself and must
be torn out of that flesh piece by piece. It is a physical as much as
a metaphysical property . . . Because of its physical location, truth
must be discovered by physical means . . . Pain is . . . the vehicle of
truth-telling, a distillation of the pure substance lodged in the
impure flesh. Pain betrays the truth in the sense of exposing it to
view through the sounds and gestures it produces.290
Thus, while the interplay between pain, suffering, guilt, and truth are
complex and challenging, there is in humoral conception a unity between
‘physical’ pain and mental or emotional experiences (such as suffering, guilt, and
fear). This scheme is less accessible in contemporary times inasmuch as in the
latter, mind and body, physical pain (that is, pain resulting from visible, material
pathologies in the body) and mental or emotional experiences are deemed, if not
quite separate, then separable.291
But the importance of pathological anatomy to the practice of medicine
during the nineteenth century signals something of a sea change. Disease began
to be conceptualized in a different sense, and a novel medical cosmology
predicated on local, discrete entities as the cause of disease began to be not simply
studied, but practiced.292
The Birth of the Clinic
Foucault characterizes this change:
The appearance of the clinic as a historical fact must be identified
with the system of these reorganizations. This new structure is
290
Silverman, Tortured Subjects, 63.
291
As I aim to show in chapters 5 and 6, mind-body dualism is alive and well in shaping
the meaning of pain in American society, with deleterious consequences for the treatment of pain.
292
Jewson, “The Disappearance of the Sick Man.”
115
indicated–but not, of course, exhausted–by the minute but decisive
change, whereby the question: ‘What is the matter with you?’, with
which the eighteenth-century dialogue between doctor and patient
began (a dialogue possessing its own grammar and style), was
replaced by that other question: ‘Where does it hurt?’, in which we
recognize the operation of the clinic and the principle of its entire
discourse.”293
Foucault’s point is that the birth of the clinic, so to speak, is inextricably linked to
localizing discrete agents of disease to specific places, structures, and tissues
inside the body. Whereas prior to the nineteenth century, tissues were far less
important than the hollow channels through which humors flowed,294 this
conceptual geography was inverted during the nineteenth century. This inversion
both reflects and explains the centrality of pathological anatomy to the birth of
clinical method. Indeed, Martensen goes so far as to suggest that “Western
learned medicine’s most distinctive knowledge-making feature has been its
historic reliance on anatomy.”295 In a particularly revealing passage that traces
the historical pathways I am discussing here, Elizabeth Hurren notes the changing
conceptions of cadavers in the Oxford anatomy department of the late nineteenth
century:
When the department opened, every body taken for dissection was
named, and funeral expenses were recorded individually. After ten
years, during which the department expanded, the bodies were no
longer named but instead were numbered. Finally, once the
293
Foucault, The Birth of the Clinic, xvi.
294
The concept of flows itself was central to the humoral conception of illness. Rankin,
“Duchess, Heal Thyself,” 129-133; Arikha, Passions & Tempers; Martensen, The Brain Takes
Shape.
295
Martensen, The Brain Takes Shape, 95. The importance of this point to my overall
thesis regarding the power of the visible and its role in producing the undertreatment of pain can
hardly be overestimated. This is why the history of anatomy is critical to my overall project.
116
department was fully established, each pauper was simply recorded
as “material” or “subject.”296
Hurren concludes that “[a]t each stage in the development of Oxford’s cadaver
business, reductionist language evolved. In a literal sense, the poor had become
objects of material interest, rather than individual cases.”297 This is exactly the
development that is central both to Foucault’s narrative in The Birth of the Clinic,
and to my focus in this chapter.
But the importance of Foucault’s analysis extends well beyond a narrative
explication of the role of anatomy to clinical method, a point which numerous
commentators have addressed before and since Foucault’s analysis. Foucault is
interested in medical perception in the nascent anatomoclinical method. Anatomy
was so important to the birth of the clinic in large part because of what the
investigating, clinical Eye could see through such practice. And understanding
the power of this sight is deeply connected to the social and cultural power that
the visible bestowed upon the scientist and physician in nineteenth century U.S.
culture. As such, a crucial rhetorical device Foucault uses to explain the birth of
the clinic is what he refers to as the “clinical gaze”:
This is the period that marks the suzerainty of the gaze, since in the
same perceptual field, following the same continuities or the same
breaks, experience reads at a glance the visible lesions of the
organism and the coherence of pathological forms; the illness is
articulated exactly on the body, and its logical distribution is
carried out at once in terms of anatomical masses. The ‘glance’ has
simply to exercise its right of origin over truth.298
296
Hurren, “Whose Body is it Anyway,” 792.
297
Ibid., 792-93.
298
Foucault, The Birth of the Clinic, xviii.
117
His analysis and terminology here has inspired a voluminous literature crossing
disciplinary boundaries, from sociology to history to narrative studies to disability
studies, all seemingly connected by a collective interest in the significance and
meaning of clinical sight.
Foucault’s conception is not meant to be taken literally; the relevance of
physically seeing the illness sufferer could hardly be said to be a creation of the
nineteenth century. As I have addressed, semiotics was an important part of
medical practice even in the early medieval period,299 though it increased in
importance during the early modern era.300 But the clinical gaze itself did mark
something fundamentally distinct from the medical cosmologies that preceded it.
Examining the sick body for localized morphological and tissue pathologies and
attributing disease causality to such discrete phenomena was absolutely a novel
development in the nineteenth century, one that has and continues to have a
dramatic impact on the undertreatment of pain in the United States. As Ray
observes in context of pain,
[a]t the dawn of the nineteenth century, physicians were looking
for a pure sign which would remove the ambiguities inherent in
symptoms. They wished to find a sign, the meaning of which
would be as certain as that provided by the lesion found at
dissection.301
299
See, e.g., Faith Wallis, “Signs and Senses: Diagnosis and Prognosis in Early Medieval
Pulse and Urine Texts,” Social History of Medicine 13, no. 2 (2000): 265-278.
300
Rankin, “Duchess, Heal Thyself;” Smith, “‘An Account of an Unaccountable
Distemper’”; Stein, “The Meaning of Signs,” Martensen, The Brain Takes Shape; and Ruggiero,
“The Strange Death of Margarita Marcellini.”
301
Ray, The History of Pain, 99.
118
The social and cultural power of such a sign ought not be underestimated.
Its power is such that characterizing it requires resort to the language of metaphor,
as Foucault highlights:302
The residence of truth in the dark centre of things is linked,
paradoxically, to this sovereign power of the empirical gaze that
turns their darkness into light. All light has passed over into the
thin flame of the eye, which now flickers around solid objects and,
in so doing, establishes their place and form.303
Explicating further these nineteenth century changes in their own right is
not my project here, especially since this has been accomplished by numerous
capable commentators and in significantly more detail than I can provide here.
Rather, since I am trying to tell a story about pain, I now turn to an analysis of
how pain without lesion was conceived of among leading scientists and
physicians in mid-to-late nineteenth century America. The nineteenth century
changes in medical culture would have dramatic effects on the way pain was
conceptualized, effects which illuminate in important ways the contemporary
meaning of pain in American society in general, and in American biomedical
culture in particular.
302
In his explication of the role of the anatomy of the brain in early modern discourse,
Martensen emphasizes the spiritual and religious aspects of the project for many of these
anatomists (Thomas Willis in particular), and documents the pervasive use of religious metaphor
and allegory in early modern anatomical discourse. Martensen, The Brain Takes Shape. In
addition, the connection between the power bestowed through nascent nineteenth century medical
and scientific cosmologies and the need for metaphor is particularly clear in the discourse of the
American roentgenologists. Herzig, “American Roentgenology.”
303
Foucault, The Birth of the Clinic, xii.
119
THE CLINICAL GAZE & PAIN WITHOUT LESION IN NINETEENTH CENTURY
AMERICA
David Morris, one of the few scholars to assess pain from the vantage
point of cultural studies, picks up the Foucauldian interpretation of the birth of the
clinic in a 1998 essay published in the Clinical Journal of Pain. The placement of
the article is itself noteworthy, as one might not ordinarily expect a social and
cultural analysis of pain to end up in the pages of a journal devoted to clinical
pain. However, Morris’s 1991 book on pain (aptly entitled The Culture of Pain)
remains quite influential in pain studies. Accordingly, Morris was invited to
present the paper that formed the basis of the publication at the March 13, 1998
symposium that was held to celebrate the opening of the John C. Liebeskind
History of Pain Collection at the University of California Los Angeles.304
Referencing the changes Foucault documents, Morris expressly connects
them to pain in context of
[a] revolutionary readjustment in the realms of the visible and the
invisible. In effect, while a new clinically based scientific medical
perception begins to make pain increasingly visible inside the
body, pain outside the nervous system and outside the clinic begins
to seem correspondingly invisible.305
The power of the visible, then, in connection with the focus on tissue pathologies
and structural lesions that was constitutive of the nascent clinical method meant
304
The collection remains one of the most important in the United States, if not the
world, largely but not exclusively for its archives related to the founding and organization of pain
medicine in the United States.
305
Morris, “An Invisible History of Pain,” 193.
120
that pain that was not visible inside the body began to vanish from sight, literally
and figuratively. Continuing to apply Foucault, Morris argues that
[t]he new nineteenth-century question–still the opening gambit in
much modern medicine–replaces an open-ended invitation to
speech with a request for specific visual information. It also
focuses the clinical dialogue on pain. Pain moreover–and here is
the crucial change for our purposes–becomes newly visible and
objectified. The physician does not see the pain directly, of course,
but the clinical gaze penetrates deep within the body to expose
pain’s hidden sources and processes. The lesion–illuminated,
mapped, and verified–increasingly comes to represent pain as it is
made newly visible to the gaze of the physician. As a corollary,
what the gaze of the clinic cannot see, cannot verify, and cannot
transform into an objectified visible image of pain becomes, so to
speak, invisible.306
These are provocative claims, made without reference to or analysis of
primary sources. They have provoked fairly strong reactions among several pain
scholars. In her 2006 dissertation on pain, objectivity, and pain-measuring
techniques in the United States, Noémi Tousignant charges that Morris has
“caricatured the modern medically-dominated view of pain,” “exaggerated the
medicalisation of pain,” “overestimated the power exercised by the medical
establishment over the definition and the management of pain,” and
“oversimplified the medical view of pain.”307 Psychiatrist Andrew Hodgkiss
devotes an entire monograph to the repudiation of Morris’s claims regarding
visible and invisible pain.308
306
Ibid.
307
Tousignant, “Pain and the Pursuit Objectivity,” 53.
308
Hodgkiss, From Lesion to Metaphor.
121
Of course, as we shall see in chapter 5, Morris is hardly alone in claiming
that the roots of our problems in treating pain are related to the objectifying
tendencies of the anatomoclinical method. As many pain scholars agree that pain
is the quintessential subjective phenomenon, it seems plausible to contend that a
method predicated on objectification of visible pathologies could present its
adherents with problems in assessing an illness experience premised on the lack
of any such pathologies.309 In any case, one way of examining the merits of
Morris’s claims is to examine some primary sources in the mid-to-late nineteenth
century. Hodgkiss does just this in his 2000 monograph on lesionless pain,
though he does so by assessing largely British and French sources (and virtually
no American sources).310 This chapter fills a niche in the literature by examining
the writings of leading late nineteenth century American healers and scientists
regarding the phenomena of pain without lesion. I make no claims that these
sources subsume the entirety, or even a significant portion of, the beliefs and
practices of average American medical practitioners regarding such pain, nor of
the attitudes and beliefs of laypeople regarding pain without lesion. Nevertheless,
there is much that examining the views of leading lights in medicine and in
nascent specialties like neurology can illustrate in terms of Morris’s claims
regarding invisible pain.
Before examining some of the primary sources, some words about
terminology and scope are needed. As to the former, Charles Rosenberg’s
admonition that illness was, for much of the nineteenth century, not
309
Exploring this argument is the primary aim of chapter 5.
310
I will address Hodgkiss’s claims in detail below.
122
conceptualized in terms of discrete entities is important.311 Though Foucault’s
point is that clinical method was moving to just such a nosology, disease entities
themselves remained fluid and ambiguous for much of the nineteenth century.
Indeed, Baszanger explains that the distinction between acute and chronic pain
was not utilized in clinical practice in the United States until the 1960s at the
earliest.312 Thus, in looking for primary sources on pain in the nineteenth century,
a search only for “pain” or “chronic pain” is likely to miss many important
treatises, articles, practice guides, and related materiel. Hodgkiss recommends
searching for sources referencing terms including “hypochondria, hysteria,
neurosis, neuralgia, spinal irritation, rheumatism, headache, spine, backache,
abdominal pain, and dysmenorrhea.”313 While time and space preclude
examination of all of these different terms, several of them are particularly
important in thinking about chronic pain in contemporary American society:
neuralgia, spinal irritation, headache, and hysteria. The first three are significant
because of the interplay of the concepts of “lesion” and “localization” in context
of pain, issues that remain significant today.314 The fourth term, “hysteria,” is
most important because of its gendered nature.
The discussion about terminology suggests an important point about
scope: even a cursory examination of attitudes towards pain in the nineteenth
311
Charles E. Rosenberg, “The Therapeutic Revolution: Medicine, Meaning and Social
Change in Nineteenth Century America,” Perspectives in Biology and Medicine 20, no. 4
(Summer 1977): 485-506; and Charles E. Rosenberg, The Cholera Years, 2d ed. (Chicago, IL:
University of Chicago Press, 1987).
312
Baszanger, Inventing Pain Medicine, 19-62.
313
Hodgkiss, From Lesion to Metaphor, 20. Here it is important to note the gendered
nature of many of these terms.
314
E.g., Harold Merskey, “Clarifying the Definition of Neuropathic Pain,” Pain 96, no. 3
(April 2002): 408-09.
123
century U.S. suggests that pain then, as now, is dynamic, ambiguous, and
multivalent. Accordingly, nowhere will I claim that nineteenth century attitudes,
practices, and beliefs towards pain that defy obvious ascription of pathogenesis
entirely capture the meaning of pain in mid-to-late nineteenth century American
society (nor in any particular region or community therein). For different reasons
and in different ways, the meaning of pain in mid-to-late nineteenth century
American society was every bit as layered and as rich as it is today. What follows
here is an attempt to explicate a small slice of these attitudes and beliefs that carry
significant implications for the current construction of the meaning of pain.315
Understanding late nineteenth century views on pain without lesion is
difficult without at least mentioning the relevance of vitalism in conceptualizing
the inner body. Akin to anatomy, the roots of vitalism in Western medicine and
science extend far back, and are certainly present in many of the seminal early
modern texts on anatomy and physiology. Much of Willis’s Cerebri anatome is
devoted to assessing how neural structures produce the flow of animal spirits that
sustains life, and Vesalius also notes the importance of such flows. Of course, the
notion of flows and animal spirits as productive of life itself is of ancient origin,
and extends back to the Greek notion of pneuma (or breath), which, in
Hippocratic tradition, was conveyed via the brain to the heart for transmission
through the (humoral) body.316
315
As numerous scholars have noted, allopathic practitioners in the United States
competed with numerous other kinds of healers including herbalists, homeopaths, and druggists
(to name but a few) in the nineteenth century. Rosenberg, Explaining Epidemics; and Paul Starr,
The Social Transformation of American Medicine (New York, NY: Basic Books, 1982). I
examine allopathic physicians exclusively because of limitations in time and space, but also
because it is the allopaths’ views that, I submit, have the largest influence in shaping
contemporary perspectives about pain, particularly within biomedical discourse.
316
Martensen, The Brain Takes Shape, 75-90.
124
The discovery of electricity in the eighteenth century had a profound
effect on vitalist thought, and many nineteenth century healers and scientists
discussed the potential and capacity of galvanism or faradism (the application of
electric current) to treat various kinds of pain.317 Within the traditions of
anatomy, vitalism, and galvanism, one can triangulate the work of the German
physiologist Johannes Müller, whose work was critical to the conceptualization of
pain during the nineteenth century. His discovery of the specialization of nerve
fibers (with concomitant electrochemical conduction of signals) is an important
scientific development in its own right, but for my purposes, is crucial because it
facilitated the development of the specificity theory with regard to pain.318
The specificity theory is not simply one theory, but is rather a general
cosmology for conceptualizing the physiology of the nervous system. In its most
basic form, the idea is that nerve fibers are specialized to respond to specific
stimuli and convey particular sensations related to the stimulus. This means that
the application of stimuli of cold, heat, and pain result in the activation of certain
nerve fibers, but not others.319 Citing Magendie, whose work was instrumental in
advancing the specificity theory, John Call Dalton observed that
it is evident that the impressions of sensibility pass to the nervous
centres exclusively by the posterior roots [of the spinal nerves],
while the stimulus which excites the muscles to contraction is
conveyed only by the anterior roots. We therefore have a separate
localization of sensation and motion in this part of the nervous
317
See Silas Weir Mitchell, Injuries of Nerves and their Consequences (Philadelphia, PA:
J.P. Lippincott & Co., 1872); Wilhelm Heinrich Erb, Handbook of Electro-Therapeutics New
York, NY: William Wood & Company, 1883); and Corning, A Treatise on Headache and
Neuralgia, 2d ed.
318
Ray, The History of Pain.
319
Ibid.
125
system; and it is easy accordingly to understand how one may be
impaired without injury to the other . . . .320
Similarly, in an early treatise on “spinal irritation,” which, as we shall see,
was a topic of great interest to leading American physicians and neurologists in
the late nineteenth century, Philadelphia physician Isaac Parrish begins by citing
the efforts of several notable European scientists working on nerve physiology in
clarifying the pathways through which the pain of spinal irritation proceeds.
Lauding Bichat,321 Bell, and Magendie, he notes that “[t]hese authors have taught
us to consider the nervous system not as homogeneous tissue, possessing an
identity of structure and function . . . but as composed of separate parts, differing
essentially from each other, both in their functional actions, and anatomical
character.”322 Decades after Parrish’s writing, the links between electricity,
lesion, and localization had become entrenched; H. Lewis Jones reports in the
July 1899 issue of The Practitioner that “[t]he crispness with which the
localisation of the nerve lesion is brought out by the electrical test is full of
charm.”323 Corning’s 1890 treatise on neuralgic pain contains two chapters on the
use of electricity in localizing and treating pain, and his 1894 treatise on headache
evidences a similar treatment.
320
John Call Dalton, A Treatise on Human Physiology (Philadelphia, PA: Henry C. Lea,
1871), 414.
321
On Bichat, Foucault notes that “Bichat is strictly an analyst: the reduction of organic
volume to tissular space is probably, of all the applications of analysis, the nearest to the
mathematical model yet devised. Bichat’s eye is a clinician’s eye, because he gives an absolute
epistemological privilege to the surface gaze.” Foucault, The Birth of the Clinic, 124. For
detailed analysis of Bichat’s role in the history of pathological anatomy, see Maulitz, Morbid
Appearances.
322
Isaac Parrish, “Remarks on Spinal Irritation as Connected with Nervous Diseases;
With Cases,” American Journal of Medical Sciences 10, no. 20 (1832): 294.
323
H. Lewis Jones, “Notes from the Electrical Department, St. Bartholomew's Hospital,”
The Practitioner 10 (July 1899): 258.
126
For my purposes, the single most important facet of the specificity theory
is what it implied about pain: that it was generally localizable. Thus in describing
neuralgia, which Corning defined as pain due to “extra-cranial causes,” he notes
the appearance of “painful spots” which are “present in the majority of cases of
neuralgia,” and about which “careful digital exploration will rarely fail to result in
their accurate localization.”324
THE SIGNIFICANCE OF LOCALIZATION FOR PAIN AMONG LATE NINETEENTH
CENTURY AMERICAN PHYSICIANS
It is crucial at the outset to clarify the meaning of “localization” in late
nineteenth century discourse on neurology and pain. Specifically, the concept of
localization does not function as a measure of spatial proximity. That is, in late
nineteenth century parlance, the term generally does not refer to the notion that an
impression or sensation is caused by a nerve that necessarily exists proximal to
the area in which the sensation is experienced. Rather, as we shall see, what is
usually connoted by the term “localization” is the idea, quite foreign to humoral
theory, and quite novel in the nineteenth century, that the material pathology
causing the impression is localizable to a discrete, specific point or area within the
relevant internal structure.
Timo Kaitaro’s analysis on the genesis of models of localization in
nineteenth century neuroscience supports this understanding, as he traces one of
the earliest examples to a paper authored by Bouillard in 1825, the title of which
is translated as “Clinical studies demonstrating that the loss of speech corresponds
324
James Leonard Corning, A Treatise on Hysteria and Epilepsy, with Some Concluding
Observations on Insomnia (Detroit, MI: George S. Davis, 1888), 64.
127
to a lesion in the anterior lobules of the brain and to confirm the opinion of Mr.
Gall on the seat of articulated language.”325 Localization here functions as a
referent for the specific area of the brain in which a lesion produces the observed
sign. The lesion is not local, but is localizable to the “anterior lobules.” Kaitaro
suggests that even “different words could have separate localizations in the
cortex” under Bouillard’s rubric. 326
A half-century after Bouillard, whose reputation suffered due to his
defense of Gall and the associated taint of phrenology, Broca and Wernicke’s
investigations provided further proof of the merits of cerebral localization. Noga
Arikha uses the term “locationism” to describe their attempts to correlate discrete
material pathology with an observed sign.327 This term further supports the idea
that the term “localization” in late nineteenth century texts on pain refers not to
the proximity of the material pathology, but rather to the fact that such a
pathology exists at a discrete location inside the body. Similarly, the fact that
physicians of the time were well aware that gross cerebral lesions were more than
capable of producing certain kinds of pain328 is consistent with this concept of
localization. The attribution of pain to cerebral lesions is an obvious causal
conceptualization of pain in reference to a specific tissue pathology.
325
Timo Kaitaro, “Biological and Epistemological Models of Localization in the
Nineteenth Century: From Gall to Charcot,” Journal of the History of Neuroscience 10, no. 3
(December 2001): 263.
326
Ibid., 266.
327
Arikha, Passions & Tempers, 261.
328
E.g., James Leonard Corning, A Treatise on Headache and Neuralgia, Including
Spinal Irritation and A Disquisition on Normal and Morbid Sleep, 3d ed. (New York, NY: E.B.
Treat, 1894); William R. Gowers, Neuralgia: Its Etiology, Diagnosis, and Treatment (New York,
NY: William Wood & Co., 1890); James Grant Gilchrist, Surgical Emergencies and Accidents
(Chicago, IL: Duncan Brothers, 1884); and William A. Hammond, On Certain Conditions of
Nervous Derangement (New York, NY: G.P. Putnam’s Sons, 1881).
128
This is why Foucault’s characterization of clinical medicine centers on
medical perception: What did the clinical Eye perceive? What did it see? What
did it project as causing illness?
The medical gaze must therefore travel along a path that had not so
far been opened to it: vertically from the symptomatic surface to
the tissual surface; in depth, plunging from the manifest to the
hidden; and in both directions, as it must continuously travel if one
wishes to define, from one end to the other, the network of
essential necessities.329
There is good reason to believe that causal attributions of disease are
significant as a window into contemporaneous social, cultural, and political
beliefs.330 That nineteenth century physicians seemed to attribute many kinds of
pain to disturbances in relevant tissues, whether “irritation” of the nerves as in
spinal irritation and neuralgia,331 or to cerebral lesions, as in some forms of
headache,332 is important for what it indicates regarding the role of clinical sight
regarding pain.
329
Foucault, The Birth of the Clinic, 133.
330
See Ulla Räisänen, Marie-Jet Bekkers, Paula Boddington, Srikant Sarangi, and Angus
Clarke, “The Causation of Disease–The Practical and Ethical Consequences of Competing
Explanations,” Medicine, Health Care, and Philosophy 9, no. 3 (December 2006): 293-306; Sylvia
N. Tesh, “Miasma and ‘Social Factors’ in Disease Causality: Lessons from the Nineteenth
Century,” Journal of Health Politics, Policy and Law 20, no. 4 (Winter 1995): 1001-1024;
Hamlin, “Predisposing Causes”; and Sylvia N. Tesh, Hidden Arguments: Political Ideology and
Disease Prevention Policy (New Brunswick, NJ: Rutgers University Press, 1988).
331
Corning, A Treatise on Headache and Neuralgia, 3d ed.; and William A. Hammond,
Spinal Irritation (Detroit, MI: George S. Davis, 1886).
332
Corning, A Treatise on Headache and Neuralgia, 3d ed.
129
LATE NINETEENTH CENTURY AMERICAN PHYSICIANS & PAIN WITHOUT LESION
Given the significance of pathological anatomy to nineteenth century
medical thought, it is unsurprising that nineteenth century neurologists, akin to
their contemporary descendants, found pain resultant to gross lesion easy to
diagnose (though not necessarily easy to treat).333 This is at least in part because
gross cerebral lesions tended to produce a number of other symptoms that
contributed to the differential diagnosis, including “progressive loss of muscular
power, vertigo, visual impairment and derangement of the faculty of
recollection.”334
But what of pain that tended to occur in the absence of lesions
discoverable at post-mortem? Corning observes in two of his texts that “[o]rganic
disease is by no means as frequent a cause of headache as might be imagined
from the percentage of gross cerebral lesions.”335 How did leading nineteenth
century physicians conceive of pain without lesion?
If one understands the term “lesion” in an expansive sense, as more than
the gross cerebral lesions that physicians had long known of in cases of syphilis,
for example, then the best answer is that leading physicians did not conceive of it
at all. This is certainly not to suggest that nineteenth century American
physicians were ignorant of chronic pain without lesion, nor that they trivialized
333
Ibid.; Mary Putnam Jacobi, Essays on Hysteria, Brain Tumor, and Some Other Cases
of Nervous Disease (New York, NY: G.P. Putnam’s Sons, 1888); and David Ferrier, The
Localisation of Cerebral Disease: Being the Gulstonian Lectures of the Royal College of
Physicians for 1878 (New York, NY: G.P. Putnam’s Sons, 1879). For a recent biography of
Jacobi with an emphasis on her role in the discourse regarding the propriety of women physicians,
see Carla Bittel, Mary Putnam Jacobi and the Politics of Medicine in Nineteenth-Century America
(Chapel Hill, NC: University of North Carolina Press, 2009).
334
Corning, A Treatise on Headache and Neuralgia, 2d ed., 52.
335
Ibid., 53; Corning, A Treatise on Headache, 3d ed., 85.
130
such pain.336
However, the claim David Morris advances is that pain without
lesion becomes invisible during the nineteenth century. At least some leading
nineteenth century physicians and neurologists suggested that even pain which
seemed to appear in the absence of any lesions must nevertheless feature such
lesions. As an object of inquiry, then, pain without somatic phenomena, without
pathology in some kind of tissue, ceases to exist in the clinical gaze.
One of the best sources for locating this view is William Hammond’s 1886
treatise on spinal irritation. Hammond is one of the progenitors of American
neurology and the founder of the American Neurology Association.337 His views
on pain without lesion are therefore particularly important.338 As Meldrum and
Hodgkiss make clear, nineteenth century physicians were quite aware of the
existence of pain that seemed to persist in the absence of any identifiable lesion;
Hammond has no patience for those who reject the existence of the disease known
as “spinal irritation”:
it must be admitted that there are not wanting those who refuse to
believe in the existence of such a disorder. Such persons must
necessarily belong to one or the other of the following categories:
Their experience must have been very limited, and therefore they
336
Meldrum, “A Capsule History of Pain Management;” Hodgkiss, From Lesion to
Metaphor.
337
As an Army Surgeon during the Civil War, Hammond was also a crucial part of the
efforts at sanitarian reforms during the War that played an instrumental part in the many public
health reforms that followed the War. Bonnie Ellen Blustein, Preserve Your Love for Science:
Life of William A. Hammond, American Neurologist (Cambridge, UK: Cambridge University
Press, 2002); William A. Hammond, A Treatise on Hygiene with Special Reference to the Military
Service (Philadelphia, PA: J.B. Lippincott & Co., 1863) For his efforts, Hammond was courtmartialed, though Congress exonerated him in 1878. Blustein, Preserve Your Love for Science.
338
Again, this is not to assert that Hammond’s views are necessarily representative of all
or most physicians and neurologists of the time on pain without lesion. But the importance of
Hammond’s views flow from his status and his influence, not from any erroneous attribution of
those views to other academics or practitioners.
131
cannot see; or they must have been endowed either with restricted
powers of observation or with minds so constituted as to cause
them wilfully to close their eyes to the facts that they did not care
to see.339
Hammond’s rhetoric is significant here, as it is the power of clinical sight that
demonstrates the worthlessness of those views denying the existence of spinal
irritation. However, the fact that Hammond undoubtedly believes in the existence
of spinal irritation does not imply that he countenances the existence of pain
without any material pathology.
According to Hammond, the general cause of spinal irritation is anemia of
the spinal cord, which in late nineteenth century terminology generally translated
as “weakness” of some sort.340 However, in spite of his acknowledgment that
anatomical work revealed no gross lesions or pathologies that would account for
the pain of spinal irritation, Hammond did not hesitate to localize the causes of
such pain to lesions in various regions of the spinal cord:
The spinal cord is a long organ, and while one part may be the seat
of anemia of the posterior columns, the others may be
comparatively healthy. It will be shown, however, that the
differences in the symptoms as manifested in the various cases
which come under notice, are in the main such as result from the
fact that different sections of the posterior columns of the cord are
the seats of the lesion.341
This excerpt also demonstrates the work that the concept of localization performs
in Hammond’s medical cosmology; the issue is not whether the material
339
Hammond, Spinal Irritation, 19.
340
See Ralph Harrington, “On the Tracks of Trauma: Railway Spine Reconsidered,”
Social History of Medicine 16, no. 2 (2003): 209-223.
341
Hammond, Spinal Irritation, 29.
132
pathology exists, but is simply where the lesion can be localized. Later in the
treatise, Hammond explains why he conceptualizes the causality of spinal
irritation in terms of lesions that pathological anatomy does not reveal:
Owing to the fact that spinal irritation is not per se a fatal disease,
we rarely have the opportunity to verify any views we may hold in
regard to its pathology. In the few cases in which post-mortem
examinations were made nothing abnormal was found, a
circumstance, however, far more compatible with the idea I have
expressed than with any other.
In all cases in which the patho-anatomy of a disease cannot be
positively ascertained, we are warranted in constructing a
hypothesis of its real nature from such data as is at our command.
It is better to do this, even if the view we enunciate is not
absolutely sufficient to account for all the observed phenomena,
than to shut up our opinions in our own minds, or, worse still, form
none whatever.342
The chain of reasoning here is significant. Hammond begins by noting
that because spinal irritation is not fatal, the power of the clinical gaze to correlate
the process of disease with tissue pathologies is frustrated. This itself underscores
the connection between pathological anatomy and clinical method that Foucault
and Martensen emphasize. Hammond moves on to admit that anatomical practice
has failed to reveal any obvious pathologies that might be attributed as the cause
of the disease. However, not just in this case, but in “all cases” in which
correlation of disease and pathological anatomy is unavailing, it is appropriate to
construct a hypothesis of the “real nature” of the disease.343 Although Hammond
342
Ibid., 53.
343
Martensen charts a link between Willis’s adoption of Harvey’s term “medical
anatomy” in the seventeenth century, to “morbid anatomy” in the eighteenth century, to
“pathological anatomy” in the nineteenth century, and to “clinical correlation” in the twentieth
133
does not expressly say so in the quoted passage, there is little doubt that the “real
nature” of spinal irritation is a reference to the specific lesion to which he
attributes causation. In fact, Hammond notes that some do not accept his general
theory of anemia in the spinal cord as the general cause, to which he responds by
defending the general notion of pathological localization:
And what is true of the spinal cord is true of other organs of the
body. There is not one which may not be the seat of a morbid
process in some exceedingly limited part, while the remainder of
its tissue presents no evidence of disease. Indeed, the reverse is the
exceptional condition.344
As such, it is assuredly not the case that the general failure to locate the lesion that
causes spinal irritation at post-mortem indicates the general unlikelihood of
finding any such lesion at all. On the contrary, given the localization of lesions, it
is all the more likely that the seat of disease exists at some specific region in the
spinal cord or central nervous system.
Thus, Hammond’s argument by analogy is that the seat of spinal irritation
is localizable in a lesion that exists somewhere in the spinal cord, but whose
precise location and character has not yet been ascertained. Hammond confirms
this:
From all these points it appears to me that the pathology of spinal
irritation is as clearly made out as that of any other disease in
which we do not have the opportunity of making post-mortem
century. Martensen, The Brain Takes Shape, 80. It is instructive to consider Hammond’s views
on clinical correlation from the vantage point of a late nineteenth century neurologist, whose
training, expertise, and experience all revolved around the sense in which pathological anatomy
largely defined clinical correlation.
344
Hammond, Spinal Irritation, 57.
134
examinations, or in which, having such opportunities, the lesion
remains undiscovered.345
The power of the role of lesion, of tissue pathology in the construction of
pain is such that the possibility that pain might exist without a lesion is not
tenable for Hammond. This does not mean that Hammond denies the existence of
spinal irritation; it does mean that he denies the existence of a disease entity
named “spinal irritation” without a concomitant tissue pathology of some sort.
Hammond even extends the analogical nature of his argument to anatomy, noting
that
[u]pon the principle of exclusion we are justified in assuming the
patho-anatomical feature to be anemia. There is no other known
condition which could give rise to the phenomena. The symptoms
of other affections of the spinal cord are well known, and are for
the most part exceedingly definite in their indications. The
alterations in the nerve structure, to which they are due, are easily
detectable after death, and hence groups of symptoms are readily
associated with well-known lesions.346
The possibility that no pathological anatomy might correlate with the pain
produced by spinal irritation is not manifest in Hammond’s medical cosmology.
There is accordingly no such clinical entity as pain from spinal irritation that
cannot be located in a tissue pathology. While, again, it does not follow from this
that Hammond or other nineteenth century physicians denied the existence of the
pain stemming from spinal irritation, the fact that even pain without apparent
lesion was assumed to be the product of a lesion is the key point for my purposes.
Moreover, Hammond’s preferred remedies follow the principle of localization as
345
Ibid., 67-68.
346
Ibid., 58-59.
135
well; he lauds the efficacy “of counter-irritants to the skin over the affected region
of the cord.”347 Similarly, Parrish notes (decades earlier) in his 1832 discussion
of spinal irritation that “many chronic nervous disorders have a local and
determinate seat in some portion of the spinal marrow or great sympathetic
ganglia, and hence that these obstinate diseases are most effectually treated by
applications directed to spinal column.”348
As Bonnie Ellen Blustein points out, however, Hammond was a
particularly committed reductionist as to the role material structure played in
defining illness.349 Thus, if Hammond’s views on pain without lesion are
isolated, the strength of my claim related to the general power of the visible
pathology in late nineteenth century American medical discourse on pain
diminishes.
Fortunately, Hammond’s account of pain without lesion–that it in fact is
pain with (undiscovered) lesion–is typical, and appears throughout nineteenth
century American texts on pain.350 In his 1854 dissertation on neuralgia (for
which he was awarded the Fiske Fund Prize Essay by the Rhode Island Medical
Society), Brown University physician Charles Parsons notes that “[n]euralgia may
have its origin in the nervous centers.”351 He declines to specify “all the
347
Ibid., 61.
348
Parrish, “Remarks on Spinal Irritation as Connected with Nervous Diseases,” 26.
349
Blustein, Preserve Your Love for Science.
350
Moreover, though time and space prevent an exposition of European sources, the
discussion below of Hodgkiss’s work will highlight similar features of many of the British and
Continental texts Hodgkiss reviews.
351
Charles Parsons, “Neuralgia: Its History, Nature and Treatment,” American Journal of
Medical Sciences 28, no. 55 (July 1854): 424.
136
affections of the brain or spinal cord” that may cause neuralgia,352 but observes
among the many potential causes of neuralgia several familiar possibilities. These
include disorder within both anterior and posterior branches of spinal nerves,
disorder in an internal organ, cerebral “congestion,” and anemia.353 All of these,
of course, represent pathology within a material structure or tissue which
produces pain.
Similarly, Edward Payson Hurd begins his 1890 treatise on neuralgia by
setting forth that the “cause [of pain] is generally an abnormal modification of
some part of a nerve of sensation.”354 Hurd identifies as exciting causes the usual
suspects, including inflammation, anemia, and tumors or other “foreign bodies”
that compress the nerve.355 Note that Hurd, like many American physicians and
scientists to consider the problem of pain without lesion, freely admits that “[w]e
know very little about the material alterations which attend neuralgia.”356 As with
Hammond, however, this does not prevent Hurd from attributing as a cause for
“neuralgic hyperasthesia,” or excessive and painful sensitivity, “[i]ntrinsic and
primary modifications of the excitability of the nerve itself in some part of its tract
from the gray nucleus of its origin to its terminal expansions.”357 In other words,
the material modification must exist somewhere along the nerve fiber itself, even
352
Ibid.
