Thoughts on “Reconsidering fetal pain” – by Stuart WG Derbyshire & John C Bockmann

Sculpture by Fabio Viale

“…we propose that the fetus experiences a pain that just is and it is because it is, there is no further comprehension of the experience, only an immediate apprehension.” – Reconsidering Fetal Pain (2019), by Stuart WG Derbyshire, John C Bockmann

I agree with this proposal.

Experiencing pain is being in an animal-like state. But, experiencing pain is not knowing that this is pain. I think experiencing pain becomes a state of knowing only if a person is a competent language user. 

A consequence of this idea is that pain experience is not always immediately transparent or lucid to the person experiencing it. Odd as it sounds, to be in pain is not to know pain. This challenges the Cartesian philosophy of mind.

Following Derbyshire and Brockman, the fetus or neonate experiences pain, but without understanding or recognition.

—

Emre Ihan asked me: “Do you think learning is a form of recognition? A lot of neonates pull their legs away when nurses and their parents touch their heels, after weeks of heel lancing (heel pricks for blood tests). Could this be an anticipation of pain, and thus recognition that pain is imminent…”

Compare the neonate’s behaviour with a dog walking beside a road with the flow of traffic. The behaviour of the dog conforms to our left-hand drive convention, but it does not do so because it understands that convention.

In the same way, a chicken that stretches its neck and wings as in the mating ritual of the wandering albatross is not stretching its neck because it understands, or has a conception of, this mating pattern.

Point 1. There is behaviour that conforms to a complex pattern.

Point 2. This behaviour is not explained through a conception or understanding of that pattern. The behaviour just accidentally realises part of a complex pattern. 

Point 3. The explanation for the behaviour is explained by its relation to the complex patterned whole.

A plausible explanation of the neonate’s behaviour is in terms of the survival value to groups of humans of this form of behavior. These behaviours are performed because they form part of a hard-wired evolutionary pattern, not because the neonate recognises or follows a set of cognitive rules that are an abstract description of the pattern.

Thus, the neonate, like the dog or chicken, does not engage in their patterned behaviour “on purpose.” The neonate does not intend to follow rules or apply social norms.

Developmentally, that skill emerges later when the neonate is a child and learns, if it is fortunate enough, the concept of pain.

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Call for Abstracts: Meanings of Pain, Volume III

Sculpture by Fabio Viale

Volume III Topic: Meanings of pain in vulnerable or special patient groups

Series Editor: Dr Simon van Rysewyk
Publisher: Springer

The Meanings of Pain book series describes how the meaning of pain changes pain experience – and people – over time.

Pain in the moment is experienced as immediately distressing or unpleasant. If pain persists over time, more complex meanings about the long-term consequences, or burden of pain, can develop. These meanings can include existential meanings such as despair or loneliness that focus on the person with pain, rather than pain itself.

Meanings of Pain offers a vocabulary of language about pain and meaning. An objective of the series is to stimulate self-reflection on how to use information about meaning in clinical and non-clinical pain settings. The book series is intended for people with pain, family members or caregivers of people with pain, clinicians, researchers, advocates, and policy makers.

Although chronic pain can affect anyone, there are some groups of people for whom particular clinical support and understanding is urgently needed. This applies to “vulnerable” or “special” groups of people and to the question of what pain means to them.

Volume III focuses on describing the meanings of pain in groups of “vulnerable” or “special” people, such as:

• Infants or children
• Women
• Older adults
• People with a physical or intellectual disability
• People with a brain injury
• People diagnosed with a disease
• Veterans
• Athletes
• Workers
• Addicts
• People with mental illness or mental disorders
• Homeless people
• People in rural or remote communities
• People in multicultural communities
• Indigenous peoples

Invited chapter types
The editor Dr Simon van Rysewyk invites contributions for Volume III on the meanings of pain in vulnerable or special patient groups. The following manuscript types will be considered:

• Original Research (e.g., original clinical, translational, or theoretical research)
• Reviews (e.g., Systematic Reviews, Meta-analytic reviews, Cochrane type reviews, Pragmatic Reviews)

Authors interested in submitting a chapter for publication in Volume III are invited to submit a 350-word Abstract, which includes the name and contact information of the corresponding author, to:

