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Response to Editorial by Anand and Craig
Pain. 66 (1996) 209-229
© 1996 International Association for the Study of Pain. All rights reserved 0304-39591961$15.00
Letters to the Editor PAIN 3236
Response to Editorial: New perspectives on the Definition of Pain
Thank you for the opportunity to comment on the editorial by Craig and Anand on 'New Perspectives on the Definition of Pain'. They present much important and interesting information about probable pain in those such as neonates who cannot tell us about it. 1 think it necessary only to deal with two aspects of the editorial which seem to me to present problems. First, the authors are correct in pointing out that the IASP defmition of pain states that the use of the word pain needs to be learned through experiences in early life. 1 agree with them that the perception of pain (whether associated with tissue damage or not) is an inherent quality of life itself and does not require prior experience in the first place. The definition does not mean that the experience of pain has to be learned, despite the interesting possibility that some part of it is learned. The definition simply indicates that we learn how to use the word. Second, the use of a word is not a statement of absolute truth but a statement of the way in which we employ a term. The term or word pain is universally used for a subjective experience and we can only know if someone has pain if they tell us truthfully that it is present. We can suspect the presence of pain - and indeed we can infer it with a high degree of probability - if we note certain circumstances and actions of living organisms which appear to be in pain as judged by their actions. This is less applicable by definition to unconscious organisms. Groaning under anaesthesia cannot indicate an awareness of pain. Anand and Craig seem to wish to rely upon behavioural responses, especially in the neonate, to furnish us with phenomena which can be included within the definition of pain itself. Yet the very words 'Pain behaviour' are often employed as a means to distinguish between external responses and the subjective condition. 1 am in sympathy with Anand and Craig in their wish to recognize that such types of behaviour are likely to indicate the presence of a subjective experience, but the behaviour can not be incorporated sensibly in the definition of a subjective event. Denying that pain behaviour means pain does not mean that 1 wish to throw out the baby with the bath water. Certain types of behaviour may be defined as probable pain indicators, albeit the baby should be both wincing and crying to qualify. We cannot assume that those responses would always be true pain indicators because there will be times when we do not know whether they indicate wind or anger rather than pain. We might talk of 'apparent probable pain' or even 'apparent very probable pain' and play with acronyms (I will not put them forward here) in the hope of finding an alternative term. For the present 1 think that that is the best that we can do. In
the mythical but perh~ps quite realistic future we may develop enough imaging capacity to be able to say that certain types of apparent pain behaviour match perfectly with the occurrence of pain in adults and physiological measurements made at the same time. Perhaps then we would be able to talk not just of 'pain like behaviour' but also of 'pain identical behaviour'. Until then pain remains a word which is both powerful, because of its restriction to the subjective state, and limited for that very reason. 1 agree of course, as Anand and Craig say, that the neonate's expression of unpleasantness does not fit within the strict definition of pain imposed by the requirements for self report and that this contributes to the failure to recognize pain and treat pain aggressively in infancy and early childhood. The remedy must be to seek better characterization of probable pain patterns or probable apparent pain patterns and to determine the benefits of treating those patterns with all seriousness. It is a misdirection of energy to attempt to change the meaning of a word that, so far as 1 can tell, has been used everywhere - or perhaps almost everywhere - in a particular way for thousands of years. Efforts should rather be directed to a steady improvement in the recognition of probable pain patterns and their predictive value in relation to treatment. H. Merskey, D.M.
PII 0304-3959(96)03236-X
PAIN 3196
Response to Editorial by Anand and Craig Drs Anand and Craig ask for an absolute yes or no answer to the question 'Is this organism in Pain?'. Dr Merskey provides a probabalistic answer 'It is very (very, very--) unlikely that this organism is in pain'. This type of question and answer is a quicksand to be avoided because those who require absolutes will not accept probabilities. A different but related question which I would personally answer in a specific situation is 'would you interfere with the integrity of an organism?' My answer is ·Yes. When the interference can be shown to benefit the individual and or the community'. The sum of benefits makes up the ethics of my community.
