Bioethics Discussion Blog: PAIN





Saturday, December 23, 2006


Today, I completed a 12 hour continuing medical education requirement set by the state of California for all licensed physicians. Why was this requirement necessary? Most physicians are poorly educated in the all the details of how to manage acute or persistent pain in their patients. In addition, there is unnecessary uncertainty both by the physicians and their patients about the legal and addiction consequences of pain treatments particularly with narcotics. And it turns out that patients are not being adequately treated for their pains. Because of this requirement, I learned many things that I never knew or only partially knew or understood about pain and pain management. For those who would like to read more about what your doctors should be learning, you can go to this American Medical Association link.

On my now inactive Bioethics Discussion Pages, I had an interesting topic a few years ago in which I wanted to read what my visitors there thought about pain in general or their own pain and how they looked at the relief of pain. I think that their comments were kind of interesting. I have posted a copy of that topic and the responses below. The more recent responses are at the top of the posting. I look forward for my current visitors to add their own views and comments to the question. Also I would like to know your own personal experiences with pain and pain management by your physicians—but no names please. ..Maurice.


Pain is one of the most common personal experiences that virtually all humans can have during their lifetime. It is a subjective occurrence that often cannot be easily quantitated and compared between individuals since it appears that each individual looks at his or her pain in their own way. Pain may be viewed by the affected individual in the context of the source of the pain, the intensity, the disability and the effect the individual's disability from the pain on others including his or her loved ones and the possibility for resolution of the pain either spontaneously or with help. In addition, religious or spiritual interpretations can be given to one's pains and how the individual responds may depend on how the individual looks at and accepts these interpretations. The medical profession in modern and post-modern times, with availability more and more tools or approaches to try to relieve pain, has looked at pain as a symptom needing to be treated by these tools and either substantially relieved or eliminated. Most patients look to their physicians to do just that. And many ethical issues have involved conflicts regarding pain and suffering and pain management. But do all patients find that relief of pain is a good action? And if not, why not? These are the questions I would like to pose for this page. I would like to know from my visitors what pain means to them and whether they consider that relief of pain is always a good.
Here is the question:
What Does Pain Mean to You? Is Relief of Pain Always a Good Thing?

The Discussions

Date: Tue, Jul 22, 2003 2:47 PM From: To:
A bioethicist, Daniel Callahan, claimed that medicine should not be used to relieve suffering caused by despair. What an ignorant claim. Only those who have not experienced the pain that depression can cause. It is medicine's duty to work with psychiatrists and counsellors to relieve all suffering, regardless of how they are caused. Sincerely, Winston

Date: Mon, Jun 23, 2003 8:53 PM From: To:
Pain to me is anything that makes me feel physically uncomfortable, a noticable difference from the way I would normally feel. I have to say that all pain is not bad. Pain serves as a wonderful radar system for our bodies to inform us of a problem. We must listen to our bodies and then tell our phsycians! Pain also is a great tool for instruction, from the toddler and the hot stove to the 40year old trying to work out and straining muscles, etc. The type of pain I have problems with is that in the terminally ill patient. I have had hospice patients who refuse to take medication for their pain and though it may bother me, I have to allow them to make that decision for themselves. The ones that really get to me are the ones when the patient is desperate for any help in getting relief from their pain and the family or the physician (ok, sometimes even a nurse) stand in the way of the patient getting relief. Folks worry about addiction, they worry about inadequacy of meds later down the road (like it will just stop working), family gets upset because if you make the patient comfortable they may sleep more and not be quite as responsive to the family then. Physicians aren't always informed well about pain management issues and all aren't comfortable with letting a nurse guide them through the nuances of good pain management. It is incredibly frustrating to have a patient in pain, who wants the pain relieved, you know what you need to have or give to alleviate the pain and the physician is not cooperative with it.
I usually think of all pain as bad but your comments on the good of pain were incredible!

Date: Wed, Jun 11, 2003 6:34 AM From: To:
I agree with many of the comments regarding pain. Pain is an important warning mechanism that body has that something is wrong. I think it is one of the reasons that brings patients to seek medical care. It can also serve as a protection against danger in the case of skin burns. And as a nursing student I have learned that pain is subjective and that everyone's threshold is different. I think proper pain management is still either facilitated or constrained by the environment, including social and political factors. Some of the factors include emotions, behaviors, beliefs and attitudes.
Pain can also have a social impact this missed work due to persistent unrelieved chronic pain causing an economical impact. Insufficient pain relief is still a problem. Some patients are still willing to endure high levels of pain instead of asking for an analgesics. Some professionals still reluctant to give adequate levels of a medication out of concern that the patient may become dependent or addicted or they have been duped by a patient in the past. However, empowering the patient to be an active partner in reporting information about pain rather than being stoic is important and one must respect the patient's response to pain.
Rebecca, Salem State College Nursing Student

