<p>Pain is commonly seen as a factor that interferes with how patients make decisions, yet clinical ethics doesn’t offer a systematic account of how different types of pain alter the conditions for autonomous agency. This paper argues that autonomy assessments inevitably rely on implicit philosophical assumptions about the nature of pain, and that these assumptions shape judgments about understanding, voluntariness, competence, and consent. Drawing on contemporary theories of pain, I show that each framework implies a distinct mechanism by which painful experience can influence cognitions, motivation, temporal orientation, and evaluative standpoint. I argue that without integrating these conceptual distinctions, clinical autonomy assessments remain inconsistent and conceptually underdetermined. A more philosophically informed understanding of pain clarifies when consent under pain is valid, when refusal is compromised, and when painful experience can reveal information rather than impairs the patient’s evaluative ability. This framework lays the groundwork for clearer and ethically sound decision-making in clinical situations where pain is present.</p>