# **Chapter 8 Painful Experience and Constitution of the Intersubjective Self: A Critical-Phenomenological Analysis**

**Jessica Stanier and Nicole Miglio**

**Abstract** In this paper, we discuss how phenomenology might cogently express the way painful experiences are layered with complex intersubjective meaning. In particular, we propose a critical conception of pain as an intricate multi-levelled phenomenon, deeply ingrained in the constitution of one's sense of bodily self and emerging from a web of intercorporeal, social, cultural, and political relations. In the first section, we review and critique some conceptual accounts of pain. Then, we explore how pain is involved in complex ways with modalities of pleasure and displeasure, enacted personal meaning, and contexts of empathy or shame. We aim to show why a phenomenology of pain must acknowledge the richness and diversity of peculiar painful experiences. The second section then weaves these critical insights into Husserlian phenomenology of embodiment, sensation, and localisation. We introduce the distinction between Body-Object and Lived-Body to show how pain presents intersubjectively (e.g. from a patient to a clinician). Furthermore, we stress that, while pain seems to take a marginal position in Husserl's whole corpus, its role is central in the transcendental constitution of the Lived-Body, interacting with the personal, interpersonal, and intersubjective levels of experiential constitution. Taking a critical-phenomenological perspective, we then concretely explore how some people may experience *structural* conditions which may make their experiences more or less painful.

**Keywords** Pain · Husserl · Critical phenomenology · Lived-Body · Intersubjectivity · Normativity

J. Stanier (B)

N. Miglio Università Vita-Salute San Raffaele, Milan, Italy e-mail: nicole.miglio@gmail.com

© The Author(s) 2021

101

This work was supported by theWellcome Trust [203109/Z/16/Z].We are very grateful to colleagues and friends at our respective institutions for their feedback on an early draft of this chapter. We contributed equally as authors to this chapter.

University of Exeter, Exeter, England, UK e-mail: js708@exeter.ac.uk

S. Ferrarello, *Phenomenology of Bioethics: Technoethics and Lived-Experience*, The International Library of Bioethics 84, https://doi.org/10.1007/978-3-030-65613-3\_8

## **8.1 Introduction**

Pain is ordinary and integral to our experiential topography; a 'background texture' of pain characterises our whole lives. I flinch away from a hot pan as it brushes against my arm at the stove. I keep walking briskly, despite the angry blister on my heel. I scratch an itch and the sensation both sooths and prickles my skin. I absentmindedly rub my shoulder, relieving the dull ache from sitting at my desk too long. If we consider these routine and mundane ways in which pain features in everyday experience, it becomes clear that—far from presenting only through unusual and excruciating events—pain is familiar and, in many ways, vital for navigating the world. Pain draws our attention to our bodies as they pertain to our surroundings. And while everyday pain is often a far cry from the overwhelming agony of extreme injury, it is nonetheless recognisable *as pain* across these various contexts.

The treatment of pain is a huge global pharmaceutical industry, largely based on a medical conception of pain as a set of quantifiable conditions in the physiological body. Nevertheless, subjective experiences of pain evade reduction to scientific explanation; pain can persist long after physical symptoms are healed or occur without any apparent physical impetus in the first place (e.g. Myalgic Encephalomyelitis). Moreover, it is not only physical hurt that painful experiences can reveal. Social and political contexts produce and sustain subjects in pain, as they are alternately marginalised, disbelieved, prioritised, or cared for; the status of their painful experience garners significance in this relational intersubjective context. The situation of people and their pain is rarely thematised in bioethical discussion of painful experience and health care. Theoretical conceptions of pain as a phenomenon have variously and equivocally presented it as simple sensation, fundamental affect, constituent of suffering, instrument of power, and condition of the lifeworld—seldom is the relational aspect of painful experience drawn out.

