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10 Articles in Volume 9, Issue #5
Dextrose Prolotherapy for Recurring Headache and Migraine Pain
Diagnosis of Low Back Pain
Ethics, Education, and Policy: Relationship and Mutual Reliance
Human Chorionic Gonadotropin in Pain Treatment
Musculoskeletal Ultrasound
Painful Herpetic Reactivation and Degenerative Musculoskeletal Injury
Post-stroke Pain
Preventive Medications for Chronic Daily Headache
The Pathophysiology of Neuropathic Pain
Use of Pulsed Radiofrequency in Clinical Practice

Ethics, Education, and Policy: Relationship and Mutual Reliance

From Science and Philosophy to Ethics

Over the past years, I have tried to illustrate how the problem(s) of pain, and intricacies of pain care, reflect profound philosophical issues and questions that are important to both the anthropologic applications of medicine, and the ethics necessary to navigate the moral terrain of medical practice. Sometimes, this has taken the form of addressing a philosophical point in relation to the moral concerns and ethical systems required to enact clinical ends; other times this has involved describing specific moral issues and questions, and posing how various ethical approaches might be employed to intuit resolutions.

As my colleague Edmund Pellegrino has noted, the intertwinement of philosophy, ethics, science, and (as well as in) clinical care must be acknowledged and regarded in any consideration of the nature and extent of the myriad problems that can and will arise, and in the moral decisions that these problems mandate.1 Unapologetically, I have taken this as a prompt to engage a deep discussion of the philosophical bases of pain, science, and medicine, so as to accurately depict the intensity and complexity of (1) the intersection of philosophy and ethics; (2) how this intersection is revealed in the realities of pain research and therapeutics; and (3) how philosophical premises might ground ethical analyses and approaches necessary to the profession and practice(s) of pain care.

In this way, I have tried to instill an appreciation for ethics as being wedded to the fabric of medicine and thus reveal ethics to lead the process of clinical decision-making, rather than being an afterthought, or intellectual “add-on.”2-4 When I was originally approached to develop and write these essays, the idea was proposed to address the main ethical issues, or principles, and discuss these as relevant to pain management. To be sure, this was viable, but I didn’t think, nor do I now, that this orientation to ethics would suffice. Rather, I feel that pain practitioners require a deeper understanding of the intellectual and moral foundations that incur and flavor the dilemmas encountered in research and practice. Simply put, I’ve tried to generate thought and reflection upon the richness of the circumstances and relationships that are part of practical pain care. Of course, I’ve also afforded the reader(s) ample bibliographies from which to acquire both background information and to advance understanding. In other words, my hope is that this column not only illustrates, but informs and educates—in the strictest sense—as well.

The Necessity of Education

This latter point is particularly important because clinicians are characteristically not exposed to, or educated in, the philosophical groundwork upon which their disciplines (as relating to pain care) are built and, further, how and why these philosophical grounds (1) are practical, in their working anthropological focus rather than merely esoteric; and (2) are critical to applied ethics as systems and approaches to enact the good that is fundamental to pain medicine and medicine at-large.5,6 While coursework in the philosophy of medicine and ethics is a component of many medical curricula, the reality is that medical school dictates a greater emphasis upon the basic and clinical sciences, if for no other reasons than 1) there is just so much clinical information to be acquired, and 2) there is a limited time to devote to this information. This tends to marginalize the time and stringency allotted and/or dedicated to both providing ethics’ education and to acquiring such knowledge.

The situation is not much better in the post-graduate training years and, for the most part, continuing (medical) education (CME/CE) and other professional CE tends to focus upon ethics in only the most superficial (and often ethico-legal) terms. From experience, I can state that this is changing as the complexity of the contemporary research and clinical environments (both independently and in concert) have instigated a demand for progressively more advanced insight to philosophical constructs and ethical issues that surround the use of new techniques and technologies (e.g., stem cells; geno-, nano- and neuro-technologies; the treatment-enhancement debate; etc.) Such considerations have also instilled renewed interest in how such progress might affect extant ethical constructs, principles and mores in clinical care.7-9

As James Couch has noted, the future of medical profession and its practices rests upon education, and this education must be responsive to, and encompassing of change.10 I agree, and like Couch argue that this is vital to accommodate the rapid and increasingly pervasive reliance upon technology, and to do so in ways that will “…further the ends of patients, and not vice versa” (i.e., the ends of technology, or the market model that drives its development and/or use).11 Ethics is a part of this shifting educational paradigm, as it is equally important to recognize the ethical responsibility to educate clinicians in the moral and intellectual basis, tasks, and challenges of being a physician and/or medical scientist, as it is to actually teach the ethical skills sets that are involved in— and crucial to—research and patient care. Couch recognizes the difficulty of instantiating such change within the medical school curriculum. Instead, the initiative forum for such change is likely to lie within CME, not as “…commercial ‘canned’ seminars,”12 but in multiple venues that are sensitive to (1) the issues facing today’s physician, (2) emerging trends that will affect the scope and conduct of medicine in the future, and (3) the information and knowledge from a diversity of fields (e.g., biomedical science, the humanities, economics) that is/will be necessary to advance and enact right and good care.

