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J Pain Manage 2014;(7)1:9-12 ISSN: 1939-5914

© 2014 Nova Science Publishers, Inc.

The ethical mind of “Dr. Feelgood:” Hero or villain?

Kimberly I McClelland, MPH Abstract

Department of Philosophy and Ethics,
Howard University College of Medicine, Deontological ethical theory (from the Greek deon,
Washington DC, United States of America meaning "obligation, duty"; and logos, meaning “discourse,
study of”) is the moral theory proposed and developed by
18th century German philosopher Immanuel Kant and
states that permissible actions are based on duty, not on any
consequences of those actions. When the physician dons the
mantle of “Dr. Feelgood”, however, there are consequences
to his/her actions, both for the patient and potentially for the
physician. The “hero” and “master” aspects of the
physician’s role are easily supported on moral grounds by
Kant’s theory regarding duty for duty’s sake—in this case,
a patient’s health. However, the “villain” and “puppet”
roles a physician may find him or herself undertaking go
unaddressed by Kant, as these both stem from
consequences of their previously “heroic” act of alleviating
a patient’s suffering. The moral theories of Kant can be
beneficially augmented with time-honored medical tenets
and bioethical principles, particularly with respect to a
physician’s duties regarding patient autonomy, professional
obligation and the difficult task of balancing the two in a
way that ultimately prioritizes the patient’s health—both
physical and psychological. This narrative will explore the
role of the physician in the context of pain management and
use Kantian ethics to determine what constitutes morally
permissible actions. Is the physician or anesthesiologist an
angel of mercy in relief of pain or a just a purveyor of
medications, i.e., a drug dealer?

Keywords: Deontology, Kantian ethics, bioethics, pain

management, opioids, prescription drug abuse, physician

The German philosopher, Immanuel Kant (1724-
1804), became well known for his theories stating that
permissible actions are based on duty, not on the
consequences of those actions. These “deontological”
ethics (from the Greek deon, meaning "obligation,
Correspondence: Kimberly I McClelland, MPH, Howard duty"; and –logos, meaning “discourse, study of”)
University College of Medicine, 4806 Rhode Island were obligatory actions and adhered to a “rational and
Avenue, 2nd Floor, Hyattsville, MD, United States.
E-mail: kim2101@caa.columbia.edu
universally applicable moral rule” (1). Kant believed
10 Kimberly I McClelland

that one’s duty was determined by established and was considered a “good thing” (2) for the sheer fact
societally accepted rules. In the field of medicine, the that its presence meant that a patient was alive and
Hippocratic Oath taken by physicians holds that: able to communicate. Pain is also considered a
punishment or a “penalty,” as its Latin etymology
…I will follow that system of regimen which, according to suggests. As stated by the American Medical
my ability and judgment, I consider for the benefit of my Association, “…the annals of every civilized people
patients, and abstain from whatever is deleterious and contain abundant evidences of the devotedness of
medical men to the relief of their fellow creatures
from pain and disease, regardless of the privation and
These tenets or “rules” clearly state the danger” (3). Thus, if given a choice, the majority of
physician’s duties and responsibilities and, therefore, individuals would elect not to experience pain.
comport with Kant’s theory that performing deeds Admittedly, Kant’s theory is inherently driven by
directly correlating with one’s duty is the morally a duty’s requirements and is non-consequential in
acceptable course of action. nature. The physician is faced with a difficult scenario
In addition to the Hippocratic Oath, there are four with respect to effective pain management if the
moral principles of bioethics requiring consideration patient becomes an opiate abuser as a result of the
before performing a morally questionable act: physician’s initial pain medication administration.
Kantian ethics still views the physician’s act as
patient autonomy morally responsible since it coincided with duties
beneficence, which involves not only delineated in the Hippocratic Oath, the Code of
performing morally upright acts, but also Medical Ethics and the moral principles of bioethics.
preventing harmful ones (“primum non Therefore, since one cannot predict whether or not a
nocere” meaning “above all, do no harm”) patient will become an opiate abuser after first use,
utility, which involves the intent of the act of alleviating suffering takes precedence over
performing acts that are more beneficial than speculation as to the potential aftermath.
harmful for all involved parties
justice, which pertains to a patient receiving
what he or she is owed, based on the concept
The role of pharmaceuticals
of fairness.
and physicians in pain management
However, a complex situation arises when a
Despite the fact that prescription opioid analgesics
patient’s perceived right to effective treatment lies in
have been used for several decades, combined
direct conflict with the physician’s duty to uphold the
influences from patient advocacy campaigns as well
aforementioned principles. In particular, the question
as pharmaceutical syndicates in the 1980’s
of pain management has generated much discussion
contributed heavily to the widespread use of opioids
over morally appropriate action regarding
for chronic pain treatment. With demand and supply
administering treatment for a patient’s perceived pain
reaching unprecedented levels, large amounts of
and withholding medication from a suspected pain
opioid medications became inappropriately used for
medication abuser.
self-medication and recreational abuse (4).
Whereas the majority of competent patients
experiencing a mild to moderate degree of pain can
The definition of pain make rational decisions regarding their care, those in
a great deal of pain (or withdrawal) are likely to place
Given the aforementioned ethical conundrum, how their need for relief as their highest immediate
does one define pain? The International Association priority. Kant’s own moral philosophy was influenced
for the Study of Pain defines pain as: “an unpleasant by the idea that people are “overly influenced by their
sensory and emotional experience associated with inclinations and desires and are only imperfectly
actual or potential tissue damage.” Historically, pain rational” (5). This perspective holds an especially
The ethical mind of “Dr Feelgood:” Hero or villain? 11

