Ethics As Applied To Pain Management

Critically evaluate the available evidence regarding the justice beliefs in context of chronic low pain in terms of Mrs. Alice’s case study.

Introduction

“The relief of pain is a core ethical duty in medicine”(Johnson2007, P.1). There are many ethical issues associates with pain management. So it is important that the health care professionals should understand the ethical principles, which may help to deal with problem effectively, (Please appendix: 3 for principles of ethics related to medical practice).

The people in the world have different views related to justice and injustice. They could describe numbers of examples of injustice and justice which might drawn from personnel experience or from the society .It is interesting to know that most people tend to uphold a the view of justice beliefs in the world that is”they live in a world where people generally get what they deserve”, Lerner and Millier (1978,p.1030), Haferand Begue(2005). The justice beliefs are individually associated with psychological adjustment and it could be a reflection on objective assessments of the justice received by other human beings, Sutton et al.(2008)

The multifaceted nature of chronic pain is influenced by pain beliefs Sloan et al. (2008). McParland and Knussen (2010) reported that a justice belief also has influence in experience of chronic pain and pain behaviors. The people who have justice belief s are motivated to belief that the world operates in a fair and legitimate manner (Sutton et al.2008), and they will be able to pursuits long-term goals and maintain physical and psychological well being,( Kathleen and Claudia 2005;Laurin et al.2011;Dalbert 2002). The human perceive injustice when they expose to a situation primarily characterised by violation from human rights or to challenge the just world beliefs. Fetchenhauer and Huang(2004).

2. Aims of the assignment

The assignment aimed to explore the available evidence regarding the impact of justice beliefs in chronic pain sufferers and their reaction to injustice based on Mrs. Alice’s Case study. The assignment also aimed to evaluate the evidences on ethic principles.

Case study

Mrs. Alice is a 39-year old nurse, mother of two, who has been suffering from low back pain for last two years. The patient has no specific medical history. She attended the general practice in past in intermittent bouts. She was taking analgesics that did not make any difference for her pain. The x-ray was normal. She has been subjected to persistent suspicions of malingering from doctors and employers, as she has no objective finding. Mrs Alice currently presenting with the statement that ” everyone misunderstood my pain as moaning but I am in pain, might be they didn’t understand me properly”

3. Search Strategy

A literature search was done using Science direct, pub med, google scholar, Medline, Ovid for relevant studies done in past 5 years. But this assignment only included one quote from 1978, which is relevant for this review. The key words included for the search were justice beliefs, injustice, justice, pain, pain management, chronic pain, unfairness and combination of these words. The search was limited to studies conducted in human beings and published in English. There was lack of literature regarding chronic back pain to assess the influence of injustice and justice beliefs. Hence searches were extended to other chronic pain conditions. Each of the papers were analysed for validity and rigour according to the framework given by (Rees 1997, cited in Taylor 2009). See appendix 2. The strength of evidence was established using the Hierarchies of evidence framework Dawson (2004). See appendix 1.

4. Literature Review

McParland and Knussen (2010) conducted a cross sectional questionnaire design to find out the impact of general and personal beliefs to moderate psychological distress in the experience of chronic pain. The study was conducted in support groups, from national chronic pain organisation in Scotland. The recruited participants were from arthritis and fibromyalgia groups and they were asked to complete the questionnaires. The findings from the study suggests that strong general justice belief is beneficial for psychological well being in the context of chronic pain and it helps cope with pain intensity and disability.

Table:1 McParland and Knussen (2010,p. 72)

The study used reliable self-report questionnaires to collect data from samples. See appendix 5 for questionnaires used in the study. The use of reliable tools for the study could the increase the internal validity of the study and maximizes the value of the results. The conducted study was using the samples from National chronic pain organization in Scotland so the beliefs could be influenced by cultural and educational factors of the area. The beliefs could differ in different ethnic populations Sloan et al. (2008). As the study was conducted in United Kingdom the results would be more applicable for clinical practice for this country.

