Has your pain been examined by a moralist?

What is pain, and why is it considered a question of morality in the minds of so many people?

To most linear, logical thinkers (and engineering types like my esteemed co-blogger M. Simon) the question will seem ridiculous, as it strikes such people as self-apparent that pain has nothing to do with morality. Pain is neither moral nor immoral; it just is. It is a condition of life that comes and goes depending on illness, stimuli, and the individual psychology of whoever experiences pain. A person either has pain or he does not. Pain varies from person to person, of course, and some people will experience more pain from the same illness or injury than others. Some people are more stoic than others; one man may demand pain meds for lower back pain, while another might endure amputation without complaint. Does the ability to endure pain touch on morality? How would that be evaluated? By setting up a graph with two axes showing who complains the loudest on one axis and the degree of pain on the other? How can degrees of pain be measured objectively? It is beyond dispute that some people are weaker than others and more likely to complain, but at the same time it is also beyond dispute that pain thresholds vary greatly. So if two different people experience identical stimuli, one may feel it while the other does not. Because of this natural variation, what we would call “stoicism” in the face of pain would not be the same thing for all people. In order for pain to be “endured stoically,” pain must first be felt. A man who feels no pain from something cannot be called a stoic in the face of what he does not feel. And if we assume stoicism in the face of pain constitutes moral superiority, the insensible man therefore cannot be more “moral” than someone who hurts.

I was reminded of this earlier when I briefly turned on the TV to see a documentary on crucifixion in what was obviously someone’s idea of Easter programming. In a fascinating medical experiment, healthy young male volunteers were suspended from a cross (without nailing, of course) while doctors carefully monitored their vital signs until they finally said they’d had enough and demanded to be let down. Even without nailing, the pain of crucifixion eventually becomes unendurable, and because of a combination of physiological processes (slow asphyxiation and stress to the heart), if someone were suspended long enough, he would die.

Whether with or without the near-fatal scourging and the driving of nails through hands and feet associated with the death of Jesus, crucifixion as developed by the Romans was intended as the ultimate pain experience. The slowest possible death coupled with the maximum amount of pain. As the documentary pointed out, the driving of nails would hasten death, while tying the victim alone would prolong it. Jesus’s death was unusual for its shortness of duration; crucifixion often took days, sometimes as long as a week. And if the “gall” Jesus refused was in fact poison as is argued here, that provides more evidence that the Romans wanted his death accelerated, and that Jesus was bravely stoic. (Something the Romans would have admired.)    

It was hard to watch a documentary like that without having it cross my mind that pain — and the endurance of it — might just have a historical and even religious connection with morality.

This is not an idle question, because if pain involves morality, then the relief of it becomes a moral issue. Many modern Americans would laugh at the Victorian doctors who refused to use anesthesia out of fear it would damage their patients’ morality, but they grew up in a time when enduring pain was considered part of life, with weakness and virtue being defined accordingly. 

At the same time, it hadn’t occurred to the moralists that the relief of pain was something that should be regulated by the government. 

Whether someone endured pain or sought relief for it was seen as a private matter. People could go to doctors if they wanted, or they could even walk right into pharmacies and buy powerful narcotics without prescription. It was not until the Progressive Era that this became a matter for the government with the 1914 passage of the Harrison Narcotics Act. Initially, it was entirely up to doctors to decide what to prescribe for their patients, but over time the government got into the business of looking over their shoulders, and constantly narrowing the medical grounds for pain relief — to the point that today many doctors are afraid to prescribe narcotic pain killers lest they be investigated and prosecuted by the DEA. (Which means the war on drugs has become a war on pain relief.)

Interestingly, the war on drugs has led to patients in certain countries being allowed no pain relief at all.

…the United States, Canada, Europe, Japan, Australia and New Zealand, together representing less than 20 per cent of the world’s population, accounted for more than 95 per cent of the total morphine consumption in 2005.