The “grass roots” change effort(s) that Couch and other scholars have called for could be implemented via CME and professional educational vehicles such as seminars, symposia, journals, and other media that positively access the wave of technology (e.g., broad-based internet delivery, Skype, etc.)13,14 Optimistically, I contend that this might instigate a responsive shift in medical school education that employs these resources to augment existing coursework (in ethics, per se, as well as in basic and clinical sciences courses so as to illustrate the interface of these disciplines), and in developing and articulating new, more integrative curricula. Realistically, however, any sea change occurs through iterative drops, at least at first. Ultimately, this may lead to a torrent of fresh ideas and directions, and constitute more revolutionary changes that are required for a true paradigmatic shift.15 But, as I have previously opined, medicine—and medical education—does not occur in a socio-political vacuum,16 and thus, as David Nash has stated, it is important to understand “…the political, educational and economic forces that are helping shape the future practice of medicine….”17 To do so will require insight to the mechanisms, intricacies and effect(s) of policy.

The Importance of Policy

I am fond of modifying the adage that while “good ethics make for good laws,” to reflect the actual situation that ethics enables the “good” to be achieved within the parameters established by law. Perhaps more appropriately, it could be stated that ethics allows systematic analysis of moral constructs and decisional processes that should (and/or must) be borne by guidelines, and the statutes of policy. Clearly, philosophical precepts and ethical approaches undergird any action(s). Still, questions remain as to 1) how such ideas, moral intent, and ethical systems can be engaged in the research and practice(s) of pain medicine; 2) how can and should we further examine the gaps in both information and resultant capabilities of research and care; and 3) what, and how can identified gaps be compensated for by translating new research into viable programs to treat those in pain. To do this requires guidelines,18 yet, as James Lapcevic has related “…in the present tumult of managed care…it remains veiled whether fungible [care] guidelines can be successfully applied to the pain patient.”19

“...it could be stated that ethics allows systematic analysis of moral constructs and decisional processes that should (and/or must) be borne by guidelines, and the statutes of policy.”

Both the pain patient and pain medicine are nested within the social fabric. This compels equal consideration of those problems of the public sphere that will not only exacerbate the issues and tensions inherent to pain care, but may impose other (extra-medical) factors that exert significant (if not greater) impact upon those in pain, and the nature and conduct of medical practice. In other words, the problems of the polis at-large affect (and may direct) the services that are conducted for the care of those who are its community. Given that (1) governing bodies are responsible to those they serve, and (2) by definition, policy dictates the high-level overall plans, procedures (and/or codified laws) that prudently embrace the purposes and goals of a governing agency and its charges,20 then it becomes evident that policy is essential to uphold the obligations of a governing body to support the good of its constituency. Dai Rees and Barbro Westerholm note that “…ethics should always be ahead of the law, and ethical standpoints change in light of new knowledge.” Still, while these authors acknowledge that “…it is important to respond to public concern,” they caution that ...”it is best to think twice before turning ethics into law,” as it is sometimes “…easy to act with ill-thought-out measures in haste, only to repent in leisure.”21

The prudence entailed in the aforementioned definition of policy recalls Pellegrino’s notion of the core questions that are inherent to ethically sound medical practice: What can be done, and what should be done?22 Discriminating these possibilities necessitates access to, and analysis of, the facts that underlie the circumstances and dimensions of the agents in relationship, and the consequences occurring from any and all actions taken (or not taken). In light of this, policy must be informed about the agents served, content and contexts of issues and problems, and (positive and negative) implications and consequences of activities and solutions that would be advocated and eventually ratified.23 People provide this information and, if the change process is to begin with (and support) a grass-roots effort that iteratively enthuses a constituency to communicate and influence policy-makers, then it is critical to educate those at the grass-roots and progressively higher levels about the issues and potential trajectories for healthcare (education, research, and practice) that policy can—and should—affect. In other words, ethics, education and policy are dynamically related, and mutually reliant.

A Tipping Point

The writer Malcolm Galdwell asserts that “…we all want to believe that the key to making an impact…lies with the inherent quality of the ideas.”24 Without doubt, the ideas of philosophy and ethics are important to practical pain management. However, without some ways of aligning these ideas with the realities that establish—and which are ingrained within—the profession and practice of pain medicine, they would tend to remain esoteric. But by addressing, informing, and being taken together with policy, these ideas can become the legs to support a workbench upon which new, innovative and sound pain care can be modeled and built. It may be that one of the outcomes of the Decade of Pain Control and Research will be a better understanding of how the sciences and humanities are important to develop policies that ethically advance the good of pain medicine into the future, and in this way create what Galdwell has called a “tipping point” in which ideas, trends and social constructs “…cross a threshold, tips, and spreads….”25 In re-visiting the original conversations that led to my writing these Clinical Bioethics columns for this journal, I believe that we are now ready to address specific ethical cases, issues, questions and principles—not abstractly, but as elements that are important to discussing education and informing policy and, in this way, reveal how “…little causes can have big effects,”26 and such might be points from which positive change can occur.

“It may be that one of the outcomes of the Decade of Pain Control and Research will be a better understanding of how the sciences and humanities are important to develop policies that ethically advance the good of pain medicine into the future...”

Acknowledgement

This essay was adapted, in part, from: “On the interfluence of philosophy, ethics, and policy in medicine: Visions and necessities for the future of profession and practice,” that is forthcoming in Philosophy, Ethics and Humanities in Medicine.

Last updated on: January 30, 2012
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