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The harm of intraoperative awareness
  1. Neil Levy
  1. Correspondence to Dr Neil Levy, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC 3010, Australia; nllevy{at}unimelb.edu.au

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As Walter Glannon notes1, Ned Block famously distinguished two central concepts of consciousness.2 ‘Phenomenal’ consciousness is the kind of consciousness that has a qualitative feel to it. It is the kind of consciousness involved in feelings and sensations. Information is ‘access’ conscious when the agent is aware of it—paradigmatically, when he/she is able to report it. Phenomenal consciousness is the kind of consciousness that is central to debates in philosophy of mind, especially debates about the hard problem and the explanatory gap, both of which concern the apparent difficulty of explaining how qualia can arise from mere matter.

Glannon thinks that, in discussions of the ethical issues arising out of the possibility of becoming conscious during surgery, it is phenomenal consciousness that is ‘the relevant type of consciousness’.1 Since only phenomenal consciousness can hurt, pain is intrinsically a matter of phenomenal consciousness (there is a lively debate concerning whether mental states with informational content have a phenomenology associated with them,3 but this is best understood as a debate about whether at least some access conscious states are also phenomenally conscious states, not about whether access conscious states can, qua such states, have a phenomenology). Phenomenal consciousness of pain may be intrinsically bad; further, it may be that only if we (phenomenally) feel pain can we suffer from it by reacting emotionally to it (and these emotional reactions may be intrinsically phenomenal too). Phenomenal consciousness of pain may also be necessary for psychological problems to arise, such as post-traumatic stress disorder (PTSD).

In this commentary, I want to suggest that access consciousness may matter more than phenomenal consciousness for the set of issues with which Glannon is concerned. There is room to doubt, first, whether the direct harm that arises from the experience of pain is a matter of phenomenal feel. Second, there is room to doubt that—even if pain is intrinsically bad as a consequence of how it phenomenally feels—the most serious harms that may arise from intraoperative awareness of pain are primarily a matter of phenomenal consciousness.

The intuitive view of pain is that it is intrinsically bad by virtue of its phenomenology: it harms a person (by setting back their interests) because of the way it feels. This intuitive view may be correct, but there is evidence that this view has difficulty accommodating. In particular, there is the phenomenon of pain asymbolia. People who experience pain asymbolia—who may be rational agents—report that their experience of pain is normal but they no longer mind it.4 To accommodate this phenomenon, defenders of the intuitive view according to which pain is intrinsically harmful by virtue of how it feels have to defend one or other of two counterintuitive claims. Either they must claim that people who experience pain asymbolia do not in fact have the same phenomenal experience they had when they minded the pain, or they must claim that these people are really harmed by the pain. Either claim is counterintuitive, because it entails disregarding the person's own reports about their experience. Given these difficulties, pain asymbolia is some evidence that the harmfulness of pain does not arise from how it phenomenally feels. Of course, given that the patient cannot report it either, it is not a matter of access consciousness as Block defines it either. Nevertheless, it may best be understood via a theory of access consciousness. Elsewhere, I have suggested that information is poised for the rational control of behaviour—and therefore access conscious—when it is available to a sufficient number of the consuming systems that constitute the mind.5 Pain asymbolia may best be understood in terms of lack of access of some of these systems to the relevant contents.

Suppose, however, that we can make good on the view that pain is harmful by virtue of how it phenomenally feels. This would not entail that the worst harms associated with intraoperative awareness arise from the phenomenal experience of pain. As Glannon recognises, the worst harms are suffering and possible adverse psychological effects. But both of these are best understood in informational terms. Suffering, as Glannon understands it, is a matter of one's emotional response to pain. It is very plausible that this response is, typically, to how it feels, but responsiveness to this quality requires more than just feelings; it requires some kind of cognitive process. As Glannon also notes, suffering may be caused by anticipating pain: again, this is a complex cognitive response that requires much more than feeling (indeed, we can suffer from anticipating a pain we never actually feel).

Adverse psychological effects of pain must also be understood in informational terms. They, too, must be understood as arising from how we respond to pain. PTSD, the most serious pathology that might be expected to arise from intraoperative awareness, seems to arise from pathological overconsolidation of memories. Memory is normally, and adaptively, heightened by emotional response, but this mechanism becomes pathological when recall itself triggers a strong emotional response, leading to a potentiation of the consolidation. This may set in motion a vicious cycle of overconsolidation, to the point when the memory becomes intrusive and the emotional response highly distressing or even crippling.6 Although qualia may be an essential component of the pathology, it is clear that it arises from how information is processed and consolidated. Whether PTSD must involve phenomenally conscious states at all is doubtful: although an emotional response is constitutive of the disorder, it may be doubted whether emotions are necessarily phenomenal. Some theorists understand emotions as essentially somatic states, rather than qualitative states.7

Do these questions matter for ethics? They might. One way in which they might be relevant for ethical debates concerns the badness of pain in non-human animals. Pain that is unconceptualised—that is, entirely a matter of how it feels—might be less bad than pain that is conceptualised. Normal adult humans have a much more highly developed sense of themselves as entities persisting over time, and therefore a much livelier sense of the future, than (at least) most non-human animals. In some circumstances, this difference may result in a human suffering more from an injury than an animal would from a similar injury, because the human alone can grasp or fear the future consequences of the injury. On the other hand, these same kinds of consideration might sometimes cause similar injuries or pains to be worse for animals than human beings. Human beings can understand the purpose of a visit to the dentist, and look forward to the time when it is over. An animal may suffer additional anxiety as a result of its inability to understand what is happening to it. Assessing the relative badness of animal pain versus human pain requires untangling the relative contributions of the phenomenal feeling of pain and downstream responses to pain; plausibly, these relative weights will alter from circumstance to circumstance.

Similar kinds of considerations will be directly relevant to the assessment of the harms that might arise from intraoperative awareness. Assuming that the patient is a typical human being, he/she is capable of conceptualising the pain, but the effect of anaesthesia may be to render them temporarily unable to do so. By dramatically lowering the number and range of the consuming systems that have access to the pain, any downstream effects may be pre-empted; this may include any consolidation of the pain in memory systems. In this case, any harm will be limited to the duration of the experience itself. However bad the experience is, it is likely to be much less harmful than PTSD can be.

Finally, these considerations matter practically, because access consciousness is much less mysterious than phenomenal consciousness. It falls, as Chalmers would have it, within the domain of ‘easy’ problems of consciousness.8 It is therefore much more amenable to scientific discovery and the development of devices that can detect or modulate it. The development of such devices may prevent any of the harms associated with intraoperative awareness from arising.

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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