significant meaning when one takes into account the deserve.” In the final analysis, the physician’s
effect of pain relief and addiction on rational integrity has also been compromised.
behavior. In Kant’s view, it would be morally
Using the Kantian theory of universality and impermissible for all physicians to prescribe pain
moral obligation, physicians prescribing opioids to medication to every patient requesting pain relief,
patients have diametrically opposed concerns. since it is unethical for a knowledgeable physician to
Simplistically, if the patient is a suspected abuser, the disregard his/her own judgment and evolve into an
patient would receive their “fix” and for those patients agent of the patient’s will. The perceived
in pain, they would receive their relief. The question omnipotence of physicians must manage a vast
then becomes: how does a physician differentiate number of possible outcomes. In terms of pain relief,
between a patient truly in pain and an abuser feigning immediate gratification for a patient can develop into
pain symptoms? If the patient’s history is insufficient a sustained habit—causing dependence, abuse,
or questionable, the physical exam and subsequent addiction and even death.
laboratory studies are crucial since the human body
cannot create pathology on demand. Conversely,
while the majority of pain-provoking illnesses have a Conclusion
specific presentation, some illnesses can be difficult
to diagnose, leaving the patient’s word as the only In summary, Kant’s position on the morality of
guide a physician has until further testing can be physicians is clearly stated in the Hippocratic Oath,
performed. the Code of Medical Ethics and the moral principles
Although Kantian ethics does not take into of bioethics. However, in medicine, an appropriate act
account the complicated and often unpredictable is not solely judged by the duty of the physician at
consequences of opioid prescription with respect to one particular time, but on the ability of the physician
physician duty, physicians in a practical society must to accurately predict and minimize deleterious
be able to negotiate the refusal of a patient’s request outcomes as a result of their actions. Using Kant’s
without fear of some form of retaliation (i.e., verbal, deontological principles, the physician’s duty when
physical, occupational, financial and/or legal) from taking into account both patient autonomy and
the patient. professional obligation incorporates the difficult task
of balancing the two in a way that ultimately
prioritizes the patient’s health—both physical and
The costs of prescription drug abuse psychological.

The consequences of opioid and sedative abuse have

been given more attention in recent years, particularly Acknowledgments
after the untimely deaths of actor Heath Ledger and
pop music icon Michael Jackson—both victims of The author would like to thank Assya Pascalev, PhD
pain medication abuse and physician impropriety. for her invaluable insights regarding the content of
Accordingly, when the physician dons the mantle of this paper, as well as the Medical Academy of
“Dr. Feelgood”, there are consequences to his/her Washington, DC for honoring the author’s work on
actions, both for the patient and potentially for the pain management at the 2013 Bioethics Essay Award
physician. Ceremony.
It is purported by some investigators (2), that it
was economically more feasible “to diagnose pain and
prescribe an opioid than to diagnose and treat
addiction… Health care providers have become de
facto hostages of these patients, yet the ultimate [1] Vaughn L. Bioethics: Principles, issues and cases. New
victims are the patients themselves, who are not York, NY: Oxford University Press, 2009.
getting the treatment for addiction they need and
12 Kimberly I McClelland

[2] Lembke A. Why doctors prescribe opioids to known [5] Ives J. Kant, curves and medical learning practice: a
abusers. N Engl J Med 2012;367(17):1580-1. reply to Le Morvan and Stock. J Med Ethics
[3] The American Medical Association. Original code of 2007;33(2):119-22. Erratum in: J Med Ethics
medical ethics. Chicago, IL: American Medical 2007;33(7):385.
Association Press, 1847.
[4] Nelson LS, Perrone J. Curbing the opioid epidemic in
the United States: the risk evaluation and mitigation Submitted: September 10, 2013. Revised: October 10,
strategy (REMS). JAMA 2012; 308(5):457-8. 2013. Accepted: October 19, 2013.