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12 Articles in Volume 7, Issue #8
A Clinical Guide to Weaning Off Intrathecal Opioids
Avoiding the Pitfalls of Opioid Reversal with Naloxone
Central Role of Dopamine in Fibromyalgia
CES in the Treatment of Insomnia: A Review and Meta-analysis
Combined Phrenic Nerve Palsy and Cervical Facet Joint Pain
Dextrose Prolotherapy for Unresolved Neck Pain
Low Level Laser Therapy - Part 1
Mistakes Made by Chronic Pain Patients
Near-infrared Therapeutic Laser and Pain Relief
Patulous Eustachian Tube: Part 2
The “Promise” of Pain Medicine: Profession, Oaths, and the Probity of Practice
Three Dimensional Imaging of the Foot

The “Promise” of Pain Medicine: Profession, Oaths, and the Probity of Practice

Promise: n.

  1. Reasonable ground for hope or expectation, especially of future excellence;
  2. To give reason for expectation;
  3. An assurance given by one person to another that the former will (or will not) engage in specified acts or actions (L. promittere – to send forward) 1

Practice: v.

  1. To do something habitually;
  2. The regular prosecution of actions requiring education; and ( n.) 1. an exchange between individuals of those goods that are defined by the intent and nature of their relationship and interaction(s).2,3

Practical: adj.

  1. Pertaining to use in action and governed by experience;
  2. That which is manifested in practice.4

The more we learn about pain, the more we must shape pain medicine to address the challenges posed by this new knowledge. But given that both science and medicine exist within culture and society, we must appreciate that socio-cultural forces influence the relative value of particular domains and dimensions of knowledge, and their practical applications in the pursuit of specific individual and social good. Clearly, medicine is such an individual and social enterprise: essentially, it is the care of patients—those who suffer the burdens of sickness and/or injury—rendered in ways that are technically right and morally sound by those who profess to have the knowledge, skills and intention to heal.5

Contemporary Pain Medicine

Pain medicine is not unlike other areas of medicine in that it involves “… the use of medical knowledge for healing and helping sick persons… in the individual physician-patient encounter.”6 To be sure, the treatment of pain is guided, at least partly, by an objective understanding of pain as neurological process, symptom, and disease. But, the suffering that the pain patient endures is, by definition, a subjective experience and thus understanding the nature of a patient’s pain depends largely upon appreciating its effects upon the individual person. This appreciation of pain as phenomenological experience distinguishes pain medicine not by virtue of its ends or goals, but with regard to the degree and importance of inter-subjectivity that is intrinsic to enacting the practice.7 In other words, to understand the existential illness of pain, the pain clinician must understand the person in pain.8 Technological approaches alone cannot provide sufficient insight to the subjective experience and effects of a particular patient’s pain. Yet far too often, results gained from the use of medical technology are viewed as the final arbiter of clinical certainty upon which the direction and trajectory of treatment(s) ultimately rest.9 Thus, while technology is important to pain medicine, a more critical balance between technical and interpersonal approaches is mandatory given that the subjective experience actually is the objective reality of pain, and this subjective-objective dyad cannot be completely accommodated through the sole use of technology in diagnosis or treatment.10

We maintain that dealing with this multidimensionality of pain compels the most contemporary knowledge of pain as object, competent use of available technology and appropriate techniques as articulative tools, and an empathic commitment to the pain patient as a moral subject. We have argued that these are the foundations that define the structure of pain medicine as a practice and, as such, establish the ‘rules’—or deontic frameworks—that are necessary (in light of pain as a clinical event in sentient persons) to enable the clinician to enact pain medicine as a practice.11 Simply, these are the parameters that must be adhered to if one enters into the practice of pain medicine. We believe that this framework is applicable irrespective of clinical approach or subspecialty; these considerations and responsibilities are of equal weight regardless of whether the orientation to practice is allopathic (i.e., neurologic, anesthesiologic, physiatric, etc.), nursing, psychologic, allied health (e.g., physical and or occupational therapy, etc.), or complementary/alternative (e.g., chiropractic, naturopathic, oriental medical, etc.).

