In The Politics of Pain Medicine: A Rhetorical-Ontological Inquiry, S. Scott Graham offers a rich and detailed exploration of the medical rhetoric surrounding pain medicine. Graham chronicles the work of interdisciplinary pain management specialists to found a new science of pain and a new approach to pain medicine grounded in a more comprehensive biospychosocial model. His insightful analysis demonstrates how these materials ultimately shape the healthcare community’s understanding of what pain medicine is, how the medicine should be practiced and regulated, and how practitioner-patient relationships are best managed. It is a fascinating, novel examination of one of the most vexing issues in contemporary medicine.
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The Politics of Pain Medicine
A Rhetorical-Ontological Inquiry
By S. Scott Graham
The University of Chicago PressCopyright © 2015 The University of Chicago
All rights reserved.
An Ontological History of Pain
O Death the Healer, scorn thou not, I pray, To come to me: of cureless ills thou art The one physician. Pain lays not its touch Upon a corpse. — Aeschylus
I would say that pain is part of the glory, or the tremendous mystery of life. And that if anything, it's a kind of privilege to stand so close to such an incredible miracle. — Simone Taylor (Klassen, 2001, p. 193)
Whether it is Aeschylus's horrible pain that can only be alleviated by death, Simone Taylor's description of the glorious pain of childbirth, or a garden-variety headache, pain is a nearly ubiquitous to the human condition. Nevertheless, I imagine most people would be hard-pressed to come up with a succinct definition of "pain." Pain defies categorization. The multiplicity of pain is probably best encapsulated in the title of one of the premier French medical journals for the study of pain, Douleurs (Pains). By adding an s to the more common mass noun douleur, French physicians and researchers are highlighting pain's multiplicity. Indeed, it is quite tempting to follow the lead of French pain clinicians and adopt "pains" rather than "pain" in this work. However, I have largely declined to do so for two reasons: It is not a linguistic move that biopsychosocial Anglophone pain researchers are making, and "pains" simply has too long a history in nonmedical Anglophone contexts (for example, in idioms like "to take great pains").
Linguistics aside, there are myriad physical, emotional, social, and cultural causes of pain and an equally myriad number of physical and emotional symptoms and manifestations. Pain management, if attempted, is often only a temporary process of symptom suppression — something done to help one cope as the underlying mechanism of illness or injury is addressed. Of course, this is not always the case. Seldom does one think of "curing" a headache. You take your preferred painkiller and wait for it to pass, all headaches forgotten until the next one. However, pain management may be different still in the case of pain as part of chronic depression. In this case there is a cause: the depression. But is there a cause of the cause? Is the depression the result of a traumatic experience, a neurotransmitter imbalance, or both, or neither? Will the pain subside with the treatment of the depression? Pain as a phenomenon and pain management as a practice are truly problematic. The complexities of each are inextricably tied up with each other and with the illness at hand — if there is one.
Of course, it's not only rhetoricians, STS scholars, and cultural theorists who have trouble formulating or articulating a succinct understanding of pain. The many natures of pain and the appropriate practices for pain management are topics of vigorous debate in and among many health-care disciplines. Pain management is an area of practice and a certifiable subspecialty in many disciplines and subspecialties — including but not limited to anesthetic medicine, neurology, psychology, pharmacy, physical therapy, and nursing. However, no two of these disciplines conceive of pain or practice pain management in quite the same way. This issue is recognized by multidisciplinary coalitional groups such as the International Association for the Study of Pain (IASP). The IASP developed the first internationally recognized definition of pain at the Fourth World Congress on Pain in 1984, and it has continued to be revised by the IASP Task Force on Taxonomy. This official IASP definition explicitly attempts to "represent agreement between diverse specialties including anesthesiology, dentistry, neurology, neurosurgery, neurophysiology, psychiatry, and psychology."
Despite the laudable nature of scientific and humanist work aimed at overcoming the myth of two pains, when viewed through the lens of the two-world hypothesis (as is typically the case) only a small portion of the conflicting issues present in pain management are manifest. In fact, the historiography of pain is typically troubled twice-over by the two-world hypothesis. In the first instance, humanist and social scientific historians tend to read pain through the disease/illness dichotomy and thus present the well-trodden argument that overly biomechanical pain scientists ignore the subjective and affective dimensions of pain as illness (Morris, 1991; Bendelow & Williams, 1995; Rey, 1993, 1995; Liebeskind & Paul, 1997). In the second case, humanist and social scientific historians of pain also tacitly deploy the hegemonic fallacy, in that they recount the history of pain science as a successive parade of totalizing paradigms, where theorists and practitioners are locked in the theoretical zeitgeist of the day only to be entirely replaced in their old age by the next generation of scientists who inhabit a new and different world of pain (Melzack, 1973; Melzack & Wall, 1982; Rey, 1993). However, neither of these two-world approaches to the historiography are quite appropriate to the multiplicity of pain, scientific and clinical, historical and contemporary.
