Doctors Describe Their Toughest Ethical Dilemmas

Shelly Reese

Disclosures

February 23, 2017

In This Article

Physician Conflicts Around Undertreating Pain

Overdose deaths involving prescription opioids have quadrupled since 1999.[1] Physicians have been blamed for contributing to the epidemic, causing state medical boards and federal agencies to crack down on prescribing practices regarded as overly liberal. At the same time, physicians are trying to alleviate suffering, including that of the more than 65 million Americans estimated to be experiencing chronic pain.[2]

In light of the current environment, nearly one half (47%) of the physicians surveyed say that addiction concerns and fear of professional repercussion would or might cause them to undertreat a non-terminally ill patient's pain. Nearly one quarter (24%) say they would or might undertreat a terminally ill patient's pain for the same reasons. That represents a seismic shift from 2010, when 84% of physicians said they would never undertreat a patient's pain.

Two family physicians' attitudes illustrate how the epidemic has divided the medical community. "Every single day, we get emails, etc about how the Drug Enforcement Administration is clamping down on narcotics and rounding up physicians who overprescribe them," writes one. "My patient cohort is very ill, and there is a ton of chronic pain. I ask you: What am I supposed to treat them with? NSAIDs? No way. It does not work, and most of them have renal failure. Am I supposed to refer to pain management? That's a joke. It never, ever works."

Taking the opposite stance, a colleague rejoins, "Doctors are under a great deal of scrutiny and no patient is worth risking my license for."

Chronic pain presents a particularly thorny problem. Some doctors say, the risk for addiction clearly justifies undertreating, because "addiction trades one source of suffering for another." Others cite Centers for Disease Control and Prevention guidelines released in March indicating that nonopioid therapy is preferred for chronic pain outside of active cancer, palliative care, and end-of-life care.[3]

"I don't believe that narcotics are indicated for nonmalignant chronic pain," writes an orthopedist. "They are for acute surgical, injury, and malignant pain. I don't believe that not prescribing narcotics is undertreatment."

Ethicists say that the solution depends upon physicians committing a significant amount of time to understanding the nature of each patient's pain and referring to specialists if necessary. "The ethical thing to do is to really know your patients," says Caplan. "We have to give doctors time to work out pain management. If you don't do that, then I think people are going to be undertreated."

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