Geriatricians have solved the hard problem of consciousness! From the July 1st issue of American Family Physician: “Some validated scales, such as Pain Assessment in Advanced Dementia…use objective measures to assess pain intensity and response to intervention.” The objective measures: abnormal breathing pattern, increased vocalizations, observed tension in the face and body, and capacity to be calmed by caregiver voice and touch. In short, agitation is synonymous with pain. And how do we know this? Because the researchers have observed that opiates attenuated agitation in their subjects with advanced dementia. That’s how the scale and its underlying assumptions were validated at once.
Many have questioned the utility of philosophy. Well, here it is. The PAINAD scale is valid, no doubt. This is something that can be determined by definition. If two different people observe the same demented patient, it is quite likely, predictably likely, that the observers will come up with the same score on the scale. But that begs the question. The real problem is not coherence. Coherence does not make truth. The real problem is the truth of the claim that agitation represents pain in a person with advanced dementia. Such information is not available to us, at least not in the defined, quantifiable way which we would prefer.
We can’t know anybody’s pain, really. That’s because it is everybody’s pain that gives us the concept of pain in the first place. The sensation I experience when I grab an electric fence, for instance supervenes on the action of the fence charger, the conductivity of my body and the ground, activation of peripheral nocioceptors, mediation by inter-neurons in my spinal cord, and finally my thalamus and cortex where it is contextualized as my very own experience of shock. My experience of the shock from the fence, indeed all my pain experience, is unique. In the case of a shock from the electric fence, my experience is trivially unique – to the extent that I can predict my friend’s response if I tell him why he shouldn’t touch the fence. But the pain-concept supervenes on all those unique experiences in the same way that my own experience supervenes on the collection of events surrounding my hand’s contact with the wire. A thing called pain doesn’t appear out of the process. If that were so, I should have ready access to it and the PAINAD scale would be unnecessary. I would just slap some electrodes on the patient’s skull and watch for the pain signature in his cortical electrical activity. But I can’t, nor will I in the future, though I might have such a tool. Cortical electrical patterns might be the narrow point in the pain experience, the place where the difference in my experience and the patient’s is most trivial. But I must still correlate the activity with some report from the individual or a set of individuals in a similar condition. Some kind of PAINAD-type analogy will always be the best that I can do.
So what does this application of philosophy to pain treatment tell me? What use is philosophy? First, it tells me that I should not expect to fix everyone’s, or anyone’s, pain by stimulating their opiate receptors. The experience becomes pain-type only when it is put in context. We can easily imagine pain experiences where the opiate receptors play a very different role. Take the poet’s description of the pain of a broken heart. Do we write off his report entirely as a quaint analogy as opposed to our serious ones? If so, how is his report effective in communicating a sense of the experience to us? What do we say when we find out that he used laudanum and found some partial relief? Addressing the mechanisms of pain can only go so far, because mechanisms only go so far in explaining the painfulness of an experience.
The application of philosophy to pain can save me from a different pragmatist’s mistake in treating pain as well. I’ll pick on my surgical colleagues for a moment. On multiple occasions, I’ve had a surgeon tell me, “Nobody ever died from pain.” Inevitably, this little bubble of wisdom surfaces in reference to a patient whose pain management has passed from the surgeon to myself. My knee-jerk response is to point out that nobody ever died from hip arthritis either, but surgeons are still quite happy to replace hip joints. Yet I understand the pragmatic meaning of the statement: people have died from opiate overdoses, so we can’t just capitulate to a person’s demands for ever-increasing doses of opiates to treat their pain. As noted above, the notion that simply stimulating opiate receptors necessarily fixes pain is misguided. But there is a subtext. Death is measurable. Respiratory suppression due to opiates does something, and therefore it is real in way in which pain is not. When you get right down to it, pain can be ignored. But it isn’t that easy. The human condition won’t be ignored anymore than it will be medicated. The hard problem remains hard. It isn’t hard because our subjectivity is some spooky ectoplasm or narcissistic property. It isn’t hard because our experiences will never move a dial or tip a scale. It is hard because things which explain and are explained have a reality to them as much as things which do something, yet we’re stuck working with the functional things, like the observed behaviors in the PAINAD scale. So we have a tightrope to walk. We can only ever come close to helping others with problems like pain, and only then if we act comprehensively. We can never completely succeed. But that doesn’t mean we must fail. We can just never get too sure of ourselves when we do something like suppress a demented patient’s agitation with an opiate – and think we can call it good.
Dedicated to the Game
Climbing and other disturbing things.
Tag Archives: meaning
Can You Keep It Real?
