Ethical Principles in Pain Management | Pain Medicine | Oxford Academic | Mark Sullivan, MD, PhD | September 2000
Introduction: The Role of Ethical Theory
The vast majority of the medical literature published concerning the ethics of pain management addresses pain relief at the end of life. This is a very important area, but does not address many of the most pressing concerns about pain management during other phases of life.
Readers are referred to the IASP Curriculum in Pain Management and Research, which lists many of the ethical issues with which practitioners should be familiar.
The purpose of this document is to give practitioners and policymakers some tools to use in thinking about the broad range of ethical questions pertinent to pain management.
While “morality” refers generally to social conventions about right and wrong,“ethics” refers to the more theoretical and systematic understanding of the moral life.
Though moral reasoning informs every choice we make about our actions, it becomes particularly important in the face of moral perplexity or uncertainty.
Ethical theory can bring some consistency and rationality to our moral judgments in these kinds of cases by describing what qualifies as relevant and adequate reasons for action.
Traditional ethical theory has conceived of moral judgment as the application of a rule to a particular case.
In this deductive model, moral justification is derived from preexisting normative precepts. The Golden Rule that “you should treat others as you would like to be treated yourself” is one example of this kind of precept.
In practical ethics, choosing an ethical theory to apply and appropriately applying it can be very difficult.
this model of deduction does not appear to capture how moral reasoning works in complicated cases. Rather than a simple movement from general principles to particular judgments about cases, a reciprocal relation exists between general rules and particular elements in experience.
The experience of philosophers and bioethicists in hospitals and clinics has taught them that clinical moral judgments involve specification and balancing of norms according to the concrete clinical situation. One often cannot determine in advance what the critical detail in a case will be.
Whether the action should be “a” or “b” often hangs on a very specific aspect of the case, one that may not have been captured by a deductive model.
The traditional deductive model of ethics is thus being combined with an inductive model that recognizes the importance of the individual precedent-setting case.
As medical technology evolves, what constitutes the critical ethical detail in a clinical case can change in ways unanticipated by theory. The inductive model allows our moral intuitions to be adjusted in light of compelling cases as well as compelling principles
Some bioethicists have thus called for a “reflective equilibrium” between theories and cases. “The goal of reflective equilibrium is to match, prune, and adjust considered judgments so that they coincide and are rendered coherent with the premises of theory ”
Bioethical principles thus exist in a dynamic relation with the clinical situation.
This is why rigid standards for medical care are inappropriate and we are moving to “personalized” healthcare, where an individual’s particular situation determines the actions taken.
Principles provide a considered and consistent way to interpret the clinical situation. The clinic provides the context within which principles should be specified, qualified, or adjusted so that they provide useful guidance.
Types of Ethical Theory
Theories differ according to which aspect of the moral situation they take as the focus of their attention.
- The agent,
- the action itself,
- the consequences of the action,
- the relationships of the agent, and
- the specific character of the situation
have all been the focus of one or more theories. A brief review of prominent theories follows with some annotations concerning their application to ethical problems in pain management
Consequentialist theories: utilitarianism
Of those theories that focus on the consequences of actions as the source of their moral value, utilitarianism is the most important. Those who focus on consequences believe the “best overall result is determined from an impersonal perspective that gives equal weight to the interests of each affected party”
One of the great strengths of utilitarianism is its simplicity. Utilitarianism accepts only one principle of ethics, the principle of utility. This principle dictates that we strive for the maximal balance, for all persons, of positive value over disvalue
Utilitarianism considers the only intrinsic good to be the happiness or pleasure that results from an action.
No action is good or bad in itself; it acquires moral value only in terms of the consequences it produces.
But applying this principle may not be as straightforward as it initially appears. In some illnesses, disease treatment has priority (appendicitis), in others pain management has priority (non-specific low back pain). Pain relief must be assigned a value relative to other medical benefits such as prevention of death and reduction of disability.
Utilitarianism has some important shortcomings as an ethical theory.
- Because the principle of utility measures the value of consequences solely in terms of preference, utilitarianism is unable to distinguish between acceptable and unacceptable preferences.
If someone were to truly prefer an opioid regimen that produced a lifelong stupor rather than some minimal discomfort from walking, utilitarianism would support such a choice.
