Clinical Bioethics: Pain and Psychopathology in Military Wounded

“The… prevailing failing… is to neglect the causes and quarrel with the effects…”
—Oliver Wendell Holmes¹

James Giordano, PhD and Joan Walter, JD, PA-C

Last issue’s article by Dr. Mordecai N. Potash on pain and co-morbid brain injury in a young soldier resulting from an improvised explosive device (IED) trauma, brought to light the intricacies inherent to such cases.² To be sure, the case of “Mr. Smith” entails many of the variables that are typical of many (non-military as well as military) chronic pain patients – multiple pathologies, existing physical and psychological dispositions, and the reciprocal impact(s) of these elements with social, cultural, and economic factors to exacerbate the scope, gravity, and duration of effect.

But, as Potash notes, while these are “…issues familiar to pain management practitioners…” the wounded veteran incurs “…new challenges within the field…” not the least of which is the “…growing number of patients with co-morbid chronic pain…brain trauma and…attendant cognitive issues.”³ The demographics of this patient population reveal these to be young(er) individuals, with characteristically multiple, compound trauma that involve substantial alterations in physical and mental status, and which require acute, sub-acute, and long term therapeutic support in both curative and palliative domains.⁴ Dr. Potash re-iterates our claims that the practical and moral obligation to treat pain dictates the need(s) for a truly patient-centered, bio-psychosocial treatment paradigm.^5,6

More importantly, however, we feel that this work was noteworthy in that it reinforced the concept that an understanding of chronic pain as a complex interaction of genotypic, phenotypic, and environmental factors is essential, and mandates an integrated approach to assessment and care. In this essay, we seek to strengthen this plea by:

1. demonstrating that the “problem” is complicated and defining a model of chronic pain and psychological co-morbidity as a spectrum disorder that is “triggered” by the environmental insult of combat injury (particularly the inflammatory cascade evoked by non-lethal blast trauma);
2. demonstrating that the incidence and prevalence of this spectrum co-morbidity are large and growing,
3. presenting viable treatment approaches that assume a contextual, patient-centered focus to the provision of curative and/or healing interventions,
4. describing the resources required to implement these approaches, and
5. illustrating how these obligations are grounded by the moral imperatives incumbent to medicine in response to the actions of society, and how society must enable these imperatives through fiscal support and policy.

Please refer to the Jul/Aug 2007 issue for the complete text. In the event you need to order a back issue, please click here.