Preferring more pain to less

In his recent Why feeling more pain may be better for you, Tom Stafford reminds us of the classic Kahneman study which yielded both the Peak End rule and succor to sadistic proctologists.

If that description didn't tempt you to go read the column, here's the super short version: Kahneman found that when asked how bad a painful experience was, people recall (roughly) the average of how bad it was at it's worst --the 'peak'-- and how bad it was at the end --the, uh, 'end'. This, Kahneman claims, raises a real ethical dilemma:

Imagine a physician conducting a colonoscopy; the patient is in intense pain. The examination is complete and the physician could terminate the procedure now, providing instant relief --and a permanently negative evaluation of the whole episode. Should the physician seek the patient's consent to extend the pain for a while in order to form and retain an improved opinion of the procedure….a patient who has had two otherwise identical procedures that differ in the abruptnees of relief will prefer [the one with] more total pain but provides a better end….When the experiencing self and the remembering self disagree, whom are we to believe? (1994, p.21)

Stafford doesn't answer this question. Rather he turns to the Peak-End Rule as a broader phenomena (as other research shows) to make a different point

"But I think the most important lesson of the Peak-End experiments is something else. Rather than saying that the duration isn't important, the rule tells me that it is just as important to control how we mentally package our time. What defines an “experience” is somewhat arbitrary. If a weekend break where you forget everything can be as refreshing as a two-week holiday then maybe a secret to a happy life is to organise your time so it is broken up into as many distinct (and enjoyable) experiences as possible, rather than being just an unbroken succession of events which bleed into one another in memory."

I have to politely demur on what's the most interesting lesson. I've spent the last 10 years ---my entire professional career thus far--- thinking about some of the deep philosophical issues Kahneman's question raises.

Presumably, as Kahneman notes, none of us as patients would agree (while in pain) to the physician prolonging our pain. But we would then look jealously upon our friend whose doctor didn't ask her permission and whose colonoscopy was (as she recalls it) easier than our own. From our deathbed perspectives, my life contained more suffering. It was in that respect worse than hers.

Of course, we're both mistaken about how our total suffering compares. Arguably, in some cases, our lives can be better or worse than we believe them to be. If your loved ones' affection had been a cruel facade behind which they constantly ridiculed you, even though you never found out, your life was still worse than you thought it was. But are mistakes about how much we suffered like this?

Look at what's going on here. We need to decide what makes pain bad. We need to figure out how to aggregate goods (e.g., do we simply add up the good and bad?). We need to understand what constitutes human well-being ---to decide what makes a life as a whole good. We need to deal with organic unities (i.e., whether the arrangement of a good and a bad may yield an overall value that's different from the simple sum --schadenfreude is a common example). We need to deal with the asymmetries of past and future pains. Indeed, this road takes us straight to fundamental questions about the nature of intrinsic value. (That's the road I followed to my dissertation)

John Broome took this issue up in his 1996 'More pain or less?' with the straightforward claim that the person's mistaken evaluations are irrelevant. Pains are intrinsically bad. There should be less of it.

Stephanie Beardman who was finishing up at Rutgers just as I entered, came up with a more sophisticated response in her The choice between current and retrospective evaluations of pain (here's a pdf). In it she sets out several alternative interpretations of Kahneman's results and articulates some ways in which our preferences about past experiences may be more sophisticated than they at first seem.

Since she does a lot of what philosophers do best ---laying out the conceptual territory--- some of you empirically-minded folks may find it a useful source for developing uninvestigated hypotheses. It's also just a very nice gateway to some of the deep philosophical issues lurking just beneath the surface of seemingly easy questions. (Though be forewarned, it's a gateway drug too. A few early conversations with Stephanie definitely played a role in my getting hooked). In any event, you should read it.

Foolproof method for succeeding in modern neurochemistry

Neurochemistry Post-Docs! Looking to publish interesting and important papers on the neurochemistry of reward but don't know what to study? Then Dr. Swenson's Revolutionary Topic Selection Method is for you!

For centuries, western philosophers have thought carefully about the nature and kinds of pleasure.* You too can benefit from their efforts!

Here's the key to Dr. Swenson's Revolutionary Topic Selection Method: These philosophers have been studying mental phenomena. You study neural phenomena. And mental phenomena are ultimately neural phenomena!

Other inferior neuropsychological research programs have tried using philosophical claims to select topics. But they would have you try to prove or disprove philosophical claims with neuroscience. That may win you friends amongst philosophers. But you don't want philosopher friends!** You want prestigious publications and lucrative grants!

