|Year : 2016 | Volume
| Issue : 3 | Page : 147-150
Ethical aspects in pain and its management!
Mridul M Panditrao, Minnu M Panditrao
Department of Anaesthesiology and Intensive Care, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda, Punjab, India
|Date of Web Publication||10-Jan-2017|
Mridul M Panditrao
Department of Anaesthesiology and Intensive Care, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda - 151 001, Punjab
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Panditrao MM, Panditrao MM. Ethical aspects in pain and its management!. Indian J Pain 2016;30:147-50
| Introduction|| |
"The greatest evil is Physical Pain"
-St. Aurelius Augustinus Augustine, Soliloquies', 1,21
Pain as a presenting complaint accounts for up to 70% of emergency department visits, making it the most common reason to seek health care.  Often, it is the only reason for which patients seek care.
Appropriate, precise, and well-balanced care for patients with either acute or chronic type of pain continues to remain, inadequate, erratic, and biased, to say the least. Results of the Hospital Consumer Assessment of Healthcare Providers and Systems Survey in the United States showed that nearly 27%-36% of hospitalized patients reported that their pain was not relieved.  Unfortunately, in our country, no such document(s) exist, which can quantify the dimensions of the problem. However, it can be safely assumed that the number would be of equal magnitude, if not higher.
Majority of the literature on Pain is devoted to mainly its clinical aspects. Even a cursory search, brings out plethora of articles on this populistic subject. Main body of the evidence/ documentation is dedicated to ongoing research on patho-physiology, diagnosis, and dynamics of both the interventional as well non-interventional modalities of Pain Management. Scant importance is given to the basic humanitarian issues of ethics, which are inherently and imperatively associated with it. In addition, whatever available literature on the subject matter, again highlights the ethical issues on management of pain, not on the ethical aspects of research in modalities of pain and its management.
Ethics in pain and its management must encompass:
- The issues related to the pain and its management
- The issues related to the research in pain and its management.
| The Issues Related with Pain and its Management|| |
Although with ongoing and continuous pain research, we have a better understanding of pathophysiology of pain and the development of new treatment modalities, the actual patient satisfaction with the management of their pain, has not proportionately increased. Uncontrolled and unrelieved pain can actually rob the dignity of the person and makes the life of the sufferer miserable.  At the same time, one can argue that the person's own dignity also depends on the extent to which one reacts to their pain and suffering. [3th ] In the often quoted words of Edwards et al. "Effective pain management has been described as both a moral imperative and a fundamental human right. Chronic pain is not only a biological experience but also a social, existential, and moral one where over time the 'self' is eroded and subverted resulting in the longing for a past or 'good' self." 
There are already well-documented guidelines on this issue, although neither very commonly understood nor followed, in the form of Kant's Conception of Human Dignity. According to Kant, a thing which represents a choice between right or wrong has a moral dimension and becomes an "End" in itself, that is, it becomes a target which must be achieved. Furthermore, he states that this "End" is not relative and is beyond all value, that is, it is priceless and must be held in highest regard. To put this in context whether it be research toward pain and its relief, or management of pain, following ethics in pain, is the "End" and must be given priority above all else. 
In this context, it can be very well established that there is a moral basis of our obligations to relieve pain and suffering of others. We respond through each other's mutual dignity and ascertain that we are and can be moral human beings. On this basis, it is an indisputable conclusion that ethically speaking failure to respond to someone's pain is not an option; however, how we respond to it has multiple options. 
That brings us to the yet rarely explored concept of contextualism, which is a doctrine which emphasizes the importance of the context of enquiry in a particular question., This in relation to pain would be, examining ethical problems associated with pain, in their institutional, cultural, social, and organizational settings. Thus, discussion of ethics in this context becomes much broader and irrefutably, a matter for interdisciplinary decision-making. Some of the questions which need to be answered are:
- Whether to consider the presence of pain and its intensity as described by the patient to be valid enough to prescribe potent medications? Pain is a subjective phenomenon, for example, the degree of pain "felt" to the same stimulus varies from person to person
- If so considered to be reliable enough, how to appropriately achieve a balance between analgesics, placebo, and therapy such as counseling?
