Last updated: Fri, Sep 13, 2024
In his 1937 decision in Theberge v. United States...[Federal Judge Learned] Hand insisted that "a man may have to endure discomfort or pain and not be totally disabled; much of the best work of life goes on under such disabilities."1 [Learned Hand was a judge on the Federal 2nd Circuit Court of Appeals from 1924 through 1951, chief justice of that court from 1948 through 1951.]
By definition, truly disabling pain must relieve the sufferer from the responsibility to work? However, there is nothing black-and-white about "disabling pain." The concept itself is indistinct and the state of facts is always ambiguous for an objective observer. Cheating is always a possiblity.
But there are subtler and deeper issues than cheating at stake in pain.
"The concept of illness expands continually at the expense of the concept of moral failure," wrote [economist Barbara] Wooten in Time magazine in 1956. "The significance of this question of who is sick and who is sinful cannot be laughed off as 'merely semantic.'"2
Consider the familiar political slogan from each according to his ability, to each according to his needs
that was proposed by Karl Marx in the late nineteenth century. Looking past the practicality or correctness or sufficiency of the slogan, it can be seen as a statement of aspiration based on underlying concepts of right. It points to our two roles as producers and consumers and posits a responsibility for each of us as a producer of good things, and an entitlement for each as a consumer of good things. Perhaps the most radical aspect of this slogan is that it implies that the entitlement to receive is independent of the responsibility to contribute.
"In our society the virtues of self-reliance and independence are so highly valued that many people feel a great deal of shame and humiliation at the idea of having to be taken care of," wrote one physician in his state medical journal in 1963. His topic was not welfare or taxes, but pain management, cancer care, and the peculiar psychology of the cancer patient. People used pain selfishly to get what they wanted from others, he noted, since "conflict over dependency may lead to a demand that the physician get him well. This demand may be expressed through an increase in the intensity of pain as a way of saying, 'Do something to get me well.'" Dependence bred its own selfish focus on pain: "it is also possible that the patient feels such a sense of guilt about the need to depend on others that his pain becomes a method of self-punishment and also a way of saying to himself, 'Look--I'm justified in having to depend on others because I'm suffering so much.'"3
I can assert confidently that the view expressed by Marx's slogan is not the operative policy of most of us. Like views about pain, views about entitlement and responsibility vary and are not necessarily consistent over time, across situations, or even internally. Still I feel confident in asserting that most of us believe that responsibility is a moral reality; that entitlement is not absolute, but is contingent on multiple factors; and that in important contexts entitlement is contingent upon responsible behavior. Ideas about this contingency vary:
"I doubt if there are many people in the world who are truly disabled," he [physician Hedwig Kuhn] barked. Technology and medical innovation, he thought, was lightening the burden of afflicted people: "Even a polio victim in an iron long is not truly disabled if he has imagination. He can even support himself by writing music, writing books, talking into dictaphones and what not."4
Pain is one of a number of situations that perturb the relation between responsible behavior and entitlement. Responsibility is connected to ability. Although some will say, "No work, no food," and some will say, "Everyone has a right to eat," most people sit somewhere between these extremes.
Issues around pain and cheating are a concrete, quotidian example of this linkage, but I believe there is good reason to treat the beliefs that people have about responsibility and entitlement as residing at a deeper, more basic, more intense level. Important in this is the connection with the idea of free will, which also is perturbed by pain and similar conditions that overwhelm it.
Watching Buddhist monks and nuns stoically burn themselves in Vietnam protests, American scientists marveled that mental training could so thoroughly sever the link between body and mind and between stimulus and perception.5
Neuroscientist Steven Pinker in his book "Blank Slate"6 argues that our beliefs about the nature and power of free will serve as an impediment to our acceptance of modern findings about the nature and workings of our brains, and especially to incorporation of the implications of this new knowledge into public policy. Free will, he argues, must (so we believe) exist because so much of our notion of justice in issues of responsibility and entitlement is predicated upon it. He says in his preface that [a]ny claim that the mind has an innate organization strikes people not as a hypothesis that might be incorrect but as a thought it is immoral to think.
7 This is because an innate organization of the brain implies that our thinking and behavior is channeled by such organization. Later he expands in terms that are relevant to the topic of pain:
The study of brains and behaviors finds itself in the middle of a conceptual shift. Historically, clinicians and lawyers have agreed on an intuitive distinction between neurological disorders ("brain problems") and psychiatric disorders ("mind problems"). As recently as a century ago, the prevailing attitude was to get psychiatric patients to "toughen up," either by deprivation, pleading, or torture. The same attitude applied to many disorders; for example, some hundreds of years ago, epileptics were often abhorred because their seizures were understood as demonic possessions--perhaps in direct retribution for earlier behavior. Not surprisingly, this proved an unsuccessful approach. After all, while psychiatric disorders tend to be the product of more subtle forms of brain pathology, they are based, ultimately, in the biological details of the brain. The clinical community has recognized this with a shift in terminology, now referring to mental disorders under the label organic disorders. This term indicates that there is indeed a physical (organic) basis to the mental problem rather than a purely "psychic" one, which would mean that it has no relation to the brain--a concept that nowadays makes little sense.8
Certainly we do seem to prefer stories about the triumph of will over adversity to stories about disciplined acceptance of fate. Oedipus is not a sympathetic character in the twenty-first century. Today we can watch movies about ancient Chinese who are able to fly, apparently through the assiduous application of willpower, or about charismatic adventurers who can literally dodge bullets. We can hear testimonial from professional athletes about the important role of the will to succeed in their careers. Contrasting with these images, we have the character who is confined to bed not by a physical illness but by a mental one. And faith healers, in their modern incarnation as psychoanalysts. But whatever "will" is, and whatever its power, there is ample evidence that its power has limitations.
The debate on pain in our culture wars is part of the broader topic of innate differences. Pinker's comment on the "so what" of innate differences is in terms of the moral philosophy of the twentieth-century thinker John Rawls:
...the existence of innate differences in ability makes Rawls's conception of social justice especially acute and eternally relevant. If we were blank slates, and if a society ever did eliminate discrimination, the poorest could be said to deserve their station because they must have chosen to do less with their standard-issue talents. But if people differ in talents, people might find themselves in poverty in a nonprejudiced society even if they applied themselves to the fullest. That is an injustice that, a Rawlsian would argue, ought to be rectified, and it would be overlooked if we didn't recognize that people differ in their abilities.9