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Episode 2: Pain / September 04, 2020

With Dr Jennifer Corns

Hosted by Ross Patrizio Alexandros Constantinou

Edited by Constantinos Stylianou

Posted in Perception Main feed

What is pain? Is it physical, mental, or both? What are the real-world implications of research in the philosophy of pain? Dr. Jennifer Corns, lecturer in Philosophy of Mind at the University of Glasgow, joins Ross Patrizio and Alexandros Constantinou to discuss these questions and many more in this episode of Thoughts.

In this episode Jennifer gives us a run-down of where research into the philosophy of pain is at the moment. We discuss how right or wrong our common ‘everyday’ intuitions about pain are. We dive a little deeper into whether or not pain is the sort of thing that can be adequately defined. More specifically, we question whether it’s possible to pin down an idiosyncratic phenomenon like pain in terms of, e.g., necessary and sufficient conditions. Jennifer also gives us her thoughts on what the proper role of the philosophy is when it comes to informing medical practise and developing pain treatments.


03:20 - The typical model of pain
08:00 – A physical structure for pain?
09:22 – The evolution of thought on pain
11:00 – The ‘idiosyncrasy’ of pain
12:20 – How Jen got into pain
14:00 – The relationship of pain and pleasure
19:30 – Real-world implications of thinking about pain (What Jen is trying to achieve)


Further reading:

Corns, J. (2020). The Complex Reality of Pain. New York: Routledge
Corns, J. Recent Work on Pain, Analysis, Volume 78, Issue 4, October 2018, Pages 737–753
Aydede, M. "Pain", The Stanford Encyclopedia of Philosophy (Spring 2019 Edition), Edward N. Zalta (ed.)


Transcript:

Dr. Jennifer Corns: Pain is bad, I know, this just in…controversial!

(laughter)

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Ross Patrizio: Hello, and welcome back to another episode of Thoughts. My name is Ross Patrizio…

Alexandros Constantinou: …and I’m Alexandros.

RP: Today we’re joined by Dr. Jennifer Corns, who’s a lecturer at the University of Glasgow. Jennifer’s work focuses broadly on the philosophy of mind, and more specifically on issues relating to the philosophy of pain. She’s recently published a book called The Complex Reality of Pain. In the episode we speak about what pain is, the relationship between physical pain and mental pain, and the real world implications of pain research, as well a bunch of other things. We hope you enjoy the episode and, yeah, here are some thoughts on pain.

AC: Right, so Jen let’s get right into it. Pain seems to be an everyday thing that we all seem to have a pretty good understanding of. So, for example if I bang my head on the wall and I get a concussion, we all seem to know and understand what that is and how that feels. So is there anything more to it than that?

Dr. JC: Well, yeah, there probably is. So, I thought it was a very simple thing too and it turns out that there are some cases of pain that are really strange and they are sort of the most interesting to think about first. So in particular, there are pains that don’t hurt, and that right there might make you think that pain isn’t so obvious. So, there are some people who have what’s called congenital indifference to pain; there are people who say they feel but that it doesn’t bother them or hurt them at all, and then there are some people who have congenital insensitivity to pain and they just don’t feel pain at all. People who don’t feel pain at all in any way, they don’t tend to live very long, yeah? Which is important for thinking about what pain does, I think. Um, but, interestingly, the people with congenital indifference to pain, they have all sorts of difficulties as well. So they can pick out the pain but they say it doesn’t bother them. My favourite case is this one guy who was sixteen, who would run around and have people give him money to hurt himself in various ways. In particular, he’d put cigarette butts out on his arm and stuff, for money, and do all sorts of daring tricks on his motorcycle and things, because if he got hurt it didn’t hurt him at all, right? So you might have thought if pain was very simple, the simple thing it is is, like, this totally crappy feeling, as you say right? You run into the door and it hurts, you might think that hurting is just what pain is but if you can have pains that don’t hurt, well then, there’s more to what pain is than just that hurt feeling. Yeah? So I think it’s not quite so simple, after all.

RP: So that’s interesting…if you can have pains that don’t hurt, what’s the extra thing? How do you know someone over and above the self-report of it not hurting, or hurting, what is there more to tell you that there’s still a pain there?

