On a rainy Tuesday afternoon (Nov. 6), physicians, historians of science, and members of the general public gathered in the gymnasium at the Radcliffe Institute for Advanced Study to hear about pain.
Keith Wailoo, founding director of the Center for Race and Ethnicity at Rutgers University, began a lecture called “The Cultural Politics of Pain in America, from Percodan to Kevorkian” by presenting a New Yorker cartoon: A doctor and a patient are talking in a hospital room, and the doctor is saying, “We can give you enough medication to alleviate the pain but not enough to make it fun.”
This cartoon, Wailoo explained as he began the Dean’s Lecture Series talk, highlights one of the questions he is asking in his current work: “Why is pain medicine subject to such ongoing controversy?”
The field of pain medication, Wailoo said, is rife with cultural and political tensions. He sketched out a history of these tensions — from the 1950s to the present. Among the most prominent problems, according to Wailoo, is the fact that pain is subjective. “It’s dependent on the patients’ representation of their feelings,” he says, unlike vital signs such as temperature and blood pressure, which can be measured and quantified. This subjectivity makes pain medicine a murky area. What kind of pain is the patient experiencing and how should a doctor treat it in the absence of physiological measures?
If one believes that pain is pain and always merits medical attention, then the question of whether to administer medication may seem a no-brainer. But where there’s pain medication, there’s often potential for addiction. “Will one problem [the potentially addictive medication] replace the first problem [the pain]?” Wailoo asked. Is addiction a risk a doctor should allow?
End-of-life care and euthanasia pose a third problem, Wailoo said. Some drugs, such as morphine, suppress blood pressure and can provide tremendous pain relief, but can also hasten death. What is the right course of action in those cases? Should a physician relieve pain and risk hastening death, or leave the patient living longer in pain?
If these questions aren’t fraught enough, consider the role of culture in people’s experiences with pain. In some cultures, said Wailoo, whose current project is a study titled “The Cultural Politics of Pain: Medicine, Society, and the Struggle for Relief in America,” the “grin and bear it” approach to pain is not only acceptable but considered noble. And in some religious groups, “the idea that pain is somehow redemptive” may keep patients from accepting pain relief.
With this introduction, Wailoo set up the problem of pain treatment. He went on to show how attitudes and methods have changed in the past five decades.
According to Wailoo, the medical community in the 1950s had a hard-nosed view of pain. He offered a startling quote from a 1957 California Symposium on Pain: “Patients in chronic pain are worthy of study but not necessarily worthy of sympathy.” This was the backdrop for medical assessment and treatment of pain.
In that era, surgery was a well-accepted mode of relief for severe and persistent pain. Lobotomies were among the surgical solutions to problems of chronic pain. Also around that time, the medical community began to expand its use of Percodan, a drug that was thought to provide the same kind of relief that morphine might, but without the danger of addiction.
By the 1960s, according to Wailoo, it became clear that the promise of an addiction-free pain drug was not to be found in Percodan. He quotes the Bureau of Narcotics Enforcement as having said, “People are eating Percodan as though it were popcorn,” creating “a new class of addicts composed of otherwise honest, not criminally inclined persons.” Percodan could be used recreationally, and this kind of recreation, some asserted, was corrupting.
In the late 1960s, the previously acceptable surgical pain remedies came into question. The “Gate Control Theory” of pain started buzzing around the medical community. The theory was part, said Wailoo, of growing liberal trends in American culture and medicine, and its main contention was that pain is not just a matter of pulsating nerves — “It’s expectations, it’s psychology, it’s past history, context, and personality,” Wailoo explained. By the 1970s, he said, pain medicine began to develop as a legitimate field, and cancer patients and the hospice movement were instrumental in the rise of palliative care and pain management.
By the 1980s, the medical view of pain tended to be more liberal. As Wailoo put it: “I don’t know if you’re in pain, but I’ll take your word for it.” But in this period, questions began to arise about the government’s role in pain management. For instance, the question was asked: Which patients deserved social security disability and to what extent could their descriptions of pain affect their claim?
In the past 15 years, Wailoo said, the debate has turned to the boundaries between palliative care and the right to die. The Kevorkian trials, in which the doctor was accused of killing his patients, raised questions about how medical professionals might opt for aggressive pain treatments without fear of repercussion. Kevorkian went to court multiple times on charges related to assisted suicide. But he was acquitted each time, says Wailoo, because he claimed he had provided pain relief for his patients and their deaths were a result of that pain relief. It was only when Kevorkian was charged with homicide, which precluded the pain relief defense, that he was convicted.
In response to an audience question, Wailoo talked about the hot legal debate surrounding one form of capital punishment — lethal injection. The compelling argument, he said, is that those injected are in pain but they can’t show it. Pain, he said, “intersects with … cultural dramaturgy; in other words, what we say about pain often has to do with a performance of it. Pain becomes legitimate because it’s performed in a certain way.” For example, he said, “if you clench your teeth or double over … that scene is more legitimate” than if you don’t express pain in a way that makes it easy for others to identify. In the case of lethal injections, some argue that one of the administered drugs causes excruciating pain, but another causes complete paralysis, which makes it impossible for the condemned individual to express the pain.
After his historical tour, Wailoo turned back to his original question: Why is treatment of pain so controversial? “Pain medicine has never existed by itself,” Wailoo said, “it’s always been part of broader cultural politics.” Pain medicine is pain politics, he said. It involves questions about the subjectivity of pain, the dangers of addiction, end-of-life politics, and cultural and political trends, which change with the decades.
“There’s a disturbing cultural backdrop,” Wailoo said: “ideological tussles between liberal and conservative trends, which, unbeknownst to you … are always there shaping the decisions that doctors and patients make about heath care.”