- Is it a drug-seeking behavior on the part of the patient?
- Is it ethically correct to keep the particular patient in hospital purely for pain management or is it appropriate to send home with pain medications?
- Should our personal biases be allowed to enter the decision-making process? Because many a times, subjectivity of pain is not given due importance. A malingerer may get away with multiples of prescriptions antianxiety and sedatives/hypnotics, but a patient with persistent pain, not responding to routine pain prescriptions, may be inadvertently labeled as a "histrionic personality" type, with the drug seeking/substance abuse tendency. The unemotional, transparent principles of ethics may be useful in such cases to provide guidelines for better, more effective pain treatment. 
To answer these and such moral questions, one must understand and adhere to the Bioethicists' Theory of Ethical Principlism.  It defined as a methodology of describing solutions to the moral problems arising in medical care and health policy by appealing to fairly abstract moral principles, this has evolved into a practical approach for ethical decision-making that focuses on the common ground moral principles of autonomy, beneficence, nonmaleficence, and justice.  Principlism and contextualism are complementary to each other but help attaining the same ethical objectives. When applied in context with the "management of Pain," it raises multiples of issues.
Principlism as a system of ethics based on the four moral principles of:
- Autonomy - free will or agency. Autonomy is the right of individuals to make decisions regarding their own pain management regardless of what others think of these decisions, the right of self-determination.  The principle of autonomy or self-determination is violated, if a clinician does not honor patients' rights to decide how they want their pain to be treated, on the basis of misguided contextualism, which leads the clinician to believe that maybe the patient has some vested interest in seeking that specific treatment. Therefore, clinician must accept the fact that patients have the right to know, consider, request, and refuse any treatments that they believe will help/not help manage their pain. They also have the right to have the knowledge about medications, side effects, and other treatments clearly explained to them to make the right decisions. 
- The validation of this is observed when, under this principle, the patients are allowed self-determination, as well as all the information, their pain relief is often better managed, and they report better satisfaction with their care. Classical example of this is the growing use of patient-controlled analgesia for the treatment of acute pain. When analgesics are adequately ordered, and the pump is properly programed for the individual, patients experience personal control over their pain and receive effective analgesia. 
- Beneficence - do good. This principle can be easily understood by all of us. We have been programed for this, from the first step in our medical institution. So trying to relieve pain, irrespective whether completely or partially is "Good!"
- Nonmaleficence - Primum Non Nocere - "First, do no harm." However, the main problem in adhering to this principle is that while deciding the modality for pain relief, the clinician may not prescribe adequate treatment under the misguided belief of contextualism of "creating side effects or complications" and may paradoxically harm the patient by giving inadequate, incomplete, or inappropriate treatment
- Justice - social distribution of benefits and burdens. The principle of justice states that all persons should be treated fairly according to their situation irrespective of their sex, age, race, or religion, unless those factors have a distinct bearing on treatment.
Advocates for principlism argue that from the beginning of recorded history, most moral decision-makers descriptively and prescriptively have used these four moral principles that they are part of or compatible with most intellectual, religious, and cultural beliefs.
Some important and positive steps have been taken because of application of ethical principles:
The International Association for the Study of Pain (IASP), in September 2010, under the expertize of global pain care leaders, put forth the demand:
"To acknowledge pain care as a human right" during the 13 th World Congress on Pain in Montreal.
Main objective was to call attention to inadequate knowledge of pain management techniques by most medical workers and the lack of national policies in both the developed and developing world regarding the seriousness of pain as a global health problem. 
This was called as "Declaration of Montreal."
"Recognizing the intrinsic dignity of all persons and that withholding of pain treatment is profoundly wrong, leading to unnecessary suffering which is harmful; we declare that the following human rights must be recognized throughout the world:
- The right of all people to have access to pain management without discrimination
- The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed
- The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health-care professionals.
