Pain care is a matter of ethical and professional ethics

Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3) | Program, Purpose and Process | By James Giordano, PhD, MPhil | March 1, 2009

This philosophical article explains that pain and a doctor’s professional pain care create moral and ethical obligations to relieve suffering.

Progress: An Ongoing Process of Reflection, Analysis and Action

One of the outstanding questions of the Decade of the Mind Project (DoM) is how this incentive for cutting edge research will benefit the human and/or global condition.  

Previously, I have described how one goal-area for understanding the brain-mind is to generate better knowledge of pain and suffering and, from this, develop improved strategies and tactics of pain assessment and therapeutics.

This cannot be a myopic or unilateral effort, rather it must acknowledge that we are working at the frontiers and boundaries of the unknown, recognize that the results of this work can—and likely will—be globally manifest and take into account the plurality of society and culture(s) that could be affected by these outcomes.

This is upheld by the fact that the DoM project is trans-disciplinary and international (viz. conjoining scholars, researchers, clinicians and public in Europe and Asia over the next several years).

Identifying Problems

As a first step, we have begun to identify and analyze the difficulties inherent to pain care—both historically and currently. Perhaps the problem(s) that define contemporary pain medicine as profession and practice could be reduced to a three-fold concept:

There is controversy in the literature about whether tolerance to pain relief develops. In my clinical practice, which includes many patients treated with opioids for up to 15 years, quite a few have been on stable doses of opioids for years

Other opioid-prescribing clinicians have observed the same thing. Unfortunately there is a dearth of outcome reports in the medical literature.

When patients report increased pain after months or years of opioid treatment, their physician frequently attributes this to the development of tolerance to the pain-relieving effect of the opioids. But, remember, tolerance to all the other effects of opioids develops within days! What is much more likely is that the patient’s disease has progressed or that a new pain-producing problem has appeared.

  1. problems of understanding
  2. problems of translation
  3. problems of articulation

we still must confront the “ti esti” (i.e., what is it?) question of pain. When we do, we encounter the “hard questions” of neuroscience which directly or indirectly underlie many of the hard problems of pain medicine.

In this way, several of the first-fold issues and dilemmas instantiate those second-fold problems, that involves the translation of what we know about brains, minds and “selves” into a reasonably comprehensive system of pain care

pain medicine must be defined by the understanding of pain and its manifestations in the individual.

To do this dictates that pain research must:

1) be inter-disciplinary;

2) study the mechanistic aspects of pain, and how these affect and are affected by bio-psychosocial dimensions of patients’ life worlds;

3) obtain a finer-grained perspective of the common as well as individually unique aspects (and effects) of pain; and

4) be equally devoted to both studying “how we study” pain, and revising these approaches in acknowledgement of information and knowledge gained, to date.

the third articulative problem of pain medicine necessitates resolution through the development of a structure for the profession that entails different types of practice(s)—each and all of which are dedicated and enabled to employ the right knowledge, technologies, and skills in those ways that uphold the primacy of the pain patient’s best interest.

Given identification of these problems, the goal is to bridge evidence and knowledge gaps such that information gained in response to the first problem, and developed in response to the second, is used in the third.

Here we see how the enactment of the therapeutic dimension(s) of pain medicine can, and should, compel and ultimately sustain moral responsibility as an individual and public good. The premise is that this relationship is reciprocal: ethical obligations (i.e., to conduct pain research to empower right and good pain care) dictate the need to generate and provide right and good therapeutic action(s) and any and all therapeutic actions have moral potential and import.  

The “Promise” of Pain Care

The concept of “promise” is based upon the Latin term to “put forth” (pro-mettere), and is related to the notion and act of profession (viz. from the Latin: profiteri) as a public declaration of skill and knowledge that invites trust of those who seek the goods provided by the practice(s).

The promises of pain care are intrinsic to the profession. The structure of the profession entails obligation and responsibilities to certain intentions and actions. Thus, the declaration of what one “is” (e.g., “a pain physician” or “pain specialist”) is a communication of what one “puts forth” to both “be” and “do.”

Clearly, this relation is evident in medicine, in general, and takes on particular therapeutic and moral gravitas in pain medicine, as it explicates that the pain physician

1) has knowledge about pain as disease and illness,

2) possesses skills and abilities that enable this knowledge to be incorporated into diagnostic and therapeutic process, and

3) will use these domains of knowledge and capability in those ways that are contextual to the experience of pain in specific patient(s)—and do so in ways that are intellectually and morally consistent with the affirmations, goals, and ends that are entailed by participation in profession and enactment in practice.

The Promise in Practice

The promise of pain care entails a larger, more multi-dimensional responsibility. Each and all of the inherent domains of knowledge that are essential to medical practice—regardless of discipline—are engaged, so as to allow a theoretical, applied, experiential and contextual understanding of pain (as object), and its expression and effects in the person who is the pain patient.

It serves as the basis for both diagnosis and evaluation of how the pathological process manifests illness in the patient’s lifeworld.

the first-person nature of the pain experience and its manifestations also mandate that the clinician engage a particular inter-subjectivity so as to best assess how the pathology creates needs that must be met in the therapeutic relationship.

