Power from indirect pain: a historical phenomenology of medical pain management

The article aims at reconstructing how pain is used in contemporary societies in the process of engraving power. Firstly, a social phenomenological analysis of pain is conducted: Husserl’s and Merleau-Ponty’s ideas are used for clarifying the experience of pain itself; Elaine Scarry’s analyses are overviewed in order to reconstruct how pain contributes to the establishing of power. Secondly, this complex approach is applied in early modern context: the parallel processes of the decline of a transcendental and the emergence of a medical interpretation of pain is introduced, along with the marginalization of violence. Thirdly, the era characterized by the triumph of medical pain management is analysed: it is argued that the constitutive role of pain in establishing power does not cease to exist with the emergence of technologies of discursive governance (Foucault); it is an open question, what sort of power is engraved through pain understood in strictly medical frames.

Husserl's and Merleau-Ponty's analyses, the experience and the embodiment of pain is discussed, which is complemented with Scarry's analysis on the constitutive role of pain in the process of engraving power. This framework is applied in the second and third sections, while the idealtypes of early and late modern pain management are elaborated based on historical and medical anthropological sources. The historical comparison of the technologies of pain management and the political usage of violence outline a genealogy of a power, which is intertwined with the hegemonic biomedical paradigm. In the last section, an attempt is made to critically engage with Foucault's concept of biopower. The historical phenomenological analysis of pain complements his diagnoses of times by introducing the concept of "power from indirect pain." Such power is not based on directly hurting the subordinated ones, but relies on the withheld potential of treating pain. Such pain, which is not caused intentionally, but simply allowed to subsist (despite the promised biomedical solution) becomes a modern equivalent of hurting, which engraves a power considered to be "banally evil." 7

A social phenomenology of pain
Most pain theories attempt to clarify its ontological status, which proves to be a controversial task: on the one hand, it seems to be localizable in the body; on the other hand, it may be experienced without any obvious organic cause or bodily locus, which implies a psychic origin. According to Husserl's phenomenological analysis, in order to solve this dilemma, a differentiation is needed between the living-body (Leib) and the body as object (Körper). Pain cannot be explained by solely relying on either of these aspects, as its existence is related to both of them. While in the "natural attitude" the body is a pre-given constituent of the (embodied) self, 8 in pain a distance is born between the (disembodied) self and the body. The body in pain is transformed into an object: not anymore the instrument of free will, but a thing determined by external forces. 9 In this sense, pain is a transformative experience: it reframes the relation to the self and the world as well. 10 Husserl's analysis has been complemented by Merleau-Ponty in several ways. 11 According to him, the body and the world constitutes an undividable complex. 12 This means that pain is not simply a new experience among others, instead it transforms how the world is inhabited: what used to be full of potentials is now full of obstacles. In this sense, severe pain does not simply transform the lived-body into an object, while resulting in new experiences, but turns the world into a burdensome or unbearable totality. 13 Even though phenomenology laid down the bases for the historical analysis of pain, it was Scarry's seminal book, which further expanded the horizon. By introducing a fundamentally intersubjective approach, it helps to move away from monological models (characterizing epistemology oriented phenomenology), towards the analysis of the social dimension of pain. Scarry chooses an atypical starting point: instead of focusing on accidental injury or illness, she focuses on wounds inflicted in the process of torture or war (which are par excellence social phenomena). Such choice has consequences for the whole phenomenology of pain, as it provides access to those aspects, which remain in the blindspot of epistemological approaches. 14 According to her, even if pain is a pre-linguistic experience, it is capable of affecting the existing meanings by erasing them and providing a new framework for rewriting. 15 This destructive capacity is used in the process of torture: the continuous invasive pain gradually fills up the horizon of lifeworld, until the point the victim is reduced to a bare body in pain. The overwhelming experience of pain overwrites both memories, personality traits and dispositions. The one being responsible for such agony is not just an average other, but a quasi-omnipotent agent, who has not only the power to destroy the world, but also to give it back. Therefore, torturers always aim at presenting themselves as obvious sources of the pain: this causal relationship engraves their unquestionable authority in the victim. Their goal is to reduce the world into the opposition of a bare body in pain and an omnipotent (bodiless) will determining the fate of the former. 16 However, the mere facticity of the unlimited power of hurting is not sufficient on its own for the long term establishment of power. For this purpose, the victim has to be alienated from themselves on the most elementary level of their body functions: the capacities previously serving as the source of enjoyment are transformed into the places of agony (e.g. eating is replaced by starving, free movement by uncomfortable postures). As the body is taken over, it is not merely reduced to be an object, but rather a living-body (Leib) turned inside out: on the one hand it still belongs to the victim, while being completely controlled by the torturer. 17 This elementary experience of embodied subordination grounds the linguistic reinterpretation of the whole lifeworld. Torture is never only about causing harm; it includes the element of speaking as well. While the seeming function of asking questions during the process is to gather information, the actual purpose is the gradual reconfiguration of the victim's lifeworld. It is through the conversation that the bodily subordination is translated into a mutual interpretation of the world originating exclusively from the torturer. 18 Even though torture is an extreme situation of experiencing pain, the processes identified by Scarry have general relevance. The structure of torture not only 16 Scarry (1985, p. 57). 17 Scarry (1985 p. 51). 18 Scarry (1985, p. 49). 14 Of course, Scarry's approach also has blindspots of its own: it has been criticised both for the overemphasizing of the unsharability of pain (Fannin 2019) and the reintroduction of the body-mind dualism (Dawney and Huzar 2019). 15 Scarry (1985, p. 27).

