Feeling your pain
The news is out that a way to objectively document a patient’s pain is being developed:
A team at Stanford University in California used computer learning software to sort through data generated by brain scans and detect when people were in pain.
“The question we were trying to answer was can we use neuroimaging to objectively detect whether a person is in a state of pain or not. The answer was yes,” Dr. Sean Mackey of the Stanford University School of Medicine in California, whose study appears in the journal PLoS One.
The method is in the earliest stages. But it may someday make it possible to tell whether an infant, a coma patient, or a person who’s elderly and demented is in pain.
I can also think of some potentially troublesome uses for it: to deny pain medication to patients whose brains don’t test out as undergoing enough pain to justify the treatment, despite the fact that a machine like this could never be flawless.
A personal note: back when I was in fairly severe chronic pain for a number of years (I’ve written about that experience here), I fantasized the invention of a pain replicator, to show doctors exactly what the experience felt like, if only for a moment. I imagined the sort of machine you see in 50s science-fiction movies, a metal contraption that a patient could step into and have his or her pain recorded in detail. Then the doctor would enter it, and for a minute or so would undergo exactly the same pain as the patient. This would not only help with diagnosis, it would bring on a bit more empathy from the medical profession.
I realized, of course, that even my imaginary machine couldn’t tell them about the suffering chronic pain patients feel at the seemingly intractable quality of their pain: the perception that it may never end, that there is no relief to be had. I had read the work of Dr. Eric Cassell, who had observed in his book The Nature of Suffering and the Goals of Medicine (excerpt here) that pain and suffering are not always the same.
There are three other times when suffering in close relation to pain is commonly reported…First, when the pain is so severe that it is virtually overwhelming. The second is when the patient does not believe that the pain can be controlled. The suffering of patients with terminal cancer can often be relieved when it is demonstrated that their pain truly can be controlled. They will then often tolerate the same pain without any medication, preferring the pain to the side effects of their analgesics. Another type of pain that can be a source of suffering is pain that is not overwhelming but continues for a very long time so that it seems the pain is endless. Physicians commonly tell patients that they will “get used to the pain” but that rarely happens.
It is difficult to describe the effect this book had on me at the time I read it, which was in the early 90s, when the treatment of chronic pain was still in its relative infancy. It sounds depressing, but to me it wasn’t. It held out a ray of hope: if this doctor understood, then chronic pain patients weren’t so alone.
For most chronic pain patients, the pain is not imaginary or “all in their head.” For example, my pain had very clear antecedents, and the neural path of my pain was consistent with my injuries, so fortunately I was not usually tormented by physicians accusing me of malingering or being a whackjob. Nevertheless, I knew that pain does have a psychological component and a psychological effect, and Cassell understood both without needing a pain-replicating machine to show him.
My experience with pain has been run of the mill, never chronic. All I can say about pain is that when I am in pain, I want RELIEF.
My father was diagnosed with lung cancer 3 months before he died. As the inoperable tumor had wrapped itself around the spine, he was in pain. There was a short while when he was still home that the only thing the MD gave him was some high-strength aspirin. Fortunately, that came to an end ; he was well-medicated for the rest of his life, and did not die in pain.
When my time for pain comes up, I want the strongest medication possible. If it is addicting, so be it.
I favor drug legalization as an ideal. For practical purposes, I’d rather have 10 drug abusers take advantage of the medical system to procure fixes than have one patient endure unnecessary pain.
Unfortunately, I read that some physicians are afraid to prescribe painkillers lest they attract the attention of the spit Drug Warriors.
This is barbarous.
This seems somewhat relevant: 28 years ago, during my daughter’s difficult birth, a nice young perinatologist was monitoring her well-being and my progress with a whole tangle of electrodes. He asked me to tell him when I was having a contraction. When I did, he informed me that, according to his machine, I was not! I was in no position to argue; still, I knew darn well that it certainly *was* a contraction, and yeah, it hurt.
I wonder at what age a baby, sorry, “fetus” will show pain? This could get ugly with the abortion crowd.
Twenty weeks, approximately….
http://www.gargaro.com/fetalpain.html
Probably sooner…
1. Less important than Vegasguy’s point about abortion, but still important, is the issue of animal pain.
2. A pain detector, if one is built, will not be perfect. There will continue to be false positives, false negatives, and (if the algorithm is constructed honestly) ambiguous readings. Hopefully the breakthrough model will get supplanted by better ones.
3. Look for an enormous brouhaha about pain detectors, especially the legal status of their findings.
4. My inexpert impression is that few fields are as overhyped as the cognitive sciences. Barring civilizational suicide, I do expect pain detectors to be created–but likely later rather than sooner.
