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APS Bulletin • Volume 13, Number 5, 2003

Pain as Path

Mark Sullivan, MD PhD, Department Editor

Spirituality and Voluntary Pain

Rev. Jason Cusick, MA

Before the advent of modern pain management interventions, pain was seen as a natural part of life, carrying a variety of religious, cultural, and societal meanings. It has been argued that when ether and chloroform were introduced into obstetrics in the 19th century, pain became a medical matter that lost much of its spiritual meaning in the medical community.

The connection between pain management and spirituality emphasizes how faith can reduce anxiety, stress, and negative thoughts and aid in pain practitioners’ attempts to relieve and eliminate pain. But recent scholarship and research have rediscovered a relationship between spirituality and pain that has been widely misunderstood and is more difficult to address—when people voluntarily endure pain, even refuse pain medications—for religious or spiritual reasons (Glucklich, 1999, 2001).

On the surface, patients’ refusal of pain interventions may appear linked to medical misinformation or concerns about addiction and/or psychopathology. But their refusal may reflect deeper spiritual and religious beliefs that need to be properly assessed and included in the patient’s plan of care.

The Spiritual Meaning of Pain

As recently as the 19th century, James Young Simpson, the founder of obstetric anesthesia, unknowingly fell into religious territory as people of faith debated whether pain relief was a sign of God’s grace or modern man’s attempt to avoid the natural consequences of original sin (which is intended to draw us closer to God). Those interested in character development argued pain was a door to spiritual and moral growth. Women’s rights advocates, while in favor of obstetric pain relief, feared narcotics and sedation would add to the already patriarchal power structures of the medical establishment. And the growing religious temperance movement promoted the first “Just Say No” movement against any substance that would alter one’s sense of reality (Caton, 1999).

In the end, mainstream religious thought overwhelmingly promoted pain relief with strong theological and religious support. Anesthesia and other approaches to pain management have flourished, especially in Western medicine, but the seeds of doubt, questioning of scientific promises, and deep religious convictions still remain strong, especially among more conservative people of faith. In fact, some have even questioned whether the advent of pain management has given a new, even extreme spiritual meaning to pain—that it is “evil and must be eliminated” (Mander, 2000).

Five Spiritual Interpretations of Pain

Is pain evil? Is it inherently bad? Can anything good come from pain? And is that potential good worth enduring the pain? In my work as a hospital chaplain and member of a pain management committee, I have worked with religious people who refuse pain medications for spiritual reasons. They find deep religious significance in their pain. I have found their understanding of pain generally falls into one or more of the following categories that have been considered “normal” throughout religious history:

Pain as Punishment. Pain as a form of divine punishment is perhaps the first place of our minds go in our attempt to reconcile physical pain and religious imagery. The connection is not without theological precedent. Theologians and spiritual caregivers regularly acknowledge “God’s punishment” as one of the ways the presence of pain has been traditionally understood by religious adherents (Moss, 1996; Conwill, 1986). People of Eastern faiths such as Hinduism have long believed pain and suffering in this life are a result of sin and misdeeds in previous lives. And though modern scholarship downplays the connection between punishment, sin, and physical pain, traditional Islam, Judaism, and Christianity have always understood some direct relationship between pain and punishment. This is clearly seen in debates about whether anesthesia should be used for laboring women, since pain was perceived to be the curse for Eve’s disobedience recorded in Genesis 3:15-16. (Cohen, 1996)

But punishment is not always punitive. Many Christians, citing Hebrews 11:7-11, see pain and suffering as potentially educational. “Divine discipline” or “divine chastisement” sees the infliction of pain, suffering, or “hardship” (as the text reads) as God’s desire to train a person, similar to the traditional parental discipline of spanking. John, a 58-year-old diabetic patient, lay in pain caused by a necrotic toe, which he believed was the result of his “backslidden” relationship with God. Quoting Deuteronomy, Chapter 26, which refers to the blessings of obedience and the curses of disobedience, John spoke of how he felt the flare-up of his diabetes was connected to his “spiritual disobedience” and his noncompliance. John saw his hospitalization as a corrective punishment for sin that brought him into closer fellowship with his God.

Pain as an Opportunity for Transcendence. I asked a friend, an elder of a large Evangelical church, about his prolonged recovery from knee surgery. He said he was fine, but admitted he was not taking all the pain medications he had been prescribed. He said, “A little pain is good for the soul.” While most mainline religious faiths advise against suffering and encourage the use of pain medications when needed, they also recognize the potential for spiritual transformation through pain.

