Impossible test or reasonable aim
Editor—I read the editorial1 on the human right of patients to be pain free with some interest. I am not an acute pain specialist any more than any other jobbing anaesthetist but I felt that there was an element of strident evangelicalism in their article. Whilst the content of the article may be drawing the reader's attention to the statements of various laudable self-appointed bodies one must assume the authors are sympathetic to the views expressed, for the statements to be included. The takeaway message of the editorial is that pain relief should be a human right and that failure to treat pain is ‘substandard medicine’. To the man on the street therefore, failure to achieve pain relief is evidence of denial of their human rights. Doctors are not permitted to deny patients their human rights.
For effective treatment to be such an absolute, it must first of all be possible. Clearly it is not possible to treat all pain. The clinician dealing with the patients directly, in the environs of the muddy moat beneath the ivory castle, will inevitably be the recipient of patient's wrath. Such clinicians are clearly incompetent as they have failed to relieve the patient's pain. The authors are making promises that others may not be able to keep. All any clinician can ever do is treat to the best of their knowledge and experience and any standard higher than this will set an impossible goal. Older readers will remember the dearth of obstetricians in some States of America during the early 1980s as a consequence of the impossibly high standards set by the lawyers. If such sweeping statements alluded to above are not challenged we will all be exposed to similar tests.
Indeed the essence of the argument for making pain relief a ‘human right’ assumes effective treatments for all sources of pain. If there are effective treatments for all forms of pain then the various articles, organizations, colleges and exhortations to extend research into pain management are clearly pointless. For complete pain relief to be a human right one must assume that we have all the knowledge we require and it is only incompetence, ignorance or laziness that prevents successful pain management. If it is not any of these personality defects that prevent successful pain relief then it may just be possible that we simply do not have all the knowledge, yet. One is minded of the (apocryphal) story of the director of the US patents office who replied to Lincoln on his appointment that he would be delighted to accept the office, but he felt that he would not be busy as ‘... everything that is worth inventing had already been invented.’ We are nowhere near understanding pain.
It may be laudable for the authors to draw the attention of bureaucrats to patients' human rights, but unchallenged, it is a statement that will come back to haunt those on the front line. It is important to prevent this emerging subspecialty's reputation from falling before it is established. Please do not set impossible tests that none of us can pass, from the confines of your colleges. I would urge temperance in future publications.
E. G. Lawes
Southampton, UK
E-mail: riclawes{at}ntlworld.com
Editor—We thank Dr Lawes for his comments about our editorial1 and welcome the opportunity to reply. We agree completely that total relief of acute pain for all patients is not an achievable aim and are careful not to say this in the editorial. Unfortunately, he appears to have interpreted the words we used, that is pain relief, to mean, as he says, ‘pain free’ or ‘complete pain relief’. As the often-used pain relief scales suggest, there are degrees of pain relief. He also appears to believe that we are saying failure to treat pain is substandard medicine. In fact the quote we used is that ‘failure to treat pain appropriately is substandard medicine’. Surely, inappropriate treatment is substandard medicine.
Dr Lawes goes on to say that making pain relief a ‘human right assumes effective treatments for all sources of pain’ and that ‘for complete pain relief to be a human right one must assume that we have all the knowledge we require’. These statements would apply only if the aim was, or could be, complete relief of pain. That is, as yet, not possible for all patients. However, there is evidence that the management of acute pain is still substandard in many patients and there is also increasing knowledge and evidence that suggest improvements could be made.
It may not be enough to say that ‘All any clinician can ever do is treat to the best of their knowledge and experience’—some may not have adequate knowledge or experience and need help to access the appropriate information that will enable them to better manage acute pain. This is also surely one of the roles of the Colleges—to educate their members and set standards that will move clinical practice forward in an evidence-based manner. While no treatment will be perfect, we have a responsibility to be informed, practice up-to-date medicine and provide the best care possible in our individual practice settings (which is, for most of us, as a ‘clinician dealing with the patients directly, in the environs of the muddy moat beneath the ivory castle’), whatever our field of medicine.
One of the aims of the acute pain guidelines is to try and summarize the vast amount of knowledge now available. As with any set of guidelines, they are there to assist clinical decision-making rather than to impose fixed standards of treatment.
The bottom line is that acute pain management for many patients needs to be more effective and there is knowledge available that can help achieve this, even if we will never be 100% successful and patients will not all be pain free. While complete pain relief cannot yet be the aim for all patients; better relief of pain can be. Recent surveys continue to show that there is ample room for improvement and the introduction of even some simple measures may help improve efficacy and safety of even the most basic analgesic techniques. Maybe we can only sit back and ‘treat to the best of (our) knowledge and experience’ when that knowledge is up-to-date and based on current evidence, where at all possible.
1Adelaide, Australia
2London, UK
3Edinburgh, UK
4Perth, Australia
*E-mail: pamela.macintyre{at}adelaide.edu.au
Footnotes
Both of these are originally eletters
References
1 Macintyre PE, Walker S, Power I, Schug SA. Editorial I: acute pain management: scientific evidence revisited. Br J Anaesth 2006; 96:1–4
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