The ethics literature regarding pain management has typically
focused on end-of-life issues involved with the treatment of patients
experiencing terminal pain. But many if not most of the problems
that arise with pain treatment involve problems with the treatment
of chronic nonmalignant pain. A large portion of these problems
can be traced to underlying problems with the ability of the physician
to trust the patient. In this chapter I describe some of these ethical
dilemmas, examine the underlying problems with trust, then propose
how reconceptualizing some of the pain clinic treatment systems
might serve to diminish some of the ethical problems.
Consideration of the ethical issues involved in pain management
typically conjures up images of the terminally ill patient. The
literature and research dealing with care at the end of life is
extensive; however, there is a remarkable void of literature and
research considering the common ethical issues that arise on a daily
basis with the care of patients with chronic nonmalignant pain. These
issues tend not to receive much of our attention; however, the problems
are real and frequent. It is my hope that by focusing on these issues,
we can start to clarify the nature of the underlying problems, and
perhaps start to institute systems to minimize their frequency.
The following cases do not represent single individuals, but
condensations of several cases from discussions of the monthly Ethics
Round Table meetings at the University of California Davis Medical
Center Pain Clinic. After reviewing a case history, we examine the
ethical issues and later develop a methodology for building trust.
We then apply this methodology to additional cases.
We have employed a case-study format for discussion because it
is common practice in both medical and ethics education and best
affords the reader concrete examples of potential clinical and ethical
Ethical deliberation usually consists of the application of basic
ethical theories that support and guide ethical decision making.
Such philosophical theories, or models of deliberation, provide different
approaches for analyzing basic ethical principles and how such principles
are to be judged in relation to others. English1 states
that “an ethical theory attempts to achieve a general applicability
to considerations of moral behavior, with as few exceptions as possible.
Important characteristics of a theory include universalizability,
comprehensiveness, and consistency.” As this is a chapter
devoted to ethical issues in chronic pain management, the reader
should be aware of the relevant and predominant ethical theories
that exist to guide them in ethical analysis. Of the three theories
subsequently listed (there are many more), we have adopted a more
casuist approach for this chapter.
Utilitarianism, identified most closely with Jeremy Bentham (1748–1832)
and John Stuart Mill (1806–1873), is the theory whereby
the rightness of an act is judged by its ability to bring about the
greatest good or benefit. Therefore, utilitarians judge actions
by their consequences. In medicine, ...