By taking a critical-phenomenological approach, this paper seeks to critique and further these conceptions by elucidating the complexities of pain as a phenomenon, and by better accounting for the contextual and intersubjective variation of painful experiences. As such, we articulate how painful experience involves several phenomenological levels—from the hyletic to the intersubjective—which are differentially affected by the subject's social, political, and cultural situation. We suggest that this phenomenological account might be integrated into lifeworld-based approaches to care and treatment of pain, through social and political engagement (e.g. Hemingway 2011; Zahavi and Martiny 2019).

### **8.2 I: Review and Critique of Conceptual Analyses of Pain**

While there are, of course, nuances between the many experiential accounts of pain, there is a certain consensus in the literature regarding the broad characteristics of painful experience. In this section, we contextualise our own analysis by summarising and critiquing some of these influential accounts (Scarry 1985; Leder 1990; Svenaeus 2015). Many authors of these works describe their perspectives as being phenomenological—though they are generally motivated to explicate general structures of pain, rather than seeking to integrate their account into a wider phenomenological tradition. Moreover, while these authors are certainly interested in painful experience, they tend to work through conceptual analysis and therefore do not fully attend to the complexities of painful experiences as they are lived through phenomenologically. We argue that they therefore inadvertently compromise and over-reduce their descriptions of pain, and consequently overlook matters of significant political import. As Disability Studies scholar Alyson Patsavas notes (2014), "Even scholarship that directly challenges the biomedical dominance of pain leaves the universally private, individualized, and tragic experience of pain largely intact" (p. 209; cf. Dahl et al. 2019; Käll 2012). It matters how pain comes into experience and by whom it is borne, yet this is not often acknowledged in theoretical accounts of pain. This section will hence demonstrate the necessity of our critical-phenomenological analysis by exploring not only the subjective experience of pain but also its intersubjective constitution.

Aversiveness is frequently assumed to define painfulness. In these cases, pain is unequivocally taken to mean "the very concretization of the unpleasant, the aversive" (Leder 1990, p. 73). It is interpreted as a kind of negation, 'not me,' to be driven out: "[i]f to the person in pain it does not feel averse, and if it does not elicit in that person aversive feelings toward it, it is not in either philosophical discussion or psychological definitions of it called pain" (Scarry 1985, p. 52). In accounts such as these, pain is presented as intrinsically aversive, disruptive, and contrary to 'normal' experience. However, as literary scholar Geoffrey Galt Harpham (2001) observes, pain is not homogenous but rather it is "a combination of sensations, dispositions, cultural circumstances, and explanations" (p. 208). Historian Joanna Bourke (2014) in turn emphasises that "People do pain in different ways. Pain is practised within relational, environmental contexts. There is no decontextual pain-event" (pp. 7–8). The potentially pleasurable pain of getting a tattoo, running a marathon, or engaging in sexual masochism, for example, differs substantially from the abdominal throb of appendicitis, as do the normative meaning-complexes surrounding each experience respectively (Siorat 2006; Sheppard 2018). At its extreme, the depiction of painful experience as essentially aversive can both problematically reify pain as an agent independent of the person-in-pain and also obscure the fact that pain, under certain conditions and at different constitutive levels, can also be experienced as pleasurable or desirable. Pain here is not always an inconvenience to be borne, later deemed 'worthwhile' according to a logic of calculation, but rather it can be an intrinsically meaningful part of experience as lived-through. Moreover, pain's temporal givenness—its surprising or enduring character—gives form to the experience. Pain is rarely, if ever, a constant, but rather the shape and intensity of pain tends to vary along with embodied activity or circumstance (Leder 1990, p. 72).

