Social contract theory is a theory drawn from evolutionary psychology – a ‘cheater detection’ system if you like. Following on from yesterdays post about detecting faking in pain, this study examines the judgements observers (in this case, friends and relatives of people with pain) in a study where four vignettes were presented. Each vignette varied in terms of four cues: the person continuing or stopping liked tasks, continuing or stopping disliked tasks, the availability of medical evidence, and the pain intensity as rated by the person.
Many variables have been studied with respect to how accurately observers judge another person’s pain – attractiveness, gender, ethnicity, social class, as well as the context (return to work or post-surgical), and the characteristics of the observer (parent, caregiver, spouse, clinician).
Results from past studies have included: unattractive patients were judged to suffer from more pain than physically attractive patients (Hadjistavropoulos et al.1990, 1996, 2000). Generally, higher reported pain intensity appeared to invite higher estimated pain intensity. When comparing sufferers’ self-reports and observers’ estimates, however, low reported pain intensities were overestimated and high reported pain intensities were underestimated (Chibnall and Tait 1995; Chibnall et al. 1997; Krokosky and Reardon 1989; Tait and Chibnall 1997; Zalon 1993).
For health professionals, some studies found no associations (Dudley and Holm 1984; Everett et al. 1994; Hamers et al. 1997; Oberst 1978; van der Does 1989), others found that less experienced observers gave higher pain estimates than did more experienced observers (Mason 1981; Perry and Heidrich 1982; Lenburg et al. 1970).
In terms of contextual cues, the absence of medical evidence to support the person’s report of pain has been associated with lower estimates of pain.
Yesterday I briefly discussed the idea of malingering being the purposeful faking of health problems in order to gain financial benefit: in this study, the evolutionary value of the ‘social contract’ is used as the theoretical model for evaluating our sensitivity to these responses. Social contracting is a situation where the ‘‘individual is required to pay a cost, or meet a requirement, to an individual (or group) in order to be eligible to receive a benefit from that individual’’ (Cosmides 1989, p.197).
It makes sense that as humans we have some systems developed to determine whether we are being exploited and that the normal ‘contract’ between people is being disturbed. There is empirical support for humans being sensitive to cues for cheating from both human and animal studies (Cosmides 1989; Gigerenzer and Hug 1992;Wilkinson 1990) – but as we saw yesterday, we can be deceived reasonably readily, so it makes sense for us to be particularly sceptical about situations where we may be manipulated.
In a situation where one person is likely to receive benefits (caring or free food, for example) because of their reported pain, it makes sense for the observer to be more aware of cues suggesting that the individual receiving the ‘benefits’ is not actually in pain (Williams 2002). This has been studied before, and it has been found that suspicion of cheating or faking leads to conservatism and underestimation of pain. This can explain why such weight is given to medical evidence by health care professionals even when the relationship between ‘evidence’ from radiology and pain, for example, is fairly weak. This is especially true in cases where time off work, or other ‘special’ treatment is given as a result of confirmation of a ‘real’ problem.
The hypotheses in this paper were:
– the combination of two behaviours (continuing liked and
stopping disliked activities) would be judged as unfair
and lead to lower pain estimates, whatever the level of
– there would be no effect on pain estimates of the
presence or absence of medical evidence, and
– pain as reported by the patient would affect pain
estimates by relatives
Although the results were from a very small group of respondents in the end (only 23% of the initial group recruited actually responded with complete questionnaires), some interesting findings were obtained.
– people who stopped doing things they liked were interpreted as ‘having to stop’, and this was perceived as fair
– people who stopped things they didn’t like but continued with things they did like, were perceived as being unfair
– behaviour of characters reporting high pain was estimated to be fairer
The authors suggest that perhaps greater pain meant greater recognition of the cost in pain incurred by doing any tasks, or that more leeway was exercised in judgements of behaviour as fair or unfair.
– more pain was attributed to patients who stopped liked tasks
– highest pain levels were assigned to patients having stopped both liked and disliked activities
– lowest pain estimates were assigned to patients who had stopped disliked but continued liked chores, the combination which also received the lowest fairness ratings
The authors comment that these findings ‘support our hypothesis concerning lowering of pain estimates by individuals close to someone with persistent pain if they judge patients to be behaving ‘‘unfairly’’, that is, ‘‘accepting the benefits’’ of having pain—of being permitted not to do some tasks—‘‘while not meeting the requirement’’—of being unable to do other preferred activities.’
– participants’ estimates were not significantly affected by presence or absence of medical findings in this sample
– higher given pain intensities led to higher estimated pain intensities
– there were systematic discrepancies in estimates since low given pain intensities were estimated as higher and high given pain intensities as lower.
Some food for thought – this is a first cut study using social contract theory as a framework for determining a priori predictions as to which cues are salient, and in which direction. I look forward to finding out more on this – it may help us help our patients reflect on their behaviour, as well as the ways in which family members interpret and respond to patient’s behaviour.
There are some limitations to this study – in particular the small sample size, and the use of written vignettes rather than video-recorded scenarios. But for making us think? I think it’s great.
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Kappesser, J., C. Williams, A.C. (2008). Pain judgements of patientsâ€™ relatives: examining the use of social contract theory as theoretical framework. Journal of Behavioral Medicine DOI: 10.1007/s10865-008-9157-4