Simply put, ethics (derived from the Greek word ‘ethos’ [behaviour]) – is a branch of philosophy dealing with questions about wrong versus right, and what is good or bad. Ethics are guided by the morals, tenets, rules and practices set by society. Behaviour that does not conform to these ‘rules’ of a society are considered unethical. 2[RB1] ,3  [RB2] 

In the healthcare environment, the World Health Organization (WHO) distinguishes between health and medical ethics. Health ethics is defined as: The study and practice that seeks specifically to understand the values undergirding decisions and actions in healthcare, health research and health policy, and to provide guidance for action when these values conflict.2[RB1] 

Medical ethics ‘is concerned with ethical issues that arise in the clinical context related to the care of specific patients, as well as the broader bioethics, which refers to ethical issues arising from the creation and maintenance of the health of all living things’.2[RB2] 

The World Medical Association’s International Code of Medical Ethics, based on the Declaration of Geneva (a modernised version of the Hippocratic Oath), requires the physician, based on his/her duties in general (to patients and to colleagues) to:6[RB3] 

  • Always exercise his/her independent professional judgement, and maintain the highest standards of professional conduct
  • Not allow his/her judgement to be influenced by personal profit or unfair discrimination
  • Deal honestly with patients and colleagues, and report to the appropriate authorities those physicians who practise unethically or incompetently, or who engage in fraud or deception. Strive to use healthcare resources in ways that best benefit patients and their community
  • Not receive any financial benefits or other incentives solely for referring patients or prescribing specific products.

The Health Professions Council of South Africa’s (HPCSA) core ethical values and standards require the following:5[RB4] 

  • Respect for persons: Respect patients as persons, and acknowledge their intrinsic worth, dignity and sense of value
  • beneficence): Not harm or act against the best interests of patients, even when the interests of the latter conflict with their own self-interest
  • Act in the best interests of patients even when the interests of the latter conflict with their own personal self-interest
  • Human rights: Recognise the human rights of all individuals
  • Autonomy: Honour the right of patients to self-determination or to make their own informed choices, and to live their lives by their own beliefs, values and preferences
  • Integrity: Incorporate these core ethical values and standards as the foundation for their character and practice as responsible healthcare professionals
  • Truthfulness: Regard the truth and truthfulness as the basis of trust in their professional relationships with patients
  • Confidentiality: Treat personal or private information as confidential in professional relationships with patients – unless overriding reasons confer a moral or legal right to disclosure
  • Compassion: Be sensitive to, and empathise with, the individual and social needs of patients and seek to create mechanisms for providing comfort and support where appropriate and possible
  • Tolerance: Respect the rights of people to have different ethical beliefs as these may arise from deeply held personal, religious or cultural convictions
  • Justice: treat all individuals and groups in an impartial, fair and just manner
  • Professional competence and self-improvement: Continually endeavour to attain the highest level of knowledge and skills required within their area of practice
  • Community: Strive to contribute to the betterment of society in accordance with their professional abilities and standing in the community.

What are key ethical issues in clinical care?2[RB5] [RB6] 

According to the WHO and the HPCSA, non-maleficence (first do no harm), beneficence (doing good) and trust are fundamental ethical principles at the heart of clinical care. Some common challenges in clinical ethics are:

  • How much information is adequate?  How should complex medical information be communicated to patients who may be frightened or feeling ill, and may have trouble assessing risks, benefits and alternatives? Do all patients even want a great deal of information? Some may prefer to trust their health provider to do what is best for them. When, if ever, is it permissible for a provider to withhold information from a patient because the patient does not appear to want it?
  • When, if ever, should a clinician’s professional opinion or treatment recommendation take precedence over a patient’s right to make a voluntary and free decision to accept or reject treatment? Is paternalism (eg acting to bring about something for another individual’s own good) ever permissible?
  • What criteria should be used to assess whether a patient has the capacity to make his or her own decisions about treatment?  How much preparation and information should a surrogate or proxy have before making a health decision for someone else?

