Adam Kolber, proprietor of the fine Neuroethics & Law Blog, and I are having an interesting debate on what matters with regard to the use of neuroimaging techniques to detect pain. Though pain is the subject of my dissertation, and MH Blog is not a record of my own pursuits, I do think there is enough in this exchange to render it of interest to MH Blog readers.
The discussion begins with Kolber's assessment of a write-up that appeared in Science on the recent Pain, Neuroimaging, and the Law conference. Much of Kolber's account focused on the potential application of neuroimaging techniques to detect malingering. This prompted my response:
Adam,
Obviously, I did not have the benefit of attending the conference and engaging in the discussion. I did, however, read the write-up, and I think you know we disagree on neuroimaging and pain. You write:
"Second, we already have some evidence of correlations between chronic pain conditions and structural changes in the brain."
Yes, indeed, and these are intriguing findings. But these are correlations, and as far as I am aware we have very little evidence of cause and effect at this point.
In any case, moving from evidence of correlations to conviction that these correlations identify the actual phenomenon itself is a big leap. Given the incredible interdependence of brain function, picking out the single function (i.e., pain) from the myriad correlates that we know are linked to any observable change is difficult, to say the least.
If I were judging such a case, saw such evidence, and had a 403 objection before me, I'd kick it out immediately, especially given how readily persons are likely to engage in neurofallacies with brain imaging.
"If these correlations can reliably be detected and if these structural changes are not observed in subjects lacking pain, then we may have a way of detecting certain kinds of malingering."
These are enormous ifs, and my understanding is that given the state of the art, belief that these conditions can be fulfilled is serious optimism if not downright hubris. And I also think it is worthwhile to note the abundant historical evidence of the latter in neuroscience extending back all the way to its inception on both continents (Gall, Charcot, Hammond, Mitchell, etc.).
And I still fail to understand why discussion on imaging and pain should focus on malingering. With lie detection, we are talking about lies. With pain, we are talking about pain. Sure, some people lie about pain, but the best evidence on this subject strongly suggests that the proportion of undertreated chronic pain sufferers dwarfs those of malingerers. Given this, surely there is more that matters ethically about pain than the fact that some people lie about it.
If neuroimaging is to have any use in context of pain -- and I'm not remotely convinced that it does at this point, or even that it will in the near future -- I would argue ethical use of the techniques commends if not obligates its purveyors use it to ameliorate human suffering, rather than deploy it in the service of stigmatizing an already stigmatized population. They are not mutually exclusive, but I think the ethical priority is reasonably clear.
Given that so much of the discussion as to neuroimaging and pain focuses on whether we can objectively prove pain complaints, I have no problem saying such discourse is ethically suboptimal. That we are so desperate to objectify pain suggests some other important aspects about the meaning of pain in American society, but that is a different discussion altogether.
Nevertheless, thanks for the clarification.
Adam's Response:
Daniel,
I disagree that we disagree. (Well, I know that we disagree to some extent but not to the extent you think.) I didn't say anything about causation. The issue is whether we can identify a brain-based correlate of pain that will reliably pick out those people who have genuine pain from those people who do not.
I absolutely agree with you that we should be far more concerned with alleviating the very real pain that chronic sufferers have than we should be concerned with identifying malingerers. But I am not writing a post about the allocation of health care resources throughout society. I am writing about a particular technology and how it might someday be useful. I discuss malingering, not because it's the most desirable use for a pain detection technology, but rather because it may be easier to detect a person who has no pain but purports to have substantial pain than it would be to detect the precise extent to which a person is in pain.
I make no claim that this sort of technology is ready for use today, tomorrow, or in the immediate future. I do think it holds promise someday for use in certain contexts. Whether that is realism, optimism, or "downright hubris" remains to be seen.
Daniel's Response:
Adam,
"I discuss malingering, not because it's the most desirable use for a pain detection technology, but rather because it may be easier to detect a person who has no pain but purports to have substantial pain than it would be to detect the precise extent to which a person is in pain."
This is fair, but if it is not the ethically preferable use of the technology, I don't think you can evade the question of allocation. Note that this is not a question of absolute priority (which should we do), but relative priority (how should we prioritize each of them). Thus, the fact that it may be easier to detect malingering than utilize it to actually ameliorate pain is a terrible reason for investing signficant time and resources in the technique itself, given that the magnitude of the latter problem dwarfs the former.
