The Killing of Pain
"MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, by IVAN ILLICH, 1976"
The Killing of Pain
When cosmopolitan medical civilization colonizes any traditional culture, it transforms the experience of pain.1 The same nervous stimulation that I shall call "pain sensation" will result in a distinct experience, depending not only on personality but also on culture. This experience, as distinct from the painful sensation, implies a uniquely human performance called suffering.2 Medical civilization, however, tends to turn pain into a technical matter and thereby deprives suffering of its inherent personal meaning.3 People unlearn the acceptance of suffering as an inevitable part of their conscious coping with reality and learn to interpret every ache as an indicator of their need for padding or pampering. Traditional cultures confront pain, impairment, and death by interpreting them as challenges soliciting a response from the individual under stress; medical civilization turns them into demands made by individuals on the economy, into problems that can be managed or produced out of existence.4 Cultures are systems of meanings, cosmopolitan civilization a system of techniques. Culture makes pain tolerable by integrating it into a meaningful setting; cosmopolitan civilization detaches pain from any subjective or intersubjective context in order to annihilate it. Culture makes pain tolerable by interpreting its necessity; only pain perceived as curable is intolerable.
A myriad virtues express the different aspects of fortitude that traditionally enabled people to recognize painful sensations as a challenge and to shape their own experience accordingly. Patience, forbearance, courage, resignation, self-control, perseverance, and meekness each express a different coloring of the responses with which pain sensations were accepted, transformed into the experience of suffering, and endured.5 Duty, love, fascination, routines, prayer, and compassion were some of the means that enabled pain to be borne with dignity. Traditional cultures made everyone responsible for his own performance under the impact of bodily harm or grief.6 Pain was recognized as an inevitable part of the subjective reality of one's own body in which everyone constantly finds himself, and which is constantly being shaped by his conscious reactions to it.7 People knew that they had to heal on their own,8 to deal on their own with their migraine, their lameness, or their grief.
The pain inflicted on
individuals had a limiting effect on the abuses
of man by man. Exploiting minorities sold liquor or preached religion
to dull their victims, and slaves took to the blues or to coca-chewing.
But beyond a critical point of exploitation, traditional economies
which were built on the resources of the human body had to break down.
Any society in which the intensity of discomforts and pains inflicted
rendered them culturally "insufferable" could not but come to an end.
Now an increasing portion of all pain is man-made, a side-effect of strategies for industrial expansion. Pain has ceased to be conceived as a "natural" or "metaphysical" evil. It is a social curse, and to stop the "masses" from cursing society when they are pain-stricken, the industrial system delivers them medical pain-killers. Pain thus turns into a demand for more drugs, hospitals, medical services, and other outputs of corporate, impersonal care and into political support for further corporate growth no matter what its human, social, or economic cost. Pain has become a political issue which gives rise to a snowballing demand on the part of anesthesia consumers for artificially induced insensibility, unawareness, and even unconsciousness.
Traditional cultures and technological civilization start from opposite assumptions. In every traditional culture the psychotherapy, belief systems, and drugs needed to withstand most pain are built into everyday behavior and reflect the conviction that reality is harsh and death inevitable.9 In the twentieth century dystopia, the necessity to bear painful reality, within or without, is interpreted as a failure of the socio-economic system, and pain is treated as an emergent contingency which must be dealt with by extraordinary interventions.
