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fering) may be a disorder of the brain that directly or indirectly
effects a condition of the expressed “mind.”
In this context, Moskovitz’s work becomes particularly
noteworthy. Based upon his clinical experience and the current
body of experimental and philosophical literature, Moskovitz
has developed a theory that localizes suffering to the cingulate
gyrus and adjacent limbic forebrain. Certainly, there is evidence
from recent neuroimaging studies to support the neuroanatomical
basis of his theory, at least in part (11, 12, 13). An interesting
dimension of Moskovitz’s thesis is its solidification of
suffering as a brain event that is evoked by hierarchical mechanisms
of pain, yet allows (indeed, encourages) a philosophical
interpretation of whether suffering represents a biological effect
of the brain state (i.e., a “physical kind”), or is a distinct property
(i.e., a “mental kind”) that exists as some nonmaterial construct
of consciousness. 5 Regardless it is knowable in its entirety
only to the sufferer: even if there were some way to completely
transpose the pattern of cerebral activation from one person
directly to another (e.g., from patient to clinician), the subjective
experience of that identical brain activation would still differ,
since the connectivities shaped by genotype and the myriad
of life experiences are so widely variant (14).
Thus, while Moskovitz’s theory is attractive because it establishes
a physiological basis and anatomy of pain as suffering, I
think that it also raises the question of whether suffering can or
will be knowable through solely objective means. The authentication
of suffering cannot exclusively rely on technology (4, 6,
15, 16), and it is here that this thesis to instigate somewhat
broader considerations. By validating suffering as a neurobiological
event, Moskovitz makes it resonant with the domain of
applied biology that constitutes much of the epistemological
basis for contemporary medicine. Yet, given that these neurobiological
substrates are in some way foundational to consciousness,
he astutely states that only contextual, intersubjective knowledge
can truly afford the clinician an understanding of the unique
nature of a person’s suffering. I agree, for the focus of the clinical
encounter is upon the patient, literally as “the one who suffers.”
Comprehending the complexity of such suffering involves
both scientific and humanistic inquiry and is fundamental to
the provision of technically right and morally good care. I maintain
that this is incontrovertible, and hope that this issue of The
Pain Practitioner provides a forum to stimulate thought and discussion
about the future possibilities that such care may offer. 6
REFERENCES
1. Giordano J. Bioethics and intractable pain. Practical Pain Management,
2005
2. Woolf CJ, Borsook D, Koltzenburg M. Mechanism-based classifications of
pain and analgesic drug discovery. In: C. Boutra, R. Munglani, WK
Schmidt (eds.) Pain: Current Understanding, Emerging Therapies, and
Novel Approaches to Drug Discovery. NY, Marcel Dekker, 2003, pp. 1-8.
3. Lippe P. An apologia in defense of pain medicine. Clin. J. Pain. 1998, 14
(3): 189-190.
4. Giordano J. Toward a core philosophy and virtue-based ethics of pain
medicine. The Pain Practitioner, 2005, 15(2): 59-66.
5. Sadler JZ. Diagnosis/anti-diagnosis. In: J. Radden (ed.) The Philosophy of
Psychiatry: A Companion. NY, Oxford University Press, 2004, pp. 163-179.
6. Giordano J. Moral agency in pain medicine: Philosophy, practice and
virtue. Pain Physician, 2006, 9: 71-76.
7. Pellegrino ED. For the Patient’s Good: The Restoration of Beneficence in
Health Care. Oxford, Oxford University Press, 1987.
8. Turk DC. Customizing treatment for chronic pain patients: who, what, and
why? Clin. J. Pain, 1990, 6: 255-270.
9. Giordano J. Pain research: Can paradigmatic revision bridge the needs of
medicine, science and ethics? Pain Physician, 2004, 7: 459-463.
10. Bonakdar R. Integrative pain management: A look at a new paradigm.
The Pain Practitioner, 2005, 15 (1): 15-18.
11. Bromm B. Brain images of pain. News Physiol. Sci. 2001, 16: 244-249.
12. Apkarian AV, Thomas PS, Krauss BR, Szeverenyi NM. Prefrontal cortical
hyperactivity in patients with sympathetically mediated chronic pain.
Neurosci. Lett., 2001, 311: 193-197.
13. Bingel U, Quante M, Knab R, Bromm B, Weiller C, Buchel C. Subcortical
structures involved in pain processing: Evidence from single-trial fMRI.
Pain, 2002, 99: 313-321.
14. Coghill RC, McHaffe JG, Yen Y-F. Neural correlates of inter-individual differences
in the subjective experience of pain. Proc. Nat. Acad. Sci., 2003,
100 (14): 8538-8542.
15. Reiser SJ. Medicine and the Reign of Technology. Cambridge, Cambridge
University Press, 1978.
16. Sullivan M. Exaggerated pain behavior: By what standard? Clin. J. Pain,
2004, 20 (6): 433-439.
5 The definitions of “kind” are used here in the philosophical sense to mean
a group of things or occurrences that have inherent qualities in common.
Thus, a “physical kind” refers to those things that are directly arising from,
and belonging to, a set of purely physiological events. In contrast, a “mental
kind” refers to those things that may have arisen from something physical,
but have an inherent and unique set of characteristics that separate
them from those things that are physiological. The latter characterization
formalizes that mental processes are different from physiological ones. This
distinction allows for the fact that consciousness may be emergent from the
physiological processes of neurons, but also gives substance to the idea that
conscious processes are in some way “more” than the result of the physiology
that may have produced them.
This speaks to the major “schools,” or orientations in contemporary science
and philosophy of mind, that range from the viewpoint that any mental
event is wholly reducible to a brain event (e.g., materialism and related
orientations of theoretically reductive physicalism), to some middle-ground
positions that allow that brain events produce mind events, but that mind
events have more expansive characteristics or are greater than the sum of
the events which produced them (e.g., nonreductive physicalism, property
dualism, emergence, complementarity) and at the other extreme, the idea
that there is a discernible mental field that occurs within the brain, but is
irreducible, and perhaps unknowable (e.g., strict dualism). There are several
issues in neuroethics that are related to the implications of these distinctions
(e.g., the nature of the “self,” self-determinism, free will, etc.).
The philosopher Colin McGinn claims that our study of the mind is at a
point of “cognitive closure,” given the inherent limitations of the contemporary
human brain. Instead, I prefer to think, optimistically, that we are on a
path of extended contemplation that allows us to gain ongoing insight from
an ever-increasing knowledge base achieved through widening collaboration
within, and between, multiple disciplines. Again, it is beyond the scope of
this paper to address the nature of consciousness, but one can see how this
discussion would nonetheless be important to the study of pain, suffering,
and the ethics of science and medicine.
6 Obviously, the extent of the topic of CRPS cannot be completely or fully
addressed in a volume such as this. For a thorough summary of mechanistic,
diagnostic, and therapeutic approaches to CRPS, see: Wilson PR, Stanton-
Hicks M, Harden RN (eds.) CRPS: Current Diagnosis and Therapy. Seattle,
IASP Press, 2005.
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