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10 Articles in Volume 8, Issue #2
Anticephalgic Photoprotective Premedicated Mask
Culture and the Ethics of Patient-Centered Pain Care
Interpreting the Clinical Significance of Pain Questionnaires
Intrathecal Therapy Trials with Ziconotide
Iontophoresis in Pain Management
Maximizing Tertiary Effects of Low Level Laser Therapy
Platelet Rich Plasma (PRP): A Primer
Protecting Pain Physicians from Legal Challenges: Part 1
Right Unilateral Electroconvulsive Therapy Treatment for CRPS
Temporomandibular Dysfunction and Migraine

Culture and the Ethics of Patient-Centered Pain Care

Environment and Culture as Medium and Forum

Even the most scientifically reductionist view of the individual reveals that we are complex systems nested within complex systems.1 These interactions within and among systems are based and depend upon numerous variables of our (internal and external) environment(s). If we define ethics as a system of moral decision making, then it becomes clear that these decisions ultimately affect the situation(s) of managing our activities and relationships with others in our environment (in essence, our being in the world).2 Given that ecology literally means a “ …a study or system of wisdom and reasoning about the interrelation of organisms in their environment or place of inhabitance,”3 Owen Flanagan’s description of ethics as “human ecology” takes on considerable relevance and importance.4

To approach the ethical issues, and various systems and techniques used to address and resolve these issues, then—pro Flanagan—it is crucial to recognize the effect of “environment” upon persons’ situations and actions that constitute their life-world(s). In other words, a consideration of ethics cannot exclude regard for the environment as embodied by time, place, culture and circumstance. This mandates an appreciation of culture as an important force in determining interactively biopsychosocial dimensions of persons’ being. At the most basic level, culture refers to a “…medium for the development of living material,” and while usually reserved for connotations of experimental methods, it must be borne in mind that this definition is no less operative when considering what and how “culture” engages and sustains “…the set of shared material traits, characteristic features, knowledge, attitudes, values and behaviors of people in a common place and(/or) time.”5 This definition rightly reveals that culture establishes and reflects particular biological characteristics (that develop, and are preserved in response to environments), that can be expressed through cognitions and behaviors. In this way, culture is a medium for biopsychosocial development, and a forum and vector for its expression and manifestation.6 Thus, any attempt to identify moral issues (and ethical approaches to resolving these issues) must appreciate the effects of, and upon, “culture” from biological to social levels.

In this essay we argue that any practical consideration of an ethics of pain medicine must also recognize 1) the effects of culture upon the event, phenomenon and experience of pain; 2) the distinctions that are evoked by the “culture” of medicine (versus the “culture” of patienthood), and 3) how geographic, social and temporal variances affect these cultural dynamics. We posit that one cannot extricate persons from “culture,” and any attempt to define issues, problems, values, potential solutions, and consequences that affect individuals and groups must frame this calculus within a cultural context, at least to some extent, otherwise it will likely be unrealistic.

Cultural Effects Upon Pain: Event, Experience, and Meaning

Even if pain is solely considered as a neurophysiological event, the putative effects of culture cannot be ignored. Anthropologically, the relationship of culture and ecology is often considered to be reciprocal.7 Many environmental factors (e.g., geographical boundaries and limitations, climate, survival, and salutogenic characteristics) have been shown to effect genomic frequencies, and the expression of particular phenotypes in aggregate groups of people. Selective pressures yielded elimination of certain genotypes in favor of others, expressing phenotypes that (through environmental, epigenetic modification) fortified these variations. These factors provided the basis for developmental trajectories that would 1) maximize the success of environmental interactions, 2) tend to produce predispositions to relatively common geno- and phenotypic patterns within defined regions that reflect this survivability, and 3) therefore be sustained and fortified within these environmental niches. Environment affects physiological development, maturation and function, promotes particular phenotypes, and ultimately may shape common functions of certain phenotypic groups.8 Put more colloquially, nature is expressed via nurture,9 and common factors within the nurturing environment can affect patterns of neurologic activity and/or structure (i.e., “…neurons that fire together wire together”; both in individuals and in groups of individuals).10

