The
Failure of Biomedicine
to Explain Pain
One of the most common and important
aspects of illness that biological medicine can’t explain is pain.
The standard biomedical model of pain is called nociception
and deals with the neurons
that ‘detect’ pain, which are termed ‘nociceptors’. This term
is relatively new – in the past one spoke of ‘pain receptors’.
This term was abandoned because of its all too obvious
questionability. For how can neurons ‘receive’ or respond to pain
‘signals’, when pain as such is essentially a subjective
experience. So instead of pain
receptors neurologists speak now of nociceptors, a term derived from
the Latin noci
(meaning ‘hurt’) and emphasise that what these receptors ‘detect’
is not actually pain as we experience it in real life, i.e.
subjectively, but actual or potential injury
or damage
to external or internal tissue and organs.
As for how the actual subjective
experience of pain comes about, this is explained by the nociceptors
transmitting signals to the brain via the spinal column. The brain
then responds by ‘allowing’ or ‘producing’ a subjective
experience of pain. Yet how the brain can ‘produce’ a subjective
experience of any sort
– in this case pain – is left unexplained by this ‘explanation’.
Instead, the pseudo-explanation implicit in the old idea of ‘pain
receptors’ is simply reversed, i.e. rather than having to explain
how a neuron can detect a subjective experience such as pain, what is
now left unexplained is how it can create
such an experience as a result of tissue damage - particularly given
that biology regards bodily tissue itself as basically insentient.
The result is that biomedicine now claims that the true ‘source’
of pain is neither localised nerve receptors – nor is it wherever
you actually feel pain in your
body – but lies precisely
where you don’t and cannot
feel it – in the brain. Thus
the pain you actually feel in your toe after stubbing it, for
example, is, according to this model, nothing but a subjective
illusion or sensory hallucination
created by the brain through a neural mechanism. This standard
biomedical ‘explanation’ of pain is maintained despite the fact
that:
- 1. It is counter-intuitive, running contrary to our lived experience of the source and site of pain.
- 2. It offers no explanation at all of how the brain can produce a subjective experience of pain.
- 3. It is premised on the idea that pain is a consequence of physical injury or damage, and so cannot explain why, for example: “…about 65% of soldiers who are severely wounded in battle and 20% … report feeling little or no pain for hours or days.”
- 4. It does not explain why “…no apparent injury can be detected in 70% of people who suffer from chronic low back pain...”1.
- 5. It does not explain why even the most acute of pains can spontaneously arise and then subside without any identifiable physiological change occurring.
- 6. It does not explain why hypnosis and acupuncture can alleviate or even completely eliminate pain without any pharmaceutical or surgical intervention – even to the point of facilitating entirely pain-free surgery without any use of anaesthetics.
- 7. It does not explain acute, chronic or recurring symptoms of muscle pain (myalgia) or nerve pain (neuralgia) for example in the form of fibromyalgia, or of facial and trigeminal neuralgia – where there is often no evidence of damage to muscle tissue or to the nerves or nerve sheaths.
- 8. It does not explain many forms of common pain – for example particular types of headache with no clearly identifiable physical cause. Seeing them as a result of ‘stress’ does not explain why someone leading a generally stressfully life should experience just one particular type of pain (or any other illness symptom) or why they do so at a particular time or times and not others
- 9. It does not explain the experience of ‘phantom pain’ – pain experienced in the region of amputated limbs where there are no longer any neural pain ‘receptors’ or ‘nociceptors’.
Points 3 and 7 present just a few of many
examples
in which – contrary to and in a way wholly unexplained by the
standard neurological theories of pain – either injury occurs
without pain
or pain is experienced without
injury.
Just as biomedicine seeks to ‘explain’
illness without first of all asking or seeking to ‘explicate’
what ‘illness’ or ‘disease’ essentially
is, so also does it seek to
‘explain’ pain without first of all asking the most basic
question of all – what essentially is
‘pain’? Yet as Martin Heidegger points out:
“All
explanation
reaches only so far as the explication
of that which is to be explained…”
[my stress]
So: “What
good is all explaining if what has to be explained remains unclear?”2
Pain is a perfect example of the basic
philosophical quandary of
biomedicine as such – namely the failure of all its explanations of
illness to address and incorporate its lived, subjective dimension,
and the chicken-egg question this gives rise to: namely is the felt
subjective
experience of ‘dis-ease’ (of ‘feeling ill’) a mere effect of
‘being ill’ – of having some ‘objective’ physiological
disease or disorder? Or could it be that it is the other way round?