Other important ethical issues in clinical care relate to privacy and confidentiality. These are longstanding values in many cultures. Privacy and confidentiality should be protected. It is agreed that people have the right to control who has access to their person or to information about them and the ability to provide high quality medical care depends on patients feeling free to communicate fully and truthfully with their physician.

Furthermore, if certain information such as sexually transmitted diseases or mental illness are not protected, individuals could face stigmatisation and discrimination. Respecting privacy and confidentiality are especially important in the era of digital medical records.

Ethics and pain management

In August 2019, the International Association for the Study of Pain published a revised definition of pain for comment: The new proposed definition is: ‘An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury’.8[RB7] 

In accompanying notes, the task force added that pain is always a subjective experience that is influenced by biological, psychological and social factors. Through their life experiences, individuals learn the concept of pain and its applications. A person’s report of an experience as pain should be accepted as such and respected.  Verbal description is only one of several behaviours to express pain and the inability to communicate does not

negate the possibility that a human or a non-human animal experiences pain.

Because of its complexity and the fact that it is a subjective experience, managing pain is challenging. Some physicians feel that pain is not a priority in the care continuum, while others don’t develop adequate relationships with their patients, which means that they often don’t understand the patient’s use of language to describe their experience. Yet, others lack the knowledge to treat pain adequately and in the public sector, for example, cost constraints might play a role.6[RB8]  

Another important reason why healthcare professionals might hesitate to initiate adequate pain treatment is the because of their own personal perceptions eg the possibility of addiction.6[RB9] 

The United States for example, is in the midst of a huge opioid crisis, which act as a deterrent for some healthcare professionals in that country to prescribe pain medication. According to a 2019 brief by the South African Community Epidemiology Network on Drug Use, between 1% and 5% of South Africans treated in specialist centres in 2018, listed over the counter (OTC) and prescription (PRE) medicines as their primary substance of use.9[RB10] 

Most patients – except in the Western and Eastern Cape – were male and aged between 24 to 40 years. OTC/PRE medicines were more common as secondary drugs of use (2% and 6%). Medicines used included benzodiazepines, analgesics, codeine products and sleeping pills. During this reporting period (June to December 2018), 3% of treated patients reported the non-medical use of codeine, with the majority coming from Gauteng, followed by KwaZulu-Natal.9[RB11] 

Because of the above ‘barriers’ to pain management, all types, including traumatic, post-operative, chronic, non-cancer, cancer, and end of life pain, remain largely untreated and undertreated. Several studies have highlighted problems:6[RB12] 

  • 80% of patients who undergo surgical procedures experience acute postoperative pain
  • ~75% of those with postoperative pain report the severity as moderate, severe, or extreme
  • 40% to 85% of nursing home residents are estimated experience pain daily
  • 25% of these older adults receive no intervention for pain relief
  • 61.5% of patients with moderate-to-severe dementia experience pain, yet only 30% are treated with analgesic drugs
  • 65% of nursing home residents with cancer experience pain, of which half are undertreated
  • People who live with chronic pain are four times more likely to suffer from depression or anxiety.

Your ethical obligation as a healthcare professional

The WHO has declared access to pain treatment as a basic human right. Healthcare professionals have an ethical obligation to relief pain. Unrelieved pain may leave patients extremely vulnerable, speechless, changed, and even destroyed6[RB13] , which goes against the grain of the Hippocratic oath and ethical guidelines. Pain relief on the other hand, can potentially protect a person’s integrity and promote dignity.6[RB14] 

Four ethical principles should guide prescription of optimal pain control:7[RB15] 

Beneficence and nonmaleficence (discussed above) are grounded in the Hippocratic oath and universally accepted. Modern additions include the principles of justice and respect for autonomy, which are linked to a drive for social justice and human rights.7[RB16] 

Respect for autonomy meansnot to impose any intervention on a competent patient (relates to informed consent to or informed decline of a treatment). A higher level of respect for autonomy is achieved by shared decision-making between physician and patient. The principle of autonomy supports the practice of giving patients as broad a choice of pain treatments as can be medically justified. Many patients, if they are made aware of the risks associated with the use of opioids, might themselves choose less potent but safer medications. Respect for autonomy does not mean that the patient dictates what the physician will prescribe. Giving in and prescribing any medication that is against sound medical judgment is a disservice to patients and likely ethically indefensible, as it contradicts the principle of nonmaleficence.7[RB17] 

