Pain (34 page)

Three years later, out of rehab and back on his radio show, he put the case simply, refusing to dwell on his pain or his victimization by OxyContin: “I had a problem. I admitted it. I went and dealt with it. I have been clean from the painkillers for almost two years and eight months.”
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However his lawyers presented his case in court, on air he spoke from the old conservative script. Unlike the liberals he caricatured, his pain was real; unlike other addicts, his dependence was merely an unfortunate inconvenience; his recovery was never in doubt; and his defense of his privacy rights from government surveillance was firm, made possible by his wealth. Yet for all this, and beyond the stoic posturing, Limbaugh knew he would remain a symbol of the OxyContin era—an era that both conservatives like him and liberals had helped bring about.

P
eople in pain have been stock figures in American political theater. As the scholar Javier Moscoso has noted, “The uses of pain have nothing to do with truth, but rather with drama.”
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Illustrating the point, the 1966 American film
The Fortune Cookie
placed actor Jack Lemmon at the center of his era's pain pageant. Lemmon played a sports cameraman who had been knocked down accidentally by a player during a professional football game. Though only dazed, he was convinced to fake severe injuries by his unscrupulous lawyer and brother-in-law, played by Walter Matthau. He sued the team to win a settlement for his injury, pain, and suffering. The comedy revolves around the plaintiff's fraud, the lawyer's greed, the gullibility of doctors, the football player's sense of responsibility, and the attempts by insurance company investigators to uncover the scam. In the theatrics of
The Fortune Cookie
, the answers are satisfyingly clear to the omniscient viewers, and so are the stakes. When Lemmon lies in bed in a full neck brace watching a television program, he hears the words Abraham Lincoln says to him (and us), “If you once forfeit the confidence of your fellow citizens, you can never regain their respect and esteem.” All the more satisfying is Lemmon's decision, at the end of the film, to embrace virtue and reveal himself as a fraud. With humor and determination, he redeemed himself fully. Would that distinguishing true pain from fraud were always this simple.

When Reagan came to power in the early 1980s, this overdrawn theatrical image of the person in pain became newly embedded in public policy. As anthropologist Talal Asad has noted, “The modern nation as an imagined community is always mediated through constructed images.”
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In Reagan's time, the person claiming fraudulently to be in pain was one
such constructed persona. The disabled person in chronic pain became a symbol of much that was wrong with liberalism—its gullibility, its support for government dependence, and its embrace of welfare at the cost of hard work. The preceding pages have told the story of how these problems of pain and social welfare came to define American political theater and (perhaps more important) how the courts came to play a central role in judging pain. The book shows how and why these questions of compassion and government made good theater and good politics and how they endured as fundamental conflicts that still define the American political landscape. The problem of pain touched intimately on the problem of how the people of the country were bound together.

The questions of which kinds of pain are real, which warrant sympathy, and whose plight is deemed illegitimate have provoked constant political spectacle in the many decades before Reagan and since. Today, these remain powerful moral and political questions at the heart of American government. What to do about pain that doesn't go away but lingers, especially in a prosperous nation where hard work, frequent injury, and aging are all common? Does pain caused by chronic disease warrant special consideration, long-term attention, and ongoing relief? Whose pains should we, as a society, be willing to carry for a lifetime and at whose expense? When is pain and relief merely a fraud?

Beyond pitting liberals against conservatives, the question of pain (as I have argued here) also refined the very meaning of “conservative” and “liberal” as keywords in the American political vocabulary. “Political words take their meaning from the tasks to which their users bend them,” Daniel Rodgers has observed.
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What it means to be liberal or conservative became ideologically solidified around the problem of pain. From the years immediately following World War II until today, the political Right railed consistently against certain kinds of pain, seeing public relief in particular as a symptom of a weak, coddled, and dependent society. As liberal government expanded to address the needs of people professing to be in pain, so too did conservative ire grow. For the political Left, just as consistently, compassion toward the pain of others—the disabled soldier, society's elders, those injured at work, or people suffering from debilitating disease—underpinned an expansive view of government and a comprehensive ideology of what society owes to its citizens. Positions on pain did not always align with party ideology, but for Republicans and
Democrats, these seemingly simple questions—how much pain do you feel? and what kind of relief do you need?—slowly became ideological and policy minefields.

