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Back Pain & Rationality

Mitchell Silver ponders the problem philosophically.

Every move I make is perilous: lacing my shoes, rising from a chair, the slight lean at the bathroom sink to pick up my toothbrush – all are fraught with risk. Although the vast majority of such movements, and considerably more vigorous ones too, pass without incident, every once in a while, without warning, I feel the ominous ‘click’. There’s no pain involved; hardly any immediate effect at all. However, the consequences of that click are all too predictable: I have ‘thrown my back out’. Within hours my back will lose flexibility, and by the next day I will be unable to walk or sit without pain. Sometimes, it is disabling pain.

Within seven to twenty-one days I’ll be fully recovered, and as far as I can tell, the precise recovery time is unrelated to what I do following the inauspicious ‘click’. Bed-rest or activity, cold or heat, cold and heat, spinal adjustments, massages, drugs, acupuncture – or none of the preceding – no difference – same seven to twenty-one days. Nor has any preventative regimen been able to increase the (apparently random) interval times between such incidents. Yoga practice, morning stretches, exercise regimes of varying and sometimes conflicting approaches, good chairs, proper posture, weight loss, anxiety reduction – all have often contributed to my general well-being, but have not demonstrably decreased the occurrence of back incidents.

What’s a fellow to do? There’s no shortage of answers. Books, articles, blogs, mainstream and alternative healthcare practitioners, and approximately every other person I meet during my back episodes, or to whom I mention my back history – they all have advice. Some advisors echo others, some are in partial harmony with others, and some appear contrarian soloists. Many advisors have an almost religious conviction regarding the rightness of their remedy. More than once I’ve been told that I am a “stubborn fool” for not immediately going to a particular chiropractor (the advisor’s).

I teach philosophy and consider open-mindedness a professional as well as personal virtue. If I am to embrace any form of stubbornness, I like to think that it is because logic and evidence has rooted me firmly to a position, and that better logic and new evidence would quickly get me to uproot and plant myself in more solid ground. So the charge of ‘foolish’ stubbornness wounds. However, when dealing with the lumbar regions, avoiding foolishness, whether of a stubborn or a capricious variety, has proved difficult. My back pain is a challenge to my devotion to Reason.

Which Reasons?

Philosophers distinguish theoretical from practical reasoning. Theoretical reasoning is a process which, if done well, leads the reasoner to beliefs that are true, or likely to be true. If attaining truth is the goal for beliefs, theoretical reasoning is a tool for generating successful beliefs. However, if we are unsure that the reasoning has been done soundly, we should remain skeptical of the belief’s truth. We are even free to have no beliefs regarding many matters. Moreover, a proposition shown to be merely probable can be held to be merely probable. In theoretical reasoning, the quality of belief can be calibrated to the quality of the reasoning that generated it.

Practical reasoning is a process which, if done well, leads the reasoner to actions that are effective, or likely to be effective. (A fuller description of practical reasoning would need to include its role in judging the worth of an action’s goal. Reasoning leading to or judging an action’s effectiveness is a subset of practical reasoning best called instrumental reasoning. However, when the goal is uncontroversial, as in the context of this essay, practical reasoning is essentially instrumental reasoning.)

In contrast to theoretical reasoning, if we are unsure that some practical reasoning has been done well, we cannot often shape our actions to accord with the quality of their justifications. Many actions don’t admit of degrees of application, or of fine enough degrees, to accord with their degree of justification. Moreover, there is no practical equivalent to the ever-available theoretical agnosticism. In the absence of good evidence (or of any evidence at all), we still must act. We may continue to do what we are doing, modify it slightly in this or that direction, or embark on a radically different course, but all of these are actions. As an existentialist might say, we are condemned to choose; and that is true whether or not we are in a position to make a rational choice.

Luckily, many of our rationally-unjustified choices don’t matter much. Daily life is filled with ineffective actions whose lack of effect is hardly noticed. Other inadequately-justified choices aim at such distant or vague goals that their lack of justification is rarely brought home to us, if ever. In both cases we tend not to fret over the quality of the supporting practical reason, for in the first case it doesn’t matter, and in the second case, we know we’ll never be able to judge that quality. Does fluffing my pillow a few seconds each night really result in a more comfortable headrest or better night’s sleep? Do my political choices genuinely contribute to a better world? Who can say, even in retrospect, whether one’s choice to go to law school led to a happier life than a choice to get an MBA would have? We often act without justifying evidence; but if little is at stake, or the stakes are either distant or insignificant, we are little troubled by our acts of faith.