Institute of Medicine came out with its own principle:
"Effective pain management is a moral imperative, a professional responsibility, and the duty of people in the healing professions." 
| The Issues Related to the Research in Pain and its Management|| |
The pain research has been a very fertile and promising area. However, the ethical practices are relegated to the realm of uncertainty and ambiguity, in the execution of the trials. Hence, there have been some major developments in this direction.
The IASP acknowledged the ethical principles for research involving human participants given in the following documents: The World Medical Association's Declaration of Helsinki, Recommendations Guiding Doctors in Clinical Research (1964, revised 1975), The Ethic Principles of the American Psychological Association (1973), The Declaration of Lisbon, The Rights of the Patient (1981), The proposed International Guidelines for Biomedical Research Involving Human Subjects, and Council for International Organizations of Medical Sciences (1982),
Following this, IASP has come up with a specific code of conduct, in the form of guidelines, which it considered to be necessary to supplement the ethical principles contained in these documents. 
This entire portion of this article has been reproduced from the home page of the IASP website to highlight their relevance in context with the present discussion.
"The goal of pain research is to acquire new knowledge on the mechanisms, pathogenesis, diagnosis, and treatment of pain. This requires research on humans and animals. Human research may be undertaken on both healthy persons and patients. This research may involve painful stimuli or delaying pain relief in patients. The primary intention is to advance knowledge so that patients in general may benefit; the individual patient may or may not benefit directly.
| Guidelines|| |
The health, safety, and dignity of human participants have the highest priority in pain research. The investigator is personally responsible for the conduct of research and its effects on the experimental participant at all times even though the patients have given their consent to participate.
- Before starting any study of human participants, the proposed experimental protocol must be reviewed and approved by an independent committee on human research. The functions of the committee are as follows:
- To ensure that participants are not coerced or harmed
- To evaluate the potential for undesirable physical or psychological effects occurring during the research
- To decide whether the proposed research should be the subject of regular review. The committee should be appropriately constituted and normally should include scientists, health-care practitioners, and lay members.
The scientific merit of the proposal and the research methods proposed normally should be the subject of independent evaluation by an appropriately constituted peer review committee. The scientific review process normally should take place before the consideration of ethical matters.
- Potential participants should be informed fully about the goals, procedures, and risks of the study before giving their consent
- Healthy participants and patients must be able to decline, or to terminate, participation at any stage without risk or penalty whatsoever
- Written consent must be obtained to indicate that the participant understands the nature and purpose of the proposed study, has had the opportunity to ask questions, and agrees to participate on a voluntary basis. Where possible, informed consent should be endorsed by an independent signatory
- There is a duty to protect those who may be incapable of giving fully informed and voluntary consent. These include children, the elderly, the mentally disabled, prisoners, and those very ill with other disease. Such persons should not be used for medical research unless they are essential for the goals of the proposed research. In such cases, consent must be obtained also from those who have legal responsibility for their welfare
- In any pain research, stimuli should never exceed a patient's tolerance limit and patients should be able to escape or terminate a painful stimulus at will. The minimal intensity of noxious stimulus necessary to achieve goals of the study should be established and not exceeded
- In all circumstances including studies that employ placebo and sham treatment methods, an effective, accepted method of pain relief must be provided on request of the patient or subject. The availability of alternative pain relief should be made clear in the consent form and the instruction before the study begins."
| Conclusion|| |
The decisions regarding the pain, irrespective of whether they are in conjunction with its management or its research, must have a moral and ethical basis. The Kantian theory classically guides us regarding upholding of human dignity, and there cannot be any better example of this theory than providing relief from the pain. Considering the contextualism and questions posed under it, we must adhere to the ethical principlism. Using its four principles of autonomy, beneficence, nonmaleficence, and justice, in our clinical practice, we can provide proper pain management to our patients. In addition, adhering to the elaborate guidelines provided by IASP, the research on pain can be pursued ethically.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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