Ethical Insights to Rapprochement in Pain Care: Bringing Stakeholders Together in the Best Interest(s) of the Patient

Advances in medicine have produced an elongated lifespan often burdenedby chronic disorders. Throughout the lifespan and at end of life such disorders can give rise to intractable pain. Although clear distinctions aboutthe respective role(s) for pain therapeutics and palliative medicine remaindebatable, both are involved in chronic pain care. Such care has reacheda point of crisis fueled by tensions within and between clinical, administrative, and economic factors. We call for a strategy of rapprochement toreconcile these tensions as a means to facilitate more effective and ethically sound pain care. We describe roles and values of principal stakeholders: palliative- and pain-care physicians, chronic pain patients, insuranceproviders, and hospital administrators and elucidate how dissonances between these groups may contribute to inefficacy of the pain care systemand sustain chronic, maldynic pain. We discuss how such values affect useof evidence and resources and explicate frameworks for an ameliorativerapprochement model that acknowledges and balances relative needs andvalues of all stakeholders. While we have tried to depict why rapprochement is necessary, and possible, the more difficult task is to determine howthis process should be articulated and what shape a profession of total paincare might assume.Key words: Pain medicine, palliative care, ethics, policy, collaboration,rapprochement