Scientific and medical definitions are tools. Even when we recognize them as imperfect or provisional, awaiting replacement by an improved version, they perform work that cannot be accomplished by less precise instruments. It was thus a serious matter when in 1979 the subcommittee on taxonomy appointed by the newly formed IASP published its now familiar definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.''21 This brief definition -reaffirmed in a 1994 second edition22 - has made it possible for researchers and clinicians working in many different countries, in various languages, and in far-flung disciplines to possess at least a basic mutual understanding of what they mean (and, equally important, do not mean) by the all-purpose, ragtag, everyday English word "pain."
The IASP definition recognizes that tissue damage remains for most people - patients especially - the gold standard for pain. It also recognizes, however, that pain may occur when tissue damage is not present. The IASP definition even allows that tissue damage sometimes simply generates the language we apply to various unpleasant or traumatic sensory and emotional experiences. The extended note accompanying the IASP definition states clearly that pain is not equivalent to nociception, the process by which a signal of tissue injury is transmitted through the nervous system: "Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus,'' the IASP authors insist, "is not pain, which is always a psychological state ____'' As a psychological state, pain is irreducible to objective signs. The extended annotation begins with the blunt and unequivocal statement that "pain is always subjective.''
It is fascinating how much matter for controversy has been packed into the brief IASP definition of pain. The definition and its supporting annotations gently but surely dissolve any necessary connection between pain and tissue damage. Extensive tissue damage may occur without pain, as Henry K Beecher showed in his classic study of soldiers wounded in the Second World War.23, 24 Pain may also occur in the total absence of tissue damage, as researchers recently confirmed.25 Most important, with a daring that merits repetition, the IASP definition recognizes that pain is always a subjective, psychological state. No purely pathophysiological model of pain can encompass such recognitions. At the same time, the task force authors also state in the annotation what is surely true: that pain, despite its psychological and subjective nature, "most often has a proximate physical cause.'' In short, the IASP definition proves to be concise, flexible, and accurate. It has served the community of pain medicine very well. Naturally, there are voices today arguing that we should get rid of it.
Recent objections to the IASP definition emphasize two claims: it is Cartesian and it neglects the ethical dimensions of pain. Cartesian today is often a synonym for wrong. As the best-known proponent of mind/body dualism, Descartes has erroneously been identified as the precursor or progenitor of any theory that separates body from mind. Complaints that the IASP definition of pain is Cartesian, however, ignores several facts. The definition implies no such thing. It implies, on the contrary, that minds as well as bodies are necessarily involved in the experience of pain, an experience that is multidimensional, not the straightforward projection of sensory impulses that Descartes had described. Moreover, Descartes did not separate body from mind as neatly as his modern critics assume.26 The bodily mechanism responsible for pain in humans was ineffectual when disengaged from the mind or soul, which is why Descartes could argue that animals (soulless, by definition) do not feel pain. We should stop referring to all medical mind/ body dualisms as Cartesian: most are not the direct legacy of Descartes but flow from nineteenth century positivist science.27 True, Descartes sees the mind as a passive receiver of sensory impulses, not as an active participant in the pain process. This justifiable criticism of Descartes, however, does not underwrite unjustified criticism of the IASP definition. Mind-body interrelations are indispensable in any definition that views pain as "always psychological,'' since even painful psychological states distinct from nociception require our personal and cultural histories of tissue damage in order to generate the language in which such psychological states are described and perceived.
A second criticism of the IASP definition is that it ignores ethical concerns implicit in pain and thus indirectly sustains or promotes unethical practices. One critic observes that the definition fails to highlight pain among disempowered and neglected minorities, such as women, blacks, children, and the elderly.28 Certainly, we need to pay increased attention to pain in minority or marginalized groups, and a vigorous biomedical literature is beginning to address this lapse. The IASP definition, however, neither supports nor promotes social injustice: reform must find more effective and appropriate expressions. It is equally short-sighted to claim, as another critic observes, that the IASP definition makes pain dependent upon "full linguistic competence,'' ignoring pain in neo-nates and other nonverbal individuals,29 for example, and in animals.30 Animal pain is not identical to human pain, and the IASP definition deals with pain in humans. More important, the IASP account treats linguistic competence not as a philosophical prerequisite for pain, but as a clinical resource. Its most radical implication lies in valuing the patient's subjective self-report - still too often devalued or dismissed by doctors unable to find an objectively verifiable lesion. We know that self-reports are imperfect, influenced by variables such as memory, mood, and the questions posed to patients or research subjects.31 Like objective data, they must be evaluated within the context of a full medical record. The IASP definition, however, makes it clinically irresponsible to dismiss the patient's subjective account of pain, accounts that today go beyond verbal reports to include visual analog scales, drawings, and even electronic diaries that record numerical estimates of pain intensity.
