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11 Articles in Volume 6, Issue #4
Assessing Secondary Gain In Chronic Pain Patients
Chronic Overuse Sports Injuries
Introducing Low Level Laser Therapy to Pain Management
Managing Diabetic Peripheral Neuropathic Pain (DPNP)
Moral Virtue and the Pain Physician
Non-pharmacologic Therapy for Chronic Opioid-dependent Sickle Cell Pain
Osteoarthritis of the Knee
Smoking and Low Back Pain
Temporal Tendinitis Migraine Mimic
The Underutilization of Intrathecal Treatment
Tumblin’ Dice–Why Does Random Matter?

Moral Virtue and the Pain Physician

Agency, Intentions, and Actions

“The virtue of benevolence …is of so comprehensive a nature, that it contains the principle of every moral duty.”

-Catharine Macaulay Graham

In my previous commentary, I extolled intellectual virtue(s) as imparting the ability for discernment and utilization of domains of knowledge that were vital to practical pain management.2 Given the complexity of pain, the subjectivity of its experience, and the individuality of its expression and effects, the physician must employ distinct ways of knowing in order to acquire and process information from diverse sources. In so doing, the physician must:

  • understand the mechanistic basis of pain,
  • comprehend its effects and manifestations in the person in pain, and
  • ultimately weigh that information to determine the viability of available clinical options.

Yet, informing actions is one thing, executing them is quite another. In this essay, I posit that the unique nature of pain and the multiple dimensions of its effect establish profound moral issues that affect the patient and physician relationship. The practice of pain medicine must not simply be therapeutically correct, but the intellectual virtue(s) that compel accurate clinical decisional process must also be a pediment for both the moral validity of these decisions and the acts that are instantiated thereupon. Thus, I argue that intellectual virtues are reciprocally reliant upon moral virtue to embody the professional identity of, and thereby support, the act of profession as declared by the pain physician.

Every human interaction is characterized by circumstance(s), agents, actions, consequences, and ends. Recall that practical action is ethically informed, not merely dependent upon theory; and therefore practical pain management requires both knowing about pain, its dimensions of effect in and upon the person who is the patient, and intentionally acting to achieve the ends of treating and caring for each specific patient in ways that uphold the moral good. How then, can the ethical bases of these actions be determined? To best address this question, it becomes important to first define ethics. Ethics is a formal, critical, systematic study of morality.3 The science of ethics seeks to describe the moral foundations that underlie human intentions and actions. But ethics is not merely descriptive; as a system it can provide normative prescriptions based upon moral grounds that can be articulated in practice.4,5 These moral grounds reflect distinct philosophical premises and values that regard the notion of what is good, the character and authority of morality, and the origins and validity of such moral obligation(s).6

Philosophical Basis of Pain and Pain Medicine

Progress in neuroscience, affording considerable knowledge of the structure and function of the nervous system and the mechanisms of pain, has been reconciled to neurophilosophical constructs of brain-mind and, by extension, the broader philosophical concepts of consciousness and the internal dimensionality of a definable self. Yet, while we ponder the ti esti, or “what is” question of pain, we are faced with the fact of pain as symptom, sign, disease and illness, and thus the need to develop a meaningful orientation to the problem of pain, its humanitarian impact, and how medicine (and perhaps society) can and should address, regard, and treat pain. To do this, pain medicine must incorporate both a philosophical orientation to pain, as well as the epistemic and humanistic premises, and ends (i.e., the telos) of medicine, in general.7 However, the practice of pain medicine remains somewhat unique in that pain is wholly subjective, it’s expression and effects variable, and the pre- and co-morbidity of other pathologies (e.g., existing disease or injury, psychiatric conditions, substance abuse, and addiction), can create compound occupational, financial, and social circumstances that establish pragmatic, philosophical, and ethical situations that complicate care.

But what is pain medicine, given that numerous disciplines are positioned to provide care for the pain patient? While each of these disciplines (e.g., anesthesiology, neurology, physical medicine, psychiatry and, ever-increasingly, certain complementary therapies) provide a particular orientation, set of theoretical and technical approaches, and even ideologies, I maintain that all must be consistent with, and adherent to the core philosophical premises and telos that define medicine.8 These are articulated by clinicians through the clinical encounter, and in this light we must also, somewhat more pointedly ask, who is the pain clinician? Given the pragmatically and ethically complex milieu of pain medicine, who is it who enters this field? In other words, what kind of person voluntarily dedicates their professional identity to the care of the pain patient? In short, I offer that the pain clinician is a medical professional who accepts the objective fact that pain exists as subjective predicament, recognizes the difficulties of objectifying pain to establish diagnoses, and acknowledges the commitments that are essential to uphold their act of profession. For it is in this act of profession that the pain clinician invites the trust of the patient to enter into the medical relationship, through which the inter-subjectivity required for effective diagnosis and treatment can be achieved. This act of profession represents the physicians’ covenant to use knowledge and skill to genuinely provide care that is right and good for each individual patient.9 But how can we determine what is “good”? This is the job of an ethical system; thus we must ask which ethical system or systems can best accomplish this task.