This indicates a significant underconsumption of morphine affecting the remaining 80 per cent of the world’s population, whose combined morphine consumption represented less than 5 per cent of the global total.

And despite the World Health Organisation’s limited success in promoting poppy-based medicines for palliative care for cancer and HIV/Aids in emerging countries, the sheer enormity of the global pain crisis demands ongoing sustained action by the WHO, governments and international regulatory boards.

That sub-Saharan Africa, with a large percentage of the population in pain from AIDS and cancer, has almost no access to narcotic painkillers is itself a largely unreported international scandal which I think ought to be considered an outrage. The chief reason is the difficulty of imposing the same sort of controls over prescription and distribution which are required by the international drug police in western countries. The result is that Africans simply die in pain.

Additionally, the international drug enforcement machinery legally forces underconsuming countries to be locked into previously established patterns of underconsumption, thus preventing patients from ever getting more:

The International Narcotics Control Board which regulates opium supply throughout the world enforces the 1961 Single Convention on Narcotics Drugs: this law provides that countries can only demand the raw poppy materials corresponding to the use of opium-based medicines over the last two years and thus limits countries who have low levels of prescription in terms of the amounts they can demand. As such, 77% of the world’s opium supplies are being used by only six countries, leaving the rest of the world lacking in essential medicines such as morphine and codeine

Nice Catch-22, isn’t it? The result is a wholly artificial shortage of legal drugs, with a hugely disproportionate effect on African countries.

Apparently, it is better to let dying Africans suffer than to allow the possibility of legal drugs being diverted to the street. The absurd result is that illegal drugs are the only drugs people in such countries can get.

Legal prescription drugs are only allowed in countries which can adequately police their distribution and use. Their “shortage” in African countries is not a result of simple market forces, but legal forces. Africans have a lot more pain than people in the west, but they have to suffer without medication, thanks to higher bureaucratic standards imposed by the West. Pain relief is only available for “nice” people.

At the root of it is something I think underlies the entire drug war — an intractable debate over the morality of pain.

Here in Michigan, voters decided to legalize marijuana for medical reasons, and one was the relief of chronic pain. But now that the law has been in place long enough for statistics to come to light, the law is being hotly debated:

Advocates and opponents of medical marijuana had very different views of the first snapshot showing how patients and doctors are responding to Michigan’s 2-year-old law permitting pot’s use as a painkiller.

Attorney General Bill Schuette, who led the opposition to the voter-passed ballot proposal in 2008, said: “This is just what we predicted. It is totally out of control.”

He responded when a reporter informed him that most certifications under the law were for chronic pain, not specific illnesses and that 55 doctors were writing most of the prescriptions in Michigan.

“We were told (medical marijuana) was designed to treat a very narrow set of … chronic and severe illnesses,” Schuette said, “and what’s going on is that this poorly drafted law is being exploited by those who want to legalize marijuana or make money … or by unscrupulous doctors.”

Karen O’Keefe of the Washington, D.C.-based Marijuana Policy Project, which helped draft the legislation that was overwhelmingly approved by voters, strongly disagreed.

Chronic and severe pain is a serious medical condition, one that results in millions of Americans seeking medical treatment and receiving prescription painkillers, O’Keefe said.

“It is absolutely unfair to suggest that severe pain is not a serious condition,” she said.

The use of medical marijuana is seen by the opponents of medical marijuana as immoral, even to relieve pain. Either that or they don’t believe that the patients are actually having pain. How is the legitimacy of patient pain to be evaluated? Is pain which can be relieved by marijuana more “immoral” and less legitimate (and therefore less “real”)  than pain relieved by narcotic drugs? What is the moral difference between a pain patient who takes medically prescribed oxycontin and a patient using medical marijuana? If we assume that they’re both having pain, I am unable to come up with a distinction. OTOH, if both are lying to their doctors to get access to the respective substances, I see no moral distinction there either. So, if marijuana patients are being seen by the opponents of medical marijuana as make false pain complaints to get marijuana, then why aren’t oxycontin patients seen the same way?
I suspect that they are; hence the new laws establishing prescription drug databases and allowing authorities to rifle through them. Fortunately for the marijuana patients, Michigan’s medical marijuana law guarantees patient confidentiality. Fair or not, regular pain patients lack any such privacy. It must just gall those in drug law enforcement to see such a loophole, because if having pain that needs relief means being in a suspect category, all suspects should be treated as suspects! 

