The “Promise” of Pain Medicine: Profession, Oaths, and the Probity of Practice
The more we learn about pain, the more we must shape pain medicine to address the challenges posed by this new knowledge. But given that both science and medicine exist within culture and society, we must appreciate that socio-cultural forces influence the relative value of particular domains and dimensions of knowledge, and their practical applications in the pursuit of specific individual and social good. Clearly, medicine is such an individual and social enterprise: essentially, it is the care of patients—those who suffer the burdens of sickness and/or injury—rendered in ways that are technically right and morally sound by those who profess to have the knowledge, skills and intention to heal.5
Contemporary Pain Medicine
Pain medicine is not unlike other areas of medicine in that it involves “… the use of medical knowledge for healing and helping sick persons… in the individual physician-patient encounter.”6 To be sure, the treatment of pain is guided, at least partly, by an objective understanding of pain as neurological process, symptom, and disease. But, the suffering that the pain patient endures is, by definition, a subjective experience and thus understanding the nature of a patient’s pain depends largely upon appreciating its effects upon the individual person. This appreciation of pain as phenomenological experience distinguishes pain medicine not by virtue of its ends or goals, but with regard to the degree and importance of inter-subjectivity that is intrinsic to enacting the practice.7 In other words, to understand the existential illness of pain, the pain clinician must understand the person in pain.8 Technological approaches alone cannot provide sufficient insight to the subjective experience and effects of a particular patient’s pain. Yet far too often, results gained from the use of medical technology are viewed as the final arbiter of clinical certainty upon which the direction and trajectory of treatment(s) ultimately rest.9 Thus, while technology is important to pain medicine, a more critical balance between technical and interpersonal approaches is mandatory given that the subjective experience actually is the objective reality of pain, and this subjective-objective dyad cannot be completely accommodated through the sole use of technology in diagnosis or treatment.10
We maintain that dealing with this multidimensionality of pain compels the most contemporary knowledge of pain as object, competent use of available technology and appropriate techniques as articulative tools, and an empathic commitment to the pain patient as a moral subject. We have argued that these are the foundations that define the structure of pain medicine as a practice and, as such, establish the ‘rules’—or deontic frameworks—that are necessary (in light of pain as a clinical event in sentient persons) to enable the clinician to enact pain medicine as a practice.11 Simply, these are the parameters that must be adhered to if one enters into the practice of pain medicine. We believe that this framework is applicable irrespective of clinical approach or subspecialty; these considerations and responsibilities are of equal weight regardless of whether the orientation to practice is allopathic (i.e., neurologic, anesthesiologic, physiatric, etc.), nursing, psychologic, allied health (e.g., physical and or occupational therapy, etc.), or complementary/alternative (e.g., chiropractic, naturopathic, oriental medical, etc.).
The Pain Clinician and the Act of Profession
While this may define what pain medicine is, we posit that it is equally important to define who is the person (as moral agent) that is the pain clinician.12 We hold that it is important that the person who enters the field of pain medicine possess the intellectual and moral traits of character that sustain allegiance to the obligations of caring for those in pain. In professing to be a pain specialist, clinicians from any discipline make public declaration that they possess both 1) knowledge and skill required to both scientifically understand pain, and 2) the sensitivity, dedication and determination to inter-subjectively engage each patient as person and understand the effect(s) and impact of pain upon the person’s life.13
Is this act of profession sufficient to uphold the patients’ trust? If one declares “…I am a pain specialist” does that 1) authentically convey the depth and breadth of her knowledge and skills, 2) substantiate that she will enact those skills within the technical and moral framework necessitated by this practice, and 3) meaningfully convey her perpetual commitment to the best interest of any and all pain patients who may seek her abilities? Pellegrino claims that the act of profession is a promise: an assurance of intents and actions.14 We agree, and further opine that, as a promise, the act of profession provides grounds for the expectation of ongoing excellence (of actions and character), and gives reason for such expectation(s). As such, the act of profession within a practice is a commitment to uphold the intent and nature of the relationship that defines that practice.
But what binds the clinician to the act of profession and the act(s) of medicine? Surely, these affirmations are not explicitly reiterated at every encounter between clinician and patient, yet the clinicians’ obligation to the patient is symbolically, if not directly, manifested in the execution of their role qua clinician. What is it that substantiates the clinicians’ act of profession, not simply as an externally constructed set of prescriptions and proscriptions, but as a first person commitment? We have maintained that it is the clinicians’ oath that is testimonial to the probity of medical practice, and the primacy of the patients’ best interests in directing each and all of the clinicians’ intentions and actions.15,16
While codes of ethics are important, these tend to be just that: codifications of systematized judgments about what is right and wrong which are then agreed upon by participants of a particular discipline. While individuals may swear allegiance or obedience to such codes, the codes themselves tend to remain as conferred, third person standards that describe parameters and boundaries of practice. That is not to say that such codes are unimportant or irrelevant, in fact quite the opposite. However, we feel that such codes may lack the unique affirmation of the first person voice, which implies personal commitment and promise. In this way, an oath is not only a statement of “belonging,” but is an expression of belief that reflects individual consonance with particular moral precepts, goals and ideals.17