Pain: A Political History

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Pain is a distinctly personal experience. However, the significant economic impact of pain and the tendency to view pain through a moral lens transform the pain experienced by individuals into a contentious political issue. The politics of pain involves the questions of who is actually in pain, how much pain is being experienced, who is deserving of compensation or treatment, and how best to treat people in pain while protecting those being treated from the risks of care. These issues are among those explored in Keith Wailoo's new book, Pain: A Political History.Pain: A Political History focuses on the politics of pain in the United States from the end of World War II to the near present. Political-history buffs seeking information on the politics of pain through the ages may be disappointed in Wailoo's focus on contemporary history; however, most readers will likely appreciate this choice. The medical breakthroughs introduced during and immediately following World War II were dramatic (Porter 2001); as such, the reality of what medicine could do and the expectations of what medicine should do to improve well-being and relieve pain changed during this time. Furthermore, the large number of injured veterans returning home from World War II brought the issue of pain to the forefront of politics. Given the confluence of these pain-related events, it was a good choice to begin Pain: A Political History with a discussion of pain in the post–World War II years. With the focus on contemporary history, the issues discussed in the book are relevant to readers interested in understanding the background of pain-related politics in the United States today.A lost opportunity regarding the focus of the book is that it looks only at the politics of pain in the United States. Pain has been recognized as a global issue (Goldberg and McGee 2011), and international regulatory approaches affect the treatment of pain around the world (Taylor 2007). Recent surveys suggest that there are greater governmental, policy, and cost barriers to pain relief in many other parts of the world, including much of Africa, Asia, Latin America, the Caribbean, and the Middle East (Global Opioid Policy Initiative 2013). Thus, with its focus on pain-related politics in the United States, Pain: A Political History tells only part of the global story. That said, the United States's economy, health care system, and political history have created an environment unlike any other when it comes to the treatment of pain. The United States now consumes opioid analgesics at a greater rate than any other nation in the world, with US consumption twice the rate of the second highest-ranking country, Canada (UNINCB 2010). Statistics around analgesic medication use in the United States are shocking. For example, the US Centers for Disease Control and Prevention estimated that the painkillers prescribed in the United States in 2010 could have medicated every adult in the United States every four hours for one month (Kane 2013). Clearly, while undermedication is an issue in much of the world, overconsumption is a very real concern in the United States. However, as Wailoo discusses, there is also evidence of great disparities in pain treatment within the United States, with some patients and populations experiencing undertreatment. Given the unique history and challenges of pain treatment in the United States, limiting the scope of the book to the politics of pain within the United States was a reasonable choice.While Wailoo limited the scope of Pain: A Political History by focusing on the contemporary politics of pain in the United States, the subject matter is explored in depth. A number of recurring themes are explored in the book. The first of these is the contrasting conservative and liberal views of pain. Wailoo begins his discussion of the contemporary political history of pain by providing some historical context for these two viewpoints. In the introduction to the book, the perspectives of two political theorists who influenced the liberal and conservative views of pain are contrasted in a single paragraph. This paragraph describes how, in the eighteenth century, Edmund Burke viewed pain as being a virtue that is “fundamentally transformative,” leaving a “lasting and sublime mark” that benefited the person experiencing the pain (10). Burke's views were precursors to the modern conservative perspective on pain. Conversely, a generation later, John Stuart Mill did not view pain as a positive experience. Mill, who strongly influenced modern liberalism, believed that the absence of pain is desirable and good; as such, it is moral to relieve pain. Wailoo also points out that Burke's and Mill's views can both also be seen through different lenses of Christianity, with Burke's perception of the redemptive power of pain aligning with some Christians' views of pain bringing the sufferer closer to the experiences of Christ on the cross, and Mill's perception of the importance of pain relief aligning with some Christians' views of Jesus as a model for compassionate relief of pain and suffering. Though brief, this introductory information does a nice job of setting the stage for the contrasting political and moral views discussed throughout the remainder of the book.In every chapter, it is evident that these dramatically different perspectives help explain why pain is so politically divisive. However, Wailoo does not oversimplify this complex issue by discussing it only in binary terms. Although he describes how the conservative pain standard and the liberal relief approach generally differentiate the Republican and Democratic Parties, he provides numerous examples of how politicians and political interest groups have, at various times throughout the years, acted in ways that did not align fully with these conservative and liberal perspectives. For example, Social Security disability insurance (SSDI) was signed into law by Dwight D. Eisenhower, a Republican president. Conversely, Jimmy Carter, a Democratic president, worked to scale back SSDI decades later. The most thought-provoking discussions of the conservative and liberal views of pain related to how often the issue of pain brought together unlikely political allies and shifted groups' political perspectives. For example, the political Left was divided on the issue of physician-assisted suicide to relieve end-of-life pain, with disability advocates splitting from liberals to align with religious conservatives. Similarly, the issue of fetal pain purported to be associated with abortion divided conservatives—although conservatives would traditionally support states' rights to make policy decisions, many conservatives pushed for federal laws to shape policy related to abortion practices. As Wailoo writes, “In the politics of pain, liberalism and conservatism often blended into and depended upon one another” (204). All of the interesting gray areas in between the seemingly black-and-white political perspectives are explored in Pain: A Political History.The political challenges associated with the subjectivity of pain is another theme threaded throughout the book. Much pain-related political controversy can be traced back to the fact that there is no objective measure of pain—it cannot be measured with a blood test or with an X-ray. Pain is not just related to physiological pathology, it is also a function of a person's thoughts, emotions, social resources, financial situation, and personal history (Turk, Wilson, and Cahana 2011). People who appear to have the same degree of physical injury may experience very different levels of pain. Wailoo does an excellent job of illustrating how, decade after decade, the subjectivity of pain presents challenges to clinicians, politicians, and ultimately the courts.Pain: A Political History describes the political history of pain chronologically. Chapter 1, “The Trojan Horse of Pain,” explains how the pain of soldiers retu

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