Managing chronic pain requires a balance between professional integrity, respecting patient autonomy, providing equitable access to care, and considering ethical concerns related to deception. Chronic pain is a complex condition and often involves patients with impaired decision-making capacity (Zhang, et al., 2021), which further complicates treatment decisions. Clinicians frequently face moral concerns and systemic barriers that impede comprehensive care in managing chronic pain for various reasons.
4.1 Professionalism
One of the significant ethical challenges in chronic pain management is finding a balance between professional integrity and patient needs. Clinicians often face challenges with opioid prescriptions, weighing the need to relieve pain against the risk of long-term harm (Ekelin & Hansson, 2018). A Swedish study highlighted this conflict that general practitioners encounter when deciding whether to renew opioid prescriptions. The conflict over the benefits of opioids is worsened by the pharmaceutical industry’s influence on advocacy groups, raising concerns about conflicts of interest (McGee, Kaylor, Emmott, & Christopher, 2011).
Competency gaps in pain management contribute to the following ethical dilemmas in professionalism, as inadequate training leads to misconceptions about pain sensitivity and opioid use. Studies from Japan and Latin American countries have shown that healthcare professionals often lack adequate training in pain management, leading to misconceptions about pain sensitivity, opioid use, and alternative treatments (Moreira de Barros, et al., 2019; Shindo, Aoyanagi, Iwasaki, & Yamakage, 2019). The lack of competency in chronic pain management has led to 'opioignorance', which may have contributed to clinicians experiencing "opiophobia.". This has resulted in the under prescription of opioids and an increased reliance on self-medication by patients (Moreira de Barros, et al., 2019) and poor patient outcomes (Fontana, 2008). Similarly, there are reports of physicians refusing to prescribe opioids altogether due to personal biases or fear, leading to patient suffering and suboptimal care (Ferrell, et al., 2001). The competency problem may also be due to the lack of standardized training in the multimodal treatment of chronic pain, such as cognitive-behavioural therapy, physiotherapy, and interventional procedures (Robinson & Rickard, 2013). Addressing these gaps requires a comprehensive, multidisciplinary approach to pain education, ensuring that healthcare professionals provide holistic, ethical, and patient-centred care (McGee, et al., 2011).
Effective communication is essential for professionalism. However, many chronic pain patients report dissatisfaction due to a perceived lack of empathy and indifference from clinicians. For instance, patients with Ehlers-Danlos syndrome reported medical encounters with a lack of understanding and empathy from clinicians (CME, EW, A, & C, 2021). Poor communication, including inconsistent explanations and failure to address patient concerns, leads to frustration, distrust, and anxiety (Holopainen, Piirainen, Heinonen, Karppinen, & O'Sullivan, 2018; Wuytack, Curtis, & Begley, 2015). Language barriers and cultural misunderstandings further complicate patient-clinician relationships (Bedford, et al., 2021; Buchbinder, 2011). Trust is a fundamental principle of medical ethics, and effective communication is vital for enhancing that trust. Therefore, addressing communication deficiencies is crucial for improving chronic pain care (Robinson-Papp & George, 2015). On the other hand, fragmented care, poor communication, and territorial disputes among primary care physicians, specialists, and pain experts have resulted in inadequate, inappropriate treatments such as overreliance on benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDS), or short-acting opioids, ultimately worsening patient outcomes (Ferrell, et al., 2001).
Another issue noted in the professionalism category is the fear of regulatory scrutiny, which leads to defensive medical practice where clinicians prioritize self-protection over patient-centred care. This finding aligns with a study indicating that nurse practitioners experience fear of investigation by regulatory agencies, which consequently affects their prescribing decisions (Novy, Ritter, & McNeill, 2009). This defensive practice undermines the ethical obligation to provide adequate pain relief and reinforces systemic barriers to compassionate care.
4.2 Balancing patient autonomy, risks, and benefits
The principle of respecting patient autonomy stands as a fundamental tenet within the field of medical ethics. However, its application can become ethically intricate, especially in cases involving opioid use disorder (OUD). This complexity arises from the tension between honouring an individual's right to make informed decisions about their own treatment and the potential repercussions of those decisions on their health and well-being (Reinisch, 2007). In the context of OUD, healthcare professionals must navigate the challenges of ensuring that patients are adequately informed while also addressing the pervasive issues related to addiction, risk of harm, and the broader societal implications of opioid misuse. This interplay necessitates a nuanced understanding of both ethical principles and the dynamics of substance use disorders, emphasizing the need for a patient-centred yet cautious approach in clinical practice. Conversely, some patients with OUD may request opioid tapering, placing clinicians in a position to weigh the benefits and risks while providing appropriate medical support (Zhou, et al., 2017). Additionally, autonomy involves trusting patients’ self-reports of pain and ensuring they receive adequate information about their pain management options (Novy, et al., 2009).
