Pain

Pain and posttraumatic stress disorder frequently co-occur but underlying mechanisms are not clear. This study aimed to test the development and maintenance of pain and PTSD symptom clusters, i.e., intrusions, avoidance, and hyperarousal. The longitudinal study included 216 adults with burns. PTSD symptom clusters, indexed by the Impact of Event Scale-Revised, and pain, using a graphic numerical rating scale, were measured during hospitalization, 3 and 6 months post-burn. Cross-lagged panel analysis was used to test the relationships between pain and PTSD (...) symptom clusters. Cross-lagged results showed that in-hospital intrusions predicted pain and avoidance 3 months post-burn. In-hospital pain predicted intrusions and avoidance 3 months post-burn and a trend was found for hyperarousal. In the second wave, intrusions predicted pain and hyperarousal. Pain predicted hyperarousal. This study provides support for an entangled relationship between pain and PTSD symptoms, and particularly subscribes the role of intrusions in this bidirectional relationship. To a lesser extent, hyperarousal was unidirectionally related to pain. These results may subscribe the driving role of PTSD, particularly intrusions, which partly supports the Perpetual Avoidance Model. (shrink)

According to the evaluativist theory of bodily pain, the overall phenomenology of a painful experience is explained by attributing to it two types of representational content—an indicative content that represents bodily damage or disturbance, and an evaluative content that represents that condition as bad for the subject. This paper considers whether evaluativism can offer a suitable explanation of aversive auditory phenomenology—the experience of awful noises—and argues that it can only do so by conceding that auditory evaluative content would be guilty (...) of widespread error. Defending such an error-theory, moreover, comes with several explanatory costs. (shrink)

Several influential philosophers and scientists have advanced a framework, often called Neo-Cartesianism (NC), according to which animal suffering is merely apparent. Drawing upon contemporary neuroscience and philosophy of mind, Neo-Cartesians challenge the mainstream position we shall call Evolutionary Continuity (EC), the view that humans are on a nonhierarchical continuum with other species and are thus not likely to be unique in consciously experiencing negative pain affect. We argue that some Neo-Cartesians have misconstrued the underlying science or tendentiously appropriated controversial views (...) in the philosophy of mind. We discuss recent evidence that undermines the simple neuroanatomical structure-function correlation thesis that undergirds many Neo-Cartesian arguments, has an important bearing on the recent controversy over pain in fish, and places the underlying epistemology framing the debate between NC and EC in a new light that strengthens the EC position. (shrink)

Pain is often used as the paradigmatic example of a phenomenal kind with a phenomenal quality common and unique to its instantiations. Philosophers have intensely discussed the relation between the subjective feeling, which unites pains and distinguishes them from other experiences, and the phenomenal properties of sensory, affective, and evaluative character along which pains typically vary. At the center of this discussion is the question whether the phenomenal properties prove necessary and/or sufficient for pain. In the empirical literature, sensory, affective, (...) and evaluative properties have played a decisive role in the investigation of psychophysical correspondence and clinical diagnostics. This paper addresses the outlined philosophical and empirical issues from a new perspective by constructing a multidimensional phenomenal space for pain. First, the paper will construe the phenomenal properties of pains in terms of a property space whose structure reflects phenomenal similarities and dissimilarities by means of spatial distance. Second, philosophical debates on necessary and sufficient properties are reconsidered in terms of whether there is a phenomenal space formed of dimensions along which all and only pains vary. It is concluded that there is no space of this kind and, thus, that pain constitutes a primitive phenomenal kind that cannot be analyzed entirely in terms of its varying phenomenal properties. Third, the paper addresses the utility of continued reference to pain and its phenomenal properties in philosophical and scientific discourses. It is argued that numerous insights into the phenomenal structure of pain can be gained that have thus far received insufficient attention. (shrink)

The following argument is widely assumed to be invalid: there is a pain in my finger; my finger is in my mouth; therefore, there is a pain in my mouth. The apparent invalidity of this argument has recently been used to motivate the conclusion that pains are not spatial entities. We argue that this is a mistake. We do so by drawing attention to the metaphysics of pains and holes and provide a framework for their location which both vindicates the (...) argument’s validity and explains why it appears invalid. To this end, we show that previously proposed explanations for the apparent invalidity of the argument fail. Moreover, we show that our account accommodates and explains seemingly opposing linguistic data. We conclude that the ‘pain-in-mouth argument’ does not undermine the view that pains are spatial entities. (shrink)

