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The undertreatment of pain: Scientific, clinical, cultural, and philosophical factors

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Abstract

This essay provides an explanation and interpretation of the undertreatment of pain by discussing some of the scientific, clinical, cultural, and philosophical aspects of this problem. One reason why pain continues to be a problem for medicine is that pain does not conform to the scientific approach to health and disease, a philosophy adopted by most health care professionals. Pain does not fit this philosophical perspective because (1) pain is subjective, not objective; (2) the causal basis of pain is often poorly understood; (3) pain is often regarded as a “mere” symptom, not as a disease; (4) there often are no “magic bullets” for pain; (5) pain does not fit the expert knowledge model. In order for health care professionals to do a better job of treating pain, some changes need to occur in medical philosophy, education, and practice.

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References

  • Agency for Health Care Policy and Research: 1992, Acute Pain Management in Infants, Children, and Adolescents: Operative and Medical Procedures. Quick Reference Guide for Clinicians. AHCPR Pub. No. 92-0020. Rockville, MD: US Department of Health and Human Services.

    Google Scholar 

  • Agency for Health Policy and Research: 1994, Clinical Practice Guideline: Management of Cancer Pain. US Department of Health and Human Services Rockville, MD.

  • Albert, D., Munson, R. and Resnik, M.: 1988, Reasoning in Medicine. Baltimore: Johns Hopkins University Press.

    Google Scholar 

  • AMA, Council on Scientific Affairs: 1997, 'Good Care of the Dying Patient', Journal of the American Medical Association 275(6), 474–478.

    Google Scholar 

  • Aronoff, G (ed.): 1992, Evaluation and Treatment of Chronic Pain, 2nd edn. Baltimore: Williams and Wilkins.

    Google Scholar 

  • Atkinson, R. and Davies, G.: 1993, 'Issues in Pain Management', in: D. Clark (ed.), The Future of Palliative Care. Buckingham: Open University Press, pp. 148–166.

    Google Scholar 

  • Beauchamp, T. and Childress, J.: 1994, Principles of Biomedical Ethics, 4th edn. New York: Oxford University Press.

    Google Scholar 

  • Beecher, H.: 1956. 'Relationship of Significance of Wound to the Pain Experience', JAMA 161, 1609–1613.

    CAS  Google Scholar 

  • Bilkey, W.: 1996, 'Confusion, Fear, and Chauvinism: Perspectives on the Medical Sociology of Chronic Pain', Perspectives in Biology and Medicine 39 (2), 270–280.

    PubMed  CAS  Google Scholar 

  • Block, N., Flanagan, O. and Guzeldere, G. (eds.): 1997, The Nature of Consciousness. Cambridge, MA: MIT Press.

    Google Scholar 

  • Bradley, G.: 1993, Disease, Diagnosis, and Decisions. New York: John Wiley and Sons.

    Google Scholar 

  • Byock, I.: 1997, Dying Well. New York: Riverhead Books.

    Google Scholar 

  • Cahill, M. (ed.).: 1997, Expert Pain Management. Springhouse, PA: Springhouse.

    Google Scholar 

  • Camus, A.: 1955, The Myth of Sisyphus. New York: Vintage Books.

    Google Scholar 

  • Caplan A.: 1986, 'Exemplary Reasoning? A Comment on Theory Structure in Biomedicine', Journal of Medicine and Philosophy 11, 93–105.

    PubMed  CAS  Google Scholar 

  • Cassell, E.: 1982, 'The Nature of Suffering and the Goals of Medicine', New England Journal of Medicine 306, 639–645.

    Article  Google Scholar 

  • Cassell, E.: 1991, The Nature of Suffering. New York: Oxford University Press.

    Google Scholar 

  • Caudill, M.: 1994, Managing Pain Before it Manages You. New York: Guilford Press.

    Google Scholar 

  • Cleeland, C.: 1998, 'Undertreatment of Cancer Pain in Elderly Patients', Journal of the American Medical Association 279 (23), 1914–1915.

    Article  PubMed  CAS  Google Scholar 

  • Cleeland, C. et al.: 1994, 'Pain and Its Treatment in Outpatients with Metastatic Cancer', New England Journal of Medicine 330, 592–596.

