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Feeling Pain and Being in PainReview - Feeling Pain and Being in Pain
Second Edition
by Nikola Grahek
MIT Press, 2007
Review by Simone Marini
Nov 4th 2008 (Volume 12, Issue 45)

Nikola Grahek's fascinating book has many aims, interwoven with each other. In order to provide a sketchy overview, we should distinguish between methodological aims and philosophical aims. Methodologically speaking, Grahek draws upon empirical evidence to show that armchair philosophical reflection alone is not an appropriate tool to enquire about the nature of mental phenomena such as pain experience. On the philosophical side, his ambition is to show that, once we take clinical evidence about pain experience into account, we find that there is more to pain than its painfulness. More generally, Grahek claims that the distinctive features of mental phenomena are not exhausted by their phenomenal character. Let's see more in detail how he pursues these double tasks.

First of all, it seems sensible to say that there aren't many philosophers willing to deny that when one is in pain one feels it, and vice versa. When one feels pain it is because one is in pain. Nikola Grahek challenges precisely this philosophical view, and aims to "explain the distinction between feeling pain and being in pain, and defend it on conceptual and empirical grounds." (p. 1)

Grahek's views are not primarily directed against the commonsensical identification between these two facets of pain experience. Rather, as Dennett makes crystal-clear in his highly praiseworthy foreword to the book, they are especially directed against conceptual or a priori philosophical analyses of pain. That is, armchair analyses that are classified under the philosophical rubrics of 'subjectivism' and 'objectivism'. Broadly speaking, from the subjectivist's point what is essential to pain experience is its painfulness, that is the phenomenal, qualitative dimension of pain. On the other hand, according to the objectivist, pain experience can be explained in terms of its representational components. We will come back to Grahek's assessment of both subjectivism and objectivism later in this review. For the moment, it is important to stress that Grahek is not trying to dismiss conceptual analysis as such; rather, he is suggesting a different methodological route for philosophical investigation: conceptual truths need to be assessed in confrontation with empirical data. Most of all, philosophers should keep in mind the possibility that their conceptual tools could be inadequate to capture a priori the wealth and richness of the external world.

Grahek offers a prima facie dismissal of what many philosophers take to be a conceptual truth, i.e. that pain sensation and painfulness are inseparable. Actually, says Grahek, it doesn't require any a priori, philosophical, argument to tear apart such conceptual identification. All we have to do is to look at the clinical evidence concerning pain, specifically to two dissociation syndromes which seem to show that pain without painfulness and painfulness without pain, are possible. The book is mainly concerned with the syndrome called pain asymbolia, in which subjects report to feel pain deprived of its painful quality, while the discussion of the opposite dissociation is limited to a few pages of chapter 7 (pp. 107 ff.). Therefore, in this review I will be almost exclusively concerned with Grahek's discussion of pain asymbolia and what it is purportedly supposed to show with regard to pain.

So, what does pain asymbolia teach us with regard to pain experience? To my mind, Grahek's concern is not exhausted by the straightforward argument given above that painfulness is not essentially linked with pain. The first lesson we should learn from dissociation syndromes such as pain asymbolia is that inconceivability, i.e. intuitions (especially philosophical intuitions), are not always a guide to impossibility. In the specific case of pain, we have on the one hand the usual philosophical intuition that the overall pain experience is an unbreakable unity; on the other hand, clinical evidence shows us that pain is a complex and multilayered phenomenon.

In order to properly understand pain a few distinctions need to be made. The most fundamental one is between pain as a biological system and pain experience. Grahek discusses the biological role of pain in the second chapter of the book. As a biological system, pain comprises two subsystems: the 'avoidance system' and the 'restorative system'. Both systems instantiate two functional operations: a physiological activation and a behavioral reaction. In the case of the 'avoidance system', we find an activation of nociceptors (nerve endings responsive to potentially damaging stimuli) and a behavioral reaction in response to such activation. The 'restorative system' kicks in once the organism has been injured, and it includes physiological over-activation around the damaged area even in response to innocuous stimuli, and greatly reduced movements (in order to foster the healing process). It is important to stress that a properly functioning pain system is essential for our survival. Grahek describes pain as "certainly the most precious gift bestowed on us by Mother Nature for self-protective purposes." (p. 6)

In the third chapter Grahek focuses on pain experience. He claims that syndromes such as pain asymbolia clearly reveal the complex nature of pain, in which three basic components can be highlighted: a sensory component, an emotional-cognitive component, and a behavioral component. In the case of asymbolics, that is, of pain without painfulness, subjects are left with the sheer sensation of pain, or 'pure' pain, yet the overall pain experience has been stripped out of its cognitive and behavioral components. Grahek discusses (in chapter 3 and at more length in chapter 7) other cases in which subjects seem to show some sort of indifference to pain experience, especially when they are under the effect of morphine, or have undergone lobotomy or cingulotomy (a surgical procedure for excruciating pain alternative to pre-frontal lobotomy, in which the anterior cingulated gyrus is severed), cases that -- most importantly -- seem to show the same behavioral and cognitive patterns as asymbolics: i.e., no withdrawal actions, and no verbal reports of painfulness.