This is the essential question that is avoided in biomedical
explanations of pain. For whereas in ordinary language we speak of
‘painful’ life experiences or of feeling emotionally ‘pained’,
‘wounded’ or ‘hurt’, biomedical science discards this
everyday language of life
for neurological terminologies and explanations which seek to reduce
pain to an effect of purely ‘physical’ or ‘physiological’
phenomena – yet without any explanation of how the subjective
experience of pain arises from
them. Indeed simply by turning the pain into an object
of scientific or medical explanations, biomedicine implicitly rules
out in advance any attempt to
explicate the essentially subjective
character of pain and instead
turns this into a mere ‘secondary’ phenomenon arising from purely
‘objective’ neurological mechanisms.
“The idea of one basis for science
and another for life is from the very outset a lie.”
Karl Marx
By simply shunting off both painful life
experiences and ‘emotional pain’ into a second and entirely
separate life domain
from bodily pain, the biomedical explanation of pain is classically
dualistic
– not just separating ‘mind and body’, the ‘psychic’ and
the ‘physical’, but also and above all separating life
itself from what is claimed to
be a true account (logos)
or ‘science’ of life (Greek bios)
– namely what is called ‘biology’. Then again, by turning pain
into an object
of biological and neurological explanation however, not only does
biomedicine entirely fail to explain its subjective essence, it also
‘shoots itself in the foot’ when it comes to treating
pain – so-called ‘pain control’ or ‘pain management’. For
not only doctors but also patients tend to turn their own subjective
pain into an object
– into something they ‘have’. This is unfortunate for the
patient, because the bearability of pain and our capacity to live
with it depends principally on our capacity to be
the pain
we experience rather than experiencing as some thing or ‘object’
affecting us.
‘Being the pain’ – becoming
it – is the most effective
way to stop experiencing it as some sort of bodily entity or object
separate from
our self and therefore ‘causing’ us to suffer
in a way over which we actually have no
control at all except
through medication. Instead it allows us to identify with the pure
awareness of
pain – an awareness which is not
itself anything painful.
Indeed, actively choosing to intensify
our awareness of pain – even the most acute pain – can,
paradoxically, alleviate pain suffering – as well as releasing
insights into its source in our lives (see Case Example 1).
From the perspective of Life Medicine,
pain is first and foremost an experience of the subjectively
experienced or ‘lived’ body and not the so-called ‘physical’
body or any of its organs, not least the brain. For if the
assumptions of ‘brain science’ itself are followed to their
logical conclusion, what we perceive from the outside as the human
physical body and its internal organs – including the shape and
form of the brain itself – is ultimately but a subjective
perceptual ‘phantasm’ constructed and projected outwards by
the brain. This is the sort of philosophical reductio
ad absurdum to which, as
Heidegger indicated, ‘reductionist’ brain science ultimately
leads – both in general and in relation to pain. For taken to its
ultimate conclusion we end up with a worldview in which there is
nothing we perceive or experience that can count as real except
the brain, even though,
paradoxically, our very perception of that organ we call ‘the
brain’ is, according to neurological models of perception itself,
nothing but a construction of the brain. Despite these philosophical
paradoxes we see an increasing flood of media propaganda for
so-called ‘brain science’ – a science that identifies who we
are as human beings with our brains is evidence for this – and a
useful prop for manufacturers of brain-altering drugs, including what
can be highly addictive analgesics or ‘pain killers’. The term
itself is an interesting one – akin to the term ‘killer cells’
or the notion of ‘fighting illness’. In contrast we have the
following words of Seth and of Ivan Illich taken from the appendices
of this book.
“…
pain and suffering are also obviously
vital, living sensations – and therefore are a part of the body’s
repertoire of possible feelings and sensual experience. They are also
a sign, therefore, of life’s vitality, and are in themselves often
responsible for a return to health when they act as learning
communications.” Seth
(see appendix 6)
“A
myriad virtues express the different aspects of fortitude that
traditionally enabled people to recognize painful sensations as a
challenge and to shape their own experience accordingly. Patience,
forbearance, courage, resignation, self-control, perseverance, and
meekness each express a different colouring of the responses with
which pain sensations were accepted, transformed into the experience
of suffering and endured. Duty, love, fascination, routines, prayer,
and compassion were some of the means that enabled pain to be borne
with dignity.”