Dr. JC: Well, it’s interesting right? Notice when you hurt yourself, so let’s say you run into the door. I can ask you all sorts of questions about the pain. Not just whether it hurts and how much it hurts, but I can ask you where it is, I can ask you what kind of pain it is – so I can say, it is stabby? Is it dull? Is it sharp? Is it, I dunno, throbbing? So there’s a questionnaire called the McGill pain questionnaire and it lets you, when you go to the doctor – which of course is a place where we really care a lot about figuring out what the pain is and what kind of pain and where it is and how to treat it… When you go to the doctor, if you have like, certain kinds of pain or recurring pain or they want to get more detail about your pain, you fill out this questionnaire about pain and from that questionnaire you can see there are all sorts of different things about the pain that you might be interested in. So the sort of typical model of pain in the scientific field has three bits. There’s the hurty bit or what’s called the affect, and then there’s the sensory bit which is like where it’s located and stabby and how hot and how cold and that kind of thing, that’s the sensory bit. And there’s also the cognitive bit which is a part that I think especially we haven’t thought about it too much in philosophy too, people haven’t thought about it enough, I think. It’s the bit of pain that makes it, sort of, scary or awful or you know, takes all your attention and makes you really think about it and what’s going on and what’s happening and why did it happen and what do I need to do. So, there’s actually this cognitive dimension of pain too in the traditional scientific model. So all three of these things together, in my view, are important for understanding what makes a pain a pain.

RP: Yeah… I wanna linger, that’s a really interesting point we were actually going to ask later but I think now’s a good time for that. I mean, the cognitive side of it, is there a sense… I mean, I suppose we were thinking of it in more kind of brute, physical/mental distinction terms which is obviously not quite right. But I mean…in what sense is the mental or the cognitive, as you said, side of it feeding into an actual pain that really exists somewhere else, and in what sense is that actually part of the pain? Cos I mean it at least seems to me that there must be some pains that are almost entirely yourself mentally making it kind of worse or that being the whole thing. Does that make sense?

Dr. JC: Yeah that makes sense. Um, I think two things maybe might help to say. One thing is, the difference between physical pain and mental pain, I actually – depending on how you want to make that distinction – it could be a helpful distinction to make, or I think it could be a misleading distinction to make. So, I think it’s worth distinguishing between pains that share a lot in common with, uh, typical pain. And a typical pain is the kind that Alex started us with: where we have some damage and then you recognise you’re damaged, it sucks, it hurts, uh, you wanna do something about it. It’s located in a certain place, it feels a certain way, it’s got all the dimensions. That’s a typical pain. Now think about what you might think of – and it’s physical – right, a typical pain I think is physical. Everyone’ll agree that a case like that has all those things I just mentioned of the pain. But then you might think of something like a heartbreak or…being, I don’t know, really very grief-stricken, there are cases like this, really really jealous. These are all called social pains, sometimes, in the psych literature, and you might wonder whether those things are really pains. And here actually people disagree. Some people think psychological pains are not really pains, and some people think no, they really are pains. One thing I’m interested in doing in my research is, sort of, getting underneath this sort of talk about what’s really a pain and just looking at, well, what is it? Forget about the term for a minute. It’s got things in common, I think, with the typical paradigmatic pain and for that reason I think sometimes it can help to think of it as a pain. Sometimes it’s going to hurt – hehe, hurt – sometimes it’s going to cause problems to think of it as a pain. So I think you might have physical pains and you might have mental pains. In that sense, in the sense that some pains really involve damage and are located in the body, some pains look like they don’t involve damage and aren’t located in the body. The reason I think, so the second thing, that the cognitive bit is important no matter which one you’re thinking about, is because, um, if we intervene and mess around with your cognitive state, that can change or even eliminate the pain altogether and vice versa. And so, when we’re thinking about how to make…now, why do we say that it’s not just a cause of a pain, something that can cause it to come and go – I think that’s tricky, any way it’s tricky for thinking about when something is a cause versus when it’s a constituent. But I think when you get manipulation of it on both sides and when you think about how the signals are in the brain and the pathways that are involved when you’re in a paradigmatic pain in the brain, I think all the evidence is on the side of including it. And there’s only really bias on the side of excluding it. So you might flip the question and say, why shouldn’t I include it, given that it looks like it’s part of the same pathways in the typical cases, I can manipulate it just by manipulating the cognitive dimensions. That makes it look like we should go with the scientists and say that it’s part of pain, to me.

RP: Yeah, that makes sense, yeah.

AC: So, it seems like you’re saying that the cognitive part of pain is quite important…it maybe is the most important part, um, so is there like a physical structure in the body that represents pain? Is there like a structure in my brain that we can attribute as being the pain centre or the location where pain is, where I feel pain?

