One response is that the prescriber’s purported duty to relieve pain and suffering is much more rhetoric than a reflection of a genuinely felt sense of professional responsibility [7]. Twenty-five years ago, in a seminal article on the subject, Cassell wrote that the major goal of medicine is to reduce or relieve suffering [8]. Nearly 10 years later, he elaborated on this issue, stating that modern medicine largely fails to relieve suffering adequately [9].

A major issue involves the biomedical model of disease and the curative model of medical practice, which causes the prescriber to focus on the pathophysiology of disease rather than the patient’s experience of illness. Unless and until clinicians can focus on the patient as person, rather than the body as the locus of a disease process, they cannot begin to address pain and suffering. The major problem posed by the curative model of medical practice is that its essential features stand in stark contrast, indeed, diametric opposition to those of the palliative model (see Table 25.2) [10].

In the curative paradigm, pain is a symptom of an underlying medical condition. Patient reports of pain constitute information that facilitates the diagnosis of the underlying condition and the formulation of a treatment plan. From this perspective, measures intended to reduce or possibly even eliminate the pain would be counterproductive, as they would (theoretically) deprive the clinician of potentially important information. This propensity to categorize pain as a clinical datum to be processed rather than a personal experience calling for a compassionate response by the clinician can itself exacerbate the problem by causing the patient to feel abandoned.

The barrier of knowledge deficits on the part of clinicians in the assessment and management of pain has been documented in the clinical literature for decades [11]. These deficits can be directly linked to the virtual absence of pain management in the medical school curriculum [12]. This curricular void has produced not just knowledge deficits that clinicians themselves recognize but also myths and misinformation about the risks (especially addiction to opioid analgesics) and potential side effects of opioids that are perpetuated in the informal medical curriculum from one generation of physicians to another [13]. A clinician in the full grip of these pervasive myths and misinformation could, and commonly did, invoke the ancient medical maxim of primum non nocere as the moral basis for withholding opioid analgesics from patients who required them for pain relief.

Surveys of physicians consistently reveal a high level of anxiety concerning regulatory oversight of their prescribing of opioid analgesics [14]. The primary fear factor has been a well-established pattern and practice of state medical boards of charging physicians with “overprescribing” pain medications, particularly opioid analgesics for patients with chronic nonmalignant pain [15]. More recently, physicians who treat large numbers of chronic nonmalignant pain patients have been increasingly made the targets of DEA (Drug Enforcement Administration) investigations and federal criminal prosecutions for “drug trafficking” [16]. In a host of guidelines and policy statements, physicians are admonished to balance a patient’s need for opioid analgesics with their purported responsibility as prescribers to prevent drug abuse, diversion, and trafficking [17]. The combination of these factors perpetuated what one commentator has characterized as an “ethic of underprescribing” in the medical community [18]. Such an ethic, of course, runs counter to the ancient and core value of the medical profession concerning the relief of suffering.

The fear factor was significantly complicated when a few health-care institutions and professionals were held liable for substantial damages in civil actions alleging a failure to manage pain. The first such case was brought against a skilled nursing facility in North Carolina. The crux of the complaint was that a nursing administrator had discontinued a pain management regimen for an elderly patient with metastatic prostate cancer because she considered it to be excessive. A jury found the facility that employed her guilty of gross negligence and assessed compensatory and punitive damages in the amount of $15 million [19]. Ten years later, a California jury awarded damages of $1.5 million to the family of an elderly patient who died of lung cancer. The basis for the award was that the patient’s pain had been ineffectively managed by the physician who had been responsible for his care during a 5-day hospitalization prior to his death [20]. This case achieved substantial national notoriety for a number of important reasons. First, because tort reform legislation in California precluded the recovery of damages in a medical malpractice suit for pain and suffering following the death of the patient, the civil action against the physician and hospital was brought under the state elder abuse statute, which allowed such a postmortem award. Second, prior to the litigation, the Medical Board of California had investigated a complaint against the physician by the patient’s family. Its reviewing expert had found the physician’s pain management to be inadequate, yet the board declined to take any disciplinary action. The stark contrast between how the board saw the case and how the jury saw the case seemed to epitomize the disparity noted much earlier by Cassell.

