Ethically Pained

Ethically Pained
Dustin W. Bell
Salt Lake Community College

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2
Thesis

Ethical management of pain has become increasingly difficult as socio-political

barriers continue to influence the clinical decisions made and in many cases these barriers
create an unethical yet legal circumstance yielding inadequate management of pain. Our
current views regarding analgesics create continual ethical dilemmas on the individual
level affecting a patients care and quality of life.

Ethically Pained

Introduction
Suppose you are working in an emergency room in a hospital and a 33 year-old
woman presents at 1 a.m. with severe pelvic pain, yelling, moaning and asking for help.
Ethically one would feel obligated to help this woman. After all she did come into the
emergency room. However, you and your staff know this patient well. She had been
coming in weekly for months with the same problem. Having had an extensive workup
with no findings throughout the months prior to this visit she earns the negative
reputation among staff of coming in when her money and narcs run out. A colleague
then feels obliged to remind you of her negative reputation with intention of influencing
decision. You are completely aware of her prior history with drug addiction and
proceed. Fortunately for the patient you decide to take a more compassionate approach
and order the pain medication. After receiving the medication the patient falls asleep for a
time then wakes requesting more medication from the nurse. At this point the nurse
comes to you with the false assumption that the patients pain has mysteriously returned.
Since shes awake you return and talk to her openly regarding her abuse of drugs and
your concerns over prescribing them to her. Upon doing so she opens up to you, admits
her illegal drug use and mentions she comes into the ER because her primary physician
refuses to prescribe anything more than NSAIDs. Hearing this you decide to recommend
a detox program and a pain specialist both of which the patient agrees. Later, after the
patients detox, you learn that the pelvic pain had its root in a 20-year period of sexual
abuse imposed by her father. (Aswegan 2007)
Ethical management of pain has become increasingly difficult as socio-political
barriers continue to influence the clinical decisions made and in many cases these barriers

Ethically Pained

create an unethical yet legal circumstance yielding inadequate management of pain. Our
current views regarding analgesics create continual ethical dilemmas on the individual
level affecting a patients care and quality of life.
Medical Indication
Within this case the woman presented with severe pelvic pain after months of
weekly visits to the emergency room for the same complaint. Having visited many times,
an extensive analysis into her pain was completed with no definitive results. Lacking
anything definitive this patient received inadequate care for her pain for several months.
Creating a relationship of mistrust between the patient and providers greatly reduced
open conversation from the patient regarding her problems. Mistrust is then assumed, due
to a multitude of visits, to have been perpetuated.
Patient Preferences
Repeated visits to the hospital exhibits a cry for help and that patient preference of
care was not met. Had preference of care been met a mutual trust would have been with
established and the root cause of her complaints discovered much sooner. Establishing
the preference of the patient is crucial especially when you consider the patient-centered
concept of Care Ethics. This is crucial to create confidence and an understanding of
mutual expectations.
Quality of Life
Anyone can see this patient was seeking correction to pain that was altering her
quality of life, but without adequate diagnoses doctors were not likely to address it. Not
addressing her chief complaint was not only unethicalit continued a narrative of mistrust
negatively impacting her quality of care. Repeated demeaning visits to the ER must have

Ethically Pained

impacted this womans quality of life, especially considering the staffs growing and
noticeable distrust in her claimed symptoms. Cultivating a culture of trust between
certain at-risk populations and the medical community would greatly improve the quality
of life for those in situations like these. Reducing any preconceived notions hospital staff
may have about any individual is the only ethical goal as preconceptions alter our
perception of others and fosters inequality in care. Particularly when it involves the
uneven distribution of proper pain management medication. In this case, this patient was
viewed as drug seeker by staff and this perception altered the course of her care for many
months until a physician took a Care Ethics approach and validated the pain the patient
was feeling. Once a patient receives validation and proper intervention with the pain they
are experiencing they are able to begin the process towards recovery and or management.
Apprehension to provide narcotic pain relief due to patient history to those currently
suffering presents an ethical issue in that it categorically restricts the use of narcotics in
an entire subset of patients.
Contextual Features
Perhaps the most alarming ethical issue within this case is the attitude with which
many of the staff approached this patients contextual features. Context into the lives of
patients must be used in confidence to assess their plan of care. Context allowed an
apprehension to take place within this case as it took months for this woman to finally
receive the legitimate care she needed. Ethical boundaries are crossed if the information
at hand is used to formulate an opinion on that patient outside of clinical value.
Formulated opinion outside of clinical value fogs judgment and reduces compassion.
Medical personnel have an ethical obligation to help those in need. Clearly in one way or

Ethically Pained

another this woman was in need and the quality of her care had been negatively impacted
based on her social history and the personal opinions clinicians held. Further, this
patients past abuse of drugs does not nullify her susceptibility to painit only reduces
the efficacy of analgesics requiring larger doses for comparable effect. If this patient
indeed requires a higher dose to receive comfort care ethics tells us to give the higher
dose. As mentioned before, preconceptions have no place in patient centered care. Within
Care Ethics, care is centered on the patient and the patients concerns must be taken
seriously, regardless of physician apprehension.
Alternate Opinion
Pain and how to manage it best is often up for debate. Centers for Disease Control
assert that the wide variance between states prescription rates of opioids without
correlation to population health dynamics has been, highlighting a lack of consensus
among clinicians on how to use opioid medication.(CDC 2016) Along with this
statement came a massive guideline on the appropriate use of opioid medications.
Many outside of the medical community praised this report and guideline, referencing
deaths of loved ones as a result of opioid dependence and overdose. Proponents of
reduced opiate use in pain management believe that all options must be examined and
tried, escalating the patient up a ladder of protocol before reaching for opioid-based
medication. While some view this as a step towards controlling an epidemic, larger
ethical implications have been made. Asserting that clinicians lack a consensus on how to
use opioid medication creates a culture of fear and misunderstanding among physicians.
Physicians in fear of ramifications from strong review boards are less likely to escalate
pain coverage in a timely manner increasing the amount of patient suffering. If the aim is

Ethically Pained

to heal and elevate pain, then clinicians have an ethical obligation to act in their patients
best interest with their preferences in mind (CDC 2016).
Conclusion
For all intents and purposes this case study was a look into the complex dynamics
of pain management. Although more light has been shed on this topic than ever before,
patients are suffering at the hands of clinicians who overestimate the risks of analgesics
compared to the benefit. Failure to alleviate pain is considerably prominent in certain
patient populations as an apparent result of personal barriers. A study into the attitudes of
healthcare providers once showed that one-third believe that a patient should experience
pain before receiving an additional dose of pain medication. (Aswegan 2007) Pain has the
ability to completely alter the course of a persons life. Medical providers are ethically
required to assist in bettering a patients quality of life regardless of the means prescribed.
Care ethics requires us to value the patients opinion as to what their quality of life
involves (Munson 2012).

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Bibliography
Aswegan, A. L. (07, September). ACEP. Retrieved December 10, 2016, from
https://www.acep.org/Clinical---Practice-Management/Our-Ethical-Duty-Is-to-RelievePain-and-Suffering/
CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016.
(2016, March 18). Retrieved December 12, 2016, from
https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Munson, R. (2012). Intervention and reflection: Basic issues in bioethics. Boston,
MA: Wadsworth, Cengage Learning.