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10 Articles in Volume 6, Issue #1
Do Topical Herbal Agents Provide Pain Relief?
Infusion Catheter Epidural
New Report of a High-Dose Morphine Metabolite
Pain Education and Pain Educators
Suspecting and Diagnosing Arachnoiditis
Tennant Blood Study, First Update
The Demise of Multidisciplinary Pain Management Clinics?
The Dimensions of Pain
The Role of Psychology in Pain Management


Halfway through the congressionally-declared Decade of Pain Control and Research, it may be time for a reflective pause to ask in both conceptual and practical terms, ‘where we are?’ and ‘where might we be going?’ A review of the past five years’ progress yields abundant demonstration of ardent strides in research. However, we are also confronted with evidence that the translation of research developments into viable therapeutic applications has been less than optimal, and further, that the sustenance of treatment paradigms that meet the epidemiologically-defined problem of chronic pain is lacking. This represents a paradox: although we may know more about the basis and mechanisms of pain and how to treat it, we are becoming ever more disempowered to effectively act on this knowledge.

In this issue, Michael Schatman speaks to this by illuminating the declining number and increasingly restricted roles of accredited, interdisciplinary pain management programs. Despite several lines of evidence to support the durable effectiveness of outcomes achieved by such programs, he reports the continuing trend to discontinue, or severely limit the services provided by these centers. Schatman opines that this apparent contradiction reflects the commodification of medicine in general, and the resultant pervasion of a business ethos that disavows the benefits of long term pain care as being inordinately expensive to a healthcare system that is primarily concerned with proximate-costs. He views the problem as a conflict between business ethics and those of medicine, and in so doing questions whether the contemporary form of pain medicine has become inseparable from the effects of corporate systematization. Schatman asserts that a change is required that responds to the moral obligation to treat those who are in pain, and that provides ethical guidance to implement supportive healthcare policies.

I agree; the superimposition of the business model upon medicine has enabled the ethos of profit to suborn the ethics of care. Yet, if a change is to occur, it must not only restore the clinical empowerment of pain management programs, but must also maintain their economic viability. This will allow them to be effective and still survive in a healthcare market that is not likely to change in the immediate future. Schatman astutely notes that the ethics of business and medicine differ, due at least in part, to the divergent ends and goals of these fields. It is the ends of an undertaking that direct the ultimate focus of its activities, and often determine the nature of the conduct of those actions.1 In this light, it becomes apparent that the motives of business that foster commodification of healthcare as instrumental to ends of profit cannot be resonant with the beneficent and just provision of medical services to restore health as a fundamental good.

I argue that to change this situation, the apparent dualism of business and medicine must somehow be ameliorated to meet a more monistic paradigm in which the corporate and clinical components of medicine are equivalently dedicated to the common end of rendering right and good care to patients. Such amelioration may seem obtuse, yet I offer the following premises to support this proposal. First, while there is an aspect of business within the practice of medicine, it is crucial to recognize that medicine is not a business. It is a profession that is dedicated by covenant to the primacy of the good of the patient.2 Second, medicine is non-proprietary, and is not a commodity to be restricted through market manipulation. Third, as Gini states, business is, by its nature, about serving people.3 Thus, once the profit-focal ends of corporate medicine are aligned with those of the clinical enterprise, the ‘business’ of pain medicine could be situated to provide the administrative and financial means through which medical resources are most effectively made available to those persons who are in pain. In many ways this conceptualization reflects the prudential question of ‘what should be done’ to best afford medically right and ethically sound provision of care to the patient.4

I argue that the basis of this change requires the establishment of a teleologically-construed (i.e., ends-based) ethical framework that reconciles the apparent inimical tension between business and medicine.5 One possible way that this may be achieved is through incorporating Peters and Waterman’s “excellence model” into corporate medicine to embody what Klein has called the “craftsman ethic.”6,7 This system emphasizes quality of knowledge, skill, products, and services that are delivered within, and ultimately serve the end(s) of enhancing the substantive “goods” of the human relationships inherent to the practice.8 Working within this model, the values and ends of the clinical and corporate domains of medicine can become more effectively mutualized. By acting consistently toward these ends, any achievement of profit would not be misfeasant, because it is not gained through sacrificing patient care. Rather, the (technically right and ethically sound) success of the services rendered would foster increased utilization, and therefore continued subsidy.

