Prescribing for pain:
Ethical considerations that should guide
clinical practice
Associate Professor Mark Boughey, St Vincent’s Melbourne
Approaching a patient & their
problem: what guides your
practice?
Today’s aim
• Demonstrate how you can frame practice and decision making within a
clinical ethical basis
• Think about the elements that come into play – make you conscious of
what you may already be doing
• Use pain prescribing as an exemplar
Why pain:
• Complex medical problem
• Complex interplay between peripheral & central NS
• Complex interplay between nociceptive, neuropathic and
psychological/existential
• Dealing with a variety of distinct pain entities-acute, chronic,
progressive/palliative
• Treatment modalities are multiple and come with risk/benefits that vary
depending on what you are treating
Approaching a patient & their
problem: what guides your
practice?
Theory
Practice
?
Knowledge
Action
reflection
Tools &
algorithms
Gut
feeling
Approaching a patient & their
problem: what guides your
practice?
Theory
Practice
?
Ethical
guidance
Knowledge
Action
reflection
Tools &
algorithms
Gut
feeling
My general approach to ethical considerations……
What does the patient want?
What is going to help?
What might hinder or harm?
Who gets what?
Patient views
History
Expectations
Issues
Autonomy
Beneficence
Non Maleficence
Justice
Evidence
Guidance docs
Consensus of
opinion
Experience
Knowledge
Legal/illegal
Scope of
practice
System
supports
Availability
My approach to ethical considerations when prescribing for pain ……
What does the patient want?
What is going to help?
What might hinder or harm?
Who gets what?
Autonomy
Beneficence
Non Maleficence
Justice
My approach to ethical considerations when prescribing for pain ……
What does the patient want?
What is going to help?
What might hinder or harm?
Who gets what?
Autonomy
Beneficence
Non Maleficence
Justice
Patient views
History
Expectations
Issues
My approach to ethical considerations when prescribing for pain ……
What does the patient want?
What is going to help?
What might hinder or harm?
Who gets what?
Autonomy
Beneficence
Non Maleficence
Justice
Evidence
Guidance docs
Consensus of
opinion
Experience
Knowledge
My approach to ethical considerations when prescribing for pain ……
What does the patient want?
What is going to help?
What might hinder or harm?
Who gets what?
Autonomy
Beneficence
Non Maleficence
Justice
Legal/illegal
Scope of
practice
System
supports
Availability
What does it all mean?
Practice
Theory
Knowledge
Tools &
algorithms
Patient wants /needs
What helps
What harms
Who gets what
Gut
feeling
Opioids
Non opioids
Physical
Psycho/spiritual
Creativity
New ways to solve new problems
Flexibility
How to cope when things go wrong
Context
Knowing when to do what
Competence
Basic skills
Prescribing for pain:
Ethical considerations that should guide
clinical practice
Associate Professor Mark Boughey, St Vincent’s Melbourne