To learn about value and proportion we need to honour illness,
and ultimately to honour death. (Frank, Reference Frank2002, p. 120)
1. Methodological clarifications
The symmetry of the title was inspired by an ontological connection between pain and meaning that I noticed during my work in medical settings. As a medical interpreter, I had to lend a voice to people in pain and to witness how pain was transferred into stories, where both patients and physicians added elements of meaning and negotiated semantic possibilities.
I will not talk here about ‘spiritual’ pain, given the complexity of this area and the different approaches needed for its comprehension. Also, for the purposes of this text, I need to launch a via negativaFootnote 1 attempt of sorting out my topic, to not get lost in the richness of cultural representations around the concept of pain. I will not consider self-inflicted or anticipated pain, like the pain that we know we will experience after a new physical activity, or after an operation. The reason is that in these cases, there is a direct causal correlation between activity/fact and pain that carries a certain semantic or at least an explanatory platform. I will also exclude child-birth pain, given that it is ‘expected’ or anticipated to a certain extent, and also it abounds in cultural significations. Without diminishing the excluded types of pain, my interest here is in exploring how we describe, assess, and associate the meaning of pain that signals some problems or malfunctions of the body before we know what exactly causes it.
From this perspective – regrading a pain-signal as a semantic problem that starts a heuristic process – I am interested in constructions of meaning ranging from ‘worrying pain’ to extreme experiences of pain. I would like to keep previous philosophical thoughts on this topic as a safety net and adventure into the world of medicine, where the immediate presence of pain opens new possibilities of reflection. For this reason, I will use medical narratives on pain as the main source of reflection. The testimonies of pain I use stem mainly from two sources: Arthur Frank's book At the Will of the Body, in which he describes his experience with cancer, and Peter Dorward's collection of stories inspired by his work as a general practitioner, The Human Kind.
2. Bio-hermeneutics
My main intention is to look at pain as a sign of the body that something is wrong. I will argue that there is a meaning of pain before and after an illnessFootnote 2 is diagnosed. The diagnosis gives pain a certain meaning: an organ is damaged; a nerve is firing in a weird way, a certain disease takes over the body, a tumour is growing and pressing on other organs etc. An illness contains its own semantic paradigm. But the pain before the illness, before the diagnosis, brings the possibility of ‘something wrong’ into the pace of life. My interest here is in examining how people cope with it, how they construct their lives around unexplained pain.
The complex semantics of pain and the efforts to integrate it into discourse requires introducing what I call bio-hermeneutics. In contrast with medical hermeneuticsFootnote 3, bio-hermeneutics is not how science or medicine make sense of biological processes. It is how people make sense of inaccessible biological facts that manifest themselves as symptoms, and primarily here, as pain. More than that, bio-hermeneutics should include our interpretation of pain and illness of other living creatures from our environment: a suffering pet or an injured wild animal will require our attention and assessment and influence our actions. John Nessa, writing about medical hermeneutics, excludes veterinary medicine: ‘human medicine is, unlike veterinary medicine, an enterprise where the object is an individual, a person, not a biological being only. To understand a man is to understand a being who understands himself’ (Nessa, Reference Nessa1996, p. 372). While the second part of the quote is accurate, non-human animals are not usually mere ‘biological beings’ either. In veterinary practices, veterinarians have to deal with pet owners who care a lot about their pets, present their worries, expectations and their own interpretations of their animals’ illness or suffering. Even farm animals are not beyond farmers’ intentions and interpretations. It can be true that certain animals are not strongly included in the web-of-significance for a certain human life, but bio-hermeneutics should apply to those who are in our proximity: a pet, a horse, animals in zoos or conservation areas, many other species enacted as ‘pests’ etc. When someone takes the ‘sad’ houseplant to a garden centre to be ‘diagnosed’, this opens a hermeneutic chain of interpretation. Bio-hermeneutics opens a wider perspective for the understanding of our relationship with our living environment and how we make sense of it and interpret its problems, from pets and houseplants to forests and ultimately to the pressing and present understanding of our planet in the light of climate change.
Bio-hermeneutics deals with the symptomatic readingFootnote 4 of pain as a sign. Medicine tries to reveal ‘biological facts’, but ultimately all it can offer is an interpretation of these. However, there are incongruences between medical and personal interpretations of illnesses and also of pain. John Nessa, from the perspective of medical semiotics (inspired by Peirce and Saussure) agrees that ‘diagnoses depend heavily on the doctors’ interpretations, since diagnosing is naming, structuring of reality. None of the diagnoses are in essence facts belonging to the external world, but linguistic and cognitive structuring of reality, ways of interpreting experiences and perceptions’ (Nessa, Reference Nessa1996, p. 371). Nessa distinguishes between a scientific and a hermeneutic mode of understanding, where the latter includes personal and interpersonal dimensions of meaning and values that are imbedded in the communication process (Nessa, Reference Nessa1996, p. 373).
