Pain, Neurotechnology, and the Treatment-enhancement Debate
Neuroethical Consideration of Neurotechnology in Pain Care
In addressing the responsibility to develop and implement a neuro-ethics of pain care, it has been stated that: “…the nature of the ‘good’ of pain care in neurocentric contexts gives rise to several fundamental questions: Is there some threshold of pain and suffering that can or should be validated in order to incur and/or justify clinical intervention? Can neuroscience contribute this metric or rule? To what level(s) might we take diagnostics and therapeutics?”1 In other words, we can, and arguably should ask: At what point does the treatment of pain and suffering become “excessive” and would such intervention be considered “enhancement”? It is reasonable to assume that manipulation of neurological function—through the use of analgesic and psychotropic drugs and certain neurotechnologies—has become, and will continue to be, increasingly valued and publically accepted, as these techniques and technologies improve and are made evermore commercially available. The market will both drive and ensure that this is the case. Economic factors are such that the availability of a given technique or technology often lend it value and establish the call for its use.
Simply put, the “if we have it; use it” maxim holds and, in many cases, there is appreciable merit to at least considering such use. But if neuroscience has revealed that pain is unique to each individual (i.e., reflecting how the engagement of specific neural networks give rise to phenomenological experience) and this mitigates against a “one size fits all” approach to pain care, then it becomes obvious that the assessment and discernment of pain can be seen as the initiative element in both determining the nature and impact of the subjective experience of pain and establishing a threshold for the provision, type(s) and extent of treatment.
Technological Assessment: “Determining” Pain
What can neurotechnology contribute to this crucial step? Recent reports have claimed that neuroimaging can “depict” pain based upon representative patterns of activity in various brain regions (e.g., the anterior cingulate cortex, septal nuclei, etc).2 Without doubt, this is clinically useful toward developing an understanding of pain mechanisms and conceiving a putative brain “phenotype” of certain types of pain. But can this actually provide a generalizable, absolutely objective determination of pain, its extent and/or severity and, perhaps most importantly, its first-person experience? Such generalizability would require amassing a huge databank of neuroimages across and within populations. Even if we were to create a sufficiently large database of such neuroimages so as to match any/all new cases against this reference, this would still only be able to allow validation that the activity pattern of a particular individual is statistically similar enough to indicate a likelihood of their experiencing some sort of pain. There does not appear to be a linear correlation between extent of activation of these brain regions (or more accurately, networks) and the intensity and characteristics of pain. So, given that it is not (yet) possible to determine a completely reliable neuroimage of the magnitude of pain, we would be unable to assert its experiential characteristics or severity. These features would remain exclusively subjective.
Yet, when appropriately utilized, such technologic assessment is still of considerable value. Take for instance, those individuals who may not be able to express their subjective experience (e.g., pre-nates, neonates, the young, obtunded, locked-in, demented aged, mentally impaired, and even animals), such neurotechnological assessment might provide a baseline from which to determine that the being is in pain (or at minimum has activity in those brain networks that are involved in, and therefore capable of subserving pain).3,4 In these cases, this information would be important to sustain a precautionary stance based upon the construct that an organism’s capacity to feel pain “...must both satisfice our belief that they experience pain, and guide our treatment of such (potential for) pain and suffering.” 5,6
However, we also run the risk of what Wittgenstein referred to as “picture thinking” and defaulting to a fallacious reliance upon technology to provide “certainty” about the occurrence (or non-occurrence) of pain.7 If, for example, a patient’s functional magnetic resonance image (fMRI) does not “evidence” pain, do we simply minimize or discount the validity or value of their subjective experience and reports to the contrary? In other words, do we adopt a position of “no image, no pain”? In many ways, this is little more than a re-instantiation of the problem(s) incurred by the enigmatic lack of apparent organicity of chronic pain. So while our current epistemic capital may allow us to look back with scorn upon claims of chronic pain being “all in the head” and “factitious”—if not frankly “malingering”—we must be cautious not to succumb to new iterations of such anachronistic thinking that might be fostered by the inappropriate interpretation or misuse of neurotechnology.8
“Indeed the assessment and diagnostic step is critical as it contributes to, and at the same time evolves from, norm(s) upon which to initiate and base clinical intervention....key questions include ‘How much pain is necessary for clinical intervention?’”
Indeed the assessment and diagnostic step is critical as it contributes to, and at the same time evolves from, norm(s) upon which to initiate and base clinical intervention. We have argued that such norms establish a threshold about which distinctions of existential gain and loss, treatment and enhancement are based and therefore ultimately can be made.9 Here, key questions include “How much pain is necessary for clinical intervention?” “How much pain should be eradicated?” “In whom?” and “Why?” Our argument is that any such norms must be “inter-theoretically translatable” from, and between, biological, psychological and social domains. In this way, ontological assumptions of the medical model (i.e., realism, naturalism, reductionism, and essentialism) can be asserted and maintained, and these can ground patients’ subjective experiences of dysfunction, impairment, illness and suffering to criteria that can be utilized to establish socially relevant thresholds for care.10