Do not copy and paste, but you might [re]think this message for all undergraduate students!!!
The Killing of Pain
from,
"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.
Source: http://soilandhealth.org/wp-content/uploads/0303critic/030313illich/Frame.Illich.Ch3.html
文献
Do not copy and paste, but you might [re]think this message for all undergraduate students!!!