Pain as a Subjective and Objective

Phenomenon 13
Wim Dekkers

“Pain is as elemental as fire or ice. Like love, it belongs to the

most basic human experiences that make us who we are.”
(Morris 1993, 1)

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Two Opposing Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Scientific Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Total Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Consciousness and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Pain Experience and Expression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Pain and Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
The Measurement of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
The Meaning of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Puzzle or Mystery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Beyond the Signaling Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Ontological Dimension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Low Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Historical and Cultural Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Algophobia and Medicalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Change in Pain Sensation or Attitude? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Definition of Key Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Summary Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

W. Dekkers (*)
IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
e-mail: wim.dekkers@radboudumc.nl

# Springer Science+Business Media Dordrecht 2017 169

T. Schramme, S. Edwards (eds.), Handbook of the Philosophy of Medicine,
DOI 10.1007/978-94-017-8688-1_8
170 W. Dekkers

Abstract
Pain belongs to human life. Although pain is not a medical phenomenon per se,
reflections on pain touch upon the philosophical foundations of medicine. Pain
confronts us with basic questions such as the tension between an objective and a
subjective approach, the concept of brain disease, human consciousness, and
the relationship between body and mind. In this contribution, pain is placed in
the context of the philosophy of medicine. Attention will be paid to some basic
medical-biological and behavioral theories about pain and their underlying
presuppositions. For about four decades, several holistic approaches of pain
have existed. It appears that the meaning of pain is hard to understand from a
scientific perspective. Pain is a sensory and emotional experience, the quality of
which is difficult to express in words. Pain is a mystery; it cannot be explained
as having just a signaling function. It has also an ontological and an existential
dimension.

Introduction

Pain belongs to human life. Since the beginning of its existence, mankind in all its
historical and cultural diversities has been suffering pain, and there are no signs
that this will ever change. Every human being knows what pain is based on his or
her own experience. Pain is not a medical phenomenon per se, though it is still a
key element in the practice and theory of medicine. The relief of suffering is
considered one of the primary ends of medicine (Cassell 1991). Reflections on
pain touch upon the philosophical foundations of medicine. Pain confronts us with
basic questions such as the goal of medicine, the tension between an objective and
a subjective approach, the concept of brain disease, human consciousness, and the
interaction between physical and mental determinants, that is, between the body
and mind.
It is difficult to provide an adequate definition of pain, a fact that is reflected in the
clinical wisdom that “pain is what the patient states it is.” Nevertheless, the Interna-
tional Association for the Study of Pain (IASP) describes pain as “an unpleasant
sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage” (IASP 2014). This definition is widely
accepted and often quoted. It emphasizes that pain is not only a sensory but also
an emotional experience and that it can occur without tissue damage.
The word “pain” and related terms are derived from the ancient Greek poine and
the Latin poena, which mean “penalty” or “punishment.” From this etymological
perspective it can be seen that the original meaning of the word pain must be traced
outside the medical context. Since time immemorial, the language of pain has been
embedded in a much broader context in which cultural, philosophical, and religious
factors play an important role. Pain has attracted the attention of a wide diversity of
disciplines inside and outside medicine, ranging from basic biomedical sciences to
behavioral and cultural sciences and to philosophy and theology.
13 Pain as a Subjective and Objective Phenomenon 171

Pain is a complex phenomenon. The French surgeon René Leriche (1937) insisted
upon the difference between pain as being studied in physiological and psycholog-
ical laboratories and pain as being experienced in daily life. He claimed that pain
studied in a laboratory bears little resemblance to “living pain,” that is, pain as it is
experienced by individual patients encountered by practicing doctors. A distinction
is often made between acute pain and chronic pain. Acute pain is of recent onset and
probably limited duration. It usually has an identifiable temporal and causal rela-
tionship to injury, disease, or medical intervention. Chronic pain commonly persists
beyond the time of healing of an injury, while there may frequently not be any clearly
identifiable cause (Loeser 1991). Moreover, chronic pain is often difficult to treat.
For about six decades there has been an increasing interest in pain and its
treatment. Due to the human life span becoming increasingly longer, people suffer
from chronic diseases such as cancer, arthrosis, and rheumatoid arthritis, often
painful diseases. After centuries in which medicine was quite powerless to treat
pain, a new era with potent pain killers has started. The first multidisciplinary pain
team was established in 1948 by the American anesthesiologist John Bonica. Pain
medicine has emerged as a clinical speciality since the 1950s. Clinical studies took
into account the need for attention to chronic pain as well as acute pain and argued
for a multidisciplinary approach to research and treatment. This transition involved a
shift from the laboratory to the clinic and included the creation of a “world of pain,”
which would be addressed by teams of experts in specialist pain centers, whose
interests were quickly to fragment into highly specialized subfields concerned with
acute pain, terminal pain, cancer pain, chronic neuropathic pain, chronic postoper-
ative pain, etc. (Baszanger 1998).
Another important development is the emergence of hospice medicine and
palliative care in the 1970s. The World Health Organization (WHO) describes
palliative care as “an approach that improves the quality of life of patients and
their families facing the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems, physical, psychosocial and
spiritual” (WHO 2014). The total pain concept as developed by Cicely Saunders,
one of the founders of the modern hospice movement, has been particularly
influential.
Pain and suffering are closely related, since pain is the most commonly consid-
ered cause of suffering. People in pain frequently report suffering from pain when
they feel out of control, when the pain is overwhelming, when the source of the pain
is unknown, when the meaning of the pain is dire, or when the pain is chronic
(Cassell 1991). However, although the terms “suffering” and “pain” are generally
coupled in the medical literature, they are phenomenologically distinct forms of
distress (Pullman 2002). Pain does not necessarily involve suffering (in a pregnant
sense), for example, when someone cuts himself with a knife. A woman may
experience the pain of childbirth as severe yet “rewarding.” Hence, she would not
describe the pain experience as an experience of suffering. Conversely, it is possible
to suffer without experiencing physical pain, for example, when someone suffers
from homesickness, a depressive mood, or anxiety. A patient with an injured spinal
172 W. Dekkers

