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10 Articles in Volume 8, Issue #8
Botulinum Toxin Type-A in Pain Management
Chronic Migraine: An Interactive Case History
Consistent Documentation Drives Compliance
Muscle Physiology, Kinetics, Assessment, and Rehabilitation
Non-surgical Decompression Treatment for Carpal Tunnel Syndrome
The Pseudo-RSD Pain Patient
Therapeutic Laser Evolution: Part 1
TMJ Pain and Temporal Tendonitis with Autonomic Features
Topical Use of Morphine
Toward a Neuroethics of Pain Medicine

Toward a Neuroethics of Pain Medicine

Pain medicine must continue to progress to meet the challenges posed by advances in scientific understanding and technology and ever-widening philosophical and ethical issues and imperatives arising from them.

The Neurophenomenology of Pain: Mechanisms, Meaning, and Morality

An enhanced understanding of neuroscience, together with a broadened notion of mind, has instigated pragmatic and ethical concerns about the experience of pain. Such concerns must account for both the neural process of pain and its proximate and more durable effects—as neural event and experience—on cognitive, emotional, and behavioral effects that occur in painient beings existing within particular environments, communities, and cultures. The experience of pain occurs through the activation of hierarchical networks that may vary as a consequence of geno-phenotype-environmental interactions over time in each individual.1,2 Edelman’s concept of environmentally- and developmentally-dependent and variable functional and structural plasticity of peripheral and central nervous systems—as well as “top-down” effects that such plasticity incurs—reflects the sensitivity of these substrates to changes induced by internal and/or external conditions.3-6

This construct underscores the newly popular catchphrase of “…see one brain, see one brain,” and in light of this it is likely that the sensation and experience of pain are individually variant, subjective, and knowable only to the one in pain. In essence, we cannot know what it is like to be another being7; rather we can only recognize or know others’ experiences in relation to our own subjectivity.8,9 We do this by 1) objectifying others’ experiences by applying intellectual knowledge of common processes that are equivalent or similar in ourselves and others (i.e.- phenomenological relativism), 2) perception of some set of knowable reactions, responses and/or semiotics, and/or 3) the direct explanation of subjective experience(s) by others. This makes pain assessment pragmatically and morally difficult in those situations in which linguistic and/or communicative barriers exist—such as between cultures—when dealing with patients who are profoundly mentally impaired, demented, or obtunded, and when dealing with animals.10

The Possibilities and Limitations of Neuroscience and Neurotechnology

Knowledge of the development, structure, and function of the neural systems that mediate pain and analgesia is vital, but it is equally important to recognize how and why such objective information contributes to, and “fits” into, a contextual understanding of 1) how these systems interact with various environments to create first-person experience(s), and 2) how to deal with the uncertainty of others’ subjective experience.

The imperative to evaluate and treat pain and suffering has been a major incentive for the development of new medical techniques and technologies.11 Science and technology have allowed a more thorough understanding of neural systems, brain-mind, concepts of “self,” and pain. Perhaps neurotechnology will one day allow the completely objective assessment of pain (and its experience). To date, however, this has not been the case and, even if this were possible, we still must confront the limitations, burdens, and risks—as well as the benefits—of any technology. Scientific advancements should not be divorced from the responsibilities to use these developments and the information they deliver in ways that are both technically right and morally sound.12-14

Current neuroscience, as a consilient field, affords the most complete account of the relationship of brain, mind, and self—yet neuroscientific knowledge informs that these relationships are not linear nor wholly deterministic and we are forced to recognize and confront the boundaries of neuroscientific understanding.15 Our knowledge of the nervous systems of various organisms—and of the human organism at various stages and states of existence—allows, or perhaps more accurately compels, consideration that particular organisms can feel pain.16,17 That an organism has the capacity to feel pain should both sustain our (third person) belief that they experience pain, and guide our treatment of pain and suffering in accordance with some form of precautionary principle.

This neuroscientific orientation may be sufficient to ground an overarching obligation to treat pain. To be sure, neuroscience has lent considerable insight to how pain can alter the brain to affect the mind and self, the nature of suffering (and empathy), and the role of brain-mind in healing. But we must ask whether these explanatory models effectively represent the existential predicament of pain and suffering and if such explanations can guide the ethical decisions that arise in the care of pain as disease and/or illness. If the core incentive of neuroscientific inquiry is not simply knowledge “for knowledge’s sake,” but the acquisition of knowledge that can be applied toward the achievement of an identifiable, humanitarian purpose, then moral consideration is required to determine “why” and “how” care must be rendered so as to ethically enact pain medicine as an individual and social good.18

A Neuroethics of Pain Medicine: Purpose and Potential

This speaks to the need for an ethics that both reflects, and is directly relevant to, the current neuroscience of pain, the person as sentient being, culture(s), and healing; in other words, a neuroethics of pain medicine. Such a neuroethics must be construed in both the European tradition—as the neural basis for, and of, moral decision-making—and the American tradition—as the moral basis and ethics of neuroscientific research, applications, and related practice(s).19 This may ground pain care to a naturalistic (neuro)philosophy that allows, if not fortifies, acknowledgment of the capacity to experience pain as a quality of intrinsic moral gravitas. But this neurophilosophy also incurs ethical issues that arise directly from the intersection of neuroscience, pain medicine, and society.