353
Ibid., 417-446.
354
Edward Payson Hurd, A Treatise on Neuralgia (Detroit, MI: George S. Davis, 1890),
355
Ibid.
356
Ibid., 7.
357
Ibid., 12.
1.
137
if the contemporaraneous state of the art does not permit specification of the
precise pathology.
As does Hurd in his analysis, Gowers’ 1890 treatise on neuralgia begins
by excluding from the ambit of neuralgia the ‘easy cases’ “in which a primary
lesion of a nerve trunk causes local and limited pain.”358 Gowers frames the
question: “The problem of pathology is, What is the nature of nerve pain that has
no known organic cause?”359 Yet, among myriad possible exciting causes
(including “impairment of general health,” “exposure to cold,” and “toxic
influences”), Gowers observes that “irritation of nerves” is “another frequent
cause, especially near their peripheral distribution.”360 Gowers is well-aware that
neuralgic pain “often extends far beyond the area of the irritated nerve,”361 but
this awareness is another example of the importance of localizing the cause of
chronic pain to a particular tissue pathology, even if that pathology is
geographically located in an area of the body remote to where the sufferer
experiences pain.362
Accordingly, Gowers initially observes that the “spontaneous pain”
characteristic of some forms of neuralgia “corresponds to certain peripheral nerve
areas, and we must therefore look for its cause to the elements constituting a
peripheral nerve structure.”363 However, after noting the absence of any obvious
358
William R. Gowers, Neuralgia: Its Etiology, Diagnosis, and Treatment (New York,
NY: William Wood & Co., 1890), 4.
359
Ibid., 11.
360
Ibid., 6.
361
Ibid.
362
This example also demonstrates (again) the error of interpreting “localization” in late
nineteenth century medical discourse as a measure of spatial proximity.
363
Ibid., 11.
138
pathologies in the nerve structure that would account for the pain, Gowers
concludes that “[w]e are thus reduced, by exclusion, to the central terminations of
the nerve fibers as the source of pain in iodiopathic [sic] neuralgia.”364 The
apparent contradiction between Gowers’s insistence that pain secondary to
organic lesions is not neuralgia and his subsequent pronouncement that
spontaneous neuralgic pain is caused by pathologies in the nerve fibers is easily
resolved by the understanding that “organic lesion” and “tissue pathology” are not
interchangeable concepts in nineteenth century neurological thought. That is,
Gowers’s acknowledgement that neuralgia is pain without lesion only refers to the
possibility of gross cerebral and organic lesions; like Hammond, Gowers does not
seem to account for the possibility that pain could exist without some kind of
disturbance, deformity, or alteration in some (nervous) tissue.365
Further evidence for this assessment is the fact that Gowers apparently
cannot resist making an argument by analogy to gross cerebral lesions (just as
Hammond does), despite his declaration that pain resultant to such lesions is not
properly considered neuralgia:
The same conclusion (the central nature of neuralgia) is also
indirectly corroborated by facts of pathology of another kind which
prove that pain of neuralgic character may be produced by an
organic lesion in the gray matters which is supposed to be
deranged in idiopathic neuralgia. A lesion, for instance, involving
364
Ibid., 12.
365
Similarly, Corning refers to the irritation of the nerve that causes neuralgia as the
“primary lesion” even though it is clear in context that the concept of lesion he references as to
neuralgia is not equivalent to the gross cerebral lesions he notes in cases of syphilis. Corning, A
Treatise on Headache and Neurlgia, 3d ed. Moreover, Corning treats headache resultant to
syphilis and other gross lesions in a separate chapter from his discussion of neuralgia, which is
further evidence that the concept of “lesion” is a dynamic one capable of referring to different
kinds of pathology. Ibid.
139
part of the sensory nucleus of the fifth nerve, caused severe
neuralgic pain in the face.366
As with Hammond’s argument by analogy, the rhetorical choice here is as
important as the substantive point. The persuasiveness of this analogy is a
function of the merits of the connection between gross lesion and pain. Even
while such a connection is not neuralgia under Gowers’s definition, inasmuch as
the causation of neuralgic pain can be analogized to a gross lesion that causes
severe facial pain, Gowers buttresses his assessment of the etiology of neuralgia.
The example of gross lesion is rhetorically effective precisely because it is visible
to the clinical gaze. Accordingly, the analogy Gowers draws underscores the
importance of attributing even pain “without lesion” to pathologies in some kind
of material structure or tissue within the body.
As I have tried to suggest, late nineteenth century physicians were acutely
aware of the difficulties presented by pain without lesion. Thus, in the Preface to
his 1880 treatise On Common Forms of Functional Nervous Diseases, Leopold
Putzel, a physician at Bellevue Hospital in New York City, observes that
“[p]athological anatomy has exercised such an enormous influence upon the
advances made in practical medicine within the last twenty-five years that many
pathologists sneer at the term “functional” diseases.”367 Perhaps because he is
cognizant of the extent of that influence, however, Putzel hastens to add that “we
fully agree that there can be no morbid manifestations without a change in the
material structure of the organs involved . . . .”368 This illustrates precisely the
366
Gowers, Neuralgia, 13.
367
Leopold Putzel, A Treatise on Common Forms of Functional Nervous Diseases (New
York, NY: William Wood & Co, 1880), v.
368
Ibid.
140
points I have been emphasizing with regard to localization and pain without
lesion: the latter, insofar as the term “lesion” is understood in the
contemporaneous nineteenth century sense as material alteration/pathology in
some kind of tissue or internal structure, does not exist. The only question is
whether it is discoverable via the prevailing state of the art, as Putzel goes on to
note:
[w]e are nevertheless fully convinced, in view of the fruitless
search of pathological anatomists, that the diseases which we have
considered in this work present no primary anatomical changes
which are visible to the naked eye or to the microscope–in other
words, that the changes in structure are of a molecular nature.369
Again, following a similar path of reasoning as virtually every physician I have
examined herein, Putzel begins by noting that pathological anatomy has not
revealed the lesion that causes nervous disorders (which includes neuralgia), but
that such lesions perforce exist. Along the same lines as Putzel, Landon Carter
Gray notes his frustration with the panoply of opinions regarding the pathology of
neuralgic pain:
A great deal of energy has been spent in discussion as to whether
neuralgia is due to changes in the central cells of the sensory
nerves, in the nerve-fibres themselves, or in the end-organs . . . it is
useless to go into these differences of opinion, because they are
entirely speculative, with scarcely a respectable fact to prop any
one of them up. The truth of the matter is, that we do not know of
the molecular changes which constitute neuralgia, and we shall
never know until we have instruments delicate enough to enable us
369
Ibid.
141
to dip down into a living cell of cord or skin and have a
microscopic view of molecular life . . . .370
It is hopefully apparent how Putzel and Grey’s emphasis on the technical gaps
preventing visibility of the lesions presages the importance of the subsequent use
of medical imaging techniques in illuminating features of the inner body that were
previously undiscoverable–X-rays, electroencephalography, tomographic
techniques, and, of late, fMRI.
Time and space preclude further analysis of the additional relevant
treatises and perspectives among late nineteenth century U.S. physicians and
neurologists regarding pain without lesion. Though I make no claim that the
sources adduced are exhaustive, they are, I suggest, in important ways
representative of attitudes, practices and beliefs among leading (academic) U.S.
physicians as to pain without lesion in the late nineteenth century.
What these sources demonstrate regarding pain without lesion is its
incoherence. Severe chronic pain most certainly “existed” in the eyes of these
healers, and the general humanitarian impulse of the nineteenth century prompted
widespread social and cultural concern with pain and suffering itself.371 The fact
that these larger social movements were inextricably linked with Victorian
sensibilities help explain why, though anesthetic agents were known of at least as
far back as the late eighteenth century, investigators like Humphrey Davy were
370
Landon Carter Gray, A Treatise on Nervous and Mental Diseases (Philadelphia, PA:
Lea Brothers & Co., 1895), 180-81
371
Tousignant, “Pain and the Pursuit of Objectivity;” Karen Halttunen “Humanitarianism
and the Pornography of Pain in Anglo-American Culture,” American Historical Review 100, no. 2
(April 1995): 303-334; Elizabeth B. Clark, “‘The Sacred Rights of the Weak’: Pain, Sympathy,
and the Culture of Individual Rights in Antebellum America,” The Journal of American History
82, no. 2 (September 1995): 463-493; Pernick, A Calculus of Suffering; and James C. Turner,
Reckoning with the Beast: Animals, Pain, and Humanity in the Victorian Mind (Baltimore, MD:
Johns Hopkins University Press, 1980). I will address these concerns in more detail in chapter 5.
142
far less interested in their use as analgesics than in their use as heightening
emotional sensibilities, consistent with the transcendentalism and Romanticism of
the time.372 Anesthesia itself did not enter the world of medicine in any
meaningful sense until Morton’s demonstration in 1847,373 and there is little
question that the larger Victorian concern with pain and suffering played a
significant role in the rise in consciousness (no pun intended) of anesthesia at that
time and place.
Accordingly, the key point is neither that pain without lesion was ignored
or trivialized nor that American physicians failed to appreciate the depth of their
patients’ suffering. The best evidence suggests the contrary. For my purposes,
the crucial point is the link between material tissue pathology and pain. That
chronic, intractable, difficult pain could exist without lesion as a primary causal
factor was untenable, so much so that leading American physicians were prepared
simply to assume the existence of a lesion in a specific location in the body. Pain
itself becomes a material problem, in the sense that its existence seemed to be
predicated on the existence of a localized tissue pathology that causes the pain.
Before turning to assess the consequences of this conceptualization of pain
for contemporary understandings of the meaning of pain, one point requires
further attention. I have argued in this chapter that the primary American sources
do support Morris’s claims regarding the disappearance of pain without lesion
from the clinical gaze during the late nineteenth century. Hodgkiss, however,
vigorously disputes Morris’s arguments. Accordingly, assessing Hodgkiss’s
372
Margaret C. Jacob and Michael J. Sauter, “Why Did Humphrey Davy and Associates
Not Pursue the Pain-Alleviating Effects of Nitrous-Oxide,” Journal of the History of Medicine and
the Allied Sciences 57, no. 2 (April 2002): 161-176.
373
Ray, The History of Pain; Pernick, A Calculus of Suffering.
143
arguments are an important means of pressing the merits of Morris’s perspective
further.374
Hodgkiss attributes to Morris a version of “social constructionism” in the
latter’s belief that pain is “constructed as much by social conditions as by the
structure of the nervous system.”375 Hodgkiss argues that because the “clinical
picture and prevalence of lesionless pain is rather historically invariant, the
position falls.”376 In turn, by “historical invariance” Hodgkiss apparently means
that from the inception of the anatomoclinical method, scientists and physicians
were aware of and concerned with the problem of lesionless pain.
There are a number of problems with Hodgkiss’s argument. First, there is
widespread agreement among pain scholars, regardless of their discipline, that
social and cultural conditions deeply influence pain experience. Howard Fields, a
leading neuroscientist who works on pain, notes that
[b]ecause the impact of pain is so highly dependent on the meaning
ascribed to it by the individual, a fuller understanding of pain in
human beings requires an interdisciplinary approach that
transcends the usual biomedical model. A major limitation in our
374
Moreover, because of the influence of European medical thought on U.S.
practitioners, the perspectives of European scientists and physicians on pain without lesion are
relevant to assessing the views of leading U.S. physicians. Because this dissertation is a medical
humanities rather than a history of medicine dissertation, I have chosen to focus on an analysis of
U.S. physicians’ attitudes and beliefs regarding pain without lesion. That these views were deeply
influenced by the perspectives of European practitioners is beyond dispute, as both the general
reliance of U.S. medicine on European schools and the primary sources themselves demonstrate.
Virtually all of the sources I have examined cite European authorities extensively.
375
Hodgkiss, From Lesion to Metaphor, 8.
376
Ibid.
144
ability to relieve the suffering of patients with chronic pain is an
insufficient understanding of the role of meaning.377
Moreover, it is well-settled that pain varies across all manner of
demographic indicia including but not limited to culture, age, class, race, and
gender. Resnik, Mehm, and Minard observe that “cultural beliefs, social groups,
and religious traditions can play an important role in the response to pain by
affecting how we interpret and attend to pain.”378 The pain physician who does
not take the social context of their patient’s lives into account is contravening
basic practices of pain medicine.379 Accordingly, if maintaining that social
conditions deeply shape and influence pain experiences renders one a strong
social constructionist, then, to paraphrase Holmes, we [pain scholars] are all
social constructionists.
Second, Hodgkiss is operating under a confused notion of both social
constructionism and historical invariance. The fact that nineteenth century
scientists and physicians were aware of the challenges posed by lesionless pain
does not imply they perceived its ontological status as equivalent to pain resulting
from gross lesions. Indeed, Hodgkiss’s own evidence demonstrates precisely how
377
Howard L. Fields, “Setting the Stage for Pain: Allegorical Tales from Neuroscience,”
in Pain and Its Transformations: The Interface of Biology and Culture, eds. Sarah Coakley and
Kay Kaufman Shelemay (Cambridge, MA: Harvard University Press, 2007), 36.
378
Resnik, Mehm, and Minard, “The Undertreatment of Pain,” 281.
379
Indeed, the Joint Commission standards on pain management expressly note the
importance of taking into account the patient’s personal, cultural, spiritual, or ethnic beliefs.
Marlene Zichi Cohen, Mary K. Easley, Coni Ellis, Beverly Hughes, Kristin Ownby, Beverly
Green Rashad, Mari Rude, Ellen Taft, and Joycelyn Bailey Westbrooks, “Cancer Pain
Management and the JCAHO’s Pain Standards: An Institutional Challenge,” Journal of Pain and
Symptom Management 25, no. 6 (June 2003): 519-527; Donald M. Phillips, “JCAHO Pain
Management Standards Are Unveiled,” Journal of the American Medical Association 284, no. 4
(July 26, 2000): 428-429.
145
many influential nineteenth century European physicians, like their American
counterparts, viewed the possibility of pain without lesion as untenable.
Hodgkiss notes that “[o]ne very telling assumption in [surgeon Benjamin]
Brodie’s thought is that any lesion anywhere in the body will do to account for an
otherwise inexplicable pain.”380 Obviously, then, Brodie was aware of the
problem of lesionless pain, but just as obviously, he continually sought to explain
it by virtue of the existence of some lesion located anywhere in the body. This
hardly qualifies as evidence in favor of Hodgkiss’s claim that Morris’s (and my)
focus on the importance of the visible lesion in conceptualizing pain is mistaken.
Quite the contrary, it seems to support Morris’s and my argument.
Similarly, in describing surgeon Joseph Swan’s willingness to attribute a
patient’s severe pain over 11 years to a minor structural lesion of her digital
nerve, Hodgkiss acknowledges that
[i]t seems perverse to us that Swan should be satisfied with a trivial
lesion of a digital nerve as an explanation for a decade of multiple,
disabling pains all over the body. But what was at stake for him
were the tenets of a new anatamoclinical method. The whole
thrust of this programme was to match symptom and lesion, even if
the lesion was at a distance from the pain and the pain was out of
all proportion to the lesion.381
This too seems to buttress Morris’s and my argument. Swan was so determined
to corroborate the objectifying tendencies of the anatomoclinical method that he
was willing to ascribe virtually any pain symptoms to virtually any lesion. This
demonstrates the power and importance of matching illness and symptom to
380
Hodgkiss, From Lesion to Metaphor, 59.
381
Ibid., 63.
146
visible pathology, which is exactly how Foucault, Morris, and myself depict the
focus of the anatomoclinical method.
This pattern continues in Hodgkiss’s account across a variety of scientists
and physicians:

In lectures published in 1863, professor of anatomy and surgery Joseph
Hilton “did not entertain the possibility of pain without structural
lesion;”382

Frederic Skey, in his 1867 treatise on Hysteria, reported on a surgeon who
“relies on ‘appearance rather than the verbalized subjective complaint of
the pain patient;”383

An 1855 autopsy of a woman diagnosed with hysteria displayed apparent
spinal abnormalities, which Hodgkiss deems “an example of how the
developing field of neurology was shrinking the category of hysteria by
way of its ever more impressive clinico-pathological correlations;”384

In lectures published in 1863, University College London Professor of
Surgery John Erichsen insisted that many persons suffering disabilities
after railway accidents had incurred physical damage to the spine. Though
“[h]e acknowledged that the spinal cord was ‘without serious lesion’ in
382
Ibid., 65.
383
Ibid., 68. Hodgkiss concedes that this writing “supports Foucault’s generalizations
about the priority of the ‘medical gaze’ in the clinical method of the century.” Ibid.
384
Ibid., 116.
147
such cases, [he] argued that ‘molecular changes in its structure’ must be
present;”385 and

Charcot maintained that for any report of pain, “a dynamic lesion was
present in the cortical domain corresponding to the region of the body
implicated by the patient’s ideas.”386
In addition, Hodgkiss traces the influence of nineteenth-century German
Idealism and Romanticism, which tended to lionize emotion and individual
subjectivity, on attitudes as to pain without lesion. He makes a plausible case
that these ideals influenced at least some scientists and physicians’
conceptualization of pain in the nineteenth-century.387
However, even this claim is subject to criticism, because, as noted above,
the link between Romanticism and concern about pain is tenuous. In their
385
Ibid., 130. Hodgkiss remarks that “[t]he ‘must’ in his view reflected the primacy of
the tradition of pathological anatomy which demanded some structural lesion to account for
symptoms.” Ibid. The story of Erichsen’s views on a condition he termed “spinal concussion”
and the bitter controversies that ensued are a fascinating study in their own right, bringing together
important shifts and issues relating to railroad history, industrialization, labor history, tort
litigation, and the role of physicians in determining disability and negligence. Harrington, “On
The Tracks of Trauma,” Bill Bynum, “Railway Spine,” Lancet 358, no. 9278 (July 2001): 339.
The issue of pain without lesion runs throughout all of these matters, and would therefore make
for a compelling study in its own right. I reserve such a study for another time.
386
Hodgkiss, From Lesion to Metaphor, 142. Hodgkiss concedes that “Foucault’s
construct of the ‘medical gaze’ finds its most impressive empirical support in Charcot’s style, in
this privileging of the visual, of inspection over anamnesis.” Ibid., 137. This is relevant because
Charcot is regarded as one of the founders of neurology, and his work was crucial to the
localization of the nervous system. Indeed, in delivering the Gulstonian Lectures of 1878 (on
“The Localisation of Cerebral Disease”) to the Royal College of Physicians, Ferrier dedicates the
work to “M. Charcot, In Recognition of His Pre-Eminent Services in the Localisation of Cerebral
Disease.” Ferrier, The Localisation of Cerebral Disease. Charcot even adopted a different term
for a kind of lesion that is invisible via contemporaneous methods of anatomical investigation but
must nevertheless exist: a dynamic or functional lesion. Jean-Marie Charcot, Lecons sur Les
Maladies Du Systeme Nerveux (Paris, France: Lecrosnier et Babe, 1890); Kaitaro, “Biological and
Epistemological Models of Localization.”
387
Hodgkiss, From Lesion to Metaphor, 92-93.
148
assessment of why Humphrey Davy and associates did not utilize nitrous oxide to
alleviate pain over fifty years before Morton experimented with ether anesthesia,
Jacob and Sauter expressly reject the claim that Davy’s Romantic predilections
necessitated concern with pain. They note that
Romanticism is relevant to their scientific decisions. But . . .
romantic sentiment propelled Davy and his cohorts only toward the
search for pleasure and the augmentation of individual
consciousness. For reasons social and theoretical–as well as
technical–pain never became a serious part of their quest.388
In short, I find Hodgkiss’s claims that Morris errs in his account of the
clinical gaze and its legacy for conceptualizing lesionless pain to be
unconvincing. Quite the contrary, much of the evidence Hodgkiss cites supports
Morris’s (and my) claim that while pain without lesion was neither ignored nor
trivialized, the possibility that severe and persistent pain could exist without a
correlative pathology in some material structure in the body, be it brain, nervous
system, organ, or other, was simply untenable.
CONCLUSION
The analysis developed in this chapter lies at the core of my thesis. My
argument is that the extensive recent efforts across diverse networks of actors and
social worlds to improve the treatment of pain have generally had little
perceptible effect in no small part because such efforts have generally not been
linked to an understanding of the meaning of pain in American society. In turn,
no such understanding of the meaning of pain is possible without thinking in
388
Jacob and Sauter, “Humphrey Davy and Associates,” 164.
149
dialectic terms, about how historical attitudes, practices, and beliefs towards pain,
and in particular pain that generally resists the “ocular demonstrations”389 that
animate the clinical gaze, shape and inform the multiple meanings of pain in
American society. Having illustrated a narrow slice of how the emphasis on
visible (or hypothesized as visible) pathologies in material structures and tissues
within the body were key to conceptualizing pain without lesion among leading
late nineteenth century American physicians, I can move to explaining exactly
how this history manifests in contemporary clinical medicine in the United States
389
Martensen, The Brain Takes Shape, 202.
150
Chapter 5: The Role of the Clinical Gaze in Contemporary
Biomedical Understandings of Pain
OBJECTIVITY, OBJECTIFICATION, & THE CLINICAL GAZE
With a better understanding of the importance of material pathology in
conceptualizing pain among leading late nineteenth century U.S. physician and
neurologists, I can now turn to tracing the effects of this conception on
contemporary meanings associated with pain in the biomedical encounter. It is
crucial to recall that while I have thus far primarily investigated the
conceptualization of pain within and among physicians, the power of the visible
in shaping the meaning of illness, the body, and pain is not limited to physicians.
While the effects of the clinical gaze are understandably most prevalent and most
problematic within the culture of biomedicine and within a clinical encounter in
which the chief complaint is pain, the object that produces signs of pain is integral
to the meaning of pain within and across American society, extending to illness
sufferers, caregivers, and non-physician providers alike. This chapter will begin
the process of explaining how and why the discourse of the visible among leading
late nineteenth century American physicians reflects and is reflected by larger
movements, ideas, and conditions within American society.
In unpacking the ramifications of late nineteenth century American
understandings of pain without lesion for the contemporary treatment of pain, the
first task is to connect the former to notions of “objectivity” and “objectification.”
It is, I submit, no accident that Daston and Galison trace the inception of so-called
“mechanical objectivity,” or objectivity whose aim is to reduce as much as
possible the effect of human influence on the production of knowledge, to the
151
mid-to-late nineteenth century.390 While I have already suggested that Daston and
Galison’s approach risks periodicity because earlier movements, conditions, and
ideas converged in important ways to facilitate the idea of mechanical objectivity
during the nineteenth century, there is little reason to doubt their claim that this
form of objectivity was a creature of the nineteenth century.
The most compelling evidence for this argument is the notion that, during
the Renaissance and the early modern period, the investigating Eye/I expressly
valued the role of subjective expertise in generating scientific and medical
knowledge. As an object of analysis, Daston and Galison examine attitudes and
practices relating to the collation of scientific atlases, largely because these
compendia provide a unique means of clarifying attitudes, beliefs, and practices in
the West towards empirical investigation. Prior to the nineteenth century, the
worth of the illustrations and woodcuts utilized in many of these atlases was a
function of the combination of the artist’s skill with the subjective expertise of the
investigator’s Eye. The scientific quality of the knowledge was not a function of
the investigator’s remoteness from the process by which that knowledge was
produced; quite the contrary, the specific expertise and training of the investigator
was the primary condition upon which the quality of the knowledge was judged.
Linnaeus, for example,
would have dismissed as irresponsible the suggestion that scientific
facts should be conveyed without the mediation of the scientist and
ridiculed as absurd the notion that the kind of scientific knowledge
most worth seeking was that which depended least on the personal
traits of the seeker. These later tenets of objectivity, as they were
formulated in the mid-nineteenth century, would have contradicted
390
Daston and Galison, Objectivity.
152
Linnaeus’s own sense of scientific mission. Only the keenest and
most experienced observer–who had, like Linnaeus, inspected
thousands of different specimens–was qualified to distinguish
genuine species from mere varieties, to identify the true specific
characters imprinted in the plant, and to separate accidental from
essential features.391
Thus, the scientific epistemology Daston and Galison describe prior to the
nineteenth century reflects entirely different notions of value than contemporary
versions. In the view of Enlightenment atlas makers, “whatever merit their atlases
possessed derived precisely from [expert] discernment and from the breadth and
depth of experience in their field upon which discernment rested.”392
Particulars & Universals
As the passage about Linnaeus hints, one way of understanding these
epistemic differences is in the Renaissance and early modern dialectic between
particulars and universals. Investigators of these times were well aware that
botanical and herbal specimens, for example, displayed all sorts of particular
variations and differences. Yet what many of these investigators were after is
what Daston and Galison term “truth-to-nature,” which denoted the need to
discern a “pure phenomenon,” an archetype that captured all potential forms of
the specimen in question.393 However, despite the neo-Platonism of the sixteenth
and seventeenth centuries, these archetypes were not conceived of as Platonic
forms, because “sharp and sustained observation was a necessary prerequisite for
391
Ibid., 59.
392
Ibid., 67.
393
Ibid., 55-105.
153
determining the true genera of plants and other organisms.”394 The idea, then,
was that only by empirical investigation into thousands of particular specimen
could a universal archetype of the object of inquiry be produced. It was these
universals which tended to be imaged in scientific atlases of the time.
The particular-universal distinction is also important in Vesalius’s
conceptual scheme. The fact that the Fabrica is at least partly an anatomical atlas
suggests some commonalities with the scientific atlases Daston and Galison
survey.395 Anatomical knowledge, like many other objects of Renaissance and
early modern natural science “necessarily involved the assembling of information
about large numbers of particulars.”396 A central question for Vesalius in the
Fabrica is whether any universal–in this case, a universal human–could be
assembled from such a motley collection of particulars. Just as the botanicals and
herbals in many of the atlases of the Renaissance and early modern period were
idealized as natural universals, the skeleton in the Fabrica
was not only drawn from a specimen evidently selected for its
perfection, but also, according to one interpretation, had its
proportions adjusted to match current artistic canons for the
proportions of the ideal human body.397
394
Ibid., 58. In contrast, Platonic forms were by definition not observable in the natural
395
Siraisi, “Vesalius and Human Diversity.”
world.
396
Ibid., 66. Terming empirical investigations of the sixteenth and seventeenth centuries
“natural science” is anachronistic, as there is little doubt that a distinction between science and
natural philosophy did not exist in the Renaissance and early modern period, and scientific
investigations were commonly conceived of and characterized as natural philosophy.
397
Ibid., 70.
154
“Taken as a whole, in text and illustrations, the Fabrica establishes the
subject of the scientia of anatomy as a standardized version of the natural/healthy
human body–neither infant nor aged, unchanged in any time, people, or culture,
and male unless specified as female.”398 In spite of this predilection for the
universal body, Vesalius is assuredly aware of the tension between the universal
body and the undeniable range of particular bodies existing ‘in nature’: “[a]n
attentive reader of the Fabrica would be left in no doubt that whatever the
theoretical and practical advantages of presenting a common nature of human
bodies, in reality variations occurred in the natural/healthy body.”399 Vesalius
painstakingly documented such variations on the basis of age, sex, time, peoples,
and culture.
The point, as Daston and Galison suggest, is that objectivity in the
Renaissance and the early modern era did not prioritize “authentic” depictions and
imagery of plants, botanicals, and even human bodies ‘just as they appeared in
nature.’400 The value of scientific images was in large part a function of the
expertise of the investigator and the skill of the artist in producing an image that
demonstrated the natural ideal of the object of the inquiry.
But this notion of objectivity, which may seem peculiar to contemporary
readers insofar as it is not predicated on an attempt to represent scientific objects
‘just as they are,’ would change dramatically during the nineteenth century. The
nineteenth century idea of mechanical objectivity allocated epistemic value to
knowledge produced with minimal subjective interference on the mechanical
398
Ibid., 87.
399
Ibid., 72.
400
Daston and Galison, Objectivity.
155
processes of knowledge production. Daston and Galison characterize the
demands of mechanical objectivity as a form of self-abnegation, an intentional
blinding of the power of one’s own subjective gaze, intended to emulate the rigor
and automation of the machine: “The observer now aimed to be a machine–to see
as if his inner eye of reasoned sight were deliberately blinded.”401 The
development of the camera obscura in the mid nineteenth century was
instrumental as a technique which could theoretically capture natural phenomena
‘just as they were,’ with as little influence of the investigator as possible.402 Of
course, investigators of the time knew full well that the choices and actions of the
photographer exercised a very great influence on the knowledge produced,403 but
this had little effect on the ideal implied by mechanical objectivity, which was to
eliminate, to the maximum extent possible, human influence on scientific
knowledge production.404
Moreover, the ethos of mechanical objectivity penetrated deep into the
medical theories and practices of the late nineteenth century. The fact that
American roentgenologists at the fin-de-siécle were willing to suffer horribly and
die for the sake of seeing the solid tissues and material pathologies of the inner
body is itself testament both to the social and cultural significance of the imaging
401
Ibid., 140.
402
Ibid.; Golan, “The Emergence of the Silent Witness”; Olaf Breidbach, “Representation
of the Microcosm-the Claim for Objectivity in 19th Century Scientific Microphotography,”
Journal of the History of Biology 35, no. 2 (June 2002): 221-250.
403
Breidbach, however, notes that some nineteenth century investigators did view
scientific microphotography as a perfect representation of the natural world, such that many
scientists abandoned examination of the microscopic preparations in favor of microphotographs.
Eventually, the obvious and frequent imperfections in microphotography produced copious
cognitive dissonance and therein discredited microphotography for decades. Breidbach,
“Representation of the Microcosm,” 234-237.
404
Daston and Galison, Objectivity.
156
techniques, and to the importance of deploying an automated, mechanical process
in the production of scientific and clinical information.405 Part of the wonder and
power of X-rays was the fact that the images it produced did not depend on any
anatomical dissection to reveal the solid tissues and material pathologies of the
human body. Herzig’s primary explanation for their willingness to suffer and die
is the ethos of martyrdom and self-sacrifice that permeated fin-de-siecle scientific
and medical communities in the United States.406 As such, the self-annihilating
aspects of mechanical objectivity, the “blinded inner sight” Daston and Galison
speak of, is also an important aspect of the explanation for the roentgenologists’
actions.
Daston and Galison argue persuasively that the nineteenth century (and
contemporary) scientific emphasis on mechanical objectivity says much about the
constitution of the scientific self, which reinforces the Eye/I connection. That the
scientific Eye, or, in the context of medicine since the nineteenth century, the
clinical gaze, is in some crucial sense productive of the scientific and medical “I”
is at the core of the analysis I have attempted to sketch thus far.
The important point is not simply that the clinical gaze turned its powers
to visible phenomena during the nineteenth century. As noted in chapter 3,
semiotics had been a key aspect of healing practices in the West for almost a
milennium prior to the birth of the clinic. The novel idea, however, was to permit
the objects, the natural phenomena under investigation (which, in the context of
405
Daniel S. Goldberg, “X-Ray Imaging Techniques, Cultural Efficacy and the Power of
Sight in Fin-de-Siècle American Culture,” working paper, (University of Texas Medical Branch,
2009).
406
Rebecca Herzig, Suffering for Science: Reason and Sacrifice in Modern America
(New Brunswick, NJ: Rutgers University Press, 2005); Herzig, “American Roentgenology.”
157
anatomy and pain without lesion, were material pathologies) to reveal their
secrets. The focus of the clinical gaze shifted away from the embodied subject
and towards the discrete objects of disease, especially because the latter were
amenable to the kinds of quantifiable and mechanical investigations which
facilitated the ideal of mechanical objectivity in the nineteenth and twentieth
centuries.407
While the body in pain was not ignored during the late nineteenth century,
there is little doubt that the emphasis of the gaze shifted from the embodied,
particular subject experiencing the pain–and his or her lifeworld–to the discrete,
material entities that produced the pain. This objectification has come to have
profound consequences for the contemporary treatment of pain.
THE ROLE OF THE CLINICAL GAZE IN CONTEMPORARY UNDERSTANDINGS OF
PAIN WITHIN THE CULTURE OF BIOMEDICINE
With this rudimentary analysis of the links between objectivity and late
nineteenth century perspectives on pain without lesion, I can now explicate in
more detail the connection between these ideas and the contemporary
undertreatment of pain. The difficulties posed by the role of material pathology in
context of the contemporary treatment of pain turn on the notion that pain is the
quintessential subjective phenomenon. Pain is highly resistant to objectification,
407
The bulk of Tousignant’s analysis is devoted to explaining how different techniques
for measuring pain took hold at least in part as a function of the kinds of evidence that were
valued. Hence, the analgesic clinical trial came into favor at the expense of the previously
dominant dolorimeter (an instrument used to quantify pain thresholds) precisely because the
former provided the kinds of aggregated, standardized, formalized data as to pain that were
prioritized in the post WWII arena of scientific and clinical research. Tousignant, “Pain and the
Pursuit of Objectivity.”
158
because by definition my pain is qualitatively different from your pain.408
Though the extent of the resistance varies with the type of pain under
consideration, pain is generally only of limited susceptibility to the physician’s
armamentarium of objectifying techniques and modalities. Even if the physician
can see on an X-ray the compound fracture that is causing the patient’s pain, the
pain itself is not observed in the X-ray. More problematic, of course, are the
many varieties of chronic pain that display no material pathology (read: no lesion)
to which causation may be attributed.
A primary reason these phenomena are problematic is because clinical
method is in large part devoted to objectifying the patient’s symptoms in order to
arrive at a diagnosis and possible therapies. Stated as such, I am not derogating
the process of objectification; there is little doubt that this modality has had
powerful and salutary consequences for understanding human health and illness
and producing effective interventions.409 Nevertheless, there is little dispute that
408
Goldberg, “The Sole Indexicality of Pain,” Mark D. Sullivan, “Finding Pain Between
Minds and Bodies”; Mark D. Sullivan, “The Problem of Pain in the Clinicopathological Method,”
The Clinical Journal of Pain 14, no. 3 (September 1998): 197-201; Honkasalo, “What is Chronic
is Ambiguity;” Morris, Illness and Culture, 107-134; Morris, The Culture of Pain; and Scarry, The
Body in Pain.
409
However, given the implications of the McKeown Thesis, there is room to question
the effect of the so-called “therapeutic revolution” on human health and well-being. See James
Colgrove, “The McKeown Thesis: A Historical Controversy and Its Enduring Influence,”
American Journal of Public Health 92, no. 5 (May 2002): 725-729; Simon Szreter, “Rethinking
McKeown: The Relationship Between Public Health and Social Change,” American Journal of
Public Health 92, no. 5 (May 2002): 722-725; Simon Szreter, “The Importance of Social
Intervention in Britain’s Mortality Decline c. 1850- 1914: A Re-interpretation of the Role of
Public Health,” Social History of Medicine 1, no. 1 (1988): 1-38; Roger S. Wrigley and Edward
Anthony Schofield, The Population History of England, 1541-1871: A Reconstruction
(Cambridge, MA: Harvard University Press, 1981); Thomas McKeown, The Modern Rise of
Population (San Francisco, CA: Academic Press, 1976); Thomas McKeown, The Role of
Medicine: Dream, Mirage, or Nemesis? (London, UK: Nuffield Provincial Hospitals Trust, 1976);
Thomas McKeown and Roger G. Record, “Reasons for the Decline of Mortality in England and
Wales During the Nineteenth Century,” Population Studies 16, no. 2 (November 1962): 94-122;
and Thomas McKeown and Robert G. Brown, “Medical Evidence Related to English Population
Changes in the Eighteenth Century,” Population Studies 19, no. 2 (November 1955): 119-141.
159
objectification is a core component of contemporary clinical method. Resnik,
Mehm, and Minard note that “[t]oday’s health care professionals use objective
methods to develop and confirm diagnoses . . . These tests allow clinicians to
observe, measure, quantify, and compare various anatomical, biochemical, and
physical properties, structures, and functions to determine the presence of a
specific disease.”410
Similarly, philosopher and psychiatrist Mark Sullivan expressly notes the
implication of the clinicopathologic method for physicians: “[w]e are taught that
real disease can be identified by tissue pathology . . . In its purest and most
essential form, clinical method diagnosis consists of making the link between
symptoms reported by the patient and a lesion observed in the tissue.”411
Elsewhere, he notes that “[i]n the clinicopathologic method, the autopsy reveals
the reality of the disease as visible pathology.”412 This method imbues to
medicine
an entirely objective access to diagnosis. It is now possible for the
diagnostic process to completely bypass patients’ reports of pain or
experience of illness. Physicians need no longer rely on patients’
knowledge of or candor about their condition, because physicians
have a means to go directly to the disease.413
This is not in and of itself to deny the role of clinical medicine in improving health, but to note
that the extent of its effect remains a matter of vigorous debate. In other work related to public
health policy, I expressly address some of these issues. Goldberg, “In Support of a Broad Model
of Public Health.”
