DENIAL OF PAIN RELIEF

A Presentation to the International Health and Human Rights Organisations conference
  
The Netherlands: December 2010   

Professor Michael J. Cousins AM                                                              
MD(Syd) DSc FANZCA FRCA FFPMANZCA FAChPM (RACP) FAICD   
Director Pain Management Research Institute
Director Painaustralia Limited                                                                               

How is it possible that in the year 2010 we are discussing ‘denial of pain relief’?  After all the primary role of the physician is to relieve pain.

We now have the knowledge, we have the opioids and other analgesic drugs, as well as a wide range of non-drug pain relief methods.  If applied, such methods could relieve over 90% of cancer pain and acute pain (eg after surgery, trauma, etc) and over 80% of chronic non-cancer pain.   And yet the reality is that in the developed world less than 50% gain access to such treatment and in the developing world a tiny percentage, if at all, receive treatment.

The reasons for this lamentable situation are complex and have been explored in an editorial in the Journal ‘Pain’ in 2004 entitled ‘Pain Relief: a Fundamental Human Right’ written by myself and colleagues Frank Brennan from Australia (a Palliative Care Physician and Lawyer) and Pain Medicine Specialist and Pain Researcher Dan Carr from Boston.   This coincided with the first ‘Global Day Against Pain’ in 2004 sponsored by IASP, the WHO and EFIC.

A more extensive discussion on this subject by the same authors is available in Anesthesia & Analgesia in 2007 accompanied by an editorial by William Scholten of the WHO.   All very recent.

Many in the general community (and also too often health professionals) think this is a simple problem.   “Just give some morphine (if you have got it !).   Sometimes it is relatively simple but even for pain after surgery or cancer pain it is often not simple as is the case in other pain conditions.

Sadly there has been no concerted and consistent world-wide commitment to address the enormous human suffering due to lack of access to effective pain management.  In 2010 this unacceptable situation can only be described as a breach of fundamental human rights.

There is now much evidence that unrelieved pain results in adverse outcomes that place crushing burdens on individuals, families and communities.   This can cause a significant number of people to contemplate suicide, or euthanasia if available.  Patients with chronic pain suffer twice the suicide rate of the general population.   Financial costs of lack of access to pain management are massive, $1.85 billion per million population in Australia in 2008.   Such data place chronic pain as the third most costly health problem and yet in most countries it has no priority at all as a health problem.  But an even greater moral imperative in a civilised world should be that access to pain relief is a fundamental human right and that denial of access is unethical and a breach of human rights.

Are there any precedents to this extraordinary, unrecognized, unattended human rights blind spot ?  It was certainly not recognized per se in the UN Declaration of Human Rights in 1948.   Why not ?

In 2007 the BMJ celebrated medical milestones since 1840.   Among the leading key advances was Anaesthesia, described as a ‘symbol of humanitarianism’.

Ironically upon discovery of anaesthesia in 1846 Oliver Wendell Holmes exhalted ‘the deepest furrow in the knotted brow of agony has been smoothed forever’.  Yet 60 years later GB Shaw wrote of his postoperative pain ‘when doctors write or speak to the public about operations, they imply that chloroform has made surgery painless.   People who have been operated upon know better’.  The same is true of other pain conditions.

Of significance to our discussion, anaesthesia could easily have been developed 100 years earlier than it was as a result of some brilliant experiments with various chemicals before and during the Renaissance.   Yet in this era individual rights were not held to be important and thus there was no impetus to develop anaesthesia, since humanitarian issues were not to the forefront.

It was not until the late 18th century and early 19th century that poets, essayists and philosophers introduced a humanitarian theme.   As the late Emeritus Prof EM Papper wrote: ‘attention to individuality…in the Romantic era…was crucial to preparing the way for a change in clinical medicine, designed to relieve pain and suffering….an environment in which anaesthesia could be accepted….’.   This has enormous significance for denial of pain management.  

How did this ‘environment’ sit with influential health professionals and others wielding power in society of the day ?  The Professor of Surgery at University of Edinburgh, James Syme, initially strongly opposed anaesthesia for childbirth until Queen Victoria decreed that she would ‘take the chloroform’ for the birth of Prince Leopold in 1853.   A measure of the powerful opposition of the day is an article in the Lancet following that birth stating in no uncertain terms that the Queen could not possibly have been anaesthetised: ‘We state this with the highest satisfaction.  In no case would it be justifiable”.

This example is but one of a long list of health professional attitudes that may result in denial of pain relief.   Such attitudes may also be cultural, religious or political.  Political attitudes continue to include restrictions in some countries on the availability of opioids.   Also torture is still sanctioned government policy in some parts of the world.   We now know that in addition to the pain during torture, chronic pain prevalence is markedly increased. 

Thus strategies for improvement must include a broad range of initiatives in Medicine, Law and Ethics.   In my view the most powerful strategy and most likely to lead to timely action is to regard denial of pain management as the major moral imperative of our day.   Society needs to return to the ‘environment’ that made it possible for anaesthesia to be ‘accepted’.   Now all pain needs to not only be accepted but made a priority.  It needs to happen now.

This key initiative needs to be community led by human rights organisations, ethicists, lawyers, leading citizens with leverage and, yes poets, essayists, philosophers, etc.  supported by health professionals.   I believe the vehicle for this community based initiative is the Declaration of Montreal. 

The Declaration of Montreal – The Declaration that Access to Pain Management is a Fundamental Human Right.
This document results from a combined effort of a very wide range of health professionals, human rights organisations and other members of the community.  It results from initial input by IASP Chapters in 126 countries, following an in depth process culminating in the International Pain Summit which harnessed a further wide range of input.   The resulting document. 

• Clearly states the seven major reasons for denial of adequate pain management
• Then importantly it ‘recognises the intrinsic dignity of all persons and that withholding of pain treatment is profoundly wrong, leading to unnecessary suffering, which is harmful’.
• Then three human rights are articulated that must be recognised worldwide:

Article 1:  The right of all people to have access to pain management without discrimination.   The Footnotes elaborate on discrimination eg based on medical diagnosis – one cause of stigmatisation.
Article 2:  The right of people in pain to acknowledgement of their pain and to be informed about how it can be assessed and managed.   Again the Footnotes give details.
Article 3:  The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health professionals.   Details of treatment are in the Footnotes.

• Also in order to ensure these rights we recognise two obligations:
  
  1.  of health professionals
  2. of governments and health care institutions.

I strongly urge the International Federation of Health and Human Rights Organisations to endorse this Declaration of Montreal in view of the considerable impact of having a single agreed International Declaration rather than a series of statements with different emphases and possible loss of impact.   This issue is so important that a strong unified international approach is crucial.