Pain

Rev. Paul Beckel

First Universalist Unitarian Church ~ www.uuwausau.org

January 28, 2007

Your pain is the breaking of the shell that encloses your understanding. Even as the stone of the fruit must break, that its heart may stand in the sun, so must you know pain. And could you keep your heart in wonder at the daily miracles of your life, your pain would not seem less wondrous than your joy. Kahlil Gibran

Joy is not the opposite of suffering and pain; joy exists alongside these to make them endurable.  Matthew Fox

I have responded to placebo trials and I am always mortified and ashamed of myself. The pill could have no action on the reality of my injury and yet my sensation changed....

Some physicians think that anyone who responds to a  placebo did not have ‘real’ pain: they are wrong. Some physicians think that a placebo is the same as no treatment: they too are wrong.   Dr. Patrick Wall

“Real isn’t how you are made,” said the Skin Horse. “It’s a thing that happens to you.”

“Does it hurt?” asked the rabbit.

“Sometimes,” said the Skin Horse, for he was always truthful. “When you are Real, you don’t mind being hurt. It doesn’t often happen to people who break easily, or have sharp edges, or who have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out, and you get loose in the joints and very shabby. But these things don’t matter at all, because once you are Real, you can’t be ugly, except to people who don’t understand.”                      from The Velveteen Rabbit

��?�

Pain is a universal human experience. For most of us, I imagine, it’s a daily experience. But whether our pain is a dull part of the background noise of our lives or always fresh and surprising, pain remains elusive, and ultimately mysterious.

At the first pinch, we assume a pain is natural. We react without thinking; or when we do have time to assess the situation, whether we are hurting, or someone else is hurting, we look for the cause. We expect there to be a reason.

But sometimes there is no reason. Neither science nor religion can always offer a satisfactory answer to the question, “Why do we hurt?”

Anatomy and physiology can point to some of the mechanisms of pain: chemical pathways of breathtaking sophistication that kick into action when our bodies are under attack. Whether from sudden trauma or from an invasion of foreign organisms, pain signals our bodies to recoil and put up the defenses.

Curiously, pain is often absent in cases of severe trauma. We might not be immediately debilitated by pain because getting away from danger takes a higher priority. But later pain will come on strong to ensure that we protect our injuries and allow them rest to heal.

Even fairly simple organisms have the capacity to react to noxious stimulation by pulling themselves away. Higher animals have the ability to remember and to learn from pain so that they can anticipate and avoid it in the future.

But it’s not true that where there is life there is pain. Rather, pain as we know it is a product of consciousness and even intelligence. This is consistent with the words of Ecclesiastes, from the Hebrew scriptures: “For in much wisdom is much vexation, and those who increase knowledge increase sorrow.”

Perhaps too the story of the Garden of Eden reflects this truth: that as human consciousness grew, we were expelled from our previously pain-free existence.

==

We usually feel pain in response to bodily events over which we have some muscular control. If we can’t do anything about it, it’s less likely to hurt. Dysfunction of internal organs and even stroke can occur without pain. So in that sense we might feel thankful for pain, which generally indicates our capacity to act on it.

What would it be like if we did not feel pain? I remember my first tooth extraction. Not only did it not hurt, I was numb long enough to bite a chunk right out of my lip. That didn’t hurt either (at first). The alternative to feeling pain is exemplified by Hansen’s disease, more commonly known as leprosy.  Leprosy is a bacterial disease that causes destruction of peripheral nerves. The result is that noses, lips, hands and feet, lacking sensation, are worn away by continual unconscious self-inflicted traumas.

A healthy pain response helps us to keep good boundaries. It not only helps us to fend off that which is not us, it also motivates us to take care of the parts that are us.

==

Sometimes we hurt and there is no empirical cause to be found. Still we ask, “Why?”

Looking beyond science for an explanation we hear things like: “No pain no gain,” or the theological equivalent, “God has a reason.”

There’s also: “What doesn’t kill you makes you stronger,” and its theological equivalent, “God never gives us more than we can handle.”

