10 November 2008

Expectation and uncertainty on pain ratings

Modulation of pain ratings by expectation and uncertainty: Behavioral characteristics and anticipatory neural correlates


Christopher A. Browna, Ben Seymourb, Yvonne Boylea, Wael El-Deredyc and Anthony K.P. Jonesa
Expectations about the magnitude of impending pain exert a substantial effect on subsequent perception. However, the neural mechanisms that underlie the predictive processes that modulate pain are poorly understood. In a combined behavioral and high-density electrophysiological study we measured anticipatory neural responses to heat stimuli to determine how predictions of pain intensity, and certainty about those predictions, modulate brain activity and subjective pain ratings. Prior to receiving randomized laser heat stimuli at different intensities (low, medium or high) subjects (n = 15) viewed cues that either accurately informed them of forthcoming intensity (certain expectation) or not (uncertain expectation). Pain ratings were biased towards prior expectations of either high or low intensity. Anticipatory neural responses increased with expectations of painful vs. non-painful heat intensity, suggesting the presence of neural responses that represent predicted heat stimulus intensity. These anticipatory responses also correlated with the amplitude of the Laser-Evoked Potential (LEP) response to painful stimuli when the intensity was predictable. Source analysis (LORETA) revealed that uncertainty about expected heat intensity involves an anticipatory cortical network commonly associated with attention (left dorsolateral prefrontal, posterior cingulate and bilateral inferior parietal cortices). Relative certainty, however, involves cortical areas previously associated with semantic and prospective memory (left inferior frontal and inferior temporal cortex, and right anterior prefrontal cortex). This suggests that biasing of pain reports and LEPs by expectation involves temporally precise activity in specific cortical networks.


ScienceDirect - Pain : Modulation of pain ratings by expectation and uncertainty: Behavioral characteristics and anticipatory neural correlates

25 October 2008

Heat and pain

Hot.

ScienceDaily (Jul. 5, 2006)

The old wives’ tale that heat relieves abdominal pain, such as colic or menstrual pain, has been scientifically proven by a UCL (University College London) scientist, who will present the findings today at the Physiological Society’s annual conference hosted by UCL.
Dr Brian King, of the UCL Department of Physiology, led the research that found the molecular basis for the long-standing theory that heat,such as that from a hot-water bottle applied to the skin, provides relief from internal pains, such as stomach aches, for up to an hour.

Dr King said: “The pain of colic, cystitis and period pain is caused by a temporary reduction in blood flow to or over-distension of hollow organs such as the bowel or uterus, causing local tissue damage and activating pain receptors.

“The heat doesn’t just provide comfort and have a placebo effect – it actually deactivates the pain at a molecular level in much the same way as pharmaceutical painkillers work. We have discovered how this molecular process works.”

If heat over 40 degrees Celsius is applied to the skin near to where internal pain is felt, it switches on heat receptors located at the site of injury. These heat receptors in turn block the effect of chemical messengers that cause pain to be detected by the body.

The team found that the heat receptor, known as TRPV1, can block P2X3 pain receptors. These pain receptors are activated by ATP, the body’s source of energy, when it is released from damaged and dying cells. By blocking the pain receptors, TRPV1 is able to stop the pain being sensed by the body.

(2006, July 5). Heat Halts Pain Inside The Body. ScienceDaily. Retrieved March 19, 2008, from http://www.sciencedaily.com­ /releases/2006/07/060705090603.htm

28 September 2008

Trying to control pain

Interesting.
Trying To Control Pain Can Be A Double-edged Sword, Say Scientists

ScienceDaily (Nov. 2, 2006) — Scientists have shown for the first time why a feeling of control helps us reduce pain.....Using fMRI scanners, which allow scientists to examine how the brain operates, the research, led by Dr Katja Wiech and Dr Raffael Kalisch, showed that when people feel that they can control their pain, an area of their prefrontal cortex associated with a feeling of security is activated. The findings are published in the Journal of Neuroscience today and have been welcomed by the Expert Patients Programme.

More significantly, the team went on to show that when faced with pain beyond their control, people who tend to feel more in control of their own lives show a lower response in the prefrontal cortex, indicating that they are less effective in coping with pain than those who don't expect to have control.

"Patients with persistent pain report that often it is not the pain itself that makes their situation unbearable, but the fact that there is nothing they can do against it which makes them feel helpless," explains Dr Wiech. "Unfortunately, this feeling of uncontrollability in turn tends to worsen the pain. On the other hand, teaching persistent pain patients psychological coping strategies to handle their pain usually does help reduce its effects."

Dr Wiech and her team set up an experiment to investigate how people cope with pain. In the first stage, volunteers were given an electric stimulus to the backs of their hands and told that they could stop the pain at any point. In the second stage, they were told that the decision to stop the pain was out of their control and could only be stopped by a person or computer outside the room.

Using one of the centre's fMRI scanners, the researchers were able to show that a number of areas of the brain were activated according to whether the volunteer felt in control of the pain. Most important was the anterolateral prefrontal cortex, which is associated with successful coping with feelings of anxiety.

The findings may have implications for future therapeutics, believes Dr Wiech.

"If we were able to stimulate the prefrontal cortex through psychological intervention, medication or some other stimulus, we could help reduce the pain felt by a patient," she says. "However, we are still some way of this."

The team also analysed the subjects' outlook on life, examining whether they felt in control of their own lives. They found that whilst the subjects' outlook did not affect the anterolateral prefrontal cortex when they controlled the stimulus, when they were not able to stop the painful stimulation subjects with no control expectations were better at activating this brain region than those with a strong control belief.

The findings support the practice of "acceptance-based therapy" whereby doctors focus on training patients to cope with the pain rather than attempting to make the pain go away.