Individual pain scientists and clinicians, throughout history, have confronted myriad pains. "Individual" is an essential modifier in that last sentence. It is far too easy to read it as another expression of totalizing theory succession. When I say that pain scientists and clinicians confront myriad pains, I very much do not mean that each successive generation confronted new theories of pain. I mean that Galen, Dr. Leriche, and Dr. Melzack each confronted multiple pains simultaneously in their clinical practices of the second century, 1935, and 1970, respectively. To be sure, each clinician confronted a different (but partially overlapping) set of pains. These simultaneously extant pains fall on either side of and sometimes across the Cartesian divide and have been represented across a variety of medical and scientific disciplines. Here again, it would be too easy to read that last sentence as suggesting that each discipline has its own pain. But as this chapter will demonstrate, that neither was nor currently is the case. Most disciplines exhibit multiple simultaneous pains. Thus, the primary aim of this chapter is to offer an alternative history of pain, one that accounts for the multiplicity of simultaneous extant pains in a new materialist idiom. In so doing, I contribute to new materialist efforts to overcome the two-world problem in humanistic scholarship. Furthermore, this history will also provide essential contextualization for my discussion of the way that these many pains circulate in the contemporary practices of pain management (chapters 2–3), efforts to found and authorize new pain ontologies (chapters 3–4), and the networks of disciplines and regulatory agencies that surround those efforts (chapters 5–6).
Macrohistory without Incommensurability
Historiographers have, from time to time, offered a distinction of scope in regard to their work: macrohistory versus microhistory. While there is no easy and agreed-upon line of demarcation to be drawn between these two historiographic scopes, the difference is easy to see on the margins. Amacrohistory of evolutionary science, for example, might trace the sweeping changes from Lamarck and Lyell through Darwin and Huxley and on to the modern synthesis. In contrast, a microhistory could offer a detailed analysis of the historical contexts that contributed to Charles Darwin and Alfred Russel Wallace's virtually simultaneous development of the theory of evolution by natural selection. In the first case, the historiographic scope is a span of more than a hundred years. In the second case, the focus may fall on a single decade or less. In contemporary history of science and technology, microhistory is now the dominant form of inquiry. Ironically ushered in by the most macro of macrohistorians, Thomas Kuhn, the shift to social constructivism required an attendant shift in inquiry away from documentation of successive ideas over broad timelines (macrohistory) toward a much more detailed focus on the socio-contextual milieu in which individual ideas incubated (microhistory).
The predominant focus on microhistories over the past several decades means little attention has been paid to updating the practice of macrohistory to account for contemporary and emerging approaches like new materialisms. As such, there remain essentially two primary options for macrohistory of science and technology: the appropriately much-maligned Whig history and the rather more popular (post-)Kuhnian theory succession. Whig history was coined by Herbert Butterfield in 1944 to refer to efforts by the Whig Party of England to rewrite English history into a teleological narrative culminating in Whig ascendency. Whig approaches to the history of science and technology remain quite prevalent, especially in histories written by practicing scientists. Whig histories of science present theories currently in vogue as unassailably correct and rewrite the history of science into a teleological narrative that ends in the final and true discovery of the current concepts. Both the Whig approach and the Kuhnian approach are common in contemporary histories of pain, whether those histories were penned by biomedical researchers or more humanistic historians. The Whig approach to pain is, however, particularly common among biomedical researches who craft a narrative that leads eventually toward the current scientific theory. Fishman and Berger's (2000) The War on Pain exemplifies this tradition when identifying the work of René Descartes as essentially accurate:
Considering that Descartes' methods of exploration were limited to crude microscopes and dissected cadavers, his concept of the sensory nervous system was wonderfully advanced. Pain does travel along pathways of nervous, although not along a single primary interstate, so to speak, but via two main routes.... (p. 9)
Similarly, historian Roselyne Rey (1994) identifies C. S. Sherrington as the first person to develop a "modern theory of pain," indicating that it is somehow more scientifically accurate than its predecessors. Of course, I reject teleological historiography for obvious reasons and also find theory succession to be an inadequate explanatory heuristic given its correlative suggestion that prior theories were discarded in favor of new ones.