All this shows, claims Grahek, that Behaviorism is false and we cannot infer mental states from overt actions. Moreover, the analogy between asymbolia and other cases of apparent indifference to pain doesn't stand a closer scrutiny and it is based on a fundamental confusion between indifference to pain and indifference to harmful stimuli. In other words, lobotomics and morphinezed subjects are only indifferent to potentially noxious stimuli, not to pain itself. Moreover, such indifference is of limited scope, it

 "is strictly limited to ongoing pain or persistent pain; […] its object is not the very sensation of pain, but its lasting meaning or significance; and […] this kind of indifference does not imply that pain is no longer disliked or experienced as unpleasant. [...] In other words, only in the case of pain asymbolia patients do we see total or complete indifference to pain, because only these patients have ceased to care about any kind of pain inflicted anywhere on their bodies, and only these patients no longer experience pain as unpleasant or as something that is disliked per se" (p. 137 and p. 139)

One might wonder whether it makes any sense to speak of indifference to harmful stimuli versus indifference to pain. Grahek provides us with such distinction: "in order to be indifferent to pain, one should be able to feel it, but not mind it, and also should lack any tendency to react negatively to it. On the other hand, one can be indifferent to noxious or harmful stimuli because these stimuli do not hurt. In the first case, indifference presupposes the presence of pain or pain-feeling, while in the second case, indifference is due to the absence of pain from stimuli that would normally be painful." (p. 113. Emphasis in the original)

A lobotomic patient can classify a stimulus as 'sharp', and distinguish it from a 'dull' one. She "is aware of the stimuli as pain" (p. 120), but she doesn't care. On the other hand, asymbolics "are not able to attach proper meaning or significance to the pain they literally feel." (Ibidem) They don't really know what to answer to the question: "Is it painful?" because they lack the specific quality of pain experience.

The upshot of all this is that having a pain sensation (such as the one caused by a sharp object stuck into one's knee) is not sufficient to feel pain. Apparently, is not even necessary, as the opposite dissociation of painfulness without pain purports to show. To see how this is exemplified in the case of asymbolics, let us see how Grahek describes its main characteristics: the subject has no unpleasant feelings; she shows no aversive attitude towards pain (i.e., she is utterly and thoroughly indifferent to pain); she displays no appropriate 'pain-behavior' (i.e., withdrawal behavior), because pain no longer means danger or threat to the organism. Nonetheless, Grahek contends, pain "is recognized by the subject as pain and is felt as located in certain body parts. But it means nothing to him and is at most something he laughs or smiles at." (p. 4)

I think the following quote best captures what Grahek wants to say here. "The affective quality is crucial for the organism to learn to protect itself by avoidance or defense. It is this affective dimension that is conspicuously missing in pain asymbolia patients, despite their intact sensory discrimination of noxious stimuli. So, to repeat the main point, although these patients feel pain, it does not represent threat or danger to them." (pp. 81-2)

I take that what Grahek is suggesting is that asymbolics feel pain just because they sense pain. Although, such sensation is deprived of its meaning, as Grahek puts it, and thus it "lacks representational and motivational force." (p. 82) Given all this, and given that apparently all asymbolics are left with are some neutral or indifferent sensory stimulation, one might wonder why Grahek qualifies such sensations as sensations of pain.

The first reason, I think, is based on verbal reports of asymbolics, who generally admit to feeling pain although it doesn't bother them. A simple point might be raised here: asymbolics do know when to classify a certain stimulus as pain, either because they experienced pain before the onset of asymbolia or because they can learn it from other people (even though, apparently, they cannot learn or be trained to react appropriately to harmful stimuli. On this, see Chapters 2 and 5), thus they could be biased to classify a certain stimulus as pain because they are aware it should feel like pain.

The second reason I think Grahek has for claiming that sheer harmful sensations are enough for asymbolics to classify stimuli as painful is grounded in his view that there is a direct link between pain experience and nerve fibers (nociceptive C and A-∆ fibers) selectively activated by harmful stimuli, "because pain is exactly conceived by us as distinctively evoked by such stimuli." (p. 157. Emphasis in the original) A stimulus is defined as harmful or noxious when it has a nocuous character in relation to the organism. What I take Grahek to be claiming here is that both pain experience and nociceptive fibres share one property that make such a relationship intelligible (this fact, according to Grahek, can be further used to explain why nociceptive fibers give rise to pain experience and not to some other experience, or to no feeling at all. On this, see chapter 8). Such commonality is enough for asymbolics to classify a stimulus as painful based on mere sensorial activation precisely because we conceive pain has been caused by such stimuli. In a way, it seems that he is claiming that asymbolics can rationally figure out what pain is, its function (i.e., an experience associated with noxious stimulation), even though they cannot feel its quality.