To this end, the localisation of pain, in the body itself, can be centred in analysis. Scarry, for example, argues that pain can simultaneously present one's own body as the source of hurt (e.g. the heat and swelling in the finger caused by a splinter) and also be characterised as knifelike, pricking, stabbing, or searing *as if* an external entity were acting on the body (Scarry 1985, p. 53). Leder (1990) highlights a similar notion of 'sensory intensification' where the region of the body in pain "suddenly speaks up," surpassing and overwhelming any prior sense therein (pp. 71–72). These insights draw attention to how pain can present in an instant but, as Svenaeus (2015) notes, pain becomes something more problematic "in its more penetrating and chronic forms, [that] develop into something which permeates our entire experience" (p. 111). The duration and character of the pain influence what appears for us in the world through the Lived-Body. In order to differentiate between aversive pain as a reductive (and medicalised) notion of sensation, and aversive experience as a complex subjective manifestation in the lifeworld, Svenaeus (2015) appeals to the notion of suffering as "a richer concept than pain" that can explain how "pain changes the everyday experiences and life of a person" (p. 109; cf. Cassell 2004). Svenaeus' distinction helpfully points out that the potential for pain to be aversive depends largely on existential conditions that exceed localised and static bounds of an anonymous body. However, Svenaeus stops short of questioning the structural conditions which disproportionately affect certain people in pain, and does not account for how these conditions affect the very character of the painful experience itself. In this sense, it is not simply that pain is aversive and therefore causes suffering in the lifeworld in a linear sense. As Patsavas (2014) notes, "when cultural discourses construct pain as the cause of feelings of devastation, they oversimplify complex cultural, historical, and political phenomena. More than that, they prevent us from examining the structural conditions that make experiences of chronic pain tragic" (p. 204).<sup>1</sup>

This is not to say that pain and suffering are entirely socially constructed, with no basis in the body. Neither is this to deny the importance of analysing suffering and seeking its alleviation in many instances.2 However, as we later argue in this paper, it is essential to recognise the extent to which cultural beliefs about pain matter phenomenologically and underpin structural conditions in the lifeworld. Pain, suffering, and their associated aversiveness are not simply determined by sensations in the body; popular discourses create entrenched ways of understanding and receiving pain, in turn shaping how we experience pain itself and the meaning it comes to bear (Patsavas 2014, pp. 203–204). We aim to substantiate this somewhat radical phenomenological claim in Section II. Here we simply wish to emphasise that life might be differentially experienced as unlivable for certain social groups, and that simple medical explanations for pain in the body fail to explain whose pain is accepted as more unnatural or abnormal. These vital political insights must be folded into a new phenomenology of pain, running through additional levels of experiential

<sup>1</sup>Patsavas' cripistemology of pain (2014) aims at "tracing the discursive systems that materially produce and structure experiences of pain, laying out a *corporeally infused* cultural analysis of pain, excavating the *felt* experiences of cultural discourses, and situating those experiences within a broader cultural politics of ableism" (p. 207).

<sup>2</sup>However, as Garland-Thomson (2004) reminds us, the "cultural logic of euthanasia" underpinning difficult decisions around worthiness, care, and compulsory cure, often serves to annihilate, rather than support, those in pain.

constitution. This will require a thoroughgoing account of the recognition of pain and relationships of care, which feed into the discursive systems described by Patsavas.

Different situations—care and neglect, relative control and precarity—drastically alter the manner in which pain is experienced. I may attempt to explain my pain to someone else, repeatedly, to no avail and without sufficient words to convey the experience (Rodemeyer 2008). At such times, it may be possible to turn one's attention elsewhere and coax the pain to recede into the background of experience, since "the pain quality is dependent upon the way I choose to focus upon things in the world in different activities" (Svenaeus 2015, p. 113). However, a more intense pain might thwart any attempt to gather up the experience into words at all, rendering the subject helpless in "a situation of passivity in relation to feelings that hurt you" (p. 118). This latter disruption perhaps further reveals how pain can obliterate the contents of consciousness, making certain complex thoughts unthinkable (Scarry 1985, p. 54). Leder (1990) echoes this notion, describing how 'intentional disruption' brought about by pain "renders unimportant projects that previously seemed crucial" (p. 74). Indeed, in the deepest agony, pain can become a totality and "displaces all else until it seems to become the single broad and omnipresent fact of existence" (Scarry 1985, p. 55). The world disappears as "our horizon of meaningfulness gradually shrinks until nothing but the self-centred pain remains" (Svenaeus 2015, p. 116). Someone experiencing this may feel unreachable and inconsolable, and that their life has been emptied of meaning by the senselessness of their suffering. However, to conclude that this sense of isolation is inevitable, as some of these authors do, is to ignore the intersubjective conditions that may have led to such a crisis (p. 120).