Given mutual purpose, I maintain that any real change can only occur through the leadership of individuals who act directly as change agents. This leadership must be transformational and concerned with, and dedicated to the primacy of the good of the patient. According to Burns, transformational leaders are committed moral agents whose actions influence the vision and direction of both followers and the organization.9 Through example and empowerment, the transformational leader turns their followers into leaders, and catalyzes change by allying the actions of what Engelhardt has called “moral friends” who possess common intentions, beliefs and values.10 In this light, I argue that character is essential to the worth and good of leadership, for it provides the personal substance of agency. If we consider character to be the permanent, incised qualities of a person’s existential fabric, it is the moral virtues of character that afford the pre-disposition to consistently act toward ends that are right and good.11,12 They thus provide a grounding: 1) in situations of moral conflict, 2) toward the reconciliation of other ethical positions, and 3) in the negotiation of imposed ethical skepticism. It is from this position that I have argued, and argue here for the importance of a virtue-based ethics in pain medicine, with particular emphasis upon phronesis, the balancing virtue of practical wisdom.13,14 I feel that the moral and intellectual virtues are of equal importance to leadership in both the clinical and corporate domains of medicine, for it is this balance, in the Aristotelian sense, that allows the practically wise individual (i.e., the phronimos) to make moral decisions with integrity, insight, knowledge and experience.15,16

Who shall these leaders be? In revising the dualism of business and medicine to favor a patient-centered, monistic approach to medical enterprise, it becomes apparent that such leaders must be individuals who have knowledge, skill and experience of pain medicine. Pain management clinicians possess the requisite domains of knowledge and values that enable the execution of practical wisdom in matters that respectively affect actions and conduct pursuant to the ends of medicine. Certainly, these individuals, as “champions” of the vision and values of effective pain management, could well provide the transformational leadership necessary to catalyze the much-needed changes in the corporate culture of pain medicine. Of course, such leaders will require training that directly fortifies the application of their skills and knowledge to corporate steerage. Noren and Kindig emphasize that the development of the next generation clinician-executive necessitates experiential learning to deepen both medical insight and professional leadership competence.17 Possible educational venues to achieve this training are discussed by Waldhausen.18 Formalized didactic and applied training programs could be developed between academia and interdisciplinary treatment centers to both meet demographically identified pain management needs of particular regions and cultivate medical leaders who possess practical knowledge and sensitivity to those patient populations. Realistically however, such educational and experiential venues to develop clinician-executives cost money. Without subsidy, opportunities to create these future leaders in pain medicine will become increasingly unavailable, and the system will continue its present course, making this argument moot. Perhaps funding incentives generated by the National Pain Care Policy Act will establish reasonable junctures for training and ultimately to allow clinician-executives to assume positions of influence within the corporate hierarchy of pain medicine, and healthcare in general. It is a start, and a step in the right direction. But as Schatman notes, the gears of government grind slowly; we cannot passively wait and expect that change will occur. Indeed, it must be instigated, reinforced, and assertively led. But even the most empowered leader cannot evoke change alone,19 for although change may involve “top-down” implementation of policy, the true champions for such change are very often local leaders who contribute an initiative voice of purpose and priorities.20 The nature of the clinical relationship has the potential to establish each practitioner as a leader by choosing to do what is right and good for the patient in pain, and in so doing contribute to the moral integrity of a professional community that strives toward an end that is meaningful. n

James Giordano, PhD is Scholar-in-Residence at the Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC and is a Visiting Fellow of the John P. McGovern Center for Health, Humanities and the Human Spirit, Texas Medical Center, Houston, TX. The author of over fifty peer-reviewed publications in neuroscience, bioethics and medical philosophy, his ongoing research focuses upon neural mechanisms of chronic pain, neuroethics and the philosophical basis and ethics of pain medicine, neurology and psychiatry. Dr. Giordano was the 2004 recipient of the American Academy of Pain Management’s Richard Weiner Pain Education Award. He can be contacted at: The Center for Clinical Bioethics, Georgetown University Medical Center, 4000 Reservoir Rd, Bldg. D, Washington, DC 20057; email jgiordano@neurobioethics.org.