410
Resnik, Mehm, and Minard, “The Undertreatment of Pain,” 282-83.
411
Sullivan, “Finding Pain Between Minds and Bodies,” 148. While I have expressly
used the Foucauldian term “anatomoclinical method,” the term “clinicopathologic method” is
often used as a shorthand means of referring to the clinical method born during the nineteenth
century. For my purposes, any distinction between the two terms is immaterial.
412
Ibid.
413
Ibid.
160
The idea here is that the objectifying tendencies of clinical method are the
product of an intricate set of social, political, and cultural forces combining during
the nineteenth century to shape a method that promised to its adherents a way of
moving beyond patient self-reports into the truths of the body. Ray notes that the
nineteenth-century physician used the power of the clinicopathologic method to
“make independent observations aside from the patient’s description”414 in
diagnosing pain, and Hammond expressly declares that the patient’s report of
their own pain is immaterial when confronted with a contravening sign:
The fact that the patient denies the existence of [spinal] tenderness
should have no weight with the physician. Thus, a young lady
consulted me for severe infra-mammary pain, headache, and
nausea. I at once suspected spinal irritation, but she declared, in
answer to my inquiries, that there was no sign of tenderness
anywhere over the spinal column. I insisted, however, on a manual
examination, and to her great surprise found three spots that were
exceedingly painful to slight pressure.415
The problem of the clinical gaze as to pain should be obvious: if pain
cannot be perceived “in the body” as a material pathology, then pain is hardly
susceptible to the gaze of the clinicopathologic method. Many of the most
intense, unremitting, and difficult-to-treat pain experiences cannot be correlated
with any visible pathology or organic insult; yet pain medicine standards are
virtually unanimous in their insistence that the most reliable means of measuring
414
Ray, The History of Pain, 100.
415
William A. Hammond, On Certain Conditions of Nervous Derangement (New York:
G.P. Putnam’s Sons, 1881), 35. I shall have more to say in subsequent chapters about the
problems posed by the need to rely on the pain sufferer’s self-report. For now, the key point is to
understand the importance of finding the pure sign of material pathology in conceptualizing pain.
My argument is that the significance of this is not confined to the nineteenth century, but is alive
and well in the culture of biomedicine today.
161
pain is through the patient’s self-report.416 This, of course, puts it directly at odds
with the objectifying tendencies in the clinicopathologic method, and I submit that
this dissonance has had devastating consequences for providers, pain sufferers,
and caregivers alike. The preeminent American historian of medicine of this
generation, Charles Rosenberg, explains the significance of this objectification in
framing disease:
[T]he social legitimacy and intellectual plausibility of any disease
must turn on the existence of some characteristic mechanism. This
reductionist tendency has been logically and historically tied to
another characteristic of our thinking about disease–its specificity.
In our culture, the existence of disease as a specific entity is a
fundamental aspect of its intellectual and moral legitimacy. If it is
not specific, it is not a disease, and a sufferer is not entitled to the
sympathy, and in recent decades often the insurance
reimbursement, connection with an agreed-upon diagnosis.
Clinicians and policymakers have long been aware of the
limitations of such reductionist styles of conceptualizing disease,
but have done little to moderate its increasing prevalence.417
Though in a very real sense the bulk of what remains in this dissertation is
devoted to assessing the myriad ways in which this dissonance manifests, my
central claim is that it is this disconnect between the power of the visible in
American culture and the culture of biomedicine and the lack of any visible
pathology as to many kinds of pain that animates the majority of the American
problems in treating pain adequately. One piece of evidence supporting this
characterization of the problem is what anthropologist Jean Jackson identifies as a
416
Chris M. Pasero and Margo McCaffery, “The Patient’s Report of Pain: Believing vs.
Accepting. There’s a Big Difference,” American Journal of Nursing 101, no. 12 (December
2001): 73-74; Keela A. Herr and Linda Garand, “Assessment and Measurement of Pain in Older
Adults,” Clinics in Geriatric Medicine 17, no. 3 (September 2001): 458-478.
417
Rosenberg, Explaining Epidemics, xvi (emphasis in original).
162
moral hierarchy of pain. Where the apparent causes of pain can be observed “in
the body” through objective, mechanical instrumentation, the pain is more likely
to be treated better, and the moral value assigned to the pain sufferer is higher.418
Indeed, the evidence adduced in chapter 1 suggests that chronic nonmalignant
pain–which by definition cannot be attributed to any kind of lesion or organic
insult–is significantly more likely to be undertreated than acute pain secondary to
organic insult (whether mechanical trauma, a tumor, a burn, etc.).
Jackson documents the intense stigma experienced by chronic pain
sufferers, and notes that chronic pain is at the bottom of the hierarchy of pain.419
As such, chronic pain sufferers are less likely to receive adequate treatment than
sufferers of acute pain secondary to organic insult.420 In addition, the highest
levels observed in clinical medicine of both provider-patient hostility and
bidirectional turnover (that is, a measure of how often both patients and
physicians end the treatment relationship) are found in chronic pain encounters,
such that “[r]elations between pain patients and health care deliverers are
considered the worst in medicine.”421 While there are various reasons for this, I
submit that the primary reason is the lack of visible, material pathology that can
ground the sign of pain. In his seminal analysis on the history of the brain in
Western culture, Robert Martensen suggests the existence of “codes of
signification built into [biomedicine’s] conceptual foundations.”422 These codes
418
Jackson, “Stigma, Liminality, and Chronic Pain.”
419
Ibid.
420
Ibid.
421
Ibid., 338.
422
Martensen, The Brain Takes Shape, 203.
163
parcel out the sick body into discrete solids, solids which, when malformed or
pathological, satisfy the “ocular demonstrations” that Willis so ardently desired,
and constitute the pure sign that healers and scientists sought and continue to
seek.423 This, Martensen suggests, is the path in the West to scientia, or “reliably
universal knowledge.”424
Yet, as noted in chapter 1, there is excellent evidence that even acute pain
which results from visible material pathology is oft undertreated. One of the most
troubling examples of the undertreatment of acute pain secondary to visible
pathology is Angela Byrne, Juliet Morton, and Peter Salmon’s qualitative study of
nurses’ treatment of children’s postoperative pain.425 This study is significant for
several reasons. First, given the fact that nurses are typically much more involved
in direct patient care than physicians, and more so that hands-on patient care is in
an important sense constitutive of the profession of nursing,426 one would
arguably be justified in supposing that nurses might be more likely to treat pain
adequately than physicians. Second, the subject population of the study was
composed of children in a postoperative setting. Based on Jackson’s hierarchy of
pain, one would also be justified in expecting superior pain treatment for a patient
population which could hardly in any meaningful sense be deemed responsible for
423
Ray, The History of Pain, 99.
424
Martensen, The Brain Takes Shape, 199.
425
Byrne, Morton, and Salmon, “Defending Against Patients’ Pain.” Indeed, as noted in
chapter 2, qualitative analyses of pain are crucial to adopting a phenomenological approach to the
body in pain. Such an approach underscores the argument in the Introduction regarding the kinds
of evidence needed to produce humane and effective evidence-based policies as to pain.
426
Jean Watson, Nursing: Human Science and Human Care (Sudbury, MA: Jones &
Bartlett Publishers, 1999).
164
their pain, and in which obvious material, visible pathologies produced the pain.
However, the authors’ findings vitiate both of these presumptions.
Byrne, Morton, and Salmon note as a point of departure for the study the
body of evidence demonstrating not only that nurses tend to treat pain
inadequately, but that they tend to treat pain less adequately than physicians.
They cite the suggestion
that long exposure to the challenge of patients’ pain causes nurses
to think and behave in defensive ways, specifically by minimizing
their awareness of patients’ pain, and that this results in
depersonalizing and distancing of patients and the ritualizing of
patient care. This view can help to explain the continued reports
over twenty years that nurses underestimate patients’ pain or their
ability to cope with it and dispense less analgesia than is necessary,
that underestimation is greater in more experienced nurses and
that, although both nurses and physicians underestimate pain,
nurses’ underestimation is the greater.427
As to the “innocence” of the pain sufferers and the existence of obvious visible
pathologies that caused the pain, the authors found a number of defensive
strategies among the nurses that were used in denying the patients’ pain. These
findings could conceivably be interpreted as demonstrating that the undertreament
of pain in the United States is not reducible to the social and cultural significance
of the visible pathology in American society.
To this, I have two responses. First, the possibility that no single account
is sufficient to capture the myriad reasons why pain is undertreated in the United
States simply confirms the approach (and the associated caveats) laid out in my
Introduction and my Preface. Pain is multivalent, dynamic, and ambiguous. No
427
Byrne, Morton, and Salmon, “Defending Against Patients’ Pain,” 69 (citations
omitted).
165
single narrative can possibly encapsulate the prism of reasons and factors that
animate the undertreatment of pain, and suggesting the contrary is sheer hubris.
The impossibility of reducing the phenomenon of pain to any grand metanarrative is partly what justifies an interdisciplinary (medical humanities)
approach, and I would grievously undermine the strengths of this approach if I
were to attempt to reduce the meaning of pain to any such narrative.
Second, and however, I suspect that it is too hasty to infer from the
premise that even pain resulting from obvious visible pathologies is undertreated
the conclusion that the invisibility of many forms of pain is not a primary culprit
in its undertreatment. The argument sounds plausible, and, as noted in the Preface
and in this chapter, there are meaningful distinctions to be drawn between
different kinds of pain. Nevertheless, while some kinds of pain may present with
visible causes, even in these cases, the actual experience of pain remains–even
accounting for the analysis in chapter 2 undermining a resolutely individualistic
sense of pain–in some meaningful sense a private sensation. As such, even socalled visible pain, such as acute pain secondary to organic insult, remains
ineluctably subjective, and hence resistant to the objectifiying techniques of
clinical practice.
The point is that the significance of the visible in constructing the meaning
of pain in American society helps explain both why kinds of pain that display no
visible, material pathologies pose larger challenges to clinical medicine and why
even pain presenting with such pathologies nonetheless poses a challenge to the
objectifying techniques of clinical correlation that are rooted most firmly in
nineteenth century conceptualizations of signs, disease causality, and pain. The
phenomenon of pain itself is not what is captured in the X-ray that reveals the
166
fracture. While, in terms of causality, some kinds of pain are more visible than
others, the irreducibly subjective nature of all pain, the fact that even pain
resulting from the identical pathology may be experienced in dramatically
different ways in different persons, suggests some reasons for thinking that the
power of the visible in Western culture remains an especially significant source
for assessing the meaning of pain.
In any case, as noted above, the legitimacy of pain often depends on
whether the causes of such pain are easily localizable to visible, material
pathologies. Jackson’s hierarchy of pain is stratified according to a kind of
somatic geography: pain whose causes are obviously located “in the body” tends
to be treated better and correlates with lower levels of stigma for the sufferer.428
But what does it mean for pain to be located “in the body”? The implied
contrast, of course, is to pain that is located “in the mind,” which in turn suggests
that the clinicopathologic method incorporates another conceptual problem in the
treatment of pain: the mind-body duality.
THE POWER OF VISIBLE, MATERIAL PATHOLOGY IN SHAPING MIND-BODY
DUALISM AS TO PAIN
Though the mind-body distinction has been debunked by various scholars
from various disciplines, there is reason to believe that it is still deeply ingrained
in the clinicopathologic method. Jackson states that “in clinical practice
mind/body dualism constantly emerges.”429 Morris notes that the method
“impales the patient on the horns of a potent dilemma: either pain has a visible,
428
Jackson, “Stigma, Liminality, and Chronic Pain.”
429
Jackson, Camp Pain, 39.
167
objective, physical cause, or it is mental, emotional, imaginary, all in your
head.”430 However, as we shall see in chapter 6, the notion that pain is “all in
your head” is either trivially true or incoherent. Howard Fields notes that because
pain is modulated by neural phenomena originating from the brain (rather than
exclusively originating from the site of organic insult), there is a very real sense in
which pain is most assuredly in one’s head.431 Pain specialist John Loeser
observes the absurdity of the notion that pain is ‘in the body:’ ‘‘Does anyone
really believe that a tooth is capable of hurting? Or a back?”432 Loeser, who was
the successor to John Bonica in directing the latter’s famous pain management
clinic in Seattle, Washington, is not denying that the phenomenology of pain is in
an obvious sense localizable by the pain sufferer, but is rather challenging the
category mistake which attributes metaphysical claims to phenomenological
statements. That is, there is a very real and very important distinction between the
patient’s phenomenological pronouncement that their tooth hurts and the (invalid)
metaphysical inference that the pain itself is wholly contained within the material
structure itself (the tooth).433
Yet, the clinicopathologic method encourages the perpetuation of mindbody dualism inasmuch as it suggests that symptoms of disease ought to be
corroborated by looking into the physical and chemical composition of the body.
430
Morris, “An Invisible History of Pain,” 194.
431
Fields, “Setting the Stage for Pain.”
432
John Loeser, “What is Chronic Pain?” Theoretical Medicine and Bioethics 12, no. 3
(September 1991): 215.
433
Bennett and Hacker refer to this category error as the “mereological fallacy.”
Maxwell R. Bennett and Peter Michael Stephan Hacker, Philosophical Foundations of
Neuroscience (Malden, MA: Blackwell Publishing, 2003); see also Pardo and Patterson, “The
Philosophical Foundations of Law & Neuroscience.” I will address the underlying issues, if not
Bennett and Hacker’s specific formulation, in chapter 6.
168
Subjective phenomena like pain do not easily fit into this rubric, and this lack of
fit has consequences for providers, for pain sufferers, and for caregivers. Jackson
articulates that one reason chronic pain is so problematic because it “mysteriously
straddles the mind-body boundary.”434
Because the relationship between the mind and the body is so crucial to
unpacking the meaning of pain within American society in general (and for pain
sufferers, caregivers, and providers alike), I turn now to a close analysis of such
dualism in context of subjectivity, consciousness, and pain. It is no accident that
the history of neurology, neuroscience, and medical imaging (in particular
neuroimaging) has occupied a significant percentage of the analysis thus far;
therein lies key codes of signification435 for comprehending the culture of
biomedicine and the meaning of pain in American society. Ironically, however,
these codes derive their power from the fact that they are widely, though by no
means universally, shared across social networks that include a great many lay
persons. My primary goal in this chapter was to trace how the objectifying
tendencies of the clinical gaze manifested in conceptualizing the phenomenon of
pain in the biomedical encounter. This linkage is incomplete without an
assessment of the role mind-body dualism plays, because, I think, it is a
manifestation of the same dynamics and conceptions at work in the birth of the
clinic. That such dualism remains pervasive among clinicians, scientists, and lay
persons alike suggests that it is an important node in unpacking the role of visible,
material pathology in framing the meaning of pain in American society.
434
Jackson, “Stigma, Liminality, and Chronic Pain,” 343.
435
Martensen, The Brain Takes Shape, 203.
169
SECTION III: Ethics, Subjectivity, and Pain
Chapter 6: Mind-Body Dualism, Subjectivity, and Consciousness
INTRODUCTION
Despite countless attacks, the beast apparently will not die. The beast I
speak of, of course, is mind-body dualism, and there is good reason to think that
reports of its demise have been greatly exaggerated. Distinctions between mind,
body, and soul are ancient in origin, though they took on renewed importance in
the early modern era and into the Enlightenment. Descartes is typically perceived
as either the primary culprit of mind-body dualism or a potent symbol of its force
(hence the frequent references to “Cartesian dualism”).436 Attributing such a
crabbed perspective to as complicated and as original a thinker as Descartes
seems unwise, and indeed, there is good reason to suspect that Descartes does not
deserve the opprobrium heaped upon him. Martensen, while acknowledging that
the cogito grounds some version of mind-body dualism, notes a great many of
Descartes’s other writings which seem to reject a rigorous distinction between
mind and body.437 Morris goes further and argues that mind-body dualism is not
Cartesian in origin, and instead is more properly understood as a creature of the
Victorian age.438
436
E.g., Antonio R. Damasio, Descartes’ Error: Emotion, Reason, and the Human Brain.
New York: Quill, 1994).
437
Martensen, The Brain Takes Shape, 47-75, 129-134, 209-213.
438
Morris, “An Invisible History of Pain;” Morris, The Culture of Pain.
170
Defending Descartes is not my purpose here. What is important is to
assess the role of mind-body dualism in shaping the meaning of pain in American
society. Curiously, the fact that myriad scholars have produced innumerable
articles, books, and presentations debunking the duality does not seem to have
penetrated all that far, at least insofar as pain scholars from fields as diverse as
anthropology,439 sociology,440 narrative studies,441 psychiatry,442 and
neuroscience443 note the vigorous persistence of such dualism.
Moreover, virtually every ethnography of pain among Western
populations that I have reviewed states or implies that mind-body dualism is a
primary schema for interpreting and understanding pain for all relevant
stakeholders, including illness sufferers, providers, and caregivers.444 Given the
lack of any serious suggestion in the literature asserting that mind-body dualism is
not a key scheme for framing and categorizing pain, I submit that any analysis of
the meaning of pain that does not account for the continued relevance of mindbody dualism is incomplete. More so, as I will argue in chapter 9, any pain
439
E.g., Jackson, “Stigma and Chronic Pain.”
440
E.g., Gillian A. Bendelow and Simon J. Williams, “Transcending the Dualisms:
Towards a Sociology of Pain,” Sociology of Health & Illness 17, no. 2 (March 1995): 139-165.
441
E.g., Morris, “An Invisible History of Pain;” Morris, The Culture of Pain.
442
E.g., Sullivan, “Finding Pain Between Minds and Bodies.”
443
E.g., Fields, “Setting the Stage for Pain.”
444
E.g., Jackson, “Stigma. Liminality, and Chronic Pain;” Susan Greenhalgh, Under the
Medical Gaze: Facts and Fictions of Chronic Pain (Berkeley: University of California Press,
2001); Jackson, Camp Pain; Honkasalo, “Chronic Pain as a Posture;” Honkasalo, “What is
Chronic is Ambiguity;” Bendelow and Williams, “Transcending the Dualisms;” Arthur Kleinman,
“Pain as Resistance: The Delegitimation and Relegitimation of Social Worlds,” in Pain as Human
Experience, eds. Paul E. Brodwin, Arthur Kleinman, Byron J. Good, and Mary-Jo DelVecchio
Good (Berkeley, CA: University of California Press, 1992), 169-197; Jackson, “ ‘After a While,
No One Believes You;’” Joseph A. Kotarba, Chronic Pain: Its Social Dimensions (Beverly Hills,
CA: Sage Publications, 1983).
171
policies that do not incorporate such an understanding have little chance of
significant impact.
While detailed analysis of the link is not the objective of this chapter, it
should take little imagination to connect the importance of the power of visible
material pathology in nineteenth century understandings of illness and pain to the
rubric of mind-body dualism. This is presumably part of why Morris insists that
such dualism is more properly conceptualized as a legacy of nineteenth century
sensibilities than seventeenth century thought.445 By extension, the power that the
visible continues to exert in contemporary understandings of illness and pain
within and without the culture of biomedicine provides at least a prima facie
rationale for the continued pull of mind-body dualism.
Unlike prior chapters, in which I attempted to synthesize claims and
evidence from a variety of authorities and sources, in this chapter, I focus
primarily on a close reading of one scholar’s analysis. One reason for this is the
immensity of the literatures (sic) on mind-body dualism, which requires me to
specify exactly what aspect of it I deem most important to understanding the
meaning of pain in American society. The specific question for this chapter is
why does mind-body dualism continues to exert such a pull on Western and U.S.
concepts of pain? As to this question, the most helpful account stems from John
Searle’s analysis on subjectivity and consciousness.
Before proceeding, I want to note that neither this nor the remaining
chapters undertake a philosophical analysis of consciousness, which continues to
generate vigorous debate in philosophy, psychology, psychiatry, and
445
See note 441 above.
172
neuroscience. Yet, Searle’s perspective is crucial at least in part because of his
notion that the chief flaw in many dominant accounts of mind and consciousness
is their failure to proffer an adequate account of subjectivity. The reason that I
take Searle’s analysis on this point to be so important–apart from the fact that I
find it persuasive–is because the thesis I am developing suggests that pain is so
poorly treated in the United States primarily because the irreducibly subjective
phenomenon of pain resists objectification. In other words, I am suggesting that
the uniquely subjective nature of pain maps out poorly onto a conception of
illness in which visible material pathology occupies pride of place among both
illness sufferers and providers.
While Searle is concerned primarily with the role of subjectivity in
consciousness, it is, as I will argue, no accident that so many of his examples and
arguments reference pain.446 The experience of pain features so prominently in
Searle’s (and many other scholars’) accounts of consciousness precisely because
pain is a (the?) quintessentially subjective phenomenon. Accordingly, if
subjectivity is central in Searle’s account, one would predict that pain would be a
particularly instructive case study for thinking about consciousness.
SEARLE’S ACCOUNT OF THE ROLE OF SUBJECTIVITY IN CONSCIOUSNESS
Searle’s account of consciousness, explicated primarily through his 1992
monograph, The Rediscovery of Mind, and a 2000 essay in the Annual Reviews of
Neuroscience, begins with his solution to the mind-body problem.447 This
446
Indeed, reference to pain is commonplace among philosophical treatments of
consciousness. I will elucidate the reasons for this below.
447
Searle develops his account at length in the Rediscovery of Mind, and as such I will
focus almost exclusively on this text. There is no indication in the 2000 essay or in any other of
173
solution is deceptively simple: “Mental phenomena are caused by
neurophysiological processes in the brain and are themselves features of the
brain.”448 However, as he goes on to explain, they are not reducible to such
processes. “The brain causes certain ‘mental’ phenomena, such as conscious
mental states, and these conscious states are simply higher-level features of the
brain.”449
Searle does not regard mental phenomena as composed of a different
substance, floating in the ether, as it were: “[m]ental events and processes are as
much part of our biological natural history as digestion, mitosis, meiosis, or
enzyme secretion.”450 He is therefore happy to term himself a “biological
naturalis[t],”451 though he is not an eliminative materialist. This is because, for
Searle, there is more to mind than neurophysiological substrate, even while such
substrate is assuredly a sine qua non for mind. As such, Searle rejects both
dualism and monism in the philosophy of mind. He continually wonders why
both positions are deemed to “exhaust the field” such that mind–a term which I
will use interchangeably with consciousness452–is perceived to be either reducible
to neurophysiological substrate or to exist in the ether, independent of and not
contingent upon such substrate. “The fact that a feature is mental does not imply
Searle’s writings that he has significantly changed his views on the role of subjectivity in
consciousness.
448
John Searle, The Rediscovery of Mind (Cambridge, MA: The MIT Press, 1992), 1.
449
Ibid., 14.
450
Ibid., 1.
451
Ibid.
452
This is not to assume that “mind” and “consciousness” are identical, but merely that
whatever difference exists between the two terms is immaterial to the purposes for which I intend
to use them.
174
that it is not physical; the fact that a feature is physical does not imply that it is not
mental.”453
Linking this seemingly ubiquitous reductionism to traditional notions of
objectivity, Searle notes that
[w]e have the conviction that if something is real, it must be
equally accessible to all competent observers. Since the
seventeenth century, educated people in the West have come to
accept an absolutely metaphysical presupposition: Reality is
objective. This assumption has proved useful to us in many ways,
but it is obviously false, as a moment’s reflection on one’s own
subjective states reveals. And this assumption has led, perhaps
inevitably, to the view that the only “scientific” way to study the
mind is as a set of objective phenomena. Once we adopt the
assumption that anything that is objective must be equally
accessible to any observer, the questions are automatically shifted
away from the subjectivity of mental states toward the objectivity
of the external behavior.454
There are a number of important points in this excerpt. First, this is a
particular (historical) conception of objectivity–a proposition that x is objective if
and only if “it is equally accessible to all competent observers.”455 Second, Searle
traces this conception to the seventeenth century, which is consistent with my
analysis regarding the increasing power of the visible and its link to the
clinicopathologic method (though if Daston and Galison and I are correct, the
nineteenth century is significantly more important in framing contemporary
notions of objectivity). Third, the notion that only objective phenomena are real
in Searle’s sense is “obviously false” because one has subjective mental states
453
Ibid., 14-15.
454
Ibid., 16.
455
Ibid.
175
that, by definition, are not equally accessible to all. He notes later that “[t]here
are lots of empirical facts that are not equally accessible to all observers.”456 As
an example, he cites the evidence that birds navigate using the earth’s magnetic
field:
It is, I take it, an empirical fact whether or not birds navigate by
detecting the magnetic field actually have a conscious experience
of the detection of the magnetic field. But the exact qualitative
nature of this empirical fact is not accessible to standard forms of
empirical tests. And indeed, why should it be? Why should we
assume that all the facts in the world are equally accessible to
standard, objective, third-person tests? If you think about it, the
assumption is obviously false.457
Of course, this leaves unanswered an important question related to the
ontological status of subjective mental states. To assert that such states are real is
almost simultaneously to arrive at an important conclusion and to underscore the
crucial question: if it is the case that we have subjective mental states, and that
there are many facts in the world that are not accessible to all competent
observers, why is it that a paradigm case of such a state, one which Searle
repeatedly returns to (pain), is doubted precisely because it is not equally
accessible to all? This is simply another way of phrasing the question I have been
attempting to answer throughout this project.
Fourth, Searle indicates that the notion that reality is objective has led to a
belief that the only scientific way to study consciousness is as a set of objective
phenomena. Perhaps this explains Amanda Pustilnik’s observation that
456
Ibid., 72.
457
Ibid., 73.
176
contemporary neuroscientists are often overt and committed reductionists.458
There is therefore some reason to believe that within the praxis of neuroscience,
there is an impetus to reduce mind to brain precisely because the latter is subject
to objective modalities of knowing.459
Of course, at this point in my project, the able reader should not be
surprised by Searle’s reflection on the objectifying features of the investigating
Eye. Indeed, as I hope I have shown, such objectification is constitutive of the
clinical gaze and of nineteenth century conceptions of science. Aptly, then,
Searle observes that, in his experience, scientists frequently assert that
consciousness is beyond their ken: “The deepest reason for the fear of
consciousness is that consciousness has the essentially terrifying feature of
subjectivity.”460
458
Pustilnik, “Violence on the Brain;” see also Walter Glannon, “Our Brains Are Not
Us,” Bioethics 23, no. 6 (July 2009): 321-329.
459
In her account of the various attempts to measure and objectify pain in the United
States during the twentieth century, Noèmi Tousignant confirms just such a suspicion. Tousignant
documents how the dolorimeter, popularized during the 1940s and 1950s, fell out of favor among
scientists and physicians precisely because, it was argued, it failed to produce consistent,
replicable, objective data regarding clinical pain. In his pioneering of the analgesic clinical trial
during the 1950s and 1960s, Henry Beecher successfully undermined prevailing medical and
scientific opinion on the dolorimeter in large part because he showed that the analgesic clinical
trial could better objectify clinical pain. This suggests that the preference for a particular means of
measuring pain reflects attitudes, practices, and beliefs regarding what features of the phenomenon
of pain are most significant. The success of the analgesic clinical trial illustrates that the focus on
objectification and aggregation of pain experiences received the lion’s share of the attention and
resources during the middle decades of the twentieth century. Tousgnant, “Pain and Objectivity.”
On the role of quantification in the history of objectivity, see Theodore M. Porter, Trust in
Numbers: The Pursuit of Objectivity in Science and Public Life (Princeton, NJ: Princeton
University Press, 1995); and Peter Dear, “From Truth to Disinterestedness in the Seventeenth
Century,” Social Studies of Science 22, no. 4 (November 1992): 619-631.
460
Searle, The Rediscovery of Mind, 55.
177
Searle’s basic claim is that materialism, roughly defined as the belief that
consciousness is reducible to material (biological) substrate, leaves out the crucial
role subjectivity plays in constituting consciousness:
What we find in the history of materialism is a recurring tension
between the urge to give an account of reality that leaves out any
reference to the special features of the mental, such as
consciousness and subjectivity, and at the same time account for
our ‘intuitions’ about the mind.461
Again, he emphasizes that there is nothing about the necessity of
subjectivity in constituting mind that implies subjective mental states exist
independent of material phenomena. Even referring to “subjective mental states”
is redundant, because “[m]ental states only exist as subjective, first-person
phenomena.”462 Searle acknowledges the difficulty in defining consciousness,
and stresses a distinction between ontological and epistemic subjectivity. For
example, he argues, the claim that ‘I have a pain [in my back] is epistemically
objective because “it is made true by the existence of an actual fact and is not
dependent on any stance, attitudes, or opinions of observers. However, the
phenomenon itself, the actual pain itself, has a subjective mode of existence, and
it is in that sense which I am saying that consciousness is subjective.”463
While it is important that this quotation is only one of Searle’s many
references to pain, the distinction between ontological and epistemic subjectivity
is both less significant for my purposes and less compelling than much of his
461
Ibid., 52.
462
Ibid., 70.
463
Ibid., 94.
178
analysis. The effects of stigma and the way it is socialized draw their power
precisely because so much of our subjective mental states are defined, constituted,
and shaped through our practices and social experiences. As such, while there is
obviously some meaningful distinction between what Searle terms epistemic and
ontological objectivity, the ways in which we constitute the Self through the
Other, to borrow a Husserlian point, constantly work to undermine the distinction.
Because we are, in the phenomenologic sense, bodies in the world, the ways in
which our (“objective”) epistemic claims are deeply and profoundly affected by
our interactions with others–especially our interactions with others related to
illness and health–inevitably become entangled with the ontological
(“subjective”) status of our mental states. As such, I generally remain
unconvinced that the distinction between ontology and epistemology as to
subjectivity is as neat as Searle suspects.
In any case, for Searle, the ontological status of subjectivity is a function
of its first-person status. That is, pain is
not equally accessible to all observers . . . For it to be a pain, it
must be somebody’s pain; and this in a much stronger sense than
the sense in which a leg must be somebody’s leg, for example.
Leg transplants are possible; in that sense, pain transplants are not.
And what is true of pain is true of conscious states generally.
Every conscious state is always someone’s conscious state.464
This seems uncontroversial, but it nevertheless carries important
implications. This reference to consciousness in terms of pain, among many
others, makes sense because Searle believes that subjectivity is the key element of
464
Ibid., 94-95.
179
consciousness indeed, and one that materialists ignore or deny. As such, Searle
goes on to explain that subjectivity is inherently “perspectival” in that “[t]he
world itself has no point of view, but my access to the world through my
conscious states is . . . always from my point of view.”465
Again, though this seems trivially true, there is reason to believe that the
implications of these bedrock premises are neither widely nor fully appreciated.
Because pain is perspectival, pain is necessarily particular, acculturated, and
context-dependent. Pain scholars of various disciplines strongly endorse the idea
that cultural and social phenomena are constitutive of pain experience.466 To link
this back to consciousness, Searle reasons that “If we try to draw a picture of
someone else’s consciousness, we just end up drawing the other person (perhaps
with a balloon growing out of his or her head). If we try to draw our own
consciousness, we end up drawing whatever it is that we are conscious of.”467
This highlights an important feature of consciousness, one that follows from its
irreducible subjectivity: our own consciousness is invisible to us. To argue for
this, Searle first suggests that there is no way to observe another’s consciousness.
Instead, what is observed is “him and his behavior and the relations between him,
the behavior, the structure, and the environment.”468
465
Ibid., 95.
466
Fields, “Setting the Stage for Pain,” Laurence Kirmayer, “On the Cultural Mediation
of Pain,” in Pain and Its Transformations: The Interface of Biology and Culture, eds., Sarah
Coakley and Kay Kaufman Shelemay (Cambridge, MA: Harvard University Press, 2007), 363401; Jackson, “Stigma, Liminality, and Chronic Pain,” Jackson, Camp Pain; Morris, The Culture
of Pain.
467
Searle, The Rediscovery of Mind, 96 (emphases in original).
468
Ibid., 97.
180
This seems uncontroversial, but what of the agent who tries to observe
their own consciousness? “The very fact of subjectivity, which we were trying to
observe, makes such an observation impossible. Why? Because where conscious
subjectivity is concerned, there is no distinction between the observation and the
thing observed, between the perception and the object perceived.”469 When that
object is the agent’s own subjective mental states, any such distinction seems
even less plausible for the reason Searle notes. As Searle concludes, “[a]ny
introspection I have of my own conscious state is itself that conscious state.”470
Searle’s point is that not only are we unable to observe another person’s
subjectivity, we cannot observe our own subjectivity, “for any observation that I
might care to make is itself that which was supposed to be observed.”471 If Searle
is correct, this again demonstrates the significance of his earlier point that there
are many phenomena in this world which do not depend for their ontological
status on the ability to be accessed equally by all observers. Translated into more
concrete terms, one might well suggest that the fact that we cannot measure or
quantify a phenomenon utterly fails to establish that the phenomenon is not real.
This argument too has important implications for pain, as there is good reason to
469
Ibid.
470
Ibid. As noted in chapter 1, the truth of this concept for the pain sufferer may be
phenomenologically grotesque. For the pain sufferer may well feel trapped in the confines of their
own suffering, hyperaware of their embodied self, but unable to avoid the pain. Morris notes that
“chronic pain may expand to fill the patient’s entire being,” and that “a life filled with intractable
pain is not merely arduous and disordered but very likely pathological.” Morris, Illness and
Culture, 109. The pain sufferer, then, is acutely aware of the inescapability of one’s own
subjectivity, of one’s own consciousness, and yet it is the manifestation of that consciousness in
unremitting chronic pain that causes untold suffering. This is why Searle’s analysis on
consciousness links up in important ways with the phenomenology of pain that is the foundation
for this entire project.
471
Ibid., 99.
181
believe that a primary reason pain is managed so poorly is because it cannot be
seen, measured, or quantified “objectively.”
In addition, there is generally little dispute that consciousness is an
emergent property. This means that it arises out of the interactions of multiple
variables, but is not reducible to any of its constituent elements.472 Searle hastens
to add, however, that emergence does not imply that system behavior is the
product of some causal factor that “could not be explained by the causal behavior
of the neurons.”473 This is simply another way of suggesting that
neurophysiological substrate is a sine qua non for consciousness, but
consciousness is not reducible to such substrate.
Objectivity, Consciousness, and Reductionism
Searle addresses reductionism in detail, and suggests that what he terms
“ontological reductionism” is linked in a scientific context to the general trend
“toward greater generality, objectivity, and redefinition in terms of underlying
causation.”474 It should come as no surprise that I strongly endorse Searle’s
assessment here, though I naturally think he leaves much of the most interesting
material out, related to why scientific analyses trend to notions of generality,
mechanical objectivity, and discrete causation.
Yet, Searle argues, consciousness is irreducible. In demonstrating this, he
once again turns to the example of pain:
472
Ibid., 112. Not coincidentally, the emergent nature of consciousness also suggests that
an interdisciplinary analysis may be particularly well-suited to unpacking its meaning. For an
account of the capacity of interdisciplinary studies to make sense of complex adaptive systems
which typically feature emergent properties, see Newell, “A Theory of Interdisciplinary Studies.”.
473
Searle, The Rediscovery of Mind, 112.
474
Ibid., 116.
182
Suppose we tried to say the pain is really “nothing but” the patterns
of neuron firings. Well, if we tried such an ontological reduction,
the essential features of the pain would be left out. No description
of the third-person, objective, physiological facts would convey the
subjective, first-person character of the pain . . . [S]omeone who
had a complete knowledge of the neurophysiology of a mental
phenomenon such as pain would still not know what a pain was if
he or she did not know what it felt like.475
A phenomenological approach coheres with Searle’s argument here. Akin
to Matthews’s arguments on the incoherence of conceiving of the lived
experience of depression in terms of serotonin levels,476 it is absurd to claim that
the phenomenon of pain is exhausted by patterns of neuron firings. One way of
apprehending this apparent absurdity would be to imagine a health care provider
informing a patient suffering from intense pain that their conscious experience is
equivalent to and is nothing but neuronal firing. It is difficult to imagine the pain
sufferer who would accept the claim that their suffering is literally equivalent to
neuronal firing.
Walter Glannon adduces similar points in a very recent and aptly titled
article: “Our Brains Are Not Us.”477 Adopting a phenomenologic approach with a
focus on the mind as embodied, Glannon confirms the emergent, subjective,
nonlinear account of mind:
The mind can be described as a set of unconscious and conscious
states that emerge from the brain and its interaction with the body
and environment. The mind emerges at a higher level from lowerlevel brain functions in order to promote the adaptability and
survival of the organism within the environment. This cannot be
475
Ibid., 117-18.
476
See notes 101-120 above.
477
See note 460 above.
183
done by neurons, axons, synapses, and neurotransmitters alone . . .
