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      Ethical decision making in pain management: a conceptual framework

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          Abstract

          Introduction

          The practice and study of pain management pose myriad ethical challenges. There is a consensual opinion that adequate management of pain is a medical obligation rooted in classical Greek practice. However, there is evidence that patients often suffer from uncontrolled and unnecessary pain. This is inconsistent with the leges artis, and its practical implications merit a bioethical analysis. Several factors have been identified as causes of uncontrolled and unnecessary pain, which deprive patients from receiving appropriate treatments that theoretically they have the right to access. Important factors include (with considerable regional, financial, and cultural differences) the following: 1) failure to identify pain as a priority in patient care; 2) failure to establish an adequate physician–patient relationship; 3) insufficient knowledge regarding adequate prescription of analgesics; 4) conflicting notions associated with drug-induced risk of tolerance and fear of addiction; 5) concerns regarding “last-ditch” treatments of severe pain; and 6) failure to be accountable and equitable.

          Objective

          The aim of this article was to establish that bioethics can serve as a framework for addressing these challenging issues and, from theoretical to practical approaches, bioethical reflection can contextualize the problem of unrelieved pain.

          Methods

          This article is organized into three parts. First, we illustrate that pain management and its undertreatment are indeed ethical issues. The second part describes possible ethical frameworks that can be combined and integrated to better define the ethical issues in pain management. Finally, we discuss possible directions forward to improve ethical decision making in pain management.

          Discussion

          We argue that 1) the treatment of pain is an ethical obligation, 2) health science schools, especially medical training institutions, have the duty to teach pain management in a comprehensive fashion, and 3) regulatory measures, which prevent patients from access to opioid treatment as indicated in their cases, are unethical and should be reconsidered.

          Conclusion

          Developing an ethical framework for pain management will result in enhanced quality of care, linking the epistemic domains of pain management to their anthropological foundations, thereby making them ethically sound.

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          Most cited references 58

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          Decision making during serious illness: what role do patients really want to play?

           L Degner,  D. J. Sloan (1992)
          Two surveys were conducted to determine what roles people actually want to assume in selecting cancer treatments. 436 newly diagnosed cancer patients and 482 members of the general public participated. Preferences were elicited using two card sort procedures, each of which described five potential roles in decision making. Findings suggested that the impact of being diagnosed with a life-threatening illness may influence preferences to participate. The majority (59%) of patients wanted physicians to make treatment decisions on their behalf, but 64% of the public thought they would want to select their own treatment if they developed cancer. Most patients (51%) and members of the public (46%) wanted their physician and family to share responsibility for decision making if they were too ill to participate. Sociodemographic variables accounted for only 15% of variance in preferences. These variables are not particularly useful in making predictions about which groups want more or less active roles in medical decision making.
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            Four models of the physician-patient relationship.

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              The costs and consequences of adequately managed chronic non-cancer pain and chronic neuropathic pain.

              Chronic pain is distressing for patients and a burden on healthcare systems and society. Recent research demonstrates different aspects of the negative impact of chronic pain and the positive impact of successful treatment, making an overview of the costs and consequences of chronic pain appropriate.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                1178-7090
                2018
                15 May 2018
                : 11
                : 967-976
                Affiliations
                [1 ]Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal
                [2 ]UNESCO Chair in Bioethics, Universidade Católica Portuguesa, Porto, Portugal
                [3 ]CEGE: Centro de Estudos em Gestão e Economia (Research Centre in Management and Economics), Católica Porto Business School, Universidade Católica Portuguesa, Porto, Portugal
                [4 ]Universidade Fernando Pessoa, Porto, Portugal
                [5 ]Research and Network Development, Boston Pain Care, Waltham, MA, USA
                [6 ]Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
                Author notes
                Correspondence: Ana Sofia Carvalho, Instituto de Bioética, Universidade Católica Portuguesa, Rua Diogo Botelho 1327, 4169-005 Porto, Portugal, Tel +351 22 619 6216, Fax +351 22 619 6291, Email acarvalho@ 123456porto.ucp.pt
                Article
                jpr-11-967
                10.2147/JPR.S162926
                5962306
                © 2018 Carvalho et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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