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An Ethical Analysis of the Barriers to Effective Pain Management
['Introduction' and link to Full Text PDF]

Ben A. Rich; Cambridge Quarterly of Healthcare Ethics, 9: 54-70, 2000. Posted: 2006-02-11; Modified: 2012-07-14 (minor readability change.)

Related resources:
War on Doctors Academic Literature, Reports, Legal Documents archives
Of Smoke, Mirrors, and Passive-Aggressive Behaviors -
Ben A. Rich, JD, PhD; Pain Medicine; 7(1): 78-79; 2006
See also:
THE PATHOLOGICAL DEA - War on Docs and the Pain Crisis in the Aftermath of the DEA FAQ Debacle
- Articles from January 2006 issue of Pain Medicine and related documents; Compiled by DeLuca; 2006
The Collapse of Medical Ethics and Standards for Pain Management -
Fisher, Drug Cops / Docs conf., Cato, 2005
Pain Management for Chronically Ill Patients, and the AMA's Code of Medical Ethics - L.J. Morse, NFTP website, 2003
War on Doctors/Pain Crisis blog and RSS feed


[ENTIRE TEXT of this Article in Adobe PDF format]

Among the most significant findings of SUPPORT was that 50% of ICU patients suffered from moderate to severe pain during the last days of life.1 At the time of its publication late in 1995, SUPPORT was merely the latest in a long series of articles in the medical literature documenting the widespread and significant undertreatment of pain, beginning with a 1973 study of hospital inpatients.2 Much has been written about the phenomenon of undertreated pain and inadequate care of patients at the end of life, and many positive suggestions for reform of clinical education and clinical practice have been iterated and reiterated in the two decades separating the studies. Proposals for modifying clinician behaviors in this aspect of patient care have tended to focus on particular barriers to effective pain management and palliative care.3 The barriers considered in this article are the following:

  • The failure of clinicians to identify pain relief as a priority in patient care
  • Insufficient knowledge among clinicians about the assessment and management of pain
  • Fear of regulatory scrutiny of prescribing practices for opioid analgesics
  • The failure of the healthcare system to hold clinicians accountable for pain relief
  • The persistence of irrational beliefs and unsubstantiated fears about addiction, tolerance, dependence, and adverse side effects of opioid analgesics

Clearly this is not an exhaustive list. Two other barriers are the resistance of patients and/or their family members to the use of opioid analgesics in the management of pain and cost constraints and their negative impact on the use of the latest and most effective opioid analgesics. Those listed are the primary subject of scrutiny because they are the most frequently mentioned, and because they place the emphasis where it belongs - with the physician.

The criticism of the "barriers" literature that is the focus of this article is its consistent failure to analyze these barriers from an ethical perspective. Indeed, some discussions of the barriers treat them as though they were artifacts of nature, as formidable and immutable as mountain ranges, the succession of the seasons, and the ebb and flow of the tides. But more importantly, to the extent that they are criticized at all in the context of advocating changes in clinician practice patterns, the barriers, and the unnecessary pain and suffering that they engender, are treated as merely clinical failures, free of any significant moral implications.

There are a few notable exceptions, and they will be mentioned in the course of the discussion. However, by virtue of the fact that they are exceptions, they further highlight the generally amoral discussion of these barriers in the literature. But the practice of medicine, or more broadly, healthcare, is fundamentally a moral enterprise. Hence it cannot be practiced in a moral vacuum. No discussion of the goals and core values of medicine, from Hippocrates4 to the most recent pronouncements of the American Medical Association,5 has ever failed to emphasize the relief of pain and suffering as a pre-eminent responsibility of the physician. Consequently, the widespread failure of physicians to make effective pain management and palliative medicine a priority in patient care denotes an alarming departure of the profession from its deepest ethical roots, and the collective failure of the profession to recognize the ethical implications of undertreated pain and the unnecessary suffering that it engenders calls into question whether a majority of its practitioners continue to acknowledge that healthcare is a moral enterprise.

A remarkable illustration of this concern, to which we shall return toward the conclusion of this article, is provided by Eric Cassell as he chronicles his early inquiries into what had become both the title and the central focus of his important work in the philosophy of medicine, i.e., the nature of suffering and the goals of medicine. Cassell observed, to his surprise and consternation, that while patients and lay persons considered the relief of suffering to be one of the primary ends of medicine, medical students could not see its relevance to their work, and professional colleagues had given its role in patient care little thought.6

[ENTIRE TEXT of this Article in Adobe PDF format]



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Alexander DeLuca, M.D.

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Originally posted: 2006-02-11

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Most recently revised: 2012-07-14
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