A chunk of thesis, from about half way through the first chapter, soon to be followed by a chunk of Levinas-in-thesis… for your interest (or not!):

What does the reduction of suffering to disease allow in the cultural negotiation with it? What power relations are concealed in this reduction of suffering to the natural? How is ‘intactness’ produced as the nature of subjectivity such that particular experiences are experienced naturally as threat? In other words, what ‘material subjection’ is concealed in constitution of subjects who suffer, and in the reduction of suffering to the natural, neutral response to a wrong? What might it mean to, instead, to think suffering itself not simply as a natural response to either disease or oppression (as therefore naturally bad things), but rather as a technique of power?

To begin to explore these questions, we need to examine what kind of political significance suffering has. Given that I have, thus far, been engaging with suffering as it is understood in a medical setting, I now turn to Arthur Frank’s consideration of the medical treatment of suffering in the context of a capitalist, consumerist culture in his article, ‘Emily’s Scars: Surgical Shapings, Technoluxe and Bioethics.’ (2004) He is concerned less with what suffering itself is and how it is caused, and more with the status of demands for ‘cure’ articulated through suffering. As a result, he often problematically blurs the lines between pain and suffering; or rather more specifically, attempts to circumscribe his use of the word “suffering” to those experiences marked as, in some way, legitimate.

Frank observes that the ethical imperative to relieve suffering (or as he frames it, ‘”to alleviate pain,”‘) has historically formed medicine’s ‘original and still pre-dominant purpose.’ (Frank 2004, 22) It is this purpose that has functioned to legitimise (to varying degrees) a range of interventions, including the surgical ones Frank focuses on in this article-limb-lengthening surgery, cranio-facial reconstructive surgery, intersex “corrective” surgery and of course cosmetic surgeries. Using philosopher Alisdair McIntyre’s theory about the eighteenth century invention of the notion of selfhood, he observes that the marriage between this strong sense of a self which ought (morally speaking) to be fulfilled and the consumerism of current culture has a very specific effect. This has resulted in surgical methods being used for what Vogue magazine calls ‘”technoluxe,”‘ (cited in Frank 2004, 21); that is, medical expertise has become, he suggests, a commodity, consumed towards the fulfilment of self, a practice particularly evident in what is usually referred to as cosmetic surgery. This is far from a new complaint against cosmetic surgery: Sander Gilman demonstrates that the concern about authenticity, passing and the “unnatural” achievement of status otherwise unattainable (such as the position of Gentile through the modification of the “Jewish nose” (Gilman 1999, 124-137) or the “reproduction” of a foreskin (Gilman 1999, 137-144) has long troubled the industry. (Gilman 1999, 3-36) Indeed, the questionable position of cosmetic surgery has historically led much of the medical profession to distance themselves from the practice. But Frank’s concern is specific: it is not a concern, at least at first glance, about the authenticity, but rather that ‘technoluxe medicine distorts the allocation of medical services and distracts medicine from its original… purpose,’ (Frank 2004, 22) which is, of course, the relief of suffering. Cosmetic surgery, in other words, distracts medicine from its proper business.

He struggles, however, to make this argument, precisely because suffering is so often claimed in relation to cosmetic surgery. (see also Davis 1995 for a qualitative analysis and discussion of suffering in cosmetic surgery.) Frank interrogates an example of such suffering which is specifically drawn from the same Vogue article from which he draws the rather laden term ‘technoluxe.’ A woman had surgery performed on her feet, because she ‘”grew tired of burying [her] toes in the sand when [she] went to the beach. It was humiliating.”‘ (Frank 2004, 21) This humiliation (probably, to be fair, only one aspect of the experience that led her to have surgery performed on her feet) is not simply observed by Frank, but assessed:

Pain is not what it used to be, and here I return to the moral justification of the satisfied medical consumer who says going to the beach pre-treatment was “humiliating.” I react to this statement as an inflation in the language of pain: if having unfashionable toes counts as humiliating, in what words can we describe the lives of people living with massive facial deformities? (Frank 2004, 22)

This is a fascinating stand for Frank to take, as we shall see. The implicit understanding of language here is essentially equivalent to the Wittgensteinian notion we saw Edwards utilise: “humiliation” here is considered to be a term separate to the experience itself, which operates to pick it-a specific, known and knowable experience-out of the mass of other experience. Frank thus represents this woman’s claim to pain as being somewhat bogus; she has merely identified her experience wrongly, or failed to understand the language-game as it ought to be understood (a position I do not think that Wittgenstein would have much sympathy with).