On a cold morning, a little girl named Suzy is waiting for the School Bus at the bottom of a steep hill. It was raining the night before, and water has been flowing next to the curb. The water froze in the early hours of the morning, forming a sheet of black ice. The ice sheet extends all the way down to Suzy, and unfortunately for her, passes under the tires of a Cadillac Coupe DeVille parked in the middle of the hill. As the sun hits the hill, the ice loses its grip on the tires and the car slides silently and rapidly down the hill, striking Suzy and killing her instantly.
Now suppose the same chain of events ensues, except this time, the car breaks loose just as the cars owner, Andy, sits down in the driver’s seat and closes the door. The inside door handle is broken, so he can’t just jump back out again. The power windows are up and the horn doesn’t work, so he has no way to warn Suzy of her impending doom. He desperately turns the wheel, but it’s too slick for the tires to grab. Suzy dies just as in scenario #1.
Again, suppose the circumstances are the same, but this time, the owner of the car is different. Let’s call him Brian. When Brian realizes that he is sliding out of control, he thinks, “You know, I’ve always hated that little bitch anyway,” and he turns the wheel to direct the car toward little Suzy. Again, the tires have no purchase on the ice and the chain of events is unaltered.
Is there a moral distinction in the incident between the unoccupied car and the occupied car? Between the incident with Andy and the incident with Brian? If so, where is the independent and objective moral fact in each case?
To take things a little further, suppose Suzy doesn’t die. After the car launches her through the air, she manages to stick a perfect landing in the grassy median, apparently uninjured. But Suzy’s parents soon notice that something is amiss. When they ask her, “Did you enjoy your dinner dear?” she replies, “The meal was such that it would produce an enjoyable sensation in a person so disposed.”
When they ask her, “Are you comfortable dear?” she answers, “My condition is such that a person capable of it would feel cold.” Suzy appears completely impassive throughout. She eats, sleeps, and goes to school just like she did before the accident. A full medical workup turns up nothing. Gradually, Suzy’s parents stop feeding her anything fancy. She does not complain. They dress her in a burlap shift every day. She’s apparently fine with it. They turn off the heat in her room and only crank the thermostat back up if she begins shivering. They say they still love Suzy; the extras just don’t matter anymore.
Are Suzy’s parents behaving immorally? What is Suzy’s moral status and why?
Let’s go one step further. Suppose Suzy lands in a heap, but survives. She is apparently comatose. Her doctors think that they can help though. They begin an infusion of medication that will awaken her. As the medication flows into her vein, she bolts upright with a look of horror.
“What have you done?” she demands, “Put me back. I’ve been grown for years, I have children of my own and they need me.”
What should Suzy’s parents do? Does Suzy’s inner world have any value? If so, why? If not, why?
The Chthonic
It had a periodicity to it, but not like anything man-made. Instead, it was like a geyser. As it rose to the surface it swirled chaotically around hidden shelves and side-channels, so its interval was uneven. The uncertainty contributed to our tension, the nephew’s most of all.
“Yeeeeeeeeeee!” she screeched, then closed her mouth and relaxed again.
Between screams, she looked as peaceful as a Buddha. Perhaps, her caretakers speculated, the discomfort of prolonged immobility or some occult infirmity drove the screaming. We had given her increasing doses of pain medication, to no avail. Perhaps she somehow had enough consciousness remaining to experience the dislocation of facing the present without access to the immediate past, not knowing moment to moment how she got in the bed, why she felt like she did, whose arm lay at her side, whose mouth was screaming. We had given her anxiolytics and she just kept screaming. Perhaps she was bedeviled by visions. We gave her our best potions against inner demons and her timing did not falter.
“This is Hell,” said the nephew, “She is in Hell. I want this to stop.”
She had chosen well, or someone had. Sometimes, the decision about who would oversee the death defaulted to hereditary proximity, geographic factors, and availability. This nephew had some connection to her beyond practicality. Of course, he spoke for himself. No one knew what her vocalizations signified. We had taken our best guesses and come up short. What he wanted now was not a treatment. He wanted a cure for it all. To be clear, it was not euthanasia he was requesting. He wanted us to ablate whatever remained of her consciousness. He wanted oblivion, or at least its appearance.
It wasn’t killing, but it was taking something away from someone who appeared to have so little. We were always wary of treating extrinsic things, of giving medications to fix a person’s bad relationships or discomfort with herself. It was different for the dying though.
Everything was becoming extrinsic for her. She couldn’t be crying out for something. That time had passed. At best, her screams expressed something which we could not know, but something which was less specific, less relevant to anything inside, as she came closer to death.
He was right. The screams meant what he said: this is Hell; I want this to stop. I had an obligation to her and no choice in the matter. Of course he spoke for himself.
