Introduction

There are many perspectives from which one might consider the interrelationship between pain and society, i.e. the impact that a particular configuration of social norms, customs, and experiences has on an individual's particularized experience of pain and search for relief. Excellent studies have been conducted on ethnic and racial influences on pain.1'2'3'4 The role of religion in shaping a person's perceptions of, and responses to, pain is also especially important, as we shall consider later in this chapter (see below under Pain, suffering, and other semantic points) when the search for meaning begins.5 As David Morris has astutely observed, "The dismissive or contradictory attitudes that most people - not just health professionals - hold toward pain seem rooted not in biology but in culture.''6 These "dismissive or contradictory attitudes'' range from the trivial sloganeering of the health club set - "no pain, no gain'' - to the quasi-religious notion that the stoical, if not heroic, bearing of pain and suffering does not merely build character but tests one's ultimate spiritual mettle.

While it is certainly unwise to minimize the extent to which these cultural elements shape our encounters with pain - our own and that of others - it is a topic that has been brilliantly and comprehensively considered elsewhere and is far beyond the scope which this chapter affords.7 What has only begun to be considered, and as yet very tentatively, are the ethical and legal dimensions and implications of pain, and, more particularly, of modern medicine's legacy of undertreated pain. Heretofore, the ethical and legal aspects of pain management were considered, if at all, in an extremely simplistic fashion that typically proceeded in the following manner:

• opioid analgesics, the most effective method of treating many types of severe pain, are powerful and dangerous drugs that must be rigidly regulated and utilized infrequently at the smallest possible dosage;

• laws and regulations governing the licit use of opioids by healthcare professionals had, as their primary objective, the prevention of drug diversion and addiction;

• the traditional medical aphorism - primum non nocere (first do no harm) - has been integrated with an exaggeration of the risks and adverse side effects of opioid analgesics and a significant underestimation of the risks and adverse side effects of severe, persistent pain to produce an ethic of undertreatment.

Neither the ethical nor the legal propriety of this philosophy of patient care was ever challenged by the prevailing norms of western medicine. This "therapeutic" approach to patients with severe and persistent pain, when carefully considered, turns out to be grounded upon a mountain of myth, misunderstanding, misinformation, and flawed ethical analysis.

This chapter will, in large part, be devoted to an examination of the weaknesses of the traditional view. There will also be an exploration of an alternative view that appears to comport much better to medicine's core values and fundamental goals, which have always placed the relief of suffering on an equal level with the prevention and the cure of maladies. Before undertaking this examination, however, a few preliminary matters warrant brief consideration.

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