“The pupils of Hippocrates
distinguished many kinds of disharmony, each of which caused its own
type of pain…Pain might disappear in the process of healing, but
this was certainly not the primary object of the … treatment. The
Greeks did not even think about enjoying happiness without taking
pain in their stride … The body had not yet been divorced from the
soul, nor had sickness been divorced from pain. All words that
indicated bodily pain were equally applicable to the suffering of the
soul.” Illich (see appendix
7)
To be sure, the use of ‘pain-relieving’,
‘pain-killing’ or analgesic drugs is a godsend for many people,
though most of these (for example aspirin and opiate based drugs such
as codeine or morphine) are not modern pharmaceutical inventions but
based on natural plant remedies (willow bark or the poppy plant)
which have been known about for millennia. Yet the effectiveness of
such drugs in itself tells us nothing about the experience of pain,
its effect on patients’ lives – or its source in their lives.
Pain may, of course, be a direct result of tissue and nerve damage,
whether through inflammation, injury or surgery. Yet this does not
explain the immense subjective variation in individual pain
sensitivity and tolerance.
On the other hand, in the case of
headache for example, pain, experienced bodily, may serve to quite
literally ‘bring to a head’ painful emotional states and
experiences. From the perspective of Life Medicine bodily pain in
general almost invariably serves to localise
in a more or less acute or chronic way what might otherwise be
experienced as a more or less amorphous, unconscious and non-local
sense of dis-ease connected with painful life events or experiences.
Yet to suggest, as biomedicine does, that some experiences of pain
are purely ‘psychogenic’ – implying that they are somehow
subjectively ‘imagined’ by the patient just because they have no
identifiable anatomical ‘cause’ – is to deny the essentially
subjective nature of all
sensations of bodily pain, whether we ‘explain’ them biomedically
– as produced by the brain – or not.
The complete failure of biomedicine to
explain the nature of pain is perhaps one reason why, apart from pain
specialists, physicians in general tend to be rather disinterested in
the patient’s subjective experience of pain – except as a sign or
symptom of disease they can objectively identify or diagnose. It also
explains why in medical literature relating to different forms of
surgical procedure, one almost never finds so much as a
single mention of how patients
themselves
actually feel after their surgery – even on such a basic level of
how much pain they experience and for how long. Thus an operative
procedure may, in biomedical terms, be deemed entirely ‘successful’
even if a patient experiences intense pain for weeks, months or even
years following surgery – thus totally ignoring the damage
that pain itself (and other side effects of biomedical intervention)
can inflict on a patient’s life.
That is not to say that pain killers will not be liberally prescribed
– yet this too is often done without a thought for or mention of
their own side effects or addictive properties.
All this fits uneasily with the
Hippocratic oath of ‘Do no harm’. In all too many cases, this
harm actually begins with the very first consultation with a
biomedical physician, if, as is so often the case, the physician
completely fails to hear and empathise with the emotional pain which
the patient is, in so many cases, simply seeking an attentive and
empathic ear for. To find that a physician has ‘no time’ – in
all senses of this term – for any subjective or emotional dimension
of the patient’s communication having to do with their life outside
the consulting room is a form of empathic failure the experience of
which is in itself
a painful and harmful one. Yet it was only thanks to the pioneering
work of Michael Balint 3
– now rarely recalled, recognised or applied – that doctors were
introduced to the idea that not only their own clinical training but
also their own personal
psychological defences may
play a crucial role in leading them to completely block
or filter out any element of a
patient’s communication that might touch a raw or painful emotional
‘nerve’ in their own life
and psyche.
Such expressions as ‘touching a raw
nerve’, ‘feeling hurt’, or speaking, for example, of a life
event or experience as having been ‘painful’ or ‘excruciating’
– far from being merely metaphorical, show us how the everyday
language of life
offers us a better guide to the essence of pain as
such –
as pain
– than any biomedical ‘explanations’ of it as some purely
bodily and neurological process. For such explanations, as we have
seen, actually explain nothing about the experience of pain – and
in effect reduce it to a sensory hallucination conjured up by the
brain – thus making nonsense of ‘scientific’ distinctions
between ‘real’ pain on the one hand and so-called ‘phantom’
pain or ‘psychogenic’ pain on the other. Nor do such explanations
help us understand many cultural and religious phenomenon, for
example how a torturer may be compensating for an inability to feel
their own emotional pain by inflicting physical pain on another, or
why in certain cultures, ritually self-inflicted pain is not seen
merely as some of form of penitential act or ‘self-harm’ but is
understood instead as a medium of mystical religious experiencing –
connecting the worshipper to the pain of a revered martyr or even
that of God himself. Finally current explanations of pain fail to
explain the well-attested ability of yogins and fakirs to experience
neither bleeding nor any pain at all even whilst piercing their own
flesh – or how the use of acupuncture has been proved capable of
preventing any experience of pain during surgery, thus eliminating
the need for either local or general anaesthetics.
