Paradox or misinterpretation? Re-examining McCaffery’s maxim and the International Association for the Study of Pain definition of pain

TO THE EDITOR

I read with interest the target article by Cohen et al. [1] arguing that the 2020 International Association for the Study of Pain (IASP) definition of pain [2] is weakened by internal paradoxes. A central claim of the article is that “Pain is what the person says it is” and that “If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain.” “Such conclusions lead to an untenable paradox in the interpretation of the definition of pain when an experience ‘resembling’ one associated with tissue damage…is given weight equal to an experience that is associated with tissue damage… [1].” Cohen et al. [1] ask: “Which view is to prevail? Suppose it is that of the experiencer…In that case, there is neither a need nor a possibility for a definition of pain, as any subjective assertion qualifies—‘pain is anything that hurts.’” This misreading of McCaffery [3]’s maxim, “Pain is what the person says it is and exists whenever he or she says it does,” compromises Cohen et al. [1]’s case against the IASP definition of pain. Specifically, the target article overlooks the “rule of first-person authority” on which the maxim depends; a rule that underpins pain management and the IASP definition.

Knowledge of another person’s pain is ordinarily mediated by observation and inference, whereas knowledge of one’s own pain is not. An individual’s awareness of being in pain does not arise through self-observation or any investigative process analogous to clinical diagnosis; rather, it is immediate. When a person is in pain, that fact is known directly and without evidential mediation. To suggest that an individual might sincerely believe that they are in pain while failing to know whether this is so is not coherent. Accordingly, self-report of pain has a distinctive epistemic status. When an individual believes that they are in pain, this belief is incorrigible in the sense that no external observation or subsequent discovery can establish it to be false. While it is possible for a person to misrepresent their condition, for example, by insincerely claiming to be in pain, in the normal case, and setting aside aberrant uses of language, a sincere utterance of the sentence “I am in pain” suffices to establish its truth [4,5].

This argument proposes that any speaker who sincerely utters “I am in pain,” and who possesses a competent understanding of the relevant linguistic expressions, is thereby in pain. Such speakers are therefore authoritative with respect to their own subjective experience [4,5]. From this “rule of first-person authority” it follows that if an individual were to utter “I am in pain” sincerely while not being in pain, the most plausible conclusion would be not that the report is false, but that the speaker fails to grasp the meaning of the expression they employ. For example, “After the operation, the patient no longer complained spontaneously of pain and no longer appeared to be in distress, though when asked, he acknowledged that pain was still present” [6].

This rule follows a similar pattern of operation in non-clinical and clinical contexts. In non-clinical settings, by observing a child’s behaviour, caregivers teach the child to use the expression “I am in pain” only in the presence of pain. Once the child reliably uses this expression in appropriate circumstances, it is taken as evidence that the child has acquired an understanding of its meaning [4]. This developmental process accords with the IASP definition, which states that “through their life experiences, individuals learn the concept of pain” [2]. Similarly, in clinical practice, the healthcare professional treats the patient as an authoritative subject and, on the basis of the patient’s sincere verbal reports and behaviors, attributes to the patient particular experiences, thoughts, or attitudes. Within this framework, the patient cannot be mistaken about their own experiences, because the clinical consultation assigns the patient the role of expressing those experiences. Consequently, there is no epistemic gap between what the patient sincerely reports their experiences to be and what those experiences are [4,5]. Introducing systematic doubt at this point would alter the nature of the clinical encounter and could undermine the rule of first-person authority on which clinical communication depends. I think the rule of authority underpins this note in the IASP definition, “A person’s report of an experience as pain should be respected” [2].