References and Notes
1. Aristotle. The Nicomachean Ethics. Book I, Ch. 1, T. Irwin (trans.). Hackett Publishing. Indianapolis. 1999. pp 1-2.
2. Pellegrino ED. The healing relationship; Architectonics of clinical medicine. In: EE Shelp (ed) The Clinical Encounter: The Moral Fabric of the Physician-Patient Relationship. Reidel. Boston. 1983.
3. Gini A. Moral leadership: an overview. J Business Ethics. 1997. 16(3): 323-330.
4. Pellegrino ED. The anatomy of clinical judgments: some notes on right reason and right action. In: HT Engelhardt, SF Spicker, B Towers (eds.) Clinical Judgment: A Critical Appraisal. Reidel. Dordrecht 1979. pp 169-194.
5. The term teleological is used here in the strictest sense to describe an ethical system that is based upon, and derived from focus upon a defined end (i.e., a telos), to which any and all acts should be pursuant and with which these acts should be morally consistent. This does not imply consequentialism.
6. Peters TJ and Waterman RH. In Search of Excellence. HarperCollins. NY. 2004.
7. Klein S. An Aristotelian view of theory and practice in business ethics. Int J of Applied Philosophy. 1998. 12 (2): 203-222.
8. William F. May states that the covenantal fidelity inherent to healthcare obligates respect of three fundamental features: 1) that healthcare is a fundamental good; 2) that it is not the only fundamental good, and as such must be efficient and cost-effective. These considerations are not maintained in the economic sense, but as moral imperatives against waste or injustice; and 3) that healthcare is a public good, such that those who are involved in healthcare bear the responsibility of public investment in that fundamental good. See: May WF. The Physician’s Covenant. Revised edition. Westminster Press. Philadelphia. 2000.
9. Burns JM. Leadership. Harper Torchbooks. NY. 1978.
10. Engelhardt HT. Foundations of Bioethics. 2nd. Ed. Oxford. NY. 1996.
11. Cooper JM. Reason and Human Good in Aristotle. Harvard University Press. Cambridge, MA. 1975.
12. MacIntyre A. Dependent Rational Animals: Why Human Beings Need the Virtues. Open Court Press. Chicago. 1999.
13. Giordano J. Toward a core philosophy and virtue-based ethics of pain medicine. Pain Practitioner. 2005. 15(2): 59-66.
14. For a detailed discussion of phronesis in medicine, see Davis, D. Phronesis, clinical reasoning and Pellegrino’s philosophy of medicine. Theoretical Medicine. 1997. 18: 173-195; Robert Solomon addresses Aristotelian ethics in business (Corporate roles, personal virtues, moral mazes: An Aristotelian approach to business ethics. In: CAJ Coady, CJG Sampford (eds.) Business Ethics and the Law, Sidney, AUS, Federal Press, 1993, pp 30), and pays particular attention to Aristotelian definitions of virtues and their role in corporate integrity and cooperativity in Ethics and Excellence: Cooperation and Integrity in Business. Oxford University Press. NY. 1993.
15. Ibid, 1. Aristotle, The Nicomachean Ethics, Book II, Chapter 6, pp 23-24 (on character and virtue) and Book VI Chapter 12-13, pp 96-98.
16. A complete discussion of theoretical and applied Aristotelian concepts of virtue and excellence (i.e.- aretaics) see: WER Hardie, Aristotle’s Ethical Theory. Clarendon Press. Oxford. 1980.
17. Noren J and Kindig DA. Physician-executive development and education. In: B LeTourneau, W Curry (eds.) In Search of Physician Leadership. Health Administration Press Chicago, IL. 1998.
18. Waldhausen J. Leadership in medicine. Bull. Amer. Coll. Surgeons. March 2001. pp 15-19.
19. Bass BM and Steidlmeier P. Ethics, character and authentic transformational leadership behavior. In: JB Ciulla (ed.) Ethics, the Heart of Leadership. Praeger. Westport, CT. 2004. pp175-196.
20. The respective contribution of individuals and communities in the process of identifying purpose, developing plan and influencing programs and policies are addressed by Jack Glazer, Ann Neale et al. as components of regional dialog; see: www.OurHealthcareFuture.org.

Last updated on: November 14, 2011
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