The Kindest Thing Pain Does
A rare condition, two of my own mistakes, and what a body does that a process has to be built to do.
There are people whose bodies have to be checked at the end of the day. Not out of anxiety, and not because anything feels wrong. The checking happens because damage arrives without announcing itself, and looking is the only way to find it. A burn that never registered. A cut that has been open for hours. A joint that has moved further than it should and stayed there. In childhood, a parent does the looking. Later it is the person themselves, or a clinician, or both. Either way, the inspection is deliberate, scheduled, and conscious, and it stands in for something most of us are handed without asking: a signal that arrives on its own at the moment of the damage, whether or not we happen to be paying attention.
The condition is congenital insensitivity to pain, and it is rarer and less tidy than the name suggests.
It is not one condition. Several genetic routes lead to it, and I am going to take two of them, not because they exhaust the picture but because the contrast between them is useful.
In one, a gene called SCN9A encodes part of a sodium channel that pain-sensing nerves need to send their signal. When both copies carry disabling changes, that signal does not get through. This route comes closest to a clean experiment because most other sensations remain. Touch works, or nearly: testing has found some differences in how touch is felt at the margins. Position works. The known exception is smell, because the same channel is used by the nerves in the nose, and people with this form are typically unable to smell.
The second route runs through a gene called NTRK1 and produces what is usually called congenital insensitivity to pain with anhidrosis. Here, more is missing. Along with pain, the ability to sweat is absent, which leaves the body unable to cool itself. Sensitivity to temperature is affected. Intellectual disability of varying degree is characteristic. This is the form where the confounds are worst.
I want to be careful here. The injuries are documented, and they recur across both routes: biting of the tongue, lips, and fingertips, sometimes severely; damage to the eye; fractures walked on and healed badly; joints worn down; bone infections that took hold because nothing reported them early. What I cannot honestly tell you is that this accumulation is what shortens life. In the second form, early deaths are substantially driven by fever the body cannot shed, which follows from the missing sweat rather than from the missing pain. Reported mortality varies across the groups studied, and I am not going to hand you a figure that sounds more settled than the evidence warrants.
So the narrow claim, the one that survives both routes and all the confounding, is this. The injuries accumulate because the signal that normally reports damage as it happens is missing. Living with this condition means substituting a deliberate audit for a signal that would otherwise have arrived on its own.
Which is worth sitting with because it reveals the pain underneath the flinch.
It is not sensation for its own sake. It is a feedback loop rendered in flesh. It takes a bad outcome and converts it into something carried, something the body cannot set down, something that reaches forward and changes the next reach of the hand. Three weeks ago I described the fast loop that living things run inside a single life: the animal that touches the fire pulls back, carries the burn, and approaches the fire differently tomorrow, the same animal, changed. Pain is part of how that sentence gets implemented. It is the part of the mechanism in us that makes a burn teach.
Knowledge tells you the stove is hot, and knowledge is not nothing here. People with this condition learn a great deal, and much of what keeps them safe is learned rather than felt. What knowledge does not do is bind the lesson to the moment on its own. A person with this condition can see the flame, know the word, and explain to you exactly why fire is dangerous. What is missing is the small insistent return that says this one cost you something, arriving without having to be asked for.
One Word For A Lot Of Different Things
And here I have to correct something in my own vocabulary.
Across these essays I have said that consequence returning to the actor is what turns knowledge into wisdom, and I have said it as though consequence were a single substance arriving in varying amounts. It is not. Being embarrassed in a meeting, breaking a bone, losing a reputation, and watching an institution fail are not four sizes of the same thing. They arrive at different speeds. They reach different distances. Some can be argued with and some cannot.
Two of my own, for contrast.
Earlier this year, while driving for Uber, I hit a parked car. Low sun, a dark grey car on the shaded side of the road, and a fraction of a second spent looking down to change the radio station. The airbag went off. The smell of the powder is the detail I have kept. I called the emergency services, then my wife. She came round the corner from the house, where her parents were loading the car for the drive back to Maine. The damage looked limited to me. The insurer wrote the vehicle off.
What that taught me is narrow, and it is permanent. I am careful about parked cars on my right, leave more clearance than I used to, and have not had to decide on either since. What it never told me was which part of what I did mattered. The sun was real. The radio was real. I cannot separate them, and I have stopped trying. The cost arrived, the behavior changed, and no account came with it.
The other one cost a great deal more and taught a great deal less.
Seven or eight years before that, I was the account lead on a large data program for a retailer. Every two weeks we prepared slides for an executive update. Every two weeks, the client’s project lead edited down or removed the risks in those slides before the meeting. My colleague and I both understood what was happening. We had other problems at the time, in staffing and in delivery, and we chose not to force it. So the meetings went ahead twice a month without the real state of the work being included.
The problems did not go away. After about six months, they were obvious to everyone, and we were left explaining that we had known and had deferred to the client on the contents of the client’s own slides. We were asked to stop work. It took another six months to recover a seven-figure final payment, and it nagged at me for all of them. Worth noting where that landed. The commission on the sale had been paid long before delivery started, to someone who was not in the room for any of this. The people holding the work bore the cost.
Ask me what that changed, and the honest answer is: a little, perhaps. Because I could argue my position, and I did, and it was not a bad position. That is the thing worth noticing. The slow arrival came with a complete account attached, and an account can be reasoned with, and reasoning with something is most of the way to setting it down.
