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Thursday, April 07, 2011

New Company Markets Brain-Based Pain Assessment

I have written here and here about the pursuit of more objective methods of measuring experiences like pain.  While research is moving along quite rapidly, neuroscientists are not yet doing the sorts of experiments we really need to know how well these techniques will work.  For example, the best experiments for forensic purposes would have researchers blinded to subjects' background determine, say, which individual subjects are chronic back pain sufferers and which are not based only on brain imaging and associated number crunching.  Most experiments are not designed to be so crisp and clean.  Moreover, rarely do neuroscientists test how well subjects can develop countermeasures to try to fool whatever measurement technique is being investigated. 

Private enterprise, however, has no plans to wait until scientists perfect methods of brain-based pain assessment.  In fact, a recently-formed company, Chronic Pain Diagnostics, is already marketing a method of brain-based pain assessment associated with this patent.  And there has been at least one worker's compensation case where an injured employee seriously explored hiring experts to provide brain-based evidence of pain (though the case settled).  It's just a matter of time before courts and administrative agencies have to evaluate the merits of these new forms of evidence.

Posted by Adam Kolber on April 7, 2011 at 12:21 PM | Permalink

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Thanks for bringing the existence of this company to my attention, Adam!

Given our prior discourse on this subject, I'm sure you know that I am far less sanguine on the prospects of neuroscientists perfecting methods of brain-based pain assessment. This is itself an impossibility in time and space since pain cannot be assessed by techniques that seek to objectify a quintessentially subjective experience.

And the fact that pain sufferers themselves desire such proof is well-documented in the ethnographic literature on chronic pain sufferers, and speaks to the general intolerance and stigma of subjective knowledge of the body. As I have argued, there is a grotesque irony in this fact inasmuch as it is precisely that intolerance that is a primary culprit in the devastating and widespread chronic pain stigma in American society.

Posted by: Daniel S. Goldberg | Apr 7, 2011 4:00:52 PM

Hi Daniel,

I never expressed optimism that neuroscientists will "perfect" methods of brain-based pain assessment. It appears, though, that I am much more optimistic than you are about the prospects of developing *more objective* methods of pain assessment. That goal is much more feasible.

Putting aside the goal of perfection, we measure subjective experience all the time. Restaurant critics report on the quality of flavors. Doctors prescribe pain killers. In the absence of any grounds for assessing the pain of another person, I don't know how doctors would prescribe various pain killers at various dosages. No one is suggesting that these assessments of pain are always accurate. But we make judgments about the experiences of others all the time. Brain-based pain assessments will simply seek to make these judgments more accurate in cases where subjects cannot adequately communicate their pain or have incentives to lie.

And, yes, to be sure, more objective assessments of pain could, in principle, be used both to challenge malingered claims *and* support genuine claims of pain.

Posted by: Adam Kolber | Apr 7, 2011 4:15:58 PM

Adam,

Surely the meaning of “measure” in “restaurant critics report on the quality of flavors” and its meaning in technological “brain-based pain assessments” is quite different. The latter appears to have the goal of using “numbers” (i.e., more ‘objective’ criteria) to virtually displace clinical judgments and subjective reports, both of which may have some measure of uncertainty, ambiguity, vagueness, and so on. I’m still not convinced that neuroscientists are measuring what we intimately experience as “pain” rather than what techno-science “pictures” or brain-imaging inform us of the brain activity of subjects who are thought to be experiencing pain. What licenses the inference that these brain reports, as it were, are equivalent to the pain that subjects experience? The experience of pain involves conscious states of the mind and consciousness itself is not amenable to scientific measurement, only brain states that correlate with states of consciousness, particularly if we believe the mind is not reducible to or identical with the brain.

To be sure, we can often know when others are in pain and pain is not an inviolably private matter or involving first person privilege insofar as there exists (as Wittgenstein reminded us) a “language of pain.” And we might say that pain is in some sense and level physiologically realized in both “lower-level events” (say, at the cellular level) in the body as well as in “upper-level events” in the brain. Still, I don’t see how this gives us sufficient or reliable information for what one is subjectively experiencing AS pain, apart from saying that someone is experiencing pain full stop. In other words, at most one might say we have prima facie scientific evidence on the order of inductive correlations that someone may be experiencing pain (as in cases where someone is unable to communicate same) but this is not necessarily an objective measurement or sufficient account of the pain that subject is actually experiencing (or possibly not experiencing if they are considerably less than conscious), even if it is a measurement of some sort. What is being measured by brain-imaging techniques is not necessarily equivalent to what we intend to mean when we say someone is in pain or when I communicate through words and gestures that I’m in pain. Personally, I’d be happy to rely on a clinician’s judgment sans such techniques insofar as I can’t see how they really add anything more reliable than what we find in our normative accounts of clinical judgment. Pain has properties at once physiological and psychological, and to the extent that it involves the latter it remains recalcitrant with regard to scientific measurement unless we choose to reduce the mind to the brain or find “mind-talk” redundant in light of our possession of brains (as in eliminativism).