- Second, utilitarianism cannot distinguish between good actions that are obligatory and those that are helpful but optional. Maximizing utility is our only duty.
- Third, because utilitarianism is only interested in aggregate utility, it is indifferent to unjust distributions of benefit. Obtaining pain relief in easily treated individuals would be favored over obtaining pain relief in less easily treated individuals
Deontological theories: Kantianism
Opposite utilitarian theories are those duty-based theories that contend consequences play no role in determining whether an action is right. Immanuel Kant derived an entirely formal ethical theory that dictated only “that we rest our moral judgments on reasons that can be generalized for others who are similarly situated”
This “categorical imperative” is kin to the familiar “golden rule” cited above in its emphasis on similar treatment for similar individuals.
One must do what is right because it is in accord with our nature as rational moral agents, not because it happens to produce pleasant results. This kind of theory accords with our intuitions that certain acts are inherently right: keeping promises, avoiding murder, telling the truth.
Though elegant in form, Kantian theory has substantial problems in practical application. Because all duties are considered absolute, there is no guidance available for balancing conflicting obligations.
Where utilitarianism seems to fail by making everything negotiable, in the pure Kantian system nothing is negotiable.
Intentional killing is always prohibited, even in cases where many lives could not otherwise be saved, or in cases where severe pain could not otherwise be relieved.
Rights-based ethical theories
Much of the ethical debate in our society occurs in terms of the rights-based rhetoric of liberal individualism.
The concept of rights highlights protection of the individual from larger social institutions like religion or the state.
The positive right to pain relief has not been discussed much in the United States (apart from the end-of-life setting) because the general right to health care is so contentious.
Some ethicists have found rights-based ethics too individualistic and adversarial. Communitarianism has been proposed as an alternative. This theory sees all ethics as derived from communal values.
This is a relationship-based ethic based on an “emotional commitment to and willingness to act on behalf of persons with whom one has a significant relationship”
It is relevant to pain management because it challenges impartiality and detachment as well as universal principles in ethics. Suffering, in particular, may be perceived best in an empathic relationship characterized by a rich narrative interchange.
The emphasis in an ethics of care on mutual interdependence in relationships and a positive role for the emotions counters longstanding traditions in medical education that encourage impartiality and professional distance.
Another relatively new ethical theory of interest for pain clinicians is narrative-based ethical theory.
This is the opposite of the principle-based or top-down model. Here the story of the individual case becomes of core importance, of paramount understanding.
Modern biomedical science has extracted the problem of pain from its context, from its role in life.
pain has causes, physical causes, but no reason
Modern medical professionals have abstracted the problem of pain from its context, from its story.
As we are trying to take on more seriously the problem of suffering, we’re drawn back to narratives. This is because it is very difficult to determine whether and how much someone is suffering without being aware of the story that accompanies their experience.
Narrative-based ethical theories are not without their problems. Because they are so rich with respect to the individual case, it becomes more difficult to generalize across cases.
Principle-based Common Morality Theories
A number of modern ethicists have advanced theories that derive principles of obligation from the common morality.
The account described here derives from that presented by Beauchamp and Childress in their Principles of Biomedical Ethics.
Conflicts between principles cannot be resolved without reference to the situation where they are applied.
They have described four principles as essential for biomedical ethics:
- respect for autonomy,
- beneficence, and
Those principles have been abandoned completely when it comes to treating our pain. We should be entitled to “whatever works” for us as individuals, irrespective of what’s going on with others who have trouble with the same drugs.
Respect for autonomy
An autonomous individual is someone who is captain of his or her own ship, someone who “acts in accordance with a self-chosen plan.”
This capacity for self-rule has been held by many philosophers to be one of our most precious and distinctly human capacities.
Autonomy requires two essential conditions:
1) liberty, or independence from a controlling influence; and
2) agency, or a capacity for intentional action.
Because patients must rely on physicians’ expertise and authority when ill, there is a tendency for physicians to take over decision making for patients. This is often done with the patient’s benefit in mind. This benevolent deciding for others is called “paternalism” because the physician is acting as if he were the patient’s benevolent parent.
llness makes patients dependent on physicians. Eric Cassell explains: “For the suffering person, autonomy is removed when purposes are directed by the immediate needs of the sick body or by the compulsion to address what is perceived to be the source of the suffering”
Pain, for example, may push patients to a point where they are no longer able to carefully weigh the risks and benefits of surgery.