But who should get to decide whose pain is legitimate, and whose is not?

Gone are the days when it was a matter between a patient and his doctor.


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14 responses to “Has your pain been examined by a moralist?”

  1. Will Avatar
    Will

    Apparently I have a high tolerance for pain. Which makes it very hard to tell if someone else is faking, over-reacting, or really is in pain. I can understand how judges, officers, and others, who like myself are mystified by the reactions of pain sensitive people; could think it is just an excuse.
    I am however very reactive (emotionally so) to the sensation of nausea. Broken bones,punctures, cuts, bruises, burns, sleeved skin,…give me a shot of scotch and an aspirin and no problem. I can handle the pain of kidney stones, it is the puking that turns me infantile. Sea sick, air sick..put me in an induced coma or I will be begging to die. Two realities; unreconciled.

  2. Kathy Kinsley Avatar
    Kathy Kinsley

    Like Will, I’ve got unusual reactions. In my case, some types of pain I can handle, others would put me in the begging to die category in short order. Break a bone? Shrug. Take some ibuprofen.
    Get a migraine? Kill me, please. (With me, migraines include nausea – I could possibly handle just the pain – though I’ve never had the chance to find out because they always go together.) Luckily it’s very rare for me to get a migraine… (Years apart rare.)

  3. Kathy Kinsley Avatar
    Kathy Kinsley

    Oh – and that’s just an observation to agree with Will’s comment… “Which makes it very hard to tell if someone else is faking, over-reacting, or really is in pain.”
    That said, I also disagree with his stance that it matters. If someone thinks they are in pain, give them something to stop the pain. (Not necessarily a physical painkiller – I had two friends in my younger years kill themselves over emotional pain.) One could easily have been saved with therapy and an antidepressant or two. The other, I’m not so sure about – he was schizophrenic – but not all the time. And there wasn’t any drug that helped unless he doubled up on it and ran out… He killed himself in one of his sane periods. (Judging from the note – which made just too much sense…)
    What I think I’m trying to say here (And, Eric, you know it – as does Simon.) is that not all pain is physical. And some of the drugs that can help the non-physical pain are right up their with the physical pain drugs in being a ‘don’t subscribe too much or else’ order from the gov’t.
    Legalize them all Doctors’ prescriptions only for kid or antibiotics – and enforceable anti-lawsuit agreements would need to be drawn up ASAP. Only thing that I actually see a reason for having as subscription are antibiotics – and that’s ONLY because uneducated idiots stop them too soon and create resistant bacteria.

  4. Sarah Avatar
    Sarah

    Will,
    Wow, I’m like that too, which is why I don’t often taken pain meds, because almost all of them make me nauseous.
    And Kathy — I agree a hundred percent, and I speak as someone who DOES think most drugs are harmful to some extent. However, first — who are we to decide for other people? Second — Do we know the current system doens’t cause WORSE tradeoffs?
    it would be like… prohibition — look, I’m one of those people who crawls into a bottle for a week when something really bad hits. And then as time heals things, I stop cold. I’ve done it… three times in my life. Should I not be allowed to do this (considering my depressions are far more dangerous than that) because other people can’t quit cold turkey?