This latter argument by Grahek, I think, is quite a piece of conceptual analysis, especially if we want to stick with the view that empirical data show just a mere (although very well supported) correlation between c-fibers firing and harmful stimuli. The same point could be made, I suspect, with regard to Grahek's rejection of the so-called 'perceptual model' of pain, according to which pain, roughly speaking, is identified with injuries, on the basis that 'pain' and 'injury' are "to use traditional terminology, distinct existences." (p. 163) Although we have to remember that Grahek is not rejecting conceptual analysis as such, but only a priori analyses of pain experience as inadequate to provide "intelligible psychophysical explanations" (p. 164), I think that it could still be objected that the claim that dissociation syndromes provide evidence for a such a radical ontological picture is stretching the data perhaps a bit too far.

Grahek uses these arguments against both 'subjectivist' and 'objectivist' views of pain (chapters 6 and 7). Before I start digging into Grahek's objections, it is worth pointing out that he doesn't intend to reject either of those philosophical intuitions; rather, he claims that "[t]he main theoretical or philosophical ambition of the book is a more modest one: to appreciate the strengths and weaknesses of these intuitions and thereby to show that a less doctrinaire and more balanced approach to the study of the mind-brain phenomena is quite salutary, and, indeed, highly recommendable." (p. 5)

As already mentioned, 'subjectivism' is the view according to which the qualitative experience of pain "is the essential and component of our total pain experience and plays the central or fundamental role in it." (p. 76) If this is case, continues Grahek, then "it seems that the subjectivists are committed to the claim that a sensation of pain is sufficient for somebody to be in pain." (Ibidem) Thus, Grahek takes that the qualitative character of pain experience provides both the necessary and sufficient condition for feeling pain.

Now, dissociation syndromes such as pain asymbolia clearly show that pain without painfulness is possible; moreover, claims Grahek, "[a]s the case of pure asymbolia vividly and conclusively shows, when pain is reduced to pure qualia, it loses any force that would make one remember it, fear it, or esteem it as a threat or danger." (p. 77) Thus, in the end, the subjectivist's main claim seem to be falsified by the very existence of asymbolics: pain quality is not essential to our overall pain experience, nor does it play a fundamental role in it.

There seems to be something fishy going on here: a subjectivist does not have to subscribe to such a strong version of the theory as the one that Grahek presents as the 'standard' subjectivist approach. She might very well claim that pain quality is a necessary but not sufficient condition for feeling pain, for instance. Secondly and most importantly, Grahek claims later in the book that "asymbolics do have sensations that have pain quality." (p. 102) Assuming that he still holds to the view that pain asymbolia is pain without painfulness, it would helpful to know how 'pain quality' and 'painfulness' differ from each other. Regardless, I don't think that Grahek should assume that the subjectivists would accept such identification between pain quality and pain sensation without argument.

Unlike subjectivism, objectivism claims that there is no pain quality essential to pain experience. "According to this model, the feeling of pain is just the awareness of objective bodily states of affairs: the perception or sensory representation of bodily or tissue damage." (p. 78) In other words, painfulness without pain is what is relevant to pain experience. This is called the 'perceptual' or 'representational' view of pain, and Grahek think that pain asymbolia has shown its major faults: it "fails to explain how pain can come to represent for the subject the threat or damage to his body; the model incorrectly locates this basic, primitive representational capacity of pain in the sensory-discriminative component, rather than in its emotional-cognitive dimensions." (p. 82) In brief, objectivists fail to realize that the qualitative character of pain plays a central role in the overall pain experience.

Thus, Grahek is not rejecting subjectivism. He does claim, against the objectivist, that "the common and distinctive felt quality of pain is the essential component of our total pain experience and […] that experience is not pain experience when that component is missing." (p. 107) One might wonder how Grahek's views differ from a subjectivist's view, given that this latter -- as said earlier -- doesn't have to subscribe to the strong thesis that pain quality is both necessary and sufficient for pain.

His aim is to find a middle ground between objectivism and subjectivism, in order to show that both pain quality and the sheer empty sensation of pain are both necessary but not sufficient conditions of pain. "The two phenomena give us real pain only when they work together." (p. 111-2) Yet, it seems that Grahek's views lean towards a weak form of subjectivism.

Unfortunately, what I have just given is only a rough and dirty overview of some of the issues Grahek deals with in his book, which deserves a more thorough treatment. The many challenging and refreshing ideas in it, and its controversial claims, make it a worthy addition to any philosopher's reading list.

[I would like to thank Christopher Mole and Colleen Nichols for very helpful suggestions on a previous draft of this review]

© 2008 Simone Marini

Simone Marini, Ph.D. student in Philosophy at University College Dublin, Simone.Marini@ucdconnect.ie


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