“Thinking ethically” involves considerations of principles and duties, calculating consequences, and comparing cases . Key among archetype principles are patient autonomy (respect for individual persons), nonmaleficence (do no harm), beneficence (do some good), and social justice (the highest good for the greatest numbers). Other core principles include truth-telling, confidentiality, respect for life and respect for culture, professional autonomy, and responsible stewardship. Predominance of a principle over others may depend upon the situation—such as a pandemic. Whereas individual patient autonomy may prevail in most ethical scenarios, during times like these, social justice and responsible stewardship may be of equal importance.
Calculating consequences includes numerous considerations of consequences to patients and families, to health care professionals, institutions, and systems, and to local, regional, national, and global society as a whole. These consequences largely impact individuals, but also include gestalt, big-picture outcomes as well, and we must also beware of unforeseen or unintended consequences that may not be apparent until after the fact.
Case comparison includes looking for similarities and differences with keen attention to details and facts, application of moral maxims or rules of thumb, and reliance upon experience and practical wisdom. We live in a different world since the global viral influenza pandemics of 1918 (H1N1 Spanish flu), 1957 (H2N2 Asian flu), and 1968 (H3N2 Hong Kong flu) and have traversed the likes of HIV/AIDS, SARS and MERS2. Hence, using case comparison as the sole framework to inform ethical decision-making for the COVID-19 pandemic may fall short without principle and consequential considerations as well .
COVID-19 information is continually accruing. Rapidly evolving data can be daunting, and also highly informative for planning and decision-making for our individual practices and our professional and personal lives. Within the context of these data, the practice of medicine remains grounded on the foundational principles above and shaped by consequentialist and casuist considerations that can inform scientific and clinic evidence. It behooves pain medicine specialists to remember these basics of clinical ethics and the tenets of professionalism.
The American Board of Internal Medicine lists six behaviors of professionalism , all of which apply to our specialty—whether you call yourself a pain doctor, pain specialist, algologist, interventionalist, etc.
The physician’s responsibilities as a professional include commitments to maintaining and improving knowledge, competence, and skills leading to improving quality of care; honest communication with patients and respecting confidentiality; maintaining appropriate relations with patients; improving access to appropriate care; allocation and just distribution of limited resources; advancing scientific knowledge that translates into better evidence-informed care; and maintaining trust by managing conflicts of interest.
So, how does all of this translate into ethical practice and professionalism in the face of a pandemic?
Physicians, as the ultimate patient advocates, practice medicine to save and improve lives, and the pain specialist aims to relieve suffering from the ravages of chronic pain, which goes on even in the midst of a pandemic. Our focus must remain upon adapting to circumstances in ways that facilitate our delivering the best possible pain care for our patients within the constraints of available resources. To those ends, ethical physicians are trusted to use and deploy resources wisely, taking the view that best protects patients and systems. Individual physician decision-making and autonomy should be given priority for each individual patient.
We are legally obligated to honor and obey local, state, and national rules and regulations. This may sometimes seem to be at odds with our duty to the individual patient, but we are in a time when societal priorities prevail. Recall the words of Star Trek’s Mr. Spock—“Logic clearly dictates that the needs of the many outweigh the needs of the few.” Captain Kirk replies, “Or the one.” We take care of one patient at a time, in the context of institutions and systems that serve many.
The American College of Surgeons has published COVID-19 Guidelines for Triage of Surgery Patients , which coherently lay out recommendations for stratifying procedures as elective, urgent, or emergent, where acuity of care must be balanced with conservation of critical resources to protect patients and providers. Sound medical judgment and evidence-informed individual care decisions must be weighed against triage considerations and the larger good.
Clinicians and health care facilities should prioritize visits and procedures for an appropriate time frame consistent with guidance from local, state, and national authorities in order to help preserve personal protective equipment and patient care supplies, promote staff and patient safety, and enhance available hospital capacity during the pandemic. Appropriate steps include delaying elective ambulatory visits and rescheduling elective and nonurgent procedural cases. Patient care activities should be confined to those individuals with time-sensitive, urgent, and emergent medical conditions.
Pain medicine providers must work in conjunction with public health experts to reduce the risk of virus transmission from human to human, as well as the rate of new case development, in order to flatten the curve and not overwhelm limited medical resources, while conserving needed disposable medical supplies and focus them to the hospitals where they are most needed.
Urgency of care is determined by physician clinical judgment and considers the individual patient’s unique circumstances. There is a concomitant societal responsibility to not inadvertently be a vector of a potentially fatal disease that may not yet have widely available treatment or vaccine.
