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Sunday, September 10, 2006

Stuntz Brings the Pain

At Prawfsblawg, we've often lauded the scholarly and more informal writings of Bill Stuntz of Harvard Law School.  This week, in the New Republic, he has a strikingly more autobiographical piece describing his struggles with chronic pain stemming from an intractable back problem.  The cutline suggests Stuntz is writing a book on the topic as well.  Some of what he has to say:

    • I used to think the "chronic" part of chronic pain was the really bad part. Now I'm not so sure. Neverending pain wears you down; it's exhausting. But, on the whole, I think I'd rather have constant pain than the variable kind. . . . Pain is largely about the gap between expectation and reality: the distance between what you feel now and what your mind tells you you're supposed to feel. As reality slides downhill, expectations slide, too. Which makes reality feel less awful.
    • Something very important follows from this. Hope hurts; optimism amplifies suffering. The pain-free, healthy world is gone; this is my world now.
    • Work feels more satisfying, even though it's much harder to do. . . . Athletes have a terrific expression for this phenomenon: They say, "He left it all on the field," meaning there was nothing held back; the reserves were all spent. These days, I leave it all on the field--because there isn't any good alternative.

Stuntz's piece compels me to share some observations.  We're not normally about sharing here at Prawfsblawg, but what the hell.  I speak as someone who has had arthritis since the age of 4, who is the not-so-proud possessor of two artificial hips (implanted at the too-early age of 21), and who, alas, also suffers from some of the same back problems that Stuntz deals with.  My students are all too used to my classroom pattern of switching between brief stints of standing and longer spells in a chair at the front of the class.  (I might add that they are entirely gracious about it.)

The first, and decidedly more trivial (though not non-trivial, I think) point, is that suffering from a problem such as chronic pain, arthritis, and so on, raises interesting questions for the sufferer about self-definition and self-perception.  There is no doubt that many of my symptoms have interfered with major life activities, and continue to do so.  And I have sought a special parking permit, to spare me long walks that would otherwise be excruciating.  But beyond this, I have never filled out a form identifying myself as "disabled" (a question that law schools, at least, ask all the time), and would be loath to do so.  I consider myself fortunate not to be worse off, am all too aware of the universe of more serious diseases I could have had, and would hate to adopt a label that I generally associate with people facing far more significant hurdles than I do.  But neither can I reasonably consider myself healthy!  All this suggests that people with what I would consider intermediate illnesses, like chronic pain, face interesting questions about how they should classify themselves.  In large measure, I am sure, the unwillingness to classify such illnesses as disabilities stems not only from humility and a fear of hubris, but also from a hopeful, if misguided, urge to see oneself as dealing with a temporary, if painful, problem.  I am mindful, in thinking about these issues, of a section of my recent review of Kenji Yoshino's book Covering, in which I discuss Yoshino's attempts to convince a somewhat reluctant student to allow him to promote the fact of that student's vision problems in writing clerkship recommendations for him.

Second, although I disagree in important respects with Stuntz, I think he hits on something valuable and important when he writes that he prefers constant pain to variable pain, because constant pain helps narrow the gap between his expectations and his reality, and thus leaves him "no longer quite so disappointed when bad times come."  What Stuntz hits on here is that one of the key features of any chronic illness is a narrowing of horizons.  Only in conditions of health or recollection, when one reflects on how different and how liberated one's life was at other times, does one fully recognize how much one's world has narrowed -- to the safety of the house, or the office, or the short walk between one place and another, and so on.  Any swift and sudden change in those horizons -- for the worse or for the better -- can be highly disorienting.  I was more or less unable to walk by the time I finally had my hips replaced, and yet one of the most unsettling and, in some ways, insecure times I have experienced in my life was the months immediately after the surgery, when I suddenly found myself able to do more or less what I liked.  I suppose the experience is not unlike a thoroughly institutionalized prisoner suddenly finding himself at liberty, and uncertain which way to turn first.  Or, to change the analogy, one might say that living with chronic pain is like living in a bad marriage (not that I know anything about this!) -- it's terrible, but at least it's familiar.  (Does any of this explain why my favorite television show is House -- or why I am so fascinated with the plotline that has opened the third season?)

This sense of the narrowed horizons that accompany any chronic illness perhaps is at the root of my view that Stuntz is entirely too sunny in saying that pain "gave me one more good thing: It taught me to live in the present, not the past and future."  There is much to be said for living in the present, but it must also be said that one reason one lives in the present if one lives with a significant illness is that the past, with its memories of perfect health, can be too hard to remember (both in the sense that it is too painful to recall, and in the sense that it seems increasingly to belong to someone else's life), and the future is simply too uncertain.  One is too much confronted by the difficulties of the present moment to spend much time thinking about next month or next year; and simple plans (a vacation, a night out) can be anything but.  If "hope hurts," then what place is there for living in the future in a positive sense -- for plans, for dreams?

Finally, I think Stuntz overemphasizes the ways in which work is now "more satisfying" to him, and underplays the extent to which "it's much harder to do."  He suggests that in the past, he "never used all my capacities," but now "most things I do take every ounce of me."  What he does not say is that he might well have been able to do more in the past without using all his "capacities" than he can now, or that if most things he does now "take every ounce of [him]" -- presumably including many activities that his colleagues take for granted -- then he must perforce have less energy to accomplish anything, including work.   Usually, discussions of merit and meritocracy, success and desert, and so on center around questions of, say, race or gender.  Less often do we discuss the extent to which health, and thus a measure of dumb luck,  is a prominent factor in professional success.  Not the only factor, to be sure, as figures like Charles Ruff can remind us.  But we might devote a moment of our time to considering how much sheer good health and stamina figure, factors that are dependent on luck and may always disappear in a moment, figure in to success in all walks of life, not excluding legal academia.

