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This is often done with the patient's benefit in mind. The most important way in which physicians demonstrate respect for their patients' autonomy is by obtaining the patient's valid consent for any medical intervention. The consent process demonstrates respect for patients' values and decision-making capacity. Patients who cannot communicate their desires e. Respect for patient autonomy and promotion of patient autonomy are related but distinct duties for physicians.
Illness makes patients dependent on physicians. Pain, for example, may push patients to a point where they are no longer able to carefully weigh the risks and benefits of surgery. Interactions with physicians can further foster the dependency of patients. Patients may become dependent on the relationship with the physician or on treatments administered by the physician. Medications such as opioids or benzodiazepines that induce physiologic dependence hold special risks for erosion of patient autonomy. In these situations, respect for patient choice must be combined with awareness of the compromise of patient autonomy by unrelieved pain and by dependence-inducing medications.
At times, respect for patient autonomy and promotion of patient autonomy may conflict. Beauchamp and Childress describe a case where a patient long dependent on pentazocine was successfully withdrawn through the deceptive use of a placebo. The patient had failed in this taper many times previously and was thankful that it had been successfully accomplished, but had not approved of the deception.
Here, the patient's autonomy was not respected because of intentional deception; but patient autonomy was promoted through successful taper from a medication on which the patient was dependent. Many would find this an unacceptable compromise of patient autonomy, even though the patient was pleased with the result. Physicians have an obligation not to inflict harm on patients intentionally or carelessly. Primum non nocere , first do no harm, is one of the most frequently cited maxims of biomedical ethics. Generally these obligations to avoid harming are more stringent than those obligations to do good.
Harms can include any injury to person, property, or reputation; but is often limited in bioethics to physical harms including pain, disability, and death. This duty prohibits inflicting harms as well as imposing unwarranted risks of harm. Failing to provide adequate analgesia to neonates undergoing painful procedures, for example, would now be recognized as a violation of the physician's duty of nonmaleficence to the neonate.
Providing a surgical procedure for a patient in severe pain known to provide only short-term relief and severe problems over the long term would also be considered a violation of nonmaleficence. Some have argued, however, that hastening the death of terminally ill patients who have severe suffering is not harming them. Though physician-assisted suicide is now legal in Oregon, the ethical issues involved are far from settled.
Considerable further debate will be necessary to settle whether causing death is ever justified for the sake of pain relief. Physicians have a duty to take positive steps to help others and not just to refrain from harmful acts. Beauchamp and Childress explain differences between rules of nonmaleficence and rules of beneficence. Rules of nonmaleficence typically: 1 are negative prohibitions of action, 2 must be obeyed impartially for all persons, and 3 provide reasons for legal prohibitions of certain conduct. Rules of beneficence, by contrast: 1 present positive requirements of action, 2 do not need to be obeyed impartially, and 3 rarely provide reasons for legal punishment.
The duty not to harm usually prohibits actions, while the duty to help prescribes certain actions for certain people.
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Adequately responding to the suffering of dying persons, for example, may require a form of compassion more personal than most physicians are accustomed to providing . Physicians have a duty to relieve pain in conditions such as cancer and burns where there has been an acceptance of severe pain. However, it is unclear whether physicians have a duty to relieve all the pain of all of their patients. These practitioners might argue that the benefits of pain relief must be weighed against the potential harms of attempting to provide that relief.
On the other hand, there is recent evidence that some individuals with a family history, but no personal history, of alcoholism may have diminished endogenous hypothalamic opioid activity. This raises the possibility that some individuals are genetically deficient in endogenous opioids and may more frequently need exogenous opioids than others . The nature and limits of the general duty to provide pain relief are also not well defined. Does this duty only pertain to individual patients seeking relief from a physician, or does it include a public health component that includes all potential sufferers as might be implied by the WHO cancer pain initiative?
Does physicians' duty extend beyond pain to other forms of suffering? It might be difficult to draw a meaningful line between pain and suffering, because social and psychological suffering is so often presented to physicians in somatized form as pain. Sometimes the physician's job may be not only to reduce pain and suffering of the dying patient, but also to help this patient find meaning in this suffering . In addition to respecting autonomy, preventing harm, and promoting good for patients, physicians have an obligation to promote justice in the distribution of these goods.
Distributive justice refers to fair, equitable, and appropriate distribution in society of a privilege, benefit, or service. Problems of distributive justice arise under conditions of scarcity and competition where there is not enough to provide all that each needs or wants. It is increasingly recognized that health care resources in the United States are finite and that difficult choices need to be made about who gets what health care.
When providing for fair distribution, what specifically needs to be equalized? There are many potential candidate principles of distributive justice described by Beauchamp and Childress: To each person: 1 an equal share, 2 according to need, 3 according to effort, 4 according to contribution, 5 according to merit, 6 according to free-market exchanges. Each of these principles can justify very different distributions of goods.
Our society has rarely explicitly grappled with the just distribution of medical care.
Oregon recently attempted to provide a rational list of priorities for its Medicaid dollars. A strategy based on cost per quality-adjusted-life-year was stuck down as violating the American with Disabilities Act. It is not clear where pain relief should fit in a list of health care options to receive funding. Should all have access to state-of-the-art interventional pain control strategies? This question has arisen, for example, with respect to Medicaid funding for epidural analgesia during labor.
Principle-based ethical theories offer the most well-developed means of resolving conceptual and bioethical problems. They give us a template. They get us started. They help us see some of the critical factors. The bioethical literature on the ethics of pain management has thus far focused on the end of life.
This literature has helped us breach barriers to effective pain relief for the dying. Many other issues about the role of pain management in health care have yet to be examined in a systematic way. Hopefully, the above review of ethical theories and principles will assist the Pain Community in advancing this discussion. Oxford University Press is a department of the University of Oxford.
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