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10 Articles in Volume 9, Issue #6
Cytokine Testing in Clinical Pain Practice
Effective Monitoring of Opiates in Chronic Pain Patients
Ethics, Pain Care, and Obama’s Policy Intentions
Interventions for Radiating Upper Extremity and Cervical Facet Pain
Long-Acting Opioids for Refractory Chronic Migraine
Need for More Accurate ER Diagnoses of ACL Injuries
Neural Therapy and Its Role in the Effective Treatment of Chronic Pain
Screening Blood Panel to Evaluate New Chronic Pain Patients
Spinal Pain and Neuromuscular Deficiency
Thermal Imaging Guided Laser Therapy: Part 1

Ethics, Pain Care, and Obama’s Policy Intentions

A View Toward “the Hill”

As leaders in Congress seek consensus on how we might address and rectify problems in our nation’s health care system by year’s end, we are reminded of the need for ethically-informed pain care legislation. President Obama himself recognizes that it is a moral imperative—and not simply a practical necessity—for our elected officials to provide better care for those who suffer in “…mind and body.”1 As such, it implicitly recalls the difficulties of pain medicine in dealing with pain as an event of body and the brain-mind, as well as the subjectivity of its experience and the objective personal and socio-economic realties it incurs. Thus, for Mr. Obama and those in various tiers of politics who direct their focus to health care reform, the issue is not simply why, but what form such change(s) will assume and how these will be developed, implemented and ultimately affect the social good.

Something(s) Old, Something(s) New…

While few would doubt that our legislators have an ethical obligation to guard, preserve and attend to the health of its citizens, we suggest that it is important to view this obligation more broadly so as to encompass a meaningful definition of health and the scope of responsible pain care that arises from such a construct. This is not a new or novel task. In 350 BCE, Aristotle conceptualized true health and well-being as a function of moderation and self-restraint when he observed that it is “…the nature of (natural) things to be destroyed by defect and excess.”2 Thus, a healthy person, and (by extension) a healthy population, avoids extremes in the mundane as well as the more critical choices of daily life. Aristotle’s point was that health—of both the person and the polis—were related to, reflective of, and dependent upon temperance, wisdom, and responsibility. In an age of ever-increasing choices and call(s) for more personalized care, we must ask how policies can be created that accommodate some level of our libertarian values and, at the same time, enable the execution of expert skill and knowledge in ways that are morally sound yet economically viable. At first blush, the task at hand seems Gordian—untangling one thread of the knot imparts tensions to others.

To look ahead, we may need to reflect upon the wisdom in the classical view and Aristotle’s claim that “…legislators make the citizens good by forming habits in them, and this is the wish of every legislator, and those who do not effect it miss their mark” is just as relevant today as it was centuries ago.3 It speaks to the reciprocity between the sciences, medicine, humanities (i.e., philosophy, ethics, sociology), economics and politics to inform the public and, at the same time, be informed by the public in making those decisions that affect and sustain the social value of healthcare. Hence, as Aristotle recognized, a “healthy” citizenry makes for a stronger republic. But toward such ends, we must also recognize the responsibilities of the “strong” (viz. those in power, whether medical, economic, and/or political) to mitigate the plight of the weak (viz. those who are marginalized and vulnerable by the condition of disease, illness and suffering). In light of this, while we can state that elected officials have a duty to promote and sustain the well-being of their constituencies, they cannot force it, but can—and we argue, should—in Aristotle’s words, “effect” it.

We believe that President Obama would not disagree with Aristotle. In his address to the American Medical Association on July 15, 2009, the President expressed a concern that Washington must “…invest more in preventive care so we can avoid illness and disease in the first place” and “starts with each of us taking more responsibility for our health and for the health of our children.”4 In the opinion of the President, the ills of our health care system are due, to some extent, upon the unhealthy habits of our citizenry. This is not to point an accusative finger at the public, nor is it meant to deny the obligations of the economic and political infrastructure to provide ways and means for safe, available and affordable healthcare. However, it is meant to draw attention to the fact that as our potential choices for healthcare provision multiply (e.g., new and advanced technologies, drugs, and medical services), the mere presence of such available options does not negate the more primary responsibilities for prevention and prudent decision-making in accessing those means that are sought and utilized in medicine. Simply, as choices increase, the obligation to understand the relative value of various new tools and methods increases concomitantly, as do the needs for economic and policy support to allow responsible use, as required.

