Bioethics
by James Giordano, PhD
 Halfway through the
congressionally-declared Decade of Pain Control and Research, it may be time for a
reflective pause to ask in both conceptual and practical terms, ‘where we are?’
and ‘where might we be going?’ A review of the past five years’ progress
yields abundant demonstration of ardent strides in research. However, we are also
confronted with evidence that the translation of research developments into viable
therapeutic applications has been less than optimal, and further, that the sustenance of
treatment paradigms that meet the epidemiologically-defined problem of chronic pain is
lacking. This represents a paradox: although we may know more about the basis and
mechanisms of pain and how to treat it, we are becoming ever more disempowered to
effectively act on this knowledge.
In this issue, Michael Schatman speaks to this by illuminating the declining number and
increasingly restricted roles of accredited, interdisciplinary pain management programs.
Despite several lines of evidence to support the durable effectiveness of outcomes
achieved by such programs, he reports the continuing trend to discontinue, or severely
limit the services provided by these centers. Schatman opines that this apparent
contradiction reflects the commodification of medicine in general, and the resultant
pervasion of a business ethos that disavows the benefits of long term pain care as being
inordinately expensive to a healthcare system that is primarily concerned with
proximate-costs. He views the problem as a conflict between business ethics and those of
medicine, and in so doing questions whether the contemporary form of pain medicine has
become inseparable from the effects of corporate systematization. Schatman asserts that a
change is required that responds to the moral obligation to treat those who are in pain,
and that provides ethical guidance to implement supportive healthcare policies.
I agree; the superimposition of the business model upon medicine has enabled the ethos
of profit to suborn the ethics of care. Yet, if a change is to occur, it must not only
restore the clinical empowerment of pain management programs, but must also maintain their
economic viability. This will allow them to be effective and still survive in a healthcare
market that is not likely to change in the immediate future. Schatman astutely notes that
the ethics of business and medicine differ, due at least in part, to the divergent ends
and goals of these fields. It is the ends of an undertaking that direct the ultimate focus
of its activities, and often determine the nature of the conduct of those actions.1
In this light, it becomes apparent that the motives of business that foster
commodification of healthcare as instrumental to ends of profit cannot be resonant with
the beneficent and just provision of medical services to restore health as a fundamental
good.
I argue that to change this situation, the apparent dualism of business and medicine
must somehow be ameliorated to meet a more monistic paradigm in which the corporate and
clinical components of medicine are equivalently dedicated to the common end of rendering
right and good care to patients. Such amelioration may seem obtuse, yet I offer the
following premises to support this proposal. First, while there is an aspect of business
within the practice of medicine, it is crucial to recognize that medicine is not a
business. It is a profession that is dedicated by covenant to the primacy of the good of
the patient.2 Second, medicine is non-proprietary, and is not a commodity to be
restricted through market manipulation. Third, as Gini states, business is, by its nature,
about serving people.3 Thus, once the profit-focal ends of corporate medicine
are aligned with those of the clinical enterprise, the ‘business’ of pain
medicine could be situated to provide the administrative and financial means through which
medical resources are most effectively made available to those persons who are in pain. In
many ways this conceptualization reflects the prudential question of ‘what should be
done’ to best afford medically right and ethically sound provision of care to the
patient.4
I argue that the basis of this change requires the establishment of a
teleologically-construed (i.e., ends-based) ethical framework that reconciles the apparent
inimical tension between business and medicine.5 One possible way that this may
be achieved is through incorporating Peters and Waterman’s “excellence
model” into corporate medicine to embody what Klein has called the “craftsman
ethic.”6,7 This system emphasizes quality of knowledge, skill, products,
and services that are delivered within, and ultimately serve the end(s) of enhancing the
substantive “goods” of the human relationships inherent to the practice.8
Working within this model, the values and ends of the clinical and corporate domains of
medicine can become more effectively mutualized. By acting consistently toward these ends,
any achievement of profit would not be misfeasant, because it is not gained through
sacrificing patient care. Rather, the (technically right and ethically sound) success of
the services rendered would foster increased utilization, and therefore continued subsidy.