It is not the brain but the subject constituted by the brain and the
mind who is the agent.478
Searle elucidates this point further by explaining how the objectification
utilized in the scientific and clinical gaze is unable to account for the subjective
experiences of pain and consciousness:
We could simply define, for example, “pain” as patterns of
neuronal activity that cause subjective sensations of pain. And if
such a redefinition took place, we would have achieved the same
sort of reduction for pain that we have for heat. But of course the
reduction of pain to its physical reality still leaves the subjective
experience of pain unreduced, just as the reduction of heat left the
subjective experience of heat unreduced.479
The idea here is not that the neurobiological causes of pain are somehow
disconnected or irrelevant to the experience of pain, but that the experience of
pain as a phenomenon is simply not reducible to neurobiology. Searle continues:
Part of the point of the reductions was to carve off the subjective
experiences and exclude them from the definition of the real
phenomena, which are now defined in terms of those features that
interest us most. But where the phenomena that interest us must
are the subjective experiences themselves, there is no way to carve
anything off.480
In other words, whether the phenomenon in question is consciousness or
its manifestation as pain, it is precisely those subjective, first-person experiences
that are the subject of inquiry. This has important ramifications for the efforts to
478
Glannon, “Our Brains are Not Us,” 322.
479
Searle, The Rediscovery of Mind, 121.
480
Ibid.
184
obtain objective evidence of pain. If what we are “interested in” is irreducibly
subjective, then any effort to objectify pain is incoherent. It is, to borrow my
favorite Wittgensteinian metaphor, an attempt to open doors that are merely
painted on to walls.481 What we might like to know most about pain is precisely
what we can never capture in an ontologically objective sense, because any
objective measure by definition tells us nothing about the subjective phenomenon
of pain itself. Resnik, Rehm, and Minard concur, arguing that such attempts are
chimerical:
[P]ain assessment tools will never achieve the degree of objectivity
that one finds in most medical tests, since pain will still be a
subjective sensation or feeling . . . We can no more test for pain
than we can test for a person’s enjoyment of Mozart, distaste for
anchovies, or fear of the IRS.482
But, the objection might be couched, can we not use novel neuroimaging
techniques to test for a person’s enjoyment of Mozart, distaste for anchovies, or
fear of the IRS?
Pain, Subjectivity, and Neuroreductionism
The hypothetical study would follow the standard fMRI protocol.
Baseline readings would be taken of a subject, followed by application of the
stimulus and comparison of blood oxygenation levels in the relevant (read:
localized) region of the brain. If the observed activation levels reach the desired
481
Douglas A. Gasking and Alan C. Jackson, “Wittgenstein as a Teacher,” in Ludwig
Wittgenstein: The Man and his Philosophy, ed. Kenneth T. Fann (New York, NY: Humanities
Press 1978), 169-183.
482
Resnik, Rehm, and Minard, “The Undertreatment of Pain,” 284.
185
measure of significance, then the study has presumably identified a neural
correlate of “enjoying Mozart.” Indeed, one such study, entitled “A Functional
MRI Study of Happy and Sad Affective States Induced by Classical Music,” has
already been published.483
However beguiling, such an argument is what Racine, Bar-Ilan, and Illes
have referred to as the fallacy of “neuro-realism.”484 It is the same category
mistake referenced in chapter 4’s discussion of Loeser’s challenge (“does anyone
really think that a tooth is capable of hurting? Or a back?”). The notion that
quantifying blood oxygenation levels literally captures the experience of
“enjoying Mozart” is absurd. The very terminology used in the neuroimaging
literature underscores the absurdity, as the phrase “neural correlate” implies quite
correctly that the analysis therein simply attempts to correlate a particular
function with increased blood oxygenation. The conclusion that the experience of
pain is reducible to such increased blood oxygenation is both absurd and false.
Glannon concurs, noting that the claim is erroneous even on its own terms,
because such images “are visualizations of statistical analyses based on large
numbers of images and are more accurately described as scientific constructs than
actual images of the brain.”485 But, he continues, “[e]ven if imaging could tell us
483
Martina T. Mitterschiffthaler, Cynthia H.Y. Fu, Jeffrey A. Dalton, Christopher M.
Andrew, and Steven C.R. Williams, “A Functional MRI Study of Happy and Sad Affective States
Induced by Classical Music,” Human Brain Mapping 28, no. 11 (November 2007): 1150-1162.
484
Eric Racine, Ofek Bar-Ilan, and Judy Illes, “fMRI in the Public Eye,” Nature Reviews
Neuroscience 6, no. 2 (2005): 159-64.
485
Glannon, “Our Brains Are Not Us,” 325. See also Vul, Harris, Winkielman, and
Pashler, “Puzzlingly High Correlations in fMRI Studies”; Kelly Joyce, Magnetic Appeal: MRI and
the Myth of Transparency (Ithaca, NY: Cornell University Press, 2008); Kelly Joyce, “Appealing
Images: Magnetic Resonance Imaging and the Production of Authoritative Knowledge,” Social
Studies of Science 35, no. 3 (June 2005): 437-462; and Joseph Dumit, Picturing Personhood:
Brain Scans and Biomedical Identity (Princeton, NJ: Princeton University Press, 2003).
186
what actually occurred in the brain,” the category error still vitiates the claim: “it
could not tell us what actually occurred in the brain, it could not reproduce the
phenomenological feel of what it is like for a subject to experience events in the
world.”486
In short, there is no conceivable sense in which any method which
proceeds via objectification could entirely account for the irreducibly subjective
phenomenon of pain. Of course, this is not to suggest that objectifying modalities
have no place in diagnosing and treating pain, but rather that the notion that
neuroimaging techniques can characterize what the experience of pain is like for
the pain sufferer is dangerously misguided. This is also not to suggest any
infirmity in a causal account of intense pain that attributes the pain to patterns of
neuronal firing. Searle’s point is precisely that such neurophysiological
phenomena are a necessary cause of pain, but that this causal account alone is
insufficient to capture the phenomena of pain, just as neuronal firing alone is
insufficient to capture the phenomena of consciousness. Searle therefore
concludes that the “antireductionist argument . . . is ludicrously simple and quite
decisive.”487
However, if this is so, why are such neurofallacies so profligate? Why do
so many scholars and lay people suggest that neuroimaging techniques provide
objective evidence of that which cannot be objectified (pain)? Perhaps more to the
point, why do epistemic agents perpetually seek to objectify that which cannot be
objectified?
486
Glannon, “Our Brains Are Not Us,” 325.
487
Searle, The Rediscovery of Mind, 118.
187
My answer, of course, is that the power of the visible exerts an astonishing
influence in shaping American conceptualizations of mind, body, illness, and
pain. In McCabe and Castel’s recent study, subjects consistently found scientific
arguments featuring fMRI images more persuasive than arguments composed in
text alone, even where both featured identical logical fallacies.488 The rhetoric of
the visible is persuasive in the United States, such that the authors conclude that
“brain images are influential because they provide a physical basis for abstract
cognitive processes, appealing to people’s affinity for reductionistic explanations
of cognitive phenomena.”489
The ready belief that the overtly objectifying techniques that characterize
Western science and the clinical gaze can be used to measure the experience of
pain betrays the hold that seeing inside the body and, in particular, seeing inside
the brain exerts in American society. These scientific and clinical images bestow
the power to reify, and, as such, it is unsurprising to see the effects of such
dualism pervading the meaning-making endeavors of chronic pain sufferers
themselves.
Pain Sufferers, Mind-Body Dualism, and the Power of Imaging
The convergence between the power of the visible and mind-body dualism
for pain sufferers in the United States is powerfully demonstrated in Rhodes,
McPhillips-Tangum, Markham, and Klenk’s 1999 study, aptly entitled “The
Power of the Visible: The Meaning of Diagnostic Tests in Chronic Back Pain.”490
488
David P. McCabe and Alan D Castel, “Seeing is Believing: The Effect of Brain
Images on Judgments of Scientific Reasoning,” Cognition 107, no. 1 (April 2008): 343-352.
489
Ibid., 344; Joyce, Magnetic Appeal.
490
Rhodes, McPhillips-Tangum, Markham, and Klenk, “The Power of the Visible.”.
188
The authors randomly selected 110 patients from a larger pool of chronic back
pain patients in Atlanta, Dallas, and Seattle, of which seventy agreed to be
interviewed. Interviewers conducted sixty-seventy-five minute interviews, which
were taped, transcribed, and interpreted via thematic analysis.
Chronic back pain is an especially significant choice for analysis because,
as illustrated in chapter 1, chronic back pain is both particularly prevalent in the
United States, and back pain treatments are frequently ineffective and
unsatisfying for patients.491 Moreover, the general absence of lesions, or visible
material pathologies, is not simply a nineteenth-century problem, as chronic back
pain often presents with no evidence of visible, material pathologies.492
One theme that emerges from Rhodes, McPhillips-Tangum, Markham,
and Klenk’s study is the concreteness promised by imaging tests: “They call on
the patient to align herself with their reality, demanding to be read as factual
evidence of a match between the inside of the body as ‘specimen’ and the inside
of the body as the private and incontrovertible ground of experience.”493 Note
here the notion that the images of the inner body produced by imaging techniques
are deemed to be real, which echoes both Searle’s analysis on the “reality” of
objectivity and the notion I have been highlighting throughout regarding the
relationship between internal pathologies and external signs or symptoms.
Accordingly, the concreteness of visible images of the material structures
of the inner body is closely tied with the themes of legitimacy and justification:
491
William Hammond’s treatise on spinal irritation, among many others, suggests that the
difficulties in diagnosing and treating chronic back pain are not simply a contemporary problem.
492
John M.S. Pearce, “Chronic Regional Pain and Chronic Pain Syndromes,” Spinal Cord
43, no. 5 (May 2005): 263-268.
493
Rhodes, McPhillips-Tangum, Markham, and Klenk, “The Power of the Visible,” 1193.
189
Patients for whom something ‘shows’ on tests emphasize a feeling
of justification, of not being ‘crazy.’ Tests ‘show where it hurts’
and confirm the reality of pain: in fact, patients repeatedly use the
word real to describe this confirmation and remark that what
‘shows’ is ‘obvious’ and ‘concrete.’”494
This passage is important, and it underscores several important points. First, what
is most significant for the pain sufferers is what shows via diagnostic imaging
tests. The power of the visible in making meaning of pain is therefore not limited
solely to practitioners within the culture of biomedicine, but is a primary narrative
for pain sufferers themselves. Jackson writes of one pain sufferer’s frustration
with the inability of his physicians to produce visible images of the cause of his
pain: “He would go for tests hoping fervently that something would show up, and
after a while he did not care what it was.”495 Second, the imaging tests enable
localization of pain, they “show where it hurts.” I have attempted to illustrate that
the significance of localizing pain extends back at least as far as the nineteenth
century, and is tied to the importance of identifying visible, material pathologies
as the seat of pain. Moreover, pain sufferers as well as providers connect the
legitimacy and reality of pain to its localizability.
Likewise, Honkasalo notes that the chronic pain sufferers in her
ethnography tended to localize their pain: “In her story, Anniki said that the pain
‘usually lives in her left hip, loin and thigh.’ ‘Often it is so circumscribed that I
feel, if it could be surgically removed, I’d be healthy.’ The strict localization
affirmed her thoughts about the biomedical etiology of her pain.”496 Honkasalo,
494
Ibid., 1194.
495
Jackson, Camp Pain, 41.
496
Honkasalo, “Chronic Pain as Posture,” 202.
190
who is both a physician and an anthropologist, here connects the meaning-making
power of the localization of pain to mind-body dualism. Such localization is
crucial to the pain sufferers precisely because it indicates that the seat of the pain
is in the body. Of course, as I have argued, the notion of a distinction between
pain that is “in the body” and pain that is “in the mind” is incoherent, because
cognitive and affective processes are inextricably linked to pain. Fields’s point is
precisely that the neurobiology of pain cannot be separated from the meaning of
pain, because our ways of understanding and making meaning of pain shape and
inform neurochemical pathways and vice-versa in the circular feedback loop
patterns characteristic of complex adaptive systems. 497 Thus, he notes, “all pain
is mental.”498
But the incoherence of this distinction is not reflective of its persistence
among both lay persons and providers; pain that is localizable in the body via
imaging techniques reifies otherwise invisible pain. Without visible images
demonstrating the seat of the pain in visible, material pathologies, pain sufferers
themselves doubt the legitimacy of their pain. So powerful is the reifying
potential of seeing the visible material pathologies that cause their pain that some
pain sufferers in the study express palpable relief when anomalies show up on
imaging tests, even when such anomalies portend invasive surgeries:
In an instant [the] patient goes from feeling disbelieved –that she
has to ‘insist’ in the face of repeated disappointment–to an intense
feeling of relief, despite the fact that what has been found means
that she faces surgery. What she had been saying to her doctor
497
Fields, “Setting the Stage for Pain,” 36; Glannon, “Our Brains Are Not Us,” 328;
Newell 2001, “A Theory of Interdisciplinary Studies.”
498
Fields, “Setting the Stage for Pain,” 36.
191
could not be heard until, to her joy, it could be seen. Patients who
describe events like this express satisfaction even when the
diagnosis itself does not suggest imminent or even eventual
relief.499
The second sentence in this quotation–the difference between voicing complaints
that were not heard and seeing causes of signs and symptoms–exactly tracks
Foucault’s depiction of the changes between eighteenth-century and nineteenthcentury medical cosmologies (the difference between the questions ‘what is the
matter with you’ and ‘where does it hurt’). The meaning made in seeing the
visible, material pathologies that cause the pain is such that even the prospect of
invasive, presumably painful surgeries on the pain sufferer’s back is of
comparatively less significance.
Both of the pain sufferers whom the authors describe (“Pam” and “Stan”)
“emphasize that the role of the doctor is to look. Pam describes her doctor as
‘willing to look’ and Stan expresses frustration that his does not look farther . . .
He persists in believing that his doctors can not have run all the tests if his back
still hurts.”500 The physician’s role in constructing a meaningful story with the
patient501 centers on the physician’s ability to find the visible, material causes of
the patient’s suffering. This is why, in Honkasalo’s study, one sufferer, “Anniki,”
bore a grudge against physicians “because they did not find any special causal
agent.”502 Tracking the importance of localization and mind-body dualism I have
addressed, Stan cannot account for the persistence of his pain if no test or
499
Rhodes, McPhillips-Tangum, Markham, and Klenk, “The Power of the Visible,” 1195.
500
Ibid., 1200 (emphases in original).
501
Brody, Stories of Sickness.
502
Honkasalo, “Chronic Pain as Posture,” 202.
192
objective procedure can image it; its correspondence with ‘reality’ is diminished
in the absence of the ability to see.
Thus, the meaning-making power of the clinical gaze is not only a
phenomenon providers attempt to harness, but is also one that ties into the
importance of the visible in thinking about pain, a narrative that pain sufferers,
often desperate for validation and relief, return to as well: “Diagnostic testing
holds out the possibility that they can see where deviation occurs and despite their
expressions of hostility, they live in the same universe of explanation as their
doctors.”503
Jackson’s observations are consistent with this study, and she notes that “I
collected many statements from both patients and staff members characterizing
‘real’ pain in this way–real because one can see it on an X-ray, CT scan, or blood
test.”504 Jackson uses even stronger language to explain the collaborative
dynamic that providers and pain sufferers operate in to make meaning of the pain:
“With few exceptions, medical practitioners and patients in pain generally collude
to maintain a conceptual separation between the mind and the body and search for
objective evidence of an underlying organic condition.”505 The pain patients
Jackson studied desperately searched for “validation of their pain” and “tended to
rely on any available objective measure that made their pain as ‘real’ as
possible.”506 In a grotesque irony, the power of mind-body dualism is such that
chronic pain sufferers–who often have their pain delegitimized and invalidated–
503
Rhodes, McPhillips-Tangum, Markham, and Klenk, “The Power of the Visible,” 1200.
504
Jackson, Camp Pain, 148.
505
Ibid., 39.
506
Ibid., 148.
193
join providers in the search for objective evidence of their pain, even while that
very search is constitutive of the processes which invalidate and delegitimize their
pain.
Before concluding, I want to hasten to add that I am not remotely implying
that pain sufferers should bear blame or fault for employing meaning-making
strategies in the face of pain that may well serve to strengthen the social and
cultural dynamics which animate the general stigmatization and undertreatment of
pain. Many pain sufferers, and in particular chronic pain sufferers, are desperate
in a variety of ways. Even assuming the best of intentions from providers and
caregivers, the evidence suggests that pain sufferers are often stigmatized, are
often not heard, and frequently have their experiences invalidated and
delegitimized.507 In addition to these problems, many pain sufferers do just that–
they suffer, and they often experience great difficulty in making meaning of their
pain. I do not fault pain sufferers for seeking narratives, which, by virtue of their
social and cultural significance, seem to provide ways of relieving their
desperation and making meaning of their suffering.508
The point of the analysis was to explain how and why pain sufferers do
conceptualize and understand their own pain in very similar frames as do their
507
Jackson, “Stigma, Liminality, and Chronic Pain.”
508
Indeed, in a forthcoming and related analysis, I assess the role that the attributed link
between sin and suffering plays in making meaning of the body in chronic pain. Daniel S.
Goldberg, “Suffering for Sin: Job and the Significance of Stigma in Conceiving of the Body in
Chronic Pain,” (working paper, University of Texas Medical Branch, 2009). Utilizing the Book of
Job as a frame, I assess some of the spiritual and phenomenologic reasons why humans so often
seem to stigmatize illness and chronic pain sufferers. While such an analysis is obviously relevant
to thinking about pain, it is less salient to understanding the role of visible, material pathology in
understanding the meaning of pain in the United States. Stigma is crucial to analysis of the
meaning of pain; yet exploring all or even most of the reasons for such stigma in the United States
is a life’s work.
194
providers, and to argue that the emphasis on and power of the visible animates a
Weltanschauung in which lay and professional are both active participants. The
idea is not that pain sufferers should be blamed for seeking the power of imaging
tests or mind-body dualism in making sense of pain; rather, the key idea is that
they do understand and conceptualize their own pain experiences according to
such frames. Ultimately, as I will argue in chapter 9, any pain policies which
justify optimism must account for these deep-seeded social and cultural factors,
these ways of understanding and interpreting the meaning of pain.
CONCLUSION
The primary aim of this chapter was to articulate and defend Searle’s
account of consciousness, which prominently features an irreducible,
unquantifable subjectivity. Such an account eschews dualism, accepting neither
that consciousness is reducible to neurophysiological substrate nor that
consciousness is possible in the absence of such substrate. Consciousness is
emergent, arising from biochemical, physiological, and environmental (social and
cultural) interactions and pathways, but reducible to none of these constituent
parts.
This account has profound implications for understanding the meaning of
pain in American society. It grounds the prevailing view that pain is
quintessentially subjective, and demonstrates the mistakes of conception and
practice that necessarily attend the constant efforts to “carve out” or excise
subjective elements from objects of inquiry (such as “pain” or “consciousness”).
Unfortunately, Searle correctly notes that such efforts are constitutive of scientific
and medical epistemologies, at least since the early modern era, and especially
195
since the nineteenth century. Subjective phenomena that are not perceptible in
visible, material pathologies inside the body are invisible to the clinical gaze, and,
as such, are subject to grave ontological doubts, doubts as to the reality and the
legitimacy of the phenomena. Furthermore, such doubts underscore the persistent
and powerful grip mind-body dualism continues to exert on both lay and
professional conceptions of health, illness, and pain.
This dynamic of doubt is so powerful that pain sufferers internalize that
doubt, desperately seeking visible “proof” of the pathologies understood to be
causing or at least correlated with their chronic pain. The pain sufferers
participate, or “collude,” to use Jackson’s term, in the very process of seeking to
objectify that which defies objectification. Sadly, however, pain sufferers do not
have the luxury of doubting the lived experience of their own pain, even while
their attempts to objectify their pain merely reinforce the conceptual categories
which facilitate the stigmatization so many pain sufferers experience.
196
Chapter 7: Pain, Objectivity, and Bioethics
INTRODUCTION
Given the power of science and medicine in justifying knowledge claims
in the West and the United States, it is unsurprising that dominant categories of
understanding in science and medicine have shaped philosophical discourse. My
impression is that, particularly in moral philosophy, objectivism and realism
dominate much contemporary work. John Leslie Mackie concurs, observing that
“the main tradition of European moral philosophy includes the . . . claim that
there are objective values . . . .”509 This observation certainly applies to
traditionally dominant conceptions of bioethics, or at least in the convention in
bioethics referred to as principlism.
In this chapter, I have two aims. First, I want to describe principlism and
objectivism as it tends to function in bioethics scholarship, and to note some of
the critiques of principlist bioethics that have sprung up largely within the last
decade. Second, building on these critiques, I will articulate two entirely different
ethical theories that, unlike principlist bioethics, are well-suited to accounting for
the ethics of pain: phenomenology and moral particularism. In chapter 2 I
explained the features of the phenomenology of pain, but I expressly reserved
discussion of the implications of such an account for the ethics of pain. I will
assess these implications in this chapter before turning to moral particularism. As
to the latter, moral particularism is a controversial theory in philosophy, and it is
not my intention to exhaustively defend it here (this is a medical humanities
509
John Leslie Mackie, “The Subjectivity of Values,” in Morality and the Good Life, ed.
Thomas L. Carson and Paul K. Moser (New York: Oxford University Press, 1997), 299.
197
dissertation, not a moral philosophy dissertation). Nevertheless, the theory is an
important critique of objectivist and principlist ethics, and has significant
consequences for the ethics of pain. Unfortunately, in its most detailed
formulation (in the work of Jonathan Dancy), moral particularism is quite
technical, and even where its defense is not my objective, care must be taken to
lay out all of the relevant inferences and steps in the argument.
Principlism in morals generally refers to the notion that a stock of
principles are necessary to account for moral reasoning and moral deliberation,
and to guide action. While principlism in bioethics has come under significant
attack in the recent decade, it enjoys a long and distinguished tradition in moral
philosophy. Reliance on principles has deep roots in the Western ethical tradition,
from Plato to Kant to Rawls.
Because of this legacy, I want to be careful to delineate the narrow scope
of my aims in this chapter. It is not intended as a general critique per se of the use
of principles in moral thought, but rather as an assessment of why a particular and
dominant account of the role of principles in applied ethics is ill-suited for giving
ethical account of the body in pain. I make no claims that reliance on principles is
inadvisable in all given ethical contexts, nor do I claim that it is impossible to
enrich some of the dominant conceptions of principles in bioethics discourse.510
What I am concerned with in this chapter is a specific discourse and way of
practice within bioethics related to the operation and function of principles. In
this context, interlocutors frequently issue general, often sweeping statements
510
For example, O’Neill agrees with many critics that much of the discourse within
bioethics regarding autonomy is deficient, and more so, that it is not in keeping with a deep
understanding of Kantian moral theory. Onora O’Neill, Autonomy and Trust in Bioethics
(Cambridge, UK: Cambridge University Press, 2002).
198
about morals that I suggest are of marginal use in assessing the ethics of pain. I
acknowledge the possibility that an objectivist, principle-based ethical approach
could in theory illuminate some important features of the ethics of pain; my
argument here is simply that the specific versions that have tended to dominate
bioethics practice and scholarship are unhelpful in either assessing the ethical
implications of pain or in producing ethical pain policy.
THE ROLE OF PRINCIPLISM IN BIOETHICS
Within bioethics, the most obvious example of the influence of
principlism is the aptly titled Principles of Biomedical Ethics, authored by Tom
Beauchamp and James Childress.511 First published in 1980, and currently in its
sixth edition, the text adopts an overtly principlist approach, generally arguing
that four universal principles are most helpful in illuminating bioethics practice:
autonomy, beneficence, nonmaleficience, and justice. The text has undergone
major changes over the past quarter-century, in no small part because, I suspect,
of the merits of the various criticisms that have been launched against it.
Nevertheless, there is little question that Beauchamp and Childress remain
committed principlists, and the influence of the textbook suggests how
principlism and bioethics have been linked at a deep level almost from the
inception of the field of inquiry.512 Oonagh Corrigan, for example, documents the
ways in which a principle-based conception dominates contemporary
511
Tom L. Beauchamp, and James R. Childress, Principles of Biomedical Ethics, 6th ed.
(New York, NY: Oxford University Press, 2008).
512
Documenting this dominance has been a primary objective of what Raymond DeVries
terms the sociology of bioethics. Raymond DeVries, “How Can We Help? From ‘Sociology in’ to
‘Sociology of’ Bioethics,” Journal of Law, Medicine & Ethics 32, no. 2 (Summer 2004): 279-292;
Raymond DeVries, “Toward a Sociology of Bioethics,” Qualitative Sociology 18, no. 1 (March
1995): 119-128.
199
understandings of informed consent.513
John Evans suggests that “principlism
itself has become an institution.”514 In the sociology of knowledge, Evans
explains, an “institution” is defined as “organized, established procedure[s] . . .
[which] have taken on a life of their own, independent of the social conditions of
their founding, and are self-replicating.”515 He uses the example of Congress,
which was presumably intended as a set of organized, established procedures, but
which now is “self-replicating and self-justifying,” and which “exists independent
of the original impetus for its creation . . . .”516 Principlism, he argues, has
similarly taken on a life of its own, though its usage continues to be facilitated by
governmental and bureaucratic “appetite[s]” for bioethical decisions.517
Moreover, Evans notes that the definition of a “profession” in sociological
terms is the maintenance of a “distinct system of knowledge [the profession uses]
to solve the problems in [its] jurisdiction. This system is taught by the elite to the
average members of the profession–and the dominant system in bioethics is
principlism.”518 This is not to imply any false uniformity in bioethics discourse or
practice; as we shall see, quite a few scholars and practitioners object to
principlism. Rather, my point is that principlism in bioethics has been and
continues to be a dominant framework utilized in bioethics practice and discourse,
and that, while its dominance hardly goes unchallenged, such challenges are much
513
Oonagh Corrigan, “Empty Ethics: The Problem with Informed Consent,” Sociology of
Health & Illness 25, no. 7 (November 2003): 768-792.
514
John H. Evans, “A Sociological Account of the Growth of Principlism,” Hastings
Center Report 30, no. 5 (September-October 2000): 36.
515
Ibid.
516
Ibid.
517
Ibid.
518
Ibid.
200
more likely to come from within the field than from without. Evans concurs:
“[T]he average member of an ethics committee is unlikely to question the system–
who has the time?–and is going to open his or her copy of Beauchamp and
Childress because it sets out a legitimate method for making decisions.”519
However, what Leigh Turner refers to as the “common morality
presumption”520 is not limited to self-identified principlists within bioethics
scholarship, as casuists, common morality proponents such as Bernard Gert, and
theorists drawing on the Rawlsian notion of reflective equilibrium all seem to rely
on the notion of a universal, common morality. Detailed analysis of the overlap
between proponents of casuistry, a common morality approach, and a reflective
equilibrium approach is not my project here. Nevertheless, Jonathan Dancy,
whose version of moral particularism is a central subject of this chapter, suggests
that inasmuch as all would be comfortable being identified as “moral generalists,”
they all seem to rely to a greater or lesser extent on principles. Dancy expressly
links generalism in morals to principlism by defining moral generalism as the
notion that “the very possibility of moral thought and judgment depends on the
provision of a suitable supply of moral principles.”521
Regardless of the extent to which moral principlists identify with casuists,
common morality proponents, or reflective equilibrium theorists, I submit that one
characteristic many of these approaches have in common is that they are
objectivist in nature. By this I mean that these approaches, which have
519
Ibid.
520
Leigh Turner, “Zones of Consensus and Zones of Conflict: Questioning the ‘Common
Morality’ Presumption in Bioethics,” Kennedy Institute of Ethics Journal 13, no. 3 (September
2003): 193-218.
521
Dancy, Ethics Without Principles, 7.
201
traditionally dominated both bioethics discourse and practice, tend to presume
that morality is metaphysically objective, that there exists a notion of morality
which does not depend for its rightness or wrongness on any subjective states or
propositions. For the moral objectivist, the fact that a moral agent deems abortion
to be immoral does not in and of itself suffice to establish the immorality of
abortion. This is because the moral objectivist maintains that there exists an
objective, mind-independent morality which does not depend on any moral
agent’s beliefs about ethics. Admittedly, this proposition seems highly intuitive,
which may help explain the “dominance of the objectivist tradition” in moral
philosophy.522
Mackie notes further that the assumption that “ordinary moral judgments
include a claim to objectivity . . . has been incorporated in the basic, conventional
meaning of moral terms.”523 Indeed, in his defense of moral objectivism, Justin
Felux states that because moral skeptics and anti-realists “are presenting a metaethical system that is very counter-intuitive and defies common sense” it is they
who bear the burden of proof.524
As my example suggests, Felux defines moral objectivism as the thesis
that “at least some of our moral judgments are objectively true or false, and that
they are true or false regardless of the beliefs or feelings of any particular person
or group about them.”525 He acknowledges that “our ethical judgments are both
522
Mackie, “The Subjectivity of Values,” 299.
523
Ibid., 301.
524
Justin Felux, “A Defense of Moral Objectivism,” Symposia: The Online Philosophy
Journal, http://journal.ilovephilosophy.com/Article/A-Defense-of-Moral-Objectivism/10
(accessed June 5, 2009).
525
Ibid.
202
context-dependent and subject-dependent,”526 but nevertheless argues that
propositions such as “It is wrong to punish someone for a crime she did not
commit” and “Genocide is wrong” constitute objective moral statements. His
argument for this conclusion rests on a version of moral intuitionism in which the
chain of reasoning flows as follows:
1. There are moral propositions
2. Propositions are either true or false (Law of Excluded Middle)
3. They are not all false
4. Some correspond to reality (from (2), (3), and the correspondence theory
of truth)
5. Moral values are a part of reality (which is moral objectivism).527
In contrast, some, like Mackie, contend that “[t]here are no objective
values,” and that subjectivism in morals overlaps substantially with skepticism in
morals.528 As do all of the theorists whose work I will assess in this chapter,
Mackie quickly dispenses with the straw man that moral subjectivism constitutes
a wholesale rejection of morality; he readily concedes, as do most moral
subjectivists, skeptics, and particularists, that what he terms “first order normative
moral views” do exist. Moreover, he does not assert a first order claim such as
“that everyone really ought to do whatever he thinks he should.”529 Mackie, like
Turner and Dancy, is making a meta-ethical claim, an argument that accounts for
526
Ibid.
527
Ibid.
528
Mackie, “The Subjectivity of Values,” 291.
529
Ibid., 292.
203
a kind of embodied, contextualized sense of the way in which humans tend to
utilize moral frameworks in practice.
In The Moral Imagination, Mark Johnson terms the dominant conception
of Western ethics as the “Moral Law Folk Theory.” Central to this theory is the
presumed existence of “general laws given by universal human reasons
concerning which acts we must do (prescriptions), which acts we must not do
(prohibitions), and which acts we may do, if we so choose (permissible acts).”530
While not identical to the rough conception of generalism and principlism that I
am working with, I submit there is enough of a family resemblance between
Johnson’s heuristic and generalism and principlism to make his analysis useful.
Johnson does not deny the existence of moral rules, and acknowledges in a
Burkean sense that, “[a]s accretions of the moral wisdom of a tradition or culture,
moral rules can serve as summaries of the experience of a people. But it does not
follow at all from this that acting morally is reducible to acting in strict
accordance with a system of rationally derived rules.”531
In any case, the overlapping concepts of objectivism, generalism, and
realism in morals present complicated, difficult terrain that I cannot hope to fully
account for in a medical humanities analysis centered on the subject in pain. I
nevertheless maintain that as a heuristic, there exists enough meat on the bones to
pick out the key point, for my purposes: the suggestion that within Western moral
philosophy in general and American bioethics in particular, belief in some version
of moral generalism and/or moral principlism has been central. Indeed, if the
530
Mark Johnson, The Moral Imagination: Implications of Cognitive Science for Ethics
(Chicago, IL: University of Chicago Press, 1993), 17.
531
Ibid., 30.
204
reaction to moral particularism is any indication, an ethical theory which purports
to challenge generalism and principlism in morals incites vigorous debate and
consternation.
However, before turning to moral particularism, it is worth noting some
other criticisms of both principlism and objectivism within bioethics discourse.
These criticisms both set the stage for the discussion of particularism that follows,
and suggest some important points for thinking about the ethics of pain.
CRITICISMS OF MORAL PRINCIPLISM
At this point, critiques of the dominance of principlism in bioethics are not
new. Many of the most compelling criticisms center on a notion of ethics
informed by social science research. For example, Leigh Turner argues that the
common morality proponents “simply do not provide the comparative and
historical research that might begin to support the argument for the existence of
common moral norms found in all societies throughout history.”532 Moreover, he
contends, such evidence does not exist:
[S]cholarship in social history and cultural anthropology attests to
the remarkable malleability of communal understandings of
morality. The plasticity of understandings of morality across
cultures and through time suggests grounds for skepticism
concerning the development of a transcultural basis for crosscultural moral norms . . . “Human nature” or some shared, crosscultural sense of moral intuitions does not seem to be a particularly
reliable basis upon which to build universalist models of the
common morality.533
532
Turner, “Zones of Consensus,” 196.
533
Ibid., 197 (citations omitted).
205
The idea is that the common morality position seems empirically dubious
given what we know about cultural relativism, namely, that different communities
and societies often have widely variant conceptions of morality.534 Turner
suggests that what he terms moral pluralists “pose the greatest challenge to the
common morality approach, because the moral pluralists insist that careful
comparative and historical research reveals considerable variability in what
constitutes ‘moral worlds.’”535 Given this variability, even if one wants to assert a
normative claim that moral agents ought to act according to universal, objective
moral rules, the descriptive claim that in fact humans deliberate about and account
for morals using such frameworks rests on shaky ground, to put it mildly.
Of course, arguing that this extreme heterogeneity has meta-ethical
implications is not to commit the naturalistic fallacy; the fact that morality seems
to vary across cultures and contexts does not in and of itself imply that moral
agents ought not act according to “universal” principles and rules of morality.
But if the existence of such principles and rules is itself dubious, it is fair to
criticize an ethical theory which indisputably relies on the notion that a universal,
common morality or set of principles both exists and is knowable. If such
principles or general rules are either not knowable or not understandable across
different moral worlds, moral agents can hardly be charged with the obligation to
be guided by them. As Mackie puts it, “the argument from relativity has some
force simply because the actual variations in the moral codes are more readily
534
I am astonished at the number of analyses of otherwise commendable quality that
seem to confuse the descriptive notion of cultural relativism with the normative conception of
ethical relativism. The former, which generally amounts to the claim that different communities
do in fact demonstrate remarkably variant and malleable beliefs, attitudes, and practices about
morality, seems to me to be beyond dispute.
535
Ibid., 206.
206
explained by the hypothesis that they reflect ways of life than by the hypothesis
that they express perceptions, most of them seriously inadequate and badly
distorted, of objective values.”536
A more devastating critique of principlism, which Turner also adopts, is
the notion that principlism in morals is unhelpful as an action guide. My own
difficulty with moral principlism is that, in my view, it is either false or it is thin.
Either reference to a common stock of principles is dubious for the reasons Turner
suggests, or reliance on a notion of “autonomy” or “justice” requires for its
commonality a level of abstraction that renders it of little use in guiding action in
concrete, particular circumstances. A basic implication of phenomenology is that
our experiences are irreducibly local and particular; our social worlds are
inevitably shaped by the particular relationships, contexts, and networks in which
we are embedded. Thus, giving content to the acts required or prohibited by a
commitment to justice depends greatly on the local, particular social and moral
worlds that we inhabit. Accordingly, even if moral agents from divergent moral
worlds might share a broad commitment to “justice,” they might well understand
what “justice” requires in any given situation entirely differently. Thus, the
appeal to a common or shared sense of justice is thin, because it is only in context
and in practice that thick notions of justice can be conceptualized.537 As Turner
puts it:
536
Mackie, “The Subjectivity of Values,” 302.