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Power from indirect pain: a historical phenomenology of medical… highlights the destructive and constitutive aspect of pain, but at the same time reveals how the experience of subordination is born in the act of causing harm. Of course, in case of pain, which is not inflicted by a recognizable agent (i.e. not the result of harming or torture), the impression of authority does not emerge explicitly. However, that does not make it non-existent: the experience of pain implies the seeking of answers to the questions concerning its causes and the related responsibilities. 19 Thus, even in case of a seemingly non-social pain, questions, such as "why is it happening?" and "who or what is responsible for the agony?" are inevitable. A need for interpretation arises, which is never a neutral explanation, but includes the element of a latent subordination (to the presumed source pain). In other words, pain implies power attributed to its source, even if it is unidentifiable. In this latter case, power is delegated to those, who provide the dominant interpretative narratives and the related treatments. 20 This conclusion opens the path for a social phenomenology of pain in modernity. Making sense of pain is a historically contingent process involving not only interpretative frameworks, but also those structures, which implicitly or explicitly maintain them. This social phenomenological approach is applied in the following sections, while attempting to answer the questions: what kind of interpretations of pain are born in early and late modern constellations?; and what sort of power is grounded by the praxes based on them?

Early modern pain: between transcendental and medical
In order to reconstruct how pain is used and interpreted in contemporary societies, a comparison with the direct social historical antecedents proves to be useful. Early modernity is a liminal constellation characterized by gradual departure from medieval civilization to the secularized modern form of life. The transforming interpretative frames of pain can be reconstructed from social historical sources focusing on the attitudes of everyday actors; the emerging medical discourses; and the reconfiguration of violence. Of course a comprehensive overview of such vast literature is an impossible task within an article, so the aim of the present analysis is humbler: an 19 Bendelow and Williams argue that the experience of pain implies a question of theodicy (1995: 93). Scarry also explains the emergence of belief (that is the establishment of a transcendental authority) by pointing to the ontological difference between the immaterial (thus invulnerable) God and the vulnerable human, which grounds an unquestionable subordination (1985: 183). 20 In order to provide a comprehensive model, a typology of forms of pain and the related forms of authority should be elaborated-a task going beyond the scope of the present article. Provisionally several differentiations may be indicated: beside a pain induced by a concrete other (which grants direct authority, e.g. the master and slave) and a pain of unidentifiable origins (which implies authority for those experts, who provide legitimate explanatory narratives, e.g. religious experts relying on transcendental narratives, such as divine punishment, or scientific experts relying on naturalised narratives, such as unhealthy lifestyle), at least two more types should be mentioned. In case of instrumental self-induced pain an authority of the goal is reinforced (e.g. a striving athlete fetishizing a new record); in case of selftorture an attempt of denying external authority as such is assumed (e.g. self-harming- Edmondson et al. 2016). attempt is made to elaborate an idealtypical model of how pain has been interpreted, treated and used in the transforming early modern Europe. 21 The most important transformation affecting the everyday relation to pain can be described as a reluctant secularization. In medieval civilization pain was inseparable from the transcendental: at the most fundamental level it implied a godly punishment, which had to be endured for the sake of salvation. Pain of labour, illness or injuries were equally treated as inevitable consequences of the original sin (and also personal sins), so their reduction was not considered to be a legitimate goal. 22 Within this context pain was either cultivated as a means to salvation (e.g. the flagellant movement), or accepted as a necessary element of human existence (e.g. the neo-stoic reinterpretation of pain as something beyond our control 23 ). In early modernity, such religiously grounded moral economy of pain was gradually complemented by an instrumental paradigm: pedagogy started to use corporal punishment in order enhance learning skills, based on a theory linking pain and memory 24 ; the bourgeoisie started to rely on self-exploitative work ethics (exchanging personal suffering for profit). 25 These examples of instrumentalized pain did not follow anymore a transcendental logic. Instead they followed a calculative logic: pain was viewed as a necessary means to an end. As a consequence, the medieval unconditional acceptance of agony was gradually complemented with the intention of differentiating between useful and useless pain. 26 Enduring agony was not anymore a religiousmoral obligation, but depended on the evaluation of its usefulness. If it did not serve any purpose, its elimination remained the only logical way to relate to it.
