To this day, my eyes shine with childlike curiosity whenever I visit the surgical-instrument room at my old hospital. There, cleaned tools, packed individually, sit side by side in metal cages. They come in all geometric shapes. Some are straight, others are curved, and still others break in the middle at right angles. Some are round, some are linear, and one, an abdominal stapler, comes in the shape of a trapezoid. The odd shapes give off the aura of modern art or exceptional jewelry, and whenever I see them, I feel as if I had entered an exhibition. Indeed, it is hard for me to resist the urge to take one of the instruments out of its sterile package, touch it with my hands, and play with it.
Yet as an anesthesiologist, sometimes the room also makes me sad. The sense of sadness probably comes from the incompleteness of medicine’s conquest of disease. What are these instruments? Not the porcelain basins and blunt wooden probes of yesteryear; nevertheless, there are still scissors, scalpels, saws, and drills. Everything in the room causes a person pain, attesting to the primitive nature of existence. The room always hovers on the brink between the primeval and civilization, and however enticing the steel instruments may be to look at, however brightly they may reflect the overhead fluorescent lights, still civilization cannot claim the ultimate victory. Life still hurts because of the things in this room.
A philosopher might seem out of place here, as if a pink flamingo had suddenly strayed into an old English garden. But other than the hospital’s psychiatric wing, where doctors sometimes touch on philosophy to explain mental illness, the instrument room is probably the most logical place in a hospital for a philosopher to be. Philosophy’s focus tends to be arcane, and words, as is well known, are the great foes of reality. But philosophy has much to say about pain, which is an anesthesiologist’s chief concern. Philosophy has not only corroborated my own experience managing pain, but it has also influenced some of my clinical decisions.
Surgical patients hate pain, but sometimes they need to feel it. They wake up too slowly from general anesthesia and forget to breathe. Shouting fails to rouse them. Putting an alcohol swab under their noses is equally useless. All I can do is knead my knuckles into their sternums to stimulate them. But when they open their eyes in pain and start breathing again, those same eyes express total hatred for me. It is the paradox of pain: We come to life through pain, yet we hate pain.
The History of Life Is the History of Pain
Many philosophers have described pain’s elemental role in our lives. Hobbes said, “To have no desire is to be dead.” Since desire means “not yet having,” every living person feels the pain of not yet having. Schopenhauer said pain is the enduring fact in our lives and that all enjoyment merely stems from its removal. The so-called “state of nature” imagined by some philosophers was full of misery and pain.
Pain’s elemental place in our lives has a correlate in one of anesthesiology’s enduring mysteries. Sometimes patients lose consciousness under spinal anesthesia, usually because their pulse and blood pressure have dropped. At other times, the reason is unclear. Some researchers believe the anesthetic creeps up toward the patient’s brainstem and knocks out consciousness directly. But experiments that track drug movement inside the spinal canal suggest this may not be so.
The most intriguing explanation I have encountered is that wakefulness depends on feeling the tiny stimuli that bombard our nervous systems every moment, below the level of awareness—for example, the feel of clothes on our bodies, the feel of shoes on our toes, or the feel of air on our skin. We typically ignore these tiny stimuli, even when they are irritating, but taken together they prod our brains to stay alert. When the skin over most of our bodies ceases to feel them—for instance, under spinal anesthesia—we sometimes lose consciousness. We lack sufficient sensory input—nuisance input, bothersome input, and even slightly painful input—to stay awake.
This theory, and the philosophies that complement it, once helped me out of a dicey clinical situation. A patient of mine under spinal anesthesia lost consciousness despite normal blood pressure, pulse, and oxygen levels. Even with a shake of the shoulder, she remained asleep.
I debated what to do. If she had not had a full stomach from eating an hour before, I would have simply continued to observe her and monitor her vital signs. But, because of her full stomach, I worried she might be somnolent enough to aspirate her stomach contents. True, people go to bed with a full stomach all the time without aspirating. People don’t lose their protective cough reflex just because they fall asleep. The question I faced was whether she was merely asleep or something else. If it were something else and she had lost her cough reflex, then the safest thing would be for me to induce general anesthesia and place a breathing tube in her windpipe to protect her lungs. Yet the very act of inducing general anesthesia poses its own risk of aspiration.
