Millions of Americans suffer from chronic pain. A Gallup survey taken in 1999 reported that “pain is so common that about 9 in 10 Americans suffer from pain at least once a month, and data as of 2000 suggest that almost 1/3 of all Americans will experience severe chronic pain at some point in their lives” (Nathan 156). Chronic pain sufferers whose best chance of relief often comes in the form of opioid pain medicines are often met with frustration when they turn to doctors for relief in the face of a system influenced by a society that discourages the use of narcotic analgesics. Considering that “pain constitutes the most common reason why individuals seek health care” (Nathan 156) an ethical approach to pain management must be found that meets the needs of both patients and the medical community. To meet those needs, a two-fold formula of narrative-based ethical theory implemented through a comprehensive clinical team approach should be adopted throughout the medical community.
An examination of the broad-based consequentialist and deontological theories will illuminate the need for an approach that has the flexibility to address individual needs of patients with chronic pain. Looking at the narrative approach the focus will move from the patient’s own story, to the need for patient autonomy, to issues of physicians’ trust in patients’ self-presentation, and to issues of drug addiction. The team approach to treatment will address issues of physician autonomy, overcoming patient manipulation, and the government’s role in providing an ideal environment for physicians to utilize their skills to the fullest of their abilities to deliver the best possible patient care.
The idea of positive rights to pain relief, while worthy of debate, are beyond the scope of this paper. Also exempt from the discussion are issues regarding treatment of cancer pain and terminal illness as “improving palliative care [care for those whose conditions are incurable] for the dying, including relief of pain, has been a national policy priority for nearly a decade. There is broad and deep agreement that pain management is a core medical and ethical duty for the dying patient” (Johnson 220), so the focus will be on illustrating an ethical model for the broader chronic pain community.
A problem facing the pain management community is that “we now have high quality evidence about what works in pain management, but patients still experience moderate to severe pain and the consequences of this can be long lasting and severe” (Seers 4). Competing ethical views of approaches to pain management prevent physicians from “consistently meeting the challenge of optimal pain management for a variety of reasons, including lack of knowledge; the values and beliefs that affect our judgments; how we make decisions and use evidence about pain management; and a lack of prioritization of pain and its management both at an individual and institutional level” (Seers 4-5). An individualized, flexible and comprehensive approach is needed to address the growing disparity between patient needs and treatment norms.
In formulating ethics in pain management, it is necessary to gain an understanding of the complexity inherit in tensions between conflicting patient needs and the needs of the physician, forcing the question as to “what other duties must be balanced against the duty to provide pain relief” (Sullivan 274). The Kantian might argue that as long as the doctor adheres to the concept of the categorical imperative, of acting from a sense of duty, the doctors will always do the right thing. But physicians often find themselves in a dilemma of conflicting obligations “due to the dual imperatives of the pain management movement and the prevention of prescription drug abuse” (Miller 54). Extrinsic social factors weigh upon physician decision making and influence treatment approaches. On one hand, “the ethical principle of beneficence mandates physicians to do good for their patients” (Lebovits 441). Advocates of the pain management movement for chronic pain sufferers adhere to the principle that “when the primary disease/condition cannot be eliminated, the objective of medical intervention needs to focus on the relief of pain and suffering” (Nathan 155). On the other hand, societal views and government policy on drug abuse create a duty to refrain from doling out narcotics without justification. The trouble for the Kantian is that “because all duties are considered absolute, there is no guidance available for balancing conflicting obligations” (Sullivan 276). When doctors are required by duty to do both x and y, but x and y conflict, there is no mechanism for reconciliation in the Kantian framework.
The consequentialist would say that the “best overall result is determined from an impersonal perspective that gives equal weight to the interests of each affected party” (Sullivan 275). The problem here is that utilitarianism would allow patients to drug themselves into oblivion. From a patient’s perspective, “if someone were to truly prefer an opioid regimen that produced a lifelong stupor rather than some minimal discomfort from walking, utilitarianism would support such a choice” (Sullivan 275). The consequentialist view from a physician’s perspective would allow that “obtaining pain relief in easily treated individuals would be favored over obtaining pain relief in less easily treated individuals” (Sullivan 275) as that would promote the best interest of the physician. If a utilitarian agrees with the notion that drug abuse is harmful to individuals and/or society, given that “the National Institute on Drug Abuse (NIDA), a division of the National Institutes of Health, reports that an estimated 4 million people—almost 2% of the population aged 12 and older are currently using prescription drugs, including pain relievers, sedatives, and tranquilizers, nonmedically” (Miller 56) the utilitarian must acknowledge the need for regulating physicians’ abilities to prescribe these drugs. But Lebovits asks, “what is the harm if treating chronic pain adequately means that opioids may get into bad hands—if the overall good is that patients will suffer less and be more productive members of society, have better relationships with their spouses, and be better parents to their children” (441)?
