JLME Volume 33:4, 2005
    JLME Volume 31:1, 2003
    JLME Volume 29:1, 2001
    JLME Volume 26:4, 1998
    JLME Volume 24:4, 1996

(c) 2003 by the American Society of Law, Medicine & Ethics. All rights reserved.

As medical technology becomes more sophisticated, 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. The multiplicity of factors that influence the perception and expression of pain take on special importance in the health care setting, where pain becomes an interpersonal experience between the sufferer and the reliever. How pain is signified by the patient and understood by the provider determines in large measure how it is valued and, ultimately, how it is treated.

If the perception of and response to pain are to be understood in a useful way, they must be examined in the context of culture, gender, imbalances of power, morality, and myth. This paper will not address the anthropological dimensions of pain--how patients of different cultural and ethnic backgrounds experience and express pain. Rather, we focus on professional attitudes toward pain management, and we suggest there is a moral imperative for relieving pain that transcends (1) the expressed wish to be treated, and (2) the informed consent process. Even though informed consent has become the lens for viewing the doctor-patient relationship, it is not a singularly useful model in the treatment of pain. We argue that the ethical duty of beneficence is sufficient justification for providers to relieve the pain of those in their care absent rejection of analgesia by a capacitated patient.

Accordingly, this discussion will be framed by the following questions:

• What is the philosophical significance of pain and how is it reflected in the physician's obligation to relieve pain?
• Do ethnicity, gender, age, and race make a significant difference in how people perceive, experience, and react to pain?
• Do the differing values placed on the expression and relief of pain affect the interaction between patients and providers, or the effectiveness of care giving?
• How are the ethical principles of autonomy and beneficence implicated in the pain experience?
• How is the process of informed consent changed by incorporating issues of pain?

The moral imperative to relieve pain

Pain, suffering, and choice

During the past thirty years, the ethic of medical care in the United States has changed radically. The traditional paradigm was largely paternalistic--the doctor would decide what was medically appropriate and present it to the patient, not for consent, but for assent. Today, the governing ethic is anti-paternalistic. Bioethicists, philosophical and legal scholars, physicians, and judges all have made a powerful case for patient autonomy and have objected to paternalistic medicine on the grounds that it supplants patient values and preferences with those of the provider.

Given personal idiosyncrasies, frequent denial of reality, and greater or lesser dependence on others for strength and direction, autonomy becomes very complex. Because it focuses primarily on self-determination and liberty, with less attention to the needs for support, autonomy alone cannot provide a sufficiently rich doctrine to inform the doctor-patient relationship. In defining the moral framework for this relationship, we must consider other values.

Principled analyses of the doctor-patient relationship suggest that it is the dual obligation of physicians to respect and promote the autonomy of their patients and to protect and enhance their well-being. This obligation of beneficence requires physicians to do good and prevent harm, the list of goods typically including prolongation of life, restoration of function, and relief of pain and suffering. Whether something is counted as a good or a harm depends on the specific circumstances, the patient's values, and some shared notions of suffering and well-being.

Despite its subjective quality, the experience of pain is both real and reverberating. As one writer describes it,

Pain is dehumanizing. The severer the pain, the more it overshadows the patient's intelligence. All she or he can think about is pain: there is no past pain-free memory, no pain-free future, only the pain-filled present. Pain destroys autonomy: the patient is afraid to make the slightest movement. All choices are focused on either relieving the present pain or preventing greater future pain, and for this, one will sell one's soul. Pain is humiliating: it destroys all sense of self-esteem accompanied by feelings of helplessness in the grip of pain, dependency on drugs, and being a burden to others. In its extreme, pain destroys the soul itself and all will to live.

The lay, medical, and bioethics literatures tend to equate pain and suffering, and most people assume that the greater the pain, the greater the suffering. However, as Dr. Eric Cassell points out, pain and suffering are, in fact, distinct phenomena. He gives as an example childbirth: although the pain can be extreme, many women regard the experience as joyous and life-enhancing. Conversely, some people may suffer greatly even when they are not in great (physical) pain, perhaps in anticipation of pain.

