XXXII, 1, 2022: The Experience of Pain. Epistemological, Hermeneutical and Ontological Aspects. Edited by Luca Vanzago
Pain is a complex phenomenon. The study of the experience of pain represents in this respect an exemplary case as regards the question of whether epistemic uncertainty is a lack or should be understood differently. In fact, the description and understanding of pain pose two different types of problems, even if interconnected: on the one hand, it is a question of deciding whether the phenomenon is in principle determinable, and therefore its indeterminacy derives from an epistemic lack or insufficiency; on the other hand, it is a question of understanding whether pain is in itself a simple phenomenon or not, and in this case it is then rather an ontological question. To these two types of considerations, however, we must add another, that is transversal with respect to them: that is, we can also ask whether the dilemma relating to the determinacy or indeterminacy of the experience of pain, ought to be reformulated in terms of overdetermination. In this case, it is a question of admitting the plausibility of a plurality of lines of understanding or explanation relating to the experience of pain, which could allow a different formulation of the question.
In other words, the problem can be preliminarily summarized as follows: first of all, it is a question of understanding whether the experience of pain, the most common and probably universal experience that can be had, is related to simple or complex phenomena; if we accept the hypothesis that we are dealing with complex phenomena, it is a question of deciding whether this complexity is epistemic or ontological, and for both alternatives it can be foreseen that this complexity can be understood either in terms of the lack of a definitive explanation which, however, one can hope to obtain in the future, or in terms of an intrinsic lack, that is, in other words, of a positive indeterminacy. If this possibility were to be chosen, then it could be further suggested that such positive indeterminacy must be understood in terms of overdetermination. What is meant by overdetermination is itself an open question. In this connection I will limit myself to mentioning that this term was used by Freud, who in various places speaks of Übereinstimmung in terms of the condition of what is determined by a plurality of factors, such as some phenomena of the unconscious, in particular dreams ( but also lapsus, missed acts, etc.) in which, due to condensation, a manifest image is made up of several latent contents that the correct interpretation must try to reconstruct.
To delineate more precisely the problems inherent in a type of experience apparently as simple and banal as physical pain, it may be useful to consider the definition given by the IASP in 1979. The International Association for the Study of Pain, which publishes the important international journal Pain, was founded in 1973 and now has more than 7000 members from 133 nations, has 90 national offices, and 20 special interest groups, dedicated to as many relevant topics related to general research on pain. In the original 1979 definition, pain is defined as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.
In proposing this definition, the IASP has added accompanying notes, which say the following: “The inability to communicate verbally does not negate the possibility that an individual is in pain and needs adequate pain relieving treatment. Pain is always subjective. Each individual learns the application of speech through experiences of early childhood injury. Biologists recognize that those stimuli that cause pain can damage tissues. Consequently, pain is that experience that we associate with actual or potential tissue damage. It is undoubtedly a sensation in one or more parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences that resemble pain but are not unpleasant, such as a sting, should not be called pain. Unpleasant abnormal experiences (dysesthesia) may also be painful but are not necessarily painful because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any probable pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the direction of the subjective relationship. If they regard their experience as pain and report it in the same way as pain caused by tissue damage, it should be accepted as pain. This definition avoids linking pain to the stimulus. The activity induced in the nociceptors and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, although we can consider that pain often has a proximate physical cause”.
As can be seen, the notes provide numerous clarifications regarding a definition which, otherwise, could be considered rather decidedly reductionist. Nonetheless, this definition is not without controversy and this led the IASP, on 7 August 2019, to propose a new definition, publicly asking anyone interested and studying this phenomenon to suggest comments to a task force composed of scholars of various nations, sending their contribution by 11 September. The new wording is as follows: “An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury”.
There are two substantial changes between the first and second definition. The adjective “unpleasant” has been replaced by “aversive”, that is, adverse. Furthermore, what in the first definition was rendered in terms of the association between experience and actual or potential tissue damage is now instead described in terms of a sensory and emotional experience generally caused or similar to that caused by an actual or potential tissue injury. Also in this case, the IASP provides accompanying notes: “Pain is always a subjective experience that is influenced on various levels by biological, psychological and social factors.
Pain and nociception are different phenomena: the experience of pain cannot be reduced to activity in the sensory pathways.
Through their life experiences, individuals learn the concept of pain and its applications.
A person’s relationship to an experience such as pain should be accepted as such and respected.
Although pain usually plays an adaptive role, it can have negative effects on social and psychological function and well-being.
The verbal description is only one of several behaviors for expressing pain; the inability to communicate does not negate the possibility of a human or non-human animal in pain”.
Clearly, these notes are above all food for thought pending comments. However, we can immediately identify some particularly significant issues. Pain is primarily regarded as an experience influenced by different and competing factors, that is biological, psychological and social. Here it seems to be understood that the residue of physicalist reductionism still implicit in the original definition has been attenuated. This attenuation is reaffirmed by the second proposition, which underlines how the notion of nociception, common in neurology, cannot cover the whole semantic spectrum that that of pain represents. When we talk about sensory pathways, explicit reference is made to the thesis that pain is essentially a neurological event connected to the central and peripheral nervous systems, to afferent and efferent structures, and therefore to the communication of chemical-electrical signals. This thesis has been taken up in philosophy in particular by the current known as eliminativism, of which Paul and Patricia Churchland are among the best-known exponents.