P.D. Wall
PII 0304-3959(96)03l96-X
© 1996 International Association for the Study of Pain. All rights reserved 0304-39591961$15.00
Letters to the Editor PAIN 3236
Response to Editorial: New perspectives on the Definition of Pain
Thank you for the opportunity to comment on the editorial by Craig and Anand on 'New Perspectives on the Definition of Pain'. They present much important and interesting information about probable pain in those such as neonates who cannot tell us about it. 1 think it necessary only to deal with two aspects of the editorial which seem to me to present problems. First, the authors are correct in pointing out that the IASP defmition of pain states that the use of the word pain needs to be learned through experiences in early life. 1 agree with them that the perception of pain (whether associated with tissue damage or not) is an inherent quality of life itself and does not require prior experience in the first place. The definition does not mean that the experience of pain has to be learned, despite the interesting possibility that some part of it is learned. The definition simply indicates that we learn how to use the word. Second, the use of a word is not a statement of absolute truth but a statement of the way in which we employ a term. The term or word pain is universally used for a subjective experience and we can only know if someone has pain if they tell us truthfully that it is present. We can suspect the presence of pain - and indeed we can infer it with a high degree of probability - if we note certain circumstances and actions of living organisms which appear to be in pain as judged by their actions. This is less applicable by definition to unconscious organisms. Groaning under anaesthesia cannot indicate an awareness of pain. Anand and Craig seem to wish to rely upon behavioural responses, especially in the neonate, to furnish us with phenomena which can be included within the definition of pain itself. Yet the very words 'Pain behaviour' are often employed as a means to distinguish between external responses and the subjective condition. 1 am in sympathy with Anand and Craig in their wish to recognize that such types of behaviour are likely to indicate the presence of a subjective experience, but the behaviour can not be incorporated sensibly in the definition of a subjective event. Denying that pain behaviour means pain does not mean that 1 wish to throw out the baby with the bath water. Certain types of behaviour may be defined as probable pain indicators, albeit the baby should be both wincing and crying to qualify. We cannot assume that those responses would always be true pain indicators because there will be times when we do not know whether they indicate wind or anger rather than pain. We might talk of 'apparent probable pain' or even 'apparent very probable pain' and play with acronyms (I will not put them forward here) in the hope of finding an alternative term. For the present 1 think that that is the best that we can do. In
the mythical but perh~ps quite realistic future we may develop enough imaging capacity to be able to say that certain types of apparent pain behaviour match perfectly with the occurrence of pain in adults and physiological measurements made at the same time. Perhaps then we would be able to talk not just of 'pain like behaviour' but also of 'pain identical behaviour'. Until then pain remains a word which is both powerful, because of its restriction to the subjective state, and limited for that very reason. 1 agree of course, as Anand and Craig say, that the neonate's expression of unpleasantness does not fit within the strict definition of pain imposed by the requirements for self report and that this contributes to the failure to recognize pain and treat pain aggressively in infancy and early childhood. The remedy must be to seek better characterization of probable pain patterns or probable apparent pain patterns and to determine the benefits of treating those patterns with all seriousness. It is a misdirection of energy to attempt to change the meaning of a word that, so far as 1 can tell, has been used everywhere - or perhaps almost everywhere - in a particular way for thousands of years. Efforts should rather be directed to a steady improvement in the recognition of probable pain patterns and their predictive value in relation to treatment. H. Merskey, D.M.
PII 0304-3959(96)03236-X
PAIN 3196
Response to Editorial by Anand and Craig Drs Anand and Craig ask for an absolute yes or no answer to the question 'Is this organism in Pain?'. Dr Merskey provides a probabalistic answer 'It is very (very, very--) unlikely that this organism is in pain'. This type of question and answer is a quicksand to be avoided because those who require absolutes will not accept probabilities. A different but related question which I would personally answer in a specific situation is 'would you interfere with the integrity of an organism?' My answer is ·Yes. When the interference can be shown to benefit the individual and or the community'. The sum of benefits makes up the ethics of my community.
P.D. Wall
PII 0304-3959(96)03l96-X