The Metaphysics of The Pain Scale

Protagoras is famous for having noted that man is the measure of all things. Hamlet appears to concur when he states that "there is nothing either good or bad, but thinking makes it so". In medicine, when speaking of the pathologic, specifically of pain, we quite naturally take a similar subjective tack and ask our patients to describe it in their words and to rank it on the now ubiquitous "pain scale". You may be asking yourself, what, pray tell, is the pain scale? Allow me a brief historical aside.

Back around the turn of the century there was a large push, mostly by the government, to begin to think about the concept of "oligoanesthesia"-also known as the undertreatment of pain. A quantitative pain scale, from 1 to 10, was created in order to allow lucid adults to rank their pain for their physician when compared to all the previous episodes of pain they may have had in their life. It was required, as part of a billable chart, to be asked and became a standard part of the history of present illness.

Most patients, at least in the emergency department setting, rank their pain a 9 or a 10 (or often some random number much higher than a ten, thus, of course, making the entire exercise a farce). After all, why would they have come to the emergency department, ostensibly created for the purpose of medical emergencies, if their pain was not a ten? Also, how does one rank emotional distress? Can this also be placed on to a subjective pain scale and titrated up and down with appropriate medication? It seems less clear and yet surely we would not want to downplay the importance of the psyche in any medical complaint.

Yet, none of these mild concerns about the utility of the pain scale, as rational and common as they are, compare to the objection which has led me to ponder about the subject for so long. The truth about the pain scale score question, at least in my experience in the ER, is that a healthy majority of my patients don't understand how to answer the question and, subsequently, do so incorrectly. As noted above, the pain scale score is supposed to be an entirely subjective account of your current pain quantified into a number that represents its relative position to you at that moment in time compared to all the other pain you have experienced in your life. It is entirely solipsistic. If breaking your hip 3 years ago was a 10/10 then your toothache today is a 4/10, etc. This seems fairly straightforward but this is not how most of my patients intuitively interpret the pain scale.

Rather, many people will introduce their answer with an unfortunate introductory clause that usually sounds something like this: "well, I have a very high pain tolerance..." (Interestingly enough, many people admit to very high pain tolerances but very few believe themselves to have low ones, which seems to speak to another kind of truth about humanity). This is all well and good but it represents a fundamental misunderstanding of the question. The patient in this scenario is, rather, doing something both quite interesting and quite impossible without being asked to. He is comparing his unique and subjective pain experience to what everyone else in the world would consider it to be were they themselves suffering from the same problem even though it is impossible for another person to experience his pain or vice-versa. He assumes he has a "high pain tolerance" compared to the rest of the world based on previous illnesses or injuries but of course, this type of knowledge cannot be known. In other words, he has taken an entirely subjective question of pain compared to previous pain he's had in the past and conflated it with his pain compared to the pain experienced by all other people everywhere. This is an impossible proposition but it happens multiple times on every shift I work in the ER.

Why do people confuse a subjective question with an objective one? I would cautiously propose that it seems to suggest that there is an unspoken universal understanding that pain is a part of all of our lives. This logical and obvious truth hints at a greater one-that if something like pain exists for us all then there are other things in the world that are objective and apply to everyone as well. Pain, yes, but also love, dignity, character, friendship, the beautiful and the good. These things exist just as much as gravitational constants, mitosis or the speed of light and they are just as necessary though they are not so empirical. These first things are intuitive glimpses of the hidden essence of the world rather than rational proofs of its organizational structure and function. We are often loathe to accept these more revelatory manifestations of objective truths rationally even though we act in such a way as to implicitly acknowledge them. The answers I receive on the pain scale question are a daily reminder of humanity's almost unconscious understanding of the world as it is. We compare our pain to others because we understand that pain is something that exists for all of us and that we are born into a community of souls. We too will pass from the scene and hopefully we can pass to the next generation a small amount of wisdom that they will be able to put to advantage and, in turn, pass on themselves improved a bit, and so on ad infinitum.

And so this admission of truth appears fundamental to the present world in which we live, the past world which we have inherited and the future world which we will bestow upon our children. This accidental admission is not "my truth" or "your truth". It is not an opinion shrouded in a cloak of objective double-speak. It is universal and therefore, it has something to say about the metaphysical structure of the universe and our role within it. It is the truth.

All this from the little pain scale.

And so now when I hear, as I do on every shift, that so and so has a high pain tolerance, I no longer roll my eyes a little but rather I smile inwardly at a small but important truth of the world that has just been acknowledged and of how a world in which there is one truth, just one even, is a world that cannot be, at its fundamental core, relativistic. With apologies to Protagoras, man seems to be defined by first things rather than busy defining them (though much ink has been spilled on that score as well). Put another way, it seems impossible to say that there is no absolute truth in the world because to do so would be to assert a truth, which would of course be paradoxical. Ultimately, it is this truth, that there is such a thing as the true, that I think will help us strive to become better people and to apply ourselves to the best things of the universe-to what Matthew Arnold referred to as "sweetness and light"; to kindness and to illumination; to charity and to wisdom. I wonder if it is to these things that we grasp at and bend toward, like a plant to a light source, not with scientific laws but with moral imagination. I worry that we're losing our ability to detect that lovely intuition of humanity, that glimpse of the nature of things that real art can briefly pull back the veil from, but hints of which are hiding in plain sight. It is tucked away in great literature and music and art and architecture but it is also there sneaking around among the mundane and the contrived. It is quietly existing behind the inadvertent misunderstandings of the pain scale and hiding within the everyday tasks of the world just waiting to be rediscovered and once again remembered, embraced and passed along.