However, there are situations were the absence of adequate justification for our choices is very troubling: situations in which we care greatly about the outcome, and for which we believe the outcome will be affected by and fairly clearly attributable to the choice we make. Prominent among these situations are choices of medical treatment. And when it comes to medical treatment, prominent among the rationally-unjustified choices, are the choices made for the treatment of back pain.

I don’t know what causes back pain, I don’t know what relieves it, and I don’t believe that anyone else knows, either. I do know that there are many conflicting claims about it; but as a theoretical matter, I don’t have to commit to any of these claims. I have no obligation to judge them. Even if, for the sake of having true beliefs, I did go through the evidence and weighed the arguments, I am free for any theory to believe that the evidence is insufficient to rationally support its propositions regarding the cause or proper treatment of back pain. As a theoretical matter, agnosticism regarding back pain is a comfortable place to be.

Yet even having decided that I can at this time reach no theoretical conclusion about back pain, I must reach a practical conclusion – as a back pain sufferer back agnosticism is decidedly not a comfortable place to be in practice. What, if anything, am I going to do about my back?

When I’m in the throes of back pain, this question presents itself as important, and I pride myself on responding to important questions rationally. Is there any truly rational practical response to back pain? More generally, is there a rational response when no specific response is truly rationally justified?

Scientific or Common Sense Solutions?

Alas, it appears that if science is the arbiter of rational belief, then there are no rational beliefs regarding the cause and cure of most back pain about which one should not be sceptical. (I say most, because there are a few clearly and uncontroversially diagnosed conditions that cause back pain and for which there are effective treatments; but this is probably less than 15% of back pain cases. The overwhelming majority of back pain sufferers cannot be diagnosed as having one of those conditions.) A recent (5/13/08) New York Times headline ‘Back Pain Eludes Perfect Solutions’ seriously underrepresents the article it introduces. Many problems elude perfect solutions – but the article speaks of “a world of medical confusion”; a “mystery that begins with the first doctor’s visit”; a condition for which “there really hasn’t been a breakthrough treatment” – and it quotes the Chair of the Department of Pain Medicine at New York’s Beth Israel Medical Center as believing it’s good to inform the public of “how little we know” about back pain. Dr. David Turk, of the University of Washington and past President of the American Pain Society, claims the exact cause of back pain is never found in 85% of patients.

Scientifically speaking, we don’t lack perfect solutions, we lack solutions: there is no convincing evidence that any course of action is more effective than a host of incompatible alternatives. Our most sophisticated imaging techniques reveal the same spinal abnormalities, in the same frequency, among those without back pain as among those with it. In the best-designed studies, patients who undergo surgery to relieve sciatica have been shown to recover at about the same rate as those who forgo surgery and simply let time pass (‘Surgical Treatments of Lumbar Disk Disorders’, Eugene Carragee, JAMA, 296, 2006). In general, studies of a variety of non-surgical therapies tend to support the same conclusion – there is no good evidence for anything working better than anything else. (See, for instance, ‘Review of the Literature of High Quality Controlled Trials for Preventing Episodes of Low Back Pain’, S. Bigo et al, The Spine Journal, Vol. 9, Issue 2, Feb. 2009.) However, an absence of scientifically-supported solutions is not the same as an absence of proffered solutions, and, unless we make the extraordinary claim that only scientifically proven effectiveness is a rational basis for action, this dearth of scientific support for any therapy doesn’t make doing nothing the obviously rational course. (This is especially so because there are constantly new therapies offered which haven’t been tested, and even old therapies have seldom gone through trials large enough to definitively demonstrate that they’re useless.) After all, I am interested in getting better, not in explaining how I got better or objectively justifying my choice of treatment. I just want something that works for me, even if my philosophical pride wants some reason for attempting one something rather than another.

