On coercion and ethics

NB: this post is opinionated.  It represents my own opinions and not those of my employer, my colleagues, my family or my dog.  It’s mine all mine.

If there is something that gets me really riled up, it’s bullying.  Maybe I had too much bullying when I was a kid, maybe I just believe in justice, but for whatever reason I get very grumpy when I see bullying.  Unfortunately this time, I think I’m being bullied – and not by a small-time bully either.

This is a very large organisation that refuses to pay an invoice for services provided because of a paragraph I wrote in the final report.  The paragraph is factual and directly related to the issues the patient raised during the pain management programme.  It just doesn’t suit some members of the organisation that have received it.

I’ll name no names, and I’m being deliberately coy about details, but I’m not a happy woman.

What did I say that was so dreadful?

I said that functional capacity evaluations can’t be used to predict daily function.

A couple of weeks ago I posted on this topic saying that the cumulative evidence over years has not changed: functional capacity evaluations, no matter how well they are carried out, do not have good predictive validity. I’m not going to say it again, once is enough!  In fact, a document that a colleague and I produced for a very large health purchaser in 1999 came to the same conclusion, and produced a set of guidelines for case managers to use when considering a referral for FCE.

Could it be that this report was written for the same corporation that wants me to withdraw my comment? My lips are sealed!

I wrote about this  for RTW Matters just recently.  The fact is, we don’t have any magic way to find out whether someone can or can’t return to a job except through doing it.

I understand that it’s incredibly difficult to determine whether someone deserves a benefit on the basis of whether they are incapacitated.  One author calls doctors who decide this ‘designated guessers’. The main reason health providers find it so difficult is that the decision is not a medical one.  It’s a socio-political one.  It’s based on  a ‘contract’ between members of a community.  It’s fraught with issues of honesty, intent, morality – and yes, in the case of ‘invisible illnesses’, it has the potential to be abused.

But is that something I need to think about when I write a report about things relevant to a client’s pain management programme?  It seems that I do, when the organisation paying for this report uses FCE as part of its process to decide whether someone has ‘capacity for work’.

Let’s put that aside for a moment and consider some of the ethical issues that I think are being challenged if I do what this organisation wants.

  1. Not accurately recording the issues relevant to the client’s programme
  2. Not disclosing the limitations of an assessment process
  3. Denying the client social justice by not providing him with information relevant to the assessment he has completed (I have to ask what the provider of the FCE was thinking about in terms of ethics: isn’t there a responsibility to advise people about the limitations of any assessment?)
  4. Asking me to collude with providing an inaccurate representation of the client’s concerns and content of the programme

There could be more..but that’s enough, don’t you think?

I guess the most worrying aspects of this whole affair are these:

  • this organisation isn’t saying I’m inaccurate in what I say about FCE – they just don’t like it, and think I shouldn’t say it.
  • they are using (and abusing) their position of power to coerce me into doing something that I think is unethical.
  • at the same time they’re trying very hard to deny a client the information he should have access to in order to defend against the opinion of the FCE provider.
  • AND the organisation is prepared to require this client attend another unnecessary programme just so they can get a report that suits their purpose.

What am I going to do?

If I was expressing an opinion, I might change or temper what I said.

If the client hadn’t raised this as a specific concern during the programme (and hadn’t identified ‘establishing functional abilities for work’ as a goal from the Plan of Action), I might have reconsidered a little.

But by not paying for the whole programme and report, and by suggesting the client might be required to go through another programme (unnecessarily) with another provider just to get a report this organisation likes, I’m Not Happy Indeed.

If I worked as a private practitioner in a solo practice, how would I respond to this kind of – well, let’s be honest, bullying?  Who would support me against a large organisation with a lot of purchasing power?  And who’s looking after the interests of the client?

At this stage the client doesn’t even know about the furore (and is probably wondering why the report hasn’t reached him yet – we’re not allowed to give him a copy of the report directly).

What do you think about it?  I’m keen to know your thoughts.