In this way, environments can “culture” groups of individuals, and cultures develop in response to, and meaningfully affect environments. Moreover, keeping in mind that the boundaries between internal and external environment are somewhat arbitrary and interactive on a number of levels, then we must appreciate the effects of culture on individuals across biopsychosocial domains. Analyses of genetic and epigenetic influences have validated the effects of environment and culture on phylogenetic and ontogenetic patterns of certain physiological traits. The work of Mogil and colleagues has shed light on genotypic predispositions to neural substrates that can give rise to (susceptibility and expression of) certain types of pain.11 Our ongoing characterization of pain as a spectrum disorder suggests that there are putative families (i.e., clades) of genotypes and phenotypes that are differentially sensitive to environmental influence(s) for the expression of pain (thresholds, experience, and most likely cognitive/ behavioral manifestations).12,13 Thus, while pain is a universal human experience, biopsychosocial influences of culture can alter the development of neural systems, cognitions, and behaviors that affect the sensation of pain, its experience, and its expression, respectively.

Such distinctions have been anecdotally noted since antiquity.14 Zborowski’s classic—yet methodologically (if not philosophically) flawed—study of pain thresholds, perceptions, and responses in various ethnic groups was nonetheless important in that it shed light upon the possibility that various cultures could be susceptible to biopsychosocial influences that affect pain.15 Several subsequent studies revealed differences in sensitivity to, and expression of pain between various ethnic, social, and geographically distributed groups.16-18 But it is important to heed A.L. Kroeber’s warning not to confuse “culture” with “a culture,” as the latter is connotatively prejudicial.19 Rather, we must consider “culture” as presciently described by E.B. Tylor over a century ago as being a “…complex whole” that can dynamically shape almost all aspects of human experience.20 Culture—as a complex whole—gives rise to identifiable groups that cluster together based upon geographic isolation, niche occupation, physiological functions, kin selection, and social characteristics and activities. It is these biospychosocial effects and artifacts that promote and sustain beliefs, knowledge, and the resultant behaviors of individuals, and the groups to which they belong. These socio-cultural characteristics can determine accepted interpersonal roles, and modes of action and expression that can affect how the sensation of pain may be perceived, interpreted, communicated, and treated.21

Cultural Orientations of Patients and Clinicians: Knowledge, Beliefs and Realities

It is in this broader context that we must consider the effect(s) of culture on ways of understanding pain, the experience of patienthood, and the role(s) of pain medicine and the clinician. There is a reciprocal relationship between the sensation and meaning of pain.22 The subjectivity of pain reflects distinctions in neurophysiological processing of pain as a sensation, and neurocognitive interpretation of pain as an experience of the lived body.23-25 Given that cognitive constructs (i.e., meanings) are socio-culturally influenced, the perceived identity and impact of pain are often contextual.26 Elaine Scarry has claimed that pain can deconstruct patients’ lives and defy language.27 But to fully grasp the extent of these effects, it is important to understand 1) the life-world of the patient to determine how it has been deconstructed by pain, and 2) that this life-world is inextricably bound to the patient’s culture. As well, while pain may defy language, its experience compels communication in an attempt to communicate subjective suffering to others.28,29 We opine that the effectiveness of this communication is semiotically and semantically constrained by socio-cultural capacities and limitations.

We can conceive this potential communication as a Borromean interaction: the interplay of three domains whose relative intersection reflects both the extent of commonality and the possibilities for mutual engagement.30 As shown in Figure 1, such a Borromean interaction of 1) pain, 2) the pain patient, and 3) the clinician, dictates both the patient’s and the clinician’s attitudes and activities. Clearly, the patient and clinician bring their respective cultural influences and effects to the fore within the fabric of the clinical encounter. In this way, both maintain and manifest beliefs, knowledge, and attitudes about the nature and meaning of pain, disease, illness, personhood, and responsibility. Beliefs should not be minimized; to paraphrase Augustine, to believe is to understand, such that our individual conceptualization of the world allows and guides our ways of knowing, and colors our interpretations of life.31 For the patient, these beliefs may incorporate considerable “folk knowledge,” and may not be consonant with the beliefs upon which the epistemology of medicine is based.32 Thus, the beliefs of patient and clinician can ultimately enhance or disrupt the Borromean dynamics of the medical relationship.

