The Politics of Pain Medicine

New Materialisms, STS, and Rhetoric

“New materialisms” is a term used by STS scholars like Diana Coole and Samantha Frost (2010) to describe a growing interest in and emphasis on the material/matériel. Here “material” is inextricably heteroglossic and refers both to the matter of physical reality and the conditions of economic production and social stratification. The introduction to Coole and Frost’s New Materialisms outlines key issues at stake for STS scholars vis- à- vis new materialisms. Several of these themes also lie at the core of The Politics of Pain Medicine and its rhetorical-ontological inquiry. Specifically, these include (1) the recognition of new ontological orientation in STS scholarship, (2) an increased focus on biopolitical and bioethical issues in contemporary technoscience, and (3) a reengagement with the socioeconomic conditions of everyday life (p. 7). And out of these issues arise necessary correlative questions about agency and the extent to which it is circumscribed by both physical and economic determinisms.

Traditional rhetoric of science and SSK/social constructivist approaches in STS have focused— somewhat myopically—on internal scientific discourse to the exclusion of the institutional and the material. Recognizing this issue, many scholars have called for a reincorporation of materiality in rhetoric and STS. Of course, as mentioned above, “materiality” means different things to different people. For some, this call for materiality is a call to investigate the economic and institutional forces that surround discourse (Haraway, 1997, 1998; Herndl, 2002; Kinsella, 2005; Latour, 1993, 1999; Scott, 2003, to name just a few). For others, however, the argument for materiality focuses on the objects of reality and might more aptly be described as an argument for a reincorporation of ontology (Bennett, 2010a, 2010b; Jack, 2010; Mol, 1999, 2002; Pickering, 2010; Graham, 2009; Harman, 2009; Herndl, 2002; Lynch, 2009; Marback, 2008; Rickert, 2013). Regardless of the focus (matter or money), these demands for a return to ontology and materiality in rhetorical studies and STS are gaining volume and momentum. As Coole and Frost note, “Everywhere we look, it seems to us, we are witnessing scattered but insistent demands for more materialist modes of analysis and for new ways of thinking about matter and processes of materialization” (p. 2). As suggested above, the arguments of new materialisms can be enacted with a variety of different overlapping foci— but these are foci of the same arguments made by the same scholars. There is no physical- material camp and no socioeconomicmaterial camp. When it comes to new materialisms, it’s a both/and rather than an either/or approach.

Scholars that focus on the physical tend to focus on the role of matter—the brute objects composed of colliding particles— in the laboratory and experimental practices. In STS, this mode of new materialism is enacted under a wide variety of different theoretical rubrics. A few prominent examples include Hans- Jörg Rheinberger’s (2010) epistemology of the concrete, Graham Harman’s (2009) object- oriented metaphysics, Levi Bryant’s (2011) object- oriented ontologies, Jane Bennett’s (2010b) vibrant materialism, Andrew Pickering’s (2010) nonmodern ontologies, Ian Bogost’s (2012) alien phenomenology, and Annemarie Mol’s (2002) multiple ontologies. While the theoretical nuances of each these approaches can vary significantly, they each share a strong focus on and engagement with physical objects as one primary locus of analysis. The cases addressed vary widely and include Rheinberger’s analysis of model organisms in the biological sciences, Bennett’s engagement with a collection of junk in a storm drain, Pickering’s interest in robotic turtles, Bogost’s study of computer code, Bryant’s interrogation of cats and coffee mugs, and Mol’s investigation of the clot- matter found in leg veins.

