“Puzzling Pain Conditions”: A Puzzling Article

When I realize I am in pain, at least three things are happening: 1) I have a sensation of the pain, which usually is quite keen but sometimes can be vague. In any event, the sensation and my raw feeling of it are one and the same. In fact, the dependent clause of my opening sentence, “When I realize I am in pain,” goes contrary to the way we normally talk about pain. I don’t turn to my friend and say, “You know what? I’m ‘realizing’ that I’m in pain.” The pain experience is usually so direct—that is, it hurts such that a pain that didn’t hurt would be very odd—that perhaps the best way to declare it is to say simply but ungrammatically, “I pain.” 2) A very complex neurophysiological process is at work that neuroscientists tell us is causing the pain feeling. This process is mediated by a host of neural transmissions to and from the brain and the pain causing stimulus, or the “physical disturbance” as the authors of this article put it, that are ultimately interpreted in the brain as pain. 3) In addition to its purely felt quality, pain is also representational in that it signals an affected body part. I believe this article is flawed in that it frequently conflates these different pain phenomena such that rather than clarifying the very tricky and often confounding language we use to speak about pain, we instead get numerous confusions that not only do not clear things up but that sometimes fly in the face of what we presently hold to be scientifically true. I shall justify my criticisms by citing specific passages in the article that I find confusing or unhelpful. I do want to congratulate this journal, however, for its interest in a philosophical approach to clarifying pain language because such language can be immensely confusing. I simply don’t think that this article does a very good job. Consider the following passages from the manuscript: (1) “The way a pain feels can be explained as the relationship between this perception and some bodily damage occurring.” Now, in my view that statement is absolutely correct, and it speaks to my item ♯2 above. But notice, this is an explanatory account of why pain exists; that is, the relationship of which the authors speak is a causal one. Where I will frequently be at odds with the authors is in my belief that we are never aware of nor do we feel this causal relationship. We only “feel” the pain. Without Ron Melzack and his predecessors and progeny telling us about the incredible intricacy of pain pathways and activation patterns, we’d never know they existed. Purely on the basis of the pain as felt, I’d never know there was some area of my brain performing the interpretation of neural messages mediating my sensation of pain nor would I know about the neural assemblage whereby those pain signals are transmitted. Notice, then, that the word “feel” is tricky in the parlance of pain. I feel the result of the pain neurophysiology, that is, the pain itself, but not the neurophysiological assemblage that is causing the pain. I want to argue strongly for this observation because if I could feel that neurophysiological assemblage causing my pain, then I could at least sometimes describe it. But purely on the basis of what I “feel,” neither I nor anyone else can. So, when the authors say, “[Y]our pain would be accurate if the way you feel the disturbance is the way the disturbance really is,” or “[W]hen you’re in pain you’re experiencing something, and what you’re experiencing is some bodily disturbance, which is external to the experience itself,” I want to be very scrupulous in how those words “feeling” and “experience” are used because they can be immensely troublesome. I want to say that one does not “feel” the physical disturbance because it would make no sense to say that “I feel X” but then be categorically unable to describe X. On the other hand, I might “experience” psychophysical events all the time and not be aware of them. (Most of our brain experiences occur out of awareness, for example.) The point is that sometimes our bodily feelings or sensations are indeed vague, but no one could describe physical disturbances that cause pain the way neurophysiologists have because we don’t feel or experience them that way. We rather experience the pain as a felt quality and as representing a bodily part. On the first account, we are never wrong; on the second we can be. (2) “Your visual experience is accurate when the way something looks to you reflects the way it really is.” Always beware of any epistemological account that purports to tell you how something “really is,” because there is no perceptual way of telling how something really is or is “in itself.” That is, every perception we have of our bodies or of the world, for example, of my pain, of this computer screen, of this vase of fake flowers sitting on my desk, is filtered through my sensorium and interpreted somewhere in my brain. I am always trapped in my sensorium; I can’t get outside of it to see how the fake flowers look “in themselves.” Rather, my perception that there is a vase of fake flowers on my desk appears to be accurate because others would agree that, indeed, there is such an object on my desk, that is, “out there.” But I cannot “see” how this object “really” is—I can only “see” how it is for me, or discern it according to the way my sensorium and brain interprets it. Remember this point when we discuss the redness of the apple, but for now consider the next point. (3) “I believe that when you have a pain, you’re feeling something in your body. But the way you