The Problem of Painkillers and Our Attitudes towards Pain Relief

by Dr. Nileema Conlon Vaswani in

Do you remember Dianne Pretty? Mrs. Pretty suffered from Motor Neurone Disease and asked that her husband, Brian Pretty, be allowed to help her die. Suicide is legal in the UK but assisted suicide is a criminal offence. Mrs. Pretty was too ill to be able to carry out the physical act of suicide, an act that would have released her from the clutches of a painful and debilitating illness. She argued that she had a very poor quality of life and that she should be allowed to die with dignity. The courts, both here in the UK, and the European Court of Human Rights, could not deny that she was suffering and should be allowed to die. But they did rule that were she to ask her husband to help her, they could not guarantee that he would not be prosecuted. Eventually, Mrs. Pretty lost her battle with the courts and, unfortunately, for her, had to die exactly the sort of death she wanted to avoid: one where she was in pain and where she felt her dignity would be compromised.

The rights and wrongs of Dianne Pretty's case are not under discussion here. What is important to note is that as a society, we felt that it was morally permissible to allow someone to suffer a serious and debilitating illness in the interests of preserving life. The idea of preserving the "sanctity of life" or even "prolonging life at all costs" is an idea that many people hold onto. The medical profession, not withstanding its obligation to heal, often places the sanctity of life above the notion that healing might in fact entail allowing the ending of life as was the case with Mrs. Pretty. It is considered simply wrong to help another individual to die even in cases of unbearable pain and suffering.

Is it not ironic that patients, like Mrs. Pretty, who request help to die because of the pain they are experiencing do not have their wishes honoured but patients who do not wish to die but simply experience pain-relief do end up dying? This is exactly the problem that we are faced with this week. It has recently emerged that GPs are over-prescribing painkillers to patients and that, in many cases, patients are dying because of taking too much of this sort of medication. In some cases, GPs fill out repeat prescriptions without even seeing the patient. It is estimated that patients are taking certain painkillers for a lot longer than is considered safe and it is their GPs who are enabling them to do so.

In medical contexts, if it is considered wrong to bring about the death of an individual who wants to die we would find it difficult to provide any moral justification for bringing about the death of an individual who does not want to die. The very purpose of dispensing certain medicines via prescription only is to ensure that these medicines are patient-appropriate and that they are taken safely, i.e., in the right quantities. Providing repeat prescriptions without even seeing the patients defeats the very purpose that is meant to be achieved via a system of prescriptions.

Of course GPs are not intentionally bringing about the death of their patients by providing repeat prescriptions. But does bringing about an outcome indirectly, yet knowingly, make one less morally culpable than one would be if one brought about the same outcome directly? It can be argued that patients may exaggerate their symptoms or that, in requesting prescriptions, may not know that they are asking for quantities that might be unsafe to consume. But none of this should matter because the very concept of the prescription, i.e., that which the doctor "prescribes" can ultimately override any desire that the patient may have to be given the medication. I remember a time I was desperate for a certain antihistamine that was available only on prescription. It was the weekend and my GP was not available to provide the prescription. I went to the pharmacy, explained my problem, explained that it was the only effective solution and that I had taken it before. The pharmacist agreed with me but still refused to give me the antihistamine. I had to settle for a milder antihistamine to help me through the weekend until my GP provided the prescription for the one I needed on the Monday. Such is the power of prescriptions. How then can anyone except GPs be blamed for the consequences of over-prescribing painkillers?

Consider a scenario where a patient in hospital continually requests painkillers. If the medical professionals believe that honouring the patient's request will be detrimental for the patient, they are likely to refuse to administer the painkillers. If they did, they would be negligent and, both morally and legally culpable, for any adverse effects on the patient. Why, then, would their moral culpability be any different when they administer repeat prescriptions to patients for medications where they know that they are prescribing beyond quantities that are safe? Does the physical absence of the patient in the GP surgery provide some sort of moral shield?

Providing a repeat prescription without seeing the patient may appear to be acceptable given the stressful conditions under which GPs work and the long days they put in. However, what may be intended as an innocent short-cut and a means to shorten the queues might well have severe moral consequences. Prescriptions exist to protect the patient. If this is paternalistic in nature and denies individual autonomy, the issue can be debated separately. But the fact remains that when prescriptions exist to protect, the doctors that hand them out ought to ensure that this purpose is achieved and not its complete opposite.