  5. Thomas Avatar
    Thomas

    A few days ago I went to one of the local urgent care centers near my home because something was in my eye. I checked in and was thankful that no one else was in the waiting room. Being bored I read a sign in bold letters saying if your here to get pain medication please contact the chronic pain center, doctor so and so at so and so and gave the phone number. I thought man is it really that bad that they had to put up a sign. The waiting room began to fill up. I said to myself man am I glad I came in when I did.
    While being examined I could hear a woman in the next examination room complaining loudly that she needed her pain meds. She was saying she was driving through the area on vacation and forgot her meds at home. I could not hear what the doctor said. She stormed out yelling at the top of her lungs.
    Another doctor informed me that I needed to see a specialist because he did not want to risk removing the object from my eye. As I was leaving I could hear another person wanting a pain medication. As I exited a woman yelled out to the people in the waiting room if your here to get da cotton they ain’t given out shit and she walked out. Obviously the sign did not mean anything to these people.
    For those of you who care about such things, all the people were white and kind of trashy if you get my drift.
    When I arrived at the eye specialist, I saw three of the five people I saw at the urgent care center, that I went to, at another urgent care center next to the eye specialist. They were all on the phone walking back and forth. You could tell they were on edge.
    While the eye specialist was removing the item from my eye I told her about the pain medication incidents I just observed. She said it happens all the time and it is a huge problem.
    When my wife came home I told her about it and she said it gets worse closer to the weekend. You see my wife works in a doctors office. Doctors get played all the time by people wanting pain pills. My wife said that these people will go to as many doctors as they can and then go to every pharmacy in town to get their scripts filled. I just had to shake my head. She said most of the people snort the pain medication.
    I know for a fact that DEA monitors doctors when large quantities of pain meds are being given to people. Of course some doctors just right the script and collect the fee. All this does is hurt the doctors who treat people for chronic pain.
    I hurt my back a year ago and I am glad it healed just fine. I did need some pain medication to get me through the tough days. I do not remember what they were but they stopped the pain and made my stomach turn. It bothered my stomach so much I asked the doctor if he could give me something else. He said if this was a medical marijuana state he would give me a script for marijuana. I think it was his way of telling me to go buy some weed.

  6. Eric Scheie Avatar

    Thanks Will, Kathy, Sarah, Thomas. I think drugs are mostly harmful and agree with legalization. It is also quite clear that forcing doctors to be drug cops is messing with the practice of medicine. In the really old days (before drug laws) people just got whatever they wanted. In the more recent old days (before the 80s drug war and mandatory DEA-physician-monitoring kicked in), they had a sub-rosa system under which older, less-competent doctors (known as “croakers”) would write prescriptions to patients claiming to be in pain. It took the pressure off the real doctors. Society looked the other way. Nowadays, such doctors cannot get away with it; they are caught and sent to prison. So the addict population spills over into the ER system where they waste huge amounts of time and resources which ought to go to patients with actual emergencies.
    So now I find myself wondering whether medical marijuana might constitute a way to take the pressure off doctors by diverting at least some of these drug-seeking patients to marijuana clinics.
    OTOH, I know a doctor who told me that she absolutely refuses to write marijuana certification letters — not so much out of opposition to medical marijuana, but out of fear that once the word was out, it would lead to her being inundated with druggie patients seeking stronger prescriptions, which might cause her to get in trouble with the DEA.
    Because doctors are in the unique and privileged position of being the only legal suppliers of substances so much in demand that street prices exceed their real legal value by a one hundred fold ratio (a 50 cent pain pill can be “worth” $50.00), they end up being squeezed and gamed, while everyone else is inconvenienced. (And don’t think for a moment that elderly patients suffering from real pain won’t be tempted to sell some of their meds!)
    Economics can be a powerful incentive.
    Wouldn’t it be better for everyone to just let these people buy what they want at pharmacies with whatever prescriptions their doctors might see fit to write? If doctors (and pharmacists) didn’t have to worry about the DEA, the market would sort things out rather quickly.
    The present system reminds me of what I wrote about prescription gasoline.
    http://www.classicalvalues.com/archives/2010/11/libertarianism_1.html

  7. Eric Scheie Avatar

    Oh, I forgot. What I just proposed would be immoral!

