McGovern, Kevin Physician and ethicist Professor Paul Komesaroff and former judge Stephen Charles QC have proposed legislation to protect health professionals from the risk of criminal prosecution when in appropriate circumstances they provide pain relief which may shorten a patient's life. For this protection, they recommend that four conditions must all be satisfied: the patient has a terminal illness; the intention is to relieve pain and suffering; the treatment is reasonable in terms of current medical practice; and (...) the treatment is necessary to relieve pain and suffering. This article examines their proposal, supports it, and joins in the call for Victorian legislation which achieves this purpose. (shrink)

The experience of having to suffer debilitating pain is far too common in the United States, and many patients continue to be inadequately treated by their doctors. Although many physicians freely admit that their pain management practices may have been somewhat lacking, many more express concern that the prescribing of heightened levels of opioid analgesics may result in closer regulatory scrutiny, criminal investigation, or even criminal prosecution.Although several researchers have examined the regulatory environment and the threat of sanction (...) or harm it poses to physicians and patients, few have examined the likelihood of investigation or prosecution stemming from the aggressive use of opioids in physician-directed pain management. Accordingly, in an effort to assess whether the fear of prosecution is realistic and, if so, what factors contribute to its likelihood, we surveyed chief prosecutors in four states about their knowledge, opinions, and attitudes concerning opioids and the prosecution of physicians stemming from the treatment of patients who were either terminally ill or suffering from chronic noncancer pain. (shrink)

The experience of having to suffer debilitating pain is far too common in the United States, and many patients continue to be inadequately treated by their doctors. Although many physicians freely admit that their pain management practices may have been somewhat lacking, many more express concern that the prescribing of heightened levels of opioid analgesics may result in closer regulatory scrutiny, criminal investigation, or even criminal prosecution.Although several researchers have examined the regulatory environment and the threat of sanction (...) or harm it poses to physicians and patients, few have examined the likelihood of investigation or prosecution stemming from the aggressive use of opioids in physician-directed pain management. Accordingly, in an effort to assess whether the fear of prosecution is realistic and, if so, what factors contribute to its likelihood, we surveyed chief prosecutors in four states about their knowledge, opinions, and attitudes concerning opioids and the prosecution of physicians stemming from the treatment of patients who were either terminally ill or suffering from chronic noncancer pain. (shrink)

: This paper considers whether a physician is criminally liable for administering a dose of painkillers that hastens a patient's death. The common wisdom is that a version of the doctrine of double effect legally protects the physician. That is, a physician is supposedly acting lawfully so long as the physician's primary purpose is to relieve suffering. This paper suggests that the criminal liability issue is more complex than that. Physician culpability can be based on recklessness, and recklessness hinges on (...) whether a physician has taken an unjustifiable risk of hastening death. The authors identify three conditions of justifiability. Their analysis helps to explain the distinction between euthanasia, which is legally banned, and the use of risky analgesics, which is permitted in limited circumstances. (shrink)

The Helsinki Declaration is the universally accepted standard for ethical behavior in research involving human subjects. The Declaration calls for research studies to compare new therapies to the best current therapies. Despite this standard, multiple studies of pain relief interventions in newborns have recruited placebo controls instead of active controls using the best current therapy. These studies are evaluated using the standards required by the Helsinki Declaration, and the reasons for the ethical shortcomings of these studies are explored.

