Pain and Ethics

Specialists in pain management are guided by the ethics as are clinician in other areas. But some issues of particular relevance to the specialty also occur. Ethics is not merely an excuse for a good debate. It involves things that we ought and ought not to do. We often discuss medical ethics as if we expressing our view on movies or soccer match. As compare to other profession such as engineers or geologists, we physician are more close to humanity and their bodily suffering. The society, by virtue of our healing profession considered us ethical expert. The medical ethics as it exists to day in the western countries was born not more than 50 years ago. During this period it has been chasing the rapidly evolving medical science. As we know the medical science has many branches so does the medical ethics. Pain medicine and palliative care are relatively new and rapidly developing fields

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What is medical ethics?

Medical ethics is a branch of moral philosophy, in a simplest way it can be defined as “The obligations of a moral nature which govern the practice of medicine”. There are three key words in this definition (1) Obligation (2) Moral & (3) govern. Obligation in medical ethics is the concept of rights and duties, where as morals deals with right and wrong and with good and bad. Moral governs the medical practice rather than vice versa. Moral have roots. Moral originating from different religious and or philosophical bases will lead to very different course of action.

What are the components of ethics?

It has been accepted that morality concerns with both character and behaviour. Character involves what sort of people we should become so that we routinely identify and fulfil our duties to each other. Character is shaped by the virtues. Behaviour concerns how we should act toward each other. Ethical principles guide behaviour. Therefore, medical ethics begin with an account of the virtues that should define a physician as a professional and then identifies ethical principles that should guide the physician's behaviour toward patients.

Virtues

There are four professional virtues of the physician as fiduciary, which means that the physician should make the commitment to the patient's health-related interests his or her primary concern. A virtuous doctor would place the recognition, monitoring, and treatment of pain as a high priority. He or she would inquire regularly about pain, respond appropriately, and refer wisely if unable to control it.

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Ethical principles

Beauchamp and childress recognized the difficulties of attaining agreement on the most fundamental question of ethics, on the nature of the good, on the ultimate source of morality. To bypass these problems, they followed Ross and turned to principle that, on face value should always be respected. In this prima facie category, they chose principles especially appropriate for medical ethics [₁]. Two of these principles, nonmaleficence and beneficence are synonymous with Hippocratic obligations i.e. to avoid doing harm and to act in the best interests of the patient. On the other hand two others (autonomy & justice) were unfamiliar and are innovation of recent time. The importance of pain relief as a core of the medical ethics is clear. The relief of pain is a classic example of bioethical principle of beneficence. The principle of nonmaleficence prohibits the infliction of harm. Chronic untreated pain inflicts both physical and psychological harm to the patient. Failure to adequately address the patient's pain contravenes the autonomy of patients and self-determination of their medical care. Apart from principlism, a virtuous doctor would place the pain management as a high priority.

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How ethical problems are solved?.

In our practice we have to make decision in a morally defensible way. In a society where there are many different fundamental beliefs, it is impossible to come to consensus. Edmund Pelligrino proposed methodology involves three levels of any ethical decision making; (a) Presuppositions- or core beliefs, (b) Ethical Theory and (c) Practical decision-making frame work [₂].

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• Core belief or presuppositions we developed from our personal experience, people we admire, religious belief, politics and traditions. These are basic values or precepts believed to be true. In the context of these beliefs we build to a logical conclusion or decision our presupposition are culturally based and there may vary widely.

• Ethical Theories, principles and rules are utilized at the second level of moral reasoning. Bioethicist Beauchamp & Childress promote a common-morality, principle based method of solving ethical problems in medicine.

• Case-Based Reasoning: Jonsen siegler promote a practical method for solving ethical problem. This method takes the fact of a case and analyzes them in a logical and ordered fashion. Facts are compared to those of pragmatic cases that have been decided by prior consensus. This is analogous to the concept of precedence in judicial proceedings.