From its origin, medicine had to interpret signs and symptoms of the body. Therefore, as an art, medicine has always been a hermeneutic process. However, modernity and the Cartesian representation of the body-machine led medicine towards a scientific paradigm of explanation (Gadamer, Reference Gadamer, Gaiger and Walker1996, pp. 6-8) while hermeneutic aspects became marginal. Hermeneutics as a discipline was designed for the interpretation of religious and literary texts. It was only the existential analytic of Heidegger and Gadamer's late work that re-established the centrality of hermeneutics for the process of understanding how things are, therefore for ontology. Although Heidegger wrote about care and angst, about the centrality of experience, authenticity, and being-towards-death, he did not attempt to develop a medical hermeneutics. Gadamer first reconnected hermeneutics and medicine in order to understand the ‘enigma of health’. Contemporary attempts to recognise hermeneutical aspects of medicine include Donna Orange's hermeneutics of clinical practice (Orange, Reference Orange2011), Fredrik Svenaeus's hermeneutics of medicine (Svenaeus, Reference Svenaeus2018), and Havi Carel's phenomenology of health (Carel, Reference Carel2016). Even if hermeneutics of medicine can restore the centrality of meaning and interpretation in the bio-sciences, the widening of hermeneutics towards other interpretative processes within our living environment needs some basic interpretation scaffolding. Analysing the interpretation theories of Schleiermacher, Dilthey, Heidegger, and Gadamer, Richard Palmer (Reference Palmer1969, pp. 242-53) proposed thirty theses on interpretation. Many of them are appliable only to literary texts. The main points presented in these theses and useful for my project of a bio-hermeneutics are:
1. The hermeneutical experience is intrinsically historical and linguistic. Language articulates meaning, and temporality cannot be eluded from interpretation.
2. The hermeneutical experience is ontological, as it discloses a specific way of being of things/people/animals.
3. The hermeneutical experience is a disclosure of truth and is dialectical.
‘The emergence of truth in hermeneutical experience comes in that encounter with negativity which is intrinsic to experience; in this case the experience comes as “aesthetic moment” or “language event”. Truth is not conceptual, not fact – it happens’ (Palmer, Reference Palmer1969, p. 245). For Palmer, the encounter with negativity broadens and illuminates self-understanding. Pain and illness can be regarded as experiences of negativity. The ‘disclosure of truth’ is for the case of pain, the diagnosis. Many medical tests function as exclusion of certain hypotheses. Patient's symptoms and even medical signsFootnote 5 are for the vast majority of cases not univocal. Thus, a differential diagnosis becomes necessary as the process of differentiating between two or more conditions which share similar signs or symptoms. A disease is normally identified after excluding other possible maladies. It requires a delicate dialectic process, where the negation of one possibility – usually done by a test result or by an imaging process – opens space for the exploration of a new hypothesis and so on.
The dialectic movement of interpretation is generated by the fact that the vast majority of medical signs and symptoms are not pathognomonic Footnote 6, meaning they are not characteristic of a particular disease, or not beyond any doubt. When a sign or symptom is specific to a disease, it can be used to make a quick diagnosis. A univocal connection between a sign and a disease is for example the presence and location of ‘Koplik spots’ in the mouth as a pathognomonic sign of measles (Markel, Reference Markel2015). But many other symptoms, and even medical signs are not specific. An abdominal pain a patient complains about can be anything from appendicitis to cancer. Similarly, a cough or high temperature can be considered medical signs, but again they can be present in a wide array of diseases from viral to bacterial infections. The occurrence of more signs and symptoms together make the process of diagnosis easier because they can add to the picture of a certain disease. The medical hermeneutic process of diagnosis is the subsumption of a particular case under the generalities of a disease (Gadamer, Reference Gadamer, Gaiger and Walker1996, p. 19). The patient's personal and subjective experience of illness is confronted with the anonymity of the clinical apparatus (Gadamer, Reference Gadamer, Gaiger and Walker1996, p. 20) designed to identify what is ‘out of place’ (Gadamer, Reference Gadamer, Gaiger and Walker1996, p. 129). However, there is an essential difference Gadamer missed between what is ‘out of place’ in terms of medical semiotics (e.g.: a higher or lower value of a blood test, the presence of a tumour) and how this ‘out of place’ interferes with subjective, personal, historical experience and interpretation of a disease.