One can criticize the IASP definition on various grounds - such as a circularity in defining pain as "unpleasant'' - but pain is a complex state, resistant to language, and the IASP definition provides a solid, workable, valuable tool. It was created specifically, as subcommittee chair Harold Merskey writes, "for use in clinical practice.''22 Nobody ever claimed it was perfect or eternal. Moreover, a definition is exactly the wrong place to address serious ethical issues (some of which will be addressed below under The ethics of pain and suffering: narrative analysis). The burden lies on critics to provide a better tool capable of achieving widespread use. They should also come clean about what submerged medical, social, or philosophical agendas their own new definitions advance. A workable definition of pain need not be - and should not be - a theory of pain. We still lack a fully agreed-upon theory of pain that accounts for all the multiple combinations of causes and effects in numerous different diseases, syndromes, and cries for help. Thanks to the IASP definition, researchers and clinicians, even if they cannot always explain or treat it, mostly agree on what they do and do not mean by pain. General agreement disappears when we turn from pain to suffering.
There is no consensus about whether suffering falls within the boundaries of pain medicine - or even within medicine - but the medical neglect of suffering is palpable. Suffering rarely gets an entry in medical textbooks, and only a few authors with medical training discuss it directly.32, 33 In a practical sense, health professionals confront the problems of suffering every day - as suffering emerges during the course of illnesses that range from cancer and depression to Alzheimer's disease. This practical, everyday approach, however, fails to tell us what suffering is - and suffering as a distinctive state (a state that transcends specific illnesses) tends to be ignored. Paradoxically, the demands of everyday patient care often manage to insulate biomedicine from any real contact with suffering, which may be regarded as a nonmedical consequence of illness and thus reassigned to pastoral care, a discipline where suffering is taken seriously.34 The standard institutional separation between theologians and physicians only deepens medical unawareness of suffering. Despite some welcome signs of change, the stark question remains as to whether pain medicine will come to view suffering - at least suffering directly related to pain - as a condition that demands serious thought and effective responses. If so, we must begin (as the IASP did with pain) to define what we mean by suffering.
Suffering is sometimes employed as a synonym for pain - as if pain were the cause, suffering the effect, and their linguistic relation interchangeable35 - but they are theoretically distinct. A broken bone may bring pain without suffering; a broken heart may bring suffering without pain. Suffering and pain thus cannot be exactly identical or synonymous. This theoretical difference, however, often collapses in practice, where suffering and pain may occur together in ways that not only undermine hypothetical distinctness, but also alter their relationship. The special complications that mark the unstable relations between pain and suffering have received attention from psychologist C Richard Chapman and pain specialist Jonathan Gavrin.36 They define suffering as "threat or damage to the integrity of the self'' - following physician and bioethicist Eric J Cassell32 - and they specify that the threat or damage entails "a disparity between what one expects of one's self and what one does or is.'' Persistent pain, they observe, often causes "serious disruption'' of a human life, and such disruption may constitute a crisis of identity that is experienced as suffering and perpetuated by physiological processes similar to the maladaptive stress response. Chapman and Gavrin do not set out to propose a solution to the problem of suffering, but they assert that physicians who understand suffering can learn how to prevent the predictable damage to the self that often accompanies persistent pain.
The medical discussion of suffering is at such an early stage that any account must remain incomplete, valuable especially for the questions it raises. Chapman and Gavrin offer an appropriately complex account of human self-hood in its neurological, behavioral, cognitive, and developmental aspects. Such complexity, however, also raises questions about whether most selves ever manage to possess a wholeness or harmony that would constitute the "integrity" presumed lost in suffering. Sociologists write about normative human identity today as characterized by a "destabilization" in which selves are not understandable as private inner cores but rather as a fluid melange of public roles, performances, and appearances.37'38 In private communication, Chapman emphasizes his view that the self is "not so much an entity as a process of constant redefinition in reaction to a changing world.'' He describes the loss of integrity as a failure of "coherence," noting that "awareness of incoherence within one's self is a powerful negative experience.'' He observes that there is perhaps no more powerful source of human incoherence than the failure or loss of the relationships that bind us to others, including not only family and loved ones, but also peoples, nations, deities, or even cherished abstract versions of otherness, such as justice and freedom. Suffering understood as an experience of radical incoherence may prove ultimately to be a more useful concept than self-hood regarded as the possession of integrity, wholeness, or harmony. Unfortunately, a review of the pain literature by Fishbain et al.38 showed that personality states were influenced both by personality trait and the presence of chronic pain. They cautioned that post-pain personality profiles were not necessarily indicative of pre-pain personality. Relief of the pain might restore the pre-pain status and integrity.