5. Re Neo’s pain replicator: Perhaps our so-called best and brightest would benefit from having their cognitive levels and emotional balance temporarily debased to various levels representative of the general population.
Positron-emission tomography is fairly accurate in detecting activity of different zones of brain. The real problem is not detection, but interpretation of these brain scans. There was a rapid progress in identification of such activity patterns and their correlations with different emotions, cognitive tasks and psychological phenomena since the technique was introduced. So I expect the problem of pain detection by objective method is solvable in near future. No new gizmos are needed, only better understanding of available information.
1) As a rule I don’t like things that rank the interpretations of experts or third parties over those of what subjects themselves offer. By contrast, as someone who has had to deal with caring for someone very close to me in a “persistent vegetative state,” the benefits of such a pain detector for people in comas is clearer to me.
Pain is an inherently subjective experience, and even if you could transfer the “objective” level of pain you felt to another, that person’s threshold and ability to bear and comparative history of pain will all come into play.
Sergey is right that interpretation is everything; but I don’t agree that the problem is solvable. We can get better and finer-grained data, yes; but we will never get to a place where “the data speaks for itself.” Pain, to use an example I’ll invoke later, is not like tumescence. Mental phenomena are conceptually irreducible to brain phenomena, and pain is always in part mental, unlike such purely physical phenomena as tumors and lesions.
I myself have looked at PET and fMRI scans in doing research, and I have to stress for those who haven’t seen them just how crude these imaging-technologies really are.
How crude?
Very crude.
When I saw how willing my professors were to just assign this or that reading to the images, I was, for lack of a better word, shocked. In essence, there is usually good reason to attach general meanings to certain results (here is a pain-related response; here is an anomaly in a motor-area; etc.); but when we get down to attaching specific measures in pursuit of an unattainable precision, we get ourselves into deep trouble.
EEG’s of course are just as crude, and those are amazing machines. Nonetheless, when my loved one was in a coma, none of the brain doctors present were able to determine even such a patent matter (compared to “degree of pain”) as whether or not she was having seizures. The readings are filled with noise, and they always will be – patterns mimic each other, thresholds are indeterminate, and so forth. I’m not blaming the science; I’m saying there are intrinsic limits to it.
2) I will always recall the most haunting words I ever heard from the brain doctor who was caring for my loved one: “If I didn’t know anything about this patient except the results of her MRI’s, EEG’s, brain biopsy and spinals, I would tell you that she was a perfectly healthy young woman.”
One thing I learned in my torturous foray into brain science and in various arguments with endocrinologists is that what we know about the brain is still a drop in the bucket compared to what we know of other physiological areas – and, I am saying, it always will be. Most of the doctors were surprisingly open about their views: there are certain things we will never understand.
They were never able to determine what happened to the brain of my loved one. And they recounted countless horror stories for me of similar cases – patients just showing up in sudden comas, deteriorating and then dying. For no apparent reason. The doctors even began to speculate about mind over matter phenomena. I’m not religious and I don’t believe in spirits; and if you’re like me, the closest you will come to believing in demonic forces and impalpable etherealities would come from hanging around communities that deal with the brain and their patients.
All of the technologies are useful, given proper interpretive precaution. And to their credit most practicing endocrinologists are extremely cautious in their interpretations. It’s other people who use or will attempt to mandate certain policy directions based on the data who are dangerously over-confident. None of these technologies are or can be as definitive as they are often presented as being by these people.
3) I would also note that too much of neuroscience is rooted in a flawed conceptual apparatus derived from Descartes and, latterly, Sherrington. In this regard, I cannot recommend the book “Philosophical Foundations of Neuroscience,” by the neuroscientist M.R. Bennett and the philosopher P.M.S. Hacker, highly enough.
To put it in extremely oversimplified terms, the reduction of the mind to the brain (or the person to his enkaphalon), renders us conceptually bereft in dealing with such apparently simple matters as how sense-data are “bound” into perceptions, how memories are “stored” and “retrieved,” and how volition relates to cortical specifications of various functions.
With respect to pain, it as obvious as anything that just like hemophiliacs bleed more from a little cut than non-hemophiliacs, so a lot of people experience more intense pain from the same stimuli than others. There is no way to objectively account for that, just as there is no way to objectively account for volition (which also differs in people exposed to the same stimuli). We’re not Pavlovian dogs.
4) What will come will come, so there’s no point in raging against something like this pain detector. I’m sure there will be many benefits. But the tendency that I see in all of the social sciences – and neuroscience increasingly overlaps with them in fields such as cognitive psych and neuroeconomics – to try to purge the subjective in favor of objective measures which are placed in the hands of experts is extremely troubling. It’s one thing for a doctor to tell me I have a tumor, which is inherently an objective matter. It’s another thing for a doctor to tell me my pain isn’t all that bad, when I feel that it is.