The Hippocratic tradition of medicine recognised the temporal dimension of a symptom, articulating past (anamnesis), present (diagnosis) and future (prognosis) (Honkasalo, Reference Honkasalo1991). The insertion of temporality in the hermeneutic analysis of symptoms accentuates the confluence of personal history as curriculum vitae with the history of something else, an alien state or entity (virus, bacteria, abnormal growth) that inhabits the body. An anamnesis (medical history or case history) regards only the history of this alien state of the body. As an example, the present-day pandemic statistics register patients who have died within 28 days of a positive Covid test. In this case, the history of the disease takes precedence – as public interest – over the personal history of the people who have died. At the beginning of the Covid pandemic, especially when Italy was ravished by the virus, the age of patients was highlighted in the news, somehow leading people to believe that especially old people are at risk. The point here is that although it relates to the same body and person, a patient's medical and personal history (other than ‘age’ as a further medical criterion) is rarely considered in their existentially relevant conjunction.
Coming back to the connection between pain and the experience of the world, Honkasalo's ethnographic study analysed the spatial experience of the body in chronic pain and how pain as a way of being in the world (referring to Merleau-Ponty) limits the spatial experience and interaction, by shrinking, distorting, and circumscribing the world of those affected (Honkasalo, Reference Honkasalo1998). Even if chronic pain is normally different (not always diagnosed) from the unexplained pain I focus on, it is relevant for the understanding of pain as an experience that limits our world and with it our existential possibilities.
In the following sections, I will talk about how this alienation – focusing on pain – is metaphorically reflected in language and how the different rhythms of body-engulfed-by-illness and body-as-used-to-be creates existential incoherence.
3. Pain and meaning
The case of undiagnosed pain outside of the diagnosis-paradigm remains the most fascinating type of pain from a hermeneutical perspective. Without diagnosis, pain remains a symptom outside comprehension, and somehow its ontological status cannot be disclosed. Peter Dorward, a general practitioner, recalled one of his patients, Moira, and her confusion about undiagnosed pain: ‘“What I don't understand”, she says, angry with me, as she often is, ‘is what's actually wrong with me? Is it arthritis like the scan says? Or is this fibromyalgia, like the achey joint specialist says? Or is it chronic pain like the pain person says? Or is it all in my head? Like you seem to be saying? Or do you all just not have an effing clue?”’ (Dorward, Reference Dorward2018, p. 317). The failure of a consistent diagnosis to explain what is ‘out of place’ somehow cannot articulate pain's temporal existence either, and with this ontological non-situationality, the very existence of a symptom is questionable. Without diagnosis there is no present and no prognosis for the future, so that Moira wonders if someone really believes that her pain exists. This example shows the importance of spatio-temporal situatedness and understanding of a symptom.
To contrast unexplained with ‘situated’ pain, childbirth offers a good example. In this case pain has a meaning, it is expected and connected with labour and birth. It has a location and a duration, and nobody is contesting its ontological status, or its ‘objective’ nature. Yet, even with expected pain, the intensity of it during childbirth brings many women to a ‘regression’, to an ‘animal’ stage, which comes with the incapacity to keep rational, or keep control over one's body. In this extreme case, pain and reason reveal themselves as incompatible. Intense pain can become a state where meaning dissolves.
To counter the aporia of pain, and to re-install a kind of order or criteria, pain-scales were invented. Their use is based on the assumption that there are degrees of pain, and people can assess and describe the quantity or quality of pain (e.g. the McGill pain questionnaire as one of the most complex pain assessment tools (Melzack, Reference Melzack1975)). Most certainly, everybody who has ever complained about pain to a physician has heard the question: ‘On a scale from 1 to 10, how would you rate your pain?’ This is an attempt to situate pain, even if only on a numerical, imaginary scale. While pain in different scalar stages opens the possibility of meaning, absolute pain dissolves meaning. Physicians search for the quantity of pain mainly for the medical triage. Urgency and gravity are established by the quantification and qualification of pain as a symptom. And yet, the use of traditional Aristotelian categories to assess such a complex human experience – as being in pain – might be inadequate from the point of view of an existential analyticFootnote 7. Categories can reify pain, transpose it from the private experience to an object of medical intervention. Following an existential analytic, pain as human experience should be examined using existentials as fear, care, meaning and being-towards-death. Under such a frame, pain might reveal its power to absorb the whole human being, or to distort every other experience.