Given mutual purpose, I maintain that any real change can only occur through the
leadership of individuals who act directly as change agents. This leadership must be
transformational and concerned with, and dedicated to the primacy of the good of the
patient. According to Burns, transformational leaders are committed moral agents whose
actions influence the vision and direction of both followers and the organization.9
Through example and empowerment, the transformational leader turns their followers into
leaders, and catalyzes change by allying the actions of what Engelhardt has called
“moral friends” who possess common intentions, beliefs and values.10
In this light, I argue that character is essential to the worth and good of leadership,
for it provides the personal substance of agency. If we consider character to be the
permanent, incised qualities of a person’s existential fabric, it is the moral
virtues of character that afford the pre-disposition to consistently act toward ends that
are right and good.11,12 They thus provide a grounding: 1) in situations of
moral conflict, 2) toward the reconciliation of other ethical positions, and 3) in the
negotiation of imposed ethical skepticism. It is from this position that I have argued,
and argue here for the importance of a virtue-based ethics in pain medicine, with
particular emphasis upon phronesis, the balancing virtue of practical wisdom.13,14
I feel that the moral and intellectual virtues are of equal importance to leadership in
both the clinical and corporate domains of medicine, for it is this balance, in the
Aristotelian sense, that allows the practically wise individual (i.e., the phronimos) to
make moral decisions with integrity, insight, knowledge and experience.15,16
Who shall these leaders be? In revising the dualism of business and medicine to favor a
patient-centered, monistic approach to medical enterprise, it becomes apparent that such
leaders must be individuals who have knowledge, skill and experience of pain medicine.
Pain management clinicians possess the requisite domains of knowledge and values that
enable the execution of practical wisdom in matters that respectively affect actions and
conduct pursuant to the ends of medicine. Certainly, these individuals, as
“champions” of the vision and values of effective pain management, could well
provide the transformational leadership necessary to catalyze the much-needed changes in
the corporate culture of pain medicine. Of course, such leaders will require training that
directly fortifies the application of their skills and knowledge to corporate steerage.
Noren and Kindig emphasize that the development of the next generation clinician-executive
necessitates experiential learning to deepen both medical insight and professional
leadership competence.17 Possible educational venues to achieve this training
are discussed by Waldhausen.18 Formalized didactic and applied training
programs could be developed between academia and interdisciplinary treatment centers to
both meet demographically identified pain management needs of particular regions and
cultivate medical leaders who possess practical knowledge and sensitivity to those patient
populations. Realistically however, such educational and experiential venues to develop
clinician-executives cost money. Without subsidy, opportunities to create these future
leaders in pain medicine will become increasingly unavailable, and the system will
continue its present course, making this argument moot. Perhaps funding incentives
generated by the National Pain Care Policy Act will establish reasonable junctures for
training and ultimately to allow clinician-executives to assume positions of influence
within the corporate hierarchy of pain medicine, and healthcare in general. It is a start,
and a step in the right direction. But as Schatman notes, the gears of government grind
slowly; we cannot passively wait and expect that change will occur. Indeed, it must be
instigated, reinforced, and assertively led. But even the most empowered leader cannot
evoke change alone,19 for although change may involve “top-down”
implementation of policy, the true champions for such change are very often local leaders
who contribute an initiative voice of purpose and priorities.20 The nature of
the clinical relationship has the potential to establish each practitioner as a leader by
choosing to do what is right and good for the patient in pain, and in so doing contribute
to the moral integrity of a professional community that strives toward an end that is
meaningful. n
James Giordano, PhD is Scholar-in-Residence at the Center for Clinical Bioethics,
Georgetown University Medical Center, Washington, DC and is a Visiting Fellow of the John
P. McGovern Center for Health, Humanities and the Human Spirit, Texas Medical Center,
Houston, TX. The author of over fifty peer-reviewed publications in neuroscience,
bioethics and medical philosophy, his ongoing research focuses upon neural mechanisms of
chronic pain, neuroethics and the philosophical basis and ethics of pain medicine,
neurology and psychiatry. Dr. Giordano was the 2004 recipient of the American Academy of
Pain Management’s Richard Weiner Pain Education Award. He can be contacted at: The
Center for Clinical Bioethics, Georgetown University Medical Center, 4000 Reservoir Rd,
Bldg. D, Washington, DC 20057; email jgiordano@neurobioethics.org.
References and Notes
1. Aristotle. The Nicomachean Ethics. Book I, Ch. 1, T. Irwin (trans.). Hackett
Publishing. Indianapolis. 1999. pp 1-2.