There is a huge stigma attached to many painful experiences. Particularly for those in chronic pain, neoliberal medical discourses individualise and decontextualise factors that make pain unbearable: by interpellating subjects as responsible for their own pain and suffering, framing their decisions on pain management as matters of personal choice and moral failure, gendering and racialising notions of stoicism and compulsory able-bodiedness, and proliferating a sense of being a burden who must overcompensate for care (McRuer 2006, pp. 2–3).<sup>3</sup> In reality, of course, pain is rarely, if ever, experienced in isolation. We might ask, as Patsavas (2014) does, how a context in which "interdependence is acknowledged and valued" might transform experiences of pain (p. 209).

This critical perspective is lacking in some conceptual accounts of pain, and can lead to problematic conclusions. Scarry (1985) famously argues that pain can "destroy language" (p. 53), and claims that pain "brings with it all the solitude of absolute privacy with none of its safety, all the self-exposure of the utterly public with none of its possibility for camaraderie or shared experience" (p. 53). However, while the radical alterity of the other is preserved in empathy—I feel this pain as yours, not mine—it hardly follows that this is a distinction unique to painful experience, nor that

<sup>3</sup>Patsavas (2014) explores this point when rereading diary entries by her younger self, where she had written "I need to be punished, for all the pain I can't control. I'm ashamed of that. I'm ashamed of not being able to handle the pain. I'm ashamed of the pain I cause so many people because of it. For that I deserve to hurt" (p. 208).

pain is private and impossible to share. Intersubjective encounters are moments for *possible* shared recognition of pain. Others can turn away from our pain in disbelief and disregard however indisputably real it feels to us, but it does not follow that it is never possible to empathize. Evidence of others' experience is always mediated: their pain, joy, boredom, and ecstasy alike. Different situations can alternately lead people to reveal or conceal their experiences, in turn altering what it is possible for others to recognise and receive—and these situations can be changed.

So while it would be insensitive and wrong to claim that we can fully 'know' another person's experience, it is certainly true that, in empathy, we have our own experience of others' pain (Patsavas 2014, p. 206). In a sense, there is a coexperiencing of the phenomenon—my friends and family will know what it is like to live with my pain in their own way, and their responses will in turn make the experience feel problematic or recognised. The overlapping boundaries between my pain, their pain, and our pain constitute a co-experiencing of pain together, and this can happen at home but also in the clinical encounter. My doctor's incredulity or openness to my experience also alters how I live through my pain (p. 215).

These considerations already demonstrate an interplay between sensation, temporality, intersubjectivity, affectivity, and association already bound up in pain as a phenomenon. It is possible to critically enrich experiential accounts of pain without recourse to Husserlian analysis. However, we suggest that problematic claims to the universal aversiveness of painful experiences, for example, or of its ultimate incommunicability, can be challenged phenomenologically—and this is particularly important when it comes to treatment of pain or pathologisation of behaviour. For this reason, we turn to the rigorous work of Edmund Husserl, as well as the recent work of critical phenomenologists, in order to contribute an account of pain that can attend to these complexities at different levels of experiential constitution.

## **8.3 IIa: Critical Phenomenology of Pain**

We have explored how painful experiences can feel complexly both aversive and pleasurable, how localised pain bears personal meaning, and how different contexts of care can make pain more or less difficult. We can now draw upon the work of critical-phenomenologists to further explicate painful experiences and the constitution of the intersubjective self. Many other academic disciplines concern themselves with the level of intersubjectivity, which is sometimes neglected or bracketed off as separable by phenomenologists—especially with respect to structural and political conditions. The intersubjective level would not merely encompass *experiences of* other people but also more generally the domain of intersubjective norms, sociality, politics, and collectivity—modes discussed by some scholars in operative terms of social constructivism. It is perhaps one of the merits of the critical-phenomenological approach that it both acknowledges and moves beyond the remit of this framework (Rodemeyer 2017). The importance of structural intersubjective systems is accounted for phenomenologically, but consciousness is not reduced to this level. Particularly when analysing value-constituting sensations like pain, it is problematic that so few phenomenological accounts reflect back at the structural and political situatedness which alters and influences the experiential complex across other levels.

