Welcome to the second installment of the quarterly “Ethics Forum,” a collaborative effort of the ACR Ethics and Conflict of Interest Committee and The Rheumatologist to foster dialog among rheumatologists and rheumatology health professionals concerning real-life ethical issues that they may encounter in medical practice or research.
Before we get to this month’s case, we would like to thank those who wrote us letters with comments and suggestions regarding the July “Ethics Forum” case. Keep those letters coming!
If you have an ethics question that you’ve encountered in practice, or if you have comments about an “Ethics Forum” case, write us at [email protected]. We may publish your letter or question in a future “Ethics Forum.” We look forward to hearing about your experiences with professional ethics.
The Case
A 45-year-old man was referred to me for treatment of low back pain of multifactorial etiology. At the beginning of our conversation, the patient asked if I would refer him for an epidural steroid injection. Based upon my knowledge and practice experience, I think a more conservative course of therapy is indicated. How should I proceed?
Ethical Problem: How can the physician best fulfill his or her professional obligations to his or her patient?
Discussion: As rheumatologists, we strive to practice evidence-based medicine. Unfortunately, there is a lack of evidence-based guidance for diagnosis and treatment of back pain. Even the etiology of the pain is an interplay of physical and psychosocial phenomena. The pain can be influenced by smoking, anxiety, financial issues, job satisfaction, and even satisfaction with medical treatment.1 There are many causes of chronic lumbosacral pain and identification of anatomic cause cannot be made with certainty in up to 90% of the cases.2
If you have an ethics question that you’ve encountered in practice, or if you have questions or comments about an “Ethics Forum” case, write us at [email protected].
The clinical trials documenting what works for treatment of back pain are confusing at best. While the astute physician recognizes the multifactorial etiology of this common clinical entity, studies that compare physical therapy, weight loss, and epidural injections, either as specific therapeutic interventions or, more importantly, in multimodal combinations, are few and far between. Part of the problem with such multidisciplinary approaches is that every discipline has both a restricted experience and familiarity with certain approaches and, it must be acknowledged, self- interest in their particular therapies. It is important that we recognize these considerations because, as rheumatologists, we have an important role in the education of our patients and great influence on the therapeutic choices that will be made. In this context, fully informed consent is imperative. An informed patient understands the many treatment alternatives, as well as their potential risks and benefits. Examples of potential treatments include exercise, physical therapy, weight loss, transcutaneous electrical neural stimulation, acupuncture, and yoga, all of which should be presented. The discussion should also include questions about stress in the workplace as well as at home. Cost—to the patient and to society—is also a factor because the more invasive approaches to back pain therapy are expensive. Does the evidence supporting the use such treatments as epidural and facet joint injections justify their widespread use? Do they have a role in the care of your patient? Does the patient understand the risks? In this example, the patient should be informed that there is a small risk of paraplegia, quadraplegia, and death associated with the epidural injection.3
Ethical reasoning also considers existing professional guidelines. Although the ACR does not currently have guidelines for the treatment of low back pain, the American Academy of Neurology (AAN) does. The AAN notes that epidural steroid injections may provide temporary relief in back pain associated with radiculopathy. It would be reasonable to share this information with the patient.
Finally, the patient’s wishes must be considered. A fully informed patient can participate in a shared decision-making process to select the best option for him or her. Of course, such discussions take more time, yet they remain a central responsibility to the provision of optimal medical care for our patients.
Recommendation: Good medical practice must strive to educate patients concerning treatment options and the complexity of the pain itself.
Send us Your Case!
If you have comments or questions about this case, or you have a case study that you want to see in “Ethics Forum,” e-mail us at: [email protected].
Dr. MacKenzie is associate professor of clinical medicine and public health at Weill Cornell Medical College, Hospital for Special Surgery in New York. Dr. Kitsis is director of Bioethics Education and a member of the rheumatology division at Albert Einstein College Medicine in the Bronx, N.Y. Dr. Meltzer is assistant professor of medicine at Thomas Jefferson University in Philadelphia.
References
- Chibnall JT, Tait RC, Andresen EM, Hadler NM. Clinical and social predictors of application for social security disability insurance by workers’ compensation claimants with low back pain. J Occup Environ Med. 2006;48:733-740.
- Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332:1430-1434.
- Nahm FS, Lee CJ, Lee SH, et al. Risk of intravascular injection in transforaminal epidural injections. Anaesthesia. 2010 Jul 13. [Epub ahead of print]