537
If this notion of moral thickness seems vaguely Wittgensteinian, it should, as Dancy’s
analysis will demonstrate. Indeed, it is no accident that one of the leading moral particularists,
Margaret Olivia Little, has published extensively on Wittgensteinian conceptions of moral
philosophy, and authored an essay entitled “Wittgensteinian Lessons on Moral Particularism,” in
Slow Cures and Bad Philosophers: Wittgenstein, Medicine, and Bioethics, ed. Carl Elliott
(Durham, NC: Duke University Press, 2003), 161-80. In addition, Kevin Buzinski’s recent
dissertation addresses the convergence of Wittgenstein and moral particularism in context of
207
Even if some highly abstract notion of the four principles could be
found in a core common morality, this shared understanding at the
level of abstract principles need not in any way promote agreement
during the process of specifying and balancing principles. For
example, although it is possible to respect “autonomy” in general
or to defend “justice” in the abstract, it is quite another matter to
defend specific autonomous choices that are understood to lead to
particular practical outcomes.538
This has deep relevance for the inevitably local, particularized problems which
tend to dominate the attention of bioethicists and bioethics practice because
“[d]ifferent kinds of disputes occur in encounters within clinical settings.”539
Reliance on a general stock of principles, or a common morality
contains little practical advice concerning how to navigate
situations in which there is substantial disagreement about initial
presumptions and ‘reasonable’ conclusions at the level of policy
and practice. This is a rather significant shortcoming given that the
United States contains many religious traditions, ethnic groups,
and cultures where there can be different substantive accounts of
moral practices and policies.540
As such, “social theorists who emphasize the local, temporal character of
‘moral worlds’ challenge accounts presuming the existence of a universal moral
euthanasia. Kevin Buzinski, “The Hinges of Morality: An Investigation of Moral Particularism,
Wittgenstein and Euthanasia,” (PhD dissertation, York University, 2007). Again, however,
despite the relevance of Wittgenstein’s work for both particularism and pain, I reserve analysis of
that work for a later time and place.
538
Turner, “Zones of Consensus,” 207.
539
Ibid., 208.
540
Indeed, this criticism has profound implications for the medical humanities. This is
because a chief element of the medieval and Renaissance educational program known as the studia
humanitatis was its rejection of the abstract disputations and dialectics of the high Scholastics in
favor of an emphasis on the use of erudition and scholarship in the service of improving everyday
people’s daily lives and practices. While I had initially planned on discussing the relevance of the
Renaissance humanists to thinking about pain in this project, my sense is that doing so would
unduly detract from the focus on the problem of pain itself. Thus, aside from brief mention in
chapter 8, I reserve extensive discussion of the humanists for subsequent work.
208
Esperanto.”541 Moreover, both the practical problems that attend principlism in
bioethics and its difficulty in accounting for the undeniable fact of cultural
relativism imply problems of ethical imperalism, a charge which has long been
leveled at dominant (principlist) traditions of Western bioethics.542 For example,
Turner observes that Beauchamp and Childress–who are hardly alone in this
respect–
mention human rights as examples of cross-cultural moral norms
that fall within boundaries of the common morality. However, the
language of human rights is not a transhistorical, transcultural
phenomena found in all communities throughout time . . . Indeed,
some critics of the rhetoric of human rights argue that conceptions
of human rights emphasizing individualism constitute a form of
“Western imperialism” that fails to acknowledge sufficiently
communitarian understandings of duties and obligations.543
Ultimately, whatever its flaws in helping stakeholders find meaning in
experiences of health and illness in general, principlism is especially poorly suited
to illuminating lived experiences of pain because, as conceptualized in the
dominant traditions of bioethics, it gives short shrift to local, particular, specific
circumstances. By virtue of the generality of principlism and related moral
541
Ibid., 206.
542
E.g., Heather Widdows, “Is Global Ethics Moral Neo-Colonialism? An Investigation
of the Issue in the Context of Bioethics,” Bioethics 21, no. 6 (July 2007): 305-315; Paul Farmer
and Nicole Gastineau Campos, “New Malaise: Bioethics and Human Rights in the Global Era,”
American Journal of Law, Medicine & Ethics 32, no. 2 (Summer 2004): 243-251; Erich H.
Loewy, “Bioethics: Past, Present, and an Open Future,” Cambridge Quarterly of Health Care
Ethics 11, no. 4 (Fall 2002): 388-397; Solomon R. Benatar, “Reflections and Recommendations
on Research Ethics in Developing Countries,” Social Science & Medicine 54, no. 7 (April 2002):
1131-1141; and Paquita de Zulueta, “Randomised Placebo-controlled trials and HIV-infected
Pregnant Women in Developing Countries: Ethical Imperialism or Unethical Exploitation,”
Bioethics 15, no. 4 (August 2001): 289-311.
543
Turner, “Zones of Consensus,” 207.
209
traditions, focus is directed away from the local social worlds which characterize
the phenomenology of pain. This is in part why the phenomenology of pain is so
crucial to formulating an ethical framework for pain policy; in such an account,
the embodied person in pain is by definition central.
THE ETHICAL IMPLICATIONS OF THE PHENOMENOLOGY OF PAIN
In chapter 2, I detailed some of the insights into the lived experiences of
pain that are possible via application of phenomenology. I expressly reserved
specific analysis of the ethical implications of such a phenomenology for this
chapter. How is understanding the phenomenon of pain helpful in producing
ethical policy and practice as to pain?
Recall that for many pain sufferers, their lived experiences are marked by
isolation, stigma, and exile, even from their own bodies. Thus, in
phenomenologic terms, the primary means of alleviating the pain patient’s
existential suffering is to bring them back into the social world and into a sense of
community. If part of what is so devastating about pain is its languagedestroying, isolating nature, repatriating pain sufferers from their exile might be
an important component of healing the pain sufferer.544 Even the very act of
listening to the pain sufferer and taking a narrative can be an important step in
bringing the pain sufferer into society: “An epistemic bridge is built. In this
restoration of intersubjective understanding, the relief of pain has already
begun.”545
544
Goldberg, “Exilic Effects of Illness and Pain.”
545
Leder, “The Experience of Pain and Its Clinical Implications”; see also Rita Charon,
“A Narrative Medicine for Pain,” in Narrative, Pain, and Suffering, ed. Daniel B. Carr, John
David Loeser, and David B. Morris (Seattle, WA: IASP Press, 2003), 29-44.
210
Two other examples may help to illuminate the ethical significance of
building the epistemic bridge to which Leder refers. First, there is the healing
tradition of the laying on of hands, which has both diverse and ancient roots.546
Wuthnow notes that “[c]ave paintings in the Pyrenees 15,000 years old depict
such healing as do written records of 5,000 years ago.”547 In the medieval and
early modern Western incarnations of this ritual, the illness sufferer, who
characteristically lived with disfiguring illnesses like scrofula, sought out the
king’s healing touch, generally referred to as ‘royal touch.’548 Multiple French
and English kings utilized royal touch during the Late Middle Ages.549 But why
seek out the king? Why not the physician or professional healer? Why not the
clergy? What was it about the king’s touch that was deemed to heal?
The superficial answer is that in much of Europe during the Middle Ages,
kingship was allied with divinity, such that supplicating before the king was, in an
important sense, seeking divine intervention in one’s suffering.550 The deeper
answer, more relevant to my purpose here, is that the medieval and early modern
monarch was broadly identified as the body politic, as the society and community
itself. Therefore, in a phenomenological and ritualistic sense, for the king to lay
546
Elizabeth L. Lewton and Victoria Bydone, “Identity and Healing in Three Navajo
Religious Traditions: Sa'ah Naagháí Bik'eh Hózh,” Medical Anthropology Quarterly 14, no. 4
(December 2000): 476-497; Sara Wuthnow, “Healing Touch Controversies,” Journal of Religion
and Health 36, no. 3 (September 1997): 221-230; and John G. Bruhn, “The Doctor's Touch:
Tactile Communication in the Doctor-Patient Relationship,” Southern Medical Journal 71, no. 12
(December 1978): 1469-1473.
547
Wuthnow, “Healing Touch Controversies,” 221-22 (citation omitted).
548
The phenomenon of royal touch is exhaustively analyzed by the great medievalist
Marc Bloch in The Royal Touch: Monarchy and Miracles in France and England, trans. James E.
Anderson (New York, NY: Dorset Press, 1990).
549
Ibid.
550
This obviously encroached upon ecclesiastical prerogative. Ibid.; Wuthnow, “Healing
Touch Controversies.”
211
hands on the disfigured, isolated illness sufferer meant that the sufferer had
literally been brought back into the body politic, and hence into society. The
sufferer had therefore been healed in a profoundly phenomenologic sense. It is a
minimalist conception indeed that dismisses the power of this form of healing
because of its apparent lack of clinical efficacy.551 Indeed, part of my point is
that, as important as clinical efficacy is–and I do not mean for a moment to
discount its importance–there are dimensions of illness and pain for which a
narrow focus on clinical interventions and efficacy cannot account.
Thus, it is important to note that this repatriation has ethical content. To
understand the isolation imposed by pain and to actively seek to restore the
sufferer into a compassionate community is to act virtuously, to practice
excellence in healing. van Hooft reasons that
in the case of pain, the ethical challenge is to reopen the patient’s
world so as to break open the isolation into which their pain has
forced them . . . The pain of the other, which tends to their selfenclosure, must be made into an opening through which the care of
the clinician flows through to the patient.552
This reopening, of course, must be undertaken with great sensitivity and
caution, for the pain sufferer is frequently isolated, vulnerable, and wary. “The
clinician must bring to this encounter a mode of apprehension which does not
objectify the other or their pain.”553 Yet the ethical significance of such a
551
On the fallacy of conflating clinical efficacy with social and cultural efficacy, see
Rosenberg, “The Therapeutic Revolution.” In my view, this essay, on the therapeutic revolution
of the nineteenth century, is one of the most important works in the history of medicine and the
medical humanities of the last thirty-five years.
552
van Hooft, “Pain and Communication,” 260.
553
Ibid.
212
reopening can only be understood through a phenomenology of pain, through
apprehension of the ways in which pain shapes the pain sufferer’s lifeworld.
The second example of the ethical significance of the phenomenology of
pain is a contemporary version of the royal laying on of hands: touch therapy.
Through touch therapy, the phenomenological use of “laying on hands” to bring
illness sufferers back into the body politic continues to the present: “Therapeutic
touch is a healing modality practiced by thousands of registered nurses.”554
Long derided as another unproven complementary and alternative treatment, the
tone has changed as the evidence base increased. There is now solid evidence
that different forms of touching–massage, cradling, etc.–can be clinically
beneficial in a variety of illness encounters. Cochrane reviews indicate
reasonable evidence of benefit for the use of touch therapy in treating pain,555
dementia,556 and chronic/recurrent headache.557 Moreover, systematic reviews
also suggest some benefit to infants from skin-to-skin contact with their mothers
under six months of age.558 Finally, there is a great deal of evidence outside that
554
Wuthnow, “Healing Touch Controversies,” 226.
555
Pui Shan So, Yu Jiang, and Ying Qin, “Touch Therapies for Pain Relief in Adults,”
Cochrane Database of Systematic Reviews 4, Art. No.: CD006535 (October 2008), doi:
10.1002/14651858.CD006535.pub2, http://dx.doi.org/10.1002/14651858.CD006535.pub2
(accessed June 1, 2009).
556
Niels Viggo Hansen, Torben Jørgensen, and Lisbeth Ørtenblad, “Massage and Touch
for Dementia,” Cochrane Database of Systematic Reviews 4, Art. No.: CD004989 (October 2006),
doi: 10.1002/14651858.CD004989.pub2, http://dx.doi.org/10.1002/14651858.CD004989.pub2
(accessed June 1, 2009).
557
Gert Brønfort, Niels Nilsson, Mitchell Haas, Roni L. Evans, Charles H. Goldsmith,
Willem J.J. Assendelft, and Lex M. Bouter, “Non-invasive Physical Treatments for
Chronic/Recurrent Headache,” Cochrane Database of Systematic Reviews 3, Art. No.: CD001878
(July 2004), doi: 10.1002/14651858.CD001878.pub2,
http://dx.doi.org/10.1002/14651858.CD001878.pub2 (accessed June 1, 2009).
558
Elizabeth R. Moore, Gene C Anderson, and Nils Bergman, “Early Skin-to-Skin
Contact for Mothers and Their Healthy Newborn Infants,” Cochrane Database of Systematic
Reviews 3, Art. .: CD003519 (April 2007), doi: 10.1002/14651858.CD003519.pub2,
213
produced by randomized controlled trials559 suggesting benefit in a wide array of
illness scenarios.560 Although there is no shortage of clinical and molecular
explanations for these findings, given the insights of the phenomenology of illness
and pain, it should be fairly obvious, and yet obvious in important ways, why the
act of touching another human being can be therapeutic.
Though repatriation through listening may seem easy enough for the
provider, this is a dangerous assumption. Too many providers simply do not hear
their patients’ pain talk. I have already documented the existence of a profound
communication gap between pain sufferers and their physicians.561 Akin to
Heath’s analysis of the preeminence of diagnosis in communication about pain
between patients and physicians, Thomas and Johnson note that for many
http://dx.doi.org/10.1002/14651858.CD003519.pub2 (accessed June 1, 2009); and Angela
Underdown, Jane Barlow, Vincent Chung, and Sarah Stewart-Brown, “Massage Intervention for
Promoting Mental and Physical Health in Infants Aged Under Six Months,” Cochrane Database
of Systematic Reviews 4, Art. No.: CD005038 (October 2006), doi:
10.1002/14651858.CD005038.pub2, http://dx.doi.org/10.1002/14651858.CD005038.pub2 (last
accessed June 1, 2009).
559
On the problems with assuming that only evidence produced via RCTs “counts” in
healing, see e.g., Grossman, “A Couple of the Nasties Lurking in Evidence-Based Medicine”;
Adam La Caze, “Evidence-Based Medicine Can’t Be . . .”; Brody, Miller, and Bogdan-Lovis,
“Evidence-Based Medicine: Watching out for Its Friends”; and Upshur, “Looking for Rules in a
World of Exceptions.” In addition, vol. 22, no. 4 of Social Epistemology (Oct.-Dec. 2008) is a
theme issue addressing evidence-based medicine. Jason Grossman lists as “Dumb Claim Number
1” the idea that “[a]ny randomised controlled trial (RCT) gives us better evidence than any other
study.” Grossman, “A Couple of the Nasties Lurking in Evidence-Based Medicine,” 335.
560
Lesley Cullen and Julie Barlow, “‘Kiss, Cuddle, Squeeze’: The Experiences and
Meaning of Touch among Parents of Children with Autism Attending a Touch Therapy
Programme,” Journal of Child Health Care 6, no. 3 (September 2002): 171-181; Tiffany Field,
Touch Therapy (London, UK: Churchill Livingstone, 2000); Paulette Sansone and Louise Schmitt,
“Providing Tender Touch Massage to Elderly Nursing Home Residents: A Demonstration
Project,” Geriatric Nursing 21, no. 6 (November 2000): 303-308; and Maria Hernandez-Reif,
Tiffany Field, Josh Krasnegor, Elena Martinez, Morton Schwartzman, and Kunjana Mavunda,
“Children with Cystic Fibrosis Benefit from Massage Therapy,” Journal of Pediatric Psychology
24, no. 2 (April/May 1999): 175-181.
561
E.g., Jackson, “Stigma. Liminality, and Chronic Pain;” Thomas and Johnson, “A
Phenomenologic Study of Chronic Pain;” Baszanger, Inventing Pain Medicine; and Heath, “Pain
Talk,” 115-16.
214
physicians ‘listening’ “mean[s] hearing words as diagnostic cues, not placing the
words into the context of the patient’s life world.”562 Leder explains that “[t]he
contemporary medical care system does not always foster this restoration of the
world. A callous or uncommunicative doctor can heighten rather than relieve the
patient’s sense of isolation.”563 Moreover, one should not doubt the importance of
diagnosis; Charles Rosenberg suggests that it is the very linchpin of the process
that knits together the chief players, institutions, and strategies for defining,
categorizing, and assimilating experiences of disease itself in the United States564
I will revisit the phenomenology of pain in chapter 9, where I discuss how
the implications of such a phenomenology can be incorporated into pain policy.
Aside from phenomenology, however, there is another ethical theory that may
have much to offer in thinking through the ethics of pain and the implications
therein for producing pain policy. This is the controversial theory of moral
particularism, and I turn to it now.
DANCY’S MORAL PARTICULARISM
By any account, moral particularism is a controversial theory.565 It is not
altogether difficult to see why; the title of Dancy’s book on the subject is Ethics
Without Principles. I have no intention of doing this controversy justice, nor of
562
Thomas and Johnson, “A Phenomenologic Study of Chronic Pain,” 695.
563
Leder, “The Experience of Pain,” 101.
564
Charles E. Rosenberg, “The Tyranny of Diagnosis: Specific Entities and Individual
Experience,” The Milbank Quarterly 80, no. 2 (June 2002): 237-260.
565
It was the subject of a 2007 symposium issue of the Journal of Moral Philosophy, and
McKeever and Ridge issued a sustained critique of Dancy’s arguments in 2006 entitled Principled
Ethics: Generalism as a Regulative Ideal (New York, NY: Oxford University Press, 2006). In
addition, Routledge Press recently published an anthology entitled Challenging Moral
Particularism, eds. Matjaz Potrc, Vojko Strahovnik, and Mark Noriss Lance (London, UK:
Routledge Press, 2008).
215
delving deeply into the professional philosophical interchange on the merits of
moral particularism. I will argue that moral particularism has important
consequences for conceptualizing pain, but I do not claim that treating pain
effectively requires the adoption of a wholly particularist approach. I also do not
claim here that moral particularism is uniquely suited to making sense of pain.
My argument is simply that we can illuminate some important aspects of an
individual’s lived experience of pain by examining that experience through the
lenses of moral particularism.
In Dancy’s terminology, the word “particularism” refers to the notion that
“the possibility of moral thought and judgment does not depend on the provision
of a suitable supply of moral principles.”566 The word “generalism,” by contrast,
refers to the notion that “the very possibility of moral thought and judgment
depends on the provision of a suitable supply of moral principles.”567
Dancy’s argument for particularism rests on his claim for holism in the
theory of reasons. He defines “holism” as the notion that “a feature that is a
reason in one case may be no reason at all, or an opposite reason, in another.”568
The contrast here is with atomism in the theory of reasons, which posits that “a
feature that is a reason in one case must remain a reason, and retain the same
polarity, in any other.”569 In turn, Dancy’s argument for holism in the theory of
reasons is quite technical, but is crucial inasmuch as it is the bedrock for his
conclusions about particularism in ethics.
566
Dancy, Ethics Without Principles, 7.
567
Ibid.
568
Ibid.
569
Ibid.
216
Holism in Reasons
Dancy begins his argument by noting the importance of contributory
reasons in moral decision-making. Specifically, he argues that contributory
reasons do different work from the overall normative proposition. He contends
that
[i]f an overall ‘ought’ commands, it cannot be that contributory
reasons command as well . . . We have reasons on both sides of the
question, often enough. Is it that each reason on either side
commands, and then that somehow the sum total of them
commands as well. I don’t think this is a coherent scenario; there
are too many commands floating about.570
If contributory reasons are not equivalent to overall normative judgments,
two options follow for Dancy: first, the entire notion of contributory reasons must
be abandoned, or second, a different account of what contributory reasons “do” is
needed.571 Scanlon opts for the first route in his insistence that principles can be
appropriately specified such that they each mark a decisive or conclusive
reason.572 Dancy finds this analysis unconvincing because the idea that principles
cannot truly conflict seems to require jettisoning the “idea that two principles can
combine.”573 If each principle, properly understood, is discretely decisive, there
seems little way of understanding the “examples in which the idea of a
contribution seems to be required if we are to make sense of what is going on . . .
.”574 Moreover, he argues, the process of specifying in all future cases which
570
Ibid., 17-18.
571
Ibid., 25.
572
Ibid., 26.
573
Ibid.
574
Ibid.
217
principle governs right action is not even desirable–let alone possible–inasmuch
as it seems to preclude moral sanction of a “trivial breach of promise and a very
large good to be done” by doing so.575
Dancy opts for the second path, which is to sketch an entirely different
picture of the role of contributory reasons. He identifies three different classes of
contributory reasons: favorers, enablers, and disablers. He begins by
differentiating between the first two. “That I promised to do it . . . is a reason in
favor of doing it.”576 On the other hand, a premise that
(p) “[t]here is no greater reason not to do it”
is, in Dancy’s theory, not a favorer because (p) is verdictive, it is to “pass
judgment on the balance of reasons present in the case. If [(p)] was itself a further
reason over and above those on which it passes judgment, we would be forced to
reconsider the balance of reasons once we had asserted [(p)], in a way that would
continue ad infinitum. Which is ridiculous.”577 Other reasons, such as
(q) “[m]y promise was not given under duress”
Dancy classifies as an enabler, because in the absence of (q), (p) does not
favor the action. If we do not know whether the promise was given under duress,
the promise to do it is disabled; “the absence of an enabler will disable what
would otherwise be a reason.”578
Dancy takes the distinction between favorers and enablers to be “of
considerable importance in the general theory of reasons,” in no small part
575
Ibid., 27.
576
Ibid., 39.
577
Ibid., 40.
578
Ibid., 41.
218
because it can be “generalized: there is a general distinction between a feature that
plays a certain role and a feature whose presence or absence is required for the
first feature to play a role, but which does not play that role itself.”579 Enabling is
one such role. The point for Dancy is that “there is more than one conception of
moral relevance, or more than one way of being relevant to the answer to moral
questions.”580
From Holism in Reasons to Particularism
After explaining this distinction, the Dancy begins his move to connect
holism in the theory of reasons to moral particularism. First, he argues, there is
little dispute that theoretical reasons (“reasons for belief”) are holistic. Typically,
the appearance of something that seems red is a reason to believe “that there is
something red . . . before me.”581 However, if under the influence of “a drug that
makes blue things look red and red things look blue, the appearance of a redlooking thing before me is a reason for me to believe that there is a blue, not a red,
thing before me.”582
As for “ordinary” practical reasons (“reasons for action”), Dancy reasons
that they too are holistic:
that there will be nobody much else around is sometimes a good
reason for going there, and sometimes a very good reason for
staying away. That one of the candidates wants the job very much
579
Ibid., 45.
580
Ibid., 52.
581
Ibid., 74.
582
Ibid.
219
indeed is sometimes a reason for giving it to her and sometimes a
reason for doing the opposite.583
Beyond “ordinary” practical reasons, Dancy identifies aesthetic and moral
reasons for action. Are these atomistic? Dancy does not believe so. Aesthetic
reasons are largely holistic; “there are reasons to introduce the metaphor in the
one case and reasons not to do so in the other.”584 In any case, he argues, no one
has ever suggested that aesthetic judgments are subject to a “principle-based
structure . . . in the sort of way that almost everybody thinks one can do for moral
judgment.”585
So, all that is left are moral reasons. Dancy finally links holism in the
theory of reasons to the particularist attack on principle-based conceptions of
morality. He argues that there is no reason to think that moral reasons alone are
unique in their atomism: “it just seems incredible that the very logic of moral
reasons should be so different from that of others in this sort of way. Consider
here the sad fact that nobody knows how to distinguish moral from other reasons.
Every attempt has failed.”586
If moral reasons function holistically, then principlism in morals seems
dubious. “Moral principles, however we conceive of them, seem all to be in the
business of specifying features as general reasons.”587 As an example he cites the
quintessential Kantian imperative, that it is wrong to lie, noting that the
imperative “presumably claims that mendacity is always a wrong-making feature
583
Ibid.
584
Ibid., 76.
585
Ibid.
586
Ibid.
587
Ibid.
220
wherever it occurs (that is, it always makes the same negative contribution,
though it often does not succeed in making the action wrong overall).”588
Ultimately,
[i]f moral reasons, like others, function holistically, it cannot be the
case that the possibility of such reasons rests on the existence of
principles that specify morally relevant features as functioning
atomistically. A principle-based approach to ethics is inconsistent
with the holism of reasons.589
Yet Dancy concedes the possibility that some invariant reasons may exist.
Perhaps “the causing of gratuitous pain on unwilling victims . . . is always for the
worse, even if overall we might in some case be morally forced to do it.”590
However, he argues, such reasons are invariant by virtue of their particular
content, rather than due to any structural feature of moral reasons per se.
Moreover, “admitting the possibility of some invariant reasons is a far cry
from admitting that the very possibility of moral thought and judgment is
dependent on our being able to find some such reasons.”591 Dancy is prepared to
admit that holism may be consistent with “the existence of at least some
principles” inasmuch as the “occasional appearance of invariant reasons” does
“not take us straight to the claim that we are here dealing with a principle.”592 Or,
as he puts it later in the book, “I may allow the possibility of invariant reasons, in
588
Ibid. (emphasis added).
589
Ibid., 77.
590
Ibid.
591
Ibid.
592
Ibid., 81.
221
ethics as elsewhere, without allowing that in the absence of such things moral
thought and judgment could not be thought of as rational.”593
While this is the basis of Dancy’s move from holism in reasons to
particularism, he does caution that any “simple attempt to present particularism as
a direct consequence of holism will not work.”594 The principal reason for this is
because the “favouring relation” is normatively distinct from the “right-making
relation.”595 The argument thus far has only established “holism of the favouring
relation,” and it is not obvious how holism of the right-making relation follows, if
at all. However, he reasons, it would be curious indeed if the moral epistemology
implied by holism of the favoring relation were fused with a moral ontology in
which the right-making relation is generally atomistic. He therefore concludes
that “if either of these two domains is holistic, so must the other be.”596
In addition, a “principled but holistic ethic” can be specified in the form:
“(r) If you have promised, that is some reason to do the promised act,
unless your promise was given under duress.
A large enough set of similar propositions may supply such an ethic.”597
Accordingly, Dancy admits that the move from holism of reasons to
holism of the right-making relation is “at best indirect.”598 Nonetheless he
observes that “given the holism of reasons, it would be a sort of cosmic accident if
it were to turn out that a morality could be captured in a set of holistic
593
Ibid., 118.
594
Ibid., 78.
595
Ibid., 79.
596
Ibid., 80.
597
Ibid., 81.
598
Ibid., 82.
222
contributory principles of the sort that is here suggested.”599 More so, given
holism of reasons, “there is no discernible need for a complete set of reasons to be
like this. If our (or any other) morality turned out to be that way, there could be
no possible explanation of that fact. It would be pure serendipity.”600
The key is the question of “why the behavior of moral reasons might need
to be capturable in some principled way, even though we continue to respect the
truth of holism.”601 Dancy articulates one possible answer, relying on a
conception of morality as a “system of social constraints,” which seems to closely
resemble a formalist vision of law.602
But morality was not invented by a group of experts sitting in
council to serve the purposes of social control . . . The particularist
claim would be that people are quite capable of judging how to
behave case by case, in a way that would enable us to predict what
they will in fact do, and which shows no need of the sort of explicit
guidance that a set of principles (of a certain sort) would
provide.603
Practical Reasoning for the Moral Particularist
What does practical reasoning looks like in Dancy’s particularist world?
In a problem featuring many possible solutions,
599
Ibid.
600
Ibid., 82.
601
Ibid., 83.
602
On some of the problems with a formalist model of law, see Daniel S. Goldberg, “And
the Walls Came Tumbling Down: How Classical Scientific Fallacies Undermine the Validity of
Textualism & Originalism,” Houston Law Review 39, no. 3 (2003): 463-497; Daniel S. Goldberg,
“I Do Not Think It Means What You Think It Means: How Kripke and Wittgenstein’s Analysis on
Rule Following Undermines Justice Scalia’s Textualism and Originalism,” Cleveland State Law
Journal 54, no. 3 (September 2006): 273-308.
603
Dancy, Ethics Without Principles, 83 (internal citation omitted).
223
[w]e need to consider the reasons in favour of available
alternatives, as well as the reasons against each one . . . Common
though it is to read of the balance of the reasons, and of weight, the
matter should not be understood on the model of the kitchen scales.
That model is far too atomistic to fit the subject matter of ethics (or
of practical reason in general). On the kitchen scale model, each
consideration has a practical weight, which it keeps irrespective of
what it is combined with – just as a kilogram of butter weights a
kilogram whatever it is added to. A more holistic picture – one
that recommends itself to me – has it that the presence of one
feature can affect the weight of another.604
Here, then, one can begin to see the outlines of what an application of the
particularist approach to moral reasoning might look like. The effect of favorers,
enablers, and disablers is crucial in specifying the valence of the reasons. Dancy
puts it this way: “the features that make an action wrong do not entail that the
action is wrong; it remains possible that those features be present on another
occasion where the context is different and where the action is not wrong.”605
And in the paradigm case of wanton cruelty, long thought to ground the
existence of a core set of objective principles, “competence with [the concept of
cruelty] requires an understanding of the sorts of way it can function as a reason
for action, and an ability to tell in new situations how it is actually
functioning.”606 Dancy’s point here is not to defend wanton cruelty, but simply to
contest the notion that objective, unchanging rules are needed to issue moral
judgments. Interestingly, Dancy grounds this claim in Wittgenstein’s analysis on
rule-following. He argues that
604
Ibid., 105.
605
Ibid., 107.
606
Ibid. (emphasis in original).
224
[t]o be competent with the concept of lewdness is to be able to tell
when lewdness is a reason for action and when it is a reason
against, and this sort of ability need not be conceived either as
rule-bound or even as capturable in anything worth calling a
rule.607
Brandom argues “that since Wittgenstein has shown that rationality cannot
be understood in terms of responses to explicit rules, it must be understood in
response to implicit ones;” yet Dancy (and myself)
would rather see Wittgenstein’s point, not as arguing that there
must be implicit grasp of a rule, but as suggesting that we do not
need rules to apply concepts coherently. What it is to go on in the
same way need not be capturable in any rule, and what we bring to
the new situation need not be an implicit grasp of a suitably
context-sensitive rule, but simply an understanding of the sort of
difference that can be made by the applicability of this concept . . .
.608
Dancy does not further develop the implications of this Wittgenstenian
picture of meaning in his architecture of moral particularism. Yet it does not
seem altogether surprising that he is sympathetic to a Wittgensteinian moral
epistemology, as it seems difficult to imagine any moral particularist who did not
attend to the focus on (particular) practices central in later Wittgenstein. As such,
Little, adopting an overtly Wittgensteinian approach to moral particularism,
argues that whether any given instances “qualify as cruel depends on the context
in which they are situated.”609 Echoing claims made by Mark Johnson on the
indeterminancy of moral reasoning, she notes that “[h]owever many cases of
607
Ibid., 108.
608
Ibid.
609
Little, “Wittgensteinian Lessons,” 165.
225
cruelty one is shown, reflection on their natural properties will not afford patterns
that will enable one to catch on to what cruelty really is.”610 Similarly, relying on
research in cognitive science that demonstrates how much of human reasoning–
moral and otherwise–is metaphorical in nature, Johnson argues that a moral
concept does not simply exist with a determinate essence that can
be ‘understood in itself.’ Rather, it has its meaning only in relation
to a culture’s shared, evolving experience and social interactions,
and it is the existence of stable structures of such interactions that
lends stability to the concept.611
While Dancy never expressly declares that his particularism is a
nonessentialist theory, it seems difficult to understand how a theory in which the
valence of reasons varies depending on the context could be made consistent with
a theory positing determinate essences to morality. Rooting the possibility of a
nonessentialist account of meaning in social practices resonates strongly of later
Wittgenstein, and also coheres with Dancy and Little’s particularist account
inasmuch as in all of these theories, ethical significance is found in local,
particular, contextualized social worlds, rather than the abstract essences, rules,
and laws favored in principlism, generalism, and many varieties of moral
objectivism.
Before turning to the implications of these ideas for the concept of moral
thickness, which I have suggested is an important part of the critique of
objectivism and principlism in bioethics, it is worth noting that Dancy does
consider pragmatic objections to particularism, such as those articulated by Brad
610
Ibid., 166.
611
Johnson, The Moral Imagination, 90.
226
Hooker and Onora O’Neill. O’Neill argues that we need “some common ground
if we are to resolve serious practical conflict–and the sort of common ground we
need is general, since it must be prior to the circumstances of any particular
conflict . . . .”612 Little notes that “the presumption that there are moral principles
capable of codifying morality is deeply tied to the presumption that there had
better be such principles.”613 Dancy does not deny the importance of common
ground, but contends that “the idea that basic principles of morality have been
arrived at by this route quite apart from the idea that they constitute some sort of
basic common element in our divergent thoughts about how to behave, strikes me
as quixotic.”614 Similarly, Little argues that one must be careful not to confuse
the usefulness of a moral heuristic with its truth.615
Moral Thickness
The implications of Dancy’s particularism for moral thickness are crucial
to unpacking the ethics of pain. In my brief critique of principlism I have already
argued that morally thick actions are embedded in practices.
Abstract notions of
right, wrong, good, evil, duty, and obligation are morally thin concepts precisely
because their significance and meaning is only appreciable in practice. Dancy,
akin to Turner, argues that much of what seems most significant in the moral life
occurs on the particular level:
612
Dancy, Ethics Without Principles, 133.
613
Little, “Wittgensteinian Lessons,” 162.
614
Dancy, Ethics Without Principles, 135.
615
Little, “Wittgensteinian Lessons.”
227
The sense in which all agree that justice is important is far less
important than the substantial disagreements between us about
what sorts of things are just and what unjust. The common stock
of terms by appeal to which disagreements can alone be resolved–
terms like ‘just,’ ‘fair,’ and ‘equal’–are exactly the ones in which
disagreements are formulated. To use an old distinction: we have
common concepts of justice, fairness, and equality, perhaps, but
widely divergent conceptions of these things.616
The argument is thus not that principles do not exist, but rather that they
are not required for ethical meaning, and more strongly, that they are thin
concepts which remain unhelpful in making sense of ethics and in guiding action.
Likewise, in her account of moral particularism, Little observes that “no one
(sensibly) rejects principles that tell us to ‘respect autonomy’ or ‘to be just.’ But
the particularist denies that we can unpack those very abstract principles into
generalizations that are accurate and contentful enough to guide action.”617
Dancy and Little’s analysis also corresponds in important ways with some of
Johnson’s meta-ethical arguments. Though Johnson does not identify as a moral
particularist, he rejects many of the generalizing features of moral principlism.
His language strongly resembles Dancy’s:
My view, then, is not that we don’t have moral principles, but
rather that such meaning, relevance, and guidance as they offer
depends ultimately (though perhaps not always immediately) upon
the narrative settings in which they have emerged and to which
they are being applied.618
616
Dancy, Ethics Without Principles, 134.
617
Little, “Wittgensteinian Lessons,” 184.
618
Johnson, The Moral Imagination, 160.
228
Moreover, like Dancy, Johnson addresses the problem of lying, and
considers a scenario in which the Central Intelligence Agency lies to protect its
agents. Acknowledging the general moral prohibition against lying, Johnson
argues that because the moral agent “must claim a higher moral principle or value
that overrides the prohibition against lying . . . the nature of the reprehensibility of
lying is relative to our framing of the situation!”619 Of course, Johnson is quick to
admit that the principlist can account for this fact by claiming that “‘official lies’
and ‘social lies’ are indeed, lies, and then formulate other principles to specify
when certain kinds of ‘lie’ are permissible.”620 Dancy also concedes that
principlists may preserve their account by “expanding [principles] in the hope of
assimilating all counter-examples.”621 However, Dancy points out that such
method does not show that “without principles moral thought and judgment are
impossible. For there is no reason why, without stable stopping points for the
expansion, the rationality of moral thought and judgment would suddenly be in
doubt.”622
In other words, Dancy is suggesting that, even if invariant principles do
exist, the holistic structure of reasoning implies that any account of ethics which
posits that principles are required for the structure of ethics to be meaningful is
dubious. Likewise, Johnson argues that what he terms the radial structure of
moral concepts–how they are defined only by recognizing networks of meanings
clustered around prototype cases rather than by determinate essences–constitute
619
Ibid., 93 (emphasis in original).
620
Ibid., 97.
621
Dancy, Ethics Without Principles, 26.
622
Ibid., 127.
229
“overwhelming evidence against the classical objectivist view accepted by
[moral] absolutists.”623
Implications for Pain
Moral particularism seems to have important implications for pain. I have
argued that a primary culprit in the undertreatment of pain is the objectifying
tendencies of the clinicopathologic method. The power of the clinical gaze was
and remains a function of its capacity to diminish the significance of the patient’s
subjective illness complaints in favor of objective evidence of tissue pathology or
organic insult. The patient may not be complaining of nausea, sleeplessness, and
loss of appetite, but if an MRI reveals the presence of a malignancy in their
pancreas, the lack of patient complaints is, for the clinicopathologic method,
immaterial. Treatment is immediately indicated, even if the patient does not feel
ill.
The problem for pain, of course, is the converse situation, in which the
patient most assuredly feels pain, but the tools of the clinicopathologic method do
not reveal any visible, material pathology. As we have seen, this is a particular
problem for many kinds of chronic pain, which typically does not present with
such pathology. Because of the power of the clinicopathologic method and mindbody dualism in legitimizing the production of knowledge in Western culture,
chronic pain sufferers often join providers in the search for objective evidence of
pain, and typically voice great frustration with their physicians for the latter’s
inability to localize their pain to a specific, visible cause.
623
Johnson, The Moral Imagination, 97.
230
But the core of Dancy’s ethical claim is that we do not need objective
principles to satisfactorily account for right and wrong and that we can justify
moral decisions perfectly well without the existence of moral principles. As
mentioned above, this conclusion coheres with the claims of a number of other
scholars who are dubious of the necessity–and the dominance–of principles in
meaningfully assessing ethical problems, particularly within bioethics.