In lieu of an abstract, here is a brief excerpt of the content:A New Look at Animal-to-Human Organ TransplantationCharles R. McCarthy (bio)The acute shortage of organs available for transplantation into human beings combined with a new scientific understanding of the immune systems of both humans and animals make it probable that animal-to-human solid organ transplants (xenografts) may soon be attempted at a frequency rate unknown in the past. 1 Optimism about successful animal-to-human organ transplantation is greater than at any previous (...) time. The creation of a reliable supply of animal organs appears to be technically feasible. At least five major transplant centers in the United States are currently considering plans to pursue xenotransplantation. Although, at the time of this writing, no federal guidelines prohibit animal-to-human organ transplantation, the institutions considering such programs are awaiting deliberations on the subject by the Institute of Medicine (IOM), the Food and Drug Administration (FDA), and the Department of Health and Human Services (DHHS).The demand for organs suitable for transplantation into human beings greatly exceeds the supply. According to the United Network for Organ Sharing (UNOS 1996a), approximately 44,000 patients in the United states awaited organ transplantation at the end of 1995. In 1994, more than 3,000 patients died while on the transplant waiting list, and the demand for transplantable organs increases annually (UNOS 1996b). The figures do not include the hundreds or perhaps thousands of patients who could profit from a transplant, but who do not meet the requirements of the UNOS waiting list. Even if efforts to persuade persons to donate organs are redoubled, and even if the consent to donate organs should become a legal presumption, there is little prospect of developing a sufficient supply of transplantable human organs to meet the growing demand.As technical and biological barriers to successful animal-to-human xenografts are lowered, the prospect of raising dedicated colonies of animals, genetically altered to reduce the chances that human hosts will reject organs derived from them, is being seriously discussed. 2 Such colonies do not exist at the present time. [End Page 183] However, if new techniques for animal-to-human transplantation prove successful, it is likely that animal colonies will be established to provide a ready and predictable supply of organs for transplantation to humans. Some believe that commercial investment in colonies of purpose-bred animals to serve as a source of transplantable organs is close at hand (Leventhal 1994).New drugs and new combinations of existing drugs have improved the chances of successful medical outcomes for patients who receive solid organ transplants. It is now recognized that serial application of immunosuppressive drugs can reduce the likelihood of both short- and long-term organ rejection (Makowka 1994). Improved understanding of both human and animal immune systems, insights into histocompatibility, new agents to control graft-versus-host disease, animal breeding programs for the production of transgenic animals, and improved surgical techniques have opened, as never before, the possibility of successful transfer of organs from animals to humans. Some rate the chances of good patient outcomes (usually measured in terms of time of patient survival) as high, others make more conservative predictions, but virtually all experts believe that the chances for successful human patient outcomes resulting from xenotransplantation are improved. Because many patients face immanent death unless their organs can be replaced, there can be little doubt that many humans will readily consent to xenotransplantation.History Suggests CautionDespite the advances in immunosuppression, the frequency of failure in past animal-to-human xenograft attempts should temper the optimism of the transplant community. To date, all efforts to prolong human life by implanting solid organs from animals into human recipients have failed. The first attempts at animal-to-human xenotransplantation early in the twentieth century resulted in the early death of all recipients (Neuhof 1923). More sophisticated efforts at xenotransplantation occurred in the late 1960s and early 1970s, a period when anti-rejection drugs began to make allografts more feasible. Although one human recipient of a xenograft survived for nine months (with poor quality of life), most patients died within a matter of minutes, hours, or a few days following the transplantation of organs from chimpanzees or baboons (Starzl... (shrink)

The Helsinki Declaration, first published in 1964, is the universally accepted standard for ethical behavior in research involving human subjects. The Declaration was formulated in response to the abuses of human subjects by the scientists in Nazi Germany and to update the Nuremberg Code. Amended in 1975, 1983, 1989, 1996, and 2000, the Declaration provides the foundation for the United States federal regulations for research involving human subjects.To conform to standards developed in the Declaration, a researcher must fulfill the following: (...) respect the autonomy of the individual; promote and safeguard the individual’s health; provide informed consent without coercion; take special measures with vulnerable populations; compare new therapies to the best current therapies; have a thorough scientific knowledge of the subject; assess risk versus benefit of the intervention; perform studies that will ultimately benefit the population involved in the research; accurately report their findings; and fully disclose ethical concerns in their research protocols. (shrink)

The problem is pain. Patients and their families tell the story:He is your son. You love him. You want to help him in every way you can, but when he is in that kind of pain, you are helpless in a sense. Im his daddy. It was-what was I supposed to do for him? I felt, you know, helpless.It terrifies you. You want to run away from it. Pain is something you wish would kill you but does (...) not. Agony results from the pain that does not have the decency to knock you out.[W]e had a good family, but how much can you watch? How much suffering can you watch from your child, your 7-year-old child, and still keep your mind?I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life. (shrink)

The problem is pain. Patients and their families tell the story:He is your son. You love him. You want to help him in every way you can, but when he is in that kind of pain, you are helpless in a sense. Im his daddy. It was-what was I supposed to do for him? I felt, you know, helpless.It terrifies you. You want to run away from it. Pain is something you wish would kill you but does (...) not. Agony results from the pain that does not have the decency to knock you out.[W]e had a good family, but how much can you watch? How much suffering can you watch from your child, your 7-year-old child, and still keep your mind?I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt (...) with pain medications that might have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

