Pain (10 page)

The kind of care provided to the person in pain was not merely a medical concern: it was cultural and political issue through and through.
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By the early 1960s, many Americans (lawyers, physicians, bureaucrats, patients) understood disability and pain in broad moral terms. The grassroots conservative movement that was stirring, ultimately bringing Ronald Reagan to the California governorship, tapped into this belief that people were turning professed pain into profit and that the liberalization of government benefits (in the name of better health care) did nothing except feed social dependence. “In our society the virtues of self-reliance and independence are so highly valued that many people feel a great deal of shame and humiliation at the idea of having to be taken care of,” wrote one physician in his state medical journal in 1963. His topic was not welfare or taxes, but pain management, cancer care, and the peculiar psychology of the cancer patient. People used pain selfishly to get what they wanted from others, he noted, since “conflict over dependency may lead to a demand that the physician get him well. This demand may be expressed through an increase in the intensity of pain as a way of saying, ‘Do something to get me well.'” Dependence bred its own selfish focus on pain: “it is also possible that the patient feels such a sense of guilt about the need to depend on others that his pain becomes a method of self-punishment and also a way of saying to himself, ‘Look—I'm justified in having to depend on others because I'm suffering so much.'”
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These psychological theories about the person in pain had taken root in the contentious postwar years of hope and Cold War anxiety. These years saw the construction and reconstruction of the psychological motivations of such people. Pain “may become the sufferer's chief occupation,” Albronda warned, a self-sustaining social pathology, with the doctor as unwilling accomplice. Compassionate responses only indulged complainers and fixed their underlying neuroses in place. The “medical relief of such severe pain, unless accompanied by early diagnosis and careful personality assessment and therapy, will only lead to another pain complex,”
he insisted. Other critics loudly echoed the California psychiatrist, worrying that relieving pain too easily masked underlying problems. But what were such practitioners to do when faced with a person in chronic pain? “Listen without anger to the patient's undue complaints and gain his confidence,” Albronda urged. But also “understand that unwise probing, injecting, massaging … in trying to relieve pain that is psychically perpetuated serves to fix the neurosis and lessen the chances for cure.”
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Psychologizing of the pain complaint became common fare as critics linked liberal medicine to an insidious social and political threat. When the doors of the wooden horse swung open, Louis Orr and others saw hordes of people with chronic headaches, backaches, and arthritis. In the case of people with arthritis, the social threat came not from the disease per se but from the so-called arthritic personality—men, and also women, who were allegedly maladjusted, hostile, and prone to complain. Experts would create an elaborate psychological profile of these guileful, infiltrating, warriors: “factors such as repressed hostility, poor marital, social, and vocational adjustment, and obsessive-compulsive character structures are among the reported manifestations of psychological maladjustment in these patients.” These people were prime targets for manipulation by a government that coddled them so much that they ceased to take action for their own lives.
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Physicians in the AMA saw themselves as leading the way by ringing alarm bells; but they were not alone, as other experts also worried about the hidden costs of new disability exemptions.

Who was the pain complainant? Was he or she truly deserving of relief? These questions, which had opened with soldiers and now applied more broadly, gained poignancy because of the political debate over liberal relief. As the influential sociologist Talcott Parsons theorized, “The privileges and exemptions of the sick role may become objects of ‘secondary gain' which the patient is positively motivated, usually unconsciously, to secure or to retain.” Experts had first worried about soldiers; now women more and more appeared as another vortex of concern. “The patient with painful degenerative knees is usually a female, and she is often obese,” observed the Cleveland-based orthopedic surgeon Frederic Rhinelander in a 1960 issue of
Arthritis and Rheumatism
. “She is generally middle aged, and she is apt to be much worried about her condition,” he continued. Such people posed an organic as well as a moral problem.
For them, even mentioning the word “arthritis” could foster intense fear of permanent dependence, so “at the outset, she must be assured that she does not have ‘arthritis' (in the sense that she fears that she is not on her way to becoming a deformed cripple). She must be assured that her joints are simply wearing out a bit prematurely, and that the process can be alleviated by simple measures.” To even use the term, he implied, could create the dependence that so many people feared. A Michigan epidemiologist offered another theory—arguing that angry men who repressed their hostility were particularly prone to arthritis.
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Whether the typical arthritis patient was a skittish woman or an angry repressed man, the need for a theory of pain that took into account perception, gender, identity, and psychology seemed clear—not just for the good of the patient but also for the good of society.

Asked by the Bradley Commission to assess pain, anguish, and suffering as a compensable disability, many physicians were hostile because they understood the political stakes. Speaking passionately against liberalization, they opposed the idea on practical as well as political grounds.
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“It would be an insurmountable task to rate pain, suffering, social handicap, and mental anguish,” wrote William Altemeier.
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Like Louis Orr, a chorus of such men saw pain as a ruse. The outlines of a great American pain debate were now evident. The stakes and major players were in view. It had begun with the ailing, wounded, or perhaps arthritic veteran. Were his illnesses connected somehow to mortar shelling on the beaches of Anzio, or was his pain a sign of social weakness? In this dispute, pain was a Trojan horse because indulging such complaints would open the way for all kinds of abuse, dependency, and social pampering. The fragile, coddled pain complainant had emerged as a stock figure in the conservative attack on liberalism and liberalization.

Call no faith false which e'er hath brought relief to any laden life.

SIR MORRIS LEWIS, “TOLERANCE”

W
hen President Dwight D. Eisenhower signed the new disability law (SSDI) in July 1956, he opened a gateway to relief for Texas resident Rosie Page and thousands of others. A middle-aged mother, Page had entered the workforce during the World War like thousands of other American women; she continued working after the war. After four years as a packer in a Texas manufacturing plant, in 1959 she began feeling stiffness and aching in her hands and neck. By the time she quit work soon afterward, Page was in extreme pain and extraordinarily nervous as well.
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Forced to quit one manufacturing job, Page tried another, but pain and the question of her nervousness stalked her every move.