Placebo debates go on…

It’s been a long time since I posted on placebo, but it’s a topic I keep returning to whenever I think about the complexities of carrying out randomised controlled trials on pain management. I’ve recently joined an on-line group called SomaSimple in which some of the most interesting debates I’ve seen in a while have been raging on… one of which is about placebo.

And it was while I was on there I was lead to this site which actually sells REAL small, inert, side-effect-free sugar pills that are often used in drug research as the control condition (otherwise called ‘placebo’).

One of my favourite sites is Ben Goldacre’s Bad Science site. He’s one of my favourite writers, and has been featured on BBC Radio talking about placebo. He’s written about it here and here’s the link to ‘listen again’ from BBC Radio 4. There are two parts to the discussion, and you can listen to part two here.

Another writer I particularly enjoy with regard to placebo is Dan Moerman. He’s written a book called ‘Meaning, medicine and the ‘Placebo Effect’. It’s been out since 2002, but the concepts haven’t dated one bit. He describes the placebo as being ‘inert’ – which it is, and states that the ‘placebo effect’ can’t be – because placebo is an inert substance. Therefore the term needs to be redefined, and he suggests ‘meaning response’ – something I won’t get into at all here, because he takes a whole book to discuss it, and I’m not about to attempt it. But at the heart of his thesis is that there is meaning ascribed to the relationship and interaction between someone seeking help and the person giving it. And this meaning is culturally-bound, susceptible to change over time, and profoundly involved in the ‘healing’ process, which is more than simply recovering from illness or injury. Worth thinking about really – he also adds that given that we can’t eliminate the meaning response in any healthcare situation, we should really learn as much about it and be effective with it, rather than pretending that it simply doesn’t exist.

A BMJ article just published discusses a recent survey of 1200 practising internists and rheumatologists in the United States. To quote a brief excerpt from the article, ‘Investigators measured physicians’ self reported behaviours and attitudes concerning the use of placebo treatments, including measures of whether they would use or had recommended a “placebo treatment,” their ethical judgments about the practice, what they recommended as placebo treatments, and how they typically communicate with patients about the practice.’

The results? Just over half of the 1200 participants responded (679), and of these ‘about half of the surveyed internists and rheumatologists reported prescribing placebo treatments on a regular basis’, they mainly thought this was ethical (Most physicians (399, 62%) believed the practice to be ethically permissible.). There are heaps of Rapid Responses to this article, well worth reading if you’re interested in the ethics of this sort of ‘treatment’. It’s certainly at odds with the American Pain Society position statement on the use of placebo, published in 2005.

Thoughts anyone?

Finally – truth and opinion

This is the last post in this mini-series on why I use science when deciding what interventions to use as a therapist.  As I did yesterday and the day before, I refer to William Palya’s book on research methods – it’s easy to read, available on the internet for free, and although it gives only one view of scientific method, it’s a good start.

After having discussed the first onus – which is to be ethical, and the second, which is to be pragmatic, the third is to use a method to help achieve one or both aims. There are two basic things you need to do:
(1) Demand truth and
(2) Have good understanding

So, what is truth?
Well this can get into murky waters – especially if you listen to the philosophers! But for practical purposes, we can assume that ‘truth is an accurate description of something that is real’. It’s process of building up evidence from many sources, at different times, in different places that describe the same thing, using the least number of assumptions or appeals to special factors that can’t be tested, and describing the majority of the thing under examination. We can use the word ‘phenomenon’ instead of ‘thing’, or ‘event’ or ‘factor’.

Empiricism is one way that is used to determine ‘truth’. Something that is empirical is observed – through technology, to be sure, but can in some way, correspond with something that exists in the real world. As Palya puts it ‘If we wish to claim that something we cannot experience is real then the burden is on us to prove it to a skeptical audience; that is only fair.’

The evidence needs to be reliable – that is, if you look at it more than once, it should be the same. It should also be the same if anyone looks at it.

