Map of life expectancy at birth from Global Education Project.

Wednesday, January 16, 2008

Head trip

In my last post, I asked people to think through the implications of accepting the idea that fibromyalgia (for example -- the analysis extends much further) is, yes, a real phenomenon and a physical phenomenon, and also is located in the brain, not the body parts that hurt. C. Corax notes, correctly, that making the diagnosis psychiatric or psychological both stigmatizes sufferers, and may limit their insurance benefits for the condition. But why is this?

My main purpose here is to think harder than we usually do about the mind/body problem in the context of health and illness. What, in general, makes a disease psychiatric in the first place? In a nutshell, as I have argued before at greater length, just two criteria: the manifestations are principally behavioral, and the etiology -- the causal process -- is unknown. Complaining of pain and fatigue is a behavior, by the way. FM sufferers may also show other behaviors such as not working or not exercising very much (they tend to gain weight as a result), but they can be diagnosed simply because they report symptoms, even if they work through them.

Complaints of pain that can be linked to a known etiology, that is to say some physical finding or even a coherent physical explanation which cannot be physically detected or demonstrated, receive diagnoses which are not psychiatric. For example, chronic pain syndrome resulting from a long-healed injury is attributed to priming of pain circuits which then become permanently overactive. This diagnosis is considered neurological. (The phenomenon, by the way, was first noticed during the Civil War and has had various names, but nowadays it is usually just called chronic pain syndrome.)

In my previous post, I suggested that FM is, at least in some cases, essentially a more generalized version of this phenomenon. The only reason that it would be construed as a psychiatric, rather than a neurological diagnosis is because there isn't any specific injury or insult that can be identified which might have triggered it, in other words, there isn't a good etiological story. So why should that matter?

Here's why, in my view. Most people, including most people with FM and most of their doctors, whether they will say so or not, believe in a ghost in the machine. (That is philosopher Gilbert Ryle's derisory summary of Cartesian dualism.) Once we locate an explanation in the brain, but we can't point to a specific physical anomaly, we blame the ghost, and that is tantamount to blaming the individual sufferer. The ghost is you, the machine merely your body. If we can find the problem in the machine, you are the victim, but if the problem lies in the ghost, you are the perpetrator. Hence the stigma, the lack of insurance coverage, and the disparagement of the condition.

What I am saying is, that is entirely false. All pain is located in the brain. If you are in pain because your hand has been crushed by a falling safe, it isn't your hand that hurts after all. Nerves in the hand are sending signals to the brain, but it is the brain that is producing the sensation of pain which you feel consciously when the right signals are delivered to your frontal cortex. People with FM feel pain for the same reason, because their frontal cortex generates it somehow. We don't know quite why, in this case, but the ghost is not responsible.

Is the ghost an illusion? That might seem contradictory, because in order for there to be an illusion there must be experience, and experience, ultimately, is not the same as the physical substrate which generates it. Here we come to the mystery of consciousness, which I will be the first to concede is the single great difficulty and embarrassment for realism. Positivism in its original form also has great difficulty with probability and statistics, but a version of realist philosophy can survive that challenge.

The remnant of the ghost survives the assault of reason in the form of conscious experience, but the illusion is that consciousness can be a cause of anything. This finding creates difficulties for morality -- if the ghost is only an effect, how can we be responsible for our actions? -- but the solution to that problem is pragmatic rather than metaphysical. We retain moral principles because they are useful, because they make human society and human happiness possible, and in some cases it is necessary to promote or enforce moral principles through the mechanism of blame. But if we recognize that free will is an illusion, blame must be coupled with compassion.

Don't worry, all this blowing of smoke matters. It's going to lead us back to that question of the fundamental concept of health and what a health promoting society is all about.

Update: Upon re-reading I see that I raced through some complicated ideas very quickly toward the end there. If you aren't following me, let us know and I'll try to explain myself better.

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