cord might suffer because of the loss of bodily functions, even though physical pain
is absent or well managed. Pain can be considered a perceived threat or damage to
one’s biological integrity. Suffering is the perception of a serious threat or damage to
one’s personal integrity. It is a specific state of severe distress induced by the loss of
integrity, intactness, cohesiveness, or wholeness of the person or by a threat that the
person believes will result in the dissolution of his or her integrity (Cassell 1995;
Chapman and Gavrin 1999).
The aim of this contribution is to place pain in the context of the philosophy of
medicine and to present the most important philosophical aspects of pain. Attention
will also be paid to some basic scientific theories about pain. Because suffering is
also the topic of another article in this Handbook of the Philosophy of Medicine, the
focus here is rather on physical pain than on the broader phenomenon of suffering.

Two Opposing Theories

Pain has been the object of fundamental laboratory research as well as practical
clinical studies. From the beginning of scientific inquiry, there have been many
diverse ideas about the neural mechanisms underlying pain. Scientific concepts
about pain have emerged, evolved, and changed over time, dependent on cultural
influences and philosophical presuppositions. The conceptual changes show that
many current controversies have old roots (Perl 2011). In particular, two opposing
views on the medical-biological explanation of pain exist: the specificity theory and
the pattern theory (Cervero 2009).
The specificity theory proposes that a specific pain system carries messages from
pain receptors in the skin to a pain center in the brain. Pain is considered to be a sense
similar to sight, hearing, smell, taste, and touch, that is, a component of the sensory
system that provides the brain with accurate information about injuries, warns us of
impending damage, and helps us to heal. The specificity theory maintains that there
are elements of the peripheral and central nervous system specifically and exclu-
sively dedicated to the processing of pain-related information. The French philoso-
pher René Descartes is often mentioned as the one who gave the first classical
description of this theory. His observations on pain, illustrated by the famous
drawing of the kneeling boy by the fire in his Traité de l’homme (Descartes 1963),
have been an important point of reference in medical writings. His reputation for
inaugurating a reductionist and dualist conception of pain seems to rest especially on
this drawing. It is often said that Descartes conceived of the pain system as a simple
straight-through channel from the skin to the brain.
It is, however, inaccurate to see the drawing of the kneeling boy by the fire as
representative of Descartes’ understanding of pain. His more detailed remarks about
pain in his Méditations touchant la première philosophie suggest a more complex
view. In the sixth meditation he argues that pain confronts us with the fact that we do
not just have bodies, but that we are our bodies (Descartes 1967; Van Dijkhuizen and
Enenkel 2009). On a general level, Descartes is rightly seen as a dualist philosopher,
arguing that the body and mind are essentially two entirely different substances.
13 Pain as a Subjective and Objective Phenomenon 173

In this sixth meditation, however, he seems to refer to a non-dualist relationship

between the body and mind, something that was later on explicitly brought forward
by twentieth-century phenomenologists such as Gabriel Marcel and Maurice
Merleau-Ponty. Descartes’ writings also demonstrate that the phenomenon of pain
plays a central role in his philosophical thoughts, particularly in one of the key
modern reflections on the mind-body problem.
The pattern theory of pain denies that pain is just a sense, such as sight and
hearing. It attaches to both pain and its opposite, pleasure, fundamental roles in
shaping emotions and behavior. From this point of view, pain is considered a trigger
of emotional states, a behavioral drive, as well as a highly effective learning tool. It is
often mentioned that the pattern theory of pain dates back to Aristotle. According to
Aristotle, pain and its opposite pleasure are not sensations but emotions, that is,
“passions of the soul.” In his theory, to have an emotion is to experience pain,
pleasure, or both, this pain or pleasure being intentional and representational. Pain
and pleasure also play a crucial role in his virtue ethics, especially in his doctrine of
the mean, that is, the idea that virtue is the mean between two extremes (Aristotle
1976).
The choice between the specificity theory and the pattern theory is not just an
academic question: it has implications for the experimental paradigms used to study
the nervous system. If pain is regarded as a sense, one will look for sensors that are
selectively activated by painful stimuli and for sensory pathways in the brain and
spinal cord that carry pain information in the same way as photoreceptors in the
retina and visual pathway to the cortex are identified. If pain is not considered a sense
such as sight, hearing, etc., then there is no need to look for specific neural pain
mechanisms. If pain is a “passion of the soul,” one will need distributed networks
and parallel interactive processing, rather than a specific pain pathway.

