Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3)
Progress: An Ongoing Process of Reflection, Analysis and Action
One of the outstanding questions of the Decade of the Mind Project (DoM) is how this incentive for cutting edge research will benefit the human and/or global condition. Without doubt, a number of answers are possible and many of these are contained within the mission statement of the project (www.dom-4.com). Previously, I have described how one goal-area for understanding the brain-mind is to generate better knowledge of pain and suffering and, from this, develop improved strategies and tactics of pain assessment and therapeutics.1 I’ve claimed that for this to be successful, we will need to take a reflective pause and look back upon our work thus far (inclusive of that assumed under the aegis of the Decade of Pain Control and Research, Decade of the Brain, and Human Genome Project) and be frankly critical of successes, failures, potential, and problems. This cannot be a myopic or unilateral effort, rather it must acknowledge that we are working at the frontiers and boundaries of the unknown, recognize that the results of this work can—and likely will—be globally manifest and take into account the plurality of society and culture(s) that could be affected by these outcomes.
In the former regard, only a consilient effort of the sciences and humanities can accommodate the philosophical, technical, and social richness of the tasks at hand and, in the latter, a more world-wide effort is needed if we are to truly instantiate a think-tank milieu that generates meaningful application(s) in socially relevant contexts. This is upheld by the fact that the DoM project is trans-disciplinary and international (viz. conjoining scholars, researchers, clinicians and public in Europe and Asia over the next several years). It is toward these consilient, international ends that I am now in Germany working with my colleagues Drs. Gerhard Höver, Heike Baranzke, and Hans-Werner Ingensiep (among others) at the Universities of Bonn and Essen. Our working group is a collaborative involving the natural sciences, medicine, philosophy, and ethics. We are focused upon the problem(s) of pain and pain care and the development of a neurophilosophy and ethics that can substantively meet the challenge(s) of engaging brain-mind studies to create a pain medicine that affords moral and practical good.
As a first step, we have begun to identify and analyze the difficulties inherent to pain care—both historically and currently. Perhaps the problem(s) that define contemporary pain medicine as profession and practice could be reduced to a three-fold concept:
There is controversy in the literature about whether tolerance to pain relief develops. In my clinical practice, which includes many patients treated with opioids for up to 15 years, quite a few have been on stable doses of opioids for years. Other opioid-prescribing clinicians have observed the same thing. Unfortunately there is a dearth of outcome reports in the medical literature. Recently, Tennant3 reported on a series of cases in his practice in whom long-term opioid doses were stable. When patients report increased pain after months or years of opioid treatment, their physician frequently attributes this to the development of tolerance to the pain-relieving effect of the opioids. But, remember, tolerance to all the other effects of opioids develops within days! What is much more likely is that the patient’s disease has progressed or that a new pain-producing problem has appeared.
1. problems of understanding
2. problems of translation
3. problems of articulation
In the first case—despite considerable progress into studying the mechanisms of pain, analgesic drugs and therapeutic interventions—we still must confront the “ti esti” (i.e., what is it?) question of pain. When we do, we encounter the “hard questions” of neuroscience which directly or indirectly underlie many of the hard problems of pain medicine.2
In this way, several of the first-fold issues and dilemmas instantiate those second-fold problems, that involves the translation of what we know about brains, minds and “selves” into a reasonably comprehensive system of pain care. This is a paradigmatic problem. I’ve stated previously, and re-iterate again, that pain medicine must be defined by the understanding of pain and its manifestations in the painient individual.3-8 To do this dictates that pain research must:
“Beginning with a low dose of an immediate-release opioid and increasing as needed is a good way to determine the patient’s opioid requirement. My recommendation at that point is to convert to a similar dose of a sustained-release opioid product...”
1) be inter-disciplinary;
2) study the mechanistic aspects of pain, and how these affect and are affected by bio-psychosocial dimensions of patients’ life worlds;
3) obtain a finer-grained perspective of the common as well as individually unique aspects (and effects) of pain; and
4) be equally devoted to both studying “how we study” pain, and revising these approaches in acknowledgement of information and knowledge gained, to date.9-11
Certainly this is an expansive agenda and, given the need to consider problems and issues in pain medicine in light of an appreciation of pain as a brain-mind event, then it too, requires a fuller understanding of embodied selves and their embeddedness in environments, society, and cultures.
To be sure, one of these cultures is that of medicine itself.12 For pain medicine to “work” it must not only develop a normative basis for profession, but must enact these norms in and across a number of clinical domains. Thus, the third articulative problem of pain medicine necessitates resolution through the development of a structure for the profession that entails different types of practice(s)—each and all of which are dedicated and enabled to employ the right knowledge, technologies, and skills in those ways that uphold the primacy of the pain patient’s best interest.13
Given identification of these problems, the goal is to bridge evidence and knowledge gaps such that information gained in response to the first problem, and developed in response to the second, is used in the third. Here we see how the enactment of the therapeutic dimension(s) of pain medicine can, and should, compel and ultimately sustain moral responsibility as an individual and public good. The premise is that this relationship is reciprocal: ethical obligations (i.e., to conduct pain research to empower right and good pain care) dictate the need to generate and provide right and good therapeutic action(s) and any and all therapeutic actions have moral potential and import.