2. Pellegrino ED. The healing relationship; Architectonics of clinical medicine. In: EE
Shelp (ed) The Clinical Encounter: The Moral Fabric of the Physician-Patient Relationship.
Reidel. Boston. 1983.
3. Gini A. Moral leadership: an overview. J Business Ethics. 1997. 16(3): 323-330.
4. Pellegrino ED. The anatomy of clinical judgments: some notes on right reason and right
action. In: HT Engelhardt, SF Spicker, B Towers (eds.) Clinical Judgment: A Critical
Appraisal. Reidel. Dordrecht 1979. pp 169-194.
5. The term teleological is used here in the strictest sense to describe an ethical system
that is based upon, and derived from focus upon a defined end (i.e., a telos), to which
any and all acts should be pursuant and with which these acts should be morally
consistent. This does not imply consequentialism.
6. Peters TJ and Waterman RH. In Search of Excellence. HarperCollins. NY. 2004.
7. Klein S. An Aristotelian view of theory and practice in business ethics. Int J of
Applied Philosophy. 1998. 12 (2): 203-222.
8. William F. May states that the covenantal fidelity inherent to healthcare obligates
respect of three fundamental features: 1) that healthcare is a fundamental good; 2) that
it is not the only fundamental good, and as such must be efficient and cost-effective.
These considerations are not maintained in the economic sense, but as moral imperatives
against waste or injustice; and 3) that healthcare is a public good, such that those who
are involved in healthcare bear the responsibility of public investment in that
fundamental good. See: May WF. The Physician’s Covenant. Revised edition. Westminster
Press. Philadelphia. 2000.
9. Burns JM. Leadership. Harper Torchbooks. NY. 1978.
10. Engelhardt HT. Foundations of Bioethics. 2nd. Ed. Oxford. NY. 1996.
11. Cooper JM. Reason and Human Good in Aristotle. Harvard University Press. Cambridge,
MA. 1975.
12. MacIntyre A. Dependent Rational Animals: Why Human Beings Need the Virtues. Open Court
Press. Chicago. 1999.
13. Giordano J. Toward a core philosophy and virtue-based ethics of pain medicine. Pain
Practitioner. 2005. 15(2): 59-66.
14. For a detailed discussion of phronesis in medicine, see Davis, D. Phronesis, clinical
reasoning and Pellegrino’s philosophy of medicine. Theoretical Medicine. 1997. 18:
173-195; Robert Solomon addresses Aristotelian ethics in business (Corporate roles,
personal virtues, moral mazes: An Aristotelian approach to business ethics. In: CAJ Coady,
CJG Sampford (eds.) Business Ethics and the Law, Sidney, AUS, Federal Press, 1993, pp 30),
and pays particular attention to Aristotelian definitions of virtues and their role in
corporate integrity and cooperativity in Ethics and Excellence: Cooperation and Integrity
in Business. Oxford University Press. NY. 1993.
15. Ibid, 1. Aristotle, The Nicomachean Ethics, Book II, Chapter 6, pp 23-24 (on character
and virtue) and Book VI Chapter 12-13, pp 96-98.
16. A complete discussion of theoretical and applied Aristotelian concepts of virtue and
excellence (i.e.- aretaics) see: WER Hardie, Aristotle’s Ethical Theory. Clarendon
Press. Oxford. 1980.
17. Noren J and Kindig DA. Physician-executive development and education. In: B
LeTourneau, W Curry (eds.) In Search of Physician Leadership. Health Administration Press
Chicago, IL. 1998.
18. Waldhausen J. Leadership in medicine. Bull. Amer. Coll. Surgeons. March 2001. pp
15-19.
19. Bass BM and Steidlmeier P. Ethics, character and authentic transformational leadership
behavior. In: JB Ciulla (ed.) Ethics, the Heart of Leadership. Praeger. Westport, CT.
2004. pp175-196.
20. The respective contribution of individuals and communities in the process of
identifying purpose, developing plan and influencing programs and policies are addressed
by Jack Glazer, Ann Neale et al. as components of regional dialog; see:
www.OurHealthcareFuture.org.
— Jan/Feb 2006
The full article is now available as a PDF and may be
purchased for $5 and downloaded immediately:
|