And this newfound focus on the physical- material is not limited to STS. Indeed, many in rhetorical studies now argue, like Marback, that the field’s traditional focus on hermeneutics and representation creates a situation wherein “rhetorical studies . . . fails to give the object its due” (p. 53). Even more specifically for the rhetoric of science, Herndl argues that rhetoric needs to embrace “a [new] model of science and scientific argument that integrates the social and the material with the discursive, but which does not abandon the real” (2002, p. 217). Additionally, Lynch argues that rhetoricians of science tend to be blinded to objects through their own particular terministic screens that “deflect attention from material practice” (p. 442). Furthermore, he suggests that “separating the material in the rhetorical prevents rhetorical critics from considering the interanimation of the two and, more specifically, how the relationship with specific material elements influences rhetorical practice” (p. 442). Thankfully, this trend toward antimaterial deflection seems to be reversing. The work of a variety of rhetorical scholars is now beginning to address the role of physical objects within a broader material- semiotic milieu. The work of scholars like J. Blake Scott (2003), Jessica J. Mudry (2009), Joanna Ploeger (2009), Elizabeth Parthenia Shea (2008), Rickert (2013), in addition to my own work (Graham, 2009, 2011; Graham and Herndl, 2013; Teston, Graham, Baldwinson, Li, and Swift, 2014), has moved strongly in the direction of new materialisms and their object- oriented foci. Indeed, this spate of scholarship interrogates a variety of objects including human blood, genes, particle accelerators, food calories, and pathological conditions alongside inquiry into the rhetorical and discursive issues at work in concert with these objects.

Arguments for a focus on the institutional- material aspects of science have a long pedigree in STS. Indeed, scholars like Donna Haraway, Evelyn Fox Keller, Andrew Pickering, and Bruno Latour are famous across disciplinary boundaries for their work in this area. The most recent work in this line—that is, the scholarship that explicitly identifies itself as new materialist—is intensely revisiting notions of agency, individualism, subjectivity, freedom, and biopolitics within the economic- materialist milieu. For example, Elizabeth Grosz (2010) argues that these issues have typically been addressed— especially in feminist scholarship— through “the discourses of political philosophy, and the debates between liberalism, historical materialism, and postmodernisms regarding the sovereignty and rights of subjects and social groups” (p. 140). Her aim, in contrast, is to reinterpret such notions within an ontological/new materialist idiom. That is, she asks questions about the very nature of freedom within something like an Althusserian (1971) concept of constraint borne of state apparatuses— repressive and ideological. Similarly, Rosi Braidotti (2010) seeks to relocate discussions of embodiment and embodied materialism away from the typical focus on the physical material of biomatter— bones, sinew, lipoproteins, and pathological conditions. Indeed, this argument compellingly suggests that the reinterpretation of embodiment within the economic- material milieu has a great deal to contribute to Foucauldian notions of biopower. Certainly there are myriad number of different research questions which could be (and are being) addressed under the economic material rubric of new materialisms. See Braidotti (2010), Coole (2007), Chow (2010), Grosz (1994), and Rose (2001) for some additional prominent examples. In each of these cases, readers will find the same strong emphasis on reimagining issues of agency, subjectivity, and biopolitics in the light of new materialisms.

Arguments for an institutional- material rhetoric of science typically focus on large scientific institutions and the complicated socioeconomic mechanisms that surround them. Scholars from this camp typically draw on resources from critical/cultural studies and seek to criticize the leveraging of power in material-semiotic networks such as the military and medical industrial complexes. As William Kinsella notes, “Contemporary science and technology are characterized by unprecedented degrees of institutionalization, and that in these settings the locus of agency has shifted increasingly from the individual to large systems of power/knowledge” (2005, p. 303). Interrogating these systems of power/knowledge requires new theoretical and methodological tools— tools that account for institutional-materiality. Recognizing this, Scott (2003) argues for a hybrid rhetorical- cultural study of science wherein the goal “is to map the connections and power relations among science’s heterogeneous actors” (p. 355). Reflecting on the affordances of this approach, Scott argues that

it also departs from the traditional subordination of these notions to the individual text. Rather than accounting for cultural entanglements as a way to situate and elucidate texts, a rhetorical-cultural mapping discusses specific texts as a way to elucidate cultural entanglements. In such an approach, the shifting intertext itself becomes the primary object of study. (p. 355)

In a move that anticipates Galison’s interest in context, Scott articulates a way of folding the notion of discursive intertextuality into the more historical- cultural notions of context qua socioeconomic. It is arguments like these that pave the way for highly productive synergies between rhetoric and STS.