More compelling but still ultimately problematic histories of pain are offered in the theory succession tradition. In The Culture of Pain (1991), David Morris explicitly references the work of Kuhn in his explanation of the discovery of tic douloureaux/trigeminal neuralgia as a departure from normal puzzle-solving science (pp. 164–165). Perhaps more interesting, however, is the case of world-renowned pain theorist Ronald Melzack, who explicitly and intentionally presents a narrative of theory succession in his canonical The Puzzle of Pain (1973) as a way of warranting his "revolutionary" new theory of pain:
However, when all the theories — from specificity theory onward — are examined together, it is apparent that each successive theory makes an important contribution. Each provides an additional mechanism to explain some of the complex clinical syndromes of experimental data that were previously inexplicable. Despite the seemingly small differences, each change contains a major conceptual idea that has had a powerful impact on research and therapy. (p. 152)
Lest there be any doubt of Melzack's own view of his new theory as a noncumulative developmental episode à la Kuhn, he (with Wall) later writes in The Challenge of Pain, the 1982 update to his 1973 classic, "We consider ourselves extremely privileged to have taken part in a genuine scientific revolution in the past two decades" (p. viii). Ultimately, as I argue above, neither the teleological Whig history nor theory succession are appropriate to the manifest multiplicity of pain. The history of pain medicine is a history of multiple practical and theoretical emergences. However, only periodically did a newly emerged theory supplant a prior theory, as the theory succession model would have it. Furthermore, the Kuhnian approach to historiography puts us firmly on the path to social construction, incommensurability theory, and the hegemonic fallacy, all things I hope to avoid. Thus a new approach to macrohistory is required — one that is consonant with the dictates of new materialism.
Now, incommensurability studies, which arise from theory succession historiography, have a long pedigree in history of science and rhetorical studies. Nevertheless, I must reject both Kuhnian historiography and incommensurability theory as both inappropriate to a macrohistory of pain and untenable under the rubric of new materialisms. In short, as I've argued elsewhere (Graham & Herndl, 2013), incommensurability theory is a legacy of the two-world problem. It invokes that problem in at least two ways: Incommensurability is inextricably modernist in that it posits a binary reality composed of a world and a view, and it commits the hegemonic fallacy by offering a totalizing theory of paradigmatic ideology. Mol's multiple-ontologies approach transcends each of these problems by providing a compelling alternative to incommensurability, one that neither is modernist nor commits the hegemonic fallacy. As Mol repeatedly reminds us, postmodern theories of paradigms or ideology are irrevocably perspectival. They are shot through with visual metaphors that serve to (re-)establish the profound modernist separation between a subject and an object, culture and nature, a view and the world.
Indeed, ocular metaphors are pervasive in Kuhn's Structure of Scientific Revolutions (1996) and persist through rhetorical inquiry into incommensurability. For example, Kuhn's perspectivalism finds its clearest expression in the title of the tenth chapter in Structure: "Revolutions as Changes of World View" (p. 111). In this chapter, as in the others before and after it, Kuhn makes recurrent references to how scientists see the world as a result of their paradigms. The gestalt switch metaphor — though troubling for Kuhn — is recurrent. And there is, furthermore, example after example of revolutionary scientists who see and inhabit an entirely new world post-paradigm revolution: "The very ease and rapidity with which astronomers saw new things when looking at old objects with old instruments may make us wish to say that, after Copernicus, astronomers lived in a different world. In any case, their research responded as though that were the case" (p. 117). Kuhnian paradigms are fundamentally the goggles through which one sees the world:
In their most usual form, of course, gestalt experiments illustrate only the nature of the perceptual transformations. They tell us nothing about the role of paradigms or of previously assimilated experience in the process of perception. But on that point there is a rich body of psychological literature, much of it stemming from the pioneering work of the Hanover Institute. An experimental subject who puts on goggles fitted with inverting lenses initially sees the entire world upside down. At the start his perceptual apparatus functions as it had been trained to function in the absence of goggles, and the result is extreme disorientation, an acute personal crisis. But after the subject has begun to learn to deal with his new world, his entire visual field flips over, usually after an intervening period in which visual is simply confused. Thereafter, objects are again seen as they had been before the goggles were put on. The assimilation of previously anomalous visual field has reacted upon and changed the field itself. Literately as well as metaphorically, the man accustomed to inverting lenses has undergone a revolution transformation of vision. (p. 112)
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Table of ContentsContents Acknowledgments Abbreviations Introduction Chapter 1. An Ontological History of Pain Chapter 2. Praxiography of Representation Chapter 3. Ontological Calibration and Functional Stases in the MPG Chapter 4. Neuroimaging Detours Chapter 5. Rarefactive and Constitutive Calibration Chapter 6. Networks of Calibration Conclusion: Finding the Groove Notes References Index