Intellectual and Moral Tasks in Intersection – Part 1
Pain medicine is a human practice in every sense, confronting us with the limitations of our understanding and compelling us to strengthen the bonds between ourselves and others. As much as it is a human practice, pain medicine is a stewardship of knowledge. It requires objective judgment and assessment and must confront the formidable task of objectifying the subjective phenomenon of pain to determine the right treatments for both the pain syndrome and the patient in whom the pathology is expressed.
It is this expression of the experience of pain that remains enigmatic. The chief reason communication of pain is so difficult is that we, as a human and scholarly community, are far from reaching agreement on what exactly it is that we are talking about. This essay is the first of a two part series that explicates how the intellectual tasks of knowing about pain—as well as its experience and expression in the pain patient—are constituent to the moral responsibility of pain medicine and fundamental to the ethical processes of informed consent, respect for autonomy, and sustenance of agency.
Herein, we present a sampling of ideas addressing both what should be defined as pain and what dimensions should be included in an assessment of pain. We then synthesize those ideas into a conceptual model using a multi-dimensional vector representation of the experiential pain space. This model gains applicability when coupled with standardized, easily administered, assessments. We will discuss the tools that may be most useful in this regard. The goal is to expand understanding of the unique challenge of clinical pain assessment while keeping the ethical integrity and value of this encounter well in view.
Hermeneutics and Dynamics of the Clinical Encounter
We have claimed that “…knowledge of pain is limited by problems of understanding and explanation: what is subjectively understood cannot be directly explained, and what can be explained does not reflect that which is subjectively understood.”1 Empirical knowledge of etiology and treatment is fruitless without knowledge of the patient’s subjective existence as a person in pain. Pain, by its very nature, cries out to be understood.2 Medicine, as a hermeneutic endeavor, attempts to resolve this paradox via the inter-subjective structure of the clinical encounter. Within this hermeneutic framework, the physician uses interpretive skill to synthesize the clues gathered in the clinical meeting into a more meaningful picture of the patient’s pain experience. As this domain deepens and expands to foster appreciation for the ways in which pain-as-pathology affects the patient-as-person, the pain practitioner’s abilities and efforts—to both understand pain and make prudent clinical decisions as relate to therapeutics—will likely become increasingly adept.
At the juncture of the clinical encounter, the life-worlds of patient and physician are united by a common goal of healing. The responsibility each party assumes in order to achieve this goal lays the foundation for an ethics of pain medicine. The core ethical issues of the clinical encounter in pain medicine can be posed by two fundamental questions:
1) Is the pain physician fulfilling the telos of pain medicine by providing effective and beneficial treatment of pain?
2) Is the pain physician upholding the values inherent to the profession of pain medicine?
To affirmatively answer these ethical questions requires not only knowledge of pain writ large, but knowledge of pain as it is manifested in the individual. Therefore, as a first step toward right and good treatment, the primary goal of pain medicine is to make the subjective experience of pain objectively accessible, assessable, and appreciable.
Challenges of Communicating Pain
Although one can point to the part of the body where pain seems to originate or to the instrument inflicting that pain, neither patient nor physician can point to the pain itself. As Wittgenstein argues, even if we manage to fix our attention inward and “point” to the pain itself, there can be no language for our introspective, immediate private sensations.3 Despite these difficulties, we do have ways of talking about pain. We use metaphor, as well as pain behavior and visual cues, to signal pain to others. However, pain behavior can be faked or repressed, visual cues such as blood or tissue damage do not correlate to pain intensity—as anyone who has experienced a paper cut will attest—and metaphors may not be useful across cultural borders.
Effective communication requires both someone who signals and someone who understands. To understand someone who speaks of her own pain, we must imagine pain we do not feel based upon the model of pain which we have felt.3 In light of this, any understanding of another’s pain is dependent just as much on our personal experience as it is on an other’s ability to express it. Valerie Hardcastle claims “…our ways of discussing pain are beyond repair…our best strategy is simply to scrap them and start over.”4 But we ask if such a complete overhaul is really necessary. Using existing language, many astute and compassionate practitioners successfully diagnose and treat patients’ pain. If we stop talking about pain altogether, how can we possibly continue to help those who suffer? A counterpoint to Hardcastle’s bold and rather nihilistic assertion is put forth by Ronald Melzack, who has sought to use the linguistic tools we have at present to assess and identify the dimensions of pain. But, if such linguistic tools for describing pain are to some extent inadequate, then the task is to analyze the scope and nature of these informational gaps and augment those means of assessment and evaluation until we develop new tools that more fully compensate, or wholly bridge, the gaps.
Value of Narrative in Pain Medicine
We posit that pain often compels expression in order to satisfy the need for meaning and relief. Thus, narratives of pain not only communicate self, but create self. Consequently, from a physician’s perspective, the pain narrative can be important as both a diagnostic tool, and as a form of therapy.5 In this way Rita Charon’s definition of narrative as “a story with a teller, a listener, a time course, a plot, and a point”5 is most useful. Narrative entails more than just simple answers to a series of questions asked by the physician. Rather it can become an open-ended reflection on aspect(s) of the patient’s life that facilitate communication with the physician and participation in the clinical encounter through sharing of values, goals, needs, and first-person experience.