  8. Sarah Avatar
    Sarah

    Two funny comments — at least I hope they’re funny — to lighten up the mood a little…
    The day CO became an MMJ state, my husband had just put up an ad on Craigs to sell some exercise equipment (space. We needed a smaller bench) and got no calls which is unusual. So he went to look and found his ad (under health) was swamped under MMJ buy/sell adds. Then he shouted with laugh and called me over. There was a guy saying he had a script but his normal dispensary had closed and he needed “one to two kilos” to see him through the weekend. Neither of us have ever done the stuf — don’t like to be out of our minds — but friends who have told us the amount is as ridiculous as we thought. We hope he was intending to resell or perhaps just confused on what a kilo is.
    The other one is kind of well… bitter sweet. When we moved from North Carolina, dead broke and with a small child, I threw away A LOT of things including most of our medicine cabinet. You know, the type of thing you go “WHY have I kept expired cough syrup around?”
    One of the things I threw away was a relatively large (one week but high dose) prescription of morphine. See, when I gave birth to older son, I was in labor too long and caught what apparently killed Henry VIII’s Jane Seymour. They used to call it “White Leg” but it’s a massive uterine infection, which apparently is one of the more painful things you can have. They kept me in the hospital for a week much of it on morphine drip, but when they sent me home (we had no insurance and I was screaming about the expense.)they thought I still wouldn’t be able to withstand the pain, so they gave me MASSIVE bottle of morphine. I took ONE tablet but it fuzzied my head too much and I decided the pain was preferrable.
    So, I’m holding this bottle, about to throw it in trash, and my husband says “if it weren’t that we have no clue HOW to do it and for the risk of legal complications, do you know HOW MUCH that bottle is probably worth?” For people 20k in the hole from the birth, this was a bitter-sweet reflection. We threw it away, anyway.
    Oh, something else on how wide-spread the issue is: our cat doctor has a HUGE sign on the window saying “NO PAIN MEDICINES KEPT ON PREMISES AFTER CLOSING.”

  9. Veeshir Avatar

    Sarah, I had leg surgery once and they gave me a bunch of pain pills.
    I had some that I was supposed to take a few times a day and also oxy-contin twice a day.
    I took it the first day and it made me jittery.
    I talked to a friend whose husband had taken it and she said he felt the same.
    I have a high tolerance for pain so I just threw them all away (Oxy-… and the other stuff, darvocet maybe) never really thinking that I could have made a bunch on a full,and refillable, bottle of oxy-contin and another, refillable, of darvocet or whatever.

  10. Eric Scheie Avatar

    Hmmm….
    I think there is entirely too much discussion of controlled substances on this blog!
    I expect a subpoena and a cease and desist order from the DEA at any time….
    Hey wait!
    Can they raid blogs with SWAT teams?

  11. Firehand Avatar

    Sometimes I wonder about how medical people decide things. The day after my appendectomy(big incision, long story) I was asked if I had any pain, “Yes”, so they gave me standard extra-strength Tylenol. Two days later as I was checking out the doctor gave me a prescription for Demerol(pretty heavy dose). I asked why Tylenol the day after but sending me home with this? and the only answer was “Just in case you have trouble resting.”
    Eric, not the blog, but you might want to keep Coco safe if you see anybody in a ninja suit sneaking up.

  12. class factotum Avatar

    I don’t care how many people want to drug themselves to death as long as people who are in pain can get relief. I get migraines and they are not even the bad throwing up have to be in a quiet dark room kind, but they are bad enough that they make me mildly miserable. (Unfortunately, cheap vicodin does not stop the pain. Only very expensive imitrex does.)

    If people want to ruin their lives with heroin or codeine, I don’t care. Make it legal. Just don’t make people who have chronic pain suffer.

  13. […] evolving view of the war on drugs as a war on pain relief. (See M. Simon’s recent post, and my typical posts on the […]

  14. […] I’t surprised. I have been warning about these unconstitutional prescription drug databases for years […]