The philosophy of pain
Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CCRP, CVA, MS
Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CCRP, CVA, MS in Clinical Bioethics, is a founder and past-president of the International Veterinary Academy of Pain Management. She owns Windsor Veterinary Clinic and The Downing Center for Animal Pain Management in Windsor, Colorado.
Why borrowing four principles of human clinical bioethics will enhance the lives of our veterinary patients.
Animals deserve to be hurt as little as possible in the application of veterinary medicine. (Photo Getty Images)“ … [O]ur love for our pets should be shaped and informed by our recognition of the ways in which their needs and their lives are their own, peculiar to the sorts of animals they are … ”1
-Rosalind Hursthouse, philosopher
I chased a clinical bioethics degree because I believe philosophy can help reinvigorate the moral imperative to elevate our standard of acute pain care and provide patients with the pain relief they need and deserve. This article is an abbreviated excerpt of my master's thesis that I think contains lessons for all veterinarians.
Rather than inventing a new, veterinary-specific bioethical framework for medical and ethical decision-making on behalf of companion animals facing acute pain (and any other medical issue), I believe we can look to the human discipline of clinical bioethics and the four foundational principles as described by the philosophers Tom Beauchamp and James Childress.2
Veterinary professionals haven't previously used such a formal framework to make decisions in the exam room and treatment area. But I think we should recognize the opportunity for these same principles to benefit companion animals as they have benefitted human patients since 1979.
1. Respect for autonomy
The right for autonomous choices by individuals runs deep among our cultural norms. Autonomy implies self-rule and the exercise of self-chosen actions, free from controlling interference by others. Within the veterinary world, the pet owner will always be the decision-maker for the companion animal patient. Thus, it is the pet owner's autonomy that is the veterinary professional's primary concern, especially in regard to these basic rules: to tell the truth, to respect clients' privacy, to protect clients' confidential information, to obtain consent for interventions with patients, and, when asked, to help clients make important decisions.2
It was once thought to be acceptable to actually use pain as a restraint strategy to limit movement following surgery.
But veterinarians have an opportunity to respect the autonomy of patients as well, presuming the companion animal patient's preference will always be to avoid pain, as Richard Ryder argued in Painism: A Modern Morality.3 From a traditional veterinary perspective, it was once thought to be acceptable to actually use pain as a restraint strategy to limit movement following surgery. Current science demonstrates that this approach is completely unreasonable.
Respecting the companion animal's autonomy in the face of acute pain demands two things:
> The veterinary professional must anticipate, prevent and manage the patient's pain as effectively as possible.
> The veterinary professional must reassess that patient frequently in order to modify the pain management plan as needed over time.
Companion animals receiving treatment for acute pain can express additional preferences that can and should influence the treatment they receive. They may have preferred textures of food or preferred ways of being handled by caregivers. They may prefer a place to hide and feel protected from their environment. There are countless ways that companion animals may express their preferences, and a part of the veterinary professional's moral obligation to those patients is to honor those preferences-and to assist the pet owner in honoring those preferences-whenever possible. Respecting the companion animal's expressed preferences becomes even more important in the face of chronic care that must be delivered.
In medical ethics, this principle is often expressed as Primum non nocere-First do no harm. Specific rules that support and are supported by nonmaleficence and may easily be applied to veterinary medicine include: don't kill, don't cause pain and suffering, don't incapacitate, don't cause offense, don't impose undue risk of harm and don't be negligent.2
It's easy to see how nonmaleficence applies to companion animals and their human family members. For companion animal patients facing acute pain, it's inherent upon the veterinary professional to prevent the suffering that accompanies unmitigated or poorly managed pain. This means both adhering to the current state of acute pain treatment knowledge and reassessing the patient frequently in order to continue to prevent pain and suffering.
