The emphasis of this journal is upon those issues that are practical in the effective and sound management of pain. These issues are diverse, and include understanding the mechanisms of pain, their manifestations, and the use of various approaches and paradigms of assessment and treatment. The information provided in this, and recent issues about deterministic testing, and methods of evaluation are critical elements in the armamentarium of the pain practitioner; so too, are strategies and tactics for treating different types of pain.1,2 To be sure, this knowledge is diverse in kind, scope and application. But what makes this information practical? By definition, that which is practical is action manifested by an agent based upon ethical decision.3 Thus, I argue that knowledge must be used in ways that are both technically and ethically sound. Specifically, this essay will address the questions of 1) what are the domains of knowledge of pain and the pain patient; and 2) how the clinician should utilize this multi-dimensional knowledge in applied practice of pain management. In so doing, I propose that how we know about pain and the pain patient is both a foundation and a guide to what we know, and ultimately impels the type, nature and extent of care.
The rapid progress of technology in medicine has afforded enhanced capacity to detect, depict and discriminate various pathologies. Undeniably, the use of such methods as imaging, biochemical tests, and new molecular assays have greatly enhanced the ability to evaluate the objective features of pain. In quantifying particular physiological characteristics, these approaches are used to classify pain as a pathological condition that is generalizable across individual persons and groups, thereby befitting the disease-model.4
Certainly, the focus upon these properties of pain is important, and the efficiency of technological approaches is particularly viable in certain pain conditions that result from identifiable organic insult. But I posit that we must be cautious in the use of such technology and its resultant depictions for several reasons. First, technologic value-ladeness has resulted in a pervasive reductionism reflective of the disease-model throughout the epistemic and evaluative dimensions of medicine.5 Given that an implicit goal of pain medicine is to objectify the subjective, the lure of technology with its ease of application and rapid provision of quantities and images can be exceedingly seductive, appeal to the contemporary epistemological bias, and incur a self-deceptive complacency of clinical rigor.6 Second, pain is not objective, but is by its nature, a subjective state. Thus, the sole reliance upon objective measures fails to provide the completeness of insight necessary to enable apprehension of the subjective realm of pain as illness, and thereby understand its existential impact in a specific patient. Last, pain is not simply a disease, rather it is disorder that is subjectively manifest as phenomenal illness in a person.7 If illness dimensions are left un-heeded and/or un-attended, two possible adverse scenarios could easily occur: 1) that pain is treated using a solely curative approach; or 2) that disease-based markers of pain may not be present. In the first case, the failure of a wholly curative approach could exacerbate symptoms in those patients whose pain progressed to a point that has assumed predominant characteristics of illness. In the second, the absence of detectable measures could suggest that a patient’s pain is ‘not real.’ In both situations, these misperceptions could incur patient and clinician frustration, lead to inappropriate care, and threaten the therapeutic and moral integrity of the patient-clinician relationship.8
By no means do I wish to suggest that the use of technology or objective assessment is without merit. To the contrary, these tools are both practical and important, but cannot represent a unitary approach to diagnosis, discernment, and determining the care of the pain patient. Domains of knowledge that reflect distinct ways of understanding the problem, the patient, and the potential treatment(s) must be stewarded through intellectual virtue(s) to execute the skill and art of medicine. I have argued elsewhere, and re-iterate here, that as a therapeutic and moral agent, the pain practitioner must use these forms of knowledge, in the right ways, at the right times, to guide the technically right and ethically good care of the person in pain.9,10
Domains of Knowledge and Intellectual Virtues
There is equivocal discussion of whether or not medicine is purely applied science.11 On one hand, there can be no doubt that the growth in scientifically-derived epistemic capitol continues to influence medicine as a culture, and has inextricably woven scientific reasoning into its inherent intellectual fabric.12,13 However, while this may be more or less the case for certain medical disciplines, I concur with Davis, Feinstein, Wieland and others who hold that it is not universal.14-16 Specifically, I believe that the decisional processes in certain medical practices must be more broadly construed to reflect and deal with the particularities of the maladies upon which they focus. I argue that this is the case for pain medicine, as pain is subjective, not wholly objectifiable, evokes unique, experiential manifestations in each patient, and is not a static process with a determinate pathologic course. Thus, while scientific knowledge is important to the establishment of a diagnosis, such knowledge must be incorporated into a more expansive base to allow ongoing assessment and direct appropriate care.
Theoretical knowledge. Still, I maintain that theoretical knowledge needs to be the foundation upon which other forms of knowledge and understanding can be built. Such theoretical knowledge must concede that the conceptual “truths” of science represent a progressive, cumulative understanding that must be ‘framed’ within the intellectual climate of society and culture.17 Medicine exists within particular paradigms that acquiesce to, and hence exemplify the intellectual and social worldview of the time.18, 19 For example, the current paradigm is one that conceptualizes pain within a complexity-based system. This model is important to understand and utilize both because of its resonant value to practitioners and patients, and its contribution to evolving theoretical insight (i.e., about the mechanisms of pain, their effects upon the function of the nervous system as part of a body-brain-mind-environment interaction, etc.). But this theoretical knowledge changes, and therefore the clinician must insure that this knowledge base is maintained and current.20