Brain and Mind 1: 193–207, 2000.© 2000Kluwer Academic Publishers. Printed in the Netherlands.

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Target Article with Invited Peer Commentary

Pain as a Folk Psychological Concept:A Clinical Perspective

DAVID B. RESNIKDepartment of Medical Humanities, Brody School of Medicine, East Caroline University,Greenville, NC 27858, U.S.A.

(Received: 25 July 1999; in final form: 22 February 2000)

Abstract. This paper develops an instrumentalistic argument against an eliminativist approach tousing the folk concept of pain in clinical medicine and draws some implications for biomedicaltheories of pain. The paper argues that the folk concept of pain plays a fundamental role in severalaspects of clinical medicine, including the diagnosis and treatment of diseases and symptoms, reliev-ing human suffering, and the doctor-patient relationship. Since clinicians must be able to applybiomedical theories of pain in medical practice, these theories should not stray too far from pain’sclinical realities. Biomedical theories of pain should at least incorporate an analog of the folk conceptof pain, even if this concept is revised in light of scientific advances.

Key words: pain, folk psychology, eliminativism, clinical medicine, biomedical science.

1. Introduction

The status of folk psychological (or mentalistic) concepts and terms, such as‘belief,’ ‘desire,’ ‘intention,’ ‘fear,’ and ‘anger,’ is one of the central issues in thephilosophy of mind and psychology. Will mentalistic idioms be eliminated, revised,or kept intact? Will folk psychology join alchemy, astrology, and other erroneoustheories in the conceptual junkyard? During this century, folk psychology hassustained attacks from a variety of disciplinary perspectives, ranging from behav-iorism and neurobiology to computer science. In these debates about the status offolk psychology, three basic positions have emerged:

Eliminativism: Folk psychological concepts and terms will be eliminated fromscientific psychology in favor of other terms that have more precision, realism,and predictive power. Folk psychology is an erroneous, misleading, fiction(Churchland, 1986).

Instrumentalism: Folk psychological concepts and terms will not be elimi-nated from scientific psychology because they have practical and scientificuses even if they are imprecise and erroneous. Folk psychology is a usefulfiction (Dennett, 1987).

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Realism: Folk psychological terms will not be eliminated from scientificpsychology because they are methodologically useful and they describe realcausal (and teleological) processes and regularities. Folk psychology is anapproximately true empirical theory that may be revised as we learn moreabout human behavior, cognition, and neurobiology (Lycan, 1987).

It is not my intention to summarize or evaluate these positions here. I willsimply refer the reader to some useful reviews of the debates.1 I would like toadd a different perspective to discussions about the status of folk psychology,however. Most arguments concerning the status of folk psychology focus on itsrole in scientific explanation and description. In this paper, I focus on folk psychol-ogy’s role in clinical medicine. In particular, I will examine the role that a specificconcept, the concept of pain, plays in clinical medicine.

In The Myth of Pain, Valerie Hardcastle (1999) defends an eliminativistapproach to our folk psychological concept of pain. In the book, she discussesscientific theories about the pathophysiological, neurobiological, psychosocial, andbehavioral aspects of pain. She argues that modern science shows us that pain isactually a very complex phenomenon that is not captured by our folk psychologicalconcept of pain. Our folk concept of pain is based on a theory of pain that isimprecise, confused, and false. A scientific theory of pain needs to rid itself ofthis folk concept in order to be accurate, clear, and precise. Like other myths andfolk ideas, our folk concept of pain will be eliminated in favor of more scientificconcepts.

Although Hardcastle does not explicitly defend eliminativism in a clinicalsetting, I introduce her view here in order to give the reader a sense of this paper’sintended target. My aim in this paper is to develop a counter-argument to elimi-nativist views about the folk concept of pain based on an understanding of pain’srole in clinical medicine. I will argue that the folk concept of pain plays a funda-mental role in several aspects of clinical medicine, including the diagnosis andtreatment of diseases and symptoms, relieving human suffering, and the doctor-patient relationship. As far as clinical medicine is concerned, there are someinherent, practical limits to our ability to eliminate or revise the concept of painfor the simple reason that clinicians need to talk to patients about pain. As longas these conversations play a key role in clinical medicine, clinicians will need toemploy a lay concept of pain in clinical practice. In the clinical setting, discussionsof pain are important, indispensable, and meaningful. Thus, my paper will offer aninstrumentalistic argument against eliminativism in clinical medicine.