Dr. JC: No! And it’s really surprising that there isn’t. So, I think when people started getting serious in science, just altogether, you know there’s been research into pain for a long long time. And the expectation was that there would be pain receptors, and pain areas, uh, all in the brain, and a pain centre in the way that you mentioned. And it turns out that there just isn’t. So, actually what happens in your brain, is almost your whole brain goes crazy when you have a paradigmatic pain experience, right? Massive areas across your brain are involved. If you think about the fact that we can’t, sort of like get in there and just get rid of pain, that kind of helps I think. So when you take something that’s like a painkiller, notice that sometimes it doesn’t help at all. So, ibuprofen doesn’t help all pain. If there was just this one thing – the pain – that some one thing could help, you might think we could just get in there and nab it out. So too there’s not a surgery you can do that’ll just get rid of all kinds of pain. You can do surgeries and take drugs that will just mess with your affect altogether. So of course some drugs that you might take or some surgeries that you might have just make everything feel good. But notice you’re not just getting rid of pain in that case – you’re just messing around with the way everything feels, the affect of everything. Yeah, so you can’t sort of just pick out the pain bit all by itself as it turns out. A surprising scientific discovery, I think, that looks like there’s no pain centre, no pain pathway in particular. So, historically I think a lot of…I mean it was sort of taken for granted that pain was a simple thing, I think, um, at various points by some philosophers. But I think for a long time there was some recognition, um, that pain was sort of emotional but also sort of physical. So, Descartes thought it was a mixed sort of thing that had a bodily bit and a mental bit, um, which is interesting on Descartes’ view, right? Because he’s this substance dualist so it had sort of bits of both substances. So, the complexity of it, I think, has been around for a while without anyone sort of really trying to seriously nail down necessary and sufficient conditions until David Armstrong really, in philosophy. So, you had a big move in philosophy of mind where people started trying to get serious about what all the mental stuff was; there was a sort of mentalistic turn. So it’s really only been since the seventies-ish, sixties, seventies really that you got people really trying to give you something like a very strict focussed account of what pain is. You had views before that, but that sort of necessary and sufficient game in analytic philosophy applied to pain really I think only in the sixties and seventies did you start to have it…and on my view, it’s the wrong game to play, and none of it works, but that’s a very controversial…I am a sort of controversial pain figure.

RP: And just to be clear, the reason you think that is that, we can get more or less specific depending on the context and our purposes, but it’s the actual reason that pain doesn’t lend itself to that game, as it were, is just the muddiness of it, it’s too idiosyncratic? Is that what it is, pain itself doesn’t lend itself to that sort of analysis – is that right?

Dr. JC: I think very few things lend itself to that analysis, including pain. I think there are further complexities about pain that make it even more tricky than something like water, which I think also necessary and sufficients aren’t particularly helpful, um, but for pain it’s even worse because of, as you say, pain is very idiosyncratic, I think. It’s also very complex in the kind of way we’ve talked about, and that idiosyncratic complexity, on my view, also means that it’s not a very useful scientific kind. So, a type of thing. And that’s even more controversial. So unlike something like water or something like a virus, or all sorts of, um, things that go on in medicine that started out maybe in everyday life, you know. We sort of had this idea of something and grouped it together and then we went and did some research and we found the type of thing it really was. You know, we kind of cleaned up how we thought about the type, and then we found the type of thing that was useful for science. Everyone thought that would happen with pain, and a lot of people still think that’s the way it is, but as it turns out I think because pain as we’ve picked it out for our purposes in everyday life is so idiosyncratic and complex, I don’t think it’s useful, um, for science actually as it turns out.

RP: Yeah, that makes sense.

AC: That’s interesting. Right, so, how did you get into researching pain?

Dr. JC: Ah, I was interested in ethics first. So, one popular theory in ethics that I was really interested in is utilitarianism, and that’s the idea that what makes things right or wrong is the amount, if you like, or how much pain and pleasure they cause. And everybody just seemed to be assuming that they knew what pain was when they said that. And pain looked like it wasn’t such an obvious thing, much less was it obvious how you could like add it up and see how much of it you had. Um, and so I wanted to sort of figure out what pain was so that I could think about whether utilitarianism was true, um…and then I never have got back to utilitarianism. I kinda got stuck in pain and the brain and things related to treating pain. Some day I’ll maybe get back to the ethics. I can tell you this though – utilitarianism is not gonna be so easy to, uh, characterise and use once we get serious about what supposedly we’re adding up.

AC: Right. So you’re stuck in the pain game, trying to add things up and…define them.