Guided by philosophies that speak of pain’s centrality in our lives, I decided that my patient had grown so “bored” from insufficient tactile stimulation, due to numbness over most of her body, that she had simply fallen deeply asleep. Rather than insert a breathing tube, I watched her extra carefully and waited for her to wake up naturally. Ten minutes later, she did.
And so the philosophical point was demonstrated. The opposite of pain is not pleasure but sometimes unconsciousness. Nuisances, irritants, and other forms of resistance that we feel but barely acknowledge in our everyday lives, and that we toss into the general category of “pain,” joggle our minds enough to make waking life possible.
The Art of Managing Pain
Anesthesiologists in training often blame themselves when their patients feel pain. They think they have failed or done something wrong. Over time, they realize that sometimes a patient’s own state of mind is the cause.
A course correction in philosophy allowed this realization to take hold in medicine. Cartesian dualism had persuaded doctors that pain was a bodily reflex caused by a noxious stimulus that sent a signal to the brain. There, metaphorically speaking, a bell rang, representing an awareness of pain, followed by a return signal that caused the injured body part to pull back. This paradigm led to the long-standing division in medicine between so-called “organic” pain (meaning pain arising from obvious injury) and “psychic” pain (meaning pain with no clear cause.) Doctors dismissed the latter as being “all in the head,” while downplaying the mind’s role in pain altogether. Gradually, attacks on dualism changed doctors’ thinking, culminating in the “gate-control” theory of pain, medicine’s first official approach to pain that mingled mind and brain.
The new theory, published in 1965, had clinical consequences. For example, I once noticed a post-surgical patient suffer breakthrough pain every evening around six o’clock. The nurses and I investigated. We found that the man’s mother always visited around this time. Their strained relationship caused the man emotional stress and exacerbated his pain. I prescribed him an extra dose of narcotic each evening to fix the problem.
Philosophy refined my approach to pain in a second way—again, with later philosophies correcting an earlier one. In this case, the earlier one was the philosophy of science itself.
Over the centuries, science kept searching for a more fundamental order in nature, hidden from immediate view yet behind everything. Physicists broke down particles into smaller particles; in doing so, they discovered new universes, infinitely small, each of them complex. Biologists looked through microscopes for a secret world lying hidden within the cell. Mathematicians looked for more infinitesimals. Psychologists divided the mind into a growing number of cognitive, behavioral, and emotional categories, while researchers sought the tiny neurotransmitters that presumably held the mind together.
In practical form, the new psychology encouraged professionals to probe ever more deeply into others around them, to find mysterious thoughts and motivations unknown even to the subjects themselves. Doing so allowed for a better sense of the complexity of people, yet sometimes at the cost of a sense of their unity. A person risked becoming a colony of feelings, a coral reef of diverse personalities, a succession of states of mind, grouped together but not united.
The new psychology put blinkers on me while a young physician. The gate-control theory taught me to watch out for negative feelings that could heighten a patient’s narcotic needs. But by the time I analyzed a patient’s organs and his anxiety levels, there was hardly anything left by which to recognize the patient save his name, his body, and a few external mannerisms. My patient’s urge to make sense of the cold, impersonal world of the hospital and the predicament he found himself in was lost to me, belonging as it did to no specific psychological category.
To reduce that urge to a mere “negative feeling” is to disrespect it, and to overlook what is needed to treat it. It is the universal urge in all people to introduce some intelligible order into an anarchic situation. When patients lie passively in the hospital, action is impossible; so they pass from action to representation, from reality to illusion. They seek a substitute, some mixture of reality and illusion, to serve as an explanation for what is going on around them and what will happen to them. It is no different from the desire that led people to create legends and myths centuries ago.
Artists have traditionally met this need. Their illusions complement reality. In music, for example, funeral marches are purposely slow, with a strong beat, to help bring the passions under control. A symphony may sound like a storm of sounds and conflict, but the music has an order to it that subdues the tempest, and listeners experience the illusion of victory over the disorder. Haunted by the world’s inhumanity, painters and sculptors suggest new interpretations of reality, allowing us to imagine the possibility of a more humane world. I realized that my job as an anesthesiologist was not just to be the scientist who charts vital signs, or the philosopher who adjusts narcotic dosages according to mental state; it was also to be the artist who cultivates a comforting illusion in confused patients.
