Pain: medical, ethical, and legal considerations
Abstract
Pain management as a human right implies medical, ethical, and legal issues. This concept gained momentum with the 2004 European Federation of International Association for the Study of Pain and World Health Organization-sponsored “Global Day Against Pain,” where it was adopted as a central theme. Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes. The biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. In surgery treatment and especially in vascular surgery vascular this is very important. Strategies currently applied for improvement include framing pain management as an ethical issue; promoting pain management as a legal right, defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies. Unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.
Tablet of Contents:
1. Introduction
2. Causes for deficiencies in pain management
3. Pain management as an ethical issue and a legal right
4. Pain management: the convergence of medicine, law, and ethics
5. Conclusion
1. Introduction
Acute and chronic pain is a widespread public health issue. Despite the advent in developed countries of acute pain teams, the relief of acute pain in medical settings remains more rhetoric than reality [1]. Even with therapeutic intervention, 40% of postoperative patients report inadequate pain relief, or pain of moderate or greater intensity [2]. It seems that
15%-25% of adults suffer from chronic pain at any given time, a figure that increases to 50% in those older than 65 year [3]. It is universally acknowledged that pain, on a global scale, remains inadequately treated because of cultural, attitudinal, educational, legal, and system related reasons. Inadequately treated pain has major physiological, psychological, economic, and social ramifications for patients, their families, and society. It is within the capacity of all developed and many developing countries to significantly improve the treatment of pain.
The history of pain treatment is extensive, and amply documents a pervasive influence of pain on every facet of life since the earliest human experience. Experiments with natural analgesics, including opium, belladonna, and mandragora, are recorded in very ancient times.
Nearly every religion has dealt with the problem of pain. Culture influences the individual and collective response to all aspects of human activity, including health and disease. All cultures have clear attitudes to pain and the treatment of pain. Societal attitudes toward pain relief during surgery and childbirth illustrate the complex interactions between cultural concepts of pain, pain relief, and social behaviour. Knowledge of medicinal with analgesic properties expanded greatly during the Renaissance. There was no concerted effort, however, to develop anaesthesia for surgery or childbirth, as analgesic interventions were unreliable, often leading to death. An emphasis on individual perceptions and well-being emerged during the Romantic era in the late 18th and early 19th centuries, as visual artists, essayists, poets, and philosophers drew attention to the individual and introduced a more personal focus into these fields. Surgical anaesthesia with ether was introduced in 1846, and analgesia for childbirth with chloroform in 1847. Both events were initially attended by scepticism, ridicule, and opposition from powerful contemporaries. The shift in societal attitudes toward acute, chronic, and cancer pain to echo the humanitarian triumph of pain relief during surgery and childbirth has been much slower and it has come only recently.
Under-treatment of pain is poor medical practice that results in many adverse effects. Unrelieved pain after vascular surgery increases heart rate, systemic vascular resistance, and circulating catecholamine, placing patients at risk of myocardial ischemia, stroke, bleeding, and other complications [4]. Unrelieved acute pain commonly elicits pathophysiologic neural alterations, including peripheral and central neuronal sensitization, that evolve into chronic pain syndromes. Chronic pain is linked with a constellation of maladaptive physical, psychological, family, and social consequences, and can be regarded as a disease entity per se [5]. Physically, these responses include reduced mobility and consequent loss of strength, disturbed sleep, immune impairment and increased susceptibility to disease, dependence on medication, and co-dependency with solicitous family members and other caregivers. Patients with chronic pain are four times more likely than those without pain to suffer from depression or anxiety [6], consistent with other statistics on chronic pain as a risk factor for both conditions [7]. In addition to physical and psychological burdens on the individual, chronic pain incurs massive social and economic costs to society. Persons with chronic pain are more than twice as likely to have difficulty working, to be unemployed for health reasons or to receive disability benefits [8]. Chronic pain is associated with low socioeconomic status as well as reduced participation in the labour force. Contemporary rehabilitation medicine seeks restoration of as normal level of function as possible, whether or not pain can be eliminated. Chronic pain contributes significantly to the overall costs of rehabilitation. To these direct costs are added the indirect, frequently hidden costs and burdens of caregiving by family and friends, the costs of health care services and medication, the loss of wages, non-productivity in the home, the costs of worker compensation and disability payments [9]. Pain, especially chronic pain, is a key patient-reported outcome whose poor control undermines quality of life and whose physical, psychological, social, and economic ramifications evolve, overlap, and compound one another. Effective treatment of chronic pain improves the overall quality of life, including maintenance of function and interaction with family and friends. Such principles have already been well accepted by and indeed form the foundation of palliative care, in which they extend to the treatment of all symptoms [10].
