by John O'Brien, 1988
Those with professional power over people with severe disabilities face an ethical question: is it good to use pain as a tool in their work?
My answer is no. Pain as a tool increases the power professionals have over vulnerable people while it decreases the changes of a positive human relationship between those who choose pain and those who are hurt. People who wish to build positive rela tionships and less violent social settings will follow two simple rules: if in doubt, do not cause pain; and, act positively to create conditions that decrease the occurrence of pain. Right living lies in the long-term struggle to apply these two rules in the creation of fitting responses to the difficult situations arising from engagement with people with severe disabilities who injure themselves or others.
Pain, Punishment, or Aversive Treatment?
Some participants in the current debate over what they call aversive procedures may say I have answered a question formed in ignorance. Behavior analysts might rather talk of punishment, which they define as a contingency that deceases the rate at which behavior occurs. In their jargon, punishment need be neither painful nor purposeful. This definition helps analyze behavior, but it confuses argument over the legitimacy of pain as a tool. Skinner (1984; Griffin et al., 1988) notes how frequently behav ior analysis is misunderstood by people who reduce it to causing pain in the service of social control. I don't want to add to the misunderstanding. I only want to discuss those professionally-arranged punishers that inflict pain.
"Aversive treatment" and "intrusive procedure" seem to me unhelpful euphemisms which cloak the use of pain beneath a long white lab coat. These terms confuse because they are sometimes defined to include both activities that intentionally inflict pain (such as electric shock, unpleasant noises or odors, humiliation designed to cause pain, taking away things impoverished people value most, hair pulling, and pinching) and activities that might seem odd or even offensive but may not be intended to inflic t pain (such as some procedures based on the principle of satiation and some forms of time-out). Activities that deprive or offend against a common sense of decency deserve scrutiny and should be avoided. But because professionals in control of people w ith severe disabilities lack agreement on whether it is right to inflict pain, focus on the narrower question of purposeful use of pain comes first.
What is Distinctive About Pain as a Professional Tool?
The choice of pain itself as treatment distinguishes it from many ordinary occasions of pain. Pain is often taken as the signal of a problem; it is seldom taken as the solution. Having a tooth filled can be painful, but the pain is a consequence of t echnique and not itself the tool. Pain does not cure caries. Working out to increase physical strength and stamina can be painful, but the pain is a consequence of exercise. Simply hurting oneself does not build muscle.
Self-administration of pain as a means to attain personally-chosen goals is different from application of pain by people who control the everyday life of others who are the object of their work. The penitent who chooses self-inflicted pain as a spirit ual discipline and the psychologist who wants to stop smoking and decides to self-administer rubber band snaps live in different worlds from the person who depends on program staff who structure twenty-four hours of each day and have the last word in the selection of goals and methods.
Measured application of pain as a procedure distinguishes it from spontaneous, violent reaction to provocation. "Severely intrusive procedures" are deliberately planned by professional teams to replace spontaneous reactions with measured ones. Profess ional choice of pain--that is, choice within the impersonal context of expert and client--set it apart from the most typical purposeful use of pain: deliberate punishment of children by their parents. (To distinguish pain as a professional tool is not, of course, to advocate spontaneous violence or child beating.)
The use of pain as a tool with those over whom they have power connects therapists with teachers who administer corporal punishment (Mancuso, 1972), some inquisitors, (note 1) some jailers, (note 2) and professional torturers. The important similarity is not in the choice of methods for delivering pain, or in the pain's intensity, duration, or immediate purpose, but in the deliberate selection of pain as a tool and the social context of in equality within which they choose to use pain. Some reports of the use of pain as therapy rival accounts of torture, but these abominations can confuse the issue. When practitioners of less harsh or less bizarre hurt distance themselves from extremists, they deny their fundamental links to other professional users of pain. This denial distracts from necessary ethical argument: why choose to hurt someone you hold power over?
Is the Warrant for Pain Found in Professionalism and Due Process?
Some justify the use of pain as a tool by the professional status of those who plan its use and their observance of proper form in its planning and administration. In its simplest form, this argument asserts that pain is a good thing (or the least bad thing) as long as it is chosen by a properly accredited professional or team of professionals. Pain as treatment is justified by conventions of practice based on facts collected and screened within the rules of a society of experts. Certified profession als may disagree, so a spectrum of approaches to pain define conventional practice. Only other experts are competent to judge the appropriateness of a professional's decision.
