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Abstract

Might science need philosophy for a precise and complete understanding of pain?
Reflections
MJA 196 (6) · 2 April 2012410
The Medical Journal of Australia ISSN: 0025-
729X 2 April 2012 196 6 410-411
©The Medical Journal of Australia 2012
www.mja.com.au
Reflections — feature
e were invited to reflect upon brain–mind–
pain interactions and to opine on whether
modern neuroscience adequately considers
pain phenomena and experience. One might suggest that
adequacy is not a particularly lofty goal in this respect.
However, if we were to consider whether modern
neuroscience thoroughly, or precisely, considers pain
phenomena and experience, we would have to conclude
in the negative.
Classically, clinicians have been taught to ask patients a
series of questions to extract the information required to
establish a diagnosis. Although this is standard practice,
it may mean that the individual patient’s experiences are
not heard. This is not always seen to be a bad thing —
removing the patient’s perspective might be considered
to make the interview more objective. Contrast this view,
however, with the common complaint from patients with
longstanding pain that they feel they have never had a
chance to fully explain what is going on with them, that
no one has ever fully understood what is wrong and,
moreover, that no one is listening. Dissatisfaction and
disempowerment are not the only risks here — scientists
show us that such feelings are likely to be associated with
up-regulation of our protective systems, most notably
the nociceptive pain system.1 Aside from that, the folly
of eliminating a patient’s report from his or her pain
assessment has been highlighted for decades. Patrick
Wall, perhaps the forefather of modern pain science,
repeatedly stated that pain research was a waste of time
unless it directly answered questions that are of interest
to patients as well as clinicians.2
Brain neuroscience as it relates to our understanding of
pain really only arrived a century ago. It was pioneered by
such Cartesian dualists as Charles Sherrington and John
Eccles, who separated the concept of the mind from the
brain, and whose data paved the way for an alternative
perspective — that the mind could be directly attributed
to the brain. Quickly, aspects of the mind were attributed
to specific areas of the brain, and the brain was
considered to directly possess experiences. The brain
was seen as able to reason, to perceive and to construct
schemata. These abilities were, more and more,
considered properties of specific anatomical centres
within the brain.
Philosophy offers a different viewpoint, classifying
such conclusions as mereological fallacies — or the
misattribution of a property of the whole being to a single
part of that being.3 The problem arises because the
terminology of these “fallacies” fits with common
language and syntax and represents a logical argument
for the way things “are”. While the linguistic aspects of
such fallacies are easy to appreciate, the philosophical
perspective suggests that the “logic” is seriously flawed.
For example, taking time to consider commonly used
statements such as “the brain thinks” or “the brain
produces pain” leaves fundamental questions over their
plausibility. Could we really enact Roald Dahl’s fantastic
story of William,4 who is kept alive and conscious by an
eccentric neuroscientist as only a brain and an eye,
floating for eternity in a tub of fluid with a heart–lung
machine pushing blood in and out? Could we seriously
expect the brain formerly belonging to William to be
capable of thinking or of producing pain? A philosopher
might disagree with William’s neuroscientist friend, and
suggest that it is instead the whole person who
experiences, reasons, perceives and constructs schemata.
If so, it is also clearly the whole person who is in pain.
The study of pain has historically been closely linked to
dualism and therefore to similar mereological fallacies,
that raise their head in both the clinical and research
settings. Increasingly, patients are being told that their
pain is in their brain. We have no doubt that such
messages are delivered by well intentioned clinicians,
who are rightly dissatisfied with outdated concepts of the
biology of pain. Such dissatisfaction certainly lends itself
to ready acceptance of new paradigms, however
implausible they may be — fancy proposing that one’s
pain is in one’s head when it is clearly in one’s back! It is
a fine line, though, between embracing the critical role
of brain-held mechanisms in producing pain and
presuming that it is in these mechanisms where the
pain itself resides.
Our perspective is that pain is emergent. Emergent
properties are those that are possessed by entire systems.
A system comprises several distinct parts, and these parts
interact with one another to give the system its emergent
properties. There are two ruling criteria of emergence:
that the one system, comprising the same components,
can produce a range of emergent properties; and that
none of the individual units comprising the system are
capable in themselves of producing any of the emergent
properties. The temptation is to simplify things a little
and state that pain is an emergent property of the brain.
First-person neuroscience and the understanding
of pain
W
Michael A Thacker
PhD, MSc, FCSP,
Lectur er1
G Lorimer Moseley
BAppSc(Phty)(Hons), PhD,
Professor of Clinical
Neurosciences and Chair in
Physi other apy,2 and Senior
Research Fellow3
1 Centre of Hu man and
Aerospace Ph ysiological
Sciences, and Pain Research
Section, Department of
Neuroimaging, I nstitute
of Psychiatr y,
King’s College London,
London, UK.
2 Sansom Institute for
Health Research, University
of South Australia,
Adelaide, SA.
3 Neuroscience Research
Australia, Sydney, NSW.
lorimer.moseley@
gmail.com
doi: 10.5694/mja12.10468
Might science need philosophy for a
precise and complete understanding
of pain?
Reflections
Feature
Reflections
411MJA 196 (6) · 2 April 2012
Indeed, either or both of us have fallen into this
oversimplification in our writing at some stage. However,
on what grounds do we confine the system to the brain?