Scientific Approach

In his standard study The Puzzle of Pain, pain researcher Ronald Melzack (1973)
focuses on pain as a neuroanatomical and neurophysiological phenomenon. His
purpose was to explain the phenomenon of pain in a biological-scientific way.
Melzack’s gate control theory has influenced medical theories on pain for many
years. Basically, the theory proposes that a neural mechanism in the dorsal horns of
the spinal cord acts like a gate, which is able to increase or decrease the flow of nerve
impulses from peripheral fibers to the central nervous system. Somatic input is
therefore subjected to the modulating influence of the gate before it evokes pain
perception and response. According to Melzack, the key to the puzzle of pain was
thought to lay in medical-biological knowledge.
The gate control theory of pain is a good example of a pattern theory. Correlates
of higher brain processes such as attention, anxiety, anticipation, and past experience
exert a powerful influence on pain processes. However, this comprehensive pain
theory still contains certain elements of the specificity theory, for example, the
function and activity of various peripheral nerve fibers involved in pain processes.
174 W. Dekkers

Although the central nervous system plays a crucial role in the gate control theory,
this theory is not able to explain some severe chronic pain problems that require a
greater understanding of brain processes. Phantom limb pain, for example, occurs in
the absence of a specific limb, that is, in the absence of peripheral nerves and other
structures that underlie nociception. Therefore, a revised theory has been developed
that conceives of a so-called neuromatrix that extends throughout selective areas of
the whole brain (Melzack 1996). In this theory, the brain, in particular the
neuromatrix, can generate painful sensations on its own in the absence of peripheral
input. The origins of phantom limb pain are thought to lie in the brain. When
someone loses a hand, he or she experiences a phantom hand because the central
representation of the hand remains intact.
Pain is not only a medical-biological phenomenon. Many authors argue that we
can explain the phenomenon of pain only by placing it in the context of the whole
human existence. A well-known example of such a holistic approach is the pain
model developed by the American pain specialist John Loeser in the 1970s. The key
tenets of this model are identical to the so-called biopsychosocial model, which has
also been influential for the theory and practice of medicine (Engel 1977). Loeser
developed his pain model in order to describe “the universe of pain” via four nested
circles that identify four components of pain. (1) The physiological basis of pain is
nociception, that is, the process whereby noxious stimuli in case of tissue damage are
transmitted and further modulated by specialized transducers to specific pain fibers.
(2) The perception of pain is the awareness of a painful event, frequently triggered
by a noxious stimulus such as an injury or a disease. Pain can also be generated
without nociception, when the peripheral or central nervous system has been dam-
aged. (3) Suffering is a negative personal response induced by pain, but also by fear,
anxiety, stress, loss of loved objects, and other psychological states. (4) Pain behav-
ior results from pain and suffering and consists of the things a person does or does
not do as a response to experienced pain. This model has been heuristically useful
and has been appropriated in diverse fashions (Loeser and Melzack 1999). It reminds
us of the fact that “nerves exist in a patient, who is, first and foremost, a human being
and not just a biological machine” (Loeser 2000, S2).
Melzack’s gate control theory and Loeser’s model are well-known examples of
attempts to explain pain in a scientific way and to lay the ground for a scientifically
based treatment of pain. Diagnostic and therapeutic interventions of physicians are
based on a biomedical explanation of the pain symptom and/or a behavioral under-
standing of the pain complaint. This approach is based on the conviction that all
illnesses and other pathological processes can be explained by the laws of the
biomedical and behavioral sciences. However, this conviction can be regarded as
one of the reasons why pain continues to be a problem for the practice of medicine.
Pain does not entirely conform to the scientific, in particular, biomedical approach of
health and disease. It is argued that pain is the principal reason for patients to go to
their physicians, while pain is routinely undertreated in health care (Resnik
et al. 2001).
13 Pain as a Subjective and Objective Phenomenon 175

Total Pain

Pain is one of the most common and distressing symptoms described by cancer
patients. One of the reasons to initiate modern hospice care was a critique of the
reductionistic way in which medicine in the mid-twentieth century dealt with cancer
pain. In palliative care, the clinical management of patients suffering pain from
advanced cancer is paramount. Innovations in this field can be summarized in three
points: (1) the development of a patient-centered approach to analgesic evaluation,
which resulted from the search for an alternative analgesic to morphine, (2) the
reintroduction by John Bonica of the idea that pain is what the individual feels and
thinks it is, and (3) the work of Cicely Saunders in establishing the foundations of the
modern hospice and palliative care movement. The work of these clinicians must be
considered in the context of their time, when new hopes emerged that cancer could
be cured and, at the same time, the cancer patient began to be remolded from a
passive participant in treatment and care to an active collaborator (Seymour
et al. 2005).
Since the 1970s there has been a widening of interest from acute, mainly
postoperative pain to the question of chronic pain. Some of this new interest focused
on the apparent purpose or function of pain. In an acute context, pain is seen as
functional in drawing attention to injury or as an indicator of the need for rest and
recuperation. By contrast, chronic pain in advanced cancer appears dysfunctional
and without adaptive purpose, while posing particular challenges at the level of
meaning. The lack of clarity in how to understand pain for cancer patients contrib-
uted to the persistence of poor pain management. It was partly because of this that
the study of chronic pain became open to influences from the human sciences (Clark
1999). It is in this context that Cicely Saunders in the 1960s developed the idea of a
holistic approach of pain. In the course of her clinical work with dying people, she
coined the term “total pain,” one of the most powerful concepts of the modern
hospice movement, to characterize the multidimensional nature of the patient’s pain
experience and to include the physical, psychological, social, and spiritual domains
of pain (Saunders 1967; Clark 1999). The combination of these elements is believed
to result in a “total pain” experience that is individualized and specific to each
patient’s particular situation.
The complexity of treating patients with total pain is often compounded by the
patients’ inability to distinguish exactly which component is causing pain, because
all they can express is that “they just hurt.” Patients may not be capable of expressing
or even demonstrating an awareness of the fact that the pain they are experiencing is
a result of a combination of factors. For example, pain manifested physically can be
caused by a combination of a child not visiting, a despondent feeling that “God has
left me,” and a bedsore developed during hospitalization. These examples demon-
strate the experience of pain as a total experience. Effective pain relief follows the
acknowledgment and management of the physical, psychological, social, and spir-
itual dimensions (Mehta and Chan 2008).
176 W. Dekkers