The biggest difference in veterinary medicine, of course, is in rule No. 1: Do not kill. There are times when humane euthanasia is truly the final gift that veterinary professionals can provide patients whose suffering cannot be relieved or for whom quality of life is seriously compromised. Humane euthanasia may be, for some companion animal patients, the preferred outcome over a heroic intervention.
Whereas nonmaleficence demands that we avoid causing harm, beneficence demands that we take positive action on behalf of another. Examples of rules that support and are supported by the principle of beneficence include: to protect and defend the rights of others, to prevent harm from occurring to others, to remove conditions that will cause harm to others, to help persons with disabilities and to rescue persons in danger. The rules of beneficence provide a positive requirement to actively help those with whom we have a relationship, but they do not necessarily obligate us to help those with whom no relationship exists.2
Older pets with chronic pain and chronic metabolic disease present a different patient population when contemplating exposure to advanced or invasive procedures.
For companion animals facing acute pain, beneficence demands that the veterinary professional consider all the ways in which the pain may be anticipated, prevented and (when it cannot be prevented) treated. Big pain requires big pain treatment. As straightforward as this statement may seem, there are potential complications. The pet population is aging, more companion animals are living with physiologic morbidities like heart disease and renal disease, and the majority of aging companion animals deal with the chronic pain of osteoarthritis. Veterinary medical procedures continue to increase in sophistication and the potential for bodily invasion. Older pets with chronic pain and chronic metabolic disease present a different patient population when contemplating exposure to advanced or invasive procedures. The concept of utility must also be considered in order to weigh benefits, risks and costs so as to set the stage for the best outcome possible for the patient.
The traditional interpretation of the bioethical principle of justice focuses on the distribution or allocation of healthcare resources and rationing. In human healthcare, there are many theories for addressing disparities, inequities and discrimination as well as protecting human research subjects.2
It's different for us in traditional veterinary practice. Animal ownership is purely voluntary, and pet care is paid for out-of-pocket. Allocation of veterinary medical resources is generally determined by pet owner choice coupled with the ability to pay for whatever procedures or techniques are recommended by the veterinarian and accepted by the pet owner. But it's not unreasonable to consider ways in which to apply the concept of justice on behalf of companion animal patients facing acute pain, specifically.
It's also justice for the veterinary professional to focus efforts based on pets owners' own efforts: their financial options, their commitment to treatment, their willingness to be compliant with aftercare, etc.
One key concept implied by the term justice is fairness. Fairness during interactions with pet owners means providing each of those individuals with the very best effort that can be expended on behalf of each companion animal patient, avoiding prejudice directed toward either pet owner or pet. In the case of a companion animal facing acute pain, justice implies that the pet owner will be presented with a plan that reflects the most appropriate strategy for handling that pain. It implies that interactions with the pet owner will be open and transparent about risks, benefits, the timing of treatments and costs. It implies that the treatment provided will reflect the standard of care in order also to best respect and balance the other foundational principles of clinical bioethics. It's equally just for the veterinary professional to focus efforts based on pet owners' own efforts: their financial options, their commitment to treatment, their willingness to be compliant with aftercare, etc. The veterinary professional and pet owner must engage in shared decision-making in order to settle on the treatment plan that will be followed.
As veterinary professionals face complex medical decisions on behalf of companion animal patients-especially when it comes to pain control-I hope I've shown that it's possible to balance your recommendations to pet owners and your conversations with pet owners by evaluating treatment options in light of these four foundational principles.
1. Hursthouse R. Virtue ethics and the treatment of animals. In: Beauchamp TL, Frey RG (eds). The Oxford handbook of animal ethics. New York: Oxford University Press, 2011.
2. Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press, 2013.
3. Ryder RD. Painism: A modern morality. London: Centaur Press, 2001.
Robin Downing, DVM, MS, DAAPM, DACVSMR, CVPP, CCRP, is a founder and past president of the International Veterinary Academy of Pain Management and the owner of Windsor Veterinary Clinic and The Downing Center for Animal Pain Management in Windsor, Colorado.