Undertreating Chronic Pain
Kathleen Koman’s article about pain (“The Science of Hurt ,” November-December 2005, page 46) brilliantly articulates the science surrounding the subject. The piece, however, does readers a profound disservice in its failure to address the issue of the undertreatment of chronic pain, which is an ongoing humanitarian and public-health disaster for the segment of the population that suffers from the most severe form of this disease.
Most patients who suffer from severe chronic pain are not receiving effective treatment. This was established in the survey “Chronic Pain in America: Roadblocks to Relief,” posted on the website of the American Pain Society (www.ampainsoc.org/whatsnew/conclude_road.htm ): “Just over one-half of chronic pain sufferers say their pain is pretty much under control. But, this can be attributed primarily to those with moderate pain. The majority of those with the most severe pain do not have it under control and among those who do, it took almost half of them over a year to reach that point. In contrast, seven of every 10 with moderate pain say they have it under control and it took the majority less than a year to reach that point.”
It doesn’t have to be this way. The problem is neither scientific nor medical. It is social and political.
As a clinician, I learned from my experience in treating this population that their pain can almost always be effectively controlled with opioid analgesics when titrated to optimal therapeutic effect. I also learned that the reason physicians don’t adequately prescribe these safe and effective medications is fear of criminal prosecution. In 1999, I was charged with multiple murders and threatened with lifetime imprisonment, before being exonerated at the end of a terrifying and exhausting six-year legal battle.
The root of the problem is nineteenth-century morality, manifested as prohibition law in the form of the Controlled Substances Act of 1970. It is dismaying to see the scientific community caught up in this mentality, and essentially abandoning an entire class of vulnerable patients as a result. Shame.
“Throughout history,” said Haile Selassie, former emperor of Ethiopia, “it has been the inaction of those who could have acted; the indifference of those who should have known better; the silence of the voice of justice when it mattered most; that has made it possible for evil to triumph.”
Frank B. Fisher, M.D. ’78
El Cerrito, Calif.
Koman writes of the “language of pain.” As a psychiatrist, my father’s life was the language of pain, both psychological and physical. His art was helping patients express what is so hard to express.
When I became an anesthesiologist, he gave me the best description of pain he knew—a worn, yellowed copy of an Emily Dickinson poem—and thus far in my career, I have found nothing better:
Pain has an element of blank;
It cannot recollect
When it began, or if there were
A day when it was not.
It has no future but itself,
Its infinite realms contain
Its past, enlightened to perceive
New periods of pain.
Martin B. Wehlage ’84, M.D.
There does not need to be any conflict between evolution and intelligent design, between science and religion. The article in the November-December 2005 issue by Edward O. Wilson, “Intelligent Evolution ” (page 29), and the book review “Better Living through Evolution ” (page 22), by Daniel L. Hartl, presented the “facts” of evolution in a very powerful way. Those religious people who are making a fight or conflict are making a big mistake. If there is a creator or intelligent designer, then evolution is the methodology by which that creator created the world as we know it. Science can have no argument with people who want to believe in some supernatural, primary force who started it all. That is an article of faith, not science.
Robert B. Youker, M.B.A. ’61
|Drawing from The Descent of Man, and Selection in Relation to Sex, by Charles Darwin, in two volumes (New York: D. Appleton and Company, 1871) unless otherwise noted. Scans of drawings courtesy of Kathleen Horton|
Wilson argues that science and religion are incompatible; he only demonstrates that they should be kept apart. For whenever essentially religious thinkers stray into the realm of science, as with intelligent design, the results are usually bad science and bad religion. The same results obtain when scientific thinkers, however brilliant, wander into the realms of religion, philosophy, or beyond. Thus, by contrast with his eloquent defense of evolution and the autonomy of science, Wilson’s pronouncements on “the toxic mix of religion and tribalism,” the “input of religion on human history,” and his curious cost-benefit analysis of religion and scientific humanism, are embarrassingly naive, simplistic, and banal. And what are we to make of the patently metaphysical assertion that “The revolution begun by Darwin…showed that humanity is not the center of creation, and not its purpose either”? Can a scientist know that?
Andrew Sorokowski, A.M. ’75
Wilson’s impassioned defense of Darwin and evolution goes further in advocating the replacement of God-centered religion by scientific humanism. His argument rests on the superior ability of science to explain natural phenomena, at least to a degree. While this provides unequivocal support for the value of scientific inquiry, it does not follow that science should replace religion, or serve as its “effective antidote.” Religion, Abrahamic or otherwise, continues to serve a critical purpose in helping many confront and accept life’s mysteries. If evolution renders creation mythologies obsolete there is no shortage of other mysteries still relevant.