Early modern medicine was not independent from the transformation of these theological-moral frames. For a long time, pain was not at the centre of medical attention, it was rather treated as an inconvenience (e.g. it made surgical interventions difficult). It was localized in the body, while being framed as a fundamentally mechanical question. 27 While lay and expert discourses on painkillers were not separated throughout the early modern era, gradually an autonomous medical discourse emerged. It interpreted pain as an phenomenon, which should be measured objectively by medical science. 28 Later on, this unique access granted the monopoly of knowledge about pain to doctors, while excluding the subjects in pain themselves from the process of interpretation. Nevertheless, the monopolisation of pain management was not a sudden transformation, as it is expressed by the diffuse usage of 21 The historical sources referred below identify early modernity as a period roughly between the 15th and 18th centuries characterized by the parallel existence of non-secular worldviews and social structures, which are complemented by phenomena questioning their validity, such as reformation, the exploration of the new world, the birth of empiricist science, commercialization, political revolutions (Enenkel 2009). 22 Le Goff (1992, p. 235 Schoenfeldt (2009). 28 Tousignant (2014). the first painkillers. They were used as a multifunctional tool for preventing or treating just about any negative conditions ranging from depressed mood, exhaustion, anxiety or physical pain. In this sense these drugs were treated as general countermeasure to the various forms of suffering of modernizing life. 29 In this sense, painkillers were born as alternatives-and later on, rivals-of the religious narratives and rituals of pain management.
The discovery of technologies capable of reliably eliminating pain indicate the end of early modernity in the history of pain management. The real capacity of eliminating pain became undoubtable with the birth of anaesthesiology. While previously the surgical interventions reproduced the "pain of the martyrs," these new technologies transformed the clinic into the sterile, supervised space, as it is known today. 30 Of course, as the efficiency of controlling pain remained contingent for a while, the neurological interpretation describing it as a bodily function, which can be turned on or off, did not become hegemonic until the perfection of biomedical painkillers. It was challenged throughout the whole era by several approaches: Protestantism argued that suffering still carries a religious meaning, which has to be revealed in the worldly existence 31 ; romanticism and sentimentalism defended the necessity of pain for human existence, thus continued a medieval interpretation even if in a secularized manner 32 ; theories of hypnosis questioned the bodily nature of pain. 33 In this sense early modernity is characterized on the one hand by the weakened, but persisting theological-moral framing and the emerging, but not hegemonic medical framing of pain. Such ambiguity characterized the transformation of the technologies of hurting as well. The "civilizing process" fundamentally reconfigured the role of physical violence in social relationships: while in medieval times the ones in power (i.e. the nobility) had the privilege of act according to their affections (even in a violent way), gradually self-restraining became a virtue, resulting in the banishment of violence from public interactions. 34 This transformation of manners was enabled by the emergence of several new praxes capable of setting boundaries for those young, unmarried men, who were responsible in the biggest number for the various forms of violence. These praxes included not only the perfection of the policing technologies of the state monopolizing violence, but also the increased surveillance of adolescents considered to require "special attention." 35 In parallel with the civilization of manners and the pacification of potential perpetrators, the system of justice also transformed: the spectacle of public torture and execution was replaced by the logic of prison aiming at disciplining instead of publicly demonstrating revenge and deterrence. 36 Elias (2000). 35 Muchembled (2012). 36 Foucault (1977).
