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10 Articles in Volume 9, Issue #9
Neuroethics at the Close of the Decade of Pain Control and Research
Cumulative Response from Cranial Electrotherapy Stimulation (CES) for Chronic Pain
Dextrose Prolotherapy for Unresolved Wrist Pain
Adult Growth Hormone Deficiency in Fibromyalgia
Middle Ear, Eustachian Tube, and Otomandibular/Craniofacial Pain
Computerized Dynamometry in Impairment Evaluations
Co-Morbid States Are the Rule—Not the Exception—in Pain Practice
Nutritional Supplements in Pain Practice
Testosterone Replacement in Female Chronic Pain Patients
A Practical Guide for the Use of Opioids in Chronic Pain

Neuroethics at the Close of the Decade of Pain Control and Research

Changing Views from the Cave to the Crest

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

Complementarity

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).

These individual and social issues arise from what it means to “…have a brain yet be a mind.”15 I believe that progress incurred through an expanded science of the brain-mind will yield significant impact(s) in pain care and these may have implications for national security (i.e., “neuroweapons”)16; social value(s), con-texts and conduct (e.g., re-defining what is “normal” and “abnormal”, and what constitutes “treatment” or “enhancement”)17,18; and the progressive integration of neurotechnology into various aspects of culture (i.e., “cyborgization”).19 The philosopher Colin McGinn has claimed that we may never fully understand how brain evokes mind, as human cognition has reached its limit of mechanistic introspection and therefore we are at a point of “…cognitive closure.”20

Somewhat more optimistically, I prefer to think that we are on a “cognitive crest,” riding an epistemic wave that is propelled by the nature of mind, advanced by the inquiry and knowledge gained to date, and existing at a point that allows us to apprehend both what has come before and the uncertainties and possibilities of what may lie ahead. To carry this analogy further, I argue that we cannot stop the wave, nor should we—as it is driven by the human need to know, and fueled by an imperative to flourish and reduce pain and suffering. But, as we advance, our vantage allows iterative purchase to reflect and respond in ways that can direct the wave of inquiry and utilization; avoid drowning in uncertainty; and mitigate the social, economic and political misuse of the tide of knowledge and technology.

Actively Influencing the Future

Still, new questions arise: namely, (1) can we direct this tide; (2) how can and should we; and (3) will we? Perhaps, as we come to the close of the DPCR, these are the challenges that pain medicine must face as both profession and practice. But then we must ask, what is pain management? To be sure, it is nested within the larger fabric of medicine as a whole. Thus, to address the meaning and definition of pain management, we must ask what is medicine? Writ large, medicine may be considered to be the art and science of treating those made vulnerable by disease, illness and injury.21 It is clear that the purpose of medicine is the care of the person who is the patient. What has become less clear is what defines medicine as art and/or science and how these definitions are intimately related to the premises and practicalities of treating disease and illness.

Even in classical definition, the natural sciences establish a foundation upon which medicine can be based, for the practice of medicine involves an understanding of bodily functions and dysfunctions as events that are knowable according to laws of nature.22 Certainly, contemporary medicine’s reliance upon scientific experimentation, the expansion of our understanding of natural science(s), and evidence-based practice has fortified this relationship. Much of this understanding has been gained through the use of technology and it is easy to see how and why the regnant medical mindset has become so deeply ingrained with a self-perception of applied biotechnology.23 But as Gadamer notes “…the science of medicine is the one which can never be understood entirely as a technology, precisely because…its own abilities and skills belong(s) to nature.”24

And herein lies what the Hippocratics,25 and more recently Osler26 referred to “the art”—the combinatory use of objective knowledge with subjective appreciation in practical application; in other words, a praxis. The praxis of medicine has been described to be a tekne, an intellectual, practical pursuit that includes the generalizability, precision and explanatory value(s) of science together with the wisdom, insight and subtlety of art.27,28 It is this practicality that relates medicine to its work—the treatment of persons made vulnerable by disease and illness—for practicality obtains that disease and illness are not one and the same, and thus cannot be approached and treated as such. Discerning illness from disease is not simply a matter of differentiating effect(s) from cause, but rests upon apprehension of the person that is the patient. This preserves the humanitarian dimension that compels the acquisition and use of particular knowledge, informs decisions, and ultimately guides actions to sustain medicine as what Paul Ramsey calls “moral art.”29 This approach is dialectical and allows for seemingly different perspectives to be communicated, discussed, and reconciled in a synthesis of complementarity—in other words, the dialectic process allows unique and differing perspectives to inform each other in a fusion that precipitates learning and positive change.

Commitment to Prudent Action

Pain management, as a profession and practice, must be committed to a classical Asclepian (curative) and Hygieian (healing) dialectic. The balance of curative and healing domains are focused upon the patient and create an environment that is an integrative whole and, therefore, by definition, healthy and thriving within itself.30 To achieve this balance requires communication within the pain management community at large, and thus responsibility to foster discourse rests not only upon the individual practitioner but upon their professional organizations, as well. To be sure, many professional pain (science and medicine) organizations exist, each with somewhat differing missions and agendas. However, a harmonizing task might be to reflect upon the intent and outcomes of the DPCR and look ahead to how progress in the sciences and humanities could create improved opportunities for understanding, ethics, and care.

I opine that it is often far too easy to look back and comment about the “darkness” of unfulfilled intentions and tasks left incomplete. The real challenge in facing the future—at least with any sense of purpose—is to proverbially “light a candle” so as to illuminate the potential paths, pitfalls and possibilities that lie ahead. In exploring how contemporary neuroscience impacts the philosophical and pragmatic basis of pain care—as well as the socio-economic and political implications of these concepts—the burgeoning discipline of neuroethics may help to refine our current knowledge of what is known, what is unknown, and what is unknowable about the brain, mind, self and pain. This discourse may help in charting a course forward by both providing meaningful vision into the goods, benefits, risks, and burdens that we might incur as well as using this insight to inform and develop guidelines, policies and laws.

Last updated on: December 13, 2011
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