However, the paper will also carry this instrumentalistic argument beyond theclinical setting to discuss its implications for biomedical science. Since clini-cians must bridge the gap between medical theories and clinical realities in orderto talk to patients about pain, lay concepts of pain should also guide theoryconstruction in scientific disciplines that have a strong clinical orientation. Thus,

1 For a review of the literature, see Rosenberg (1995), Lycan (1996) and Jacquette (1994). For auseful collection of articles, see Christensen. and Turner (1993).

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a clinical perspective on pain can have some bearing on debates about the statusof this concept in scientific psychology because scientific theories about pain haveimportant uses in clinical medicine.

2. Pain as a Folk Psychological Concept

‘Pain’ has been a favorite example in the philosophy of mind for many years (Hard-castle, 1997). It has been used to illustrate mind/body interactions (“excess heatcauses pain”), the mind/body identity theory (“pain = C-fibers firing”), behaviorism(“pain = pain behavior”), the privacy of the mental (“one cannot feel another’spain”), knowledge of other mind (“how do we know that other people feel pain?”),as well as the multiple realizability of psychological states (“dog pains and humanpains are realized in different brain structures”).

Pain is also a striking example of a very basic folk psychological concept.Folk psychology, according to many authors, is a kind of theory lay people use todescribe, justify, predict and explain their behaviors, attitudes, and feelings (Lycan,1996). One of the central assumptions of this theory is that people are rationalagents: most people tend to choose actions that they believe will enable them tosatisfy their wants or desires or achieve their goals (Dennett, 1987). For example,a folk psychological explanation for a man carrying an umbrella to work is that hebelieves that there is a significant chance of rain and he does not want to get wet.Pain plays a prominent role in folk psychological descriptions and explanations ofhuman behaviors, attitudes, and feelings. For example, we might explain a person’swincing behavior by saying that she is in pain. We might explain a person’s fear ofsurgery by claiming that the person is afraid that his surgical pain will not be wellcontrolled or relieved. We might predict that a man who wishes to avoid the painof dental work will do a good job at brushing his teeth. Finally, we might justifya woman’s angry outburst on the grounds that she is suffering from a sinus head-ache.

Although I cannot defend this view fully here, I will assume that we use ourfolk psychological concept of pain to refer to or describe aspects of consciousexperience that are: subjective, qualitative, knowable by introspection, unpleasant,interpersonal, and primitive. I acknowledge that all of these statements are debat-able. I offer this list only as a set of characteristics that are frequently associatedwith our folk concept of pain, not as a set of necessary or sufficient conditionsfor defining this concept. I recognize that one might challenge any of one of thesecharacteristics.2 I will, however, provide a brief description of how I interpret thesecharacteristics.

“Pain is subjective” means that only the person who is experiencing pain candetermine whether they are in pain; an outside observer cannot demonstrate that aperson in pain if that person does not indicate that they are in pain, and an outsideobserver cannot prove that a person is not feeling pain if they indicate that they are

2 For further discussion, see Gustafson (1998) and Hardcastle (1997).

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in pain (IASP, 1986; Hawthorne and Redmond, 1998). “Pain is qualitative” meansthat we use the concept of pain to describe the qualitative aspects of experience.Pain has much in common with other qualitative concepts (or “qualia”), such ascolors, sounds, tastes, and feelings (DeSousa, 1991).

“Pain is knowable by introspection” means that we can know that we are inpain through our direct awareness of pain; we do not discover that we are in pain byobserving our own behavior or tissue damage (Cupples, 1992). “Pain is unpleasant”means that most people (excluding masochists) prefer to avoid pain if they can.Even those who value pain as a way of building character do not prefer to feel painfor its own sake (Pitcher, 1976). “Pain is interpersonal” means that we recognizeand acknowledge pain in other conscious beings including adults, children, andeven animals (Cupples, 1992). We also recognize that other conscious beings havesimilar experiences of pain, and this enables us to empathize with another person’spain (Cassell, 1991). Although we cannot feel another person’s pain, we can havesome understanding of what their pain feels like.

“Pain is primitive” means two things. First, that our concept of pain describesa simple and basic experience that lacks the phenomenological richness or detailof other types of experiences, such as visual or auditory experiences (Hardcastle,1997). Second, that our ordinary ways of talking about pain are not very sophisti-cated compared to our ways of talking about other psychological states, suchas ‘belief,’ ‘desire,’ ‘love,’ ‘anger,’ or ‘pleasure.’ Although we now have fairlysophisticated scientific theories to explain pain, the ordinary language we use todescribe pain is not very precise, sophisticated, or well-developed (Hardcastle,1999).

