++
A 41-year-old man is seen for a 3-month history of complex regional
pain syndrome (CRPS, also known as RSD, reflex sympathetic dystrophy)
of his left foot. He reports debilitating pain. Examination reveals
classic features of CRPS, including severe allodynia. The patient’s
past medical history is significant for heroin abuse. He has not
abused any drugs for the past year. For the last 2 months his primary
care physician has prescribed acetaminophen with codeine (30 mg),
one tablet three times per day. The patient reports that this does
not touch his pain. The physician refuses to provide more or stronger
narcotics. The pain clinic consultant develops a treatment plan.
Many of the treatments yield slow and uncertain results. Meanwhile,
in spite of concerns regarding potential drug abuse, the consultant
establishes a pain medication contract with the patient for the
use of long-acting oral morphine: 15 mg, two times per day. Five
days later, the patient calls the clinic and reports that the new
narcotic prescription is better, but still inadequate. The consultant
feels that she has increased the narcotic dose by a large amount
and is not willing to increase it further at this time. She tells
this to the patient.
++
Discussions with the consultant reveal that she is uncomfortable
with a number of aspects of this case. She recognizes that her opinion
regarding an appropriate drug dose is influenced by the patient’s
prior history of drug abuse. This history suggests that the patient
may be at higher risk of developing an addiction, but this history
does not have a direct impact on how much pain the patient is experiencing.
She finds herself uncertain about whether the patient is accurately
reporting his pain levels. Furthermore, the physician notes that
the patient appears to be adopting a defensive attitude, as if he
needs to justify his pain and his need for treatment. Finally, upon
introspection, the consultant realizes that if this patient were
suffering with pain from a malignancy, she would be more aggressive
with her prescribing of analgesics; yet she knows that the pain
of CRPS can be more intense than the pain associated with malignancy.
++
Within the framework of the basic bioethical principles described
earlier, we can see that the scenario in case 1 describes an infringement
of the obligation to respect the patient, or more specifically to
respect the autonomy of the patient. The consultant is assuming
a paternalistic attitude—which typically is considered
to be contrary to the principle of autonomy–and determines
for the patient what is the appropriate amount of medication. However,
according to English,1 there are circumstances
in which the initial status of respect for autonomy (of the patient)
is overruled by, among other reasons, the concept of professional
autonomy (a professional is not obliged to act against personal
or professional ethical convictions). Given the complicating factor of
prior drug use in this case, it is possible that the consultant,
concerned that this patient is at higher risk for developing another
addiction that would be harmful, could employ the concept of professional
autonomy to justify at least a prudent delay in prescribing more
or increasing the dose of narcotics. Such concerns and reasoning
should also be shared with the patient so that they may understand
the physician’s concern for his or her best interest, especially
with regard to the patient’s risk of developing another
addiction. However, had this patient no prior history of drug abuse,
the principle of professional autonomy would not be as applicable.
The physician likely feels that her drug limits are required by
the principle of nonmaleficence, since she feels that higher doses
of narcotic medication significantly increases the risk of addiction.
In her efforts to do no harm, however, the physician may not be
following the other half of the principle of beneficence; that is,
the requirement to maximize the potential benefits while minimizing
the risks. Finally, this case may also demonstrate a violation of
the principle of justice. By virtue of a previous medical problem
(heroin addiction), the patient is now not receiving medication
for the relief of pain equal to what would be prescribed for a patient
without such a history. If this is the result of prejudice, as opposed
to a considered assessment of the involved risks to the patient,
then this would represent unfair limits on the access to medical
resources (i.e., medications). Similarly, if the patient would receive
more analgesic medication if the underlying cause of his pain was
cancer, and if the reason for more medication was simply a reflection
of societal attitudes regarding cancer pain versus nonmalignant
pain, then this too may reflect an ethically unjustifiable limit
on the provision of medical care.
