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9 Articles in Volume 10, Issue #4
Chaos (Nonlinear Dynamics) and Migraine
Enhancement of Nerve Regeneration by Therapeutic Laser
Functional Capacity Evaluation (FCE)
Making Practical Sense of Cytochrome P450
Non-pharmacologic Treatment of Shingles
Pain, Neurotechnology, and the Treatment-enhancement Debate
The New Age of Prolotherapy
Treating Myofacial and Other Idiopathic Head and Neck Pain
Treatment of Painful Cutaneous Wounds

Pain, Neurotechnology, and the Treatment-enhancement Debate

Protocols for the use of medical interventions should be frequently assessed, revised, and followed by reflective evaluation and prudent governance to establish guidelines and policies.

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

Treatment and/or Enhancement: A Call for Caution

Previously, we have raised the issue that if treatment is “…oriented toward ‘ameliorating an abnormal condition to a normalized baseline,’ while ‘enhancement’ is the betterment or augmentation of capability in the absence of dysfunction,” are we not in some way seeking enhancement—even if such enhancement only elevates us to some arbitrary baseline level of subjective experience, performance or ability?11 Are these personal, clinical, legal or social criteria, or some Gordian combination of each and all that we must try to unravel with our nomenclature, guidelines and policies?12 As Paul Root Wolpe has noted, the question at hand may not be whether to draw the line, but “…where, and what kind of line do we draw?”13 To be sure, social, economic and legal concerns about inequitable use and distribution, while valid prima facie, do not substantiate claims about a technique or technology’s status as a treatment or enhancement, as there are numerous valid treatments that are not commutatively provided to those who need (or desire) them. In light of this, perhaps equally as important as getting the Healthcare Bill passed is defining the terms and conditions with which any intervention will be utilized and provided.14

Recently, Singh and Kelleher have posited that the trickle-down effect of such values and acceptance will likely lead to a progressive desire for the use of pain-related neurotechnologies in, and among, the young.15 We argue that particular caution—and prudence—must be exer-cised when considering how these issues can and should affect pain care in this population. An important caveat is that the impact of such interventions upon the development and long term function(s) of the nervous system remain unknown.16 Working with our group, Anita Gupta has addressed this issue and has posed primary questions that must be addressed when considering analgesic intervention in the neonate and young:

  1. Does the pathological condition affect the life potential or potentiality of the patient significantly enough to warrant medical intervention?
  2. Does the pathologic disturbance negatively affect the developmental trajectory and function of the pain and pain modulatory systems so as to produce significant (predisposition or occurrence of) pain?
  3. Can/should we reduce pain incurred by the pathology?
  4. How–and to what extent can such pain be treated?17

From these are derived additional questions that revolve around the ways that any decision(s) to treat or not treat could affect the resultant development of the nervous system and the cognitive, behavioral and/or emotional manifestations that may occur as a result. So, for example, if we do not treat pain, are we predisposing the system to progressive sensitization that could be expressed as a lifelong disposition for neuropathic pain? On the other hand, can we be sufficiently exact in the dose calculations and delivery of analgesics so as not to incur pharmacologic de-sensitization and predisposition for tolerance, loss of therapeutic effect, need for continuous dose-escalation and possibilities of increased adverse side effects?18

Singh and Kelleher stress the safety of any neurological interventions (irrespective of whether deemed treatment or enhancement) in young people, and opine that only agents and/or technologies with low misuse/abuse potential should be employed. We concur, and believe that two fundamental issues come to the fore. First, it is important to examine what is meant by constructs of “normality” as relevant to pain, what this infers about thresholds for intervention as treatment or something supererogatory (viz.- enhancement), and the resulting existential gains and losses that might be achieved.19,20 Second, we must evaluate whether the profession and practice of pain medicine maintains the knowledge of these issues, and economic support necessary for: 1) technical rectitude in light of rapidly expanding information about interventions, mechanisms and effects, and 2) deciding upon what treatments can and should be provided to maximize the best interest of each patient —what Pellegrino has referred to as the “right and good” use of any available techniques and technologies in pain diagnosis and care.21

Prudence as—and in—Purpose, Process and Practice

Yet these issues are not situated solely within the milieu of clinical practice. Ethical, social, and legal questions will indubitably arise in, and from, the prescribed uses of any such advanced neural interventions, and reflect 1) an expanding fund of neuroscientific (and socio-cultural) knowledge, and 2) the philosophical premises of science in general that mandate self-criticism and self-revision.22 Another important consideration is what effect restriction of such interventions would have upon illicit acquisition and use through the “black” or “grey” markets. Thus, we advocate a systematized process of full content medical, ethical and social reflection to precede and inform prudently-regulated use of new (and older, existing) techniques and technologies in pain care provided to both young and adult patients alike. Axiomatic to this stance is the notion of prudence as practical wisdom that dictates working familiarity with both current multi-disciplinary research, and the relevance and viability of any and all treatments in practice.23,24

These factors are critical and it is important that 1) protocols for use be frequently assessed and revised so as to ensure sound and stringent provision of these interventions—as medically required, and 2) reflective evaluation, and prudent governance be employed to establish the guidelines and policies necessary to afford equitable access to, and distribution of, these resources and interventions. The pace and extent of neurotechnological development mandate few other options. As often noted, we must “…measure twice and cut once, for far too often there is no turning back.”25

Acknowledgements

This essay was based upon a paper by the authors recently appearing in the American Journal of Bioethics-Neuroscience and a forthcoming paper to be published in Philosophy, Ethics and Humanities in Medicine. This work was supported in part by funding from the Nour Foundation (JG), the William H. and Ruth Crane Schaefer Endowment (JG) and a research support grant from TechProjects Initiatives (JG).

Last updated on: December 20, 2011
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