While intelligent design lacks for evidence, neither is there evidence that science can answer the fundamental question posed by Gottfried Leibniz in 1714, “Why is there something rather than nothing?” Nor is it likely to resolve the question of prime mover. In any case, one need not be an adherent of organized religion, nor a proponent of intelligent design, to be left cold (and unconvinced) by the mechanistic assumption that science will one day explain everything.
Scientific humanism, to give credence to the latter half of its name, must come to terms with its own limitations and accept that there are some things science cannot explain. This need not be an abdication to superstition and the religious worldview, but it is a step toward realism and ending the “winner take all” struggle between religious and scientific fundamentalism.
Edwin J. McCarthy, S.M. ’89
It is not sound thinking, or even sound science, to disrespect and reject thousands of years of human thought and discourse on the major questions of our existence and the universe, let alone what may have been divine revelations offering us humans needed moral and practical guidance. Arrogantly discarding all we have learned in the way of civilizing wisdom, including the riches of religion, is an invitation for the apocalypse.
John A. McVickar, M.P.A. ’59
Like the vast majority of scientists, I believe the Darwinian theory of evolution is valid, but I do believe that many of evolution’s defenders make a mistake when they demand that all discussion of intelligent design be banned from science classes. It would be far better to meet the challenge head on. A brief description of the intelligent design concept should be given, noting that it rests entirely on claims that there are gaps in the description of life given by Darwinian evolution. In effect, it is only a critique of Darwinism; it offers no evidence for its validity beyond the assertion that evolutionary theory has not yet answered every question concerning the complexity of life.
It is only fair, then, that any discussion of intelligent design should also include a critique of it. First, the many ways in which the supposed inadequacies of Darwinism have been exaggerated should be noted. Second, note the many questions intelligent design cannot even pretend to answer: Why do many organisms possess vestigial organs that no longer provide useful function (e.g., the human appendix)? What kind of intelligent design is it that allows some of its highest creations (including humans) to be slaughtered by the uncontrolled proliferation of their own cells (i.e., cancer), or by the most incomplete of living forms (i.e., viruses)? How to explain evolution we see occurring before our very eyes (e.g., disease microbes developing resistance to drugs)?
Third, and most important, intelligent design lacks the fundamental epistemology of any scientific theory: it is neither verifiable nor falsifiable by any experimental observations. It makes no predictions as to what should be observed in circumstances not yet studied, and thus no observational result can either strengthen or weaken the evidence for or against intelligent design. It therefore lacks this most fundamental attribute of a scientific theory.
David C. Williams ’57
I believe that the persistence of belief in “god and all that” is actually further evidence of Darwin’s argument. Consider this question—is scientific humanism a comfortable place to live one’s life? Possibly, if you have a house in the suburbs, your mortgage is paid off, you have access to some six-figure salaries, you have a couple of happy, well-adjusted children, and your mother-in-law has joined the Cistercian monks. Most of us don’t live like that, and we have lives filled with crisis and pain both real and imagined. Likewise, I would argue that the majority of humans take life uncritically—that is, they don’t think about it too much. For them it’s just less stressful to take the Soma and accept that there is some bearded intelligence out there to give it all the meaning that they can’t be bothered to work out for themselves. This is evolution at work. Religion protects the species from the doubt and the difficulties inherent in this reality, and in our ephemeral nature as individuals. It might be argued that people function better as individuals (from a natural-selection perspective) when they possess some all-singing-all-dancing belief system. For in science, if humans make any sense at all, it is not at the individual level but as a species. The drawback, or the evolutionary price you pay for the persistence of religion, is war, but then that, too, could be seen as culling the herd.
People will cling to atavistic ideas because they are warm and familiar in a cruel and capricious reality, not because they’ve thought it all through. In the interim, we fear (probably somewhat unreasonably) that religious zealots will try to replicate their beliefs in subsequent generations. Then, through overt and covert proselytization, they will do what zealots have done throughout the ages, try to impose it all on the rest of us. The battleground for that will be in our schools, in our constitutions, and in our courts. In the end, religion will lose the battle because it is primarily based on ignorance and fear. One day, assuming we survive as a species, we will be less ignorant and have less to fear.
Pricey Principles at HLS
The dean of Harvard Law School has now twice reversed the school’s policy on alleged discrimination against gays by recruiters (“Money and Military Recruiting ,” November-December 2005, page 62). Why? Dean Elena Kagan, with the support of a majority of the faculty, explicitly and openly admits that the change was made solely because the University would be deprived of federal grant money if the law school adhered to its principles.
The lesson all law students will inevitably draw from this is that when faced with a conflict between money and principles, their senior leadership chooses the money, and no amount of classroom posturing (I wonder how Kagan’s decision will be treated in the school’s required legal-ethics course?) will be able to persuade them differently. If this is the way the law school is being run, I suggest that the motto on its seal be changed from “Veritas” to “Show Me the Money.”
