Ethics of Pain Management UTTyler 041709

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Ethics of Pain ManagementUT-Tyler 041709
Larry C. Driver, MD Professor, Department of Pain
Medicine Adjunct Ethicist, Clinical Ethics
Consultation
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What is Ethics?

• Ethics is a branch of philosophy
• Ethics is the formal, rational, systematic
  examination of the rightness and wrongness of
  human actions.

Pellegrino E Toward a Reconstruction of Medical
Morality The American Journal of Bioethics
2006665-71
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Why treat pain?

• Control of pain is important for
• Optimizing patient outcomes and satisfaction
• Compliance with guidelines and standards
• Moral and Ethical reasons
• (Blau, SMJ, 1999)

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Clinical Ethical Issues

• What are the clinicians obligations based on
  the principles
• If there is a conflict of principles, which one
  takes precedent?
• For example the patient demands treatment that
  the clinician feels is harmful or the patient
  refuses treatment that is known to be life
  savings? (Non-maleficence and autonomy

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Clinical Ethical Issues

• Risks, harms, burdens of disease
• Risks, harms, burdens of treatment
• Potential Benefits of treatment
• Best interests of the patient
• Clinician perspective
• Patient Perspective
• Goals of therapy

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Thinking Ethically

• Principles and Duties
• Calculating Consequences
• Comparing Cases

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Value-laden Situations

• Between Professionals and Patients
• Patient refusal of recommended treatment
• Patient demand for specific Rx/treatment
• Patient demand for medically futile treatment
• Between Patients and Surrogates
• Conflicted understandings of a patients advance
  directive
• Absent/Unclear surrogate decision maker
• Among Professionals
• Nurse/Physician(s) disagree re treatment plan
• Disagreement about what a patient or family
  member should be told

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Medical Decision MakingWhat Do Patients Want
and Expect from their clinician?

• Respect as an individual
• Understanding and care
• Not to be abandoned

Kagawa-Singer
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Medical Decision MakingRole of Societal Values

• Societal values vary among cultures
• Independence -- Collectivism
• Self-reliance -- Interdependence
• Autonomy -- Community

Kagawa-Singer
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Medical Decision MakingWestern Cultural Values

• Life is sacred
• Patient autonomy in decision-making
• No one should suffer

Kagawa-Singer
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Six Behaviors of Professionalism

• Altruism best interests of patients, not self
• Accountability fulfilling the multiple levels
  of the contract of the clinical relationship, to
  the profession and society
• Excellence exceed ordinary expectations
• Duty free acceptance of commitment to service
• Respect for others patients, staff, et al
• Honor Integrity highest standards of behavior
  and the refusal to violate ones personal and
  professional codes

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Professional Responsibilities

• Commitment to professional competence
• Commitment to honesty with patients
• Commitment to patient confidentiality
• Commitment to maintaining appropriate relations
  with patients
• Commitment to improving quality of care
• Commitment to improving access to care
• Commitment to just distribution of finite
  resources
• Commitment to scientific knowledge
• Commitment to maintaining trust by managing
  conflicts of interest
• Commitment to professional responsibilities