The compound term "pain and suffering'' has certain legal connotations currently being explored by legal scholars, the judiciary, legislators, and juries. One goal is to define and to rationalize approaches so that "deserving" supplicants are not penalized and "undeserving" litigants do not "win the lottery.'' There is no assumption that such payments, which make up about 50 percent of total tort awards, should not occur.39,40 The question rather is when and how, within specific legal and insurance systems, to provide just compensation that take into account the difficulties inherent in quantifying - let alone in identifying - suffering and pain.
The work of Chapman and Gavrin invites us to ask why some pain patients suffer when others who face serious disruption of their lives seem to prosper under adversity? Suffering, in the view of some social scientists, is not only an individual experience, but also a cultural practice that certain societies or subcultures or ethnic groups code quite differently.41 The differences in individual responses to disruption may reflect different ways of "coding" adversity that are learned from families or cultures. We might also understand more about suffering from studies in "learned helplessness.''42 Suffering is by definition a state of helplessness, as few people would choose to suffer if they could avoid it. The helplessness typical of suffering, however, is also learned and reinforced by repeated failures to find aid. The repeated failure of efforts to find assistance is not the same as suffering conceived as a state of helpless passivity. In an analysis of how suffering is learned, the therapeutic value lies in active interventions designed to break the self-reinforcing cycle of helplessness - as demonstrated in feminist responses to battered women, for example -through specific techniques designed to empower the disempowered.43 Responses to the helplessness intrinsic to suffering allow sufferers to recognize the (limited)
power they do not know they possess, which creates a basis for small steps forward.44 From this perspective, suicide is less a product of suffering than suffering transformed to a state in which helplessness is absolute, immutable, and toxic.
A clinical definition of suffering, in addition to acknowledging threats to the self from incoherence and helplessness, will need to account for an elusive quality within suffering that resists any probe that seeks to lay it bare to objective analysis. Pope John Paul II acknowledged this elusiveness when he wrote about the "oppression of mind and spirit'' that often accompanies pain. Suffering encompasses, like pain, an irreducible subjective dimension, but it is distinctive in shattering the norms of life in which even pain can be understandable and thus bearable. For contemporary philosopher Emanuel Levinas, suffering is "the impasse of life and being''; what he calls "the explosion and most profound articulation of absurdity.''45 We must not expect a crystal clear account of suffering when it constitutes an experience that plunges our most basic assumptions about life into utter chaos and absurdity. Suffering is like a text that suddenly plunges into an unknown language -or outside language. We do not so much know suffering (in ourselves or in others) as much as suffer or witness it. Yet, granted this resistance to understanding, a new challenge is emerging in connections between pain medicine and palliative care.46 When cure is impossible, palliative care focuses on the alleviation of symptoms and on the relief of suffering.47 Fear of pain is a regular source of suffering, especially among patients who fear dying in pain, and pain medicine is thus an indispensable resource for assisting hospices in the effort to relieve suffering at the end of life.48 McNamara indicated that the "good death'' - often an explicit goal in the original hospice movement - has become an increasingly inappropriate objective in the current climate that emphasizes patient autonomy and consumer choice. Without good pain relief, patients cannot think about preparing for death. The focus at end of life is thus shifting from the question of dying well to living well (until death). Patients must be given options to accept or refuse any treatment, including life-prolonging interventions or even interventions to relieve pain. The question of pain at the end of life is complex. Living wills and other medical power-of-attorney instruments typically request terminal pain relief, even at the cost of awareness, but also DNR/DNI (do not resuscitate, do not intubate) in cardiac or respiratory arrest. Some contend that protagonists of euthanasia and of physician-assisted suicide have taken arguments for patient autonomy to an inappropriate extreme.49 The treatment of pain and suffering at the end of life remains an issue about which patients, families, and caregivers need to establish clear lines of communication that acknowledge emotional distress, ethical controversy, and cultural or personal differences.
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