While Buddhism recognizes suffering as the basic human condition, some religious traditions consider suffering a mark of holiness, a sign of being chosen by God. Medieval Christian saints were honored for enduring the ravages of illness or even self-inflicted injury. Saint Marguerite Marie Alconque, in the 1600s wrote: “Nothing but pain makes my life supportable.”

The Easter myth of redemptive suffering -- bearing the sins of world to appease an angry God -- continues to play out in our search for martyrs and heroes.

Gangs, fraternities, and indigenous people around the globe practice initiation rites that involving severe physical pain.

All these examples show that at some level we think of pain as noble or romantic -- with those who suffer serving as symbols of spiritual depth, artistry, or compassion.

And if these mythologies of honorable suffering aren’t twisted enough, we also have conventions about dishonorable suffering. One story we tell is that inflicting pain upon prisoners can be an effective foreign policy tool.

Another pervasive myth is this one: that you get what you deserve. And since you get what you deserve, pain is simply the consequence of sin, your own acts, and the risks you’ve chosen.

I don’t buy any of these notions, but I still find that pain can have meaning beyond its biological function. At its best, pain calls us to attention, alertness, focus, orientation, and response. It causes us to be aware, to explore, to reflect, and to understand.

However, that is only pain at its best. Pain can also numb us, distract us, deceive us, and isolate us. I am not a fan of pain for its own sake.

II. Pain is a universal human experience. And yet it is a mystery. It is so subjective. Though we have all known pain, it’s probably not possible to know just what another person is feeling. And it’s usually not useful to try to compare one person’s suffering to that of another person.

For one thing, we cannot tell, from the degree of someone’s injuries, how much pain they will feel. Also, some kinds of pain don’t show to the outside world; they bring us no sympathy, no understanding. Other pains are distorted by their context: the heroic injury feels different from the embarrassing one.

Even if we’re not experiencing pain now, the anticipation of pain can be torturous. And if it goes on and on, pain, or the fear of pain, can lead us into a difficult-to-escape cycle of fatigue, grouchiness, and even hallucinations.

So even when it’s all in our head, pain can be very real. Nothing demonstrates this better than the completely illogical and completely real experience of pain from an amputated limb.

But if the mind can perceive pain even when it isn’t there, could we perceive painlessness even when there “should” be pain?

Medical trials are usually run with one set of patients receiving treatment and another set receiving a placebo, typically a sugar pill. Surprisingly, of people given placebos under a wide range of circumstances, 40-50% will report benefits. This tells us that the power of the imagination cannot be dismissed. Because the placebo even affects things that are beyond conscious control: blood pressure, heart rate, even the immune response.

Why does this happen? Perhaps it’s a function of our expectations. Placebos have been especially effective when patients are given post-operative narcotics, then after experiencing the real thing, the next time they are given placebos. (They even produced the same side effects!)

Even animals experience the placebo effect when they’ve had a chance to learn what to expect.

So maybe placebo results are based on expectations. Or maybe they’re based on authority. The medical provider gives you a treatment so you know that you are supposed to get better. This has even worked with placebo heart surgery, in which people had their chest opened up simply to make them believe they had received a curative procedure. Though it often worked, this experiment is no longer considered ethical, but it leads to a tantalizing question: if you find a way to stop the pain, why not try it?

Thomas Jefferson called the placebo “a pious fraud.” He thought that treatment could not be condoned unless it could be shown to operate by a rational mechanism. Of course what was considered a rational physiological mechanism in his day is very different from today.

The placebo effect is amplified when administered by an enthusiastic provider. This raises difficult questions about alternative therapies and quasi-religious medical practices.

Hippocrates taught that medicine is the art of entertaining people until they heal themselves. Counseling, chiropractic treatment, steroids for acute pain: are such temporary comfort measures good medicine even if they cannot cure us?

Shamanism, faith healing, hypnosis, guided imagery, acupuncture, prayer, massage, yoga, relaxation, heat, cold, exercise, casseroles and visits from friends. If these “therapies” change the reporting of pain but not necessarily the existence of pain, how bad can they be?