When pain and suffering are closely related, Cassell claims, it is for one or more of the following reasons: the pain is overwhelming; the patient does not believe the pain can be controlled; the source of the pain is unknown; or the pain is apparently without end. Suffering is preeminently a threat to the personhood of patients--a threat not merely to their lives, but also to "their integrity as persons." Only when one's continued existence is threatened in this way can the experience of pain properly be said to cause suffering. Thus, when patients are told their pain cannot be managed, diminished, or controlled, they frequently experience suffering because they believe their personal intactness is jeopardized. In some instances, emotional isolation adds to patients' suffering, as when the physician suggests that the pain is only imagined.

Common parlance often distinguishes among physical, spiritual, or emotional pain, that is, between pain that is physiological or psychological in origin. But, whether we speak of different kinds of pain or of pain and suffering, the relief of physical pain is regarded as a primary moral goal of medicine because of its intimate connection with patient well-being.

As a threshold matter then, it is necessary to understand this relationship between pain and well-being, and why the obligation to serve patient well-being encompasses the obligation to relieve pain. "No one wants to be in pain," is a rather careless way of expressing a commonly shared assumption. It is important to distinguish between (1) wanting to live a life that is free of pain, and (2) wanting to be relieved of the pain one is currently experiencing. Given a choice between living pain-free and living with some admixture of pain and pleasure, it would not seem wise to choose the former. A life without pain would be rather shallow and uninteresting, and would leave one vulnerable to the injury and disease that pain often signals.

The obligation of physicians to relieve pain is what moral philosophers call a prima facie or conditional obligation, something physicians ought to do unless some other duty or moral consideration takes precedence. One such consideration is the refusal of a decisionally capacitated patient to have her pain relieved. Pain control may be welcomed by some who are capable of choosing, while others may view it as yet another instance of unwarranted physician paternalism. For example, if a patient with the capacity to make health care decisions says she wants the pain to continue because for her it has redemptive meaning, then the obligation to relieve pain is overridden. The patient is saying that, although in pain, she is not suffering or that the suffering is chosen and accepted.

A more common reason for electing to experience pain is the choice of cognition and affective response over relief. Many patients refuse higher doses or more potent pain medication because they do not want chemically to compromise their intellectual and emotional awareness. For these individuals, the choice is a deliberate and delicate value-based balance between relief of pain and erosion of personality.

But suppose a patient is incapacitated and clearly in pain. Should efforts always be made to provide relief? Does the incapacity automatically abrogate choice? Although honoring the wishes of a capable individual shows respect for the person, withholding relief from one who cannot decide or communicate is a form of abandonment, indefensible for caregivers. Compassion, then, is the basis of a moral presumption favoring pain relief. It will always tip the balance in favor of pain relief if the patient can no longer choose or if the patient's intent is in question. Pain is not always devalued, but it is something we need a compelling reason not to treat. The most humane approach, and the one to which caring physicians are disposed, is to relieve pain until evidence of patient refusal is forthcoming.

The response of caregivers to patients' pain behaviors

Just as patients' attitudes about and responses to pain are affected by their personal and cultural values, so are those of their caregivers. For example, physicians' clinical judgments about pain are influenced by group-based factors, including age, gender, race, and ethnicity, as well as physical appearance, with the more attractive patients perceived as experiencing less pain than those who are physically unattractive.

The effect of age and gender stereotyping on how patients are medicated for pain was studied by Karen Calderone. Because physicians and nurses saw women as more emotionally labile and prone to exaggerating pain complaints, they were given analgesia less frequently and sedatives more frequently than male patients. These gender distinctions were not related to the patients' sensory perceptions, only to their overt expressions of pain, with women seen as more expressive. Both men and women under sixty-one years of age received more frequent pain medication than their elders; younger men were medicated most frequently and older women least frequently.