The Reagan era more than any other time solidified partisanship around people in pain. In the relentless political messaging of Reagan-era conservatives, people with pain and disability who made special claims on the government were a problem created by liberals; indeed a gullible belief in subjective pain as real pain defined liberalism itself. This skepticism had simmered for decades (articulated by the AMA's Louis Orr and many others). Pain, especially the coddling of people claiming to be in pain, was a Trojan horse bent on destroying the nation. But in Reagan's time as president, this argument became a potent part of the Right's script; it has continued to define Republican politics for generations since. Thus could the president make the shocking case that the face of disability in 1980s America was that of a serial killer, Son of Sam, who (while imprisoned for committing horrific crimes) continued drawing generous disability benefits. The accusation, made in a meeting with newspaper editors, was scathing; and these renderings of whose pain mattered left an enduring mark on American politics—creating a stark, if caricatured, portrait of how liberals think and how conservatives respond to people's complaints. The power of this pain discourse explains why, years later, Bill Clinton's off-the-cuff “I feel your pain” comment was greeted on the right with such scorn and yet also why it had such positive resonance for those who believe in liberal compassion. The 1992 presidential candidate's words had touched a sensitive political nerve for both the Right and the Left.

But it is too simple to accept as truth the binaries that Reagan-era Republicans enshrined—that liberals believed that all subjective pains were real and that conservatives embraced cold objectivity on the pain question. Nor is it useful to see the liberal pain standard and the conservative case against learned helplessness as mirror images of one another or as opposing discourses in the political world. In truth, in the politics of pain, liberalism, and conservatism often blended into and depended upon one another—the disability entitlement (SSDI), for example, had been established by liberals in Congress, embraced by some moderate conservatives, and endorsed by the Republican Eisenhower. Decades later both conservatives and liberals, including the Democrat Carter, attempted to
scale it back. At the political edges, however, the Right and Left often drew the starkest battle lines, often becoming inflamed and fractured around whose pain mattered, whose claims to suffering warranted relief, and what kind of pain relief (market based or governmental) should prevail.

People in pain, sadly, have carried two types of burdens—first, the onus of their own pain, and, second, the burden of being props in this political theater which saw actors assign conflicting meanings to their experiences. The theatrics surrounding pain did not stop with mere rhetoric or ideology but, as we have seen, crept into policymaking, touching fundamentally on matters of governance and power. In the eyes of the AMA, the veteran's complaint could never be just about his bodily injuries (no matter how severe); such complaints were inevitably bound up with his claims on the government, claims that the doctors' lobby saw as a threat to them and to free enterprise in general. The ensuing disputes over pain and disability drew in other actors concerned with governance and power: Congress, disability activists, lawyers, physicians, and increasingly a wide array of judges. The rise of pain also gave rise to merchants and managers of relief, and the preceding pages reveal the ways in which political calculations informed how anesthesiologists like John Bonica, surgeons, drug companies, and physicians like Harold Glucks-berg and Jack Kevorkian defined their place in the pain relief economy. Pain (as an experience and as a symbol) also gradually and systematically became a social and legal problem, with the courts drawn into a heated process of evaluating and giving definition to the nature of peoples' pains. To this day, the argument over whose pain should matter (pain at the end of life, “fetal pain,” chronic pain) remains a legal quagmire.