The algorithm of tests and interventions based on pain-scales evokes another actor: the painkiller. The concept of the painkiller is highly metaphorical and specific to the English language. In German, medicines against pain are called Schmerzmittel, analgésiques in French, antidolorifici in Italian. In these examples, the concepts describe something against pain, a negation of algos/dolor (pain in Old Greek/Latin), but none of them has the power of killing the pain. Now, it is questionable if painkillers really kill pain (in the sense of completely extinguishing it), or if they just diminish or mask it. Paracetamol, for example, blocks chemical messengers in the brain that tell us we have pain. Ibuprofen reduces hormones that cause pain and swelling in the body. But they will of course work only for specific types of pain caused by inflammation. In many cases, over-the-counter painkillers do not work. Medicine has constantly refined substances that can alleviate pain. An interesting example are opiates. ‘This is how opiates work: They don't take away the pain, they render you indifferent to it. Which tells you something important: in this context at least, the nature of pain lies not in sensation, but in the anguish that it brings’ (Dorward, Reference Dorward2018, p. 294). The interpretation of how opiates work reveals the centrality of meaning associated with pain. Indifference points not towards quantity and quality of pain, but towards existential aspects like angst and meaning.
The difficulty to assess, understand and address pain in its diffuse nature makes it hard to comprehend pain through a phenomenological approach. Pain is in many respects (or at least certain types of pain) aphanological, faceless, hard to define and locate. Arthur Frank, while describing his pain before he was diagnosed with cancer, emphasises the facelessness of pain: ‘pain has no face because it is not alien. It is from myself. Pain is my body signalling that something is wrong. It is the body talking to itself, not the rumblings of an external god’ (Frank, Reference Frank2002, p. 13). The internal dialogue of the body with itself is felt, but not comprehensible in the way rational discourse is. The pain signals are not univocal, they are polyphonic and cacophonic, leading to the greatest incoherence between body and mind. The body's internal talk can only be approximated by language, and not totally expressed. For Frank, the strong sedatives he took to be able to sleep made pain gain a form and a face as nightmares (Frank, Reference Frank2002, p. 32). But even the image provided by his nightmares seemed to be preferable to an aphanological experience. The ultimate act of giving pain a face transforms it into something else, into a kind of companion one has to accept in one's life.
In order to surpass these difficulties in addressing pain in a phenomenological way, I am adopting a different perspective, focusing on pain's linguistic manifestation. Elaine Scarry, in her book The Body in Pain (Scarry, Reference Scarry1985), argues that the concept of pain is something that resists language or, even more, it destroys language by transforming speech into grunts, moans and cries. Although Scarry is right in noticing the capacity of extreme pain to dissolve language, people use a wide range of metaphors to describe pain. I will examine the language of pain according to the triad of semantics (enquiring metaphors of pain), syntax (looking at the incoherence generated by pain) and pragmatics (how people deal with chronic pain).
3.1. Semantics: Metaphors of pain
Dorward noticed that people ‘become artists, masters of self-expression when it comes to the communication of this urgent thing: I am in pain’ (Dorward, Reference Dorward2018, p. 312). He talks about the negotiation of pain metaphors between doctors and patients. Pain is sometimes expressed in terms of electricity: it feels like an electric shock. Older representations of neuropathic pain described it as scalding or lancinating: ‘at a time when a person might understand what that was, how it felt to be lanced’ (Dorward, Reference Dorward2018, p. 312). In the 19th century, pain was described as ‘fury’. Joanna Burke, in The Story of Pain (Burke, Reference Burke2014), advances the hypothesis that the metaphors used to describe pain have a profound impact on the way we feel pain. In other words, language influences the experience of pain. The metaphors she selected and analysed show historical and cultural changes in the sensation of pain (Burke, Reference Burke2014, p. 53). Burke classified pain metaphors and situated them historically (Burke, Reference Burke2014, pp. 60-65): pain as something moving inside the body (1770s), something that ruptures, shatters or rips apart the body (1960s), weapons breaching the integrity of the body (1890s), pain as a weight or a colour (1930s) etc. Burke explains the changes in metaphorical representation as being mainly influenced by three factors: changes in how we understand the physiological body, developments in the external environment, and ideological shifts (Burke, Reference Burke2014, p. 66). The configurations of the social world contribute to shape not only in the way we communicate internal experiences, but also in the way we feel them.