Date: Thu, Jun 5, 2003 6:02 AM From: To:
I also agree and think that some pain is necessary. Pain in life can be behavioral, cognitive, sensory and physiologic. In life some pain is good as it can serve as a protector against danger or a possible opportunity to for the person to grow spiritually or intellectually after experiencing cognitive pain. Pain can serve as a protector; for example when exposed to a possible danger like fire when pain is felt the body's immediate response to pull way because of a pain trigger. I also feel that it is the body's way of warning that something is wrong internally or a signal that it is time to take better care and slow down in the case of headaches.
As a nursing student, I know that pain is subjective and pain thresholds vary from person to person. Pain can interfere with the things in life that bring joy and satisfaction. Unrelieved pain can cause emotional responses such as fear, depression, anxiety and anger that can be detrimental to recovery; and no one needs to suffer needlessly.
Rebecca, SSC

Date: Tue, Jun 3, 2003 3:31 PM From: To:
Pain mean that I will have some difficulty functiong on a daily basis. I would try alternative methods such as yoga and relaxation before I became dependent on a drug because the implications of using prescription drugs can be addictive and can cause other problems. I have to admit that my pain tolerence is low and I am the first one to pop an asprine when I have a headache. kim

Date: Fri, Apr 25, 2003 3:37 PM From: To:
While I think that we agree that all pain is not bad, we must look on the impact of pain to the person. In western society, a person's function in society does play a role in ethics according to Garrett, Baillie, and Garrett's book Health Care Ethics: Principles and Problems (2000). If pain that is manageable is keeping a person from functioning in society or limiting his or her autonomy, then it is a tragic instance. In this situation, if the person requests, the pain should be managed. As in every topic, there is no black and white. In some instances pain is a good thing (in alerting someone that something is wrong with their bodies) and in some instances, a bad thing (when chronic pain that cannot be cured limits a persons activity, autonomy, and independence). Thanks.

Date: Tue, Apr 8, 2003 9:20 PM From: To:
This summer, I had a paradigm shift about pain. Throughout my first year of nursing school, I had been taught that pain is subjective and we must control it. I believe that patient comfort is one of a nurse's highest priorities.
However, my ideas and beliefs about pain were tweaked a bit this summer when I read a book called, The Gift of Pain by Dr. Paul Brand. Paul Brand grew up in India, the child of missionary parents. After many years back in England struggling with what to do with his life, he became a doctor (like his father) and returned to India. There he treated leprosy patients.
After several years of treating his patients and studying their disease, Dr. Brand created what are now the international standards of care for leprosy patients. You see, for hundreds of years almost no one had treated a leprosy patient or even been near one. It was assumed that leprosy patients were extremely contagious and that they lost fingers, toes, feet, noses, and various other parts of their anatomy due to the disease process itself. Dr. Brand found that this was not true. What was true was that leprosy patients lost not their body parts due to leprosy, but their ability to feel any pain at all. Leprosy patients can set their hand on a hot stove and never know anything is wrong until they smell the odor of burning flesh!
Now, you may be wondering where I am going with this. In his book, Dr. Brand presented a new perspective of pain--that of a precious gift to be appreciated, not a curse to be avoided. Dr. Brand very eloquently made his case for understanding that pain is a gift God gave when he created us. It serves to warn us that something is amiss in our bodies. Imagine how many patients would die from the infection of a ruptured organ if they did not feel the classic one-sided pain of appendicitis!
After reading The Gift of Pain, I have become truly grateful for sore feet and indigestion, for they tell me when I need to buy new shoes or eat less at the next meal! I truly believe that a patients pain needs to be controlled, but while I will do my best to keep my patients comfortable, I will be sure to investigate the cause of their pain in order to fix the problem that prompted it.
So what was my paradigm shift? To me, pain is no longer the enemy, but is one of my closest allies.

Date: Tue, Apr 8, 2003 2:13 PM From: To:
I believe that everyone is going to have pain at one time or another. I think that pain can be a good thing at times and that it should not always be treated. Pain is a way of our bodies letting us know that something is wrong. Instead of going straight for the pain pill or asking for an Rx, find out the real reason for the pain. Too many people are abusing pain meds these days. And I think that Rx's for pain meds are way overwritten also.I feel that a patient that is terminally ill should get as much pain med as needed to keep that person comfortable, and also a woman in labor as well. But just everyday aches and pains dont need narcotics or even a Tylenol every single time. Give your body a chance to tell you what's going on.