increase of the sensitivity of the spectators: as compassion became an imperative, pain was not perceived anymore as an educative punishment, but as an uncomfortable spectacle, which-unless being justified by a rational goal-needs to be eliminated, minimalized or hidden. 37 Even though these parallel processes tended to the same direction of the overall decrease of violence, such transformation was not linear and general at all. Based on the long-term homicide rates, it seems that instead of a general decrease, it is more valid to refer to the marginalisation of violence: instead of disappearing completely, violence was banished to the social and spatial peripheries. 38 Overall, the early modern treatment and usage of pain outlines an ambiguous picture. The passive, undifferentiated medieval interpretation (originating from a theological grounding) was complemented with an instrumental one; the ignorant medical practice was complemented with more and more effective treatments of pain and a consequent instrumentalist discourse; violence as unconstrained privilege was banished from the public sphere to the margins of society. However, none of these tendencies became exclusive, as the earlier practices survived even if in a weakened form. In this constellation the main characteristics of pain became its contingency: it was not anymore defined by premodern frames, not yet by modern ones. Unlike in medieval times, when pain implied guilt, while strengthening the worldly and transcendental power relations, the early modern construction of pain ceased to be a definitive experience. The space opened up for interpreting pain from the interchangeable perspectives of transcendental and naturalizing semantics: if either of them proved to be inefficient, the other could have been used as a substitute. This also affected the structure of power, which could be built upon it: it was neither an unquestionable heavenly order, nor an undeniable natural order, but a non-hegemonic constellation based on the oscillation between these two realms.
In this sense, in early modernity the question of pain was opened up, without any conclusive answers. As a consequence, the very fabric of power was weakened. As violence was banished from the public sphere and the control over pain was yet to be established, authority as such became contingent. In a certain way, these transformations contributed to the expansion of freedom both on individual (i.e. personal autonomy) and collective levels (i.e. political revolutions). 39 As traditional power was weakened due to the temporary vacuum of both transcendental and naturalized paradigm of pain management and violence, actors had the opportunity 37 Moscoso (2012, p. 70). 38 McMahon et al. (2013). 39 Even if the grounding of such claim would require a profound historical analysis, there are several supportive results available. Many historical research focusing on democratization argues that the decrease of inequality and the related risk of violence plays a key role in the process: if inequality is high, the reigning elite views the expansion of political rights too costly (due to the presumed claims of redistribution); if inequality is low, the expected profit from increased tax paying balances such fears (Boix 2003). In this equation of "rational choice," the presence of violence is also a decisive factor. As the whole calculus relies on the possibility of a non-violent transition, the experience of the ever-present, naturalised violence undermines it: if redistribution cannot be envisaged as non-violent, then the reining elite will not be interested in any form of democratization (Zibblatt 2006: 329). This means that the general reduction of violence is a latent prerequisite of emancipatory political movements.
Power from indirect pain: a historical phenomenology of medical… of reconfiguring themselves autonomously. Contemporary power can be understood from a comparison with such liminal constellation: the elimination of its contingency did not only result in the emergence of a hegemonic interpretation of pain, but it also lead to the birth of a new power structure.

