Pain and Suffering: Non-dualism and Affect

When we feel miserable, when we are suffering, it is an embodied1Embodiment is, at its most simplest, a direct refutation of the Cartesian dualism of mind/body. The core idea finds the mind/spirit emerging as a function and part of the physical being, instead of a separation of a vessel (the body) and passenger (spirit/mind). response. We receive bad news and our head begins to ache. Our breathing becomes shallow, mouth dry, and tension spreads down into our neck, causing the muscles to cramp. If it’s really bad news, our stomach may turn and twist. Physical reactions that cause discomfort, perhaps even pain, caused by nothing more tangible than words. How can this be? After all, according to Eric J. Cassell in “Pain, Suffering, and the Goals of Medicine,” suffering and pain are closely related but separate forms of distress.2Cassell, Eric J. “Pain, Suffering, and the Goals of Medicine”in The Goals of Medicine: The Forgotten Issues of Health Care and Reform, edited by Mark J. Hanson and Daniel Callahan. Georgetown University Press, Washington DC; 1999. pp 105 The problem with Cassell’s piece is that he still falls into the dualism trap, separating out mind from body, reaction from action. Spinoza’s notion of affect, especially as interpreted by Antonio Damasio, gives us a way to see the differentiation Cassell would like to draw between pain and suffering while simultaneously maintaining a non-dualistic holism of the body. This paper will briefly summarize the argument Cassell makes in “Pain, Suffering and the Goals of Medicine” and then more closely examine the notion of affect and how understanding the body as a singular unit indicates the necessity for treating suffering as well as pain.

For Cassell, the placing of time in relation to suffering is crucial. “A sense of future is necessary to continue suffering”3ibid pp 106 because

[o]nly imagination, beliefs, memories, or ideas can supply the information necessary to provide a “future.” In other words, to suffer, there must be a source of thoughts about possible futures. 4ibid

He goes on to elaborate that suffering is a state of severe distress that threatens the integrity of the person, of self-hood, and most importantly for this argument, that “[p]ersons, while they may be identified with their bodies, cannot be whole in body alone.”5ibid pp 107 Cassell is very clearly placing the experience of self outside of, or separate, from the body, continuing the Cartesian tradition of mind/body dualism. Suffering, then, affects the mind, while pain is solely the province of a non-cognitive biological machine known as the body. Because imagination lies outside of the body, it cannot worry about the future; without the ability to worry about the future, it cannot suffer. It can, however, react to pain via the nociceptive apparatus.

The body is supplied with nerve endings that come from several differing types of nerve fibers. These varying fibers give rise to the noxious physical sensation, nociception. The nociceptive apparatus is responsible for transmitting (as well as modulating) physical sensation from these nerve endings, allowing us to experience a wide variety of sensation, not simply pain. Once at the brain, the signal sensation can be further modulated by chemical neurotransmitters.6ibid pp 102 This is a summary of Cassell’s section on how the nociceptive system works, and any mistakes in condensing and repeating the information are solely my own. Pain, then, is merely perception of sensory information from the nociceptive system, interpreted by the mind that lives within the body.

This comes back to the mind within the body, the ghost in the machine. According to Cassell, you can have both pain without suffering, and suffering without pain. One is caused by a physical response to the body, the other is distress brought on by a notion of time and ability to fear. The end result of this separation means that pain becomes something we attempt to quantify by physical measuring, while suffering becomes a black hole of the mind. The problem with this is that the ghost is not separate from the machine.

While Descartes gives us the split between the body and the mind, it is his contemporary Spinoza that brings the halves back together into a single whole. Spinoza did not believe that the mind or spirit was separate from the body, but instead was what we would now look at as an embodied whole, mind emerging as function of biology. Within this, and specific to a counterpoint for Cassell is Spinoza’s notion of affect, especially as it has been interpreted by Antonio Damasio.

Affect, at its very simplest, is the ability to touch and be touched in return. It is an emotive, embodied response to stimulus, “the modifications of the body by which the power of acting of the body itself is increased, diminished, helped or hindered, together with the ideas of these modifications.”7Spinoza, Baruch. Ethics. Hafner Press, New York; 1949 That is to say, affect is the sum of our drives, our motivations, feelings and emotions. But it is not just a mental construct; there is a physicality to affect. Our emotions exist within our body; as we have them we react instinctively — to pain and pleasure and their derivatives. There is a dynamic engagement of the body; these reactions race across our bodies prior to our experiencing the feeling related to the emotion.

In his book Looking for Spinoza: Joy, Sorrow and the Feeling Brain, Damasio specifically separates out emotion and feeling before bringing them back together as affect. Emotion, for Damasio, is a physicality, a reaction to stimulus. A sea anemone is poked by a stick and recoils. A student’s stomach twists as they stand in front of a classroom for the first time. While both anemone and student are experiencing emotion, a physical response to their environment, it is doubtful that the anemonae is also feeling8 Spinoza considers all emotive, embodied responses to be a reaction to either pain or pleasure; feeling, in this case, is the interpretation of that response, and not the tactile nature of touch., which is a cognitive interpretation of the experience of emotion.9Damasio, Antonio. Looking for Spinoza: Joy, Sorrow and the Feeling Brain. Harcourt Books, New York; 2003. Unfortunately, my copy of this book is currently lent out to a colleague who’s trying to tie affect into Deleuze’s time-movement, and I cannot give more than a summary of Damasio’s intent. Suffering is a feeling, a cognitive response to a physical experience.

