Carl Y. Saab ^1,2,3,4* Charles Djordjevic ^2,5

• ¹ Cleveland Clinic Lerner College of Medicine, School of Medicine, Case Western Reserve University, Cleveland, United States
• ² Cleveland Clinic, Cleveland, Ohio, United States
• ³ Brown University, Providence, Rhode Island, United States
• ⁴ Case Medical Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
• ⁵ Lorain County Community College, Elyria, Ohio, United States

To an individual, pain is unambiguously real. To a caregiver, assessing pain in others is a challenging process shrouded in doubt. To explain this challenge, many assume that pain 'belongs' exclusively to the bearer of that experience and accept the dogma that pain is private. However, privacy also entails that it is not possible to identify, share, or communicate that experience with others. Obviously, this is not true and the consequences of pain privacy would be devastating for healthcare. Pain is indeed unique and subjective, but not necessarily private. Pain is in fact readily communicable, though perhaps not as effectively and reliably as caregivers would like. On the other hand, healthcare systems mandate objective metrics in pain diagnosis. Smiley face caricatures are a staple of clinical practice and a universal standard for reporting pain levels. These conditions create a double paradox: Assess a private experience that is inaccessible, and use numerical scales to measure subjective attributes. Navigating this stressful environment, medical professionals experience intellectual dissonance, patients are frustrated, and value-based care is undermined. Offering a way out, first, we refute the privacy and objectification of pain citing philosophical, behavioral and neuroscientific arguments. We discuss Wittgensteinian views against privacy, explore the clear evolutionary advantage of communicating pain to others, and identify neural circuits in the mammalian brain that contribute to empathy. Second, we highlight the subjectivity of pain, embracing the complexity and uniqueness of an individual's pain. We also provide compelling evidence for brain mechanisms that actively shape the pain experience according to predictive coding principles. Third, we offer a vision for the development of biomarker technologies that assess pain fairly without engendering bias against the patient's narrative. Our recommendations are based on the overwhelming appreciation that 'medicine by emoji' is inadequate for capturing the multidimensional nature of pain. Our view is that the most promising candidates for pain biomarkers consist of self-reports as ground truth augmented by physiological signatures of biological relevance to pain. Integration of subjective and objective multimodal features will be key for the development of comprehensive pain assessment models.