February 2000
Volume 64 |
Number 2
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LETTERS TO THE EDITOR
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| 'CONTROVERSIES...' |
Editor's Note:
Occasionally the NEWSLETTER receives comments that
serve to stimulate discussion on evolving practice issues. They
will appear in short essay form under this section.
I read the recent article "Controversies in Pain Management:
Ethics in Business Practice" (October
1999 NEWSLETTER) and, frankly, I was disappointed.
Pain management is an area where there are numerous ethical controversies.
However, even major pain societies devote only a small percentage
of time discussing ethics. While there are certainly many difficulties
in the business side of a pain practice, the article left me with
an ill feeling, as there are numerous ethical issues in pain management
that we really should be addressing. For example:
Chronic Opioid Usage and Addiction
Is chronic opioid therapy an option for the treatment of chronic
"nonmalignant" pain in a patient with a history of addiction?
It could be, if all other options have failed and the patient
has shown functional improvement with chronic opioid therapy.
Most practitioners would consider this appropriate for a patient
with a "remote" history of addiction, e.g., a 40-year-old with
a history of drug experimentation in his teens. But what about
a patient who has a current history of addiction and all other
forms of therapy have failed? Even an addict can develop chronic
intractable pain. When all else has failed, should the patient
with a history of addiction be denied opioid therapy? Does this
circumstance require treatment only by a practitioner qualified
in both chronic pain and addiction medicine? What if no such practitioner
is available?
Medicaid... or Worse: The 'No Pay' Patient
How often do we guide our treatment by the method of payment?
Even the best-intentioned private practitioner realizes that there
are financial constraints in the treatment of a patient. No practitioner
can afford to bankrupt one's practice while trying to provide
good treatment. But how often do we make treatment decisions based
on payment potential? How often do we say, "the insurance will
pay for the block" or "he has no psychiatric benefits." Thus these
questions often lead to the problem of...
...Dumping
This is the practice of sending Medicaid or "self-pay" patients
to the local state-supported medical school. While this might
seem to be an instinctually unethical practice, there are some
sound arguments made by private practitioners who do this, e.g.,
if you have a patient with psychiatric problems and your local
psychiatrist will not accept Medicaid or self-pay patients. What
about a patient who requires numerous or expensive procedures
and has no means to pay for it? While most of us can absorb some
of these patients in our practice, I have known of pain clinics
that closed due to these types of financial burdens. Deciding
when to send a patient elsewhere, or to terminate treatment for
financial reasons, is not as clear-cut of a decision as some would
make it out to be.
Expensive Technology
Similarly, there are some unclear ethical issues relating to
expensive new technologies in pain management. Pumps, stimulators,
epiduroscopy, etc. are all expensive technologies. Although there
are debates about the clinical appropriateness of these techniques;
realistically, decisions about these new technologies are based
on financial means. While it is obviously unethical to use such
technology only because a patient can afford to pay for it, there
are similarly unsettled ethical issues related to not offering
the same technology to a patient who cannot afford it.
'Secondary Gain'
Whether we wish to admit it or not, we all view the patient
with secondary gain suspiciously. But exactly what role does secondary
gain have in diagnosis? Any person injured due to the fault of
another would likely file a lawsuit. In a patient with unidentifiable
pain generators, however, secondary gain becomes highly suspicious.
How
much does this phenomenon affect our clinical decisions?
How do we deal with a situation in which an insurance carrier
gets a second opinionÓ from a physician who routinely sides with
the insurer, while the patientÕs lawyer gets exactly the opposite?
Using your best clinical judgmentÓ is not always clear-cut. What
is your level of responsibility to trust and supportÓ your patient?
Policy Statements Have we made a mistake by informing the public
about all our current policies?
Recently, a new patient adamantly demanded that I treat him with
chronic opioid therapy as this was not only the appropriate treatment
for his problem, but also the recommendation of numerous pain
societies.Ó This patient came armed with numerous official statementsÓ
taken from various respected medical societies. All acknowledged
the appropriateness of using chronic opioid therapy for chronic
benign pain. We understand what these policy statements were meant
to accomplish; but to the uninformed public, they can become misleading
or even become fuel that places inappropriate pressure on treating
physicians. Again, have we made a mistake by making these policy
statements so widely publicized to the lay public?
Whether we wish to accept it or not, we have both a duty to inform
and a duty to protect the public. In an ideal world we can inform
and educate. In our imperfect world, however, we often fail to
do both. Have we erred by publicly posting these policies in an
effort to gain political and regulatory gains?
Limits to Our Help Is there a limit to what we can do? When we
have tried everything and failed to find a cause or a treatment,
why is it that we seem to be unable to accept our limits? Is there
always a specific diagnosis and pain generator? I realize I am
only scratching the surface, but I think the NEWSLETTER
would be an ideal means of initiating some much needed education
and discussion on ethical issues.
Eddy Fraifeld, M.D.
Danville, Virginia
Well Ventilated!
As a retired member of the ASA, I am moved to express the pride
I felt after reading your article concerning the perspectives
we feel as anesthesiologists when dealing with the issue of pain
and death (Ventilations, The Quiet Terror of Dying,Ó October NEWSLETTER).
After 30 years as an anesthesiologist, preceded by 10 years in
family medicine, I readily identify with the feelings you expressed
with such great sensitivity. The excellence of your article should
be proudly noted by our colleagues who deal with pain management
in daily practice.
William H. Rice, M.D.
St. Cloud, Minnesota
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