We are three specialists in internal medicine, practicing as a group. Many of our patients are covered by a managed choice insurance plan; for them, we provide primary care. Working together, we can see patients when they need us at any hour on any day, and we frequently see one another’s patients. On the whole, the arrangement works well. However, in one area we find ourselves frequently and seriously disagreeing. Our conflict concerns different philosophies on prescribing pain killers and drugs such as tranquilizers, stimulants, and antidepressants.217
We all agree that our primary responsibility is to diagnose and treat the causes of physical dysfunctions. But one of us, jokingly dubbed “Dr. Feelgood,” considers it equally important to see to it that patients experience no pain and suffer no distress that can be counteracted by means of medication. Another of our group, dubbed “Dr. Letemsuffer,” argues that the merely subjective experiences of patients are not our concern except insofar as they are symptoms of underlying conditions we can do something about. I, the writer, am the middle-of-the-roader, but on a common sense basis rather than any general principle.
If our disagreement were over some issue within the purview of scientific medicine, we could study the question and work things out. In this case, though, we have found no way of doing that, and so are beginning to think the problem is more one of philosophy. How can we resolve our differences? Are there some principles to help us do that?
This question calls for the derivation of moral norms for prescribing psychoactive drugs. The two extreme approaches are unsound. Emotional disorders call for health care, and severe pain should be treated; but trying to eliminate light or moderate pain and normal psychological distress interferes with healthful functioning and encourages drug abuse. Managing physical pain must be distinguished from treating emotional problems. Physicians should know current techniques of pain management, and should prescribe analgesics carefully but sufficiently to meet patients’ needs. Patients unreasonably demanding psychoactive drugs or experiencing severe and/or continuous psychological problems should be referred to an appropriate specialist, whose plan of treatment the questioner’s group should follow.
Your responsibility as physicians is to help your patients not only to sustain their lives but to maintain healthful functioning. The relevant functioning is not only physical but psychic, insofar as psychic functioning pertains to the nature of the human person as a sentient organism. While your area of concern as physicians excludes the mind’s functioning as logical, the will’s as moral, and the person’s as skillful, it surely includes the functioning of the psyche as an inseparable dimension of the human body (see LCL, 519–21). People are not vegetables; sensory cognition—not least the awareness of pain—and emotional reactions are among a human person’s natural functions, and disorders in them call for health care no less than do diseases of the circulatory or digestive systems.
On this basis, Dr. Letemsuffer seems to be taking too narrow a view of your responsibility. He surely is right to insist that patients’ experiences be viewed as important symptoms, so that underlying dysfunctional conditions will be discovered and effectively treated. Many physicians who are more psychologically oriented seriously fail in this regard, tending too quickly to prescribe pain killers, tranquilizers, and so forth when patients really need treatment for their blood pressure, digestion, renal functioning, and so on. Still, pain and suffering must not be dismissed as merely “subjective” experiences. In many cases, they not only are signs of underlying dysfunction but are themselves an important, and even the primary, part of the dysfunction calling for your help. For instance, severe pain is an integral part of migraine headache, and emotional distress is the primary part of the psychological shock of an unexpected disaster, such as the sudden loss of a loved one.
At the same time, Dr. Feelgood’s approach errs in regarding light or moderate pain and normal psychological distress as if they were pathologies, whereas in reality they usually are integral parts of healthful functioning. Light and moderate pain ordinarily are helpful signals of the need to limit and regulate behavior that otherwise would damage the organism or interfere with its functioning, while normal emotional distress is an effective motive for appropriately dealing with and adjusting to reality—both the physical and social environments, and ultimate evils such as death and sin. Feelgood’s efforts to ensure that patients experience no pain and suffer no distress do not help patients function well but instead interfere with healthful functioning. Moreover, though patients no doubt often request, and probably usually are grateful for, prescriptions given in accord with his philosophy, it seems certain that his approach sometimes initiates and often supports irresponsible uses of psychoactive substances to promote desired experiences as ends in themselves. Making experiences a goal in this way, without regard to their significance for psychosomatic functioning, interferes with appropriate functioning and evades reality. Consequently, Feelgood’s approach not only is medically faulty, insofar as it interferes with rather than supports health, but is a morally indefensible abuse of his power to prescribe, insofar as he encourages patients’ irresponsible use of psychoactive substances (see LCL, 534–40).
In contrast with your colleagues, your middle-of-the-road approach seems to me nearer the truth. Perhaps I can help you articulate what you have accepted as a matter of common sense. In trying to do this, I think it will be helpful to distinguish between managing physical pain—that is, the sensation of pain in its many diverse degrees and modalities—and dealing with emotional distress: anxiety, depression, and so on.