On Responsible Choice

Even though the President exerts considerable influence over the shape of America’s health care overhaul, it is Congress that must codify such an ethic into law. As it stands today, House Resolution 3200, known as “America’s Affordable Health Choices Act of 2009” mandates that $2.4 billion be spent on preventative measures in 2010 alone (this would rise to $3.5 billion by 2014). In actuality, this would not only fund biomedical research and direct clinical applications of public health, but would also support more indirect aspects of health, such as parks, bike trails, etc. But despite this somewhat ‘holistic’ orientation to health, all wellness plans through which individuals might be able to lower insurance premiums by undergoing medical screenings, have been stripped from the bill. To be sure, this approach has been criticized as being too obtuse and, even if restricted to more seemingly clinical domains, HR 3200 falls short of incentivizing moderation in health care options and choices and supporting such prudence through economic allocation. Regardless of political affiliation, these omissions should concern all members of the medical community.

It seems that this fiscal plan might require further deliberation so as to better evaluate where and how the needs of the public and the medical community intersect, and how a more finely-grained economic package might be developed that would (1) sustain research in disease prevention, treatment and management, (2) translate these research efforts into clinically-relevant resources, (3) make available and justly distribute both low- and high-tech resources, and (4) prompt fiscal programs that support, allow, and reinforce responsible choice (of such resources) in both preventive and treatment paradigms.

In this vein, the system of medical delivery needs to act with the same level of temperance encouraged by Aristotle. Later in his AMA speech, President Obama rightly described the current state of health care in America as “…a system where we spend vast amounts of money on things that aren’t necessarily making our people any healthier; a system that automatically equates more expensive care with better care.”5 Despite the fact that technology has dramatically enhanced the quality of health and healthcare, we have argued that imprudent use of any technology—old or new—can be problematic if not practically and ethically erroneous.6 The goal therefore, is not simply to discard old(er) or low-tech approaches simply because they are, in fact, ‘not new’, nor is it reasonable to blindly accept (or reject) new(er) or high-tech methods because of their novelty. Instead, we call for a more complementary orientation in which the ‘either/or’ mentality of contemporary healthcare provision and subsidy is abandoned in favor of a ‘both/and’ construct.7 Acting in the best interest of the patient may require the combination of older and newer techniques and technologies, as appropriate, and this decision remains the province of the clinician in concert with individual patients’ needs and values.8

“Acting in the best interest of the patient may require the combination of older and newer techniques and technologies, as appropriate, and this decision remains the province of the clinician in concert with individual patients’ needs and values.”8

Revision, Rapprochement, and Reformation

To do this will require a revision of current schemes and programs of clinician reimbursement. Acknowledging this, the President insisted that we need to reform “…the way we compensate our providers... we need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition…but, instead, paid well for how you treat the overall disease...we need to give doctors bonuses for good health outcomes so we’re not promoting just more treatment but better care.”9 To this end, the President made it clear that he intended to “…create incentives for physicians to team up because we know that when that happens, it results in a healthier patient.”10 President Obama appears to understand that good medicine is qualitatively measured in an environment of trust between the patient, health care professional, and the health care community at large. All parties must demonstrate a measure of good faith. Toward this end, we have advocated a stance of rapprochement in which the major stakeholders in pain care frame their individual values relative to those of the primacy of patients’ best interests.11