There are some weak points for this study as mentioned the questionnaires wre given to interested patients from the group. This might attract samples that have strong personal and general beliefs into the study. This way of sample recruitment might bias the result and affect the validity. The sample was collected from community support groups of arthritis and fibromyalgia where they receive personal and social support from health professionals. This could be argued that these patients might already affect psychosocial distress because of their condition. Mcparland and Knussen (2010) that people experience less psychosocial distress when they hold strong personal beliefs. So there could be a chance for bias in sample selection that affects the validity of the study results. The accuracy of the completed questionnaires is uncertain as participants might already suffer psychological distress or pain. The self-report questionnaires could naturally bias the persons feeling at the time they complete the questionnaire as the participants were requested to complete and return the questionnaire by post. It would be better if the researcher asked to complete the questionnaires in a controlled time and site. This method biases the data collection and could affect the validity and reliability of the result. More over the researcher and assistant met the participants to introduce the study and given contact details. So the study was not blinded.

According to just world theory the people who has strong belief just world will be motivated to defend their belief when they encounter any evidence of injustice McParland (2011). They might find a positive explanation for injustice that is occurred and blame themselves. The reviewed study also agreed that justice beliefs in the recruited sample helped to cope with pain intensity and disability. Mrs Alice believed that she would receive a fair approach from health professionals but she experienced unfairness and injustice with the treatment. It is interesting to note that the way she tried to defend her feeling ‘ they didn’t understand me properly’. The reaction with injustice might not be the same in chronic pain sufferers.

The chronic pain sufferer who perceives injustice or unfairness can influence their physical and mental health. This is also proposed in Perceived Unfairness Model, Jackson et al. (2006). See appendix 4 for perceived unfairness model. The recurrent episodes of perceiving unfairness (ie. Micro Agressions) can be coupled with helplessness, lack of control and compromise to physical health, (Jackson et al. 2006; Zempsky 2009). Sullivan et al. 2008; Sullivan et al.2009 also reported that perceived injustice has an impact on pain severity in samples after muskuloskeletal injury. Based on hierarchy of evidence the strength of evidence achieved for this is level 2b. So there is a need for further stronger studies to elucidate the role of justice beliefs in psychological distress, pain variables and disability.

McParland et al. (2010) conducted a study to investigate the impact of justice and injustice in context of everyday life of a chronic pain sufferer. The samples from general practice recognized chronic pain as a major problem in United Kingdom. The participants recruited from different socio-economic areas upper (n=5), middle (=4), lower (n=6) to explore the impact of justice and injustice from different viewpoint. The study examined injustice related concepts like fairness, deservingness and entitlement. The finding from the study is presented in Table 2.

Table:2

The main findings from McParland et al. (2010)

-The justice related issues in chronic pain sufferer influenced by their social and personnel concerns and needs.

-The concepts fairness, deservingness, entitlement of was dominated in participants and reflected in terms of distributive justice prin­ciples equality and need.

-The middle and lower socio economic class samples presented with egotistic construction of justice in terms of equality and need.

-The chronic pain appeared as a social problem as much as a medical problem

This study was conducted, as a semi-structured interview by the interviewer, which could perceive appropriate feelings of the participants that may not be possible in self-report questionnaire. It is worth mentioning that the study carefully examined the mental status of the participants and ensured the appropriateness of samples for interview. The justice beliefs, psychological distress and pain variables are interrelated McParland and Knussen (2010). Choosing the appropriate study sample is essential to achieve accurate and trusted study results. The sample size of this study was small (n=15) would affect the validity of the study. More over the recruited sample were between ages 18-65. McParland and Knussen (2010) reported that people get strong personal and general beliefs when they get older. So inclusion of these age groups (18-65) could affect the rigor of the study and validity of result.

The study was exploring the ideas of injustice in chronic sufferer based on their socio-economic classes. The chronic pain sufferers from different socio-economic classes evaluated injustice based on their on social concerns and needs. The sample response highlighted that chronic pain sufferers are facing social issues which might due to injustice, that could contributing to their chronic nature of pain. So chronic pain should consider as a social problem as much as medical problem. Social issues can cause chronic pain or chronic pain can cause social issues. The heath care professionals can play a role to minimize the injustice from medical filed and they also can play a role to minimize the chronic pain too.

