October 1988 X/2
PAIN: SOME ETHICAL CONSIDERATIONS
Pain is a continual concern of the human community. Indeed, one can envision pain, in one form or another, as the raison d'etre of all professions. Pain may arise from many sources: spiritual, social, emotional, or physiological. For health care professionals, pain is described as "an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage" (Inst. Assoc. for Study of Pain). At one time pain was considered an unwanted but necessary by-product of disease and illness. Terminal cancer patients, for example, would usually experience severe pain as death approached. In recent years, however, a significant progress has been made in the control of pain. Our interest is not in pain as a medical reality, but rather in pain and pain control as they present ethical concerns. Thus, we shall consider the meaning of pain, and the ethical response to pain on the part of health care professionals.
The Meaning of Pain
For the most part, health care professionals and patients alike avoid the question: Why pain? But a few considerations garnered from the wisdom of experience and religious tradition may help to put pain in better perspective. The term pain is derived from the Latin term poena which means penalty. Unfortunately, as the book of Job attests, many people take the term poena literally and consider illness, disease, and the pain which accompanies them as a penalty for evil behavior. Thus pain becomes for many people a sign of God's displeasure and a punishment for moral faults. But if this were true, only evil persons would suffer and we know that this is not the case. While some religious traditions do trace the presence of evil and pain in the world to a general shortcoming of the whole human race, it is not presented as part of God's original plan nor as a punishment for personal sin.
Having said what pain is not, can we say anything about the meaning of pain? To question the meaning of pain is to question the meaning of all evil, even death. The problem of pain and evil is a Gordian knot which all great religious tra8itions seek to unravel. How could an all merciful God allow pain and suffering to exist in the world? How could a loving God allow a young child to suffer from the pain of leukemia; or allow the generous mother of five to die in pain when others dedicated to their own pleasures are left untouched? The depth of this question about a loving God and the suffering of the innocent has turned many to agnosticism.
People of faith realize that the questions of pain and suffering will always be a mystery. While people of faith perceive God as provident and loving, they do not know God as God knows himself and so cannot understand why God allows pain and suffering. To say that pain and suffering are a mystery is simply an admission that human beings are dependent upon God and cannot know everything. In the Christian tradition, pain and suffering have been considered as an opportunity for the individual to join his or her suffering to that of Jesus and thus dispose for greater spiritual union with God. Most world religions envision some form of transforming experience through the proper acceptance of pain and suffering. Because of the effort to transform pain and suffering, Christianity and other world religions have been considered masochistic by critics. However, accepting pain and suffering as a necessary component of human life is not the same as saying that pain and suffering are good nor that they are desired by God. Hence, world religions have always considered the conquering and alleviation of pain and suffering as a fundamental responsibility of the human community.
Ethical Response to Pain
What is the ethical response to pain for health care professionals? When a patient is in pain, the health care professional has three ethical responsibilities: (1) to recognize the effect that the pain and suffering of patients will have upon the health care professional; (2) to help the patient transform the pain into a beneficial experience; and (3) to alleviate or remove the pain if possible.
1. A seldom realized phenomenon is the detrimental effect that living with the pain and suffering of patients may have upon health care professionals. Sound understanding of human personality helps us realize that those who live in the presence of pain will be affected by it. If one does not have a beneficial method of dispelling the sorrow of pain and suffering, one becomes insouciant to the suffering of others.
2. While suffering should never be sought for its own sake, at times it cannot be avoided. In these circumstances it may become a source of spiritual growth. Helping patients use their fear and suffering as a transforming experience requires personal involvement on the part of the health care professionals. Faced with a suffering and dying patient, some health care professionals turn the patient over to the pastoral care team and remain very much in the background. Others see the care of suffering and dying patients as a mutual responsibility with pastoral care persons. Pediatricians seem to consider it part of their responsibility to help children die in peace.
3. Alleviating and eliminating pain is much more possible today than in the past. As in any other medical procedure, the patient or the proxy for the patient should be consulted in regard to the use of devices to control pain. Many of the methods to relieve pain or alleviate suffering result in reduced awareness or consciousness in the patient. Some people would prefer to experience manageable pain than to lose their power of concentration. Moreover, different persons have different thresholds of pain. Assigning the same therapy for all persons in pain therefore is not an ethical procedure.
At times the need to alleviate pain may require the use of analgesics which indirectly shortens life. In such circumstances this is an act of mercy designed to relieve pain, not an act of euthanasia designed to kill the person. While the side effect of this act of mercy may be to hasten death, the side effect is unintended. For example, a person removed from a respirator because life-sustaining efforts are unsuccessful, will experience dypsnea or severe discomfort. In this case, morphine sulphate or other barbiturate may be administered to alleviate the pain even if death is hastened. (1) In such circumstances, however, it seems that analgesics should not be administered "before the ventilator is withdrawn." (2) To utilize morphine before determining the actual pain of the patient might cause death rather than relieve pain. True, most patients removed from ventilators follow a predictable pattern involving pain, but this pattern of pain is not verified in the case of all patients.
Kevin O'Rourke, OP
Footnotes 1. Scheiderman and Sprag, "Ethical Decisions in Discontinuing Mechanical Ventilation." NEJM, vo1.318, Apr.l5, 1988; 984.
2. Hyers et al., "Withholding and Withdrawing Mechanical Ventilation." Am. Rev. Respir. Dis, 1986; 134, 1327.
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