Puzzles with Pain Reports

We all know what pains are, don't we?

We act as if we do; we tell other people that we are in pain and we accept others' reports of pain without confusion. If I tell you that I have a pain in my stomach, or a doctor asks if you have any postsurgical pain, you wouldn't reply, "pain? What's that?"  Instead, we would respond with a rather strong bizarreness reaction if an otherwise neurotypical adult human seemed unable to accept or make a pain report.

We don't find pain puzzling. Distracting. Concerning. Horrific, even. But, not puzzling. It is a common feature of our everyday life. Humdrum in its ubiquity. It may be surprising, then, that contemporary analytic philosophers disagree about the nature of pain.1 Some even take the position that it doesn't exist.2

Though there are others, pain reports are one way to approach some of the strangeness of pain. Surprisingly, they raise difficult puzzles. Puzzles that matter most significantly because treatment, in response to pain reports, matters.

Consider this simple pain report that I hopefully offered up to my doctor a few years ago: "I have a nasty, recurrent pain in my right foot."

On its face, a humdrum pain report such as this appears to be telling the doctor that there is something, a pain, in my foot. It suggests, that is, that there is a thing in my foot: namely, a pain. A thing that is sometimes there and sometimes isn't (recurrent) and that is unpleasant when it is there (nasty). On its face, this pain report seems to tell the doctor about something literally just there in my foot.

But do we really think pains are things in our bodies?

If we thought pains were things in our bodies, wouldn't we want them removed? While we want the pain to go away, removing something from our bodies is nonetheless not what we expect doctors to set about doing in response to pain reports. Wouldn't we be surprised if we told the doctor of our pain and they went looking for it? Sent us, say, for an x-ray or MRI to try to precisely locate the pain? Imagine the absurdity of a postsurgical exclamation: "A very successful procedure! We got all the pain!"

When I hopefully tell my doctor about my pain, I am not hoping him to find and remove it.  If my doctor set about trying to find my pain, I would set about trying to find a new doctor. Though we often report pains as if they are things in our bodies, we would not accept anyone else's report of having found them there.

I have the pain, all right, but to have it doesn't seem to be to have a tangible, physical object inside my body.

Instead, we might think that pains are mental episodes. Like having a wish, a hope, or a thought, pains seems to be something that happens "in" our mind. Our mind is, if anywhere, where the pain is. We sometimes talk like this. We say things like I am in pain, or I hurt all over. We don't here locate the pain in our bodies in any particular place. Instead we say that we, the whole person, have the pain. We, the whole person, are undergoing an episode. We are having an experience. In the case of my report above: a nasty, recurrent pain experience.

But what do I mean, then, by hopefully telling the doctor that there is a pain in my right foot? Surely I don't literally have an experience in my foot.

It might seem that we mean that there is something in my foot causing the pain, something wrong with my foot that is causing me (the person, with the mind) pain.

After all, what I am hopeful that the doctor will do is identify what is wrong with the foot and causing the pain, and fix it. If my foot is fixed, we might think, then my pain will go away. So too, we might think that the reason the pain is so concerning — concerning enough to get me to go to the doctor — is that it indicates that something is wrong with my foot.

This idea encapsulates what's called the disease or medical model of pain. Until recently, pain medicine — both research and diagnostics — almost exclusively employed a model of pain focused on pathologies. According to this model, a patient presenting with pain is to be diagnosed such that the presumed pathological origin of their pain is identified and, if possible, eliminated. This model might seem obvious, or even inevitable, but it turns out to be problematic.

One problem with the model is the presumed causal connection isn't close enough to capture what we seem to be reporting. With pain, it seems not only that something is wrong with my foot, and is causing me pain, it seems that I feel the pain to be in my foot. When I feel hopeful, I do not feel the hope to be anywhere. Certainly not wherever the cause of my hope is. I may metaphorically say that my hope is with the younger generation, but I never confuse their causing my hope with their containing it. With pain, however, I seem to myself to really feel it, and not merely its cause, there, in my body.

Going further, the central problem with the medical model is that pain, as reported by people seeking treatment in the clinic, isn't well-correlated with pathologies. We don't have correlation, much less causation. Instead, it turns out that, for anything wrong with the body we can identify, we can have pain without it and we can have it without having pain. As Smart et al (2008)3 put the point (p.2):

Interpretations and classifications of pain based on the medical/disease model and its structure-oriented approach have been criticized since such approaches do not explain the complexity and variability of pain presentations observed clinically; where pain is observed to persist after healing, where patients' reports of pain in response to similar injuries differ greatly or where the magnitude of a pain report does not match the injury or pathology. Nor do they account for the variations in patients' outcomes in response to interventions directed towards its treatment since by the tenants of the traditional medical model treatment of the pathological process should be accompanied by relief of pain.

The medical model turns out to be problematic for doctors, like mine, trying to intervene to help in response to pain reports, because those pain reports don't reliably identify problems in the body that they should then aim to fix.

While this may seem surprising, notice that many of us already accept it. We may both have a stubbed toe, and only one of us suffer much pain, without either of us being a liar. If it turns out there is no pathology, we do not think a person reporting pain is thereby not really in pain. It hasn't always been so. Those suffering from pain with no identifiable pathological cause have sometimes been dismissed as malingerers. As those suffering from chronic pain will know, this still happens too often.  The pain reports of women, children, and people of color have, often, been dismissed. Many of us, rightly to my mind, are now outraged by this. I think this outrage is tacit recognition that pain is not well-correlated with pathology.

My doctor examined my foot and found nothing wrong. I believed him. If he had then told me that I wasn't in pain, I would not have believed him. I would have been angry.