3. Pain and Clinical Medicine

This section of the paper presents some factual details about the role that the folkconcept of pain (described above) plays in contemporary clinical medicine. Thesepoints made in this section will function as empirical premises in my generalargument. In a clinical setting, pain is also viewed as a subjective, qualitative,interpersonal, knowable by introspection, unpleasant, and primitive (Hawthornand Redmond, 1998). Although clinicians learn about and study the neurological,biochemical, pathophysiological, and psychosocial causes of pain (or nociception)and its behavioral and physiological manifestations, their primary interest in painis how pain affects the health and wellbeing of patients. Basic sciences, such asneurobiology, attempt to describe and explain nociception, but clinical medicine isan applied science. Clinicians are more concerned with solving practical problemsrelating to patient care than in discovering the basic modes of pain signal transmis-sion and modulation. In solving these problems, clinicians are guided by severalgoals (or values), including (1) treating human diseases; (2) preventing humandiseases; (3) prolonging human life; (4) reducing human suffering; (5) promoting

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public health (Pellegrino and Thomasma, 1981; Culver and Gert, 1982; Cassell,1991).

The folk concept of pain plays an essential role in achieving two of the keygoals of clinical medicine. First, consider the treatment of disease. In order totreat a patient with a disease, clinicians must diagnose the medical problem.Diagnosis is the process of generating and confirming medical hypotheses thatexplain the patient’s medical condition (or signs and symptoms). Some of the firstquestions clinicians ask patients during diagnosis concern pain, e.g., “are you inany pain?,” “where does it hurt?,” “does it hurt when I do this?,” etc. Answersto questions about pain can provide evidence for or against specific hypotheses.Talking to patients about pain can be useful in generating or suggesting a varietyof possible diagnoses in considering a medical problem. When a patient presentswith chest pain, for example, the clinician may consider several hypotheses, suchas myocardial infarction, heartburn, or muscle strain. Pain also plays an importantrole in confirming diagnoses. For example, if a patient presents with nausea, lossof appetite, foul breath, vague abdominal discomfort, and a slight fever, a clinicianmay suspect that the patient has appendicitis or an intestinal virus. However, ifthe patient then complains of a sharp pain in the lower-right side of the abdomen,this will provide the clinician with strong confirmation for the diagnosis of appen-dicitis. Finally, reports of pain (or a lack of pain) can be useful in disconfirming(or ruling out) diagnoses. If a person presents with chest pain that occurs duringphysical exertion but goes away after 15 minutes of rest, this evidence disconfirmsthe diagnosis of myocardial infarction and confirms the diagnosis of angina. If apatient presents with a stiff neck and flu-like symptoms, the clinician may considermeningitis as possible diagnosis. However, it the patient reports that he does nothave a severe headache, this evidence would disconfirm the meningitis hypothesis.Thus, talking to patients about pain is an important tool in medical diagnosis (Soxet al., 1988; Bradley, 1993).

Pain discussions still play a role in treatment even after clinicians havediagnosed the medical problem. Talking to patients about pain is important inorder to implement various therapies and to assess the effectiveness of medicalinterventions (Bradley, 1993). For instance, in order to treat a patient with rheum-atoid arthritis, the clinician needs to know the correct dosage of medications foreffectively controlling pain and promoting movement. In order to adjust thesedosages, the clinician needs to talk to the patient about pain. If the patient stillhas an unacceptable level of pain at a low dosage, the clinician may increase thedosage. Or consider the patient recovering from lower back surgery. In order todetermine whether the surgery has been effective, the clinician must talk to thepatient about his pain and movement in the lower back.

It is also important to remember that clinicians often inflict a great deal of painduring medical testing and treatment. Many tests, such as a bone marrow biopsyor colonoscopy, involve a great deal of pain and inconvenience. In order to preventunnecessary human suffering, clinicians must do their best to minimize or control

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the pain that results from testing and treatment and avoid unnecessary tests (Resnik,1995). To do this, it is once again important for clinicians to talk to patients aboutpain.

Second, consider the goal of relieving human suffering. Pain, especially uncon-trolled pain, is one of the chief causes of human suffering (Cassell, 1991). Inorder for clinicians to relieve human suffering, they need to be able to reduceor control pain. Many of the diseases that cause a great deal of human suffering,such as cancer, arthritis, lupus, AIDS, sickle cell anemia, multiple sclerosis, andcongestive heart failure, cause a great deal of pain. The pain associated withthese diseases is often difficult to manage because it is frequently chronic andoften debilitating. Pain assessment is essential to good pain control (Cahill, 1997;Hawthorne Redmond, 1998). Pain specialists have developed a variety of tools forassessing pain in the last two decades, including pain scales, pain diaries, and painsurveys. All of these tools require clinicians to communicate with patients abouttheir pain, and this communication uses the folk concept of pain described above(Cahill, 1997; Hawthorne and Redmond, 1998).

