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AANS Neurosurgeon | Volume 26, Number 3, 2017

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Pain, Physician and Patient: Monumental Challenges

Doctors often encounter patients with significant pain. As the social gatekeepers for the medical and surgical treatment of pain, physicians also have the power and responsibility to try to help patients understand the treatment options that are available to try to help alleviate pain. The subspecialty of neurosurgery is not immune to the challenge of helping patients to confront their pain. Unfortunately, pain is entirely subjective, despite efforts to quantify it, and many pain syndromes currently have no effective treatment. 

Treating and preventing pain whenever and wherever possible is a basic duty of physicians. Sadly, due to the frequency with which patients present with pain syndromes and the current drug abuse epidemic in the U.S., this is a monumental challenge. The near constant presence of patients seeking help with pain can feel overwhelming. The changes in the legality of prescribing practices and experiences with prior patients who have been engaged in drug diversion, or other drug abuse practices, can also contribute to the challenge of treatment. 

Life Changes With Pain
Pain is an intrinsic part of life. Pain is also a powerful motivator. Patients in pain may engage in activities that they would otherwise not consider for inclusion in their daily lives. Some of these types of activities might include visiting a doctor, missing work, avoiding social relationships, paying for complex medical treatments or devices, considering having surgery and taking dangerous medications. Certain approaches are considered appropriate ways to deal with pain; however, other activities can be self-destructive or socially destructive. These include:

  • Loss of employment;
  • Social alienation;
  • Depression;
  • Drug abuse and even physical and/or psychological self-harm; and/or
  • Attempted or completed suicide.

Ethical dilemmas associated with the treatment of pain include how to:

  • Appropriately and effectively screen patients for potentially abusive behaviors;
  • Adequately quantify pain and the individual patient’s ability to adequately manage pain;
  • Avoid contributing to the U.S. opioid abuse crisis; and
  • Support the patient’s desire for improved quality of life while simultaneously balancing that goal with the physician’s right to avoid practices, which are not morally acceptable from the physician’s standpoint.

These ethical concerns can be related to the often-articulated principles of medical ethicsnon-maleficence, beneficence, social justice and autonomy for both the patient and the physician.

What’s the Right Choice?
Frequently, neurosurgeons have patients with a long history of ineffective pain management, some compliant and some not. The challenge of dealing with such patients is compounded by a patient overly insistent in further surgical treatment, even when such treatment is either not recommended or contra-indicated. In such situations, the surgeon is obligated to consider the extent of duty which is owed to the patient. Ethically, the surgeon is obligated to balance the principles of having a duty to do good for the patient and to try to help the patient against the simultaneous duty to first do no harm. 

  • If surgery is contra-indicated, it is the surgeon’s obligation to help the patient understand why surgery is not indicated and why the risks would clearly outweigh the benefits in that scenario.
  • If surgery is not specifically contra-indicated but is not recommended, then the surgeon and patient need to both individually and collectively explore the potential benefits and risks of surgical intervention and to eventually decide where the balance lies for the individual situation.

The surgeon cannot carry an absolute obligation to perform surgery if it is not felt to be in the patient’s best interest. If an agreement cannot be reached, it is advisable for both parties to seek another opinion. 

Evaluation is Key
Similarly, patients presenting with chronic pain are challenging to treat. There is typically not one single pain generator in these patients such that any one individual treatment is unlikely to adequately address the patient’s pain syndrome. In such situations, the physician must comprehensively evaluate the patient with attention to the patient’s psychological and psychosocial situation in trying to understand the patient’s major pain generators. In this situation, the type(s) of care needed are likely to fall beyond the boundaries of typical neurosurgical practice.

Physicians do not carry an absolute obligation to perform evaluations and/or treatments that fall largely outside their typical scope of practice. There remains an important duty to show compassion and to facilitate referral to practitioners that might be able to more adequately evaluate and treat the scope of the patient’s problems – as long as the patient is accepting of a referral. Unfortunately, the current system provides limited resources in this realm.

Devastating consequences are also possible. Patients with pain feel impaired to the point of considering self-harm. Suicidal patients can present to a variety of practitioners in a multitude of settings. All medical providers are obligated to seriously consider the danger patients may pose to themselves and others and are required to report or refer these patients for emergency intervention. However, other patients may seek self-administered or physician-assisted suicide with a sincere desire for pain relief.

The legality of the practice of physician-assisted suicide is not uniform within the US. Additionally, the moral acceptability or culpability associated with the practice of physician-assisted suicide is not universally denounced or accepted by practitioners. The doctor-patient relationship requires a commitment from the two individuals to be honest and non-judgmental in exploring potential treatments for disease and affliction. Both parties are moral agents and neither should be called upon to violate their own personal ethos in trying to relieve pain and suffering. Physicians must be able to maintain a right to exercise their own conscience – especially in areas within medicine and society where there is no clearly defined universal social norm (1).

Perhaps, in the future there will be better answers. Today, the ethical and practical issues surrounding patients with pain and the physicians they encounter remains a Herculean venture.

References
1. Crigger, B.J., McCormick, P.W., Brotherton, S.L. & Blake, V. (2016). Report by the American Medical Association’s Council on Ethical and Judicial Affairs on Physicians’ Exercise of Conscience.  The Journal of Clinical Ethics.  27(3), 219-226.

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