There has been a lot of discussion about our painful essay, “Questioning Border In the midst of suffering.” We have argued that pain is not the only cause of suffering, but that the two have a more complex relationship that is mutually dependent. This stems in part from our decades of caring for patients with chronic pain. The standard view of many patients and doctors is that these patients have one central problem, chronic pain, from which all their other problems flow. But these patients have many problems: medical problems, psychological problems and social problems that feed each other. They have both real pain and real suffering.
Modern pain medicine clinicians are accustomed to understanding the suffering caused by pain with pain reduction as the primary means of pain management.. When the relationship between pain and suffering is understood as bidirectional, suffering can be understood as a cause as well as an effect of pain. Suffering and pain can be relieved by changing the meaning as well as reducing the intensity of the emotions. More than 300 years ago, René Descartes initiated the modern mechanistic understanding of pain with his illustration Treatise on man from the boy whose foot was in the fire. This image has created a scientific ideal of meaningless pain mechanisms that must be rejected. We need to put Descartes’ boy with his foot on fire back into context to explain why his foot is on fire and also how the flame causes pain. Years ago, pain pioneer Patrick Wall compared how a person feels after hitting their thumb with a hammer to how it feels after someone else hits their thumb with a hammer. This difference cannot be explained by the Cartesian model.
Some pain experts continue to argue that we cannot explain pain without reference to tissue damage and nociception (nerve activation associated with tissue damage). This ignores some very common chronic pain syndromes fibromyalgia. These are considered a type of “nociplastic” pain that originates from processes in the brain and may involve no tissue damage or nociception. It is believed that this type of pain has particularly weak links to tissue damage and strong links to psychology injury.
These pain experts argue that both suffering and pain are experiences, not “things” that can cause other things, events, or experiences. This is a version of the philosophical doctrine of “epiphenomenalism,” which recognizes mental experiences like pain as real but denies them any causal power. According to this view, the brain creates experiences that do not affect brain processes or anything else, including voluntary actions (which are considered illusions). This view considers only mechanical causes as real causes, since only they hit each other like billiard balls. Furthermore, we must ask, if experiences such as pain do not have causal power, how did they evolve and persist? How can the evolution of pain be explained if pain has no causal power or survival value?
Our main argument is that we have too easily separated suffering from pain and understood suffering as a product of the cause of pain. In its purest form, this perspective depicts pain as the product of impersonal causes (such as tissue damage and nociception) and suffering as the product of personal meanings (such as threat, danger, and loss). But this does not correspond to modern pain neurologyrather than the complex interplay of pain and suffering encountered in the clinical practice of pain medicine and pain psychology.
Perhaps we should credit suffering as a cause of pain to nociception. This transition to chronic pain will be easier than acute pain. But therein lies a major unsolved problem in pain medicine. Indeed, some of the newer psychotherapies for pain, such as pain management Therapy (PRT) and Feelings Awareness and Expression Therapy (EAET), practices targeting threat, danger and trauma as a means of pain relief.
This subordination of pain to suffering undermines the medical model underlying most pain medications. It stops prioritizing pain as the physical cause of suffering. Instead, it subsumes pain under suffering, understood as an inevitable feature of human existence. This is similar to the Buddhist understanding of suffering philosophy as described in The Four Noble Truths. The first of these is the Truth of Suffering (Dukkha). It states that life naturally involves dissatisfaction, pain and instability. This includes physical pain, emotional distress, and incomplete pleasure. The rest of the truths explain that suffering is caused by desire, desire, and desire attachment to temporary things. And that suffering can be ended by letting go of craving and attachment.
This is not to suggest that pain medication be turned into a form of religion. It is only to suggest that if we move suffering from the periphery of our clinical and research concerns to the center.
