Halfway through the congressionally-declared Decade of Pain Control and Research, it may be time for a reflective pause to ask in both conceptual and practical terms, ‘where we are?’ and ‘where might we be going?’ A review of the past five years’ progress yields abundant demonstration of ardent strides in research. However, we are also confronted with evidence that the translation of research developments into viable therapeutic applications has been less than optimal, and further, that the sustenance of treatment paradigms that meet the epidemiologically-defined problem of chronic pain is lacking. This represents a paradox: although we may know more about the basis and mechanisms of pain and how to treat it, we are becoming ever more disempowered to effectively act on this knowledge.
In this issue, Michael Schatman speaks to this by illuminating the declining number and increasingly restricted roles of accredited, interdisciplinary pain management programs. Despite several lines of evidence to support the durable effectiveness of outcomes achieved by such programs, he reports the continuing trend to discontinue, or severely limit the services provided by these centers. Schatman opines that this apparent contradiction reflects the commodification of medicine in general, and the resultant pervasion of a business ethos that disavows the benefits of long term pain care as being inordinately expensive to a healthcare system that is primarily concerned with proximate-costs. He views the problem as a conflict between business ethics and those of medicine, and in so doing questions whether the contemporary form of pain medicine has become inseparable from the effects of corporate systematization. Schatman asserts that a change is required that responds to the moral obligation to treat those who are in pain, and that provides ethical guidance to implement supportive healthcare policies.
I agree; the superimposition of the business model upon medicine has enabled the ethos of profit to suborn the ethics of care. Yet, if a change is to occur, it must not only restore the clinical empowerment of pain management programs, but must also maintain their economic viability. This will allow them to be effective and still survive in a healthcare market that is not likely to change in the immediate future. Schatman astutely notes that the ethics of business and medicine differ, due at least in part, to the divergent ends and goals of these fields. It is the ends of an undertaking that direct the ultimate focus of its activities, and often determine the nature of the conduct of those actions.1 In this light, it becomes apparent that the motives of business that foster commodification of healthcare as instrumental to ends of profit cannot be resonant with the beneficent and just provision of medical services to restore health as a fundamental good.
I argue that to change this situation, the apparent dualism of business and medicine must somehow be ameliorated to meet a more monistic paradigm in which the corporate and clinical components of medicine are equivalently dedicated to the common end of rendering right and good care to patients. Such amelioration may seem obtuse, yet I offer the following premises to support this proposal. First, while there is an aspect of business within the practice of medicine, it is crucial to recognize that medicine is not a business. It is a profession that is dedicated by covenant to the primacy of the good of the patient.2 Second, medicine is non-proprietary, and is not a commodity to be restricted through market manipulation. Third, as Gini states, business is, by its nature, about serving people.3 Thus, once the profit-focal ends of corporate medicine are aligned with those of the clinical enterprise, the ‘business’ of pain medicine could be situated to provide the administrative and financial means through which medical resources are most effectively made available to those persons who are in pain. In many ways this conceptualization reflects the prudential question of ‘what should be done’ to best afford medically right and ethically sound provision of care to the patient.4
I argue that the basis of this change requires the establishment of a teleologically-construed (i.e., ends-based) ethical framework that reconciles the apparent inimical tension between business and medicine.5 One possible way that this may be achieved is through incorporating Peters and Waterman’s “excellence model” into corporate medicine to embody what Klein has called the “craftsman ethic.”6,7 This system emphasizes quality of knowledge, skill, products, and services that are delivered within, and ultimately serve the end(s) of enhancing the substantive “goods” of the human relationships inherent to the practice.8 Working within this model, the values and ends of the clinical and corporate domains of medicine can become more effectively mutualized. By acting consistently toward these ends, any achievement of profit would not be misfeasant, because it is not gained through sacrificing patient care. Rather, the (technically right and ethically sound) success of the services rendered would foster increased utilization, and therefore continued subsidy.
Given mutual purpose, I maintain that any real change can only occur through the leadership of individuals who act directly as change agents. This leadership must be transformational and concerned with, and dedicated to the primacy of the good of the patient. According to Burns, transformational leaders are committed moral agents whose actions influence the vision and direction of both followers and the organization.9 Through example and empowerment, the transformational leader turns their followers into leaders, and catalyzes change by allying the actions of what Engelhardt has called “moral friends” who possess common intentions, beliefs and values.10 In this light, I argue that character is essential to the worth and good of leadership, for it provides the personal substance of agency. If we consider character to be the permanent, incised qualities of a person’s existential fabric, it is the moral virtues of character that afford the pre-disposition to consistently act toward ends that are right and good.11,12 They thus provide a grounding: 1) in situations of moral conflict, 2) toward the reconciliation of other ethical positions, and 3) in the negotiation of imposed ethical skepticism. It is from this position that I have argued, and argue here for the importance of a virtue-based ethics in pain medicine, with particular emphasis upon phronesis, the balancing virtue of practical wisdom.13,14 I feel that the moral and intellectual virtues are of equal importance to leadership in both the clinical and corporate domains of medicine, for it is this balance, in the Aristotelian sense, that allows the practically wise individual (i.e., the phronimos) to make moral decisions with integrity, insight, knowledge and experience.15,16