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11 Articles in Volume 6, Issue #5
Clinical Pearls for Treating Headache Patients
Determining Which Low Level Laser to Use
Guidelines for Opioid Management of Pain
Interventional Therapies in the Continuum of Care
Lessons Learned from a Headache TMD Study
Potential Hazards of Vertebroplasty
Splenius Capitis Muscle Syndrome
The Moral Community of the Clinical Pain Medicine Encounter
Urine Drug Testing and Monitoring in Pain Management
Vitamin D Deficiencies in Pain Patients
Why Electromedicine?

The Moral Community of the Clinical Pain Medicine Encounter

In arguing for the importance of agent-based virtue ethics to pain medicine, I have relied upon the presumption that any interpersonal interaction is composed of a circumstance, the agents involved, their actions, and the resulting consequences. This calculus of factors is undeniable, and it is important to recognize that circumstances differ, and agents each bring distinct motivations, intentions and desires to the exchange. One of the criticisms of a virtue-based ethics is that the diverse needs and values of individual agents weigh against any possibility of moral uniformity.1 This reflects the fact that progressive globalization has led to cultural plurality throughout many domains of society, including medicine. In some ways, this can be seen as an asset, exemplified by the notion of a ‘world medicine’ that appreciates the role(s) of genome, environment, and social-anthropological influences that all contribute to bio-psychosocial constituents of health and illness.2 However, one of the concomitant ‘fallout’ effects of this socio-cultural diversity has been an expanding skepticism that has questioned the possibility of any common moral premises, assertions, and obligations within medicine, in general, and by extension to the practice of pain medicine.3 Thus, the question becomes whether an agent-based virtue ethics of pain medicine can be realistically considered, given the doubt whether there is, or can be, any moral structure that is wholly ‘internal’ to medicine in light of this contemporary socio-cultural pluralism and the heterogeneity of individual values. In this essay, I posit that the intersection of the pain patient and pain physician establishes a specific community that defines particular, shared moral values, and that a moral structure of medicine is recognizable and justifiable based upon the inherent nature of medicine as enacted through the clinical encounter.

The Possibility of a Common Morality

Bernard Gert, working together with Charles Culver and K. Danner Clouser, has claimed that there are a set of moral affirmations and a supportive, two-step process of moral judgment that reflect common considerations for interpersonal conduct both within and across cultures in society.4 The notion of such a ‘common morality’ is sensible in many ways as an interpretation of a generalized human ecology.5 Grounded in a maxim of non-harm, the cardinal and derivative moral statements provide premises upon which to base structured principles and obligations, and are relevant to various philosophical orientations to human behavior and systems of ethics. Yet, the idea of such a common morality has been criticized in that it is so general, and may not appreciate the unique elements that arise from particular human relationships and situations.6 Gert, Culver and Clouser have defended the applicability of a common morality by stating that the elements of their moral precepts are based upon values that are definable within diverse circumstances, and have specifically applied these common moral rules to standard medical situations.7,8 Indeed, I agree that common moral rules, reasoning, and ideals as Gert has proposed can be relevant to, and meaningful for, medicine given that these describe foundational concepts which guide the acts of morally responsible agents, and aim to ameliorate potential moral ambiguities that may be incurred by cultural differences.9

Yet, Gert, Culver and Clouser take particular care in noting that general moral assertions and rules can only have ‘common’ relevance (to any group of agents) if, and when, they are unified to a particular practice or contexts. In this way, there is a systematization of the moral constructs within specific interpersonal relationships of some institution. This is where I believe that any notion of medical morality must take into account the particularities of the patient-physician relationship if it is to be valid and/or have value.