Finally, in order to achieve the goals discussed in the previous two paragraphs,clinicians must establish effective relationships with their patients. Trust is themost important aspect of an effective clinician-patient relationship (Pellegrino andThomasma, 1981). Patients who trust their clinicians are more likely to discloseinformation honestly and openly and to follow recommended courses of therapy.Patients who do not trust their clinicians are more likely to be uncommunicative,uncooperative, and non-compliant (Pellegrino and Thomasma, 1981). In order tobuild trust, it is important for clinicians to talk to patients about pain, since patientsare more likely to believe that their clinicians care about their needs and concerns ifclinicians talk to them about pain. Discussions of pain, suffering, and other aspectsof illness also help to promote empathy in medicine, which can also solidify trust(Little, 1995; Spiro, 1992). Finally, to promote empathy and trust, clinicians needto acknowledge that pain and suffering are “real” and meaningful. Patients really dosuffer and feel pain. The doctor who discounts pain or says that patients exaggeratetheir pain is likely to fair poorly when it comes to empathy and trust.

Thus, this clinical perspective on pain supports three important, practicalreasons for retaining the folk concept of pain in a clinical setting:1. Discussions of pain are useful in the diagnosis and treatment of diseases and

symptoms.2. Discussions of pain are useful in relieving human suffering.3. Discussions of pain are useful in establishing clinician-patient trust.

4. Can Pain Discussions be Eliminated?

In response to this clinical perspective, one might acknowledge that the folkconcept of pain currently plays a key role in clinical medicine, yet maintain thatmany discussions that use this concept can be eliminated without any loss to

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medical practice. This seems to be a position that is implied by Hardcastle’s (1999)eliminativist approach to pain. As medical science advances, the folk concept ofpain will become less necessary or useful. For example, one might argue that whilethe folk concept of pain currently plays a prominent role in diagnosis and treatment,its usefulness as a diagnostic and treatment tool will wane as medical technologyimproves. During this century, we have developed a wide variety of medical tests.It is now possible to diagnose many diseases without asking patients about pain.For example, it is possible to detect breast cancer with a mammogram long beforea patient feels any pain or discomfort. Many other medical conditions, such as HIVinfection, TB, hepatitis, hypertension, diabetes, infertility, and osteoporosis can bediagnosed without knowledge of the patient’s pain symptoms.

In response to this point, I agree that discussions of pain that employ our folkconcept may become less important in diagnosis and treatment as medical tech-nology improves. However, there will always be a variety of medical conditionswhere it will be essential to talk to the patient about pain using this concept.I cannot imagine how one could diagnose and treat migraine headaches, tenniselbow, arthritis, backaches, tendonitis, or heartburn without talking to patientsabout pain. Even if discussions of pain do not play a key role in diagnosis, they maystill be crucial in treatment. For example, if an x-ray provides the decisive evidencefor a broken foot, discussions of pain will still play a key role in understandinghow well the broken foot is healing. During childbirth, discussions of pain help theclinician to understand how labor is progressing and whether the mother is havingcomplications or difficulties. Thus, although many discussions of pain in diagnosisand treatment may be eliminated somewhat – clinicians may rely on them less thanthey do now – these discussions cannot be eliminated altogether.

Concerning the usefulness of pain discussions in easing human suffering, thesediscussions cannot be eliminated as long as clinicians aim to meet this goal. Thefolk concept of pain plays such a key role in our understanding of suffering thatno serious attempt to deal with human suffering can ignore this concept (Cassell,1991). Pain causes suffering because most people regard pain as an unpleasantexperience that they would like to avoid. When people anticipate pain, they oftenbecome anxious and fearful. When people view pain as unmanageable or intrac-table, they may become depressed and angry. Patients that experience the mostintense suffering from pain are people with chronic pain conditions, which canlead to a psychosocial condition known as chronic pain syndrome (Hawthorne andRedmond, 1998). In this syndrome, pain becomes the entire focus of one’s life andpeople with this condition often become clinically depressed or disabled as a resultof uncontrolled, chronic pain.