Late modern pain: the consequences of hegemonic medicalization
Even though the transcendental and naturalizing paradigm was coexisting for a few centuries, their rivalry concluded as modern medicine became more efficient. The new technologies capable of not only decreasing pain, but also treating its biological causes provided an unquestionable authority for medical discourse claiming to represent the objective truth of nature. Such authority relies on the aura of efficiency, which is supported by the statistical charts of decreasing mortality rates 40 and also by everyday experiences. Previously risky life events (such as giving birth) and infections became manageable 41 ; while the public awareness of healthy environment (hygienic and unpolluted working and living areas) and lifestyle (appropriate health behaviour) was also raised. 42 Due to these tendencies, not only the life expectancy, but also the health quality was improved, which greatly contributed to the legitimacy of the biomedical paradigm. Despite the inarguable success, its blindspots and paradoxes also became more and more visible, which resulted in the emerging criticism of biomedicine. 43 The expansion of medical authority is at the centre of many of these criticisms: by stepping out from the clinical context to the realm of everyday life, it provides normalizing technologies of the self, which are fixated on the narrow criteria of hygiene, physical and mental health. 44 These transformations complement the continuation of the civilizing process 45 : since violence has been sanctioned by law, its prevention gradually became a priority. At this point, the previously parallel histories of biomedical expansion and the civilizatory reduction of violence becomes intertwined. Standardized models of "normal behaviour" and "personality development" are elaborated by psy-sciences, which reinterpret violent behaviour as a deviation from the normalcy. Such models influence not only the public sphere, but also ground the operation of state institutions and social policies. 46 As a result of all these efforts combined, violence was not only expelled from the public, but its 46 Rose (1999b, p. 123). 40 Woods (2007). 41 McKeown (2004). 42 Madsen (2017). 43 Needless to say, most of the below analysed reflections are not moral in their approach (i.e. they do not question the general benevolence of modern biomedicine), but rather structural: by highlighting the unintended consequences, they reveal the distortive potentials of healing and pain management independently from the intention of the practitioners. 44 Rose (1999a, p. 74). 45 Of course that does not mean the elimination of violence as such: its exported or marginalized forms not only exist, but also flourish with the introduction of new technologies of hurting (McSorley 2019). reframing by the psycho-medical discourses also led to its legal persecution in the private sphere. 47 Overall, in its mature form, the broad medical discourse became a key constituent of interpreting and handling every forms of pain including illness and violence. Such hegemony represented the dawn of a new power structure relying on discourse and discipline instead of direct violence. According to Foucault, this is the basis of modern "biopower," which is capable of establishing control over the elementary aspects of life (such as nurture or sexuality) through technologies of "governance." 48 Many analyses of the construction of pain in contemporary societies rely on these diagnoses as a theoretical background. However, if we take seriously Scarry's social phenomenological analysis and the early modern history of pain management (discussed in the first two sections), then Foucault's concept of discursive biopower proves to be one-sided. Even if the secularization of pain and the parallel decrease of violence undoubtedly contributed to the emergence of a new logic of power, that does not make pain irrelevant for the modern engraving of authority. Even if discursive technologies of governance are capable of structuring one's behaviour through normalizing self-discipline, from a phenomenological perspective it may be argued that subordination still depends greatly on the experience of pain. As Foucault focuses fundamentally on the interrelatedness of subjectivation and power, 49 pain appears on his horizon as a subsidiary problem being relevant for the social history of both medicine and punishment, but not an indispensable element of explaining power. That is why he considers the experience of pain to be relevant for power mostly in premodern times, while the praxis of grounding power through pain becomes obsolete in modernity. Accordingly, Foucault and those who follow his footsteps miss the chance of raising the question of modern power from the perspective of the medicalized experience of pain.
In order to answer this question, I suggest to take the phenomenology of pain as the starting point: according to these analyses, pain inevitably implies the experience of subordination, even if its source is not trivial. As pain is not eliminated in modernity by far, it may be argued that its experience still contributes to the engraving of a certain from of power, even if in an indirect way. This means that medicalization and civilization do not simply establish a new discursive logic of power, which replaces the traditional one (that used to rely on directly causing pain). Instead, my hypothesis is that the biomedical paradigm of pain management can be reinterpreted as a new, indirect source of power, which is nevertheless still a power from pain.
The power from medicalized pain complements the theory of biopower in several ways: it focuses on the failures of medical knowledge resulting in the persisting experiences of pain, instead of its success resulting in normalizing self-governance; it takes into consideration the hegemony of medical discourse as a special burden (making helpless those, who cannot be treated within its frames), instead of viewing it solely as a technology of control; it understands power as being constituted 1 3 Power from indirect pain: a historical phenomenology of medical… in a negative way (through the missing treatment of pain), instead of a positive way (through the expansion of normalizing discourses justified by their painkilling potential). In order to empirically describe power from medicalized pain, those anthropological case studies can be overviewed, which analyse medical practice dealing with pain in contemporary societies. Their insights help to understand not only how the hegemonic paradigm can fail in treating pain, but also the consequences of a pain, which is not supposed to exist.
