ETHICAL CONCERNS IN ASSESSING AND TREATING PAIN

There is a universal agreement that patients have a right to adequate pain management and clinicians have a duty to provide it. The widespread issue of undertreated pain appears to be a product of a risk/benefit calculation by clinicians that the risks of addiction to opioids were unacceptably high, whereas the benefits of pain relief were relatively inconsequential.

Ethical concerns include:

  • Is there an ethical and moral duty to relieve pain and suffering?
  • There is no acceptable objective measure of pain.
  • Is it ever ethically permissible to allow pain to continue untreated?
  • Are people who complain that pain is ongoing being manipulative?
    (Bernhofer, 2021)

Ethical Principles and Pain Management

Adherence to ethical principles by clinicians is critical in effectively managing pain.

Autonomy is the individual’s right to make healthcare decisions based on their own beliefs and values, even if a clinician disagrees. If a patient chooses not to receive a treatment that could potentially provide a benefit, the healthcare provider must respect that choice. When a practitioner does not honor the patient’s right to make a choice regarding pain treatment, this right is violated. It is important to understand, however, that pain may impact a person’s autonomy or that a practitioner may make an assumption that the person is incompetent.

Beneficence is the act a provider takes that benefits the patient, minimizes harm, and promotes the good. This means that pain relief will be provided as quickly as possible and to the highest degree possible in order for an act to be considered “good” care. Healthcare providers must make the management of pain a priority, and to not do so is neglecting the principle of beneficence.

Nonmaleficence means to do no harm. Many treatments for pain have potentially harmful side effects; however, it is important to recognize that untreated pain may be more harmful to the patient than the side effects of drugs used to treat it. Withholding a medication for safety reasons can be a violation of this principle. This principle is likely the most difficult to uphold.

Justice means that treatment for pain is equitable. This principle is violated when treatment for pain is withheld or not administered solely on the basis of a person’s age, race, religion, or social or economic status, unless these factors have a distinct bearing on treatment (e.g., drug choices or doses based on a patient’s age).

Ethical Dilemmas in Pain Management

An ethical dilemma requires a choice between conflicting alternatives, each of which is based on an ethical principle. Ethical dilemmas may occur when there is a conflict with the clinician’s personal values or with their code of ethics. For example, clinicians may be faced with an ethical dilemma when there is no advance directive and families or other surrogates refuse to consent to pain medications for the patient or insist on lower doses than medically appropriate despite obvious signs of pain in the patient.

In such an instance, without the explicit direction from the patient, an ethical assumption must be made that the patient would want relief from pain and suffering. The provision of pain medication is assumed as part of basic care for the patient in accordance with the principle of nonmaleficence (Faubion, 2022).

CASE

XIA

Xia is a 32-year-old Hmong patient diagnosed with advanced ovarian cancer with metastasis to the retroperitoneal, pelvic, and para-aortic lymph nodes. She is enrolled in hospice and has been cared for by her family at home. She has been receiving a morphine infusion, which was effectively controlling her pain. Two days ago, Xia’s condition indicated that death was close at hand, and her family became concerned that they were not really prepared to have her die at home. She was, therefore, admitted to the inpatient hospice unit.

Her immediate family called members of the extended family, and about 40 people arrived to support the family and to perform their culture’s “soul calling” ceremony. Extended family members became concerned that the opioids Xia was receiving would interfere with her ability to hear them call her soul back to her body. They demanded that the morphine infusion be stopped.

After consulting with the hospice team, it was determined that Xia’s consent for opioids had been given prior to entering the hospital and that discontinuing them without her consent could cause her to experience increased pain and discomfort. In order to avoid conflict with the family, the infusion was discontinued and replaced with morphine boluses via indwelling saline lock around the clock while providing nursing care with the family members out of the room.

The staff understood that collective decision-making is a norm in many cultures but that such decisions may clash with the ethical value of autonomy and an individual’s right to make decisions about health and dying. Although deception was practiced with the family, the goal was to do what was of benefit to the patient and to avoid doing harm.