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Pain as Disease and Illness: Part Two

The structure and function of the ethics of pain medicine: Ryder's Painism revisited
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“Everything that the human race has done and thought is concerned with the satisfaction of deeply felt needs and the assuagement of pain.”

- Albert Einstein

I believe that any meaningful definition of pain involves physiologic, psychological, and anthropological factors that are part of an “expanded” neuroscientific approach to brain-mind and the genotypic- phenotypic- environmental interaction(s) that Matt Ridley refers to as “…nature via nurture” effects.2 I’ve tried to show how our current neuroscientific understanding informs the theoretical bases of a neurophilosophy of pain and pain medicine3 and have attempted to relate this neurophilosophy of pain medicine to the core philosophy of medicine in general.4-7 I hold that this establishes, or at the very least contributes, a framework of moral duties (i.e., a deontic foundation) of pain medicine as a practice.8 This deontic foundation is based upon and compels an overall understanding that the practice of pain medicine is a moral enterprise between persons, and that this enterprise entails an asymmetrical relationship between the physician as moral agent/moral object and the person in pain as a moral patient/moral subject. The architecture and nature of this relationship positions and emphasizes the therapeutic and moral agency of the physician, and therefore sustains agent-based moral grounding as the foundation for ethics of pain care.9 I have argued that intellectual and moral virtues are important to establishing and maintaining the moral agency of the pain physician, but have also acknowledged that these virtues must be enacted within a larger ethical sphere, and have recognized the value and potential viability of several ethical systems including, but not limited to, principlism, feminist ethics, and certain forms of communitarianism.

Irrespective of the ethical system utilized, what we know about pain (ie.- the epistemic tradition informed by neuroscience) should engage and direct the real-world applications of practice, research, and education. But what specific premises, moral values, and obligations attest to and consistently sustain telos of the right and good treatment of persons in pain as moral patients by 1) individual physicians as moral agents, 2) through the practice, and 3) by pain medicine as a resource within society?10

Ryder’s “Painism” Revisited

It is in this context that Hans Werner Ingensiep of the University of Essen, and Heike Baranzke of the University of Bonn, and I recently re-examined and re-appraised Richard Ryder’s thesis of painism as a viable constitution of ethical precepts to direct the communal attitude(s) and activities of pain medicine.11 Ryder, a psychologist by training, developed a set of constructs that established a code of moral conduct toward any and all sentient beings that was originally directed toward anti-specieism, animal protection, and environmental ethics.12,13 Ryder’s early work was subsequently expanded to include attitudes and actions toward all beings capable of feeling pain, and was developed into a sweeping set of forty two moral precepts and affirmations (somewhat colloquially called “rules”) that encompassed basic elements of what a moral theory and practice should be, and hierarchically ordered the specific moral obligations regarding the understanding, treatment and infliction of pain as applied to individual, social and political circumstances. In its entirety, the work has been, and continues to be, somewhat contentious, to say the least.

By addressing and making particular claims about broad issues such as sexuality, divorce, taxation, government process, and foreign policy, the whole of Ryder’s painism serves as a manifesto for social change. As such, when taken in its entirety, it is not directly relevant to the specific practice of pain medicine. Yet, to totally disregard the work because of its breadth of scope would be to proverbially throw out the baby with the bath water, as we feel that there are twenty key precepts that may have important ethical value in light of a contemporary neurophilosophy of pain. With respect to Ryder, we have taken these premises and obligations out of the lexical hierarchy in which he lists them, and re-present them (in Table 1) in an grouped order that may be somewhat more meaningful to developing bedrock moral affirmations of clinical pain medicine, pain research, and policy.

Table 1. Painism Revisited: Premises for a Structural Ethic of Pain Medicine
  1. Morality provides a framework which facilitates our choice of actions.
  2. Ethics is about unselfishness.
  3. The experiences of the moral patient are always of greater moral importance than the motives of the moral agent.
  4. Pain and suffering are the only evils.
  5. The moral objective is to reduce the pain of others
  6. We have an obligation to try to reduce the pains of others wherever they are and however they are caused.
  7. Pain is more powerfully wrong than pleasure is right.
  8. It is always wrong to cause pain to subject A merely to increase the pleasure of subject B (that is, there should be no pain inflicted for trivial purposes).
  9. Only if there are no alternatives may causing unconsented pain to subject A be allowed to reduce the pain in subject B.
  10. The pain to be reduced in subject B must be severe.
  11. The actions (viz. 9-10) must be likely to succeed.
  12. Whatever the benefits, it is wrong to deliberately produce pain that is prolonged or severe.
  13. Moral standards should apply equally to all painient individuals (regardless of species).
  14. As a general rule, we should adopt the precautionary principle that whenever painience is uncertain in a living being, it should be assumed.
  15. All procedures which cause pain for the fetus are wrong prima facie. The fetus must be treated as a painient individual with all moral protection that this entails.
  16. There is a duty upon those caring for the dying to administer analgesics to remove pain (*but also to administer psychoactive agents so as to enhance the patient’s sense of well being as much as possible until they die).
  17. Aims and ideals such as justice, democracy, peace, equality and liberty are good only as means…to reduce pain.
  18. Politics and law are applied ethics writ large.
  19. The failure to apply existing technology to treat the ill and relieve their sufferings is currently one of the greatest immoralities of Western governments.
  20. The public needs to be fully informed about biotechnologic development(s). Bioscience and associated industry must be regulated and controlled by agencies sensitive to public opinion and be entirely and demonstrably independent of commerce.

(*this point is contestable in light of particular cultural traditions)

Note that all statements are from ref. 11, as follows: 1: p.6; 2: p.65; 3: p.41; 4, 5; p.27; 6: p.100; 7; p. 57; 8-11: p.30; 12: p.31; 13: p.119; 14: p.70; 15: p.67; 16: p.71; 17: p.27; 18: p.10; 19: p.87; 20: p.114.

Last updated on: December 20, 2011
First published on: October 1, 2006