In order to understand the consequences of the medicalization of pain, firstly those mechanisms need to be taken into consideration, which disqualify alternative interpretations. Foucault connects the birth of modern "clinical gaze" to a fundamental transformation: while the 18th century doctors asked the patient "What is the matter with you?," the clinicians relying on biomedical discourse do not focus anymore on the whole subject, only on the symptoms indicating a disease. 50 Medical discourse is organized in opposition to what is considered to belong to the realm of "belief": it is strictly based on measurable bodily parameters, while anything outside of them is defined as superstition. 51 In this sense, medical discourse considers irrelevant-or explicitly denies-those cultural constituents of pain, which are responsible for making it comprehensible beyond its sheer facticity. 52 This exclusivity creates an aura of omnipotence: even if medical paradigm explicitly does not claim to be able to treat every condition, by disapproving all alternatives, it ends up implying that if a treatment exists, it is possible only within its framework. This conviction justifies the practice of automatically translating any lay description of pain to naturalizing language games, without attempting to understand them in their original cultural context. 53 The technical reduction of the patients' narratives does not mean that the interpretation of pain becomes irrelevant for the experience per se, instead it contributes to the alienation from its cultural background, which encloses the patient in a passive and helpless role. 54 In this sense, medical practice not only denies the relevance of cultural and subjective constituents of pain, but also creates an alienated discursive framework. 55 The patients being deprived of the narrative competence about their own experiences find themselves in a precarious situation. As medical discourse is hegemonic, the only way to find solution to agony is following the expert instructions. However, if these praxes turn out to be inefficient, instead of reflecting on its own method, 50 Foucault (2003, p. xviii-xix). 51 Even though attempts of expanding the horizon of the biomedical approach, such as "holistic medicine" or the "biopsychosocial model" are not unknown, their impact still remained marginal compared to the mainstream positivist paradigm. The former approach is usually criticised for not being scientific enough (Kopelman and Moskop 1981), the latter is considered by many to be "vague, useless, and even incoherent-clinically, scientifically and philosophically" (Bolton and Gillett 2019). 52 Good (1994). 53 Kleinman and Kleinman (1991) and Good (2007). 54 Kleinman (1973). 55 Of course, the criticism of these reifying tendencies is not completely unknown for the medical paradigm. Recently, reflections advocating the further need of improvement towards a client centred, reflexive medicine became more frequent (Prilleltensky 2005)-however, they are still far from becoming the mainstream approach. medical discourse tends to question the credibility of the patient. Many patients suffering from chronic pain report the experience of being doubted by the doctors claiming that the pain exist only in their heads. 56 In some cases, those, who cannot be treated within the medical paradigm are moved to more and more marginal institutions, which are not operating with the promise of finding solutions, but as final depository for the hopeless patients. 57 In other cases, the medical discourse hides its failures by delegating pain untreatable by biological means to the competence of psy-sciences. They are supposed to reinterpret pain as a consequence of a distorted personality, maladaptation, traumas or mental disorders, also they are entitled to provide treatment. 58 Such tendency highlights not only how medical discourse can protect the image of its omnipotence by re-labelling the failures, but also how pain unfitting to the biological framework can be addressed in a seemingly legitimate way. By reinterpreting it as mental disorder (e.g. depression, anxiety), it can still be placed in the medical universe, even if under a non-bodily label. As a consequence of such practice, the dividing line between physical pain and other forms of suffering becomes blurred. 59 Accordingly, medical paradigm of pain maintains its hegemonic status either by blaming the victims, by marginalizing them or by redirecting them to psy-therapies.
While medical discourse promises a general solution to various forms of pain, it is often incapable of fulfilling such promise. Pain and unbearable mental distress does not occur randomly: they burden disproportionately the members of disadvantaged social groups. People working in physically demanding positions cannot choose between pain or comfort, as the former is a constitutive element of their tasks. Thus they turn to technologies of "bricolage" including elements of expert medicine (e.g. prescribed painkillers) and lay treatments (e.g. alcohol as painkiller), while inhabiting a fundamentally painful world. 60 Pain does not only affect those who work in physically demanding positions: in the world of global capitalism, the flexibility demanded by market is burdened on the employee, who experience it as a constant mental stress, 61 or as actual pain due to the fragmentation of biological cycles of regeneration. 62 Beside of work related burdens, pain also originates directly from inequalities: the experience of exclusion or deprivation from recognition is a painful one, not only in metaphorical sense. These forms of agony show that in many cases, it is the social structure being responsible for pain, not any particular institutions or actors. 63 These variants of "social pain"reveal a hidden "politics of life" Beside governing the subjects, medical practice also produces inequalities: as any particular intervention (or its denial) involves a decision about worthy and unworthy 56 Jackson (1992) and Snelgrove (2017). 