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5 Pain and ethical practice: How do we resolve dilemmas in pain care?

Modern healthcare ethics stands on four pillars: beneficence, non‐maleficence, autonomy, and distributive justice (Beauchamp and Childress 2013; Figures 5.1 and 5.2). Beyond this, an exemplary career in pain‐competent healthcare is guided by high levels of compassion, interpersonal insight, resilience, and self‐regulation. Every day in pain care, these ideals are tested and tempered. As noted by Giordano (2006) “there is a core philosophy of medicine that reflects the intellectual and moral quality of the healing relationship”. The same is true in nursing, pharmacy, dentistry, physical therapy, social work, clinical psychology, and all health professions. Pain‐focused care is rich and fulfilling when actuating the ethical virtues through compassionate connections with patients and others in a joint effort to relieve pain.

Figure 5.1 Healthcare ethics rests on the “four pillars.”

Figure 5.2 Each of the four pillars has distinctive aspects that shape ethical decision‐making.

Beneficence

Pain care presents frequent opportunities to practice beneficence. In pain care, the overarching goal is the relief of pain, but parallel goals include the improvement of function and quality of life. In restoring the patient's confidence in their ability to manage chronic pain or in alleviating acute pain, there is tremendous beneficence. By learning pain care, whether studying a drug dose, route, and potential interactions; in exploring the mechanisms of focal pain, or in learning how to support patients emotionally, we gain an opportunity to help people in the most direct manner: applying our clinical competence to relieve pain and improve lives.

Non‐maleficence

The principle of non‐maleficence or “doing no harm” has immediate application in pain care where both “not treating” and “treating” have the capacity to harm a patient. For many years, pain was viewed as entirely subjective and not quantifiable, all too often quickly dismissed. No longer; the bygone solution of ignoring or minimizing pain is soundly rejected in modern civilized society. With the advent of functional MRI, we know that pain activates numerous brain centers, including those associated with suffering. Medicolegal case law has concluded that ignoring a patient with pain, particularly a dying, incapacitated patient, is inhumane. The Joint Commission has determined that pain must be assessed, safely treated, and re‐assessed for relief (Baker 2017).

Another aspect of non‐maleficence focuses on safety in implementing a pain treatment plan. The Joint Commission recommends that patients treated with opioids be assessed and monitored for respiratory compromise (Joint Commission 2012). The assessment of patients for the risks of potential opioid abuse or misuse is also part of non‐maleficence. Opioids can be safely tapered without direct risk of mortality, but almost all patients find that withdrawal from opioids is painful and excruciatingly difficult, some attempt suicide. Thus, opioid tapering after chronic therapy is often a slow, incremental process (Chapter 49). Finally, we now know that prolonged opioid therapy lowers pain threshold and tolerance potentially worsening pain; the use of opioids for chronic pain should be approached with abundant caution (Chapter 48).

Autonomy

The principle of autonomy is critically important in pain care for both the provider and the patient. It is easy to fall into a pattern of issuing instructions to patients in the belief that this is time efficient. This does not respect a patient's autonomy and may not result in a treatment plan that respects the patient's inclinations and healthcare beliefs. Motivational interviewing and shared decision‐making bring autonomy appropriately into the pain‐focused clinical encounter (Chapter 14).

Distributive Justice

The practice of pain care is a continual, pragmatic study of distributive justice. This is because pain medications are viewed as expedient, providing inexpensive pain relief albeit producing cognitive dysfunction, constipation, sedation, abuse risks, and other side effects. In counterpoise with medication risks and benefits, is the substantive investment of time, energy, and money required to implement most non‐pharmacological strategies. It is a principle of distributive justice that patients should not be exposed to more medical risk than necessary while balancing the costs to society. Why do we still prescribe potentially harmful pain medications when a short course of physical or cognitive therapy would be equally efficacious?

Medical tradition teaches that there were two Pillars at Delphi inscribed with simple but indispensable guidance: Know thyself, and Know thy limits. All too often, we find ourselves stretching to meet the demands of our patients for better, faster, and less expensive solutions. We may be tempted to perform procedures that we don't know well or try treatments that we don't completely understand. While it is laudable to relieve pain as expeditiously as possible, safety is always the first concern. Clinical practice should never overstep the scope of training. Perform a procedure or prescribe a treatment only if you are (i) can perform it with technical proficiency, and (ii) can manage the complications, common and less so. If not trained to recognize and manage the complications of any therapy, interventional, opioid‐based, or even NSAIDs, one must refrain from intervening. Unfortunately, not treating pain also carries burdens: patients can despair of improved circumstances. There are many pain clinics and always more options for treatment of pain, do not destroy hope. Provide a referral if you cannot act. It is ethical to sustain a patient's hope that pain relief or at least pain mitigation is a reasonable goal.

Finally, pain care offers opportunities to work with patients to advance a sense of self‐efficacy and personal accomplishment. The best outcome is engaging with a patient to identify appealing lifestyle changes and active non‐pharmacological steps that correct a long‐standing pain condition. The opportunity to celebrate these victories with our patients is the true reward of the committed and ethical practice of pain care.

References

1 Baker, D. (2017). The Joint Commission’s Pain Standards: Origins and Evolution. Oak Brook, IL: The Joint Commission.

2 Beauchamp, T. and Childress, J. (2013). Principles of Biomedical Ethics, 7e. New York: Oxford University Press.

3 Giordano, J. (2006). Moral agency in pain medicine: philosophy, practice and virtue. Pain Physician 9 (1): 41–46.

4 Joint Commission (2012). Safe use of opioids in hospitals. The Joint Commission Sentinel Event Alert 49: 1–5.