Culture and the Ethics of Patient-Centered Pain Care
Environment and Culture as Medium and Forum
Even the most scientifically reductionist view of the individual reveals that we are complex systems nested within complex systems.1 These interactions within and among systems are based and depend upon numerous variables of our (internal and external) environment(s). If we define ethics as a system of moral decision making, then it becomes clear that these decisions ultimately affect the situation(s) of managing our activities and relationships with others in our environment (in essence, our being in the world).2 Given that ecology literally means a “ …a study or system of wisdom and reasoning about the interrelation of organisms in their environment or place of inhabitance,”3 Owen Flanagan’s description of ethics as “human ecology” takes on considerable relevance and importance.4
To approach the ethical issues, and various systems and techniques used to address and resolve these issues, then—pro Flanagan—it is crucial to recognize the effect of “environment” upon persons’ situations and actions that constitute their life-world(s). In other words, a consideration of ethics cannot exclude regard for the environment as embodied by time, place, culture and circumstance. This mandates an appreciation of culture as an important force in determining interactively biopsychosocial dimensions of persons’ being. At the most basic level, culture refers to a “…medium for the development of living material,” and while usually reserved for connotations of experimental methods, it must be borne in mind that this definition is no less operative when considering what and how “culture” engages and sustains “…the set of shared material traits, characteristic features, knowledge, attitudes, values and behaviors of people in a common place and(/or) time.”5 This definition rightly reveals that culture establishes and reflects particular biological characteristics (that develop, and are preserved in response to environments), that can be expressed through cognitions and behaviors. In this way, culture is a medium for biopsychosocial development, and a forum and vector for its expression and manifestation.6 Thus, any attempt to identify moral issues (and ethical approaches to resolving these issues) must appreciate the effects of, and upon, “culture” from biological to social levels.
In this essay we argue that any practical consideration of an ethics of pain medicine must also recognize 1) the effects of culture upon the event, phenomenon and experience of pain; 2) the distinctions that are evoked by the “culture” of medicine (versus the “culture” of patienthood), and 3) how geographic, social and temporal variances affect these cultural dynamics. We posit that one cannot extricate persons from “culture,” and any attempt to define issues, problems, values, potential solutions, and consequences that affect individuals and groups must frame this calculus within a cultural context, at least to some extent, otherwise it will likely be unrealistic.
Cultural Effects Upon Pain: Event, Experience, and Meaning
Even if pain is solely considered as a neurophysiological event, the putative effects of culture cannot be ignored. Anthropologically, the relationship of culture and ecology is often considered to be reciprocal.7 Many environmental factors (e.g., geographical boundaries and limitations, climate, survival, and salutogenic characteristics) have been shown to effect genomic frequencies, and the expression of particular phenotypes in aggregate groups of people. Selective pressures yielded elimination of certain genotypes in favor of others, expressing phenotypes that (through environmental, epigenetic modification) fortified these variations. These factors provided the basis for developmental trajectories that would 1) maximize the success of environmental interactions, 2) tend to produce predispositions to relatively common geno- and phenotypic patterns within defined regions that reflect this survivability, and 3) therefore be sustained and fortified within these environmental niches. Environment affects physiological development, maturation and function, promotes particular phenotypes, and ultimately may shape common functions of certain phenotypic groups.8 Put more colloquially, nature is expressed via nurture,9 and common factors within the nurturing environment can affect patterns of neurologic activity and/or structure (i.e., “…neurons that fire together wire together”; both in individuals and in groups of individuals).10
In this way, environments can “culture” groups of individuals, and cultures develop in response to, and meaningfully affect environments. Moreover, keeping in mind that the boundaries between internal and external environment are somewhat arbitrary and interactive on a number of levels, then we must appreciate the effects of culture on individuals across biopsychosocial domains. Analyses of genetic and epigenetic influences have validated the effects of environment and culture on phylogenetic and ontogenetic patterns of certain physiological traits. The work of Mogil and colleagues has shed light on genotypic predispositions to neural substrates that can give rise to (susceptibility and expression of) certain types of pain.11 Our ongoing characterization of pain as a spectrum disorder suggests that there are putative families (i.e., clades) of genotypes and phenotypes that are differentially sensitive to environmental influence(s) for the expression of pain (thresholds, experience, and most likely cognitive/ behavioral manifestations).12,13 Thus, while pain is a universal human experience, biopsychosocial influences of culture can alter the development of neural systems, cognitions, and behaviors that affect the sensation of pain, its experience, and its expression, respectively.