The Pain Clinician and the Act of Profession

While this may define what pain medicine is, we posit that it is equally important to define who is the person (as moral agent) that is the pain clinician.12 We hold that it is important that the person who enters the field of pain medicine possess the intellectual and moral traits of character that sustain allegiance to the obligations of caring for those in pain. In professing to be a pain specialist, clinicians from any discipline make public declaration that they possess both 1) knowledge and skill required to both scientifically understand pain, and 2) the sensitivity, dedication and determination to inter-subjectively engage each patient as person and understand the effect(s) and impact of pain upon the person’s life.13

Is this act of profession sufficient to uphold the patients’ trust? If one declares “…I am a pain specialist” does that 1) authentically convey the depth and breadth of her knowledge and skills, 2) substantiate that she will enact those skills within the technical and moral framework necessitated by this practice, and 3) meaningfully convey her perpetual commitment to the best interest of any and all pain patients who may seek her abilities? Pellegrino claims that the act of profession is a promise: an assurance of intents and actions.14 We agree, and further opine that, as a promise, the act of profession provides grounds for the expectation of ongoing excellence (of actions and character), and gives reason for such expectation(s). As such, the act of profession within a practice is a commitment to uphold the intent and nature of the relationship that defines that practice.

But what binds the clinician to the act of profession and the act(s) of medicine? Surely, these affirmations are not explicitly reiterated at every encounter between clinician and patient, yet the clinicians’ obligation to the patient is symbolically, if not directly, manifested in the execution of their role qua clinician. What is it that substantiates the clinicians’ act of profession, not simply as an externally constructed set of prescriptions and proscriptions, but as a first person commitment? We have maintained that it is the clinicians’ oath that is testimonial to the probity of medical practice, and the primacy of the patients’ best interests in directing each and all of the clinicians’ intentions and actions.15,16

While codes of ethics are important, these tend to be just that: codifications of systematized judgments about what is right and wrong which are then agreed upon by participants of a particular discipline. While individuals may swear allegiance or obedience to such codes, the codes themselves tend to remain as conferred, third person standards that describe parameters and boundaries of practice. That is not to say that such codes are unimportant or irrelevant, in fact quite the opposite. However, we feel that such codes may lack the unique affirmation of the first person voice, which implies personal commitment and promise. In this way, an oath is not only a statement of “belonging,” but is an expression of belief that reflects individual consonance with particular moral precepts, goals and ideals.17

The Hippocratic Oath

Does the Hippocratic Oath serve this function? Recently, the Hippocratic Oath has been criticized as anachronistic with its Pythagorean, fourth century B.C.E. origins being viewed as at least outdated, if not frankly antithetical to Judeo-Christian ethical traditions.18 Predominantly based upon contemporary liberal and libertarian philosophy, such criticisms tend to target the Hippocratic Oath as overtly paternalistic, somewhat cultist, and disavowing both regard for the physician and patient as existing in community, and consideration of justice. Edelstein cautions that the Oath is not “… an expression of an absolute standard of medical conduct…”19 We concur, and recognize that the value of the Hippocratic Oath is multifold: first, it provides a vehicle to literally “bring forward” (i.e. promise) the standards of medicine as a humanitarian endeavor enacted between two persons. Second, it explicates the asymmetries of knowledge, ability and power that are inherent to the relationship of physician to patient, and bespeaks the responsibilities incumbent upon the physician that arise from this asymmetrical relationship. Third, it is a symbolic investiture that links the individual who is speaking the Oath to both the community of clinicians (past, present and future), and the community of patients who seek healing. Fourth, as spoken in the first person voice, it prompts the individual to reflect upon the history, tradition, responsibilities and moral obligations of medicine as a vocation. It is this latter characteristic— its declarative and affirmative first person expression—that allows the Oath to stand as an assurance and reason to expect habitual adherence to the ends of medicine. In other words, it is a promise to both medicine (as a community and field) and patients (as both individuals and within society).20 The Oath need not be accepted word for word although, if historically framed and then considered in a contemporary light, many of its precepts may—like other forms of vows and rituals—manifest considerable modern relevance. Alternatively, we hold that the Oath, again like other vows and/or rituals, may serve as a metaphor for one’s personal beliefs or ideals. Miles provides a discussion of how the specific content of the Oath might be regarded in either of these perspectives.21