In the decades since the Reagan era, one notable trend has been the broadening uses of pain in political argument, with the emergence of end-of-life pain as a vehicle for a new politics of compassionate relief and the rise of fetal pain on the Religious Right. With the assertion that fetuses feel pain, the Right readjusted its ideological position on pain in America to signal rhetorical “compassion” in their conservatism while also narrowing their sympathies. While largely dismissing disability pain in ways similar to the iconic Reagan and while also looking skeptically on end-of-life pain relief as an opening for physician-assisted suicide, the Right pushed “fetal pain” to the political forefront. The move refracted women's experiences
in pregnancy and claim of abortion rights through another lens: the imagined experience of the fetus. In 2007, Kansas Republican senator Sam Brownback (and Republican New Jersey representative Chris Smith) sponsored the Unborn Child Pain Awareness Act. The hope, as discussed by historian Sara Dubow, was that this type of pain (which they attached to fetal innocence) would help to establish personhood for the fetus, to gain traction in the law and to mobilize public sentiment for the campaign against legal abortion.
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That this political invention was unsupported by neurological science did not matter; pain was too valuable a political prop to leave to scientific experts. The Brownback-Smith bill died in committee but won 120 cosponsors in the House and 29 in the Senate.
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In the cultural symbolism of pain, liberals had their own portrait of the deserving person in pain in the same era—building on physician-assisted suicide and end-of-life compassion in the 1990s, many successfully enacted, state by state, measures accepting marijuana as pain relief for people with a wide range of ailments. As the New Jersey Compassionate Use Medical Marijuana Act of 2010 stated, for example, “Compassion dictates a distinction be made between medical and non-medical uses of marijuana … to alleviate suffering from debilitating medical conditions.”
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Since the 1990s, then, the political theatrics of pain continued to fragment along partisan political lines, and these maneuvers have also moved into the states, continuing a debate over federalism and the distribution of powers. The states have been flexing their political muscles, seeking to write their own laws of compassion while the federal government has sought to influence pain policies from afar. In this new politics of pain, an underlying liberal trend prevails. More states that lean Left and libertarian, from California, Washington, and Colorado to New Jersey have embraced compassionate medical marijuana legislation (in the name of chronic and end-of-life pain relief); by contrast, only a handful of those right-leaning states (like Georgia and Kentucky) proposed and passed so-called Pain-Capable Unborn Child Protection Acts to ensure that pregnant women seeking abortions were told about “fetal pain.” The battle is far from over. In the divided states of analgesia, the political theatrics of relief tilts decidedly toward liberalized compassion for persons living with pain, with a much more modest attempt to trump abortion rights by recognizing and validating pain in persons yet to be.

In this political drama scientists and physicians have been important actors on the stage—but their pronouncements on pain have, by and large, been conflicted, and they have played second fiddle to ideologues and lawmakers orchestrating pain policy. Medical theories about why some people cry when hurt and others face pain with grim stoicism, why some seek help and others soldier on alone, have often followed (rather than led) society's cultural arguments. The common 1950s belief that the pain was a sign of the maladjusted personality is a case in point, supporting cultural skepticism about disability and relief. The rise of the gate control theory in the 1960s and 1970s, however, both followed and led. It echoed new thinking about the legitimacy of subjective pain as real pain, but it also provided a powerful rationale for therapeutic experimentation and helped usher in a decade of openness to new kinds of relief from patient-controlled analgesia to acupuncture and electrical nerve stimulation. The theory of learned helplessness that arose in turn in the 1980s had a more modest scientific appeal, but it (like so many theories of pain) gave a thin veneer of legitimacy to policy—in this case, the politically charged conservative claim that relief too easily obtained bred intractable dependence. As disputes over pain and relief migrated to the courts, it should not surprise us that medical theories of subjective pain and objective measurement figured prominently in court rulings. By the end of the twentieth century, other theories like the double effect of painkillers at the end of life were crucial for judges in accepting and ruling on the complexities of physician-assisted suicide. In more recent times, another theory about people in pain (pseudoaddiction, the notion that a restrictive system tending toward the denial of pain care could make even honest sufferers behave furtively in seeking relief) sought to reframe the pain debate and light the fire of reform. In the history of pain management (carried out as a political and medical craft), such medical and scientific theories never stood completely apart from politics—and the evolution of pain theories has been particularly fraught because they exist in such close dialogue with political ideologies and legal theories of relief.