Buchman Daniel Z, Ho Anita
Interdisciplinary Studies Graduate Program and National Core for Neuroethics, The University of British Columbia, Vancouver, British Columbia, Canada.
W. Maurice Young Centre for Applied Ethics, The University of British Columbia, Vancouver, British Columbia, Canada.
J Med Ethics. 2014 Oct;40(10):673-7. doi: 10.1136/medethics-2013-101320. Epub 2013 Sep 7.
Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are 'drug seeking', 'abusing' and 'diverting' prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some scholarly attention, with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient-physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient-physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient-physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients' subjective knowledge in enhancing physicians' self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain.
处方阿片类药物滥用（POA）是一个日益严重的临床和公共卫生问题。在开具处方会带来专业和法律后果，进而营造出对慢性疼痛管理不信任氛围的背景下，医生担心医源性成瘾以及患者是否在“寻求药物”“滥用”和“转移”处方阿片类药物。规避这些担忧的一种尝试是使用阿片类药物合同，该合同概述了患者为获得阿片类药物必须同意的条件。阿片类药物合同受到了一些学术关注，信任和可信赖性被视为关键价值观和美德。然而，很少有文章对这种背景下的信任和可信赖性进行批判性阐述，特别是当对于它们在增强或损害医患关系方面的作用存在分歧时。本文认为，阿片类药物合同对医患信任构成了一种误导性的诉求。假设患者不可信可能会错误地损害患者证词的可信度，这可能会加剧疼痛患者的某些脆弱性。然而，对某些患者的信任错位可能会使医生容易受到处方阿片类药物滥用潜在危害的影响。如果患者不信任他们的医生，或者觉得被医生不信任，这可能会破坏治疗关系并影响护理。认知谦逊的过程可能有助于培养医患之间的相互信任。认知谦逊是医生和患者之间的一种合作努力，它认识到患者主观知识在增强医生对其理论和实践框架、价值观以及对某些报告慢性疼痛患者动机假设的自我理解方面的作用。
