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11 Articles in Volume 6, Issue #7
An Overview of Sleep Medications
Editor's Memo
Ernest Syndrome and Insertion of the SML at the Mandible
Low Level Laser Therapy – A Clinician’s View
Microcurrent Electrical Therapy (MET): A Tutorial
Observational Study of Dural Punctures
Pain as Disease and Illness: Part Two
Practice Patterns of Clinicians Treating Vulvar Pain
Share the Risk Model
Treating Sports-related Injury and Pain with Light Therapy
Using Topiramate in the Treatment of Migraine

Pain as Disease and Illness: Part Two

The structure and function of the ethics of pain medicine: Ryder's Painism revisited

“Everything that the human race has done and thought is concerned with the satisfaction of deeply felt needs and the assuagement of pain.”

- Albert Einstein

I believe that any meaningful definition of pain involves physiologic, psychological, and anthropological factors that are part of an “expanded” neuroscientific approach to brain-mind and the genotypic- phenotypic- environmental interaction(s) that Matt Ridley refers to as “…nature via nurture” effects.2 I’ve tried to show how our current neuroscientific understanding informs the theoretical bases of a neurophilosophy of pain and pain medicine3 and have attempted to relate this neurophilosophy of pain medicine to the core philosophy of medicine in general.4-7 I hold that this establishes, or at the very least contributes, a framework of moral duties (i.e., a deontic foundation) of pain medicine as a practice.8 This deontic foundation is based upon and compels an overall understanding that the practice of pain medicine is a moral enterprise between persons, and that this enterprise entails an asymmetrical relationship between the physician as moral agent/moral object and the person in pain as a moral patient/moral subject. The architecture and nature of this relationship positions and emphasizes the therapeutic and moral agency of the physician, and therefore sustains agent-based moral grounding as the foundation for ethics of pain care.9 I have argued that intellectual and moral virtues are important to establishing and maintaining the moral agency of the pain physician, but have also acknowledged that these virtues must be enacted within a larger ethical sphere, and have recognized the value and potential viability of several ethical systems including, but not limited to, principlism, feminist ethics, and certain forms of communitarianism.

Irrespective of the ethical system utilized, what we know about pain (ie.- the epistemic tradition informed by neuroscience) should engage and direct the real-world applications of practice, research, and education. But what specific premises, moral values, and obligations attest to and consistently sustain telos of the right and good treatment of persons in pain as moral patients by 1) individual physicians as moral agents, 2) through the practice, and 3) by pain medicine as a resource within society?10

Ryder’s “Painism” Revisited

It is in this context that Hans Werner Ingensiep of the University of Essen, and Heike Baranzke of the University of Bonn, and I recently re-examined and re-appraised Richard Ryder’s thesis of painism as a viable constitution of ethical precepts to direct the communal attitude(s) and activities of pain medicine.11 Ryder, a psychologist by training, developed a set of constructs that established a code of moral conduct toward any and all sentient beings that was originally directed toward anti-specieism, animal protection, and environmental ethics.12,13 Ryder’s early work was subsequently expanded to include attitudes and actions toward all beings capable of feeling pain, and was developed into a sweeping set of forty two moral precepts and affirmations (somewhat colloquially called “rules”) that encompassed basic elements of what a moral theory and practice should be, and hierarchically ordered the specific moral obligations regarding the understanding, treatment and infliction of pain as applied to individual, social and political circumstances. In its entirety, the work has been, and continues to be, somewhat contentious, to say the least.

By addressing and making particular claims about broad issues such as sexuality, divorce, taxation, government process, and foreign policy, the whole of Ryder’s painism serves as a manifesto for social change. As such, when taken in its entirety, it is not directly relevant to the specific practice of pain medicine. Yet, to totally disregard the work because of its breadth of scope would be to proverbially throw out the baby with the bath water, as we feel that there are twenty key precepts that may have important ethical value in light of a contemporary neurophilosophy of pain. With respect to Ryder, we have taken these premises and obligations out of the lexical hierarchy in which he lists them, and re-present them (in Table 1) in an grouped order that may be somewhat more meaningful to developing bedrock moral affirmations of clinical pain medicine, pain research, and policy.