One of the most challenging aspects of ethical decision-making is finding a balance between providing pain relief and minimizing harm. While opioids have a role in pain management, long-term use has been known to cause opioid-induced hyperalgesia, a condition in which opioids worsen pain sensitivity (Taylor, McKibben, DeCamp, & Chisolm, 2014). This is evident in a case discussed by Reinisch (2007), where clinicians debate whether treating a patient's pain with opioids would be beneficial or could reinforce the patient’s drug-seeking behaviour (Reinisch, 2007). This concern also extends to primary care physicians who often feel manipulated by patients into prescribing opioids, which leads to professional distress and ethical fatigue (Ekelin & Hansson, 2018). In another study, some clinicians reported dilemmas in managing chronic pain patients who violate opioid contracts, given that often, they remain the only providers willing to treat such patients, leaving them ethically torn between discharging these individuals or continuing care despite repeated breaches (Ferrell, et al., 2001). Beyond opioids, there is a growing demand for medical cannabis, with patients believing in its health benefits, while physicians remainsceptical due to a lack of standardized clinical guidelines and concerns about the long-term safety (Rochford, Edgeworth, Hashim, & Harmon, 2019).
Grounded in the principle of respecting patient autonomy, informed consent and ethical decision-making are crucial elements in managing chronic pain. Transparent communication about risks and benefits is essential, as demonstrated by structured consent forms, for example, in acupuncture, which empowers patients to make well-informed treatment choices (Witt, et al., 2009). Clinicians must also ensure that treatment recommendations remain evidence-based, with prescribing decisions and interventional procedures guided solely by medical necessity rather than external influences that could be detrimental to patients (Ferrell, et al., 2001; Robinson & Rickard, 2013). However, one study found that disclosing side effects can impair decision-making by triggering nocebo effects. Therefore, authorized concealment, where patients pre-consent to limit certain information, has been proposed as a means to balance these risks through shared decision-making (Clemens, et al., 2024).
Harm reduction strategies offer a more balanced approach than restrictive prescribing practices. A study suggested that individualized opioid tapering can significantly reduce opioid dependence while preserving trust (Goodman, Guck, & Teply, 2018). Some clinicians advocate for opioid agonist therapy, such as methadone or buprenorphine maintenance therapy for OUD as a first-line treatment rather than a last resort (Novy, et al., 2009; Zhou, et al., 2017). Broader harm reduction efforts also include safe opioid prescribing guidelines (Robinson-Papp & George, 2015) and access to support during tapering (Bedford, et al., 2022).
4.3 Disparity of access to care
The disparity of access to care is highly unequal, influenced by factors such as socioeconomic status, governance limitations, and stigma. Research shows that non-native speakers and the elderly with limited financial means are often excluded from pain rehabilitation programs (Stenberg, Pietilä Holmner, Stålnacke, & Enthoven, 2016). First-time mothers with persistent pelvic pain also have financial and logistical barriers, such as the cost of private treatment and the need for childcare while seeking treatment (Wuytack, et al., 2015). Economically disadvantaged, young, elderly, and marginalized individuals experience the most significant barriers to care (McGee, et al., 2011). These findings highlight the issue of distributive justice, where vulnerable patients are systematically denied access to effective care.
Governance issues further restrict access to pain management, as institutional constraints on time and resources limit clinicians’ ability to provide comprehensive care (Ekelin & Hansson, 2018). Even when multidisciplinary rehabilitation is available, healthcare systems often prioritize cost-effectiveness over improving quality of life, leaving many patients without the necessary care (Stenberg, et al., 2016). This ethical challenge reflects a tension between economic constraints and the duty to provide patient-centred care.
The relationship between chronic pain, gender, education level, and opioid use has resulted in systemic discrimination within healthcare settings. Women and young patients frequently report that their symptoms are dismissed or misattributed to psychological causes, delaying appropriate diagnosis and treatment (CME, et al., 2021). Lowly educated women with chronic pain are also less likely to be referred to multidisciplinary rehabilitation programs, indicating implicit bias in medical decision-making (Hammarström, et al., 2014). Patients undergoing long-term opioid therapy often face added stigma, with their symptoms frequently dismissed as opioid toxicity without proper medical evaluation (Peppin, 2009). Similarly, individuals with sickle cell disease frequently experience severe stigma and neglect in healthcare settings, often being denied timely pain treatment until they are in extreme crisis, leading to long-term physical, psychosocial, and behavioural complications (Ferrell, et al., 2001). These biases exacerbate disparities and violate the principle of non-maleficence by potentially causing harm through inadequate or inappropriate care.