"Throughout our lives, we are taught that we should aim to take control of our lives, to get the best job, find the best partner," says Dr Wiech. "But sometimes we should accept what we have and make the most of it. Rather than constantly battling pain, our research supports the view that it is better to provide a patient with the tools to cope with his or her persistent pain."

The findings are welcomed by Pete Moore, lead trainer in pain management for the Expert Patients Programme Community Interest Company.

"This is interesting work by UCL. We have found that many people with pain are over achievers and tend to do more than they have to. This is why when people with persistent pain attend an Expert Patients Programme they are provided with a toolbox of self-management skills to support them to manage their day-to-day pain."


Wellcome Trust (2006, November 2). Trying To Control Pain Can Be A Double-edged Sword, Say Scientists. ScienceDaily. Retrieved March 19, 2008, from http://www.sciencedaily.com­ /releases/2006/10/061031191327.htm

27 August 2008

Suit of Armour

Skevington notes:
By supplying lists of pain adjectives, practitioners and researchers are effectively teaching their patients a pain language that...provides a legitimate lexicon that may be recycled in later consultations as the 'correct' descriptor to use. By supplying the words and following the prescribed instructions, we blinker ourselves to our patients' ability to describe pain in their own varied language, which in many cases is not reducible to a single word in the English language. For example, a patient with early synovitis who was asked to describe her pain said, 'it is like a suit of armour which is too tight'. The author is still struggling to translate this into a single descriptor from the McGill Pain Questionnaire. [p.52]

18 August 2008

Pain and self control

As some of you know, one of my abiding research interests is the relationship between pain and self-control. Thus I bring you this:

A scientist developing a prosthetic pain detection system to help lepers who had lost sensation in their limbs avoid damage describes its failure:

In the end we had to abandon the entire scheme. Most important, we found no way around the fundamental weakness in our system: it remained under the patient's control. If the patient did not want to heed the warnings from our sensors, he could always find a way to bypass the whole system. Why must pain be unpleasant? Why must pain persist? Our system failed for the precise reason that we could not effective duplicate those two qualities of pain. They mysterious power of the human brain can force a person to STOP! --something I could never accomplish with my substitute system. And 'natural' pain will persist as long as danger threatens, whether we want it to or not, unlike my substitute system, it cannot be switched off."

Brand, P. and P. Yancey. 1993. Pain: The Gift Nobody Wants. New York: Harper Collins. Pp.195-186

08 August 2008

Marijuana and HIV Neuropathic Pain

From the always informative Science Daily:

ScienceDaily (Aug. 7, 2008) — In a double-blind, placebo-controlled clinical trial to assess the impact of smoked medical cannabis, or marijuana, on the neuropathic pain associated with HIV, researchers at the University of California, San Diego School of Medicine found that reported pain relief was greater with cannabis than with a placebo.

[....]

The proportion of subjects achieving pain reduction of 30 percent or more was greater for those smoking cannabis than those smoking the placebo.

"Neuropathy is a chronic and significant problem in HIV patients as there are few existing treatments that offer adequate pain management to sufferers," Ellis said. "We found that smoked cannabis was generally well-tolerated and effective when added to the patient's existing pain medication, resulting in increased pain relief."

[....]

Using verbal descriptors of pain magnitude, cannabis was associated with an average reduction of pain intensity from 'strong' 'to mild-to-moderate' in cannabis smokers, according to Ellis. Also, cannabis was associated with a sizeable (46% versus 18% for placebo) proportion of patients reporting clinically meaningful pain relief.

The study's findings are consistent with and extend other recent research supporting the short-term efficacy of cannabis for neuropathic pain, also sponsored by the CMCR.

"This study adds to a growing body of evidence that indicates that cannabis is effective, in the short-term at least, in the management of neuropathic pain," commented Igor Grant, M.D., professor of psychiatry and director of the CMCR.

Grant noted that this is the fourth CMCR sponsored study to provide convergent evidence that cannabis can help in relieving these types of pain.

Link

30 July 2008

July Pain Carnival

July's Pain-Blog Carnival is up:
http://www.howtocopewithpain.org/blog/261/july-pain-blog-carnival/

Lots of good stuff as usual.

19 March 2008

Fibromyalgia and pain memory

This is old, but useful.
ScienceDaily (2000-11-01) -- The symptoms of fibromyalgia may be the result of a central nervous system that "remembers" pain sensations for an abnormally long time, according to research presented at the American College of Rheumatology Annual Scientific Meeting Oct. 29 -- Nov. 2 in Philadelphia, Pennsylvania.
Link

18 March 2008

Being realistic about labor pain

Interesting.
ScienceDaily (Mar. 17, 2008) — A pain-free and drug-free labour may be many expectant mothers' dream but a review in the open access journal BMC Medicine reveals that reality hits hard. Most women's labour experiences differ markedly from their expectations. They are often ill-prepared for what might happen and consequently may be disappointed when the birth does not "go to plan".

The study's authors conclude that antenatal programmes should "get real". "People involved in antenatal care should listen to women's hopes for labour whilst also preparing them for what might actually happen during labour," said Joanne Lally of Newcastle University, who led the investigation. "Plans for a labour free of pain relief need to be complemented by preparing women for the possibility that they might need pain relief. Education can help to fill the gap between expectation and experience and thus ensure women are realistically prepared for their birthing experience."

The research team from Newcastle University studied published literature on women's expectations and experience of pain and pain relief in labour. They found that a gap exists between expectations and experience in four key areas: the level and type of pain, access to pain relief, the level of participation in and control over decision--making, and the level of control during labour.

Most of the literature reviewed showed that women underestimate the intensity of the pain they will experience and sometimes hold an unrealistic ideal for a drug-free labour. Indeed, in one study, more than half of the women interviewed who said they would not use pain relief actually did use it.