The reason that Dancy’s arguments have consequences for the way we
think about pain is precisely because the tendency to objectify illness and pain
complaints, to categorize the patient’s subjective self-reports according to
principles, standards, and objective measurements in clinical practice, is a
significant factor in the undertreatment of pain. If Dancy’s particularism has any
validity, it follows that the ethics of pain, and ethical (clinical) strategies for
treating pain, should pay vastly more attention to the particular pain sufferer and
the social world they inhabit that shapes the meaning of their pain.
If moral particularism suggests that there is reason for doubting that
objectification is both valid and useful in making sense of ethics in general and
ethics in medicine in particular, perhaps this suggests some reasons for doubting
that such objectification in and of itself is the optimal ethical path for improving
the undertreatment of pain. Both the most compelling critiques of principlism and
moral particularism suggest that the central loci of ethical significance are the
local social worlds and contexts which frame moral agents’ meaning-making
endeavors.
I maintain that this is equally valid in thinking about the meaning of pain,
which also varies greatly according across the local, particular worlds pain
sufferers live within. Thus Giordano, Engebretson, and Benedikter argue that
231
any practical consideration of an ethics of pain medicine must also
recognize (1) the effects of culture on the event, phenomenon, and
experience of pain; (2) the distinctions that are evoked by the
culture of medicine (vs. the culture of patienthood); and (3) how
geographic, social, and temporal variances affect these cultural
dynamics.624
Though the authors do not discuss moral particularism, there is much in that
approach that coheres with my thesis, which closely tracks #1 above: any attempts
to improve the undertreatment of pain in the United States that do not account for
the social and cultural meanings of pain in American society are unlikely to
succeed. The second point underscores another key aspect of my argument, that
providers as well as pain sufferers (and caregivers) participate in framing a culture
of pain in which pain is undertreated. Note that this is not to imply that pain
sufferers are responsible for such undertreatment, but simply that the larger social
and cultural narratives I have traced here shape the meaning of pain for providers,
pain sufferers, and caregivers, alike.625
While the role these larger conceptions of objectivity, illness, and the
power of the visible play in American and biomedical culture are crucial to
understanding the meaning of pain in society, at the same time, particularism
suggests that it is the local worlds that actors move through that frame ethical
significance. This meshes with Giordano, Engrebetson, and Benedikter’s point #3
above, that a myriad of local variances–“geographic, social, and temporal”–
shapes and informs the meaning persons attach to pain in different ways. Thus
the meaning of pain, like many intricate, complicated phenomena is shaped both
624
James Giordano, Joan C. Engebretson, and Roland Benedikter, “Culture, Subjectivity,
and the Ethics of Patient-Centered Pain Care,” Cambridge Quarterly of Health Care Ethics 18, no.
1 (January 2009): 48.
625
I discuss this issue in detail in chapter 9.
232
by larger social trajectories and by the particular features of the sufferer’s local
moral and social world.
In addition, as I have noted, Leder suggests that if health care providers
were more attuned to the particular, subjective pain experiences their patients
reported, not only would pain be likely to be treated better, but the provider would
be more likely to heal the patient, as opposed to merely treat the disease.626
Insofar as moral particularism requires epistemic agents give a great deal more
attention to the specific context of a moral encounter (because it is that context
which specifies the valence of reasons), such particularism has significant
implications for the individual, irreducibly subjective experience of pain.
Finally, it is of course true that the objective modalities that characterize
Western and American science and medicine have had powerful salutary effects.
Inasmuch as these modalities can improve the treatment of pain and reduce
unnecessary human suffering, their use should be encouraged. But a central aim
of my project is to suggest what such a turn has diminished, what other ways of
knowing and thinking and conceptualizing pain and illness have been lost or
reduced in the process.627 Thus, while it would be absurd to deny the utility of
objectification in the treatment of pain, it does not follow that the optimal means
of healing the pain sufferer is by objectifying modalities and interventions.
Moreover, some methods of objectification, such as many kinds of diagnostic
imaging techniques, may turn out to be of little use in treating certain kinds of
626
Leder, “The Experience of Pain.”
627
E.g., Arthur Kleinman, “Opening Remarks: Pain as Experience,” in Pain and Its
Transformations: The Interface of Biology and Culture, eds. Sarah Coakley and Kay Kaufman
Shelemay (Cambridge, MA: Harvard University Press, 2007), 17-20; Kleinman, “Pain as
Resistance”; and Hamlin, “Predisposing Causes.”
233
pain, and may instead do much to decenter, stigmatize, and ultimately augment
the person-in-pain’s suffering.628
CONCLUSION
The relevance of the ethical theories surveyed in this chapter–
phenomenology of pain and moral particularism–is that they embody the primary
objective of this project, which is to center an analysis of why pain is so
dramatically undertreated in the United States on the pain sufferer. This is neither
trivial nor facile; the clinical gaze inexorably directs focus away from the subject
in pain and towards attempts to diagnose, to view the objects that are presumed to
cause the experience of pain. Moreover, the dominant approach to ethics and pain
policy in the United States focuses almost entirely on the opioid regulatory
regime, which centers the physician-prescriber. Phenomenology and
particularism are important to the ethics of pain because they each imply that the
primary locus of ethical significance is the being-in-the-world, the particular
subject moving through their local, social world and experiencing and
understanding the meaning of their pain in terms of these local worlds.
Principlism, objectivism, and generalism in morals almost by definition are poorly
suited to accounting for these contextual factors, though again, this is not to
suggest such approaches simply could not be used in developing a richer account.
However, the specific modes and practices of such ethical approaches in bioethics
do not, in my view, inspire confidence that such an enriched framework is
forthcoming.
628
This argument is taken up in earnest in chapter 9.
234
What I have tried to do in this project is to suggest the primacy of some of
the social and cultural factors that animate the meaning of pain in American
society, and to explain how the dominance of objectivity in American society and
in the culture of biomedicine is a major reason why pain continues to be
undertreated. With such an understanding, what remains to be done is to translate
this evidence into policy recommendations that justify a hope that improvement in
treating pain in the United States is possible. This task is the subject of the final
two chapters in my analysis.
235
SECTION IV: Towards Ethical, Evidence-Based Pain
Policy
While detailed discussion of the relationship between the Renaissance
educational program known as the studia humanitatis and contemporary issues of
health and illness is not my project here, it is worth noting here a key feature of
the humanist ethos: its focus on practical engagement.
The humanism of the Middle Ages and of the Renaissance largely arose in
dialectical response to the perceived shortcomings of Scholasticism.629
Scholasticism, practiced within the walls of the great medieval universities and
monasteries, featured, Proctor argues, a “well-known obsession with formal logic,
an obsession . . . which corrupted both their thinking and their writing.”630
Bouwsma notes that scholasticism “was increasingly remote from the concrete
world of actual human experience and human needs . . . .”631 In contrast, the
incipient humanists of the Late Middle Ages were concerned with reading the
works of antiquity with an eye to the cultivation of virtue and individual
betterment.632 This is a key aspect of humanism: the turn to classical knowledge
in the hope of encouraging the cultivation of virtue, and of having an effect on the
everyday practices of those outside the traditional centers of learning.633
629
See, e.g., Nauert, Humanism and the Culture of Renaissance Europe; and Bouwsma,
“The Culture of Renaissance Humanism.”
630
Robert E. Proctor, Defining the Humanities, 2d ed. (Indianapolis, IN: Indiana
University Press, 1992), 23
631
Bouwsma, “The Culture of Renaissance Humanism,” 9.
632
See note 630 above.
633
Nauert, Humanism and the Culture of Renaissance Europe; Ullrich Langer,
“Introduction,” in The Cambridge Companion to Montaigne, ed. Ullrich Langer (Cambridge, UK:
Cambridge University Press, 2005), 1-8.
236
In contrast to the emphasis on logic and disputation characteristic of the
high Scholastics, the humanists prioritized rhetoric for several reasons. First, in a
world of increasing urbanization, “the practical needs of men living together in
cities required a larger concern with rhetoric.”634 Second, in contrast to logic,
rhetoric “alone could speak to the hearts of men, quicken faith, and transform
lives.”635 Unlike logic, rhetoric was perceived as deeply connected to an
individual’s lived experiences, and study of rhetoric (via the wisdom of antiquity)
was intended to promote virtue.636 Rhetoric was perceived as transformative,
which spoke to the bankruptcy of Scholasticism for Petrarch; “its lifeless
abstractions were incapable of moving men to reform their own lives and to
remedy the evils of the age.”637 Humanist emphasis on rhetoric “saw words as
power and a rhetorician as an expert in the use of unique and highly developed
gifts to move other men.”638
Thus, as mentioned in the Introduction, the humanists were early
translational researchers. The term “translation” is something of a catchphrase in
academic medicine and science these days, emphasizing the need to translate the
knowledge produced via scientific and clinical research into practices that will
benefit communities and individuals, including illness sufferers.639 The reasons
for the gap between evidence and practice are extremely complicated, and in
634
Bouwsma, “The Culture of Renaissance Humanism,” 10.
635
Ibid., 26.
636
Ibid.; see also Gary Remer, Humanism and the Rhetoric of Religious Toleration
(University Park, PA: Pennsylvania State University Press, 1996).
637
Bouwsma, “The Culture of Renaissance Humanism,”14.
638
Ibid., 15.
639
The literature on this topic is immense. For a helpful introduction, see the NIH
Roadmap for Translational Research, http://nihroadmap.nih.gov/ (last accessed Jan. 8, 2009).
237
some of my work related to public health policy I explore the social, cultural,
political, and legal reasons why American public health policies do not seem to
incorporate the best evidence regarding ways of sustaining and improving
population health.640
The translational question lies at the heart of this project. I have expressly
argued that the undertreatment of pain in the United States is not a function of
insufficient technical knowledge and capacity. If it is the case that, in the United
States, there exist interventions sufficient to ameliorate the vast majority of pain
experiences, it follows that the problem is at its root one of translation. This is
one reason why a medical humanities approach is particularly well-suited to
analysis of the problem. However, mere analysis of the problem is inconsistent
with the ethos of practical engagement embodied by the humanists. As
worthwhile as it might be to identify, as I have tried to do, some of the primary
social and cultural reasons connected to the meaning of pain that animate its
undertreatment, a medical humanities approach demands more. The evidence
must be translated into a medium that fulfills the criterion of practical engagement
with the world. There are many such media; the one I utilize in this final section
is public health policy. Why choose policy? Policy by definition affects a
multiplicity of communities and persons, and has the potential to change behavior
across and within various sectors. Under the best of circumstances, policy can
have a broad impact on shaping a society’s lived answer to Aristotle’s
foundational question, “how shall we live?”
640
Goldberg, “In Support of a Broad Model of Public Health.”
238
In this chapter and the one that follows, I will attempt to bring together the
various strands of analysis and disciplinary tools I have been working with into a
bundle of public health policies that incorporate in their very structure key ideas
related to the meaning of pain in the United States. I submit that however wellintentioned, currently dominant policy approaches leave out such an assessment,
and as such, are not tailored to the root social and cultural causes that drive the
undertreatment of pain. While I have mentioned this problem throughout my
analysis, this chapter is devoted to a focused assessment of some of the dominant
approaches and suggestions to ethical pain policy. In highlighting the strengths
and weaknesses of these policies, I will contextualize my own pain policy
recommendations, which follow in chapter 9.
Chapter 8: Opioids & Pain Policy
INTRODUCTION
In this chapter, I will lay out what I perceive as the dominant policy
approach to pain, which centers on the opioid regulatory scheme. I will then
critique this approach. My criticisms do not arise from a fundamental
disagreement with the objectives of the dominant policy approach, but rather from
what I perceive as the robust evidence that such an approach has had little
measurable impact on the undertreatment of pain in the United States. I then
provide a brief analysis, picking up on themes and arguments advanced in the first
seven chapters, of why I find the dominant policy approach to be deficient, of
why it is that the undoubtedly well-intentioned approach has apparently had so
little demonstrable effect.
239
While this chapter is devoted more to explaining why I eschew an
approach that focuses on opioids than to addressing the particulars of the
discourse on opioids, it is useful to lay out the state-of-the-art regarding the safety
and efficacy of opioids for the treatment of pain. As there is reasonable evidence
that long-term usage opioids for pain may be only marginally effective for small
subsets of a general population of pain sufferers, this undermines further the
notion that liberalizing access to opioids will dramatically improve the
undertreatment of pain.
Finally, I end the chapter by surveying some of the issues related to the
meaning of opioids in American society. This too is a deficiency in the dominant
policy approach; even if I am mistaken and the opioid regulatory regime is
paramount in improving the treatment of pain, attempts to reshape and correct the
policy scheme are unlikely to have significant impact if they are divorced from an
appropriately nuanced and complex (interdisciplinary?) account of the meaning of
opioids. Though I do not provide such an analysis–both because opioids are not
my project here and also because I remain unconvinced that such an approach is
central to improving the treatment of pain in the United States–I close the chapter
by sketching some features of what such an account might look like. This last
segment of the chapter addresses some of the furor over the prosecution of opioid
prescribers, which far and away generates the lion’s share of the focus on the
undertreatment of pain in the United States. Such focus is, I suggest, unjustified,
not because it is irrelevant to the culture of pain, but because doing so is unlikely
to improve the treatment of pain in the United States
240
THE DOMINANT POLICY APPROACH TO PAIN: BALANCE IN OPIOID
REGULATIONS
There is exactly one entity in the United States that is expressly housed at
an academic medical center and that is specifically devoted to pain policy: the
Pain & Policy Studies Group (PPSG), affiliated with the University of Wisconsin
Paul B. Carbone Cancer Center. For over twenty years, they have dominated
academic and political discussions of pain policy in the United States.
Since 1997, the PPSG has produced several editions of two documents
whose influence on pain policy can barely be overstated. These documents are
the “Achieving Balance” reports, which include a “Progress Report Card” and an
“Evaluation Guide,” containing profiles of each U.S. state and the federal
government. The criteria for evaluation center on the government entity’s
compliance with the guiding principle of the PPSG, which is “balance” in
regulation of opioid analgesics.641 “Balance” is sought between the legitimate law
enforcement aim of preventing the abuse and diversion of powerful narcotics like
opioids, and the key role opioid analgesics play in the effective treatment of
pain.642 As stated in the Introduction, I see nothing inappropriate about seeking
balance in pain policy, or in public health policy of any kind. As such, I endorse
without hesitation the efforts to attain balance in pain policy on local, state, and
federal levels, and the PPSG documents are valuable tools in this endeavor.
However, my criticisms of the PPSG approach proceed along several
lines. First, the efforts to achieve balance in the opioid regulatory scheme
641
Gilson, Joranson, Ryan, Maurer, Moen, and Kline, 2008 Achieving Balance in Federal
and State Pain Policy, § V.
642
Ibid.
241
typically do not explain or account for the reasons why opioid policy has
historically been and remains unbalanced in the United States.643 That is, to
reconfigure opioid policies in ways that come closer to an ideal state of balance, it
seems important to tailor these efforts to address the root causes that have driven
the imbalance in opioid policy. Policy that is not so tailored is unlikely to have
the practical effect intended or hoped for, and is in my view a central reason why
the best efforts of the PPSG and its allies do not seem to have had the expected
and hoped-for impact as of the current date. C. Stratton Hill, Jr., a retired cancer
physician and pain specialist who has been advocating for improved pain
treatment for over three decades, maintains that an approach which focuses almost
exclusively on the regulatory scheme is simply doing what was tried over thirty
years ago, with little success.644
The second deficiency in the PPSG approach is the unstated assumption
that achieving balance in opioid policy is and ought to be the primary means of
improving the undertreatment of pain in the United States. The reason this
assumption is problematic is because a focus on opioid policy leaves opaque the
role that social and cultural beliefs, attitudes, and practices regarding the meaning
of pain in the United States play in animating its undertreatment. The example I
provided in the Introduction noted the tendency of elderly persons in the United
States to underreport their pain, which is a significant barrier to effective
treatment.645 There is little reason to believe that achieving balance in the opioid
regulatory scheme will remedy this problem.
643
Acker, Creating the American Junkie; and Acker, “From All Purposes Anodyne to
Marker of Deviance.”
644
C. Stratton Hill, Jr., personal communication to author, 2009.
645
Goldberg, “The Sole Indexicality of Pain.”
242
Moreover, a focus on opioid policy inevitably centers in the analysis the
opioid prescriber, which in the United States, is exclusively the physician. As I
have expressly argued, this is a serious problem because so much of the attitudes,
practices, and beliefs about the meaning of pain that shape the clinical gaze are
part of a cultural frame shared by pain sufferers, caregivers and non-physician
health care providers (of which elderly populations tending to underreport their
pain is an excellent example). Furthermore, I have documented throughout my
analysis the ways in which these broader narratives shape the practices and
attitudes of all participants in the pain encounter–physicians, caregivers, and pain
sufferers alike. Focus simply on the prescribers obscures the larger contexts
which deeply influence practices and beliefs towards pain and its treatment.
Thus, pain sufferers frequently

join physicians in the attempt to objectify their own pain;

doubt the pain talk of fellow pain sufferers;

join physicians in worrying about the risks of becoming addicted to opioid
analgesics.646
This last point, regarding fears of addiction, is a key aspect of the overall
policy landscape, one I have intentionally skirted to this point. The PPSG’s
approach to pain policy focuses almost exclusively on the opioid regulatory
regime. Why? On one level, the answer is obvious: for centuries if not milennia
opioids have been a frontline therapy for the effective treatment of many kinds of
646
Nessa Coyle, “In Their Own Words: Seven Advanced Cancer Patients Describe Their
Experience with Pain and the Use of Opioid Drugs,” Journal of Pain and Symptom Management
27, no. 4 (April 2004): 300-309.
243
pain. There is little question that they remain so today, but an increasing body of
evidence suggests that the efficacy of opioid analgesics for different kinds of pain
is uncertain at best. If this evidence is legitimate, this obviously suggests yet a
third reason for contending that an undue policy focus on opioid regulation is
unlikely to substantially improve the undertreatment of pain–opioids themselves,
however important, are not the answer to the undertreatment of pain. Examining
this evidence briefly is important to thinking about the strengths and weaknesses
of the “balance” approach.
Evidence Related to the Use of Opioids in Treating Pain
The present state-of-the-art regarding the use of opioids for treating pain is
in flux. There is little question both that opioids remain an important therapy, and
that the total volume of opioid dispensation is increasing. Deshpande et al.
observe that despite the fact that
the use of opioids . . . remain[s] a controversial issue in the
management of chronic non-cancer pain, and chronic [low-back
pain] in particular, there is a steadily growing trend toward
prescribing opioids for the management of [chronic non-cancer
pain]. Market data indicate that since 2000, long- and short-acting
opioids experienced a 26.5 percent and 39 percent compounded
annual growth rate, respectively.647
Yet the controversy over the extent of the efficacy of opioids for chronic
nonmalignant pain (which, to the best of my knowledge, is synonymous with
647
Amol Deshpande, Andrea D Furlan, Angela Mailis-Gagnon, Steven Atlas, and Denis
Turk, “Opioids for Chronic Low Back Pain,” Cochrane Database of Systematic Reviews 3, Art.
No.: CD004959 (July 2007), doi: 10.1002/14651858.CD004959.pub3,
http://dx.doi.org/10.1002/14651858.CD004959.pub3 (accessed June 1, 2009) (citation omitted).
244
“chronic non-cancer pain”) seems to be growing concomitant to its usage.648 In
their systematic review of the efficacy of opioids in improving pain or function in
persons with chronic law-back pain, Deshpande et al. conclude that “there was no
statistically significant difference between [subjects given strong opioids like
oxycodone and morphine and subjects given naproxen] for either pain relief or
functional improvement.”649
Similarly, Noble et al. note that while many pain sufferers discontinue
long-term usage of opioids for chronic nonmalignant pain due to either or both
adverse effects or insufficient pain relief, only weak evidence exists to support
such long-term usage.650 Moreover, both Deshpande et al. and Noble et al. note
the paucity of high-quality studies that would generate high confidence in
assessments of the safety and efficacy of long- term usage of opioids for chronic
nonmalignant pain. Ultimately, Deshpande et al. suggest that “[a]s the pendulum
swings from an ‘opiophobic’ to an ‘opiophilic’ society, physicians should
question whether the current trend is based on evidence or simply the outcries of
well-intentioned patient advocates and aggressive marketing efforts by the
pharmaceutical industry.”651
648
Jane C Ballantyne, “Medical Use of Opioids: What Drives the Debate? A Brief
Commentary,” European Journal of Pain Supplements 2, no. 1 (October 2008): 67-68.
649
Deshpande, Furlan, Mailis-Gagnon, Atlas, and Turk, “Opioids for Chronic Low Back
Pain,” 13.
650
Meredith Noble, Stephen J. Tregear, Jonathan R. Treadwell, and Karen Schoelles,
“Long-Term Opioid Therapy for Chronic Noncancer Pain: A Systematic Review and MetaAnalysis of Efficacy and Safety,” Journal of Pain and Symptom Management 35, no. 2 (February
2008): 222.
651
Deshpande, Furlan, Mailis-Gagnon, Atlas, and Turk, “Opioids for Chronic Low Back
Pain,”13.
245
Here, two points are relevant. First, it is becoming increasingly less
plausible, if ever it was so, to suggest that opioids are a panacea for any kind of
chronic nonmalignant pain, let alone for any kind of acute pain. Opioids remain,
of course, an important intervention for ameliorating many kinds of acute and
chronic pain, but the evidence supporting efficacy for long-term use regardless of
the particular kind of pain experiences is weak. Given the multivalence, the many
phenonmenologies of pain,652 it is unsurprising that no single intervention suffices
to ameliorate all or even most different kinds of pain. This possibility in turn
suggests even further reason for doubting that undue focus on the opioid
regulatory regime is likely to result in substantial improvement in the
undertreatment of pain in the United States. If in fact opioids are both important
and yet more limited in relieving (especially chronic) pain than we might have
imagined, it follows that even a perfectly balanced opioid regulatory scheme may
not result in significantly better treatment of American pain sufferers.
The second point arising from this more complicated picture of the
efficacy of opioids is whether such a view undermines the claim I have advanced
throughout this project, that we generally enjoy the technical capacity to treat pain
far better than we currently do. One could argue that if opioids are less effective
than had previously been imagined in treating chronic pain, perhaps the ability to
ameliorate pain I have noted is correspondingly lesser as well.
This argument seems superficially tenable, but breaks down upon closer
examination. The notion that because opioids are not a cureall for pain we do not
enjoy the technical ability to ameliorate pain far better than is currently done is
652
For more on the idea that there exist multiple phenomenologies of pain, see the
Preface and chapter 2.
246
question-begging inasmuch as it implies that our capacity to relieve pain is mostly
a function of facility with opioids. The briefest glance at any textbook or manual
on clinical pain management is sufficient to disabuse this notion, as it is almost
universally acknowledged that effective treatment of pain requires multimodal,
multidisciplinary efforts.653 Despite the apparent emphasis on the use of opioids
in the treatment of pain, there is no serious clinical suggestion that the exclusive
use of opioids is an effective means of treating pain. Numerous other
interventions, pharmacologic and nonpharmacologic, are of demonstrated efficacy
in treating certain kinds of pain. Acetaminophen, aspirin, and nonsteroidal antiinflammatory drugs are all effective analgesics for some kinds of pain, as are
massage,654 yoga,655 and cognitive behavioral therapy (especially with regard to
improving mood in chronic pain sufferers).656 The suggestion that we enjoy the
technical capacity in the United States to treat pain far better than we do is
justified if the assessment of that capacity encompasses the variety of approaches
and interventions that demonstrate efficacy in treating pain. Opioids are one of
these interventions, and perhaps they are even the most important intervention,
but they are nevertheless simply one tool in the multimodal, multidisciplinary
653
E.g., Carol A. Warfield and Zahid H. Bajwa, Principles and Practice of Pain
Medicine, 2d ed. (New York, NY: McGraw Hill Companies, 2004).
654
Chapter 7 discusses the role of touch, including massage, as therapy for pain.
655
E.g., Denise O’Connor, Shawn C. Marshall, and Nicola Massy-Westropp, “Nonsurgical Treatment (Other Than Steroid Injection) for Carpal Tunnel Syndrome,” Cochrane
Database of Systematic Reviews 1, Art. No.: CD003219 (January 2003), doi:
10.1002/14651858.CD003219, http://dx.doi.org/10.1002/14651858.CD003219 (accessed June 12,
2009).
656
Christopher Eccleston, Amanda C de C Williams, and Stephen Morley,
“Psychological Therapies for the Management of Chronic Pain (Excluding Headache) in Adults.
Cochrane Database of Systematic Reviews, 2, Art. No.: CD007407 (April 2009), doi:
10.1002/14651858.CD007407.pub2, http://dx.doi.org/10.1002/14651858.CD007407.pub2
(accessed June 13, 2009).
247
pain treatment toolbox that supports the claim that there is no technical reason
why, for example, 40-80 percent of residents in long-term care facilities should
suffer daily, persistent pain.657
Thus far in this chapter, I have suggested some reasons for doubting that
an almost single-minded focus on opioid regulation is likely to substantially
improve the undertreatment of pain in the United States. Given these reasons,
there is undoubtedly something compelling about opioids themselves–about, I
daresay, the meaning of opioids in American society–that animates the undue
emphasis on the distribution and application of opioids in thinking about pain.
Moreover, even if I am wrong, and in fact pursuing balance in the opioid
regulatory scheme is the most effective means of improving the undertreatment of
pain, it is still crucial to understand that scheme as a discursive product, the result
of a constant, dynamic interaction of various actors and stakeholders regarding the
distribution of powerful narcotics. Understanding something about the meaning
of opioids in American society is therefore integral in pursuing a policy agenda
regarding those opioids. Fortunately, there is no shortage of social and cultural
analyses of the meaning and significance of opioids in American society. As such,
an exhaustive analysis is not my project here.
But given the centrality of opioids in the PPSG approach, as well as the
undeniable fact that opioids remain an important intervention in treating pain, this
project would be incomplete if it did not at least briefly address some of the issues
swirling around the use and abuse of opioid analgesics. Consistent with the ethos
657
Won, Lapane, Vallow, Schein, Morris, and Lipsitz, “Persistent Nonmalignant Pain and
Analgesic Prescribing Patterns in Elderly Nursing Home Residents”; Teno, Weitzen, Wetle, and
Mor, “Persistent Pain in Nursing Home Residents”; and Ferrell, Ferrell, and Rivera, “Pain in
Cognitively Impaired Nursing Home Patients.”
248
of this dissertation, my chief interest is in the ways that the meaning of opioids in
American society is reflected in opioid policy.
OPIOIDS & THE MEANING OF ADDICTION IN AMERICAN SOCIETY
Pain scholars frequently argue that the undertreatment of pain is
inextricably intertwined with the undermedication of pain.658 Morris focuses on
acute pain resultant to terminal illness perhaps in part because of the “bitter irony
that in almost all cases effective medications are available but not used.”659 He
acknowledges that physician fears regarding possible addiction to opiates drive
undermedication, but is also aware that fears about opioids permeate society in
general, and are shared by the pain sufferers themselves, who are often “no less
wary of opiates and opioids than are many doctors.”660 Nessa Coyle’s 2004 study
of terminally ill cancer patients revealed that virtually all of them expressed great
concern over opioid therapy, voicing anxiety that the side effects of opioids would
“make them sleepy or dull their minds.”661 One patient could not “countenance”
the possibility that both his increasing pain and his increasing sensation of being
“zonked out” “were associated with progressive disease as well as opioid side
effects . . . .”662
658
E.g., Morris, “An Invisible History of Pain,” Ben A. Rich, “An Ethical Analysis of the
Barriers to Effective Pain Management,” Cambridge Quarterly of Health Care Ethics 9, no. 1
(January 2000): 54-70; Ben A. Rich, “A Legacy of Silence: Bioethics and the Culture of Pain,”
Journal of Medical Humanities 18, no. 4 (December 1997): 233-259.
659
Morris, Illness and Culture in the Postmodern Age, 113.
660
Ibid.
661
Coyle, “In Their Own Words,” 304-05.
662
Ibid.
249
Morris proceeds by challenging the merits of these concerns. He notes
that the risks of inpatient addiction are extremely small (a fraction of a percent),
and that even if they were more significant, there is little reason to fear opioid
addiction for a patient with little time left to live.663 The same holds true for two
other common fears that attend the use of opioids: respiratory depression and
tolerance. The best evidence suggests that the probability of these effects
occurring concomitant with the use of opioids is much lower than had been
surmised, to the point that withholding otherwise indicated opioids for these
reasons is generally suboptimal if not substandard care.664
However, there is reason to suspect that explaining to prescribers and
patients alike that their fears of addiction are unwarranted may do little to
dislodge those who hold these views, especially if such views are deeply rooted in
American culture. This is all the more true with a highly publicized fear attending
opioid prescription, that of criminal prosecution.
Criminal Prosecution for Opioids
The debate over the extent of the risk of criminal prosecution for opioids
is both current and vigorous. For at least two decades, numerous books and
articles on the subject have been produced, and the contest shows no signs of
diminishing in vigor. Just by way of example, within the last eight months of this
writing, an article appeared in Pain Medicine analyzing the “big picture”
regarding the nature and characteristics of both criminal prosecution and
663
Morris, Illness and Culture in the Postmodern Age, 107-134.
664
Consensus Statement of the American Academy of Pain Medicine and the American
Pain Society, http://www.ampainsoc.org/advocacy/opioids.htm (accessed June16, 2009).
250
administrative enforcement (generally actions taken by state medical boards
against prescribers).665 The authors found that only .1 percent of prescribers
between 1998 and 2006 experienced either criminal prosecution or administrative
action, and concluded that both criminal and administrative enforcement activity
was rare.666 The authors also noted that their data did not suggest that pain
specialists faced any increased risk of enforcement activity.667 The article ignited
a storm of controversy. Major newspapers covered the article in detail, and the
media coverage included several choice quotations from critics of the study.
Among those quoted was Ronald T. Libby, a political scientist and the recent
author of a book entitled The Criminalization of Medicine: America’s War on
Doctors.668 Libby maintains that the risks of enforcement activity are quite real,
so much so that they amount to a virtual “war” on opioid prescribers, and he
referred to several “serious and obvious flaws in the research” covered in the
Goldenbaum et al. study.669
Of course, it is not simply academic publications that stoke the fire of
public discourse on this matter. It is unlikely that an academic article could merit
such media attention without the visibility of several high-profile criminal
665
Donald M. Goldenbaum, Myra Christopher, Rollin M. Gallagher, Scott Fishman,
Richard Payne, David Joranson, Drew Edmondson, Judith McKee, and Arthur Thexton,
“Physicians Charged with Opioid Analgesic-Prescribing Offenses,” Pain Medicine 9, no. 6
(September 2008): 737-747. Among the nine authors of the paper are two representatives of the
Center for Practical Bioethics (Goldenbaum and Christopher), the Attorney General for Oklahoma
(Edmonson), one of the most visible palliative care physicians in the United States (Payne), and
one of the principals of the PPSG (Joranson).
666
Ibid.
667
Ibid.
668
Ronald T. Libby, The Criminalization of Medicine: America’s War on Doctors
(Westport, CT: Greenwood Publishing Group, 2007).
669
Ronald T. Libby, e-mail message to author, September 27, 2008.
251
prosecutions of pain physicians during the last few years. Several of these cases
produced a flurry of media coverage and academic commentary, suggesting that
the issue is occupying more of a central space in public as well as academic
discourse. The most recent and arguably most visible of these cases are the trials
of William Hurwitz, a pain physician prosecuted by the federal government for
narcotics trafficking. Hurwitz was originally convicted in 2004 and was
sentenced to twenty-eight years in prison, but prevailed on appeal, with the Court
of Appeals for the D.C. Circuit reversing and remanding for a new trial.670 The
government prevailed (again) on retrial, and in 2007, Hurwitz was sentenced to
serve fifty-seven months in prison. The Hurwitz case evoked extensive coverage
from all manner of actors and stakeholders interested in the treatment of pain.
Numerous pain advocacy organizations, professional societies, and editors of
relevant journals followed the case closely, many of whom expressed heated
reactions to Hurwitz’s second conviction and subsequent incarceration.
There are two overarching points I want to make regarding criminal
prosecution for opioids. First, in a very real sense, it makes little difference
whether those who claim that the risks of enforcement activity for opioid
prescribing are small or their adversaries are correct. This is because the fears of
enforcement are quite real. Regardless of the absolute risks, the fact remains that
prescribers of opioid analgesics maintain such fears. As such, telling those
prescribers in essence, that their fears are unwarranted may do little to dispel
them. In an editorial accompanying the Goldenbaum et al. study, Sandra Johnson,
a leading pain scholar, noted that the “consistent evidence-based message” that
670
United States v. Hurwitz, 459 F.3d 363 (4th Cir. 2006).
252
the risks of enforcement are small “cannot compete with the grapevine and news
headlines of the horror story.”671
Moreover, Learned Hand’s seminal formula for assessing negligence notes
that what matters in thinking about what the reasonably prudent person would do
is not simply the probability of the harm occurring, but that probability multiplied
by the magnitude of the harm that could occur.672 Thus, Johnson observes that
prescribers’ fears may track Hand’s insight, because while the “incidence may be
rare,” the injury, if it were to occur, would be great indeed.673 Finally, Johnson
notes the abundant social science research demonstrating that
debunking false information actually contributes to its persistence.
People who hear information they believe is true–for example, that
prescribing controlled substances for pain is risky–and then hear
multiple times that the information is actually false are more likely
to remember the false information as true than are those
individuals who do not hear the multiple refutations.674
The point is that, while not quite irrelevant, precisely calibrating the risks
opioid prescribers face of enforcement activity is of secondary importance,
largely because prescribers do in fact fear such enforcement activity. Informing
671
Sandra H. Johnson, “Editorial,” Pain Medicine 9, no. 6 (September 2008): 748-749.
672
Learned Hand is one of the most famous judges in American history. His authored his
formula for negligence in the case of United States v. Carroll Towing Co., 159 F.2d 169 (2d Cir.
1947). The formula is written as B < pL, where B is the burden of the act needed to prevent the
harm, p is the probability of the harm occurring, and L is the magnitude of the harm were it to
occur. Where the burden of acting is lower than the probability of the harm multiplied by its
magnitude, the actor’s failure to act accordingly constitutes negligence. The reasonable doubts as
to whether the concept of negligence can be formalized in this way should not prevent the reader
from grasping the utility of Hand’s frame in thinking through some of the moral and legal
implications of risk.
673
Sandra H. Johnson, “Editorial,” Pain Medicine 9, no. 6 (2008): 748.
674
Ibid., 749.
253
prescribers that their fears are out of proportion to the risks–assuming this is in
fact correct–may do little to dispel such fears. If Johnson is correct, a constant
flow of information suggesting the disproportion of the fears may actually worsen
them.675 A preferable means of proceeding, then, is to focus less on specifying
the nature of the risk prescribers face, and instead to attempt to understand
something about the meaning of the fears of enforcement. Why do prescribers
fear prosecution or administrative action for prescribing opioids? Note that this
question is a corollary of the question that the PPSG’s focus on balance in opioid
policy implies but does not answer: why is it that opioid policy in the United
States has historically been imbalanced?
One other example will hopefully suffice to demonstrate the importance of
unpacking the meaning of opioids and addiction in American society in producing
ethical opioid policies that will be tailored to address the root causes of such
imbalance. In the retrial of William Hurwitz, the government introduced as one
of its expert witnesses Robin Hamill-Ruth, a pain medicine physician and the
Director of the Pain Management Center at University of Virginia Health
Systems, in Charlottesville, Virginia.676 Upon cross-examination, defense counsel
questioned Hamill-Ruth’s care of a chronic pain patient named Kathleen
Lohrey.677 Lohrey suffered from severe, debilitating migraines, and sought relief
675
Norbert Schwarz, Lawrence J. Sanna, Ian Skurnik, and Carolyn Yoon, “Metacognitive
Experiences and the Intricacies of Setting People Straight: Implications for Debiasing and Public
Information Campaigns,” Advances in Experimental Social Psychology 39, ed. Mark Zanna (New
York, NY: Academic Press, 2007), 127-161; Kimberlee Weaver, Stephen M. Garcia, Norbert
Schwarz, and Dale T. Miller, “Inferring the Popularity of an Opinion From Its Familiarity: A
Repetitive Voice Can Sound Like a Chorus,” Journal of Personality and Social Psychology 92,
no. 5 (May 2007): 821-833.
676
John Tierney, “At Trial, Pain has a Witness,” New York Times, April 24, 2007.
677
Ibid.