So far, we've identified two things that my seemingly simple pain report apparently doesn't do. It apparently doesn't report a thing, the pain, in my foot. If my doctor thought it did, I would leave. It apparently also doesn't report a pathological cause of my pain in my foot. While there may in fact be a pathology in my foot, causing my pain, there may not be — and my report may still be accurate for all that. If my doctor thought it wasn't, I would leave.

So, what is my doctor to do?

What does the medical profession say he is supposed to do?

The most well-respected definition of pain is offered by the International Association for the Study of Pain (IASP).4 The IASP declares that pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."  Pain is here characterized as a mental thing "associated" with a bodily thing — perhaps merely by being described with words normally used to describe a bodily thing (damage).

Crucially, however, the IASP goes on to add a note to the definition. Here is part of that note (emphasis added):

Many people report pain in the absence of tissue damage or any likely pathophysiological cause... If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

The IASP here adopts a subjective criterion for pain. Pain is not here tied to anything in the body. This goes along with the idea we saw above that we don't really think (or expect the doctor to think) that pains are things in our bodies, and it avoids the problems we saw above of taking pains to be correlated with (much less caused by) pathologies.

It is understandable that the IASP has adopted this subjective criterion for pain, since all attempts at identifying a valid biological marker, even for specific types of pain, have failed. If pains are mental episodes, not even reliably caused by things in the body, then maybe the only way we can characterize them is by what people say about them. Maybe the subjective report is all we have.

The subjective pain report is now taken within medical practice to be the only valid marker for pain. Whether all medical practitioners consistently act accordingly or not, best practice is currently to accept all pain reports as veridical. If a patient says they are in pain, then they are in pain. Lacking any reliable biological markers for pain, pain is now defined purely subjectively.

So, one thing my doctor is now supposed to do is accept my pain report as accurate. Always. Pain is, in short, whatever I say it is.

As definitive of a medical condition, for use in clinical practice, a purely subjective definition is extraordinary. Imagine our surprise if the only accepted valid marker for any other medical condition, e.g. diabetes or cancer, was the subjective report. Imagine the absurdity of suggesting that the gold standard for diagnosing any other medical condition were patients' reports that they had it, or that the patient report was the only valid indicator of the condition.

Even worse, if we accept this purely subjective definition of pain, then it's not clear what the pain report is a report of. If pains are whatever the patient says they are, then they could apparently be anything, or nothing, at all.

This is a purely logical point independent of any particular facts about pain. Part of the way that words and thoughts get to have meaning is by not meaning other things. If my pain report means something, it has to not mean other things.

When I tell the doctor that I have a pain, I am apparently telling them something. Presumably, some kind of happening that I am aware of happening. Something that I could say is happening when it isn't. As people "calling in sick" are well aware, we can lie and say we have pains that we don't. The something that I report, then, isn't defined purely by my reporting it. When I make a pain report, I am reporting something. But, what?

We need, here, a theory of pain. I have my own view. I think it's the right view, but I admit that it's one among many others.5 I hold that pains are roughly what we take them to be in our everyday lives. However, because each token pain results from the complex idiosyncratic convergence of the activity of multiple mechanisms, generalizations about pain are inevitably inadequate for scientific purposes. I argue for this view elsewhere.6

I have used my space to try to convince you that a theory is needed, but I don't have the space to explain or convince you of mine.

I have further space to draw a final moral.

Whatever pains may be, we should at this point be able to agree on a few key things about pain reports. They are not a report of a thing (the pain) in our bodies and they are not a (reliable) report of a pathology in our bodies. And yet, pain reports nonetheless report something. Something that isn't purely subjective.

In light of these things, think again about my seemingly simple pain report above offered.

Think about me. I'm in pain. That's why I went to the doctor. Something is happening to me and I need help addressing it.

Think about my poor doctor. What should he do in response? The official guidance is for him to accept my report. Okay. But as a report of what? How can he use my (accepted) report to help me?

I submit we would here do well to follow the advice of pioneering pain researcher, Patrick Wall. According to Wall (1996)7, the clinician should take pain reports as invitations to ask further questions.

It is through asking further questions, in response to my pain report, that my doctor can uncover appropriate treatment targets. Okay, my doctor should say, so you're in pain. Now, let's figure out what that might mean in your particular case. He should ask me more questions: where, how long, what qualities, how intense, and so on. These questions will lead to yet further questions. They will lead to examinations of particular parts of the body and tests to identify or rule out suspected injuries and happenings.

The nature of pain is not obvious. It's puzzling. But that shouldn't stop us from giving and accepting pain reports in both the clinic and everyday life. These reports are useful for, among other things, getting help. When we make them, we hope that others will care enough about us to accept our report, and figure out the particular kind of help that we need.

In short, the concluding moral I want to draw is that an accepted pain report is the beginning of the diagnostic process, not the end. It signals that there is a problem that needs to be identified. It doesn't identify the problem. Pain is not a useful diagnostic category.

The radical nature of this moral cannot be overemphasized. To accept it is to accept that pain is not an appropriate treatment target. Paradoxically, seeking to treat pains is one reason that treatment in response to pain reports has remained woefully inadequate. We should instead seek to treat patients reporting pain by targeting a wide range of potential problems.

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Jennifer Corns is Lecturer in Philosophy at the University of Glasgow, UK. Her research focuses on pain, affect, suffering, and death. In addition to published articles on these topics, she is the author of The Complex Reality of Pain (Routledge, 2020), editor of The Routledge Handbook of Philosophy of Pain (Routledge, 2017), co-editor of Philosophy of Pain: Unpleasantness, Emotion, and Deviance (Routledge, 2018) and Philosophy of Suffering: Metaphysics, Value, and Normativity (Routledge, 2020)

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