The Birth of an Ethics Charter for Pain Medicine

In Webster's New International Dictionary, Second Edition, 1953, “ethics” is defined as “the science of moral duty; more broadly the science of the ideal human character and the ideal ends of human action.” From a more pragmatic point of view, ethics in the medical world and, more specifically, in pain medicine, is, by and large, a roadmap that allows us to keep practicing in the face of an increasingly complex—and often confusing and contradictory—environment without losing our way and ending in bedlam, jail, or forced retirement. Ethics has always been part of medicine. Through human history, morality has been an integral part of any medical decision. However, in the last 50 years, the field of medical ethics has been formally established and is now an essential part of the teaching and practice of medicine. Some sort of guidelines or laws for practicing morally acceptable medicine have existed for at least 4,000 years, through, for instance, the Code of Hammurabi in Babylonia (1727 b. c.), the Book of Toth in ancient Egypt, and, of course, the Hippocratic Oath (about 400 b. c.), which focused primarily on the perception of physicians' behavior. While the Hippocratic Oath survived until modern times as a principle of moral behavior in medicine, the Nuremberg military tribunal of World War II raised modern concerns about the ethical treatment of human subjects for research under Nazi Germany and led to the Nuremberg Code of 1947. This was followed by the initial Declaration of Helsinki (1964) from the World Medical Association, which has since been revised and updated several times. In the United States, the Belmont Report, published in 1978, was a major step in instituting medical ethics, setting forth the national policy on ethics in human-subject research. It was soon followed by a flurry of federal regulations, which have continued unabated. The multiplication of medical interventions associated with an explosion of new technologies in the second half of the twentieth century has created complex and sometimes puzzling clinical situations. This increasing complexity has served to solidify the need for medical ethics as a permanent part of modern medicine. As old references to traditional moral authority crumbled, medical ethics soon became indispensable in grappling with ethical issues in clinical practice. More recently, pain medicine asserted itself as a new specialty. Key ethical issues specific to this field were raised. Soon, the need for a specific ethics charter dedicated to pain medicine became obvious. For the last 10 years, an ethics committee within the American Academy of Pain Medicine (AAPM) has been dealing with these issues on a regular basis. In 1999, a survey of the membership of both the American Pain Society and the AAMP, published later in the Journal of Pain [1], not only demonstrated the wide interest of medical professionals in ethics applied to pain management, but also underlined the need for examining a number of growing issues that we all face in our practice. In order to address this problem, in 2000, Pain Medicine began publishing a regular “Ethics Forum” [2]. To date, 16 case analyses have been featured, ranging from abusive interventions and the use of unproven techniques, to confidentiality between colleagues, and professional incompetence. Additionally, a special issue of Pain Medicine, published in 2001 [3], was dedicated to “Ethical Issues and Dilemmas Faced by Today's Pain Practitioner.” During the same period, the AAPM Ethics Committee expanded and formed an advisory group composed of seven physicians with ethical interests and six ethicists with medical expertise. This group soon focused on writing an ethics charter for pain medicine. Their efforts culminated in a two-day workshop in Chicago in December 2003, which laid the groundwork for a charter. In the following year, the draft charter underwent revisions, editing, and additions, before the final completed version was presented at the 2005 AAPM annual meeting in Palm Springs. Of course, what is right today may be wrong tomorrow. Medical ethics is a dynamic field in need of continuing evaluation (see, for instance, the original version and the modern interpretation of the Hippocratic Oath[4]). In order to continue this process, contributing writers of the AAPM Ethics Charter have become members of the present AAPM Council on Ethics, whose function and present work are to examine additional ethical dilemmas, as they arise in our field, and to give recommendations and opinions on these issues. Additional experts have volunteered to join the council. I am honored and delighted to be part of this multitalented group. I am also deeply grateful for the outstanding effort that each member has provided and continues to furnish in order to make this invaluable project a success.