    Article  PubMed  CAS  Google Scholar 

  • Clouser, K. and Zucker, A.: 1974, 'Medicine as an Art: An Initial Exploration', Texas Reports on Biology and Medicine 2, 267–274.

    Google Scholar 

  • Cohen, F.: 1980, 'Post-surgical pain Relief: Patients’ Status and Nurses’ Eedication Choices', Pain 9, 265–274.

    Article  PubMed  CAS  Google Scholar 

  • Culver, C. and Gert, B.: 1982, Philosophy in Medicine. New York: Oxford University Press.

    Google Scholar 

  • Cupples, S.: 1992, 'Pain as a Hurtful Experience: A Philosophical Analysis and Implications for Nursing Care', Nursing Forum 27 (1), 5–11.

    PubMed  CAS  Google Scholar 

  • Dennett, D. 1991, Consciousness Explained. Boston: Little and Brown.

    Google Scholar 

  • Deshano, C.: 1997, 'Michigan Moves Toward Better Pain Management', Michigan Medicine 96 (1), 16–21.

    PubMed  CAS  Google Scholar 

  • De Sousa, R.: 1991, The Rationality of Emotion. Cambridge, MA: MIT Press.

    Google Scholar 

  • Emanuel, E., Daniels, E., Fairclough, D. and Clarridge, B.: 1998, 'The Practice of Euthanasia and Physician-assisted Suicide in the United States', Journal of the American Medical Association 280, 507–513.

    Article  PubMed  CAS  Google Scholar 

  • Emanuel, L.: 1998, 'Facing Requests for Physician-assisted Suicide', Journal of the American Medical Association 280, 643–647.

    Article  PubMed  CAS  Google Scholar 

  • Foley, K.: 1985, 'The Treatment of Cancer Pain', N Eng J Med 313, 84–95.

    Article  CAS  Google Scholar 

  • Foley, K.: 1997, 'Competent Care for the Dying Instead of Physician-assisted Suicide', New England Journal of Medicine 336 (1), 54–58.

    Article  PubMed  CAS  Google Scholar 

  • Gatchell, R. and Turk, D.: 1996, Psychological Approaches to Pain Management. New York: Guilford Press.

    Google Scholar 

  • Goldstein, N.: 1997, 'Inadequate Pain Management: A Suicidogen', Journal of Clinical Pharmacology 37 (1), 1–3.

    PubMed  CAS  Google Scholar 

  • Gorovitz, S. and MacIntyre, A.: 1976, 'Towards a Theory of Medical Fallibility', Journal of Medicine and Philosophy 1, 51–71.

    Google Scholar 

  • Greenville Daily Reflector: 1999, 'VA Doctors and Nurses will Treat Pain as “Fifth Vital Sign” ', Greenville Daily Reflector, 1 February, A2.

  • Hardwig, J.: 1994, 'Toward an Ethics of Expertise', in: D. Wueste (ed.), Professional Ethics and Social Responsibility. Landham, MD: Rowman and Littlefield, pp. 83–101.

    Google Scholar 

  • Harrold, J. and Lynn, J.: 1998, A Good Dying. New York: The Haworth Press.

    Google Scholar 

  • Harvey, W.: 1993, On the Motion of the Heart and Blood in Animals, R. Willis (trans.), Buffalo: Prometheus Books.

    Google Scholar 

  • Hawthorne, J. and Redmond, K.: 1998, Pain: Causes and Management. Oxford: Blackwell.

    Google Scholar 

  • Hill, C.: 1995, 'When Will Adequate Pain Control Be the Norm?', Journal of the American Medical Association 274, 1881–1882.

    Article  PubMed  Google Scholar 

  • Horgan J.: 1997, 'Seeking a Better Way to Die', Scientific American 276 (5), 100–105.

    PubMed  CAS  Google Scholar 

  • Ingham, J. and Foley, K.: 1998, 'Pain and the Barriers to its Relief at the End-of-life: A Lesson for Improving End-of-life Care', The Hospice Journal 13 (1 & 2), 89–100.

    PubMed  CAS  Google Scholar 

  • Jaquette, D.: 1994, Philosophy of Mind. Englewood Cliffs, NJ: Prentice-Hall.