Do we remember what pain feels like? Investigations into this question have sometimes led to ambiguous or apparently contradictory results. Building on research on pain memory by Rohini Terry and colleagues, I argue that this lack of agreement may be due in part to the difficulty researchers face when trying to convey to their study's participants the type of memory they are being tasked with recalling. To address this difficulty, I introduce the concept of 'qualitative memory', which, arguably, is the (...) sort of memory we have of what red looks like yet lack with respect to pain. I also briefly address a number of consequences the acknowledgment of qualitative memory would potentially have for philosophy, arguing that if we fail to have qualitative memories of certain sensations, such as pain, the standard philosophical accounts of experience, rational choice, and the sources of moral action may all need revision. (shrink)

Bodily sensations, such as pain, hunger, itches, or sexual feelings, are commonly characterized in terms of their phenomenal character. In order to account for this phenomenal character, many philosophers adopt strong representationalism. According to this view, bodily sensations are essentially and entirely determined by an intentional content related to particular conditions of the body. For example, pain would be nothing more than the representation of actual or potential tissue damage. In order to motivate and justify their view, strong representationalists often (...) appeal to the reliable causal covariance between bodily sensations and certain kinds of bodily conditions or to the corresponding biological function that these bodily sensations are supposed to fulfill. In this paper, I argue on the basis of recent empirical research that arguments from reliable causal covariance and biological function cannot motivate the introduction of corresponding intentional content. In particular, I argue that bodily sensations are caused by a heterogeneous class of physiological and psychological factors and their biological functions are too diverse to be reduced to the representation of a particular bodily condition. Responses are available to strong representationalists, but they either require substantial alterations to their core assumptions or incur a significant empirical burden. (shrink)

The surface grammar of reports such as ‘I have a pain in my leg’ suggests that pains are objects which are spatially located in parts of the body. We show that the parallel construction is not available in Mandarin. Further, four philosophically important grammatical features of such reports cannot be reproduced. This suggests that arguments and puzzles surrounding such reports may be tracking artefacts of English, rather than philosophically significant features of the world.

Nanay (2017) argues for unconscious mental imagery, inter alia based on the assumption that successful performance in imagery tasks requires the manipulation of mental imagery. I challenge this assumption with the help of results presented in Shepard and Metzler (1971), Zeman et al. (2010), and Keogh and Pearson (2018). The studies suggest that imagery tasks can be successfully performed by means of cognitive/propositional strategies which do not rely on imagery.

Dans On What Matters Parfit défénd un objectivisme moral sur lequel il espère que les philosophes finiront par converger. Au cœur de cet espoir sont des vérités normatives irréductibles telles que l’affirmation que la souffrance est intrinsèquement mauvaise. Parfit se demande si Nietzsche menace son édifice et lui consacre un chapitre entier chapeautant la discussion du désaccord moral et de la convergence, et conclut que Nietzsche soit n’est pas en vrai désaccord, soit ne raisonne pas dans des conditions satisfaisantes. Je (...) mets ici à l’épreuve la prédiction de convergence de Parfit et montre que Nietzsche pose une menace encore plus sérieuse que ne le prétend Parfit. Je montre que l’idée que la souffrance peut être bonne est intelligible, cohérente et plus complexe que la lecture de Parfit ne le révèle. (shrink)

We examine conceptual and methodological problems that arise in the course of the scientific study of possible influences of religious belief on the experience of physical pain. We start by attempting to identify a notion of religious belief that might enter into interesting psychological generalizations involving both religious belief and pain. We argue that it may be useful to think of religious belief as a complex dispositional property that relates believers to a sufficiently thick belief system that encompasses both cognitive (...) and non-cognitive elements. Such a conception of religious belief is more likely to correlate with psychological properties of believers that are both sufficiently shared and sufficiently unique to distinguish their psychology from believers in another religion or from non-believers. If the dispositional psychological property that constitutes religious belief does influence pain, then our analysis suggests that it doesn’t do so directly but rather through one of its occurrent manifestations. We offer a taxonomy of the different ways in which occurrent states of belief or experience may interact with physical pain, and we try to identify those that are more interesting or promising. We then proceed to employ the conceptual framework we developed to some of the existing evidence about the neural and psychological correlates of religious belief and experience, and about the cognitive modulation of physical pain. Finally we turn to analyse two experiments that directly investigated the relation between religious belief and pain. We draw attention to the limitations of existing evidence and end by suggesting directions for future conceptual and empirical inquiry. (shrink)

