A history of spinal injury left Mr. B, aged 49 years, with daily pain levels that rendered him unable to work a steady job. The most helpful medication is a narcotic pain medicine. Mr. B signed a pain-management contract with the provider and stated his understanding of the contents. Several months later, marijuana was found on a routine drug screen of the patient’s urine. According to the contract, this was a violation, and the medical director of the pain program insisted on stopping Mr. B’s narcotics. The patient, however, denied any other infraction of the contract and blamed the result on a bad decision made while getting together with some of his old friends. Mr. B stated that he would not be able to sleep or enjoy any quality of life without his pain medications and would lose his part-time job.

Level 2 issue

Issue: Violation of pain-management agreement

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Players: Patient, provider, and system (pain-management program)

Existing regulations/laws: Hospital policy defining the consequences of violating narcotic contract

Autonomy: Patient admits that he knowingly violated contract.

Balance: Other than the regulatory breach, use of marijuana did no detectable harm. Discontinuation of narcotic pain medications would have a significantly negative effect on the patient’s life.

Justice: Narcotic pain medication was inexpensive; when the patient’s pain was controlled he could perform part-time work. The violation had resulted in no other negative impact.

Course of action: The provider met with the medical program director to discuss this case. Based on the terminology of the regulation, the medical director was able to enact a probationary period. The patient was allowed to continue the narcotic pain medication with stipulations: Instead of a 30-day supply, only a week’s supply was dispensed at a time; frequent, random urine drug screens were performed; any further infraction would result in the medication being stopped.


Ethical questions in health care will never have easy answers, primarily because the issues have such a significant impact on the lives of the people involved. These matters are, by nature, weighty, often with life-or-death consequences. In spite of the staggering medical and technological advances, the basics of humanity do not change. In the absence of a clear right or wrong, clinicians must focus on the shoulds or oughts. n

Dr. Sego is a primary-care nurse practitioner at the Department of Veterans Affairs Medical Center, Kansas City, Mo.


1. National Institutes of Health. The Hippocratic Oath. 

2. Association of American Physicians and Surgeons. A Modern Hippocratic Oath by Dr. Louis Lasagna. 

3. Silberfeld M. Beneficence and autonomy in health care. Humane Med. 1987;3:93-98.

4. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 4th ed. New York, N.Y.: Oxford University Press; 2001:326-328.

5. Stanford Encyclopedia of Philosophy. Moral Dilemmas.

6. Miami Dade College Institute for Ethics in Health Care. Ethics teaching primer.

7. Beidler SM. Ethical issues experienced by community-based nurse practitioners addressing health disparities among vulnerable populations. International Journal for Human Caring. 2005;9:43-50.

8. American Bar Association. Health care facility ethics committees: New issues in the age of transparency. 

9. Department of Veterans Affairs. VHA Directive 1004.

All electronic documents accessed May 15, 2011.