ASBH, Day One

One thing about the American Society for Bioethics and the Humanities conference was clear after just one session: don't expect a very deep discussion about anything. Not that there is a lack of quality speakers. To the contrary. It is just that within a 15-20 minute time-frame, there is only so much room for maneuver, and in fact the abbreviated time slots inspire speakers to race through their talks at a manic pace -- this conference comes but once a year, and they are going to get all the information out, come hell or high water. Ideas can get blurred or hollowed out this way. So it is best to let intellectual expectations drop somewhat and regard the sessions as 'samplers', where you are offered tastes of a diversity of themes and directions in bioethics.

Choosing what to taste is always difficult. Do you go to sessions on topics you already know something about? Or on something that you are clueless about? Both have potential pitfalls and benefits. A session on vaccines offered little information beyond the usual puzzlement (on the part of scientists) about why there are people who refuse to have their children vaccinated; I quickly took off to a large, thinly populated and appropriately spooky hall where the discussion focused on the ethics of using human remains. The idea was floated of a market in cadavers, and I involuntarily recalled what is said to happen in South Africa, the stealing of body parts from cadavers to be sold and used for muti, a sort of witchcraft. The session was rounded off by an interesting talk on the images of (and fascination with) the vampire in popular culture, and what vampire fiction could mean for bioethics. I thought of the persistent image, in Africa, of foreign researchers as vampires, coming to literally suck blood of locals.

The exhibit hall had an impressive display of well-stocked book stalls, conveniently located at a short distance from the coffee. My browsing experience, however, was somewhat disrupted by a couple of booksellers who were both selling what you might call 'other-help' books (as opposed to 'self-help') about clinical ethics decision-making. They both were aggressive, in their own ways: one was quite literally in my face, smiling and waving brochures, while the other was greasing the wheels of trade by offering free sunglasses and hand sanitizers. And both merchants featured books with algorithms and flow-charts, their own preferred paths to successful ethics conflict resolution. All very cheerily practical, like those who sell vegetable cutters in supermarkets. There really is a market for everything.

Low point of the day: a talk on international health research that was all over the map, conceptually muddy and in places, factually wrong. The cringe factor was high, and it was a pity, given that there is no little international bioethics on offer here. Fortunately, the session had two redeeming and stimulating talks after that, on the challenges faced by those wishing to provide compensation for research-related injuries (Jonathan Jay) and another on the parallels between moral responsibilities of photojournalists and international health researchers towards their respective 'subjects' (Valarie Blake). I was thus cheered up by presentations which were, on the face of them, pretty depressing.

Highlight of the day: the session on ethics and pain treatment. The general consensus among the speakers was that pain is undertreated in the US, at least partly due to the inability to visualize any physical source of pain by medical devices. A question of out of sight, out of practice and policy. The affable Daniel Goldberg (who writes his own excellent Medical Humanities blog) stormed merrily through his talk, making a strong case for a need to cultivate (political, socially and policy-wise) a greater receptivity to the subjectivity of pain, rather than merely tweaking current opiate policy. I couldn't help but think if pain is undervalued and undertreated in the US, what must the situation be in the developing world, where there are less diagnostics and less availability of opiates. A new twist on the phrase: a world of pain.

A world of pain

Pain is oddly subjective and universal. Although you may sympathize, you cannot literally 'feel my pain.' It's mine. But everybody, regardless of historical period or culture, knows what pain feels like: it hurts. And in hurting, it debilitates. Pain has been installed in us (and other sentient beings) for good evolutionary reasons: we need to know when our bodies are damaged. But, unfortunately, pain is a crude messenger. Pain often continues on, and even increases in strength, when we have already long got the point.

The journal Anesthesia and Analgesia is not exactly daily fare of the average bioethics worker, but the July issue contains a number of fascinating articles about the ethics of pain management. One striking consideration is the unequal global distribution of untreated pain. Pain may be universal, but access to pain management is certainly is not: if you suffer from chronic or acute pain, you are better off being Austrian than African. The former stands a good chance of getting opiate or non-opiate treatments; the latter is more likely to have to bite the bullet. And given the HIV/AIDS epidemic, the effects of war, poor sanitation, and the effects of treatable (but not treated) diseases, there may be just more pain needing treatment -- and not getting it -- among poor countries.

While there is distributive injustice in untreated pain between rich and poor countries, the undertreatment of pain is a worldwide phenomenon. Contributors to Anesthesia and Analgesia tackle explanations of the undertreatment of pain, what is ethically wrong about the status quo, and what to do about it. There seems to be a consensus that legal and political pressures (remember the 'war against drugs'?) about potential drug abuse and addiction have hindered aggressive pain treatment by clinicians, even in better-off nations. There are also cultural barriers, such as the belief that pain is natural and inevitable, or that it is a sign of a strong moral character to bear pain than have it relieved. Authors work both sides of the ethical street, arguing that appropriate pain management should be regarded as a human right while also documenting the social and economic consequences of untreated pain.