"Our analysis highlights the importance of antenatal education. It can empower women to have realistic expectations and make informed decisions," notes the author.

"If women can be better educated they can express their preferences but also be aware that things may not always go to plan. They can then be prepared for different eventualities and so make more realistic decisions and have a better experience."

Birth plans or other decision aids can assist women when making decisions about pain relief in labour, but evidence suggests these are not widely used. Recent guidelines published by the National Institute for Clinical Excellence (NICE) call for more research into how health professionals can effectively support pregnant women in making informed decisions about labour.

Journal reference: More in hope than expectation: Women's experience and expectations of pain relief in labour: A review. Joanne E Lally, Madeleine J Murtagh, Sheila Macphail and Richard G Thomson. BMC Medicine (in press)

Adapted from materials provided by BioMed Central, via EurekAlert!, a service of AAAS.

Link

05 March 2008

BLEG: Opiates and renal failure

Hi all,

As I mentioned, I'm suddenly in the position of helping coordinate my grandpa's palliative care. Since I'm not a clinician, I need to get up to speed on some of the pharmacology so that I can have meaningful discussions with the real doctors.

Thus I'd really appreciate it if you could point me in the right direction toward any resources on treating acute pain in patients with severe renal impairment/failure.

Here's an example of the sort of information I'm looking for:

After reading through a bunch of journals early this morning, it seems like there's pretty good reason to not give people with severe renal impairment/failure morphine or hydromorphone. Two of the metabolites don't clear very well and can build up to cause coma or respiratory failure (in fact, at least one of the dangerous metabolites --6MG I think-- doesn't really affect pain, so the danger well outlasts the analgesic effect of the dose).

Codeine is probably even worse. The evidence with oxycodone isn't entirely clear; fentanyl is probably okay. But methadone seems to be all around pretty safe.

These are just my impressions from a bunch of journal articles. But I feel like I can now intelligibly ask his doctors whether they might consider trying methadone instead of giving him morphine for breakthrough pains and then giving him nothing (occasionally APAP) for very long periods. I don't want to second-guess their judgment, but I do want to be able to understand the treatment options....

I'll appreciate anything you can recommend.

Thanks again.

[also, sorry that these posts are pretty sloppy. I'm posting from my phone outside the hospital.]

Well, this sucks....

My 89 year old grandpa has graciously decided to allow me to put my several years of dilettantism with the pain sciences into practice. He's entered the hospital in pretty dire straights. I'm trying to help my parents be involved with decisions about his palliative care (without getting in the real clinicians way).

So, I'll be posting some reflections about his/my experiences with pain care, ethical issues, and other topics, as we go. I'm sure much of this will be naive; especially compared with many of your experiences and backgrounds. But perhaps I'll stumble across something interesting or useful to you.

Also, from time to time I'll probably be soliciting advice on where to find information on certain specialized topics. I'll really appreciate any help I can get.

02 March 2008

Awesome.
Was torture part of the pep talk?
Suit alleges waterboarding used as motivational technique
By Erin Alberty
The Salt Lake Tribune
Salt Lake Tribune

A supervisor at a motivational coaching business in Provo is accused of waterboarding an employee in front of his sales team to demonstrate that they should work as hard on sales as the employee had worked to breathe.
In a lawsuit filed last month, former Prosper Inc. salesman Chad Hudgens alleges his managers also allowed the supervisor to draw mustaches on employees' faces, take away their chairs and beat on their desks with a wooden paddle "because it resulted in increased revenues for the company."
Prosper President Dave Ellis responded that the allegations amount to "sensationalized" versions of events that have gone uncorroborated by Hudgens' former coworkers.
"They just roll their eyes and say, 'This is ridiculous . . .. That's not how it went down,' '' Ellis said.
The suit claims that Hudgens' team leader, Joshua Christopherson, asked for volunteers in May for "a new motivational exercise," which he did not describe. Hudgens, who was 26 at the time, volunteered in order to "prove his loyalty and determination," the suit claims.
Christopherson led the sales team to the top of a hill near the office and told Hudgens to lie down with his head downhill, the suit claims. Christopherson then told the rest of the team to hold Hudgens by the arms and legs.
Christopherson poured water from a gallon jug over Hudgens' mouth and nostrils - like the interrogation strategy known as waterboarding - and told the team members to hold Hudgens down as he struggled, the suit alleges.
"At the conclusion of his abusive demonstration, Christopherson told the team that he wanted them to work as hard on making sales as Chad had worked to breathe while he was being waterboarded," the suit alleges.
Ellis said the exercise was a dramatization of a story in which a young man asks Socrates to become his teacher. Socrates responds by plunging the student's head underwater and telling him he will learn once his desire for knowledge is as great as his desire to breathe.
However, Ellis said Christopherson explained the exercise before Hudgens volunteered, no one held Hudgens down and Hudgens was free to get up if he was uncomfortable.
"It was meant to be a team-building exercise," Ellis said. "Everybody was . . . involved and enthusiastic."
Hudgens claims he complained to Prosper managers about the exercise, but no action was taken against Christopherson until Hudgens left Prosper.
Prosper attorney George Brunt said Hudgens lodged the complaint six weeks after the exercise; in the meantime, Hudgens joined his team on a water skiing retreat and drove the boat, Brunt said. Ellis said Christopherson was suspended for two weeks while managers investigated Hudgens' complaint. Christopherson returned to work and remains the sales team leader, Ellis said.
"It's incredible to even suggest that he would put anyone under a level of discomfort," Ellis said. "He's a really nice, pleasant, polite young man. He's very dedicated and takes his job very seriously."
However, the suit claims Christopherson "intentionally engaged in physically and emotionally abusive conduct" to punish workers who did not meet company performance goals.
"Prosper's management passed by and through Christopherson's team area and was able to see mustaches on its employees, missing chairs and Christopherson's paddle," the suit alleges. Ellis said no managers have said they saw the activities described in Hudgens' suit, and the employees reported they are "more along the lines of fun."
"It's voluntary, it's humorous, it's team and camaraderie-building," Ellis said.
Hudgens left Prosper because of sleeplessness, anxiety and depression he experienced after the waterboarding, the suit claims. He required psychological counseling for emotional trauma, the suit claims.
The suit accuses Christopherson and Prosper of assault and battery, intentional infliction of emotional distress and wrongful termination. It accuses Christopherson of interfering with Hudgens' employment relationship with Prosper.
Prosper "provides executive-level coaching for individuals," according to its Web site. Personal coaches offer mentoring that focuses on business and finance.
"Our mission is to provide our students with the education and hands-on experiences they need to achieve their personal and professional goals," the Web site claims. "We strive to make the road to personal achievement meaningful, rewarding, and enjoyable."
Link
H/T TPM

