The pain-procedure-insurance triad: bonds to help may hurt.

Abstract

In Ethics Forum , we will present clinical cases selected on the basis of diagnostic dilemmas and/or difficult therapeutic decisions that occur in the practice of pain medicine. We will ask several pain specialists to help identify the ethical issues raised in these cases and to give their opinions based on their perceptions and experience. Please send or e-mail (ch53@drexel.edu) your comments or remarks to Colleen Healy, Editorial Assistant, Pain Medicine , Pain Center, Graduate Hospital, 1800 Lombard Street, Philadelphia, PA 19146. Also, if you believe you have witnessed a case that presents an interesting ethical dilemma for examination, send it for possible inclusion in the Forum. The patient is a 69-year-old widowed white female with a 10-year history of chronic low back and leg pain. She has had two back surgeries in the past for presumed spinal stenosis. These did not produce significant pain relief. They were followed by multiple interventions to address her pain, including selective nerve root blocks, lumbar epidural steroid injections, facet injections, and rhizotomies. The patient did not experience any lasting pain relief from any of these procedures. The patient's overall functional status has deteriorated steadily since the beginning of treatment. Before her first surgery she played tennis regularly. Now she is essentially bedridden. Insurance coverage of her care is becoming more difficult, leaving more and more out-of-pocket expenses, which the patient can barely meet. The patient has been reading information on the Internet and now requests implantation of an intrathecal pump for opioids. The insurance company is balking at this expense, given her lack of response to other therapies. The patient wonders how they can deny her this last chance at relief. ### Comment no. 1: Mark Sullivan, MD, PhD This case raises a number of ethical issues. One concerns the insurance company's perspective on the case. Another concerns the nature and …