Health care providers are expected both to relieve pain and to provide anticipatory guidance regarding how much a procedure is going to hurt. Fulfilling those expectations is complicated by the cognitive modulation of pain perception. Warning people to expect pain or setting expectations for pain relief not only influences their subjective experience, but it also alters how nociceptive stimuli are processed throughout the sensory and discriminative pathways in the brain. In light of this, I reconsider the characterization of placebo analgesia (...) as pharmacologically inert and the use of it as deceptive. I show that placebo analgesia exploits the same physical mechanisms as proven analgesics and argue that it should be utilized to relieve pain. Additionally, I describe factors to help identify situations in which clinicians have the obligation to disclose the potential for pain coupled with ways of mitigating the risk of high-intensity pain by setting positive expectations. (shrink)

In a series of recent publications, orofacial researchers have debated the question of how ‘bruxism’ should be defined for the purposes of accurate diagnosis and reliable clinical research. Following the principles of realism-based ontology, we performed an analysis of the arguments involved. This revealed that the disagreements rested primarily on inconsistent use of terms, so that issues of ontology were thus obfuscated by shortfalls in terminology. In this paper, we demonstrate how bruxism terminology can be improved by paying attention to (...) the relationships between (1) particulars and types, and (2) continuants and occurrents. (shrink)

To cause pain, it is not enough to deliver a dose of noxious stimulation. Pain requires the interaction of sensory processing, emotion, and cognition. In this paper, I focus on the role of cognition in the felt intensity of pain. I provide evidence for the cognitive modulation of pain. In particular, I show that attention and expectation can influence the experience of pain intensity. I also consider the mechanisms that underlie the cognitive effects on pain. I show that all the (...) proposed mechanisms of pain modulation affirm the view that cognition impacts the sensory and discriminative aspects of pain. I conclude that pain perception is a cognitively penetrated phenomenon. (shrink)

While it is widely agreed that the infliction upon innocents of needless pain is immoral, many have argued that, even though nonhuman animals act as if they feel pain, there is no reason to think that they actually suffer painful experiences. And if our actions only appear to cause nonhuman animals pain, then such actions are not immoral. On the basis of the claim that certain behavioural responses to organismic harm are maladaptive, whereas the ability to feel pain is itself (...) adaptive, this article argues that the experience of pain should be viewed as the proximate cause of such occasionally maladaptive behaviour. But as nonhuman animals also display such maladaptive traits, we have reason to conclude that they feel pain. Hence, we have reason to hold that it is indeed possible to inflict needless pain on nonhuman animals, which would be immoral. (shrink)

People seem to perceive and locate pains in bodily locations, but also seem to conceive of pains as mental states that can be introspected. However, pains cannot be both bodily and mental, at least according to most conceptions of these two categories: mental states are not the kind of entities that inhabit body parts. How are we to resolve this paradox of pain? In this paper, I put forward what I call the ‘Developmental Challenge’, tackling the second pillar of this (...) paradox, i.e. the introspectionist view of pain according to which genuine pain reports are introspective reports. This view forms an inconsistent triad with two other widely held positions: young children make genuine pain reports, and young children do not make introspective reports. After introducing the paradox and the introspectionist view of pain in part 1, I present the developmental challenge, and defend both and. I conclude that the inconsistent triad can only be resolved by reconsidering the introspectionist view of pain. In discussing three potential factors that lead to the puzzling intricacies of our concept of pain, I argue that the concept of pain might not be paradoxical after all. (shrink)

Pain is far more than an aversive sensation. Chronic pain, in particular, involves the sufferer in a complex experience filled with ambiguity and paradox. The tensions thereby established, the unknowns, pressures, and oscillations, form a significant part of the painfulness of pain. This paper uses a phenomenological method to examine nine such paradoxes. For example, pain can be both immediate sensation and mediated by complex interpretations. It is a certainty for the experiencer, yet highly uncertain in character. It pulls one (...) to the present but also projects one outward to a feared or desired future. Chronic pain can seem located in the body and/or mind; interior to the self, or an alien other; confined to a particular point and/or radiating everywhere. Such fundamental paradoxes, existential and epistemological, can challenge those living with long-term pain. (shrink)

In this paper, I argue for the modest claim that people's apparent indifference to animal pain may not be predicated upon speciesism. I defend that claim by developing an analogy between current attitudes toward at least some non‐human animal pain — that which pigs endure while having their tails ‘docked’— and our culture's indifference to the pain that male human infants experience while being circumcised. And I conclude that to convince more of their philosophical and social critics, ‘animal liberationists’ need (...) to spend more time analyzing the pain that non‐human animals experience and defending its moral significance, rather than assuming that such pain is significant and then simply arguing that unnecessary forms of it exist. (shrink)