2. Causes for deficiencies in pain management
The United States has introduced federal clinical practice guidelines on treatment of acute pain and, subsequently standards for pain assessment and treatment by the Joint Commission for the Accreditation of Healthcare Organizations. Indeed, the US Congress declared 2001 through 2010 as the “Decade of Pain Control and Research” [11]. The European Federation of International Association for the Study of Pain (IASP) Chapters (EFIC) declared a “European Week Against Pain,” within which the WHO, IASP, and EFIC cosponsored a “Global Day Against Pain.” In addition, there has been a recent promulgation of statements on patients’ rights to pain management by professional bodies, and publication of books and articles in the lay press based on eloquent descriptions of the harmful effects of severe unrelieved pain and strongly advocating the right of patients to having their pain addressed [12].
The belief that pain is an inevitable part of the human condition is widespread. The word “patient” itself is derived from the Latin patients, meaning “one who suffers.” Examples of pain myths shared by health professionals and patients alike include the notions that pain is necessary, natural and hence beneficial, that pain is essential for diagnosis, that “good patients” do not complain and never challenge health professionals, that undertreated pain has negligible economic consequences, that severe pain after surgery or in association with cancer is unavoidable and that many patients with chronic noncancerous pain are malingerers or have purely psychological problems [8]. These myths are further confounded with specific concerns about opioid analgesia.
In addition to cultural, medical and religious impediments, entrenched political and legal barriers discourage adequate pain management. Opioids remain the drugs of choice for the treatment of moderate to severe pain, regardless of aetiology. Fears of opioid diversion, abuse, and addiction, however, continue to shape policies on opioid importation, manufacture, distribution, and prescription [13]. Two principal impediments to opioid availability are restriction and cost. As narcotics, opioids are subject to international, national, and local control. Although the mere availability of opioids is insufficient to force prioritization of pain management or palliative care as public health issues, overly stringent regulations discourage the medical use of controlled drugs. Many countries have inefficient procurement, manufacture, and distribution of opioids or impose limits on their prescription. In some countries, opioids cannot be prescribed for cancer pain yet are available for postoperative pain. In other countries, they cannot be prescribed for children yet are available to adults. In some countries, only immediate-release preparations of morphine tablets are available [13].
Principal among the attitudinal barriers of health care professionals to pain relief are misconceptions about medications. There is considerable concern about opioid addiction, tolerance and hyperalgesia, including dose escalation and dependence. Many physicians and patients harbour unrealistic anxieties about precipitating adverse side effects, believing that opioids should be reserved for the “end” in cancer pain. There is also an unfounded assumption among physicians and patients that chronic opioid treatment necessarily impairs quality of life. Patients may believe that opioids can only be given parenteral. Physicians may believe that opioid analgesia may delay accurate initial diagnosis of a change inpatient condition. Lastly, there is widespread belief that at least some pain is inevitable, and that opioid doses should be related to the severity of the disease rather than the intensity of the pain [14].
Public policies of adequate pain management and restriction of illicit opioid use should be pursued concurrently and with mutual respect. There are inconsistencies between the educational efforts of some government agencies to encourage the appropriate prescribing of pain medications, and prosecution by other agencies of physicians who do so.
3. Pain management as an ethical issue and a legal right
For centuries, medical and surgical treatment has emphasized saving the life of the patient rather than ameliorating the patient’s pain, particularly when there were few options for the latter. Medical understanding of pain mechanisms and treatment has progressed slowly, with a few notable exceptions such as the introduction of general anaesthesia. The rise of the modern biomedical model of disease emphasized pathophysiology rather than the patient’s quality of life, and objective quantitative measurement rather than qualitative patient narrative [15].
The “right” to pain management has a variable foundation in law. Separate from, and indeed underlying the pursuit and enforcement of this right by the law, are the ethics of pain relief. The earliest articulations of the responsibilities of doctors to their patients are not legal but ethical. The health professional associations of many countries enunciate a similar ethical basis for the relief of pain. The American Medical Association states that “physicians have an obligation to relieve pain and suffering” [16], and the American Nurses Association’s position is that “nursing…the alleviation of suffering…” [17]. The importance of pain relief as the core of the medical ethic is clear. The relief of pain is a classic example of the bioethical principle of beneficence. Central to the good actions of doctors is the relief of pain and suffering. The principle of non-maleficence prohibits the infliction of harm. Clearly, failing to reasonably treat a patient in pain causes harm; persistent inadequately treated pain has both physical and psychological effects on the patient. Failing to act is a form of abandonment [18].
The bioethical principle of justice, seeking the equitable distribution of health care, is the greatest challenge to inadequate pain management worldwide. However admirable the ideal of pain management as a universal human right, the reality is a world in which massive resource discrepancies preclude fulfilment of such a right [19]. Thus, unequal access to pain relief is but one example of the broader problem of health disparities that arise due to inequities of socioeconomic status or from membership in a minority racial or ethnic group [20].
