CASE
Ms. M. is a 19-year-old African-American female, presenting to the emergency department (ED) with bilateral leg and back pain that has been present for 3 months but has worsened over the past week. She is not able to sleep and has recently had recurrence of suicidal ideation. Ms. M. is withdrawn with a flat affect, and she has the hood of her sweatshirt pulled over her eyes. She is wearing headphones and is singing along to the music. Ms. M. states that attempts to manage her pain at home with ibuprofen and alcohol have been unsuccessful. She smells of alcohol and of urine, and her wet clothes appear to indicate she has been incontinent of urine. She describes her pain as a 9 on a 10-point scale.
The PA providing the triage evaluation sends Ms. M. to the waiting room, where she sits for several hours before being seen by another PA, who elicits a medical history of depression, suicidal ideation, and psychiatric care. Ms. M. also requests a prescription for Vicodin. Unemployed, she lives with her female partner and their two children, who are also present. Ms. M.'s partner is upset about what she perceives to be a delay in care. On examination, Ms. M. has a BP of 136/95 mm Hg. The PA also notes that none of the patient's other vital signs are elevated, demonstrating an absence of uncontrolled pain, and therefore recommends ibuprofen or acetaminophen.
The PA then presents his findings to his supervising physician. To support his view that the patient is drunk and seeking drugs, he cites the odor of ethyl alcohol, the incontinence, and the flat affect—all of which the PA feels are inconsistent with uncontrolled pain. The supervising physician notes that there has been no neurologic examination and shares her concern that the history and symptoms may be consistent with cauda equina syndrome. Subsequent examination and testing affirm this diagnosis, indicating a lumbar plexus tumor compression.
THE ETHICAL QUANDARY
This case raises several key questions. Can PAs be made aware of stereotypes and unconscious biases that may impair clinical decision-making? Will the use of evidence-based medicine and guidelines fully eliminate these factors? What constitutes reliable evidence? Do evidence-based medicine checklists provide for the contextual issues unique to each patient? Can PAs integrate evidence while ignoring contextual issues and still practice within ethical guidelines? Does selective utilization of medical evidence violate ethical principles and harm patients? Is there an ethical responsibility to address the evidence that clinicians are not value-neutral? Finally, can disparities in care be reduced more quickly by looking outside the examination room? Although we will not resolve all of these conundrums in this column, we propose that resolution will be facilitated by consideration.
DISCUSSION
Medical indications (beneficence and nonmaleficence) Ms. M. had a severe spine injury and presented promptly to a nearby ED. Cauda equina syndrome is a neurologic condition that requires prompt decompression of the spinal cord. It can be caused by trauma or a tumor and is often characterized by saddle anesthesia, severe bilateral leg pain, and incontinence.1
Patient preference (autonomy) Ms. M. and her partner felt that the denial of pain medication was unreasonable, noting that the patient had not consumed alcohol for 12 hours. Ms. M.'s futility in advocating for prompt care and appropriate pain treatment appeared to have been made more difficult by the PA's belief that people in uncontrolled pain will present with consistent and predictable signs and symptoms. Pain expression is known to be influenced by cultural factors, and variations in expression are not reliable predictors of pain.2,3