However, the current call for personalized medicine does not imply that best interest equates to absolute patient choice. To the contrary, a system of individualized medical care that is built upon, and respects, fiduciary concerns must sustain non-trumping autonomy and thus must support (1) the capacity of the patient as a person; (2) the responsibilities of the physician as a therapeutic and moral agent, and (3) the achievement of ‘good’ (on multiple levels) within the context of the clinical encounter. As David Rosenfeld has recently illustrated,12 the treatments that pop star Michael Jackson received were expensive, intemperate, and cynically administered in private, and serve as a hyperbolic example of how market-driven, disjointed incentives for clinical services are in stark contrast to both an authentic definition of ‘medical practice’ and to the policy intentions of President Obama. Pain care policies for the coming decade, if they are to be in accordance with the best of the Western ethical tradition, should resist and defer pressure(s) for inappropriate, abundant and expensive consumption of resources that are in violation of the medical fiduciary—both on an individual scale (i.e., between patient and clinician.) and, more broadly (i.e., between medicine as profession, government and the society they serve).13

In turn, it is clear that President Obama and the Congress will expect and, in some cases, enable the medical community to exercise its independence from the market forces of supply and demand. He is advocating a reformation of the current model which has “…taken the pursuit of medicine from a profession—a calling—to a business.” In asserting that physicians “…entered this profession to be healers,”14 Mr. Obama reinforces the fact that, as such, clinicians must acknowledge and ascribe to the inherent moral structure and obligations of the profession,15 and should possess the personal integrity, fortitude and authority to exercise meaningful care through the combination of both clinical assertiveness and restraint.16 At times, this will require the ability to intuit existing economic infrastructure(s) so as to secure the resources necessary for sound patient care and, at other times, resist extreme and/or unscrupulous financial incentives. Aristotle well articulated the wisdom and moral courage required to “do right” in his observation that “… anyone can take money, but to do [right] to the right person, to the right extent, at the right time, with the right motive, and in the right way, that is not for every one, nor is it easy.”17 Pain care is the domain of the pain practitioner and must be practiced with the dexterity of prudence, and not be manipulated by the invisible, yet forceful hand of the market.

“Pain care is the domain of the pain practitioner and must be practiced with the dexterity of prudence, and not be manipulated by the invisible, yet forceful hand of the market.”

Potential, Caveat, and Hopes for the Future

Perhaps the greatest promise of the proposed health reform is the increased funding for the marginalized and uninsured to receive medical treatment. The President has made clear to both Congressional chambers that he will only sign a health care bill that provides insurance to the 40 million Americans who currently lack coverage. By making the medical system more efficient and mandating individuals to be insured, this broadened coverage is intended to lower premiums and overall cost of medical treatments. This offers great potential for positive change in pain care. Put simply, more patients would be covered for more clinical services and resources. Under the auspices of Medicare reform and expansion, H.R. 3200 makes special provision to ensure treatment for the elderly, citizens in rural areas, under-served urban neighborhoods, and non-English speaking minorities. Furthermore, the bill promulgates the use of proven medical technologies to broaden the available treatments for the most vulnerable patients.

However, from the perspective of “best practices” in pain medicine, this expansion of coverage remains uninformed. The word “pain” is remarkably absent from President Obama’s major speeches on health care, as well as the 1,018 pages of H.R. 3200. Past essays in this journal have addressed the need to recognize the complexity of pain and pain care and revise the medico-legal paradigm accordingly. Unfortunately, it seems that provisions to address the tensions that exist in the doctor-patient relationship in regards to pain care are copiously lacking. As a result, we might expect these strains to worsen and create unintended consequences—especially for newly insured patients who suffer psychological co-morbidities inclusive of a history of substance abuse.

Conclusions

As Congress continues to modify health care legislation in the Fall of 2009, we opine that they should (if not must) consider funding a deeper and wider scope of pain care options, including the apt use of new techniques and technologies and the re-constitution of multi-disciplinary pain care facilities.18 Such action would—if taken together with an increase in well-trained pain specialists via the Medicare Graduate Medical Education clause—allow for more readily available, accessible and affordable pain care that is optimized, integrated and individualized to the experience and therapeutic needs of each patient. Without doubt, the road ahead may appear to be long and steep and no one—whether scholar, physician, pundit, or President—can see over the horizon of possibility. But if we are to advance along the path of providing right and good health care, then we must look not only to the horizon of what “could be,” but to “the Hill” to turn our hopes into realities.

Last updated on: January 30, 2012
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