“...an oath is not only a statement of “belonging,” but is an expression of belief that reflects individual consonance with particular moral precepts, goals and ideals.17

The Oath and Contemporary Pain Medicine

Julia Annas speaks to some of the difficulties of drawing upon ancient philosophical and ethical precepts for guidance in current philosophical and/or pragmatic issues.22 She states that:

“…because ancient moral epistemology is rather different than modern kinds, two kinds of danger arise when we try to compare them. On the one hand, we may produce a historical account which fails to engage with modern concerns. On the other hand, we can pose… modern assumptions about knowledge, and then find that the ancient’s answers…appear naive or off the point…”23

Annas asserts that the second condition is more problematic than the first in that it tends to take a narrow view, devalues historical experience, and restricts us from both learning from the past and recognizing historical “starting points” from which we have come.

In this light, we agree with Pellegrino that some of the anachronistic shortcomings of the Oath do not negate its importance for the practice(s) of modern medicine.24 We have urged a consideration of a core philosophy of medicine to serve as the epistemic, anthropologic, and ethical grounds upon which the practice of pain medicine could and should be based.25 This philosophy is validated by its history and progress, and the philosophy of medicine, as any philosophy, must incorporate methods that allow self- reflection and self-reflexivity.26 Ed Brandon maintains that older perspectives may serve a valuable role in self-reflection, critical revision, and imparting practical wisdom.27 If we regard the practical as that which is “…governed by experience,” then we cannot afford to turn our backs on ancient wisdom that imparts insight(s) to the essence of medicine simply because of a seemingly antiquated vocabulary or anachronistic orientation. To do so would be to throw out the baby with the bathwater.

At its core, the Oath instills beneficence and non-maleficence in the Hippopcratic tradition. If one considers the multifold conceptualization of beneficence as described by Frankena,28 and Pellegrino and Thomasma,29 then the importance of (being and doing) good, is irrefutably critical to medicine as both virtue and principle. In this regard, considerations for respecting autonomy, and (commutative and distributive) justice are equally provided, and such considerations of the good in medical contexts are applicable and inherent to a number of systems of medical ethics (e.g., Principlism, deontology, feminist/care ethics, casuistry, etc.).

We contend that many of the critiques of the Oath are valid (only) if we consider its statements in purely literal terms.30 These criticisms become less applicable if we regard the Oath as a statement of self identification, metaphorical reflection, and community investiture that bespeaks a tradition that prescribes beneficence, and proscribes against harm, and it is in this respect that we argue for its durable meaning and value. We have identified aspects of the Oath that are particularly relevant to the pain clinician,31,32 namely, that it places great importance on the skill and ability of the physician to utilize diverse forms of knowledge and moral capacity in rendering medical judgments.33 This explicitly 1) directs the pain clinician to entail both an objective and (inter)-subjective approach to the assessment and treatment of pain, 2) affords an appreciation of medicine as an inexact science that must deal with uncertainties, and 3) dictates that the needs of the patient must guide the clinician’s decisions about the scope, nature, and extent of treatment. These points are just as relevant (if not more so) today than they were some 2,500 years ago when the Oath was written.34

In light of this, perhaps we need to revisit the Hippocratic Oath, regard its anachronisms in historical context, take a somewhat constructivist view, and recognize its value to the practice of pain management. Whether as a stand-alone affirmation, or positioned together with other oaths and codes of ethics of the various disciplines that constitute the field of pain management, the Oath—both in its original and several of its more contemporary iterations, promises—literally “carries forward” the beneficence that has been the perdurable basis of caring for those in pain.

Last updated on: January 4, 2012
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