McParland et al. (2010) highlighted that chronic pain sample experienced social issues due to injustice. In Mrs. Alice case she has the right to get appropriate treatment but her autonomy has been removed and felt unfairness. The experience of unfairness and unrelieved pain would make an impact of her family finance and employment. These factors also costs disability care and benefit system. So there is a need to uphold ethic principle, which is the duty of care to protect the patient from harm (Non-maleficence). The appropriate pain management respects the ethic principles, which included autonomy, non-maleficence, fairness and duty of care.

McParland and Knussen (2009) presented a research report after conducted a second phase for the above study, which aimed to explore the justice related concept in chronic pain using Q methodology. The sample included chronic pain sufferers (n=33), spouses (n=9), health professional lecturers (n=15) and members of public (n=22). The participants are provided a grid with 47 comments ranging from +5 to -5. See appendix 5 for grid. In Q factor analysis eigen values >1 represented participants with similar concepts about injustice related to chronic pain. This study analyse six factors with eigen value >1. See table 3 for analysed factors. Participants expressed concepts of injustice in related to chronic pain in terms of blame, victimisation and perceive neglect of need after Q factor analysis.

Table:3

McParland and Knussen (2009,p.1-4)

The factors emerged after Q factor analysis

1) Pain is normal. It’s not about injustice

2) Pain is awful. It’s society’s fault

3) Chronic pain is not your fault, but it is your responsibility to address it

4) It’s not fair. There should be a cure for pain

5) If you are unlucky enough to suffer chronic pain, you deserve help

6) There is hope that the injustice of chronic pain will be rectified

.

There are some good points about this study. The statistical analysis was presented in a clear and meaningful way. The study used Q methodology, which assess the subjective viewpoints effectively like life experience, stress, satisfaction etc. , Noori (2008). So the Q methodology was an appropriate method to find the participants view about injustice that increases internal validity and maximise the result strength for the study. One of the weak points in this study was that the chance of selection bias as the study sample was recruited from primary, secondary care, support group and public from United Kingdom. The method of sample selection might extract data based on nations culture and beliefs. The beliefs could be influence by cultural and educational factors, also differ in different ethnic populations Sloan et al. (2008). Thus recruiting sample from specific population could limit extrapolating the results into general population. But will promote applicability of this study to UK population. The chronic pain sufferer from the study sample expressed concepts regarding injustice as blame victimisation and perceived neglect of need. McParland and Knussen (2009) reported that the sufferers perceived injustice when they perceived something wrong, might be about pain or related to pain management or lack of acceptance from society or influence pain in everyday life. Miler (2001) also reported that people perceives injustice when they go through sufferings that would originate from an undeserved manner. The reflection of this statement could find from Mrs. Alice’s case when she perceived unfairness in her treatment.

The life with chronic pain may lead to significant loss to finance, employment and independence (Harris & Barton 2003). These losses can be permanent or temporary, Evans et al. (2001). It’s a human tendency that putting blame on others when they feel a discrepancy in their life. The chronic pain sufferer who blames others for their situation could experience more depression, stress and weak response to treatment, Sullivan et al. (2008). Sullivan et al. (2008) also reported that when chronic pain patients perceive injustice they may focus on injustice happened rather than their treatment or rehabilitation processes.

According to hierarchy of evidence used in this assignment, this research report achieved level 2c. This research is still continuing, awaiting more interpretation and analysis related to concepts of injustice among chronic pain sufferers. In future more evidence-based studies should be considered to revel the complex nature of injustice in chronic pain sufferers.

Zempsky (2009) presented an article, which was reinforcing the importance of fostering trust and justice in the treatment of chronic pain conditions. The article discussed a case of a 19-year-old man with sickle cell disease presented with progressive leg and back pain. The patient appeared in emergency department with pan score 9-10 but appeared in a relax manner. He was using headphone and singing songs. The perceived disbelief by clinical staff sent him into waiting room and received requested dose of morphine with doubt and disdain after several hours. In this case the clinical staff stigmatised the patient as a drug seeker or drug abuser and neglected the intensity of pain. The patient who is in pain expects justice and fairness with their treatment, where they could express their problem. They anticipate that the health care staff will listen, understand, treat with empathy and approach them in a non-judgemental way, Serpell(2011). When patients feel injustice, the situation can link with psychological and physical abnormalities. In case of chronic pain perceived injustice can leads to stress severe pain and disability, Zempsky (2009). This article emphasized that pain is an individual experience, which a person sometimes not able to express as well as they felt. There are chances for underestimating pain by health professionals’ even tough patients express the pain as they felt. Patients in chronic pain sometimes don’t present with signs autonomic response (changes in blood pressure, pulse, sweating etc.) or behavioural features (moaning, wincing), Serpell (2011). The healthcare professionals should understand that severe pain with absence of physiological and behavioural changes is common in chronic pain conditions, Zempsky (2009).