The experience of pain that results from pain messages received by the brain depends in its quality and in its quantity on genetic endowment10 and on at least four functional factors other than the nature and intensity of the stimulus: namely, culture, anxiety, attention, and interpretation. All these are shaped by social determinants, ideology, economic structure, and social character. Culture decrees whether the mother or the father or both must groan when the child is born.11 Circumstances and habits determine the anxiety level of the sufferer and the attention he gives to his bodily sensations.12 Training and conviction determine the meaning given to bodily sensations and influence the degree to which pain is experienced.13 Effective magic relief is often better provided by popular superstition than by high-class religion.14 The prospect which is opened by the painful event determines how well it will be suffered: injuries received near the climax of sex or that of heroic performance are frequently not even felt. Soldiers wounded on the Anzio Beachhead who hoped their wounds would get them out of the army and back home as heroes rejected morphine injections that they would have considered absolutely necessary if similar injuries had been inflicted by the dentist or in the operating theater.15
As culture is medicalized, the social determinants of pain are distorted. Whereas culture recognizes pain as an intrinsic, intimate, and incommunicable "disvalue," medical civilization focuses primarily on pain as a systemic reaction that can be verified, measured, and regulated. Only pain perceived by a third person from a distance constitutes a diagnosis that calls for specific treatment. This objectivization and quantification of pain goes so far that medical treatises speak of painful diseases, operations, or conditions even in cases where patients claim to be unaware of pain. Pain calls for methods of control by the physician rather than an approach that might help the person in pain take on responsibility for his experience.16 The medical profession judges which pains are authentic, which have a physical and which a psychic base, which are imagined, and which are simulated.17 Society recognizes and endorses this professional judgment. Compassion becomes an obsolete virtue. The person in pain is left with less and less social context to give meaning to the experience that often overwhelms him.
The history of medical perception of pain has not yet been written. A few learned monographs deal with the moments during the last 250 years in which the attitude of physicians towards pain changed,18 and some historical references can be found in papers dealing with contemporary attitudes towards pain.19 The existential school of anthropological medicine has gathered valuable insights into the development of modern pain while tracing the changes in bodily perception in a technological age.20 The relationship between the medical institutions and the anxiety suffered by their patients has been explored by psychiatrists21 and occasionally by general physicians. But the relationship of corporate medicine to bodily pain in its real sense is still virgin territory for research.
The historian of pain has to face three special problems. The first is the profound transformation undergone by the relationship of pain to the other ills man can suffer. Pain has changed its position in relation to grief, guilt, sin, anguish, fear, hunger, impairment, and discomfort. What we call pain in a surgical ward is something for which former generations had no special name. It now seems as if pain were only that part of human suffering over which the medical profession can claim competence or control. There is no historical precedent for the contemporary situation in which the experience of personal bodily pain is shaped by the therapeutic program designed to destroy it. The second problem is language. The technical matter which contemporary medicine designates by the term "pain" even today has no simple equivalent in ordinary speech. In most languages the term taken over by the doctors covers grief, sorrow, anguish, shame, and guilt. The English "pain" and the German "Schmerz" are still relatively easy to use in such a way that a mostly, though not exclusively, physical meaning is conveyed. Most Indo-Germanic synonyms cover a wider range of meaning:22 bodily pain may be designated as "hard work," "toil," or "trial," as "torture," "endurance," "punishment," or more generally, "affliction," as "illness," "tiredness," "hunger," "mourning," "injury," "distress," "sadness," "trouble," "confusion," or "oppression." This litany is far from complete: it shows that language can distinguish many kinds of "evils," all of which have a bodily reflection. In some languages bodily pain is outright "evil." If a French doctor asks a typical Frenchman where he has pain, the patient will point to the spot and say, "J'ai mal là." On the other hand, a Frenchman can say, "Je souffre dans toute ma chair," and at the same time tell his doctor, "Je n'ai mal nulle part." If the concept of bodily pain has undergone an evolution in medical usage, it cannot be grasped simply in the changing significance of any one term.
A third obstacle to any history of pain is its exceptional axiological and epistemological status.23 Nobody will ever understand "my pain" in the way I mean it, unless he suffers the same headache, which is impossible, because he is another person. In this sense "pain" means a breakdown of the clear-cut distinction between organism and environment, between stimulus and response.24 It does not mean a certain class of experience that allows you and me to compare our headaches; much less does it mean a certain physiological or medical entity, a clinical case with certain pathological signs. It is not "pain in the sternocleidomastoid" which is perceived as a systematic disvalue for the medical scientist.