Critical phenomenology is a theoretical attitude that takes up and critiques classical phenomenological conceptions of power relations (see e.g. Beauvoir 1949; Fanon 1952). It also employs the traditional phenomenological 'toolkit' to explore topics usually neglected or overlooked within the phenomenological canon, such as marginalization and oppression. Taking this latter approach, we start our analysis of pain with a rereading of Husserl's reflections on the sensible body as developed in *Ideas II*.

The body can be perceived and experienced by the subject in at least two different ways: as Body-Object (*Körper*) and Lived-Body (*Leib*). This is perhaps the most fundamental insight offered by phenomenology. Our bodies are given as objects, with extension in space and time, and are subject to perceptual rules and structures. On the other hand, my living body is the body which I experience—the body I feel and the very nexus of my acting, thinking, and being in the life-world. Sensation is an integral constitutive aspect of this double experiential structure. This is famously explored in §36 and §37 of *Ideas II*, where Husserl focuses on the concept of Sensings (*Empfindnisse*). Here he characterises the body as "the perceptual organ of the experiencing subject" (Husserl 1989, p. 152), and considers how this corporeality is constituted when the Lived-Body comes into contact with itself—for example, when my two hands touch one another.4 Each hand senses and constitutes these sensations as an object but also as living—namely, the other hand. This combination is not merely the additive result of the physical thing plus the sensations: "it is not that the physical thing is now richer, but instead it becomes Body, it senses" (p. 52).

This case shows that touch between two parts of one's body entails a doubling of the sensations in the two parts of the body engaged in the process. In Husserl's words:

If this happens by means of some other part of one's Body, then the sensation is doubled in the two parts of the Body, since each is then precisely for the other an external thing that is touching and acting upon it, and each is at the same time Body. (p. 153)

Hence, the body is originally constituted as a physical thing with extension, exhibiting perceptible properties such as color, smoothness, hardness, and so on. But more than this, the body senses "on it and in it"; it has "specifically bodily occurrence," which Husserl defines as *Empfindnisse*—something missing in mere material things,

<sup>4</sup>Husserl also, importantly and relatedly, examines the relationship between domains of tactility and visibility. The body is perceived from outside—with all the limits and rules that pertain to the process of visual perception—and some parts which may be perceived by touch cannot be seen: "Touching my left hand, I have touch-appearances, that is to say, I do not just sense, but I perceive and have appearances of a soft, smooth hand, with such a form. The indicational sensations of movement and the representational sensations of touch, which are Objectified as features of the thing 'left hand', belong in fact to my right hand. But when I touch the left hand I also find in it, too, series of touch-sensations, which are 'localized' in it, though these are not constitutive of properties (such as roughness or smoothness of the hand, of this physical thing)" (Husserl 1989, p. 152).

like rocks and tables (p. 153). These localised sensations are defined as "effectproperties": they arise when the Body is touched, pressed, etc., where it is touching and at the time it is touched. In the example of hands touching one another, we witness the unfolding of two sensations, where "each is apprehendable or experienceable in a double way" (p. 154). This distinction between Body-Object and Lived-Body is instructive when applied to the case of pain—since the subject of painful experience is neither a disembodied consciousness nor a mere physiological organism, but rather it is the *Lived*-*Body* as experienced by myself and as myself. Pain is experienced by a subject, who *has* and *is* their body at the same time (Merleau-Ponty 1945). More precisely, however, pain is experienced as localised in the body—with varying degrees of precision—such that it might be possible to gesture and show 'where it hurts.'

