On the one hand, it may seem impossible. Call to mind the last time you believed you were in pain and now imagine someone telling you that you aren’t. Would you buy it? Probably not.
On the other hand, it may seem incredible that there could be anything that we can’t be wrong about. Being in pain is one thing, believing you’re in pain is another. The space in between leaves space to be wrong, doesn’t it? And besides: humans are not known for their infallibility.
Let’s think about some other examples.
Imagine that I start screaming, pointing, and say “There’s a spider on my bookshelf!” You glance up and have a look. No spider. You conclude: I was wrong. Even if I confidently stick to my guns, you will confidently say I’m wrong. The more other people confirming, independently, that there’s no spider on my bookshelf, the more confident you will be. You use this independent confirmation to determine whether or not my report is right or, as in this case, wrong.
One thing I might say (indeed, one thing you might say) is that I just thought I saw a spider—though of course, I didn’t. And it might seem like there is an important difference between my being wrong that there’s a spider on the shelf and my being wrong that I thought that—or as (only) philosophers like to say it appeared to me that—there was a spider on the shelf. Could I be wrong that I thought there was a spider on the shelf?
It’s very easy to know whether or not I am wrong about whether there’s a spider on the shelf. You use independent confirmation. How can you tell whether or not I am wrong about what I thought I saw? What independent confirmation can you get?
You, and only you, have the first-person point of view on yourself. (And I, and only I, have this point of view of myself.) It’s the perspective you have towards yourself. Roughly speaking: your first-person point of view includes the way you see yourself, know yourself, and understand yourself. In a tortured philosopher’s phrase it’s “what is like for you” to be you.
The third-person point of view, however, is the point of view that even your closest confidant has on what it is like for you to be you. It’s the point of view from, as we might say, the outside—no matter how close up from the outside. The way another person has of seeing, knowing, and understanding you might be very different from how you see, know, and understand yourself.
Arguably, however, unless and until we can connect what we say from the first-person point of view to things we say from the third-person point of view, we won’t be able to evaluate what is being said. Since only each person has the first-person point of view of each person, getting any independent confirmation about any person requires the third-person point of view. So to evaluate what people say from the first-person, we are going to need some third-person confirmation. (Some philosophers argue that what people say from the first-person point of view doesn’t even make sense unless and until we can connect it up with what other people say from the third-person point of view.)
In philosopher speak: ultimately, we have to use some sort of third-person method to evaluate anything someone says from the first-person. Now with less jargon: we need some independent way of determining what people think, feel, want, wonder, and so on, from the outside.
Returning to pain: to tell whether or not I am in pain when I say I am, you need some way of confirming, independently, whether or not I am in pain. Just like you needed some way of confirming, independently, whether or not there was a spider on my shelf.
Unfortunately, there is no agreed upon third-person way of determining when someone is in pain. No agreed way of telling, from the outside, whether someone is in pain. This is also true in pain science and medicine whose goal is to treat pain: there is no accepted biological marker for pain—no agreed upon pain mechanism, pain pathway, or pain brain area.
Since there’s no agreement for a third-person way of determining when someone is in pain, maybe we should just accept all the first-person reports even without being able to confirm them. Maybe, that is, we should just say that pain is whatever anyone says it is.
In 1986, the International Association for the Study of Pain (IASP) put forward a definition of pain that does just that. (And they have since re-released the definition many times!)
The IASP defines pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” And they really mean this “or”; they offer a lengthy appended note to make this clear:
Note: … Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. … Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. … If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. …
This definition seems to assume that we can never get it wrong about our pains: if someone describes their experience as if it’s pain, then it’s pain.
The authors of the definition have been consistently clear that they do not think this means much for research, theorizing, or even the treatment of pain. And that’s a good thing!
If a kind of something is whatever anyone says it is, then not much is going to follow from something being that kind of something. If pain is whatever anyone says it is, then knowing that someone is in pain isn’t going to be very useful. Imagine if we did that for spiders!
That means that for treatment, if we can’t confirm pain reports independently, we’ll need to ask more questions about the pain being reported—and hopefully get to something more specific that can be independently confirmed and targeted for treatment.
Even if it isn’t used for research or treatment, this definition has a bigger problem. People report all sorts of things that are obviously not pains in pain language. A headline reads “pain at the pump”; I tell you that my trip to the bank was “a real pain”; your cousin tells you that the last Marvel comic movie was painful. These are all, of course, not pains, even though we describe and report them in pain language.
The point is that pain language is often used in ways metaphoric, hypberolic, or otherwise extended. That means the IASP definition is not going to work.
So, what should we do?
Most of the time, a person’s belief that they are in pain matters just as much, if not more, as whether or not they are in pain. It matters when a person believes that they are in pain—experiences themselves as being in pain—even if they aren’t.
After all: something is going on such that a person believes that they are in pain, even if that something isn’t pain.
Your belief that you are in pain may be a good enough reason for me to take your situation seriously; a good enough reason to provide you care and treatment. Even if we can’t confirm whether or not you are wrong about being in pain. Pain reports, even if mistaken, can be used as a prompt to identify an appropriate target treatment.
So my suggestion, at least for now, is that when the aim is treatment, we should follow the good advice hidden in the poor IASP definition and treat the pain report as if it’s infallible.
People might be wrong about whether they are in pain, but the belief that they are in pain will often matter more than its accuracy and taking that belief at face value may, at least for now, be the best that we can do anyway.
When someone says they are in pain, whether you are a doctor or a friend, the best response will almost always be to listen, and see what you can do to help. It will almost never be to try to evaluate, and see if they are wrong.