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Moral Moments

Iatrogenic Torture: Just when you thought you had enough to worry about

by Joel Marks

The doctor and I were discussing my upcoming (minor) surgery for a spot of basal cell carcinoma. Only a local anaesthetic is called for, but the injection of that is itself somewhat painful, he informed me. Therefore a sedative may also be appropriate. But the decision about the sedative is mine. So I asked how painful the injection was likely to be. No big deal, really, replied the doctor; it’s the same pain as during the biopsy (for which I was not sedated), but lasting twice as long… maybe five seconds.

Well, that ought to be endurable. And the sedation procedure sounded a little involved – intravenous insertion, perhaps uncomfortable after-effects, who knows what? Why bother? Is there even a net reduction of pain in the long run? But I was curious, so I asked, “What happens during the sedation: Do I not feel the pain?” “Well, that’s not it exactly,” saith the doctor. “You are relaxed or even doze off for a few minutes; but it’s not a pain-killer per se. In fact sometimes people cry or shout when the anaesthetic is finally being injected.”

Now, to my way of thinking, that sounds, if anything, worse than not being sedated at all. For it makes sedation appear to be nothing more than the patient’s inability to do anything about the pain, even to summon up mental defense mechanisms, such as I did while enduring the stinging pain of the anaesthetic injection for my biopsy. It seems an opening up of oneself to pain in all its painfulness – which is hardly an amelioration thereof. In this kind of case the patient may actually indicate (by exclamations) that pain is being felt. So how could the doctor conclude that sedation is a boon?

My doctor’s answer: “You won’t remember anything, and if you don’t remember it, it didn’t happen.”

Whoa. I can see the appeal of this reasoning… for the doctor. Like the ‘painless dentist’, it doesn’t hurt him a bit! And it then enables the doctor to proceed with his work. But has the patient’s welfare truly been served? So I asked the doctor what he thought about this parallel reasoning: whatever pain we endure in life is not really important, because after we die we (presumably) do not remember it. By his principle, it didn’t happen! This argument, it seemed to me, reduces the doctor’s dictum to absurdity.

Ah, but my doctor is also a subtle philosopher. In a move that would honor Wittgenstein, he replied that one does not strictly speaking not remember things when one is dead, since you have to be alive to either remember or not remember something.

Nevertheless, I remain unconvinced by the doctor’s assurances. I will opt not to use the sedative, thank you. I must say, though, that I was delighted to see this real-world application of what hitherto I had considered an utterly abstract epistemological teaser. “Do you feel a pain if you won’t remember it?” seems at first blush not so very different from, “Does the tree falling in the forest make a sound if there is nobody there to hear it?” Yet I maintain that at the very least this sort of pain issue should be presented to the patient for him or her to judge by his or her own philosophical lights.

It turns out, however, that the problem is not merely speculative after all. In recent years the general public has been informed by news reports about ‘anesthesia awareness’, which is the same phenomenon, except that it applies not to sedation but to full-blown anesthesia, and memory, sometimes of pain, is retained. It is explicitly recognized by the American Society of Anesthesiologists. Reading about it made me realize that I had forgotten that I remembered (phew!) just such an episode during another minor surgical operation. I had drifted into consciousness during the operation and noticed a definite sensation in my innards where the surgeon was probing. I also remember thinking at the time that this was highly worrisome since the experience could (for all I knew) turn dreadfully painful at any time, and I would be in no position to indicate my distress; for I was still drugged enough not to be able to move or speak or perhaps even utter a cry.

In that respect it was like a more common experience of mine, of becoming conscious in the middle of a nap yet unable to move (or scream!), although feeling a sense of foreboding that something horrible might enter my bedroom doorway while I was thus helpless. Upon analysis I wonder if these are really only dreams, since I seem to see my surroundings – yet I would assume my eyes are closed while I am napping. But I do not doubt the veracity of my surgical awareness. There is also the point that something that is not accessible by conscious memory may nonetheless leave its lasting impression on the psyche.

Meanwhile my conversation with my doctor indicates that even when a patient does give indications of feeling pain while supposedly desensitized, the surgeon and anesthetist may be in the habit of ignoring them because the patient “won’t remember anything.” In fact not using anesthesia, during operations on premature babies and the circumcision of newborn boys, for example, has been justified by the same principle. But this principle is really just an unexamined assumption. To the medical personnel who hold it, therefore, I recommend a change of attitude, as a useful first step toward addressing the problem of iatrogenic torture.

© Joel Marks 2008

Joel Marks is Professor of Philosophy at the University of New Haven in West Haven, Connecticut. More of his essays can be found at moralandothermoments.blogspot.com.

[Iatrogenic means ‘induced by a doctor’s treatment or manner’ – Ed.]

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