Pain ostensibly occupies a marginal position in Husserl's phenomenology when contrasted with touch more broadly, but it plays an important role in the transcendental constitution of the Lived-Body (Vesey 1961).<sup>5</sup> In *Ideas II*, Husserl counts pain among the tactile sensations that constitute not only the *Leib* but also Higher Objectivities. This insight is integral to our thesis that painful experience discloses several interconnected and intertwined levels of constitution. Painful sensations, Husserl says, play a role in acts of valuing "analogous to that played by the primary sensations […] for the constitution of Objects as spatial things" (Husserl 1989, p. 160).<sup>6</sup> It is not the case, as some have interpreted it, that through "acts of 'taking up,' I transform pure sensations into intentional experiences" or objects (Geniusas 2014, p. 11). Instead, sensations like pain, as they are lived through, arise kinaesthetically through the body and in associative synthesis in ways that affectively move us:

Sensation accounts for the fact that once certain thresholds are reached, we *follow* the pulsations and organization of the perceptual field. Rather than our actions leading us to the object, rather than our perceptions being 'explicative', these noematic constituents bring the object to us and introduce it to us. (Welton 1977, p. 63)

A sharp pain might awaken me at the level of personal consciousness, and gradually the location of the pain might become constituted and objectivated through a temporal process. I move my body this way and that, I press where it hurts and discover how the pain modulates and worsens. Experience is founded by affective primal sensation (*hyle*) prior to this objectivation. These sensations feature in a flow of temporal experience—time-constituting consciousness—within which objectivation through the passive syntheses of temporality and association is possible. Retention, primal impression, and protention play their role here. More than this, habits, inclinations, and associations accrued over time influence what acts and objects of experience appear for me. These are, one might say, conditions of possibility for conscious action

<sup>5</sup>Husserl's nuanced conception of pain begins in the *Logical Investigations* as a response to the debate between Brentano and Stumpf on this matter, where he acknowledges the inherent ambiguity of pain as *both* an intentional and non-intentional object (Geniusas 2014).

<sup>6&</sup>quot;A human being's total consciousness is in a certain sense, by means of its hyletic substrate, bound to the Body, though, to be sure, the intentional lived experiences themselves are no longer directly and properly localized; they no longer form a stratum on the Body" (Husserl 1989, pp. 160–161).

such that "the perceptual field is not one which has to be traversed by consciousness but, rather, is a field inhabited by consciousness" (p. 66).

Through the process of objectivation, the pain becomes an intentional object to be investigated, located, imagined, remembered, and so on. The cause of the pain emerges as a naturalistic concern to be reflected upon, as opposed to the pain as it is lived through.<sup>7</sup> In seeking a causal explanation for the painful experience, and thus objectifying the pain, the subject also seeks recognition and legitimation of the pain as some *thing*. My personal history with painful experiences will come into play perhaps I have felt like this before, recognise it, and experience personal meaning associated with this kind of pain. I may be able to 'tune out' the sensation of pain as the experience is constituted for me in these various ways; I may distract myself or it may become more normal or habitual for me.

This painful experience will also have garnered intersubjective significance, depending on my circumstances and the care available. I may wonder whether I am likely to be believed if I seek help, for example. Fundamentally, my experience is phenomenologically given to me in a particular way that is inaccessible to the other. However, Husserl notes that this does not preclude the possibility of entering into a mutual understanding or empathetic relation [*Einfühlung*], explaining the precise limitations carefully:

[In] a now which, as intersubjective presence, is identical for the different subjects who mutually understand one another, these subjects cannot have the same 'here' (the same intersubjective spatial presence) nor the same appearance. The index of this phenomenological state of affairs is the impenetrability of the different contemporaneous Bodies as such. Two bodies can be Objectively bound into one thing, can 'grow together' into one, but the concrescence into one thing does not create a Body filling the same temporal duration, does not create a here, a space with phenomenal orientation, and an identity of the appearances of things with respect to the world of things surrounding both subjects. (Husserl 1989, p. 216)

Nevertheless, if my experience does not appear as concordant with the experience of others, and does not conform with the norms of the mutual understanding, then it will be received intersubjectively as invalid or indeed pathological (p. 85). While this can emerge between two individuals in a relationship of care, it is heavily influenced by broader political norms and structures. Other questions arise within the painful experience. Do I trust in any healthcare provision to which I have access? How long do I anticipate this pain will continue as a result, and does that anticipation feel bearable? Does this pain feel shameful, and do I feel worthy of care? These aspects of the painful experience may, in fact, problematically intensify or normalise these very pain sensations, depending on the intersubjective social and political context within which I find myself.