254
at the Pain Management Center Hamill-Ruth directed, but, according to the New
York Times, found to her dismay that the “clinic’s philosophy ‘includes
avoidance of all opioids in chronic headache management.’”678 Given the
evidence suggesting that opioids are an effective treatment for at least some
persons who suffer from chronic head pain,679 the question must be asked, what
would prompt a center devoted to treating pain to expressly disavow using an
evidence-based intervention? The terseness of this question should not mask the
fact that at issue are real persons with real pain, often desperately seeking
treatment and healing. The phenomenology of pain is crucial here; indeed,
Kathleen Lohrey abandoned Hamill-Ruth’s pain clinic in despair and frustration
after she was prescribed buspirone, an anti-anxiolytic drug whose known side
effects include headaches.680 After receiving opioid prescriptions from Hurwitz,
she testified as a witness in his defense.
In any case, the question remains: why did the pain clinic expressly state
as its philosophy that it would generally avoid treating headaches with opioid
analgesics? Any answer to this question that does not include an analysis of the
678
Ibid.
679
Dewey K. Ziegler, “Opioids In Headache Treatment: Is There a Role?” Neurologic
Clinics 15, no. 1 (February 1997): 199-207. In a longitudinal study of clinical efficacy of daily
scheduled opioids for intractable head pain, Joel R. Saper et al. noted that while a select group of
the subjects (26 percent, n=41) benefited considerably from the regimen, the remaining 74 percent
(n=119) either failed to show improvement or were discontinued from the program for clinical
reasons. Therefore, again it is important in discussing the use of opioids for treating pain to
understand that the effectiveness of such treatments for any particular type of pain remains
unsettled. Joel R. Saper, Alvin E. Lake III, Robert L. Hamel, Thomas E. Lutz, Barbaranne
Branca, Dorothy B. Sims, and Mary M. Kroll, “Daily Scheduled Opioids for Intractable Head
Pain: Long Term Observations of a Treatment Program,” Neurology 62, no. 10 (May 25, 2004):
1687-1694.
680
For an excellent introduction into some of the historical issues surrounding the
treatment of headaches in the United States, see Jan R. McTavish, Pain & Profits: The History of
the Headache and Its Remedies in America (New Brunswick, NJ: Rutgers University Press, 2004).
255
meaning of opioids in American culture is hopelessly flawed. While I will not
provide such an analysis here, I will in broad strokes discuss some of the issues
related to the meaning of opioids.
The Meaning of Opioids
Fears of addiction attending the use of opioids are hardly a novel concern.
The renowned medieval physician Guy de Chauliac warned as such during the
fourteenth century, and the risks of addiction were well understood in the early
modern era as well.681 Nevertheless, there is no question that the issue took on
particular importance in the nineteenth century, with the advent of anesthesia and
the Victorian focus on the general relief of suffering and pain.
Perhaps the most intriguing aspect of this period is the fact that fear of
pharmaceutical analgesics was readily apparent virtually from the inception of
modern anesthesia itself. Pernick notes that “in mid-nineteenth-century America,
humane, conscientious, highly reputable practitioners and ordinary lay people
held many misgivings about the new discovery.”682 This comment underscores
another reason for preferring an approach to pain that goes beyond opioid policy:
a focus only on the gatekeepers for opioid dispensation risks casting the
prescribers into a hero/villain dichotomy. It is reasonable to presume that the
majority of prescribers do not wish ill upon their patients, and that the reasons
why pain is undertreated are only poorly correlated, if at all, with the existence of
681
See Silverman, Tortured Subjects.
682
Pernick, A Calculus of Suffering, 35.
256
vicious prescribers. Morris concurs, noting that “[b]laming doctors as inhumane
just won’t work.”683
There were very real drawbacks to the use of anesthesia in midnineteenth-century America. On the technical level, very little was known about
anesthesia, so it was difficult if not impossible to determine safe dosage levels.684
Chloroform, for example, has been proven to have a panoply of dangerous side
effects. Anesthesia itself is inherently dangerous, as “[t]he administration of
anesthesia necessarily involves some practices and procedures that might be
viewed as ‘resuscitation’ in other settings.”685 As such, anesthesiologists have
generally voiced concern over do-not-resuscitate orders, fearing legitimately that
without careful wording, such orders could be construed to prohibit the typical
resuscitative measures that attend the use of general anesthesia.686
To handle these issues, nineteenth-century healers typically undertook
what Pernick terms a “calculus of professionalism,” in which the healer queried
which was the “‘lesser evil’–the harm likely to be caused by the pain or the harm
that might be caused by the painkiller?”687 Yet Pernick cautions that “the strength
and longevity of nineteenth-century fears about the safety of anesthesia cannot be
explained simply by the fact that modern medicine shares some of these
concerns.”688 Indeed, the calculus at issue was both moral and clinical; the
683
Morris, Illness and Culture in the Postmodern Age, 195-96.
684
Pernick, A Calculus of Suffering.
685
American Society of Anesthesiologists, “Ethical Guidelines for the Anesthesia Care of
Patients with Do-Not-Resuscitate Orders,”
http://www.asahq.org/publicationsAndServices/standards/09.html (accessed June 16, 2009).
686
Ibid.
687
Pernick, A Calculus of Suffering, 95.
688
Ibid., 39.
257
question of which “evil” was morally worse deeply influenced healing practices
of the time.
The point is that the fear that the cure for pain is worse than the ‘disease’
is hardly a novel phenomenon. It has its roots in the earliest attitudes to modern
anesthesia. Hill suggests that such attitudes are “systematically transferred from
one generation of physicians to another,”689 which reflects an appropriately
dialectic model of history. In such a model, prior events, ideas, and conditions
shape current attitudes and beliefs. Understanding current fears about opioids and
addiction therefore benefits from a culturally and historically informed
understanding of traditional fears about medical interventions used to ameliorate
pain.
Central to Pernick’s analysis is the notion that the treatment of pain
needed and dispensed through opioids varied depending on the demographic and
social characteristics of the person in pain. It was widely believed that AfricanAmericans had much higher pain thresholds than white persons.690 Indeed, this
belief was the primary justification J. Marion Sims offered for conducting his
vesicovaginal fistula experiments on black slaves as opposed to some of his more
well-heeled (white) patients.691 The current evidence regarding the scope of
disparities in assessing and treating pain suggests there are some important links
689
Hill, “When Will Adequate Pain Management be the Norm,” 1881.
690
Pernick, A Calculus of Suffering.
691
Ibid; Caroline M. De Costa, “James Marion Sims: Some Speculations and a New
Position,” The Medical Journal of Australia 178, no. 12 (June 16, 2003): 660-663.
258
between the history of opioids in the nineteenth century and current attitudes,
practices, and beliefs related to the use of opioids.692
Furthermore, the concept of addiction must itself be historicized. Gabriel
has documented how the concept of addiction itself is a peculiarly twentieth
century phenomenon.693 Challenging the notion that drugs themselves are purely
biological entities, Gabriel argues that
[t]he fact that the physical drug that is put in the body is itself
constituted through the processes of agriculture, pharmaceutical
research, and manufacturing – which are themselves constituted
through various hybrid forces that partake of both the material and
cultural aspects of the world–means that drug chemistry is no more
outside of human culture than any other aspect of the drug
experience.694
He continues by arguing that while addiction “obviously did not exist
before people started consuming certain types of commodities . . . it also did not
exist before people started understanding themselves in terms of the binary
between autonomy and self-discipline on the one hand and a lack of self-control
and bondage on the other.”695 While opium, hashish, ether, morphine, and
cocaine were “used therapeutically before becoming sites of social panic . . . [B]y
the end of the nineteenth century . . . the consumption of these substances outside
of direct medical supervision had become an area of profound concern for doctors
692
For a brief analysis of this connection as to elderly patients, see Goldberg, “The Sole
Indexicality of Pain.”
693
Gabriel, “Gods and Monsters.”
694
Ibid., 9.
695
Ibid., 10.
259
and pharmacists.”696 Similarly, Acker notes that the notion of the ‘American
junkie’ is a twentieth century construction.697
The notion that addiction itself has a history, and would have been poorly
understood, if at all, even by habitual ‘users’ of opioids and other ‘dangerous’
drugs in the nineteenth century is crucial in making sense of contemporary fears
of addiction. Properly historicizing addiction is assuredly not equivalent to
denying the contemporary reality of addiction or suggesting that fears of opioid
addiction are irrational. Rather, they help locate such fears in context, and
suggest some of the deeply entrenched social and cultural reasons why so many
prescribers and pain sufferers alike fear the power and the apparent danger of
opioids.
In any case, as I have noted, detailed analysis of the meaning of opioids
and addiction are beyond the scope of my project. Notwithstanding the
importance of this meaning to understanding the historical imbalance in opioid
policy and some of the fears providers, pain sufferers, and caregivers alike with
respect to opioids, the meaning of opioids and addiction is not coextensive with
the meaning of pain. Moreover, undue focus on the meaning of opioids and
addiction seems to suggest a policy focus on opioid regulation, which is a
direction I do not endorse, for reasons noted earlier in this chapter.
The following chapter is devoted to detailing and justifying the policy
directions I do endorse as to pain. I hope to demonstrate how these policy
recommendations incorporate the social and cultural evidence I have adduced, as
696
Ibid., 14.
697
Acker, Creating the American Junkie.
260
well as the ethical imperative to center the pain sufferer, and justify a hope that, if
implemented, improvement in the culture of pain is possible.
261
Chapter 9: Evidence-Based Pain Policy Recommendations
INTRODUCTION
Recommending public health policy is difficult. I say this as someone
with the good fortune to have practical experience in doing so, primarily in
serving as the chief policy advisor on a project devoted to producing and
disseminating policy related to disparities in clinical trials. A number of the
lessons I learned in the course of this work are applicable to pain policy. Perhaps
the most important of these lessons is Deborah Stone’s admonition that policy is
inevitably contested space.698 Even seemingly innocuous policies require a tradeoff of time and resources invested in their production, pursuit, and
implementation. This means that the justification for any proposed policy must
be robust, and the rhetoric employed in the service of such justification is
crucial.699 This notion of rhetoric suggests the second important lesson I have
learned in the course of my policy work: because policy and politics are
inextricably linked, and because the political process involves myriad
stakeholders and actors with myriad interests and concerns, building the
relationships needed to produce, pursue, and implement desired policy requires
698
Deborah Stone, Policy Paradox: The Art of Political Decision Making, rev. ed. (New
York, NY: W.W. Norton, 2002).
699
I expressly disavow the pejorative sense of the term “rhetoric.” As noted in the
Introduction to chapter 8, rhetoric was the most significant liberal art for the humanists, at least in
part because rhetoric was most able to “move men’s hearts” to the cultivation of virtue, to
paraphrase Petrarch. Of course, this is not to claim that rhetoric is intrinsically good–Socrates
disabused this notion effectively in the Gorgias–but that because of the power of rhetoric to
encourage virtuous practice, its capacity to facilitate virtuous health policy is ethically important.
262
exquisite care be taken to utilize rhetoric and arguments that are responsive to the
interests of the particular audience(s).700
The disparities project I participated in brought together over 300
collaborators drawn from public, private, and nonprofit community-based
sectors.701 To assist this diverse network, the project leaders and I, with the
assistance of several process consultants, produced a list of so-called “Policy
Process Questions.” The work required to answer these questions essentially
provided both the rationale and the general form of the policy recommendations
themselves, which were then revised and edited numerous times before being
released in April 2008. The two lessons mentioned above–the notion of policy as
a contest and the importance of tailoring rhetoric to suit the interests of the
audience–were instrumental in shaping these Policy Process Questions:
1. What is the problem? How does it manifest itself?
2. What would success look like? (Goal)
3. Whose behavior needs to change in order to achieve the goal? (Target
Audience)
4. Who has the ability to change the behavior of the target audience?
(Political Actor)
700
This, of course, is the classic(al) notion of decorum in rhetoric. See Gary Remer,
“Rhetoric as a Balancing of Ends: Cicero and Machiavelli,” Philosophy and Rhetoric 42, no. 1
(2009): 1-29; Remer, Humanism and the Rhetoric of Toleration.
701
Daniel S. Goldberg, EDICT Project Methodology,
http://www.bcm.edu/edict/PDF/EDICT_Project_Methodology.pdf (accessed June 6, 2009).
263
5. What policy is recommended to achieve the behavior change in the target
audience? (Ignore perceived limitations)
6. What is the feasibility of this policy?
7. Unintended consequences
8. Social, political, ethical, financial obstacles
9. What is the underlying thinking on why this policy will be effective?
The questions which seemed to prompt the most confusion, but which I
submit are most significant in light of the lessons mentioned above, were numbers
(3) and (4). These questions required the participants to apprehend the crucial
difference between those actors whose behavior the policies are intended to
change and those actors and entities who enjoy the power needed to actually
implement the recommended policies. If, for example, it is physicians’ whose
behavior a given health policy is intended to change, targeting the language of the
policy only to individual physicians essentially guarantees that it will accomplish
little qua policy, because individual physicians generally do not find themselves
in a position to implement broad-based health policy.
This is not to imply there is no value in a recommendation geared to
individual physicians, but rather that such a recommendation more closely
resembles a position statement than a broad-based health policy. Asserting that
individual physicians ought to do X may be a perfectly plausible position to
adopt, but there is a very great difference between adopting a position and
producing a policy with the hope that it could be implemented. If in fact the
proposed policy is intended to change practices of individual physicians, the
264
actors or entities that maintain the capacity to do so are from a policy perspective
the prime audience. Depending on the specific policy in question, examples of
such actors include a professional physician society such as the American
Medical Association or the American College of Surgeons, the American
Association of Medical Colleges (which exerts a strong influence on medical
education), or the Centers for Medicare & Medicaid Services (CMS), the federal
agency that determines Medicare and Medicaid reimbursement policy.
Thus, an optimal health policy is neither too general nor too specific. If
the proposed policy is too general, it runs the risk of appearing to be a position
statement that is not closely tied to the audience possessing the capacity to effect
change on a broad level. If the proposed policy is too specific, it runs the risk of
having only a narrow impact, limiting the potential reach and signaling effect of
the policy even before it is implemented.
The Policy Process Questions, of course, are neither formula nor
algorithm. Rather, they are simply a guide, a rough heuristic incorporating some
of these key policy points, which proved helpful in the course of my work on
disparities. The bulk of this chapter is devoted to determining whether they will
be of any use as applied to the undertreatment of pain.
PAIN AND THE POLICY PROCESS
Question #1: What is the problem? How does it manifest?
The problem is the undertreatment of pain. It manifests in myriad health
care encounters in which a person seeks treatment of their pain, or presents with
other health problems, of which pain is simply one. Such encounters are not
limited to visits to a doctor’s office, but include a number of different situations in
265
which illness is assessed and treated and care provided (for example, long term
care facilities, ambulatory clinics, emergency rooms, etc.).
In the vast majority of these encounters, health care providers and entities
possess the technical capacity to treat the pain effectively. Chapter 1 shows that
while precise assessment is difficult for a variety of reasons, the best evidence and
the overwhelming consensus is that in far too many of these encounters, pain is
either not treated at all or is not treated effectively. In addition, the treatment that
is provided is dispensed along various social fault lines such as race, class,
gender, and age, and disparities in pain are a significant and arguably growing
problem.
Question # 2: What would success look like? (Goal)
Success in the undertreatment of pain most obviously and most directly
looks like an American society in which the best evidence suggests that pain is
treated commensurate with the technical proficiency available. In this
hypothetical society, inequities in the assessment and treatment of pain are
decreasing, and vulnerable and marginalized populations are the recipients of
increased focus and resources as to the assessment and treatment of pain.
However, such objectives are not the only indicia of success. In many
ways, they are the ultimate goals, but are in my view only tenable if facilitated by
a different culture of pain than the version(s) which presently tend to dominate
American society. Thus, success could also be a function of more immediate,
concrete goals related to cultivating an improved, more virtuous culture of pain.
Of these second-order goals, the most important criterion of success is whether
the pain sufferer’s lived, subjective experiences are centered, by providers,
266
caregivers, and sufferers alike. A society in which the pain sufferer’s experiences
were the primary desideratum in any pain encounter would, in my opinion, be
much more likely to construct and reflect cultures of pain in which its effective
treatment is more likely and more equitable.
Question #3: Whose behavior needs to change in order to achieve the goal?
(Target Audience)
One of my central claims throughout this project has been that the
meaning of pain is a dynamic, ever-changing product of the interactions of a
number of different stakeholders. Of these, the most important are the provider,
the caregiver, and the pain sufferer. I have expressly criticized approaches to the
problem of undertreated pain that focus on only one of these key agents, typically
the provider, and even more typically, the physician. As important as the provider
and the physician are to improving the culture of pain–and they are indeed
crucial–it is not only providers whose practices need to change to improve the
undertreatment of pain. I have noted multiple times that elderly populations in the
United States tend to underreport their pain, at times substantially so. This
tendency is a barrier to the effective treatment of members of this population. It is
uncomfortable on a variety of levels to suggest that changing some aspects of pain
sufferers’ behavior could produce a more virtuous culture of pain, at least in part
because it seems to imply a blame-the-victim mentality, that pain sufferers bear
responsibility for their pain. Given the intense stigma that pain sufferers face in
the United States, it would be a grievous sin indeed for me to in any way imply
that such alienation is self-inflicted.
267
Let me be as clear as possible: pain sufferers are neither culpable for their
pain nor is the stigma they often endure “self-inflicted.” This conclusion simply
does not follow from the premise that pain sufferers themselves are active
participants in a discourse which tends to deemphasize and delegitimize the lived
experiences of pain. What does follow from this premise is that socialization is
inordinately powerful. The social and cultural narratives and conceptualizations
of objectivity, the power of the visible, and the relationship between the mind and
the body that shape American attitudes, practices, and beliefs towards the
meaning of pain are deeply rooted. As such, it should not be surprising that these
deep-seeded conceptualizations frame the forms of life and patterns of practice of
pain sufferers themselves.
Centering the pain sufferer does not imply that the role of the pain sufferer
is simply to teach the other participants in the culture and discourse of pain. Quite
the contrary, teaching and learning are or at least ought to be corollaries of one
another. There is no reason that pain sufferers cannot both teach others about
their lived experiences of pain and learn about the ways, subtle and otherwise, in
which American society tends to decenter such experiences. Such learning can
and should include information related to the ways in which even pain sufferers’
behaviors can contribute to such decentering.
So, whose behavior needs to change? Principally, providers, caregivers,
and pain sufferers, and likely in that order of importance.
268
Question # 4a: Who has the ability to change the behavior of the target
audience? (Political Actor)
Recall again the difference between questions #3 and #4. The actors
whose behavior needs to change frequently are not identical to the actors and
entities who have the ability to change the relevant behaviors. Thus, if it is
principally the behavior and ways of understanding pain among providers,
caregivers, and pain sufferers that should change, who or what enjoys the capacity
to influence each of these actors’ practices and conceptions as to pain?
As to health care providers, the answer depends, of course, on which
providers we identify as relevant. Physicians, to be sure, but not simply
physicians: nurses, psychologists, social workers, and allied health professionals
are also involved in treating persons in pain. What stakeholders maintain the
capacity to change behavior of all of these different professionals? In the
disparities project I participated in, many of the answers to question #4 seemed to
converge on the merits of working both from the top-down and from the bottomup. In my view, this tendency reflects the idea that while large and powerful
actors often exert a significant effect on practices, at the same time, our social
worlds are inevitably local, and thus a great deal of what shapes and informs
habits and practices are correspondingly local.
While there are several suitable actors that are well-positioned to exert a
top-down influence on the practices and conceptions of providers, the one that in
my experience and in the literature seems most appropriate in the United States is
CMS. This is primarily because CMS sets federal reimbursement policy for
Medicare and Medicaid. Given that in 2007 Medicare funds alone represented
269
approximately 3.2 percent of U.S. GDP,702 or roughly $432 billion,
reimbursement policy is a powerful tool indeed in regulating behaviors of those
actors who rely on federal reimbursement.
Many different kinds of health care providers, of course, are so reliant, but
so too are the vast majority of hospitals, whether for-profit or nonprofit, and
health care entities as defined under applicable federal and state laws. Though a
growing number of providers and entities are refusing to provide care to any
person covered by a third-party payor, it nevertheless remains true that Medicare
reimbursement remains a crucial axis through which health care is delivered and
financed in the United States. The undeniable fact that Medicare is a linchpin
throughout the fragmented, discombobulated structure of health care in the United
States is not lost on the federal government, which wields the power to limit or
bar entities from participating in the Medicare program as a sword to regulate all
manner of conduct.703 So too do private actors like the Joint Commission rely on
this sword; hospitals and health care entities which satisfy the Joint Commission
accreditation standards are deemed to qualify for participation in the Medicare
program,704 which is about as powerful a financial incentive as exists to ensure
compliance with such standards.
702
“Social Security & Medicare Trust Fund Report,”
http://www.ssa.gov/OACT/TRSUM/trsummary.html (accessed June 6, 2009).
703
Jonathan Oberlander, The Political Life of Medicare (Chicago, IL: University of
Chicago Press, 2003); Theodore R. Marmor, The Politics of Medicare, 2d ed. (Hawthorne, NY:
Aldine De Gruyter, 2000).
704
42 C.F.R. § 488.5 (2006). The Autumn 1994 (vol. 57, no. 1) issue of Law and
Contemporary Problems is a theme issue on Joint Commission’s deeming power, entitled “The
Place of Private Accrediting Among the Instruments of Government.”
270
However, the impact of CMS policy is not limited solely to those whose
livelihood depends on federal reimbursement. It is well-established that private
actors of all stripes and colors closely scrutinize CMS policy.705 Private thirdparty payors such as managed care organizations frequently incorporate
significant portions of CMS reimbursement policy into their own coverage
determinations,706 which means that CMS policy exerts a significant impact even
on providers who do not rely on federal reimbursement.
In any case, I will not press the point any further, though there is an
immense literature on the importance of Medicare to public health policy in the
United States. Suffice it to say that there is good justification for thinking that
CMS is a prime actor capable of utilizing its reimbursement power to regulate
behavior that operates at a level substantially downstream from CMS itself. With
a suitable actor identified, I can move on to answer policy process question #5 as
to CMS:
Question # 5a: What policy is recommended to achieve the behavior change
in the target audience? (Ignore perceived limitations)
I designate this question #5a because different policies will obviously be
needed to accompany the different actors that possess the capacity to change the
behavior (question #4) of the different target audiences (question #3). So, as to
CMS, what policy is recommended to achieve the behavior change? The answer
to this question constitutes Pain Policy Recommendation #1:
705
Stanley B. Jones, “Medicare Influence on Private Insurance: Good or Ill?” Health
Care Financing Review 18, no. 2 (Winter 1996): 153-161.
706
Ibid.
271
Pain Policy Recommendation #1
Because centering the pain sufferer is crucial to improving
the undertreatment of pain, CMS should amend its
reimbursement structure so as to provide maximum
coverage for time spent listening to the patient.
At some level, this recommendation seems absurdly simple, even naïve.
With all of the urgent problems plaguing the delivery and financing of health care
in the United States, the first policy recommendation as to improving the
treatment of pain is simply to encourage listening to the patient? The answer to
this question is an emphatic “yes.”
First, there is excellent evidence that listening to illness sufferers is a skill
in short supply in American health care.707 There are many reasons for this,
though one of the most significant is the focus I have identified in this analysis on
the objects that cause disease in place of attention to the illness sufferer him or
herself. As explained in detail in chapters 3-5, the imperative to engage the
illness sufferer’s lifeworld and listen to their stories and experiences lessens as the
clinical gaze rises in importance to medicine and healing during the nineteenth
707
Jozien M. Bensing, Debra L. Roter, and Robert L. Hulsman, “Communication Patterns
of Primary Care Physicians in the United States and the Netherlands,” Journal of General Internal
Medicine 18, no. 5 (May 2003): 335-342; Anthony L. Suchman, Kathryn Markakis, Howard B.
Beckman, and Richard Frankel, “A Model of Empathic Communication in the Medical
Interview,” Journal of the American Medical Association 277, no. 8 (February 26, 1997): 678-82;
Michael Simpson, Robert Buckman, Moira Stewart, Peter Maguire, Mack Lipkin, Dennis Novack,
and James Till, “Doctor-Patient Communication: The Toronto Consensus Statement,” British
Medical Journal 303, no. 6814 (November 30, 1991): 1385-87; Arthur Kleinman, The Illness
Narratives: Suffering, Healing and the Human Condition (New York, NY: Basic Books, 1988);
Brody, Stories of Sickness.
272
century. Where the primary (exciting) cause of the illness sufferer’s diptheria is
identified as a cornyebacterium, and a specific antitoxin is available, the
importance of engaging the sufferer’s lifeworld to determine which permutation
of conditions, events, and habits converge to produce illness is diminished.
Moreover, the theme of this entire project, which I argue must be
incorporated into pain policy for the latter to deserve the term “evidence-based,”
is that the pain sufferer’s subjective, lived experiences must be centered. This, of
course, is intended as a counter to the objectifying tendencies of Western
(American) culture in general and of the American culture of biomedicine in
particular. The particular, local lifeworld of the pain sufferer must occupy pride
of place in clinical pain encounters if any improvement in the treatment of pain
and the culture of pain in which treatment practices are situated is to be expected.
This centering has deep ethical content, as it is consistent with the ethical
implications of both a phenomenologic and a moral particularist approach to pain,
and eschews the abstracting, objectifying tendencies of dominant traditions of
Western moral philosophy in general and American bioethics in particular.
Finally, I have noted the evidence suggesting that communication between
pain sufferers and providers is poor. Jackson expressly argues that relationships
between chronic pain sufferers and physicians are the worst in American health
care.708 Chronic pain sufferers consistently report stigmatization and
delegitimization at the hands of providers (including nurses). It is therefore not
difficult to understand why improving the capacity of providers to listen to and
engage the lifeworld of their patients, to hear the sufferers’ lived experiences of
pain, would almost certainly improve the culture of pain, and thereby facilitate
708
Jackson, “Stigma, Liminality, and Chronic Pain.”
273
improved treatment of pain. Drew Leder makes exactly the same point in his
essay on pain and phenomenology.709
The reason this imperative is served by the recommendation regarding
CMS is the fact that the problems in listening are exacerbated–though not caused–
by the structure of Medicare reimbursement policy.710 Medicare, like the vast
majority of structural features of health care in the United States, reflects the acute
care paradigm on which it was modeled.711 Medicare is essentially a fee-forservice program, which suggests that it tends to reimburse discrete, identifiable
tasks associated with acute care episodes relatively well.712 Despite the fact that
Medicare, because of its roots in traditional fee-for service indemnity, is ill-suited
to caring for chronic illness sufferers, “the Medicare program is in reality a
program serving people with chronic conditions–typically, multiple chronic
conditions–for whom traditional indemnity insurance principles and coverage are
not appropriate and whose health status presents a challenge for both cost and
quality of care.”713 Wagner, Austin, Davis, Hindmarsh, Schaefer, and Bonomi
documented in 2001 “growing discrepancies between current reimbursement
709
Leder, “The Experience of Pain.”
710
The reason I doubt CMS causes such problems in listening is because of the evidence
adduced in chapters 3-5, which, in my view, suggests some of the deeply rooted social and cultural
factors, conceptual schemes, and narratives which combine to impede listening to the illness
sufferer. Such problems are well-documented in the historical record in the United States for at
least a century, well before Medicare was instantiated in 1965.
711
See, e.g., Robert A. Berenson and Jane Horvath, “Confronting The Barriers To
Chronic Care Management In Medicare,” Health Affairs Web Exclusive (June 2003): W3-37-W3-53, http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w3.37 (accessed June 14,
2009); Oberlander, The Political Life of Medicare; Marmor, The Politics of Medicare.
712
Berenson and Horvath, “Confronting the Barriers.”
713
Ibid., W37-38.
274
policies of the Centers for Medicare and Medicaid Services . . . and private
insurers and interventions shown to improve chronic disease care.”714
Moreover, U.S. Senate Finance Committee Chairman Sen. Max Baucus
(D – MT) noted in a hearing held in September 2008 that “the current system
reimburses doctors for each service they provide and encourages excessive
treatments.”715 This produces all sorts of deleterious effects, most of which have
been documented by a group at Dartmouth Medical School, who have for the last
several decades documented how a staggering percentage of Medicare funds have
been expended on interventions that are not evidence-based and that have had no
discernible impact on either morbidity or mortality. 716
As to pain, an additional side effect of Medicare’s fee-for-service nature is
that time spent communicating with and listening to the illness sufferer generally
does not qualify as a discrete “service” under applicable federal regulations. This
means that time and resources expended on simply speaking with and listening to
the illness sufferer are either not reimbursed at all, or are reimbursed at lower
levels and with greater uncertainty of expected reimbursement.717 Thus, the
general social and cultural narratives in American culture and in the culture of
714
Edward H. Wagner, Brian T. Austin, Connie Davis, Mike Hindmarsh, Judith Schaefer
and Amy Bonomi, “Improving Chronic Illness Care: Translating Evidence Into Action,” Health
Affairs 20, no. 6 (November/December 2001): 76.
715
Erin Shields, “Senate Committee on Finance News Release: Baucus Examines
Framework Americans Use to Decide on, Purchase, and Receive Health Care,”
http://finance.senate.gov/press/Bpress/2008press/prb091608.pdf (accessed June 15, 2009).
716
The website of the Dartmouth Atlas of Health Care states that “For more than 20
years, the Dartmouth Atlas Project has documented glaring variations in how medical resources
are distributed and used in the United States,” http://www.dartmouthatlas.org/ (accessed Jan. 27,
2009).
717
Christine K. Cassel, Medicare Matters: What Geriatric Medicine Can Teach
American Health Care (Berkeley, CA: University of California Press, 2005).
275
American biomedicine that tend to discourage listening to and engaging the
lifeworld of the pain sufferer are exacerbated by a Medicare reimbursement
structure which provides financial disincentives for doing so (because time spent
listening to a patient is time not spent on optimally reimbursable services).
Discrete clinical services used in treating (acute) visible, material pathologies tend
to be maximally reimbursable under Medicare; listening to the pain sufferer does
not.
Of course, the fact that Medicare reimbursement policy discourages
listening to the patient is entirely unsurprising given the power and impact of the
cultural and social factors which combine to deemphasize the importance of
listening to the illness sufferer in general (in favor of a cultural emphasis on
greater abstraction, greater objectification, and greater quantification).718 This too
underscores the notion adduced in the Introduction that a given legal and
regulatory regime is itself a discursive product, which both shapes and reflects
deeper social and cultural conceptual schemes.
Nevertheless, the fact that such a reimbursement scheme should not be
altogether unexpected given the role objectification and categorization plays in
American culture does not imply that it is ethically acceptable. Given the scope
and impact of CMS policy on providers and entities across and within American
health care, there is reason to suspect that a superior reimbursement structure, one
that encouraged rather than impeded the process of listening to the pain sufferer,
718
On the history of quantification, see J. Rosser Matthews, Quantification and the Quest
for Medical Certainty (Princeton, NJ: Princeton University Press, 1995); Porter, Trust in Numbers;
and Richard H Shryock, “The History of Quantification in Medical Science,” Isis 52, no. 2 (June
1961): 215-237.
276
could have a salutary effect on the culture of pain and could thereby facilitate
better treatment of pain.
There are a dizzying number of ways and methods for implementing such
a different kind of reimbursement structure into the Medicare program, but the
focus of this dissertation is assuredly not on the bowels of Medicare law and
regulation. I am hardly alone in calling for reform of the basic structure of
Medicare, though I daresay there are relatively few, if any, policy scholars
justifying their call on the phenomenologic and particularist basis that I do.719
Nevertheless, I maintain that a reasonable basis exists for thinking that a reform of
Medicare reimbursement policy to encourage the processes of listening to and
engaging the lifeworld of the pain sufferer could have a significant impact on
changing the behavior and practices of providers for the better in terms of the
treatment of pain.
CMS is one actor who maintains the capacity to change the behavior of
one of the intended target audiences (providers). However, they are not the only
actor that possesses such power. While CMS represents the top-down means to
altering practices and behavior as to the treatment of pain, a bottom-up approach
is also needed to increase the likelihood of changed practices. Aristotle was quite
correct in his emphasis on the significance of habits in society; similarly,
anthropologists have long pointed out that changing behavior is extraordinarily
difficult. To maximize the opportunity to do so, pain policies should exert effects
from multiple directions at once. If CMS is among the best-positioned
stakeholders to apply top-down force to the behavior of providers in constructing
719
This itself suggests the potential for applying a medical humanities approach to public
health policy, which I practice on a daily basis, but discussion of which must await another time.
277
the culture of pain, who or what entity is appropriately positioned to apply
analogous force from the bottom-up?
Another way of asking this question is to query what forces play the most
significant roles in shaping the professional practices providers will carry with
them into encounters with pain sufferers. If we want to change the culture of
pain, presumably a prime place to begin is by reassessing the ways in which
providers are educated and learn the practices that far too often seem to at least
contribute to the ubiquitous undertreatment of pain. Thus it is no surprise that
many pain scholars suggest that one of the most important loci for improving the
undertreatment of pain is via professional education (medical, nursing, etc.).720
As I currently work full-time at a medical school, I frequently interact
with health educators, students, trainees, faculty and medical administrators, and I
agree with those pain scholars who suggest that provider education plays an
important role improving the undertreatment of pain. Where I part ways with
some of these observers, however, is in my assessment of the form such education
should take. Nevertheless, because I agree that education is one of the most
important means of shaping healing practices among providers, it is a suitable
720
E.g., Ben A. Rich, “The Politics of Pain: Rhetoric or Reform,” DePaul Journal of
Health Care Law 8, no. 3 (Spring 2005): 515-555; Ann L. Horgas and Karen S. Dunn, “Pain in
Nursing Home Residents: Comparison of Residents’ Self-Report and Nursing Assistants’
Perceptions,” Journal of Gerontological Nursing 27, no. 3 (March 2001): 44-53; Rich, “An
Ethical Analysis of the Barriers to Effective Pain Management”; Doreen Oneschuk, John Hanson,
and Eduardo Bruera, “An International Survey of Undergraduate Medical Education in Palliative
Medicine,” Journal of Pain and Symptom Management 20, no. 3 (September 2000): 174-179;
Bruce A. Ferrell, Betty R. Farrell, and Lynne Rivera, “Pain in Cognitively Impaired Nursing
Home Patients,” Journal of Pain and Symptom Management 10, no. 8 (November 1995): 591-598;
Sidney H. Schnoll and James Finch, “Medical Education for Pain and Addiction: Making Progress
Toward Answering a Need,” Journal of Law, Medicine & Ethics 22, no. 3 (September 1994): 252256; Morris, The Culture of Pain.
278
bottom-up approach for impacting the behavior of such providers within the
culture of pain. As such, my Pain Policy Recommendation #2 reads as follows:
Pain Policy Recommendation #2
Because education is crucial in determining providers’
healing practices, administrators at medical, nursing, and
allied health schools should implement programs and
modules for both faculty and students whose primary
objective is to cultivate tolerance for subjective knowledge.
There is much in this Recommendation that requires explanation. First, it
is true that undergraduate medical students receive no instruction in pain
medicine, and their exposure to pain typically comes in the form of a singlesemester course in anesthesiology, which, of course, is not equivalent to pain
medicine.721 The same generally holds true as to specific courses related to pain
in nursing schools and in allied health programs.
As such, most calls to improve the culture of pain management suggest a
higher priority for pain in medical and nursing education. This is a reasonable
idea, but there is reason to question how much improvement is likely to follow
from granting pain elevated status in the hierarchy of medical and nursing
721
Rich, “The Politics of Pain.”
279
pedagogy. The reason for my skepticism is because the overarching conceptual
schemes I have traced in this analysis facilitate general discomfort with
subjectivity and in the culture of biomedicine, even more discomfort with
invisible pathologies like pain. These representations deeply shape the meaning
of pain in American society, and, I submit, are primary culprits in its
undertreatment. It is therefore unclear to me how providing more instruction in
the material causes and explanations of pain–the only explanations that fit
comfortably into the biomedical model–will substantially improve the treatment
of pain.
There is, however, an even deeper problem with simply adding formal
courses to professional education. Namely, a solid body of evidence suggests that
formal pedagogy plays only a small role in determining the healing practices of
physicians.722 In contrast, what appears to be significantly more important in
shaping these practices are the “informal” and the “hidden curriculum,”
respectively.
722
The bulk of the literature on this matter (generally referred to as the issue of the
hidden curriculum) addresses medical education. There are, however, some indications within
nursing scholarship that the same dynamic affects nurses and nursing education. Katharine E.
