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Ethics of Interventional Pain Management

Serdar Erdine MD, FIPP

Medical Faculty of Istanbul University, Istanbul Pain Center, Istanbul, Turkey

Medicine must relieve the pain of the sick, and lessen the violence of their diseases …

—Hippocrates

Interventional pain management is defined by the Medicare Payment Advisory Commission as “minimally invasive procedures including percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves; and some surgical techniques such as laser or endoscopic discectomy, intrathecal infusion pumps and spinal cord stimulators; for the diagnosis and management of chronic, persistent or intractable pain” [1].

Ethics has been a subject of medicine since the beginning of humankind both for physicians and patients. The Hippocratic Oath has existed since the times of ancient Greece [2]. However, pain medicine still does not have ethical guidelines although, in recent years, the principles of ethics are considered more as the number of interventional pain procedures is increasing.

Ethical and morality theories of biomedical ethics should be a part of pain medicine. Beauchamp and Childress in their Principles of Biomedical Ethics, have described four principles essential for biomedical ethics: respect for autonomy, non maleficence, beneficence, and justice [3].

Respect for autonomy: Patients with capacity are free to make their own healthcare decisions. Health professionals should act in a way that respects patients’ beliefs and decisions, values, and culture. This may be realized by obtaining the patient’s valid consent for any intervention. If the patient is without the capacity to present their desires, or cannot decide for themselves, they should be more protected [4].

Non malefaisence: Health professionals should act with the intent of avoiding harm, or first do no harm, “primum non nocere”. Performing an interventional procedure on a patient which may provide only short-term pain relief but cause severe problems in the long term may also be considered as a violation of non maleficence.

Benefaisence: Physicians are responsible not only for refraining from harmful acts but also for promoting the good of the patient (bene facere).

Justice: Health professionals act with the intent of ensuring fair allocation of resources among those who have need, and distribute benefits and inconveniences equally.

Since Descartes, the physician has seen the body as a machine, and himself as a mechanic who fixes its broken parts. The patient applies to the medical system and is transformed into an object, then reduced to a symptom, syndrome, MRI image or a laboratory finding. There is great discrepancy between the physician’s narrow vision of finding and treating the disease and the demand of the patient clearly asking for a better quality of life by treating the disease. This is called the biomedical model.

The biopsychosocial model, which emerged in the 1980s, provides a framework for understanding how diverse biologic (e.g., injury, infection), psychologic (e.g., negative mood, coping), and social/environmental (e.g., social support, access to services) factors can interact to influence a person’s overall experience of pain [5].

A patient is a human being living in their society with a cultural, religious, societal background and history. As they become a chronic pain patient, and apply to the medical system, they are not only a syndrome or a complaint although the biomedical system “pushes” them in that direction.

Pain physicians are frequently confronted with the dilemma of scientifically unproven techniques, with treatments largely out of their control, and with lack of outcome assessment.

Inappropriate utilization of interventional techniques has been a topic of discussion in recent years. Benyamin et al. highlighted the “explosive growth of physicians performing these procedures without training” [6, 7]. Manchikanti et al. described the ethical issues of interventional pain management in the following terms: overuse, abuse, waste, and fraud; inappropriate application of EBM; and organizational issues related to multiple societies [8].

Overuse: There was an explosive growth in the number of Spinal Interventional Pain Management Techniques between 2000–2011. The total number was 1 469 498 in 2000 while it was 4 815 673 in 2011. The increase from 2000 to 2011 is 228% with an annual geometric average change equal to 11.4%. There was also an exponential increase in facet joint and sacroiliac joint injections [9, 10].

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