This is the pedestal upon which Pellegrino’s critical inquiry of the clinical encounter can be built:

“What is wrong with this patient?”

“What can be done?” and

“What should be done to effect a right and good healing action?”

The first two questions reflect the theoretically intellectual domains of pain care, while the third involves a more applied contextualization and therefore must obtain some greater sense of who and what this pain patient is, in the bio-psychosocial sense. From this point, the values, goals, and needs of the patient—as relative and relevant to clinical intervention—must be accorded so as to determine the nature and trajectories of care.  

Often, the obvious goal of pain relief may, in fact, not be wholly possible. Intractable pain is a reality of several pain conditions. However, it is important to recall that the “intractability” of pain need not imply that treatment and/or management is untenable.

We argue that persistent, chronic pain need not devolve into maldynia. The pars malus (i.e., “badness”) of maldynia refers to the lack of purpose for, and denigrative effect upon the person in pain.

Maldynia: pathophysiology and management of neuropathic and maladaptive pain | Pain Med. 2010 Nov

Therefore, for those with intractable pain, the clinical goals are not only to attempt to reduce pain to tolerable levels, but to accomplish this within the larger aim(s) of working with the patient to re-constitute the life that has been de-constructed by pain.

Obviously, this necessitates developing an understanding for how pain has incurred such effects, and what values and goals are vital for this patient to re-claim so as to be lifted, in as many ways possible, from the existential burden(s) pain has incurred.

To re-iterate, the claim is not that technology does not comport with medicine, but rather that technological protocols and capabilities often do not, nor cannot, determine the type and quality of care to be rendered.

This determination necessitates the knowledge, insight, creativity, and both intellectual and moral judgment that constitute practical wisdom (i.e., phronesis, or prudence).

A Paradigm for Pain Care on the World-Stage: Importance of an Ethics of Responsibility

In the main, the challenges are determining what needs to be studied, how such study can and should be undertaken, and what and how research findings should best be translated into care to meet the needs of those in pain.

We argue that such challenges must be met through the use of normative and applied ethics that are built upon core responsibilities intrinsic to pain medicine—in both research and practice.

there is a centrifugal quality to these responsibilities that reflects an understanding of the nature of the human condition (i.e., neuroscientific, and neuroanthropological perspectives of the brain, mind and self, pain, etc), recognition of self-responsibility, and acknowledgement that responsibilities to others are asymmetrical.

The latter are based, in part, upon both self-other relationships and vulnerabilities incurred by such relationships (e.g., inequalities of knowledge, power, and the differential effects of pain, illness, etc.)

Roger Scruton’s contention is that any approach to improving the human condition (and pain medicine certainly seeks this end) must first reflect upon, and seek to understand, the nature and essence of what it means to “be” human

in terms that are relevant to both our present circumstance(s) and future possibilities

The goal, therefore, is to engage this knowledge to develop a meta-construct of pain and pain medicine that reflects and contains neuroscientific, (neuro)philosophical, and (neuro)ethical domains, and then employ this construct as a basis for ongoing internationalized efforts in research, education, and translation into practice.

A Program Within a Project—N3P3: Purpose, Potential and Invitation

This is the mission of the Program in Neuroscience, Neurophilosophy, and Neuroethics of Pain, Pain Care, and Policy (N3P3). Working within the larger agenda of the DoM Project, N3P3 focuses ongoing efforts in the sciences, technology, and humanities upon the problem of pain and the potential of pain care (inclusive of palliative medicine), and engage knowledge gained from these projects toward informing and developing ethically sound and socially effective policies for research and therapeutics.

By design and intent, it is inter- and trans-disciplinary, international, and iterative.

the first part of this program will attempt to define the meaning of pain and dimensions of pain care to date.

This will serve as the groundwork upon which to develop and funnel a component of the energies and activities of the DoM project upon the problem of pain and the potential for improving pain care.

To do this requires a deeper and more analytic examination of the human condition and the ways that this nature and expression is affected by, and affects, pain and its meanings.

To be sure, this work must

  1. acknowledge the occurrence of pain across the lifespan,
  2. identify and examine the various contingencies when pain occurs in the fetus, neonate, child, adult and aged—as well as when death is imminent—and
  3. employ this knowledge to develop improved methods, protocols, and paradigms of diagnosis, treatment, and management.  

Through a progressive series of workshops, seminars, feasibility studies, and publications, N3P3 is intended to work in partnership with DoM to create a nexus for the

  • exchange of ideas; identification and analysis of evidence and practice gaps;
  • development of new methods of inquiry, protocols for study and practice; and
  • guidelines and policies that enable articulation.

Acknowledgments

This essay was adapted from the chapter:

Prolegomenon: Philosophy, ethics and policy in and for pain medicine (Giordano J, Boswell MV). In: Giordano J, Boswell MV. (eds.) Pain Medicine: Philosophy, Ethics and Policy. Linton Atlantic Press. Tennessee and OxfordTennessee and Oxford

 

1 thought on “Pain care is a matter of ethical and professional ethics

  1. Dave

    And they say i talk mumbo jumbo. Giordano- a bright and caring guy but and obtuse obfuscator who is about perspicuous as a porcupine in a baloon factory.

    Like

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