Medications such as opioids or benzodiazepines that induce physiologic dependence hold special risks for erosion of patient autonomy. In these situations, respect for patient choice must be combined with awareness of the compromise of patient autonomy by unrelieved pain and by dependence-inducing medications.
Physicians have an obligation not to inflict harm on patients intentionally or carelessly. Primum non nocere, first do no harm, is one of the most frequently cited maxims of biomedical ethics. Generally these obligations to avoid harming are more stringent than those obligations to do good.
his duty prohibits inflicting harms as well as imposing unwarranted risks of harm.
Failing to provide adequate analgesia to neonates undergoing painful procedures, for example, would now be recognized as a violation of the physician’s duty of nonmaleficence to the neonate.
Providing a surgical procedure for a patient in severe pain known to provide only short-term relief and severe problems over the long term would also be considered a violation of nonmaleficence.
Physicians have a duty to take positive steps to help others and not just to refrain from harmful acts.
It makes the further claim that
“since moderate to excruciating pain can be physically and psychologically harmful, preventing or alleviating such pain is not merely a matter of doing good (beneficence) but also of preventing harm (nonmaleficence).”
differences between rules of nonmaleficence and rules of beneficence.
Rules of nonmaleficence typically:
1) are negative prohibitions of action,
2) must be obeyed impartially for all persons, and
3) provide reasons for legal prohibitions of certain conduct.
Rules of beneficence, by contrast:
1) present positive requirements of action,
2) do not need to be obeyed impartially, and 3) rarely provide reasons for legal punishment
The duty of nonmaleficence is more universal than the duty of beneficence because “it is possible to act nonmaleficently toward all persons, but it would be impossible to act beneficently toward all persons”
Physicians have a duty to relieve pain in conditions such as cancer and burns where there has been an acceptance of severe pain.
Then why can’t doctors “accept” our severe pain that’s *not* caused by cancer? There’s NO DIFFERENCE between cancer and non-cancer pain.
However, it is unclear whether physicians have a duty to relieve all the pain of all of their patients. Some practitioners contend, for example, that the “goal in pain management for those with chronic pain often cannot be complete relief of pain” and even that “not all pain should be treated”
there is recent evidence that some individuals with a family history, but no personal history, of alcoholism may have diminished endogenous hypothalamic opioid activity.
This raises the possibility that some individuals are genetically deficient in endogenous opioids and may more frequently need exogenous opioids than others.
That sure sounds like me. I’ve always been ridiculously pain sensitive, to the point that even a wrinkle in the bedsheet underneath me can become painful.
I’ve always attributed that to EDS because our skin (connective tissue) is frailer and thus cannot buffer us against pressure like it should.
The nature and limits of the general duty to provide pain relief are also not well defined. Does this duty only pertain to individual patients seeking relief from a physician, or does it include a public health component that includes all potential sufferers
It might be difficult to draw a meaningful line between pain and suffering, because social and psychological suffering is so often presented to physicians in somatized form as pain.
Sometimes the physician’s job may be not only to reduce pain and suffering of the dying patient, but also to help this patient find meaning in this suffering.
I’m perfectly aware of the meaning of my suffering: it means I have EDS.
physicians have an obligation to promote justice in the distribution of these goods. Distributive justice refers to fair, equitable, and appropriate distribution in society of a privilege, benefit, or service
It is increasingly recognized that health care resources in the United States are finite and that difficult choices need to be made about who gets what health care.
There are many potential candidate principles of distributive justice described by Beauchamp and Childress:
To each person:
1) an equal share,
2) according to need,
3) according to effort,
4) according to contribution,
5) according to merit,
6) according to free-market exchanges.
Each of these principles can justify very different distributions of goods.
Our society has rarely explicitly grappled with the just distribution of medical care.
It is not clear where pain relief should fit in a list of health care options to receive funding.
Should all patients be entitled to some “bare minimum” of pain relief services? Should all have access to state-of-the-art interventional pain control strategies?
Principle-based ethical theories offer the most well-developed means of resolving conceptual and bioethical problems. They give us a template. They get us started.
But it is very clear in medicine, and particularly with respect to pain management, that they need some bottom-up, case-based supplementation through casuistry and/or narrative methods.