Consciousness and the Brain

For a few decades pain researchers have been increasingly interested in the structure
and function of the brain, especially in chronic pain. The cerebral cortex appears to
play an active role in chronic pain. Working models have been developed outlining
the mechanism by which acute pain transforms into a chronic state and by which
distinct chronic pain conditions impact on the cortex in unique patterns. Such models
incorporate knowledge of underlying brain structures and their reorganization, while
also including specific variations as a function of pain persistence and injury type,
thereby providing mechanistic descriptions of several unique chronic pain condi-
tions (Apkarian et al. 2009). This type of brain research, especially brain imaging,
has led to two problems which are relevant for the philosophy of medicine.
The first is the question whether the subjective pain experience can be objecti-
fied in a way by brain imaging. Today, some scientists believe that cortical imaging
can provide an objective measure of the pain experience (Basbaum and Bushnell
2009, ix). Lee and Tracey (2010), for example, describe how neuroimaging
techniques provide an account of neural activity in the human brain when pain is
experienced. They admit that pain and suffering as subjective experiences are
private and not directly quantifiable. Only behavioral responses and verbal com-
munication can be observed and measured. However, according to them, the
physiological recordings of brain activity during pain via neuroimaging are not
merely surrogate measures of pain: they have informed us through which our
experiences of pain, suffering, and relief emerge. They argue that, although
nociception is most often the cause of pain and undoubtedly required for survival,
it is neither necessary nor sufficient for the consciousness of pain. They conclude
that pain and suffering are highly complex conscious experiences that are ulti-
mately generated by the brain. In the brains of patients with chronic pain, neuro-
imaging has revealed subtle but significant structural, functional, and
neurochemical abnormalities. Converging evidence suggests that the chronic
pain state may arise from a dysfunction of the frontal-limbic system.
This conclusion gives rise to a second problem, namely, whether the cause of
chronic pain can be discovered by neuroimaging and whether chronic pain can be
considered a brain disease. Nowadays, it is quite a common understanding that
chronic pain is not a symptom of disease, but rather a disease entity itself, namely, a
disease of the nervous system function (Basbaum and Bushnell 2009, ix). This,
however, is not an undisputed view. It is argued, for example, that disease is a
clinical concept and that conceiving of chronic pain as a brain disease can have
negative consequences for research and clinical care of patients with chronic pain
(Sullivan et al. 2013). It cannot be simply assumed that the changes associated with
chronic pain on neuroimaging are causal. Considered scientifically, one may be
looking for the cause of chronic pain through neuroimaging, but considered clini-
cally, one is in fact often looking to validate pain complaints. It is argued therefore
that we should resist the temptation to validate pain with the magnetic resonance
imaging scanner. Pain cannot be seen as caused by the brain alone. Pain is not felt by
the brain, but by the person (Sullivan et al. 2013).
13 Pain as a Subjective and Objective Phenomenon 177