    Google Scholar 

  • Jost, T.: 1998, 'Public Financing of Pain Management: Leaky Umbrellas and Ragged Safety Nets', Journal of Law, Medicine, and Ethics 26, 290–307.

    PubMed  CAS  Google Scholar 

  • Judge, R., Zuidema, G. and Fitzgerald, F. (eds.): 1989, Clinical Diagnosis, 5th edn. Boston: Little, Brown, and Company.

    Google Scholar 

  • Kerns, R., Turk, D. and Rudy, T.: 1985, 'The West Haven-Yale Multidimensional Pain Inventory', Pain 23, 345–356.

    Article  PubMed  CAS  Google Scholar 

  • Kitcher, P.: 1993, The Advancement of Science. New York: Oxford University Press.

    Google Scholar 

  • Knoben, J. and Anderson, P.: 1988, Clinical Drug Data, 6th edn. Hamilton, IL: Drug Intelligence Publications.

    Google Scholar 

  • Little, M.: 1995, Humane Medicine. Cambridge: Cambridge University Press.

    Google Scholar 

  • Lynn, J. and Wilkinson, A.: 1998, 'Quality End-of-life Care: The Case for a Medicaring Demonstration', The Hospice Journal 13 (1 & 2), 151–163.

    PubMed  CAS  Google Scholar 

  • Marks, R. and Sachar, E.: 1973, 'Undertreatment of Medical Inpatients with Narcotic Analgesics', Annals of Internal Medicine 78, 173–181.

    PubMed  CAS  Google Scholar 

  • Martino, A.: 1998, 'In Search of a New Ethic for Treating Patients with Chronic Pain: What Can Medical Boards Do?', Journal of Law, Medicine, and Ethics 26, 332–349.

    PubMed  CAS  Google Scholar 

  • McCabe, M.: 1997, 'Ethical Issues in Pain Management', The Hospice Journal 12 (2), 25–32.

    PubMed  CAS  Google Scholar 

  • McCaffery, M. and Beebe, A.: 1989, Pain: Clinical Manual for Nursing Practice. St. Louis Mosby.

  • McGivney, W. and Crooks, G.: 1984, 'The Care of Patients with Severe Chronic Pain in Terminal Illness', Journal of the American Medical Association 25, 1182–1188.

    Google Scholar 

  • Meadows, J.: 1992, The Great Scientists. New York: Oxford University Press.

    Google Scholar 

  • Melzack, R.: 1984, 'The Myth of Painless Childbirth', Pain 19, 321–337.

    Article  PubMed  CAS  Google Scholar 

  • Melzack, R.: 1990, 'The Tragedy of Needless Pain', Scientific American 262, 27–33.

    Article  PubMed  CAS  Google Scholar 

  • Melzack, R. and Wall, P.D.: 1965, 'Pain Mechanisms: A New Theory', Science, 150, 971–975.

    PubMed  CAS  Google Scholar 

  • Merton, R.: 1973, The Sociology of Science. Chicago: University of Chicago Press.

    Google Scholar 

  • Morris, D.: 1991, The Culture of Pain. Berkeley: University of California Press.

    Google Scholar 

  • Munson, R.: 1981, 'Why Medicine Cannot be a Science', Journal of Medicine and Philosophy 6, 183–208.

    PubMed  CAS  Google Scholar 

  • Ng, B., Dimsdale, J., Sharagg, G. and Deutsch, R.: 1996, 'Ethnic Differences in Analgesic Consumption for Postoperative Pain', Psychosomatic Medicine 58, 125–129.

    PubMed  CAS  Google Scholar 

  • Owen, H., McMillan, V. and Rogowski, D.: 1990, 'Postoperative Pain Therapy: A Survey of Patient's Expectations and their Experiences', Pain 41, 303–307.

    Article  PubMed  CAS  Google Scholar 

  • Pellegrino, E. and Thomasma, D.: 1981, A Philosophical Basis of Medical Practice. New York: Oxford University Press.

    Google Scholar 

  • Pellegrino, E. and Thomasma, D.: 1993, The Virtues in Medical Practice. New York: Oxford University Press.

