I don’t want the title to imply that I am some sort of expert on pain; I am, like most people, pain averse. I do not necessarily understand pain; I see it in others and assume it has similar characteristics in common with what I experience and so I avoid it whenever feasible. I understand when others have a similar response. Some less charitable souls might characterize this as cowardice, but I suspect pain is something that the majority of us would not willingly endure if at all possible.
I would like to separate the concepts of pain and suffering, however. They are not at all the same. Cassell in his 1991 book The Nature of Suffering, talks of people reporting ‘suffering from pain when they feel out of control, when the pain is overwhelming, when the source of the pain is unknown, when the meaning of pain is dire, or when the pain is apparently without end.’ He goes on to suggest that ‘In these situations [that is, when they suffer] persons perceive pain as a threat to their continued existence -not merely to their lives but their integrity as persons.’ Further, that ‘suffering has a temporal element. For a situation to be a source of suffering, it must influence the person’s perception of future events.’ And so, ‘suffering would not exist in the absence of the future.’ Yes it is still pain of course, but it has different meanings, different attributes, in different situations and those in turn are influenced by what the person may have experienced in the past. Expectations rule.
And as a physician these expectations that are engendered by past experiences are important. Not only do they influence how I interact with my patients, they often dictate how those interactions are interpreted: the meaning they assign to the pain, and that I assign to the pain. Take the pain of labour as an example. It is very likely one of the most severe pains the average woman will endure in her lifetime. It comes wrapped in culture, past experiences of other pains -or past labours for that matter- expectations, and even self-image. As Cassell again observes, ‘Events of the present can be checked against the past, and events of the past contribute to the meanings assigned to present happenings.’ As a physician -as another person- I can only guess how the experience might be construed in the situation. And that guess is often based on such things as body language, stated preferences, previously expressed preferences and so on. My interpretation, of course.
So should I -or the nurse, the midwife or the doula- assume suffering and act on what is externally presented? And even if there is no suffering, should that alter the decision? Should we, that is, assume we are somehow able to read the internal mental status of the woman and yet act objectively enough to react to her anguish in a thoughtful and appropriate fashion? Should all pain be eliminated regardless of its meaning to the person? Regardless of the possible effects on the labour, the woman, or the context in which she finds herself inextricably embedded? Or is even thinking like this merely subterfuge: insensitivity to the situation, the woman, the need? Am I, who could not possibly be immersed in the same intensity of experience, projecting my prejudice, my reading of cultural demands, -my male viewpoint- on her? My meaning?
It is something I have struggled with -and indeed all others interacting with those in labour have encountered- all my professional life. I do not live in another’s body, nor am I privy to her past and lived experiences. I cannot presume to know the answers. Indeed the answers are more like contextually based questions that are impossible to phrase. I suppose an important guiding principle is contained in our Hippocratic oath: Primum non nocere -most importantly, do no harm. And even this is simplistic: how do I know it is not harming the situation? Simply that I don’t injure her or the baby? If I somehow caused the need for a Caesarian Section because of, say, an inappropriate timing or type of analgesia, is that non nocere? Or if I convinced her that she would indeed benefit from an epidural for her pain, and so took away her feeling of self-control, or the image that she had set for herself -that her mother had set for herself, maybe- would that constitute non nocere even though both mom and baby got through the labour relatively unscathed?
I suspect I would have thought I knew the answer when I was younger, when I at last escaped from medical school and my interminable residency program, when I first started in practice as an academically sound, yet experientially naive individual. I knew an answer, of course. Now I am no longer certain I ever knew anything other than what I was taught. But the answer? I don’t think so. I’m not sure I ever will.