Some Ethical Systems10

Perhaps the most familiar ethical system in medicine is the use of mid-level principles (i.e.,beneficence, non-maleficence, autonomy, justice) as advocated by Beauchamp and Childress.11 The merit of this system is that it provides practical definition of broadly based moral concepts that can be directly applied based upon situational interpretation of what principle or order of principles best “fits” the facts and issues of a particular case. In some ways, this allows flexibility for using the principles within a deontological (i.e., rule based) or utilitarian (i.e., welfarist/consequentialist) perspective. Certainly, using principles, (as rules or duties) appeals to the notion that such ethics are derived from the interpersonal relationships and professional responsibilities that prescribe what should be done in particular circumstances, seeking to afford good, while affording generalized proscriptions against other acts (e.g.. lying, killing, etc.).12

Yet, there is considerable disagreement over the absolute scope of rules, the extent of constraints, and questions of conflict of duty. Moreover, the prima facie use of principles and the use of more rigid deontologic approaches cannot solely provide resolution to the ethical issues and questions which arise from the diversity of situations encountered in the practice of pain medicine. To be sure, the universal application of a rule and/or the absolute ordering of principles would be difficult, if not impossible, given the need to appreciate the role and position of agents and consequences in any particular clinical encounter.

If we were to only to consider the goodness of consequences (i.e., patient welfare), then a utilitarian approach might be feasible. Recently, a version of utilitarianism has been lauded by Baron, who states that a patient-centered welfarism would focus on actions, as well as rules, to maximize the provision of good care.13 This can be considered either in a total form (i.e., acts and rules that produce the greatest total level of good), and/or an average form (which considers the benefit of an action and rule in providing an average amount of good across the greatest number of persons) and, in many ways, appeals to both moral intuitionism and particular conceptualizations of distributive justice. At face value, at least, utilitarianism seeks the achievement of good as the most viable goal or end in resolving ethical conflicts. Thus, the attractiveness of utilitarianism is that it would place considerable ethical value on human wellbeing and, contextually to pain medicine, the treatment of pain and the reduction of suffering.

But, while it may be that utilitarian approaches acknowledge and may indeed work within some communitarian system—and therefore might be identifiable to, and acknowledge a common system of morality)14,15—the utilitarian approach is, by its nature, consequentialist.16 In considering consequences, any ethical, practical reasoning must also regard the entire calculus of circumstance, intention, and acts. Great care must be taken to ensure that the moral value of agents, means, and goals are not subordinated by the relative good—or perception of good—of desired consequences or ends.

To be truly effective, any ethic must take this calculus into consideration.

The casuistic approach offers a methodology for ethical reasoning that attempts to analyze such compound factors in paradigmatic cases to resolve issues that have arisen from present situations.17 While exceedingly useful, particularly in comparatively determining the circumstantial use of particular rules and/or principles, this approach is obviously tangential in that two cases are rarely, if ever, identical, and the ethical decision process is therefore contingent upon this level of approximation.18

Each of these ethical systems has obvious merit and apparent limitations, and it may well be that analysis of a particular circumstance, action, consequence, or ends may determine which ethical approach has the most meaningful application.19 But who shall determine this? The responsibility to apprehend circumstance, recognize ethical issues, and utilize knowledge to best reflect appropriate moral value(s) ultimately rests upon the physician as moral agent, sentient to the relative needs of the individuals involved, and to the relation of acts and consequences. It is clear that the problems, issues and questions of pain medicine cannot be accommodated by the use of rules or principles alone. Furthermore, if using the casuistic approach, how shall paradigmatic cases be chosen and analyzed, and decisions and actions made with appropriate probity? For even if we employ an analytic or statistical model of resolving clinical equipoise, we must rely upon the intentions and integrity of the deciding agent to utilize the right intellectual capacities, appreciate the epistemic and moral value(s) of decisional options, and implement choices and acts for the right reasons.20-22

It is for this reason that I argue for an agent-based, virtue ethics that is built upon and consistent with the core moral values and philosophical premises of medicine.23 Virtue, as an ingrained dynamic of character (i.e., a hexis), establishes the moral discernment, reasoning, valuing and sensibilities of an individual, and predisposes intentions and actions that are good.24 Hence, I hold that moral virtue empowers the physician to appreciate and utilize particular ethical approaches and guide clinical decision making and actions as consonant with the telos of pain medicine.

Moral Virtues of the Pain Physician

I offer here the moral virtues that I feel are integral to the pain physician. This list is not complete, as numerous authors have proposed and addressed other moral virtues that are generally important,25 and specifically meaningful for the physician and other professionals.26 Nor is this list absolutely ordinal; each of the virtues maintains independent value, and together they form the bedrock of characterologic integrity necessary to allow appropriate inter-subjectivity, sensitivity to cause, consideration of circumstance, and deliberation of intention and action(s) focal to the best interest(s) of the patient.

Reverence

As a virtue, reverence refers to the awe and respect that is derived from a sincere understanding of human limitations and potential. In medicine, this regards the power of nature, the enigma of life, pain, suffering, and death.27 From this respect comes a deep appreciation not just for human dignity but, perhaps, for the inherent dignity of all sentient beings.28 As well, this respect is a basis for the use of intellectual virtue to appreciate what is good in, and about life and, as such, directs the development of good intention(s) and action (benevolence and beneficence, respectively, vide infra).