Table 1. Painism Revisited: Premises for a Structural Ethic of Pain Medicine
  1. Morality provides a framework which facilitates our choice of actions.
  2. Ethics is about unselfishness.
  3. The experiences of the moral patient are always of greater moral importance than the motives of the moral agent.
  4. Pain and suffering are the only evils.
  5. The moral objective is to reduce the pain of others
  6. We have an obligation to try to reduce the pains of others wherever they are and however they are caused.
  7. Pain is more powerfully wrong than pleasure is right.
  8. It is always wrong to cause pain to subject A merely to increase the pleasure of subject B (that is, there should be no pain inflicted for trivial purposes).
  9. Only if there are no alternatives may causing unconsented pain to subject A be allowed to reduce the pain in subject B.
  10. The pain to be reduced in subject B must be severe.
  11. The actions (viz. 9-10) must be likely to succeed.
  12. Whatever the benefits, it is wrong to deliberately produce pain that is prolonged or severe.
  13. Moral standards should apply equally to all painient individuals (regardless of species).
  14. As a general rule, we should adopt the precautionary principle that whenever painience is uncertain in a living being, it should be assumed.
  15. All procedures which cause pain for the fetus are wrong prima facie. The fetus must be treated as a painient individual with all moral protection that this entails.
  16. There is a duty upon those caring for the dying to administer analgesics to remove pain (*but also to administer psychoactive agents so as to enhance the patient’s sense of well being as much as possible until they die).
  17. Aims and ideals such as justice, democracy, peace, equality and liberty are good only as means…to reduce pain.
  18. Politics and law are applied ethics writ large.
  19. The failure to apply existing technology to treat the ill and relieve their sufferings is currently one of the greatest immoralities of Western governments.
  20. The public needs to be fully informed about biotechnologic development(s). Bioscience and associated industry must be regulated and controlled by agencies sensitive to public opinion and be entirely and demonstrably independent of commerce.

(*this point is contestable in light of particular cultural traditions)

Note that all statements are from ref. 11, as follows: 1: p.6; 2: p.65; 3: p.41; 4, 5; p.27; 6: p.100; 7; p. 57; 8-11: p.30; 12: p.31; 13: p.119; 14: p.70; 15: p.67; 16: p.71; 17: p.27; 18: p.10; 19: p.87; 20: p.114.

Precepts 1-6: General Premises and Moral Tasks

As shown in Table 1, precepts (i.e., Ryder’s “rules”) 1-6 provide general statements about what moral affirmations and ethics are, and what such moral affirmations and ethical obligations in pain medicine should, and could, seek to achieve (i.e.-, the “tasks” of a moral theory and/or ethical system relevant to pain).14 To be sure, statements such as “…ethics is about unselfishness”, and “…the experiences of the moral patient are always of greater importance than the motives of the moral agent” instill a sense of the moral fabric of the practice itself,15 and this binding of the physician to rules and obligations of the clinical relationship inherent in the practice is strengthened both by its focal orientation (“…pain and suffering are the only evils“) and the defined moral ends (“…the moral objective is to diminish the pain of others…wherever they are and however…caused ”). While it is debatable whether pain and suffering stand alone as the “…only evils” in the most general sense in the specific context of pain medicine much, if not all, of the objective and subjective harms within the life world of the pain patient are directly, or indirectly, attributable to pain and/or its effect(s) and manifestations. In establishing a deontic framework, these affirmations also reflect that the physician is the moral agent of the practice, and thus support the necessity of particular agent-based virtue(s) of the pain clinician (e.g.- beneficence, relative effacement of self-interest, fidelity, intellectual honesty , and humility16,17 ).

Precepts 7-12: Distinguishing Pain and Implications for Just Treatment(s)

Pain is defined as being more “…powerfully wrong than pleasure is right.” It is rational to assume that pains and pleasures do not balance, that is, great pains are not “negated” by great pleasures. The goal, both philosophically and practically, is not simply a superimposition of pleasure, but the amelioration of pain, which then incable effect. This speaks strongly to the ends of pain medicine. From the position of discriminating the relative superiority of the power of pain versus pleasure, one can establish 1) the absolute merit of relieving and effectively managing pain, 2) the value of pain relief as the focal “good” that is exchanged within the practice of pain medicine, 3) the importance of this accomplishment to the explicit ends of pain medicine, and 4) how this task is fundamental to the fiduciary invited by the pain physicians’ act of profession.