Date: Tue, Mar 18, 2003 8:06 AM From: To:
Pain is a part of life.It may not always be your favorite part but it is around for a reason. Pain is like a 6th sense a warning sign if you will. People need this sensation to comprehend how their body is feeling. Life without pain is like shoes without lases, it just dosen't fit. People have limitations and boundries and pain provides these boundries. Pain gives the limitations to people and is a must have even though it is unpleasant.

Date: Sun, Mar 9, 2003 10:04 PM From: To:
What Does Pain Mean to You? Is Relief of Pain Always a Good Thing?
I think that before we ask this question we should consider different pain tolerances of different people and patients. To one person a needle prick might be a slight irritation and to someone else it might feel like someone had just stuck a knife into thier limb. I think that every patient should be asked what his or her tolerance is to pain by filling out a simple survey. This survey could tell how often medications could be given and by what route. This could be intertwined with costs of drugs and what route to give.
Now the real question is what is Pain to you and is Pain relief always a good thing. Pain to me means that something is wrong. Of course everyone knows that Pain is the body's way of saying "hey something bad is happening" But i believe after the intial pain it is felt it is ok to get rid of the pain. If one is in control of the patient and knows what is going on, I believe it is ok to make the patient comfortable. We must be careful of which drugs we are giving to make sure that patients do not become addicted. This can lead to a case of addiction which is a whole different topic.

Date: Sat, Mar 8, 2003 7:42 AM From: To:
I define pain, in the physical sense, as noticeable discomfort during any waking activity of daily living. For example, if your ankle joints hurt when you walk, this is pain. If you are lying in bed and your neck and shoulders ache, this is pain. If you normally bound down stairs 2 or 3 at a time, but now you have to go one at a time and use the railing because your knees are sore and popping, that's pain. Like beauty, pain is in the eye of the beholder, or in this case, the one who feels it. I know from my experience in health care that different people would describe and qualify the same pains altogether differently than others...tolerance levels cover the gamut. And how people deal with and react to pain is very different as well. But ultimately, pain is defined by and quantified/qualified by the one who feels it.
Jeff Keener, Joplin, MO

Date: Tue, Jan 28, 2003 8:49 PM From: To:
Hi. Recently I had a myomectomy. A large fibroid mass was taken from my uterus. This happened because of pain and other complications. I know I made the right choice even though I know must deal for a time with post-operative pain. The doctors wanted me to be able to "manage" my pain. I don't think the idea was to completely mask it. Anyway, while I still have pain--I've got about four more weeks to go at least, it is much less than the first day after the operation. I look at it as a sign that my inside is not healed up. In fact, my sutures on the outside could heal before my uterus does. As far as drugs go, one day a couple weeks back, I inadvertantly took too much vicadin. I had to drink a lot of water and tea to wash it out of my system. I decided afterwards that I would rather feel as much pain as I can handle right now then be in the doped-up zombie-like state I was in. Yes, I think pain has its purpose, if for no other reason, to tell you when you are fine and not fine. It forces you to listen.

Date: Thu, Nov 14, 2002 11:52 PM From: To:
I worked for 8 weeks in a Leprosy Research Centre in India on a clinical Physiotherapy placement.
And on of the main reasons people develop the deformities of leprosy is a "Lack of their ability to feel Pain". Because of this, they can't feel that little stone or pebble or thorn which has hurt their foot and is bleeding, and they carry on (pebble in shoe) and cause it to ulcerate and become infectious, granted this would not happen as often in a developed country BUT the example still illustrates the IMPORTANCE OF PAIN and as with anything it should not be in excess.
The right amount of pain in other words is very helpful as a a warning to something going wrong. Its in cases when it goes out of control or is not present,that we need to worry about.
Abrar 'MagicHands' Waliuddin,

Date: Thu, Nov 7, 2002 9:51 PM From: To:
What does pain mean to me? What it means to everyone! I hurt!!
Is relief of pain always good? Absolutely not! I know this is not going to be popular with the whiney ones out there, but pain is, by itself, not life threatening, unless it is so intense that it brings on shock, which can kill. It is also a way to monitor the recovery process. Less pain, more recovery. I know it sounds simplistic, but it is a necessary way to determine the seriousness of an injury or, less commonly, a disease.
If you have suffered a back injury, then the intensity of the pain you feel may be a way to judge the intelligence of the activities you engage in after the injury. If you mask this feedback with drugs, then you may cause yourself irreparable harm.
If you have a toothache, and you DON'T medicate to relieve the pain, you could suffer incredible pain for no reason. If you DO medicate for the pain, and continue to medicate without seeking professional relief through surgery to remove the cause of the pain, then you risk complications that could be very dangerous.
What level of pain shoud you accept? Whatever you can bear without damaging your physical or mental self. And whatever level of pain you chose to accept, be aware of the physical effects that non-treatment of the CAUSE might have.

