A Crisis in Chronic Pain Care: An Ethical Analysis Part Two: Proposed Structure and Function of an Ethics of Pain Medicine

In this paper, we propose a constructive approach to an ethics of pain medicine that is animated by a core philosophy of medicine as specific and focal to the uniqueness of pain, thepain patient, and the pain clinician. This philosophy of pain medicine 1) defines the natureof pain, 2) recognizes the variability and subjectivity of its expression in the pain patient, 3)acknowledges and explicates the vulnerabilities rendered by pain, 4) describes the inherent characteristics and asymmetries of the patient-clinician relationship, and 5) defines theends of pain care. That these ends entail the provision of “good” care links the epistemicdomains of pain medicine to its anthropologic focus and ethically sound conduct.We posit that an ethics of pain medicine should define the profession and sustain the practice. Facts establish (the need for) certain duties and rules of pain medicine. These emphasize the duty to self and others, and an appreciation for relational asymmetries, and dictates that those who enter the profession of pain medicine should be generally alignedwith this set of core practical and ethical affirmations and duties.To maintain contemporary relevance, rules, duties, and moral reasoning must adjust tochanging conditions. Applied ethics shape the practice within the infrastructure of corerules and duties of the profession. An applied ethics of pain medicine must be pragmatic,and therefore, cannot rely upon, or be reduced to, a single principle or ethical system. Anumber of ethical systems (such as the use of principles, utilitarianism, casuistry, feminist/care orientations) all have relative merit and potential limitations. We argue that the obligation to recognize ethical issues, and utilize knowledge to best reflect appropriate moralvalues rests upon the clinician as a moral agent, and therefore advocate the relevance andimportance of an agent-based virtue ethics, recognizing that virtue ethics cannot standalone, but must be employed within a larger system of ethical intuition. Yet, if such a structure of normative and applied ethics is to be realized, moral consideration must guide evaluation of the current system of pain care, and provide direction for the development andimplementation of therapeutically and ethically integrative pain medicine for the future.Key words: Pain medicine, normative ethics, applied ethics, deontology, virtue ethics,humanities