Ethics

It's All In Your Head (Goldberg)

By Daniel Goldberg

I have been interested in pain for at least five years now, and I entered my Ph.D program with an eye towards doing some work on pain.  In doing some of my basic reading on the subject, I devoured Jean Jackson's phenomenal 2005 essay on stigma and chronic pain.  In that article, which has a wonderful bibliography, she noted the forthcoming research of Howard Fields, a neuroscientist at UCSF.  I was enthralled by her description of his theories, and I have literally been waiting for 2 years for the anthology containing his essay to be published.

The wait is over, and I cannot recommend highly enough the entire collection: Pain and Its Transformations: The Interface of Biology and Culture.  One of the aspects of studying pain I've always found so puzzling is why that virtually any clinical handbook or textbook on pain management will pronounce that pain can only be managed multimodally and through multidisciplinary efforts.  Yet there are virtually no truly interdisciplinary approaches to thinking about pain itself.  Most of the law, policy, and ethics' approaches tend to be focused on law, policy, and ethics, without any of the benefits of the integration that is possible through interdisciplinary work (One of the most common erroneous beliefs about interdisciplinary work is that it is really the sum of its parts; rather, such work is emergent in the sense that its lenses arise out of its parts without being reducible to them.  As such, it is, or at least can be, integrative, and is therefore not simply ethics + law + history of medicine).

This book proposes to begin the process of filling that gap by analyzing pain using an interdisciplinary approach, including ritual theory, art studies, music history, and religion.  I was most excited to read Fields's essay, and I was not disappointed.  His most interesting idea is that the presumed distinction between physical and mental pain is incoherent.  Why?

Without delving too much into the history of pain, the dominant biological model of pain over the last 40 years has been Melzack and Wall's gate control theory.  This theory works very well for many kinds of nociceptive pain, but is notoriously unhelpful in unpacking many kinds of chronic pain, such as neuropathic pain and phantom limb pain.  The latter is particularly difficult for gate control proponents to explain, as it is impossible to fit such pain into the gate control theory where there is by definition no organic insult to any tissue (this is because the limb no longer exists!). 

Fields argues that newer models of pain suggest, in point of fact, that pain does not exist in your hand, or your leg, or your back.  Pain is all in your head.  What he means is that our brains have a detailed somatic map, a representation of three-dimensional somatic space.  Pain is projected -- by the brain -- onto the relevant area of this somatic map.  This explains how there can exist phantom limb pain: such a phenomenon is "not surprising since the brain's representation of the limb is intact" (Fields, 43).  Fields concludes: "Once one understands and accepts the concept of projection, it becomes obvious that all pain is mental" (Ibid.)

I think this is phenomenal, and coheres well with the belief that many pain scholars maintain -- including myself -- that, despite our best attempts to dislodge ourselves, mind-body dualism remains an extant and active heuristic in Western conceptualizations of pain, and that this heuristic has deep consequences particularly for those who suffer from chronic pain.  The idea that "pain is all in your head" is either incoherent (to the extent it relies on a strong and dubious mind-body dualism) or means exactly the opposite of what the utterer usually intends.

Thoughts?   

Full post as published by Neuroethics and Law on March 16, 2008 (boomark / email).