This paper examines pain and pain relief in the Caribbean, where pain is widely perceived as an unavoidable part of life, and where unnecessary suffering results from untreated and under treated pain. Barriers to pain relief in the Caribbean include patient and family attitudes, inadequate knowledge among health professionals and unduly restrictive regulations on the medical use of opioids. Similar barriers exist all over the world. This paper urges medical, nursing and public health (...) professionals, and educators to examine attitudes towards pain and pain relief and to work towards making effective pain relief and palliation more accessible. It recommends that i) health professionals and officials be better educated about pain, palliation and opioids, ii) regulatory restrictions be updated in light of clinical and scientific evidence, iii) opioid procurement policies be adjusted to facilitate increased medical use, iv) medical charts and records be modified to routinely elicit and document patients levels of pain, and v) educational campaigns be developed to inform the public that moderate and severe pain can be safely relieved at the end of life and other stages of life. The professional, respectful, and beneficent response to patients in pain is to provide rapid and aggressive pain relief or to urgently consult a pain or palliative specialist. When a health system hinders such efforts the ethical response is to identify, facilitate and advocate for overcoming barriers to improvement. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt (...) with pain medications that might have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

This paper examines pain and pain relief in the Caribbean, where pain is widely perceived as an unavoidable part of life, and where unnecessary suffering results from untreated and under treated pain. Barriers to pain relief in the Caribbean include patient and family attitudes, inadequate knowledge among health professionals and unduly restrictive regulations on the medical use of opioids. Similar barriers exist all over the world. This paper urges medical, nursing and public health (...) professionals, and educators to examine attitudes towards pain and pain relief and to work towards making effective pain relief and palliation more accessible. It recommends that i) health professionals and officials be better educated about pain, palliation and opioids, ii) regulatory restrictions be updated in light of clinical and scientific evidence, iii) opioid procurement policies be adjusted to facilitate increased medical use, iv) medical charts and records be modified to routinely elicit and document patients levels of pain, and v) educational campaigns be developed to inform the public that moderate and severe pain can be safely relieved at the end of life and other stages of life. The professional, respectful, and beneficent response to patients in pain is to provide rapid and aggressive pain relief or to urgently consult a pain or palliative specialist. When a health system hinders such efforts the ethical response is to identify, facilitate and advocate for overcoming barriers to improvement. (shrink)

BackgroundEnhancement involves the use of biomedical technologies to improve human capacities beyond therapeutic purposes. It has been well documented that enhancement is sometimes difficult to distinguish from treatment. As a subtype of enhancement, neuroenhancement aims to improve one’s cognitive or emotional capacities.Main bodyThis article proposes that the notion of neuroenhancement deserves special attention among enhancements in general, because apart from the notion of treatment, it also overlaps with other concepts such as prevention, pain relief, and pleasure seeking. Regarding (...) prevention, patients’ mental endurance can be enhanced when a patient is prescribed a selective serotonin reuptake inhibitor for the purpose of preventing the relapse of depression following a stressful situation. As for pain relief, psychiatrists use medication to alleviate distress in patients who experience various types of anxiety; the alleviation of distress is equal to psychological pain relief, but is also an enhancement of the patient’s temperamental traits. Regarding pleasure seeking, insidious transition exists between neuroenhancement and pleasure seeking when using psychotropic drugs. It is well known that people use psychostimulants for recreational purposes and to induce overconfidence in one’s performance. The polysemy of psychotropics derives from their effects on human sensibility. Therefore, when using psychotropic agents, psychiatrists should pay close attention to what the agent is used for on each patient in each situation, and explicitly share the continuity and overlap in the purpose of prescribing a medication with the patients to make a better clinical decision.ConclusionsThe notion of neuroenhancement overlaps not only with the notion of treatment, but also with other concepts of prevention, pain relief, and pleasure seeking. The continuity between those concepts makes the issues concerning the prescription of psychotropic drugs subtler. Psychiatrists should explicitly share the continuity with the patients to make a better clinical decision. (shrink)

... We will turn our attention to the current state of pain relief technology and the ethical questions surrounding the use of advanced technology, otherwise referred to as "high-tech," pain relief. It is obvious that pain may decrease the quality of life for cancer patients. The availability of long-acting narcotics, such as MS Contin or methadone, affords cancer patients long-duration pain relief at minimal cost. The use of adjuvant medications may also be important. (...) Clinical examples of the effective use of adjuvant medications include the addition of a nonsteroidal, anti-inflammatory agent to help patients cope with bone pain and the use of a serotonin blocking agent to reduce the transmission of pain impulses in the spinal cord. Only a small percentage of patients are good candidates for high-tech delivery systems for narcotic administration. In our pain management clinic, all patients are initially placed on oral medications. When the side effects of oral medications become excessive, or the patient becomes unable to take oral medications, high-tech modalities are considered for use. (shrink)