There should be more than one source of evidence for the ‘thing’. Palya’s example may help – ‘The more evidence from the wider a variety of sources, the more believable. If the police find a finger print the same as yours at a murder scene, maybe it means you are guilty, maybe it doesn’t. However, if the police also find your wallet there, and the murder weapon in your house, and the tire tracks of your car at the murder scene, and the victim’s jewelry at your house, and your teeth marks on the victim’s throat, and a VCR tape of the murder with you in the starring role – well, then you’re in trouble.

You can’t be the only person to say it’s so – and the others that agree with you also need to hold to the same ideas about what is ‘true’ and ‘real’. ‘If several observers who abide by the “rules” of science all agree concerning an event then it is probably true. It is reliable, it is objective. If only one person observes something and others do not observe the same thing then it is subjective.’

The phenomenon needs to be carefully defined so we all agree on what it is and that it describes the essence of the phenomenon. ‘The concept of a horse is false if it includes the saddle or fails to include four legs; it is false if it includes speaking English or fails to include galloping.’
The implications of this aspect of ‘truth’ is that the words we use to describe need to include the critical or essential elements, while excluding those that are not essential. A good definition is unambiguous with respect to what is included and what is not.

The definition you provide must actually have an impact on something that can be measured – because if you can’t confirm that it affects something, it might as well not exist.
Things cannot be said to exist outside the impact they have on sensation (resulting measures) or the impact on other things (functional definition). If your idea of the correct concept of a thing exceeds its operational/functional definition, the burden of proof or burden of communication is on you to prove, explain, and communicate the difference.’

I leave the best summary again to Palya: ‘we start with the notion of empirical, reliable evidence with multiple converging support which is operationally/functionally defined and has consensual validation and ask what is beyond. If someone wants to offer something else as a “truth” it must be proven. Truth does not mean anything anybody wants it to mean. Anyone wanting to extend the meaning of truth to something beyond what science has already substantiated must explain to us what they are talking about.’

Some people say that because various ideas that were once strongly supported by scientists have been rebutted in recent years that there is no such thing as ‘truth’ and science is nothing more than a set of opinions that change all the time. (eg disc prolapses on MRI were once thought to indicate the source of back pain and therefore needed surgery, now they are thought to be incidental and possibly a ‘normal’ variant in many cases)

Some things do change over time – not because the ‘truth’ part changes, but because more information comes to hand that explains more, or explains more with fewer special assumptions, or has more robust support than the previous ‘truth’. This is, in part, why we describe ‘truths’ as theories – theories can be and should be continually tested and as a result, refined. If a theory cannot be tested – then it’s really a model and needs to be evaluated in terms of how useful it is. If it doesn’t help with making decisions that can be tested, then it’s not useful at all.

Whew!! That’s a lot of theory and philosophy of science!
I think though, that it’s really important that we, as therapists, work out why we use the interventions we do, and that we can point to a method that means we feel we can rely on the interventions – and that we really do understand what we mean by evidence and science. Otherwise we are only reciting by rote, or working by habit and convention rather than seeking to understand.

What’s understanding?
It means you can describe, predict, know how to influence, synthesise and explain what you are actually doing.

This is from Palya’s chapter – summarises it quite neatly I think!

Have a great weekend – it’s Friday here, and I’m about to look for a Friday Funny. Be back soon!

Why I care about science and evidence

I caught myself wondering in the last few days about why I am so keen to pursue science and evidence-based approaches to health care.  I’m definitely consistent about wanting to know why something works, and equally consistent about knowing that it works – at the same time I meet people every day who don’t believe in science, but do want to believe in alternative health practices.

An excerpt from a great website that I refer to often might help to explain why I appeal to science when I am working in health care:

When you have something important at stake you demand truth. … whenever it matters to you, you already know enough to demand truth, and to understand what’s going on (i.e., to be “scientific”).
Suppose that you and I were going to bet $100.00 on the outcome of a coin toss. I flip; you call heads while it is in the air; it lands, I cover it, sneak a look, call it tails, and quickly put it in my pocket.
You would not pay. You would demand that you see an outcome before believing it or you would require that trustworthy people see an outcome and report it to you.

