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Pain does not suffer misprision: an inquiry into the presence and absence that is pain
  1. J D Katz
  1. Correspondence to:
 J D Katz
 Associate Professor of Medicine, Division of Rheumatology, The George Washington University, 3-416, 2150 Pennsylvania Ave, NW, Washington, DC 20037, USA; jkatzmfa.gwu.edu

Abstract

The reigning questions of metaphysics generate passion. These are questions such as concern death, a hereafter, and the meaning of suffering. They are questions that haunt us. Philosophical inquiries into these topics are often constructed Socratically. In turn, such logical machinations are founded upon the belief that a discernible outcome or answer to metaphysical questions exists. Western thought labours under the tenet that the impasse of “unknowableness” can be bridged with the brute force of intellect. Pain is not only the motivation for metaphysical inquiry; it becomes the universal metaphor for loss. It absorbs displaced fears and becomes a vehicle for expressing a “lack”. The essence of pain, therefore, is negative. It is absence (and hence not an existence). Even though pain is a lack, however, we relate to it as if it were a presence that denies us of our passion for life.

  • pain
  • suffering
  • existentialism
  • humanism
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Suffering speaks to the core of human experience. Philosopher Hannah Arendt (1906–1975) wrote from personal experience, having escaped from Nazi internment in southern France during the German occupation of the second world war. Her writing suggests that within the ether of human reality there exists a communal understanding of suffering. “Only pain is completely independent of any object, only one who is in pain really senses nothing but himself; pleasure does not enjoy itself but something besides itself. Pain is the only inner sense found by introspection which can rival in independence from experienced objects the self evident certainty of logical and arithmetical reasoning.”1 To Arendt, the inescapable phenomenon of pain is the motivating impulse for the historical development of philosophical introspection as a mechanism of worldly escape. In short, pain does not allow for misreading: it does not suffer misprision. It has essence without existence.

As a prelinguistic phenomenon, we are at once afraid of, and at the same time, in awe of, suffering. Cassell tackles this concept and begins by defining it in negative terms. He distinguishes suffering from physical distress.2 He correctly asserts that suffering is not confined to physical symptoms. In developing his thesis, he introduces the idea that suffering may be conceived as a response to a threat to the integrity of the individual. These are helpful tools for medically “operationalising” difficult concepts. The essay put forth here strives to call into play a philosophical perspective as well. To this end, I would further assert that suffering resides outside of the physical realm. It is neither emotion nor thought. Nor is it a state of lesser perfection, as Spinoza would have it. Rather, as we shall see, suffering is the cynosure, the point of attraction, at the centre of the whirlpool of linguistic instability.

Even pain without suffering inhabits a metaphysical zone. Arendt hints at this radicalisation of the interpretation of pain. She goes so far as to suggest that the most intense human experiences, (including specifically pain), challenge our “assurance” of reality. In The Human Condition she ponders the intimate core around which public and private life tensely revolve:

Indeed, the most intense feeling we know of, intense to the point of blotting out all other experiences, namely, the experience of great bodily pain, is at the same time the most private and least communicable of all. Not only is it perhaps the only experience which we are unable to transform into a shape fit for public appearance, it actually deprives us of our feeling for reality to such an extent that we can forget it more quickly and easily than anything else. There seems to be no bridge from the most radical subjectivity, in which I am no longer “recognizable,” to the outer world of life. Pain, in other words, truly a borderline experience between life as “being among men” (inter homines esse) and death, is so subjective and removed from the world of things and men that it cannot assume an appearance at all (Arendt,1 pp 50–1).

To Arendt, pain exemplifies a “radical subjectivity” that both relates and separates a social species. It relates humanity by virtue of being a common experience and it separates humanity by virtue of being a private experience. Martin Buber recognises this futility of the “pain narrative” and emphasises, instead, the visceral comprehension of the nature of pain. Pain is not thought; rather, it is experienced. Buber feels that the pain narrative is a distancing phenomenon. “The nature of pain”, he writes,

is not recognized by the spirit as it were standing at a distance from it, sitting in a box and watching the drama of pain as an unreal example. The man whose spirit does this may have all sorts of brilliant thoughts about pain, but he will not recognise the nature of pain. This is recognised by pain being discovered in very fact.3

In essence, Buber attributes a spiritual dimension to pain. It is likely that Arendt would agree that although pain is not subject to scepticism, and hence cannot be revealed by interpretation, it retains the power to define humanity and human intercourse. In other words, pain has the capacity to generate emotion. It is an impetus for action.

