Deliberative decision making and the treatment of pain.

In recent years, increased emphasis has been placed on the ethical duty of physicians to relieve pain and suffering. According to a 1992 report from The Agency for Health Care Policy Research (AHCPR), the "ethical obligation to manage pain and relieve the patient's suffering is at the core of a health care professional's commitment." However, despite the increased emphasis on the ethical duty to relieve pain, the undertreatment of pain continues to be a serious problem. This problem has been widely discussed, but so far efforts to respond to it have focused almost exclusively on institutional and educational solutions. Yet surprisingly in this discussion very little attention has been paid to articulating a constructive role for the patient in combating this problem. In this article I argue that adequate pain treatment will often require the active participation of the patient in the decision making process. Given the special nature of pain and the special problems that arise in the treatment of pain, adequate pain treatment requires that physicians and patients realize a particular model of shared decision making--one that I refer to as deliberative decision making. As will become clear, my defense of this model is limited to the context of pain management and may not apply in other clinical contexts.