Abstract In order to avoid the occurrence of boar taint, castration of piglets without pain relief is a common practice in pork production. Due to increasing animal welfare concerns, the practice will be banned in organic agriculture from 2012 and alternative methods will have to be implemented. An important factor for the successful implementation of such alternatives is consumers’ acceptance of the methods, as consumers’ daily buying decisions are crucial to the further development of the organic pork sector. (...) Thus, this paper explores organic consumers’ attitudes towards piglet castration without pain relief and three alternative methods and examines which aspects of these alternatives are important to consumers of organic products. The analysis of nine focus group discussions in Germany conducted in fall 2009 and involving a total of 89 participants, shows that castration without pain relief in organic farming was unacceptable for participants. Animal welfare, food safety, taste, and costs were principal aspects that participants used to assess the three alternatives. Participants had mainly favorable attitudes towards castration with anesthesia and analgesia. Although participants had some concerns regarding the fattening of boars (taste), there was openness towards this alternative due to its perceived naturalness. Immunocastration was seen quite critically because participants feared that this alternative might lead to (hormone) residues in meat. Overall, the results suggest that fattening of boars and castration with anesthesia and analgesia could be acceptable alternatives to consumers of organic pork. Content Type Journal Article Category Articles Pages 1-20 DOI 10.1007/s10806-011-9350-2 Authors Astrid Heid, Department of Agricultural and Food Marketing, University of Kassel, Steinstraße 19, 37213 Witzenhausen, Germany Ulrich Hamm, Department of Agricultural and Food Marketing, University of Kassel, Steinstraße 19, 37213 Witzenhausen, Germany Journal Journal of Agricultural and Environmental Ethics Online ISSN 1573-322X Print ISSN 1187-7863. (shrink)

As medical technology becomes more sophisticate the ability to manipulate nature and manage disease forces the dilemma of when can becomes ought. Indeed, most bioethical discourse is framed in terms of balancing the values and interests and the benefits and burdens that inform principled decisions about how, when, and whether interventions should occur. Yet, despite advances in science and technology, one caregiver mandate remains as constant and compelling as it was for the earliest shaman—the relief of pain. Even (...) when cure is impossible, the physician's duty of care includes palliation. Moreover, the centrality of this obligation is both unquestioned and universal, transcending time and cultural boundaries.Although universally acknowledged, pain is a complex phenomenon for both the patient and the caregiver, influenced as much by personal values and cultural traditions as by physiological injury and disease. (shrink)

Scholarship has intrinsic value, of course; but when good scholarship can stimulate change for the better in an area as fundamental to human dignity as health care and the relief of suffering, there is a special satisfaction. This has been our experience since 1996, when the first of now four special issues of this journal focused on legal, regulatory, ethical, professional, and financial issues in medical treatment for pain.With the generous and steadfast support of the Mayday Fund, the (...) American Society of Law, Medicine & Ethics has generated a significant body of scholarship published in the Journal of Law, Medicine & Ethics. This research has proven absolutely essential in changing public policy to support better care for those who suffer pain.Over these years, the Mayday Project at ASLME has tackled many of the real and perceived barriers to effective pain relief. In pain management, both real and perceived obstacles can have a powerful negative effect. (shrink)

Scholarship has intrinsic value, of course; but when good scholarship can stimulate change for the better in an area as fundamental to human dignity as health care and the relief of suffering, there is a special satisfaction. This has been our experience since 1996, when the first of now four special issues of this journal focused on legal, regulatory, ethical, professional, and financial issues in medical treatment for pain.With the generous and steadfast support of the Mayday Fund, the (...) American Society of Law, Medicine & Ethics has generated a significant body of scholarship published in the Journal of Law, Medicine & Ethics. This research has proven absolutely essential in changing public policy to support better care for those who suffer pain.Over these years, the Mayday Project at ASLME has tackled many of the real and perceived barriers to effective pain relief. In pain management, both real and perceived obstacles can have a powerful negative effect. (shrink)

This paper discusses the question of when pain and distress relief known to hasten death would cross the line between permissible conduct and killing. The issue is discussed in the context of organ donation after cardiac death, and considers the administration of analgesics, sedatives, and the controversial use of paralysing agents in the provision and withdrawal of ventilation.