<sup>7</sup>Pain has also been conceived not only in relation to corporeality but also as a psychic object, enduring like a melody: see Svenaeus (2015), "Pain is not primarily objectified and reflected upon, but rather lived as a melodic style of human experience" (p. 113).

# **8.4 IIb: Pain That Matters**

This framework for understanding levels of constitution provides a powerful toolkit for integrating phenomenological accounts with other critical traditions. Norms and normativity garner significance at all these various levels of constitution, and therefore do not so much suffer from equivocation as indicate an irreducible interrelation. A sophisticated social theory ought to account for levels of value-constituting sensory experience. Likewise, a good phenomenological inquiry will account for the intersubjective (social, political, cultural, and inter-corporeal) influences on objectivation and processes of meaning-making. Bringing this perspective to bear on the experience of pain, we might ask: How does our being-in-the-world shape our experiences of pain? How does our social and political situation affect the constitutive levels of experience? Whose pain matters to whom?

We argue that structural conditions may make one's experience more or less painful, bearable, or dangerous. The experience of pain is mediated by a complex web of social and political structures, in ways that parallel experiences such as that of being pregnant, being ill, dying, ageing, breastfeeding, or living through changes in mental health. The common denominator is the intersubjective context, directly influencing the quality and the value of the experience for the subject. Our Lived-Bodies, as both natural and cultural (Merleau-Ponty 1945), are dynamically co-determined in situ by our subjective responses and the intersubjective context and environment (Beauvoir 1949). As explained phenomenologically in Section IIa, personal and clinical histories and idiosyncrasies influence how painful experiences are lived through. In particular, however, *structural violations* have a crucial role in experiencing pain, in such a way that the intersubjective level affects the most immediate sensory experience of pain. Pain tolerance can become eroded through enduring pain without support, care, or belief from others, for example. It can be especially difficult to make sense of pain without any shared understanding and if not believed by those who might ease our pain, such as health practitioners. And senses of helplessness or shame in pain are more pervasive across certain intersections and positionalities.

Structural violations such as gaslighting (Cohen Shabot 2019) and silencing (Maitra 2009; Caponetto 2017) profoundly affect experiences of pain. For instance, medical practitioners' racist, sexist, classist, ableist, and ageist preconceptions (among others) can and do result in differential pain treatment for patients when their experience is dismissed (Carel and Kidd 2014; Kidd and Carel 2017), further aggravating health and well-being inequalities and limited access to healthcare (Jones 2019). Avenanti et al. (2010) have argued that human subjects react empathically to strangers' pain. And yet, these empathetic responses may change according to racial bias and stereotypes. It has also been found that stereotypes about gender, race, and age differences influence people's estimation of others' pain (Wandner et al. 2012). These phenomena do not simply deprive patients of appropriate pain treatment (see e.g. Bonham 2001). Indeed, gendered and racialised biases have been shown to cause inaccuracy in pain assessment and treatment recommendations (Hoffman et al. 2016; LeResche 2011).

