In recent years, several publications have appeared in German medical ethics that had as their thematic focus the ethical reflection on the topic “pain and medicine”. No wonder – estimates of the proportion of people in Germany who are affected by chronic pain and who are confronted with the consequences of chronic pain are varying between 14 and 28%.[1] At the same time, some studies, on which recent ethical publications are based, talk about the fact that in the future we can probably expect a further, possibly significant, increase in diseases with chronic pain.[2] Other studies on which the ethical articles are based conclude that in Germany up to 60% of patients with chronic pain “do not receive adequate pain therapy that takes into account the entire biopsychosocial issue.”[3] The ethical debate in German medical ethics, which has recently been paying more intensive attention to the topic, responds to the deepening urgency of the topic under investigation. I would like to present some of the points of this debate in the following lines:
One of the points of the ethical debate is the differentiated distinction between acute and chronic pain: In the case of acute pain, we can talk about a primarily physiological problem (the key role here play a ‘medical-technical solution’); in the case of chronic pain, it turns out that the solution requires a multi-perspective approach, since chronic pain has varying degrees of impact in the social, existential, psychological, and perhaps also spiritual areas for patients who are confronted with it.[4] The first challenge for an ethically anchored approach to pain therapy with respect to chronic pain is therefore to strive for a multidisciplinary perspective that respects and implements a holistic approach to chronic pain therapy in pain management.
Alleviating pain, as well known, is one of the central tasks of medicine. For example, a Hastings Center report from the late 1990s lists the alleviation of pain as one of the four goals of medicine.[5] As one of the main tasks of medical action, the alleviation of suffering was seen already in antiquity and throughout the following centuries. However, it was not until the discovery of effective analgesics and anesthetics during the 18th and 19th centuries that we had truly effective pain relief drugs available.[6] On the one hand, this development has resulted in a significantly more effective fight against pain compared to earlier times, which of course must be evaluated positively, on the other hand, however, medicine is currently “confronted with very high expectations of the possibilities of alleviating or eliminating pain.“[7] This fact, in addition to a multi-perspective or holistic approach to the treatment of (especially chronic) pain, is another point that repeatedly appears in the ethical publications on pain and medicine in the recent ethical debate. This debate emphasizes also the following points:[8]
The first group of considerations points to the limits of medicine’s possibilities in the field of alleviating and eliminating pain. The actors of the debate point out that it would be illusory to expect from medicine, despite the unmistakable and enormous advances in this field of medicine in recent decades and centuries, that medicine could completely remove pain from human life, or even that it would be possible to expect the creation of a society in which pain would not exist at all. Medicine and medical practice should strive for the maximum possible removal and alleviation of pain. At the same time, however, it cannot be expected that medicine can always eliminate all pain (after all, pain is sometimes even accepted as a suffered side effect during medical operations for the purpose of important, meaningful and intended therapeutic goals, as is the case, for example, when taking blood). In acute pain, moreover, pain can also play the role of a warning signal for solving a more serious health problem as such. Therefore, it remains a challenge for medicine not only to treat pain correctly, effectively and with a holistic interest in the person of the patient who is suffering from pain, but also for medicine to balance responsibly in the following field of tension – to “prevent preventable pain, but at the same time establish acceptance for the contingent things, which also belong to human life.”[9]