Even before diagnosis, patients make efforts to integrate the expression of pain into a shared paradigm of understanding and to make the fuzzy, inchoate internal experience more concrete. Metaphors of pain have their phylogeny, which goes hand in hand with the science of the time and with social practices. For example, the word ‘gout’ comes from French gouttelette, which means droplet. ‘It alludes to drops of molten lead splashing on the skin: the metaphor communicating vividly the common understanding shared then by the doctor and his patient, but not shared now, of how a drop of molten lead splashed on the last joint of the big toe would feel. “Gout” is a word and a metaphor that has lost its ground’ (Dorward, Reference Dorward2018, p. 313).
To be able to communicate pain, to mitigate the subjective experience of it, people need to share language and cultural assumptions, and to find a common emotional connection. Pain is enacted through metaphors, gestures, grunts, and noises, and this display made Dorward call it the theatrics of pain. Physicians have to interpret it and face the difficulty of being situated between the ‘evidence-based medicine’ and the theatre of human expressions. The theatrics of pain and its metaphors constantly pendle between the individual part and the whole. To understand this complex picture and movement, Dorward (Reference Dorward2018, p. 323) noticed that we are always social beings in pain. How we experience and understand pain depends on our history, beliefs and culture. The theatrics of pain is actually the need to put a face, a mask,Footnote 8 to something that is aphanological by its very nature.
3.2. Syntax: Pain as incoherence
I use the term syntax here to refer to the idea of order, rhythm and coherence that we feel not only in the use of language – impossible without its grammar – but also in the use of a healthy body that integrates seamlessly into our routine or generally into our rhythm of life. A healthy body has its internal ‘invisible harmony’ mentioned by Gadamer. Pain is capable not only of breaking this harmony and incapacitating the body, but also of spreading incoherence and engulfing our entire experience of being-in-the-world.
Burke noticed that ‘by using metaphors to bring the interior sensation into a knowable, external world, sufferers attempt to impose (and communicate) some kind of order onto their experiences’ (Burke, Reference Burke2014, p. 55). Without communication, the attempt to restore coherence seems to be impossible: Frank experienced the silence and with it the isolation generated by pain, and for him this isolation that actually even increases pain is the beginning of incoherence.
A first aspect of incoherence depicts pain as a disruption of life as rhythm. The routine that keeps us anchored in our daily living becomes less and less possible. It also becomes a reminder of death as the final disruption. In the chapter ‘Seeing through pain’, Frank states that his pain was experienced most at the beginning of the illness, before physicians understood what was happening, and ‘at the end, when the body becomes unpredictable’ (Frank, Reference Frank2002, p. 29). Stories of illness are attempts to restore order and coherence, very similar to the process of diagnosis as a way of making sense of pain, of transposing the incoherence of the body into the coherence of a disease description and prognosis (as an attempt to predict what happens with the body).
In the previous section, I talked about the multitude of words describing pain, from piercing to lancinating. Pain can be burning or stubbing, but while these words describe how a certain type of pain feels like, they do not describe the experience of pain, its debilitating effects. Franks agrees that ‘we lack terms to express what it means to live ‘in’ such pain. Unable to express pain, we come to believe there is nothing to say’ (Frank, Reference Frank2002, pp. 29-30).
A healthy body can be read as a coherent body, with parts working in harmony, sustaining the pace of normal activities that insert us into a certain environment. A body in pain loses its natural rhythm, and with it our future plans or expectations are shadowed. ‘Order breaks down and incoherence takes its place’ (Frank, Reference Frank2002, p. 30). Frank, like many other cancer patients experienced pain especially during the night. ‘As the tumours took over my body, pain took over my mind. Darkness compounds the isolation and loneliness of pain (…). In darkness the world of those in pain becomes unglued, incoherent’ (Frank, Reference Frank2002, p. 30). For him, as mentioned before, isolation is the beginning of incoherence. When confronted with something incoherent that escapes understanding, we start to create a mythology of what threatens us, we start putting theatrical masks on a faceless actor who is probably nobody else than an unknown version of the self. The stories we try to create about inexplicable pain are nothing but an attempt to gain coherence. Much has been written about the therapeutic effect of narratives (Charon, Reference Charon2006). The order of words replaces – or at least tries to mend – the disorder of a body in pain. The narrative efforts here do not concern only what people depict about their pain, but also covers what doctors normally propose as a diagnosis hypothesis. Many times, a diagnosis not supported by bio-medical ‘hard evidence’ is actually a negotiated story between patients and physicians, as the dialogue between Peter and Moira illustrated above. Not having an answer about the source of pain spreads the incoherence of the body towards the entire world of an individual. World is no longer a possibility of expression and action, but something to bear and to ‘cope’ with.
