I recently dislocated my right shoulder and not surprisingly this experience has caused me to reflect on the nature of pain. In this post I will use my own experience coupled with a thought experiment to argue for two distinct types of pain: reflective pain and nonreflective pain. Having spelled out this distinction, I will raise some difficult questions about their respective moral significance.
If you are right-handed like myself, a dislocated right shoulder is an example of an injury that occasions reflective pain par excellence. In essence, reflective pain is pain that interferes with your day-to-day functioning by causing you to consciously reflect on it more than normal. Everything is now harder and more painfully deliberate to do e.g. taking a shower, putting on clothes, hugging my wife, wearing a backpack, opening a beer, etc. The thousands of micro-tasks I typically used my dominant hand for in coordination with my non-dominant left now must be performed awkwardly with my left hand alone in order to minimize pain in my right shoulder. This has halted my daily productivity significantly. For example, as a grad student and denizen of the 21st century, I spend much of my time on a laptop. It’s amazingly slow to type with only your left hand on a QWERTY keyboard. You actually type significantly less than half of normal speed because you have less fingers but you also have to stretch your fingers more to reach across the whole keyboard. This has made day-to-day academic housekeeping and research painfully tedious in a literal sense.
Thus, the salient feature of reflective pain is that you can’t help but reflect on it because throughout the day you are continually reminded of your injury every time you go to do something that you previously would have done without hesitation. Now every motor intention is tentative and the perception of thousands of lost affordances is palpable. Reflective pain intrudes and interferes with your thought processes because you are acutely aware of the bodily powers you have lost and the pain that has replaced them.
What about nonreflective pain?
Nonreflective pain is quite different from reflective pain. Imagine you are walking across a desert keenly intent on getting to the other side. It’s sweltering hot so you expose your back to the air. In so doing you introspectively notice a pain sensation localized to a patch of skin on your back. You can’t remember how long that pain sensation as been there. The pain isn’t screamingly intense nor does it burn or throb. It’s more like a light tingle or steady buzz. It doesn’t itch and you feel no compulsion to reach behind you and scratch or rub it. In fact, the pain seems to be minimized by simply leaving it alone. The pain is localized such that the movement of your muscles and skin across your skeleton doesn’t exacerbate the pain. In fact the pain doesn’t interfere with your walking at all.
The pain doesn’t necessarily command your full attention and often when you are absorbed in watching out for rattlesnakes or walking across tough terrain you entirely forget the pain is there. It’s only when you get on flat easy ground again and your mind begins to wander that you can notice the pain, buzzing with the same steadiness as always.
As you walk you begin to use the pain as a source of introspective entertainment. The pain becomes more of an interesting sensation to play with than a genuine nuisance. The pain is neither pleasant nor unpleasant. It’s simply there. You can choose to attend to it or not. You can describe the sensation and localize it to a particular patch of skin, but you don’t mind the sensation; it doesn’t bother you. In fact you have grown to like it because it gives you something to reflect on as you walk mindlessly across the desert. What’s interesting about the pain is when you are not reflecting at all but entirely in the flow of walking the pain is not consciously noticed at all. There is seemingly no conscious awareness of the pain as you are absorbed in walking. There is only the ground before you and your movements. But even if you don’t consciously attend to the pain the pain is there nonetheless (presumably). It’s a steady sensation, but it seems then that not all sensations are necessarily conscious. This is what David Rosenthal might call “nonconscious qualia”. If you didn’t introspect and reflect on the pain sensation, it’s hard to imagine it interfering with your cognitive functioning except at the grossest level of physiological nociception.
The Ethics of Pain
Now that I’ve distinguished these two types of pain, I want to ask a series of rhetorical questions. Do animals have reflective pains or are all their pains nonreflective? If so, which animals have reflective pain? All of them, or only the super-intelligent animals like apes, dolphins, and elephants? What about fish, insects, rats and cats? What is the evolutionary function of reflective pain, if it even has one? Is nonreflective pain just as morally significant as reflective pain? If we knew that a vegetative state patient had nonreflective pain, are clinicians obligated to give them pain medication?
Perhaps these are bad questions because the distinction is a false dichotomy, or conceptually or empirically mistaken. Maybe it’s a matter of degree. But it seems intuitive to me that there is something morally distinctive about the type of pains that cause us suffering and anguish on account of our reflecting on them and not just in virtue of the first-order sensory “painfulness” of them. I don’t mean to suggest that first-order painfulness has no moral significance but it seems to me that it should be weighted differently in a utilitarian calculus.