Date: Mon, Oct 14, 2002 2:13 PM From: To:

Hi, Pain is a natural an important response that must not be ignored if we are to maintain maximum health. Whether it is physical or emotional, pain is necessary to help us respond to the changing needs of our minds and bodies. Although it is important, at times, to mask pain in order to begin the journey through the healing process, pain is good and should not be ignored. Pain allows us to acknowledge there is a problem, and later, to evaluate the progress of treatment. While we are learning how to manage pain and keep patients as comfortable as possible, we must not forget that it is an effective way for our mind and body to communicate to us.

Respectfully, Sue


At Saturday, December 23, 2006 9:11:00 PM, Anonymous Anonymous said...

I fell earlier this year and broke my hip. The hospitalization was the first I'd experienced since a childhood illness (except for giving birth). I slept mostly for the two days following surgery, but a nurse periodically knelt by my bed and asked me to rate my pain on a scale of one to ten. I was in no pain, but in my foggy mind felt I was required to give a number, so I did. But sometimes a very low number, sometimes a six or seven. It didn't seem to matter anyway because I continued to be without pain and sleeping a lot.

On discharge I was given pain medicine prescriptions with orders to take them every four hours, which I did til I began to notice I wasn't emptying my bladder fully and was becoming constipated. I researched those pain meds on the internet and found those were the side effects. So, I began to cut back on the pain meds, using half dosages just before working with the physical therapist who came to my home. Otherwise, I just moved carefully, slowly, and did the exercises a few times several times a day instead of a lot at once. And was fine.

I also stopped sleeping continually, and stopped feeling irritable. I concluded that the pain meds at the hospital and initially at home were probably necessary; certainly the extra rest while also doing the exercises must have been good for my recovery.

At the post-operative office visits with my surgeon he wanted me to renew my pain med prescriptions, but I still had half the pills and used the pain to guide me in how much physical therapy to do at a time during the day. I refused the prescription renewals.

Normally I have a low threshold for pain, but I do use pain as a guide to what's happening in my body. If I found I could not manage the pain, then that would be a sign I need to see a doctor to discover the cause of it.

I am retired, but most people live such high-pressured lives that it doesn't take much pain to interfere with their normal functioning. I would never condemn anyone for seeking medical relief for pain.

At Wednesday, January 10, 2007 4:10:00 AM, Anonymous Anonymous said...

As a nurse for many years, speciality in labor and delivery, but years of experience in ER, Trauma, OR, and intensive and acute care as well as skilled care and Hospice I have seen my share of pain.

As a nurse my first concern is my patient, nurses are the ones caring for the patients day in and day out and physicians often see dozens of patients in a day therefore they rely upon nurses to keep them abreast of their patients progress, problems (both physical and emotional) and so on.

I have always and will continue to be a strong advocate for my patients and their rights. And a patient has the right to live in dignity and to die in dignity and to be cared for by those that respect and understand that concept.

Yes, pain is subjective, but it is also becomes objective when you are the nurse caring for the patient, as you know that patient, you can recognise changes in your patients vital signs, physical behaviours, affect, amount of activity they can or can not do and so on.

Once your patient tells you he/she is in pain, make sure you have taken the time to know the patients complete background (medically and socially)information, it is amazing to me when I see a nurse caring for a patient that is in for pneumonia and is being treated for such, but has no knowledge of the patients past medical history, such as a triple by-pass, or a history of some other health problem.

I do not believe that in today's society we listen to our patient, be it in the hospital setting, clinical setting or out patient walk in clinic who complain of pain, if you listen the patient will tell you about his/her pain, how bad it is and yes, we use the 1-10 scale, but keep in mind that all people can not understand nor comprehend this form of identification of their pain, you may just have to dig a bit deeper into your brain and try the 1-10 scale, but follow up with asking the patient, "how does the pain make you feel, how does it effect your life, your family, your work, what changes have you had to make because of the pain and so on..."

If you take the time to LISTEN, truly listen you will learn a great deal more about your patient and his/her pain then a number scale will ever tell you.