Posted by: Patrick S. O'Donnell | Apr 7, 2011 7:31:33 PM

Patrick,

You are implying that I have lots of views that I don't have and which are certainly not reflected in anything I've written. For example, you write, "What licenses the inference that these brain reports, as it were, are equivalent to the pain that subjects experience?" I never said that they were equivalent. The issue is whether we can make reliable inferences about a person's experiences based on certain data about their brain activity. These inferences need not be 100% reliable. They need only be cost-effective supplements to the methods we already use.

You also wrote, "Personally, I’d be happy to rely on a clinician’s judgment sans such techniques insofar as I can’t see how they [meaning brain imaging techniques] really add anything more reliable than what we find in our normative accounts of clinical judgment." The point of my post is to describe research AIMED AT identifying techniques that will be better than relying solely on clinical judgment. If the techniques fail to improve on clinical judgment, then surely they do fail. But they will fail because the science isn't (yet) good enough, not because the task is somehow fundamentally impossible. Once you acknowledge that clinicians' judgments have some (non-zero) level of reliability, then the game is over, for clinicians rely on inferences about a person's pain from facts about their anatomy, behavior, and so on.

Posted by: Adam Kolber | Apr 8, 2011 5:21:25 AM

Adam,

I don’t think I attributed nor did I intend to attribute “lots of views” to you, rather my point was that while I can agree that “The issue is whether we can make reliable inferences about a person’s [in this case ‘pain’] experiences based on certain data about their brain activity,” the belief one can make reliable inferences of this sort is tethered to arguable assumptions about the relation between the mind and the brain, irregardless of whether or not you yourself hold such beliefs. The questions I raised in this regard were not directed to you in particular, although it may turn out you hold arguable or contestable beliefs (as most of us do) about the brain-mind relation and at least one or more of those beliefs are what allow one to think that reliable inferences regarding a subject’s experience of pain (after all, we’re still referring to a subject’s pain experience, are we not?) are possible in the first place. Assuming we could make such inferences, I would not hold them to a “100% reliable” standard, but I obviously think it’s eminently questionable that we can make useful inferences of any sort from these techniques that would prove availing for medical purposes, in other words, that would trump or supersede a clinician’s judgment sans brain imaging technology or supplement such judgment in a medically meaningful way and thus contend the medical profession has nothing to gain from such technology, at least with regard to making inferences about a subject’s experience of pain.

Perhaps I failed to get the point of your post, but I certainly read it as “describ[ing] research AIMED AT identifying techniques that will be better than relying solely on clinical judgment,” and thus my point is that I think such research is mistaken or misguided because the techniques as described are by the very nature incapable of adding anything of value to clinical judgment regarding the subject’s experience of pain owing to the fact that their deployment in the first instance as (possibly) capable of producing something clinically useful depends upon arguable assumptions about the brain-mind relationship, and thus only if one subscribes (explicitly, covertly, or unknowingly) to what (in philosophy of mind) are described as reductionist and naturalist or eliminativist premises of one kind or another is one going to believe that one day such techniques might play a role in aiding and abetting clinical judgment. But if one thinks these premises are problematic, believing, as I happen to, that the psychological and phenomenological properties of pain are importantly other or more than can be sufficiently captured by inductive correlations from brain-imaging reports, then one is going lack any faith whatsoever about the future medical benefits envisaged in this techno-scientific enterprise. And thus I clearly believe, rightly or wrongly, that (as described) this is in fact a fruitless scientific endeavor.

Posted by: Patrick S. O'Donnell | Apr 8, 2011 9:15:30 AM

erratum (penultimate sentence of last para.): "going to lack any faith whatsoever in the future medical benefits envisaged...."

Posted by: Patrick S. O'Donnell | Apr 8, 2011 9:38:59 AM

Hi Adam,

I am fairly sure I neither said nor implied the impossibility of measuring subjective experiences. Such a claim would of course be absurd. What I said is that techniques that seek to capture subjective experiences via objectification are ultimately incoherent. Thus the examples you cite are inapposite, since they are all wonderfully subjective means of assessing subjective experience. There is nothing problematic or surprising about this.