The expensive one taught less than the cheap one. What those two suggest to me is that pain sits at one end of a range. It arrives during the event rather than after it; it lands on the body that acted, and it comes with no reasoning you can take issue with. Embarrassment is social and fades. Financial loss arrives as a document, and a document can be answered. Collapse arrives once, by which time the people who might have learned from it are rarely still in the room.
What This Comparison Can Carry, And What It Cannot
It would be neat to say that these machines, by which I mean here and throughout this series the AI systems many of us now talk to daily, are painless bodies grown large. I don’t think that holds, and I would rather say so than hope you didn’t notice.
Someone with the first form I described, the one that leaves most other sensation intact, is missing one channel out of an otherwise working set. They can still be embarrassed. They still learn from outcomes, and they learn protective rules well enough that the rules become much of what keeps them safe. What is absent is a single protective signal inside a loop that is otherwise running. The absence in these systems is larger. They do not carry a correction forward as the same continuing thing; the durable fixes are made to later versions, by processes outside the system itself. This is not a small version of that. It is a different absence, in a body that is not otherwise like them.
There is a harder objection beneath the surface, and I would rather take it up than leave it for you to find. People live with this condition. Not easily, and not without cost, but they manage it through rules, inspection, treatment, and the attention of other people. If knowledge and procedure can stand in for the missing signal, then perhaps consequence was never what mattered, and what matters is having a working system for finding and fixing errors.
I think that is right. It sharpens the question rather than ending it: what exactly was the signal supplying that now has to come from somewhere else?
For my purposes, separate four jobs that event was doing at once. It registered that something harmful had happened. It made that hard to ignore. It tied the harm to the moment it occurred. And it applied pressure on what the hand did next.
Note the third one, because it is smaller than it looks. Pain ties damage to the moment, not reliably to the cause. My own collision is the proof. Something arrived that changed my driving permanently and never told me whether the sun or the radio was the problem. Working out what actually caused a failure is one of the things a deliberate process does far better than a body does.
Take the signal away, and none of those four becomes impossible. Each becomes something that has to be built. But what goes missing is not any of the four. It is that they arrived already joined. No step sat between them where someone had to decide to pass the signal along.
That does not make the automatic version better. Pain is noisy; it fires long after the damage has healed, and much medicine consists of overriding it. Built systems can be more accurate and more redundant than any signal a body produces. The advantage is narrower than superiority. In the body, the joins were given. In everything we build to replace it, the joins have to be made, and a made join can be left unmade.
Here are two more of mine, and they came out differently.
Two or three months into that retail program, before anything had visibly failed, I raised it internally. I told our office leadership that progress was behind our projections, that I believed there was a serious architectural problem, and that we were being discouraged from raising the concern with the client. The check worked. It detected what it was meant to detect, early, and reported it accurately to the people it was designed to report to. What came back was encouragement to keep reporting internally and to stay positive with the client. Nobody above me was obliged to answer what the report contained. So it was received and absorbed, and the work continued.
Earlier this month, a reader went through one of my working papers and found an arithmetic error in it, an adjustment I had applied in the wrong direction, along with a comparison I had drawn that did not hold dimensionally. He was right on both counts. I had read that paper many times. Nothing in the reading reported it. I corrected it, published the revision, credited him, and the whole thing took days.
Two feedback events, one person, opposite outcomes. And notice that the one that worked was the less automatic of the two. It arrived late, from outside, in writing, from someone I had never met. What it had was a join I could not quietly leave unmade. Ignoring him was an option, but once his correction was public, ignoring it would have been its own visible act.
The internal warning had no such join. Whatever else may have failed, and I cannot tell you from the inside whether leadership found it credible or simply doubted my diagnosis, the last one certainly did. The report was received, and nothing followed, because nothing had to, and nothing showed that nothing had.
So a built chain is not weaker than a body because it is deliberate. It is weaker wherever its joins are held by someone’s discretion rather than by design. That is what the scheduled inspection quietly depends on, and it is easy to miss. Checking for damage you cannot feel only protects you if finding it leads to treating it. An inspection whose findings go nowhere is not a replacement for the missing signal. It is the appearance of one.
What The Substitute Needs
We have no way to give a body back a signal it was born without. What we have instead is a chain: someone looks on a schedule, what they find is made to count, and something acts on it. That works. It works in clinics every day. What it costs is that every join in it is somebody’s, and has to keep being somebody’s.
Which puts everything on a range rather than in two camps. Pain sits at one end, where nothing sits between the harm and the response. A safety interlock that cuts power without asking is not far behind it. An audit with real enforcement is further along. A risk edited out of a slide deck before the meeting is at the other end entirely, where every join is somebody’s decision and any one of them can quietly not be made.
So I am not making a case for suffering. Pain is still the thing we medicate and still the thing we hope to be spared, and I would not argue otherwise. I am pointing at what it is doing while it is there.
The kindest thing pain does is not protect us, though it does. It is that it needs nobody’s cooperation. No one has to approve it, or pass it upward, or decide it is worth raising. It arrives, at the time, at the one who acted. Everything we build to stand in for it has to have that joined on purpose, at every step where a body had it for free.
Originally published on Substack.