The Clinical Encounter: Pain Patient and Pain Physician as Community

The encounter between the person in pain and the physician who professes to treat is a relationship of inherent vulnerability and inequity.10 The pain patient is a person for whom pain has ‘taken away’ the familiarity of their lived body, the comfort of much of their life, and the security of health.11-13 In its place are the existential manifestations of illness and the incurred dependence upon the physician to alleviate pain and restore health.14 This dependence is engendered by the physicians’ act of profession which serves as a public declaration of ability.15 By claiming to be a pain physician, the clinician invites prospective pain patients to trust that her judgments and actions will involve the application of authentic knowledge and skill, and be based upon a moral integrity that is sensitive to the unique needs of each patient as an individual. These needs are defined by the effects of pain and illness upon the patient, and initiate the clinical encounter as the basis for diagnosis and care. In other words, the medical relationship itself is determined by, and dependent upon, the illness of the patient, and the enjoinment of the physician.16

In this way, patient and physician exist as a community, engaged by common interest in the basic tenet of the clinical encounter: the provision of care that is both technically competent and regards the good of the patient.17 This community is framed by 1) the needs of the patient — for healing, continuity of care, empowerment, and 2) by the needs of the physician— to exercise the capacity to heal and sustain medicine as a humanitarian endeavor. As a community, the medical relationship maintains common moral values: reciprocal trust, truthfulness, empathy and sensitivity. The common moral rules, ideals and reasoning as described by Gert can, in fact, provide direction for ethical systems that may be ‘externally’ applied to address particular decisional issues and provide guidepost(s) to resolve certain ethical disagreements within medicine. However, the actual moral basis of medical practice is derived from the nature of the practice itself –and therefore is not extrinsically delineated, but is instead internal to the reality of the phenomenal interaction of patient and physician, and reflects the unique circumstances, acts and consequences of that relationship.18,19

Furthermore, I would argue that pain medicine is made somewhat more unique by the facts that 1) pain is wholly subjective – the objective fact of pain affirms its completely first person experience; 2) as such, the use of a solely objective approach to assessment and discernment cannot afford the information necessary to apprehend the nature of pain, and/or its impact upon a particular patient; and 3) a balanced inter-subjectivity is required for the physician to utilize distinct types and domains of knowledge toward prudent decision-making in diagnosis and treatment.20 Hence, the interaction between pain patient and pain physician cannot be relegated to the sole use of technology and/or exchange of objective data – the fact of pain is inseparable from its subjective effect(s), and the practice of pain medicine must therefore regard the moral values, and obligations inherent to this inter-subjective relationship.

Communitarian Appeal

While a complete discussion of communitarianism is beyond the scope of this essay, suffice it to say that most communitarian ethicists have advocated the importance of shared understanding of values, the good (at very least within the scope of particular relationships and/or practices) and the self.21 As such, communitarian perspectives strongly regard the sphere of relationships in medicine and view this as the focal point for any moral deliberation toward the achievement of commonly held good(s).22 In many ways this is highly supportive of, and attractive to, practical pain management. I hold that the relationship between pain patient and physician is essentially a union of a particularly intimate nature (viz. its inherent inequity, vulnerabilities of disablement and disclosure, etc.) that occurs between initial strangers. The relationship focuses upon shared needs and values, and these define the parameters of individuals in community. This does not diminish the concept of an autonomous self; to the contrary, as Mark Kuczewski has noted, a person “…is shaped by and responds to … participation in the process of self-discovery with others,”23 and thus identity, at least in part, becomes “inseparable from the… community in which the person participates.”24 Indeed Kuczewski notes that persons’ deliberative abilities and decisional processes are fostered within the values of the community in which they are involved.25

