Anticipating Biotechnological Trends in Pain Care
The past decades have evidenced considerable progress in capability and applications of technology in neurosciences. Neurotechnology— the science and devices that allow analysis, understanding, and treatment of the brain and nervous system—has changed the face of both health care and society, at-large. In the former case, the use of new technologies, and novel applications of existing techniques and devices, have allowed heretofore unforeseen ability to depict, assess, and manipulate the neural system in vivo. In the latter case, the information and knowledge gained from the use of these technologies has affected public expectations of the technological type and extent of medical care, as well as an alteration of social conduct.
Pain care reflects this technological turn, as there is increasing reliance and hope resting upon technological innovation to advance research—of both technology itself, and use of the technologies as tools—and to translate this research into clinical therapeutics.2,3 The tools of neurotechnology also conjoin advances made in other disciplines, namely genetics, nanoscience and computation (i.e., cyber-science). Each and all of these offer somewhat unique properties and capabilities that affect multiple dimensions of neural systems. For example, genetic manipulation that provides means to change the expression of particular neural phenotypes over various timeframes (e.g., generationally; within an individual’s lifespan, etc.). Nanotechnology allows articulation and manipulation at the sub-cellular scale, while cyber technology creates almost boundless access to information. Clearly, these technologies may be focused upon neural applications and/or coupled to other technologies that directly engage neurological systems and functions. We posit that taken together, geno-, nano-, neuro-, and cyber-science may converge to constitute something of a ‘singularity’ as described by Ray Kurzweil.4 The fusion of these technologies will likely lead to a paradigm shift that changes what we know, how we know it, and the social attitudes and actions that arise from this new knowledge and capability.5
Effects of Biotechnological Convergence Upon Pain Care
How might this change in the scientific and social order affect the scope and conduct of pain care? Given that (1) an underlying maxim of achieving ‘good’ is the driving force that generates the development and use of technology, at least in health care (albeit implicitly); and (2) pain is construed as an existential loss (i.e., negatively impacting the ‘good’ of life); then the employment of these new technologies toward ameliorating, if not wholly eliminating, pain would be axiomatic.6,7 However, it is important that while striving for good, we remain aware of potential burdens, risks and harms. For example, while progress in the field may be conceptually ‘aimed’ and pulled by profound philosophical and practical questions of the human condition (e.g., pain, suffering, physical degeneration, etc.), in reality, the pace and extent of technological advancement(s) may be ‘pushed’ by other, non-medical agendas (e.g., market forces, sociopolitical imperatives).8 As well, our understanding of the brain-mind remains speculative and the ‘hard problems’ of neuroscience (viz., what is consciousness, the mind, the self?) persist.9
Of course, it could be argued that these very same hard problems compel the development and use of multiple biotechnologies. We agree, however, it is equally important to acknowledge that the rapid pace of technological advancement tends to be greater than that of profound discoveries of the sort that will shed light upon such perdurable questions. So, we are faced with a rapidly expanding technological set that allows access to, and manipulation of, substrates that are not yet fully understood. In light of this, it becomes almost impossible to predict what effects these technologies might have, insofar as their use will incur potentially unforeseen trajectories and outcomes. It is unreasonable to consider impeding technological advancements given the strong and multi-dimensional ‘pushing forces’ that drive such progress. Rather, we call for a dialectical approach that balances technological incentives with responsibility in inquiry, application and consequences.
To be sure, the advancements in neurotechnologies have the potential to generate major ethical, legal, and social issues (ELSI) and so we advocate that these must be considered early, as well as throughout the research and development process. Several neurotechnologies are already available (e.g., neuroimaging, transcranial magnetic stimulation, deep brain stimulation, nano-pharmacology, neurogenetic assessments, neuroprostheses, brain/machine interfaces, etc.) and these give rise to concerns that require immediate consideration.10,11 For example, while neuroimaging provides unprecedented ability to view the living brain, it is important to exercise caution about the actuality of the images, individual differences and basic limitations of the technologies themselves. Thus, given what is known about the structure and function of the brain, pain as a process of networked neural activity and the uniquity of its phenomenal experience, it is unlikely that current iterations of neuroimaging technology will be able to create a wholly objective measure and/or discernment of pain.12,13 Obviously, similar discernment of the lack of pain (e.g., malingering) is equally problematic. But, let’s presume that we accept neuroimaging as a reasonably valid assessment for the presence or absence of pain. How then, should we treat the individual whose neuroimage objectively depicts pain, but who does not subjectively feel or express it? Conversely, how might we treat the patient who complains of pain, but whose neuroimage fails to ‘depict’ brain activity reflective of nociceptive processing?
When considering deep brain stimulation, (either in it’s current form, or as projected to involve implanted micro- and/or nano-devices) it is important to acknowledge the long-term viability of the implant and unintended outcomes that may occur as patterns of neural network activity are altered over time. Many of these same concerns apply to transcranial magnetic stimulation. Ultimately, we must ask whether we are prepared to maintain responsibility for the longitudinal management of any such unforeseen consequences and effects.
Nano-neurotechnologies initiate additional concerns, given that the behavior of materials and systems at the nano scale are not fully known. Thus, when taken together with the unknowns of neural function, the pairing of nano- and neurotechnologies and their employment in neural systems may create compound unknowns that give rise to entirely unanticipated effects.14 Neurogenetics hold promise to elucidate genotypic predispositions to certain types of pain. However, it is not yet possible to manipulate the genome to mitigate these pain syndromes.15 And, even if it were possible—either through genetic or some combination of other technologies—should we?