The fundamental elements of care that pain medicine specialists should consider during a time of pandemic should include:
There is no substitute for sound clinical judgement that balances respect for individual patients with the needs of our health care system and society . Our goals include providing safe and timely pain care to patients while optimizing available patient care resources (e.g., hospital and intensive care unit beds, personal protective equipment, ventilators, etc.) and preserving the health of involved health care professionals. We must stay current with and adhere to evolving local, state, and national guidelines, rules, and regulations that impact our practice and patient care. We should continue regular follow-up and remain available for patients via telemedicine, minimizing face-to-face clinic visits to mitigate disease transmission risks and optimize use of critical PPE. We must ensure that ongoing pain medication regimens remain uninterrupted to avoid withdrawal and other potential adverse effects and maintain pain control to the extent that pharmacotherapy can. We should explain to patients the current need to postpone pain management procedures until the crisis passes. They will likely understand the imperative to preserve supplies of PPE. Interventional pain management procedures should be performed only if delaying the procedure is likely to cause harm to the patient. Use your best clinical judgment in determining whether doing a procedure will prevent serious adverse medical consequences, or if not doing the procedure will likely lead to serious adverse medical consequences. Thoroughly document the medical necessity of doing some pain management procedures on an urgent, must-do basis, for example, continuity of spinal infusion therapy (especially baclofen and opioids), explanting of infected implanted neuromodulation devices. Other possibly urgently needed procedures might include neurolytic injections for refractory and intractable pain of advanced cancer; vertebral augmentation to relieve acute suffering and avoid potential life-threatening sequelae of immobility; interventional treatment of CRPS to relieve suffering and mitigate potential long-term disability. If you normally could or would wait a few weeks to provide a procedure being considered for a specific patient based on the patient’s unique circumstances, then that might be the preferred course of action now. Conversely, if you normally could not or would not wait a few weeks to provide the procedure being considered for a specific patient based on the patient’s unique circumstances, then that might help you decide what to do. If you do proceed with a procedure during this time, then be sure to clearly document why you made that decision, including referencing legitimate literature and specialty guidelines to underscore your decision-making process, and/or utilize a case review conference approach to document expert consensus about the acuity of the need to move forward [4,6,7,9]. Procedural case status determinations (in terms of patient suffering, type of treatment, and likelihood of benefit vs resource consumption) may be made by individual physicians or in a multiclinician setting using a case review conference model. Multidisciplinary shared decisions regarding procedural scheduling should be made in the context of acuity and available institutional resources that will be variable and rapidly evolving. Key considerations specific to pain management strategies are delineated in the Cohen et al article where an expert panel from academia, the military, and the Veterans Health Administration provides guidelines for provision of services while conserving resources in a context of risk mitigation for patients and providers . Knowing that multidisciplinary, multimodal pain care has an established record of supportive evidence, remember to advise patients about various approaches that they can pursue on their own at home using online resources for instructions. These strategies may include physical exercise, yoga, Tai Chi, mindfulness meditation and other mind–body methods, relaxation techniques, and online supportive counseling sites, among other therapeutic methods. Consider reassignment of clinical staff to minimize numbers of people on site and mitigate disease exposure risk. Explore various avenues of assistance for the financial health of your practice in order to be able to continue providing care for your patients and employment for your staff. Practice management, business, and financial considerations are secondary to preserving health and life, but they cannot be ignored. Various programs are arising that should be explored to sustain practice viability. Pain physicians have a societal responsibility to attend to self-care and remain healthy for our own patients and in the event that our services are needed outside our specialty for acutely ill patients . Learn from this experience to facilitate planning for a future scenario, for example, overstock or reserve supplies of PPE in your individual practice settings and institutions.
The key strategies of multidisciplinary, multimodal pain care coordination should be followed as much as possible using virtual technologies. It may be helpful to virtually gather your multidisciplinary colleagues in order to consider individual cases (especially discussions on prioritizing urgency of care) or for institutional guidance. Collaborative shared decision-making with patients remains preferable, but in the current situation, our professional expertise and experience may take precedence. Patients should be informed that decisions regarding nonurgent pain management procedures are consensus-based and informed by resource availability and specific guidelines.
During a pandemic, decisions regarding provision of chronic pain care must be made in the face of evolving data and the threat environment of the disease. Strategies may change with evolving scientific and clinical understanding of the pandemic’s unique challenges and impacts on the local, state, and national health care environments.
Even though ethical principles remain constant, their application to guidelines is relevant in the context of overarching federal, state, and local directives, clinical situations with pertinent judgments and consensus, and availability of resources. In a fluid setting with substantial uncertainty around an evolving pandemic, information may change rapidly, and it is likely that some approaches outlined in this document may change along with understanding of the challenges specific to the pandemic.
Conflicts of interest: No relevant conflicts of interest.
Disclaimer: Some comments and recommendations were adapted from the sources listed below as references and transposed into proposals applicable to the practice of pain medicine.