It is also important to recognize those situations in which the infliction of pain and/or failure to relieve pain may be considered toward a less proximate goal of achieving a defined good. These circumstances often arise in clinical practice.18 Such cases are frequently addressed using the well-known doctrine or principle of double effect (PDE). Precepts 7-12 generally reflect and reinforce the basic tenets and spirit of the PDE in that it is presumed to always be wrong to intentionally cause pain for trivial purposes, merely as means to an end, and without consent so as to lessen another’s pain and/or harm.19

Precepts 13-16: Equitable Consideration of the Painient

The claim that “…moral standards should apply equally to all painient individuals, regardless of species” binds pain research, and the clinical treatment of the most vulnerable subjects (e.g.- the fetus, neonates, the comatose and moribund) to the imperative of acknowledging all beings’ potential for feeling pain, and to the responsibility to alleviate this harm. The anachronistic and exclusory view that pain can only be experienced by a select group of organisms (e.g.- fully developed humans, organisms with “higher” brain function) is refuted by current neuroscientific understanding both of human brain function during mid- to late fetal development,20 comatose and certain vegetative states,21 and during the process of brain-death,22 as well as painient capacities in animals.23 This evidence has prompted a reconsideration and re-conceptualization of what “higher” versus “lower” neural function may actually mean, both as relevant to the aforementioned human neurological conditions, and as relates to “higher” versus “lower” rankings of particular living organisms.24 The compelling rationale is that sentient and painient processes are reasonable expectations in any organism with the neuroanatomical and physiologic capabilities for hierarchical, integrative cognitive functions. In other words—to employ a computational metaphor—if the neurological “wetware” is present, it is reasonable and likely to expect that “the program” (i.e.- the potential for painience) can, and will, be run.25

The implications of this stance are multifold. First is that this compels a potentially expanded role for pain medicine in pre-natal, neo-natal, chronic neurological, geriatric, and palliative care. Recent progress in, and increasing viability of invasive pre-natal diagnostic and surgical intervention(s), and the technological capabilities that have allowed the durable maintenance of comatose, vegetative, and moribund patients all speak to the need to acknowledge that pain can, and may well, occur in patients within these clinical scenarios, and thus substantiate the equal obligation and need to treat such pain. Second is that it accommodates an anti-specieist position and fortifies benevolent practice(s) in pain research using animals26 and, perhaps, paradigmatic revision in certain human clinical trials, as well.27-29

Precepts 17-20: The Potential of Power and Policy

Here again it is important to reiterate that the premises presented are focused upon the ethical basis of pain medicine. In this context, that “…the aims and ideals such as justice, democracy, peace equality and liberty are good… to reduce pain” takes on considerable meaning for the dictates of political agenda and the formation of policy and law(s) that are relevant to pain care. If we consider Ryder’s claim that “…politics and law are applied ethics writ large” then clearly a good ethic has the potential to be the basis for good political policies and laws that create professional and social environments that enable the good practice of pain medicine on both an individual level and as a public good. There are apparent implications not only for the power of politics, policy and law, but also for the ethical direction of the development and use of new techniques and technologies capable of treating pain. This speaks as a warning against medical commodification30,31 and in anticipation and recognition of frontier issues of neuroethics.32 By committing attention to the possibilities and problems that could be incurred by the power of the market model and technology, such speculations allow us to imagine both utopian or dystopian potentials. As Ryder notes: “…of course, there will be dangers…This will be a great challenge for science and…ethical and democratic structures that control science.”

Figure 1. From the Facts of Pain to the Functional Morality of Pain Medicine as Prac-tice and Social Good. A schematic conceptualization of how the neuroscience of pain informs and sustains the philosophical basis of pain medicine, and together how these establish the premises, telos and moral obligations of the practice, and compel the need for agent-based virtues.

Looking Ahead

In many ways, these warnings, reflecting Foucault’s notions of bio-power and bio-politics,33 frame pain medicine within the larger context of being a social force, and yet reveal the pain physician to be the final common vector for either moral integrity or moral complacency. In sum, there is a direct linkage between the facts of pain, the claims and defined ends of pain medicine as a practice, the premises and moral tasks of what the practice seeks and attempts to achieve, and the reliance upon the practitioner as the executor of right and good actions in the care of moral patients (see Figure 1). For once we view pain as a primary, disempowering harm and appreciate the resultant asymmetry in vulnerability that exists between the person in pain and those that profess to cure, heal and help, it becomes clear that the attendant responsibilities arising from these relationships are no less than leviathan. The magnitude of these responsibilities bespeak the need for moral solidity in the ethical structure of pain medicine on an individual and social level, so as to realize its potential both now and most certainly in the future.

Acknowledgements

Special thanks to Visiting Scholars Prof. Dr. Hans Werner Ingensiep of the University of Essen and Dr. Heike Baranzke from the University of Bonn, for their collegiality and insight during our work together. Thanks also to Sherry Loveless for graphic artistry.

Last updated on: December 20, 2011
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