A 1993 study by Knox Todd et al. of patients treated for long-bone fractures at the UCLA Emergency Medicine Center found that Hispanics were twice as likely as non-Hispanic whites to receive no medication for pain. Todd et al. explain the distinction as (1) culturally influenced expressions of pain, and (2) the failure of health care professionals to recognize the presence of pain in patients whose cultural backgrounds differ from their own. The study suggests that the difference in how doctors managed the two groups may occur either when pain is assessed or when analgesia is ordered. A subsequent study of the same population found that, although physicians did not assess pain differently in the two groups, their estimates of pain in both were consistently lower than those of the patients themselves. The ethnically based inequity in pain treatment was found again in the follow-up study, with Hispanics receiving analgesia less often than non-Hispanic whites. Nevertheless, Todd et al. reject the notion that cultural bias among physicians aware of similar pain in two patient groups could account for their undertreating one group.

The balance of power between provider and patient is yet another theme in the pain management interaction. So long as therapeutic control is vested in the caregiver, the patient remains the passive victim of pain. In examining the "regularly and systematically inadequate" treatment of severe pain in hospitalized patients, Dr. Marcia Angell asserts that the standard "prn" (administer as needed) regimen makes patients powerless supplicants, forcing them to endure pain until the next scheduled opportunity to ask for medication. Even then, she concedes, the request might be inhibited by the patient's "desire to please the medical staff and not be a nuisance." The result is an adversarial, rather than a therapeutic, relationship. Dr. Angell suggests a more flexible regimen, which prevents rather than treats pain and better balances the treatment benefits and risks.

Caregivers' responses to their patients' pain are also shaped by their understanding--often misunderstanding--of pain and the agents for its relief. Numerous studies have demonstrated that inadequate professional education and the susceptibility of health care providers to misconceptions and unfounded fears about opioid addiction and related regulation undermine effective analgesia. These misconceptions are also shared by the lay public. A 1993 survey found that 92 percent of Americans accept pain as an inevitable part of life, with most having either experienced severe pain or observed it in someone close to them. Even so, most Americans were found to reject what they believe to be effective medicinal pain relief because they fear overreliance and/or addiction. These fears, plus concerns about legal liability, are reflected in the stringent laws regulating drug prescription and the suspicion of health care providers who see patient requests for pain relief as drug-seeking behavior related to addiction. The unsurprising result is the routine undermedication of even terminally ill patients.

These interesting and counterintuitive findings may have their roots in beliefs that are not peculiarly American, but common to Western cultures generally. Commenting on the Agency for Health Care Policy and Research practice guidelines on pain, Patricia Crowley asserts that the current health care standard of treating acute pain retroactively rather than preventively stems from two well established myths of Western culture: (1) enduring pain is a character-building, moral-enhancing endeavor, and (2) patients who receive pain medication will become addicted to the drugs.

Pain, suffering, and death

An article by Dr. Timothy Quill presents the obligation of health care providers to help terminally or severely ill patients achieve a "good death." He focuses on the needless suffering of those whose experiences have left them terrified of a bad (painful, prolonged, lonely) death. He argues that it is the provider's duty to relieve pain, suffering, terror, and fear of abandonment. Dr. Quill notes that, given data that 50 to 100 percent of pain can be effectively relieved, dying patients must be reassured and then provided effective pain control while being helped to remain as alert as possible.

An oft-quoted article by Dr. Sidney Wanzer et al. about the care of hopelessly ill patients examines an array of accepted treatment policies, their implementation and deficiencies, including pain management. Dr. Wanzer et al. assert that not only should patients be treated aggressively with pain medication, as much and as often as necessary, but they must also be reassured early in the terminal disease process that they will not be allowed to suffer.

