Pain (2 page)

The doctors counseled him that there could be psychological and physiological dependence on pain medication. This was hardly a surprise. But they had to make the decision about using the medication or suffering the pain. They used a drug called OxyContin which everybody has talked about, which came into effect, I think, in 1996 was issued by the drug company. Today it is listed as the most potentially addictive medication that is legally available. It is being investigated in Congress, in the FDA and there's a huge number of lawsuits that have been filed against the pharmaceutical company for the issuance of OxyContin.
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The fact that this fierce advocate for conservatism, rugged individualism, and law and order was hooked on painkillers and that his attorneys
looked to government and lawsuits for answers even as he railed against governmental dependence and social engineering posed a contradiction on many levels.

Was Limbaugh merely being duplicitous, and did his duplicity expose the contradictions of the conservative position? This book argues, in part, that his addiction to painkillers was more than lies and contradictions; it was a natural by-product of the deregulated, market-oriented world that Reaganism created. As an OxyContin addict, Limbaugh was the beneficiary of a drug market revolution that had been unleashed by the conservative deregulation of the industry that started in the 1980s. He was, in a sense, both the beneficiary and the victim of those forces. He was also the face of a new pain and abuse problem that blossomed in the wake of conservative government. By 2000, the Drug Enforcement Administration (DEA) had named the diversion of prescription drugs into the illicit drug market as the leading abuse threat in the nation—with OxyContin pushing aside heroin, crack cocaine, and ecstasy as the drug problem for this era. The rise of OxyContin abuse showed how the pain market and American consumerism had changed since the Reagan revolution, with direct-to-consumer advertising and the rise of Internet pharmacies putting painkillers more easily within the consumer's reach. In an age where advertising flourished and regulation lagged, Limbaugh's mode of relief was an obvious and troubling consequence. Conservatism's conceit was that liberalism indulged complaints; wherever true pain existed in society, private enterprise was envisioned as the best remedy. Limbaugh's OxyContin addiction suggested otherwise, marking another turning point in the politics of pain.

In the chapters ahead, Eisenhower's conflicted disability politics (
chapter 1
), the expansion of liberal government in the name of remedying pain (
chapter 2
), Reagan's attempt to purge the disability rolls in the 1980s and the curious rise of “fetal pain” (
chapter 3
), the politics of pain, disability, and Physician Assisted Suicide in the Clinton era (
chapter 4
), and the 2003 Limbaugh OxyContin case (
chapter 5
) are re-examined not as medical stories but as important markers in American political history. Whether and to what extent was it possible for Bill Clinton, Ronald Reagan, a physician, or a judge (or any person) to know another's pain? The question went to the emotional core of a public policy dispute that lasted decades. Should social policies be driven by compassion toward such pain?
Did the market provide better relief than government? These questions became hot-button political problems for Americans debating the “welfare state” and questions of citizenship and government. Pain's reality—which pains were real, which were false, and who was the best judge—was a recurring question. Pain's variety—which were severe, which were mild—bedeviled observers from the age of Dwight Eisenhower's disability law to the era of Barack Obama's Affordable Care Act, which contained its own pain-related provisions. Pain perception inflamed politics and vexed policy makers and social scientists. And, as we shall see, given these recurring and intractable disputes, it has been the courts (far more than physicians) that have decided, time and time again, how to measure distress and how to define the right to relief.

In American politics, pain comes in such variety—the pain of the disabled person seeking benefits, pain associated with fibromyalgia, the pain of the dying patient, the pain of the child, and so on—that the question of pain's legitimacy is open to a stunning array of manipulations.
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All pains are not the same or equally deserving of relief. When, for example, Larry Kudlow, President Reagan's former economic advisor, admitted in 1994 to a drug and alcohol addiction, news reports rendered him sympathetically—not as a fraud or a man seeking wanton pleasure. He was portrayed as an ambitious and fiercely competitive man—the quintessential entrepreneur driven by a will to succeed. The very qualities that conservatives prized had, in the conservative pain narrative, led him to painkillers. Kudlow attributed his slide into drug use to the “pressure to produce” on Wall Street. “You think you're a superman,” Kudlow explained. “You think you can do anything.” This drive and hubris threw him, he admitted, into drugs' embrace. In this telling (as in the Limbaugh coverage years later), the nature of the pain for which the man sought relief was assumed to be excruciatingly legitimate pain.
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Thus, when we examine the history of pain and relief in America, we must attend to the persistent problem of whose pains are being discussed and how those pains are rendered. The conservative critique of compassion in Reagan's time was not just a critique of pain itself; it was a criticism of particular people (minorities, women, AIDS sufferers, and so on) associated with and benefiting from the nation's liberal turn in the 1960s and 1970s and defending liberalism into the 1980s. As we shall see, the question of who is the modal, or standard, sufferer—whose pain matters and occupies center stage (soldiers,
workers, women, black people, and so on)—also tells a political story of America's recent decades, as does the question of who is qualified to judge real and imagined pain.

FIGURE 1.1.
Peter Steiner's cartoon captures an enduring tension at the heart of pain and politics—the line where relief becomes pleasurable.

New Yorker
, February 21, 2000.

