The Problem of Pain

Pain.  Pain is something that, as health care providers, we learn is subjective.  Subjective: meaning belonging to the subject (patient) rather than the object (the “objective” practitioner).  Subjective pain: pain that is perceived by the patient and not by the provider.  Pain: an area of healthcare where the objective practitioner can have the ability to, and often does, perhaps unconsciously, objectify his or her subject.  This may be doubly true in assessing laboring women who all present differently at different stages and who may or may not meet certain clinical expectations in response to the pain of childbirth.

I won’t talk about patriarchy and women’s experiences of their bodies.  I won’t talk about how women punish one another into utilizing or forgoing modern pain relief methods for some weird feminist ideal of woman/motherhood.  I won’t even talk about language such as “low pain threshold” or “no pain tolerance” in discussing another person's pain.  No. Just for today, I won’t. Instead, I will give you this anecdote.

A patient is admitted for intractable pain, not in labor.  This intractable pain is accompanied by some intermittent vomiting… and a suspicion by providers that this patient might be drug seeking. It is never totally clear why. She is poor.  She is a minority.  So there are two strikes against her from the get go.  She is perceived as something before she is anything in the clinical realm... before she is even a patient. “What makes you think that? About the drug seeking?” someone asks in team meeting.  “Well,” responds the attending provider, “Her pain seems very out of proportion to her early labor status and no one has ever witnessed her vomiting.  Also, we were going to perform a tox screen but she can’t seem to void, which I find very suspicious.”  Suspicious.  Not concerning but suspicious. A good practitioner should, right about now, have counted at least five symptoms that could be used to rule out a host of issues other than drug seeking behavior. But this is where we are.  So a wise doctor seated beside me addresses the pain issue by asking, “And have you given her anything for this pain?”  “No,” responds his colleague, “Nothing but an antiemetic for the supposed vomiting.” 

The inquiring doctor rolls his eyes and turns to me, sotto voce, “Drug seeking for ondansetron. Now that’s a problem.”

*The Problem of Pain is a very brief and worthy little book written by C.S. Lewis and Virginia Woolf touches on the subject in her essay On Being Ill.  For a little non-medical perspective to inform practice, you can also read some Heidegger and Nietzsche among others.