For example, the principle of respect for autonomy has played a central role in much of contemporary bioethical thought, based upon varying constructs of the “self.”20 In the strictest sense, autonomy can be understood to be 1) a particular kind of potentiality of being, 2) the ability of such a being to make independent decisions and actions, and 3) the negative right of refusal.21 Autonomy in the first sense (i.e.- a being as an autonomous moral subject) is in some ways related to the manifestations of a being’s independent decisions and actions.22

But who (or what) is a moral subject? What of those circumstances in which the level of neural function makes a being unable to act autonomously? This often occurs because of individuals’ immaturity (e.g.- neonates, young children), not being fully conscious, or being mentally impaired. Very often, these individuals also cannot express their sentience or pain. Because of this, should we not regard pain in the very young, very old, and the very sick? And what of non-human pain? Probably, like never before, an understanding of animal nervous systems has allowed a consideration of the possibility of pain equivalence in animals—if not of animal minds more broadly—and this latter possibility has initiated dispute about previously held notions of consciousness, mentation, autonomy, and moral value.23-25

A purely Kantian account of autonomy, the notion of a “self” and dignity might be anachronistic,26 if not restrictive, in light of our neuroscientific knowledge. So, if neuroscience is to inform philosophy and ethics, a more contemporary definition of such basic, intrinsic dignity might be grounded in the moral value that is derived from respect for any being that possesses the potential for sentience.27,28 But we must also recognize that while others have dignity, our relationship to any and all other (human and even non-human) beings is not uniform. Asymmetries exist in our relationships with others based upon their relative ability to exert autonomous action, level of dependence, and vulnerabilities. Clearly, there is a moral obligation to acknowledge this relational asymmetry and tend to those who are vulnerable.29 Thus, the existential vulnerability of the pre-nate, neonate, young, infirm, obtunded/vegetative, and aged (as well as non-human sentient beings) makes them our responsibility for care. Pain can incur greater harm(s) to those who are most vulnerable. In this way, the moral imperative to treat pain and alleviate suffering is not directed at pain as an object, but rather is a regard for the impact and effects of pain in, and upon, a vulnerable, sentient being who is the subject of our respect.30-32

Such respect reflects a reverence for the experience and value of life in both oneself and others33,34 and, in this way, becomes a fundamental characteristic of medicine.35,36 In upholding a regard for the “…power of nature, enigma of life, health, pain, suffering, and death” it provides a basis to appreciate both what has the potential to harm, as well as what is good, and thereby “… direct…good intentions and actions.”37 It is this latter dimension of reverence that gives rise to benevolence, and guides beneficence—the intentions and actions toward achieving and/or enhancing the “good” of life and life experiences.

When enacted within pain medicine, as a practice, beneficence becomes definitive in striving toward the ends of providing right and “good” care to patients.38,39 We have opined that to do this the clinician must have knowledge of 1) the pathology of pain, 2) available treatments that could possibly mitigate the harm(s) incurred by pain, and 3) the being who is the pain patient, so as to discern (a) the nature and extent of such harms, (b) the relative and appropriate “goodness” of potential interventions, in order to (c) determine what care can, and should, be provided.40,41

Still, defining what is “good” in a pluralized population can be problematic, and becomes ever more so given the imperative to establish a framework for ethically sound, globalized pain care.42 Discernment and dissonance of notions of “the good” have been a source of tension and even conflict between medical communities’ benevolent intentions and actions, social policies and values, and the probity of respect for patients’ (and cultural) autonomy. This tends to occur when mid-level principles are regarded at face value. The diversity of patients’ and physicians’ values, various exigencies, and general uncertainties that are the reality of the medical relationship and clinical encounter are such that rarely, if ever, do circumstances allow for consideration or use of a simple definition of the good—or any given principle—with “all things being equal.”43 Such discord is often directly relational to the scope of the social sphere in which health care is provided. Characteristically, the larger the recipient population, the greater the potential or likelihood for 1) diversity of circumstance(s) and values, and 2) values’ dissonance.44

Neuroethical Questions and Issues in Pain Medicine.

