A Review of Graham's The Politics of Pain Medicine

A Review of The Politics of Pain Medicine: A Rhetorical/Ontological Inquiry by Scott Graham, 2015; University of Chicago Press

Kate Maddalena, University of North Carolina Wilmington

(Published: June 9, 2016)

Scott Graham's The Politics of Pain Medicine: A Rhetorical/Ontological Inquiry, is, like the phenomenon it describes, many things, simultaneously. It is an explicit argument for the cross-pollination of Science and Technology Studies (STS) and rhetorical perspectives. It is an extended exercise in rhetoric, history of science, and philosophy, with an object of study that matters to many. It is a nuanced and thorough description of the complicated existence of a brain-body phenomenon that medicine has heretofore failed to address in anything other than oversimplified and non-integrated ways. It is an extended case study of the implications of new materialisms, as well as a concrete example of what “the ontological turn” in philosophy and STS can mean. Reviewing the book as only one of any of these things would sell it short. Anything worth talking about can’t be delimited to one territory. That’s part of Graham’s whole point.

But reviews require opening summaries, and since theory always seems to be the biggest Russian doll in the box, I will first summarize by describing Graham’s philosophical stakes. In this dense and compact text, Graham takes on the “two-world problem” that has vexed philosophers before and especially after Rene Descartes by writing a detail-oriented, rhetoric-driven consideration of science and medicine’s approaches to the problem of pain. Pain, Graham observes, makes an excellent “real-world” case study for this philosophical endeavor because, thanks to pain, medical practitioners have explicitly identified and grappled with philosophy’s two-world problem in their own fields. Moreover, STS accounts of pain treatment (as technoscience) and rhetorical accounts of pain and pain treatment (as social/discursive construction) would be incomplete without each other: one pits technology against phenomenology and the other pits expertise against patient reports. Graham proposes an approach—a set of “calibrations” (via Anne-Marie Mol)—that interweaves the medical and patient communities’ theories of pain, STS, and rhetoric as a theoretical framework with which to characterize the problem of pain as a “biopsychosocial” one. (This last coinage is a term Graham excavates from the pain-treatment community of practice circa 1970.)

After an introductory chapter that establishes the territory and stakes that I have described above, Chapter One provides the reader with an “ontological history of pain.” Such a history requires a methodological definition, and Graham aligns himself with Mol, Pickering, Latour, and other historical approaches that work to avoid both teleological overstatements and social constructivist reductions. He then moves through historical theories of pain’s existence (from Greece, to Galen, and on into a problematic post-modernity) with an eye to the manifestation of the body-mind dichotomy. This brief history provides context for the rest of the book, which moves into a more detailed and contemporary set of case studies.

Each subsequent chapter presents an object of focus, then considers that object in rhetorical, then new-materialist terms, with a move to rhetorical-ontological integration at the end of each. Chapter Two describes in detail Graham’s embedded, observational research (beginning in 2006) of the Midwest Pain Group (MPG), a constellation of medical, psychiatric, and pharmaceutical professionals who come together to seek interdisciplinary, “integrated,” solutions to the persistent and vexing problem of pain. The MPG’s ontolog(ies) of pain are derived from a movement that, Graham notes, began in the 1970s and strives to avoid reductivism. MPG as a multidisciplinary, “calibrating” body is Graham’s focus for the next few chapters. He begins with a layer of rhetoric: he names and analyzes genres, focusing on textual/discursive representations of pain, and then balances with a description of calibration (Mol) as the social action that the MPG pursues. Chapter Three focuses (rhetorically) on argument via the stases and how stasis level plays into MPG calibration. In Chapter 4, technoscience, expertise, and lived patient experience fight a battle. Graham approaches the mess in Latourian terms: black-boxed processes and the process of articulation and enrollment. Rhetoric’s contribution to the picture is the trope; Graham coins “trope-shifting” as an expert means of discursively black-boxing processes. Graham finds these tropes—manifest, in this chapter, in neuro-imaging technologies—as powerful shifts that re-enlist expertise and lend legitimacy to technoscientific explanations of pain.

The remainder of the book moves away from the MPG to incorporate other loci of Graham’s ongoing research. Chapter 5 focuses on phenomena, whereas Chapter 6 focuses on disciplinary reflexive/reflective (re)articulation of those phenomena. Chapter 5 uses constitutive rhetoric (which, with his rhetorical to new-material oscillation becomes “constitutive calibration”) to describe how pharmaceutical companies and medical professionals produce phenomena—a process Graham calls “rarefaction.” His examples: the sinus headache (which doesn’t, positivistically, “exist,” except in the constructions of drug companieis and doctor-patient assemblages for whom it serves as a helpful explanation of an experience), and fibromyalgia (which didn’t “exist” for doctors until it could be represented by an imaging technology, but long existed for patients, who had to try to argue it into existence with personal pain narratives). Readers will recognize the story of the technoscientific/rhetorical production of fibromyalgia from Graham’s excellent article about the same subject and its implications for rhetorical agency —the article begins Graham’s consideration of rhetoric and the new materialisms’s (this awkward possessive plurality is intentional) shared territories. Chapter 6 revisits calibration at the level of governing bodies and professional organizations (FDA, CDER) in terms of the same two phenomena—sinus headaches and fibromyalgia.