The moral right to pain management emerges from, and is directly founded upon, the duty of the doctor to act ethically. If one accepts that a health professional has an obligation, where appropriate, to manage pain, then the patient has a concomitant right, where appropriate, to receive such care. One response to the inadequacy of pain treatment is to question the ethical foundations of the modern medical profession [21]. Equally, any campaign of promotion of better pain management should have, as its basis, precisely that ethic: that pain management is a moral enterprise and emanates from the heart of bioethics.
Patients with chronic obliterate arterial disease of the lower limbs have chronic noncancerous pain that warrants increased attention. Romania, like so many countries, especially those with limited resources and scarce medical personnel, these patients often had great difficulty in accessing opioid analgesics. Many of the world’s nations have written constitutions, some of which enumerate the right of their citizens to receive adequate health care. None expressly articulate a right to pain relief. A potential legislation for best practice in chronic pain relief should involve the following components: reasonable chronic pain management is a right; doctors have a duty to listen to and reasonably respond to a patient’s report of pain; provision of necessary pain relief is immune from potential legal liability; doctors who are neither able nor willing to ensure adequate analgesia must refer to a colleague who has this expertise; pain management must be a compulsory component of continuing medical education [22]. There are several aspects of pain relief where doctors may potentially breach their standard of care: an unreasonable failure to take an adequate history of pain from the patient; an unreasonable failure to adequately treat pain; and, in the context of uncontrolled pain, an unreasonable failure to consult an expert in pain management.
4. Pain management: the convergence of medicine, law, and ethics
The unreasonable failure to treat pain is an unethical breach of human rights. At the same time as the global “pain community” has declared pain management to be a human right, colleagues in the worldwide palliative care community have likewise referred, in international statements and declarations, to palliative care as a fundamental right [23]. Further, the Montreal Statement on the Human Right to Essential Medicines in 2005 expressly linked the international right to health with a universal access to WHO essential medications [24]. This statement, presented in November 2005 to a high-level task force of the UN Human Rights Commission in Geneva, has a clear relevance to pain management, especially in the accessibility and affordability of opioids.
The “right” to pain management has a multidimensional foundation in law at the international (the “right to health” in international human rights law); national (a constitutional right in many countries); and personal (the law of negligence) levels. Separate from, yet in many ways underlying, that pursuit by the law are the ethics of pain management.
In terms of pain management, all four main principles of bioethics (autonomy, beneficence, non-maleficence, and virtue) have their correlates in the law. Indeed, the earliest articulations of the responsibilities of doctors to their patients are not legal, but ethical. They consist of broad statements, from the writings of Hippocrates onwards, of principles that should guide doctors, both clinically and personally. In modern jurisprudence, the duty owed by a doctor to a patient does not require novel ethical language, but simply extends a general and universal principle that the law applies to all parties with proximity to each other. One aspect of this duty is the provision of reasonable treatment to patients. The bioethical principle of beneficence, to act for the good of the patient, and the neighbourhood principle of avoiding negligence derive from the same wellspring: the doctor has a duty to the patient to act in good faith, and patients have a right to expect the doctor to act always in good faith. Alleviating pain is not merely a matter of beneficence but also forms part of the duty to prevent harm. The principle of non-maleficence prohibits the infliction of harm. An unreasonable failure to act is arguably negligent, a breach of human rights, and professional misconduct. The scope of the bioethical principle of autonomy is wide. It includes the right of patients to be informed of all aspects of their disease and treatment and allows them to make informed decisions about their care. It further includes a doctor’s duty to listen to a patients’ complaint of pain, to make a reasonable effort to provide pain relief, and to permit autonomy of the patient to self- determination of medical care. Conversely, failing to listen to patients’ complaints of pain, and to make a reasonable effort to provide pain relief, may be found by a court to constitute negligence. Thus, both the law and the medical profession offer a strong ethical foundation for a coherent policy of pain management as a right of all patients.
5. Conclusion
Unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right. Much work and continuing vigilance will be required to make the transition from asserting that pain management is a fundamental human right, to a future in which appropriate pain management is a global reality.
The Authors:
TANASE Daniela Maria [1] [2]
OUATU Anca [1] [2]
BAROI Livia Genoveva [1] [3]
FLORIA Mariana [1] [2]
[1] Grigore T. Popa University of Medicine and Pharmacy, Iasi (ROMANIA).
[2] III Medical Clinic of Sf. Spiridon Emergency Hospital, Iaşi (ROMANIA).
[3] Vascular Surgery Clinic of Sf. Spiridon University Hospital, Iaşi (ROMANIA).
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