When we consider the case of Mrs Alice the physician might not recognise the pain appropriately. According to Notcutt (2011) there is lack of formal and continuous education regarding the pain and its management among health professionals. The American academy of code of ethics for pain management mentioned that the practitioners are responsible for maintain their professional competence and they are obligated to reveal their education, training, experience and continuous education to public. The pain management field is fast growing and moving towards more effective treatment modalities. So it emphasis the importance of continuous education for all who works in this field. The practitioners who abstain from continuous education may cause harm to the patient ( maleficence), which is against the ethic principles. Mrs Alice might be poorly managed or abandoned due to lack of knowledge of chronic pain management among health professionals. The principles of ethics emphasize that the patients in chronic pain are entitled to get fairness in their treatment, which is beneficial for the patient by minimising harm (non-maleficence).

The pain management practitioner or all working in for pain management should keep good understanding of ethical framework regarding pain management. Notcutt (2011), presented structured criteria to face with clinical ethics situation. See appendix 7 for criteria. It is not always easy to deal with situation because of many reasons. The proper understanding of basic principles will tackle the situation appropriately. Lauris et al (2005) presented an approach for ethical reasoning and a comparison of clinical and ethical reasoning. See appendix 8 & 9. According to hierarchy of evidence reviewed in this assignment this article achieved level 5. So there is a need for clinical experimental studies to reinforce these findings.

Sullivan et al. (2009) conducted a study to evaluate the role of pain and perceived injustice in posttraumatic stress. The samples were 112 individuals who attended rehabilitation clinics after whiplash injuries. In logistic examination the perceived injustice appeared as a unique predictor for persistence of posttraumatic symptoms. The study emphasise the importance of effective interventions which is intending to manage perception of injustice in case of posttraumatic stress after whiplash injuries. See the results in table 4.

Table:4

Sullivan et al. (2009,p.329)

There are some weak points for this study. The sample recruited from rehabilitation clinics where they provide multidisciplinary rehabilitation programme for patients after whiplash injuries. It could be argued that these patients might already influence by the rehabilitation programme. So the sample might not represent a generalisation of the study that result into a general population. The sampling also biased the inclusion of more female participants (76 women, 36 men), according to Sullivan et al. (2008) the men perceive more injustice than women. This would affect the internal validity of the result. The participants were asked to complete questionnaires to assess physical, cognitive and affective variables related to their posttraumatic stress. This would have been done better if the data collected based on structured interview as self-report questionnaires could naturally biased by people’s feelings at the time they complete it. Hence the method of data collection might bias the result and affect the result validity. The identification of problems related to perception of injustice helps to identify the reason for suffering among chronic pain sufferers. Mrs. Alice perceived injustice might be due to poor interaction from practitioners or due to the attitude of negativity from practitioners. The interaction between practitioners and patients is imperative in management of chronic pain. All health care professionals should understand as part of patient treatment we have a duty of care to work towards their beneficence. The other issue might happen because of the attitude of negativity towards the patient from health care professionals. The negativity could develop due to patient’s appearance (eg. Obesity) or due to behaviour. The health care provider should understand listen and provide them justice in their treatment and uphold the principle of duty of care. Based on hierarchy of evidence used in this assignment, the strength of evidence achieved for this study is level 2b. Further studies should be considered based on weak points of the present study.