feel this something may not reflect the way it really is.” Notice that there are at least two ways I’m “feeling” my pain: as an unpleasant sensation and as located somewhere in my body. The philosopher Bertrand Russell would say that the sentence “I have a pain in my forearm” actually yields two sentences: 1) “I’m in pain,” and 2) “The pain is located in my forearm.” About the first statement, I cannot be mistaken—or at least it would be foolish to try to convince me otherwise. As far as I am concerned, that pain is very real and efforts to convince me otherwise would fail. Also, as a purely felt quality, the pain is painfully accurate: It hurts! In those senses, then, that is, that I am in pain and that the pain feels this way, the pain is real and questioning its “accuracy” seems curiously misplaced or confused. The second statement that locates the pain in my forearm, however, is a belief and not a feeling—or at least it would clear things up immensely to think of the second statement as a belief for the following reason: beliefs can be true or false, especially when they call up a correspondence theory of truth as this one does. Now the authors appear to address this point in the manuscript when they have Dr. Roberts say, “Well, I don’t think that Mr. Laurenzo believes there is something painful in his arm, so it wouldn’t be correct to say he has a false belief.” and Mr. Laurenzo concurs by saying, “That's right. I don’t believe that I have a pain in my forearm. How could I? I know that I don’t have a forearm.” Good try, but no cigar. Mr. Laurenzo doesn’t believe he has a pain in his arm because he has counter-evidence: he can see that he doesn’t have an arm. But if Mr. Laurenzo was blind and paralyzed such that he could only rely on his pain sensation to inform him of what is going on, he most certainly would believe he had an arm. Furthermore, when the authors say, “[T]he way you feel this something (i.e., bodily disturbance) may not reflect the way it really is,” we have to underline the ambiguity of “it.” “It” can refer to either 1) the bodily disturbance itself, that is, the neurophysiological events that cause the feeling, or 2) what the feeling is representing, such as a pain in my arm when I don’t have an arm. I want to say that a pain must necessarily reflect ♯1 because the pain is caused by ♯1. Pain always reflects a neurophysiological disturbance because the disturbance is precisely what causes the pain. On that account, pains—as reflecting their disturbances—are neither accurate nor inaccurate. They simply are. Otherwise, we’d have to say that some occult non-neurophysiological phenomenon is accounting for what I feel, which flies directly in the face of science; or that I feel something more than the physical disturbance itself, which is equally implausible. What the authors really mean, I suspect, is not the way the pain feeling reflects its neurophysiological substrates, but rather what the feeling implies or suggests about an affected body part. On that account, the feeling can indeed be wrong such as my feeling that I have phantom limb pain or that I’m having a heart attack when I’m having a gall bladder episode. But I fail to see what an “externalist theory of pain perception” contributes to all this. Often it appears that the authors wholeheartedly concur with the point I wish to make about the separation between the physical disturbance or pain-causing stimulus and the pain itself. But we’ve certainly known that for a long time, just as we’ve known that pains can often be inaccurate about an affected body part. I’m concerned that a patient hearing from a pain medicine specialist that “Your pain is inaccurate” would interpret that statement to mean that the professional is dismissing the reality of the patient's pain. and that would be very counterproductive indeed. On the other hand, if one of the objectives of this article is to point out that a person might be mistaken about the source or location of his or her pain, that will hardly be news to algologists. (4) “I know of another condition in which someone can feel pain without actually having some disturbance in the body that causes the pain.” Impossible. No one can have a pain sensation or any kind of sensation or perception without “a disturbance in the body.” Your reading this article right now is causing “disturbances” in your body; you know you’re in a sitting position because of bodily disturbances; you are feeling provoked, bewildered, or bored by these articles because you are having neurologically based “disturbances.” Obviously, I am interpreting “disturbance in the body” liberally—namely, as some neurophysiological change going on in my mind–body neural architecture that is causing me to have this sensation or that perception. In his fairly recent books The Feeling of What Happens and Looking For Spinoza, Antonio Damasio makes this point rather nicely. The reason we have phantom limb pain is because those neural tracts that signal limb pain to the brain are still intact despite the amputation. The arm itself might no longer exist, but the pain pathways from the stump to the brain are still there and can be activated. (5) The authors discuss excessive pain behavior or acting out and say that “the pain is inaccurate about the amount of disturbance that's going on in the body.” Here, I take them to be saying that a pain is inaccurate when it does not adequately reflect or represent the amount of tissue damage or physical disturbance that is present. I would suggest instead 1) that we as yet do not have good explanatory models that account