Pain Experience and Expression

The idea of pain as a subjective experience has given rise to further philosophical
investigations which problematize standard models, such as Loeser’s distinction
between nociception, pain perception, suffering, and pain behavior. How do we
know for sure, for example, that someone else is in pain? In tackling this question,
Nelkin (1986) takes as his starting point the cases of lobotomized patients and
patients who are given morphine after the onset of pain, as discussed earlier by
Daniel Dennett. On the one hand, we believe that being in pain is being in what can
be called a “transparent mental state,” such that the person having the pain is in the
best position to judge whether he or she really is in pain. On the other hand, we
believe that one cannot be in pain without hurting and that hurting is tied up with
certain kinds of affects, beliefs, and behavior, such as trying to do something to
alleviate the pain. In fact, if grimacing, groaning, and similar behavior occur and if
we have no reason for suspecting pretense, then we believe we are in a position to be
certain that someone else is in pain.
It is these various sorts of intuition that come into conflict in the cases of the
lobotomized and morphined patients. Both types of patients claim to feel pain but
also state that it no longer hurts them. One way to solve this problem is to say that
these patients, despite what they say, do not really have pain sensations. The changes
in their brains brought about by lobotomy or morphine have caused them to be
mistaken when they say they do have pain sensations. Another way is to say that
such patients had been caused to forget how to use the concept of pain sensations or
have even forgotten what the word “pain” means. Nelkin, however, argues that in
these cases it would be better to sacrifice our intuition that one is in pain if one has a
pain sensation: one can have pain sensations without being in pain and one can be in
pain without having pain sensations. From a philosophical perspective, it is therefore
crucial to be clear on what we mean when we say “being in pain” and what we mean
by “pain sensation.”
Pain is an unpleasant sensory and emotional experience. From a scientific point of
view, one can analytically distinguish between nociception, perception, suffering,
and behavior, but from a phenomenological perspective, for the person in pain, there
is just the painful experience. The patient’s experience of pain is lived as a whole,
difficult to split up in several dimensions and difficult to express (Kleinman
et al. 1992, pp. 7–8). Perhaps more than other somatic experiences, the experience
of pain resists verbalization. Speaking about pain is one of the most difficult
linguistic activities, as pointed out by Ludwig Wittgenstein. The language of pain,
he argues, is something very different from the language of customary descriptions
(Ehlich 1985).
Physical pain has no voice, but when it at last does find a voice, it begins to tell a
story, by the person suffering, by his relatives and friends, and by his physician. In
those pain stories, metaphors play a crucial role: the phrase “as if” is crucial. Patients
say that it hurts “as if” needles have been stuck in the body, “as if” a hammer knocks
on the head, etc. It is difficult or even impossible to describe the pain experience
directly without the use of metaphorical or symbolic language. According to Scarry
178 W. Dekkers

(1985), pain defies verbal objectification: “Physical pain does not simply resist
language, but actively destroys it, bringing about an immediate reversion to a state
anterior to language, to the sounds and cries a human being makes before language is
learned” (Scarry 1985, p. 4). It is not only the intensity but foremost the quality of
pain which is difficult to express. Much cited in the literature on pain is the following
quote from Virginia Woolf’s essay On Being Ill: “English, which can express the
thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the
headache. [. . .] The merest schoolgirl, when she falls in love, has Shakespeare and
Keats to speak for her; but let a sufferer try to describe a pain in his head to a doctor
and language at once runs dry” (quotation by Melzack 1973, p. 45).

Pain and Narrative

Although it can be said that (severe) pain has no voice, almost all pain patients have
personal stories to tell about their pain. While listening to patients’ stories is as old as
medicine, for a few decades much attention has been paid to so-called narrative
medicine, in line with a much wider interest in narrativity in philosophy, theology,
and the humanities. Basic to this new approach is the idea that human beings are
essentially characterized by the fact that they tell and live through stories. A human
being is a “storytelling animal,” as Alasdair MacIntyre has put it, or a “self-
interpreting animal,” in the words of Charles Taylor. Narrative medicine is medicine
practiced on the basis of “narrative knowledge” and with “narrative competence”
(Charon 2006). Nowadays, a growing list of literature exists about the relevance of
narrative competence for the treatment of pain patients (Morris 2002, 2012). Medical
practitioners must learn to deal with the two most significant sources of predictable
uncertainties basic to every narrative encounter and basic to every valid claim of
narrative knowledge: interactivity and intersubjectivity. The recent medical literature
on pain contains specific studies of patients’ stories. Narrativity, therefore, makes a
solid contribution to pain, both in research and in treatment. The value of narrativity
to pain medicine can be traced in five specific areas: communication, diagnosis,
treatment, ethics, and education (Morris 2012).

The Measurement of Pain

Pain as a subjective experience cannot be measured in a strict sense, that is, the way
the heartbeat, blood pressure, or glucose levels can be measured. Noxious stimuli
and nociceptive responses can be quantified, but not pain. Pain is usually accompa-
nied by all kinds of quantifiable physiological parameters, such as an increase in
stress hormones, blood pressure, and heartbeat, but the pain as such is not measur-
able. Even those closest to a patient cannot truly observe his pain or share in his
suffering. Yet an assessment of the degree of pain of individual patients is a daily
concern for the practicing physician. Pain, particularly chronic pain, thus challenges
one of the central tenets of biomedical epistemology, namely, that there is objective
13 Pain as a Subjective and Objective Phenomenon 179