Often tranquilized, nervous, and out of work, Page turned to the federal government, seeking disability benefits and relief through the Social Security disability program that Eisenhower had reluctantly established. Rejected by the agency, she appealed, setting her sad case on a momentous legal journey. Her case was a vexing puzzle. Did her pain have origins in her “nervousness”? Did it truly prevent her from working? Was she, in fact, disabled and thus owed relief under the new law? As doctors, lawyers, and federal bureaucrats weighed Page's complaint, her pain would be slowly transformed—from a personal struggle into milestone in the era's debates over disability and citizenship. The
Page v. Celebrezze
case, as it came to be known, would be followed by anyone who looked to government to open the gates to true relief. Page's claim opened an opportunity for other plaintiffs, lawyers, and judges to craft new policy at
this juncture where questions of health collided with problems of work and citizenship.

Page had lots of company in her quest for federal relief. Pain hobbled the elderly with arthritis and burdened thousands of wounded war veterans. It haunted the lives of athletes, housewives, politicians, and other people in a society that was being transformed by more wage-earning women. Pain bothered men like Philip Kerner, a sixty-five-year-old World War I veteran with diabetes, who had recently won a ruling that put the burden on the government to prove the case against his disability. In an aging society, it ate away at the savings of retirees like seventy-year-old Edwin Brinkley, who pressed the visiting Senate Special Committee on Aging to visit the prescription counters of Fort Lauderdale, Florida, “and see the oldsters having to pay exorbitant prices for the necessary remedies to relieve their pain.” The answer Brinkley hoped for was Medicare—the battle over which would go on for another three years. Americans like Page, Brinkley, and Kerner seemed to be facing a rising tide of crippling arthritis pain, migraines, back pain, cancer-related pain, and unspecified subjective pains. Here was a society apparently in an epidemiological and social transition—making an affluent turn, leaving behind an era of high mortality from infectious disease, and entering a new era when a host of chronic degenerative ailments became society's chief burden. Chronic, degenerative disease was “a price we pay for living longer,” noted one health institute's report, and chronic pain was one of the tragic perils of progress especially for a society being altered by aging and work.
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The battle over Page's pain introduced into the legal record the many questions swirling around the government's promise of relief. First, was the pain real? Second, could the federal government be trusted to deliver relief, and could it do so without condoning dependency, fraud, and socialism? Third, might the booming market in pain drugs be a better pathway to true, lasting relief? These questions linked Page's pain to the most turbulent political questions of the 1960s—government's role in ensuring equal opportunity, in safeguarding the most vulnerable, and in regulating industry so that it would be a promoter of good and not a means of exploitation. As the decade of the sixties opened, a familiar partisan debate continued: some saw government relief as a false promise; others saw market claims to provide “fast relief” with new drugs—Demerol, Miltown, Percodan, and so on—as a sham exploiting the vulnerable. Could
claims of relief from these products be validated, trusted, or embraced? Here too government in the 1950s and 1960s was asked to speak to the pain problem. The decision before Americans was whether pain complaints of people like Rosie Page should be borne silently and stoically or whether such citizens in distress should be supported by law and relieved by a sympathetic government. The problem of pain was in a sense a question of trust. Who could be trusted to know and relieve another's pain and to handle this growing problem of relief?

Five years after Eisenhower signed the disability bill establishing SSDI, the task of judging Page's pain fell on President Kennedy's Department of Health, Education, and Welfare (HEW). As the federal bureaucracy turned its attention to plaintive people, it became deeply engaged with a task that would haunt the expansion of liberal government—the challenge of distinguishing people with true pain from “chiselers,” HEW secretary Anthony Celebrezze's term for people seeking undeserved government handouts through deceit and fraud. It was Celebrezze's job to police the boundary between deserving pain and undeserving fraud—and after HEW administrators turned down Page's disability claim, he followed suit, rejecting her appeal. The issues embedded in pain management were profound in their moral, fiscal, and civic implications. Underpinning the question of what a compassionate, liberal government owed to such citizens was the problem of evidence. What sufficed as evidence to validate a person's need? Another question shadowing the rise of liberal governance was dependency and how the government would safeguard against the twin dangers of pain relief—on the one hand that its policies would produce dependency, on the other that hucksters and scam artists would inevitably arise, preying upon the vulnerable with their false promises of other forms or relief. As a “nervous” housewife, Page's case was one among a flood of new challenges for government as the decades opened.
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How far would liberal government expand? How much should the gates of relief be opened, and for whom? The key to the health of liberal reform was distinguishing honest need from fraud. During the 1960 election, Kennedy had criticized his opponent Richard Nixon's apparent disregard for disability, reminding voters that “in 1949, 79 percent of the House Republicans voted against any inclusion of disability benefits under social security, and [then-senator] Richard Milhous Nixon was among them. Why he would ever discuss social security and try to defend his
party's record on this matter—I don't understand.” SSDI has since become an established entitlement. But once in office Kennedy took up the challenge of governance, seeking to both expand and to manage those commitments—for example, finding money for mental health reform and further liberalizing disability benefits, while practicing fiscal restraint and managing the requests of thousands who had filed SSDI requests and appeals.
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Page's story of woe, nervousness, and hardship was many things wound tightly into one person—her pain was at once a sensitive administrative and political concern, a contentious clinical dispute, a fiscal worry, and (in a sign of the growing role of the courts and law in this momentous decade) a vexing legal problem.