But the neurolegalists' claims about fMRI are quite different, since the hubbub resides in the claim that through them one can obtain objective evidence of subjective experiences like chronic pain. This is error, and much of the reason for the error rests on the dubious conceptions of mind and brain that generate the apparent optimisim, as numerous commentators have pointed out (e.g., Glannon, Pardo and Patterson, and Patrick here in the comments).

Posted by: Daniel S. Goldberg | Apr 8, 2011 10:02:00 AM

Patrick,

I can understand being pessimistic about the current state of the science, but I don't understand how I am relying on controversial mind-brain premises, other than those we already rely on when allowing clinicians to testify about the pain of litigants. (Since you seem to accept the use of clinicians' judgments in this context, I take it we share sufficient premises that I have demonstrated the *theoretical possibility* of using brain imaging to help assess pain.)

We can even imagine a test to determine whether traditional clinical approaches are better or worse than brain-imaging approaches. We take subjects who have no incentives to lie about their pain (and have whatever other indicia of reliability you'd like) and classify each as either a chronic pain sufferer or a control. We can also train the controls to pretend like they have chronic back pain and instruct them in methods of fooling traditional clinicians and methods of fooling researchers who use brain imaging tools. Then, we have our experts examine and classify each subject and compare the performance of traditional clinicians to the neuroscientists and see who does a better job. Where's the problem?

Daniel,

It's true that some people speak inartfully of "seeing pain" in brain images or of identifying a region of the brain with pain itself. But I think that: (1) it means your comment speaks not to the technology of brain-based pain assessment and its scientific merits but rather to the way people describe what the technology does and (2) I believe that at least some of the instances that you and some of the other authors you cite would identify as errors are simply instances where people speak metaphorically or casually.

I'm all for precision in the way we think and speak about the world. But you cannot assume that everyone is using "subjective" and "objective" in the same way that you are. For example, when I say that brain-based methods of pain assessment may someday give us more objective methods of assessing pain, I simply mean that they may someday be cost-effective supplements to other techniques we use now in a way that improves our accuracy.

Posted by: Adam Kolber | Apr 8, 2011 11:11:41 AM

Adam,

I'm not sure there's anything I can say at this point to advance the discussion or further illuminate the terms of our disagreement. And while quite a bit can be conceded to the realm of "theoretical possibility," not everything that happens to fall within that rubric is worthy of translation into clinical and legal praxis. As to what has been or is allowed in the courtroom, I'll defer to your expertise here although I'm sure there's occasions in which the philosophical and psychological premises either assumed or relied upon in such cases would trouble me owing to several arguments culled from the philosophy of mind (arguments that, admittedly, are not regnant today among those working in this branch of philosophy).

With regard to the test you imagine, again, owing to my understanding of the mind and the nature of pain that follows from that understanding I don't think there's any scientific or empirircal test capable of adjudicating the respective merits of the argument, this being, at bottom, at least from my vantage point, a question of normative conceptual disagreement not amenable to empirical testing: the neuroimaging simply doesn't allow us to make the inferences you imagine it to be capable of making, unless we grant, as I'm not willing to do, that the phenomenological and psychological properties of consciousness, and by extension pain, are in the relevant sense at bottom physical or material (or 'naturalized'). Those holding positions currently predominant within the philosophy of mind christend, for instance, as emergentism, epiphenomenalism, and supervenience (nonreductive physicalists complicate matters a bit here: I've not the time to address that, especially in a blog comment), may find reason to endorse the use of such techniques or believe that an empirical test might help settle such matters, but I think they're profoundly mistaken, for there's no empirical test capable of decisively confirming their respective positions in the philosophy of mind, as their arguments are not themselves on the order of hypotheses awaiting confirmation/disconfirmation, waiting to rise or fall, in other words, on the basis of (allegedly) relevant evidence.

By way of conclusion from my end, as long as the centrally important properties of the mind, namely, consciousness, intentionality and normativity are not reducible to what the brain does, so long as we'll not be able to rely on neuro-imaging techniques to make the putatively more "objective" pain assessments by way aiding clinical judgments in the manner envisioned.

Posted by: Patrick S. O'Donnell | Apr 8, 2011 3:14:07 PM

Back Pain types of situations are very painful we get relief from these types of situations by doing regular exercises.

Posted by: Upper Back Pain Treatment | Aug 3, 2011 5:53:38 AM

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