Faculty Bibliography

Advances in medicine have produced an elongated lifespan often burdened by chronic disorders. Throughout the lifespan and at end of life such disorders can give rise to intractable pain. Although clear distinctions about the respective role(s) for pain therapeutics and palliative medicine remain debatable, both are involved in chronic pain care. Such care has reached a point of crisis fueled by tensions within and between clinical, administrative, and economic factors. We call for a strategy of rapprochement to reconcile these tensions as a means to facilitate more effective and ethically sound pain care. We describe roles and values of principal stakeholders: palliative- and pain-care physicians, chronic pain patients, insurance providers, and hospital administrators and elucidate how dissonances between these groups may contribute to inefficacy of the pain care system and sustain chronic, maldynic pain. We discuss how such values affect use of evidence and resources and explicate frameworks for an ameliorative rapprochement model that acknowledges and balances relative needs and values of all stakeholders. While we have tried to depict why rapprochement is necessary, and possible, the more difficult task is to determine how this process should be articulated and what shape a profession of total pain care might assume.

We posit that in order to realistically, fully, and most positively affect the capability of implementing a more comprehensive paradigm of pain care it is necessary to: 1) recognize the complexity of chronic pain; 2) account for economic factors imposed upon the healthcare system, and 3) enable articulation of any paradigmatic revision within the contemporary medico-legal environment. Three primary ethical problems arise from the interaction(s) of these contingencies--namely 1) the under-treatment of pain, 2) the inappropriate over-utilization of pharmacologic agents and techniques, and 3) tensions and conflicts that develop within the relationships of pain medicine. All can lead to a failure of technically apt and ethically sound pain care. This essay--the first in a 3-part series--employs the method of ethical analysis to approach the circumstances, issues, questions, and problems of contemporary practice of pain medicine, to allow insight(s) to the facts, define the agents involved, appreciate how problems are generated, and develop more thorough evaluation and articulation of potential resolutions. We contend that resolution of these problems must offer practical responses to the circumstances and issues. Such practicality entails affording "good" in ways that are grounded to the facts and realities of situations, and are not merely theoretical or conceptual. Determining the "good" is the work of ethics--as systems and analyses of the moral decisional process. Ethics establishes norms and articulates their use in practice, and we opine that the distinction between the normative and applied is more of a continuum that is dependent upon case and circumstance(s). Given the variety of circumstances in the practice of pain medicine, no single ethical system would be totally adequate, and we believe a discursive approach to be most effective. Subsequent papers in this series will describe the systems, structure, and function of a putative ethical infrastructure of pain medicine, and will attempt to illustrate how these could be articulated within an integrative paradigm of pain care.

In this paper, we propose a constructive approach to an ethics of pain medicine that is animated by a core philosophy of medicine as specific and focal to the uniqueness of pain, the pain patient, and the pain clinician. This philosophy of pain medicine 1) defines the nature of pain, 2) recognizes the variability and subjectivity of its expression in the pain patient, 3) acknowledges and explicates the vulnerabilities rendered by pain, 4) describes the inherent characteristics and asymmetries of the patient-clinician relationship, and 5) defines the ends of pain care. That these ends entail the provision of "good" care links the epistemic domains of pain medicine to its anthropologic focus and ethically sound conduct. We posit that an ethics of pain medicine should define the profession and sustain the practice. Facts establish (the need for) certain duties and rules of pain medicine. These emphasize the duty to self and others, and an appreciation for relational asymmetries, and dictates that those who enter the profession of pain medicine should be generally aligned with this set of core practical and ethical affirmations and duties. To maintain contemporary relevance, rules, duties, and moral reasoning must adjust to changing conditions. Applied ethics shape the practice within the infrastructure of core rules and duties of the profession. An applied ethics of pain medicine must be pragmatic, and therefore, cannot rely upon, or be reduced to, a single principle or ethical system. A number of ethical systems (such as the use of principles, utilitarianism, casuistry, feminist/care orientations) all have relative merit and potential limitations. We argue that the obligation to recognize ethical issues, and utilize knowledge to best reflect appropriate moral values rests upon the clinician as a moral agent, and therefore advocate the relevance and importance of an agent-based virtue ethics, recognizing that virtue ethics cannot stand alone, but must be employed within a larger system of ethical intuition. Yet, if such a structure of normative and applied ethics is to be realized, moral consideration must guide evaluation of the current system of pain care, and provide direction for the development and implementation of therapeutically and ethically integrative pain medicine for the future.

A number of variables have contributed to the current crisis in chronic pain care and are affected by, and affect, the philosophies and politics that influence the socio-economic climate of the American healthcare system. Thus, we posit that managing the crisis in chronic pain care in the United States is contingent upon the development of a multi-focal healthcare paradigm that more thoroughly enables and fortifies research, its translation (in education and practice), and the implementation of, and support for, both the curative and healing approaches in medicine in general, and pain care specifically. These steps necessitate re-examination, if not revision of the health care system and its economics. The ethical imperative to consider and prudently employ cutting-edge diagnostic and therapeutic technologies in pain medicine is obligatory. However, "supply side prudence" is of little value if "demand side accessibility" is lacking. Revisions to health insurance plans advocated by the in-coming administration seek to create uniformity in basic health care services based upon re-assessment of the clinical effectiveness (versus merely cost) of treatments, including those that are "high tech." These plans attempt to allow every patient a more complete ability to deliberatively work with physicians to access those services and resources that maximize health functioning and goals. But even given these revisions, authentic pain care must take into account the interactive contexts of the painient individual. The biopsychosocial model of chronic pain management may have significant practical and ethical worth in this regard. A system of pain treatment operating from a biopsychosocial perspective necessitates integrative multi-disciplinarity. We propose a tiered, multi-disciplinary paradigm based upon the differing needs of each specific patient. But establishing such a system does not guarantee access, and distribution of these services and resources requires economic support to ensure that capabilities are more broadly available (i.e., supplied), and afforded as needed and wanted (i.e., demanded). Toward this end, we posit the need to focus upon, and more fully integrate 1) education, 2) multi-disciplinary care (including re-vivification of MPCs), 3) policies that allow financial subsidies that afford patients the latitude to access and utilize such expanded resources appropriately to meet identified medical needs, and 4) medico-legal initiatives and statutes that protect and enable patients and physicians. The proposed changes comport with a number of ethical systems in that they support the basic deontic structure of the profession and allow for a richer, more finely grained articulation of clinical and ethical responsibilities within the scope of particular general, specialty, and sub-specialty practices.