This paper is another of the papers presented at a conference on Pain organised under the auspices of the London Medical Group. Mark Swerdlow deals with the work of pain relief clinics and explores their value. He gives the background as to what these clinics are, describes who is treated, how they are staffed and finally offers his opinion as to their effectiveness.

In this article I clarify the concepts of ‘pain’, ‘suffering’. ‘pains of body’, ‘pains of soul’. I explore the relevance of an ethic to the clinical setting which gives patients a strong prima facie right to freedom from unnecessary and unwanted pain and which places upon medical professionals two concomitant moral obligations to patients. First, there is the duty not to inflict pain and suffering beyond what is necessary for effective diagnosis. treatment and research. Next, there is (...) the duty to do all that can be done to relieve all the pain and suffering which can be alleviated. I develop in some detail that individuality of pain sensitivity must be taken into account in fulfihing these obligations. I explore the issue of the relevance of informed consent and the right to refuse treatment to the matter of pain relief. And I raise the question of what conditions, if anv, should override the right to refuse treatment where pain relief is of paramount concern. (shrink)

Our emotional lives are full of temporal asymmetries. Salient among these is that we tend to feel differently about painful or unpleasant events depending on their temporal location: we feel anxiety or trepidation about painful events we anticipate in the future, and relief when they are over. One question, then, is whether temporally asymmetric emotions such as relief have any ramifications for the metaphysics of time. On what has become the standard way of finessing this question, the asymmetry (...) of relief is an instance of the phenomenon of future-bias, a tendency to prefer painful events to be located in the past than in the future. The main question then posed is whether this pattern of preferences can be justified in the light of different metaphysical theories of time. In this paper I argue that this whole dialectic is misconceived. While many people may have future-biased preferences and these are a legitimate object of psychological study, this should be distinguished from the more basic phenomenon of relief that an unpleasant experience is over. Acknowledging the distinctness of these phenomena has two main consequences. First, if relief is not a manifestation of a time-biased preference, it is unclear what it would be for it to be justified or unjustified. This, in turn, should lead us to reassess how the psychology of relief bears on our metaphysical commitments. As I shall suggest, the real significance of the temporally asymmetric emotions for the metaphysics of time is that they manifest, and so reflection on them serves to draw our attention to, a structural feature of our awareness of the passage of time that resists re-articulation in other terms. (shrink)

Physician concern about regulatory scrutiny as a barrier to appropriate prescribing for pain management has been identified and studied. A 1991 Pain Research Group survey demonstrated a need to provide updated information about opioids and pain management to state medical board members. Indeed, a national survey even showed a need to provide more education about pain management to oncology Physicians. Two approaches for responding to these concerns have been undertaken in several states by the state medical (...) boards and the pain management community: the development and adoption of administrative policies designed to bring disciplinary standards in line with clinical practice; and the creation of education programs for state medical board members and staffs. Each can have a substantial impact on removing real and perceived regulatory barriers to effective pain relief. (shrink)

Physician concern about regulatory scrutiny as a barrier to appropriate prescribing for pain management has been identified and studied. A 1991 Pain Research Group survey demonstrated a need to provide updated information about opioids and pain management to state medical board members. Indeed, a national survey even showed a need to provide more education about pain management to oncology Physicians. Two approaches for responding to these concerns have been undertaken in several states by the state medical (...) boards and the pain management community: the development and adoption of administrative policies designed to bring disciplinary standards in line with clinical practice; and the creation of education programs for state medical board members and staffs. Each can have a substantial impact on removing real and perceived regulatory barriers to effective pain relief. (shrink)

In a familiar moral dilemma faced by physicians who care for the dying, some patients who are within days or hours of death may experience suffering in a degree that cannot be relieved by ordinary levels of analgesia. In such cases, it may sometimes be possible to honor a competent patient's request for pain relief only by giving an injection of narcotics in a dosage so large that the patient's death is thereby hastened. Doctors rightly worry that taking (...) an action likely to result in a patient's death may violate the Hippocratic injunction against the direct killing of anyone in their care. (shrink)

In a familiar moral dilemma faced by physicians who care for the dying, some patients who are within days or hours of death may experience suffering in a degree that cannot be relieved by ordinary levels of analgesia. In such cases, it may sometimes be possible to honor a competent patient's request for pain relief only by giving an injection of narcotics in a dosage so large that the patient's death is thereby hastened. Doctors rightly worry that taking (...) an action likely to result in a patient's death may violate the Hippocratic injunction against the direct killing of anyone in their care. (shrink)