That's where Dr. Swenson's Revolutionary Topic Selection Method can help! You needn't worry about proving or disproving philosophical claims. With Dr. Swenson's Revolutionary Topic Selection Method, you will use writers ranging from the ancient Greeks to the modern utilitarians to help you design experimental paradigms that are the key to scientific fame.

Here's just one taste of what the system has to offer. Philosophers have, in various guises, debated whether some pleasures are better than others by virtue of being more refined and intellectually infused.

Now a lesser program might have you consider whether opera or pop music produces greater activity in dopaminergic pathways in subjects with past exposure to both. But that will impress only philosophers.

With Dr. Swenson's Revolutionary Topic Selection Method you will instead find in these disputes some promising leads for experimentation. You may, for example, design your experiments to investigate connections between the reward pathway activity, memories, and higher order processes. You don't care whether the refined music elicits more apparent reward. You care about whether pop music and opera elicit systematically different connections throughout the brain.***

Now, it is true that Dr. Swenson's Revolutionary Topic Selection Method can't promise experimental results that will woo philosophers.**** But Dr. Swenson's Revolutionary Topic Selection Method can help you select topics which will uncover processes which underlie our complex mental lives. And that's what you want.

And lucrative grants!

Act now and Dr. Swenson's Revolutionary Topic Selection Method can be yours for a pathetically small amount of money. First 10 callers get a free T-shirt and Shamwow.


*Yes, this comes dangerously close to 'since the dawn of time'. I cringe too.

**I'm serious.

***I know, music isn't the best example. But it's easy to set out. Thanks a lotOliver Sacks.

****Philosophers will nonetheless distort your results and woo themselves.

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This post was inspired by

Heterogenerity of Reward Mechanisms

SpringerLink - Neurochemical Research, Volume 35, Number 6: "The finding that many drugs that have abuse potential and other natural stimuli such as food or sexual activity cause similar chemical changes in the brain, an increase in extracellular dopamine (DA) in the shell of the nucleus accumbens (NAccS), indicated some time ago that the reward mechanism is at least very similar for all stimuli and that the mechanism is relatively simple. The presently available information shows that the mechanisms involved are more complex and have multiple elements. Multiple brain regions, multiple receptors, multiple distinct neurons, multiple transmitters, multiple transporters, circuits, peptides, proteins, metabolism of transmitters, and phosphorylation, all participate in reward mechanisms. The system is variable, is changed during development, is sex-dependent, and is influenced by genetic differences. Not all of the elements participate in the reward of all stimuli. Different set of mechanisms are involved in the reward of different drugs of abuse, yet different mechanisms in the reward of natural stimuli such as food or sexual activity; thus there are different systems that distinguish different stimuli. Separate functions of the reward system such as anticipation, evaluation, consummation and identification; all contain function-specific elements. The level of the stimulus also influences the participation of the elements of the reward system, there are possible reactions to even below threshold stimuli, and excessive stimuli can change reward to aversion involving parts of the system. Learning and memory of past reward is an important integral element of reward and addictive behavior. Many of the reward elements are altered by repeated or chronic stimuli, and chronic exposure to one drug is likely to alter the response to another stimulus. To evaluate and identify the reward stimulus thus requires heterogeneity of the reward components in the brain. "

(Via http://mindhacks.com/.)

Review of David Biro's The Language of Pain

Short story: David Biro's The Language of Pain: Finding Words, Compassion and Relief is very good.
Go buy it.

Longer story: The publisher sent me an advance copy of Biro's The Language of Pain a few months ago. I've read it several times and been working on a review to share with y'all. But the review is getting too long and though I think I agree with most of his conclusions, I'm still not entirely sure what I think about about several of his arguments. Nonetheless, I've certainly profited from engaging with them.

Thus in the interest of posting something while the book is still (somewhat) fresh, I've pasted some of the early parts of the review below. I may post the rest later, or I may work it into something for a more formal venue. I'm omitting the philosophical discussion of the arguments. Though I will list a couple of the topics that concern me. I'm sure the list won't make sense until you've read the book. But perhaps they'll serve as discussion-starters

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Those interested in learning about pain can profit from David Biro’s The Language of Pain: Finding Words, Compassion and Relief. It will probably be the most useful to people with chronic pain and those close to them. At the very least, the vast array of nuanced metaphors and literary sources he canvases can serve as raw material for their attempts to communicate and understand the experience of pain. But I expect that his lucid exploration of the structure of these metaphors will provide important conceptual tools for crafting more systematic and effective narratives. Though the applicability of some of his particular insights may be limited by culture and language.

