Grappling with the Ethics of Practical Pain Management
One of the difficulties in discussing medical ethics is that it often tends to be perceived as something “external”—something which must be applied to the internal machinations of the practice of medicine. While this approach is not wholly impossible, it is often inadequate or becomes superficial because it fails to recognize how medical practice gives rise to the moral issues and/or problems that require deliberation and the use of one or more ethical systems for resolution. Moreover, this externalized approach tends to foster a view of ethics as an “after the fact accoutrement”—something akin to an “add-on” to be used when situations get sticky and problems arise—rather than being an essential dimension of medicine as a profession. Yet the “work” of medicine is classically defined as a moral, humanitarian enterprise.2 Clearly, when one claims to be a medical professional, it is assumed that s/he can be trusted to be morally and ethically responsible.3
Ethics as Component Knowledge, Skill, and Art
Therefore, it becomes apparent that ethics is vital to the body of knowledge and skills that constitute medical practice. In this way, it is what my former college wrestling and judo coach used to call “grappling legs.” The point was simple, to be a good grappler (in both wrestling and judo) one needs a strong set of legs to remain well-planted, and to provide pivotal and driving force in order to generate the whole-body power to make “…the right moves”—even when down on one or both knees. So it is with ethics. Recalling that ethics is defined as a formal systematized description and analysis of moral decision processes,4 then for ethics to have any utility, integrity and/or value, it must be well grounded and be able to function efficiently as a part of the working tools that enable decisively right actions to achieve success in the circumstances at hand. To extend this analogy a bit farther, wrestling and judo are sports of technique, power, and timing that combine skill with a fair bit of finesse. Knowing what techniques to use; how, why, and when to use them; and coupling this technical acumen to balance, strength, situational awareness; and a sense of fair play and adherence to the rules are intrinsic to becoming a champion grappler.
Rollin Gallagher, Editor-in-Chief of the journal Pain Medicine, and Director of Pain Management Services at the Philadelphia VA Medical Center, has called for clinicians to accept the challenge(s) of becoming “champions of pain care” in the spirit of the late John Bonica.5 What will it take to become such a champion? While medicine is a skill and art, philosophers Albert Jonsen and Steven Toulmin assert that all clinical judgments are a form of moral decision-making.6 Based upon this premise, the act of medicine—as the provision of right and good care—cannot be divorced from ethics when grappling with the issues and problems that are inherent to its practice. This being the case, the inseparability of therapeutic and moral agency in clinical decision-making compels having, and using, the right (types of) knowledge to allow situational assessment and the execution of good action(s).7 As James Rachels notes, it is “…morality [that] guides one’s conduct by reason…to do what there are the best reasons for doing, while giving equal weight to the interests of each individual who will be affected…”8
A Working Ethics of Practical Pain Management
Just as the wrestler needs preparatory training in order to build “grappling legs,” a working medical ethics also requires preparation to establish a firm foundation. This entails an understanding of:
- why and how moral responsibilities are generated by the facts of disease and illness (in this case pain and suffering),
- how the expression of pain, needs of the pain patient, and various (social, financial, and legal) demands and exigencies create issues and problems within the reality of pain medicine, and
- how the strengths and limitations of particular ethical approaches may allow or impede their use in resolving these problems.
This background information is not esoteric; rather it clarifies that and how ethical issues are woven into the fabric of pain medicine’s practice. Over the past two years, my overarching goal for this column was to establish and inform this background. Instrumentally I’ve tried to accomplish this in three ways: first, I’ve attempted to shed light on how the physiology of pain and the experience of the patient and clinician give rise to the moral obligations of pain medicine.9-14 Second, I’ve sought to define the basis of morality and ethics, and its importance to, and in, practical pain management.15,16 Third, I’ve posed the argument that these obligations are wedded to the core philosophical foundations and premises of medicine,17,18 and fourth, I’ve tried to explain how this philosophical basis (i.e., the knowledge, humanitarian applications and ethics that constitute, bio-psychosocially focused pain care19-21) should underscore any and all practice guidelines, health policy, and laws.22-27 Table 1 provides a template for how these papers might be arranged to depict what Pellegrino calls “…ethics from the ground up.”28