The Moral Community of the Clinical Pain Medicine Encounter
In arguing for the importance of agent-based virtue ethics to pain medicine, I have relied upon the presumption that any interpersonal interaction is composed of a circumstance, the agents involved, their actions, and the resulting consequences. This calculus of factors is undeniable, and it is important to recognize that circumstances differ, and agents each bring distinct motivations, intentions and desires to the exchange. One of the criticisms of a virtue-based ethics is that the diverse needs and values of individual agents weigh against any possibility of moral uniformity.1 This reflects the fact that progressive globalization has led to cultural plurality throughout many domains of society, including medicine. In some ways, this can be seen as an asset, exemplified by the notion of a ‘world medicine’ that appreciates the role(s) of genome, environment, and social-anthropological influences that all contribute to bio-psychosocial constituents of health and illness.2 However, one of the concomitant ‘fallout’ effects of this socio-cultural diversity has been an expanding skepticism that has questioned the possibility of any common moral premises, assertions, and obligations within medicine, in general, and by extension to the practice of pain medicine.3 Thus, the question becomes whether an agent-based virtue ethics of pain medicine can be realistically considered, given the doubt whether there is, or can be, any moral structure that is wholly ‘internal’ to medicine in light of this contemporary socio-cultural pluralism and the heterogeneity of individual values. In this essay, I posit that the intersection of the pain patient and pain physician establishes a specific community that defines particular, shared moral values, and that a moral structure of medicine is recognizable and justifiable based upon the inherent nature of medicine as enacted through the clinical encounter.
The Possibility of a Common Morality
Bernard Gert, working together with Charles Culver and K. Danner Clouser, has claimed that there are a set of moral affirmations and a supportive, two-step process of moral judgment that reflect common considerations for interpersonal conduct both within and across cultures in society.4 The notion of such a ‘common morality’ is sensible in many ways as an interpretation of a generalized human ecology.5 Grounded in a maxim of non-harm, the cardinal and derivative moral statements provide premises upon which to base structured principles and obligations, and are relevant to various philosophical orientations to human behavior and systems of ethics. Yet, the idea of such a common morality has been criticized in that it is so general, and may not appreciate the unique elements that arise from particular human relationships and situations.6 Gert, Culver and Clouser have defended the applicability of a common morality by stating that the elements of their moral precepts are based upon values that are definable within diverse circumstances, and have specifically applied these common moral rules to standard medical situations.7,8 Indeed, I agree that common moral rules, reasoning, and ideals as Gert has proposed can be relevant to, and meaningful for, medicine given that these describe foundational concepts which guide the acts of morally responsible agents, and aim to ameliorate potential moral ambiguities that may be incurred by cultural differences.9
Yet, Gert, Culver and Clouser take particular care in noting that general moral assertions and rules can only have ‘common’ relevance (to any group of agents) if, and when, they are unified to a particular practice or contexts. In this way, there is a systematization of the moral constructs within specific interpersonal relationships of some institution. This is where I believe that any notion of medical morality must take into account the particularities of the patient-physician relationship if it is to be valid and/or have value.
The Clinical Encounter: Pain Patient and Pain Physician as Community
The encounter between the person in pain and the physician who professes to treat is a relationship of inherent vulnerability and inequity.10 The pain patient is a person for whom pain has ‘taken away’ the familiarity of their lived body, the comfort of much of their life, and the security of health.11-13 In its place are the existential manifestations of illness and the incurred dependence upon the physician to alleviate pain and restore health.14 This dependence is engendered by the physicians’ act of profession which serves as a public declaration of ability.15 By claiming to be a pain physician, the clinician invites prospective pain patients to trust that her judgments and actions will involve the application of authentic knowledge and skill, and be based upon a moral integrity that is sensitive to the unique needs of each patient as an individual. These needs are defined by the effects of pain and illness upon the patient, and initiate the clinical encounter as the basis for diagnosis and care. In other words, the medical relationship itself is determined by, and dependent upon, the illness of the patient, and the enjoinment of the physician.16
In this way, patient and physician exist as a community, engaged by common interest in the basic tenet of the clinical encounter: the provision of care that is both technically competent and regards the good of the patient.17 This community is framed by 1) the needs of the patient — for healing, continuity of care, empowerment, and 2) by the needs of the physician— to exercise the capacity to heal and sustain medicine as a humanitarian endeavor. As a community, the medical relationship maintains common moral values: reciprocal trust, truthfulness, empathy and sensitivity. The common moral rules, ideals and reasoning as described by Gert can, in fact, provide direction for ethical systems that may be ‘externally’ applied to address particular decisional issues and provide guidepost(s) to resolve certain ethical disagreements within medicine. However, the actual moral basis of medical practice is derived from the nature of the practice itself –and therefore is not extrinsically delineated, but is instead internal to the reality of the phenomenal interaction of patient and physician, and reflects the unique circumstances, acts and consequences of that relationship.18,19