It is true that we now have a better understanding of the other symptoms andcauses of human suffering besides pain, such as nausea, constipation, shortnessof breath, dizziness, insomnia, disability, loss of control, loss of hope, depression,isolation, anxiety, and fear. However, our ability to address these other aspects ofsuffering does not detract from our need to address pain. If human beings were a

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“lower” form of life or they could not communicate, then clinicians might not needto talk to people about pain and suffering. Since medicine is an applied sciencewith moral and social goals and concerns, clinicians must talk to their patientsabout pain and deal with their suffering (Cassell, 1991; Little, 1995). Given thisperspective, it is unlikely the folk concept of pain can or should be eliminated fromclinical medicine.

5. Can the Language of Pain be Revised?

One might accept these practical arguments for talking to patients about pain ina clinical setting yet maintain that the words and statements we currently use todescribe pain can be modified or revised in light of scientific advances in theunderstanding of pain. Some authors maintain that the language of folk psycho-logy is useful in describing the functional organization of the human mind butthat it can be modified in light of scientific discoveries concerning cognitive,emotive, and behavioral mechanisms (Horgan and Woodward, 1985; Bickle, 1992).A more sophisticated folk psychology would include new or modified categoriesthat roughly correspond to folk concepts like “belief,” “desire,” and “anger.” Thesenew categories would still be “folk” concepts in that they would be part of ourcommon vernacular, but they would reflect the knowledge and insights we havegained from science (Bickle, 1992). For example, the word “fish” at one timemeant “animal living in the ocean.” Under the old way of talking, whales wereregarded as fish. We now know that our old concept of fish was inaccurate andimprecise – a whale is a mammal, not a fish – and our new folk vernacular reflectsthis conceptual evolution. Most people now do not regard whales as fish. Otherfolk concepts, such as “gold,” “air,” “heat,” “star,” and “disease,” have changedin response to scientific advances (Bickle, 1992; Kitcher, 1994). In some cases,folk concepts have fragmented into several distinct ideas as a result of scientificadvances. For example, the disease once known as “palsy” is now understoodto include a number of distinct neurological disorders, including cerebral palsy,Parkinson’s disease, and amyotrophic lateral sclerosis.

Could the language of pain undergo a similar kind of conceptual evolution?One might argue that advances in neurobiology, neurophysiology, pharmacology,palliative medicine, and anesthesiology could allow us to revise our folk conceptof pain (Gustafson, 1995). I have some sympathies for this revisionist view. Ourpain vocabulary could be transformed in light of scientific advances in the under-standing of pain. Currently, our folk pain concepts are very sparse and vague. Theword “pain” is often used to refer to main different kinds of pain. For example, thepains associated with cancer, a broken arm, labor, and teething are all regarded as“pain” even though they have very different causes, effects, and phenomenologicalcharacteristics. Lay people may some day learn to do a better job of describingtheir experiences of pain. For example, pain assessment tools allow patients to usedifferent words to describe pain, such as “dull, throbbing, stinging, turning, itching,

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etc.” Patients can also learn to rate their pain using a pain scale and to accuratelydescribe the location of pain, such as “in my thigh, in jaw, etc.” Clearly, there isroom to improve our folk phenomenology of pain. It is conceivable that we couldone day learn to talk about “pain” with the kind of precision and clarity we employin talking about other aspects of our experience. (As an aside, Hardcastle’s view canbe taken to imply radical revisionism rather than eliminativism, when it comes toour concept of pain. The difference between eliminativism and revisionism is thatthe revisionist recognizes that we must retain some semblance of the old concept.)

Thus, I think that our folk concept of pain can and should be revised in light ofscientific and technological advances. Many of our folk concepts, such as “light,”“element,” “water,” “plant,” and “number” have changed as a result of advancesin science without being eliminated. However, there are some significant barriersto any momentous revisions that may take place. As mentioned earlier, our folkconcept of pain is primitive: sensations of pain are more “vague” and “impre-cise” than visual, auditory, tactile, or even olfactory sensations (Hawthorne andRedmond, 1998; Hardcastle, 1997). The sensory organs and neural pathways thatenable us to see, hear, touch, and smell provide us with much more specific, precise,and discriminatory knowledge than we obtain from nociceptive receptors and path-ways.3 For example, consider the wealth of detailed knowledge one can gather bylooking at landscape for less than in a minute. In less than a minute, one can learnthe location of various trees, mountains, houses, and streets, one can detect motion,one can sense differences in lighting, and so on. As they say, a picture is worth athousand words. But how much knowledge can one gather from feeling a pain inthe neck for one minute? One can learn about the location, intensity, and quality ofthe pain, but that is about all.