The exceptional kind of
disvalue that is pain promotes an exceptional
kind of certainty. Just as "my pain" belongs in a unique way only to
me, so I am utterly alone with it. I cannot share it. I have no doubt
about the reality of the pain experience, but I cannot really tell
anybody what I experience. I surmise that others have "their" pains,
even though I cannot perceive what they mean when they tell me about
them. I am certain about the existence of their pain only in the sense
that I am certain of my compassion for them. And yet, the deeper my
compassion, the deeper is my certitude about the other person's utter
loneliness in relation to his experience. Indeed, I recognize the signs
made by someone who is in pain, even when this experience is beyond my
aid or comprehension. This awareness of extreme loneliness is a
peculiarity of the compassion we feel for bodily pain; it also sets
this experience apart from any other experience, from compassion for
the anguished, sorrowful, aggrieved, alien, or crippled. In an extreme
way, the sensation of bodily pain lacks the distance between cause and
experience found in other forms of suffering.
Notwithstanding the inability to communicate bodily pain, perception of it in another is so fundamentally human that it cannot be put into parentheses. The patient cannot conceive that his doctor is unaware of his pain, any more than the man on the rack can conceive this about his torturer. The certainty that we share the experience of pain is of a very special kind, greater than the certainty that we share humanity with others. There have been people who have treated their slaves as chattels, yet recognized that this chattel was able to suffer pain. Slaves are more than dogs, who can be hurt but cannot suffer. Wittgenstein has shown that our special, radical certainty about the existence of pain in other people can coexist with an inextricable difficulty in explaining how this sharing of the unique can come about.25
It is my thesis that
bodily pain, experienced as an intrinsic,
intimate, and incommunicable disvalue, includes in our awareness the
social situation in which those who suffer find themselves. The
character of the society shapes to some degree the personality of those
who suffer and thus determines the way they experience their own
physical aches and hurts as concrete pain. In this sense, it should be
possible to investigate the progressive transformation of the pain
experience that has accompanied the medicalization of society. The act
of suffering pain always has a historical dimension.
When I suffer pain, I am aware that a question is being raised. The history of pain can best be studied by focusing on that question. No matter if the pain is my own experience or if I see the gestures of another telling me that he is in pain, a question mark is written into this perception. Such a query is as integral to physical pain as the loneliness. Pain is the sign for something not answered; it refers to something open, something that goes on the next moment to demand, What is wrong? How much longer? Why must I/ought I/should I/can I/ suffer? Why does this kind of evil exist, and why does it strike me? Observers who are blind to this referential aspect of pain are left with nothing but conditioned reflexes. They are studying a guinea pig, not a human being. A physician, were he able to erase this value-loaded question shining through a patient's complaints, might recognize pain as the symptom of a specific bodily disorder, but he would not come close to the suffering that drove the patient to seek help. The development of this capacity to objectify pain is one of the results of overintensive education for physicians. By his training the physician is often enabled to focus on those aspects of a person's bodily pain that are accessible to management by outsiders: the peripheral-nerve stimulation, the transmission, the reaction to the stimulus, or even the anxiety level of the patient. Concern is limited to the management of the systemic entity, which is the only matter open to operational verification.
The personal performance of suffering escapes such experimental control and is therefore neglected in most experiments that are conducted on pain. Animals are usually used to test the "pain-killing" effects of pharmacological or surgical interventions. Once the results of animal tests have been tabulated, their validity is verified in people. Painkillers usually give more or less comparable results in guinea pigs and humans, provided those humans are used as experimental subjects and under experimental conditions similar to those under which the animals were tested. As soon as the same interventions are applied to people who are actually sick or have been wounded, the effects of the drugs are completely out of line with those found in the experimental situation. In the laboratory people feel exactly like mice. When their own life becomes painful, they usually cannot help suffering, well or badly, even when they want to respond like mice.26
Living in a society that values anesthesia, both doctors and their potential clients are retrained to smother pain's intrinsic question mark. The question raised by intimately experienced pain is transformed into a vague anxiety that can be submitted to treatment. Lobotomized patients provide the extreme example of this expropriation of pain: they "adjust at the level of domestic invalids or household pets." 27 The lobotomized person still perceives pain but he has lost the capacity to suffer from it; the experience of pain is reduced to a discomfort with a clinical name.
