Ethics in the Management of Chronic Pain

J. K. Lilly, MD MSClinical Professor of Anesthesiology

And Pain MedicineRobert C. Byrd Health Sciences Center of

West Virginia University/Charleston Division

Ethics Principles in Pain Management• Disclosure and

Informed Consent• Benefit verses Burden• Autonomy &

Surrogacy • Pro Patria -

Professionalism• Double Effect –

Greater Good• See Handout for Expanded

Explanation

Case Study #1

A 40 year old HIV sero-positive, estranged woman with drug resistant cryptococcal meningitis and anemia. Her son and sister disagree on the “the right thing to do.” She cries from head & body pain, is intermittently oriented & refusing medications, says…”I deserve to die for my sins.” What to do?

Ethics Principles in Pain Management

• Identifiy the ethics principles involved• Identify the cultural, social and

personal dilemmas in this circumstance

• Develop talking points for resolutions• Expect confusion, provide sensibility

& professionalism

“Now, The Rest of the Story”• Abused as a girl • Several Psych

Admissions • IV drug abuse Hx• 25 yr old Son “…

sick and tired of this”

• 39 yr old sister is also disabled on SSI

Case Study #2

A 51 year old medically retired coal miner, s/p four laminectomies, walks with two canes, reports constant, severe burning pain in all extremities. Local physician declines initiation of narcotics and co-analgesics. “I only give those drugs to terminally ill patients! Go to Pain Clinic”. What to do?!

Ethics Principles in Pain Management

• Identifiy the ethics principles involved• Identify the cultural, social and

personal dilemmas in this circumstance

• Develop talking points for resolutions• Expect confusion, provide sensibility

& professionalism

“Now, for the Rest of the Story.”• Sister is Deputy Sheriff

in their community …many drug-related arrests, both youth and adult…”very anti-drug”

• Brother detox’d x2• Patient is “Family

Leader” for his and his brother’s kids

• High Medication Requirements for Relief

We can’t see what we don’t look for.