Since nociception is our most unsophisticated form of sensory perception, wehave good reasons to assume that there are some limits to our ability to revise theconcepts and terms we use to talk about pain. We can visually identify and observethousands of different types of birds because our visual apparatus provides us witha wealth of detailed knowledge about our environment. But one wonders whetherwe could ever learn to recognize thousands of different types of pains, given theinherent limits in our ability to perceive pain.

The second barrier has to do with the socioeconomic aspects of the language ofpain. All neurologically normal persons feel pain, regardless of social or economiccircumstances, age, race, gender, or intelligence.4 Clinicians must be able tocommunicate with many different patients about pain, and many of these patients,such as children and incompetents, cannot use anything but rudimentary words orsymbols. Although well-educated, intelligent patients might learn to use a sophis-ticated and “scientific” vocabulary to talk about pain, other patients will not be able

3 For the purposes of this paper I will not attempt to define the term ‘knowledge’, but I willassume it is a form of reliable, true belief (Goldman, 1986).

4 There are some extremely rare cases of people who have been born with no nociceptors, but thisdoes not affect my general point.

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to accomplish this feat. (As an aside, one wonders how a neurobiologist would talkabout a toothache or sore back.) Hence, in a clinical setting, there is a need tomaintain and use some fairly basic means of communicating about pain. Whenclinicians communicate with each other, they can use technical language to talkabout pain, e.g., “The patient’s facial pain appears to be a post-herpetic neuralgia;because this is a neuropathic condition, it may well respond to an anticonvulsantlike gabapentin.” However, they must be able to translate this language into some-thing that the patient can understand. If the patient happens to be a neurobiologist oranesthesiologist, then the patient may be able to understand and employ technicalterms. But most patients do not have this level of expertise when it comes to pain(nor are they likely to have this level of expertise in the future), and cliniciansmust be able to translate scientific and medical idioms into “common” or “folk”language. This “translation gap” may not place significant limits on the languageone uses to talk about the pain in a scientific paper or lecture, but it does pose asignificant barrier to revising or changing the language one uses to talk about painin a clinical setting.

In response to this argument, one might object that I am underestimatinghumanity’s ability to develop and use sophisticated concepts and ideas. In thelast few hundreds years, Western culture has emerged from the darkness of ignor-ance and superstition to the light of science and technology. Most people todayare quite comfortable with sophisticated theories and concepts from chemistry,physics, biology, geology, medicine, and mathematics. People are also capable ofusing sophisticated tools, such as computers, automobiles, and microwave ovens.Given our comfort with science and technology, it is likely that we will embracea sophisticated concept of pain, if one is developed. One might also argue thatclinicians could develop assessment and measurement tools for pain that wouldallow them to bridge the translation gap between scientific and folk concepts ofpain (Hawthorn and Redmond, 1998).

My first response to these objections is that they only pertain to Western culture,which constitutes less than one quarter of the World’s population. The vast majorityof human beings still exist under conditions of ignorance, superstition, and povertysimilar to the conditions found in Medieval Europe. But we can dismiss this nit-picky point for now. Even if we look at Western culture, we still see that people arenot entirely comfortable with science and technology. Although Western cultureincludes many highly educated and sophisticated people, many people who livein the West lack a basic understanding of science and technology. Even highlyeducated people must rely on experts to navigate through life. Although manypeople can use a computer or microwave oven, few people understand how thesedevices work. Although many people have heard about quantum mechanics orgeneral relativity, few people understand these theories well enough to grasp theirbasic concepts. Since many people remain at a “folk” level of understanding inmany areas of life, it is likely that some “folk” understanding of pain will continueto persist despite tremendous advances in science and technology. Clinicians must

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be able to communicate with patients on this folk level, despite having a great dealof expertise.

6. From Clinical Medicine to Biomedical Science

So far paper has examined our folk concept of pain and has presented some argu-ments against eliminativism in a clinical setting: in order to practice medicine,clinicians must talk to patients about pain. Discussions about pain are useful in thediagnosis and treatment of diseases and symptoms, in relieving human suffering,and in promoting empathy and trust in the clinician-patient relationship. They area key part of medical practice. Moreover, although it may be possible to revise our“folk” concept of pain in response to scientific and medical discoveries, there aresome neurological and socioeconomic barriers that will impede our ability to makethis folk concept more precise or sophisticated.