I had never had a headache until after I had my second baby, when she was 1 month old I had the first of what has been 25 years of severe migraine headaches. When they first started, I still remember that first day, I truly thought I was going to die. I have since ran the gammet of tests, special clinics, specialists, medications, you name it, whatever hoop I have been asked to jump through I have done it.

Over the years they have gotten less frequent, but as a nurse you can not call in everytime you have a migraine, well I guess you could, but I am not sure how long your employment would last at that facility. And I have worked and functioned through horrible migraines, mainly because my patients are my first priority and secondly because my employer had 'headaches and managed fine, so what was the problem'?

I do believe that most physicians do not treat pain in their patients as it should be treated. Fear of litigation is in my opinion the underlying reason that most physicians are so reluctant to prescribe pain medications, try a different medication and or administration of one they are willing to prescribe as a patch, but not as a sucker, such as Actic (hope I spelled that correctly).

The office nurse and how the office nursing staff is managed can also be a HUGE contributing factor to the problem, if a patient calls in at 8 in the morning, talks with the triage nurse, or his/her doctors nurse about their pain problem and askes for a prescription (if this is not a new onset of pain, meaning that the physician is well aware of the patient and his/her history of pain or chronic pain and the reason for it (if one can be found), often nurses do not communicate phone messages to the physician until certain times of the day, meanwhile the patient waits at home for the call back, sometimes not getting called in time to even get to the pharmacy before closing, or in the end gives up and goes to the emergency room, where they are greeted by an unfamiliar physician, often given un-necessary tests and as I have seen many times treated as if they are seeking drugs.

In my opinion as a nurse and as a patient, they teach us a great deal about pain and how to care for our patients in school, how to be the patient advocate, to pick up the phone and call the doctor and request additional or a new med if needed, so when are more medical programs going to start putting the shoe on the other foot and teaching physicians that to treat the patient, a body in pain can not heal nor lead a normal life, eventually the patient withdraws from society, loses his/her job, is effected in so many ways you could go on forever, when are physicians going to WAKE up and treat their patients and quit worrying about losing their license?

Sorry so long, but after being on both ends of the 'pain spectrum' I just felt like adding my two cents.

At Monday, October 01, 2007 10:19:00 AM, Anonymous danielle said...

I dont know if anyone here can help me or if i am in the right place. but someone i know and love is being prescribed metahadone and oxycontin about 90 a month each and this person takes them and makes up pain so it is ok to take them in there mind. i feel that this person is dependent on these pills and i really want to know how to help this person before i find this person dead or badly injured. please email me back with your thoughts anyone please i need help. this doctor hasnt even seen this patient in over one year. thanks

At Monday, October 01, 2007 11:08:00 AM, Blogger Maurice Bernstein, M.D. said...

Danielle, I would advise you to communicate directly with this patient's doctor and tell him or her exactly what you told us on this thread. If the doctor has any considerations about malpractice or his or her loss of license to practice medicine he or she will most likely promptly investigate and update knowledge about this case and see to it that the prescribed pain meds are not being abused. Don't wait. Do it now. ..Maurice.

At Sunday, March 09, 2008 10:02:00 AM, Blogger Maurice Bernstein, M.D. said...

A visitor wrote me the following e-mail that I thought would be appropriate as a comment to this thread on pain. How would you explain this visitor's resolution of depression by experiencing and fighting chronic pain? ..Maurice.


Well I have had depression most of my life and never could get any good relief and It made my life really hard, but when I turned 44 I developed arthritis and was in a lot of pain for 4 years and had to quit work and fight for disability income for three years.
But then it began to get better to the point I could live it. And one day someone asked me how was my depression and I realized that the pain seemed to take up too much energy for me to be depressed. Wow

At Thursday, September 16, 2010 9:44:00 PM, Blogger Maurice Bernstein, M.D. said...

A visitor to my inactive "Bioethics Discussion Pages" wrote me the following e-mail. ..Maurice.

"Pain to me, like mentioned in the excerpt, is strictly subjective. As health care providers it is not our choice to determine whether the presence of pain is reality or not. However, it is our obligation to treat symptoms within a safe range. I think treatment of pain is patient specific and it would be difficult to say that every ones pain relief goals be similar. Some people have managed chronic pain for several years... would those people have the same pain relief that a young child may have. Or consider a young woman's idea of pain compared to that of a bodybuilder. Much different precept ions and much different pain management techniques. To say "relief" of pain is a good thing is inaccurate. To be pain free for most all people would be ideal but for a pretty large population it is unrealistic. Managing pain to the best of ones ability while still maintaining quality of life and not causing harm is a good thing... anything beyond is not."


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