‘Common sense’, based on personal experience and folklore, although often wrong, is the ground on which I base much of my action. Because I like to be punctual for appointments, I give myself more travel time than I estimate I’ll need. Yet I know of no studies which establish that leaving extra traveling time promotes punctuality. I haven’t even kept a record of my extra-time behavior and punctuality to see if there actually is a correlation. But it feels like there is, most people will readily agree that there is, and indeed, even without a study, it ‘stands to reason’ that if you leave plenty of time to get somewhere, you are less likely to be late than if you don’t. Alas, even if the less rigorous standard of common sense is employed, justified beliefs about back pain are still not to be had. That is because common sense is scattered among competing schools, each of which has its champions, and each of which provides a coherent narrative that makes sense (to them). If your friends are like mine – no doubt an intelligent and well-meaning group – then based on their personal experience and common sense, they know just what you must do. Some send you to Maggie’s Back Book (Maggie Lettvin, 1976) – where, besides being given a specific set of exercises, you will learn that you should keep a careful pain chart detailing with obsessive precision the when, where and how of your back pain. Maggie also has specific instructions on the right and wrong ways to stand, sit, lift weights and lie in bed. Another friend swears by Jonathan Sarno’s 1984 book Mind Over Back Pain. This pretty much claims that everything Maggie recommends is exactly wrong, and actually contributes to back pain. Sarno says it’s all in your head: stop worrying about your back pain and get psychotherapy for whatever it is that is really bothering you. According to Sarno, back pain is usually a bodily realization of emotional stress; and worrying about your chairs, mattresses and postures just adds stress. While Sarno is telling you to fuhgeddaboutit, Harris H. McIlwain and Debra Bruce in their The Pain-Free Back (2004) – a favorite book of still another friend – emphasize diet’s role in back health. The book contains dozen of recipes for dishes that are good for the back. A cousin insists her acupuncturist has a near-perfect record providing complete relief; a colleague knows a neurosurgeon whose patients all bid back pain a permanent farewell after submitting to microsurgery at his hands; a neighbor’s regular chiropractic visits has answered his prayers for freedom from back pain; an in-law thinks anyone not doing daily yoga is a back-abuser, and I can go on and on. All the advice is kindly meant, all comes with a compelling tale based on personal experience, all appeals to common sense, and little of it is compatible.

Is Unjustified Effective Treatment Irrational?

So what is to be done? Perhaps one must just frankly acknowledge that the rule of rationality is limited, even with regard to consciously-chosen behavior. However, there may be another option, which in a paradoxical way can bring rational justification to the back sufferer’s choice: The Placebo Framework.

The placebo effect is well-known to be very powerful: if one believes a treatment will be effective, that belief goes a long way to making it effective. We typically think that the effective use of a placebo requires deception. The logic seems to be that as placebos by definition have no therapeutic properties independent of the patient’s belief that she is being given effective treatment, if the patient knows that she is being given a placebo she will stop believing in its effectiveness, and thereby deprive it of its effectiveness (which will confirm the truth of her belief that it is ineffective). But we can flip that causal chain around. If upon learning that a treatment is in fact a placebo a patient continues to believe in its effectiveness, it should remain effective – vindicating their continuing belief in its effectiveness. There is no irrationality or self-deception here, but rather the rational leveraging of one’s knowledge of the general truth that placebos work.

The moral for back treatment? Until we have adequate rational justification that any specific diagnosis and treatment for lower back pain does better than placebos, we ought to use placebos with the confidence that we will get some relief and protection. It doesn’t matter what our placebo of choice is; our personal histories will determine which sort of placebos each of us will find easiest to believe.

We need not theoretically justify that belief. Just as there may be no reason to prefer apples to pears as long as you eat some fruit, so there may be no reason to prefer belief in chiropractic to belief in acupuncture, or belief in daily yoga to belief in not giving- any thought whatever to your back – as long as you believe in something. Very recently I have started a regimen of doing a variety of things for my back, and believing a variety of things about my back. There is no particularily good evidence for anything I am doing or believing, but so far, it works for me – and isn’t there reason in that?

Mitchell Silver is a Senior Lecturer in Philosophy at the University of Massachusetts/Boston.