Duke Medical Ethics
The High Stakes of Philosophy
The four lofty pillars of beneficence, non-maleficence, justice, and autonomy are the main principles of medical ethics that govern how medical professionals provide care (Colwell 2013). These pillars dictate them to act in the patients’ best interests, do no harm, protect and advocate for patient choices, and champion equitable distribution of health care opportunities.
These four ideals seem to work together in perfect harmony to clarify uncertain moral implications and consequences to help the care provider make the correct decision. However, when examined under the lens of philosophy, the ethical framework crumbles and becomes a mess of intertwining and dilemma-inducing options that are at odds with each other. While each of the individual pillars are ethical in and of themselves, grouping them under a supposedly cohesive framework could be the reason for the inconsistency in trying to decide if one ideal overpowers another in a particular situation. This proposed idea can be investigated in the ethics of pain management, a field in which existing literature, accounts of health care providers (Colwell 2013) , and mission statements of professional medical societies ( Sulmasy and Bledsoe 2019) show that the four pillars are very relevant in the discussion of pain management delivery.
Pain is a universal yet personal indicative of an underlying distress, and contributes to the feeling of suffering (Fradelos et al 2014). Although pain cannot be truly measured, it can be rated on a qualitative scale of 1-10, with 10 being the most severe pain. However, since it is just a self-report that is only sometimes accompanied by known physiological manifestations (Colwell 2013), its credibility and value are lessened in providing a full picture of the illness narrative.
There is also a fascinating neurobiological side to this. On one hand, not giving pain attention could mean neglecting an underlying problem, while too much attention to pain makes it more of a focus and a problem than it really is (“The Fifth Vital Sign”). The amount of attention we give to pain needs to strike the right balance, a task that is not obvious or objective.
Keeping the theme of subjectivity versus objectivity in mind along with the various contradictions presented, pain management can reveal the complexity of ethically ranking the pillars. Current headlines relevant to this include the opioid epidemic, particularly the physician malpractice of opioid over-prescription, the $200 billion worth of annual chronic pain costs (Cohen et al. 2015), and alarming rates of untreated or wrongly treated pain (Carvalho et al. 2018). It is a mental tennis match of going back and forth between ideals that are all ethical and correct in their own sense, but somehow one could still be more correct than the other(s). The choice made plays a deciding role in the physician’s competence and accountability as well as patient’s outcomes and the quality of healthcare received.
Some examples: 1. Beneficence versus autonomy: a patient might express immense pain and a wish to have more opioids prescribed for pain control. Autonomy is important, since they are experiencing the pain and have a say over their choices. However, if the physician suspects drug seeking behavior, they might think that not giving the patient opioids is truly the best course of action. 2. Beneficence versus non-maleficence: a physician might recommend some intervention, say surgery of some sort, with the intention of helping with an illness or long-term harm but in the short term it might have harmful effects, whether it be psychological, spiritual or physical. 3. Justice versus non-maleficence: the justice ideal would say that a physician needs to treat all patients equally and give the same kind of treatment to a problem. But if one patient has a history of substance abuse while another does not, the physician might be hesitant to treat them the same and not give the same dosage to the former to prevent harm.
A pattern of easily getting into a bind with these arguably opposing ethical frameworks starts to emerge. There are no objectively correct choices. However, then the question becomes if it is even important to stay objective in medical ethics. Having explored how pain is subjective and each illness experience is defined by the person experiencing it, maybe it is so difficult to create an objective framework because it is impossible. Perhaps it is important to be less detached and have one’s own experiences, education, and opinions inform how pain management is handled. Again, the answer is unclear but the inconsistencies have intense consequences.
Given that a lot of medical decisions need to be made quickly and after consideration of a myriad of factors, it is an additional barrier for a provider to go through such a philosophical quandary in urgency. An ethical framework that is able to provide a well-defined foundation to productively make choices when there are opposing principles is key. A relatively more solid, clear-cut ethical foundation could make it easier for doctors who entered this profession in the first place with the desire to do good to be able to do so successfully.
This article was written by Priya Iyengar of Brandeis University. References and acknowledgements can be found in our journal, under "Current Issue"