CHAPTER 105: Ethical Issues and Problems of Physician Trust in the Chronic Pain Patient

INTRODUCTION

The focus of the ethics literature regarding pain management has shifted from issues related to the treatment of patients experiencing terminal pain to the concept of pain management as a human right¹ for patients with nonmalignant pain. International, federal, and state initiatives; new guidelines and standards; and numerous studies that document the high costs of chronic pain have fueled this attention to untreated or undertreated pain in nonterminal patients. Thus, the new ethical pressure to provide pain medication to patients with nonmalignant pain may be experienced by physicians as putting them in legal jeopardy. This is complicated further by Hall and Boswell's¹ assertion that there is no clear legal or ethical basis for pain management as a right; others conclude that failure to treat pain is a breach of human rights.² Hellman³ examines whether trusting patients even constitutes a legitimate and accepted medical practice, although she provides a compelling argument that doctors can be morally justified in trusting patients’ reports of pain.

Crucial to the physician's ability to practice ethically in the current environment² is for the physician to be able to trust the patient. The two areas of trust that are needed are in the patient's self-report of pain level and in the patient's reporting of judicious use of pain medication.

In this chapter, we describe some of these ethical dilemmas and examine the underlying problems with physician trust in the patient with chronic pain. We then propose how a reconceptualization of pain clinic treatment systems might serve to diminish some of the ethical dilemmas in relation to the emerging standard of the human right for pain management.

Legal and ethical considerations relate not only to the concept of pain management as a right but also to the interactions between the patient and the doctor. Although the literature and research dealing with rights versus ethics is both thoughtful and influential, there is a remarkable void of attention on the common ethical and relationship issues that arise on a daily basis with the care of patients with chronic nonmalignant pain. An exception to this is literature about the patient–provider relationship that has largely focused on provider issues and the trust that patients have in their doctors. Patient trust in a physician has been identified as the expectation that the physician will behave in a way that allows the patient to take the risk of sharing personal information, and it can be a predictor of adherence, satisfaction with care, and health improvement.^4,5 Educational modules and standards are available for doctors to help promote trust, and several trust scales have been developed to assess the trust that patients have in their physicians.⁶

In contrast, consideration of the doctor's trust in the patient tends not to receive much of our attention;⁷ however, the problems are real and common. Researchers have identified that ...