The second area of consideration points to the need for “stronger targeting of the conditions for a successful life with and despite pain.”[10] Thus, the question of how “persons who suffer from pain can lead a dignified life with pain and despite pain and how they can be supported while doing so”[11] also comes to the fore. This does not mean in the slightest that alleviating and eliminating pain, which represents one of the central tasks of medicine, is put aside, but it is meant to point out the fact that pain therapy includes, in addition to the fight against pain, also commitment to a successful life with pain and despite pain.[12] Giovanni Maio uses the following image to describe this approach: “Pain is unwelcome, it is unpleasant, one will never be able to make friends with it – but one can manage it, manage it by keeping it, so to speak, as a guest in a house that is unwelcome, but with which one can still live, even if one would rather leave it out. […] One cannot determine when the pain will come, one cannot determine whether one wants to have the pain or not, because the pain simply imposes itself without asking. But one can determine what kind of experience the person makes with the unwelcome guest. One can determine whether he/she will experience a life that does not make sense, or he/she will open himself up to the experience that pain will also show him/her resources, resources that every person has. Resources to relate to pain just like that or otherwise, to stand up to the totalizing tendencies of pain, to stand up to the tyrant. Not by being able to control or prevent the pain, but by showing her that she is only a guest in the house, not its master.”[13]
When taking a holistic view of the topic of pain and medicine, however, it appears that other levels, such as the social, psychological or existential levels, also play an important role in the management of chronic pain. This fact should be reflected in the treatment of chronic pain. This brings me to the next point, which resonates in the German medical ethics debate (and this point may well take over the role of the final word): The tasks of medicine in terms of alleviating and eliminating pain also include “the duty not to leave sufferers alone in their suffering, even when, or precisely when it is not in its power to completely free the patients from their pain, suffering and despair.”[14] Claudia Bozzaro supplements this consideration with two conditions:
“First of all, one must be prepared for one’s own confrontation with existential questions, since the suffering of others immediately reflects one’s own vulnerability and finitude. Second, it presupposes space and time. Space and time for conversation, listening, attention, compassion. All these are not, on closer inspection, purely medical tasks. And this task does not belong exclusively to physicians and health professionals and should not be unilaterally shifted to them. Providing support to those who suffer is not primarily a medical issue, but an issue of the humanity of each person and society as well as an expression of the mutual responsibility we as humans have for one another.”[15]
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[1] Cf. K. Kieselbach; M. Schiltenwolf; C. Bozzaro: “Versorgung chronischer Schmerzen: Wirklichkeit und Anspruch”. Schmerz 2016, 30, 351–357, 351; D. Koesling; K. Kieselbach; C. Bozzaro: “Chronischer Schmerz und Gesellschaft: soziologische Analyse einer komplexen Verschränkung”. Schmerz 2019, 33, 220–225, 220.
[2] Cf. F. Besle et al..: Morbiditätsprognose 2050: ausgewählte Krankheiten für Deutschland, Brandenburg und Schleswig-Holstein. Kiel: IGSF-Stiftung, 2009.
[3] K. Kieselbach; M. Schiltenwolf; C. Bozzaro: “Versorgung chronischer Schmerzen: Wirklichkeit und Anspruch”. Schmerz 2016, 30, 351–357, 351.
[4] Cf. C. Bozzaro; D. Koesling: “Zur Phänomenologie des Schmerzes und zu dessen ethischen Implikationen”. In: H. Bornemann-Cimenti; K. Lang-Illievich (Hg.): Schmerz: ein facettenreiches Phänomen. Wien: Maudrich, 2019, 27–42, 33; G. Maio: Den kranken Menschen verstehen: für eine Medizin der Zuwendung. Überarbeitete Neuausgabe. Freiburg i. Br.: Herder, 2020, 33–34.
[5] Cf. D. Callahan: “The Goals of Medicine: Setting New Priorities”. Hastings Center Report 1996, 26(6), 1–28.
[6] Cf. C. Bozzaro: “Der Leidensbegriff im medizinischen Kontext: ein Problemaufriss am Beispiel der tiefen palliativen Sedierung am Lebensende”. Ethik in der Medizin 2015, 27, 93–106, 102–103.
[7] D. Koesling; K. Kieselbach; C. Bozzaro: “Chronischer Schmerz und Gesellschaft”, 223.
[8] Cf. M. Schiltenwolf; K. Kieselbach; C. Bozzaro: “Schmerz aus anderen Perspektiven”. Schmerz 2016, 30, 315–316.
[9] C. Bozzaro: “Zum anthropologischen Stellenwert des Schmerzes”. Schmerz 2016, 30, 317–322, 321; C. Bozzaro: „Schmerz und Leiden als anthropologische Grundkonstanten und als normative Konzepte in der Medizin“. In: G. Maio; C. Bozzaro; T. Eichinger (Hg.): Leid und Schmerz: konzeptionelle Annäherungen und medizinethische Herausforderungen. Freiburg i. Br.: Alber, 2015, 13–36, 29.
[10] M. Schiltenwolf; K. Kieselbach; C. Bozzaro: “Schmerz aus anderen Perspektiven”, s. 315.
[11] C. Bozzaro; D. Koesling: “Zur Phänomenologie des Schmerzes und zu dessen ethischen Implikationen”, 41.
[12] Cf. G. Maio: Den kranken Menschen verstehen, 42.
[13] G. Maio: Den kranken Menschen verstehen, 42–43.
[14] C. Bozzaro: „Schmerz und Leiden als anthropologische Grundkonstanten und als normative Konzepte in der Medizin“. 33.
[15] C. Bozzaro: „Schmerz und Leiden als anthropologische Grundkonstanten und als normative Konzepte in der Medizin“, 33.