Whether in the holding area or in the operating room, a patient thinks, This situation is absurd. Here I am, about to lie naked on a hard table, then be cut on. What is the meaning of this strange carnival? How did this happen? All I want is peace, and lo and behold, here I am about to be sliced. Will it hurt? Patients do not understand the hospital. They do not understand how anesthesia works. They do not understand the strangers around them dressed in scrubs. They do not even understand themselves, as they wonder how they got into such a difficult, perhaps embarrassing, situation and whether a bad decision on their part had been the cause. They feel so exhausted by their mental struggle that they dream of an intelligible universe, of a world where disease, the hospital, the people around them, and even their own fates are no longer unanswerable enigmas.
The philosopher Henri Bergson helped me to understand this point by identifying the blind spots of science. Science sometimes errs when it respects labels more than the underlying truth of what is going on, he explained. While focusing on the categories it generates through analysis, it sometimes forgets those aspects of individuals that cannot easily be summed up in a word.
Here is an example of how I created an illusion to help navigate a patient safely through an operation: My patient was undergoing a repeat cesarean section under spinal anesthesia. After her baby came out, she complained of feeling pain around her chest and shoulders, which is common during this operation. Confused and scared, she began to cry and even became hysterical, at one point reaching toward her open abdominal wound. All my usual methods of dealing with the situation were blocked. She had very high blood pressure, so I could not give her ketamine. She was allergic to narcotics, so I could not give her fentanyl. The amnestic drug midazolam had little effect on her. Converting her anesthetic to full general anesthesia was the dreaded last resort, because of the risks posed by her blood pressure and morbid obesity.
Instead of seeking a scientific solution, I created an imaginary world that she could share in, to help restore in her a sense of order, thereby calming her down sufficiently to get her through the rest of the operation without having to put her to sleep.
I told the nurse to put on soft music. The musical rhythm seemed to bring my patient the same reassurance that a rocking cradle brings to an infant. The recurrence of musical themes gave her the pleasure of recognition and allowed her to anticipate, giving her a semblance of order.
I showed her a copy of her old anesthesia record. I told her I had given her the exact same dose for her spinal anesthetic she had received during her first cesarean section, and therefore she shouldn’t worry. She was fine before and would be so again. Although spinal anesthesia is hardly so reproducible based on dosage alone, I pretended to her that it was. The universe became even more orderly for her. Again, she felt reassured.
I told her that she was probably feeling “pressure” rather than pain. True, she was the person in pain, not I. I could not know how she felt. But just as anxious people centuries ago sought someone who they believed was peculiarly attuned to the universal rhythms of nature and who might interpret pain and its meaning for them, so my patient sought the reassurance of both belief and knowledge at that moment. Someone capable of uniting both in legend could assuage her fear of the unknown. I told her the pressure in her chest and shoulder was simply the result of air that had slipped underneath her diaphragm and not from the surgeon cutting. Was it so? Perhaps. Legends always have some basis in fact. It is one of several theories that doctors have put forward to explain the mystery of chest and shoulder pain during a cesarean section. In any event, my patient believed in the well-ordered world I had created for her. She believed her pain was only pressure, something common and predictable rather than unusual and shocking.
I was an artist during that crisis, as subjective as the scientist is objective. And I succeeded in calming my patient so that we could finish the operation using spinal anesthesia alone.
The Mystery of Narcotics
Narcotics do not get rid of your pain. They simply make you care less about it.
It is hard to capture in words the feeling of having pain that no longer interests you. Narcotics transport you into a condition of such remote absence from yourself that existence becomes a thing almost without meaning. Rather than resent your pain, it’s as if you had closed your account with life, to the point where you no longer seem to know what use to make of life. You feel full.
True, there is the so-called narcotic “rush” that is more akin to ecstasy than indifference. Yet this is limited in duration. Our bodies, it seems, were not equipped to enjoy ecstasy perpetually. Most surgical patients on narcotics seem cold, unemotional, and sober rather than “high.”
