Special Section: Open Forum Culture, Subjectivity, and the Ethics of Patient-Centered Pain Care JAMES GIORDANO, JOAN C. ENGEBRETSON and ROLAND BENEDIKTER Environment and Culture, Medium and Forum Even the most scientifically reductionist view of the individual reveals that we are complex systems nested within complex systems. 1 These interactions within and among systems are based and depend on numerous variables of our (internal and external) environment(s). If we define ethics as a system of moral decision- making, then it becomes clear that these decisions ultimately affect the situation(s) of managing our activities and relationships with others in our environment (in essence, our being in the world). 2 Given that ecology literally means ‘‘a study or system of wisdom and reasoning about the interrelation of organisms in their environment or place of inhabitance,’’ 3 Owen Flanagan’s description of ethics as ‘‘human ecology’’ takes on considerable relevance and importance. 4 To approach the ethical issues, and various systems and techniques used to address and resolve these issues, then—pro Flanagan—it is crucial to recognize the effect of ‘‘environment’’ on persons’ situations and actions that constitute their life-world(s). In other words, a consideration of ethics cannot exclude regard for the environment as embodied by time, place, culture, and circum- stance. This mandates an appreciation of culture as an important force in determining interactively biopsychosocial dimensions of persons’ being. At the most basic level, culture refers to a ‘‘medium for the development of living material,’’ and while usually reserved for connotations of experimental methods, it must be borne to mind that this definition is no less operative when consid- ering what and how ‘‘culture’’ engages and sustains ‘‘the set of shared material traits, characteristic features, knowledge, attitudes, values and behaviors of people in a common place and(/or) time.’’ 5 This definition rightly reveals that culture establishes and reflects particular biological characteristics (that develop and are preserved in response to environments) that can be expressed through cognitions and behaviors. In this way, culture is a medium for biopsychosocial development and a forum and vector for its expression and manifestation. 6 Thus, any attempt to identify moral issues (and ethical approaches to resolving these issues) must appreciate the effects of and on ‘‘culture’’—from biological to social levels. In this essay we argue that any practical consideration of an ethics of pain medicine must also recognize (1) the effects of culture on the event, phenomenon, and experience of pain; (2) the distinctions that are evoked by the ‘‘culture’’ of medicine (vs. the ‘‘culture’’ of patienthood); and (3) how geographic, social, and temporal variances affect these cultural dynamics. We posit that one cannot Cambridge Quarterly of Healthcare Ethics (2008), 18, 1–10. Printed in the USA. Copyright Ó 2008 Cambridge University Press 0963-1801/08 $20.00 doi:10.1017/S0963180108090087 1