Might it be that the normalization of torture in our culture has not really been a good thing?

The Catholic Church on torture

Also from the same Harpers article, the official Catholic Church position on torture:

Respect for bodily integrity.

[2297.] Kidnapping and hostage taking bring on a reign of terror; by means of threats they subject their victims to intolerable pressures. They are morally wrong. Terrorism threatens, wounds, and kills indiscriminately; it is gravely against justice and charity. Torture which uses physical or moral violence to extract confessions, punish the guilty, frighten opponents, or satisfy hatred is contrary to respect for the person and for human dignity. Except when performed for strictly therapeutic medical reasons, directly intended amputations, mutilations, and sterilizations performed on innocent persons are against the moral law.

[2298.] In times past, cruel practices were commonly used by legitimate governments to maintain law and order, often without protest from the Pastors of the Church, who themselves adopted in their own tribunals the prescriptions of Roman law concerning torture. Regrettable as these facts are, the Church always taught the duty of clemency and mercy. She forbade clerics to shed blood. In recent times it has become evident that these cruel practices were neither necessary for public order, nor in conformity with the legitimate rights of the human person. On the contrary, these practices led to ones even more degrading. It is necessary to work for their abolition. We must pray for the victims and their tormentors.

Link

Scalia on torture

Sometimes its obvious why I'm not cut out for the judiciary. My little mind is not capable of such genius:

From Harpers:

Justice Scalia said it was “extraordinary” to assume that the ban on “cruel and unusual punishment”—the US Constitution’s Eighth Amendment—also applied to “so-called” torture. “To begin with the constitution… is referring to punishment for crime. And, for example, incarcerating someone indefinitely would certainly be cruel and unusual punishment for a crime.”

Justice Scalia argued that courts could take stronger measures when a witness refused to answer questions. “I suppose it’s the same thing about so-called torture. Is it really so easy to determine that smacking someone in the face to determine where he has hidden the bomb that is about to blow up Los Angeles is prohibited in the constitution?” he asked.

“It would be absurd to say you couldn’t do that. And once you acknowledge that, we’re into a different game. “How close does the threat have to be? And how severe can the infliction of pain be?”

Just so we're clear. We've now learned that the 8th Amendment is only about punishment. It does not cover what the state can do to you before they get around to punishing you.

20 February 2008

The subjective experience of punishment

Friend of PFP has an intriguing article on sensitivity to punishment and punitive practices here.

Abstract:
Suppose two people commit the same crime and are sentenced to equal terms in the same prison facility. I argue that they have identical punishments in name only. One may experience incarceration as challenging but tolerable while the other is thoroughly tormented by it. Our sentencing policies seek to equalize the duration of their incarceration, yet largely ignore the differences in their experiences of isolation, stigma, and confinement. In this article, I argue that, according to our prevailing theories of punishment, the subjective experience of punishment matters. There is, therefore, a disconnect between our punishment practices and our best attempts to justify those practices.

There are three possible responses. First, we could try to modify or expand our theories to avoid the obligation to calibrate punishment. I show why this approach is unlikely to succeed. Second, we could conclude that, even though we ought to calibrate our punishments, doing so would be too costly or difficult to administer. This response is too hasty. In civil litigation, we do make subjective assessments of damages. Advances in neuroscience may someday make these assessments more accurate and less expensive. Even if we cannot individually calibrate punishments, we can surely enact sentencing policies that are more subjectively-sensitive than the policies we have now. We are left, then, with only the third response: to recognize that subjective experience matters in assessments of punishment severity and to take at least modest steps toward calibrating punishment, either through individual measurement or, more feasibly, by enacting punishment policies that are subjectively sensitive.

18 February 2008

Hick on suffering

John Hick on suffering

by suffering we mean that state of mind in which we wish violent or obsessively that our situation were otherwise. such a state of mind involves memory and anticipation, the capacity to imagine alternatives, and (in man) a moral conscience. For the characteristic elements of human suffering are such relatively complex and high-level modes of consciousness as regret and remorse; anxiety and despair; guilt, shame, and embarrassment; the loss of someone loved, the sense of rejection, of frustrated wishes, and of failure. These all differ from physical pain in that they refer beyond the present moment. To be miserable is to be aware of a larger context of existence than one's immediate physical sensations, and to be overcome by the anguished wish that this wider situation were other than it is. [Evil and the God of Love, pp.354-5]

Two questions:
(1) Is this a privation account of suffering's badness in any traditional sense?

(2) He certainly means that suffering is (usually?) worse than physical pain alone. But how broad a time span does he have in mind? That is, it's plausible that over a week long period, suffering --as distinct from physical pain-- might be intrinsically worse. But could he plausibly say this about a stubbed toe 2 seconds after impact?