After being on narcotics for a few days, some surgical patients refuse any more doses, even upon risk of their pain returning. It is as if the drug had produced in them a state of mortal boredom: Permanent satiety itself had grown painful to them. Such a state is analogous to how some people feel after playing video games for hours. The head can ache from work. But it can also ache from amusement.
Oddly enough, when people without pain or anxiety are given narcotics, they often complain of unease. Narcotics work best in people who feel miserable.
Here, narcotic-induced pleasure is like liberty. Both are not primary within us; neither is evoked without being provoked. We never think we are free when nothing shows us that we are not free or that we could not be so. Similarly, we rarely feel the pleasure of narcotics unless in response to some sensation of pain or anxiety.
Philosophy supports this last principle. Nietzsche wrote in Untimely Meditations that people need walls. They cannot feel free unless they have walls to feel free from. Isaiah Berlin suggested something similar when defining “negative liberty.”
This principle once helped me out of a difficult clinical situation. A woman was going for minor gynecological surgery. The anesthesiologist in charge had decided to give her what is called a “nitrous-narcotic” anesthetic, where a patient is loaded up with narcotic, then pushed into unconsciousness with nitrous oxide right before the operation begins. Because morphine often takes at least twenty minutes to work, the anesthesiologist began injecting the drug while the patient was still in the holding area. After the full dose had been given, the surgeon suddenly called to postpone the case, saying she had to rush down to obstetrics to perform an emergency cesarean section. Without any pain or anxiety to combat, and with so much morphine onboard, the patient felt horrible. She complained of nausea, grew agitated, and started to cry. Her anesthesiologist didn’t want to give her any other sedatives, since, when combined with morphine, they might stop her breathing.
To calm her down, the staff soothed and pampered her. They put her in a quiet area and propped her up with soft pillows. But that only seemed to agitate her more. Thinking philosophically about how pleasure is felt, conceived, and desired in response to pain, I suggested the staff do the opposite. Upon my advice, they brought her into the cold operating room and laid her on the hard operating table. They took away her pillow and used a hard blanket for a cushion instead. They irritated her with noise and the nuisance of monitors being applied to her arms and chest. Now the morphine had something to work against. The patient fell right to sleep and remained peacefully asleep until the surgeon arrived to say hello and apologize for the delay.
The Greater Mystery
Anesthesia brings out the strangeness in people. Even the most conventional people become unpredictable in the operating room, as body and mind enter a kind of outer limbo, beyond life and sleep. Yet this strangeness is instructive. By virtue of the extreme reactions it provokes, anesthesia offers up discrete insights that cannot easily be discovered about people in normal life.
It is what makes anesthesiology the natural home in medicine for both science and philosophy. Much about people’s reactions to anesthesia is not obvious, and therefore, to explain things, both the scientist and the philosopher must start with intuition. Pursuing the dream of a hypothesis, both follow the same mental process, the only difference being that the scientist, having conceived a hypothesis at one radiant glimpse, then submits it to the test of experiments, while the philosopher must nourish what his moment of illumination revealed with memory, logic, and observation. Although their subsequent labors diverge sharply, the starting place of the scientist and the philosopher is often the same.
Combining science and philosophy helped make me a better doctor. While spending so much of my working day in a life far beyond normal human dimensions, I encountered many oddities and curiosities in people’s behavior. Yet even at the end of my career, I cannot say that I know more about those oddities and curiosities than when I started out. Knowing more was nothing other than having knowledge of them. I could not really explain them.
Thus, there remained for me a gap between ignorance and truth, between illusion and reality, which I could never cross, and when caring for patients, I often found myself instead drawing distinctions between different qualities of belief. Anesthesiology is considered one of the most scientific medical specialties because of its emphasis on physiology and pharmacology, equations and formulas, gases and tubes. Indeed, I went into anesthesiology because I thought, here, science had shrunk the mental area within which illusions were possible—and I disliked illusions as much as I disliked imprecision and unprovable maxims. But toward the end of my career, I realized that my task as an anesthesiologist had been not simply to implement the science of pain management but to rely on science, philosophy, and even art, and to assign each field its place in reality in order to make it do its proper work. I had been a philosopher, even an artist, without knowing it.