For an experience of pain to constitute suffering in the full sense, it must fit into a cultural framework.28 To enable individuals to transform bodily pain into a personal experience, any culture provides at least four interrelated subprograms: words, drugs, myths, and models. Pain is shaped by culture into a question that can be expressed in words, cries, and gestures, which are often recognized as desperate attempts to share the utter confused loneliness in which pain is experienced: Italians groan and Prussians grind their teeth.
Each culture also provides its own psychoactive pharmacopeia, with customs that designate the circumstances in which drugs may be taken and the accompanying ritual.29 Muslim Rayputs prefer alcohol and Brahmins marijuana,30 though they intermingle in the same villages of western India.31 Peyote is safe for Navajos32 and mushrooms for the Huicholes,33 while Peruvian highlanders have learned to survive with coca.34 Man has not only evolved with the ability to suffer his pain, but also with the skills to manage it:35 poppy growing36 during the middle Stone Age probably preceded the planting of grains. Massage, acupuncture, and analgesic incense were known from the dawn of history.37 Religious and mythic rationales for pain have appeared in all cultures: for the Muslims it is Kismet,38 god-willed destiny; for the Hindus, karma,39 a burden from past incarnation; for the Christians, a sanctifying backlash of sin.40 Finally, cultures always have provided an example on which behavior in pain could be modeled: the Buddha, the saint, the warrior, or the victim. The duty to suffer in their guise distracts attention from otherwise all-absorbing sensation and challenges the sufferer to bear torture with dignity. The cultural setting not only provides the grammar and technique, the myths and examples used in its characteristic "craft of suffering well," but also the instructions on how to integrate this repertoire. The medicalization of pain, on the other hand, has fostered a hypertrophy of just one of these modes—management by technique—and reinforced the decay of the others. Above all, it has rendered either incomprehensible or shocking the idea that skill in the art of suffering might be the most effective and universally acceptable way of dealing with pain. Medicalization deprives any culture of the integration of its program for dealing with pain.
Society not only determines how doctor and patient meet, but also what each of them shall think, feel, and do about pain. As long as the doctor conceived of himself primarily as a healer, pain assumed the role of a step towards the restoration of health. Where the doctor could not heal, he felt no qualms about telling his patient to use analgesics and thus moderate inevitable suffering. Like Oliver Wendell Holmes, the good doctor who knew that nature provided better remedies for pain than medicine could say "[with the exception of] opium, which the Creator himself seems to prescribe, for we often see the scarlet poppy growing in the cornfields as if it were foreseen that wherever there is hunger to be fed there must also be pain to be soothed; [with the exception of] a few specifics which our doctor's art did not discover; [with the exception of] wine, which is a food, and the vapours which produce the miracle of anaesthesia . . . I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes."41
The ethos of the healer gave the physician the capacity for the same dignified failure for which religion, folklore, and free access to analgesics had trained the common man.42 The functionary of contemporary medicine is in a different position: his first orientation is treatment, not healing. He is geared, not to recognize the question marks that pain raises in him who suffers, but to degrade these pains into a list of complaints that can be collected in a dossier. He prides himself on the knowledge of pain mechanics and thus escapes the patient's invitation to compassion.
One source of European attitudes towards pain certainly lies in ancient Greece. The pupils of Hippocrates43 distinguished many kinds of disharmony, each of which caused its own kind of pain. Pain thus became a useful tool for diagnosis. It revealed to the physician which harmony the patient had to recover. Pain might disappear in the process of healing, but this was certainly not the primary object of the doctor's treatment. Whereas the Chinese tried very early to treat sickness through the removal of pain, nothing of this sort was prominent in the classical West. The Greeks did not even think about enjoying happiness without taking pain in their stride. Pain was the soul's experience of evolution. The human body was part of an irreparably impaired universe, and the sentient soul of man postulated by Aristotle was fully coextensive with his body. In this scheme there was no need to distinguish between the sense and the experience of pain. The body had not yet been divorced from the soul, nor had sickness been divorced from pain. All words that indicated bodily pain were equally applicable to the suffering of the soul.