A more accurate position is that pain is an emergent
property of the person who is suffering it. There is a
compelling body of research that clearly challenges a
“neurocentric” view of pain and, in so doing, allows the
propagation of new conceptual models with which to
investigate conditions such as complex regional pain
syndrome.5,6
Does this Gestalt-like view have any relevance for
the attempts of modern neuroscience to elucidate pain?
A cynical view might suggest that neuroscientists are
bothered by data that deviate from the expected results (a
problem confined to neither neuroscientists nor modern
times7). In such instances, outliers might be omitted until
the data fit the expected and “acceptable” level, or the
composite images from functional imaging studies may
be “cleaned up” to look more like the predicted pain
matrix. Furthermore, the concept of emergent properties
requires clinicians and scientists to understand pain
across several domains: to have contextual knowledge of
neuroscience, immunology, endocrinology, psychology,
sociology and philosophy. Most of us have been trained
as specialists in one area and are reluctant to dip even a
toe into other specialties, especially, perhaps, philosophy,
which is notoriously challenging due to its strange and
difficult terminology.
Yet pain is well within the scope of philosophers —
Brentano, Husserl, Heidegger, Sartre and Merleau-Ponty
all discussed pain as a phenomenological entity.
Phenomenology refers to the study and understanding of
human experience and the way in which things are
perceived, as they appear in the structure and processes
of consciousness, and therefore directly deals with the
subjective aspects of pain. As biomedically trained clinical
scientists, we have a growing interest in how this
philosophical field may influence both the scientific and
clinical understanding of pain. Phenomenology takes a
first-person perspective — it is based on what the person
experiences. This contrasts with empirical science and
clinical observations, which have an observational,
objective, third-person perspective. The dialectical
challenge here is patently obvious: there seems to be
a very large gap between the two perspectives that
requires considerable confidence to leap.
What might be needed to help us make this leap?
Several groups have proposed methods with which to
bring the first- and third-person perspectives together8-10
— collectively forming a new field of “first-person
neuroscience”, or the study of a “first-brain
perspective”.9 First-person neuroscience attempts to
combine the subjective experience of an individual with
physiological data obtained in the third-person domain.
The first-person perspective is dependent on both
introspection and phenomenological analysis, and its
proponents claim that they are elucidating the “science of
experience”. This is where the whispering in our minds
becomes distracting — “How can we control for
confounders?”; “Look at all the bias-related threats to
validity!”. Yet ground is surely being made — a small
community of first-person neuroscientists has formed
the vanguard in this area, with elegant studies of
psychopathological abnormalities, mental illness and
neurological disease.9 Work has been done in the pain
field,10 but, perhaps not surprisingly, it has received little
attention from the wider pain community.
Might the clinical community more readily embrace
first-person neuroscience in their pain practice? We
suspect that there are already a select few who go beyond
the routine medical history to extract the feelings and
experiences of the individual patient, together with the
meaning for the person and its impact on his or her life.
Psychologists are charged with first-person assessment,
although few schools of psychology pay attention to
phenomenological aspects. Most other specialties apply
third-person analysis to evaluate a series of answers in
the hope of identifying the source structure or
dysfunction that is causing the pain. Clearly, the
conceptual gap between pain as an injury, a dysfunction
or even a disease and pain as a state that emerges from
the whole person is vast. If we are to bridge this gap,
we need conceptual frameworks that provide a way of
integrating first- and third-person perspectives into our
thinking about pain. Long have we all lamented the
barriers that seem to stand between clinicians and
scientists as they search for better treatments for people
in pain. But the ante may well have been upped, for it is
time to also bring the philosophers to the table.
Competing interests: Lorimer Moseley has received consultancy fees from Grünenthal
and spea ker’s fees or t ravel expenses for meetings organised by NOIGroup Au stralia,
Boehringer Ingelheim Europe, Grünenthal Europe and Sandoz.
Provena nce: Commissioned; not externally peer reviewed.
1Butler DS, Moseley GL. Explain pain. Adelaide: NOIGroup Publications, 2003.
2Wall P. Pain: the science of suffering. London: Orion Books, 1999.
3Bennett MR, Hacker PMS. Phi losophical found ations of neuros cience. Oxford:
Blackwell Publishing, 2003.
4Dahl R. Willi am and Mary. In: Kiss kiss. Harmo ndsworth: Penguin, 1960.
5Marinus J, Moseley GL, Birklein F, et al. Clinical features and pathophysiology of
complex regional pa in syndrome. Lanc et Ne urol 2011; 10: 637-6 48.
6Mose ley GL , Galla ce A, Spence C. Bod ily il lusion s in h ealth a nd di sease:
physiological and clinical perspectives and the concept of a cortical ‘body
matrix’. Neurosci B iobehav Rev 2012; 36: 34-46.
7James W. The principles of psychology. New York: Henry Holt, 1890.
8Gallagher S . Phenomeno logy and experi mental design : toward a
phenomenologically enlightened experimental science. J Conscious Stud 2003;
10: 85-9 9.
9Northoff G, Qin P, Feinberg TE. Brain imaging o f the self — conceptual,
anatomical and methodological issues. Conscious Cogn 2011; 20: 52-63.
10 Price DD, Barrell JJ, Rainville P. Integrating experiential-phenomenological
methods a nd neuroscience to s tudy neural mech anisms of pai n and
consciousness. Co nscious Cogn 2002 ; 11: 593-608.
the conceptual
gap between
pain as an injury,
a dysfunction or
even a disease
and pain as a
state that
emerges from
the whole
person is vast
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