Jinks and Annette M. Ferguson, “Integrating What is Taught with What is Practised in the Nursing
Curriculum: A Multi-dimensional Model,” Journal of Advanced Nursing 20, no. 4 (October 1994):
687-695; Stephen H. Cook, “Mind the Theory/Practice Gap in Nursing,” Journal of Advanced
Nursing 16, no. 12 (December 1991): 1462-1469. Reflecting the state of the evidence, much of
my discussion of the hidden curriculum refers to physicians; however, unless otherwise noted, I
expressly assume that the same arguments hold true for nurses and nursing education. Indeed, the
notion of the hidden curriculum reflects a theory of education, and as such there is no inherent
reason why it should not apply to healing professionals of any discipline.
280
In a seminal 1998 article, sociologist Frederic Hafferty argues that “a great
deal of what is taught–and most of what is learned–in medical school takes place
not within formal course offerings but within medicine’s ‘hidden curriculum.’”723
Hafferty defines the “hidden curriculum” as a
set of influences that function at the level of organizational
structure and culture . . . The hidden curriculum highlights the
importance and impact of structural factors on the learning process.
Focusing on this level and type of influence draws our attention to,
arnong other things, the commonly held “understandings,”
customs, rituals, and taken-for-granted aspects of what goes on in
the life-space we call medical education.724
In addition to the hidden curriculum, the informal curriculum is a significant
component of medical education, and refers to “an unscripted, predominantly ad
hoc and highly interpersonal form of teaching and learning that takes place among
faculty and students.”725 The hidden and informal curricula construct some of the
moral bases for the medical school community: These concepts “also challenge
medical educators to acknowledge their training institutions as both cultural
entities and moral communities intimately involved in constructing definitions
about what is ‘good’ and ‘bad’ medicine.”726
The idea, then, which is by now well-known to medical educators, is that
if change in the practices of providers related to pain is desired, introducing a
course on pain into the formal pedagogy may be unlikely to have the desired
723
Frederic W. Hafferty, “Beyond Curriculum Reform: Confronting Medicine’s Hidden
Curriculum,” Academic Medicine 73, no. 4 (April 1998): 403.
724
Ibid., 404.
725
Ibid.
726
Ibid.
281
effect. If indeed much of physicians’ practices and conduct are shaped through
both the informal and the hidden curricula, a pain policy recommendation should
target these paradigms. As Kelly Fryer-Edwards has succinctly put it, the
emphasis should be on what is learned, rather than what is formally taught.727
Hafferty suggests that the learning that occurs within the hidden and informal
curricula “must be acknowledged as a legitimate source of learning, and, when
necessary, countered.”728 I argue that the practices, attitudes, and beliefs towards
subjective knowledge about illness experiences habituated in the hidden and
informal curricula ought to be countered. I say this even acknowledging that
these habits and practices are themselves reflective of deeper and larger cultural
and social narratives regarding invisible pathologies, objectivity, and pain. From
a policy perspective, the idea is that countering these attitudes and beliefs as they
are incorporated within the professional practices of healers is an important node
for action.
The question is, to improve the undertreatment of pain, what should
medical, nursing, and allied health students and teachers learn? I say “teachers”
here because the basic lesson of the literature on the informal and hidden curricula
is that medical students form habits in large part by modeling their behavior,
habits, and attitudes from their mentors, teachers, and superiors. This is what it
means to understand medical education itself as a cultural phenomenon; habits
and practices are formed in local social worlds, and primarily by and through the
727
Kelly Fryer-Edwards, Addressing the Hidden Curriculum in Scientific Research
American Journal of Bioethics 2, no. 4 (April 2002): 58-59.
728
Frederic W. Hafferty, “Measuring Professionalism: A Commentary,” in Measuring
Medical Professionalism, ed. David Thomas Stern (New York, NY: Oxford University Press
2006), 405.
282
peer and mentoring relationships at the literal heart of medical education in the
United States. Accordingly, if changing practices is the goal, it is inadequate to
focus on the students, for so much of their behavior and practices are constructed
through modeling their mentors. Thus, one problem with the proposal to
introduce pain courses in the undergraduate medical curriculum is that they do
nothing to address practices, attitudes, and beliefs of the senior educators,
mentors, faculty, and administrators towards the meaning of pain. Due attention
must be paid to the models (the teachers) themselves, for it is these models’
practices, attitudes, and beliefs towards pain that almost certainly exert a strong
influence in shaping practices of medical students and trainees.
So, what should medical, nursing, and allied health students and teachers
learn? And if formal pedagogy is not the most effective means of teaching
virtuous practice, what are the applicable points of insertion, so to speak? How
should the teachers learn? How can they be taught?
These are enormous questions, to be sure. I cannot hope to resolve them
here. However, I can suggest a promising direction, one that is expressly
mentioned in Pain Policy Recommendation #2: cultivating respect for subjective
knowledge. Recall that the roots of the problem are the objectifying tendencies of
the clinicopathologic method. From a medical humanities perspective, then, the
most promising means of improving the treatment of pain is to develop and
encourage modes of clinical knowing that respect and value subjectivity, and all
the uncertainty and ambiguity which follows.
How can this be done? There are any number of possibilities, though some
of them–like requiring phenomenological instruction–require a fundamental
reconceptualization of the goals and structure of (formal and informal) medical
283
education. Other suggestions, however, do not seem to necessitate any such
radical reshaping. One is as simple as encouraging admissions committees to
actively seek out and even prefer applicants with humanities backgrounds over
students with natural science backgrounds. Lest I be accused of patent selfserving, the justification for this is the evidence that students with natural science
backgrounds display significantly more intolerance of ambiguity than students
with humanities backgrounds.729 Commenting on the DeForge and Sobal study
more recently, Dogra, Giordano and France suggest “that selection bias toward
students with such applied scientific backgrounds may contribute to a pervasive
technocentrism and technophilia, and with it cognitive dissonance toward
appreciating the presence and value of subjectivity and/or uncertainty in medical
practice.”730 Hopefully, in this project I have disentangled at least some of the
historical, social, and cultural links between technocentrism, mechanical
objectivity, and intolerance for subjective, invisible phenomena in American
culture in general and in the American culture of biomedicine.
If there is merit to this view, the value of targeting for admission
applicants with humanities backgrounds is nothing so amorphous as the
“enhancement of educational diversity”–though this may be worthwhile in its own
right–but that doing so may facilitate the development of clinical character in
ways that respect and value the subjectivity of the illness sufferer. Given the
729
Gail Geller, Ruth R. Faden and David M. Levine, “Tolerance for Ambiguity Among
Medical Students: Implications For Their Selection, Training and Practice,” Social Science &
Medicine 31, no. 5 (May 1990): 619-624; Bruce R. DeForge and Jeffrey Sobal, “Intolerance of
Ambiguity in Students Entering Medical School,” Social Science & Medicine 28, no. 8 (August
1989): 869-874.
730
Nisha Dogra, James Giordano, and Nicholas France, “Cultural Diversity Teaching and
Issues of Uncertainty: The Findings of a Qualitative Study,” BMC Medical Education 7, no. 8
(2007), http://www.biomedcentral.com/1472-6920/7/8 (accessed June 16, 2009).
284
significance of informal peer groups and modeling in determining healing
practices, encouraging the selection and development of students more able to
understand the importance of ascertaining what it is like for the patient to live in
pain is all the more important.
In addition, insofar as cultural diversity education requires tolerance of
subjectivity, ambiguity, and uncertainty, the methods used to teach the role of
culture in health and illness–in the patient’s lifeworld, that is–may also encourage
the development of physicians who value subjectivity, or at least tolerate it. Such
cultural instruction is frequently targeted at both practicing physicians and
medical students, therefore suggesting a possible point of insertion for working
with both mentors and the students in cultivating a different, more virtuous
culture of pain.
Dogra, Giordano, and France found that “physicians in training wish to
receive concrete information from which they can generate ‘do and don’t lists’ for
use in clinical practice . . . while students recognize that cultural diversity training
is needed . . . they still expressed a strong desire for certainty-based, factual
information.”731 Such pedagogy, however, “cannot establish the subjectivity and
731
Ibid. Among others, Linda Hunt argues persuasively that this tendency in so-called
cultural competence training in medical schools is both unhelpful and counterproductive inasmuch
as it signals to students and teachers alike that culture is a static, objective phenomenon containing
a roster of discrete cultural truths. Linda M. Hunt, “Beyond Cultural Competence: Applying
Humility to Clinical Settings,” The Park Ridge Center Bulletin no. 24 (November/December
2001): 3-4, http://www.parkridgecenter.org/Page1882.html (accessed June 15, 2009). Though
detailed discussion of race, medicine, and culture is well beyond the scope of this project,
Christian McMillen recently suggested that that this notion of culture is merely a stand-in for
discredited and discriminatory concepts of race. Christian W. McMillen, “‘The Red Man and the
White Plague’: Rethinking Race, Tuberculosis, and American Indians, ca. 1890-1950,” Bulletin of
the History of Medicine 82, no. 3 (Fall 2008): 608-45. Moreover, this conception obviously
reflects the influence of the objectifying, categorizing tendencies of the clinical gaze, in which
cultural variables are parsed out into entities roughly analogous to the objective “stuff” of
biomedicine.
285
humanitarian appreciation that is the conduit for the medical relationship.”732
Thus, the mode and structure of cultural instruction itself carries a great deal of
weight in shaping what is meaningful about subjective, ambiguous phenomena
like culture. This is exactly what Hafferty suggests is integral about the hidden
curriculum; the simple act of changing cultural instruction in medical, nursing,
and allied health education away from the notion of objective facts about culture
and towards appreciation of the dynamic, multivalent, highly subjective ways in
which cultures and subcultures inform experiences and understandings of health
and illness may have a positive impact in changing attitudes, practices, and beliefs
towards the dynamic, multivalent, highly subjective phenomenon of pain.
These suggestions–increasing recruitment of students with a humanities
background and altering the method of instruction as to the role of culture in
experiences of health and illness–are simply two examples of many possible ways
of cultivating greater respect for subjective knowledge as to illness experiences
into the education of professional healers.
These first two Pain Policy Recommendations reflect a two-pronged
approach to one of the three target audiences identified in response to Policy
Process Question #4: providers. To change the practices, attitudes, and beliefs of
providers towards the treatment of pain, recommendations were issued as to CMS
(Pain Policy Recommendation #1) and as to provider education (Pain Policy
Recommendation #2).
However, as I have emphasized throughout my analysis, focusing simply
on health care providers is unlikely to improve the undertreatment of pain in the
732
Dogra, Giordano, and France, “Cultural Diversity Teaching.”
286
United States. Providers are an important policy node, but their attitudes,
practices, and beliefs as to the treatment of pain are deeply shaped by larger social
and cultural factors related to the meaning of pain in American society. Pain
sufferers and caregivers themselves participate in this broad discourse about pain,
and the conceptual frameworks I have attempted to depict here also shape the
attitudes, practices, and beliefs pain sufferers and caregivers maintain towards
pain. Yet simply identifying the actors whose practices should change is
insufficient; it is crucial to take the additional step of inquiring which actors or
entities have the power to change pain sufferer and caregiver practices?
Question # 4b: Who has the ability to change the behavior of the target
audience? (Political Actor)
Though there are many possible actors who could change the behavior and
practices of both pain sufferers and caregivers, a clue to the best-suited
stakeholder is apparent in thinking about the phenomenology of pain. Despite the
fact that for many pain sufferers, their most direct experiences with stigmatization
come at the hands of their providers, the social role of health care providers, and
in particular physicians, is such that pain sufferers rely on physicians in
qualitatively different ways than sufferers rely on their intimates and/or
caregivers. In chapter 2, I reviewed the evidence for the notion that the alienation
pain sufferers experience from their physicians is in some ways even more
devastating than that which they experience from their caregivers.
This counterintuitive observation is explicable in terms of the social role
physicians play in the United States, and in the investiture that vulnerable,
sometimes desperate illness sufferers make in perceiving their physician as their
287
savior. In prior work I have examined this phenomenon from a religious studies
perspective, exploring the conceptual and phenomenological reasons why the
links between physicians and spiritual figures like priests or shamans are so
common in both Western history and in non-Western traditions.733 I posited
significant interconnectedness between religion and the culture of biomedicine734
in context of Erwin Goodenough’s metaphor that religion is humanity’s way of
adjusting to the tremendum. The tremendum simply refers to the eternal
unknown, the great beyond, contemplation of which obviously produces a deep,
existential fear. Goodenough’s notion is that religious practice is a means of
mediating, or adjusting to that great existential fear, and in my article, I contended
that a family resemblance exists between formal religious practice in this sense
and medical practice.735 Further, I argued that the culture of biomedicine is, like
all post-axial religions, soteriological, which means that it is characterized by its
focus on salvation.736 Physicians mediate the fear of the tremendum for the
supplicant, just as shamans and priests.737
This is one way of explaining the commonality of the rescue fantasy,738
which is not intended as a pejorative, but as a characterization of a key device
illness sufferers, caregivers, and physicians alike utilize to make meaning of
illness experiences. Thus, because of the social and phenomenologic importance
733
Goldberg, “Religion, the Culture of Biomedicine, and the Tremendum.”
734
See also Harold Y. Vanderpool, “The Religious Features of Scientific Medicine,”
Kennedy Institute of Ethics Journal 18, no. 3 (September 2008): 203-234.
735
Goldberg, “Religion, the Culture of Biomedicine, and the Tremendum.”
736
John Hick, An Interpretation of Religion (New Haven, CT: Yale University Press,
737
Goldberg, “Religion, the Culture of Biomedicine, and the Tremendum.”
738
Brody, The Healer’s Power.
2005).
288
physicians play in treating illness sufferers, physicians in particular and providers
in general are well-positioned in terms of policy to alter attitudes and beliefs of
pain sufferers and caregivers as to pain. Accordingly, my third and final Pain
Policy Recommendation addresses these actors.
Question # 5b: What policy is recommended to achieve the behavior change
in the target audience?
The answer to this question constitutes Pain Policy Recommendation #3:
Because pain sufferers and caregivers’ attitudes, practices,
and beliefs towards pain are crucial to improving its
treatment, health care providers should educate pain
sufferers and caregivers on the legitimacy of subjective
knowledge of the body in pain.
There are several points that need to be made about this recommendation.
First, I am well aware of the possibility that it could be read as insulting and
pedantic to the pain sufferer in particular. This is not my intention, and is not a
necessary interpretation of this recommendation. Given my focus on centering
the experiences of the pain sufferer, one immediate question is why it is necessary
to educate the pain sufferer him or herself of the legitimacy of their own
subjective experiences? After all, in a phenomenologic sense, the pain sufferer
does not enjoy the same capacity as others to deny the experiences of their own
pain.
289
However, I have tried to explain in this project the empirical fact that pain
sufferers do deny the legitimacy of their own pain experiences (and those of
fellow pain sufferers) as well as some of the social, cultural, and historical reasons
for such denials. I recognize the apparent paradox in which pain sufferers seem to
attempt to deny that which is undeniable–the fact of their pain–but also want to
note that there is a distinction to be drawn between denying the reality that one is
in pain and denying that one’s pain is legitimate. One can logically accept that
one is pain but simultaneously deem such pain to be socially and culturally
illegitimate. Moreover, the tension between these two states is in keeping with
the ambiguous, dynamic, paradoxical nature of pain itself, which I have tried to
highlight as a running theme in this entire project.
Ethnographies of pain sufferers demonstrate that they do tend to
delegitimize their own pain, and that they participate in rituals and acts that
contribute to the general invalidation of subjective knowledge of the body in
pain.739 The clearest example of such a ritual is the frequency with which pain
sufferers join providers in the use of diagnostic and imaging techniques, in a
sometimes desperate search for visible, material pathologies and lesions that can
objectify their pain.740 The fact that pain sufferers and caregivers actively
participate in such a ritual is unsurprising given the ways in which the clinical
gaze and the emphasis on objectivity play such fundamental roles in constructing
the meaning of illness in American society. The clinical gaze is not simply a
perceptual frame which providers operate within; it is part of a larger social and
739
See chapter 2 and chapter 5 above.
740
See chapter 5 above.
290
cultural milieu, one which deeply influences and frames the meaning pain
sufferers and caregivers attach to pain as well.
As mentioned earlier in this chapter, acknowledging that the actors in the
culture of pain have much to learn from pain sufferers does not preclude the
possibility that pain sufferers can learn from other participants in the discourse.
Indeed, there is an active literature on the importance of patient education, of
which a particularly important facet is the current movement towards enhanced
support and utilization of teaching disease self-management to chronic illness
sufferers. The available evidence suggests that the toll of suffering for many
chronic diseases could be ameliorated through use of self-management
techniques.741 There is little reason to think that, especially in its chronic forms,
pain is an exception to these findings. Of course, the kind of education I am
suggesting with regard to pain is different in important ways from the selfmanagement techniques addressed in the relevant literature, though I suspect that
both types of education do rest on some similar, if not identical theoretical bases.
741
E.g., Tanja Effing, Evelyn EM Monninkhof, Paul van der Valk, Gerhard GA Zielhuis,
E. Haydn Walters, and Job J van der Palen, “Self-management Education for Patients with
Chronic Obstructive Pulmonary Disease,” Cochrane Database of Systematic Reviews 4, Art. No.:
CD002990 (July 2003), doi: 10.1002/14651858.CD002990.pub2,
http://dx.doi.org/10.1002/14651858.CD002990.pub2 (accessed June 16, 2009); Joshua Chodosh,
Sally C. Morton, Walter Mojica, Margaret Maglione, Marika J. Suttorp, Lara Hilton, Shannon
Rhodes, and Paul Shekelle, “Meta-Analysis: Chronic Disease Self-Management Programs for
Older Adults,” Annals of Internal Medicine 143, no. 6 (September 20, 2005): 427-438. Four CMS
analysts recently published an article noting that evidence of cost savings and quality
improvement from disease management programs for chronically ill Medicare beneficiaries is
uneven at best. David M. Bott, Mary C. Kapp, Lorraine B. Johnson and Linda M. Magno,
“Disease Management For Chronically Ill Beneficiaries In Traditional Medicare,” Health Affairs
28, no. 1 (January/February 2009): 86-98. However, Foote notes that the programs evaluated in
the Bott et al. paper are extremely heterogeneous, that the primary criterion for evaluation is
whether budget neutrality was obtained, and that much of the raw data for the study is either
incomplete or is not publicly available. Sandra M. Foote, “Next Steps: How Can Medicare
Accelerate The Pace Of Improving Chronic Care?” Health Affairs 28, no. 1 (January/February
2009): 99-102. Thus, judging disease management as either a failure or a success at this point
seems hasty.
291
In keeping with the other recommendations, Pain Policy Recommendation
#3 is issued at a fairly high level of generality. Thus, it is helpful to cite some
examples of what cultivating respect for subjective knowledge for pain sufferers
and caregivers might consist of.
First, as noted above, one of the most common meaning-making rituals in
the clinical pain encounter for both providers and pain sufferers (and presumably
caregivers as well) is the use of imaging techniques in the attempt to objectify
pain. This is in keeping with the general proliferation of imaging techniques in
the culture of biomedicine; a very recent study documented enormous increases in
both the number of CT and MRI units between 1995-2004 in the United States
and in utilization (Figures 7 and 8).
Figure 7742
742
Laurence C. Baker, Scott W. Atlas and Christopher C. Afendulis, “Expanded Use Of
Imaging Technology And The Challenge Of Measuring Value,” Health Affairs 27, no. 6
(November/December 2008): 1467-1478.
292
Figure 8743
Thus, an obvious means by which providers could work with pain
sufferers and caregivers to cultivate deeper understanding of the legitimacy of
subjective experiences of pain is to suggest that objectification of pain via clinical
imaging techniques are, depending on the type of pain, unlikely to reveal
anything, and, more importantly, are needed neither to legitimize the sufferer’s
pain nor to treat it effectively. The concern over treating pain in the absence of
determining the underlying cause of that pain has quite a long history in Western
medicine. McTavish documents this during the nineteenth century in particular:
“Analgesics would only conceal the symptom, not cure the condition. Because
pain usually indicated that something had gone wrong in the body, it was
demonstrably foolish and harmful to mask it with drugs before its source had been
determined.”744
Nevertheless, there is good evidence that a great many pain experiences
can be relieved even in the absence of a finding of visible, material pathologies.
In other words, despite the inexorable and powerful structural forces in American
743
Ibid.
744
McTavish, Pain & Profits, 20.
293
culture and in the culture of biomedicine that link pathological anatomy with
clinical reality, the phenomenon of illness experience is not a necessary function
of the presence of visible, material pathologies. And helping pain sufferers and
caregivers understand these matters would to my mind qualify as a virtuous
practice, one consistent with the ethical implications of the phenomenology of
pain and of moral particularism. In their study on the meaning of diagnostic
imaging tests as to chronic back pain, Rhodes et al. conclude that
[w]hat these patients suggest, and what studies confirm is that
diagnostic imaging tests often fail to provide a solution–or even a
meaningful diagnosis–for chronic back pain. Our work suggests
that we might consider looking elsewhere for sources of
satisfaction and meaning for these patients. One possibility might
be the exploration of creative ways to develop the potentially
healing gesture of ‘looking at results together.’745
This is at the heart of Pain Policy Recommendation #3: we should consider
looking away from objectifying imaging techniques in helping pain sufferers and
caregivers find meaning in their lived experiences of pain, and that helping pain
sufferers and caregivers do so by eschewing the automatic turn to imaging
techniques is a means of cultivating respect and tolerance for the subjective, lived
experiences of pain. Rhodes et al. also suggest that providers “actively engage
patients’ desire for agency and self authorship in the exploration of alternative
solutions” as a means of assisting pain sufferers on their meaning-making
journey.746 This is an excellent example of a way of working to equip pain
745
Rhodes, McPhillips-Tangum, Markham and Clenk, “The Power of the Visible,” 1201.
746
Ibid.
294
sufferers and caregivers with different and viable tools for making meaning of
pain, though there are many other possibilities.
Two further points are warranted here. First, my critique here is not
intended to condemn the use of imaging techniques in the treatment of clinical
pain. Insofar as such techniques actually help providers diagnose and treat pain,
that is all to the good. But it does not follow that the almost reflexive turn to such
techniques, especially with troublesome or contested disease categories such as
pain, is without economic and social cost. And one of the social costs is that the
proliferation of such techniques reinforce the social and cultural frames which
contribute to the delegitimation and stigma experienced by so many pain
sufferers. Moreover, there is reason to believe that such imaging techniques are
both not helpful in many of the clinical encounters for which they are used747 and
even greater reason to believe that imaging techniques are decidedly unhelpful in
treating many kinds of chronic pain.748 Carragee notes specifically that “MRI or
radiography early in the course of an episode of low back pain do not improve
clinical outcomes or reduce costs of care.”749 Similarly, a very recent systematic
review and meta-analysis of the efficacy of lumbar imaging for chronic low-back
pain demonstrated the lack of any significant difference in clinical outcomes
747
E.g., Steven D. Pearson, Amy B. Knudsen, Roberta W. Scherer, Jed Weissberg and G.
Scott Gazelle, “Assessing The Comparative Effectiveness Of A Diagnostic Technology: CT
Colonography,” Health Affairs 27, no. 6 (November/December 2008): 1503-1514.
748
See Eugene J. Carragee, “Persistent Low Back Pain,” New England Journal of
Medicine 352, no. 18 (May 5, 2005):1891-1898; Rhodes, McPhillips-Tangum, Markham and
Clenk, “The Power of the Visible,” 1201.
749
Carragee, “Persistent Low Back Pain;” Fiona J. Gilbert, Adrian M. Grant, Maureen G.
C. Gillan, Luke D. Vale, Marion K. Campbell, Neil W. Scott, David J. Knight, and Douglas
Wardlaw, “Low Back Pain: Influence of Early MR Imaging or CT on Treatment and Outcome–
Multicenter Randomized Trial,” Radiology 231, no. 2 (May 2004): 343-351.
295
between those who received such imaging and those who did not.750 One of the
co-authors of this review, Richard Deyo, referred in a recent editorial to what he
termed “imaging idolatry,” and expressly connected it to the culture of pain I have
described at length: “Patients are often desperate for an explanation of their pain,
and visual evidence is particularly compelling.”751
Second, my call that providers work to cultivate in pain sufferers and
caregivers greater respect and tolerance for subjective knowledge of the body in
pain obviously assumes that providers themselves work to cultivate greater
respect and tolerance for subjective knowledge of the body in pain. Indeed, this is
precisely the subject of Pain Policy Recommendation #1 and #2. Pain Policy
Recommendation #3 therefore builds off of the prior recommendations, and is an
expression of my commitment to understanding the meaning of pain as a product
of the larger social and cultural frames in which it is situated. Providers, pain
sufferers, and caregivers alike are all key actors in shaping the meaning of pain,
and evidence-based pain policies must address all of them if such policies justify
a hope that the undertreatment of pain can be improved upon.
These three policy recommendations, if implemented by actors who enjoy
the capacity to change behavior, justify at least a hope that such action would
improve the treatment of pain. I fundamentally concur with David Morris’s
argument that understanding of and change of the American culture of pain is the
750
Roger Chou, Rongwei Fu, John A. Carrino, Richard A. Deyo, “Imaging Strategies for
Low-Back Pain: Systematic Review and Meta-Analysis,” Lancet 373, no. 9662 (February 7,
2009): 463-472.
751
Richard A. Deyo, “Imaging Idolatry: The Uneasy Interaction of Patient Satisfaction,
Quality of Care, and Overuse,” Archives of Internal Medicine 169, no. 10 (May 25, 2009): 922.
Deyo is more correct than he realizes insofar as the compelling nature of visual evidence of pain is
a primary determinant not simply of imaging but of the undertreatment of pain itself.
296
key to improving the treatment of pain.752 This is in some ways unfortunate,
because changing culture is arduous and protracted under the best of
circumstances, and may be quite impossible in others. Nevertheless, I see no
alternative. Outside of fundamental efforts to understand and reshape some of our
most deeply rooted social and cultural frameworks for understanding pain, I
maintain there is little reason to think that even the most well-intentioned efforts
to improve the undertreatment of pain will continue to produce little tangible
results.
I close this project in my Conclusion with a personal narrative of pain, one
that does not belong to me, but which I have been graciously been permitted to
share.
752
Morris, “An Invisible History of Pain;” Morris, The Culture of Pain.
297
Conclusion: Raison d’Être
“We are doomed historically to history, to the patient construction of
discourses about discourses, and to the task of hearing what has already been
said.”
Michel Foucault, The Birth of the Clinic
In April 2004, I planned a weekend visit to my mother’s home in Miami
Beach, Florida. On the Saturday morning that I departed for Miami, Mom
decided to purchase some fresh bagels for us. Having always loved the free
feeling that cycling gave her, she began riding her bicycle the few blocks to the
bagel shop.
She did not make it. When I walked out of the arrival gate at Miami
International Airport, my younger brother Seth greeted me and informed me that
Mom had been struck by a car while cycling. She did come home from the
hospital later that evening, but, like many illness sufferers, her story unfolded
over weeks and months. In many ways, her story is ongoing.
My father showed up after mom had laid in agony for hours on a gurney in
the hallway of the hospital to which she was taken. To paraphrase Mom, my
father’s arrival felt like a visit from the angel of mercy. Dad is a physician, and is
one of the most gentle, humane persons I have ever encountered. Naturally, I am
biased in this perspective, but I have watched over the years the adoration and
appreciation expressed by his hundreds if not thousands of patients. Mom and
Dad divorced in 2000, but remain close friends and supporters.
298
Once Dad arrived, to no surprise, the pace of care picked up considerably.
Yet the agony continued, not just for that day, but for months on end. Mom had
suffered a fractured pelvis, which can make the slightest movement excruciatingly
painful. However, the almost unendurable pain continued well beyond the
expected healing time of the fracture. Mom is no shrinking violet. Ascribing to
the radical feminist notion that women are people, being highly health literate,
and having years of experience advocating for illness sufferers–mostly elderly
persons on dying trajectories and, later, AIDS patients–as a social worker, Mom
had little difficulty with assertiveness in health care encounters.
Yet, as the literature on the phenomenology of illness amply demonstrates,
when one is in constant unending pain, it tends to be extremely difficult to
advocate for oneself. Mom needed others to advocate for her in this situation.
We all tried–myself, Dad, my brother Joshua, himself a highly trained critical care
and burn surgeon, and Mom’s friend Marguerite, a gifted and experienced nurse
and administrator. But Mom still did not get the pain control that she needed.
She flitted back and forth between rehab centers, outpatient clinics, and hospitals,
suffering all the while. The nadir, as both I and Mom see it, was a visit from her
attending neurologist during one of her later inpatient admissions. Enraged,
desperate, and weeping, Mom paged physician after physician, pleading with her
providers for better pain control. While the pain medicine specialist was
marginally responsive and did prescribe some of the opioid analgesics through
which Mom had during those dark months achieved some semblance of relief, the
attending neurologist canceled the order.
When the neurologist came to visit with Mom, a time in which she was
basically beyond speech, so struck was she with pain and horror, the neurologist
299
advised her to think ‘mind over matter’ and ‘meditate’ in lieu of opioids. After he
left, Mom regained her voice long enough to inform all available providers–
nurses, physicians, allied health personnel–that she was summarily firing this
neurologist for his abominable behavior.
One might say, in response to this occurrence, that the neurologist was
simply an unvirtuous, even vicious provider, and that the solution was simply to
find a more sensitive, caring provider. But then, something curious occurred.
Having obtained some relief from opioid analgesics, Mom requested, as best she
could, that Dad or Josh help her obtain the medications. Prescribing controlled
substances to an immediate family member is risky under applicable laws, but
direct prescription was certainly not the only means of assisting Mom in this
request, nor was it what Mom was asking for. Both Dad, who was a longtime and
recognized member of the local physician’s community, and Josh, who as a burn
surgeon is well-acquainted with pain management modalities and interventions,
certainly possessed ample capacity and resources to help facilitate access to the
medications, through channels and pathways that had nothing to do with direct
prescription. Yet, when I spoke to Dad and Josh about Mom’s request, I sensed
significant reluctance to facilitate access to the requested opioids.
Though I am biased, if ever I fall ill, whether chronic or acute, the best I
could hope for with a provider would be to experience the quality of care and the
humanity exemplifed by Dad and Josh. When Josh chose to train as a surgeon,
virtually everyone who knew him was shocked, as his warmth, generosity of
spirit, charisma, and bedside manner did not fit the stereotypical mentality of the
surgeon. Indeed, Josh had been favoring training as an obstetrician-gynecologist,
300
which seemed to me at the time to make much better use of his interpersonal and
phenomenologic skill set.
So why did I sense so much reluctance, so much hesitation on the part of
these gifted, highly trained, humane, virtuous healers? What could explain this?
The issues at the heart of these questions convinced me that the
undertreatment of pain in the United States was both an important issue, and one
far more complicated than the typical reasons provided (opiophobia, fear of
prosecution). If even the most virtuous, most humane healers I have ever had the
privilege of knowing expressed hesitation and reluctance in helping the matriarch
of our family unit access needed and apparently effective treatments for her
unspeakable and enduring pain, centering an analysis of the undertreatment of
pain on the virtue or vice of the individual healer is obviously deficient. I quoted
David Morris on this point earlier, but it is worth quoting again, as it succinctly
captures a key theme of my dissertation: “Blaming doctors as inhumane simply
won’t work.” It won’t work because, among other reasons, there is little
convincing evidence that, whatever their collective and individual flaws,
providers are any more or less humane than the rest of us, and because it is
difficult to conceive that physicians are generally callous or indifferent to their
patients’ suffering. There is much to criticize in physician practices in the United
States, but ascribing American problems in treating pain to provider inhumanity
implies a level of wantonness that is both uncorroborated and unwarranted, in my
view.
So, I was convinced in 2004 and remain convinced that the reasons why
pain is treated so poorly in the United States include but go far beyond physician
reluctance to dispense opioids. I believed then and now that if even the best and
301
most phenomenologically-inclined physicians could display reluctance in
responding to an intimate’s cry for succor, the deepest and most powerful
explanations for such practice had to reside in social and cultural representations
of the meaning of pain. There was, I suspected, a culture of pain, and it was
something about this culture and the ways in which pain is conceptualized and
socialized that seemed to impede even the best and most humane providers from
easing the pain sufferer’s agony.
In the fall of 2005, I entered graduate school, and while I resolved to
remain open on the topics and matters that most interested me, the issue of pain
was never far from my mind. My mentors, colleagues, and professors have kindly
indulged me in this endeavor, and this is the project that resulted, a labor of love
in multiple senses.
I have, of course, purposely withheld any detailed information about the
cause of Mom’s pain. Does it matter? The answer is obviously ‘yes’ and just as
obviously ‘no,’ depending on the dimension at issue. Ascertaining the cause of
Mom’s pain was certainly a useful task for a provider to engage in, but
ascertaining the cause of Mom’s pain was not remotely necessary to treat her far
better than was done. If nothing else, readers can hopefully apprehend my
suggestion that focusing on Mom’s lived experiences of pain rather than the
objective, discrete causes of that pain are the most promising avenue to changing
the culture of pain and ameliorating its undertreatment.
Eventually, Mom did find relief, and recovered from the injuries and the
trauma of her accident. But Mom now suffers from migraines and persistent low
back pain, so she is still living her pain narrative. All but a very few of us either
already are or one day will be doing so as well.
302
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Vita
Daniel S. Goldberg was born in Johannesburg, South Africa, on May 21, 1977. His parents’ names
are Nathalie Rudy and Ronald Byron Goldberg. He is married to Yuko Kishimoto, and his
daughter is Maya Kishimoto Goldberg. His professional work experience includes employment as
a Briefing Attorney for Justice Nathan L. Hecht on the Supreme Court of Texas in 2002-2003 and
as an associate at Vinson & Elkins LLP between 2003 and 2005. Mr. Goldberg was employed “Of
Counsel” at the law firm of Cook & Roach in 2005-2006, as a Research Professor at the University
of Houston Law Center’s Health Law & Policy Institute in 2006-2007, and has been employed as a
Health Policy & Ethics Fellow at Baylor College of Medicine since 2007, where he remains at the
time of this writing.
Education
B.A., May 1999, Wesleyan University, Middletown, Connecticut
J.D., May 2002, University of Houston Law Center, Houston, Texas
Publications
Goldberg, Daniel S. “In Support of a Broad Model of Public Health: Disparities,
Social Epidemiology, and Public Health Causation.” Public Health Ethics
2, no. 1 (April 2009): 70-83.
––––– . “Exilic Effects of Illness and Pain in Solzhenitsyn’s Cancer Ward:
How Empathy Can Facilitate Repatriation.” Journal of Medical
Humanities 30, no. 1 (March 2009): 29-42.
–––––. “Concussions, Conflicts of Interest, and Professional Football: Why the
NFL’s Policies are Bad for Its (Players’) Health.” HEC Forum 20, no. 4
(December 2008): 337-355.
–––––. “The Sole Indexicality of Pain: How Attitudes Towards the Elderly Erect
Barriers to Adequate Pain Management.” Michigan State Journal of
Medicine & Law 13, no. 1 (Winter 2008): 52-72.
–––––. “The Coherence of Virtue Ethics with Pragmatism in Clinical Research.”
American Journal of Bioethics 8, no. 4 (April 2008): 43-45.
–––––. “The Detection of Constructed Memories and the Risk of Undue
334
Prejudice.” American Journal of Bioethics – Neuroscience 8, no. 1
(January 2008): 23-25.
–––––. “Justice, Health Literacy, and Social Epidemiology.” American Journal of
Bioethics 7, no. 11 (November 2007): 18-20.
–––––. “Against Genetic Exceptionalism: An Argument for the Viability of
Preconception Genetic Torts.” Journal of Health Care Law & Policy 10,
no. 2 (2007): 259-286.
–––––. “Religion, the Culture of Biomedicine, and the Tremendum: Towards a
Non-Essentialist Analysis of Interconnection.” Journal of Religion and
Health 46, no. 1 (March 2007): 99-108.
–––––. “The Ethics of DNR Orders as to Neonatal & Pediatric Patients: The
Ethical Dimension of Communication.” Houston Journal of Health Law
& Policy 7, no.1 (Fall 2006): 57-83.
–––––. “I Do Not Think It Means What You Think It Means: How Kripke and
Wittgenstein’s Analysis on Rule Following Undermines Justice Scalia’s
Textualism and Originalism.” Cleveland State Law Review 54, no. 3
(2006): 273-307.
Winslade, William J., and Daniel S. Goldberg. “Dying in America: Legal
Decisions, Ethical Conflicts, and the Kinetics of Cultural Change.”
Annual Review of Law & Ethics 13, no. 2 (2008): 523-563.
Goldberg, Daniel S., and Howard A. Brody. “Spirituality: Respect But Don’t
Reveal.” American Journal of Bioethics 7, no. 7 (July 2007): 21-22.
Permanent address:
2520 Robinhood # 1604, Houston, Texas 77005
This dissertation was typed by Daniel S. Goldberg.
335