Clinicians and scientists should be impressed by the conceptual structure that Biro uncovers in the language many sufferer's use to describe their pains. He succeeds in showing that this metaphorical talk, while necessarily imprecise and often obscure, must be taken seriously. In his wake, the same cannot be said for those who dismiss or deride these ways of talking about pain.

At a minimum, researchers interested in developing pain measurement tools and many philosophers will find in it a rich repository of examples and ideas to use in their work.

Philosophers should also find much to be intrigued by in Biro’s arguments. Here are a few of points that I think are worth engaging with:

• Chapter 2 is occupied with a theoretical response to the charge that pain is completely resistant to language. This is unnecessary. The main thrust of the book is an empirical argument that, in several important ways, pain is in fact amenable to language.
• The Wittgensteinian argument of chapter 2 can at best show that we must be able to communicate that we are in pain. But his project is to show that we can communicate what it is like to be in pain. He's not confusing the two in chapter 2. He wants to use the former as a wedge to open the door for the latter. But later on they sometimes seem to get run together in significant ways.
• His discussion of the language/metaphors of agency does a lot to support and build on Elaine Scarry's articulation of the concept (I profited a great deal from this part since the pain-agency connection is important in my own work). The discussions of the x-ray and mirror metaphors/language are much weaker. Indeed, I'm not convinced that these can't be folded into the agency metaphor. [Unlike the others, this concern has significant philosophical consequences for our understanding of pain]
• I'm probably being overly picky --but, hey, that's what analytic philosophers are for-- but his project is about language (hence the title and the claim to be constructing a 'rhetoric'). I usually think of language as propositional. His discussions using art to express pain thus seem incongruous. This is probably innocuous. At most it's a concern about whether the thesis should be framed in terms of language or more broadly in terms of our ability to meaningfully communicate. Though I sometimes think that there may be something lurking here that's related to the more substantive questions about whether the x-ray and mirror metaphors are really separate from the agency metaphors.
• I'm betting that analytic philosophers of language who work on metaphor will find a great deal to disagree with in some of his arguments. Though I myself don't know enough about these issues to have more than hazy suspicions at various points.
  

Like I said, I'm not entirely sure what I think about these and other points. But I've certainly profited from thinking about them. And in any event, none of them undermine the practical import of the book or the philosophical suggestiveness of the overall picture. Indeed, his subtle discussions of pain language’s structure do not require the conceptually strong thesis that the experience of pain is necessarily expressible. By weaving together art, literature, personal experience, and patient testimony, he has demonstrated that many aspects of many pain experiences can, to a practically useful degree, be meaningfully shared.

Fetal pain

I think this sort of debate runs together two separate questions:

(1) Is the neurophysiology upon which pain-involving mental states supervene present in fetuses of x weeks?

and

(2) Is fetal pain --if it exists-- bad for the fetus?

Here's two reasons for thinking they come apart.

First, it's worth remembering that the aversiveness of pain is to some extent learned (see, for example, the famous McGill dog study). It might be that there is a pain sensation, but that the fetus has not learned to experience it as something bad. There might be evidence for or against this. But it probably wouldn't come from the fetus exhibiting near-reflex escape behaviors. IIRC, in adults many such behaviors are triggered very early in pain processing, even before much of the emotional processing occurs.

Second, there's the very hard question of whether fetuses are yet the sort of creatures that can have things be bad for them. Though I'm obsessed with the general problem (what makes something the subject of agent-relative value) I won't even try to articulate this one here. Especially because it actually a complex of several different super-hard issues.

Omaha.com - The Omaha World-Herald: Metro/Region - When can fetus feel pain?: "Knowing when a fetus first feels pain is like many scientific endeavors: It involves speculation and disagreement.

A bill before the Nebraska Legislature, the Abortion Pain Prevention Act, would ban abortions 20 weeks after conception, because it's at that point, Speaker of the Legislature Mike Flood says, that a fetus begins to sense pain.

‘The science is compelling,’ the Norfolk lawmaker wrote on his Web site about the bill that is scheduled for a hearing Feb. 25.