Is it fraudulent for drug makers to communicate to patients in a powerful way that their product will help them? For example, by advertising or coloring and shaping pills in a way that patients believe/expect will ‘work”?

Is it unethical for herbalists and ear candlers to do the same thing? Is it wrong to communicate forcefully and to raise expectations...when those expectations increase the likelihood of success?

Maybe. Maybe not.

What would Buddha do? He said we should destroy our illusions. So he might not approve of fantasy therapies. But he also said that we should be our own authority. So the question becomes: can we be our own authorities over pain? Can we create personal or family or cultural expectations of wellness?

Often we can. Consider post-operative pain medication. Those who have the self-controlled analgesic pumps tend to use less, and report better results.

The Stoics of ancient Greece were masters of authority over themselves. They might acknowledge pain, but they would add: pain can chain my body, but that’s only a small part of me.

We might imagine that people who respond to placebos have personality quirks. But there is no link between responsiveness to placebo and personality type. The distinction of not responding to placebo goes to people who are in chronic pain. If our experience has repeatedly shown us that nothing can help, our expectations are going to be low. The best placebo responders are people who have had positive experiences. Perhaps the moral of this story is that, whenever we can, we need to provide people with positive experiences.

Alternative therapies defy rational explanations. But what they may provide, in comparison to the traditional medical model, is more attentive time, warmth, and optimism. Medical professionals may be at a disadvantage because they know too much about how often treatment fails. “For in much wisdom is much vexation, and those who increase knowledge increase sorrow.”

III. Pain is no mystery. It is inevitable. Aging tissues lose strength and elasticity. Aging bodies are less resilient, and recover more slowly. When I stopped competing athletically in my early 20s, I was in awe of anyone over age 25 who could run. Now at age 42 all of my old injuries are reappearing for no apparent reason. New muscle strains that seem minor take months to heal or do not heal at all. If this is the trajectory of pain in aging, then I’m in awe of anyone over 60 who can even get out of bed.

Maybe the problem is that God made Adam and Eve to walk on all 4s. Perhaps by standing up to get that apple our ancestors condemned us to stresses that our bodies were never designed to endure.

Pain is with us from beginning to end. As relatively intelligent beings, we not only feel pain when it happens, we can hurt over what happened to us in the past. And we can also imagine for ourselves a painful future, accurately or not. We can work ourselves up like the man who went into the emergency room with his hand in bloody towel. Sweating, retching, and barely able to stand, he reported to the nurse that he had cut off his thumb with a circular saw. But when the towel came off it turned out he’d only taken off a bit of skin.

We hurt in response to the pain of others, and even feel empathy when actors get hurt in the movies. I’ve fainted twice when I’ve brought family members to the hospital.

So pain may help us to keep good boundaries, but empathy reminds us that the boundaries of our hearts often overlap.

It is so hard to not be able to help when someone you love is in pain. Even if we can’t know what they’re going through we still hurt for them.

I’m speaking about pain today because I know that you hurt. I may not know quite how you feel, but I know that you have hurt, and I want to say that I care. Also, I want you to remember the suffering of those around you. Suffering that you cannot accurately judge.

Alfred, Lord Tennyson wrote one of his greatest poems, “In Memoriam,” after the death of his closest friend. Unable to rely upon a personal god for comfort[1] he wrote instead about the longing to be with another human being in their pain:

Be near me when my light is low,

When the blood creeps, and the nerves prick

And tingle; and the heart is sick,

And all the wheels of Being slow.

Be near me when the sensuous frame

Is rack’d with pains that conquer trust;

And Time, a maniac scattering dust,

And Life, a Fury slinging flame.

Being with another person provides no apparent mechanism for the relief of pain. But the fact is, we can benefit, even from causes we don’t understand, and cannot see.

Long before our modern understandings of the biochemical process that makes it “work,” people were ingesting aspirin in the form of willow bark.

So sometimes the meaning is simply in choosing to endure the mystery until a reason, a purpose, will appear.