Telling the Truth About Pain: Informed Consent and the Role of Expectation in Pain Intensity

Abstract

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.

Keywords:

• placebos
• brain imaging
• cognition
• informed consent
• perception
• truth

Notes

1 The pain matrix is also sometimes referred to as the pain system, and in this article, I use the two designations interchangeably.

2 For an overview of how classical conditioning theory can account for placebo effects, see Alfano (2015).

3 For a defense of the cognitive penetration of pain against some recent criticism of cognitive penetration, see Gligorov (2017).

4 For a meta-analysis that supports the claim that different descriptions of the sensation associated with venipuncture affects the actual experience of pain with common needle procedures, see Boerner et al. (2015).

5 For more on how health care professionals contribute to the learning of the concept of pain, see Gligorov (2016).

6 There is evidence that placebo analgesia does not generalize across analgesics; rather, placebo effects are specific to the analgesic the individual has been successfully treated with in the past (Kong et al. 2013).

7 For an overview of the different sources of placebo effects, see Alfano (2015).

8 Cohen (2014) has argued that the obligation to minimize harm might in some situations outweigh the obligation to disclose information and that in circumstances where pain is particularly susceptible to suggestions, the obligation to minimize harm is greater than the commitment to autonomy. My argument here does not rest on the primacy of nonmaleficence, but it does not conflict with it either, because I am aiming to address situations in which pain is less susceptible to suggestion: for example, in situations where pain is the result of tissue damage that we know is very likely to produce pain in individuals with intact pain perception.