The third proposition emphasizes the role of learning, which basically means both that pain is transformed over the course of each person’s life, and that it can vary culturally. This thesis opens to the problem of relativism, as in principle it seems to allow the inclusion of different if not conflicting definitions relating to what everyone understands by pain.
The fourth proposition somehow reinforces the previous one, because it asks to admit that someone’s claim of being experiencing pain should not be opposed, refuted, or rejected. In fact, until relatively recently pain was considered in medicine simply as an unavoidable side effect and as such unrelated to treatment. Today, however, pain is increasingly understood as a real form of pathology in itself. This is not solely due to the fact that chronic pain is one of the most widespread forms of debilitating experience in a world of people reaching once unthinkable ages. In addition to this, which in any case is a very relevant problem for both social and economic reasons, there is also a significant theoretical question, since it requires us to ask what kind of connection exists between pain and consciousness, as well as to examine the way in which consciousness can modify itself and eventually hide the causes or motivations of the pain from itself. This question arises only if one admits that physical pain is not a purely neurological event and therefore as such independent of consciousness.
The fifth proposition deals with the complex issue of the role of pain in the evolutionary configuration of subjective experience, both at the level of individual history and also from a collective perspective. Without pain, no personal emotional and cognitive growth is possible, but this does not mean that every single pain has a virtuous sense. On the contrary, there are painful experiences that are totally debilitating and useless, capable only of destroying the subjective integrity of a person and therefore also the coexistence and in general the intersubjective relationships of this person.
The sixth proposition is among the most innovative since it poses two different, although interconnected, questions: first of all, it tends to open the expression of pain to a range of possibilities that go beyond linguistic ones; secondly, this is also connected to the theme relating to animality and animal rights. This is undoubtedly a significant opening with respect to the positions held by many scholars until very recently and in some cases still held today. The connection between the two issues naturally emerges when one considers the problem of how to understand the pain of others. The manifestation of pain is in fact one of the most controversial aspects of the complex of problems that are emerging.
In sum, one could say that the question is that of examining whether pain is an experience that can be traced back to an organic basis or requires a different approach. The dilemma here is therefore represented by the possibility of implementing a reductionist or anti-reductionist approach, and the choice between the two models depends both on epistemic considerations and on more strictly ontological issues.
Clearly the question of understanding pain reopens a chapter in the more general debate on what experience is, and in particular whether consciousness plays a role or not. But, as is knwon, the aspect of communication, not necessarily linguistic, of the painful experience must also be considered. In fact, many questionnaires used by doctors to understand the pain felt by their patients propose an evaluation of facial expressions or gestural behaviors, when it is not for example. possible obtain a meaningful verbal exchange with the person suffering. In this sense the body “speaks” even if it does not use language.
These two problems are clearly interconnected and open to an epistemological debate that calls into question the more general problem relating to what experience is and in particular how one should understand the phenomenal aspect, in this case connected to suffering, with respect to a more or less clearly conceived bodily or material substrate. Ultimately, the experience of pain reopens the Pandora’s box of the contrast between dualism and monism and therefore the great question of the relationship between mind and body. Perhaps, however, the investigation into pain can offer a different look at these traditional issues.
(click on the titles to view the abstracts)
Luca Vanzago, Introduction
Rudolf Bernet, I limiti della libertà in relazione a dolore e sofferenza
Françoise Dastur, Souffrance, douleur, deuil et condition humaine
Roberta Lanfredini, Letizia Cipriani, Esperienza ed espressione del dolore. Un’indagine preliminare tra fenomenologia ed ermeneutica
Philippe Cabestan, Exister, souffrir, mourir. Esquisse d’une phénoménologie existentielle de la souffrance
Luca Vanzago, The Sense of Pain. Some Phenomenological Remarks
Michela Summa, Pain Memory and Actualization. Opening and Foreclosing Possibilities
Pilar Fernández Beites, Atención e interés en las estrategias de afrontamiento del dolor
Francesco Saverio Trincia, L’esperienza del dolore in Sigmund Freud
Mª Carmen López Sáenz, Conciencia verdadera del dolor sentido y sentidos del dolor. Estudio fenomenológico
Deborah De Rosa, Realtà virtuale e dolore fantasma. Uno sguardo fenomenologico
Natalie Depraz, Le viol : épreuve de soi, épreuve du corps, épreuve de l’autre, épreuve du collectif. Comment en sortir, et comment s’en sortir ?
Elena Alessiato, Del corpo, dell’anima o dell’esistenza? Ambiguità e pluralità del dolore nel contributo di Karl Jaspers
Andrea Calandrelli, Alessandra Nicolini, Il dolore nella fibromialgia. Dal sintomo alla dialettica corpo-mondo