knowledge, knowable apart from subjective experience. Three strands of activity can
be identified in the history of pain measurement (Noble et al. 2005).
The first, psychophysics, dates back to the nineteenth century and measures the
effect of analgesia by quantifying the noxious stimulation required to elicit pain, as
well as the maximum stimulation tolerated. Methods to measure the so-called single
dimension of pain in the laboratory and in the clinic are used to assess the pain
threshold as a response to a single painful stimulus. Gross changes in the pain
threshold can be assessed in a quantitative way by administering a standard stimulus
such as pricking with a safety pin and manual palpation and by asking whether the
evoked sensation is painful. The pain threshold marks the transition from the absence
of pain sensation to the presence of pain sensation and is quantified as the amount of
stimulus needed to evoke a painful sensation (Gracely and Eliav 2009).
In daily life and medical practice, however, pain cannot be seen as a single
dimension of sensory intensity. Pain refers to a category of complex experiences,
not to a specific sensation that varies only along a single intensity dimension. The
second strand of activity uses standardized questionnaires for patients, developed to
categorize pain according to its emotional impact, distribution, character, and other
dimensions. A number of approaches have extended the evaluation of pain to include
all of the qualitative and affective dimensions such as emotions, cognitions, and
autonomic and behavioral responses. The most popular and widely used
multidimensional pain instrument is the McGill Pain Questionnaire (MPQ). The
MPQ presents 20 categories of verbal descriptors with two to six descriptors per
category for a total of 78 pain-related descriptors.
The third strand of activity asks patients to report on pain intensity using rating
scales and is used in clinical trials where analgesics are evaluated and results can be
combined to influence clinical guidelines and protocols. Although all three strands
have found a place in modern clinical practice, it is the reporting of pain by patients
undergoing treatment using simple scales of intensity which has emerged as the
crucial method by which analgesic therapies can be evaluated and compared. Two of
the most commonly used techniques to measure evoked and spontaneous pain are
the Numeric Rating Scale (scale from 1 to 10) and the Visual Analog Scale (VAS
pain). The VAS pain is a single-item scale for pain intensity. The scale is most
commonly anchored by “no pain” (score of 0 in a scale of 100) and “pain as bad as it
could be” or “worst imaginable pain” (score of 100 on a scale of 100).

The Meaning of Pain

A quite common presupposition in medical theory and practice is that pain has a
biological cause. Pain is also explained with all kinds of psychological determinants,
such as specific cognition patterns, emotions, stress, or anxiety (Price et al. 2009).
However, there are many forms of pain that cannot be explained in biological or
psychological terms. And even if one can trace a biological cause or a psychological
determinant of pain, this does not mean that one understands pain. Scientific
explanations fall short of understanding the phenomenon of pain. It is often argued
180 W. Dekkers

that pain is a phenomenon that transcends the borders of science. Pain is a mystery
and cannot be explained as having just a signaling function. It also has an ontological
and existential dimension (Bakan 1976).

Puzzle or Mystery?

Most of the scientific literature describes pain as a problem, a puzzle or riddle,

something to be solved or unraveled. However, the conviction that pain can be
explained entirely by the biomedical and social sciences is not self-evident. The
increasing interest in pain and suffering, which started in the 1960s, can be attributed
both to the increased attention being given to the experience of the sick person and to
the fact that they defy explanation on a purely biomedical basis (Cassell 1995).
Many authors have argued that the phenomenon of pain cannot be understood by
means of the sciences and that we would do better to speak of the “mystery” of pain
(Buytendijk 1962). Morris writes: “A true mystery, as opposed to a puzzle or riddle,
cannot be known apart from the veil that separates us from a true understanding.
[. . .] A mystery, then, is not something that exists principally to be solved” (Morris
1993, p. 24). Morris goes on by saying that while the doctor typically approaches
pain as a puzzle or a challenge, the patient typically experiences it as a mystery. It
seems likely that mystery can never be entirely eliminated from pain as long as pain
remains a subjective experience. The term “mystery” here refers to the existential
interpretation as provided, for example, by the French philosopher Gabriel Marcel.
Pain is not considered to be a solvable scientific puzzle. It is rather a phenomenon
that will never betray its secrets, but toward which human beings nevertheless must
take a philosophical stance.

Beyond the Signaling Function

Pain is often considered to be a functional warning sign. By producing a retraction

from the painful stimulus, the body tries to avoid further harmful situations and
damages. There are rare cases of children who are born without the ability to feel
pain. This pathological condition of a congenital insensitivity to pain clearly demon-
strates the biological function of pain. Many of these children sustain extensive burns,
bruises, and lacerations during childhood and frequently bite deeply on their tongue
while chewing food, and only with difficulty are they able to learn to avoid inflicting
severe wounds on themselves (Melzack 1973). We constantly employ the sensation of
pain, even at very mild levels, to adjust our posture or shift our position. We learn how
to feel pain and to learn what it means. Children unable to feel pain lack this adaptation
mechanism and easily suffer from bodily damages and infections.
An explanation of pain in terms of a signaling function might be adequate in
cases of trauma, injury, and infections such as an appendicitis or an inflammation of
the ear. In general, however, this theory does not suffice. One might, for example,
think of phantom limb pain, which is clearly at odds with this signaling theory.
13 Pain as a Subjective and Objective Phenomenon 181

Another example is the severe pain that accompanies some forms of cancer. In this
case, the diagnosis of a malignant process which might be incurable has been well
established. The patient is well aware of the diagnosis; he knows that he is incurably ill
and is going to die soon. If one considers the function of pain as signaling (possible)
threats only, then cases like this one cannot be understood. The experience of pain,
especially chronic pain, includes much more than a physical sensation, a signaling
function, or a psychological explanation: it creates problems of control and meaning.
Morris argues that we must proliferate the meanings of pain in order not to reduce
human suffering to the dimensions of a mere physical problem, for which there is
always a medical solution. Pain is not just a biological fact, but “an experience in
search of an interpretation” (Morris 1993, p. 38). We experience pain only and
entirely as we interpret it. Morris speaks about the “hermeneutics of pain” (Morris
1993, p. 33): “We experience our pain as it is interpreted, enfolded within formal or
informal systems of thought that endow it with a time-bound meaning – whether
theological, economic, scientific, or psychological. We make sense of pain in much
the same way that we make sense of the world. Sometimes pain can even reveal to us
beliefs and values we did not know we held” (Morris 1993, p. 45). In other words,
pain can be considered to be a heuristic instrument.