Pain is modulated by cognitive factors, including attention and emotions. In this study we evaluated the distractive effect of aesthetic appreciation on subjectively rated pain and multi-channel evoked potentials induced by CO2 laser stimulation of the left hand in twelve healthy volunteers. Subjects were stimulated by laser in the absence of other external stimulation and while looking at different paintings they had previously rated as beautiful, neutral or ugly. The view of paintings previously appreciated as beautiful produced lower pain scores (...) and a clear inhibition of the P2 wave amplitude, localized in the anterior cingulate cortex; the inhibition of P2 wave amplitude was lesser or not significant during the presentation of the ugly or neutral paintings, respectively. Dipole source localization analysis of the LEP peaks showed significant changes during different conditions, with a shift from the posterior to the anterior right cingulated cortex while looking at paintings previously rated as beautiful. (shrink)

Recently, due to a number of converging factors, there have been significant shifts in public policy regarding the legitimacy of treating chronic pain with opioids. Traditional tenets handed down in medical, dental, nursing, and pharmacy education created a distinct reluctance on the part of practitioners to prescribe opioids on a continual basis. Much has been written about the reasons for these attitudes. One of the barriers that is very consistently reported by prescribers is the fear of regulatory and legal repercussions (...) to ongoing prescription of this class of medications. It is in this arena that sentinel changes have occurred, the most recent of which is the promulgation of a document prepared by the Federation of State Medical Boards, which suggests a set of guidelines meant to be endorsed or adopted by individual medical licensing boards on how to approach this particular aspect of practice. These guidelines, representing a broad consensus from a wide constituency, were developed in a relatively open forum and detail a balanced approach to the prescription of opioids for chronic pain. (shrink)

ABSTRACT: In this article we aim to see how far one can get in defending the identity thesis without challenging the inference from conceivability to possibility. Our defence consists of a dilemma for the modal argument. Either "pain" is rigid or it is not. If it is not rigid, then a key premise of the modal argument can be rejected. If it is rigid, the most plausible semantic account treats "pain" as a natural-kind term that refers to its causaI or (...) historical origin, namely, C-fibre stimulation. It follows that any phenomenon that is not C-fibre stimulation is not pain, even if it is qualitatively similar to pain. This means there could be phenomena that feel like pain butare not pain since they are not C-fibre stimulation. These possible phenomena can be used to explain away the apparent conceivability of pain without C-fibre stimulation. On either horn of the dilemma, the identity theorist has ample resources to respond to Kripke's argument, even without wandering into the contentious territory of conceivability and possibility.RÉSUMÉ: Nous souhaitons explorer ici dans quelle mesure il est possible de défendre la thèse de l'identité sans contester l'inférence de la concevabilité à la possibilité. Nous proposons un dilemme pour l'argument modal: soit «da souffrance» est sévère ou elle ne l'est pas. Dans le second cas, une des prémisses fondamentales de l'argument modal se voit rejetée. Dans le cas contraire, le traitement sémantique le plus plausible présente «la souffrance» comme un type naturel qui se réfère à son origine causale ou historique, c'est-à-dire à une stimulation de la fibre C. Il s'ensuit que tout phénomène qui ne résulte pas de la stimulation de la fibre C n'est pas souffrance, même s'il est qualitativement similaire. Il existerait donc des phénomènes qui créent une impression de souffrance mais qui ne le sont pas. Face à ce dilemme, le théoricien de l'identité a anlplenlent de quoi répondre à l'argument de Kripke, sans même toucher au domaine controversé de la concevabilité et de la possibilité. (shrink)

: Research done in recent years shows that Virtual Reality can be an effective tool for distracting attention from pain. The purpose of this study was to test how the complexity of Virtual Environment influences the experienced intensity of thermal pain stimuli. A within-subjects design experiment was conducted, using cold pressor test for pain stimulation. Research was done on 31 students of Wroclaw Universities. Participants played games created for the purpose of the study, using head mounted displays and movement sensors. (...) Two Virtual Environments differing in the level of complexity and non-VR control condition were used. The order of all conditions was counterbalanced. Participants reported significantly lower pain intensity after playing the high complexity game, compared to the low complexity game. There were also significant differences between non-VR control condition and high complexity game, but not between non-VR and low complexity game. The pain tolerance was significantly higher in both VR conditions comparing to non-VR conditions. However, no significant differences between VE’s were found in pain tolerance ratings. Results of this study provide preliminary evidence that game complexity can be related to pain experience during VR interventions. (shrink)