In view of that heritage, it would be a grave mistake to believe that resignation to pain is due exclusively to Jewish or Christian influence. Thirteen distinct Hebrew words were translated by a single Greek term for "pain" when two hundred Jews of the second century B.C. translated the Old Testament into Greek.44 Whether or not pain for the Jew was considered an instrument of divine punishment, it was always a curse.45 No suggestion of pain as a desirable experience can be found in the Scriptures or the Talmud.46 It is true that specific organs were affected by pain, but those organs were conceived of also as seats of very specific emotions; the category of modern medical pain is totally alien to the Hebrew text. In the New Testament, pain is considered to be intimately entwined with sin.47 While for the classical Greek pain had to accompany pleasure, for the Christian pain was a consequence of his commitment to joy.48 No culture or tradition holds a monopoly on realistic resignation.
The history of pain in European culture would have to trace more than these classical and Semitic roots to find the ideologies that supported personal acceptance of pain. For the Neo-Platonist, pain was interpreted as the result of some deficiency in the celestial hierarchy. For the Manichaean, it was the result of positive malpractice on the part of an evil demiurge or creator. For the Christian, it was the loss of original integrity produced by Adam's sin. But no matter how much these religions opposed each other on dogma and morals, all of them saw pain as the bitter taste of cosmic evil, the manifestation of nature's weakness, of a diabolical will, or of a well-deserved divine curse. This attitude towards pain is a unifying and distinctive characteristic of Mediterranean postclassical cultures which lasted until the seventeenth century. As an alchemic doctor put it in the sixteenth century, pain is the "bitter tincture added to the sparkling brew of the world's seed." Each person was born with the call to learn to live in a vale of pain. The Neo-Platonist interpreted bitterness as a lack of perfection, the Cathar as disfigurement, the Christian as a wound for which he was held responsible. In dealing with the fullness of life, which found one of its major expressions in pain, people were able to stand up in heroic defiance or stoically deny the need for alleviation; they could welcome the opportunity for purification, penance, or sacrifice, and reluctantly tolerate the inevitable while seeking to relieve it. Opium, acupuncture, or hypnosis, always in combination with language, ritual, and myth, was applied to the unique human performance of suffering pain. One approach to pain was, however, unthinkable, at least in the European tradition: the belief that pain ought not to be suffered, alleviated, and interpreted by the person affected, but that it should be—ideally always—destroyed through the intervention of a priest, politician, or physician.
There were three reasons why the idea of professional, technical pain-killing was alien to all European civilizations.49 First: pain was man's experience of a marred universe, not a mechanical dysfunction in one of its subsystems. The meaning of pain was cosmic and mythic, not individual and technical. Second: pain was a sign of corruption in nature, and man himself was a part of that whole. One could not be rejected without the other; pain could not be thought of as distinct from the ailment. The doctor could soften the pangs, but to eliminate the need to suffer would have meant to do away with the patient. Third: pain was an experience of the soul, and this soul was present all over the body. Pain was a nonmediated experience of evil. There could be no source of pain distinct from pain that was suffered.50
The campaign against pain as a personal matter to be understood and suffered got under way only when body and soul were divorced by Descartes. He constructed an image of the body in terms of geometry, mechanics, or watchmaking, a machine that could be repaired by an engineer. The body became an apparatus owned and managed by the soul, but from an almost infinite distance. The living body experience which the French refer to as "la chair" and the Germans as "der Leib" was reduced to a mechanism that the soul could inspect.51
For Descartes pain became a signal with which the body reacts in self-defense to protect its mechanical integrity. These reactions to danger are transmitted to the soul, which recognizes them as painful. Pain was reduced to a useful learning device: it now taught the soul how to avoid further damage to the body. Leibnitz sums up this new perspective when he quotes with approval a sentence by Regis, who was in turn a pupil of Descartes: "The great engineer of the universe has made man as perfectly as he could make him, and he could not have invented a better device for his maintenance than to provide him with a sense of pain."52 Leibnitz's comment on this sentence is instructive. He says first that in principle it would have been even better if God had used positive rather than negative reinforcement, inspiring pleasure each time a man turned away from the fire that could destroy him. However, he concludes that God could have succeeded with this strategy only by working miracles, and since, as a matter of principle, God avoids miracles, "pain is a necessary and brilliant device to ensure man's functioning." Within two generations of Descartes's attempt at a scientific anthropology, pain has become useful. From being the experience of the precariousness of existence,53 it had turned into an indicator of specific breakdown.