4.4 Deception in medicine
Deception in the medical field presents a significant ethical dilemma, particularly when medical professionals withhold essential information from patients. This issue invites extensive debate regarding the moral responsibilities of healthcare professionals and the implications for patient autonomy and informed consent. For instance, not informing a patient about the limited effectiveness of alternative treatments or the unlikelihood of discontinuing medications can mislead them and hinder informed decision-making (Novy, et al., 2009). This lack of transparency can lead to false hope and potentially result in distress when treatments fail.
The use of placebos without informed consent is a controversial practice. The American Pain Society opposes the use of placebos, except when studying therapeutic efficacy in consenting participants (Sullivan, et al., 2005). Research considers deceptive placebo instructions as unethical, resulting in negative emotions and reduced trust in clinicians (N. Kisaalita, Staud, Hurley, & Robinson, 2014). When educated about placebo mechanisms, patients demonstrate greater acceptance of placebo-based treatments, even in situations involving some level of deception (N. R. Kisaalita, Hurley, Staud, & Robinson, 2016).
Concealed opioid tapering is a deceptive practice in which patients are not informed that their medication dosage is being gradually reduced. While some argue that this approach minimizes negative expectations (nocebo effects), critics highlight its potential to violate autonomy, erode trust, and increase anxiety (Bedford, et al., 2021). A study indicates that both patients and clinicians are more open to a pre-authorized concealed taper, in which patients agree in advance to a gradual reduction strategy. However, even when this approach is used, patients often feel anxious about losing control, and clinicians have concerns about the ethical implications (Bedford, et al., 2022).
4.5 Recommendations to overcome ethical challenges in chronic pain management
To address these challenges, healthcare institutions should implement multidisciplinary pain education programs that incorporate training for effective communication, multimodal pain management, opioid stewardship, ethical decision-making, and informed consent. Ongoing training should also integrate harm reduction strategies to address individualized opioid tapering plans and access to opioid agonist therapy. Additionally, educational institutions that train future clinicians should incorporate chronic pain into their curriculum, given the complex nature of this disease, which was previously perceived as a symptom, and a lack of understanding that it is a disease once it becomes chronic and affects the quality of life his is supported by its recent inclusion in the International Classification of Diseases, ICD-11 (Barke, et al., 2022).
Beyond education, there is also a need for more research on medical cannabis to bridge the gap between patient demand and physician scepticism. This is important because the currently available evidence is conflicting and lacks high-quality research in terms of the long-term and short-term safety of cannabis and cannabinoids, as well as regulatory, societal, and policy challenges (Haroutounian, et al., 2021). At the same time, regulatory agencies should collaborate with stakeholders when developing guidelines and policies to reduce defensive medical practices and support clinicians in practicing evidence-based pain management effectively.
Addressing disparities in access to care requires systemic reforms. This is easier said than done, as different country has different healthcare policies. For instance, in some countries, healthcare insurance coverage for non-pharmacological pain management should be improved, as it primarily covers acute medical conditions and has little to no coverage for rehabilitation programs. Other countries might need to increase funding for public health services and outreach programs to help bridge gaps for marginalized populations, such as non-native speakers, low-income individuals, and women. Finally, healthcare institutions should establish ethics committees knowledgeable in chronic pain management to assist clinicians in making patient-centred decisions while upholding professional integrity.
Several limitations must be addressed in this scoping review. First, the review was limited to publications in English only, which may have excluded relevant studies published in other languages and could introduce language bias in the findings. Additionally, the search was confined to three databases, which may have resulted in the omission of studies from other databases. Furthermore, there was a significant geographical bias, affecting the generalizability of the findings to low- and middle-income countries where the ethical challenges in managing chronic pain may differ substantially.
In conclusion, this scoping review emphasizes the pressing ethical challenges inherent in managing chronic pain, a condition that, despite being known for centuries as a symptom, has only recently been acknowledged as a distinct disease. This recognition is vital, as it encourages clinicians, healthcare institutions, academic organizations, and policymakers to address these ethical challenges in a collaborative manner. By strengthening collaboration and commitment to ethical practices, we can create a supportive environment that enhances the overall well-being of individuals with chronic pain, benefiting society and the country as a whole.