The Kantian and the consequentialist ethical theories are too broad-based to effectively apply to pain management, for “where utilitarianism seems to fail by making everything negotiable, in the pure Kantian system nothing is negotiable” (Sullivan 276). Instead, the complexity involved in making pain management decisions calls for flexibility in understanding and accepting individual circumstances to allow for tailoring appropriate approaches to each patient.
A two-fold approach is called for, one part theoretical and one part empirical. The theoretical approach must be rooted in the unique narrative brought by each patient “because it is very difficult to determine whether and how much someone is suffering without being aware of the story that accompanies their experience” (Sullivan 276). A narrative-based ethical theory “is the opposite of the principle-based or top-down model. Here the story of the individual case becomes of core importance, of paramount understanding” (Sullivan 275). Differences in condition, severity, pain tolerance, genetics, psychological state, upbringing, and cultural background all affect the patient’s level of comfort, response to pain, and response to treatment. The only way to begin developing a program that works is to understand the narrative that addresses how all of these issues are affecting the patient.
The concept of applying a narrative-based ethical approach immediately brings up two questions: can it be done, and can patients receiving narcotics be trusted? (A third question, should it be done, is a valid question, but it goes beyond the scope of this paper.) In attempting to treat a patient suffering from chronic pain the physician finds that “the complexity of pain management decision-making is compounded by the subjective nature of pain, the necessary communication between patient and clinician to understand and treat the pain problem, and the dependent relationship promoted by the healthcare system” (Seers 5). In order for the narrative process to work the patient must have autonomy and “autonomy requires two essential conditions: 1) liberty, or independence from a controlling influence; and 2) agency, or a capacity for intentional action” (Sullivan 277). Enabling patients to retain and utilize their agency means that “patients need to be educated about the risks and benefits associated with pain treatment. They need to be cognizant of the trusting relationship that must exist between themselves and their physician in order for their pain to be adequately treated” (Nathan 160). Difficulty in maintaining patient autonomy arises with the introduction of pain and the desire of the patient to be rid of his/her own suffering as “pain, for example, may push patients to a point where they are no longer able to carefully weigh the risks and benefits of surgery” (Sullivan 277). Adding to the difficulty is the fact that “medications such as opioids or benzodiazepines that induce physiologic dependence hold special risks for erosion of patient autonomy. In these situations, respect for patient choice must be combined with awareness of the compromise of patient autonomy by unrelieved pain and by dependence-inducing medications” (Sullivan 275). Since autonomy requires freedom from controlling influence, addiction to pain killers can create “patients who are unable to make choices that avoid harm” (Richeimer 396). But addiction is often overstated and misunderstood.
The Cleveland Clinic defines addiction as “characterized by loss of control, cravings, and adverse consequences resulting from use of a substance” (Webpage). The Cleveland Clinic makes a distinction between “physical dependence [and] tolerance. In cases of physical dependence, there are withdrawal symptoms if a person suddenly stops using a substance. Tolerance occurs when the initial dose of a substance loses its effectiveness over time” (Webpage). Chronic pain patients who take narcotic pain medication as prescribed will develop tolerance and physical dependence over time, by that does not, by definition, constitute addiction. Contrary to popular belief, “the risks of addiction to opioids in chronic pain patients is low” (Lebovits 441). But that fact doesn’t eliminate distrust.
Physicians prescribing narcotics must be continually aware of the possibilities of manipulation by the patient “because treatment of pain with opioids, unlike most other professionally sanctioned medical treatments, is subject to a heightened level of scrutiny from outside agents, some of which have the power to levy significant legal or professional sanctions” (Miller 57). As a result, “trust in patients in this context can be hard to achieve and easily fractured” (Miller 57). Here, the major argument against the narrative approach is that “doctors are continually faced with patients whose clinical presentation appears to be influenced by other motivations: seeking disability income, drugs, a work excuse, a jail excuse, or to gain attention” (Richeimer 396). As a result, “doctors are now likely to refuse to give opioids. Many doctors also refuse to deal with disability issues. It is almost as if the default position has become one of distrust” (Richeimer 396). Yet, Richeimer’s implications fail to address the fact that “a patient who legitimately experiences chronic pain does not assure honesty or reliability in the control of prescribed medications. In the same respect, a patient with a criminal history or history of addiction is not prevented from the emergence of painful conditions” (Nathan 159). The solution to these issues comes from the empirical side of this two-fold approach.
The narrative approach implemented through a comprehensive approach utilizing a team of physicians and clinicians moves to solve both the problems of patient deception and the danger of sanctions faced by physicians. For patient honesty “the use of multiple team providers, physicians, and nonphysicians would help detect deception. In particular, the employment of a psychologist who is trained in behavioral assessment as part of the interdisciplinary team” (Lebovits 441) would help to address patient needs even if the patient was suffering from addiction in addition to pain. As it stands today, “an addicted patient in chronic pain presents physicians with two of the conditions with which medical education in the US least prepares them to cope” (Miller 59). As such, the best chances for success lie within the clinicians’ abilities to work with one another and know each others’ abilities and limitations; “for health professionals to collaborate in meeting patients’ needs, they must understand each other’s role and expertise. This understanding is the foundation for valuing and respecting others’ contributions to the management of complex problems, particularly for people with persistent pain” (Seers 5). This comprehensive approach gives the patient the best chance of success by combining the efforts of specialists in various fields such as internal medicine, anesthesiology, psychology, and family practice. The approach also gives the team of clinicians greater indemnity, enabling them to focus more on treating the patient and less on extrinsic influences like Drug Enforcement Administration investigation and social biases that tend to be pervasive in decisions made by individual physicians treating chronic pain patients.
