Monday 7 June 2010

The bureaucratization of pain

Analgesia - pain-relief, especially in the broadest sense of relief of suffering - was for most of history the primary interventional benefit of the physician (as contrasted with the surgeon) in medicine.

Among the primary benefits of medicine, perhaps prognosis is the greatest benefit - that is, the ability to predict the future; because prognosis entails diagnosis and an understanding of the natural history (natural progression) of disease.

Without knowledge of the likely natural history of a patient, then the physician would have no idea whether to do anything, and what to do.

However, through most of history, physicians were probably unable to influence the outcome of disease - at least in most instances they would diagnose, make a prognosis then try to keep the patient comfortable as events unfolded.

Keeping the patient comfortable. Relief of suffering. In other words: analgesia.

Much of medicine remains essentially analgesic (in this broad sense), even now.

But relief of actual pain is the most vital analgesic function: because at a certain level of severity and duration, pain trumps everything else.

So, perhaps the most precious of all medical interventions are those which relieve pain - not just the general pain-killers (of which the opiates are the most powerful) but the effective treatments of specific forms of pain - as when radiotherapy treats the pain of cancer, or when GTN treats the pain of angina, or steroids prevent relentless itching from eczema and so on.

The *irony* of modern medicine is that while it has unprecedented knowledge of analgesia, of the relief of pain and suffering - these are (in general) available only via prescription.

So, someone who is suffering pain and seeks relief, and effective analgesia is indeed in principle available, must *first* convince a physician of the necessity to provide them with relief.

If a physician does not believe the pain, or does not care about the pain, or has some other agenda - then the patient must continue to suffer. They do not have direct access to pain relief - only indirect access via the permission of a physician.

Pain and suffering are subjective, and it is much easier to bear another person's pain and suffering than it is actually to bear pain and suffering oneself.

Yet we have in place a system which means that everyone who suffers pain must first convince a professional before they can obtain relief from that pain.

This situation was bearable so long as there was a choice of independent physicians. If one physician denied analgesia for pain, perhaps another would agree?

The inestimable benefits of analgesia have been professionalized, and that means they have nowadays been bureaucratized since professionals now operate within increasingly rigid, pervasive and intrusive bureaucracies.

So the inestimable benefits of analgesia are *now* available to those in pain only if they fulfill whatever bureaucratic requisites happen to be in place.

If the bureaucracy chooses (for whatever reason - saving money, punishing the 'undeserving', whatever) that a person does not fulfill the requirements for receiving analgesia, then they will not get pain relief.

That is the situation, at the present moment.

Why do we tolerate this situation? Why do we not demand direct access to analgesia? Why do we risk being denied analgesia by managerial diktat?

Because, bureaucracy does not even need to acknowledge pain - it can legislate pain and suffering out of existence. It creates guidelines which define what counts as significant pain, what or who gets relief, and what or who gets left to suffer.

It is so easy to deny or to bear *other people's* pain and suffering, to advise patience, to devise long-drawn out consultations, evaluations and procedures.

Bearing pain ourselves is another matter altogether. Pain of one's own is an altogether more *urgent* business. But by the time we find ourselves in that situation, it is too late for wrangling over prescriptions, guidelines, and procedures.