Health care providers are expected both to relieve pain and to provide anticipatory guidance regarding how much a procedure is going to hurt. Fulfilling those expectations is complicated by the cognitive modulation of pain perception. Warning people to expect pain or setting expectations for pain relief not only influences their subjective experience, but it also alters how nociceptive stimuli are processed throughout the sensory and discriminative pathways in the brain. In light of this, I reconsider (...) the characterization of placebo analgesia as pharmacologically inert and the use of it as deceptive. I show that placebo analgesia exploits the same physical mechanisms as proven analgesics and argue that it should be utilized to relieve pain. Additionally, I describe factors to help identify situations in which clinicians have the obligation to disclose the potential for pain coupled with ways of mitigating the risk of high-intensity pain by setting positive expectations. (shrink)

Disability scholars have critiqued medical models that pathologize disability as an individual flaw that needs treatment, rehabilitation, and cure, favoring instead a social-constructionist approach that likens disability to other identity categories such as gender, race, class, and sexuality. However, the emphasis on social constructionism has left chronic illness and pain largely untheorized. This article argues that feminist disability studies must attend to the common, chronic gynecological condition endometriosis when theorizing pain. Endo is particularly important for FDS analysis because (...) the highly feminized and sexualized nature of endo pain is a major source of disability. Because medical treatments of endo enhance fertility rather than provide pain relief, those with endo must not only have access to medical services to manage their pain, but also demand better medical management of their pain as well as disability accommodations for their pain. Thus, I propose a pain-centric model of disability that politicizes pain through social-constructionist and medical models of disability by attending to the lived experiences of pain. (shrink)

In a recent article in this journal, Carl Knight and Andreas Albertsen argue that Rawlsian theories of distributive justice as applied to health and healthcare fail to accommodate both palliative care and the desirability of less painful treatments. The asserted Rawlsian focus on opportunities or capacities, as exemplified in Normal Daniels’ developments of John Rawls’ theory, results in a normative account of healthcare which is at best only indirectly sensitive to pain and so unable to account for the value (...) of efforts of which the sole purpose is pain reduction. I argue that, far from undermining the Rawlsian project and its application to problems of health, what the authors’ argument at most amounts to is a compelling case for the inclusion of freedom from physical pain within its index of primary goods. (shrink)

Physicians’ fear of criminal prosecution for prescribing opioid analgesics is a major reason why many chronic pain patients are having an increasingly difficult time obtaining medically appropriate pain relief. In Ruan v. United States, 142 S. Ct. 2370 (2022), the Supreme Court unanimously vacated two federal convictions under the Controlled Substances Act. The Court held that the government must prove that the defendant knowingly or intentionally acted in an unauthorized manner.

The chapter explores the sufferingSufferingassociated with MAIDMedical Assistance in Dying (MAID) giving special attention to assessmentAssessment and the psychological responses elicited in caregivers highlighting the need for all MAIDMedical Assistance in Dying (MAID) enquiries to activate a period of intense assessmentAssessment and the provision of detailed treatment alternatives. This chapter calls for a renewed commitment to compassionCompassion (‘sufferingSuffering together with’) as the communal dynamic to relieve and assuage such sufferingSuffering. Using the four domains of ‘total pain’ (Saunders in The (...) management of terminal malignant disease. Edward Arnold, London, UK, 1978), we summarize the evidence for the multiple opportunities available to ‘relieve often and comfort always.’ Finally, we review evidence on the impactImpactof MAIDMedical Assistance in Dying (MAID) suggesting that the overall burden of sufferingSuffering in Canada has increased since legalization. (shrink)

The ethical concerns of Japanese nurses are compared with those of previously described nurses from the USA. Patient comfort was a primary concern of nurses from both countries. Participants described an ethical imperative to provide adequate pain medication for patients and prevent unnecessary and uncomfortable invasive tests and procedures, especially at the end of life as the focus changed from ‘cure’ to ‘care’. The notion of regard for personhood varied, based on the communication styles and definition of the self (...) inherent in the different cultures of the nurses. A common meaning centred around knowing patients as persons, listening to their needs and preferences, supporting their everyday choices through advocacy, and maintaining their dignity. Despite background cultural differences, there are common ethical concerns between nurses in Japan and the USA. This article invites readers to reflect on everyday nursing practices that exemplify ethical expertise, and the significance of this expertise in uncovering and articulating nursing ethics across cultures. (shrink)