It is precisely this essence of motivation that makes suffering a prime candidate to serve as a hermeneutical principle. Religion intuitively capitalises on the power of pain. Western religion—for example, motivates with the imagery and raw violence of circumcision and crucifixion. Even as the religious requirements for redemption may be clear, however, the agony of Hell remains vaguely conceptual. This is the irony of pain. Although pain consists of a generally appreciated experience, pain remains a poorly communicated experience. Nowhere is this view of the instability of language underscored more heavily than in the attempts at the expression of pain. The communication of pain in no way approximates the mundane. Specifically, the language of pain is necessarily that of metaphor and metonymy (substitution or association). We are left to describe our hurt in comparative terms. We displace the language of pain onto the language of dysfunction. More to the point, the “narrative of pain” can never satisfy the demand for convention imposed by the “ordinary language” of Wittgenstein. To assume that a communal “sense making” of the pain narrative ultimately reflects textual realism is to ignore the fact that pain can be both cause and effect. In particular, pain can be the effect for a political cause of the injured, for example, a call for redress, such as the cause for greater research funding into orphan diseases, can be bolstered by the testimonials of personally suffering advocates. Hence, Wittgenstein’s “ordinary language” is none other than a claim of “dominant convention” vulnerable to deconstructive scepticism.4 This is, in essence, Arendt’s motivation. She emphasises suffering as a completely subjective experience. To take this one step further, the corollary to the subjectivity of the pain experience is that it is not possible to “testify” to another being’s pain. No one can presume the expertise to objectify that which is subjective through and through. Therefore, the universal understanding of pain remains inextricably coupled with the universal understanding that the pain of another is ultimately unknowable. The complete comprehension of the pain of another is no more an achievable end than the structuralists’ search for total intelligibility of communication.

Not knowing the pain of another does not, however, necessarily dictate that our response marginalise the sufferer. In fact, we go to great lengths to alleviate pain. This is exemplified by the institutionalisation of altruism. It is here that we comprehend the pain of another in a meta-experiential fashion; we know such pain as our own potential pain. Hospitals and organisations dedicated to the welfare of various afflicted individuals are obvious examples of the ethics of altruism. Admittedly, this communal ethic suffers a shortcoming, for it does little to illuminate the personal emotions attached to pain. This is a lack that is attached to pain. Specifically, it is a lack of language. This “lack” of language is the property of pain that renders it inaccessible to the deconstructive challenge. Essentially, pain has meaning that exists both within and outside of communication. In other words, although pain is both a linguistic and a societal cynosure, the essence of pain remains recondite.

THE POSITIVE AND NEGATIVE ATTRIBUTES OF PAIN

Conceptualising pain in terms of positive and negative attributes (a presence and a lack) is entirely dependent upon a history of experience of pain. One must consider the duration, tempo, and magnitude of “experienced pain” as well as calculate whether historical pain is immediate-past, past, or remote. This escalates the complexity of a rigorous understanding of pain at both a personal and collective level. In science, such a challenge is normally met by the fundamental construction of a matrix of “understanding”, which first and foremost derives from a defined language creating both positive and negative distinctions, polarities which of course include that between centralisation and marginalisation of thought.

Polarities force hierarchical thought. Hierarchical thought exposes presupposition.5 Uncovering such bias is embodied in the reversal questioning technique of deconstructionists. Thus, is it necessarily true that the absence of pain opposes pain? And, is the state of not-pain a state of insensibility? If so, does this not result in isolation and in turn the pain of loneliness? The very moment that we employ speech or writing to communicate pain or capture hurt is at once the moment that all meaning is lost. The extraconceptual nature of chronic pain stymies the expressive process as we become constrained by the comparative and figurative nature of language. Pain at once embodies and exceeds the non-linguistic medium of social psychology. Such complexity is augmented by the fact that, even though pain does not suffer misprision, the personal passion of hurt varies from individual to individual.

THE PHENOMENOLOGY OF PAIN

A brief foray into the fragile latticework of rheumatology quickly exposes how our limited language for pain does not adequately communicate the private experience of arthritis. Though we, ourselves, may be unafflicted by the gnarled grip of arthritis, it still reaches into our souls to tear away a swatch of empathy. Consider the unconscious berth that we carve out for an individual with a limp. Consider, too, the seat we yield to the stranger obviously bent with osteoporosis. Recall the visceral reaction we suppress at the sight of deformity and disfigurement when our basic nature touches upon a sense of dread. These corporeal feelings are often encapsulated by the secret prayer, “there but for the grace of God go I”. This internal comprehension of pain possesses a fundamental meaning for us, both personally and collectively.

It is precisely because pain does not favour words over deeds (the concept termed logocentricism) that it can be analysed from a phenomenological perspective. The pain of a broken heart is as real as a third degree burn and cannot be any different from the same awareness experienced 2500 years ago. Pain is the true “fullness of presence”. Yet, since pain cannot be objectified, it cannot be subject to scepticism. Therefore the tautology of the Western presupposition of the existence of hermeneutics as a mechanism for approximating truth does not invalidate the use of pain as an organising principle for interpretation of human thought, feeling, and interaction. Otherwise stated, even though pain cannot be objectified, it can be generalised.

