Principles in the ethical management of cancer pain

6 Aug 2015  |  Print

Principles in the ethical management of cancer pain

Hippocrates probably had no idea how big a can of worms he was opening. Now almost 2,500 years old, his famous Oath is still a cornerstone of medical bioethics[1] – but despite its age, bioethics remains a complex and ever-changing discipline.

In the modern world, the global medical community continues to grapple with major bioethical questions, on issues like the role of regenerative medicine and the privacy of patients’ genetic information.

As physicians, how can we navigate the complexities of medical bioethics?

Thankfully, four core principles have been laid out (Table), and these provide valuable guidance.[2] Importantly, they also leave considerable room for clinical judgment in specific cases..

Table. Four core principles of medical bioethics[2]

1 Respect for autonomy Respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices.
2 Beneficence Considering the balancing of benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient.
3 Non-maleficence Avoiding the causation of harm; the healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment.
4 Justice Distributing benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner.

Below, we briefly examine how these principles affect the practice of medicine, particularly with regard to treating cancer pain.

Respect for autonomy

As an ethical principle, ‘respect for autonomy’ demands that every patient should retain the right to know the cause of their illness. However, in Asia, it is common for families to ask a physician not to tell the patient that he/she has cancer.[3]

This may reflect a fundamental difference in the concept of autonomy in Asia compared with Western countries. While the Western principle of autonomy typically requires self-determination and individual independence, the Asian principle seems to be based more strongly on family determination and harmonious dependence.[4]

Furthermore, this family-based principle may persist even when people of Asian descent move to the West. For example, in a US study, elderly Korean-Americans (47%) were significantly less likely that European-Americans (87%) or African-Americans (88%) to believe that a patient should be told of a metastatic cancer diagnosis.[5] Instead, they were more likely to believe that family members should take the lead in these matters.

However, this raises important questions about the value we place on patients making informed decision for themselves, regarding both anti-tumor therapy and cancer pain treatment. There are no easy answers.

Beneficence and non-maleficence

The key concept with these two principles is to give benefit while avoiding harm (Table).[2] However, they sometimes come into conflict. Pain medicine provides an important example of the so-called ‘double effect’ – in which providing benefit risks significant harm – in the case of opioid use for pain control during palliative cancer care. In this scenario, while the use of an opioid will control pain, there is an ongoing fear of the probable risk of respiratory depression that may hasten death.[6]

However, it should be stressed that current guidelines do not consider the use of opioids to be ethically questionable in appropriate palliative care patients.[7,8]

Justice

Suboptimal availability of opioid analgesics is a major concern in much of the Asia Pacific region. This is backed up by 2011 statistics from the International Narcotics Control Board. In the developed countries of Western Europe and North America, opioid consumption is typically greater than 100 mg/capita. By contrast, opioid consumption is less than 10 mg/capita in countries like Vietnam (7 mg/capita), Indonesia (3 mg/capita) and the Philippines (1 mg/capita).[9]

Even in some of Asia Pacific’s wealthiest nations and territories, such as Japan (24 mg/capita) and Singapore (8 mg/capita), opioid usage lags behind their Western counterparts.[9]

There are many possible reasons for this disparity, but a key factor may be widespread ‘opioid phobia’ – an unfounded fear of opioids – which is reflected in national opioid policies and regulations that are highly restrictive and imbalanced.[10]

From an ethical perspective, this discrepancy between different parts of the world may even go against the basic principle of bioethical ‘justice’ – the notion that patients in a similar position should be treated in a similar way (Table).[2]

Medical bioethics in everyday clinical practice

Decision-making in clinical practice often requires physicians to make ethical judgments. At times, it may feel like there is little concrete guidance to aid this process.

Perhaps when these situations arise, it would be wise to return to Hippocrates and his Oath. His entreaties that physicians should work “for the benefit of the sick” and ensure that they suffer “no harm or injustice”[1] remain as powerful today as they were over two millennia ago.

References:

  1. 1. National Library of Medicine. National Institutes of Science. The Hippocratic Oath. Available at: www.nlm.nih.gov/hmd/greek/greek_oath.html. Accessed June 2015.
  2. 2. UK Clinical Ethics Network. Ethical frameworks. The four principles of biomedical ethics. Available at: www.ukcen.net/index.php/ethical_issues/ethical_frameworks/the_four_principles_of_biomedical_ethics. Accessed June 2015.
  3. 3. Benowitz S. To tell the truth: a cancer diagnosis in other cultures is often a family affair. J Natl Cancer Inst 1999;91:1918-1919.
  4. 4. Fan R. Self-determination vs. family-determination: two incommensurable principles of autonomy: a report from East Asia. Bioethics 1997;11:309-322.
  5. 5. Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. Ethnicity and attitudes toward patient autonomy. JAMA 1995;274:820-825.
  6. 6. Fohr SA. The double effect of pain medication: separating myth from reality. J Palliat Med 1998;1:315-328.
  7. 7. National Institute for Health and Care Excellence. CG140. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. Available at: www.nice.org.uk/guidance/cg140. Accessed June 2015.
  8. 8. NCCN Clinical Practice Guidelines in Oncology. Palliative care. Version 2.2015. Available at: www.nccn.org/professionals/physician_gls/PDF/palliative.pdf. Accessed May 2015.
  9. 9. International Narcotics Control Board. Opioid Consumption Motion Chart. Available at: ppsg.medicine.wisc.edu/chart. Accessed June 2015.
  10. 10. Krakauer EL, Wenk R, Buitrago R, Jenkins P, Scholten W. Opioid inaccessibility and its human consequences: reports from the field. J Pain Palliat Care Pharmacother 2010;24:239-243.

 

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