Adequate treatment of pain is essential to alleviate suffering, yet studies show that patients with terminal or serious illness receive inadequate pain relief. In the case of terminally ill patients, adequate palliation of pain may be likely to reduce requests for physician-assisted suicide. This issue of the journal addresses barriers to effective pain relief and suggests how treatment of pain can be improved. The symposium features the Pain Relief Act, which is (...) designed to provide practitioners who prescribe controlled substances for pain with protection from inappropriate legal sanctions. The Act is the product of the Project on Legal Constraints on Access to Effective Pain Relief, whose principal investigators were Nancy Neveloff Dubler, LL.B., Sandra H. Johnson, J.D., LL.M., Robert J. Levine, M.D., and Benjamin W. Moulton, J.D., M.P.H.The Project was supported by the Mayday Fund and the Emily Davie and Joseph S. Kornfeld Foundation. (shrink)

Adequate treatment of pain is essential to alleviate suffering, yet studies show that patients with terminal or serious illness receive inadequate pain relief. In the case of terminally ill patients, adequate palliation of pain may be likely to reduce requests for physician-assisted suicide. This issue of the journal addresses barriers to effective pain relief and suggests how treatment of pain can be improved. The symposium features the Pain Relief Act, which is (...) designed to provide practitioners who prescribe controlled substances for pain with protection from inappropriate legal sanctions. The Act is the product of the Project on Legal Constraints on Access to Effective Pain Relief, whose principal investigators were Nancy Neveloff Dubler, LL.B., Sandra H. Johnson, J.D., LL.M., Robert J. Levine, M.D., and Benjamin W. Moulton, J.D., M.P.H.The Project was supported by the Mayday Fund and the Emily Davie and Joseph S. Kornfeld Foundation. (shrink)

Pain management has improved in the past few decades. Opioid analgesics have become the mainstay in the treatment of cancer pain whilst inter-disciplinary pain management programmes are the generally accepted approach to chronic pain of non-malignant origin. Recently some pain specialists have advocated the use of opioids in the long-term management of non-cancer pain. This has raised some fundamental questions about the purpose of pain management. Is it best to opt for maximum (...) class='Hi'>pain relief and comfort, or should one emphasise function and activity as higher priorities? Will the use of opioids create more autonomy for pain sufferers or will this add handicaps to lives which are already limited? Until more clinical outcome data are available we advocate caution in the use of opioid analgesia. Such caution can, and does, raise questions about the rights of the patient and the rights of the prescriber in a context where the facts do not point to a clear course of action. (shrink)

Pain is most often an unpleasant experience that alerts us to actual or possible tissue damage. However, insisting that pain is always bad news may hinder understanding of pain’s many facets. Despite its unpleasantness – or perhaps because of it – pain is known to enhance the perceived value of certain activities, such as punishment or endurance sports. Here, we review evidence for a series of mechanisms involved in putative benefits of pain. A byproduct of (...) pain’s attention-grabbing quality can be enhanced perception of concurrent pleasurable stimuli. This is thought to explain why pain may augment the pleasure of spicy foods. By providing an aversive contrast, pain can also improve the experience of events that follow pain’s offset and lead to pleasant relief. Other potential benefits of pain derive from its ability to inhibit other unpleasant experiences and to elicit empathy and social support. The experience of pain can benefit our defence systems, since pain can enhance motivation to accumulate resources such as social support and calorie-rich foods. It can also reduce the guilt we feel after self-indulgence or moral transgressions. In sum, we highlight a series of potentially positive effects linked to pain. This framework can aid the understanding of why people sometimes seek out, enjoy, and gain rewards from pain as well as pleasure. (shrink)

At graduation, some North American medical students repeat the Prayer of Maimonides "never to forget that the patient is a fellow creature in pain, not a mere vessel of disease." [2] How could a physician ever forget that a patient is in pain? Don't physicians confront constant reminders­moans, groans, winces, and other obvious manifestations of pain? Yes, but it is those very "reminders," as I shall explain, that provoke at least two kinds of forgetting common among physicians­one, (...) psychological and the other, conceptual. The psychological kind of forgetting is primarily self-protective, but the conceptual kind has deeper roots in the very definition of modern Medicine as curative and life-preserving. If my analysis is right, more lecture time on pain and pain relief in medical schools will do little to correct this "forgetting" of pain. But there may be better remedies for pain-forgetting, some already at work in North American medical practices. (shrink)