Values-based Practice

Fulford and Colombo have proposed a model of values-based practice (VBP) that relies on recognition, awareness and respect for value(s) of individuals in community.26 By its nature, VBP is patient-centered, and multi-disciplinary. Values’ recognition and awareness are not based upon bias or externally superimposed predisposition(s), but instead occur through interactive processes of qualitative and quantitative empiricism, narrative and philosophically relevant approaches (e.g., phenomenology and hermeneutics).27 In this way, both explicit and implicit values that are directly meaningful to the context of the communal interaction (i.e., the community of the clinical encounter)are revealed, allowing for a dynamic balancing of these values, evidence and knowledge in the clinical decision making.28 This process of not excluding differing views and values, but incorporating them as positive resources (as weighable options, meanings, etc.) into the decision as shared information is known as “dissensual decision-making.”29 The beauty of this model is that it acknowledges the range of values, goals, ideals, rules and possible judgments that are meaningful and viable to both the patient and physician and, in so doing, enthuses and expands the community relationship through the decisional process itself. Still, however, the physician must bring expert knowledge, exercise awareness, and engage multi-dimensional reasoning that contributes to, and reflects the values of the relational community.30

Values And Virtue(s)

So while the idea of moral values developed in community is both useful and important, it remains apparent that the responsibility of intuiting these moral rules, ascribing moral ideals and engaging in moral reasoning still rests upon the physician as moral agent. Ultimately, the physician must evaluate the viability of rules in particular situations, address the needs of the patient, discern goals, ideals, and values, and stand accountable for decisions and actions implemented. Moreover, the reasons (i.e., the intentions) for both decisions and acts are fundamental to the moral context(s) of the clinical encounter, and can be an important determinant in sound and good reasoning.31 The general moral rules prescribed within the contexts of medicine as an institution provide considerable ethical guidance, but I argue that the character of the pain physician is important to recognize the moral nature of medicine as a practice, apprehend the sensitivity and intimacy of the patient-physician relationship, and utilize any set of common moral precepts. Gert, Culver and Clouser raise justifiable concerns about the use of virtue ethics as a stand alone ethical system, but acknowledge that an identified framework of common moral values, rules, and ideals may provide “...a way of determining what counts as a virtuous way of acting in any particular situation.”32 I agree given that characterologic dispositions toward good intention and action must be enacted within some system of rules and principles. However, I disagree with Gert’s simplification; virtue is not merely about a way of acting but rather informs and sustains ways of knowing needed to discern circumstances so as to compel ways of acting to achieve the good.33 Thus, intellectual and moral virtue(s) are conjoined, and function synergistically to enable making the right choices, toward the right actions, and for the right reasons.

Social Function and Protective Insularity of Internal Moral Structure

Here I must also make a point of noting that the community of patient and physician represents a specific and special coalition within the larger community of society. This is important because it emphasizes that—although medicine affords a fundamental good to individuals and, in so doing, provides a social good—it is not, and should not be, a social tool and the morality internal to medicine should not be purloined by capricious social forces (e.g., consumerism, nationalism, etc.).34 Recently, my colleague Paul Hutchison and I have argued that while different aspects of good will entail particular subjective impressions that may be influenced by societal trends, this does not mean that medical morality is externally determined. Medicine is not a means to achieve some instrumental good; but nor is it wholly an end to itself. Rather medicine serves the greater end of health through the provision of right and good care for each patient. Thus, the optimal end of medicine is the good of the individual patient (within the community defined by the clinical encounter), not the good of society.35 So while the moral values, rules and ideals of the community of patient and physician may reflect certain qualities of the societal community at-large, the medical relationship is not simply the social community writ small.

Society can change, and definitions of right and good can be influenced by economic, political and cultural agenda. What is morally unacceptable in society today may become de rigeur in the future, but the community of patient and physician must preserve the internal values of medicine as humanitarian act, and remain insulated against moral de-construction. Medicine remains an inter-personal act between individuals—one who is ill and one who professes to heal. The values inherent to this relationship reflect the respective needs and reciprocal commitments of patient and physician. Simply put, the patient must be able to trust in the skills, abilities, and integrity of the physician as a both a therapeutic and moral agent, and the physician must be enabled to exercise the intellectual and moral virtues that engender such agency. The obligation to relieve pain is common to most if not all ethical systems. It is the foundational moral affirmation of the pain patient and pain physician in community, and thus serves as the philosophical basis for practical pain management in any society.

Last updated on: December 28, 2011
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