Chronic low back pain affects 50-80% of the population, while its consequences may impair the functioning of patients suffering from it, in many spheres of life. Hope is a factor which may influence coping with pain as well as cognitive reflection of pain experience. The aim of the study has been to check: 1) whether dependencies exist between hope-trait and hope-state and the perception of pain; 2) whether experiencing pain at the time of filling questionnaires matters for the assessment of (...) the level of hope; 3) whether there is interaction between hope, the pain experienced at the moment of investigation, and memory of the intensity of previously experienced pain. 150 patients participated in the study, they all reported aggravation of the chronic low back pain syndrome. The study was a cross-sectional study, based on questionnaires. On the third day of treatment the subjects were given the following questionnaires: Trait Hope Scale, State Hope Scale, and Numerical Rating Scale of Pain to fill. Poor correlation was demonstrated to exist between hope-state and hope-pathways on the one hand, and the intensity of minimum pain level experienced during the first three days of treatment. It has been noted that the presence of pain at the time of filling questionnaires results in reducing the hope-state, but only in those persons, who had experienced severe pain previously. On the other hand, in case of patients who had experienced slight pain previously, the pain present when filling in the questionnaires is conducive to enhanced hope-state. The results of the study confirm the complex character of relations between hope and pain. (shrink)

In What the Body Commands, Colin Klein proposes and defends a novel theory of pain. Klein argues that pains are imperative; they are sensations with a content, and that content is a command to protect the injured part of the body. He terms this view "imperativism about pain," and argues that imperativism can account for two puzzling features of pain: its strong motivating power and its uninformative nature. Klein argues that the biological purpose of pain is homeostatic; like hunger and (...) thirst, pain helps solve a challenge to bodily integrity. It does so by motivating you to act in ways that help the body recover. If you obey pain's command, you get better. He develops his account to handle a variety of pain phenomena and applies it to solve a number of historically puzzling cases. Klein's intent is to defend the imperativist view in a pure form -- without requiring pain to represent facts about the world.Klein presents a model of imperative content showing that intrinsically motivating sensations are best understood as imperatives, and argues that pain belongs to this class. He considers the distinction between pain and suffering; explains how pain motivates; addresses variations among pains; and offers an imperativist account of maladaptive pains, pains that don't appear to hurt, masochism, and why pain feels bad. (shrink)

: Traditional definitions of pain assume that an individual learns about pain through verbal usages related to the experience of injury in early life. This emphasis on the verbal correlates of pain restricts our understanding of pain to the context of adult human consciousness. In this paper we instead support the idea that our understanding of pain originates in neonatal experience and is not merely a verbally determined phenomenon. We also challenge the definition of pain as a merely sensory message (...) related to peripheral tissue trauma. We aim to move beyond this definition by considering the relationship between the centre and periphery, taking into account certain phenomena such as phantom limbs and interoception. We show that pain helps an individual to develop a sense of awareness of himself immersed in a social context, and is thus a complex and adaptive phenomenon, that supports bodily integrity and social behavior. Keywords : Awareness; Consciousness; Experience; Pain; Self-representation Dolore e coscienza negli esseri umani. Ovvero, perché il dolore favorisce l’identità e la rappresentazione di sé Riassunto : La definizione classica di dolore presuppone che l’individuo ne apprenda l'uso verbale attraverso esperienze dolorifiche legate all’infanzia, favorendo una maggiore attenzione per i correlati verbali del dolore. Questo spesso relega il dolore nel contesto della coscienza dell’uomo adulto. Il presente lavoro si propone, in primo luogo, di sottolineare alcune evidenze, a partire dall'esperienza neonatale, a sostegno dell’idea di dolore come esperienza umana e non solo come fenomeno determinato verbalmente. Un secondo aspetto emerge dalla definizione di dolore, il concepirlo come un semplice messaggio sensoriale in seguito a lesioni dei tessuti periferici. Ci si propone, pertanto, di andare oltre tale ipotesi considerando il rapporto tra centro e periferia, a partire da alcuni fenomeni come l’arto fantasma e l’interocezione. Il dolore aiuta inoltre a sviluppare un senso di consapevolezza di sé immerso nel contesto sociale; si tratta dunque di un fenomeno complesso e adattivo, dall’integrità fisica alla dimensione sociale. Parole chiave : Consapevolezza; Coscienza; Esperienza; Dolore; Rappresentazione di sé. (shrink)

