This article has been developed from the original work of Revd Robert Lloyd Richards who wrote the material for the MSc in Pain Management when he was a Senior Anglican Chaplain at the University Hospital of Wales NHS Trust and has now been updated.
We are all now very familiar with the different people who have some responsibility for pain control, from those with a pharmacology input, to members of ‘pain teams’ and so on. We have ways in which we can ‘score’ pain and try to measure it, and yet pain management remains as much an art as it is a science. If we really believe in a collaborative process of health care, then some part, if not a major part of the responsibility rests with the patient. However, as we well know, a number of factors might hinder the clear expression of pain and the appropriate responses of the carers.
Lisson cites Hans Manlisch (1975) as saying that the goal of the hospitalised patient quickly changes from a desire to get well to the objective of simply surviving the hospital experience. Lisson  goes on to comment when entering hospital, the hospital patient comes to believe that they are entitled to a limited number of ‘care chips’ and that they must play these with the cunning of a professional gambler.
Unmitigated pain and suffering are often thought to rob people of their dignity . However, it has been equally argued that how one responds to their pain and suffering contributes to an individual’s dignity . Kant’s conception of dignity established the moral basis of our obligations to relieve pain and suffering. We respond to the pain of suffering of others through our mutual dignity and in doing so, we express what we are and can be as moral beings. Failure to respond is not then an ethical option but how we respond has many options. Our ideas of dignity are tied to socially and culturally mediated conceptions of how we view ourselves and is a powerful concept.
The importance is in knowing what the facts of the matter are and then acting in a way appropriate to each patient. What we have in Fig 1 is what Hoffmaster calls in a slightly different argument contextualism ; that is to say, examining ethical problems in their institutional, cultural, social and organisational settings. If we do this in pain management, what we mean by ethics in this context becomes much broader and inevitably becomes a matter for interdisciplinary decision-making. The sorts of questions that this approach raises, for example:
- Is it appropriate to deliver pain management for this specific patient at home or in hospital?
- What factors e.g. family context, cultural beliefs, might influence the kind of pain management offered?
- What level of awareness has the patient of the stage of the disease and likely prognosis?
- How far and at what level can patients express preferences about their pain management?
- What balance would be appropriate between analgesia and therapy such as counseling, etc?
- What can the supporting group, family and others so to maximise the patient’s self-worth?
Contextualism and the beginning of pain management, illustrating the many influences
Fig 1. Contextualism and the beginning of pain management, illustrating the many influences
When all of these issues, and you may think of others, are taken into consideration then a judgment can be made about what ought to happen. It will inevitably be a value judgment but of the right kind because all the values of patient, carer and others will be brought together and hopefully a consensus is reached. There are two other ways that Hoffmaster suggests medical ethical behaviour can be decided upon. Firstly, what he calls a return to casuistry, that is the analysis of specific cases analogous to the one in hand and parallel judgments made. Secondly, making ethical judgments as a result of insight gained through people’s stories or narratives. A simple example of the later might be the experience of one set of carers who agree to allow the doctors to withdraw treatment, say of an intensive care patient only to experience the devastation of a near relative arriving by plane from Australia six hours too late to say goodbye. The ‘story’ highlights for others that the ethical way to behave in such circumstances would be to try to prolong treatment until the relative arrives and then to manage the final dying time of the patient better. Many examples of the former approach can be found in various journals on ethics of philosophy as well as other mainstream medical journals.
How pain is portrayed in the media, certainly how pain management is portrayed leads to poor understanding, myths and stigma and clearly presents us with ethical issues. Notcutt & Gibbbs  discuss the media coverage of issues with analgesics and how they are over dramatic and demonstrate widespread ignorance of how pain should be managed leading to doctors being reluctant to prescribe adequately (, , ). However, by contrast, there is never such a coverage of when pain management is inadequate.
In looking at the ethics of pain management, we have found no one answer to the opening question as to why it is important to do one’s best but what you should be able to do now is find a number of underlying reasons why, for you, it is important. It may be that it is important to have a clear theoretical basis for managing care. This might be deontological or teleological, a theory of justice or the importance of maximising utility.