In fact, there still is considerable disagreement among scientists, physicians and other experts. It's fairly common for a person's position on the question to mirror his position on abortion. But it's not clear when the complex communication circuitry in the body, spine and brain are developed enough for pain to be felt.

Nerve fibers designed to sense pain are present in a fetus's skin seven or eight weeks after conception, said Dr. Terence Zach, chairman of pediatrics at the Creighton University School of Medicine.

Surely by 20 weeks, Zach said, a fetus is mature enough to respond to what scientists call ‘noxious stimuli,’ or pain.

‘I believe that — yep,’ said Zach, who described himself as pro-life.

Another Omaha physician, Dr. Robert Bonebrake, agrees with Zach. Bonebrake, a perinatologist at Methodist Hospital, sometimes must give blood transfusions to fetuses or drain fluid from them at 21 or 22 weeks.

Those procedures involve inserting a needle or shunt into the fetus. Bonebrake said the fetus will ‘back away a little bit’ from the needle, indicating to him that it has felt the jab.

‘He or she will try to move away if possible,’ said Bonebrake, who also described himself as pro-life.

But in a review of fetal pain literature, University of California-San Francisco physicians reported in 2005 that ‘fetal perception of pain is unlikely before the third trimester,’ or about 27 weeks into the pregnancy.

The review, published in the Journal of the American Medical Association, said reflex movement isn't proof of pain, because it can occur without the brain being developed enough for conscious pain recognition.

The article also stated that only 1.4 percent of abortions in the U.S. occur at or after 21 weeks.

In Nebraska, fetal age doesn't have to be reported and usually isn't, according to a state health spokeswoman. But in cases where it was reported, none of the abortions that occurred in Nebraska in 2008 involved fetuses of 20 weeks or older.

The American College of Obstetricians and Gynecologists' position is that it ‘knows of no legitimate scientific information that supports the statement that a fetus experiences pain at 20 weeks' gestation.’

A Children's Hospital Boston anesthesiologist and researcher, Dr. Roland Brusseau, has studied the subject to determine whether a fetus undergoing a surgical procedure should have anesthesia. His institution is the main children's hospital of Harvard Medical School.

Brusseau calls discussions of fetal pain ‘complicated and controversial.’

He has suggested a broad timeline for when fetal pain might start: ‘If we are to accept that consciousness is possible by 20 weeks (or more conservatively, 30 weeks), then it also would appear possible that fetuses could experience something approximating ‘pain,'’ he wrote a little more than three years ago.

The possibility, he said, would appear to mandate the use of appropriate anesthesia when performing fetal surgery.

Federal legislation has been unsuccessfully introduced over the past several years to require abortion providers to inform the mother that the fetus could feel pain at 20 weeks and offer anesthesia directly to the fetus.

Six states — Oklahoma, Arkansas, Utah, Georgia, Louisiana and Minnesota — have passed similar legislation, according to the Center for Reproductive Rights in New York.

In Iowa, a bill to that effect in the Legislature failed in 2005.

What makes Flood's legislation different is that its answer to the question of fetal pain is to ban abortions after 20 weeks. Exceptions would be allowed if an abortion is deemed necessary to avoid substantial harm or death to the mother.

Flood said that laws protect animals in slaughterhouses from excessive pain, and that fetuses deserve that level of sensitivity.

He said he based his beliefs that fetuses feel pain at 20 weeks in part on assertions by Drs. Jean Wright and K.J.S. ‘Sunny’ Anand. Wright is former chairwoman of pediatrics at Mercer University School of Medicine's Savannah, Ga., campus and Anand is chief of pediatric critical care at the University of Tennessee Health Science Center.

Flood said experts have found, for instance, that stress hormones spike when fetuses undergo invasive procedures.

Wright couldn't be reached for comment, but Anand, who was reached while doing humanitarian work in Haiti, said fetuses show signs of sensory perception around 20 weeks.

‘Whether this happens at 20 weeks or 22 weeks or 18 weeks is still open to question,’ Anand said. Some fetuses might develop more quickly than others, he said.

Anand said he believes the sense of pain in a fetus isn't turned on like a light switch. ‘It's more like a dimmer switch that very slowly — very, very gradually — turns on particular sensory modalities.’

Anand said the chain of connections for pain perception includes nerve fibers, spinal cord circuitry, brain stem and other portions of the brain. It's impossible to know for sure whether a fetus feels pain, he said.

But denying there is pain, he said, means there's no incentive to study it, no reason to work out ways to anesthetize fetuses, and no need for a doctor to consider whether pain is being inflicted.

