“If a person feels pain, she is in pain.”
If you’re like me, this statement will seem to be true on first examination. In fact, for nurses, this is the current orthodoxy on pain: namely, that a person’s subjective experience of pain is the necessary and sufficient condition for that person to have a pain.
If you read the second panel of the comic attached to this post, you’ll see an example of the way that nurses are actually instructed to assess a patient’s level of pain. We ask a patient to rate her pain on a scale from 1 to 10, where 1 is almost no pain and 10 is the worst pain imaginable, and the level of pain reported is taken to be the level of pain that the patient is experiencing. For a nurse, there is no conception of pain outside of the patient’s subjective experience of it.
The attached comic brings up one of the major problems with this system for rating pain. The point of the comic is that because the scale is entirely subjective, there is a kind of incommensurability built in to the scale from the outset. Imagine two people who have exactly the same subjective experience of pain. If one of them has a better imagination for painful experiences, she will rate her pain much lower than her counterpart who is having the same objective experience of pain.
Nurses, however, are not worried by this definition in the slightest. In fact, it is heartily accepted and defended vehemently. At our skills lab a couple weeks ago, this definition of pain was defended roughly as follows: If you ignore a patient-client’s claim that she is in pain and withhold pain medication, you are torturing her.
Is subjective experience of pain a sufficient condition?
I completely agree with a desire to avoid putting a patient through unnecessary pain. Further, I think I would want health professionals to adopt a policy where a person’s subjective experience of pain is considered to be a sufficient condition for that person to be in pain.
The only candidate case that I can think of for a pain that is unreal but felt would be a pain in a phantom limb. In some cases of people who have had limbs amputated, they still feel sensations or pains in the limbs even though they have been removed, and the person cannot be experiencing pain in that limb.
But even this case isn’t a very convincing counter-example to the sufficiency of a person’s subjective experience as a criterion for pain. I still want to say that a person with a pain in her phantom limb is experiencing a genuine pain, even though there is no limb to be feeling the pain.
And because the pain may be distressing to the patient, of course I would want health professionals to adopt a policy where such pain is treated like a genuine pain, and steps to alleviate it are taken.
Is subjective experience of pain a necessary condition?
But is it a necessary condition? That is, could a person be in pain, even though that person is not having a subjective experience of it? David Palmer wrote a moderately famous article called Unfelt Pains, in which he argues that this might be the case.
What would an “unfelt pain” look like? Palmer gives the example of a headache that goes unnoticed.
If a distraction makes me forget my headache does it make my head stop aching, or does it only stop me feeling it aching? (Analysis, vol. 14 [1953–54], p. 51 ff.)
Intuitions on this will differ, and I won’t recapitulate Palmer’s argument in its entirety here. (It’s worth looking over though.) But let’s imagine that it is the case that being distracted from a headache doesn’t stop the head from aching—rather, being distracted from a headache only stops one from feeling it aching.
If that is the case, then we have an example of an unfelt pain—an ache that is (at least for a time) unfelt.
Why does this matter?
This is more than just an academic concern. If unfelt pains exist, then this might impact a nurse’s practice in certain cases.
Let’s take distraction from pain as an exemplar case. Imagine that a person was having a pain, but has been distracted. The patient is not having a subjective experience of pain, due to the distraction. If we take the orthodox nursing position on the matter, this means that the person does not have a pain while she is distracted. If we side with Palmer, it means that the person is still in pain, but she is distracted.
Another good example to consider might be the case of a person who is in constant pain, but who has fallen into a dreamless (but unfortunately restless) asleep, in which she is having no subjective experience of pain.
If you are a nurse in charge of patient pain medication, do you discontinue pain medication in these examples? Depending on whether you think the pain still exists even though it is unnoticed, the answer may differ.