Dr. JC: That’s it, so I got kind of stuck in the pain game. And then that, you know, because I got interested in other things in the pain neighbourhood, so now I work on suffering too and death and, uh, but someday maybe I’ll get back to utilitarianism. But I think it matters, it’s worth thinking about, I think, you know, for people who are interested in thinking about right and wrong in terms of pain and pleasure, I think it’s worth taking seriously trying to figure out what pain and pleasure are. Supposedly that’s what makes everything right and wrong so we should have a good grip on what it is.

AC: So, like, utilitarianism just puts everything on a spectrum where on the right side you have pleasure and on the left side you have pain and then a line in-between where you can be at different points on that line and then you add things up and then you find out if it’s good or, or bad. So is there a special relationship between pain and pleasure? Are they connected? Are the two connected with each other?

Dr. JC: That’s a great question. Um, so people disagree about that, and I think one thing…there’s a lot of research right now trying to think about how pain and pleasure are related, what they have in common, what thinking about pain can tell us about thinking about pleasure, whether different…you know we talked about pain as a complex, so in the scientific community there recognise the sort of complexity, so there’s work in the empirical sciences about, um, which parts or dimensions of pain might be a spectrum with parts or dimensions of pleasure. So, in my own view what I think they have in common in the affective bit. So that’s a like, this feels good, this feels bad bit – whether or not you’re aware of the good or bad feeling. Um, and that’s something that I think, you know, you could maybe use potentially for something like a utilitarian calculation, but I haven’t done that work. But you might be able to think about affect instead of pain and pleasure that way. And then notice you wouldn’t have a sharp line, you’d have something like a spectrum. So, take any old state you like, so right now we’re having this chat, it’s a lovely chat, isn’t it? People are listening to it, they’re having the time of their life, it feels great. And that state that they’re in, that auditory state of listening – or the state I’m in of talking, right? What it feels like for me to be talking. That has a feeling that you might rate as positive or negative on some scale, and you might think there’s some scale there that you might be able to use, potentially. But it wouldn’t be the pain and pleasure scale, cuz notice not all pains feel bad and, you know, a lot of things that aren’t pains also have a bad feeling and so on and so on. But, it’d be an affective scale of good and bad feeling and you might think something like that is really important, um, for thinking about a fix.

RP: Yeah, I mean I suppose you’ll tell us what’s right in terms of how to characterise them, but people who actively enjoy pain, actively, are they getting pleasure from pain or do they just not have pain at all? I mean, how much of an issue – I take it this is a much discussed, erm, problem case maybe? In your area? What do they, how do they work?

Dr. JC: It is discussed, it is discussed…I don’t know about much discussed, I think some people are a bit prudish, um, but no it has been discussed and I’ve looked into that literature a little bit, um, and we had, here at Glasgow we ran a workshop on pain, and one of them focused on, sort of, abnormal pains, pains that were abnormal in various ways, and we have sort of a leading work expert on masochism who wrote the DSM category come and give us a talk and it was really interesting to listen to him and ask him questions about different cases and practice. And it seems to me, um, that there are cases and cases, right? So some people that we might still call masochists – it’s not the pain itself they like, it’s the humiliation, uh, it’s the lack of control, it’s the power dynamics, that’s the kind of thing. And the pain is, like, you know, part of the story about why they’re humiliated and it’s part of the causal picture about who has the power and how they manifest their power but it’s not the pain itself they want. But there are other people I think, where it really is the sensation itself, right? Um, and for some people, you know, it looks like then, for them, you can ask, is it certain kinds of pain – some people are really into very particular kinds of intense sensations. And if the sensory bit is just one part of the pain then we have a choice about what we want to say, remember it’s our term, it’s our idea, we’re using it for a certain purpose – do we want to say those people are after pain or do we want to say they’re after this really intense sensation? You know, you want to talk to those people, well, what makes sense for trying to get in there and understand their drives, and get in there and see if they need treatment, if they have a problem.

RP: If the badness of pain just isn’t a thing for some people – of maybe for loads of people in lots of different ways – does that put a real spanner in the works of your theory, even if you’re not trying to give necessary and sufficient conditions? Like, does it not just make it unbelievably difficult to pin down in any way?

Dr. JC: I think it depends on what theory you’re trying to work out. So, if you have a view of pain that means that just part of what it is to be a pain is something to be avoided, right, and you also think that, you know, these people are seeking pain, well then it looks like you have at least an apparent tension that you have to try and explain away in some way. And a typical way to do that would be to say it’s not really the pain they’re seeking. So that’s the kind of move I made in the beginning, I think a lot of people who have this kind of problem tend to make that kind of move. You might also think that people have conflicting desires, that’s not so strange. Think about all sorts of everyday sort of cases of masochism – maybe I go to the gym, I wanna feel the burn, I wanna feel all the good benefits of having gone to the gym: am I really seeking the pain? Well, maybe instrumentally, maybe I actually kind of like the feeling of “oh I’m really getting into it”, I guess I kind of do, but it’s not clear that that, like, means that I don’t want the sensation in another kind of way, in another sense it’s bad.

