The Experience of Pain
We hold ideas that are as familiar to us as the coins in our pockets. Every now and then it’s useful to take those ideas out of our pockets and think about their validity and about their value. Two events that dominate our political and our professional awareness coalesce and prompt me to reconsider how we assess and treat painful conditions such as CRPS in the larger context of health care. Our health care system may be so fraught with economic, moral and political conflict that meaningful reform might be impossible. When health care reform becomes limited and piecemeal, social and moral considerations will be replaced by technical ones. At the same time that the conflict over health care reform reaches crisis, witness the maturation—not necessarily in the best sense—and the publication of Cockrane-model analysis of what is now enshrined in the health care bureaucracy as Comparative Effectiveness Research (CER) and evidence-based medicine. Evidence-based guidelines hold the promise of establishing “best practices” that will make diagnosis more accurate and treatment more rational and efficient—that is, less costly.
At the intersection of these two events—the current debate on health care reform and recent publications of evidence-based guidelines—I seek to raise the following questions, though I may not set down proper answers:
- What is health and what is illness?
- How does pain affect the experience of health and illness?
- What is the place of health care, and, therefore, of pain care, in the social contract (the rights and responsibilities of each individual in society)?
- If pain cannot be measured, how can society rationalize pain care for each individual patient whose experience it cannot know?
Defining Health and Health Care
The fury that rages around health care reform comes, in part, from confusion about what really is health care. More importantly, no one seems interested in defining health itself—no less in declaring the reciprocal role of society and health care—before everyone offers various prescriptions for reforming it. Starting with the definition of “health,” the reliably unreliable Internet defines health as “a healthy state of wellbeing free from disease.” Merrian-Webster offers this: “the condition of being sound in body, mind, or spirit; especially: freedom from physical disease or pain” (italics by Merrian-Webster).
A proper definition of health should declare what health is, not what it isn’t or what it lacks, as in “free from disease.” The World Health Organization (WHO) tried to rectify this flaw when it defined health in 1948: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” WHO’s Ottawa Charter for Health Promotion (1986) further proposed that health is “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities;” and finally: health is “the overall state of physical, mental, and social wellbeing and not just the absence of disease.”
Such definitions are inadequate because they are circular; they equate health and wellness or wellbeing. A synonym is not a definition. Health, wellbeing, and wellness stand in for each other. Generally, health is considered a condition or state that can be good or ill. In such a case wellbeing is a synonym of good health. Good health is wellness, bad health is illness. Neither constitutes a definition.
Several dictionaries make a good try: Random House (1967), “The general condition of the body or mind with reference to soundness and vigor,” and the Oxford English Dictionary (OED, 1998), “Soundness of body, that condition in which its functions are duly and efficiently discharged.” These are positive statements of what health is without too much circularity. Both of these definitions defines health as a condition or state of the individual—a state of being. One might better think of health as a process—a composite of dynamic functions, not static ones. To this end the OED gets close but not close enough. The 1986 Ottawa definition got closer. If we view health as a momentary condition of the body, of the mind, or of the spirit, then health care is a disjointed series of investigations and interventions into that state of things. We treat conditions and diseases instead of treating people who suffer them.
In his new book, Technological Medicine: The changing world of doctors and patients,1 physician, historian and ethicist Stanley Joel Reiser makes the convincing case for defining health as the ability of the individual to adapt to the physiological, emotional, social and ecological world with whose imbalances and perturbations one must contend. To paraphrase Reiser, health is the capacity of the person to flourish in the face of adversity. The definition does not assume mind-body-spirit unity, but it applies whether or not one views “personhood” that way.
The “person” is bounded by the biology of a beating, breathing, energy-consuming and -producing body that is situated in ever-widening relationships: internally among chemicals, cells, internal organs and systems, and external to the body’s boundary among family, community, work, society, culture, moral and spiritual predispositions, the environment, the ecosystem and realms beyond. George Engel described this layered, onion-like set of spheres of the human condition in 1977 and introduced the “biopsychosocial” model2 as an alternative to the prevailing biomedical model of disease. The biomedical model views health care as finding and treating disease, including injury and deformity. The biopsychosocial model views health care as the understanding and treating of illness—the effect of a disease, injury or deformity that causes the decline of the embodied and situated person, and this decline threatens or degrades the quality of life. In other words, health is the capacity to flourish, illness is decline.
Pain in Health and Illness
When a patient complains of pain, we observe the pain at some remove, not unlike trying to measure the redness of the red, ripe tomato from its photograph. For pain, “the thing itself” is nociception, and we are trying to observe the patient’s experience of nociception. Nociception is the transduction, transmission, encoding and storage as a neural representation of a stimulus. The experience of that representation was given two names by Phillip Lippe in 1998,3 eudynia and maldynia. Eudynia or “good pain” does not degrade the quality of life. Most of the time is passes without much notice or even enhances the quality of life in that it is being instructive and corrective of our behavior. Maldynia, or “bad pain,” on the other hand, degrades the quality of life by making the sufferer fearful, sad, angry and generally miserable.