Ontological Dimension

Buytendijk’s classic study Pain. Its modes and function (1962) is a good example of
giving pain a personal meaning based on scientific explanations, philosophical insights,
and religious convictions. According to Buytendijk, pain can serve multiple purposes
and hold multiple meanings beyond its basic function as a signal of tissue damage. He
speaks of the ontological dimension of pain, referring to the way in which pain is one of
the constituting factors of human existence. According to Buytendijk, the essence of
pain is “a state where man is afflicted in his most intimate unity, his psychophysical
nature: self is brought into conflict with the body while remaining bound to the body in
its painfulness” (Buytendijk 1962, p. 148). Pain leads to a dissociation between the ego
and the body. In daily life, when we are involved in all kinds of practical tasks and are
close to the things in the world, we often tend to forget our body, as if we do not have
one. In (severe) pain, for example, when my hand hurts, this body part takes over control
and dominates the whole situation: “We are not tormented by some foreign agent, it is
not an incident, a word, a thought, or even sickness or death, however we may
acknowledge the power of these: it is our own body” (Buytendijk 1962, p. 26).
Pain does not have an intentional object. Although the capacity to experience pain
is as primal a fact about the human being as is the capacity to hear, to touch, to desire,
to fear, etc., it differs from these events by not having an object in the external world.
While hearing, touch, desire, and fear refer to something in the outside world, pain
“is itself alone” (Scarry 1985, p. 162). This objectlessness, the complete absence of
referential content, almost prevents pain from being rendered in language. But it also
impacts severely on our existence. According to Scarry (1985), suffering pain might
be the most evident character of what we call certainty. Suffering pain leads to the
182 W. Dekkers

highest possible certainty that we are: doleo, ergo sum. The experience of pain is a
breaking point in the obvious nature of our normal, healthy existence. Pain awakens
us, not only literally but also metaphorically speaking, that is, out of our “metaphys-
ical heedlessness” as Max Scheler has called it (quotation in Buytendijk 1962, p. 22).

Low Back Pain

The existential dimension of pain appears both at an individual and at a general level
and can be illustrated by the phenomenon of chronic low back pain. Since time
immemorial low back pain belongs to the “evergreen” of bodily complaints. It is
already mentioned in the papyrus Edwin Smith (about 1500 before Chr.), in the
Hippocratic writings, and in the works of Galen (Allan and Waddell 1989). Even
today, low back pain is one of the most common reasons for consulting a primary
care physician in industrialized countries. Although low back pain is one of the most
common types of pain, it is often said that it is poorly understood (Melzack and Wall
1988). Low back pain is related to physical abnormalities such as arthrosis,
spondylotic deformations, and intervertebral disk problems, but very often no
biological cause can be found. There are people with anatomical degenerations of
the spine who do not complain about their back. And, the other way around, people
with low back pain often show no physical abnormality. At an individual level,
patients with low back pain have to search for a meaning of their pain and to give it a
place in the context of their life story (Dekkers 1998).
At a general level, low back pain is related to one of the characteristics of the
human condition, that is, the “uprightness” of the human being. Since time imme-
morial an upright posture was considered to be one of the essential characteristics of
man. Biologically oriented philosophers such as Helmuth Plessner, Adolf Portmann,
and Buytendijk specifically described the human posture as upright. In their view,
human posture cannot be considered solely from an anatomical and biological
perspective. According to Buytendijk, man’s upright posture is to be understood as
a specifically human posture in a specifically human world. He writes: “It is nature
and culture, expression of emancipation and independence. It is also a sign of being
threatened: the righteous man is threatened by a collapse” (Buytendijk 1974, p. 230).
When standing up, balancing on the small plane of his feet, the human being adopts a
distinct positional relation vis-à-vis the world. This new relation is only possible
through a loss of security, while at the same time offering a new freedom. From such
a perspective, the existence of low back pain could be interpreted as a negative side
effect of the human upright posture.

Historical and Cultural Aspects

Pain not only has a biological, psychological, and existential dimension but also a
cultural dimension. The experience of pain is powerfully mediated by the cultural
and historical context (Moscoso 2012). Studying pain is a way of studying the
13 Pain as a Subjective and Objective Phenomenon 183

intersections between the physical human body, the product of evolutionary pro-
cesses, and the cultural body, that is, the human body as it is experienced and
perceived by people in specific cultural and historical circumstances (Porter 1999;
Van Dijkhuizen and Enenkel 2009). Cultural beliefs, social values, and religious
traditions play an important role in the response to pain by affecting the way we
interpret and attend to pain.

