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Bioethical Analysis of Pain Management – Pain Relief

Bioethical Analysis of Pain Management – Pain Relief

Bioethical Analysis of Pain Management – Pain Relief

QUESTION
Bioethical Analysis of Pain Management – Pain Relief
Bioethical Analysis of Pain Management – Pain Relief

ANSWER
Ethical Theory Varieties
A brief overview of the various types of ethical theory developed is required so that pain management practitioners are aware of the range of possible moral judgment perspectives. Theories differ depending on which aspect of the moral situation they choose to focus on. One or more theories have focused on the agent, the action itself, the consequences of the action, the agent’s relationships, and the specific character of the situation. A brief overview of prominent theories is followed by annotations on their application to ethical issues in pain management.

Utilitarianism is a consequentialist theory.
Utilitarianism is the most important of the theories that focus on the consequences of actions as the source of their moral value. Those who place emphasis on outcomes believe that the “best overall result is determined from an impersonal perspective that gives equal weight to the interests of each affected party”[2]. One of utilitarianism’s greatest strengths is its simplicity. Utilitarianism accepts only one ethical principle, the principle of utility. This principle requires us to strive for the greatest possible balance of positive value over disvalue for all people. The happiness or pleasure that results from an action is considered the only intrinsic good by utilitarianism. No action is good or bad in and of itself; it only has moral value in terms of the consequences it causes.

Because of its emphasis on the concrete outcomes of action, utilitarianism makes intuitive sense to many medical professionals. Applying the utility principle to pain management is simple at first because it directly states that the aggregate amount of pleasure should be maximized while the aggregate amount of pain should be minimized. However, applying this principle may not be as simple as it appears. In some cases, disease treatment takes precedence (appendicitis), while in others, pain management takes precedence (non-specific low back pain). Pain relief must be valued in relation to other medical benefits such as death prevention and disability reduction.

As an ethical theory, utilitarianism has several significant flaws. Because utilitarianism measures the value of consequences solely in terms of preference, it is incapable of distinguishing between acceptable and unacceptable preferences. If someone truly preferred an opioid regimen that resulted in a lifelong stupor over some minor discomfort from walking, utilitarianism would support that choice. Second, utilitarianism is incapable of distinguishing between good actions that are required and those that are beneficial but optional. Our sole responsibility is to maximize utility. More utility is always preferable to less, but it does not necessitate some actions over others (e.g., paying taxes versus donating to charity). Third, because utilitarianism is only concerned with aggregate utility, it is unconcerned about unequal benefit distributions. Pain relief in easily treated patients would be preferred over pain relief in less easily treated patients.

Kantianism is a deontological theory.
The duty-based theories that oppose utilitarian theories contend that consequences play no role in determining whether an action is right. Immanuel Kant developed an entirely formal ethical theory that only required “that we base our moral judgments on reasons that can be generalized for others in similar circumstances”[2]. This “categorical imperative” is similar to the well-known “golden rule” in that it emphasizes similar treatment for similar individuals. However, Kant went on to say that good consequences could not be used to justify ethical behavior: “One must act not only in accordance with, but for the sake of obligation.” It is necessary to do what is right because it is consistent with our nature as rational moral agents, not because it produces pleasant results. This type of theory corresponds to our intuitions that certain actions are inherently right: keeping promises, avoiding murder, and telling the truth.

Though elegant in form, Kantian theory has significant practical application problems. There is no guidance for balancing conflicting obligations because all duties are considered absolute. Where utilitarianism appears to fail by making everything negotiable, nothing is negotiable in the pure Kantian system. Intentional killing is always prohibited, even when many lives could not otherwise be saved or severe pain could not otherwise be relieved.

Ethical theories based on rights
Much of our society’s ethical debate is framed by the rights-based rhetoric of liberal individualism. As a result, we hear about the right to privacy, the right to free expression, and, on occasion, the right to health care. The concept of rights emphasizes the individual’s protection from larger social institutions such as religion or the state. “The liberal individualist tradition has generally found it easier to justify negative rights (i.e., non-interference), but in modern societies, the recognition of welfare rights (i.e., entitlements) has extended the scope of rights to positive rights”[2]. Someone might argue that workers have the right to a safe workplace but not to medical treatment if they are injured on the job. Because the general right to health care is so contentious, the positive right to pain relief has received little attention in the United States (except in the end-of-life setting).

Some ethicists believe that rights-based ethics are overly individualistic and adversarial. As an alternative, communitarianism has been proposed. According to this theory, all ethics stem from communal values. This viewpoint has had a greater impact in political science than in bioethics, though some (e.g., Ezekiel Emanuel[3]) have advocated for a larger role for community standards in health care decisions. Another alternative to rights-based ethics is a “ethics of care.” This is a relationship-based ethic founded on “emotional commitment to and willingness to act on behalf of people with whom one has a significant relationship”[2]. Feminists advanced this emphasis on empathic association rather than individual rights, which nurses in the health care setting adopted [4]. It is relevant to pain management because it calls into question impartiality and detachment, as well as universal ethical principles. Suffering, in particular, may be perceived most effectively in an empathic relationship marked by a rich narrative exchange. Some argue that nurses are in a better position than physicians to assess the effectiveness of pain management for patients in their care [5]. The emphasis in a care ethics on mutual interdependence in relationships and a positive role for emotions runs counter to long-held traditions in medical education that encourage impartiality and professional distance.

Narrative-based ethical theory is another relatively new ethical theory of interest to pain clinicians. This is the inverse of the top-down or principle-based model. Here, the story of the individual case takes on critical importance, necessitating a thorough understanding. The author of The Culture of Pain, David Morris, makes this point very well. Pain has been removed from its context, from its role in life, by modern biomedical science. Morris displays a drawing from Descartes’ Treatise of Man of a child with his hand in the fire. In that picture, he explains, pain has physical causes but no reason. You have no idea why the child’s hand is in the fire, why the child would be near the fire, or whether the fire poses a danger to the child. Pain has been abstracted from its context, from its story, by modern medical professionals. As we attempt to address the issue of suffering more seriously, we are drawn back to narratives. This is due to the difficulty in determining whether and how much someone is suffering without knowing the story that surrounds their experience. A roller coaster ride may be the most thrilling and wonderful experience of a person’s entire summer for one person. The same roller coaster ride could easily be the most terrifying, awful experience of another person’s summer. The difference, in reality, has nothing to do with the physical properties of the roller coaster ride, but rather with the stories that they create around the roller coaster ride.

There are issues with narrative-based ethical theories. Because they are so rich in terms of the individual case, generalizing across cases becomes more difficult. When the principle of similarity becomes so fluid, it is difficult to discuss how similar cases should be treated similarly. How do you create policy that is tied to a narrative? I believe that good answers to these types of questions require a lot of basic thinking.

Bioethical Analysis of Pain Management – Pain Relief

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