Disabling pain or symptoms can occur at any age from many different causes. Pain and palliative specialists are able to relieve most pain and symptoms, although repeated adjustments to modalities, medications and doses may be needed. Because pain and palliative specialists comprise only a small percentage of physicians, many patients find it difficult to access them or obtain pain relief. Globally, there are too few such specialists to meet existing needs. Most are affiliated with (...) hospice and palliative units, so their accessibility to patients without terminal conditions is negligible. Doctors outside pain and palliative specialties are often unfamiliar with pain guidelines and sceptical about patient reports of unrelieved pain. They are therefore likely to undertreat it. Undertreating pain, however, violates respect for persons and beneficence. This paper reviews literature supporting these claims and offers a narrative description of the author’s attempts to find relief from shingles and postherpetic neuralgia. It argues that physicians in most specialties are not, but should be, familiar with palliative evidence and guidelines so that they are equipped to relieve pain and symptoms quickly and effectively. Such information should be routinely introduced in medical curricula to encourage the mastery of knowledge, attitudes and skills necessary to upholding ethical principles and to ensure that more doctors in any discipline are willing to believe and be compassionate to patients whose pain is unresponsive to initial treatments. Routinely exposing students to such information would better prepare them to fulfil their professional duties to patients and society. (shrink)

Historically, treatment for pain relief has varied according to the social status of the sufferer. A similar tendency to make arbitrary distinctions affecting pain relief was found in an ethnographic study of animal research laboratories. The administration of pain-relieving drugs for animals in laboratories differed from standard practice for humans and, perhaps, for companion animals. Although anesthesia was used routinely for surgical procedures, its administration was sometimes haphazard. Analgesics, however, were rarely used. Most researchers had (...) never thought about using analgesics and did not consider the subject worthy of serious attention. Scientists interviewed for this study agreed readily that animals are capable offeeling pain, but such assertions were muted by an overriding view of lab animals as creatures existing solely for the purposes of research. As a result, it was the exceptional scientist who was able to focus on anything about the animal's subjective experience that might lie outside the boundaries of the research protocol. (shrink)

At the centre of Arthur Prior’s ‘Thank goodness’ argument for the A-theory of time is a particular form of relief. Time must objectively pass, Prior argues, or else the relief felt when a painful experience has ended is not intelligible. In this paper, I offer a detailed analysis of the type of relief at issue in this argument, which I call temporal relief, and distinguish it from another form of relief, which I refer to as (...) counterfactual relief. I also argue that existing discussions of the ‘Thank goodness’ argument—including Prior’s own—fail to give a satisfactory account of temporal relief, and that it needs to be seen as an emotion linked to the ability to engage in fairly sophisticated forms of planning. I also suggest that this has an impact on Prior’s claim that the idea of points in time plays no fundamental role in the semantic analysis of tenses. (shrink)

Mary was angry. Youre going to take my pain medications away, aren't you? These were the first words she spoke as I walked into the examining room. Mary had a complex medical history, beginning with a back injury in 1988 that led to several surgical procedures, multiple injections of local anesthetic and corticosteroids, and placement of a dorsal column stimulator, none of which provided significant relief of her pain. Crippled by severe and sharp pain in her (...) lower back and left leg, she had sought help from several physicians, and had most recently been referred to me specifically, as she put it, to take away the pain medications.Not that the pain medications had afforded Mary a normal life by any stretch of imagination. She was taking eight to ten moderate strength opioid tablets per day in an effort to decrease her pain. She was not active, choosing to spend most of her time at home. She had quit her job shortly after the work-related accident. In fact, the workman's compensation board is still disputing her claim, and this dispute took a toll on Mary. (shrink)

Mary was angry. Youre going to take my pain medications away, aren't you? These were the first words she spoke as I walked into the examining room. Mary had a complex medical history, beginning with a back injury in 1988 that led to several surgical procedures, multiple injections of local anesthetic and corticosteroids, and placement of a dorsal column stimulator, none of which provided significant relief of her pain. Crippled by severe and sharp pain in her (...) lower back and left leg, she had sought help from several physicians, and had most recently been referred to me specifically, as she put it, to take away the pain medications.Not that the pain medications had afforded Mary a normal life by any stretch of imagination. She was taking eight to ten moderate strength opioid tablets per day in an effort to decrease her pain. She was not active, choosing to spend most of her time at home. She had quit her job shortly after the work-related accident. In fact, the workman's compensation board is still disputing her claim, and this dispute took a toll on Mary. (shrink)