Pain, one of the basest emotions according to Spinoza, can be caused by a physical sensation, such as being poked with a sharp stick — a prodding of the nociceptive system. Pain can also be non-external distress echoed onto the body. So the suffering of living in a ghetto can and often does resonate and manifest itself into the physical body, causing a non-external source of pain. While pain does not need to be linked to suffering (you can have a nociceptive, emotive response without a higher cognitive feeling; Cassell even notes that even high levels of pain can be tolerated as long as a person knows relief is possible10 Cassell, Eric J. “Pain, Suffering, and the Goals of Medicine” in The Goals of Medicine: The Forgotten Issues of Health Care and Reform, edited by Mark J. Hanson and Daniel Callahan. Georgetown University Press, Washington DC; 1999. “When their pain has been adequately relieved and it has been demonstrated that such relief will be forthcoming if the pain should return, they will frequently tolerate the same level of pain (by their report) without requesting medication.” pp 105) suffering is always linked to pain because suffering, feeling, always has a physical component to it. Cassell argues against this, saying that just the thought of pain that may happen can bring about suffering, but, in line with Damasio, I would argue that a stress response to a potential pain is a physical response. If we were to look, we would find that elevated blood pressure, those tense muscles, that nervous stomach.

The implication of the idea of affect and a singular embodied being on medicine and the treatment of suffering is simple, and does not actually deviate far from Cassell. Doctors should simply always investigate causes of suffering to rule out a material “stick”11The stick poking the sea anemone, the classroom staring at the student. generating the reaction. Affect allows us to negotiate the differences between pain and suffering without placing a value on one over the other, as well as supports the notion that suffering is within the purview of medicine and a valid condition for doctor’s to treat. It is entirely possible that a doctor may discover that the feeling of suffering is not being generated by a pathological concern, there is no physical deviation from the patient’s baseline normal. Perhaps the suffering is caused by poor living conditions, and the doctor can treat some of the symptoms (prescribing anti-anxiety drugs, sleeping medications, etc) while simultaneously bringing in other health care professionals or public assistance for the patient.12Several of the essays in The Goals of Medicine contemplate changes in our health care and public health system, some in line of addressing issues like this. However, a detailed addressing of the role of public health and other professionals is outside the scope of this particular paper.

A critic could respond to this argument by saying that it is an attempt to refute the subjective nature of pain, and that while “the body and its physiology are part of the person, and nothing happens to one part that does not happen to all,”13Cassell, Eric J. “Pain, Suffering, and the Goals of Medicine” in The Goals of Medicine: The Forgotten Issues of Health Care and Reform, edited by Mark J. Hanson and Daniel Callahan. Georgetown University Press, Washington DC; 1999. pp 103 persons cannot be known by reducing them down to their parts, because as you do that the person literally disappears.14ibid pp 107 I believe Cassell would see the idea of a nondualistic, affective approach to understanding the connection between pain and suffering as an attempt to actually reduce the body down to a simpler, less complicated form of being.15There is irony here, as one of the arguments of embodiment says that you cannot reduce an emergent property down to essentials; once a chocolate chip cookie becomes a chocolate chip cookie, you cannot break it back down into its components of flour and eggs. This could be seen as an attempt to somehow lessening the experience of suffering because it is retied to a physical experience, and thinking that the physicality of suffering would result in further attempts to quantify the experience to find some sort of universal, inclusive experience of suffering. But acknowledging that suffering has cause does not mean that it is simplistic or reductivist, only that when we experience something, we experience it with the whole of our body. There is no division, no ghost, no machine. There is only affect, a homeostatic loop between the nociceptive apparatus and cognitive ability to rationalize sensation.

Cassell attempts to differentiate the health of the body from the health of the person.16ibid pp 115 But, where does the person reside?

The flesh and skin are not the “I”,
And neither are the body’s warmth and breath.17Shantideva. The Way of the Boddhisattva. Shambhala, London; 1997. “Wisdom” stanza 59. pp 145

Likewise, since it is a group of fingers,
The hand itself is not a single entity.
And so it is with fingers, made of joints-
And joints themselves consist of many parts.
The parts themselves will break down into atoms,
And atoms will divide according to direction.18ibid “Widsom,” stanza’s 85-86. Pp 149

No, Cassell is right: “the error is in conceiving of persons in terms that have not changed for centuries.”19Cassell, Eric J. “Pain, Suffering, and the Goals of Medicine” in The Goals of Medicine: The Forgotten Issues of Health Care and Reform, edited by Mark J. Hanson and Daniel Callahan. Georgetown University Press, Washington DC; 1999. pp 116 However, his interpretation of the separateness of pain and suffering, of a dual nature of self, is not stepping outside those centuries of conceptions of personhood, but merely perpetuating the very idea he purports to speak against.