Thoughts on the privacy of pain – #1

Gordon, also known as “Whipped Peter”, a former enslaved African American man, shows his scarred back at a medical examination, Baton Rouge, Louisiana, on 2nd April, 1863. The scars were the result of whipping during his time as an enslaved person at a Louisiana plantation. (Source: Wikimedia Commons)

A reason for thinking that pain is private – hidden to external observers – is the uncertainty that affects our judgements about the pain of others.

When someone appears to be in pain, it seems self evident that what matters is not the pain behaviour that we observe, but the pain experience that lies ‘behind’ the behaviour. We find it natural to say that ‘pain is private; we infer it only inconclusively from the behaviour.’

We naturally think: first-person experience is certain; third-person observation is uncertain. The person in pain has privileged, or immediate, access to his or her pain. Doubt is excluded in the first-person case.

Is this thinking correct?

Following the philosopher Wittgenstein, doubt in the first-person is excluded, not because pain is a private experience, but because the practice of pain excludes it. In the practice of pain, the individual has the role of expressing pain experiences; these expressions include a diverse range of verbal and non-verbal behaviours. In the swing and play of the practice, we treat these behaviours as authentic. To introduce doubt here would alter the practice of pain; importantly, it would undermine our concept of the person.

In clinical settings, this is reflected in McCaffery’s maxim that “Pain is what the person says it is, and exists whenever he or she says it does.” This brings the person to the fore, and makes patients the authority in their pain experience. This approach to pain assessment is also aligned with the principles of patient advocacy and ethical clinical treatment.

Why can’t a person be wrong about his or her own pain? The reason Wittgenstein proposed is that assigning the individual the role of expressing pain means there is no gap between what the person sincerely says her experience is, and what it really is. If we are trying to determine the effect of pain on a person’s quality of life, it is what the person says, and not anyone else, that is correct.

The point is not that the individual feels pain only she can feel, but that we treat her as a person, and on the basis of her behaviours, including self-report, assign to her particular sensations, thoughts, and moods. The ‘privacy of pain’ reflects not the intrinsic privacy of pain experience, but our practice of pain based on the notion of a person whose behaviours are treated as authentic expressions of pain.

Still, a person’s utterances may only partly signify the complexities of pain experience, and some situations warrant people be careful what they reveal. Some pain behaviour may therefore reflect perceived best interests, and this is contextual. Care-delivery in pain settings can involve a threat to the caregiver, and is conditional on the authenticity of pain behaviour. As observers of pain behaviour, we are sensitive to signs of exaggeration, suppression, or malingering. Thus, fine shades of behaviour are important in the evaluation of ‘what is going on’ in the setting of pain, and lead our relation to each other as persons. The practice of pain does not always connect behaviour and pain experience in a rigid way.

Navigating these complexities can make patient-clinician interactions challenging.

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“Pain and perception” – some questions and answers

Argument:

Imagine I see a white rose. The rose is white, not my seeing of it. Right? To think my seeing of the rose is white is to confuse what is perceived, with my perceiving of it. It’s a category mistake.

Now, compare: ‘I feel a burning pain’. To think my feeling of the pain is what burns is, again, to confuse what is perceived, with my perceiving of it.

The pain is what burns, not the feeling of it. Therefore, pain is not a perception.

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Question: Whether the pain ‘burns’ or not is down to the perception of the person feeling the pain. It could just as easily be perceived as a ‘stinging’ sensation, a ‘grazing’ sensation, or any other way they wish to describe it. Just because something feels like a burn, doesn’t mean it is, and doesn’t mean it should be treated as such.

Reply: Let me try a different tack: how do you know that you have a pain? Suppose you say, ‘I know I have a pain because I feel (perceive) it’. Makes sense. But ‘I feel it’ means the same as ‘I have it’. Feeling a pain is having a pain. Therefore, ‘I know I am in pain because I feel it’ says no more than ‘I know I have a pain because I have a pain’, which doesn’t explain how you know that you have a pain.

