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.