In this part of the paper I would like to extend this argument beyond the clinicalsetting and give some reasons why our folk concept of pain should also play aprominent role in biomedical theories of pain developed by psychology, neurology,and other sciences. According to the “biopsychosocial” model, clinical medicineis a discipline that solves practical problems by applying scientific knowledgeobtained from a wide variety of biological and social sciences, such as anatomy,physiology, pharmacology, biochemistry, genetics, psychology, and sociology(Schaffner, 1994). Since medical theories and hypotheses are proposed and testedin order to help clinicians make decisions concerning diagnosis, prognosis, andtreatment, a criteria of clinical usefulness should guide theory choice and conceptformation in medicine.5 A principle of clinical usefulness should play a role inguiding theory construction and concept formation in medicine much in the sameway that other epistemic criteria, such as simplicity, testability, generality, andexplanatory power, guide epistemic choices in nonmedical sciences (Thagard,1988). Clinical usefulness should govern theory choices in disciplines that havea strong clinical orientation, such as pathology, immunology, cardiology, endo-crinology, psychiatry, anesthesiology, public health, and so on. One might state theprinciple as follows: “Attempt to develop, test, and confirm medical theories andconcepts that clinicians can use to make decisions concerning diagnosis, prognosis,and treatment.”

To return to our main point, if discussions of pain have important clinical uses inmedicine, and biomedical theories should be clinically useful, then it follows thatbiomedical theorists should articulate and develop approaches to pain that supportand promote discussions of pain in clinical medicine. Thus, biomedical theoriesshould support explanations and descriptions of pain that can be translated into

5 To my knowledge, this is the first discussion of a “principle” of clinical usefulness in thephilosophy of medicine. Although many other authors have discussed this point, they have notarticulated their points as a “principle” of theory-choice. For useful discussions, see Albertet al.(1988), Pellegrino and Thomasma (1981), and Wulffet al. (1990).

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folk concepts and terms. Since clinicians must be able to bridge the gap betweenbiomedical theory and clinical practice, our theories of pain should not stray too farfrom the clinical reality of pain, i.e., how patients understand, interpret, describe,and feel pain. It must be possible for clinicians to apply scientific concepts of painto medical practice and to translate those concepts into the vernacular. Just as aclinician must be able to bridge the gap between folk concepts of “cancer” or“immunity” and scientific concepts, the clinician must also be able to bridge thegap between folk concepts of “pain” and scientific ones.

It is difficult to say precisely how far from common understanding a biomedicaltheory can stray before it loses its applicability. It is conceivable that biomed-ical theories of pain could become fairly sophisticated without sacrificing clinicalusefulness. That is, the concept of pain employed in biomedical theorizing couldbe revised significantly in light of scientific discoveries. For example, cardiolo-gists have developed very sophisticated theories and concepts of cardiovascularstructure and function that go way beyond commonsense notions like “the heart”and “blood.” One reason why it is still possible to apply these theories to clinicalpractice is that cardiologists have revised but not eliminated folk concepts like“heart,” “heartbeat,” and “blood.” Although these theories show that some of ourfolk ideas about hearts are false, e.g. that the heart is where we feel emotions, theyretain our basic concept of the heart and circulation. If a cardiological theory didnot even have anything like the folk concept of “heart,” it would be difficult toapply in a clinical setting. One might extend this analogy to our theory of pain: ifneurobiology has no place for a concept of “pain,” it will be difficult to apply thistheory in a clinical setting.

Now one might object that even if a principle of clinical applicability constrainssome theories with strong connections to clinical practice, this principle has littlebearing on neurobiology and other basic sciences. Neurobiologists would still befree to develop theories of pain, which may or may not be clinically applicable.What matters most is neurobiology is that a theory is highly confirmed, accurate,and precise, not that it is clinically useful.

While I appreciate this objection, I think that the principle of clinical applica-bility extends beyond biomedical theories to encompass other theories in science.The reason that this principle extends as far as it does is because medicine isan applied science that uses many different theories from the natural and socialsciences. Medical, nursing, and pharmacy students learn a great deal of basicbiology, chemistry, and psychology, and practicing clinicians make use of theoriesfrom these sciences. Neurobiology plays a key role in medical education and clin-ical practice. Today’s medical student learning about the neurobiological basis ofpain may be tomorrow’s anesthesiologist. Thus, it makes sense to hold a disciplineaccountable to a principle of clinical usefulness insofar as that discipline has clin-ical applications. That is, the relevance of this principle should be proportional tothe degree of the discipline’s clinical orientation. The principle should not applyto sciences that have virtually no clinical applications, such as particle physics