Diagnostic Consensus: The Two- World Problem

With this bewildering array of alien phenomenologies, epistemologies of the concrete, institutional-material rhetorics, object- oriented ontologies, vibrant materialities, and biopolitical theories, it can sometimes be hard to see new materialisms as a coordinated endeavor. The plethora of proposed solutions elides the near complete uniformity of diagnostic consensus. That is, scholars from fields as far ranging as rhetoric, philosophy, sociology, political science, and history have all come to agree on the central failing in Western intellectual history, the so- called two- world problem (see fig. I.2): the series of bifurcations that includes the subject/object, culture/nature, and mind/body dichotomies. These binaries not only establish the core territory of modernism, they create an epistemological crisis. This crisis is what Harman (2011) refers to as “the problem of access” and Bryant (2011) as “the epistemic fallacy.” The irreversible, unbridgeable dichotomy between the subject and the object forces a constant reengagement with the question of whether or not the subject has access to the object. Elaborating Latour’s critique of modernist epistemology, Bryant argues:

As a consequence of the two world schema, the question of the object, of what substances are, is subtly transformed into the question of how and whether we know objects. The question of objects becomes the question of a particular relationship between humans and objects. This, in turn, becomes questions of whether or not our representations map onto reality. (p. 16)

Of course, at the outset, there doesn’t appear to be all that much “new” about new materialisms. The rejection of modernist and/or Cartesian binaries has a long pedigree in postmodern thought tracing back to the (proto-)postmodernist Martin Heidegger and his hermeneutic circle and popping up in a wide variety of scholarship ranging from Derrida’s deconstruction of the metaphysics of presence to Rorty’s critique of the mirror of nature.

Indeed, the rejection of modernist binaries has similarly been a staple of STS for decades, finding perhaps its fullest expression in Haraway’s Simians, Cyborgs, and Women (1991) where she recognizes the incredible pervasiveness of the two- world problem (although not by that name) and the litany of dualisms it authorizes:

To recapitulate, certain dualisms have been persistent in Western traditions; they have all been systemic to the logics and practices of domination of women, of people of colour, nature, workers, animals— in short, domination of all constituted others, whose task is to mirror the self. Chief among these troubling dualisms are self/other, mind/body, culture/nature, male/female, civilized/primitive, reality/appearance, whole/part, agent /resource, maker/made, active/passive, right /wrong, truth/illusion, total/partial, God/man. (p. 177)

So if the recognition of this proliferation of dualisms is such well- trodden territory, one might be justifiably compelled to ask what makes new materialisms new. Why do I point to it as an appropriate path forward if it appears repetitive in its founding diagnosis?

The newness of new materialisms comes from its full acceptance of Latour’s well- known critique of postmodernism—namely, that despite claims to the contrary, postmodernism’s rejection of positivism/modernism does not so much deconstruct the two- world problem as it does reify it. As he notes, “Postmodernism is a symptom, not a fresh solution. It lives under the modern Constitution, but no longer believes in the guarantees the Constitution offers” (1993, p. 46). Translating from Latourian, this is the argument that the postmodernists do not actually reject the two- world hypothesis. They instead reify it, privileging the “other” side, placing subject over object, words over things, culture over nature.

Indeed, Annemarie Mol highlights the pervasiveness of this postmodern reversal in her objection to the now standardized disease/illness distinction in humanistic and social scientific studies of health and medicine. In a passage that has striking parallels with Liebeskind and Paul’s criticism of pain science, Mol (2002) argues:

Social scientists have made it their trade to listen for feelings when they interview patients. And they have persistently and severely criticized doctors fo neglecting psychosocial matters, for being ever so concerned about keeping wounds clean while they hardly ever ask their patients what being wounded means to them. In addition to attending to blood sugar levels, bad arteries, wounds, and other physicalities, or so social scientists have been arguing in all kinds of ways, physicians should attend to what patients experience. This is how they have come to phrase it: in addition to disease, the object of biomedicine, something else is of importance too, a patient’s illness. Illness here stands for a patient’s interpretations of his or her disease, the feelings that accompany it, the life events it turns into. (p. 9)

Here we see the typical postmodern intellectual move in action: a rejection of modernism’s hegemonic focus on the so- called real replaced with a new discursive hegemony where the real is elided entirely. Or as Mol puts it, “In a world of meaning, nobody is in touch with the reality of diseases, everybody ‘merely’ interprets them. There are different interpretations around, and ‘the disease’— forever unknown— is nowhere to be found. The disease recedes behind the interpretations” (pp. 11– 12). (I use the word “hegemony” very consciously here.)