++
Without exploring the causes that underlie these dilemmas, resolution
will be difficult. The physician is stuck trying to balance the
potential benefits and risks of higher doses of narcotics. She knows
that the history of prior addiction and the diagnosis of chronic
nonmalignant pain do appropriately affect the treatment decisions,
but she has a difficult time being sure that societal or personal
prejudices are not also affecting her decisions. The consultant
wishes that she could rely on the patient to make these judgments
for himself, but she realizes that she does not trust that the patient
is capable of this.
++
Trust is, in fact, the critical element that underlies all of
these problems. It is commonly recognized that we ask our patients
to trust us—their physicians. Somerville5 takes
the medical profession to task for expecting the blind trust of
our patients rather than earning their trust. However, as noted
by Sass,6 there is another side to the equation: “. .
medicine necessarily will have to shift attention from physician
ethics toward patient ethics and a partnership in health care. From
the perspective of trust-based communication and trust-based cooperation,
it is only logical to strengthen the other side of the partnership
and make difficult cases of clinical decision making an issue for
trust-based decision making in partnership.” Sass is not
suggesting that we increase our blind trust in our patients, but
rather that we enable our patients to earn our trust, and that such
earned trust “safeguards all expert-lay interactions.”6
++
On reexamination of the ethical problems in Case 1, we see that
each of these problems is triggered by a problem with trust, or
more specifically with a problem of the patient not having earned
the trust of the physician. In all cases involving the treatment
of chronic nonmalignant pain, the clinician must rely on the subjective
reports of the patient. The physician has no means of entering or
examining the reality of the patient. Scarry7 notes
that “to be in pain is to have certainty, while hearing
about pain is to have doubt.” Therefore, there is an automatic
or basic lack of trust: Is the patient accurately reporting his
or her experience of pain? In this particular case, the lack of
trust is exacerbated by the patient’s history of prior
drug abuse. Because of this lack of trust, the consultant feels
that she cannot rely on the patient’s autonomy and his
ability to accurately determine his own need for medication; she
therefore acts in a paternalistic fashion and determines her own
limits for the medications. Similarly, because she feels that she
cannot rely on the patient’s reports of his pain, she has
no gauge for judging when she has provided maximal benefit. Without
the ability to judge the degree of benefit, it is natural to rely
more heavily on the obligation to minimize risk and harm. Finally,
lack of trust may often underlie the tendency to treat nonmalignant
pain less aggressively than cancer-related pain. Vrancken8 gives
a telling description of the attitude of many pain physicians regarding
cancer pain patients. “They really have something, it is
also recognized by everybody that they really have something. Their
problems are also very real which makes it more easy for doctors
as well as patients to face psychosocial factors too.” Vrancken
is telling us that cancer pain patients are trusted more than patients
with nonmalignant pain. There is nothing inherent about nonmalignant
pain that makes its sufferers less trustworthy; therefore, problems
with trusting patients with nonmalignant pain may lead to encroachments
on the ethical principle of justice.
++
Pappagallo and Heinberg7 raise another point
in regard to chronic pain patients with a past history of addiction,
which is that they may not want opioids to manage their pain for
the fear of relapse. Considering both potential responses from such
patients, Pappagallo and Heinberg give further treatment suggestions
for reducing the risk of relapse in dealing with chronic pain patients
with a past history of addiction. They recommend:
++
- 1. The distinction between physical dependence, which
is to be expected, and addiction, which should be avoided, should
be clarified for the patient.
- 2. The patient should be encouraged to join or increase involvement
in a recovery program or in individual psychological care in order
to garner support and develop and bolster relapse prevention strategies.
- 3. A behavioral contract should be made, to provide the patient
with a clear definition of problematic use, misuse, and abuse behaviors.
- 4. Close supervision should be provided by the physician,
including frequent follow-up appointments, the use of only one prescribing
physician and dispensing pharmacy, and toxicology screenings.
- 5. Long-acting opioids, or around-the-clock dosing, may be
helpful in reducing the reinforcing, and therefore addictive, properties
of these medications.
++
From such suggestions, one can develop an ethical and clinically
sound standard of practice for such patients, and help move the
burden of decision making solely from the physician to the patient-physician
team.