RP: It’s like…you could think of it as a wider pleasure or a wider, broader, good thing. But the now, where pain is just the kind of thing you have to go through to get this bigger thing, maybe?

Dr. JC: Yeah, that’s right, I think it can be instrumental in that way.

AC: So, what are the real world implications of research in pain? So, what are you trying to achieve with your research?

Dr. JC: I really appreciate that question because, um, I think philosophers don’t ask it enough, how what they’re doing in their philosophy is going to connect to the real world. So I appreciate your asking that. And in my case, I think one real potential benefit is for improved treatment of pain. One thing I think philosophers are good at is thinking critically about what follows from what, and also thinking about how we should understand a concept and make sense of things. So one thing I’m doing in my work on pain is arguing that pain isn’t useful for scientific enquiry, and also that our understanding of pain has been overly simplified, and I think those two things together can help with treatment in the sense that…I came out with a book recently; one moral of that book was that for treatment purposes, I think we should think of the doctor – the diagnostician, the person you talk to when you go to get help – as being a translator between our everyday way of talking and thinking, where we talk about pain and where it’s helpful to talk about pain, into the scientific picture of your body, the scientific categories, and figuring out which of those things they should target for treatment. So, sort of ironically, I think that we’ll get better treatment for pain if we stop trying to treat pain and instead, when you say you’re in pain, you have a pain report, then we figure out exactly which thing from the many many things that might be coming together to give you trouble, which of those things we should actually target. Instead of trying to get pain treatment better. Pain is this everyday category; it’s not working for us, for science, and so it’s not working for us as a target for medical interventions, so I think what we need to do is keep it where it belongs in our everyday way of thinking and let the doctor translate our reports about pain, and the many many things I might say about this particular pain I’ve got right now and that might let them figure out which particular mechanism in my body, which particular scientific kind they can target for treatment. We gotta stop thinking about pain, or even types of pain I think, as a thing that is an appropriate target for treatment. And that’s a real practical consequence: it would change the way we do treatment. Let’s say you go in and you say, forget about the word pain for a minute, and you just say “I really feel like shit” and then the doctor – and that’s what you say, you start there – the doctor doesn’t then go “oh, well I have just the medicine: it’s the shit killer!” Right? That’s not a thing you do.

(laughter)

Dr. JC: Right? That’s an everyday way of talking, you mean something when you say it, and you’re there and it’s what made you go to the doctor, that you don’t feel so good, but that would be an inappropriate response by the doctor. And that’s how I think about pain, it’s just at the moment pain is like a more serious scientific category than feeling like shit. And what I’m saying is basically, you know, it’s more particular, we use it to mean something in everyday life that’s more specific than just feeling bad. If I’m bored I can bad but I’m not in pain. It has a meaning for us, it’s just as it turns out not a scientific kind, I think, so we shouldn’t be trying to target it for treatment.

RP: Is there any advice you would give to someone who is looking to get into your area, the philosophy of pain?

AC: Is there like a minimum pain you have to endure to get into it, or is it a free for all?

Dr. JC: I think it’s a free for all! Hopefully it’s not too…if you find it painful to study pain you probably should do something else.

RP: That’s a good indication that it’s not a good idea, yeah!

Dr. JC: Yeah, um…if I were starting out and interested in pain I would go – not to sound too cheeky about it – I would go get this volume that I put together a few years ago for this reason. It’s called the Routledge Handbook of Pain, and what I tried to do there was solicit the best people from across a range of disciplines to write introductory level, short pieces on that area of pain research. And I would start there, and see what bit interests you most, which bit of it you find totally boring, and see what you wanna take further. All the sort of leading folk are in there trying to write for undergraduates or early graduate students, and so that’s a good resource. I mean, I wrote it wishing that I had had it as a student – that was my goal in putting it together. So, hopefully it serves that purpose for anyone else who wants it.

RP: Perfect, perfect.

AC: That sounds great. Well, thank you for being here with us, Jen.

Dr. JC: Thank you very much.

AC: We had a great time, we hope you did too. Thank you for everybody who’s been listening. And remember you can find us on social media: Facebook, under ThoughtsUofG, on Twitter under the same name, and on Instagram under Thoughts_UofG. See you guys next time!

Transcript written by Frances Darling