Algophobia and Medicalization

In some non-Western cultures, pain and suffering are regarded as facts of life that
must be accepted. In Western cultures, many people tend to regard pain as a
pathological condition that should be eliminated and prevented, if possible.
There is some evidence that Western attitudes toward pain have changed over
time. People have become less accepting of pain as medicine has provided them
with more effective ways of controlling it (Resnik et al. 2001). Never before in
human history has the explanation of pain fallen so completely to medicine.
This has led to a seemingly distinctive paradox: although biomedical research
has enormously expanded our knowledge of the anatomy, physiology, and phar-
macology of pain, never before has pain, particularly chronic pain, reached its
present proportions. We possess more knowledge and better remedies than ever
before (Morris 1993). Pain has become a medical problem asking for a medical
solution. The individual and social willingness to tolerate and accept pain has
decreased.
According to Buytendijk, modern man takes offense at many things that used to
be accepted by older generations with resignation. Modern man can be irritated by
growing old, a long sickbed, and certainly by pain. Its occurrence is unacceptable. In
modern society, the demand to do away with pain has become progressively
stronger. This has led to the development of an “algophobia [. . .] which is itself an
evil and sets a seal of timidity on the whole of human life” (Buytendijk 1962, p. 16).
Morris (1993, p. 60) speaks about “medicalization of pain.” By what Ivan Illich has
called “cultural iatrogenesis,” modern medicine has deprived us from our ability to
suffer from pain. Pain has become a medical problem which doctors need to solve.
Nowadays, adequate pain management is understood to be a fundamental human
right and an integral part of the patient-centered part of modern medicine (Cousins
et al. 2004).

Change in Pain Sensation or Attitude?

The question raised by the concepts of “algophobia” and “medicalization” of pain is

whether modern algophobia can be attributed purely and simply to a decreased
willingness to endure pain, that is, a changed mental attitude. Or are we conceivably
observing a change in the tolerance of pain, an increase in the pain experience as
such, and an increase in the painfulness of pain?
184 W. Dekkers

Leriche (1937) gives an affirmative answer to the question whether sensitivity to

pain, conceived of as a physiological quality, may have increased in the course of
time. His argument is based on his experience as surgeon serving at the front during
the First World War and a historical analysis of well-known cases of people who
have been suffering from very painful medical conditions. Leriche believed that the
increase of sensitivity to pain must have come about in the nineteenth century, where
it was strongly promoted by the introduction of surgical anesthesia and of aspirin.
Also, the Dutch physician and philosopher Van den Berg (1963) argues on historical-
phenomenological (metabletical) grounds that pain sensitivity has increased in the
first half of the nineteenth century, more precisely between 1780 and 1845. Since
then patients had much more need of analgesics than their fellow sufferers in
previous centuries. A key point in Van den Berg’s metabletical approach is that
pain is linked to social isolation and loneliness: experiencing pain means a lack of
human relationships. This view is open to criticism and can naturally not be taken
literally. However, what Van den Berg wishes to point out is that the phenomenon of
pain should always be studied in its historical and cultural context.
There is some evidence that the pain we feel today differs from the pain our
ancestors felt. Most authors, however, come to the conclusion that it is a change of
mentality rather than a physiological increase in sensitivity that has caused our
changed attitude toward pain. In a historical-phenomenological study of bodily
pain, the medical historian Daniel de Moulin argues that on historical grounds one
cannot come to the conclusion that medieval man bore his pain in any way distinct
from that of patients today. In view of the reaction of the patient, the attitude of the
physician, the attention that medieval textbooks have given to the management of
pain, as well as the interest at the time in the problem of surgical anesthesia, it is not
plausible that pain perception was less acutely felt than today. Pain appears to have
been experienced in the same way and with the same intensity as today. De Moulin
comes to the conclusion that, finding no arguments that the sensitivity of the nervous
system has increased in recent times, we have to attribute the rapidly dwindling
readiness to accept pain to a change in mental attitude. The threshold of pain may
vary from culture to culture, and even from time to time in the same person: “Pain is
[. . .] a subjective way of being an experience as well as an evaluation of the actual
situation, and as such the creation of a human being in his sense-giving existence”
(De Moulin 1974, p. 570).
The question of how to understand our modern attitude toward pain and how to
explain possible differences with the past sounds like an empirical question. In fact,
however, this question is intermingled with philosophical problems to such an extent
that it is hard to solve the question in an empirical way. From a philosophical
perspective it is, for example, crucial to know what is meant in discussions like
these by the terms which are central in Loeser’s model: nociception, perception,
suffering, and behavior. And what about the discussion previously mentioned about
the relationship between being in pain and pain sensations? Nevertheless, putting
these philosophical questions aside, the conclusion can be drawn that an explanation
of our modern attitude toward pain in terms of a change in neurophysiological
nociception is difficult to defend.
13 Pain as a Subjective and Objective Phenomenon 185

Definition of Key Terms

Pain: “an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage” (IASP 2014).

Summary Points

• Two opposing views on the medical-biological explanation of pain exist: the

specificity theory and the pattern theory.
• The emergence of modern palliative care, particularly the concept of “total pain,”
was an important impetus for a holistic approach to pain.
• It is debatable whether chronic pain is a brain disease and whether the subjective
experience of pain can be objectified by neuroimaging.
• It is not only the intensity but foremost the quality of pain that is difficult to
express in words. In pain stories, metaphors play a crucial role.
• Pain, particularly chronic pain, challenges one of the central tenets of biomedical
epistemology, namely, that there is objective knowledge, knowable apart from
subjective experience.
• Pain is a mystery; it cannot be explained as having just a signaling function. It also
has an ontological and an existential dimension.
• An explanation of our modern attitude toward pain (algophobia, medicalization)
in terms of a change in neurophysiological nociception is difficult to defend.

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