If you are uncertain about something that is personally important, you appeal to direct observation [my emphasis – adiemus] as your final arbiter.

It is what you can experience for yourself that ultimately determines what you accept as truth. If someone tells you something,

  1. whether there are several lines of evidence supporting it;
  2. whether the information is consistent with information from several other sources which are generally reliable or
  3. whether the information is consistent with what you already know.

When this informal notion of appealing to direct observation is used in an explicit, open, and consistent fashion, it is called the scientific method.

The website is Research Methods Lecture Notes written by William L. Palya, Jacksonville State University, 2000.
Palya gives a wonderful, logical rationale for why psychologists should follow a scientific path – and I’ll quote chunks of it and paraphrase bits of it for you here (but go and read it for yourself, in full – it’s worth it!)

The onus:
The first step in building a logical foundation for your practice of psychology is to decide what is at the heart of your system of wants, beliefs or values. An onus is the most primitive or most basic demand a person feels obliged to meet, even if it is not fun and even if it is not easy.
Here are some onuses that people in general accept:
a. Treat others in the way you would expect/hope to be treated
You would want to go to a maximally competent therapist who understands what is really going on and how to fix it.
b. Greatest Good for Greatest Number
Where things are complex, and there is no ‘completely right’ or ‘completely wrong’ decision, it makes sense to make decisions that maximise the results for most people.
What is the best answer for the big picture out of the possible alternatives? What will most positively affect the greatest number?
c. Others’ Interest Before Self Interest
If you have to assess more to understand a problem; work harder to get the job done; or give up a position to which you are emotionally committed but is actually wrong, then so be it. Decisions should be based on the truth rather than self interest.
d. Efficiently Eliminate Ignorance or Relieve Suffering
If you do therapy you must know how to help people and help them in the best possible way. The best solution requires a clear understanding of the actual factors involved.
e. Deal With Your Limitations Honestly
Know what you can or cannot do. Solve the problem when you can, but refer to others when appropriate. Stop seeing someone if you are not helping, even if it means a loss of income. Your decisions must be based on your ability to understand the requirements of the task.

These onuses are usually called ‘Ethics’ or ‘Ethical behaviour’

Now although this is written directly for students of psychology, I don’t see any difference between these requirements for psychologists to be ‘ethical’ than for anyone else to be ethical, whether it be a tradesperson fixing something, a physiotherapist helping someone recover the ability to walk, an occupational therapist helping someone to organise their daily activities, or a nurse helping someone return to health.

As a health consumer I really want to be assured that:
– the person I’m seeing is being honest about their ability to help me
– that by receiving my treatment, no-one else is being truly disadvantaged (no, I don’t want a kidney ‘donated’ by a starving person selling their body to make money)
– that my health care provider will put his or her own self interest to one side and not milk money from me because I’m a captive audience (how much money do they make from the products they sell?), after all I’m paying for their expertise already
– that they don’t spend a long time working out ‘what to do with me’ and in so doing make me spend hours there, just because they’re not efficient
– that when they don’t know what to do because it’s outside their expertise, they let me know and refer me elsewhere

Does any of this sound unreasonable? I don’t think so… you could replace ‘therapy’ or ‘healthcare’ with ‘plumber’ or ‘lawyer’ or ‘librarian’!

More tomorrow from this site – on being pragmatic, and how this affects why I use science to justify the therapies I use.

A nice lay summary of pain

I ran across this post today in my ongoing search through the net – Why do we have pain?. It’s a very brief article written by someone with fibromyalgia giving a pretty useful description of the difference between pain and injury or tissue damage. And a bunch of links to articles found on Associated Content.

I’m not comfortable with her definition of pain as ‘perception of pain’ because that’s tautological and circular and tells me nothing. So – pain is the perception by the brain of signals that the brain detects as harmful or threatening to the person and wants to ensure action is taken. Howzat for an on-the-run definition? Overall though, I don’t think you can go far from Professor Harold Merskey and co’s original IASP definition of pain. But for lay people, or people in the community, perhaps the definition needs to be a wee bit shorter.

