'You wouldn't do that to an animal, would you?' Ethical issues in managing pain in patients with substance dependence.

In this article, we present a secondary analysis of a descriptive phenomenological study that we conducted in the United Kingdom exploring nurses' experiences of working with patients with substance dependence and pain. Our aim was to focus upon the ethical issues that emerged in the empirical data and so we used the Four Principles of Biomedical Ethics plus attention to scope to guide and inform our analysis. We present six key themes: trust, paternalism, coercion, failure to respect autonomy, advocacy and withholding. We discuss how these themes intersect with the four principles plus scope to illuminate practice and the ethical issues that emerge when managing this patient population's pain. We recommend that clinicians adopt a collaborative approach to managing pain for patients with substance dependence that they remain aware of the power differentials inherent within the clinical setting and ensure that communication and teamwork remain at the forefront of decisions. Clinicians need access to ethical guidance to inform their practice decisions and clinical ethics support services could provide one solution.