Blog Posts (23)
February 7, 2015
Chronic Pain -- The Invisible Public Health Crises
A Call for Moral Leadership“I am an invisible man. No I am not a spook like those who haunted Edgar Allen Poe: Nor am I one of your Hollywood movie ectoplasms. I am a man of substance, of flesh and bone, fiber and liquids- and I might even be said to possess a mind. I am invisible, simply because people refuse to see me.”
- Ralph Ellison
Ralph Ellison’s famous novel, The Invisible Man
, starts with this passage, which also reminds me of the problem of chronic pain. The Institute of Medicine (IOM) report, Relieving Pain in America, documented the more than 100 million Americans (almost 1 in 3 and surely someone whom you know and love) suffers from chronic pain, at an economic cost of $6 billion and an incalculable psychological cost. We named pain as a “disease” because of its profound effects on the brain and its interference with multiple domains of the quality of life of sufferers. The committee identified chronic pain as a public health problem, given the sheer numbers affected, and the opportunities to intervene to prevent acute pain from becoming chronic pain. However, the report is now almost four years old, and it is fair to say has not really moved the needle in doing what we implored in the IOM report—“changing the way in which pain is judged, managed and perceived.” Why is that?
Because pain is subjective -- and therefore difficult to measure by the usual medical tests -- it is often doubted. As someone once said, my pain is real, your pain is in doubt. Also, we live in profound cultural ambivalence about pain. Cultural icons such as Julius Caesar and Albert Schweitzer have been quoted as saying that pain is worse than death, but there is also an ethos of “no pain, no gain.” Medical interventions, particularly powerful opioid drugs such as morphine and oxycodone, although essential to manage acute and persistent pain, come with a cost of many side effects and may induce psychological dependence in some. Persons in pain and their doctors fear addiction, although we do not truly know the risk of addiction in persons taking opioids who have not abused recreational or illicit drugs. For these and other reasons, on an individual and societal level, we prefer to ignore the problem of chronic pain
, unless confronted by it in our personal lives.
So how do we advance the moral imperative to address pain and suffering in contemporary medical practice, as required by our ethical codes and professional oaths? How do we bring the invisible suffering of so many to light and work to alleviate it? I think we commit ourselves to five big goals:
1. We advocate for more and better science to understand the underlying neuroscience of pain production and modulation. This requires advocacy at the NIH and other federal agencies to fund worthy science related to pain mechanisms and clinical trials of pain treatments.
2. We advocate for more and better drug development, including the creation of abuse deterrent opioid formulations and novel non-opioid based analgesics. This will require advocacy for effective public-private partnerships between the pharmaceutical industry, academia and federal agencies.
3. We advocate and demand better education of health care professionals to live up to their obligations to be competent and to attend to pain and suffering in their patients. We also advocate for better public education so that persons suffering with chronic pain understand that this is a disease, and not subject to quick fixes.
4. We advocate and demand better policy solutions to provide sustainable and patient-centric interdisciplinary pain treatment programs that truly address patient and provider needs.
5. Finally, we need effective collaboration on a shared policy agenda between pain specialists and substance abuse specialists to advocate for comprehensive, rehabilitation-focused care for chronic pain
, and greater access to substance abuse treatment for those persons who have a dual diagnosis of chronic pain and addiction.
These are my thoughts. What do you think?Richard Payne, MDJohn B. Francis Chair, Bioethics
Center for Practical Bioethics
Esther Colliflower Professor of Medicine and Divinty
June 23, 2014
On May 6, 2014, Barron Lerner, MD, PhD, kicked off the Lerner Lectureship series with a talk that explored the evolution of medical ethics through the lens of his father's and his own practice of medicine. Dr. Lerner's father, Phillip I. Lerner, MD, was "a revered clinician, teacher and researcher who always put his patients […]
August 28, 2013
How Future Doctors Think
Flanigan Lecture Explores How Medical Students Make Sense of Their World
What kind of physician do you want? Do you want someone who, out of respect for your autonomy, explains treatment options but makes no recommendations, leaving the decision up to you? Or do you want something more?