for perceptions of pain magnitude; that is, that people whose pain behavior or expression seems disproportionate to their injury are indeed experiencing that kind of pain magnitude, but that we as yet don’t know why—for example, the neural tracts between their thalamus and amygdala might be overconditioned and cause excessive amounts of cortisol to be released into their bodies, which could heighten their pain sensations—but also 2) that the great paradox of pain perception is that there remains an “ontological disconnect” between the pain and its neurophysiological (causative) substrates. A group of extraterrestrials could dissect a human body and biologically examine its pain pathways, but they would NEVER be able to deduce what a bee sting “feels” like to humans or what it feels like to step on a nail. Consequently, the authors saying, “[Y]our pain would be accurate if the way you feel the disturbance is the way the disturbance really is,” invites immense unclarity and casts serious doubts on the very validity of talking about “accurate” versus “inaccurate” pains because on that latter account, no pain is accurate “about the kind of disturbance in the body” because no pain tells us anything about how our bodies process and interpret pain sensations. On the other hand, every pain follows from or “reflects” a bodily disturbance and, on that basis, cannot be more or less “accurate” than the bodily disturbance determining it. (6) Consequently, I think the authors make a serious error or court immense confusion when they talk about the pain reflecting a bodily disturbance accurately or inaccurately. They discuss stepping on a nail and say that the pain is accurate when it “truly” reflects the tissue damage and bodily disturbance—which in this case they say should be pulsating rather than aching. On their account, the pain experience of aching would be inaccurate if the tissue damage normally would cause pulsation. They say, “The feeling of something painful is accurate if the way the person feels the disturbance reflects the way the disturbance really is.” According to my view, “the feeling of something painful” never tells us anything about the neurophysiological substrates mediating the pain. According to the best theory, the disturbance causes the pain and, hence, no pain can be otherwise than it is. Again, the felt quality of the pain might constitute an experience upon which we form a false belief, such as phantom limb pain, but as far as “the pain reflecting the disturbance,” the pain can neither be more nor less than exactly what that disturbance causes it to be. If I have a throbbing pain, it is because my pain pathways are signaling “throbbing.” It cannot be that I am having a throbbing pain when my pathways are signaling “aching” since that would contradict neurophysiological theory. Of course, I might misreport the pain, that is, use the vocabulary of throbbing and aching incorrectly. But that's different from saying the pain itself is “inaccurate.” According to the sheerly felt, nonlingual dimension of the pain, that is, the raw pain sensation, it can neither be accurate nor inaccurate because it is entirely determined by my brain–body wiring at that particular moment. (7) Any person who has had Psychology 101 or Epistemology 101 should know that the color of an object is not a “true” property of the object anymore than, in the case of the authors' apple example, is its fragrance or sweetness. These “secondary qualities” as the 18th century British epistemologists called them result from our neurological wiring. If our rods and cones and the sensory cortices that interpret visual stimuli were differently constructed, humans might customarily see flaming pink or navy blue apples. Color is a product of the human visual system; it does not reside in the apple. We’ve evolved that sensory ability because of its incredible survival value: being able to visually distinguish red, poisonous plants from look-alike but safe-to-eat green or yellow ones can be the difference between life and death. An inaccurate visual experience is one that fails to report the way other visually able persons would describe the visualized object, not one that fails to report on what the object's color “really” is because the object has no color. Rather, in the case of the apple, the molecular structure of its skin reflects light waves whose Angstroms are in the “red” range as the “normal” human brain interprets those neural signals. And if those light waves bouncing off the apple's surface or my own visual apparatus was modified such that the apple appeared purple, the apple itself remains unchanged; it is neither red nor purple. It only seems so to us humans—and not even to all of us, such as those of us who are color-blind. Just as the apple's color is the result of subjective neurological processes that represent colors to us, so pains are perceived the same way. They are distinctly human experiences, and why a pain feels the way it does is ultimately a mystery. As neurophilosophers like to point out, “The mind is something the brain does.” In conclusion, if the authors want to talk about inaccurate pain as a shorthand for saying that some pains lead us to incorrect beliefs about where they originate, then that is hardly news. The authors more ambitious endeavor to establish an “externalist theory of pain perception,” however, occasionally fails to square with our neurophysiological comprehension of pain, at least as I understand it, and employs the vocabulary of “feeling” and “experience” in an ambiguous or occasionally incoherent way.