Whether people in chronic pain have been granted a hearing or some measure of legitimacy as true sufferers depends on contextual factors—the political and economic milieu of the time, the social status and context of the suffering, and the meanings associated with the particular pain experiences. Over the decades, the face of pain keeps changing, shaping the terms of the political debate along with it. Elderly pain carried a particular valence in the 1960s, as did the pain of sickle-cell disease in African
Americans; the pain of housewives in the 1950s meant something different from the pain of industrial workers. Specific economic and demographic trends have driven pain into the foreground of politics: the persistence of industrial labor as a source of disability, the steady rise of white-collar sedentary work and its own implications for pain, and the growth of the elderly population and its infirmities. Wars, too, have shaped the character of anguish and the demands on government for relief. Since the 1950s, then, aches, hurts, and chronic anguish have come in multiple forms—low-back pain, injury-related pain, and headache predominated at first, but arthritis and cancer-related pain rose, decade by decade, in importance. New maladies and complaints, like fibromyalgia and even “fetal pain,” rounded out the American pain profile by the late twentieth century, raising new questions about false and true pain and making pain management all along the life course—from birth to death—into a fraught political exercise.

The problem with pain in America is that there are so many different kinds of hurt—with so many questions swirling around each—and that the political milieu determines the meaning of complaint. For a growing government, one question came to dominate: Did the person in pain deserve disability benefits, and, if so, how long should these benefits be granted? This question became a central worry of conservatives, who were concerned about the perverse incentives of welfare, the citizen's capacity for fraud, and the rise of government dependence in lieu of market labor. For them, the pain of the hardworking businessman or woman warranted far more sympathy than the pain of the industrial laborer. Pain, in the conservative and liberal worldviews, raised different worries about the market, government benefits, rights, and citizenship. From the 1950s through the 1980s and still today, conservatives worried—as the ranks of people with disabilities swelled—about whether subjective pain was real pain and whether chronic pain was a symptom of underlying maladjustment. More recently, religious conservatives have turned the pain of the fetus into potent politics. For liberals, by contrast, the pain of the terminally ill cancer patient seeking “death with dignity” has served similar functions by politicizing pain in ways that mesh neatly with liberal values and commitments.

This history of pain focuses on both the political sphere and the medical realm—and also on how closely they have been conjoined. It examines
the micropolitics of doctoring (that is, whether caregivers offer liberal, conservative, alternative, or radical care) and the macropolitics of what pain means in the United States. Writing in 1977 on pain management, sociologists Anselm Strauss and Shizuko Fagerhaugh distinguished between these two kinds of politics, noting that “political processes are involved in the interaction surrounding patients in pain. By political processes we do not mean the activities that spring most readily to mind, namely party politics or the vying for votes by aspirants to public office.” The sociologists called attention to politics on a more intimate level—“such political actions as persuading, appealing to authority, negotiating, threatening, and even employing force in order to get things done.”
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This small clinical world with its micropolitics of pain would be their focus. Other scholars defined pain politics more broadly. Philosopher Martha Nussbaum observed that compassion has long been “a central bridge between the individual and community … a way of hooking the interests of others to our own personal goods.” Political debates about the future of the good society, Nussbaum insisted, revolve around pain and compassion, with many modern moral theories seeing compassion as “an irrational force in human affairs, one that is likely to mislead or distract us when we are trying to think well about social policy.” When Nussbaum wrote these words in the 1990s (as we shall see), this claim had reached a crescendo; so much of American political turmoil was framed in these stark terms of compassion, pain, welfare reform, and so on.
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The pages ahead investigate just how these two worlds of pain and relief (the medical and the political, the micro and the macro) have informed one another, shaping each other's ideologies, intersecting with the law, and constraining the possibilities of relief.

Reagan's conservative pain standard and Schlessinger's diatribe against Clinton's “I feel your pain” rhetoric were not new inventions; they both responded to an ideal going back almost two centuries before World War II that had been central to the formation of the liberal state and its commitments to its citizens. In the writings of eighteenth-century conservative icon Edmund Burke, pain stood at the center of matters of social order. For Burke, pain had a fundamentally transformative and beneficial aspect. Unlike the experience of pleasure, which Burke saw as fleeting and superficial (“when it is over, we relapse into indifference”), the pain experience left a lasting and sublime mark on the person. Tolerable pain that
did not threaten life, for him, was a virtue: “If the pain is not carried to violence,” Burke wrote, “and the terror is not conversant about the present destruction of the person … they [pain and terror] are capable of producing … a sort of tranquillity tinged with terror; which, as it belongs to self-preservation, is one of the strongest of all passions.”
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To appreciate the lessons of pain, in other words, one needed to tolerate it and to look past distress to the larger message it carried for the sufferer—opening the doors into the sublime itself. Thus, at the start of the conservative intellectual tradition, pain had its value and redemptive virtue—in much the same way that some ardent Christians might say that pain redeems and brings the Christian sufferer closer to the experience of Jesus Christ. In contrast, for John Stuart Mill (one of the architects of modern liberalism and born early in the nineteenth century, a decade after Burke died), pain had no such redemptive value. For “according to the Greatest Happiness Principle [that he espoused], the ultimate end … is an existence exempt as far as possible from pain, and as rich as possible in enjoyments … This, being, according to the utilitarian opinion, the end of human action, is necessarily also the standard of morality.”
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(Here too, ardent Christians could point to Jesus as a model—not to his suffering and his redemption but to his compassion toward and relief of those who suffer.) Seen in this light, the political battles over pain in American society continue a moral struggle with deep roots in Western religion, politics, and society. The pain debates of the past sixty years joined this long philosophical and spiritual discussion—a discussion informed by new developments in medicine, drug policy, science, and government, which crosses back and forth into the legal realm.