The physicians need autonomy as well in order to function to the fullest of their abilities. Government is slowly giving doctors the protections they need to freely treat patients. State “legislatures, withCaliforniain the lead, have enacted statutes to protect physicians from inappropriate disciplinary action; to encourage effective treatment of patients in pain; and to ensure that physicians receive appropriate training” (Johnson 220). While the patients and their stories may be unique, standards can still be applied to the prescribing of narcotic medications. To this, “twenty-two states have adopted all or part of the Federation of State Medical Boards (FSMB) ‘Model Guidelines for the Use of Controlled Substances for the Treatment of Pain’” (Miller 55). Doctors are given enough flexibility within those standards to accommodate for reasonable parameters in pain assessment. “These guidelines, published in 1998, are meant to provide protection to physicians who prescribe opioids for pain, by encouraging clear and consistent standards and by educating the regulatory and physician communities on treatment with controlled substances” (Miller 55). The fine-tuning and further adoption of these guidelines by the nation’s medical communities can put the decision making back into the doctor’s office and out of the administrator’s office.
At the end of the day the most important aspect of the narrative approach is forging of a strong physician-patient relationship because, “at the most fundamental level, in a good physician-patient relationship, the physician typically trusts the patient as a moral agent” (Miller 53). Acting in a trusting physician-patient relationship within the parameters of flexible but consistent standards, with a team of clinicians all focused on the best interests of the patient gives the patient the best chance of success, which, after all, is the point of medicine.
Other related issues that are beyond the scope of this paper, but are none-the-less worthy of consideration include: the requirement of patients trusting their doctors and the ethical implications of mutual trust between actors of unequal power and authority (the doctor being the authority and the patient retaining autonomy in a quasi-paternalistic relationship), the effects of requiring physicians to act in the capacity of law enforcement in detecting and preventing drug abuse, criminal prosecution of physicians for drug trafficking and the effects of those cases on the medical community’s approach to pain management, and the over-arching question of whether or not society has the right to regulate how people medicate themselves in the first place.
ClevelandClinic. “Pain Medicines: Understanding Addiction.” 1995-2009. 27 Apr. 2009 <http://my.clevelandclinic.org/disorders/chronic_pain/hic_pain_medications_understanding_addiction.aspx>
Johnson, Sandra H. “Commentary: Sandra H. Johnson, JD, LLM.” Pain Medicine 5.2 (June 2004): 219-221. Academic Search Complete. EBSCO.KentStateUniversityTrumbull Library,Warren,OH. 27 Apr. 2009 <http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=13355879&site=ehost-live>.
Lebovits, Allen. “Physicians Being Deceived: Whose Responsibility?.” Pain Medicine 8.5 (July 2007): 441-441. Academic Search Complete. EBSCO.KentStateUniversityTrumbull Library,Warren,OH. 27 Apr. 2009 <http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=25905230&site=ehost-live>.
Miller, Jessica. “The Other Side of Trust in Health Care: Prescribing Drugs with the Potential for Abuse.” Bioethics 21.1 (Jan. 2007): 51-60. Academic Search Complete. EBSCO.KentStateUniversityTrumbull Library,Warren,OH. 27 Apr. 2009 <http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=23414138&site=ehost-live>.
Nathan, Jonathan I. “Chronic Pain Treatment: A High Moral Imperative with Offsetting Personal Risks for the Physician—A Medical Student’s Perspective.” Pain Practice 9.2 (Mar. 2009): 155-163. Academic Search Complete. EBSCO.KentStateUniversityTrumbull Library,Warren,OH. 27 Apr. 2009. <http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=36606225&site=ehost-live>.
Richeimer, Steven H. and Lisa Victor. “Response to Commentaries.” Pain Medicine 6.5 (Oct. 2005): 396-396. Academic Search Complete. EBSCO.KentStateUniversityTrumbull Library,Warren,OH. 27 Apr. 2009 <http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=18589960&site=ehost-live>.
Seers, Kate, Judy Watt-watson, and Tracey Bucknall. “Challenges of pain management for the 21st century.” Journal of Advanced Nursing July 2006: 4+. Academic Search Complete. EBSCO.KentStateUniversityTrumbull Library,Warren,OH. 27 Apr. 2009 <http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=21023432&site=ehost-live>.
Sullivan, Mark. “Ethical Principles in Pain Management.” Pain Medicine 1.3 (Sep. 2000): 274-279. Academic Search Complete. EBSCO.KentStateUniversityTrumbull Library,Warren,OH. 27 Apr. 2009 <http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=5511991&site=ehost-live>.