Conclusion

The people who believes in just world uphold the concept that “they live in a world where people generally get what they deserve.” Lerner and Millier (1978,p1030). The people who have justice beliefs could be able to pursuits long-term goals and maintain physical and psychological well being, (Kathleen and Claudia 2005; Laurin et al. 2011; Dalbert 2002). McParland and Knussen (2010) conducted a cross sectional study and reported that justice beliefs have influence in experience of chronic pain and pain behaviours. The study proved that strong justice beliefs are beneficial for psychological well being and helped to cope with pain intensity and disability. The also reported that older people uphold stronger justice beliefs and experience less pain. Human beings perceive injustice normally when they expose to a situation primarily characterised by violation from human rights or to challenge just world beliefs, Fetchenhauer and Huang (2004). According to just world theory the people who has strong belief in just world motivated to defend their belief when they encounter any evidence of injustice, McParland (2011). The chronic pain sufferers who perceive injustice or unfairness can influence the physical and mental health (Jackson et al.2006; Sullivan et al.2008; Sullivan et al.2009; zempsky2009). Mc Parland et al. (2010) reported that justice related issues in chronic pain sufferers influenced by their own social and personal concerns and needs. McParland and Knussen (2009) reported that the participants expressed concepts regarding injustice related to chronic pain in terms of blame, victimisation and perceived neglect of need.

The case of Mrs. Alice highlighted that she perceived unfairness in her treatment. The reason for perceived unfairness could be the attitude of health professionals’. It is essential to analyse the route cause of this attitude in order to implement efficient pain management among chronic pain sufferers. Some of the problems could be poor interaction between practitioners and patients or could be a attitude of negativity towards the patient from health care professionals or lack of individualised care plan for pain management or lack of knowledge to manage the pain, Notcutt (2011). According to Notcutt (2011) there is lack of formal and continuous education regarding pain and its management among health professionals. The appropriate pain management respects the ethic principles which includes autonomy, non-maleficence , fairness and duty of care. The reviewed studies proved that justice beliefs and perceived injustice are relevant among chronic pain sufferers. So it would be necessary to conduct more experimental studies to find more about role of perceived injustice and justice beliefs among chronic pain sufferers. The proper understanding of these subjects would be more helpful for efficient management plan for chronic pain sufferers.

6 References

Dalbert,C. 2002 Beliefs in a Just World as a Buffer Against Anger. Social Justice Research, 15(2), pp.123-145.

Dawson A 2004 Asthma in the Australian indigenous population: a review of the evidence. The international electronic journal of rural and remote health research. [cited 18th November 2009] Available from internet:

Evans, T. H., Mayer, T. G. and Gatchel, R. J. 2001 Recurrent disabling work-related spinal disorders after prior injury claims in a chronic low back pain population. Spine, 1(3), pp.183-189.

Fetchenhauer, D. and Xu, H. 2004 Justice sensitivity and distributive decisions in experimental games. Personality and Individual Differences, 36(5), pp.1015-1029.

Hafer, C. L. and Bègue, L. 2005 Experimental research on just-world theory: problems, developments, and future challenges. Psychological Bulletin, 131(1), pp.128-167.

Harris, S., Morley, S. and Barton, S. B. 2003 Role loss and emotional adjustment in chronic pain. Pain, 105(1), pp.363-370.

Jackson, B., Laura, D., Kubzansky. Rosalind, J. and Wright. 2006 Linking Perceived Unfairness to Physical Health: The Perceived Unfairness Model  Review of General Psychology, 10(1), pp.21-40.

Johnson, S. H. 2007 Legal and ethical perspectives on pain management. Anesthesia and analgesia, 105(1), pp.5-7.

Kathleen, O. and Claudia, D. 2005 Belief in a just world and its functions for young prisoners. Journal of Research in Personality, 39(6), pp.559-573.

Laurin, K., Fitzsimons, G. M. and Kay.A.C 2011 Social disadvantage and the self-regulatory function of justice beliefs. Journal of personality and social psychology, 100(1), pp.149-171.

Lauris, C. K., Robert, F. W. and Thomas, P. 2005 A Clinician’s Approach to Clinical Ethical Reasoning. Journal of General Internal Medicine, 20(3), pp.306-311.

Lerner,M.J. and Miller,D.T. 1978 Just world research and the attribution process: Looking back and ahead. Psychological Bulletin, 85(5), pp.1030-1051.

Mcparland, J. (2011) What is fair about pain? A quantitative and qualitative examination of justice beliefs [ppt] Glasgow Caledonion University

Mcparland, J. L. and Eccleston, C. 2009 Exploring justice issues in chronic pain: sufferer and partner perspectives. Glasgow Caledonian University.