Our phenomenological focus is therefore the so-called "quasi-transcendental structures" of painful experience (Guenther 2019). According to Guenther's analysis, there are some structures which are not a priori "in the sense of being absolutely prior to experience and operating in the same way regardless of context", but they otherwise have a key role in the constitution of our experience of ourselves, others, and the world, and "in shaping the meaning and the manner of our experience" (p. 11). Patriarchy, white supremacy, and cisheteronormativity, for instance, are "ways of seeing" that actively inform our natural attitude and shape the quality of our experiences, in turn becoming ways of "*making the world*" (p. 12). These structures shape our bodily experiences, often in insidious ways, and accounting for these can reveal the power relations and socio-political structures at play (Weiss et al. 2019). While people may not share the same experience of pain strictly in terms of sensation, they may together experience the same structural conditions which make their experience more or less painful. In this sense, while painful experience may feel irreducibly isolating and marginalising, it might be possible to find recognition from others with similar conditions—medical, political, or both—even without words or bodily markers to signify the pain itself.

As discussed in Section I, this aspect of painful experience rarely features in the experiential accounts of pain. We contend that this stressful structural context may, in fact, permeate, affect, and modify sensations of pain and the possibility of its recognition, intensifying the overall painfulness of the experience. As Zeiler (2010) points out, "analyses of how the body appears to the subject need to explore the interplay between the subject's experience of injury, disease and/or pain, the social support or lack of support of others, and cultural norms as regards whether and how the subject can express these experiences" (p. 338; cf. Cohen Shabot 2017). The way we make sense of our pain deeply affects our very lived experience.

In this way, the intersubjective level of painful experience—including the management and treatment of pain—directly affects the 'lowest' and most immediate sensory level of the pain. Furthermore, it supports our thesis that, far from exclusively being a primal and pre-reflective experience, pain is complexly co-determined by social, structural, and political features. We believe that acknowledging pain as a constitutive experience of subjectivity may help to shape alternative approaches to healthcare, such as intervening in the passive-active patient-practitioner dynamic; translating practices of care to cultural contexts; challenging the oppressively normative and naturalised notions of 'good' or 'deserving' pain; and extending an understanding of epistemic injustice (Fricker 2007). For these reasons, it may be advisable that medical practitioners and carers not only take a lifeworld-based, person-centred approach to treatment and care—as is often and rightly espoused—but also attend to the specific political and cultural environments integral to both the patient and practitioner's experiences. By attending to these complexities of painful experience and associated suffering, a radically different notion of care may emerge as appropriate for each person beyond unsympathetic and clinical elimination of pain altogether.

# **8.5 Conclusion**

In this paper, we put forth a critical conception of pain as a complex multi-levelled phenomenon, deeply ingrained in the constitution of one's sense of bodily self and emerging from a web of social, cultural, and political relations. In the first section, we reviewed and critiqued some experiential accounts of pain. We explored how pain is involved in complex ways with modalities of pleasure and displeasure, enacted personal meaning, and contexts of empathy or shame. Our primary goal was to show why a phenomenology of pain must acknowledge the richness and diversity of peculiar painful experiences.

The second section interwove these critical insights with Husserlian phenomenology of embodiment, sensation, and localisation. We introduced the distinction between Body-Object and Lived-Body to show how pain presents intersubjectively (e.g. from a patient to a clinician). Furthermore, we stressed that, while pain seems to take a marginal position in Husserl's whole corpus, its role is central in the transcendental constitution of the Lived-Body on multiple levels. We then concretely explored how some people may experience structural conditions which make their experience more or less painful. A stressful structural situation may, in fact, permeate, affect, and modify sensations of pain, intensifying the overall painfulness of the experience and, in some cases, threatening lives.

Painful experiences draw our attention to our bodies as they pertain to our surroundings, not only in their physicality but also in their sociality. Acknowledging pain as a constitutive aspect of subjectivity may help to shape alternative approaches to healthcare, through a reconsideration of the situated experience of the subject, not only in terms of 'personhood' and abstract 'rights' but, also and above all, as embodied and situated.

### **References**


Bonham, V.L. 2001. Race, ethnicity, and pain treatment: Striving to understand the causes and solutions to the disparities in pain treatment. *The Journal of Law, Medicine and Ethics* 28: 52–68.

Bourke, Joanna. 2014. *The story of pain: From prayer to painkillers*. Oxford: Oxford University Press.


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