    Google Scholar 

  • Pitcher, G.: 1976, 'Pain and Unpleasantness', in: S. Spicker and T. Engelhardt (eds.), Philosophical Dimensions of the Neuro-Medical Sciences. Dordrecht: Reidel, pp. 181–196.

    Google Scholar 

  • Popper, K.: 1963, Conjectures and Refutations. New York: Harper and Rower.

    Google Scholar 

  • Porter, R.: 1997, The Greatest Benefit of Mankind. New York: WW Norton.

    Google Scholar 

  • Quill, T., Cassell, C. and Meier, D.: 1992, 'Care of the Hopelessly Ill: Proposed Clinical Criteria for Physician-assisted Suicide', New England Journal of Medicine 327, 1380–1384.

    Article  PubMed  CAS  Google Scholar 

  • Quill, T., Lo, B. and Brock, D.: 1997, 'Palliative Options of Last Resort', Journal of the American Medical Association 278, 2099–2104.

    Article  PubMed  CAS  Google Scholar 

  • Resnik, D.: 1995, 'To Test or not to Test: A Clinical Dilemma', Theoretical Medicine 16, 1–12.

    Article  Google Scholar 

  • Rich, B.: 1997, 'A Legacy of Silence: Bioethics and the Culture of Pain', Journal of Medical Humanities 18, 233–259.

    Article  PubMed  Google Scholar 

  • Rollin, B.: 1997, 'Pain and Ideology in Human a Veterinary Medicine', Seminars in Veterinary Medicine and Surgery 12 (2), 56–60.

    Article  CAS  Google Scholar 

  • Rosenberg, A.: 1995, Philosophy of Social Science, 2nd edn. Press, Boulder, CO: Westview.

    Google Scholar 

  • Schaffner, K.: 1994, Discovery and Explanation in Biology and Medicine. Chicago: University of Chicago Press.

    Google Scholar 

  • Schaffner, K.: 1986, 'Exemplary Reasoning about Biological Models and Diseases: A Relation Between the Philosophy of Medicine and the Philosophy of Science', Journal of Medicine and Philosophy 11, 63–80.

    PubMed  CAS  Google Scholar 

  • Shaffer, J.: 1976, 'Pain and Suffering', in: S. Spicker and T. Englehardt (eds.), Philosophical Dimensions of the Neuro-Medical Sciences. Dordrecht: Reidel, pp. 222–233.

    Google Scholar 

  • Singer, P. and Siegler, M.: 1990, 'Euthanasia: A Critique', New England Journal of Medicine 322, 1881–1883.

    Article  PubMed  CAS  Google Scholar 

  • Sox, H., Blatt, M., Higgins, M. and Marton, K.: 1988, Medical Decision Making. Boston: Butterworths.

    Google Scholar 

  • Starr, S.: 1992, 'The Politics of Pain: A New Attitude Toward Treatment', Drug Topics 136 (18), 60–70.

    Google Scholar 

  • SUPPORT Principal Investigators: 1997, 'A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients', Journal of the American Medical Association 274 (20), 1591–1598.

    Google Scholar 

  • Sullivan, M., Rapp, S., Fitzgibbon, D. and Chapman, C.: 1997, 'Pain and the Choice to Hasten Death in Patients with Painful Metastatic Cancer', Journal of Palliative Care 13 (3), 18–28.

    PubMed  CAS  Google Scholar 

  • Todd, K., Samaria, N. and Hoffman, J.: 1993, 'Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia', Journal of the American Medical Association 269, 1537–1539.

    Article  PubMed  CAS  Google Scholar 

  • Whitbeck, C.: 1995, 'Teaching Ethics to Scientists and Engineers: Moral Agents and Moral Problems', Science and Engineering Ethics 1, 299–308.

    Google Scholar 

  • World Health Organization: 1996, Cancer Pain Relief. Geneva: World Health Organization.

    Google Scholar 

  • Ziman, J.: 1984, An Introduction to Science Studies. Cambridge: Cambridge University Press.

    Google Scholar 

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Resnik, D.B., Rehm, M. The undertreatment of pain: Scientific, clinical, cultural, and philosophical factors. Med Health Care Philos 4, 277–288 (2001). https://doi.org/10.1023/A:1012057403159

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