Physician-assisted suicide, a subject of growing concern within the lay, medical, and legal communities, also has implications for any discussion of pain attitudes, behavior, and management. A substantial body of evidence indicates that many if not most people who request assistance in ending their lives are really seeking their doctors' help in ending their pain, and that what patients fear more than the prospect of death is the prospect of life with unrelieved pain. The clear implication is that severe and unremitting pain may make even death seem preferable, and that such a request may in fact signal the need for more aggressive palliation rather than assisted suicide.

Decision making, informed consent, and pain

Autonomy, beneficence, and consent to pain relief

The ethical principles that classically inform a bioethical analysis are autonomy (respecting the privacy and self-determination of the individual), beneficence (providing benefits and balancing risks or burdens against those benefits), nonmaleficence (avoiding harm), and justice (fairly distributing the risk, burdens, and benefits). Pain and its relief implicate especially autonomy and beneficence, and discussions of pain management and informed consent highlight the tension between the two principles.

Autonomy underlies decision making that gives priority to the values and wishes of the individual when they are not legitimately restricted by the rights of others. It is only when the individual's wishes are obscure, inaccessible, or overridden by competing principles that the judgment of others is substituted. This concept of the individual and independent self is accorded near reverence in Western cultures. Indeed, commentators challenge the attempt of American bioethics to define its concepts and frame its discourse in terms so unbiased and culturally neutral as to create the impression of universality. In fact, its principles reflect mainly Western values and it is asserted that patient autonomy is almost exclusively a product of the Western preoccupation with individuality and self-control.

The principle of beneficence underlies obligations to benefit others and the ways in which these obligations are fulfilled. These behaviors include actions that defend, prevent harm, and rescue those in danger. Beneficence is the principle with arguably the greatest resonance for care-givers, whose mission is to provide patients with therapeutic benefit and shelter from harm. These notions of nurturing and protecting reach fullest expression in caring for those who are the most vulnerable, conferring a special responsibility on those who care for the very young, the very old, those who are suffering, and those who are incapable of looking after themselves.

In the health care setting, autonomy is reflected most prominently in the doctrine of informed consent. This paradigm of self-determination is the process of knowledgeable and expressed choice whereby a decisionally capacitated individual, who has been apprised of the risks and benefits of a proposed treatment, grants explicit permission for or rejects a particular intervention. It is by now well established theory, although not always well established practice, that the contemporaneous or prior expression of treatment wishes by a capacitated individual controls the health care decision. The doctrine of informed consent represents the legal embodiment of the right to self-determination in health care. In addition, it guides the process of medical decision making by defining the parameters of the patient-physician dialogue.

The roots of informed consent

The ethical and legal roots of informed consent provide the basis for its power. The notion of informed consent was initially grounded in the law of assault and battery, holding that any unconsented-to touching constituted an unlawful act. The subsequent trend toward negligence rather than battery reflected judicial dissatisfaction with the artificial notion that consent either did or did not happen. The doctrine of negligence permits a nuanced examination of whether the discussion reflected the risks and benefits that were material to this patient. Although modern law treats failure to disclose as an action in negligence, the patient's right to make knowledgeable health care decisions has expanded the focus to make the informed consent process act as a protection of privacy and autonomy, rather than as a barrier to negligent failure of a "duty to warn." Finally, in the current climate of malpractice, cost containment, and managed care, informed consent has become a defensive weapon of risk management.

Courts hearing negligence cases based on absence of informed consent tend to rely on an objective reasonable person standard, which assumes that the reasonable person is one holding Western values and favoring Western-defined approaches to medical decision making. In contrast, a subjective standard requires physicians to disclose information relevant to the particular patient and judges whether that individual would have reached the same decision absent disclosure. Ultimately, a subjective standard evokes a richer notion of informed consent by considering the diverse ways and the different contexts in which patients and physicians communicate and make decisions. Although courts have not adopted a pure subjective standard, recent statute and case law have considered the importance of patients' particular values in making medical decisions and suggest a trend toward a more patient-centered notion of informed consent.