• Framework for Analysis. Applying the facts of a clinical case in light of presupposition and ethical theory is best accomplished using a frame work for analysis.

The promotion of pain management as an ethical issue

The earliest articulations of the responsibilities of doctors to their patients were not legal but ethical. The Hippocratic Oath, the Declaration of Geneva, The health professional associations of many countries enunciate ethical basis for the relief of pain. The Pain management is relatively a new field. Medical ethics as a discipline is even younger. The recent formation of standing ethic committees by American pain society (APS) & American association of pain management (AAPM) reflects about growing concern about ethical issues in pain management. The special issue of Pain Medicine represents an important interface between bioethics s and pain physicians [₃]. It gives a over view of the field of bioethics, the application of ethical principle to pain medicine and application of ethics to specific area of pain medicine. Ethical charter gives recommendations and opinion on ethical issues and dilemmas[₄]. Recently, Frank Brennan , David carr and Micheal Cousins wrote a landmark review article on “Pain Management: A Fundamental Human Right” published in Anesthesia & Analgesia [₅]. They are at the fore front in propagating the concept of pain management as human right. In this article, they framed pain management as an ethical issue as a strategy for the improvement of pain management. They concluded that we presently are at the “Infliction point” in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right. The major problem of ethical decision making is ethical dilemma, which emerges where two ethical principles or obligations appear to conflict with each other

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Ethical dilemma in chronic pain: why and in whom it appears.

There are several factors which are important in the development of peculiar and different ethical dilemmas in chronic pain management. Broadly these factors are categorized under three headings a) Characteristic of pain b) Pain Patient and c) The system we practice in.

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Some important factors are listed here.

1. Treating the symptoms, not the disease: The primary objective is to treating the symptom (pain) and not the cause.

2. Vulnerability of patients: These are patients where ethical dilemma is more likely to develop, such as those (a) desperate nature of pain make them trying any thing. (b) who can not communicate (infant, elderly, in ICU) (c) cancer patients (d) dying patients and (e) economically disadvantage patients. This later group in particular, tests the ethical principle of “justice”.

3. Psychiatric problems : Chronic pain patients might have significant psychiatric problem existed premorbidly but may also be reactive to pain and/ or the lack of relief and exacerbated by iatrogenic or traumatic injuries. Patient-Physician relationship: The patient-physician relation-ship in chronic pain arena can be quite difficult due to complexity of chronic pain and prior failed attempts at relief, which can lead to anger on the part of patient and frustration on the part of provider.

4. Litigation: Many chronic patients are in litigation as a result of conditions of the onset of their pain, which frequently is the result of road traffic accident or an accident on the job. Litigation is a very powerful secondary gain issue, which may consciously or subconsciously reinforce pain, illness behaviour, and health care utilization. It often works against the goals of treatment. The ethical dilemma becomes whether or how to treat the patient in the face of such a powerful reinforcer of pain.

5. Unproven Methods: Some interventions used by pain centers have not been shown in scientific manner to be efficacious. Additionally the growing popularity and acceptance by medical community of complementary techniques, which are used most often for pain further intensifies the ethical dilemma of using or referring patients for unproven techniques.

6. Financial pressure: The clinician may be under pressure to do higher reimbursement. Patients can be categorized as more, less or not profitable

What are the ethical dilemmas in chronic pain management?

In a survey, 1105 members of APS & AAPM were asked about ethical dilemmas they faced in chronic pain management[₆]. The most common is the pain management at the end of life. The common denominator in this survey was the ethical dilemma of under treatment vulnerable population such as the dying, the elderly and children. Special reference is made to the under treatment of persistent pain, sickle cell pain, and pain in those with psychiatric disorders or addiction problems. The same survey revealed that there is great desire for guidance through ethical dilemmas in pain management[₆]. Specialist in pain management are guided by the ethics that are appropriate of the profession in general, but some issues of the particular relevance to the speciality also occur .There fore it is essential to increase the awareness among our own community and provide ethical education & guidelines, and also set the professional standards.

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