That pain is a universal motivator is part and parcel of the Western medical model: almost by definition patients hurt. More to the point, however, it is how patients individually respond to pain that determines how they relate to suffering. Whether that pain is physical or psychological is moot. Dysphoria is not easily ignored. It presents itself in many guises; some more recognisable than others. A paradigm for the study of chronic pain is arthritis. It is a vivid portrayal of private hurt made public. At such times, the narcissistic struggles of everyday life fall away. Merely to witness rheumatic vulnerability and relentless pain touches upon our subconscious sense of the collective. Arthritis illuminates radical subjectivity. The philosophical irony of arthritis is that it emulates the senescence that is our individual fate.

As observers of the natural experiment of suffering, rheumatologists are witnesses to the recurrent human drama of struggle with pain and dependency. Rheumatologists fully comprehend that the onset of arthritis is like watching the ontogeny of existential awareness in slow motion. Chronic disease is a window onto the process of transforming what Søren Kierkegaard termed “unconscious” despair into “conscious” despair. Chronic disease allows us to observe the spectrum of failures of repression. We see regression and we confront denial.

A HUMANISTIC INTERPRETATION OF PAIN

A more modern perspective on the interpretation of pain can be found in the writings of the humanist, Erich Fromm. He echoes the existential premonitions of Kierkegaard. Specifically, chronic pain parallels the psychological process of developing individuation whereby the being “becomes aware of being alone, of being an entity separate from all others. This separation from a world, which in comparison with one’s own individual existence is overwhelmingly strong and powerful, and often threatening and dangerous, creates a feeling of powerlessness and anxiety.”6 The humanist therefore must first embrace existentialism. For Fromm, success in negotiating this tension requires reconciliation with psychoanalytic theory. Kierkegaard, during the pre-Freudian era, viewed this as the evolution into conscious despair. Ultimately, as originally exposited by Kierkegaard, conscious despair unlocks “passion”. Consequently, by drawing a parallel between dread and suffering, this suggests that embracing pain may invigorate the passion for life.

What, then, are the stages of pain maturation? First and foremost the pained individual seeks validation. Whether that validation derives from an internal or external source, the same question must be answered: “is this really happening to me”. Close upon the heels of validation crystallises an internal authentication of personal distress. In turn, this is what ultimately allows anger to germinate. A sparring spirit is called into play processing the threat to personal integrity. Eventually a sense of futility takes hold and then profound anguish is experienced. This in turn is a kind of grieving process that is often described in surrealistic terms and associated with a sense of hopelessness. Eventually, for a more grounded outlook to be achieved, acceptance and humility must then lead down a path to at least a partial closure. And ultimately, for true redemption to occur, simple joy in any remaining autonomy must be realised.

In this manner chronic pain takes us on a journey. It is a reproducible travail characterised by predictable stages. Any misstep down the path of maturing pain renders happiness derailed. This is especially the case when hidden fears about mortality contaminate the fuel feeding the maturing of pain. Denial at any one of these necessary stages results in a stalled individual; one who is sputtering and not progressing. Such a one who is unable to carry on is in search either of validation or of hope. That individual is arrested in a stage that is characterised by endless digging. This is a process of ever reinventing denial and never uncovering peace.

I, as a physician, am charged with the responsibility of defining and validating distress. This is fundamental to any helping profession. Acknowledging suffering affirms humanity. It says: “your pain is/was/will be my pain”. Martin Buber feels that this is a pre-eminently spiritual act (Buber,3 pp 192–3). “Only then does his own pain in its ultimate depth light a way into the suffering of the world. Only participation in the existence of living beings discloses the meaning in the ground of one’s own being.”3 But acknowledging suffering also entails a process of searching. The patient is searching for relief; I am searching for an answer. Sometimes when I divine the correct diagnosis, the relief of the patient is palpable. The devastation of not knowing is suddenly reversed. Newfound knowing becomes an opportunity to regroup and insert some ordered direction to the chaos of directionless disorder. In an instant a label is put forth and one aspect of suffering is over. But self fulfilling meaning is no different from self deluding explanation. Although the label is taken as an explanation, it does not, of course, explain anything. Explanations merely serve to allow us to classify the future: to better brace ourselves for the insurmountable and the irresolvable. We do not need to know why something has gone wrong or why we get sick. We need to know that we are as prepared as possible for the future. Knowing, itself, functions as a further constraint on the sense of randomness encompassing the essence of the future. Knowing functions as a reminder of the state of security rendered by mantic (that is, prophetic) comprehension. It is a modifier of hope. It is knowing what we are up against that makes pain more bearable. Therefore, self prescribed meaning, when substituted for nescience, enables us to face uncertainty and move through dread.