10 February 2008

Pics of pain

Check out some pain art: PainExhibit.com

08 February 2008

Carnival of PAIN!!!!!

The always excellent and informative How to Cope with Pain carnival for January is up here. Check it out.

06 February 2008

Efficacy of morphine

ScienceDaily (Feb. 3, 2008) — Opioids, such as morphine, are effective and widely used drugs for the control of pain.

However, tolerance to opioids can develop with repeated administration (that is, higher and higher doses of the drug are required to achieve the same level of pain relief).

Nonetheless, there is some evidence to suggest that tolerance to opiods does not develop when they are used to treat individuals with diseases that are accompanied by inflammation.

Support for this hypothesis has now been provided by Christian Zöllner and colleagues from Charité--Universitätsmedizin Berlin, Germany, who found that peripheral tolerance to morphine did not develop in the chronically inflamed paws of rats.

Furthermore, blocking the action of endogenous opioid compounds in the inflamed tissue enabled tolerance to morphine to develop.

These data indicated that under conditions of chronic pain, endogenous opioid compounds prevent morphine from causing tolerance, inferring that the use of peripherally acting opioids for the prolonged treatment of inflammatory diseases such as chronic arthritis, inflammatory neuropathy, and cancer is not necessarily accompanied by opioid tolerance.

Journal of Clinical Investigation (2008, February 3). Managing Chronic Pain: When Does Morphine Become Less Effective?. ScienceDaily. Retrieved February 6, 2008, from http://www.sciencedaily.com­ /releases/2008/02/080203101431.htm#


Irritable Bowel Syndrome and sexual abuse

Important.
ScienceDaily (Feb. 3, 2008) — UCLA and University of North Carolina researchers have found that women with irritable bowel syndrome (IBS) who have experienced sexual and/or physical abuse may have a heightened brain response to pain that makes them more sensitive to abdominal discomfort. IBS is a condition that affects 10 to 15 percent of the population and causes gastrointestinal discomfort along with diarrhea, constipation or both.

Researchers used brain imaging to show that patients with IBS who also had a background of abuse were not as able to turn off a pain modulation mechanism in the brain as effectively as were IBS patients who had not suffered abuse.

According to previous studies, more than 50 percent of patients with IBS have been physically or sexually abused at some time in their lives. The new finding may help explain why those in this subset of IBS patients experience greater pain and poorer health outcomes than others with the disorder.

Such insight provides a greater understanding of how the disorder develops and may offer new pathways for treatment. Brain imaging studies were performed at the UCLA Brain Mapping Center.

The research appears in the Feb. 1 online edition of the journal Gastroenterology. Authors include Dr. Emeran Mayer, professor of medicine, David Geffen School of Medicine at UCLA; Dr. Douglas Drossman, professor of medicine, and Dr. Yehuda Ringel, lead study author and assistant professor of medicine, both at the University of North Carolina at Chapel Hill.

The study was funded by the National Institutes of Health (NIDDK and NCCAM).
Link

University of California - Los Angeles (2008, February 3). Abuse History Affects Pain Regulation In Women With Irritable Bowel Syndrome. ScienceDaily. Retrieved February 6, 2008, from http://www.sciencedaily.com­ /releases/2008/02/080201085752.htm

04 January 2008

Krauthammer: The Truth about Torture

Remember this little bit of sunshine and rainbows?

The Truth about Torture
It's time to be honest about doing terrible things.
by Charles Krauthammer
12/05/2005, Volume 011, Issue 12


DURING THE LAST FEW WEEKS in Washington the pieties about torture have lain so thick in the air that it has been impossible to have a reasoned discussion. The McCain amendment that would ban "cruel, inhuman, or degrading" treatment of any prisoner by any agent of the United States sailed through the Senate by a vote of 90-9. The Washington establishment remains stunned that nine such retrograde, morally inert persons--let alone senators--could be found in this noble capital.

Now, John McCain has great moral authority on this issue, having heroically borne torture at the hands of the North Vietnamese. McCain has made fine arguments in defense of his position. And McCain is acting out of the deep and honorable conviction that what he is proposing is not only right but is in the best interest of the United States. His position deserves respect. But that does not mean, as seems to be the assumption in Washington today, that a critical analysis of his "no torture, ever" policy is beyond the pale.

Let's begin with a few analytic distinctions. For the purpose of torture and prisoner maltreatment, there are three kinds of war prisoners:

First, there is the ordinary soldier caught on the field of battle. There is no question that he is entitled to humane treatment. Indeed, we have no right to disturb a hair on his head. His detention has but a single purpose: to keep him hors de combat. The proof of that proposition is that if there were a better way to keep him off the battlefield that did not require his detention, we would let him go. Indeed, during one year of the Civil War, the two sides did try an alternative. They mutually "paroled" captured enemy soldiers, i.e., released them to return home on the pledge that they would not take up arms again. (The experiment failed for a foreseeable reason: cheating. Grant found that some paroled Confederates had reenlisted.)

Because the only purpose of detention in these circumstances is to prevent the prisoner from becoming a combatant again, he is entitled to all the protections and dignity of an ordinary domestic prisoner--indeed, more privileges, because, unlike the domestic prisoner, he has committed no crime. He merely had the misfortune to enlist on the other side of a legitimate war. He is therefore entitled to many of the privileges enjoyed by an ordinary citizen--the right to send correspondence, to engage in athletic activity and intellectual pursuits, to receive allowances from relatives--except, of course, for the freedom to leave the prison.