During the past thirty years since the explosion of the various rights movements, the ethical principle of autonomy has become the major support for individual empowerment and self-determination. In virtually every social sphere, the aim has been to level the playing field by eliminating power imbalances caused by race, gender, class, and education. In the health care setting, the twin notions of patient as partner in medical decision making and patient as informed health care consumer reflect patient autonomy as the controlling principle. Simultaneously, malpractice litigation involving informed consent placed the wishes of the patient, rather than the conventions of physician practice, at the core of possible liability for negligent disclosure. In time, patients came to see informed consent as their offensive security against physician overreaching, while doctors perceived it as their defensive protection against charges of malpractice--the medical equivalent of a pre-nuptial agreement. The unfortunate result is an adversarial rather than therapeutic climate, with informed consent as the weapon of choice.

Because of its ethical and legal supports, informed consent is now broadly accepted as indispensable to patient rights, the violation of which essentially invalidates the legal and ethical propriety of medical treatment. However, autonomy itself is a doctrine that may be imposed on individuals whose values support a more communally experienced ethic. The elevation of patient autonomy to its preeminent position has increased the potency of explicit patient permission to the point where it effectively trumps all other avenues for determining and implementing what is in the patient's best interests. Exalting the patient's right to exercise autonomy has correspondingly restricted the doctor's discretion and opportunities for therapeutic intervention. Ironically, the pursuit of greater patient power has actually devalued the physician's duty of beneficence. The obsession with autonomy has led to a fetish of informed consent that substitutes delivery of consumer-chosen health care for the provision of patient-oriented health caring.

Barriers to a universal and inflexible informed consent requirement

Although the principle of autonomy, manifested through knowledgeable consent, is routinely required for therapeutic interventions, we argue that, for at least two reasons, informed consent should not be invoked in decisions about pain management. Substantial evidence confirms that the key elements in the pain experience (the perception and expression of pain; the relief-seeking behavior and response to it; and the capacity or willingness to assume decisional responsibility) are highly complex and dependent on numerous variables. The informed consent doctrine depends entirely on the elevation and expression of self-determination. Under these conditions, requiring that pain management rely exclusively on or be constrained by an affirmative act of patient consent threatens to undermine the very foundations of the caregiver duty of beneficence.

Legally valid informed consent can only be provided by a decisionally capable individual. The presence or absence of decisional capacity is evaluated according to the specific decision under consideration, with a higher level of capacity generally required for those decisions carrying greater risks. If a person clearly has the capacity to understand and process his situation, reference values, consider the consequences, and make his wishes known, then his decision should control and his consent is required.

This analysis does not apply to the formerly capable and communicative individual. Often, when choices must be made, age or illness has destroyed the abilities of reasoning and expression. If this incapacitated individual, while still capable, had articulated treatment wishes prospectively through advance directives (by appointing a health care proxy agent, by executing a living will, or by leaving explicit oral instructions), those directions should be respected and implemented even though capacity has lapsed.

Likewise, people unable to grant informed consent either because they have lost capacity through age or infirmity and left no advance directives, or because they never were capacitated (such as newborns, children, and mentally retarded adults) are excluded from the requirement to provide consent. Their health care decisions must be made by surrogates using substituted judgment (based on what is known about the patient's values and preferences) or the best interest standard (based on the surrogate's evaluation of the patient's welfare). For these individuals, many of whom require pain control, the informed consent requirement is fulfilled by others acting on their behalf, although some notion of their assent may be important. In these situations, surrogate refusal of pain treatment is ethically problematic, especially if it is based on fear of addiction. Consider, for example, the young man who is dying of end-stage AIDS. He is wasted, obtunded, and writhing in pain. His mother, who cannot accept either his diagnosis or his prognosis, refuses to allow him to be given pain medication because she does not want him to become addicted. In this instance, the caregivers would have to overrule a mother's misplaced attempt to protect her son in order to do what is, in fact, in his best interests.

