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Legal and ethical perspectives on pain management.

Sandra H. Johnson, JD, LLM Frank Brennan, Dan Carr, and Michael Cousins (1) provide us with a treatise on the consequences and causes of neglect of pain in medicine. Their broad scope is appropriate for a problem that continues to plague us, even after more than a decade of aggressive efforts at improvement in the United States, efforts in which Dan Carr has been a key leader. The particular strength of their work in this article is that it approaches the questions of pain and pain relief from every direction: as a social issue, an ethical norm, and a legal concern. This is appropriate because the time during which it seemed that discrete, and perhaps easy, changes in policy or education could revolutionize the treatment of patients in pain has passed. Instead, we now have to recognize that what really appears to be operating is a complex ecosystem that supports ambivalence, denial, and suspicion of the circumstances of patients in pain and of those who treat them. Law certainly can influence the system for good or ill; and so legal standards, including recognizing a right to treatment for pain, are significant.