He goes so far as to compare her suffering with that of someone with a form of suffering whose recognition has long been legitimised: that of a person with massive facial deformities. Part of Frank’s difficulty with accepting this woman’s pain to be real is that he sees terms such as “pain,” and “suffering,” and “humiliation” as referring to a single experience. He cannot recognise this woman as suffering, for to do so would be to claim that it is equivalent to other forms of suffering, such as someone with massive cranio-facial deformities. This equation may well be deeply troubling. However, it also adopts the medical framework Cassell critiques, in which a particular experience is reduced to its ‘truth’: there can be, it supposes, only one true experience of suffering, one in which all bodies partake, regardless of their differences. In this respect, he assesses her experience against what he has already identified as “real suffering.” In so doing, he seems to fall into precisely the trap he warns against:

Research places whatever cannot be operationalized, objectified, and rewritten within the stylistics of universality among “all the things [that] do not fit”. Whatever cannot be reinscribed as an instance of some extralocal category must be rejected and censored. (Frank 2001, 359)

Thus the problem lies not in the experience of suffering itself, but medicine’s (and ‘research’s’ as Frank identifies above) unwillingness and inability to respond to the specificity of different experiences of suffering. As we have already seen with Cassell, suffering is always different because subjects are differently consituted. It is important to acknowledge this difference, not simply in order to be ethical, but because it also shifts the focus back onto the cultural elements that contribute to different kinds of suffering. Frank’s response to this, however, is not to challenge medicine’s conception, but rather to eliminate certain claims to suffering. If we simply deny some forms, cultural constructions which play into the production of suffering go uninterrogated.
Yet perhaps this is not entirely fair: he does acknowledge that the woman’s experience is significant, just not as suffering. Rather, the woman’s claim to humiliation becomes not an expression of her suffering but simply an articulation of a social problem, ‘as troubling as I find the usage of humiliating in this instance, it is important to hear the very real problem that this woman is working to express.’ (Frank 2004, 22) On the one hand, this gives the woman’s claim some weight, but on the other, it strips her claim of its ethical imperative, the imperative which Frank has already suggested directs medicine. In the end, according to Frank, the problem that this woman is articulating is actually that suffering, within a Western capitalist culture, has been made into a kind of currency, such that many will (implicitly inauthentically) inflate their experience such that it becomes an exchange value which legitimises the use of medical resources on ‘technoluxe.’

Yet this is a dangerous claim to make, given, as we have seen, suffering is contextually defined. The problem the woman with ugly feet is working to express does not have to do with what kind of experience is regarded as legitimate for surgery by the medical profession: it is, rather, her suffering. It is this woman’s experience that needs to be heard, not merely the way or the fact that she expresses it. More than this, a subject’s experience of suffering does not occur in isolation from the culture in which he or she occurs. Suffering is not linearly felt, known and named in that order, as Frank seems to assume, but operates in the inescapable context of a subjectivity constructed in the entangling of representation and experience, of culture and embodiment. The construction of subjectivity here is not the creation of an ‘ideology’ overlaying a “true, free self,” for which Foucault critiques Marxism (although Frank may well agree with this). Rather, suffering is constructed, where construction takes the dual meaning of the building of a subject, and also the construal of them: suffering is not safely ensconced in a prior ‘taken-for-granted ontology,’ and as such, this construction is not something the subject can shake off. It is part of what makes them a subject in the first place. The point is, in the end, that because subjects are discursively constructed, the use of the words “pain” or “suffering” in the context of technoluxe surgeries ought not to be reduced or dismissed as merely an ‘inflation in the language of pain’ but as an inflation in suffering itself.

Alongside this, we need to consider the question of ethics, as Frank reveals. In the end – and despite his problematic dismissal of “inflated” pain – he claims that,

trying to compare forms of suffering – comparing the woman humiliated by her toes with a young person deformed by a facial hemangioma – is not useful. The attraction of such a comparison is that it promises apparently clear-cut medical guidelines for practice. Unfortunately, practice will have to confront a reality that is not clearly divisible into categories. The issue may be better thought of not in terms of what suffering we allow as legitimately in need of fixing, but rather, what form of decision-making we respect. (Frank 2004, 26)