In following the rule of authority, the clinician privileges patient self-report of pain even when no clinical determination about tissue damage, or about the patient’s beliefs regarding damage, is present. The patient in pain need not believe nor assert that tissue damage exists; the only requirement is that she sincerely expresses her experiences or thoughts. Cohen et al. [1]’s objection that observers cannot know with certainty whether the patient is making an association between personal pain and tissue damage seems beside the point of the IASP definition, as it was intended to operate under conditions of uncertainty [2]. The uncertainty of the IASP definition reflects a deeper indeterminacy in our concept of pain, due to the fact that human behavior is unpredictable, and our reactions to it is diverse and culturally relative [4,7]. A related criticism concerns the inclusion of “potential tissue damage,” which Cohen et al. [1] claim is indefinable because it admits multiple interpretations, and therefore includes “all possibilities.” However, clinical medicine routinely depends on open-textured concepts, the meanings of which are not fixed by strict necessary-and-sufficient conditions but are instead stabilized through shared and sustained patterns of use across diagnostic, therapeutic, and communicative practices. Concepts such as pain, inflammation, fatigue, dyspnea, and dizziness lack singular, exhaustive mechanistic definitions. Nevertheless, they remain indispensable to clinical reasoning and care because they are capable of accommodating heterogeneity in presentation, epistemic uncertainty, and the progressive refinement of scientific knowledge [8].

Cohen et al. [1] ask: “If ‘pain is what the person says it is,’ then how would it ever be possible to deny an assertion of pain?” The rule of first-person authority does not entail that every utterance of “I am in pain” is necessarily true. Rather, it entails that when a self-report of pain is false, its falsity cannot be attributed to epistemic error, misinterpretation, or the absence of corroborating evidence of tissue damage or pathology. Instead, such falsity must be explained in terms of patient insincerity or self-deception [4,6]. An implication of this emphasis on sincerity is that, in cases where a patient falsely reports being in pain, the clinician may legitimately challenge the report and withhold treatment. In this context, the patient cannot retract the declaration by appealing to ignorance or error; the only defensible explanation is that the report was not sincerely meant. Under the rule of first-person authority, the patient is held accountable for his or her utterance and is responsible for the act of self-reporting.

According to Cohen et al. [1], this may suggest that the patient can say anything she or he likes—“pain is anything that hurts”—but that is not so. During the clinical consultation, the clinician’s concern is not the response that would be most advantageous to the patient at a given moment, but the report that the patient is sincerely disposed to provide about their experience. Within this context, self-reports of pain are not evaluated according to an external standard of factual accuracy, in the manner of third-person observational claims. Rather, they are assessed in terms of the patient’s sincerity in expressing their subjective state. Accordingly, a central distinction in clinical practice is not between accurate and inaccurate reports of pain, but between sincere and insincere ones. Pain, a subjective experience, lacks an independent criterion against which first-person reports can be straightforwardly verified or falsified [4,9]. As a result, the epistemic standing of patient self-report derives from the assumption of good faith in the clinical encounter. A sincere report is treated as authoritative because it is an expression of the experience itself, rather than a hypothesis or inference about it. In this view, the relevant measure of the “accuracy” of a pain report is the patient’s sincerity in reporting it [5]. To doubt such reports systematically would not enhance diagnostic precision but could undermine the normative structure of the clinical consultation, which depends on the patient’s role as the primary informant of their own experience.

Clinically, “patient insincerity” should not be inferred from the absence of corroborating pathology; it should be considered when there is affirmative evidence of intentional deception or non-credible responding (e.g., persistent internal contradictions after clarification, implausible symptom endorsement on validated methods, or validity-testing patterns) [10–13]. Even then, clinical conclusions should be cautious (“non-credible responding” rather than “lying”), and used to guide tolerable treatment and monitoring, rather than to deny patient pain. Observational data can justify clinical limits, such as refusing high-risk prescribing, seeking collateral information, or using structured monitoring, because these decisions focus on what the clinician should do, not about whether the experience is pain [13].

A correct understanding of McCaffery [3]’s maxim and the rule of first person authority clarifies that the IASP definition of pain need not collapse into paradox. Rather than undermining clinical practice, respecting sincere self report of pain preserves the epistemic structure required for effective clinical communication and care. Misinterpretation of this principle weakens critiques such as Cohen et al. [1]’s, whereas proper interpretation reinforces the conceptual and clinical integrity of the IASP definition.