If you want something more, the research conducted by Felicia Cohn, Ph.D., who presented the 19th Annual Rosemary Flanigan Lecture on July 30, 2013, underscores the importance of knowing how your doctor thinks and helping him or her to understand your story. Patterns in Their Stories
When Dr. Cohn taught medical ethics at the University of California-Irvine School of Medicine, she noticed patterns in the stories medical students shared concerning conflicts they encountered between their personal values and professional obligations and what they did about them. Her colleague at UCI, Humanities Director Johanna Shapiro, wondered if there might be a way to analyze and identify themes from these stories as told in 299 papers Dr. Cohn had collected.
“The themes of the students’ narratives really did fall quite neatly into six categories,” said Dr. Cohn.
• Restitution (38%) - Appealed to a moral norm or ethical principle.
• Compromise (16%) – Conceded core values.
• Journey (16%) – Grew through experience.
• Witnessing (13%) – Felt empathy but stood by and watched.
• Resistance (9%) – Rejected professional ethics in favor of personal views
• No Problem (2%) – Never experienced any conflict.
“I thought the papers would tell a lot more stories about witnessing and compromise, which were the type of stories that the students mostly shared in class,” said Dr. Cohn. “But it turned out that restitution – appeal to principle – was the most common story they told. And more often than not the principle the students appealed to was autonomy. In other words, it’s okay for me to do this because it’s what the patient said he wants.”Autonomy or Guidance?
Dr. Cohn explained that this emphasis on autonomy in modern medical culture has important implications for both healthcare professionals and their patients.
“If physicians really think what a patient is doing is wrong but feel that respecting autonomy takes precedence, they’re going to be spending a lot of time doing things that they think are wrong. Then they’re miserable and we go and ask them to be nice to patients. I can’t help but think that’s where a lot of the dissatisfaction and even burnout from healthcare professionals comes from.”
Conversely, for the patient who wants more than options from their physician – who wants their physician to consider how their illness and treatment will integrate into their life and make honest recommendations based on that – then the doctor who tells a restitution story probably isn’t the doctor for them.
Learn more at http://www.PracticalBioethics.org
December 18, 2012
Medical interpreters help patients, doctors communicate Kirsti Marohn and Stephanie Dickrell USA Today December 9, 2012Health care regulations require medical providers who receive federal funding to provide interpreters. There's al...
November 27, 2012
Editor's Note: This is the third of four installments from guest blogger Dwai Banerjee, a doctoral candidate in NYU’s department of social anthropology. Images illustrated by Amy Potter, courtesy of Cansupport. Part III In a later visit with the homecare teams, I met Rajesh - a 29-year-old man who has been battling cancer since his […]
November 14, 2012
Editor’s Note: This is the second of four installments from guest blogger Dwai Banerjee, a doctoral candidate in NYU's department of social anthropology. Images illustrated by Amy Potter, courtesy of Cansupport. Part II However, at this point, Shambu and Rohini's story took a sharp turn. The palliative care team I was visiting with discovered that, […]
November 2, 2012
Editor’s Note: This is the first of four installments from guest blogger Dwai Banerjee, a doctoral candidate in NYU’s department of social anthropology. Images illustrated by Amy Potter, courtesy of Cansupport. Introduction The contemporary landscape of healthcare in Delhi inspires very little confidence. The lack of public insurance, scarcity of resources and rising cost of […]
March 15, 2012
The American Journal of Bioethics is proud to announce that its March issue, a special issue discussing issues related to lying in medicine, is now available online.…
January 12, 2011
According to Playbill.com, the writer and executive producer of such shows as HBO’s “In Treatment” and network TV’s “Law & Order: Criminal Intent” Warren Leight is developing a new medical show that is focused exclusively on medical ethics.…
July 21, 2010
We all know that there is honor among thieves, but apparently a similar code exists among physicians, both good and bad.…
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October 23, 2012 6:44 pm
In their upcoming paper, “Ethical concerns for maternal surrogacy and reproductive tourism” in theJournal of Medical Ethics, Professor Raywat Deonandan et al. enumerate the specific ethical challenges posed by this emerging new industry. Along with six other concerning issues, the authors identified the tension between business ethics and medical ethics as being at the heart of the industry’s ethical problem, along with an insufficiently broad definition of “informed consent.” When desperately poor, illiterate and vulnerable village women are entering into complicated contracts to sell their reproductive health to wealthy foreigners, often some of the softer social risks are not communicated to them, such as their risk of estrangement from their communities, or the risk of domestic unease with their spouses and existing children.