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and astrophysics, but it should apply (at least to a certain degree) to sciences thathave significant clinical applications, such as genetics, biochemistry, cytology, andmicrobiology. Thus, it follows that sciences that attempt to explain and describepain, such as neurology, should not ignore the clinical implications of their theoriesof pain. Even a “scientific” psychology may retain a revised “folk” concept ofpain.6

7. Conclusions

In this paper I have attempted to show that since the folk concept of pain plays akey role in clinical medicine, it also has a place in a scientific psychology. Sinceclinicians must be able to apply biomedical theories of pain in medical practice,these theories should not stray too far from pain’s clinical realities. Biomedicaltheories of pain should at least incorporate an analog of the folk concept of pain,even if this concept is revised in light of scientific advances. Thus, my paperdefends an instrumentalistic approach to the status of our folk concept of pain in ascientific psychology, which is based on an analysis of the concept’s usefulness ina clinical setting. If my argument is sound, then one might use this same strategy toassert that biomedical theories should also contain concepts that are analogous toother folks concepts which have important uses in clinical medicine, such as life,death, suffering, consciousness, nausea, weakness, dizziness, health and disease.However, I will not explore that point here.

Does my paper have any implications for dispute between eliminativism, instru-mentalism, and realism concerning the status of folk psychology? The paperconstitutes an argument against eliminativism and for instrumentalism relating todiscussions of pain in clinical medicine. One might even argue that it supports arealist attitude toward pain in clinical medicine, since clinicians must also acknowl-edge or assume the reality of pain in a clinical setting in order to explain theeffectiveness of particular diagnostic tools and therapies, such as those discussedearlier in this paper. This argument could be extended beyond a clinical settingif one assumes that biomedical theories must also be able to explain thesephenomena.7

This defense of realism concerning pain constitutes a form of argument – infer-ence to the best explanation – familiar to those who follow debates about scientificrealism (Kitcher, 1994). If assuming the existence of electrons provides us with thebest explanation of specific chemical and electrical phenomena, then we may infer

6 There are important issues here concerning the conceptual identity and change. When is our aconcept of pain no longer our folk concept of pain? I can’t address this issue here, but refer the readerto Thagard (1993).

7 One might object that my view is absurd because it implies that other decidedly unscientificconcepts, such as God, the soul, and beauty, also have a place in scientific theories. However, myview does not have this implication if we limit my argument to folks concepts that have clinicaluses. Currently, these play no fundamental role in diagnosis, treatment, or other aspects of clinicalpractice.

206 DAVID B. RESNIK

that electrons exist. Likewise, if assuming the existence of pain provides us withthe best explanation of specific medical and psychological phenomena, such asresponses to analgesics, pain behaviors, and the relation between pain and injury,then we may infer that pains exist.8 This argument for the reality of pain providesus with an interesting and ironic twist to our debates about pain, since most peopleregard their own experiences of pain as sufficient proof for the reality of pain.

One might argue, however, that it would still be possible to explainthese medical and psychological phenomena without assuming the existence ofconscious experiences of pain. We might one day be able to explain why peoplewince, cry, limp, or become depressed when they are in pain without assumingthe reality of the conscious experience of pain or the scientific legitimacy of thefolk concept of pain. This would be like explaining the Moon’s orbit around theEarth without assuming the existence of the Earth’s or Moon’s centers of gravity.The concept of a center of gravity is a very useful tool in Newtonian physics,but it is only a useful fiction that is not required in a highly advanced physics.However, we still retain the concept of a center of gravity because it plays such akey role in applications of physics in engineering and other disciplines. Likewise,the concept of pain currently plays a key role in explaining psychological andmedical phenomena, but it may one day be no longer required. It is not possibleto address this issue fully here, but I think a great deal depends advances in painscience. In the future, highly sophisticated pain sciences may not require the folkconcept of pain. Nevertheless, we might retain this folk concept because it wouldstill play a key role in applications of pain sciences in disciplines such as medicineand clinical psychology.9

Acknowledgements

For useful discussions and comments, I would like to thank John Bickle, ValerieHardcastle, Loretta Kopelman, and several anonymous reviewers.

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8 This argument for the reality of pain is entirely interest-relative, since creatures that are notinterested in explaining these medical and psychological phenomena would not need to assume theexistence of pain. I admit this. The concept of the “best explanation” of something is an interest-relative notion (Van Fraassen, 1980). This point applies to all arguments that use inference to thebest explanation to justify beliefs in various entities, whether these entities be clouds, electrons,elephants, or black holes.

9 For further discussion, see Gustafson (1995), Hardcastle (1999).

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