Second, there is the captured terrorist. A terrorist is by profession, indeed by definition, an unlawful combatant: He lives outside the laws of war because he does not wear a uniform, he hides among civilians, and he deliberately targets innocents. He is entitled to no protections whatsoever. People seem to think that the postwar Geneva Conventions were written only to protect detainees. In fact, their deeper purpose was to provide a deterrent to the kind of barbaric treatment of civilians that had become so horribly apparent during the first half of the 20th century, and in particular, during the Second World War. The idea was to deter the abuse of civilians by promising combatants who treated noncombatants well that they themselves would be treated according to a code of dignity if captured--and, crucially, that they would be denied the protections of that code if they broke the laws of war and abused civilians themselves.

Breaking the laws of war and abusing civilians are what, to understate the matter vastly, terrorists do for a living. They are entitled, therefore, to nothing. Anyone who blows up a car bomb in a market deserves to spend the rest of his life roasting on a spit over an open fire. But we don't do that because we do not descend to the level of our enemy. We don't do that because, unlike him, we are civilized. Even though terrorists are entitled to no humane treatment, we give it to them because it is in our nature as a moral and humane people. And when on rare occasions we fail to do that, as has occurred in several of the fronts of the war on terror, we are duly disgraced.

The norm, however, is how the majority of prisoners at Guantanamo have been treated. We give them three meals a day, superior medical care, and provision to pray five times a day. Our scrupulousness extends even to providing them with their own Korans, which is the only reason alleged abuses of the Koran at Guantanamo ever became an issue. That we should have provided those who kill innocents in the name of Islam with precisely the document that inspires their barbarism is a sign of the absurd lengths to which we often go in extending undeserved humanity to terrorist prisoners.

Third, there is the terrorist with information. Here the issue of torture gets complicated and the easy pieties don't so easily apply. Let's take the textbook case. Ethics 101: A terrorist has planted a nuclear bomb in New York City. It will go off in one hour. A million people will die. You capture the terrorist. He knows where it is. He's not talking.

Question: If you have the slightest belief that hanging this man by his thumbs will get you the information to save a million people, are you permitted to do it?

Now, on most issues regarding torture, I confess tentativeness and uncertainty. But on this issue, there can be no uncertainty: Not only is it permissible to hang this miscreant by his thumbs. It is a moral duty.

Yes, you say, but that's an extreme and very hypothetical case. Well, not as hypothetical as you think. Sure, the (nuclear) scale is hypothetical, but in the age of the car-and suicide-bomber, terrorists are often captured who have just set a car bomb to go off or sent a suicide bomber out to a coffee shop, and you only have minutes to find out where the attack is to take place. This "hypothetical" is common enough that the Israelis have a term for precisely that situation: the ticking time bomb problem.

And even if the example I gave were entirely hypothetical, the conclusion--yes, in this case even torture is permissible--is telling because it establishes the principle: Torture is not always impermissible. However rare the cases, there are circumstances in which, by any rational moral calculus, torture not only would be permissible but would be required (to acquire life-saving information). And once you've established the principle, to paraphrase George Bernard Shaw, all that's left to haggle about is the price. In the case of torture, that means that the argument is not whether torture is ever permissible, but when--i.e., under what obviously stringent circumstances: how big, how imminent, how preventable the ticking time bomb.

That is why the McCain amendment, which by mandating "torture never" refuses even to recognize the legitimacy of any moral calculus, cannot be right. There must be exceptions. The real argument should be over what constitutes a legitimate exception.

Let's Take An Example that is far from hypothetical. You capture Khalid Sheikh Mohammed in Pakistan. He not only has already killed innocents, he is deeply involved in the planning for the present and future killing of innocents. He not only was the architect of the 9/11 attack that killed nearly three thousand people in one day, most of them dying a terrible, agonizing, indeed tortured death. But as the top al Qaeda planner and logistical expert he also knows a lot about terror attacks to come. He knows plans, identities, contacts, materials, cell locations, safe houses, cased targets, etc. What do you do with him?

We have recently learned that since 9/11 the United States has maintained a series of "black sites" around the world, secret detention centers where presumably high-level terrorists like Khalid Sheikh Mohammed have been imprisoned. The world is scandalized. Black sites? Secret detention? Jimmy Carter calls this "a profound and radical change in the . . . moral values of our country." The Council of Europe demands an investigation, calling the claims "extremely worrying." Its human rights commissioner declares "such practices" to constitute "a serious human rights violation, and further proof of the crisis of values" that has engulfed the war on terror. The gnashing of teeth and rending of garments has been considerable.

I myself have not gnashed a single tooth. My garments remain entirely unrent. Indeed, I feel reassured. It would be a gross dereliction of duty for any government not to keep Khalid Sheikh Mohammed isolated, disoriented, alone, despairing, cold and sleepless, in some godforsaken hidden location in order to find out what he knew about plans for future mass murder. What are we supposed to do? Give him a nice cell in a warm Manhattan prison, complete with Miranda rights, a mellifluent lawyer, and his own website? Are not those the kinds of courtesies we extended to the 1993 World Trade Center bombers, then congratulated ourselves on how we "brought to justice" those responsible for an attack that barely failed to kill tens of thousands of Americans, only to discover a decade later that we had accomplished nothing--indeed, that some of the disclosures at the trial had helped Osama bin Laden avoid U.S. surveillance?

Have we learned nothing from 9/11? Are we prepared to go back with complete amnesia to the domestic-crime model of dealing with terrorists, which allowed us to sleepwalk through the nineties while al Qaeda incubated and grew and metastasized unmolested until on 9/11 it finished what the first World Trade Center bombers had begun?