The second reason why informed consent cannot always frame health care determinations about pain is that individual autonomy is not the universal paradigm for decision making. The architecture of informed consent represents a legal attempt to find and secure the patient's voice in medical deliberations and to equalize the balance of power between patients and their physicians. It is also increasingly a risk management strategy to protect the institution from later liability by demonstrating that the risk of negative outcomes was known and accepted by the patient. The patient voice sought, however, echoes a notion of autonomy based on Western cultural values that favor the individual over the community, self-reliance over dependence, action over passivity, scientific rationality over spirituality, and forthrightness over harmony. This doctrine focuses on the right--often, it seems, the obligation--of the individual to make decisions concerning medical treatment. In addition, it advocates candor and assertiveness regarding the disclosure of medical prognosis, treatment options, and their risks and benefits. Finally, it promotes the active participation of the individual patient, rather than family, community, or other surrogates, in medical treatment decisions.

It is important to bear in mind that this preoccupation with patient autonomy does not apply universally. Western values often clash with world-views held by non-Western cultures that may place greater emphasis on spirituality, family and community, or authority and social stratification. These communitarian ethics may value less assertive decision-making processes and encourage deference to physician judgment. By mechanically applying narrow Western-defined doctrines of autonomy and informed consent, American law deprives non-Western cultures of their proper position of power and actually devalues the notion of autonomy. The very meanings of health, illness, and healing are shaped by cultural values. Sensitivity to these distinctions encourages critical thinking about how they affect medical care discussions and decisions, as well as the experience and expression of illness, disability, and discomfort--issues that form the essential background for considerations of pain control.

Finally, it has been suggested that, when a person is in extreme pain, truly informed consent may not be possible. Caregivers have an ethical obligation to inform the capacitated patient about the salient effects and side-effects, benefits and risks of pain management options, especially those related to use of narcotics, to help the patient to reach an informed decision about treatment. But, despite the best efforts to provide relevant information and elicit the patient's values and wishes, severe pain may erode an individual's cognition and autonomy. A patient suffering such pain often can think of nothing except relief and will agree to anything that will provide it. For such patients, truly free and informed consent may be an illusion.

Exceptions to informed consent

Inevitably, the rigid express permission requirement has necessitated the invention of ways to get around it in order to provide patients with the care they need. These loopholes are embodied in three well established exceptions to the informed consent requirement: medical emergency, therapeutic privilege, and waiver.

In an emergency, the patient might be precluded from consenting because of unconsciousness or incapacity, and life-saving treatment delay or failure would result in harm so grave as to outweigh any potential harm of a proposed treatment. Under these critical conditions, courts agree that physicians may dispense with informed consent, so long as they conform to practices customary in such emergencies. Some courts even hold that in emergencies, consent is implied.

The second exception falls within therapeutic privilege, under which information may be withheld from the patient when, in the physician's judgment, disclosure of the information would itself be harmful to the patient. Some commentators strongly criticize this exception, arguing that it risks destroying the theory of informed consent and signals a return to medical paternalism.

The third recognized exception, waiver, provides either statutory or judicial support for patients to give up their right to receive and to act on medical information. The notion of waiver acknowledges that some patients lack the confidence to analyze risk data or prefer to depend on their physician's professional judgment; others simply prefer not to hear adverse information, or choose to depend on family judgment. Patients may waive their right to receive relevant information, and they may also waive the right to make a specific decision or any decision at all. As a result, the waiver mechanism accommodates diverse cultural values by respecting alternative approaches, such as family-centered decision making and deference to physician authority. Because the patient remains in control of the decision-making process by choosing when to allow others to make the actual treatment decision, the waiver also upholds the value of self-determination. In theory, then, the law allows patients who understand their right of waiver to relinquish their right to grant informed consent so long as the waiver is given with full information and without coercion. In fact, in the health care setting, waiver is rarely used because risk management concerns require the patient's expressed consent to protect the institution from liability.

