What is Ethics and what Constitutes an Ethical Dilemma?
Ethics is defined as moral principles that governs the conducting of an activity. Ethical dilemmas arise when there are two decisions that seem morally right to do but one must prioritize between the two. (Rainer, Schneider & Lorenz, 2018). As healthcare providers we should always seek to do what is right but what is right and acceptable is not always laid out in a clear path. According to Rainer, Schneider & Lorenz (2018), there is insufficient guidance in literature guiding resolutions of ethical dilemmas. Feinsod & Wagner, (2008) defined justice as fair treatment of individuals. It is essentially how the rights of various individuals are realized. Many questions arise from distributive justice like who decides what treatments are done and is it based on age, prognosis or needs.
The Opioid Crisis and Justice
The opioid crisis that we now face resulting in the death of over 90 persons per day from opioid overdose is crippling and has shown major impact on the prescription of narcotics as well as the unwillingness of recovering addicts to take prescribed narcotics because they fear that they might relapse. Patients on chronic opioids are at risk of receiving inadequate analgesia due to prejudices of clinicians towards opioid addicts.
“Recent warning on the risk of abuse among opioid users in chronic non-cancer pain, including the Center for Disease Control and individual state guidelines, have generated a sort of opiophobia.” (Coluzzi et al; 2017). Opioid addicts are stigmatized due to the common perception of addiction as a crime rather than as a disease so when they request more opioids for pain relief, they are labeled as drug seekers.
The principle of justice calls for healthcare providers to assess their own biases and to do what is in the best interest of their patients. We must weigh the risks and advantages of treatment options based on evidence-based practice and not based on whether a patient is an opioid addict. (Coluzzi et al; 2017) To Kant, all humans must be seen as inherently worthy of respect and dignity. Kant also argued from a deontological perspective that right or wrong does not depend on consequences but on whether our actions fulfill our duty. (Misselbrook, 2013)
The Doctors Choice
Below I briefly describe one incident that stands out in my mind and which I have seen on multiple occasions both in my practice abroad and in the United States. Patient X, an African American homeless male was admitted to the unit for fracture to right femur following a motor vehicle accident. He is a known opioid abuser but toxicology screens on this admission was negative for cocaine and opioid use. Patient X complained of pain 10/10 and was prescribed suboxone 16mg BD, ibuprofen and Tylenol which he stated wasn’t relieving his pain.
The nurses and doctors whom patient X was being treated by believed that he was not in pain as he said he was and so the nurses refused to advocate aggressively in the same fashion they would for other patients and the doctors refused to prescribe any other medication to provide pain relief. When patient X complained of pain the staff nurse informed the doctor in the hopes that he would prescribe something stronger for the patient but the doctor refused to prescribe narcotics stating that patient was a known opioid abuser and in his judgement did not want to help the patients addiction.
The doctor’s choice was to use non opioid medications and offer opioid rehab center suggestions for discharge. The doctor’s choice in my opinion conflicts between non maleficence, beneficence and Justice. Non-maleficence is to do no harm while beneficence is to do good. The patient is in pain and without another treatment option that will alleviate his pain I think that the doctor is doing more harm than good. However, from the Dr’s perspective he is doing good because he is assisting the patient away from the path of addiction.
Using the utilitarian view, he may believe that he is doing good for the benefit of the majority because opioid abuse can lead to overdose which may lead to fatalities. The utilitarian approach according to Mandal, Ponnambath & Parija (2016) is based on the concept of doing the greatest good for the greatest number of persons. According to Stuart et al; (2018), opioid fatalities have increased between 2013 and 2014. Justice as mentioned above is being fair in all aspects of our practice regardless of age, ethnicity, race or socioeconomic background. Is it right for providers to withhold treatment because of our own prejudices? Are we doing good at all costs for our patients? (Feinsod & Wagner, 2018).
It is evident that the increase in opioid abusers have brought about ethical issues and challenges for healthcare professionals when prescribing analgesics for pain management. According to Coluzzi et al (2017), clinicians have been encouraged to plan perioperative medications and refer opioid abusers to addiction specialists for evaluation. Coluzzi et al, (2017) suggests that despite ongoing or previous opioid abuse history patients’ pain should be managed effectively. The physician might have done good in choosing to refer patient to an addiction specialist out-patient post discharge but what about the patients right to be comfortable and free of pain during hospital admission?
What would I have Done?
On the contrary I would have prescribed the patient with a low dose of opioid because opioids are more effective in relieving the level of pain a patient would have postoperatively. “There is no evidence that analgesic opioids will exacerbate addictive disease.” (Coluzzi et al; 2017). According to Stuart et al; (2018) medication-assisted treatment is a first line treatment for opioid use disorder. Three common medications used are naltrexone, methadone and buprenorphine/naloxone.
Referring to the scenario the patient was prescribed “Buprenorphine which is a partial opioid agonist that has rapidly expanded the treatment of opioid use disorder in the United States with some promising results. For instance, buprenorphine reduces opioid use and increases retention.” (Stuart et al; 2018). Coluzzi et al; (2017) suggests that we could minimize relapsing by planning perioperative pain management and having a written opioid pain care plan agreement with patients.
Other approaches for treating severe acute pain that requires opioid analgesia in patients under buprenorphine maintenance treatment as a first choice is to continue buprenorphine and use a different opioid for analgesia, by titrating an oral short-acting (immediate release [IR] morphine or oxycodone) or IV opioid analgesic (morphine or fentanyl) to the desired analgesic effect (continuous infusions are not recommended). Consider that higher doses of opioids could be necessary for competing with buprenorphine. (Coluzzi et al; 2017)
What if the Scenario was Different?
What if Patient X was a reputable member of society who also has a history of opioid abuse? Would the treatment decision be different? What if he was a reputable member of society and had no drug history? Would your decision be different? Who decides what treatment is just for an individual based on socioeconomic background and past opioid misuse? How do you know that a person will become addicted or relapse? Is it just to withhold medications that are deemed to be the gold standard for treatment of a condition just because of our fears of relapse?
- Coluzzi, F; Bifulco, F; Cuomo, A; Dauri, M; Leonardi, C; Melotti, R. M; Natoli, S; Romualdi, P; Savoia, G; & Corcione, A. (2017). The challenge of perioperative pain management in opioid-tolerant patients. Therapeutics & Clinical Risk Management. 13, 1163-1173.doi: 10.2147/TCRM.S141332.
- Feinsod, F.M & Wagner, C. (2008). The ethical principles of justice: The purveyor of equality. Annals of long-term care. 16(1). Retrieved from https://www.managedhealthcareconnect.com/article/8210.
- Mandal, J; Ponnambath, D.K; & Parija, S. C. (2016). Utilitarian and deontological ethics in medicine.Trop Parasitol. 6(1): 5–7.doi: 10.4103/2229-5070.175024
- Misselbrook, D. (2013). Duty, Kant, and deontology. The British journal of general practice: the journal of the Royal College of General Practitioners, 63(609), 211. doi:10.3399/bjgp13X665422.
- Rainer, J; Schneider, J.K; & Lorenz, R.A. (2018) Ethical dilemmas in nursing: An integrative review. Journal of clinical nursing, 27, 3446–3461. DOI: 10.1111/jocn.14542.
- Stuart, G.L; Shorey, R. C; France, C.R; Macfie, J; Bell, K; Fortner, K.B; Towers, C.V; Schkolnik, P; & Ramsey, S. (2018). Empirical studies addressing the opioid epidemic: An urgent call for research. Substance Abuse: Research and Treatment, 12 (1-4). doi: 10.1177/1178221818784294.