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January 5, 2000

The Unnatural Nature of Pain

Author Affiliations

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JAMA. 2000;283(1):117. doi:10.1001/jama.283.1.117-JMS0105-5-1

No other physical experience is as heavily imbued with meaning as pain. The idea that pain is simply the result of an internal physical condition is relatively recent. For many philosophers and cultures, pain has been seen as having an external source such as "God's arrows."1 With this externalizing of pain comes the understanding of pain as meaningful in a social and moral context. The Biblical story of Genesis depicts the introduction of pain and suffering in the human experience as a divine punishment for transgression, and this Judeo-Christian ethos has permeated the West's understanding of pain.

Throughout literary history, representations of pain have been based on the doctrine of punishment. At the center of Dante's hell, the monstrous figure of Lucifer torments the 3 men who betrayed their lords: Cassius, Brutus, and Judas Iscariot.2

In Paradise Lost, Milton describes the "doleful shades" of Hell, relishing the agony of the fallen angels after their violent subordination. In lurid detail, he describes their "torture without end."3 Both Dante and Milton carefully emphasize that the pain is permanent, because it is necessary to differentiate punitive pain from the moral cleansing associated with transitory pain. The sacrifice of Jesus on the cross, the ascetic starvation of Siddhartha, and the religious sects that self-flagellate on holy days all manifest the use of pain for purification, purging transgression through temporary painful ablutions. And yet, striving to construct any consistent parallel between morality and pain ultimately must be answered with Hamlet's bitter question, "Use every man after his desert, and who shall scape whipping?"4 Despite the ancient association of pain with a person's moral character and social behavior, it is only in literary and theological texts that such an association is precise.

The notion that pain results from transgression is not solely relegated to the graphic imaginations of writers. One need look no further than certain recent vitriolic assertions that AIDS is God's way of punishing homosexuals5 to see that for many today, physical suffering is not detached from perceived spiritual health. The consequences of such assertions for those who suffer are significant, both in the individual's solitary struggle to come to terms with suffering and as they might affect those making health policy.

Because of differing moral and narrative traditions, cultures ascribe meaning to pain in different ways. There have been numerous attempts to discern the extent to which the experience of pain differs among ethnic and national groups. Although some researchers have managed to produce statistically significant data that suggest culturally affiliated influences on the perception and response to experimental, acute, and chronic pain,6 the confounding factors, often based on differences in expressing pain, usually make any distinctions untenable. 7 Just as the relationship between morality and pain cannot be clearly identified, so too the correlation between physiology and the experience of pain remains elusive.

More pertinent to immediate concerns is the way physicians respond to people in pain based on ethnicity. In an Israeli study, Jewish doctors and midwifes assessed the pain ("exhibited pain") of 225 Jewish and 192 Bedouin parturients, who also assessed their own pain ("self-reported pain") during delivery. The Jewish and Bedouin women evaluated their pain equivalently, but the doctors and midwifes reported less pain in the Bedouin women.8 We may not be able to explain cultural differences in pain, but we nevertheless perceive such differences.

Medical research has provided us with a rich understanding of the mechanisms of pain, but the physiology of nerves and the anatomy of dermatomes cannot describe the experience of being in pain. Pain is one of the very few experiences that every person will have, and yet it is intensely private. When Virgina Woolf writes that the "merest schoolgirl when she falls in love has Shakespeare or Keats to speak her mind for her, but let a sufferer try to describe a pain in his head to a doctor and language runs dry," she is pointing to that intrinsic difficulty of conveying to another the personal experience of pain.9

In asking about pain, the physician attempts to interpret it as a message coding a pathological process, reading the pain in its relationship to a problem in the body's functioning that can then be addressed. Not only is this limited by the painless nature of many pathological processes (such as the stealthy streaking of arteries with fatty deposits), but more importantly, the physician will never be able to empathize with his or her patient without trying to understand how that person is experiencing pain.

While the investigation of pain as a physiologic phenomenon is important, pain cannot be reduced to physiology any more than it can be neatly explained by a social or moral paradigm. The difficulty in talking about and understanding another person's pain stems from its complicated origin in both realms, as a function of our bodies and of our identities.

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Dante  Not Available The Divine Comedy Volume 1: The Inferno. Canto XXXIV.
Milton  J Paradise Lost. Book 1, lines 65-69.
Shakespeare  W HamletAct 2, scene 2, lines 524-525.
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