From the Editor

Feb 2025

How We Lie About Pain

Amy Lorber, MD and Andrew Lynch, MD, MSE
AMA J Ethics. 2025;27(2):E69-71. doi: 10.1001/amajethics.2025.69.

 

 

The phrase, “This might sting,” is perhaps the phrase that best captures the inspiration behind this issue of the AMA Journal of Ethics. Throughout our training, we have both learned and struggled with hearing this phrase. Across clinical settings and patient populations, we have witnessed pain managed well, pain that persists despite our best efforts, and, most hauntingly, pain ignored. While pain is a frequent topic in ethical inquiry in health care, we believe the overwhelming focus in pain ethics remains chronic pain management. Lack of attention to acute pain management, particularly in subpopulations whose needs are under- or unmet, has left us reliant on a vocabulary of vague phrasing: “sting,” “cramp,” or “a sense of pressure,” to name a few. We counsel patients to consent to important procedures that come with iatrogenic pain but find ourselves encouraged to minimize descriptions of pain during consent conversations.

This theme issue originated in the authors sharing stories from clinical rotations and identifying a lack of clear guidance about how to manage pain in obstetrics and gynecology procedures occurring outside of labor and delivery settings. In 2021, for example, intrauterine device (IUD) procedural pain rose in public attention via social media narratives.1,2 Clinical recommendations regarding pain control during IUD insertion and removal, however, remain sparse.3 Even non-labor and delivery obstetrics and gynecology (non-L&D OB/GYN) procedures arguably require patients’ bodies to be positioned in one of the most vulnerable possible ways. Patients are physically, epistemically, and emotionally at the mercy of their clinicians, so clinicians’ characters and pain management strategies during such procedures could not be more worthy of ethical investigation.

Given the limited guidance, communication and analgesia approaches are clinician dependent. They are thus heavily reliant upon clinicians’ capacities to discern patients’ needs and to charitably—and as accurately as possible—interpret patients’ behavior, which has been described as a “social transaction.”4 Furthermore, racial disparities in pain management and inadequate pain treatment are well documented.5 In the setting of acute pain specifically, quick decision-making may accentuate bias.6 Finally, expressions of gender identity, racial, ethnic, and age biases in OB/GYN settings have a treacherous, violent history with long legacies and persistent influence on many patients’ experiences. This theme issue considers these and other nuances of acute non-L&D OB/GYN pain.

We have collected manuscripts from authors across fields and institutions that consider this topic. Example cases address the current landscape of reproductive health, such as IUD insertion and abortion. Historical and policy questions address the deep roots of today’s clinical practices and highlight a potential road forward that better emphasizes patients’ experiences. Other articles publicly wrestle with pain vocabulary for clinicians, rethinking how to ensure that informed consent is truly informed. We hope this issue starts a conversation among clinicians to self-evaluate how they manage and discuss pain, lowers their tolerance of poor pain management practices, and inspires research that may, one day, lessen the pain felt by patients, especially for office-based procedures in gynecology.

References

  1. Kitchener C. Patients are warned that IUDs can be “uncomfortable.” But many say the pain is excruciating. Washington Post. July 19, 2021. Accessed May 2, 2024. https://www.washingtonpost.com/gender-identity/patients-are-warned-that-iuds-can-be-uncomfortable-but-many-say-the-pain-is-excruciating/

  2. Toscano J. People on TikTok are talking about how excruciating IUD insertion can be. SELF. April 26, 2022. Accessed May 2, 2024. https://www.self.com/story/iud-insertion-pain-management

  3. Lopez LM, Bernholc A, Zeng Y, et al. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev. 2015;2015(7):CD007373.

  4. Gordon DB. Acute pain assessment tools: let us move beyond simple pain ratings. Curr Opin Anaesthesiol. 2015;28(5):565-569.
  5. Santoro TN, Santoro JD. Racial bias in the US opioid epidemic: a review of the history of systemic bias and implications for care. Cureus. 2018;10(12):e3733.

  6. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.

Editor's Note

Background image by Kayla McCormick.

Citation

AMA J Ethics. 2025;27(2):E69-71.

DOI

10.1001/amajethics.2025.69.

Acknowledgements

The authors thank Tyler Gibb, PhD, associate professor and co-chair of the Department of Medical Ethics, Humanities, and Law at Western Michigan University Homer Stryker MD School of Medicine. His guidance and support were instrumental in the pursuit of this theme issue.

Conflict of Interest Disclosure

Authors disclosed no conflicts of interest.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.