Recommendations
Ms. C. says that pain is the major influence on her QOL. The ethical concerns for the PA include the following:
Is Ms. C. exhibiting drug-seeking behavior? Is she diverting her prescription medication because of her addiction? Is addiction a character flaw or a chronic disease needing constant vigilance and aggressive treatment? How should Ms. C.'s verbal abuse of the clinic staff be handled?
Is Ms. C. physiologically dependent upon her opioid medication?
Is Ms. C. suffering from pseudoaddiction exacerbated by fear of running out of pain medication?
Are Ms. C.'s pain regimen and dosing schedule optimal?
The ethical principles involved in QOL analysis are nonmaleficence, beneficence, and autonomy. Nonmaleficence “sanctions rather than suppresses quality-of-life judgments.”8 Does undertreatment of pain cause harm to QOL? Does creating a probability of physiologic dependence or addictive behavior violate this principle? Beneficence assumes action that helps others. Improving Ms. C.'s QOL by prescribing adequate opioid medication may uphold this principle. Autonomy requires supporting Ms. C.'s request to be as free from pain as possible.
Gilson, Weaver, and Cohen all note that appropriate pain treatment does not appear to create a significant increase in addictive behavior in those with an abuse history or present dependence.9,12,21 The challenge is the ability to treat pain, as Weaver explained, in the face of sometimes convoluted state laws and regulations.9 Again we see that the tension between beneficence and autonomy is a constant struggle. The human and professional concern to do everything medically possible for the patient, the patient's control over decisions affecting health and QOL, and issues of justice, laws, and regulations that control the practice of medicine all compete in the effort to meet the best interests of the patient. JAAPA
The author is on the faculty of the MEDEX Northwest Division of Physician Assistant Studies, School of Medicine and Center for Health Sciences Interprofessional Education and Research, University of Washington, Seattle. He has indicated no relationships to disclose relating to the content of this article.
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