The two- world of modernity and postmodernity. Both modernist and postmodernist metaphysics offer a bifurcated world that separates subjects from objects. Where modernism construes the relationship between subject and object as one of representation (proposed correspondence), postmodernism offers a theory of hegemonic relationality.

The two- world of modernity and postmodernity. Both modernist and postmodernist metaphysics offer a bifurcated world that separates subjects from objects. Where modernism construes the relationship between subject and object as one of representation (proposed correspondence), postmodernism offers a theory of hegemonic relationality.

Bryant echoes the insights of both Mol and Latour and, in so doing, identifies a second predominant fallacy of Western thought— “the hegemonic fallacy” (p. 131). The hegemonic fallacy, which also arises from the two-world problem, is predicated on the postmodern reversal of the two-world binaries. That is, where modernism privileges the real object over the perceiving subject, postmodernism recasts the object as an extension of the subject’s perception, and the object becomes an epiphenomenon of the subject (the death of the referent). For Bryant, it is this totalizing subject that gives rise to hegemony critiques, and is equally, again, of the two-world problem. As readers of Reassembling the Social (2005) will recognize, Bryant’s rejection of the hegemonic fallacy also echoes Latour’s concern that actor-network theory (ANT) is too often “confused with a postmodern emphasis on the critique of the ‘Great narratives’ and ‘Eurocentric’ or ‘hegemonic’ standpoint” (2005, p. 11). Indeed, much like Bryant, Latour caustically dismisses scholarship on hegemonic forces as accounts of an “invisible agency” (p. 53). As he declares, “In ANT, it is not permitted to say, ‘No one mentions it. I have no proof but I know there is some hidden actor at work behind the scene.’ This is conspiracy theory, not social theory” (p. 53). And while I’m not willing to go as far as Latour in rejecting the role of elided forces, as I will explore in chapter 6, the too easy deployment of hegemonic narratives obscures viable possibilities for positive change in pain science and pharmaceutical regulation.

Ultimately, the two- world problem and its twin fallacies (epistemic and hegemonic) help to explain both the unity and the dizzying array of new materialisms. To transcend the two- world problem is to transcend both the epistemic and hegemonic fallacies simultaneously. This, of course, presents any work attempting to do so with a previously inconceivable task. For the two- world problem authorizes the traditional divisions between research projects in rhetoric of science and STS. That is, investigations of laboratory practice and science-policy debates are required to be distinctly different tasks under the two-world problem. In contrast, a thoroughgoing embrace of new materialisms and its attendant rejection of the epistemic and hegemonic fallacies requires a dissolution of not only the modernist binaries but also the boundaries typically enforced between complementary areas of scholarship. As Latour (1999) puts it:

There is thus no longer much sense in pursuing in isolation questions like “How can a mind know the world outside?” “How can the public participate in technical expertise” “How can we protect nature from human greed?” “How can we build a livable political order?” Very quickly inquiries into these matters stumble over so many aporias, since the definitions of nature, society, morality and the Body Politic were all produced together, in order to create the most powerful and most paradoxical of all powers: a politics that does away with politics, the inhumane laws of nature that keep humanity from falling into inhumanity. (p. 293)

Separating these questions from one another in this book would be doubly inappropriate given the primary subject under investigation. As I have alluded to above, the pursuit of a biopsychosocial, nonmodern theory of pain is borne of a nearly identical diagnosis of the failure of the two-world problem. Indeed, the two- world problem, in its various instantiations, and through its various fallacious corollaries, simultaneously gives rise to and authorizes the primary problems in pain medicine (the myth of two pains, the rejection of subjective patient report) as well as many of the central theoretical problems in rhetoric of science and STS (the death of agency, the illness/disease dichotomy, the incommensurability thesis, the problem of expertise). See figure I.3 for a more detailed schematic.

The two-world problem in pain, rhetoric, and STS. This schematic details how the two- world problem, as the central conceit in (post-)modernist thought, simultaneously gives rise to and authorizes the major problems of both pain science and rhetorical-STS inquiry. The two-world hypothesis creates the epistemic fallacy, which gives rise to the problem of expertise in rhetoric/STS and the rejection of subjective patient report in pain medicine. The two-world problem further creates the hegemonic fallacy and, in so doing, the incommensurability thesis and the death of agency become necessary corollaries. And finally, the two-world problem also legitimizes the manifold dualisms (nature/culture, body/mind, disease/illness, myth of two pains) recognized by contemporary medical science and postmodern rhetoric and STS.

