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, the pain patient, and the pain clinician. This philosophy of pain medicine 1) defines the nature of 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 the ends of pain care. That these ends entail the provision of "good" care links the epistemic domains 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 aligned with this set of core practical and ethical affirmations and duties. To maintain contemporary relevance, rules, duties, and moral reasoning must adjust to changing conditions. Applied ethics shape the practice within the infrastructure of core rules 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. A number 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 moral values rests upon the clinician as a moral agent, and therefore advocate the relevance and importance of an agent-based virtue ethics, recognizing that virtue ethics cannot stand alone, 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 and implementation of therapeutically and ethically integrative pain medicine for the future.