David Clayton Carrad, J.D. ’72
A Modest Proposal for HBS
Film studies at Harvard (“Cinema Veritas ” by Harbour Fraser Hodder, November-December 2005, page 35) needs more money and a generous endowment, not humble pie and thank-yous for a few crumbs. And in the same issue, a solution to the program’s financial plight can be found in the news report “Generous Givers ” (page 57). Of the $590 million donated to the University last year, Business School alumni accounted for $120 million.
Now, I think it would be unfair and churlish to carp over the $53.4 million spent on renovating the business school’s Baker Library (page 55, same issue ). No, rather than decry the abundant offices, spacious conference rooms, the oiled-wood paneling and trim, and the sumptuous lounges, I say it’s only fair for the B-school to share a portion of its wealth with the cinema-studies program.
Ellis Kaplan ’46, Ds ’50
Mill Valley, Calif.
“Puppi” and a Correction
“In Bronze for Posterity ” (November-December 2005, page 104) refers to the sculptor of the bronze bust of Professor Werner Jaeger as “Puppi” Sarre. Her proper name was Marie-Louise Sarre. She lived in Berlin before World War II. Her friends called her “Puppi,” meaning “small doll” in German.
While Sarre may have resembled a small doll as a girl, she was anything but that when she became active in the German resistance against Hitler. In the summer of 1944 she was involved in a scheme to secure the support of none other than Heinrich Himmler in a plan to assassinate Hitler. After the failed coup attempt of July 20, 1944, she and many others were arrested and imprisoned by the Gestapo. She managed to escape through the help of a low-level orderly, while receiving medical treatment for a serious infection. She ended up in Ascona, Switzerland, where she lived until her death at age 95, in 1999. She was a lifelong friend of our parents and was Max’s godmother. She was the daughter of Friedrich Sarre, the first director of the Department of Islamic Art at the Kaiser Friedrich Museum (today’s Bode Museum) in Berlin. Her maternal grandfather was Carl Humann, the discoverer and excavator of the Pergamum Altar in Turkey in the 1880s.
The article brought back memories of Sunday lunches at the house of Professor and Mrs. Jaeger in Watertown in the early 1940s, during the height of World War II. We were privileged to be present because of our parents’ friendship with the Jaegers, dating back to prewar Germany. After lunch, the Jaegers and their guests would gather in a circle in the living room, and Jaeger would describe details of battles of the war with such vividness that we thought he had been present. The battles he described, however, did not take place in World War II but in the Peloponnesian War!
As a classics major, I, Fritz, took courses with Jaeger as well as with professors John Finley, Gerald Else, Peter Elder, and Sterling Dow, all of whom gave me the background and, above all, the enthusiasm to make teaching Latin and Greek my life work.
Maximilian W. Kempner ’51, LL.B. ’54
South Royalton, Vt.
Frederick Kempner ’44, A.M ’52
I am writing to assure my classmates, classical colleagues, and Harvard friends that contrary to the statement in the article about Jaeger and his bust, I am not dead. [Ed: Professor Calder was referred to as “the late” because of a reporting error.] I am working on my forty-second book and am teaching a full load of classical courses in my one-hundredth semester. I hope to continue so for some years.
The article whitewashes Jaeger, who did not leave Germany because “he disliked the Nazis.” Rather he left, after receiving a letter of thanks from Adolf Hitler, because his second wife, Ruth Heinitz, was Jewish. He was appointed at Harvard after a short time at the University of Chicago and only when the ancient historian Michael Rostovzeff had turned down the position to stay at Yale. His books are rarely read today.
William M. Calder III ’54, A.M. ’56
Oldfather professor of the classics
Professor of comparative literature
University of Illinois at Urbana/Champaign
The model for “pedestrian walkways beside Larz Anderson Bridge” (“Allston Optionsand Actions ,” September-October 2005, page 58) showcases the kinds of grotesqueries produced by those who spend all their time “designing” at their desks instead of exploring actual streets. Where’s Weld Boathouse in this scheme? Notice the cute little boats navigating the unseen gauntlet of piers such a construction would require. I’m reminded of the whalebone hoops once used to support women’s skirts. Anyone who has walked across the Larz Anderson Bridge a few times knows it’s not any nascent Ponte Vecchio, but what in blazes is going on here? And what “improvements” have these geniuses got in mind for Weeks Bridge? Furthermore, can anyone seriously suggest putting “a new bridge from between the two halls of Winthrop House to the Business School?
Meeting needs demands good design, and that requires much better planning than what appears to be happening at Harvard; and good planning requires a clear sense of purpose. I sense that the purposes here happen to be all over the map, so to speak, and with all sorts of agendas at play, which is just the kind of recipe that leads to half-baked schemes such as these proposals.
Erik Roth ’70
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