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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.

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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.

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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.

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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 dilemmas.

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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.

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Utilitarianism

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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, ...

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