Pain management is a specialized medical field, and I cannot pretend to tell you how to do it; still, I can say a few things.218
First, many physicians apparently have not been trained adequately in pain management. If that is the case with all or some of you, additional study is in order. Current approaches to pain management include various new techniques, such as biofeedback and meditation, though analgesics (that is, pain relieving drugs) continue to play an important role in most cases.
Second, while some physicians, like Feelgood, inappropriately prescribe analgesics, especially narcotics, studies indicate that many physicians, like Letemsuffer, tend to underprescribe analgesics, even to patients experiencing intense pain. Some physicians simply are unsympathetic to their patients’ suffering; they violate the Golden Rule, allowing patients to undergo pain they would not accept for themselves or their loved ones. This is because they fail to regard their patients as persons with whose efforts to care for themselves the physician should cooperate, and instead regard them as organic systems to be tended and repaired. Other physicians either do not realize or actually forget that individuals’ pain tolerance greatly differs, and wrongly assume that everyone can easily bear what they themselves can. Still others seem overly nervous about possible addiction. They fail to see that appropriate therapeutic uses of analgesics do not involve the motivation of seeking desired experiences for their own sake, which belongs to the psychological component of addiction. Perhaps they also are ignorant of the fact that a merely physical addiction is rather easily treated, and so should not be considered a disaster to be avoided at all costs. Consequently, while the risk of addiction should not be ignored when prescribing analgesics, and while narcotics, especially, should be prescribed with care, the risk usually is reasonably accepted when relieving severe pain will contribute to a patient’s functioning.219
Third, patients often are seriously harmed by physicians’ failure to prescribe needed analgesics. Even Letemsuffer should acknowledge and act on the evidence that pain, especially when severe and prolonged, interferes with organic functioning and impedes healing. But such pain also calls for relief insofar as it interferes with psychological and behavioral functioning—for example, by increasing irritability or depression, and impeding concentration and mobility.
Fourth, contrary to Feelgood’s one-sided view, sound pain management does not always mean trying to eliminate or minimize pain. Sometimes effective pain relief would render a patient languid or unconscious, and he or she should tolerate as much pain as necessary so as to be conscious and alert in order to fulfill some responsibility. Again, since pain’s function is to signal physical threats and regulate behavior to forestall damage, suppressing it—for example, so that an injured athlete can compete—can impede healing or lead to more serious injury.
Beyond these general reflections, I suggest that you and your colleagues work together to sort out the kinds of cases in which you disagree about pain management, if necessary seek the advice of specialists in that field about how to deal with each type of case, and try to work out a common policy.
But how can you deal with what for you probably is the more difficult challenge: treating your patients’ emotional distress? While this problem seems formidable, once the mistaken elements of the approaches of Feelgood and Letemsuffer are excluded, the right approach will be obvious and rather simple.
Patients sometimes will show signs of psychological addiction to psychoactive substances, including alcohol, or will experience severe or ongoing distress, suggesting an underlying psychological illness. In such cases, you should not delay in referring the patient to an appropriate specialist. Once that physician has diagnosed the problem and worked out an appropriate treatment plan, your role will be to cooperate in carrying it out. Collaborating in accord with another specialist’s more expert judgments, the members of your group should experience no conflicts among themselves.
In other cases, patients’ psychological distress is episodic and arises from understandable causes. Unusual traumatic situations—the death of a loved one, a major operation, or a serious business crisis—can cause severe psychological distress for which short-term use of a psychoactive drug may be appropriate. More common, but still episodic, occurrences also may call for occasional use of such drugs—for example, to promote sleep when traveling. When neither of these two grounds exists for prescribing a psychoactive drug, yet a patient nevertheless persists in demanding it, he or she should be refused the prescription and referred for evaluation to a mental health specialist.
If your group follows the policy outlined, occasions of conflict among you will be virtually eliminated. At the same time, the three of you will be guiding your patients in the reasonable use of analgesics and other psychoactive prescription drugs and discouraging their abuse.
217. Psychoactive drugs refers to all these, and, in general, to anything introduced into the body for the purpose of affecting the nervous system and how one feels.
218. A two-volume work for health care professionals: John J. Bonica, ed., The Management of Pain, 2nd ed. (Philadelphia: Lea and Febiger, 1990). On the possibilities of satisfactory pain (and psychological stress) management and the multiple reasons for inadequacies in such management, see Kathleen M. Foley, “The Relationship of Pain and Symptom Management to Patient Requests for Physician-Assisted Suicide,” Journal of Pain and Symptom Management, 6 (July 1991): 289–97; The New York State Task Force on Life and the Law, When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context (New York, N.Y.: May 1994), 43–47, 158–75; A. Jacox et al., Management of Cancer Pain: Clinical Practice Guideline No. 9, AHCPR Publication No. 94–0592 (Rockville, Md.: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, Public Health Service; 1994), 7–21.
219. Some physicians deny adequate pain relief to terminally ill patients, fearing that it would shorten their lives; regarding this, see LCL, 530.