Let's assume (and hope) that Khalid Sheikh Mohammed has been kept in one of these black sites, say, a cell somewhere in Romania, held entirely incommunicado and subjected to the kind of "coercive interrogation" that I described above. McCain has been going around praising the Israelis as the model of how to deal with terrorism and prevent terrorist attacks. He does so because in 1999 the Israeli Supreme Court outlawed all torture in the course of interrogation. But in reality, the Israeli case is far more complicated. And the complications reflect precisely the dilemmas regarding all coercive interrogation, the weighing of the lesser of two evils: the undeniable inhumanity of torture versus the abdication of the duty to protect the victims of a potentially preventable mass murder.

In a summary of Israel's policies, Glenn Frankel of the Washington Post noted that the 1999 Supreme Court ruling struck down secret guidelines established 12 years earlier that allowed interrogators to use the kind of physical and psychological pressure I described in imagining how KSM might be treated in America's "black sites."

"But after the second Palestinian uprising broke out a year later, and especially after a devastating series of suicide bombings of passenger buses, cafes and other civilian targets," writes Frankel, citing human rights lawyers and detainees, "Israel's internal security service, known as the Shin Bet or the Shabak, returned to physical coercion as a standard practice." Not only do the techniques used "command widespread support from the Israeli public," but "Israeli prime ministers and justice ministers with a variety of political views," including the most conciliatory and liberal, have defended these techniques "as a last resort in preventing terrorist attacks."

Which makes McCain's position on torture incoherent. If this kind of coercive interrogation were imposed on any inmate in the American prison system, it would immediately be declared cruel and unusual, and outlawed. How can he oppose these practices, which the Israelis use, and yet hold up Israel as a model for dealing with terrorists? Or does he countenance this kind of interrogation in extreme circumstances--in which case, what is left of his categorical opposition to inhuman treatment of any kind?

But let us push further into even more unpleasant territory, the territory that lies beyond mere coercive interrogation and beyond McCain's self-contradictions. How far are we willing to go?

This "going beyond" need not be cinematic and ghoulish. (Jay Leno once suggested "duct tape" for Khalid Sheikh Mohammed. See photo.) Consider, for example, injection with sodium pentathol. (Colloquially known as "truth serum," it is nothing of the sort. It is a barbiturate whose purpose is to sedate. Its effects are much like that of alcohol: disinhibiting the higher brain centers to make someone more likely to disclose information or thoughts that might otherwise be guarded.) Forcible sedation is a clear violation of bodily integrity. In a civilian context it would be considered assault. It is certainly impermissible under any prohibition of cruel, inhuman, or degrading treatment.

Let's posit that during the interrogation of Khalid Sheikh Mohammed, perhaps early on, we got intelligence about an imminent al Qaeda attack. And we had a very good reason to believe he knew about it. And if we knew what he knew, we could stop it. If we thought we could glean a critical piece of information by use of sodium pentathol, would we be permitted to do so?

Less hypothetically, there is waterboarding, a terrifying and deeply shocking torture technique in which the prisoner has his face exposed to water in a way that gives the feeling of drowning. According to CIA sources cited by ABC News, Khalid Sheikh Mohammed "was able to last between two and 2 1/2 minutes before begging to confess." Should we regret having done that? Should we abolish by law that practice, so that it could never be used on the next Khalid Sheikh Mohammed having thus gotten his confession?

And what if he possessed information with less imminent implications? Say we had information about a cell that he had helped found or direct, and that cell was planning some major attack and we needed information about the identity and location of its members. A rational moral calculus might not permit measures as extreme as the nuke-in-Manhattan scenario, but would surely permit measures beyond mere psychological pressure.

Such a determination would not be made with an untroubled conscience. It would be troubled because there is no denying the monstrous evil that is any form of torture. And there is no denying how corrupting it can be to the individuals and society that practice it. But elected leaders, responsible above all for the protection of their citizens, have the obligation to tolerate their own sleepless nights by doing what is necessary--and only what is necessary, nothing more--to get information that could prevent mass murder.

GIVEN THE GRAVITY OF THE DECISION, if we indeed cross the Rubicon--as we must--we need rules. The problem with the McCain amendment is that once you have gone public with a blanket ban on all forms of coercion, it is going to be very difficult to publicly carve out exceptions. The Bush administration is to be faulted for having attempted such a codification with the kind of secrecy, lack of coherence, and lack of strict enforcement that led us to the McCain reaction.

What to do at this late date? Begin, as McCain does, by banning all forms of coercion or inhuman treatment by anyone serving in the military--an absolute ban on torture by all military personnel everywhere. We do not want a private somewhere making these fine distinctions about ticking and slow-fuse time bombs. We don't even want colonels or generals making them. It would be best for the morale, discipline, and honor of the Armed Forces for the United States to maintain an absolute prohibition, both to simplify their task in making decisions and to offer them whatever reciprocal treatment they might receive from those who capture them--although I have no illusion that any anti-torture provision will soften the heart of a single jihadist holding a knife to the throat of a captured American soldier. We would impose this restriction on ourselves for our own reasons of military discipline and military honor.

Outside the military, however, I would propose, contra McCain, a ban against all forms of torture, coercive interrogation, and inhuman treatment, except in two contingencies: (1) the ticking time bomb and (2) the slower-fuse high-level terrorist (such as KSM). Each contingency would have its own set of rules. In the case of the ticking time bomb, the rules would be relatively simple: Nothing rationally related to getting accurate information would be ruled out. The case of the high-value suspect with slow-fuse information is more complicated. The principle would be that the level of inhumanity of the measures used (moral honesty is essential here--we would be using measures that are by definition inhumane) would be proportional to the need and value of the information. Interrogators would be constrained to use the least inhumane treatment necessary relative to the magnitude and imminence of the evil being prevented and the importance of the knowledge being obtained.