I am arguing that knowledge of pain is not a form of perceptual knowledge (unlike perceiving a white rose). Again: When I feel a pain, there are not two things involved: the pain, and my feeling the pain. There is just the pain. Therefore, pain is not a perception.

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Question: Your pain is the perception of it. That is how it works. If you don’t perceive it, it isn’t there. Our reality is constructed from our perceptions and doesn’t exist with them. There is no notion of pain without our perception of it. Pain does not exist independently of our perception of it so I’m not sure what you’re referring to when you say ‘just the pain’.

Reply: I am arguing that pain is not analogous to perceiving a white rose, or to perception of any object in the external environment. Pain is not an ‘object’. Not so long ago, pain was widely identified with the noxious stimulus. Nowadays, some researchers identify pain with a neural activation pattern. Failure to verify pathology can lead to some patients with pain being stigmatised by HCPs.

When I perceive a white rose, there is the rose, and my perceiving it. But ‘pain perception’ is not like this, because feeling a pain is just having a pain (and vice versa). To say that ‘I know I am in pain because I feel it’ just says ‘I know I have a pain because I have a pain’, which doesn’t explain how you know that you have a pain (compare ‘How do you know that you see a rose?’).

The phrase ‘pain perception’ obscures this difference, and understanding this point can help us be a little clearer about the ‘meaning’ of pain.

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Question: But aren’t there two (or more things) involved? Say you get a paper cut. There is the cut, with mechanical and chemical nociceptors sending signals to the CNS, and your brain’s perception of the cut and those signals. Your brain perceives a threat and creates pain. There is a rose, and your brain’s perception of the light reflecting off the rose into your eyes, and your brain creates “white”.

Reply: Nice observation! But, my argument doesn’t rely on knowledge of mechanism, but personal experience. That doesn’t limit the clinical relevance of the argument, since clinical decisions are often based on scientific knowledge and personal understanding (‘prior experience’, ‘intuition’, ‘gut feelings’).

Pain and perception – clarifying the concepts

Is it accurate to say that you have a pain in your left foot because you feel – perceive – the pain there? Is pain a perception?

Many publications in the scientific pain field say so; e.g.:

“Pain is a complex, multidimensional perception that varies in quality, strength, duration, location, and unpleasantness.”

“The role of the cortex in human pain perception remained controversial until the advent of non-invasive brain imaging technologies. Over the last fifteen years solid evidence was generated indicating that multiple cortical and subcortical structures are involved in human pain perception. The general assumption from the studies performed in healthy subjects and studying primarily pain after acute, experimental stimuli, is the notion that activation of a fixed set of brain structures evoke this percept…”

Pain is a perception, not a sensation – Mick Thacker – One Thing

The way the sky looks is blue. The colour blue, however, is not an experience. Rather, it is a property of material phenomena. In this case, a property of the sky.

Experiences can be of a blue object, or the colour blue; but to think that experiences can be blue is like thinking that the number two is blue, which is a category mistake.

To make the same point with different examples:
– The white rose I see is white, not my seeing of it.
– The tightness of my new shoes is not tight, the shoes are.
– The bang I hear is loud, not my hearing of it.

The same logic applied to pain experiences:
– The pain I feel is piercing, not my feeling it.
– The burning of my pain does not burn, the pain does.
– The pain I sense is intrusive, not my sensing of it.

I think the view of pain as a perception makes a category mistake: it confuses what is perceived (‘The sky looks blue’; ‘The pain burns’), with a perceiving of it (‘I see the blue sky’; ‘I feel a burning pain’).

The pain is what is painful, not the feeling of it. Therefore, pain is not a perception.

Pain is a material phenomenon of a living organism, a phenomenon characterised by a complex array of distinctive responses and reactions.

Historically, it is correct to deny that pain is a sensation in opposition to the traditional Specificity Theory of Pain. In clinical settings nowadays, it is more accurate to call pain an ‘experience’: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

Following Wittgenstein, I propose that to feel pain is to have pain – not to feel pain and, in addition, to perceive it. When I feel a pain, there are not two things involved: the pain, and my feeling the pain. Feeling pain is just being in pain.