Figure 1. Depiction of the relationship of patient, clinician and pain and its treatment(s) as a Borromean-like interaction. In this interaction, each one of the rings represents a multi-dimensional sphere that constitutes the multi-dimensionality of the particular entity. For patient and clinician, it represents the totality of their respective life-worlds, inclusive of the biopsychosocial effects of culture, experience, beliefs, knowledge and attitudes. For pain and its treatment, the sphere reflects the objective entities, and its intersection with the patient and clinician represents the subjective characterization of this objectivity. The extent of alignment between patient, clinician, pain, and its treatment depend upon commonality of beliefs, knowledge, experience and expectations. All can be affected by culture.

With its defined set of values, attitudes, beliefs, meanings, and even language and behaviors, medicine must be viewed as a socio-cultural force,33 and its power creates, and is upheld by, biopsychosocial asymmetries in the clinician-patient relationship. We believe that one of the tasks of the clinician is to lessen this asymmetry by decreasing the vulnerability of the patient through the empowering provision of care. So, if pain medicine is to fulfill the good of its professed task (i.e., treating and healing the person made vulnerable by pain), then it is important for the clinician to not simply understand pain as object, but to understand how the objective event of pain is subjectively interpreted by, expressed in, and affects the culturally-nested patient.34

So, if pain medicine is to fulfill the good of its professed task (i.e., treating and healing the person made vulnerable by pain), then it is important for the clinician to not simply understand pain as object, but to understand how the objective event of pain is subjectively interpreted by, expressed in, and affects the culturally-nested patient.34

The Impact of Culture on Ethics

This objective and subjective understanding provides a basis for 1) diagnosis, 2) considering those therapeutic options that are available, and 3) selecting those that maximize good outcomes in a specific patient.35 Obviously, these choices must both determine the contextual meaning of good (for the patient’s best interests), and direct its provision.36,37 The relief of pain—as the tangible good of the clinical encounter and the relationship of pain clinician and patient—must extend beyond the limited proximity of the clinical environment and affect the daily realities of the patient’s life-world. Therefore, it becomes apparent that each decision is at once therapeutic and moral, and the decisional process becomes one of ethical concern.38,39 But given the cultural plurality of contemporary society, how can these ethical decisions be made with any reliability?

We have argued that the structure of pain medicine entails a particular framework of responsibilities and obligations that define its intellectual, moral and practical articulation.40 These rules define what the practice is all about and establish the requirements that one must accept if they are to enter the field. These are far-reaching statements that conjoin pain management to a general philosophy of medicine that is built upon, and defines a core epistemology (i.e., as a knowledge base, and ways of knowing), anthropology (as consideration of the factors that are involved with the conduct of pain care as a human enterprise), and ethics (as a formal, systemized analysis of moral decisions and the systems and processes involved in moral decision making).41 Hence, the “rules” explicate particular essentials of pain care, such as 1) the importance of knowing about pain and its effects, 2) an understanding of the multi-dimensionality of the person who is the patient, 3) the subjectivity of pain and the difficult yet critical necessity for inter-subjectivity, and 4) a knowledge of ethics as both a process and a set of tools.42 Simply, rules one thru three determine what ethical processes and tools might be best suited for the specific circumstances, interpersonal relations, and task at hand. Obviously, any consideration or understanding of the person who is the patient must regard the relative effect of culture; but in actuality, the entire process—that is, the rules themselves and our need and reliance upon them—does not transcend cultural influences.43