Fredrik Svenaeus analysed health as homelikeness and illness as unhomelikeness (Svenaeus, Reference Svenaeus2011) touching on Heidegger's idea of being or not being at home in the world. As Dasein, we are thrown into the world, constantly trying to find an attunement to the world. In this sense, ‘world’ refers to what we share with the other human beings as our living space. But there is another meaning of ‘world’ I will use here, as my world, meaning my representation, understanding and experiences of the ‘big world’. This is close to what Heidegger referred to as poetic living. The ‘big world’ can never be entirely my world, because it includes people and places that I will never meet, visit or experience, while my world is a unique form of cosmos created by my experiences, interactions and representations. We constantly make efforts to define and redefine ourselves in order to maintain and fuel the harmony of our micro-world. What we care about – from the ‘presentation of self’ to our house, garden, and relations with others – depends upon the invisible harmony of the body ‘at home’. ‘At the moment when the incoherence of illness and pain makes it seem that all you have lived for has been taken away or is about to be lost, you can find another coherence in which to live’ (Frank, Reference Frank2002, p. 35). To do this is to create another cosmos. From Frank's experience, and not only his, the encounter with beautyFootnote 9, the creation of a new order, and a restored coherence of expression are some of the poetic ways of returning to living in our micro-world.
3.3. Pragmatics: Nietzsche's Dog: Pain as a Companion
In many cases, chronic pain becomes an existential companion. Even if the micro-world can be redefined or at least repaired by a fragile sense of order and harmony, pain has to be integrated rather than expelled from one's world.
Nietzsche's personal struggles of dealing with pain brought him to a similar situation: the need to give a face to pain, to move from the aphanological and incoherence towards a degree of visibility or representability. Nietzsche called his pain dog, a faithful companion: ‘I have given a name to my pain and call it “dog”: it is just as faithful, just as obtrusive and shameless, just as entertaining, just as clever as any other dog’ (Nietzche, Reference Nietzsche, Common, Cohn, Petre and Levy1910, p. 244). With this act, pain is transformed into a constant life companion, into an existential companion. Other representations of pain as a feminine companion were mentioned by Burke citing Thomas Smyth, an influential Presbyterian minister (1850s) who ‘described how “we walked arm in arm, dwelt in the same house, been fellow lodgers in the same body and occupants of the same bed”’ (Burke, Reference Burke2014, p. 60).
More than giving pain a face, we always try to connect a meaning to it, a meaning that can range from punishmentFootnote 10 to a heroic view. Nietzsche's reflections on pain transforms it into the ultimate emancipator of the spirit, which is not something that necessarily makes us better as a human being, but rather something that makes us look deeper into what our humanity is about. ‘It is great pain only, the long slow pain which takes time, by which we are burned as it were with green wood, that compels us philosophers to descend into our ultimate depths, and divest ourselves of all trust, all good-nature, veiling, gentleness, and averageness, wherein we have perhaps formerly installed our humanity. I doubt whether such pain “improves” us; but I know that it deepens us’ (Nietzche, Reference Nietzsche, Common, Cohn, Petre and Levy1910, p. 7). Pain that deepens us can be regarded as an experience that makes us reflect on the limits and structure of our world, and on new possibilities of finding meaning in activities or things we might have ignored before.
Another meaning of pain for Nietzsche relates to self-preservation. The hurtful essence of pain contains a message that Nietzsche put in a metaphoric way: ‘In pain I hear the commanding call of the ship's captain: “Take in sail!” “Man,” the bold seafarer, must have learned to set his sails in a thousand different ways, otherwise he could not have sailed long, for the ocean would soon have swallowed him up. We must also know how to live with reduced energy: as soon as pain gives its precautionary signal, it is time to reduce the speed – some great danger, some storm, is approaching, and we do well to “catch” as little wind as possible’ (Nietzche, Reference Nietzsche, Common, Cohn, Petre and Levy1910, p. 247). He continues with the glorification of people who do not sail away from pain, but confront it in a courageous way, and even celebrate it. In the contemporary context of a Scottish GP practice, Dorward observed that both patients and their doctors value stoicism. ‘People don't want to be a burden, they don't want to seem to be weak, or moaning, or dull’ (Dorward, Reference Dorward2018, p. 324). Of course, a stoic presentation of self (Goffman, Reference Goffman1956) might have its advantages in terms of social interactions or even into consolidating a type of narrative people need for themselves. But it remains questionable if the stoic version (where meaning is only internally negotiated, not shared with others) has the same healing value as the narrative alternative, which expresses pain through stories. In a similar way to how Moira negotiated with her GP, we often negotiate the meaning of pain with ourselves: ‘I fantasized that pain was “just for tonight”, that it was muscular stress and would be gone tomorrow. This fantasy was fuelled by my fear of what might truly be wrong with me, but it was also supported by what my doctor was telling me’ (Frank, Reference Frank2002, p. 32).