In addition to these customary exceptions, it has been necessary to create other varieties of nonexpressed consent to validate the notion that treatment has been authorized. Most relevant are presumed consent, derived from a general theory about the way rational people behave, and implied consent, inferred from the actions of a particular individual in a specific circumstance. The presumption underlying both exceptions appears to be that, because people will invariably opt for treatment to restore health, individuals who are physically or cognitively incapacitated can also be presumed to prefer health and would consent to therapeutic intervention if they were able to do so. Thus freed from the need to obtain expressed informed consent, the physician's twin duties of beneficence and nonmaleficence trigger a default posture that supports treatment.

Informed consent and the management of pain

Predating the current emphasis on patient autonomy, the duty of beneficence has been a core value of the healing professions, incorporating the relief of pain as well as the promotion of healing. It has been claimed that relieving pain is a "moral duty, based on both beneficence and respect." And yet, despite this ethical mandate, it has been repeatedly demonstrated that caregivers routinely, often deliberately, undermedicate patients in pain.

Aside from the few exceptions noted, informed consent is required for most treatment interventions, especially those that are invasive or carry more than minimal risk. It is interesting, therefore, that pain control interventions are traditionally exempt from this requirement. As a matter of practice, physicians are expected to ask patients about drug allergies and inform them about the proper dosages and potential side-effects of prescribed pain medications, and pharmacists are required to enclose warning labels and information about synergistic effects; but there is no formal requirement that patients give informed consent for analgesia. It is true that pain medication is routinely given on a prn basis, which requires patients to request the medication and thereby affirmatively signal their consent to receive it. Recently, patients have also been given the option of patient-controlled analgesia, whereby they actively participate in the decisions about and administration of their own pain medication, usually through a self-regulated intravenous pump. Finally, it is certainly plausible that a patient who does not want pain medication at all and is able to communicate that preference would have that refusal honored. The crucial point here is that these circumstances apply only to patients who are decisionally capacitated or at least alert and articulate enough to determine and communicate whether they want pain relief.

The more challenging situation involves those patients who are decisionally incapacitated or unable to communicate, and who require surrogate decision-makers to authorize treatment interventions. Perhaps an individual has left an advance directive stating that, should he become incapacitated and be in pain, no analgesia is to be administered. Even in the absence of contemporaneous refusal or explicit advance instructions, enough may be known about him, about his values and beliefs, to determine that he is or was the sort of person who finds meaning in pain.

However, the duty to honor the refusal of analgesia issued prospectively by a currently incapacitated patient is significantly weaker than the duty to honor the contemporaneous refusal of a capacitated patient. It has even been argued that the currently incapacitated patient may be so different from the formerly capacitated one that they are in effect two distinct people with different interests. However, when there is no advance directive and inferences must be drawn about what the patient would want, not making an effort to relieve the patient's current pain is even more ethically problematic than proceeding without expressed instructions. It would be both irrational and inhumane to withhold relief because of inability to request it. Analgesia is routinely given when patients are understood to be in pain. Physicians and nurses, using their well developed skills of observation and clinical judgment, evaluate patients' body language, cardiac and respiratory function, facial expressions, emotional signals, and verbal and nonverbal cues, and do what they believe their patients would want done for them.