The two-world problem in pain, rhetoric, and STS. This schematic details how the two- world problem, as the central conceit in (post-)modernist thought, simultaneously gives rise to and authorizes the major problems of both pain science and rhetorical-STS inquiry. The two-world hypothesis creates the epistemic fallacy, which gives rise to the problem of expertise in rhetoric/STS and the rejection of subjective patient report in pain medicine. The two-world problem further creates the hegemonic fallacy and, in so doing, the incommensurability thesis and the death of agency become necessary corollaries. And finally, the two-world problem also legitimizes the manifold dualisms (nature/culture, body/mind, disease/illness, myth of two pains) recognized by contemporary medical science and postmodern rhetoric and STS.

Subsequently, it is an essential aim of The Politics of Pain Medicine to investigate and explore what it means to simultaneously overcome the two-world problem in rhetorical studies, STS, and pain medicine. Additionally, figure I.3 serves as a relational map in two ways. Most obviously, it (1) maps the various theoretical, practical, and ethical problems that arise from the two- world hypothesis and (2) details the potential for productive synergies among new materialist rhetorical studies, nonmodern STS, and a biopsychosocial approach to pain medicine. In recognizing this I hope all three areas may be improved through this colocated exploration. And lest there be any doubt on the possible reciprocal contributions
rhetorical-ontological inquiry and biopsychosocial pain management can make to each another, allow me to highlight one of my interview subject’s deft criticism of the original (post-)modern two-world situation of this project:

You used in your introduction to this study the idea of epistemology and hermeneutics. I don’t know how you’re going to use those words. There’s been 2,500 years of philosophical polemic that there’s an ontological difference [between epistemology and hermeneutics], but there’s not at a neurophysiological level. Internal versus external, that is, the subjectivity of consciousness. . . . To separate epistemology and hermeneutics is contextual only. At the neurobiological level they are the same. (Michelson, interview)

Here, Dr. Michelson, an orthopedist, rejects any dualist separation between knowledge and meaning and does so simultaneously for both philosophical and neurobiological reasons. As will be seen in the chapters that follow, this kind of detour through philosophy becomes somewhat commonplace as part of efforts to found a biopsychosocial pain. And as the clinicians involved in my inquiry reject not only medical disciplinary boundaries but also the traditional divisions among the humanities, arts, and sciences, a great deal can be learned for rhetorical-ontological inquiry.

Finally, figure I.3 also provides something of a road map for the work of the Politics of Pain Medicine. It helps to identify the central foundation from which the spiraling corollaries of the two-world problem emerge. Figure I.3 identifies the central origin of what might, through the lens of traditional scholarly boundaries, seem a collection of somewhat disparate chapters. Chapter 1 explores an intermingling between the history of pain and the incommensurability thesis. Chapters 2 and 3 focus on the relationship between physical materiality and the rhetorical as the MPG attempts to find its own version of biopsychosocial pain. Chapters 4, 5, and 6 offer an exploration of ontological adjudication in institutional spaces, at one point detouring through the history of neuroimaging and in other places exploring disciplinary and institutional disagreements over the ontologies of fibromyalgia syndrome and the sinus headache. At the root of all these endeavors is the attempt to transcend the two-world problem and in so doing develop a robust rhetorical- ontological account of pain science and medicine. A major part of that effort will be, as mentioned above, to document and investigate the modes of calibration that bring together researchers and practitioners who subscribe to different approaches to pain. In so doing, the Politics of Pain Medicine will offer a taxonomy of calibrating practices used by the multidisciplinary pain medicine practitioners, researchers, and advocates. The ultimate taxonomy will include a range of modes of calibration (cross- ontological calibration, constitutive calibration, rarefactive calibration, calibration by detour), authorizing institutional resources (principles of rarefaction, institutions of rarefaction, black- box technologies), and discursive instantiations (stasis debate, warranting topoi, trope shifting). I leave the details this taxonomy to chapters 2–6, which follow chapter 1’s historical investigation of the emergence of the many pain practices that require calibration.

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