57 Biehl (2010). 58 Goesling et al. (2018). 59 Some even argue that in modernity, the experience of pain caused by chronic illness and suffering originating from depression becomes phenomenologically undistinguishable (Ratcliff 2015, p. 87). 60 Das and Das (2007). 61 Boltanski and Chiapello (2005). 62 Castells (2010, p. 468). 63 McDonald and Leary (2005) and Singh (2017). life, the way certain pain is treated expresses the status of social recognition of the sufferer. 64,65 The paradoxes of a hegemonic medical model become the most visible in case of disability, which is a par excellence untreatable condition. The "long shadow of eugenics" over disability reveals the extreme dangers of a purely medical paradigm: if the only acceptable relation to pain is its elimination, in case of untreatable pain, the logical solution is the exclusion-or in the worst case, the elimination-of the sufferer. Even though this latter option may seem to belong to totalitarian regimes such as the Nazi Germany, as the development of new medical technologies such as pre-natal diagnostics prove it, the boundaries of indispensable lives are still challenged in various contexts. 66 Even if eugenics is an extreme example, there are subtler mechanisms dealing with various forms of pain untreatable by the medical paradigm. The overuse of painkillers or antidepressants indicate a strategy relying on the obscuring of the source of pain, while partially supressing it or suspending the interest in it. 67 By sedating the actors, the medical paradigm may prolong the existence of a hegemonic façade. However, it is rather the postponing of the facing with its controversies, not a solution to the pain itself: lives spent in partially supressed pain are still lives in pain. Counter-discourses such as anti-psychiatry 68 or anti-pharma movements 69 attempt to reveal these paradoxes by blaming the medical paradigm for causing harm instead of treating it. 70 Beside these subtler dysfunctions of the biomedical framing of pain, there are several examples of explicit agony created or maintained by new technologies and interventions. On the basic level of the political economy of biomedicine lies the negotiation of worthiness. As the bodily facticity of pain becomes the objective truth of suffering, 71 it is also the final source of legitimizing solidarity claims and political struggles of redistribution. This motivates actors to translate all of their suffering to a biological language game: as poverty, unemployment or persecution are unaccepted claims for support, being the victim of pollution, industrial accidents, 72 or illness and injuries 73 are applied. Despite the sufferers' attempts to gain recognition through pain, mechanisms of exclusion still prevail and deprive those, who are considered to be unworthy (e.g. the poor, the unemployed, the immigrant) of treatment. 74 In these situations, the very price of the treatment is often paid in biological commodity: either by participation in medical testing in exchange for treatment 75 or money, 76 or by selling one's organs on the grey market of transplantation. 77 In these cases, the medical paradigm explicitly contributes to the reproduction of already existing inequalities: by opening new territories of the body for exploitation, it intensifies former types of subordination.

Conclusion: power from indirect pain and the experience of evil
Based on the comparison of the early and late modern construction of pain, it may be concluded that the biomedical paradigm monopolizes not only the interpretation of pain originating from illness, but also the framing of violence (which became related to affective and personality disorders). Within this constellation, the medical discourse gains the exclusive right of differentiating between (superstitious) beliefs and (scientific) truth. Those experiences of pain, which cannot be handled within the medical framework are either marginalized or reinterpreted as mental disorders. Despite the claim of having exclusive access to reliable treatments, the medical paradigm is incapable of handling several forms of pain (e.g. pain reproduced by unhealthy living or working conditions), while also being responsible for generating new types (e.g. pain caused by addiction to painkillers and antidepressants). Furthermore, the medical paradigm ignores those original inequalities, which affect the process of pain management (e.g. exclusion from treatment, medical exploitation). All in all, these transformations affect not only the medical sphere, they are also responsible for reconfiguring the relation of power and pain.
Instead of causing harm in a recognizable act, medical pain management has the potential of letting pain subsist by not intervening, despite claiming to have exclusive expertise of treatment. These elements are equally important for understanding the birth of a power, which is not directly established by any authority figures, but emerges as an unintended consequence of inadequate or negligent medical praxes leaving those patients to suffer, who has no choice, but to put their trust in the hegemonic biomedical institutes. As such power-lacking the element of any intentional aggressors-is born from indirect pain, it results in the experience of insecurity or helplessness. These impressions are complemented with the consequences of the biomedical "hubris": discrediting every alternative treatment, while insisting on its own validity, a failed biomedical intervention may imply the experience of betrayal. As there are no alternatives on the horizon of the sufferer (due to the hegemonic status of biomedical discourse), the representatives of the failed biomedical paradigm appear as agents capable of treating pain, but denying the remedy. By 75 Inhorn (2010). 76 Rajan (2007). 77 Cohen (1999).