Benevolence

Benevolence is the virtue that establishes the best interests of the patient as central to the morally good intention and actions of the physician. According to Pellegrino, this entails providing care that is biomedically good, as well as that which acknowledges the patient’s choices, the good for the patient as a human being, and the patient’s existential good.29 Through such multifold beneficence, the maxim of non-harm (i.e., non-maleficence), commutative justice inherent to the medical relationship and respect for the personal autonomy of patients are directly realized. Further, in securing the primacy of the good of the patient as pivotal to the character of the physician and the intent of the medical covenant, beneficence solidifies the medical fiduciary and equally affirms philosophical and relational non-abandonment.30,31

Compassion

Literally a “feeling with” the patient,32 compassion is the sensitivity to the subjective experiences as related by the patient and the ability to objectively understand the effects of the phenomenal experience of pain upon that given patient. Compassion is the virtue that develops and assures empathy. My colleague, Peter Moskovitz, and I maintain that empathy allows for a proper balance of inter-subjectivity and rational knowing, and as such, is fundamental to equanimity.33 Compassion and empathy reflect an inherent sentieism that is fundamental to human moral psychology and. perhaps, are a basis for a common moral structure in medicine.34 As well, the reliance upon beneficence, compassion, and empathy are completely compatible with narrative, care-based, and certain feminist ethical approaches;35-37 indeed virtue ethics in general have been claimed to be essential to any ethic of care.38

Veracity

The trust inherent in the medical relationship is based on truth.39 The physician, through considerable education and experience, assumes stewardship of medical knowledge. To be sure, one application of this knowledge is in therapeutic agency. However, such therapeutic agency also entails lessening the burden of vulnerability imposed upon the patient by their incognizance of the nature of disease, its prognoses, and the impact of what treatment will entail. Thus, the physician is also teacher40 and in that role lies the importance of truthfulness in character. As teacher, the physician must recognize the needs and abilities of the patient to receive and comprehend information, and must strive to effectively inform patients so as to enable them to freely trust in entering the healing relationship, and empower their decisional processes as autonomous agents.

Intellectual Honesty

Similarly, the physician must recognize that medicine is often wrought with ambiguity and uncertainties, and must honestly acknowledge both their own limitations and that of medicine, as a whole.41 Such honesty serves to maintain the humility and relative effacement of self interest that reflect medicine’s practice as an imperfect, yet nonetheless, humanitarian endeavor. It is this relative effacement of self interest that differentiates medicine from business, and defines the distinctions in their telos, ethos, and ethics.42

Fortitude

Adherence to the patient focal telos of medicine often requires significant integrity and courage to maintain intellectual honesty and veracity in the face of the opportunism, commercialism, and technophilic absolutism that have become predominant in contemporary medicine.43 Acting in the best interest of the patient mandates the courage to practice neither defensively in light of the litigious nature of the current medico-legal climate (particularly of pain medicine), or acquiescently in response to consumerist demands that have debased the notion of patient autonomy. Of course, this is not to say that the pain physician should be unmindful or negligent of the law(s); to the contrary, I have argued that while it may be trite to think that “…good ethics make for good laws,” it is more realistic and viable to recognize how virtue ethics empower good practice within the law.44

“Benevolence is the virtue that establishes the best interests of the patient as central to the morally good intention and actions of the physician.”

 

Phronesis

Although formally defined as an intellectual virtue, I re-iterate my regard of phronesis, or practical wisdom, as also being a moral virtue that balances the right ways of knowing and right actions.45,46 Ultimately, the physician must decide what knowledge best allows apprehension of the pain patient, the circumstances of their lives, the specifics particular to this clinical encounter, and use such knowledge to support the intentions that drive acts of technical rectitude and moral good. As well, phronesis allows for critical discernment of moral values and enables appropriate use of various other ethical approaches. In this way, phronesis empowers both what should be known and what should be done to provide right and good care to the patient in pain.

Virtue Ethics in a Post-modern World

There are those that hold that the increasing scope of globalization—and resultant value plurality and moral skepticism of post-modern, contemporary society (and by extension, the medical community that serves it)—renders the concept of a virtue ethics unrealistic.47 I disagree, for while people may indeed live very different lives and maintain somewhat different values, the common human condition fosters defined needs and expectations,48 and these are expressly manifest during illness and suffering.49 Pain is an exemplar of this human commonality. For while socio-cultural constructs may influence the expression of pain and its meaning,50 the fact of pain is that it is phenomenal,51 de-constructs the lives of those who suffer,52 drives them to seek relief and place trust in those who profess to heal. Thus, I argue that the “community” of pain patients and pain practitioners share a particular solidarity. It is in this light that I posit that there are moral values’ desiderata for pain care that is engendered by the profundity of pain, and the promise of medicine as a technologically sophisticated, yet wholly humanitarian enterprise. As such, pain medicine is an internally moral endeavor and it is through virtue that the pain physician is the personification of moral agency.

Last updated on: December 13, 2011
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