More importantly however, biomedical and
physiological approaches to bodily pain deny it any intrinsic meaning
or healing purpose. Yet pain can serve many important healing
purposes besides ‘nociception’ – registering actual or
potential tissue damage.
Examples:
- Allowing painful life experiences and emotional pain – ‘inner pain’ – to be experienced in a more intense bodily way and brought to a focus through painful bodily sensations.
- Allowing an otherwise only vague or dimly experienced sense of dis-ease in one’s life to become more sharply and more acutely felt through the experience of bodily pain.
- Allowing the individual to express and elicit an indirect empathic response to their otherwise unrecognised or unfelt inner pain – their ‘inner scream’ – through such expressions of physical pain as grimacing and groaning, writhing of the body or ‘screaming with pain’.
- Allowing the individual to obtain temporary relief from their inner pain through conventional forms of bodily pain relief.
All these purposes of pain serve to
prevent not just the human body but the human
being from suffering on-going
or further ‘damage’. Conversely, even where pain is
related to actual tissue damage, this may be because it is the only
way the individual is currently able to more fully experience,
express and communicate their inner emotional or existential pain.
This is also the reason why some individuals do engage in intentional
and conscious self-harm – seeking a temporary sense of release from
their inner pain through creating sensations of physical pain. On the
other hand, a period of acute physical pain may also occur after
the painful life issues behind it have been resolved – offering a
sense of final cathartic release from them.
As a result of its failure to explain
pain, the most important question never
asked by biomedicine is whether the experience of pain can be
approached as a form of healing meditation
– rather than simply just as a sign of something ‘wrong’ or an
object of pharmaceutical medication.
So the idea that a form of ‘pain therapy’ may lie in consciously
choosing to identify with
or even intensify
sensations of bodily pain – to give them more
attention and awareness rather
than less – is never for a moment considered – even though it is
in this way alone that we may come to deeper insights into those
painful aspects of our lives (and not just our bodies) the experience
of bodily pain may itself be
an awareness of.
Worse still, if there is no recognition
on the part of biomedical physicians for the emotional pain people
experience in their lives, who knows just how many times morphine
eventually becomes necessary as a substitute for the empathy
that is both craved by and
denied to patients – and that long before their inner, emotional
pain or ‘life pain’ finds expression as bodily pain.
References:
- Melzack and Wall, The Challenge of Pain, Hardmondsworth: Penguin Books, 1982
- Heidegger, Martin Zollikon Seminars,
Northwestern University Press, 2001 - Balint, Michael The Doctor, His Patient and the Illness Churchill Livingstone, 1957.
Example: a brief case of
headache
A patient complained about having a bad
headache at the beginning of a session with her therapist and just
before she was about to go on holiday with her partner. Asked when
the headache had started she reported having woken up feeling fine
but then worrying about the holiday. This was because she had
promised her partner not to take any work-related books with her,
knowing he was afraid that reading them would preoccupy her for too
much of their time together.
However, whilst packing before the
session she had realised that she really would like to take at least
a couple of her books along with her – but also felt bound by the
promise she had made to her partner not to do so. In other words it
was the inner pain, fear and guilt about a desire whose result might
be to hurt her partner that triggered the headache.
When her therapist suggested that she
might resolve this relational dilemma by indeed taking a couple of
books with her – but at the same time resolving not to get lost in
reading them at the expense of spending time with her partner – she
immediately realised that this could indeed offer a practical way of
reconciling
her desire not to hurt or cause pain to her partner with her equally
sincere wish to enjoy at least some time reading her books. When she
came to a decision in the session to follow this suggestion and to
also share and negotiate a new compromise and new promise with her
partner she became aware that her headache had totally disappeared.
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