Stoic advice: chronic pain

[Feel free to submit a question for this column, addressing it at massimo at howtobeastoic dot org.]

K. wrote: I read your response with interest to the person who regretted their back surgery. I have a similar situation, though my first surgery (that messed up my back) was seven years ago, and although I do have regret, and have had it for years (I really think we should be allowed one “undo” in life!) my question is about how much to try and change a particular situation and how much to accept.

Since my first back operation, I have been left with constant, chronic pain which is made worse by sitting, standing or walking. I have gotten a bit better over the past few years, but many things I have tried haven’t helped (or made things worse) and my progress is incredibly slow. I am in a better place than I was a few years ago, but I still can’t do basic things, like go on public transport, work, see a film, or even sit in a taxi (I have to lie down). My question is, how much of this do I accept and how much do I try and change? People are constantly suggesting things for me to try, or recommending practitioners to see, and there are more treatments out there than people in the world, it seems. So how do I work out the subtle line between accepting my ability and pain as it is, and trying new things in the hope of it getting better? I should say that medically, it is impossible to say whether I will or will not get better, but there is the possibility, elusive as it is!

So, in a situation where one doesn’t know whether it can get better or not, is it better to keep trying (for many years) or to just accept what is? 

To begin with, I’m sorry you are having such a tough time. You are right, if life were intelligently designed we would all get at least one do-over. Unfortunately, that’s not the way it works, apparently.

Your situation is actually very similar to that of a famous ancient Stoic who quit the school and went Cyrenaic because he suffered from chronic pain. Diogenes Laertius tells us the story:

“Dionysius, who became a renegade to the doctrine of pleasure, for owing to the severity of his ophthalmia he had no longer the nerve to call pain a thing indifferent.” (Lives of the Eminent Philosophers, VII.37)

Of course, Dionysius [of Heraclea, ever since known as the Renegade…] apparently seriously misunderstood in what sense pain is an “indifferent” for the Stoics: it does not mean that one shouldn’t care or be bothered by it, but rather that one should not allow the pain to define who he is a person, especially in moral terms. Apparently, the confusion between Stoicism and stoicism was alive and well already at that time, in Zeno’s generation!

Pain, even chronic one, is for the Stoic yet another obstacle thrown at us by life, and hence an occasion to test our character, according to Epictetus:

“Provoked by the sight of a handsome man or a beautiful woman, you will discover within you the contrary power of self-restraint. Faced with pain, you will discover the power of endurance. If you are insulted, you will discover patience. In time, you will grow to be confident that there is not a single impression that you will not have the moral means to tolerate.” (Enchiridion 10)

But it is, as usual, Seneca who is capable of seeing things from the most humane perspective:

“‘What then,’ you say; ‘is there no difference between joy and unyielding endurance of pain?’ None at all, as regards the virtues themselves; very great, however, in the circumstances in which either of these two virtues is displayed.” (Letter LXVI. On Various Aspects of Virtue, 14)

And moreover:

“There is great difference between joy and pain; if I am asked to choose, I shall seek the former and avoid the latter. The former is according to nature, the latter contrary to it. So long as they are rated by this standard, there is a great gulf between; but when it comes to a question of the virtue involved, the virtue in each case is the same, whether it comes through joy or through sorrow.” (LXVI. On Various Aspects of Virtue, 19)

Marcus, on his part, strikes what sounds to me like an intermediate note between the stern Epictetus and the more approachable Seneca:

“Death and life, honor and dishonor, pain and pleasure — all these things equally happen to good men and bad, being things which make us neither better nor worse. Therefore they are neither good nor evil.” (Meditations II.11)

The message in all three cases, however, is clear: pain is a highly dispreferred condition, and naturally so. But it isn’t something that should lead us to do unvirtuous things, and indeed should be approached as any another exercise in Stoic endurance.

So far the general philosophy. Let me get now to your specific question: where, exactly, is the line between acceptance and continued hope? To begin with, I’m going to remind you of one of the precepts of modern Stoicism, the so-called axiom of futility as articulated by Larry Becker in A New Stoicism (and I remind you that Larry knows something himself about crippling conditions, so he ain’t kidding):

“Agents are required not to make direct attempts to do (or be) something that is logically, theoretically, or practically impossible.” (A New Stoicism, p. 44)

Let’s apply the axiom to your specific problem. Clearly, it is not logically impossible to find a remedy for chronic pain. The existence of such a remedy would not violate any principle of logic, such as the law of non-contradiction, for instance. As a biologist (though certainly no expert on pain), I would imagine that countering chronic pain is also not theoretically impossible, meaning that there is nothing in human biology that excludes the possibility a priori (as opposed to, say, human powered flight, which is, in fact, biologically impossible).

That leaves us with practical possibility. Some things may be both logically and theoretically possible, and yet a wise person ought not to pursue them because the practicalities of the situation put them squarely outside of one’s reach. For instance, there are neither logical nor theoretical obstacles to me becoming a Wall Street magnate, but — quite apart from the fact that I have no interest whatsoever in such venture — it would be practically impossible. I am past middle age, not sufficiently smart and educated in the pertinent fields (finance, math), and probably not endowed with the sort of aggressive character traits that are required to succeed.

I am not going to insult your intelligence by giving you advice on yet more treatments or approaches you could try. It is not my field of expertise, and I assume you have read plenty on the matter, and talked to more than enough doctors. But it is empirically the case that some people do manage to improve significantly from conditions similar to the one you describe, so the possibility is, indeed, out there.

Should you pursue it or accept your current state of things? The question is often framed, as you did, as a sharp dichotomy: either X or not-X. But the two are not logically antithetical, and the dichotomy is not, in my mind, quite that obvious. I think that, after years of trying and achieving comparatively little improvement, it is indeed time for you to accept the possibility that you may need to live with this condition for the rest of your life. In that sense, Stoic philosophy may be a powerful tool not just to lead you to such acceptance, but also to help you deal with the situation day by day. (That said, remember that Stoicism is a philosophy, not a magic wand.)

But it certainly will not hurt you to keep exploring further possibilities of improvement, so long as they appear to be both theoretically valuable, scientifically speaking (no pseudoscience, please!), and practical (in terms of expected effort-to-results ratio and financially). The best person to decide whether a potential new approach fits these criteria is you, on the basis of your experience, your readings, and in consultation with reputable doctors.

The key thing to keep in mind, however, and what will allow you to balance acceptance and hope, is the dichotomy of control, especially as explained by Cicero in book III of De Finibus:

“If a man were to make it his purpose to take a true aim with a spear or arrow at some mark, his ultimate end, corresponding to the ultimate good as we pronounce it, would be to do all he could to aim straight: the man in this illustration would have to do everything to aim straight, yet, although he did everything to attain his purpose, his ‘ultimate end,’ so to speak, would be what corresponded to what we call the Chief Good in the conduct of life, whereas the actual hitting of the mark would be in our phrase ‘to be chosen’ but not ‘to be desired.’” (III.22)

You are the archer, the pain is the target. You know the rest.