Considering the nature of the good of pain medicine along neurocentric dimensions gives rise to several fundamental questions. Is there some threshold of pain and suffering that can, or should, be validated in order to incur clinical intervention? At what point does the treatment of pain and suffering become “excessive”? Can neuroscience contribute this metric or rule? To what level(s) might we take diagnostics and therapeutics? Given the capacities and limitations of neuroimaging (e.g.- fMR, fNIR, PET, SPECT, mEEG, etc) what can we realistically expect this technology to yield in pain medicine, and how can we prudently employ these methods, and avoid both the error of attributing antecedents to the consequential (i.e.- the post hoc ergo propter hoc fallacy),45 and being seduced into the lure of what Ludwig Wittgenstein46,47 referred to as “picture thinking”?

Similarly, we must be cautious when employing neurogenetic information to diagnose the pre-disposition or likelihood of pain syndromes, so as to 1) avoid over-simplification of gene-phenotype-disorder relationships; 2)not misname or misconstrue the etiology of a disorder, 3) assume full responsibility to use this information equitably and with appropriate confidentiality in order to prevent social, economic, and/or vocational stigmatization, and disproportionate under-allocation of insurance benefits, and 4) address the problems that arise when diagnosing disorders that cannot be cured.

In addition, we must confront the crucial questions of neural stem cell research,48 and the use of stem cells in pain medicine. However, the stem cell debate is but one of the contentious issues that surround the potential of neural transplantation.49 While human-human and animal-human (i.e.- xenograft) transplantation techniques and technologies may offer considerable promise for generating and remodeling new neural pathways, we must ask what extent of new tissue is required to affect the entirety of the neural network that constitutes mind and self. The use of exogenous material to restore or repair neural function is not limited to living tissue so that we must also examine the potential benefits, difficulties, and problems that arise from the direct interface of technology and human neural systems (e.g.- transcranial magnetic stimulation, implanted bioelectric devices, nano-neurotechnology), and the iterative ‘cyborgization’ of the human body. While such ideas of cyborgization have traditionally been viewed as the stuff of science fiction, Francis Fukuyama50 and Chris Gray51 note that such integration of biologically-relevant machines have already become the norm throughout many domains of society, and Moore’s theorem (viz.- the advancement of technologies that are based upon the annual multiplication of computer-based applications and derivatives) predicts this machine interfacing to progress with fluidity and rapidity. For certain, each and all of these developments can contribute to the extant issues of over- and under-treatment of pain,52 and could lead to utopian and/or dystopian possibilities.53

Proceeding with Prudence

It may be that neuroethics provides a viable meta-construct for pain medicine by providing illustration of the facts and possibilities, as well as grounding moral decisions to a naturalistic regard for sentience and the experience of pain.54 Such a neuroethics must be “operationally beneficent.” Frankena’s conceptualization of multi-leveled beneficence—ranging from the obligatory to the supererogatory, and from the individual to social55—coupled to Pellegrino and Thomasma’s appreciation for how the acts of medicine affect the good for each patient as an autonomous being,56 allows for a broader, more useful understanding of “good” and how it could, and should, be enacted within both pain medicine and societies. This beneficence is 1) based upon reverence, 2) encompasses non-harm through a reverent regard for each sentient and painient individual, and thereby 3) encompasses respect for each individual’s autonomy, intrinsic dignity, and environmental/cultural-nestedness.57

Such consideration would compel the prudent use of the most current scientific knowledge to expand and sustain the need for, and provision of, safe, effective, and equitable pain care. To do this may require a reflective equilibrium58 to allow examination of the “…range of values…to take a more holistic approach in which moral values cohere with known facts about the world, and with basic moral attitudes, and become reconfigured as the physical, social and moral …change.”59 In its naturalizing quality, a neuroethics of pain medicine may achieve this balance, as it tends to reflect the relatedness of science and ethics, such that “…the sciences depend upon philosophy…and ethics depends upon the sciences for information upon which moral judgments are best made.”60 As a field, profession, and practice, pain medicine—in all of its constituent forms and disciplines—must continue to progress to meet the challenges posed by advances in scientific understanding and technology, and the ever-widening philosophical and ethical issues and imperatives that arise thereupon. n

Acknowledgement

This essay is adapted from the author’s paper, “The neuroscience of pain and a neuroethics of pain medicine” in the Journal of Neuroethics (forthcoming, 2009), and the chapter “Neuroethics, pain and suffering” by the author that appears in: Giordano J, Gordijn B (eds.)

Last updated on: January 5, 2012
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