Ethical Issues in Chronic Pain Management PDF

Preface

Chronic pain is a phenomenon that impacts the life of the sufferer in profound ways, as it is experienced not only nociceptively, but emotionally, socially, vocationally, financially, legally, and spiritually as well. To the patient, chronic pain represents a challenge unlike that associated with any other type of physical condition. Yet it is not only the patient who is challenged by chronic pain; the wide variety of chronic pain conditions that patients experience certainly represents a unique challenge to the health care professionals who valiantly attempt to treat them. Typically, cure is not a realistic goal for the practitioner or the patient. Accordingly, medical professionals are left with the obligation to reduce suffering, despite a frequent misunderstanding of what suffering entails. Many physicians and other health care professionals want nothing to do with chronic pain patients, simultaneously expressing feelings of frustration relating to their inefficacy in reducing suffering and contempt for the patients who are afflicted. Because of the difficulty involved in effectively treating patients with chronic pain, primary care physicians seek ‘‘dumping grounds'' for them, hoping that other practitioners will carry the burden. The physician who is brave enough to make chronic pain management a part of his or her practice is faced with a myriad of ethical dilemmas, further complicating the treatment of patients in need of assistance.

While few would question the notion that patients and clinicians experience unique challenges associated with chronic pain, other entities are challenged by this affliction as well. The medical system now includes more than the physician and the patient, between whom a moral covenant ideally exists. This covenant entails a common will, shared by patient and practitioner, to work toward reducing the individual patient's suffering. Parties not directly bound by this covenant have come to be included in the care that the patient ultimately receives, with this seemingly increasing list of parties including the insurance industry, hospital administrations, attorneys, the government (in various forms, including the Department of Elder Affairs, the legislature, the executive branch, and the courts), ethics boards of the various professions involved in chronic pain management (whose principles often collide with one another), and research review boards. Sadly, the strength of the covenant between the practitioner and the chronic pain patient is compromised by the involvement of these extraneous parties, some of whom are motivated by the desire to serve the good of society as a whole as opposed to that of the individual patient, with others simply (and, at times, selfishly) motivated by cost-containment and profitability. Both the patient and the physician have lost their autonomy to work together as an effective team, with too many cooks spoiling the broth of patient relief from suffering.

This handbook was written in order to help all the parties involved in the care of the chronic pain patient understand the ethical (and related legal) issues associated with the efforts of professionals to assist patients in their efforts to find relief and reclaim their independence. The opinions of the illustrious group of authors who contributed chapters to the book are not necessarily consistent with each other, and editorial efforts were made to maintain balance in presenting viewpoints that may not be harmonious. All the chapter authors, while renowned in their respective fields of practice and investigation, demonstrated admirable willingness to avoid dogmatic positions in interpreting the literature and offering opinions regarding what constitutes ethical practice.

Ethical Issues in Chronic Pain Management is divided into five sections. The first section, Ethical/Philosophical Issues, includes chapters looking at the pain practitioner's responsibility to practice virtuously (James Giordano), ethical dilemmas experienced by the chronic pain patient (Debra E. Benner), ethical issues associated with treatment of patients at the end of life (Richard Payne), and the ethical failure of society associated with allowing empirically supported multidisciplinary treatment programs to become progressively less accessible to patients (Michael E. Schatman). While seemingly diverse, each of these topics shares the common theme of the integration of classical philosophical thought and the optimal management of chronic pain conditions. The authors of the chapters in this section agree that on both the individual and collective levels, allowing people to suffer needlessly is simply wrong.

The second section of the book, Disparities in Treatment, emphasizes the bioethical principle of justice, which is primarily localized to the domain of distributive justice. The multitiered medical system, which is evident in the American society, results in limited access to high-quality chronic pain management services for many on the basis of socioeconomic factors (1). Chapters in this text include analyses of underservice of specific groups of chronic pain sufferers, including children (Patricia A. McGrath and Danielle A. Ruskin), seniors (Raymond C. Tait), and members of racial and ethnic minority groups (Carmen R. Green). Each of these chapters promotes the mission of the Disparities in Pain Management Special Interest Group of the American Pain Society, which is currently chaired by Dr. Tait.