“I will do as you wish,” I said.
Being and Waspishness
In the Fall, our crags are swarming with wasps. Their source is a mystery. It is rare to see wasp nests in the cracks and pockets in the limestone, and when found, the nests are no bigger than a newborn’s clenched fist. The volume of the Fall swarms doesn’t comport with the numbers seen over the Summer. The wasps in Fall also differ in quality from the busy, irritable creatures encountered in Summer. The Autumn wasps are less likely to sting, but they are also harder to shoo away. When threatened, they flare their wings and wave their antennae.
A bunker mentality seems to have taken hold of them, perhaps as a consequence of excessive introspection, depression even. In flight, they behave with no less aimlessness than when clinging to the stone. They waft from perch to perch in short hops, always staying within a few feet of the crag, extending the arc of their flight only if they encounter another intransigent insect where they would land. They are not hunting, and do not appear to engage in courtship or any other purposeful behavior in the course of their days.
To the climbers who persist at the crags through the cooling season, the wasps look a feckless lot. Some observers go so far as to advocate swatting the insects on principle, as the wasps have lost their purpose and are simply waiting to die. Why let them suffer?
The Grand Auger, who sacrificed the swine and read omens in the sacrifice, came dressed in his long dark robes to the pig pen and spoke to the pigs as follows: “Here is my counsel to you. Do not complain about having to die. Set your objections aside, please. Realize that I shall now feed you on choice grain for three months. I myself will have to observe strict discipline for ten days and fast for three. Then I will lay out grass mats and offer your hams and shoulders upon delicately carved platters with great ceremony. What more do you want?”
Then, reflecting, he considered the question from the pigs’ point of view: “Of course, I suppose you would prefer to be fed with ordinary coarse feed and be left alone in your pen.”
But again, seeing it once more from his own viewpoint, he replied: “No, definitely there is a nobler kind of existence! To live in honors, to receive the best treatment, to ride in a carriage with fine clothes, even though at any moment one may be disgraced and executed, that is the noble, though uncertain destiny that I have chosen for myself.”
So he decided against the pigs’ point of view and adopted his own point of view, both for himself and for the pigs also.
How fortunate, those swine, whose existence was thus ennobled by one who was at once an officer of the state and a minister of religion.
– Zhuang Zi as translated by Thomas Merton
The same sentiment applies to the wasps. Trivially, some of the wasps which a climber sees in Fall are foundresses of next Spring’s colonies. No one would question their having a meaningful existence, in wasp terms. They represent the sisters passed, of the colony that bore them and back down the line. When we say ‘meaning’ in regard to a creature’s existence, we imply just such a representation on the creature’s part. After all, meanings don’t have meanings, symbols do. When we speak of purpose in the same context, we refer to the relationship between the representation and the meaning behind it, with the purpose of the representation being to signify the meaning.
Next Spring’s founding females have a purpose: to represent their colonies of origin and so on, in the genes they express, the ova they carry, and the smells they remember. The colony is gone but the intention of the colony remains, represented by the heiress.
People are no different. We represent our backgrounds and their intentions. We try to live up to our potential, what we are born with and what we acquire by learning. For us, as for the wasps, this representation is always in the present, pulling at the intention groping behind it. The colony’s heiress begins her own take on her mother’s colony. Her ownership changes the intention a bit. Her smell is a little bit different. Depending on what confronts her in the Spring, she may recruit the help of her fellow survivors to start her nest or usurp another’s. No matter, the next generation will recall a different ideal in its turn. We too, will try to live up to the tales of the deeds of our ancestors (by blood or tradition), rather than the deeds themselves, and the tales of the tales and so on.
But where does all this leave the true left-overs, the workers who will soon die in the cold? For them, the colony is lost forever. They represent the end. No one could blame the human observer for imagining these insects as little Macbeths, with their petulant defense of limestone cubby-holes and their swarming a soliloquy pleading for release from the futile farce which their lives have become, maybe which their lives have been from the start.
Still, they fly. They utilize the behaviors passed to them as social insects in their new context. They sting if pressed. They taste the air for familiar scents. They seek the light and shade with the progression of heat through the day. For their part, they signify the heritage of social insects as much as the females who will survive the Winter. If they have lost anything by losing the meaning and purpose of their role in the nest, it wasn’t much.
All representations work this way and the losses associated with any loss of significance are no more than the losses a cipher suffers in moving from one equation to another. When we pose the question, “Why should we let them suffer?”, the wasps might answer us like little Mallorys rather than little Macbeths: “Because I’m here.” That is exactly what they are saying when they wave their antennae at an approaching hand.
Dedicated to the Game 