Dr Simon van Rysewyk
simon.vanrysewyk@utas.edu.au

Abstract Deadline: closed

“It is my opinion that this … work will stand as the definitive reference work in this field. I believe it will enrich the professional and personal lives of health care providers, researchers and people who have persistent pain and their family members. The combination of framework chapters with chapters devoted to analysing the lived experience of pain conditions gives the requisite breadth and depth to the subject.” – Dr Marc A. Russo, MBBS DA(UK) FANZCA FFPMANZCA, Newcastle, Australia, from the Foreword in Volume II

Towards raising awareness of qualitative pain research

While awareness of qualitative research of lived pain is slowly increasing in the field of pain, it is far from established and needs cultivating from within the field by pain researchers (Mitchell & MacDonald, 2009; Osborn & Rodham, 2010; Price & Barrell, 2012). Pain research has traditionally been dominated by quantitative research methods, which have their roots in physiology, physics, biology, and psychophysics, arising from mathematics, statistics, and psychometrics (Price et al. 2002; Price & Aydede, 2005; Price & Barrell, 2012). This trend continues unabated today, and perhaps explains why Osborn and Rodham (2010) found that many individual pain researchers have not yet accumulated a significant body of qualitative pain research. A body of qualitative pain research would enable researchers to develop their arguments in more depth concerning the nature and types of personal meanings apparent in pain experience, especially clinical pain experiences across the lifespan. The rationale for conducting qualitative pain research is likely not clear to many in the field of pain, and researchers are probably unaware of the potential richness of qualitative pain data to uniquely describe lived pain or the diverse tools available for analyzing qualitative data. In line with this, Osborn & Rodham (2010) found that many of the qualitative pain studies they reviewed used only one type of analysis (i.e., data analysis was not triangulated), description rather than interpretation prevailed in discussion of data meaning, and research methods were not thoroughly described.

A powerful reason to conduct more qualitative pain research is the common complaint from clinical pain patients that they feel they have never had an opportunity to fully explore their lived pain experiences with health care professionals, that no one has ever fully understood what is wrong with them and, most importantly, that no one appears to be listening (e.g., Melzack, 1990; Hoffmann & Tarzian, 2001; Hansson et al. 2011; McGee et al. 2011; Thacker & Moseley, 2012; De Ruddere et al. 2014). Clinical failure to sufficiently appreciate patient pain and its felt meanings can result in profound patient dissatisfaction, exacerbation of feelings of isolation and confusion, among other negative existential appreciations, and cause up-regulation of nociception (Butler et al. 2003). Despite this significant problem in the treatment and management of clinical pain, some pain researchers (e.g., Apkarian et al. 2011; Wortolowska, 2011) and government agencies (e.g., National Research Council of the National Academies, 2008; National Institutes of Health, 2011) have argued for replacing first-person patient experiential pain data with brain-imaging data.

Although qualitative research alone cannot solve these challenges, because of its exploratory nature, it can complement quantitative clinical pain research to describe lived pain and the psychosocial factors that improve or worsen the efficacy of pain interventions, as well as core intervention components that are associated with desired or undesired patient outcomes (Price et al. 2002; Price & Aydede, 2005; Price & Barrell, 2012; Thacker & Moseley, 2012).

References

Apkarian, A. V., Hashmi, J. A., & Baliki, M. N. (2011). Pain and the brain: specificity and plasticity of the brain in clinical chronic pain. Pain, 152(3 Suppl), S49–64.

De Ruddere, L., Goubert, L., Stevens, M. A. L., Deveugele, M., Craig, K. D., & Crombez, G. (2014). Health Care Professionals” Reactions to Patient Pain: Impact of Knowledge About Medical Evidence and Psychosocial Influences. The Journal of Pain, 15(3), 262–270.

Hoffmann, D. E., & Tarzian, A. J. (2001). The girl who cried pain: a bias against women in the treatment of pain. The Journal of Law, Medicine & Ethics, 28(s4), 13–27.

McGee, S. J., Kaylor, B. D., Emmott H., & Christopher, M. J. (2011). Defining chronic pain ethics. Pain Medicine, 12, 1376–1384.

Melzack, R. (1990). The tragedy of needless pain. Scientific American, 262(2), 27–33.

National Institutes of Health. (2011). Biomarkers for chronic pain using functional brain connectivity. Common Fund NIH Government.

National Research Council of the National Academies. Emerging cognitive neuroscience and related technologies. (2008). Washington, DC: National Academies Press.