Such cases established what was, but should not have been, an entirely new precedent (i.e., liability of health-care institutions and professionals for undertreating pain). The underlying premise of these civil actions was quite straightforward – pain management is like any other aspect of patient care in that if it is done negligently or otherwise inappropriately; it can give rise to professional liability and the award of substantial monetary damages [21]. Such jury verdicts indicate that lay jurors take the clinician’s responsibility to relieve pain and suffering very seriously. Similarly, state medical boards began to recognize that failure to properly manage a patient’s pain might constitute unprofessional practice and thereby justify disciplinary action against a prescriber who had, in effect, subjected a patient to unnecessary pain or suffering. In 1999, Oregon became the first state to impose sanctions on a physician solely and exclusively for failure to properly manage the pain of several of his patients who were gravely ill or dying [22]. Subsequently, in 2003, the Medical Board of California pursued disciplinary action against a physician for failing to demonstrate in his care of an elderly patient dying of mesothelioma that he understood the nature and properties of some of the analgesics he prescribed for the patient [23]. Given the failure of the California Board to take any action in the case just 2 years earlier, this suggests a remarkable shift in attitude and approach to allegations of substandard pain management practice.

Failure to appropriately assess and treat pain is now generally recognized as a form of substandard care and unprofessional practice. Many state medical board policies, and the model policy of the Federation of State Medical Licensing Boards, admonish physicians that effective pain management is an essential feature of quality patient care. Failure to provide such care, or to refer a patient to a clinician who can provide it, can constitute the basis for disciplinary action and/or malpractice liability. Organizations such as the American Academy of Pain Medicine and the American Pain Society, among others, have promulgated clinical practice guidelines to assist clinicians in fulfilling their responsibilities to all patients with pain. However, it would be presumptuous and overly simplistic to conclude that simply promulgating guidelines and promoting continuing professional education will magically remove the barriers to pain relief [24]. There are attitudes and ways of thinking in the culture of medicine and the health professions that contribute significantly to the problem of undertreated pain.

The failure to treat pain is fundamentally a failure of empathy. From a clinical and psychological perspective, there are multiple pragmatic and psychological factors that argue against the ability of the health-care provider and the patient to relate to one another. If they could, it is hard to argue that the problem of undertreated pain would be of the magnitude that it has been, even when we take the previously mentioned barriers into account. Perhaps those involved in patient care will ultimately be better served if they simply learn to accept the fact that they are unable to rely solely on their empathy. While they may be, at their core, good caring people, this is not sufficient to make them competent or effective in the treatment of pain. Ultimately, the use of rating scales and aids that facilitate the objective measure of pain, and thereby communication about it, are the only hope in allowing for better, more empathic pain care. Ultimately, the souring of the regulatory and legal climates surrounding pain management creates fear, and fear widens the gulf between doctor and patient [25].

When students begin health-care training, it is easy to elicit from them expressions that their primary motivation for doing so is the desire to help people. What aspect of intervening in the care of another human being meets this criterion more readily than treating pain? When young medical trainees first enter their clinical rotations, they are psychologically very close to patients. A study of the content of the nightmares experienced by trainees revealed that residents at the beginning of training often find themselves in the patient role in a nightmare, such as being operated on without anesthesia [26]. It is important to make a marked distinction between this early form of sympathy, wherein a trainee overidentifies with the patient and the more appropriate level and skill of empathy, which entails putting oneself objectively in the viewpoint of another without taking on their emotional investment in the situation. Medical education provides the necessary distance to allow for empathy and perspective taking, as opposed to actually feeling the pain of the patient. This distance is probably necessary to allow physicians to do what they must do to other human beings in situations where, if there were too much emotional investment, perhaps it would be impossible to perform painful procedures. Thus, distance begins to develop, and by the end of training, residents’ nightmares more commonly put them in the physician role. But is this distance good or bad thing when they are called upon to treat pain?

When we hear that older, non-white females have the highest likelihood of being undertreated for their cancer pain or that Hispanics are half as likely to receive pain medications in emergency rooms when they have the same long bone fractures as whites, are we to believe that medicine is ageist, racist, and sexist [27–29]? Or that in AIDS patients, being uneducated is a risk factor for poor pain care (along with a history of a substance abuse)? [30] Or is it possible – that in fields historically dominated by younger, educated, white men – that being different from your physician works against you somehow and drives the likelihood of their ability to empathize with your suffering even further underground?