This document discusses ethics and interventions for pain management. It acknowledges biases around pain management and explores themes in acute, chronic, and palliative pain settings. The four principles of ethics - autonomy, beneficence, non-maleficence, and justice - are applied to clinical cases. The principle of double effect and limits to intervention are also examined. Effective pain management is framed as a moral duty to relieve suffering.

1. Ethics and Interventions for
Pain Management
Presented by
Andrea Chatburn, DO, MA
Medical Director for Ethics
9.25.2015

2. “Addressing the enormous burden of pain will
require a cultural transformation… Effective
pain management is a moral imperative, a
professional responsibility, and the duty of
people in the healing professions.”
-Institute of Medicine, Relieving Pain in America, 2011

3. Objectives
• Acknowledge systemic & personal biases
regarding pain management
• Discuss themes that arise in pain ethics in
different clinical contexts:
• Acute setting
• Chronic setting
• Palliative setting
• Apply ethics questions specific to the 4 principles
of Autonomy, Beneficence, Non-maleficence and
Justice
• Explore the Principle of Double Effect and
contextual limits

4. Reciprocity
Kalki

5. WHO HAS EXPERIENCED CHRONIC
DEBILITATING PAIN?
Layering Empathy Exercise

6. ALL LIFE INVOLVES SUFFERING.
WE ARE CALLED TO RELIEVE THAT
SUFFERING.

7. TOTAL PAIN

8. BECAUSE THE RISE OF
PRESCRIPTION DRUG ABUSE HAS
OCCURRED ALONGSIDE INCREASED
USE OF OPIOIDS IN LEGITIMATE
PAIN RELIEF, IT IS TEMPTING TO
ASSUME CAUSE AND EFFECT.
-FISHMAN, SCHOTT. RESPONSIBLE OPIOID
PRESCRIBING: A PHYSICIAN’S GUIDE. FETERATION OF
STATE MEDICAL BOARDS. 2007.

9. Ethical Decision-Making Model
Clinical Integrity
Beneficence
Autonomy
Justice &
Nonmaleficence

10. The Providence Model Promotes:
• Clinical Integrity  Honesty in representing
right professional practices and delivery of
health care
• Beneficence  Dependability in delivering
care that benefits patients medically
• Autonomy  Fairness to patients in their
contexts
• Justice  Accountability to the legitimate
interests of others in light of justice
Kockler, N. Seeing Ethics Consultations for the First Time: Disclosure Models, Analytic
Design, and Ethical Decision-Making. ©2014 –Nicholas J. Kockler

11. Clinical Integrity
Beneficence
Autonomy
Justice &
Nonmaleficence
Therapeutic relationship between
patient and provider

12. Clinical Context
 Acute  Rescue, Fix
 Chronic  Maintain, Manage
 Palliative Alleviate, Enhance QOL
 Futile  Non-Beneficial
or harmful

13. Clinical Context
 Acute  ER, Trauma, Post-op
 Chronic  Clinic, ICU, hospital floor
 Complex Mixed Pain  Acute and Chronic
 Palliative Hospital floor, ICU, clinic,
& hospice

14. Case: Acute Pain Management
43 yo otherwise healthy gentleman comes to
the ER with back pain, found to have a fractured
L1 Vertebrae with mild spinal cord compression
after a construction accident.
– Emergency
– Intraoperative
– Postop

15. Case: Chronic Pain Management
43 yo otherwise healthy gentleman comes to
the ER with back pain, found to have Ankylosing
Spondylitis (Autoimmune).
– Immediate phase
– Chronic phase

16. Case: Complex Mixed Pain
43 yo otherwise healthy gentleman comes to
the ER with back pain, found to have a fractured
L1 Vertebrae after a construction accident. He
also has underlying chronic back pain and Lower
Extremity Neuropathy due to prior traumas and
has a pain agreement with his Primary Doctor.
– Immediate phase
– Chronic phase

17. Case: Palliative Pain Management
43 yo otherwise healthy gentleman comes to
the ER with back pain, found to have a fractured
L1 Vertebrae due to a new diagnosis of widely
metastatic cancer.

18. Ethical Issues in Chronic Pain
Management
• Patient access to an outpatient evaluating
provider, lack of medical home model
– Scheduling bias
• Public misconceptions about pain management
• Concerns of drug diversion
• Fears about addiction
• (Non-) “Compliance”
• Failure to recognize Psuedoaddiction
• Community lack of Pain Specialists
• Fear of regulatory or law enforcement
intervention

19. Ethical Issues in Palliative &
Hospice Pain Management
• Doctrine of Double Effect and worry about
“last dose”
• Lack of specialty referral to Palliative Care
team/lack of primary provider comfort with
high dose opioid calculations
• Recognition of Total Pain- emotional,
relational, existential, functional, physical
• Trust/relationship concerns

20. Doctrine of Double Effect
Bad Effect
Good Effect
Cause & Effect
Cause & Effect
Action/O
bject

21. Doctrine of Double Effect
St. Augustine  Thomas Aquinas  Joseph Magnan (‘49)
• Act itself must be good or at least indifferent
• Must intend the good effect
• Good effect cannot be caused by bad effect
• Proportionality

22. Criticisms: Principle of Double Effect
• Evidence Based Medicine shows that opioids
do NOT cause significant respiratory
depression that could hasten death in
terminally ill patients.
• However, most physicians report the Principle
of double effect was relevant (71%) and useful
(68%) in “justifying optimal pain and symptom
management at the end of life.”
Maccauley, Robert. The role of the principle of double effect in ethics education at US medical schools and its
potential impact on pain management at the end of life. J Med Ethics 2012; 38: 174-178.

23. “Addressing the enormous burden of pain will
require a cultural transformation… Effective
pain management is a moral imperative, a
professional responsibility, and the duty of
people in the healing professions.”
-Institute of Medicine, Relieving Pain in America, 2011