In shifting the focus from suffering to forms of decision-making, Frank is attempting to introduce the ethical element into guidelines about who ought to be permitted to undergo surgery. His concern with ethics is admirable, and well-grounded: ‘the personal is communal,’ (Frank 2004, 26) he argues, and since norms about bodies are created communally, the personal choice to undergo surgery must be understood to contribute to those norms. He echoes Canguilhem here, who argues that ‘[t]he normal is then at once the extension and the exhibition of the norm. It increases the rule at the same time that it points it out.’ (Canguilhem 1991, 239) It is worth recalling, however, that his primary concern is the distribution of medical resources.
Frank suggests that by focusing on decision-making in a communal context-a Socratic, dialogical model is his favoured method-individuals may come to understand ‘how their particular trouble relates to others’ troubles, and how their proposed solutions might cause others more trouble.'(Frank 2004, 26) Frank’s turn to decision-making in place of suffering in order to assess which claims to surgery are to be legitimate is understandable but problematic: effectively, it is the attempt to shift from the subjective space of suffering to the supposedly objective (or objectively assessable) space of dialogue and decision-making. This assumes a number of things, but perhaps most problematically, it presumes that the decision about whether to have surgery can be understood purely and simply as a rational one. Yet if this were the case, given that all the surgeries he discusses are normalising and thus as the creation of the normal confirm the norms which in turn create problems for others, the rational, ethical (if selfless) response to them would probably be never to have surgery. However, I do not think that Frank sees this as ideal; rather, he does seem to perceive some surgeries as legitimate. The confirmation of some norms is, it would seem, rationally justifiable; it is norms related to the appearance of feet that are a particular problem.

The problem is rationality: here we return to the question of what can figure as truth. He has already demonstrated that, rationally speaking, the woman with ugly toes cannot truly be understood as suffering, but he fails to ask why. The attempt to shift the focus from suffering to the rational process of decision-making is problematic because it assumes that rationality gives us some way of transcending that experience, or rendering it irrelevant – a reiteration of the liberal humanist mind/body split and perhaps more significantly, existing systems of discursive truth. It assumes we respect and respond to rationality, because it exists beyond the influence of cultural norms, and permits an “outside” perspective from which to adjudicate. This is a deeply problematic stance, and fails to take into account the normative function of marking particular discourses as “rational,” a label which has all too readily been attributed to the systems developed out of the ways that white men have thought, historically. (Lloyd 1984) It also once again denies the importance of the body in the way that we exist-always as embodied subjects. The very norms he is concerned that surgery further legitimates do not simply float about outside subjects, but are part and parcel of the subject’s embodied construction within our culture. Knowing the ethical, rational response cannot unbind the subject from that culture. The choice to not have surgery does not mean that the subject’s experience of themselves (as suffering) is altered. To presume that this is, or could be, or even should be the case is once again to suppose that the mind can transcend the body, that the two are separable.

Returning to the woman who suffered because of her ugly feet, another more disturbing problem arises: it is difficult to see the ethics of Frank’s argument that we should move away from responding to suffering to responding to someone’s capacity for rationality. In the rational, dialogical assessment of forms of decision-making, suffering may be rendered irrelevant, precisely because it is subjective, and possibly irrational. This does not, however, make the suffering not true: the individual still experiences it. Yet this is precisely the problem: whilst the rational, dialogical debate is always public, suffering is made to be only ever individual. In this respect, responsibility for suffering is (rationally) made solely the responsibility of the individual who experiences it.

However, if subjects are culturally constructed, an individual’s suffering is an articulation of broader – and communal – constructions of normalcy, abnormalcy, deviancy and suffering. The experience of the woman with “ugly” feet may be read to reveal the increasing intolerance of corporeal difference, for example, if her suffering is taken to be actually experienced rather than merely mis-named. Thus the individualising on the grounds of suffering leaves uninterrogated the way that the experience of suffering functions to dovetail with occurrences of “deviancy;” that is, it ignores the way that suffering tends to function to enforce normalcy in subjects. The danger of individualising the experience of the woman with “ugly” feet is that it fails to place responsibility where it belongs – with the communal. As van Hooft puts it, ‘If neither the gods, the cosmos, providence, nor a faith in human progress rob suffering of its tragedy, then we are left just with the brute fact that we and others suffer. And in this there is community.’ (van Hooft 1998, 20) Here, we can recognise the biggest problem with Frank’s proposed ethics. It risks rendering the ethical imperative of responding to suffering irrelevant except that which it is rationally explicated, and thus leaves us with the question: why is it ethically necessary to respond to the suffering other, and how does that imperative come about? Is it ever going to be possible to develop a rational ethical framework that does justice to that imperative?

References available on request (what, I’m feeling lazy… oh, alright). The main ones are:

Canguilhem 1991 The Normal and the Pathological Zone Books

Frank 2004 ‘Emily’s Scars: Surgical Shapings, Technoluxe and Bioethics’ Hastings Center Report 34(2), pp. 18-29

Gilman 1999 Making the Body Beautiful: A Cultural History of Aesthetic Surgery Princeton Uni Press

van Hooft 1998 ‘The Meanings of Suffering Hastings Center Report’ 28(5), pp. 13-19

If you want any others, let me know