These exceptions to the no-torture rule would not be granted to just any nonmilitary interrogators, or anyone with CIA credentials. They would be reserved for highly specialized agents who are experts and experienced in interrogation, and who are known not to abuse it for the satisfaction of a kind of sick sadomasochism Lynndie England and her cohorts indulged in at Abu Ghraib. Nor would they be acting on their own. They would be required to obtain written permission for such interrogations from the highest political authorities in the country (cabinet level) or from a quasi-judicial body modeled on the Foreign Intelligence Surveillance Court (which permits what would ordinarily be illegal searches and seizures in the war on terror). Or, if the bomb was truly ticking and there was no time, the interrogators would be allowed to act on their own, but would require post facto authorization within, say, 24 hours of their interrogation, so that they knew that whatever they did would be subject to review by others and be justified only under the most stringent terms.

One of the purposes of these justifications would be to establish that whatever extreme measures are used are for reasons of nothing but information. Historically, the torture of prisoners has been done for a variety of reasons apart from information, most prominently reasons of justice or revenge. We do not do that. We should not do that. Ever. Khalid Sheikh Mohammed, murderer of 2,973 innocents, is surely deserving of the most extreme suffering day and night for the rest of his life. But it is neither our role nor our right to be the agents of that suffering. Vengeance is mine, sayeth the Lord. His, not ours. Torture is a terrible and monstrous thing, as degrading and morally corrupting to those who practice it as any conceivable human activity including its moral twin, capital punishment.

If Khalid Sheikh Mohammed knew nothing, or if we had reached the point where his knowledge had been exhausted, I'd be perfectly prepared to throw him into a nice, comfortable Manhattan cell and give him a trial to determine what would be fit and just punishment. But aslong as he had useful information, things would be different.

Very different. And it simply will not do to take refuge in the claim that all of the above discussion is superfluous because torture never works anyway. Would that this were true. Unfortunately, on its face, this is nonsense. Is one to believe that in the entire history of human warfare, no combatant has ever received useful information by the use of pressure, torture, or any other kind of inhuman treatment? It may indeed be true that torture is not a reliable tool. But that is very different from saying that it is never useful.

The monstrous thing about torture is that sometimes it does work. In 1994, 19-year-old Israeli corporal Nachshon Waxman was kidnapped by Palestinian terrorists. The Israelis captured the driver of the car used in the kidnapping and tortured him in order to find where Waxman was being held. Yitzhak Rabin, prime minister and peacemaker, admitted that they tortured him in a way that went even beyond the '87 guidelines for "coercive interrogation" later struck down by the Israeli Supreme Court as too harsh. The driver talked. His information was accurate. The Israelis found Waxman. "If we'd been so careful to follow the ['87] Landau Commission [which allowed coercive interrogation]," explained Rabin, "we would never have found out where Waxman was being held."

In the Waxman case, I would have done precisely what Rabin did. (The fact that Waxman's Palestinian captors killed him during the Israeli rescue raid makes the case doubly tragic, but changes nothing of the moral calculus.) Faced with a similar choice, an American president would have a similar obligation. To do otherwise--to give up the chance to find your soldier lest you sully yourself by authorizing torture of the person who possesses potentially lifesaving information--is a deeply immoral betrayal of a soldier and countryman. Not as cosmically immoral as permitting a city of one's countrymen to perish, as in the Ethics 101 case. But it remains, nonetheless, a case of moral abdication--of a kind rather parallel to that of the principled pacifist. There is much to admire in those who refuse on principle ever to take up arms under any conditions. But that does not make pure pacifism, like no-torture absolutism, any less a form of moral foolishness, tinged with moral vanity. Not reprehensible, only deeply reproachable and supremely impracticable. People who hold such beliefs are deserving of a certain respect. But they are not to be put in positions of authority. One should be grateful for the saintly among us. And one should be vigilant that they not get to make the decisions upon which the lives of others depend.

WHICH BRINGS US to the greatest irony of all in the torture debate. I have just made what will be characterized as the pro-torture case contra McCain by proposing two major exceptions carved out of any no-torture rule: the ticking time bomb and the slow-fuse high-value terrorist. McCain supposedly is being hailed for defending all that is good and right and just in America by standing foursquare against any inhuman treatment. Or is he?

According to Newsweek, in the ticking time bomb case McCain says that the president should disobey the very law that McCain seeks to pass--under the justification that "you do what you have to do. But you take responsibility for it." But if torturing the ticking time bomb suspect is "what you have to do," then why has McCain been going around arguing that such things must never be done?

As for exception number two, the high-level terrorist with slow-fuse information, Stuart Taylor, the superb legal correspondent for National Journal, argues that with appropriate legal interpretation, the "cruel, inhuman, or degrading" standard, "though vague, is said by experts to codify . . . the commonsense principle that the toughness of interrogation techniques should be calibrated to the importance and urgency of the information likely to be obtained." That would permit "some very aggressive techniques . . . on that small percentage of detainees who seem especially likely to have potentially life-saving information." Or as Evan Thomas and Michael Hirsh put it in the Newsweek report on McCain and torture, the McCain standard would "presumably allow for a sliding scale" of torture or torture-lite or other coercive techniques, thus permitting "for a very small percentage--those High Value Targets like Khalid Sheikh Mohammed--some pretty rough treatment."

But if that is the case, then McCain embraces the same exceptions I do, but prefers to pretend he does not. If that is the case, then his much-touted and endlessly repeated absolutism on inhumane treatment is merely for show. If that is the case, then the moral preening and the phony arguments can stop now, and we can all agree that in this real world of astonishingly murderous enemies, in two very circumscribed circumstances, we must all be prepared to torture. Having established that, we can then begin to work together to codify rules of interrogation for the two very unpleasant but very real cases in which we are morally permitted--indeed morally compelled--to do terrible things.

Charles Krauthammer is a contributing editor to The Weekly Standard.

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The Truth about Torture