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Power from indirect pain: a historical phenomenology of medical… not eliminating pain despite their self-declared competence, from the phenomenological perspective of the sufferers, the agents of the medical paradigm are perceived as the cause of pain. In the eyes of the disappointed patients left on their own, the representatives of biomedicine commit violence-even if in a negative, indirect way. Consequently, they unintentionally generate a certain form of power, a "power from indirect pain." Such power differs from both its medieval and early modern antecedents. In the former case pain was attributed to a non-empirical, but omnipotent God, whose worldly and church representatives wielded the power. They were mostly capable of causing, not actually handling pain, but at least they provided transcendental narratives of relief, which enabled the birth of the experience of a paternalistic subordination. In early modernity, such model was complemented by the emerging medical paradigm promising to treat pain, instead of justifying it. In case of success, medical technologies provided escape from the religious authority; in case of failure, redemption still could be used to give sense to the inescapable pain. Such potential of experimenting with alternatives resulted in the experience of a less deterministic subordination including the element of the relativism of authorities (that is a form of freedom).
In late modernity, once again the chance for such freedom is missing due to the hegemony of biomedical paradigm. Exclusivity leads to paradoxes in case of the inevitable failures. The option of handling persisting pain by non-medical methods, which give transcendental sense to the suffering is extremely limited, 78 as such methods are considered to be superstitious or simply unscientific. Thus, persisting pain becomes an anomaly within the frames of biomedicine, a phenomenon which is obscured for not being supposed to exist. This anomaly is either pushed around within the medical complex (e.g. the overuse of painkillers and antidepressants, marginalization) or excluded from it (e.g. blaming the victim of chronic pain)but in the end, it remains a burden on the subjects. As no alternatives are present on the horizon, sufferers might attribute the responsibility to those actors, who are supposed to fulfil the promise of biomedicine and provide treatment. Their denial of doing so may lead to the experience of a malevolent power, which is characterized by the capability of healing and the withholding of such capability. 79 The representatives of such power may include not only those, who have the right to give or deny treatment, or supress pain (i.e. the broad medical staff); but also those who maintain painful living conditions (e.g. employers, managers, family members, traditions); who gain profit on others' pain (e.g. medical companies, exploitative usurers); who are differentiating between worthy and unworthy pain (e.g. social policies, social workers, NGOs). In various constellations, any of their combination can 78 That does not mean such praxes are completely unknown. In liminal situations, such as palliative care, the biomedical paradigm may be complemented with existentialist counselling or even with religious support (Steinberg 2011). However, these praxes represent rather the exceptions, then the usual praxes. 79 The phenomenological interrelatedness of pain and the experience of evil can also be analysed from the meaninglessness of pain: if it proves to serve no purpose, it implies a negative answer to the question of theodicy (Dahl, 2017). From this perspective, the power from indirect pain represents a social structure responsible for "useless suffering" (Lévinas, 2002). be perceived to be responsible for the denial of treating pain or the miserableness of a sedated life.
Indirect pain results in the experience of an evil power, which is not causing suffering because of an unknowable, but assumable transcendental intention, but out of pure negligence-simply because it is not motivated enough to end the agony. This sort of power belongs to the category, which was called by Arendt the "banality of evil." 80 The representatives of such power do not cause pain because of their personal cruelty. They are often insensible operators of the medical paradigm, which is not only intolerant to any alternative discourses, but at the same time incapable of treating many kinds of pain, while potentially also causing pain itself. However, it is the same negligence, which makes such power so frightening: if one cannot fit into the medical framework, then there are hardly any alternative ways to make a difference, which leaves the sufferer lost in a space inhabited by indifferent and uncomprehending others. As pain is never only about the suffering, but also serves as the original impression of power, the persisting pain in a hegemonic biomedical context also have broader consequences. The experience of being subordinated to a banally evil power plays a significant role in the political phenomenology of late modernity. 81 The broader consequences of such experience becoming the basis of political culture are unpredictable. The only thing seems to be sure is that leaving the distortive potential of medical pain management unchecked threatens with the increase of helplessness, anger and frustration towards a power considered to be negligent and evil. If these sentiments spread in the wider social world a political culture is strengthened, which builds upon these alienated experiences-potentially distorting institutions outside of the medical sphere as well.