This book is a lively and readable account of the complex and evolving interplay between pain medicine, public policy and politics in the United States, beginning with the signing into law of disability support by President Eisenhower in 1956. Physicians concerned about the complexities around pain management will find this book fascinating. Pain is inherently subjective, and one’s experience of pain is not related in a simple, linear manner to injury or illness. When access to painkillers or disability benefits is at stake, or when pain and suffering are critical to litigation, the physician’s judgement becomes politicised. Equally, the decisions of lawmakers, judges and drug regulators have profound effects on clinical management, and hence on the well-being of patients. Pain and politics cannot be kept apart, as Wailoo rightly argues.
Doubts about poorly specified or subjective pain complaints have been rife at least since the days of employer liability laws in the nineteenth century. The prospect of compensatory damages has long caused suspicion among physicians when treating cases of (what used to be known as) ‘traumatic neurasthenia’, ‘writer’s cramp’, etc. This led to the concept of ‘compensation neurosis’, a supposed psychological disorder caused by personal-injury litigation.
Wailoo gives an account of how such issues have played out in the United States in the post-war era. The US is of course the leader in pain research and pharmaceuticals over this period, and the issues surrounding social security and law in the US are similar to other advanced countries. So, this American history will have resonance for readers elsewhere, especially in the English-speaking world. Although Wailoo cautions against viewing the political debate in a bipartisan manner, he observes how broadly ‘liberal’ and ‘conservative’ political ideologies have fought over pain, personal responsibility and rights to health care and welfare. This focuses on issues such as entitlements to (and fiscal costs of) disability benefits and rights to pain-relieving drugs. It shows how those who complain of pain (the war veteran, injured worker, terminally ill patient or even the foetus) receive different levels of public sympathy and financial support at different times, and are wedged within larger political fissures.
The US has historically been a later developer than comparable countries in implementing social security systems. And the recent controversy there over ‘Obamacare’ perpetuates that tardiness and shows how politically polarised health care policies are for Americans. That controversy gives Wailoo’s account even greater significance for his American audience. This is not a criticism of his book, but one would like to see, all the same, a comparative account of countries such as Germany or Russia, where the cultural, political and social policy histories are quite different.
Critical questions for Wailoo are: Whose pain matters? And who is qualified to judge ‘real and imagined pain’? But, is this supposed difference between ‘real’ and ‘imagined’ valid? And, even if it is, could it ever be objectively ‘judged’ in either a medical or legal sense?
Wailoo contends that Melzack and Wall’s gate-control theory (which emerged in the 1960s) ‘echoed new thinking about the legitimacy of subjective pain as real pain’. As the International Association for the Study of Pain (IASP) now tells us, all pain is subjective. It is sensory and emotional, by definition and by experience. So there is no value in insisting that ‘subjective’ pain is ‘real’. There is no category of ‘unreal’ pain. If it hurts you, then you are not ‘imagining’ it. Just call it ‘pain’. The qualifiers ‘subjective’, ‘real’, ‘imagined’ and ‘true’ add no meaning at all.
In his conclusion, though, Wailoo has to ask rhetorically: ‘Who can detect true pain when they see it?’ But here’s a simple answer: ‘No-one can.’ Pain cannot be ‘seen’ by anyone; it cannot be directly ‘detected’ by a second-person observer. Propositions may be either ‘true’ or ‘false’. But pain simply hurts!
Everyone knows, though, that a good actor can convincingly simulate being in pain by adopting certain verbal and non-verbal behaviours. Indeed, anyone can pretend to be in pain. If you do feel pain, however, you can’t doubt it, but others may. And even if others accept that you are in pain, they may not comply with your demand for drugs. Thomas Szasz got it right when he said that physicians don’t classify people’s pains, they classify people’s complaints of pain. 1 Some complaints signal a need for investigation, others don’t. Some are associated with verifiable illness, others remain a mystery. So not all those who complain of pain get treated as ‘legitimate’ by physicians, by the courts and by the law. Legitimacy matters because it matters how others judge your complaint of pain.
On this, the biopsychosocial model of pain has a lot to say, but it is strangely absent from Wailoo’s narrative. Names such as Beecher and Bonica appear, but not Fordyce and Loeser. The biopsychosocial model has been very influential, medically and politically. It saw economic incentives and secondary gains as reinforcers of ‘pain behaviour’, and hence it could offer medical authority to conservative attacks on disability support and workers’ compensation in the 1980s and 1990s. The idea that social and cultural factors influence how we express pain may sound like a ‘liberal’ idea, as it upsets biomedical authority. But it also lends itself to conservative scepticism about extraneous motives reinforcing ‘pain behaviour’ and ‘iatrogenic disability’.
Wailoo also ignores the ‘taxonomy of pain’ on the IASP website. That taxonomy can be challenged, but it does offer some authority for a contemporary discussion of pain. I suggest that Wailoo’s comprehension of pain is out of date. Other than that, this book is a welcome addition to our historical knowledge of how pain and the ways we recognise others’ pains are inevitably political.
1. Thomas Szasz, Pain and Pleasure: A Study of Bodily Feelings (New York: Basic Books, 1975).