In medical ethics, justice refers to fair and equitable treatment for all. The principle is compatible with the practice of screening out people who seek opioids for non-medical use, addiction or diversion. Physicians need to be careful of labelling their patients as ‘junkies’ and denying them access to pain medication. First, the behaviour of a patient with undertreated pain might resemble that of a person with an addiction. Second, because addiction and uncontrolled pain can coexist, a patient with proven addiction cannot be dismissed without assessment and advice. Treatment of such patients might be most appropriately directed by a pain specialist.7[RB18] 

The challenge of these principles is that they at times provide conflicting advice. For example, the principle of beneficence might give a strong indication to prescribe an opioid, yet the principle of nonmaleficence might warn equally strongly against it. In such a case, the physician will have to weigh the importance of each assessment in that particular situation in order to reach the preferable ethical decision. When the situation is very complex or confusing, it might be helpful to refer the patient to another professional or to seek advice from a bioethicist. Whatever the decision, one benefit of ethically focused deliberation might be that the physician will be paying more attention to other means of achieving pain relief, thereby using pain medication less often.7[RB19] 

Decision-making should be guided by current knowledge, skills, and available tools.7[RB20]         

In 2018, the American Department of Health and Human Services published a comprehensive report on best practices in pain management.10

According to the authors of the report a balanced pain management should be based on a biopsychosocial model of care that incorporates the following:10[RB21]  (Allie, please redraw graphic and credit The American Department of Health and Human Services):

Figure 1: A biopsychosocial approach to pain management

Before prescribing pain medication they recommend:10[RB22] 

  1. A thorough initial evaluation, including assessment of both the medical and the probable biopsychosocial factors causing or contributing to a pain condition
  2. Develop a treatment plan to address the causes of pain and to manage pain that persists despite treatment
  3. Screen for risk factors (eg depression, active or prior history of substance abuse disorder (SUD), family history of SUD, childhood trauma)
  4. Familiarise yourself with medication dosing thresholds
  5. Take drug-drug interactions into consideration as well as drug-disease interactions
  6. Draft a patient-provider agreement that includes scheduled drug screening/testing
  7. Ensure that you have a prescription drug monitoring programme in place
  8. Consider non-pharmacologic treatments
  9. Consider national and international pain management guidelines.

Figure 2: Five approaches to pain management (Allie, please redraw)

Conclusion

Healthcare providers have an ethical obligation to provide pain relief to their patients. However, the need for pain relief needs to be balanced with an equally important responsibility not to expose the patient to a risk of addiction. Numerous guidelines and tools are available to guide decision-making. Furthermore, the four basic ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice can provide a framework and a starting point to help physicians make ethically appropriate and defensible decisions about pain medication prescribing. 

  1.  [RB1]WHO doc, page 12
  1.  [RB2]WHO doc, page 12

 [RB3]4. Declaration of Geneva, 2006

  •  [RB4]HPCSA doc, page 7,8

 [RB5]

 [RB6]2.WHO doc, page 19,20

 [RB7]8. IASP’s Proposed New Definition of Pain Released for Comment, page 2

 [RB8]6. Carvalho, page 2

 [RB9]6. Carvalho, page 3

 [RB10]9. SACENDU brief, page 11

 [RB11]9. SACENDU brief, page 11

 [RB12]6. Carvalho page 2

 [RB13]6. Carvalho, page 5

 [RB14]6. Carvalho page 3,5

 [RB15]7. Kotalik, pages 3-4

 [RB16]7. Kotalik, pages 3-4

 [RB17]7. Kotalik, pages 2-3

 [RB18]7. Kotalik, page 2-3

 [RB19]7. Kotalik, pages 2-3

 [RB20]8. Kotalik, page

 [RB21]10. US Report, Page 26

 [RB22]10. US Report, Page 23

  1.  [RB1]WHO doc, page 12