The Declaration of Montreal is an important recognition of an eternal truth: access to pain relief is a human right.
The following text is adapted from a video address by McGill medical ethicist Dr. Margaret Somerville to the International Association for the Study of Pain congress in Montreal. The final event of the congress was the International Pain Summit at which the Declaration of Montreal was to be presented and discussed. The declaration provides that access to pain management is a fundamental human right.
Many of us involved in trying to ensure people who require pain management get what they need have personal experiences involving pain in our background. That’s true for me. I can remember as an 11-year-old, with life-threatening peritonitis from a ruptured appendix, consciously wanting to die, the pain was so severe.
In 1983, my father was terminally ill with prostate cancer that had metastasized to his bones. I was telephoned in Montreal and told he was about to die, so I jumped on a plane to Australia.
I found my father in a university teaching hospital in horrible pain. I created a huge fuss and managed to get a pain specialist to see him – in fact, that specialist was Dr. Michael Cousins, who has piloted the development of this declaration we are considering. My father’s pain was brought under control and, as it turned out, he lived another nine months.
Dad said to me, “I want to live as long as I can, Margo, but I don’t want to live if it means such terrible pain. It’s great what you did for me, but not everyone has a daughter who can ‘go berserk’ to get them the pain relief they need. You have to do something to help other people in pain.” That was the start of my research on ethical and legal aspects of access to pain relief treatment.
That research led to an invitation to speak at the International Association for the Study of Pain’s meeting in Paris in 1993. I decided to consider whether we might be able to use ethics and law to improve access to pain relief treatment. I called the speech “Death of Pain,” meaning to convey the double-entendre message that we could kill the person with the pain or we could kill the pain.
I’m adamantly against killing the person with the pain, that is, euthanasia, and passionately in favour of killing the pain. So I argued that to implement that latter goal in practice, we should recognize that people in pain have a “fundamental human right” to have reasonable access to pain management and that unreasonable failure to provide such access was a breach of their human rights. And that is precisely what the Declaration of Montreal would establish.
Now, it’s important to understand why we need this declaration and to do so we need to understand something about the nature of human rights. “Human rights” try to ensure the rightness or ethics of our interactions with each other at the most basic level of our humanness, at the level of its essence, that which makes us human. I cannot discuss that further here, but suffice to say, as the vast majority of people acknowledge, recognizing and respecting human rights is very important in creating moral and ethical societies.
Here, I want to make just two points about human rights that I believe are important in relation to pain management.
First, I do not believe we create human rights; rather, they exist independently of being recognized by any human agency. That’s why no one can opt out of respecting them. What we do is articulate human rights. And that’s why statements of them are called declarations. The Universal Declaration of Human Rights is a major example of such an articulation, but it was not the end of our declarations of human rights. New declarations have continued to appear and need to do so.
I believe that this latest declaration, the Declaration of Montreal of the right of access to pain management for all who need it, without discrimination, will rank with the major human rights declarations.
Second, I believe that what we call “human rights” is shorthand for a tri-partite concept that consists of human rights, human obligations, and human ethics. Sometimes we need to focus on one of these limbs, sometimes on another, and sometimes on all of them.
So a human right to access to pain management means that health-care professionals and health-care institutions have ethical obligations, and sometimes legal ones, to offer patients such management.
But if, as I said, we don’t create those obligations, and they exist whether or not we declare them, why declare them? The answer is to help ensure that they are honoured and not breached. Formally recognizing them will make it much more likely that they will be respected.
The Declaration of Montreal is not just a piece of paper; it’s what we call a “verbal act.” That is, its words will change reality, just as a judge’s verdict is not just words, but changes reality. The hope is that the declaration will help to change the horrible reality of people being left in pain.
The declaration will also function as an ethics guide in relation to pain management and an educational tool for health-care professionals and trainees. Sometimes it will be used as evidence to justify giving necessary pain relief treatment, when others would prevent that. In particular, it will help to overcome the harmful beliefs of some health-care professionals who withhold pain management because they fear legal liability or that patients will become addicted. It will deliver a strong message that it’s wrong not to provide pain management, not wrong to provide it.
It will also inform and, one hopes, guide institutions and governments in formulating health policy and law with respect to pain management. The declaration will help governments understand that they have both domestic and international obligations, at the very least, not to unreasonably hinder either their own citizens’ or other people’s access to pain management.
It is an outrage and a human tragedy that, in developing countries, many people in serious pain do not have access to opioids, including as a result of the conditions some countries attach to their foreign aid to these developing countries. Imagine, as happens to many people in these countries, dying of excruciatingly painful cancer, with no pain relief.
We need to apply one of the most ancient and universally accepted maxims in making sure that everyone who needs pain management receives it: “Do unto others as you would that they would do unto you” – the Golden Rule. The Declaration of Montreal spells out what those “others” have a human right to expect when they are in pain.
There is a beautiful Sanskrit salutation, namaste, that I’ve spoken of in other contexts. It can be roughly translated as, “The light in me recognizes the light in you.” It affirms our common humanity across all barriers and borders. One very important application of it could be rendered as, “The pain in me recognizes the pain in you” — which is another way to express the insight of the “wounded healer.”
The Declaration of Montreal is a very important step forward in making sure that as many of us as possible, and especially health-care professionals, do recognize others’ pain and see it as our privilege and obligation to do what we can to assuage it.
And, finally, the Declaration of Montreal could raise our sensitivity to the horror of breaches of human rights, in general. Fortunately, most of us don’t experience breaches of our human rights in our everyday lives and, consequently, we don’t personally identify with them, much as we might abhor them. But because pain is a universal human experience that we all want to avoid, wrongful failure to manage it is one of the rare breaches of human rights with which we can all personally identify, better understanding, as a result, what breaches of human rights, in general, feel like. That is a lesson we should all heed carefully.
This article was originally published in the Ottawa Citizen. Margaret Somerville is director of the Centre for Medicine, Ethics and Law at McGill University, and author of The Ethical Imagination: Journeys of the Human Spirit. To see a video clip of this address, click here.