State authorities that regulate the use of pain as a tool elaborate this point of view in routinizing pain's application by specifying due process. A summary of one state's regulations illustrates. (note 3) To make the administration of pain legal, a team, which includes the person to be hurt or the person's guardian, must choose it. The team works under the supervision of a psychologist or a psychiatrist, who must see the person at least once a week for th e first month that pain is used and once a month thereafter. This professional must also train staff in the pain procedure, collect information, and make reports. When pain is delivered by electric shock, the supervisor must be "personally present on si te" and test the shock apparatus on him or her self before it is used to hurt the person. A physician must examine the person to be hurt and approve the plan. Team decisions must be reviewed and approved by an external review panel which includes a prof essional advocate. The team certifies that less intrusive procedures have been tried and found ineffective. They make a judgment showing that "the severity of the problem exceeds the severity of the treatment." They define detailed procedures for monit oring and revising the administration of pain. Before pain application begins, the person to be hurt or the guardian "shall give informed consent," the administrator of the program in which pain will be used must approve, and various state officials must be notified.
It is hard for me to imagine what this elaborate process seems like to a person who is hurt on schedule in its consequence.
People in controversy over the use of pain appeal to scientific aspects of professionalism to support their position.
Advocates of pain as a professional tool sum up the evidence. They argue from uncertainty; we have not tested pain long enough or systematically enough to agree on its effects; more research is needed, so pain must continue to be used. They argue from inefficiency; pain is quicker than other methods and should be used to reduce suffering in the person to be hurt and expense to the service system. They argue from ineffectiveness: in some cases, which only experts are qualified to identify, no other method can work.
Advocates against the use of pain review the evidence. They argue from inefficiency: the use of pain is costly and inefficient, other methods are more efficient. They argue from ineffectiveness: pain has not been proven effective, especially in the long term; it should be rejected in favor of other methods.
Advocates for the use of pain review the facts about "non-aversive interventions" and argue that they are themselves uncertain, inefficient, and ineffective. Advocates opposed to pain counterattack. Both sides agree that more study is needed to settle the question, though they disagree about the research agenda.
Perhaps one day this professional argument will lead to agreement on the facts. Perhaps this is how science progresses. But for now people with severe disabilities live with the consequences of polarization among those who control their lives.
As scientific debate proceeds, both sides attempt to convince judicial, executive, and legislative authorities to join their side on the basis of partial and equivocal evidence. Given the current climate of judicial deference to expert opinion, those who oppose pain have the harder going in court. Continued disagreement among qualified professionals defines the spectrum from which professionals may legitimately choose. As long as some experts sanction pain, and no argument demonstrates its fundamental incompatibility with community values, it remains on the menu until a regulation or a law that can stand constitutional test forbids it (Wiseman, 1988). Both reasonable bureaucrats and sensible legislators are more inclined to look for ways to avoid conflict by leaving room for every interest group than they are to just say no to a professional subgroup and its constituencies. (note 5) but they beg the fundamental question: is it good to use pain as a tool? Those convinced that the answer is no have to move beyond professionalism and due process.
Even when pain is finally outlawed as a professional too, some people with severe disabilities will inflict pain on self or other people. If they are to live in dignity with the rest of us, we must learn how to create the conditions that decrease the occurrence of pain among us.
Note 1 - Though many take the inquisition as
synonymous with torture to extract
confession and repentance, the power to use torture was only granted by exception
to those inquisitors who were able to convince the pope that no less intrusive
measures sufficed to root out error. Elaborate procedural safeguards insured
that each accused person had ample opportunity to respond to less intrusive
measures (cf. Kramer & Sprenger, 1486/1971). Note 2 - DiIulio (1987) points out that most
jailers today see themselves as keepers not
as punishers. For them, the function of their work is to incapacitate, possibly to
rehabilitate, but not itself to punish. Most see choosing to inflict pain as
incompatible with their profession. However, see Christie (1982) for a discussion
of imprisonment itself as the infliction of pain. Note 3 - This discussion is based on my reading of
Regulations and Handbook Governing
the Use of Behavioral Procedures in Maine Programs Serving Persons with Mental
Retardation (Augusta: Bureau of Mental Retardation, 1987). I selected these
regulations because they are thoughtful, clearly written, and representative of
the efforts of many authorities charged to regulate the use of pain. Quotations
are from section 3 of the regulations. Note 4 - If this seems pessimistic, consider the
changes to the Community and Family
Living Amendments to the Social Security Act since its introduction to Congress,
the broad tolerance accorded segregated school placements by the U.S.
Department of Education, and the reluctance of legislatures to significantly limit
the practice of chiropractic and naturopathic healing despite the weight of
scientific evidence and political influence brought to bear by conventional
medical trade groups.