August 28, 2012 12:45 pm
In an interview with WCVB-TV, Dr. Carter explained, “After three consecutive injuries (with other patients) trying to care for people over 250 pounds, my office is unable to accommodate a certain weight and we put a limit on it.”
And Carter is completely within her professional rights to do so. Under Opinion 9.12 of the AMA Code of Medical Ethics, both physicians and patients are free to decline a relationship. “A physician may decline to undertake the care of a patient whose medical condition is not within the physician’s current competence,” the code says.
August 15, 2012 1:35 pm
Dr. David Cronin, an associate professor of transplant surgery at the Medical College of Wisconsin, told ABCNews.com he does not know the case, but organ transplant denial tends to be easier for people to accept because of an anatomic problem, such as calcified blood vessels that would prevent the successful implantation of a new kidney.
August 14, 2012 7:51 pm
Doctors who order tests for hospital patients don’t always read the results before the patient is discharged, raising the risk of missing potentially dangerous conditions, an Australian study found. About half of the unread tests were ordered on the day the patient left the hospital, according to research today in the Archives of Internal Medicine. Many of those results still hadn’t been reviewed two months later, the researchers said.
August 12, 2012 6:39 pm
The Mercury News editorial page had a great column today from three experts on genetic testing that provides the medical perspective on why a physician should be involved in the direct-to-consumer genetic testing process. They argue that these are indeed medical tests, despite industry arguments otherwise. And the results are complex.
August 6, 2012 7:46 pm
A surgeon identified as Dr. Aiman O. is suspected of fraudulently manipulating dozens of his patients’ test results, making them appear sicker than they were to get them liver transplants more quickly — and possibly putting them ahead of people who more desperately needed them. The case first emerged in late July at the University Medical Center Göttingen, in the northern German state of Lower Saxony, from where the senior physician has been suspended since November for allegedly tampering with some 23 transplant cases. A gastroenterologist suspected of involvement has also been suspended.
July 26, 2012 4:20 pm
As the debate over the medical ethics of circumcision rages in Germany, some have argued that the practice provides health benefits. But many in the medical community disagree. Circumcision is not in the best interest of boys who undergo the procedure.
July 17, 2012 4:08 pm
VANCOUVER – Diagnostic tests are increasingly capable of identifying plaques and tangles present in Alzheimer’s disease, yet the disease remains untreatable. Questions remain about how these tests can be used in research studies examining potential interventions to treat and prevent Alzheimer’s disease. Experts from the Perelman School of Medicine at the University of Pennsylvania will today participate in a panel at the Alzheimer’s Association International Conference 2012 (AAIC 2012) discussing ways to ethically disclose and provide information about test results to asymptomatic older adults. In contrast to diseases like cancer – where tumor progression and genetic markers can be measured to determine appropriate preventative steps or targeted treatments – Alzheimer’s disease tests has improved diagnosis and assessment of risk, but no treatments or preventative measures are available to alter the disease progression.
July 13, 2012 1:09 pm
Itil is concerned that doctors might not be ready to opt for surgery once the law is in place: “How can a law decide when a patient requires a certain treatment? This is against medical ethics, and the art of medicine in general. Turkey will set a very negative example with this law.”
July 12, 2012 12:35 pm
NEW YORK (Reuters Health) – Although most people who participated in a new survey preferred making medical decisions together with their doctor, the majority said they wouldn’t speak up if what they wanted conflicted with their physician’s recommendations.
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