Declaration of Montréal
Declaration that Access to Pain
Management Is a Fundamental Human Right
Sign the Declaration
We, as delegates to the International Pain Summit (IPS) of the
International Association for the Study of Pain (IASP) (comprising IASP
representatives from Chapters in 64 countries plus members in 130
countries, as well as members of the community), have given in-depth
attention to the unrelieved pain in the world,
Finding that pain management is inadequate in most of the
- There is inadequate access to treatment
for acute pain caused by trauma, disease, and terminal illness and
failure to recognize that chronic pain is a serious chronic health
problem requiring access to management akin to other chronic diseases
such as diabetes or chronic heart disease.
- There are major deficits in knowledge
of health care professionals regarding the mechanisms and management of
- Chronic pain with or without diagnosis
is highly stigmatized.
- Most countries have no national policy
at all or very inadequate policies regarding the management of pain as a
health problem, including an inadequate level of research and
- Pain Medicine is not recognized as a
distinct specialty with a unique body of knowledge and defined scope of
practice founded on research and comprehensive training programs.
- The World Health Organization (WHO)
estimates that 5 billion people live in countries with low or no access
to controlled medicines and have no or insufficient access to treatment
for moderate to severe pain.
- There are severe restrictions on the
availability of opioids and other essential medications, critical to the
management of pain.
And, recognizing the intrinsic dignity of all persons and
that withholding of pain treatment is profoundly wrong, leading to
unnecessary suffering which is harmful; we declare that the following
human rights must be recognized throughout the world:
Article 1. The right of all people to have access to
pain management without discrimination (Footnotes
Article 2. The right of people in pain to
acknowledgment of their pain and to be informed about how it can be
assessed and managed (Footnote 5).
Article 3. The right of all people with pain to have
access to appropriate assessment and treatment of the pain by adequately
trained health care professionals (Footnotes
In order to assure these rights, we recognize the following
- The obligation of governments and all
health care institutions, within the scope of the legal limits of their
authority and taking into account the health care resources reasonably
available, to establish laws, policies, and systems that will help to
promote, and will certainly not inhibit, the access of people in pain to
fully adequate pain management. Failure to establish such laws,
policies, and systems is unethical and a breach of the human rights of
people harmed as a result.
- The obligation of all health care
professionals in a treatment relationship with a patient, within the
scope of the legal limits of their professional practice and taking into
account the treatment resources reasonably available, to offer to a
patient in pain the management that would be offered by a reasonably
careful and competent health care professional in that field of
practice. Failure to offer such management is a breach of the patient's
Note: This Declaration has been prepared having due regard
to current general circumstances and modes of health care delivery in
the developed and developing world. Nevertheless, it is the
responsibility of: governments, of those involved at every level of
health care administration, and of health professionals to update the
modes of implementation of the Articles of this Declaration as new
frameworks for pain management are developed.
- This includes, but is not limited
to, discrimination on the basis of age, sex, gender, medical diagnosis,
race or ethnicity, religion, culture, marital, civil or socioeconomic
status, sexual orientation, and political or other opinion.
- International Covenant on Economic,
Social and Cultural Rights (ICESCR) (1966). The State parties of the
ICESCR recognize "the right of everyone to the highest attainable
standard of physical and mental health" (Art. 12), creating the
"conditions which would assure to all medical service and medical
attention in the event of sickness."
- Universal Declaration of Human Rights
(1948): Rights to Health (Article 25); Convention on the Rights of a
Child (Article 24); Convention on the Elimination of All Forms of
Discrimination Against Women (Article 12); Convention on the Elimination
of All Forms of Racial Discrimination (Article 5(e) (iv)).
- The Committee on Economic, Social and
Cultural Rights. General Comment No.14, 22nd Session, April-May 2000 E/C
12/2000/4. "Core obligations" of all signatory nations included an
obligation to ensure access to health facilities, goods, and services
without discrimination, to provide essential drugs as defined by WHO,
and to adopt and implement a national health strategy.
- Committee on Economic, Social and
Cultural Rights. General Comment No.14, 22nd Session, April-May 2000,
E/C 12/2000/4, para. 12. General Comment No. 14 stated that health
accessibility "includes the right to seek, receive and impart
information and ideas concerning health issues."
- Appropriate assessment includes
recording the results of assessment (e.g., pain as the "5th vital sign,"
can focus attention on unrelieved pain, triggering appropriate treatment
interventions and adjustments). Appropriate treatment includes access to
pain medications, including opioids and other essential medications for
pain, and best-practice interdisciplinary and integrative
nonpharmacological therapies, with access to professionals skilled in
the safe and effective use of these medicines and treatments and
supported by health policies, legal frameworks, and procedures to assure
such access and prevent inappropriate use. Given the lack of adequately
trained health professionals, this will require providing educational
programs regarding pain assessment and treatment in all of the health
care professions and programs within the community for community care
workers delivering pain care. It also includes establishment of programs
in pain medicine for the education of specialist physicians in pain
medicine and palliative medicine. Accreditation policies to assure
appropriate standards of training and care should also be
- Failure to provide access to pain
management violates the United Nations 1961 Single Convention on
Narcotic Drugs declaring the medical use of narcotic drugs indispensable
for the relief of pain and mandating adequate provision of narcotic
drugs for medical use.
- The UN Universal Declaration of Human
Rights (1948) (Article 5) states: "No one shall be subjected to torture
or to cruel, inhuman or degrading treatment…" Comment:
Deliberately ignoring a patient's need for pain management or failing to
call for specialized help if unable to achieve pain relief may represent
a violation of Article 5.
- The UN Special Rapporteur on the Right
to Health and the UN Special Rapporteur on the question of torture and
other cruel, inhuman, and degrading treatment stated: "The failure to
ensure access to controlled medicines for the relief of pain and
suffering threatens fundamental rights to health and to protection
against cruel, inhuman and degrading treatment."
ANZCA. Statement on patients' rights to
pain management. ANZCA PS 45; 2001. Available at: www.anzca.edu.au.
Brennan F, Carr DB, Cousins MJ. Pain management: a fundamental human
right. Anesth Analg 2007;105:205-21.
Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right.
FEDELAT. Proclamation of pain treatment and the application of
palliative care as human rights, May 22, 2008.
IAHPC. Joint declaration and statement of commitment on palliative
care and pain treatment as human rights. Available at: www.hospicecare.com.
Scholten W, Nygren-Krug H, Zucker HA. The World Health Organization
paves the way for action to free people from the shackles of pain.
Anesth Analg 2007;105:1-4.
Somerville M. Death of pain: pain, suffering, and ethics. In Gebhart
GF, Hammond DL, Jensen TS, editors. Proceedings of the 7th World
Congress on Pain. Progress in Pain Research and Management, Vol. 2.
Seattle: IASP Press; 1994. p. 41-58.
Sign The Declaration of Montréal
This document has been endorsed by IASP and the International Pain
Summit Steering Committee. If you would like to show your support of the
Declaration by adding your electronic signature to it, either as an
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