Once pain is identified and understood, it can be regarded as an ally, as a warning about body malfunction or the need to change. Even with the discovery of a fatal illness, re-establishing a sense of coherence seems to be the paramount task for regaining meaning in life. The connection between meaning, coherence and beauty reinforces the Pythagorean idea of cosmos. Probably the turning point is when a person manages to restore a world ravished by pain to a cosmos, a world with a sense of beauty and order. For Frank, this point came with seeing a tree projecting an intricate pattern of light and shadows on his window. The beauty he found was also the possibility of expression: ‘Where we see the face of beauty, we are in our proper place, and all becomes coherent’ (Frank, Reference Frank2002, p. 33).
4. Between memento mori and μɛλέτη θανάτου
Pain is incoherence, but an even greater incoherence is death, which is the total disruption of all we know: how can all of this continue to exist if/when I am gone? And yet, while death – as an event – limits life, positioning ourselves into its horizon can bring structure and meaning to life. By identifying the limits of an object, we can create its shape. I like to explain it by adding a twist to the famous Aristotelian example of the statue contained in its block of marble: if we imagine death as what sculpts the statue out of an amorphous, banal lump of marble, every cut and blow contributes to the definition of a new shape. By thinking about our finitude, most of us are able to remove the existential debris that covers an authentic self. We think about death as the cessation of all existential possibilities, and in this sense issuing an imperative to develop what is still important for us. For that purpose, death paradoxically appears as a causa efficiens, an agent that actually contributes to not only the deeper knowledge but also to the actualisation of the world. This view contrasts with other ways of thinking about death, for example as an ‘experiential black’ (Carel, Reference Carel2016, p. 151), something hard to comprehend from a phenomenological point of view, therefore not in accord with our existential rhythm. The incoherence of illness, pain and death makes it seem that all one has lived for is about to be lost, our cosmos faces its irreversible destruction.
Is pain a memento mori, a slow burning green wood that brings us to our depths? Is pain, along with death, what we fear most? But while death has its inexorable mystery, pain is the dance of limits, the source of chaos and incoherence, the ultimate crisis of meaning. Pain is a constant reminder of death, but at the same time a link between life and death. Pain makes us fear that we might ‘die too early’. And yet pain engrains itself into the way we signify our existence and our finitude. For Carel (Reference Carel2016, p. 150), death is part of the illness experience, it is positioned on its existential horizon, therefore illness is a memento mori.
After a serious climbing accident, Dorward remembered moments of extreme pain, where death seemed to be very near: ‘Hunched like a beast behind the darkening crags is pain, with his claws and unblinking red eyes, waiting, and beyond him, silent, something quite unknowable, but to you none of that matters now. You are half detached from the world already, huddled and indifferent, chasing after that last remnant of warmth in your core, focused on stillness, not moving, journeying deeper and deeper within’ (Dorward, Reference Dorward2018, pp. 287-88). When pain disconnects us from the world we shared with the others, somehow it brings us back to the ‘warm core’ where we tend to search for something beyond sensation, colour or shape. We don't problematise what happened when we entered the world as much as we talk about death as its symmetrical exit.
Romain Rolland in a letter to Freud (written in 1927)Footnote 11 coined the term ‘oceanic feeling’, in which the ego is not separated from the world. Freud interpreted it as a hypothesis about our beginning in early infancy when every perception, colour, and sound reveals and constructs the external world and, through this, separates us from it as ‘exteriority’. For Freud, an ‘incentive’ for separating ourselves from the external world is the feeling of pain and the accompanying desire to avoid it. Without wandering further into the psychoanalytic discourse, we should ask what happens when pain is unavoidable, when it becomes our uninvited companion? Is our personal cosmos somewhere between the oceanic feeling and the ‘external world’? Maybe we should regard birth and death as symmetrical not merely as the beginning and the cessation of an individual life, but as the unfolding and relapsing of a uniquely articulated cosmos.