In a 1984 papal address at St. Peter’s Bascilica in Rome, Pope John Paul II said, “Suffering seems to belong to man’s transcendence: It is one of those points in which man is in a certain sense ‘destined’ to go beyond himself, and he is called to this in a mysterious way.” Monks, mystics, and martyrs have long seen pain as a way of breaking from this life to experience another. It is not odd that some people in the modern world might still use pain for such purposes.

The best example of the use of pain in modern health care is in our labor and delivery rooms. A new mother writes, “I am no masochist; I have been known to cry over cuts, menstrual cramps, and even spilt milk. Childbirth is pain like none of those, nor is it like any other pain I have had...I had no need or desire to end or diminish the sensations of birth. It was exhilaration to be part of a primal experience. I was caught up in the desire to know each moment; to discover the unique progression of events leading to the entrance of a new being—or is it ‘exit’? Not only me, but no one else can have that time again. It was an opportunity” (Caldwell, 1981).

Pain as Test or Competition. Marie, a 28-year-old Vietnamese-American woman, chose natural childbirth to give birth to her son. While intending to give birth “as God intended” (meaning without medical intervention) and later viewing the experience as an opportunity for transcendence, her primary motivation for voluntarily enduring the pain of labor was more to test her own limits and prove to herself and to others that she was not a weak-willed person. “I want to see what I can handle,” she said, speaking of the modern world’s overemphasis on personal comfort and convenience. For those who choose it, voluntarily enduring pain becomes an opportunity to discover one’s own limits and potential and connect with one’s self on the most intimate level.

Pain as Atonement. While the strongest image of pain as atonement comes from the Christian tradition of Jesus’ painful crucifixion for the atonement of humanity’s sin, other religions and cultures also believe in the redemptive value of pain and suffering. Suki, a 62-year-old Sri Lankan woman recovering from abdominal surgery, told me she believed her pain was helping many deceased friends and family pass into the next life. And we only need go back 100 years to the Native American sun dance to see an indigenous example of pain as atonement. Before being outlawed in 1904, those practicing this ritual attached themselves to large poles with hooks or eagle talons, and, symbolizing death and rebirth, captivity and freedom, and illness and healing, painfully pulled themselves from the hooks’ flesh-piercing grip. Manny Twofeathers wrote, “I prayed to the Creator to give me strength, to give me courage. I was doing it for my children. When I stood up, I did feel pain. I felt pain, but I also felt that closeness with the Creator. I felt like crying for all the people who needed my prayers. I prayed they could get enough to eat. I prayed for all the people who are sick in the world. It brought tears to my eyes...the pain did not compare to what I was receiving from this sacred experience...” (Glucklich, 2001).

Pain as Gaining or Retaining Control. Physical pain and themes of control and power are intimately connected. Buddhist monks practiced self-immolation in Vietnam for social protest; Filipino Catholics of Pampanga engage in self-crucifixions reflecting historical fights for social and religious control; and a cursory survey of psychological literature reveals the relationship between self-hurting and young American girls.

Martha, a 53-year-old Christian Scientist patient, was admitted to the oncology unit of a hospital. While visibly in pain, she refused morphine and other medications that would relieve the pain caused by the tumor growing inside her. She struggled to hold onto the faith of her youth, which taught her that matter is an illusion and that illness and pain are products of the mind. She recalled the words of Mary Baker Eddy, founder of the Christian Science Church and author of “Science and Health with Key to the Scriptures,” which proposes a spiritual approach to healing without modern medicine and is essential reading for followers of Christian Science. In 1996, Eddy wrote, “When your belief in pain ceases, the pain stops; for matter has no intelligence of its own. The full understanding that God is Mind, and that matter is but a belief, enables you to control pain.” For Martha, to treat her pain with medications would be to acknowledge that the pain (and illness) exists. Such a belief would be a renouncing of her faith. For this devout, conflicted woman, enduring pain and refusing its elimination through medical means was a way to regain control and preserve her faith.

The Idea of Voluntary Pain

Why would someone want to be in pain when they don’t have to be? The idea of voluntarily enduring pain for religious or spiritual reasons should not alarm us. We need only reflect for a moment to consider the times we all have voluntarily engaged in an activity we knew would be painful—from getting tattoos to running marathons, from childbirth to the voluntary emotional pain of psychotherapy. Ultimately, pain is not the goal of those who refuse pain medications or engage in voluntary pain. There are higher goals—goals that may be unattainable without pain.

