Neuroethics at the Close of the Decade of Pain Control and Research
As the shift from a fledgling attendance of just under 1,400 in 1971 to the 30,000-plus participants (inclusive of over 5,000 non-scientific attendees) at the recent meeting of the Society for Neuroscience in Chicago, Illinois, would indicate, there is growing interest in the study of the brain and mind within both the scientific community and the general public. The fields that are broadly grouped under the rubric of neuroscience provide increasingly more information about the structure and function of neural systems and the brain, and this certainly has been a driving force in shaping any address of pain and the challenges and opportunities of pain medicine.
Hard Questions and Contingent Answers
In this Decade of Pain Control and Research (DCPR), neuroscience has become a focal point for applications of genetic- and nano-technologies. The pace of neuroscientific discovery is fueled in part by the synergy of new technology in these and other areas. Neuroscientific advances are both being applied in medicine and integrated into the fabric of social conduct and daily life. It becomes relatively easy to accept this information as “fact,” and to use such facts both as contributions to, and reflections of, our beliefs to guide—if not dictate—our understanding and activities. But given the reality that knowledge of the brain-mind remains incomplete and contingent, the neuro prefix seems to have become synecdoche—a figure of speech in which the part represents the whole—for the reductionist/anti-reductionist debate in each and all of the areas in which it is used,1 and prompts consideration of what Matthew Crawford has called “…the limits of neuro-talk.”2
Certainly, the very same novelty that entices new and perhaps unique possibilities for progress must equally be regarded as a source of uncertainty and should generate a critical balance of both optimism and pessimism. Through the pace of discovery, we are poised at the boundaries and limits of knowledge. Like it or not, we must acknowledge that these boundaries exist, take measure of their margins, recognize the restrictions of current knowledge, and advance our investigations and applications with prudent precaution. Such caution need not impede the pace or progress of scientific and technologic development, as I believe this would be antithetic to the incentives of both philosophy and science. However, what is called for is careful reflection—upon what we know, how we know it, and the values and beliefs that drive the quest for knowledge and its use. Through this reflection, we confront what philosopher David Chalmers claims are the “hard questions” of neuroscience—namely, how the brain evokes consciousness and how our attitudes, values and actions toward selves, others, and society are impacted by what is known about the brain and yet still unknown about the mind.3
I posit that these hard questions establish that if we are to consider the impact of pain, we must also contemplate the nature of the being that is in pain.4,5 Pain is a complementarity—it is a physiological event and psychological experience, an interaction of the internal and external environment of the painient, of their body and brain, brain and mind, and ultimately the self and other(s). Thus, in the strictest sense, pain is bio-psychosocial, and such a bio-psychosocial orientation dictates an equivalently complementary approach to how pain is studied, and how the pain patient is regarded and treated. In this light, it becomes important (if not necessary) to speculate on what such complementarity of inquiry, study and treatment might entail, and how it could be enacted in pain care.6
The problem of pain compels ongoing exploration of dynamic relationships—not only of body, brain, mind and environment, but also of patients and clinicians, individuals and cultures, knowledge and values, and morals, ethics, guidelines, policies and law(s). Yet, the question remains as to how to approach these variables, not singularly, but in ways that recognize and uphold their relationality. Obviously, any authentic approach in this regard would involve both the sciences and the humanities.7 The goal is not a mere homogenization of disciplines and specialties, but more effective discourse that provides differing lenses through which disciplinary interests may be communally focused, acuities sharpened through co-participation, limitations overcome through collaboration, and outcomes enhanced through integrative complementarity. I have opined that this complementarity reflects the philosophy of pain and medicine both in concept(s) and application. Thus, a philosophy and ethics of pain management can be factually-based yet free to embrace new ideas and methods in an original, creative and resourceful way.8,9
Epistemic, anthropologic and ethical questions of philosophy have given rise to scientific investigation, social thought and moral consideration throughout history. Indeed, these questions have and continue to exert profound and perdurable ontological and cosmological influence. The notion that the phenomenal reality of pain is nested within the mind has been explicit since Socrates and, as science further investigates mechanisms of the brain-mind, such ontological questions have increasingly become contextualized within the agenda of ‘neurophilosophy.’10,11 In many ways, the rationale and perhaps “essence” of such a neurophilosophy reflect a decidedly neurocentric version of the “circle of science.” Neural functions of the brain somehow give rise to mind; mental processes give rise to intellect; and through such processes we develop both epistemic appreciation for how the brain-mind functions12 as well as ethical concern(s) about how neuroscientific research is conducted and its findings applied in individual and socio-cultural endeavors.13
Looking Back to Look Ahead
Framed in this way, these bio-psychosocial (and ethical) issues reflect Socrates’ inquiry of Phaedrus: “…where have you come from, and where are you going?”14 If we allude to the allegory of the cave as a metaphor for current neuroscientific and neurophilosophical understanding gained from the Decade of Pain Control and Research (DPCR), we too—like those in the cave—must address what we believed to be real, what we discover to be the nature of reality, the implications of this reality for the future, and the challenge(s) and obligations to make this reality apparent to others. But, as for the prisoners in the cave, the elucidation of reality and workings of the mind must ultimately be directed toward understanding and seeking “the good.” In this way, the nexus of reality, science, knowledge, and the good lies within the capacity of individuals and societies to define and articulate morally sound pursuits and activities and ultimately conjoin the political sphere. This is the work of ethics, in general, and neuroethics, more specifically, as it relates to the capabilities, roles, and limitations of neuroscience (viz, in pain care).