‘But I think the onus is on us to give the benefit of the doubt,’ he said.

Anand said he believes abortion is appropriate in some instances, such as if a teenager has been raped, and inappropriate in others, such as when a woman has broken up with a boyfriend and then learns she's pregnant.

Arthur Caplan, professor of medical ethics and director of the Center for Bioethics at the University of Pennsylvania, said that ‘on the whole, I don't think science and medicine can be drawn in to support’ Flood's bill.

Caplan, who has a doctorate in philosophy, called himself ‘a conservative pro-choicer.’ He said that there is no consensus among physicians and scientists on the subject of fetal pain and that the notion that pain is felt at 20 weeks is ‘not the mainstream opinion.’

Bellevue abortion provider Dr. LeRoy Carhart, who has said he will perform late-term abortions only in cases when the fetus can't survive outside the womb, said he doesn't believe there is fetal pain before or during his abortions.

Nevertheless, Carhart said when performing abortions in cases where the fetus is 17 weeks or older, he sedates the mother — which sedates the fetus — and then administers another injection to stop the fetus's heart. The abortion typically occurs 24 to 72 hours later, he said.

‘This should be the ‘Put Carhart Out of Business Bill,'’ he said of Legislative Bill 1103.

Flood denied that his bill was directed at Carhart's revenue and said: ‘Dr. Carhart's loss of business pales in comparison to the loss of young lives.’

Dr. Michael Barsoom, director of maternal-fetal medicine at the Creighton School of Medicine, said he has seen fetuses move away from needles when needles are put in or near them.

Whether that's a reaction to pain, though, is unclear, Barsoom said. The fetus might respond reflexively and not as a conscious pain experience, he said.

‘I honestly don't know,’ said Barsoom, who described himself as pro-life. He said he doesn't think anyone can say for sure when a fetus begins to feel pain.

‘I don't think there's any way to find out.’"

Hurts so good Q&A: Pain and transformation

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?

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

Brain imaging for pain in the courtroom

Law Professor Adam Kolber has an interesting paper on attempts to use brain imaging as evidence that a person is in fact in pain. The abstract:

Pain is a fundamentally subjective experience. We have uniquely direct access to our own pain but can only make rough inferences about the pain of others. Nevertheless, such inferences are made all the time by doctors, insurers, judges, juries, and administrative agencies. Advances in brain imaging may someday improve our pain assessments by bolstering the claims of those genuinely experiencing pain while impugning the claims of those who are faking or exaggerating symptoms. These possibilities raise concerns about the privacy of our pain. I suggest that while the use of neuroimaging to detect pain implicates significant privacy concerns, our interests in keeping pain private are likely to be weaker than our interests in keeping private certain other subjective experiences that permit more intrusive inferences about our thoughts and character

I expect to have a bit to say about this later when I've had the chance to digest the paper. And, yes, I'll share.

Mirror-touch synethesia

From The Week (not online so no link)

They feel your pain
Some people can feel others' pain --literally. When those with a rare condition called mirror-touch synethesia see another person being touched or hurt, they actually feel the sensation themselves. There are several types of synesthesia, a neurological syndrome that causes senses to cross paths in the brain. For some synesthetes, for instance, specific colors create distinctive sounds in their head. Experts had heard only ancedotal accounts of mirror-touch synethesia until neuroscientist Sarah-Jayne Blakemore discussed the phenomenon at a seminar in 2003. "There was a woman in the audience who asked 'doesn't everyone experience that? Isn't that completely normal?" Blakemore tells Nature. Since then, Blakemore has studied 10 other mirror-touch synesthetes. All of them have overactive mirror neurons, which are the brain cells that allow us to see an action and comprehend it enough to be able to mimic it. "I have never been able to understand how people can enjoy looking at bloodthirsty films," says Alice, one of Blakemore's study subjects. "I can feel it."

Two comments:
(1) To some extent all of us do this. For example, one of my students tells me that once her boyfriend accidentally pulled her hair and yipped 'Ouch!' before she said anything. He claimed that it actually hurt him when he did it (I'm presuming that he doesn't have this condition).

(2) In general, I've always thought synesthesia is one of the coolest neurological conditions. A friend with perfect pitch tells me that he can tell if a note is off by its color --for example, A 440 seems red to him. That sounds very cool (though I'm not sure how much I'd like to have the version discussed here).