Chronic pain management: What is the role of medical ethics?

“I would rather die than not have lived at all.”

These words resonated with me as I was listening to the chronic pain management session at the American Society for Bioethics and Humanities (ASBH) annual conference. Working in clinics as a medical student, I have seen this thought manifest in all corners of medicine.

Some people prefer limited quality lives over prolonged harsh ones. And although physicians try to respect a patient’s values when making clinical decisions, the issue becomes more complex when multiple parties are at stake.

A patient made this bold declaration not to his family or even his provider, but rather to a specific committee few have a chance to meet. The patient was pleading for the Controlled Substance Review Committee to not intervene with his current pain management regimen.

The patient was taking 230mg per day of methadone for 30 years to treat intractable nausea from vagal nerve disruption during a prior surgery for esophageal cancer – one of the highest opioid dose patients in the nation.

This potentially lethal dose was justified in the past by considering the alternative – the patient bedbound, unable to function due to suffering. The patient was a father and notably a physician himself. He would not be able to fulfill either of these roles from spending the day bedbound in the fetal position. The patient made it clear he would prefer to continue his life on methadone, even if that shortens his overall life expectancy.

To reach a decision, the committee worked closely with a clinical ethicist to consider how different parties could be affected. Maintaining the patient’s current methadone dosage allows the patient to continue his seemingly high-functioning life with the drawback of potentially shortening his life expectancy.

However, the patient already recognized and accepted this downside. The prescribing physician is at risk of malpractice for prescribing a potentially lethal dose of addictive opioids. The committee itself is also at risk of repercussions if it is determined in the future that this was not a medically justified pain treatment regimen.

Politics must also be considered. Even if the law sides with the prescriber, the reputation of this individual practitioner as well as perception of the health system could shift, as overprescribing opioids has become a politically charged issue.

Since the patient is a practicing physician himself, it’s also conceivable that the patient’s clinical judgment could be impaired, resulting in negative health outcomes for his patients. For this case, the patient had the privilege to provide the committee with testimonials from physician colleagues that vouched for the patient’s high-functioning status as a physician.

Ultimately, it seems that most concerns in this patient case came down to a single concept – perception. The patient had a distinct view of a life worth living. The committee was concerned how the prescriber and health system would be viewed if they were accused of overprescribing. And of course, the core issue of the perception of pain itself is highly subjective.

Key questions arise. Does the patient’s pain truly require such a high dosage to be adequately treated? Also, what race is the patient? People often turn to implicit biases in uncertain situations, and opioid prescribing is not an exception, with Black and Hispanic people less likely to be prescribed opioids compared to white patients.

The committee decided to gradually reduce the dosage with an understanding to reevaluate if the patient’s symptoms were not controlled. The committee also decided to schedule follow up appointments with GI doctors to explore other treatment options. Extreme cases often influence policy, which makes this patient case valuable.

I particularly enjoyed learning about this patient’s story because it has shaped my understanding of the role of clinical ethicists. The ethicist tapped into various perspectives and facilitated strong communication – skills I hope to cultivate myself as I enter uncertain situations with patients by my side.

-By Cyrus Daruwalla, M.D. candidate, Baylor College of Medicine Class of 2022 and recipient of the Laurence McCullough Travel Award

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