++
Two additional cases are presented to illustrate how the method
of analyzing trust may underlie potential infringements of basic
bioethical principles as the lack of trust creates an unethical
barrier to appropriate, unbiased treatment.
++
A 24-year-old woman is referred to the chronic pain clinic. The
patient reports constant, severe, mid-pelvic pain. She is unable
to concentrate on her graduate school work. She has seen numerous
specialists and has had extensive evaluations including laparoscopy,
all without result. After the laparoscopy, a new, burning pain developed
in her left labia and inguinal area. The patient’s gynecologist
reported generalized vulvar and pelvic tenderness, with more exquisite
pain responses with light touch of the left labia. The pain consultants
felt that this newer pain is suggestive of an ilioinguinal neuralgia.
There is no apparent cause for the original pelvic pain. Even narcotics
have not helped. During the clinic evaluation, the patient reveals
a childhood history of sexual abuse. Her affect is depressed and
angry. She is very frustrated by all the previous failed diagnostic
and therapeutic efforts, and their apparent complications. The patient
asks the pain clinic physicians to please do nerve blocks. The physicians
are concerned about the patient’s psychological health.
They explain the potential for interaction between physical and
emotional distress. They tell the patient that they will consider
nerve block techniques for the left inguinal and labial pain, but
she should first undergo psychological evaluation and treatment.
The patient states that she is unwilling to do this. Efforts to
address her concerns about the treatment plan fail. The patient
continues to insist that nerve blocks be performed. The clinic physicians
explain that they provide a comprehensive treatment plan, and that
they cannot proceed with only one element (the blocks) without the
other elements (the psychotherapy). The patient is upset and leaves
the clinic.
++
A 33-year-old man is being seen in the pain clinic for a 1-year
history of incapacitating low back pain. The primary care doctor,
the orthopedic surgeon, and the pain consultant are all unable to establish
a cause for the patient’s pain. Magnetic resonance imaging
of the lumbar region reveals mild disk bulges, which would not be
expected to cause the degree of discomfort that the patient reports.
A psychological evaluation reveals mild depression and somatic preoccupation,
findings common to most patients with chronic pain. Nerve conduction
studies are normal. The patient reports that the pain interferes
with his ability to concentrate, his relationships with colleagues, and
his ability to maintain prolonged sitting or standing positions.
Because of this he has been unable to return to work. The workers’ compensation
insurance company now insists on a report on whether the pain clinic
agrees with the patient’s claim that he is totally disabled.
++
In Case 2, the primary concern is regarding autonomy. The physicians
were concerned that acceding to the patient’s requests
for nerve blocks, without prior psychotherapy, carried an unacceptably
high risk of harm. Respect for autonomy requires that patients’ decisions
regarding care be made without coercion; however, the consultants
verged on coercion by telling the patient that they would only consider
providing the treatment she desired (nerve blocks) if she accepted
a treatment that she did not want (psychotherapy). As noted by Whedon
and Ferrell,10 pain patients may be exceptionally
susceptible to subtle coercion, since they are so vulnerable to any
offered possibility of relief. This situation is based on a lack
of trust. The physicians did not trust the patient’s judgment
and insight. They felt that she did not recognize her own psychopathology
and how this psychopathology was interacting with her experience
of both pain and medical treatment.
++
In Case 3, the clinician faces a dilemma. The patient may be
malingering; however, this cannot be determined simply on the basis
that there is a lack of objective data. A report of disability may reinforce
unconscious pain behaviors and diminish healthy, productive behaviors.
Therefore, such a report may not be in the patient’s best
interests, yet a failure to report disability may cause the loss
of the patient’s only potential income. The bases and rationale
for determining disability are complex and beyond the scope of this
paper; however, here too, the core of the problem is a lack of trust.
The clinicians recognize that the possibility of monetary gain may
be consciously or unconsciously influencing the patient. Since they
cannot enter the patient’s reality, they look for objective
evidence that might explain the patient’s pain. When they
cannot find such evidence, the concerns regarding the trustworthiness
of the patient are heightened.