I clicked into the link ‘pain’ on that website, and came across a whole range of brief articles of varying quality about pain and pain management. Like most things on the web, read with a good degree of thought and criticism, and be aware of the quality of what you read. If you’re wanting to establish whether a site has been reviewed for quality, the Health on the Net is a good way to determine whether the author has decided to voluntarily comply with ethical standards. You should also apply your own critical thinking by referring to the literature yourself – and not just a single reference either! You do need to survey several papers on any topic, thinking about the quality of the research supporting any contention, and particularly the generalisability of any research to your specific area of practice, before transferring any new treatment technique into your daily routine!

’nuff said – I’ll be posting on CRPS and an exposure-based treatment later shortly so – y’all come on back now!!


Over the past couple of days I’ve had the need to really think hard about my practice in pain management. Some of you will know that I hail from New Zealand, and my origins are as an occupational therapist, with subsequent study in psychology, and wide-ranging readings and training and supervision and experience in a whole bunch of other areas (including case management, health and safety, policy development and so on).

Some things are really quite essential in chronic pain management especially – adopting a cognitive behavioural approach, using an interdisciplinary team, having a biopsychosocial model of pain… nothing really controversial there (unless you LOVE hands-on therapy, or think all pain can be abolished through injections/surgery/medications!).

What I’m facing right now is a really significant challenge to what I’m able to do (and be funded for) in both assessment and intervention. A new contract has been drawn up by a major health purchaser that restricts ‘psychosocial’ assessment (usually included with biomedical and functional as parts of a comprehensive assessment of the person with chronic pain) to ‘psychological’ assessments that must be carried out by psychologists. At the same time, the content of this assessment has shifted the areas to be assessed to eliminate the ‘social’ or contextual aspects of the pain presentation.

In the interventions area, the programmes that may be provided to people with pain MUST include sessions with a psychologist, and areas of coping that are often provided by occupational therapists (such as thinking about thinking, relaxation training, graded exposure and so on) are to be provided by psychologists.

Now I’m the last person to want to get involved with a turf war – I’ve always said that it’s important to ask yourself ‘what can I contribute to this team?’ rather than ‘what is my role?’ – but this really does cast doubts on my profession, and my ability to carry out what I think are fundamental skills of all therapists working in the field of pain management. I can’t see what the benefit to people experiencing pain will be to make these sorts of changes.

For me, the question is: can I ethically provide interventions to an individual withoutusing therapies that I am both competent in, are part of my professional repertoire and from the literature, have been shown to work? I don’t think so – what do you think?

T-riffic site you must visit!

Something that is known to get my blood boiling and boiling very quickly is unverified, unsubstantiated claims for ‘treatments’ that promise to give ‘quick pain relief’ such as homeopathic remedies – or colour therapies – or magnetic underlays – or the therapeutic application of hands to ‘treat energies’ – or… well you get my drift.

Someone else who feels the same way, but does it much more eloquently than I can hope to is Ben Goldacre, medical doctor, author, broadcaster – and someone who can communicate scientific information in an incredibly satisfying way.

Go to his website Bad Science and read on – but not if you too are convinced that infinitessimal droplets of something diluted in gargantuan quantities of plain old water can ‘heal’ you…

On a more serious note, he gives some excellent commentary on unsubstantiated science, particularly health-related claims, and has been the recipient of some really vociferous and even ugly threats because he dares to make public many of the limitations of so-called ‘alternative’ therapies.

As Prof Denis Dutton has said ‘Would you fly in an airplane based on alternative physics?’ – No way sez me!! I want to travel in an airplane that has been designed on tried and tested facts in this world, not the next! In the same way I’m not going to have my body used as an experiment to see whether ‘alternative’ medicine will work, I want to know that the therapies I try have some sound science to back up their use. Visit Prof Dutton’s websites for some lively and articulate debate – Arts and Letters Daily, and his philosphy site

So, two sites that are really thoughtful, challenging – and humourous! T-riffic, I think!