By the end of the last century, pain had become a regulator of body functions, subject to the laws of nature; it needed no more metaphysical explanation.54 It had ceased to deserve any mystical respect and could be subjected to empirical study in order to do away with it. By 1853, barely a century and a half after pain was recognized as a mere physiological safeguard, a medicine labeled as a "pain-killer" was marketed in La Crosse, Wisconsin.55 A new sensibility had developed which was dissatisfied with the world, not because it was dreary or sinful or lacking in enlightenment or threatened by barbarians, but because it was full of suffering and pain.56 Progress in civilization became synonymous with the reduction of the sum total of suffering. From then on, politics was taken to be an activity not so much for maximizing happiness as for minimizing pain. The result is a tendency to see pain as essentially a passive happening inflicted on helpless victims because the toolbox of the medical corporation is not being used in their favor.
In this context it now seems rational to flee pain rather than to face it, even at the cost of giving up intense aliveness. It seems reasonable to eliminate pain, even at the cost of losing independence. It seems enlightened to deny legitimacy to all nontechnical issues that pain raises, even if this means turning patients into pets.57 With rising levels of induced insensitivity to pain, the capacity to experience the simple joys and pleasures of life has equally declined. Increasingly stronger stimuli are needed to provide people in an anesthetic society with any sense of being alive. Drugs, violence, and horror turn into increasingly powerful stimuli that can still elicit an experience of self. Widespread anesthesia increases the demand for excitation by noise, speed, violence—no matter how destructive.
This raised threshold of physiologically mediated experience, which is characteristic of a medicalized society, makes it extremely difficult today to recognize in the capacity for suffering a possible symptom of health. The reminder that suffering is a responsible activity is almost unbearable to consumers, for whom pleasure and dependence on industrial outputs coincide. By equating all personal participation in facing unavoidable pain with "masochism," they justify their passive life-style. Yet, while rejecting the acceptance of suffering as a form of masochism, anesthesia consumers tend to seek a sense of reality in ever stronger sensations. They tend to seek meaning for their lives and power over others by enduring undiagnosable pains and unrelievable anxieties: the hectic life of business executives, the self-punishment of the rat-race, and the intense exposure to violence and sadism in films and on television. In such a society the advocacy of a renewed style in the art of suffering that incorporates the competent use of new techniques will inevitably be misinterpreted as a sick desire for pain: as obscurantism, romanticism, dolorism, or sadism.
Ultimately, the management of pain might substitute a new kind of horror for suffering: the experience of artificial painlessness. Lifton describes the impact of mass death on survivors by studying people who had been close to ground zero in Hiroshima.58 He found that people moving amongst the injured and dying simply ceased to feel; they were in a state of numbness, without emotional response. He believed that after a while this emotional closure merged with a depression which, twenty years after the bomb, still manifested itself in the guilt or shame of having survived without experiencing any pain at the time of the explosion. These people live in an interminable encounter with death which has spared them, and they suffer from a vast breakdown of trust in the larger human matrix that supports each individual human life. They experienced their anesthetized passage through this event as something just as monstrous as the death of those around them, as a pain too dark and too overwhelming to be confronted, or suffered.59
What the bomb did in Hiroshima might guide us to an understanding of the cumulative effect on a society in which pain has been medically "expropriated." Pain loses its referential character if it is dulled, and generates a meaningless, questionless residual horror. The sufferings for which traditional cultures have evolved endurance sometimes generated unbearable anguish, tortured imprecations, and maddening blasphemies; they were also self-limiting. The new experience that has replaced dignified suffering is artificially prolonged, opaque, depersonalized maintenance. Increasingly, pain-killing turns people into unfeeling spectators of their own decaying selves.
Do not copy and paste, but you might [re]think this message for all undergraduate students!!!