Searching itself is, however, also painful. It confuses hope with expectation. Searching lends itself to the displacement of the need for certainty onto an uncertain existence. It inflates the bubble of false hopes and ultimately amplifies pain. At times it seems that physical pain must be amplified in order to enhance the acuity of purpose. The telos (ultimate end) of physical pain may be simply this: “enhance the acuity of purpose and thereby commandeer searching activity”. Thus searching begets searching and teleology gives rise to tautology. Ultimately, given that teleology is the language of medical science, it is no wonder that we displace goal oriented language onto the need to understand what is unfathomable.

This medical model is not unlike the Western belief in hermeneutics as a path to certainty. Here medicine presupposes that an underlying meaning can be discerned that in turn explains the multitudinous dysphoric states. Western medicine adheres to the empirical model of epistemology. Indeed, it appears that the success enjoyed by humanity over the previous 100 years justifies the belief that science is homing in on the ultimate “meaning” behind suffering. Unfortunately (or fortunately), the flaw with this belief is that successive iterations of a medical model may just as likely adhere to Zeno’s paradox. It may halve the distance without ever bridging the gap.

Alternatively, this rationalist’s model of epistemology may not be achievable simply because of tautology. For it may be that what we define as scientific advancement may predetermine our medical success. This is so if cheating death is, in truth, a value unto itself and not an end. In other words, if we find that we are motivated by an underlying sense of meaninglessness, then an internal tension is necessarily created. All too often, we delude ourselves into thinking that avoiding death is an end in itself, whereas, in truth, it is nothing more than deferred hope to die. To wit, we may be afraid to die, but we are equally afraid to live forever. This would suggest that the study of science for the purpose of revealing metaphysics is less productive than a study of interpretation. To take this one step further, we find—for example, that owing to the homology between the structure of language and the structure of the unconscious, an analysis of language is revealing when applied to human motivation and human dilemma. One need only consider a “Freudian” slip of the tongue to gain an appreciation of this relationship. Here, interpreting language may help us “interpret” human motivation and the unconscious. A deeper analysis of this concept is accessible through the writings of the French thinker, Jacques Laçan. In his discussion concerning psychoanalysis, he states: “the symptom resolves itself entirely in the analysis of language, because the symptom is itself structured like a language, because it is from language that speech must be delivered”.7 Laçan is perhaps radical in that he believes that not only is the unconscious structured like a language but in truth the unconscious resides in language. This becomes philosophically problematic because if the deconstructionist premise is true that language is unstable, then the unconscious, let alone the self, may be fundamentally unstable as well.

Alvin Reines grapples with this instability by tackling existentialism head on. He defines the neologism, “asoteria”, as the state of meaningless existence engendered by the tension between the fact of personal death and the intense longing for infinite existence (and invulnerability) that in turn results in a “conflict of finitude”. As he writes in What Happens After I Die?: “failure to deal with one’s finity—in particular one’s own death—leaves unresolved a human’s fundamental existential problem, the conflict of finitude and invites the continuing haunting problem of asoteria (p 133).”8 In other words, we must each uncover our own mechanism for diffusing existential dread. We must in essence make peace with the denial of death. Alvin Reines feels this is the task of religion.

Erich Fromm takes this concept further. He asserts that the essence of humanity is the very fact of such questioning let alone the need (“demand”) for an answer. Therefore where Reines addresses the tension born of existence, Fromm addresses the tension born of essence. But Fromm does not refine his analysis and Reines does not generalise his. At different times and various stages of life, we may invoke any number of responses to the challenge of “asoteria”. Our responses may range from displacement of dread onto dysfunction, to replacement of dread with pain and symbolism. At other times our responses may be faith based or trust affirming. In the final analysis, our responses are never cavils and hence should not readily be dismissed. In order to achieve peace with the “asoteric” challenge, we invoke these responses to achieve the courage to consent daily to die.9

It is not simply a platitude to assert that human suffering encompasses much more than disease. Suffering is inextricably tied to life and forever pitted in tense struggle with hope. Although I would not go so far as to label the response to suffering as an “answer” to the human existential dilemma, I agree with Erich Fromm that “there is one condition which every answer must fulfil: it must help man to overcome the sense of separateness and to gain a sense of union, of oneness, of belonging”.10 Succinctly put, the hierarchy of inquiry, as set forth here, has been organised around this type of radical humanism. In particular, through the analysis of the responses to the “asoteric” challenge, it becomes clear that happiness requires that we also find the courage to consent daily to live. In this manner, we are forced to make peace with the denial of life.

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