The Project on Pain Management In Cancer and Non-Cancer Patients
Siobhan Reynolds

Leaving aside the issues of inhumanity and cruelty, the only difference I can see between patients whose pain will continue and those whose deaths will terminate it in the foreseeable future is that the physician who refuses to treat cancer pain is not necessarily killing the patient. Since the patient is going to die soon, this inevitability was set into motion before the doctor entered the picture. Perhaps another doctor failed to treat the cancer in a timely fashion or it just wasn't caught in time, but that is another matter.

In the failure to treat chronic pain, however, the doctor is doing something akin to finding a small malignancy and then refusing to excise it or apply whatever other treatments known to be useful when one encounters such a dangerous but still confrontable situation. What was a pathology which could be dealt with so that the patient could lead a healthy and productive life in the future now becomes the source of the patient's ruination and ultimate death. This, as the direct and utterly preventable consequence of the doctor's failure to fulfill his or her most fundamental obligation.

So leaving inhumanity and cruelty aside, I'd say the doctor is committing a greater failure, ethically speaking, by refusing to treat non-cancer pain than by refusing to treat cancer pain. But now bringing in the question of cruelty and inhumanity, its hard to say. Both are unspeakable and yet utterly ubiquitous.

The medical community has made a science out of the classification and categorization of the thrashes and moans which accompany intense agony, but only in the case of chronic pain. I don't see much talk about pain behavior, pill popping behavior, drug-seeking behavior, doctor shopping behavior, pain as depression, etc., when the list is talking about cancer patients although if they posed as great a threat to your practices as do chronic pain patients, we'd undoubtedly see a whole new set of such terms developed, even more finely but still perversely wrought! And this is where the distinction reveals itself to be truly a practical one.

Chronic pain patients create for the doctor, the risk of an ongoing and unacceptably high level of law enforcement scrutiny which poses a significant threat to the doctor's well-being. A dying patient, mercifully, will be dead soon and so brings less risk with him when he comes to the doctor. Also, you know you will be able to say, when questioned about giving "high doses" of opioids, "But I had to, they were dying, for God's sake!" Whereas if the patient in question lives comfortably and prosperously because of your ministrations, what are you going to say, "But they were living, for God's sake!"

The recent history of prosecuted doctors shows that the latter cry is not as dramatically persuasive as the former, though, things have gotten so bad recently, even the former has lost some of its punch. Maybe it's time to quit making damaging and unhelpful distinctions between the suffering patients and to instead address the source of the inappropriate law enforcement pressure.

Siobhan Reynolds
On Beyond Films, Inc.