Part three of the book, Legal and Ethical Issues in the Pharmacological Treatment of Chronic Pain, is extensive, as the included chapters cover the greatest current ethical and legal controversies in the field of chronic pain management. Chronic pain practitioners are in agreement regarding the need to help alleviate suffering in our patients. Considerable disagreement exists, however, regarding the best means of doing so. An emphasis has been placed on chapters relating to the prescription of opioids on a long-term basis, particularly to patients with chronic pain of nonmalignant origin. During the 1990s and the early part of this decade, the pendulum swung from disdain for the practice of chronic opioid therapy to a possible overreliance upon this mode of treatment. The result of this paradigm shift has been not only problematic responses by many patients, but more aggressive monitoring of physicians by the Department of Elder Affairs as well. Chapters in this section include an argument for consideration of chronic opioid therapy (B. Eliot Cole), an argument for the need to be cautious in considering long-term treatment with opioid analgesics (Jane C. Ballantyne), and a very important set of recommendations regarding the avoidance of legal and regulatory challenges to physicians who attempt to alleviate patient suffering through the prescription of opioids (Jennifer Bolen). Finally, this section includes a chapter by Ethan B. Russo on the benefits of cannabinoids in the treatment of chronic pain. This chapter was a late addition to the book, as progressively more states are passing legislation supporting the use of cannabinoids for pain treatment. However, in June of 2005, the U.S. Supreme Court curiously ruled that the federal government can ban the possession of the drug, even in states that have eliminated sanctions against its use for the treatment of illness. Dr. Russo's chapter is particularly important given the number of sufferers who have found medicinal marijuana to be an effective pharmacologic agent in their battles with chronic pain.

The fourth section of the book, Medicolegal Issues, consists of chapters on legal issues associated with the treatment of chronic pain. As a considerable proportion of chronic pain patients are injured traumatically or through repetitive motion at work, clinicians are faced with the challenge of providing the best possible care while simultaneously demonstrating sensitivity to the legal aspect of their patients' cases. Additionally, the commodification of medicine in the United States has severely limited the ability of medical professionals to provide optimal care to chronic pain patients. Confusion relating to balancing the interests of multiple clients (i.e., the patient, insurance carriers, case managers, attorneys, the employer, and hospital administrations) often results in an ethical conundrum for the chronic pain practitioner. To provide guidance, this section of the book includes chapters discussing ethical issues associated with disability determination (Jaye E. Hefner), treating chronic patients effectively despite the efforts of managed care to limit treatment (David L. Trueman), and ethical issues associated with providing expert medical testimony in cases involving chronic pain (Barbara L. Kornblau). These chapters have been included in order to help the chronic pain clinician gain perspective on the interaction between the law, ethics, and the provision of medical services.

The final section of the book, Ethical Issues in Standards of Care and Research, covers a wide variety of topics. Chapters in this section examine issues including ethical standards in the psychological evaluation of chronic pain patients (C. David Tollison and DonaldW. Hinnant), the need for appropriate physical examination of chronic pain patients and the interaction of legal and ethical issues involved in implementing optimal treatment based upon findings (Nelson Hendler), the importance of clinical practice guidelines (Alexandra Campbell), and ethical issues involved in conducting chronic pain research (Robert J. Gatchel, Perry N. Fuchs, and Colin Allen).

Pain practitioners, as has been suggested by Giordano (2), are obligated to serve as moral agents as well as therapeutic agents to their patients. The practice of pain management is under assault by a number of forces (3), although this is thought to be true of medicine in general (4–6). Our hope is that Ethical Issues in Chronic Pain Management will provide clinicians with insights that will help them continue to practice the healing art of chronic pain management virtuously, while simultaneously avoiding potential legal pitfalls that may be deleterious not only to health care providers, but to their suffering patients as well. Patients with chronic pain, and society as a whole, cannot afford the demise of the patient–practitioner covenant. Emphasizing ethical and legal treatment will hopefully serve to keep the covenant alive.