Friday, January 4, 2008

Challenging ethics dogma; ethics of discharging opioid addicts; Pal-Pourri

1)

Some of you may have read “Salon,” a new monthly opinion column in Canadian Medical Association Journal (CMAJ). At least some of them appear to be intentionally provocative. This month’s is a case in point. “Biothethics? A Grand Idea” pretty much lambasts the basis of modern medical ethics in North America as an invention of “medical amateurs” and based on “simplistic readings of enlightenment philosophers.” The author, a bioethicist, has “never found the standard principles of bioethics useful in my work.”

Specifically, the crown jewels of autonomy & self determination are pretty much fictions. We are social creatures and cannot separate the individual from family, community, and medical institutions. Self determination is based on knowledge and knowledge on experience. How can a patient practice meaningful self determination when s/he cannot truly understand the choices to be made? Beneficence? You can almost hear the “Oh, pu-leeze!” “Bioethics is mostly a rationale for institutional objectives rather than patient desires and needs.”

This one-page article is adapted from the author’s longer article (which I haven’t read), “Bioethics as Ideology: Conditional and Unconditional Values” in Journal of Medicine & Philosophy. Of necessity, then, it is an oversimplification. If you are up for a challenge of your basic ethical training or assumptions, this sounds like an interesting read. The author doesn't want to jettison bioethics. He just thinks it needs to be reborn.

2)
Here’s one from our recurring substance abuse theme: Peggy Compton, a nurse researcher and addictionologist, has written a commentary for Pain Treatment Topics on the ethics and practical effect of discharging patients prescribed opioids who show signs of substance abuse. For those unfamiliar with the issue: there are some (many?) pain practices that essentially have a zero tolerance policy for "aberrant" drug-related behaviors. They are sometimes referred to as "One Strike Policies." Noncompliance with a treatment plan or opioid "contract" or behaviors that appear on a list of "aberrant behaviors" is regarded as prima facie evidence of "addiction." The knee-jerk reaction is too often to stop prescribing opioids and refer the patient elsewhere--in other words, to discharge the patient.

Compton's thesis is that pain and substance abuse/addiction need to be treated simultaneously. The two disorders are chronic diseases that play out in context with each other. Primary care, pain, and psychiatry/addiction treatment partnerships are the optimal team approach. If the patient is discharged for noncompliance or aberrant behavior, neither the pain nor the addiction will be appropriately addressed. Practical approaches are discussed. This approach is not unique to Compton, but it is the first article I have seen to focus on this one topic.

Pain Treatment Topics is an excellent source of information on pain of all types. Almost all resources listed are readily accessible. Some, like Compton’s commentary, are exclusive to this site. Pain Treatment Topics has just announced the launch of a new section on pain in palliative care. So far it is light on content, but I assume that the thoroughness with which other subtopics are treated will be continued with this one.

Compton has also just published an article on urine toxicology in chronic opioid analgesic therapy.
Herbal and Dietary Supplement-Drug Interactions in Patients with Chronic Illnesses--American Family Physician.

The Nov/Dec issue of Journal of Hospital Medicine (a new journal for hospitalists entering its 2nd year) has several articles of interest to palliativists (to use Christian’s term).

OK, I know we don’t usually highlight stuff in palliative care journals, but . . . Have any of our readers used the Mini-Suffering State Scale? It was developed in Israel and used to assess and prognosticate survival in advanced dementia. A new study in American Journal of Hospice and Palliative Medicine uses it with advanced cancer patients. The authors report that it can be potentially used to prognosticate survival and anticipated level of care.

Here's one we missed last month--A new report from the IOM: Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs.

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