Mcparland, J. L., Eccleston, C., Osborn, M. and Hezseltine, L. 2010 It’s not fair: An Interpretative Phenomenological Analysis of discourses of justice and fairness in chronic pain. Pain, 107(3), pp.220-226.

Mcparland, J. L. and Knussen, C. 2010 Just world beliefs moderate the relationship of pain intensity and disability with psychological distress in chronic pain support group members. European Journal of Pain, 14(1), pp.71-76.

Miller, D. T. 2001 Disrespect and the experience of injustice. Annual Review of Psychology, 52(1), pp.527-553.

Noori, A. D. 2008 Methodology in Nursing Research-A Promising Method for the Study of Subjectivity. Western Journal of research, 30(6), pp.759-773.

Notcutt,W. (2011) Everyday Ethical issues in Pain [ppt], Cardiff University.

Serpell, M. (2011) Justice and Chronic Pain [ppt], Cardiff University.

Sloan, T. J., Gupta, R., Zhang, W. and Walsh, D. A. 2008 Beliefs about the causes and consequences of pain in patients with chronic inflammatory or noninflammatory low back pain and in pain-free individuals. Spine, 33(9), pp.966-972.

Sullivan, H. A., Michael, J. L., Sharon, H., Denise, M., Dan, B. and Richard, G. 2008 The Role of Perceived Injustice in the Experience of Chronic Pain and Disability: Scale Development and Validation. Journal of Occupational Rehabilitation, 18(3), pp.249-261.

Sullivan, M. J., Thibault, P., Simmonds, M. J., Milioto, M., Cantin, A. P. and Velly, A. M. 2009 Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain, 145(3), pp.325-331.

Sutton, R. M., Douglas, K. M., Wilkin, K., Elder, T. J., Cole, J. M. and Stathi, S. 2008 Justice for whom, exactly? Beliefs in justice for the self and various others. Personality and social psychology bulletin, 34(4), pp.528-541.

Taylor, A. 2009 Critiquing quantitative research, Cardiff University [cited on 18th November 2009] Available from internet: www.cue.cf.ac.uk

Zempsky, W. T. 2009 Treatment of sickle cell pain: fostering trust and justice. The Journal of American Medical Association, 302(22), pp.2479-2480.

7. Appendices

Appendix 1:Hierarchy of evidence

Hierarchy of evidence

Level of Evidence

Description

1a

Systematic review of randomised, controlled clinical trials (RCT)

1b

Individual randomised controlled clinical trial

1c

All or none

2a

Systematic review of cohort studies

2b

Individual cohort study (including low-quality RCT)

2c

Outcomes research

3a

Systematic review of case-control studies

3b

Individual case-control study

4

Case series, poor quality cohort and case-control studies and reviews

5

Expert opinion without explicit critical appraisal

Appendix 2: Framework for critiquing quantitative research (after Rees 1997)

Focus

In broad terms what is the theme of the article? What are the key words you would file this under? Are the key words in the title a clue to the focus? How important is this focus for clinical practice?

Background

What argument or evidence does the researcher provide that suggests this topic is worth exploring? Is there a critical review of previous research on the subject? Are the gaps in the literature or inadequacies with previous methods highlighted? Are local problems or changes that justify the study presented? Is there a trigger that answers the question ‘why did they do it then?’

Terms of reference

Does the researcher state terms of reference? This will usually start with the word ‘to’ e.g. the aim of this research was to examine/determine/compare/establish/etc. In the case of clinical research there may only be a statement of the hypothesis or hypotheses that the researcher(s) wished to test. Is it possible to identify dependent and independent variables Remember level 1 questions will not have both, neither will a correlation study. Are there concept and operational definitions?

Study design

What is the broad research approach? Is it experimental? Descriptive? Action research or audit? Is it quantitative or qualitative? Is the study design appropriate to the terms of reference/hypothesis/research question?

Data collection methods

What tool of data collection has been used? Has a single method been used, or triangulation? Has the author addressed the issues of reliability and validity? Has a pilot study been conducted? Have strengths and limitations been recognised by the author?

Ethical considerations

Were the issues of informed consent and confidentiality addressed? Was any harm or discomfort to individuals balanced against benefits? Did a local ethics committee consider the study?