It is odd to think there could be goals higher than painlessness. Even in the labor and delivery units, one of the last acceptable healthcare venues of voluntary pain, the idea of accepting pain rather than relieving it is often viewed with confusion. Perhaps this shows how far we have come as a society in which the absence of pain is the chief good or ultimate value to us. As Donald Caton (1999) records in his historical treatment of the rise of anesthesia and modern pain medications, the social meaning of pain has changed. When patients refuse pain medications in healthcare settings, a dialogue about the meaning of pain that allows us to respond in meaningful, thoughtful, and compassionate ways should stir within us.

My Response to Voluntary Pain

As a chaplain, I see my role in responding to cases of voluntary pain as one of discovery, advocacy, teaching, and support. I ask, “What spiritual reasons, beliefs and history are behind this person’s choice to refuse pain medications? Are these beliefs a result of religious miseducation or are they part of this person’s otherwise healthy belief system?” For the devout Catholic who is enduring pain “because Jesus did,” I explore their thoughts about the Catholic church’s ethical and religious directives, which guide patients to appreciate the Christian understanding of redemptive suffering, but only after all attempts to relieve pain have been exhausted (United States Conference of Catholic Bishops, 2001). Can we relieve the pain but retain its spiritual significance to patients? For the Christian Scientist, I feel compelled to educate the staff, rather than the patient, and work to find a Christian Science practitioner who can come and work their healing arts as part of the patient’s plan of care.

Overall, tremendous support and team building are necessary in cases in which patients make decisions that result in voluntary pain. Apart from medical concerns, the emotional, ethical, and spiritual toll this takes on staff can be overwhelming. Spiritual care professionals are a resource for patients and staff, and they help organizations to refine their philosophy, theology, and policy regarding pain, spirituality, culture, and medicine.

Has modernity created such a desire for mystical experiences that we would use pain to get to it? We long for discovering what is beyond ourselves or within ourselves. For many people, pain creates the most profound (and for some, the only) genuinely religious promptings. Pain, whether we choose it or not, is part of our journey. Emotional, spiritual, and physical pain take us to places where almost nothing else can, both positive and negative. It unites us as a human community, providing great opportunities to grow, learn, and reach out to others, but it also invites dangerous temptations of despair, doubt, and spiritual death, as I have personally experienced (Cusick, 2000).

As healers, we are compelled to do all we can while valuing individual faith, patient autonomy, and choice. Our professional response to people in pain should create in us a desire to care for patients’ bodies and spirits. We must question our own “theology of pain” and recognize the value of struggle, sorrow, and pain in a culture that places such an emphasis on comfort, happiness, and painlessness. In a climate so open to spiritual growth, we will do well to acknowledge and explore the potentially disturbing circumstances under which spiritual growth may occur—pain being one such circumstance.

References

Caldwell, L. (1981). An essay on the labor of childbirth. Unpublished manuscript.

Caton, D. (1999). What a blessing she had chloroform: The medical and social response to the pain of childbirth from 1800 to the present (pp. 209-213). New Haven, CT: Yale University Press.

Cohen, J. (1996). After office hours: Doctor James Young Simpson, Rabbi Abraham De Sola, and Genesis chapter 3, verse 16. Obstetrics & Gynecology, 88(5), 895-898.

Conwill, W. L. (1986). Chronic pain conceptualization and religious interpretation. Journal of Religion and Health, 25(1), 46-50.

Cusick, J. (2000). Four days in the school of pain. Journal of Pastoral Care, 54(2), 201-202.

Eddy, M.B. (1996). Miscellaneous Writings 188– 1896. Boston: First Church of Christ Scientist Publications.

Glucklich, A. (1999). Self and sacrifice: A phenomenological psychology of sacred pain. Harvard Theological Review, 92, 479-506.

Glucklich, A. (2001). Sacred pain: Hurting the body for the sake of the soul. Oxford, NY: Oxford University Press.

Mander, R. (2000), The meanings of labour pain or the layers of an onion? A woman-oriented view. Journal of Reproductive and Infant Psychology, 18(2), 133-141.

Moss, S. (1996). Pain and suffering in the Jewish tradition. Journal of Psychology and Judaism, 20, 68-71.

United States Catholic Conference, Inc. (2001). Ethical and Religious Directives for Catholic Health Care Services (Part 5, No. 61, p. 32). Washington, DC: Author.