Clinical Bioethics: Intellectual and Moral Tasks in Intersection: Part 2
by Mark V. Boswell, MD, PhD; Jill Kaspar; and James Giordano, PhD
What Is Sensed and What Is “Felt”
Pain originates as a sensory signal with unique adverse qualities, and the contribution of
these qualities to the pain experience is inextricable to the concept of pain qua
“pain.” As Nikola Grahek has stated “…the common and distinctive felt
quality of pain is the essential or indispensable component of our total pain experience
and why that experience is not pain experience when that component is missing.”1
Simply, without this sensation, the experience would not be “pain.” Suffering
without the sensation is possible and perhaps even common, yet we do not universally
classify this discomfort as pain. Other types of bodily discomfort such as nausea are
imbued with an aversive motivational quality and have the potential to cause suffering;
however, we can easily differentiate these discomforts from pain by the nature of the
sensation. However, the raw sensation of pain is only pain when it provokes an emotional
reaction. This component of the pain experience has been referred to by Melzack as the
“affective dimension,”2 and it encompasses the ways which pain
changes one’s relationship to the body, his/her existence, and
“being-in-the-world.” Similarly, Grahek speaks of the
“affective-motivational aspect”; Rodriguez notes the mental dimension of pain;
Woessner, through Caudill, includes the psychological/cognitive dimension3; and Moskovitz
holds that pain is experienced emotionally due to the “…habits, goals, desires,
expectations, roles, and attachments threatened by the experience (of pain).”4 Pain
changes the existential being of the patient through the intensity and discomfort of the
sensation, its impact on normal and enjoyed activities, and the meaning that the patient
ascribes to the pain, i.e. the patient’s evaluation of the pain. The problem of
differentiating between mind and body is not one we wish to treat here but, if there is
indeed a distinction to be made, it is clear that pain affects both body and mind in
fundamental ways.
Expression and Expectation
A necessary correlate to the aversive, affective quality of pain is the pain behavior that
it inspires. Woessner, Hardcastle, Turk, and Rudy all address the behavioral dimension of
pain,5-7 and attest that to understand pain, it is necessary to note and
appreciate its behavioral expression. Roselyn Rey states that “…the manner in
which pain is expressed has a direct relation to the way in which pain is actually borne,
how it is felt.”8 Clearly then, understanding a patient’s behavioral reaction to
pain is essential to clinical assessment and diagnosis. A physician must learn the
tendency of a particular patient toward stoicism or over-representation to correctly
interpret pain behaviors and verbal ratings.
Please refer to the May 2009 issue for the complete text. In the event you need to order a back issue, please click here.
— May 2009
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