Ethical Challenges and Interventional Pain Medicine

Abstract

The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians' failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself." -Eric J. Cassel [1] We must abandon those orientations that treat pain as an object independently of the being that it affects. -Giordano and Schatman [2]Early in their professional careers, virtually all physicians endeavor to practice medicine in an ethical manner motivated by a desire to help patients. It is also clear that a significant proportion of individuals and organizations involved in the delivery of health care in this country are centrally motivated by financial concerns. Our fee-for-service reimbursement system compensates for "doing things" to patients. Because of this, great attention must be applied to assure that medical care is focused on the patient's needs rather than that of the individual provider, their practice group, or a hospital system. Pain medicine, like most medical specialties, presents this challenge of maintaining patient-centered care. There are a variety of factors, patient-, provider-, and system-related, that can encourage overemphasis on maximization of financial reward. This type of practice, which is often procedurally focused (but also may occur in the form of inappropriate medical management, as exemplified by the "pill mills"), is inherently unethical and challenges the integrity of the field. Pain medicine must be multimodal and focused on doing what is in the best interest of the patient. The challenge over the next several years will be to utilize education and the coming changes in health care delivery to favor pain practice that is both ethical and sustainable. Case Reports Patient 1A 47-year-old woman (OC) presented for initial evaluation at a pain center with the chief complaint of persistent severe axial low back pain (LBP). OC was in a state of good health until 6 years prior, when this severe pain started after a strain

Augmented Pain Processing in Primary and Secondary Somatosensory Cortex in Fibromyalgia: A Magnetoencephalography Study Using Intra-Epidermal Electrical Stimulation

“…In the present study, patients with FM reported higher ratings in response to single and repeated IES, but temporal summation of pain was not significantly different from that observed in HC subjects. This is consistent with several other studies which showed that patients with FM were not significantly different from HC subjects when testing temporal summation of pain using pinprick [ 4 , 74 , 75 ] or thermal stimuli [ 30 ], or when testing reflex responses to nociceptive electrical stimulation [ 29 ]. In contrast, several other studies have reported increased temporal summation of pain in response to thermal stimuli [ 10 , 11 ], and reduced reflex responses to nociceptive electrical stimulation in patients with FM [ 6 , 76 ].…”

The Needle and the Damage Done?

“…Trescot and Cohen refreshingly address the imperatives of cost utility and put the patient's well‐being ahead of issues of remuneration. This is encouraging, particularly given the criticism in the recent literature regarding the mercenary practice patterns of some interventionalists in the face of questionable evidence basis [1,2]. Although some would question the ethics of placing financial limitations on pain relief, Dr. Cohen notes that we live in an imperfect world, and physicians must become progressively cognizant of cost‐effectiveness.…”