An ethical analysis of crisis in chronic pain care: facts, issues and problems in pain medicine; Part I.

We posit that in order to realistically, fully, and most positively affect the capability of implementing a more comprehensive paradigm of pain care it is necessary to: 1) recognize the complexity of chronic pain; 2) account for economic factors imposed upon the healthcare system, and 3) enable articulation of any paradigmatic revision within the contemporary medico-legal environment. Three primary ethical problems arise from the interaction(s) of these contingencies--namely 1) the under-treatment of pain, 2) the inappropriate over-utilization of pharmacologic agents and techniques, and 3) tensions and conflicts that develop within the relationships of pain medicine. All can lead to a failure of technically apt and ethically sound pain care. This essay--the first in a 3-part series--employs the method of ethical analysis to approach the circumstances, issues, questions, and problems of contemporary practice of pain medicine, to allow insight(s) to the facts, define the agents involved, appreciate how problems are generated, and develop more thorough evaluation and articulation of potential resolutions. We contend that resolution of these problems must offer practical responses to the circumstances and issues. Such practicality entails affording "good" in ways that are grounded to the facts and realities of situations, and are not merely theoretical or conceptual. Determining the "good" is the work of ethics--as systems and analyses of the moral decisional process. Ethics establishes norms and articulates their use in practice, and we opine that the distinction between the normative and applied is more of a continuum that is dependent upon case and circumstance(s). Given the variety of circumstances in the practice of pain medicine, no single ethical system would be totally adequate, and we believe a discursive approach to be most effective. Subsequent papers in this series will describe the systems, structure, and function of a putative ethical infrastructure of pain medicine, and will attempt to illustrate how these could be articulated within an integrative paradigm of pain care.