I just read a paper in an anthology on neuroeconomics arguing that people with objectively determinable cognitive shortcomings (not retardation, mind you, just “low capacity”) cannot compute probabilities accurately and so wind-up being overly risk-averse. That is, they do not compute their expected utilities accurately. That is, in other words, experts can determine their utility better than they can. Eugenics always finds a way to creep-in when we think about human beings solely in terms of science – it is quite natural when people are conceived of as slabs of meat.
Understand, for example, that “risk-averse” (or “loss-averse”) is a code-word for “conservative” in the social sciences. It flows into the higher- level concepts of “intolerance of ambiguity,” “preference for the status quo,” and ultimately into the “authoritarian personality.” This is sinister and insidious precisely because they do not tell us that this is what they are driving at. They probably don’t even know that their scientific interpretations are driven by their ideological passions.
5) Now, let me re-iterate: I’m not saying that a pain detector is ideological in that way. I’m sure the intentions of those who will be developing it are as pure as can be. I’m not “against” it.
But we should not let ourselves be snookered by its promise into ignoring that this is just the sort of thing that makes “death panels” and socialized medicine sellable. It might help conservatives in the abortion debate, but probably not much (we’ll see if it goes early into the first trimester). It is a nice tool, in other words, for people who would like to further remove the patient from health care decision-making.
All the more reason, not to stop the technology, but to be damn sure we keep focused like a laser on patient-centered and decentralized medicine. Health care is where the tyrants go second to destroy free societies (first is education). Education and health care are what Arnold Kling calls “the new commanding heights” of the economy.
We have to get our butts to the high-ground before the would-be tyrants plant their flag. We also have to be the people who resist, until the end, conceiving of people as slabs of meat.
@kolnai Great stuff. You should try your own blog!
As to whether/when fetuses feel the pain of abortion is a false issue that fails in the face of the moral question: is it ever OK to kill a human for reasons of convenience?
When I take my father–91 yrs–to various docs, I always tell the doc that my dad played football in high school and college when they used leather helmets, and he was a thrice-wounded Infantry combat vet.
You have to be precise when you talk to him about “discomfort”.
Hell, I even say that, were he not a Catholic, he’d be a calvinist.
Other types of folks…not so much. Which difference gives the med pros a good deal of headache, I expect.
The Bruce Willis response to question of what he is (from the movie “The Fifth Element”):
I am a meat popsicle.
Man,
not enough
to know
he’s not enough
to stand
on his own ground.
He can,
if he wills,
believe.
Hence,
the irony:
A man who believes
is a man
who stands.
Interesting info, kolnai! Your concerns about where this could lead is alarming.
I also believe that in some way, one’s tolerance to pain, can be relative, based on the person’s overall exposure to discomfort.
My son son had heart surgeries at 4 days old, 6mths and 2 1/2. He could not tell us he was his pain at such a young age, and we learned with the 2nd surgery that his way of dealing with intense pain is to silently grit his teeth and glare. As a result, the PICU nurses did not keep up with his pain medication schedule – they were used to kids who indicate pain by crying, moaning, etc., so they assumed the quiet baby was OK. Also, he is generally less upset by the little scrapes and bruises he gets because on his scale of pain it rates at about a “1” compared to the “10” of recovering from surgery.
Welp, just took myself off to urgent care on account of a couple of infected spider bites. Talked to the nurse about pain. She grimaced, said she’d worked emergency in……. Must have been forty cultures, each responding to pain in their own way.
Yup. Headaches.
Richard Aubrey: sometimes shingles is mistaken for spider bites. Make sure it’s not shingles; if it is, there are antiviral drugs you can take to prevent complications.
1. Kudos to kolnai.
2. I agree that pain detection technology will never be perfect. I am concerned that, rather than abetting progress in the field, politics may impede it.
3. Mackey’s Stanford page is here; the links look interesting. The paper is here.
Neo. Thanks. Couple of holes in the skin, swelling and….. Hardening of the flesh around hole.
Both times after working in brush in shorts.
Neo- my mom swears that pain is the most exhausting thing possible, because it just doesn’t stop.
“Pain” is wildly subjective– I think that I’m a total wimp, given how contractions messed me up. (Was ready to kiss the lady who made the pain stop.) Then again, some folks suffer hugely from things I just shrug off.
Glad someone came up with the “pain scale” and bless the nurses who know how to use it!– after the last c-section, I never had to go over three or so. (two is ‘annoying’)
How I have wished for that machine Neo! I have suffered decades with migraine. Now thankfully, blessedly, I no longer have them. But boy, I wanted my not so understanding husband to step in that darn machine for awhile.