The actual point of the described Borromean interaction is interpersonal, occurring between the clinician and patient. Given the clinician’s roles as steward of knowledge, and executer of knowledge and skill (in the patients’ best interest), we posit that it is the clinician’s intellectual and moral responsibility to utilize those ethical approaches that 1) are resonant with his/her moral compass, 2) allow accurate account of each patient’s biopsychosocial needs, and in so doing, 3) define, and direct the provision of (right and) good care. This necessitates an agent-based ethics and, while we have argued in favor of a virtue-oriented approach, we recognize that virtue ethics cannot work in isolation.44,45 Thus, while particular intellectual virtues may allow for an understanding of culture and its effects, and moral virtues may allow prudence to direct a habitual striving toward the good, virtues must be employed within some system(s) that meet the contingencies of circumstance and persons.46 Clearly, a virtue ethics mandates examination of one’s beliefs and values toward developing the cultural understanding necessary for ethical deliberation.

To be sure, self-awareness and -reflection are cornerstones of prudent, culturally sensitive care.47 Such self-reflection fortifies the clinician’s awareness of the importance that beliefs and values have in effecting the manifestations of illness, and patients’ intentions and actions in the clinical encounter. In practicality, this enables a clarified lens with which to view the patient, may facilitate culturally sensitive communication, and allow insight to patients’ beliefs, values and goals.48 By enhancing ongoing dialogue, clinician and patient establish a problem-solving relationship that supports mutual decision making, sustains the agency of patient and clinician, and may serve as a starting point for implementing values-based and/or goal-directed pain care.49-51 Such sharing of perspectives, beliefs, knowledge, meanings, and clinical expectations can create an alliance in which the patient is empowered and the clinician is enabled.

One of the critiques of this approach is that any full consideration of cultural effects and differences implies an ethical relativism or subjectivism.52 On a somewhat deeper level, this is actually an ethical skepticism that questions whether any moral decision can be right or wrong, and if the concept of what is “good” has any validity.53 The point of contention is that once we consider or allow cultural and individual variation, then any claim to what is morally sound becomes little more than opinion or some attempt to advance and/or recruit others to a particular point of view. We disagree with this for several reasons. First, any approach to moral decision making and use of ethical systems must begin by obtaining and analyzing facts relevant to the circumstances, issues and/or problems.54 Clearly, it is a fact that culture can affect the dispositions, beliefs, actions, etc. of persons. Second, any moral deliberation must consider the agents involved—not simply as objects—but as subjects of responsibility.55 Third, while moral deliberation considers and weighs the influence and importance of culture and its effects on individuals, the process itself seeks to prescind (i.e., “step back” in reflective distance) so as to evaluate these factors in balance.56 Finally, moral deliberation is actually aimed at describing and defining the case, and molding attitudes toward certain actions. In this way, moral discourse and deliberation need not be about what is “true” or “false,” or even what is “right” or “wrong,” but rather what warrants rational consideration and supports reasonable action(s).57 Accordingly, some ethical approaches are better suited to ameliorating the differences of culture and strengthening the voice of those who are marginalized. Feminist ethics have particular merit in this regard, at least in part, in that the feminist perspective directly acknowledges the overt and covert effects of relational asymmetry, and affords tools that both allow insight to this discordance and that may equalize capability and power.58,59

But perhaps what is needed is a meta-ethics of pain medicine; a system that allows overview and analysis of the ethical issues in pain care, and what, how, and why particular ethical approaches can be engaged to resolve these issues. The task is formidable, and is the focus of our ongoing work.60 As we approach specific pragmatic and moral issues in pain care, it is critical to ground each of these problems and their potential solutions to the realities defined by persons in culture. For if pain medicine is to be truly practical, it must acknowledge an increasingly global, pluralized world-culture, and offer care that is sensitive to our similarities and differences.


This essay was adapted from the authors’ larger work: “Effects of culture on pain—biology, beliefs, knowledge, and implications for a neuro- anthropology and ethics of pain medicine” that is part of a forthcoming symposium on pain, suffering and bio-psychosocial dimensions of personhood (Bad Tölz, Germany, 2008).

Last updated on: January 28, 2012
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