Ultimately Graham’s analyses suggest that pain is neither physiological, nor sociological, nor psychological, but rather it is irreducible and multiple. This is not surprising, but it is philosophically and pragmatically important, nonetheless. The modern-minded, positivist epistemologies of science and medicine and the professional and governmental bodies that inter-relate with them therefore continue to be flummoxed by the existence of pain, much to the frustration of the patients that science and medicine ostensibly strive to serve. The problem is not that doctors (psychiatrists and medical doctors) do not recognize pain’s seemingly ephemeral but in fact material complexity; the problem is rather that their disciplines’ technologies and languages (not to mention their larger cultural idiom) are inherently modern and so constantly break the problem of pain into the old dialectic. Truly “integrated” approaches to pain, if they even exist, have failed to enter mainstream practice.

My two main critiques of this book are snobby and picky, and they can be read as compliments, in a way. First: this isn’t a “new” approach (as every book must claim to be, apparently) so much as an extremely well-articulated version of an emergent trend in multiple fields. Graham effectively, confidently distills the methodological tendencies of multiple scholars in STS and rhetoric (technical communication, especially) into a cogent argument. Second: this argument needs to find its way into the mainstream, already. I impatiently await Graham’s prescription for an activist radical materialism. Here Graham preaches to a choir of philosophy-fetishizing theory bros (I am proud to count myself as one of these, so I am not trying to sound sexist or pick fights). The book potentially speaks “for” the sufferers of pain and the frustrating ways in which they fail to communicate with doctors and other experts to find solutions, but how can it? Can a sufferer of fibromyalgia come to this text and use it to help make an argument? Where is the activist praxis of a new materialism? Of multiple, co-constitutive ontologies? How can critique prescribe some discursive action that makes any kind of dent in the binary dialectic that language constantly (re)imposes? How can philosophy visibly “matter” again in the 21^st century, as it so desperately needs to?

But the importance—yes, the sociopolitical importance as well as the disciplinary importance—of extended examples of radical materialisms and what they mean to the “real” rhetorical/ontological work of science and medicine far outweighs either of these critiques. More compelling, by far, are the productive questions of extension that Graham’s work is sure to inspire. For example, I want to diagram this account of pain on a Mobius strip with addiction (to opioid pain medications) on the converse, connected, and infinite loop. What does a similar rhetorical-ontological inquiry into addiction look like? What about depression? Childbirth? This book discourses well, in that it opens a territory and spells out an approach for future work.

As a scholar who works at the intersection of rhetoric and STS, I am also glad to now have this book at my disposal when I make the argument that rhetoric of science and STS need each other to find theoretical purchase (which certain of my colleagues and I continually do; see: Kelly & Maddalena 2015).Graham has long been a vocal proponent of continued uptake of STS into rhetoric of science, technology, and medicine (RSTM) and vice-versa. He is, for me and for others, a primary voice of materialist perspectives in our field and a voice of the emerging field of rhetoric of medicine. The Politics of Pain Medicine allows scholars like me to “use” Graham as his Foucauldian author-function. The philosophical and methodological argument is made; the (ironically ephemeral) concrete example has been given. “Rhetoric and STS Need Each Other” is a section heading in Graham’s introduction (p. 8). Thank goodness.

Finally, as a teacher of rhetoric of science, science and medical writing, and (only sometimes, but also always) STS, I see The Politics of Pain Medicine as a promising new resource for my graduate courses. Graham’s description of his rhetorical-ontological method will be especially helpful. Whether students choose to “calibrate”(Mol), “attune”(Thomas Rickert), or enact some other postmodern oscillation between the (falsely) discursive and (stubbornly) material, any project in the science-facing humanities will need to grapple with the theoretical challenges Graham’s book describes. Where I would hesitate to assign the prosaic juggernaut that is Lorraine Daston and Peter Galison’s Objectivity or the text to which Graham’s work owes the most—Anne-Marie Mol’s The Body Multiple—because of their sheer back-breaking, mind-bending heft, Graham’s book does much of the same work more quickly, clearly and incisively. Graham is a teacher and practitioner of technical communication, and his prose shows it. The book is deftly organized, densely contextualized, and clear without being oversimplified. That is to say: minds will be bent, but backs will not be broken.