Applying the primacy of patient autonomy to the issue of pain management, one could argue for yet another exception to the informed consent requirement that would be applicable to an incapacitated patient in pain. It is generally acknowledged that, except for the rare instances when pain is believed to have some character-building or redemptive quality, people desire to be rid of the pain they are currently experiencing, even though some may choose to endure it as the only alternative to diminished consciousness. If presumed consent is that which can be expected of most people, then the incapacitated postoperative, terminally ill, or grievously wounded person can be presumed to consent to pain relief intervention. Likewise, if implied consent is that which can be inferred from an individual's conduct, then the incapacitated person writhing and moaning in pain certainly can be believed to consent to the administration of analgesia. It is a short step from there to the concept of an implied waiver by which an incapacitated patient in pain is understood to delegate decisional authority regarding analgesia. It could even be argued that an individual who seeks medical attention is, by definition, seeking relief of the presenting pain and/or implying consent to the relief of any pain resulting from treatment.

Although it is tempting to subscribe to these arguments and suggest that pain management requires no expressed informed consent because the patient is believed to have given presumed or implied consent, or waived consent altogether, we decline the opportunity to use such flimsy contrivances. Rather, we submit that providing relief from pain is central to the very notion of healing and, for that reason alone, it requires no exceptions or intellectual artifice for its validity. Indeed, we agree with the following sentiments regarding implied consent:

[I]t is quite obvious that implied consent is a legal fiction. Clearly there is no consent in this [emergency medical] situation. Rather, the law gives physicians a privilege to provide treatment in emergencies, even in the absence of consent, in order to promote other important societal goals besides individual choice--namely, the preservation of life or the restoration of health.... [I]n such a situation a physician has an obligation to do what is best for the patient.

We do not accept the proposition that the caregiver's twin duties of respect for persons and beneficence are mutually exclusive in the realm of pain management or even necessarily conflicting. Rather, we argue that principled and compassionate caring embraces both the respect for and the protection of persons. It has been claimed that beneficence can legitimately outweigh autonomy when it is clearly in the best interests of the patient and, especially, when the treatment interventions are consistent with the patient's own therapeutic goals. We would go further and argue that the current obsession with patient autonomy risks courting a form of patient abandonment in which healers are prevented from healing, and those in pain are denied relief because expressed consent is lacking. To succumb to such reasoning demonstrates a lack of respect for patients and places caregivers in danger of sacrificing beneficence on the altar of autonomy.

The persuasive argument that the individual's diminishing cognitive capacity changes her needs and goals carries the implicit notion that decisions, such as advance health care directives, made by a formerly capacitated person are not necessarily appropriate for the now incapacitated person, and caregivers should not be bound to honor these directives if they are clearly contrary to the patient's current best interests. The implications for pain management are compelling. The person who, never having experienced severe pain, says, "No matter what happens, I do not want pain medication," may feel very different about the need for analgesia when experiencing an attack of renal colic. The caregiver might well be justified in giving more weight to the individual's current relief-seeking behavior than any prior theoretical statements. Likewise, an incapacitated patient's signals of pain can and should speak as clearly as any articulated request for relief.

Conclusion

Pain, although universally acknowledged, is experienced in ways that vary with ethnicity, gender, age, class, and condition. The implications for health care are obvious. If culture is a lens through which the world is perceived and understood, each refraction will depend on the particular prism employed. People bring their culturally determined values and behaviors to all consequential experiences, especially interpersonal encounters. The meaning pain holds for sufferers and the person(s) attending them determines the intensity with which it is perceived and the response it calls forth. Substantial differences among patients, families, and caregivers in their perceptions of and reactions to pain can affect significantly the ways in which pain is expressed, the ways in which relief is requested, and how it is administered.

The importance of decision making is nowhere more striking than in the health care setting. Issues of control and choice, influenced by cultural background, current illness, and perceived obligations, are brought into sharp focus as people from different vantage points grapple with complex and emotion-laden dilemmas. The twin duties of autonomy and beneficence assume special significance in this context. Self-determination, valued most highly in Western cultures, is articulated in the doctrine of informed consent, required for almost every therapeutic intervention. Yet, the duty of beneficence, reflected in the caregiver mandate to relieve pain, can be seen to transcend boundaries of culture and even self-determination. Ultimately, compassion speaks in the most forceful and universal tongue to relieve pain.

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