On a rainy Tuesday afternoon, 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, Martin Luther King Jr. Professor of History and founding director of the Center for Race and Ethnicity at Rutgers University, began a lecture entitled “The Cultural Politics of Pain in America, from Percodan to Kevorkian, with a New Yorker cartoon. In it, 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 explains as he begins his Dean’s Lecture Series talk, highlights the question he is asking in his current work, “why is pain medicine subject to such ongoing controversy?”
The field of pain medication, Wailoo says, is rife with cultural and political tensions, which he outlines from the 1950s up until today. 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? Should a patient receive pain relief medication because he says he’s in pain?
If a person believes that pain is pain and always merits medical attention, then the question of whether to administer medication may seem to be a no-brainer. But where there’s pain medication, there’s potential for addiction – which further muddies the medical waters and opens up another flood-gate in the pain debate. “Will one problem [the potentially addictive medication] replace the first problem [the pain]?” Wailoo asks rhetorically. Is addiction a risk a doctor should allow?
End of life care and euthanasia pose a third problem, Wailoo says. 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, says Wailoo, whose current project is a study entitled “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 noble. And in some religious groups, “the idea that pain is somehow redemptive” may keep patients from accepting pain relief.
With this introduction, Wailoo has set up the problem of pain treatment. He goes on to show how the subject has been approached in the past five decades.
According to Wailoo, the medical community in the 1950s had a hard-nosed view of pain. He offers 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 which 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 corrupted.
In the late 1960s, the previously acceptable surgical pain remedies also came into question. The Gate Control Theory of pain started buzzing around the medical community. The theory was part of the growing liberal trends in American culture and medicine and the idea 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 explains. By the 1970s, he says, the field of 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.
Ironically, by the time of the Regan era, the medical view of pain tended to be a liberal one. As Wailoo puts it: “I don’t know if you’re in pain but I’ll take your word for it.” But questions arose 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 last 15 years, Wailoo says, the debate has turned to the boundaries between palliative care and the right to die. The Kevorkian trials, in which the infamous doctor was accused of killing his patients, raised questions about how doctors 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 also addresses hot legal debate surrounding death: the case of lethal injections administered to carry out death sentences. The compelling argument, he says, is that those injected are in pain but they can’t show it. Pain, he says, “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 says, “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.
With this tour of the history of pain relief from Percodan to Kevorkian, Wailoo turns back to his original question: why is treatment of pain so controversial? “Pain medicine has never existed by itself,” Wailoo says, “it’s always been part of broader cultural politics.” Pain medicine is pain politics, he says. 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 says, “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.”