Most contemporary discussions about pain take place within the frame work of materialistic theories. Their general point of departure is an attempt to explain mental pain in terms of physical pain. In this article I address two major problems, which materialistic theories deal with, from within a phenomenological perspective. The first problem is to find a physiological explanation of pain that leaves space for mental pain experience. The second problem, which I focus on, consists in the attempt to offer a (...) description of the physiological basis of mental pain, which does not reduce the mental to the physical. I thereby present the thesis that pain can be understood either as the body's revolt against the mind or the mind's revolt against the body. With this thesis I want to show that pain means a rupture which in a paradoxical way mediates to us an understanding of the unity of body and mind. The purpose is to explain the meaning of pain, as a key to our understanding of our bodily existence.‘Der Schmerz selbst hat das Wort.'– Martin Heidegger. (shrink)

Part philosophical meditation, part cultural critique, The Body in Pain is a profoundly original study that has already stirred excitement in a wide range of intellectual circles. The book is an analysis of physical suffering and its relation to the numerous vocabularies and cultural forces--literary, political, philosophical, medical, religious--that confront it.Elaine Scarry bases her study on a wide range of sources: literature and art, medical case histories, documents on torture compiled by Amnesty International, legal transcripts of personal injury trials, and (...) military and strategic writings by such figures as Clausewitz, Churchill, Liddell Hart, and Kissinger, She weaves these into her discussion with an eloquence, humanity, and insight that recall the writings of Hannah Arendt and Jean-Paul Sartre.Scarry begins with the fact of pain's inexpressibility. Not only is physical pain enormously difficult to describe in words--confronted with it, Virginia Woolf once noted, "language runs dry"--it also actively destroys language, reducing sufferers in the most extreme instances to an inarticulate state of cries and moans. Scarry analyzes the political ramifications of deliberately inflicted pain, specifically in the cases of torture and warfare, and shows how to be fictive. From these actions of "unmaking" Scarry turns finally to the actions of "making"--the examples of artistic and cultural creation that work against pain and the debased uses that are made of it. Challenging and inventive, The Body in Pain is landmark work that promises to spark widespread debate. (shrink)

When one attempts to understand and grasp the seemingly simple fact of pain within the realm of human being, it may be inevitable for one to be caught by the question “why do I suffer from pain?” This question, like every other “why” question, belongs to a basic human attitude which cannot accept what is as it is. Considering pain as a manifestation of such an attitude is also determining it as intolerable and reading the experience of pain as an (...) act of rebellion. However, in order to grasp and make sense of the experience of pain, one should first determine against what this act of rebellion is. To this end, this paper tries to articulate the experience of pain within the Hegelian system by focusing on pain’s relation to pleasure, life, death, desire and self-consciousness and infers that any form of reaction to pain is an act of rebellion against death. (shrink)

Pain can be a body-wrenching curse. Yet it is often a life-defining and supporting blessing!Pain is a distinct physiological event, yet it is also an emotional, social, spiritual, and economic force. Pain in its more destructive form alters lives, changes relationships, and disrupts families.Quality pain management should not be just a pharmacological response to a medical situation; it must also be a theological, ethical, and societal response to human need. Appropriate pain management is a gift to both the receiver and (...) the provider. As a parish priest, a supervisor of pastoral services, and an ethics resource specialist, I have seen many pain-filled situations that have involved multiples of these dimensions.Born in 1969, Casey died in 1995, just a few months after his twenty-sixth birthday. Casey was an intelligent, charismatic college student, strong in religious faith, who had few problems … at least until one day in the summer of 1994. That day he began to suffer extreme pain in his lower stomach and bowels. (shrink)

Dr. M is a fifty-nine-year-old internist with a successful practice in a major Eastern United States city. He has lived in this city his whole life and is a highly esteemed citizen. Because of his broader social concerns and energetic support of activities to improve access to health care and quality of care for the underserved, Dr. M became involved in a number of local and regional medical organizations and quickly rose to prominence as as a director of a board (...) of a major national organization. In this position, he was an effective, articulate spokesperson, highly respected for his integrity and thoughtfulness.Before one of the meetings of thithis s board, Dr. M personally contacted the organization's other directors, including me, to warn us that we might be hearing some scandalous news about him. He wanted us first to hear it from him personally. This was the scandalous news.Dr. M had assumed the care of a patient of a recently retired colleague. The patient was an older woman with multiple musculoskeletal complaints related to lumbar stenosis and advanced degenerative arthritis of the spine, which left her in immense pain. (shrink)