The use of principles as illustrated by Beauchamp & Childress has more than anything allowed more and more people to access ethical debate. The downside as we have seen is that so many think that the application of principles is all there is to ethical debate and fail to see them as not substitutes for ethical theory. Good pain management respects patients autonomy, is beneficent and certainly just. When you have said all that, even Gillon  who is a principlist, would say that any conflict between principles must be resolved by reference to higher moral theory.
In the realm of pain management, it is painful to the carers to get it wrong. The management of specific patients in reported case studies (critical incidence reporting) is an important source for deciding what ought to be done. This is particularly important where special patient groups are involved such as patients who have received radio- or chemotherapy, the terminally ill and so on. In reading case studies, reports in journals and even news of developments, it is interesting to tease out the ethical assumptions of the writers.
It is often difficult to decide what is best to do. Even with a firm grasp of our philosophical theoretical starting point, even with all the action guides of principlism and the evidence of cases and stories, the final part of our ethical attitude must be the actual context of the patient. It is within the context of the patient’s situation that decisions have to be made. Without the back up of all that we have summed up here, your ethics will inevitably be subjective, difficult to defend and probably inconsistent. All your actions should be soundly based on theory and, informed by principles. Special cases and stories can be used to teach you to recognise what feels right and decisions should always be appropriate to the patient context (see Fig 2).
Theory-centred ethics of care
Fig 2. Theory-centred ethics of care
Many of the ethical challenges faced revolve around end of life decisions and can result from poor pain management. The following briefly visits some of these challenges.
The literal meaning of euthanasia is ‘gentle and easy death’. Some of us may have been asked to help a person end their life, which is active voluntary euthanasia. This is not the same as:
Passive euthanasia, which is considered to be the withdrawal of life prolonging treatments.
Involuntary euthanasia, killing someone without their consent.
Euthanasia is not legal in the UK, or many parts of Europe, nor is physician assisted suicide, palliative care opposes the legalisation of both. Their arguments include
- it is unnecessary if palliative care is good
- “slippery slope”
- religious beliefs
- motives behind the request
- is the person depressed
- accurate terminal diagnosis
- changing minds
The legal doctrine of “double effect” of pain medication enables to give good symptom (especially pain relief) – the intention is to relieve the distressing symptom rather than to shorten life, although the inevitable consequence may be that the patients life is shortened.
The ethical issues at the end of life are often related to trying to discover peoples’ wishes and dealing with family members with differing agendas. This is more problematic when the patient is physically or mentally incapable of making their decisions known.
These documents also known as “living wills” enable individuals with a mechanism to make their wishes about their future care and treatment known in advance. They became legally binding in England and Wales in October 2007, but they have been used in the United States for over 20 years. A living will:
is a document that sets out a patient’s wishes regarding health care and how they want to be treated if they become seriously ill and unable to make or communicate their own choices. Living wills are also called active declarations. Such a document may be helpful to relatives and to medical professionals in the case of a seriously ill and incapacitated patient.
are a part of planning what to do in the event of serious illness or disability.
- Lisson, E.L., 1987. Ethical issues related to pain control.. Nurs Clin North Am, Nurs Clin North Am 22, 649-59.
- Pullman, D., 2002. Human dignity and the ethics and aesthetics of pain and suffering.. Theor Med Bioeth, Theor Med Bioeth 23, 75-94.
- Hoffmaster, B., 1994. The forms and limits of medical ethics.. Soc Sci Med, Soc Sci Med 39, 1155-64.
- Notcutt, W., Gibbs, G., 2010. Inadequate pain management: myth, stigma and professional fear.. Postgrad Med J, Postgrad Med J 86, 453-8.
- Carter, H., 2009. Manslaughter GP gave second patient too much painkiller [WWW Document]. URL
- Devlin, K., 2009. Over-the-counter painkillers ‘can cause addiction within three days’ [WWW Document]. URL
- Meikle, J., Connolly, K., 2009. German GP who accidentally killed patient was advised to ‘go home’ [WWW Document]. URL
- Gillon, R., 1994. Medical ethics: four principles plus attention to scope.. BMJ, BMJ 309, 184-8.