Medical Ethics - Allhealth Medical

🏥Allhealth Medical Ethics in Pain Management, Substance Use Disorders, Psychiatric Illness, and Vulnerable Populations is based on patient-centered care. Below offers a good general framework of what we follow.

Carvalho AS, Martins Pereira S, Jácomo A, Magalhães S, Araújo J, Hernández-Marrero P, Costa Gomes C, Schatman ME. Ethical decision making in pain management: a conceptual framework. J Pain Res. 2018 May 15;11:967-976. doi: 10.2147/JPR.S162926. PMID: 29844699; PMCID: PMC5962306.

“This ethical framework of pain management will allow us to 1) further respect ethical principles (integrity, autonomy, equity, non-maleficence, and beneficence) and, thus, patients’ dignity, 2) acknowledge and explain the vulnerabilities illuminated by pain and recognize the variability and subjectivity of its expression through narratives of both patients and physicians, 3) reduce asymmetries and thereby improve patient–clinician relationships and communication, and 4) be more fully responsible and accountable for the overall management of pain. Such will result in “good” care, linking the epistemic domains of pain management to its anthropological foundations, and accordingly will be ethically sound.”

Morley G, Chumbley GM, Briggs EV. ‘You wouldn’t do that to an animal, would you?’ Ethical issues in managing pain in patients with substance dependence. Br J Pain. 2020 Aug;14(3):195-205. doi: 10.1177/2049463719888551. Epub 2019 Nov 12. PMID: 32922781; PMCID: PMC7453482.

Table 4 is taken from the article above to ethically manage pain in patients with SUD.

Key themes.

Key theme	Ethical principle	Application of the four principles plus scope to each theme	Normative recommendation
Trust	Respect for autonomy	• Heightened clinician mistrust means patients with SD are more likely to have their autonomy constrained.	Clinicians should acknowledge the potential for mistrust and unjust treatment of this patient population. This could be mitigated by being open and transparent with patients about which treatment modalities they are willing to provide.
	Justice	• The principle of justice raises the question of whether patients without SD could more effectively exercise their autonomy and therefore whether patients with SD are being treated unjustly.
	Beneficence	• Although the clinician may be driven by beneficence, it may be questioned whether this should override respect for autonomy.
Paternalism	Beneficence	• Driven by beneficence, clinicians adopted paternalistic behaviours, such as restricting opioid prescriptions which could leave patients in pain.	In the acute pain period, restricting opioid prescriptions causes unnecessary pain and increases the risk of chronic pain. There should be a legitimate justification (beyond practitioner fears of exacerbating SD) to restricting opioids and analgesics in this period. It should be acknowledged that this is not the time to fix SD.
	Scope	• In these situations, nurses reported feeling powerless to treat reported pain because of inadequate prescriptions thus causing moral-constraint distress.
	Non-maleficence	• By trying to act beneficently, clinicians were in fact violating the principle of non-maleficence as restricting analgesics caused the patient to experience further pain and increased the risk of chronic pain.
	Respect for autonomy	• Paternalistic behaviours ultimately meant that respect for autonomy was overridden.
Coercion	Beneficence	• Clinicians believed they were acting beneficently when in fact they were coercing patients.	Clinicians should not coerce patients even when motivated by the desire to act beneficently. Open, honest and transparent communication should be used to build a therapeutic relationship and when patients have decision-making capacity they should be able to make poor choices.
	Non-maleficence	• By attempting to act beneficently, clinicians were in fact causing harm as they risked damaging the therapeutic relationship by enforcing what they believed to be right.
	Respect for autonomy	• Coercion violates patient autonomy.
	Justice	• Coercing patients with SD and pain is unjust.
Failure to respect autonomy	Beneficence	• In their attempts to act beneficently, clinicians often failed to adequately respect autonomy.	There needs to be sufficient justification–beyond the diagnosis of substance dependence to constrain patient autonomy.
	Paternalism	• Failing to respect autonomy is often a consequence of paternalistic behaviours.
	Scope	• Patients with SD may be regarded as already lacking autonomy because of their addiction making them more vulnerable to power differentials.
Advocacy	Scope	• Nurses are often driven to act as the patient’s advocate but this may in fact exacerbate their feelings of powerlessness because of their position in the hierarchy.	Although nurses are taught to advocate for patients, it should also be recognised that all members of the healthcare team can act as advocates, as long as the patient’s values and preferences remain central to decision-making.
Advocacy	Beneficence	• Acting as a patient advocate can at times provide justification for acting beneficently but this must be carefully weighed with respect for autonomy as the patient’s voice must be central.
Withholding	Beneficence	• Withholding analgesics was justified by appeal to the principle of beneficence, believing they were preventing harm because they were not feeding patient’s addiction.	There needs to be sufficient clinical justification–beyond the diagnosis of SD to withhold analgesics from patients.
Withholding	Scope	• Some participants described feeling powerless because they were not in control of prescriptions and felt that withholding pain relief was not the right thing to do. This caused them to feel moral-constrain distress.