Actually, not quite "finally."  It's a shame that Stuntz doesn't bring up the role of God in forming and informing his views on his life with chronic pain, although I assume he will in his book.  Stuntz has written powerfully elsewhere about religious matters, and I would assume his faith has something to say about how he shoulders his burdens.

Read the whole thing, as they say, and pardon the shocking intrusion of autobiography into this space.

Posted by Paul Horwitz on September 10, 2006 at 12:28 AM in Article Spotlight | Permalink

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Paul,

You have set the bar high with your thoughtful and sincere commentary on Bill Stuntz’s piece in the New Republic. I too would ask colleagues to excuse my foray into the autobiographical in this comment. I would also say that I am sorry to hear about your physical condition, but if you are anything like me, that is surely the last thing you want to hear. It is hard to come to grips with your own physical limitations, especially when a chronic illness or pain hits you at a time in your life when you are used to having few limits on your physical and mental abilities. This is the first time I have stated this publicly, but I was diagnosed with a chronic illness about five years ago, and like Bill, my life has not been the same since. The first year or two after diagnosis were particularly hard because of the difficulty adjusting to the pain and limitations of my illness. Not to mention that each manifestation of a physical illness is different and the doctors have difficulty placing each patient on an effective regimen, as Bill suggests in his piece. Suffice it to say, early on I did not accept my illness, much less embrace it.

But as time goes on, you learn to cope with your own physical limitations. Although I have some constant symptoms, the course of my illness can be unpredictable. Like you and Bill, my illness is not fatal, and the course of it rarely includes premature death. In the final analysis, I have learned to live in the present, not worrying too much about what the future will bring. During the “good” times, I work longer hours and attempt to complete much of my scholarship until the next flare of the illness comes along. I also spend quality time with my family, allowing them to share in the positive times. Over time, I have learned to embrace the illness and accept the limitations that go along with it.

But you are undoubtedly correct about the difficulties of self-perception that go along with a chronic illness. I have struggled with how to define myself, and in particular how to define myself in terms of others. Although I too am thankful that my lot in life is not worse, I have decided within the past year or two to take on the label that goes with my illness: disabled. To be sure, I am still very good about hiding my illness from my colleagues and students by working from home on days when my health is failing. But within the past few months, I have started informally advising students who have physical disabilities of some sort, or are dealing with the physical disability of a loved one. I have taken steps recently to make this mentoring relationship more formal. Although it is impossible to completely understand the lot in life of others with other, more serious forms of illness, I can at least more closely sympathize with the difficulties they face on a daily basis. I have found that students seem to appreciate it, and this service helps me cope with my own physical limitations better.

I too would encourage colleagues to read Prof. Stuntz’s insightful article. There is a lot to be learned there.

Posted by: David Stras | Sep 10, 2006 10:18:38 AM

Thanks very much for the link to the Stuntz article, and for your own comments on pain. And since you mentioned "House" and its running commentary on the effects of pain on a person's behavior, I wanted to share this story by Andrew Vachss, called Dope Fiend. It had a real impact on me.

Vachss, who is an attorney, also wrote an excellent novel called Pain Management, which focuses on the "war on drugs" and its consequences for legitimate pain sufferers.

Posted by: DP | Sep 10, 2006 12:50:11 PM

Thanks for blogging about this, Paul. These are important issues, and I'm glad you -- and Bill Stuntz -- decided to write on them.

Posted by: Orin Kerr | Sep 10, 2006 1:47:14 PM

Forgive me for joining this discussion, but my husband, who reads this blog on a regular basis, sent this post to me. I, too, was diagnosed with a chronic illness about 5 years ago, and then a second one two years after that. It's the first one, interstitial cystitis, that causes pain. (IC is an inflammation of the lining of the bladder, and leads to pain, frequency and urgency.) Frankly, I've never even thought about the labeling issue. I'm too busy trying to educate myself and my doctors about the latest treatments, clinical trials, etc. I have been constantly astonished at the lack of willingness of the medical profession to improve their learning curve. Try finding a doctor who is willing to learn about a condition that is new to them. Good luck. And in trying to find a doctor who will treat the pain with actual medications that work. I, too, don't look "sick" and I've found ways to work around the limitations, while keeping my medical records as private as possible. Besides a cure, I'd give anything for doctors to be more intellectually curious and to be less fearful of prescribing opioids to those of us who cannot live a normal life without them. I understand your enjoyment of House, but it does bother me that all the doctors he is surrounded by are so disapproving of his use of Vicodin (which, by the way, he takes too much of. He should switch to Oxycontin, which doesn't have acetominophin.). Yes, he's dependent on the drug, but he's not addicted. There's an important distinction to be made. He clearly is in pain, so why criticize him for treating it? This is a normal way of thinking for doctors, and one I pray that the rest of you never have to discover on your own. And I know this is hugely political incorrect, but I'd like to see a less spending on trivial things like theatre tickets for AIDS patients (source: NYTimes article in 1997), whose political activities have brought their disease billions of dollars, while we rejoice just because we just got a mere $5 million for basic research. This is particularly true now that AIDS has an established treatment protocol (which we don't) and is now considered a chronic illness. But that is a topic for another book.

So as to your situation, I truly do understand.

Posted by: Karen M | Sep 11, 2006 2:28:51 PM

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