Moral Virtue and the Pain Physician
In my previous commentary, I extolled intellectual virtue(s) as imparting the ability for discernment and utilization of domains of knowledge that were vital to practical pain management.2 Given the complexity of pain, the subjectivity of its experience, and the individuality of its expression and effects, the physician must employ distinct ways of knowing in order to acquire and process information from diverse sources. In so doing, the physician must:
- understand the mechanistic basis of pain,
- comprehend its effects and manifestations in the person in pain, and
- ultimately weigh that information to determine the viability of available clinical options.
Yet, informing actions is one thing, executing them is quite another. In this essay, I posit that the unique nature of pain and the multiple dimensions of its effect establish profound moral issues that affect the patient and physician relationship. The practice of pain medicine must not simply be therapeutically correct, but the intellectual virtue(s) that compel accurate clinical decisional process must also be a pediment for both the moral validity of these decisions and the acts that are instantiated thereupon. Thus, I argue that intellectual virtues are reciprocally reliant upon moral virtue to embody the professional identity of, and thereby support, the act of profession as declared by the pain physician.
Every human interaction is characterized by circumstance(s), agents, actions, consequences, and ends. Recall that practical action is ethically informed, not merely dependent upon theory; and therefore practical pain management requires both knowing about pain, its dimensions of effect in and upon the person who is the patient, and intentionally acting to achieve the ends of treating and caring for each specific patient in ways that uphold the moral good. How then, can the ethical bases of these actions be determined? To best address this question, it becomes important to first define ethics. Ethics is a formal, critical, systematic study of morality.3 The science of ethics seeks to describe the moral foundations that underlie human intentions and actions. But ethics is not merely descriptive; as a system it can provide normative prescriptions based upon moral grounds that can be articulated in practice.4,5 These moral grounds reflect distinct philosophical premises and values that regard the notion of what is good, the character and authority of morality, and the origins and validity of such moral obligation(s).6
Philosophical Basis of Pain and Pain Medicine
Progress in neuroscience, affording considerable knowledge of the structure and function of the nervous system and the mechanisms of pain, has been reconciled to neurophilosophical constructs of brain-mind and, by extension, the broader philosophical concepts of consciousness and the internal dimensionality of a definable self. Yet, while we ponder the ti esti, or “what is” question of pain, we are faced with the fact of pain as symptom, sign, disease and illness, and thus the need to develop a meaningful orientation to the problem of pain, its humanitarian impact, and how medicine (and perhaps society) can and should address, regard, and treat pain. To do this, pain medicine must incorporate both a philosophical orientation to pain, as well as the epistemic and humanistic premises, and ends (i.e., the telos) of medicine, in general.7 However, the practice of pain medicine remains somewhat unique in that pain is wholly subjective, it’s expression and effects variable, and the pre- and co-morbidity of other pathologies (e.g., existing disease or injury, psychiatric conditions, substance abuse, and addiction), can create compound occupational, financial, and social circumstances that establish pragmatic, philosophical, and ethical situations that complicate care.
But what is pain medicine, given that numerous disciplines are positioned to provide care for the pain patient? While each of these disciplines (e.g., anesthesiology, neurology, physical medicine, psychiatry and, ever-increasingly, certain complementary therapies) provide a particular orientation, set of theoretical and technical approaches, and even ideologies, I maintain that all must be consistent with, and adherent to the core philosophical premises and telos that define medicine.8 These are articulated by clinicians through the clinical encounter, and in this light we must also, somewhat more pointedly ask, who is the pain clinician? Given the pragmatically and ethically complex milieu of pain medicine, who is it who enters this field? In other words, what kind of person voluntarily dedicates their professional identity to the care of the pain patient? In short, I offer that the pain clinician is a medical professional who accepts the objective fact that pain exists as subjective predicament, recognizes the difficulties of objectifying pain to establish diagnoses, and acknowledges the commitments that are essential to uphold their act of profession. For it is in this act of profession that the pain clinician invites the trust of the patient to enter into the medical relationship, through which the inter-subjectivity required for effective diagnosis and treatment can be achieved. This act of profession represents the physicians’ covenant to use knowledge and skill to genuinely provide care that is right and good for each individual patient.9 But how can we determine what is “good”? This is the job of an ethical system; thus we must ask which ethical system or systems can best accomplish this task.
Some Ethical Systems10
Perhaps the most familiar ethical system in medicine is the use of mid-level principles (i.e.,beneficence, non-maleficence, autonomy, justice) as advocated by Beauchamp and Childress.11 The merit of this system is that it provides practical definition of broadly based moral concepts that can be directly applied based upon situational interpretation of what principle or order of principles best “fits” the facts and issues of a particular case. In some ways, this allows flexibility for using the principles within a deontological (i.e., rule based) or utilitarian (i.e., welfarist/consequentialist) perspective. Certainly, using principles, (as rules or duties) appeals to the notion that such ethics are derived from the interpersonal relationships and professional responsibilities that prescribe what should be done in particular circumstances, seeking to afford good, while affording generalized proscriptions against other acts (e.g.. lying, killing, etc.).12
Yet, there is considerable disagreement over the absolute scope of rules, the extent of constraints, and questions of conflict of duty. Moreover, the prima facie use of principles and the use of more rigid deontologic approaches cannot solely provide resolution to the ethical issues and questions which arise from the diversity of situations encountered in the practice of pain medicine. To be sure, the universal application of a rule and/or the absolute ordering of principles would be difficult, if not impossible, given the need to appreciate the role and position of agents and consequences in any particular clinical encounter.