In my first year of studying philosophy, many years ago, I learned, while reading about Plato's melete thanatouFootnote 12, that philosophy prepares you for death. And yet I had my doubts that the devaluation of the body, or any other wise exercise of distancing us from life can prepare people for death. According to the Greek-English Lexicon (Liddell et al., Reference Liddell, Scott, Jones and McKenzie1996), μɛλέτη has different meanings including: care (for), paying attention to something, practice, exercise and even rehearsal (of a discourse). My attention was drawn towards the medical meanings of μɛλέτη, which include the threatening symptom of a disease: “μɛλέτη καὶ προοίμιον ἐπιληψίας” (symptom and sign of epilepsy).
How can we connect and put together these multiple meaningsFootnote 13? Probably all are linked to death as something we need to pay attention to, something that should not be ignored, but rather cared about, and this is the task of philosophy. In its existential form, philosophy must deal with the symptom of death, with the fact that as human beings, our existence is towards-death (Heidegger, Reference Heidegger and Stamburg2010, pp. 241, 232), and as such death imbues all our semantic exercises. What role does pain play in this scenario? Heidegger did not refer to the role of pain, nor did he grasp the existential dimension of it. While angst and care have rich existential meanings, pain was probably ignored due to its ‘empirical’ nature. And yet, the experience of pain and its connection with an incoherent way of inhabiting the world opens the space for redrafting the chaos-cosmos dialectic in a new bio-hermeneutical way. ‘The ultimate value of illness is that it teaches us the value of being alive. (…) illness and, ultimately, death remind us of living’ (Frank, Reference Frank2002, p. 120). In this sense, death ceases to be the enemy of life, transforming into an axiological restorer of living. Restoring living means to restore our sense of proportion and beauty. Seen from the terminal point of death as ‘the end of the road’ – one of death's representations discussed by Heidegger – our lives appear as attempts to make sense, to find the meaning of what we are living through. For Frank, like for many other people writing narratives of their illnesses, illness is a unique possibility of self-reflection, the creation of a new personal cosmos.
But how can we rehearse death? Is it enough to think of and examine our relatedness to death (Dastur, Reference Dastur and Llewelyn1996) as something that makes us human? Understandably, we project death as an event of the future, and this is covered under Heidegger's concept of ‘being-towards-death’. We want to cast it so far away into the fogginess of the future that we can forget about it for most of the time. However, there may be a trap of meaning here, an existential mistake, that we think about death by relating the present-self to a future-self (either dying or dead). We fear the pain of approaching death and the closure of all our existential possibilities. But what happens if we change the perspective and examine the meaning of death by relating the present-self to the past-self (or selves)? The past-self has also closed most of its existential possibilities except one, which is the present self. When I was a teenager, I dreamed of being a doctor, a film director, an opera singer. I still remember, and we all do so, the effervescence of life in our 20s, the wonders of early childhood. Going through life is a constant reduction and denial of many, many possibilities of being. Is our fear of dying constructed around our self-reflection around lost possibilities? And should philosophy here help us understand, dialectically, that only by losing possibilities we can actualise a few of them? This will reinforce the idea of death as causa efficiens of our present cosmos, rather than as a total closure of some imaginary world we might live in while approaching our extinction.
Faced with his terminal patients’ question of what happens when we die, Peter Dorward gives them this medical-metaphorical speculation: ‘you disappear gradually into yourself. At first you will be aware of the world around you, and the people around you, but it all becomes progressively less vivid, and it all comes to matter less, or matter less immediately. Their presence might be a comfort, especially at first, but they are a long way off, and diminishing, and your own world starts to shrink down too. Any discomfort you might have will diminish too, and you will stop feeling hungry or thirsty, and you will become more sleepy, so that you are hardly awake at all. It's like you disappear to a pinpoint, and then you disappear altogether’ (Dorward, Reference Dorward2018, p. 288). Dorward's intuition – and it is only intuitions that we can really have about the event of death – reinforces the change of perspective I mentioned above: maybe we disappear into ourselves, into our self-made cosmos. Maybe what the brain will play to us in our last moments is nothing but the beauty and memories that we have created along the way. If we don't ‘pass away’ into a pink transcendence, ‘better world’, and some such, melete thanatou should be understood as our concern for a poetic way of living, one that can generate enough beauty for the ultimate trip into oneself.
