Severe cancer pain: Testing the limits of maleficence?

An ethically challenging clinical case is presented regarding a 72-year-old man with prostate cancer followed by a palliative care service for severe pain related to sacral bone metastasis and an associated cauda equina syndrome. Subsequent disease progression was associated with increasing pain. He underwent several surgical procedures as well as radiation and multiple cytotoxic chemotherapeutic regimens. The patient's pain was treated aggressively including the placement of an intrathecal pump, and a myelotomy. The ethical questions raised by this case included whether interventional pain management did more harm than good, whether emotional distress was treated inappropriately and whether the driving force of pain was the tumor or existential distress? Three distinguished pain specialists from different disciplinary perspectives comment on his management, with an emphasis on the ethical challenges his care presents.