Book Review

Ethical Issues in Chronic Pain Management

N Engl J Med 2007; 356:2551June 14, 2007

Article

Ethical Issues in Chronic Pain Management
(Pain Management. 1.) Edited by Michael E. Schatman. 312 pp. New York, Informa Healthcare, 2007. $149.95. ISBN: 978-0-8493-9268-9

Chronic pain disables more people than cancer or heart disease and costs the American people more than both combined. The field of chronic pain management is bounded on one side by a steep cliff of indifference and on the other by a slippery slope of iatrogenic harm. Navigating this terrain is challenging enough, but there is more — the field is sown with land mines. These land mines, the ethical issues in chronic pain management, are the subject of Michael Schatman's eclectic and passionate book.

Schatman has decided to approach the topic on two levels, recruiting a variety of contributors to write about individual ethical issues but leaving the overarching ethical concern — the rapidly diminishing availability of quality care for patients with chronic pain — to himself. The individual issues represented are timely and intriguing. The book examines the challenges of treating chronic pain in the elderly and balances consideration of that subject with an essay about the appropriate assessment of pain in children. The thorny subject of opioid treatment for chronic pain is represented in two complementary arguments. One advocates for more widespread use and the other favors a much more cautious approach.

The application of ethics is variable. James Giordano introduces the book with an essay that constructs a framework of virtue-based ethics and applies this framework to the problem of chronic pain treatment. He describes the courage, integrity, and effacement of self-interest required from physicians who take on the task of understanding the needs of patients in pain, and he warns us that pervasive consumerism on the part of the patient has the potential to “bastardize the patient–physician relationship.” The book would have been more cohesive if that level of ethical discussion had been maintained throughout. The authors of subsequent chapters infuse ethics into their essays by alluding to beneficence, nonmaleficence, autonomy, and justice, and they do not attempt to stray too far from the basics. Schatman himself leans heavily on one resource — the excellent writings of Edmund Pellegrino. Some chapters, such as the one on managing the managed care system, have very little ethics content. Instead, they consist of a collection of practical suggestions, presumably included to keep practitioners out of ethical hot water.

The book is intentionally provocative. B. Eliot Cole suggests in his chapter that specialty credentialing for opioid prescribers might be the solution to the problems of undertreatment and overtreatment. Ethan Russo explores the potential benefit of approving and marketing the Canadian medicinal cannabis product Sativex. Schatman advocates the establishment of government-sponsored chronic pain centers as a way to eliminate the “telos of profit within the chronic pain system” and to untangle the red tape that third-party payers use to tie up patients and physicians in knots. The value of these suggestions lies not so much in their face value but more in their use as a starting point for more generalized discussions about treatment reform.

Schatman's approach is passionate, but his concerns are real. The number of accredited, interdisciplinary programs for chronic pain management in the United States declined from 210 in 1998 to just 84 in 2005. Our failure to adequately address the problem of chronic pain affects individuals by failing to alleviate their suffering and weakens society by adding to the cost of lost productivity. There are ethical land mines in the field of chronic pain management, and Schatman is right to identify them. But the larger context of his book makes the more compelling message. We must address the general problem of access to the effective management of chronic pain before the whole field is blown away.

Ross M. Hays, M.D.
University of Washington School of Medicine, Seattle, WA 98105