Moreover, I think it's also relevant to note the increasing utilization and waste associated with imaging techniques in general, and the fact that many imaging techniques seem to do much more harm than good with chronic pain, which by and large resists the vast majority of imaging techniques -- and I am dubious it will be drastically different with fMRI -- with devastating consequences for chronic pain sufferers, whose pain is delegitimized and invalidated in part because it is invisible to diagnostic imaging.
In short, I guess my point is that a significant portion of the problems we have with health expenditures in general and pain in particular are deeply connected to our use of imaging techniques. Thus, unless we want to say that concerns of justice are irrelevant to our development and use of imaging techniques -- which is not a compelling claim, to me -- I don't think it's a good idea to separate our discussion of neuroimaging from these larger ethical issues.
Of course, it is fair to zero in on any particular aspect of this in a blog post, but I do think that critically assessing why we develop imaging technologies and what we use them for is a matter of serious ethical concern and ought to be front and center for neuroethicists.
Adam's Response:
Daniel:
I'm not trying to "evade the question of allocation". But I am free to pick up on particular issues about which I believe I can contribute. After all, I don't expect you to explain why we are spending as much money as we do to treat the chronic pain of Americans when that money could save many more lives, as well as considerable pain and suffering, if used to treat starving, malnourished children in other parts of the world. Of course there are interesting and important allocation issues to deal with all the time in bioethics and neuroethics. I happen not to be taking them up in the original blog post.
Daniel's Response:
Hey Adam,
As I indicated, it is fair to write in a blog post about what interests you. But it does not follow that what interests one is identical to what is most ethically important. I'm not saying this on an individual level as much as I am thinking about the larger community of neuroethicists. IMO, I have trouble seeing the justification for spending the majority of neuroethical time and resources discussing technologies that will have no impact on 90% of the world's health. Is it interesting? Sure. Is it less important, IMO? Yes.
To be clear, I don't fault you for one moment for, in a blog post, addressing the aspects of pain and fMRI that most interest you. However, I am prepared to say that malingering is simply not as important from an ethical perspective as assessing the role of neuroimaging in the undertreatment of pain. As such, I believe that the neuroethics community does itself a disservice if it spends undue resources and energy on thinking about pain in context of malingering. If the point is not to improve things, so to speak, why should society allocate resources to it?
And actually, I do think it would be fair to ask me to justify allocation decisions as to chronic pain. That's the point of a concern with justice -- it forces us to think deeply about how we utilize resources in the way that we do. Though I am not so much talking about your blog post, I am perfectly happy to defend the notion that a neuroethics disconnected from larger questions of justice is an ethically suboptimal practice.
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Perhaps I am being unfair to Adam. There is no reason why he should not write about whatever happens to interest him about pain and neuroimaging. In part, I am expressing some frustration with some typical aspects of discourse in bioethics and neuroethics. Stuart Rennie kindly brought my attention to an article he co-authored in Philosophy, Ethics, and Humanities - Medicine (open access), which addresses similar issues. I'll quote from the conclusion:
Should global health inequalities, and the ethical issues associated with them, feature more prominently in bioethics discussions? As some point out, bioethicists may balk at the suggestion that topic selection in bioethics be anything other than a matter of personal choice. However, as indicated in the opening sections, one can question how personal these choices really are. The attention of bioethicists (as well as the popular medical) tends to gravitate towards agonizing dilemmas of patients, family members and clinicians at an individual level. High-technology interventions also have a prominent profile in bioethics discussions, and there is something of a bioethics fashion cycle as ethical reflections on newest inventions . . . replace those that have become less-than-fresh.
The question is whether it is desirable, or even ethically justified, for bioethics to continue to reflect something like a '90/10' gap, i.e. a situation where 90% of discussions on bioethics in the literature and the popular media may revolve around issues affecting 10% of the world's population.
These issues aptly characterize what I was trying to say in response to what I perceive as the tendency of neuroethicists working on pain to focus on issues that are simply less ethically important. Individuals, of course, have the right to focus on whatever they wish. But as Rennie and Mupenda note, these choices themselves are hardly value-free, and more to the point, if we are going to spend time, energy, and resource discussing the ethical implications of new technologies, how can issues of justice be excluded? More to the point, how can they not be prioritized?
Thoughts?