Price, D. D., & Aydede, M. (2005). The experimental use of introspection in the scientific study of pain and its integration with third-person methodologies: The experiential-phenomenological approach. In M. Aydede (Ed.), Pain: New Essays on its Nature and the Methodology of its Study (pp. 243–273). Cambridge, Mass.: MIT Press.

Price, D. D., & Barrell, J. J. (2012). Inner Experiences and Neuroscience. Merging the two perspectives. Cambridge, Mass.: MIT Press.

Price, D. D., Barrell, J. J., & Rainville, P. (2002). Integrating experiential-phenomenological methods and neuroscience to study neural mechanisms of pain and consciousness.

Thacker, M. A., & Moseley, G. L. (2012). First-person neuroscience and the understanding of pain. The Medical Journal of Australia, 196(6), 410–411.

Wortolowska, K. (2011). How neuroimaging can help us to visualise and quantify pain? European Journal of Pain, 5, 323–327.

Why are pain patients all unique? A type-token identity theory answer

Variations in response to pain have been reported in clinical settings (e.g., Bates et al. 1996; Cherkin et al. 1994; Jensen et al. 1986; Unruh, 1996; Wormslev et al. 1994). Patients with similar types and degrees of wounds vary from showing no pain to showing severe and disabling pain. Many chronic pain patients show disabling chronic pain despite showing no observable wound. Other patients show severe wounds but do not show pain. Why is it that two persons with identical lesions do not show the same pain or no pain at all? Why are all pain patients unique?

I propose that mind-brain identity theory may offer an answer to this difficult question. There are two main versions of identity theory: type and token identity. A sample type identical property is to identify “Being in pain” (X) with “Being the operation of the nervous-endocrine-immune mechanism” (Y) (i.e., X iff Y) (Chapman et al. 2008; van Rysewyk, 2013). For any person in pain the nervous-endocrine-immune mechanism (NEIM) must be active, and when NEIM is active in a person, he or she is in pain. Thus, type identity theory strongly limits the pattern of covariation across persons. According to token identity theory, for a person in mental state X at time t, X is identical to some neurophysiological state Y. However, in the same person at time t1, the same mental state X may be identical to a different neurophysiological state Y2. Token identity theory doesn’t limit the pattern of covariation across persons; it only claims that, at any given time, some mind-brain identity must be true.

In response to the topic question, I propose a hybrid version of identity theory – ‘type-token mind-brain identity theory’. Accordingly, for every person, there is a type identity between a mental state X and some neurophysiological state Y. So, when I am in pain, I am in NEIM state Y (and vice versa), but this NEIM state Y may be quite different across persons. Type-token identity theory therefore proposes a type identity model at the level of every person (i.e., it may vary across persons). A type-token identity theory implies that group-level type identities (i.e., type-type) cannot fully explain the pattern of covariation in pain responses across persons. Measuring changes of a pattern of psychological and neurophysiological indicators over time may then support a unidimensional model of chronic pain for each pain patient. Thus, being in chronic pain for me is identical with a specific pattern of NEIM activity (Chapman et al. 2008; van Rysewyk, 2013), but for a different patient, the same state of pain may be identical to a different pattern of NEIM activity. In preventing and alleviating chronic pain, it is therefore essential to best fit the intervention to the type-token pain identity profile of the patient.

References

Bates, M. S., Edwards, W. T., & Anderson, K. O. (1993). Ethnocultural influences on variation in chronic pain perception. Pain, 52(1), 101-112.

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. Journal of Pain 9: 122-145.

Cherkin, D. C., Deyo, R. A., Wheeler, K., & Ciol, M. A. (1994). Physician variation in diagnostic testing for low back pain. Who you see is what you get. Arthritis & Rheumatism, 37(1), 15-22.

Jensen, M. P., Karoly, P., & Braver, S. (1986). The measurement of clinical pain intensity: a comparison of six methods. Pain, 27(1), 117-126.

Unruh, A. M. (1996). Gender variations in clinical pain experience. Pain, 65(2), 123-167.

van Rysewyk, S. (2013). Pain is Mechanism. Unpublished PhD Thesis. University of Tasmania.

Wormslev, M., Juul, A. M., Marques, B., Minck, H., Bentzen, L., & Hansen, T. M. (1994). Clinical examination of pelvic insufficiency during pregnancy: an evaluation of the interobserver variation, the relation between clinical signs and pain and the relation between clinical signs and physical disability. Scandinavian journal of rheumatology, 23(2), 96-102.