Jan 17th 2018

Prisoners of Pain

PRINCETON – Last month, an Egyptian court sentenced Laura Plummer, a 33-year old English shop worker, to three years in prison for smuggling 320 doses of tramadol into the country. Tramadol is a prescription opioid available in the United Kingdom for pain relief. It is banned in Egypt, where it is widely abused. Plummer said that she was taking the drug to her Egyptian boyfriend, who suffers from chronic pain, and that she did not know she was breaking Egyptian law.

The UK media have been full of sympathetic stories about Plummer’s plight, despite the fact that she was carrying a quantity in excess of that for which a UK doctor can write a prescription. Whatever the rights and wrongs of Plummer’s conviction and sentence, however, the case illuminates an issue with much wider ramifications.

Last October, the Lancet Commission on Palliative Care and Pain Relief issued an impressive 64-page report arguing that relieving severe pain is a “global health and equity imperative.” The Commission is not the first to make such a claim, but its report brings together an abundance of evidence to demonstrate the seriousness of the problem. Each year 25.5 million people die in agony for lack of morphine or a similarly strong painkiller. Only 14% of the 40 million people requiring palliative care receive it.

The report begins with a doctor’s account of a man suffering agonizing pain from lung cancer. When the doctor gave him morphine, he was astonished by the difference it made; but when the patient returned the next month, the palliative-care service had run out of morphine. The man said he would return the following week with a rope; if he could not get the tablets, he would hang himself from the tree visible from the clinic’s window. The doctor commented: “I believe he meant what he said.”

Citizens of affluent countries are used to hearing that opioids are too easy to get. In fact, according to data from the International Narcotics Control Board and the World Health Organization, access to these drugs is shockingly unequal.

In the United States, the quantity of available opioids – that is, drugs with morphine-like effects on pain – is more than three times what patients in need of palliative care require. In India – where the man threatening to hang himself was from – the supply is just 4% of the quantity required; in Nigeria, it’s only 0.2%. People in the US suffer from over-prescription of opioids while people in developing countries are often suffering because of under-prescription.

Although it is generally the poor who lack access to opioids, the main problem is not, for once, cost: doses of immediate-release, off-patent morphine cost just a few cents each. The Lancet Commission argues that an “essential package” of medicines would cost lower-middle-income countries only $0.78 per capita per year. The total cost of closing the “pain gap” and providing all the necessary opioids would be just $145 million a year at the lowest retail prices (unfairly, opioids are often more expensive for poorer countries than richer ones). In the context of global health spending, this is a pittance.

People suffer because relieving pain is not a public policy priority. There are three main explanations for this. For starters, medicine is more focused on keeping people alive than on maintaining their quality of life. And patients suffering a few months of agony at the end of life are often not well positioned to demand better treatment.

Third, and perhaps most important, is opiophobia. The misplaced fear that allowing opioids to be used in hospitals will fuel addiction and crime in the community has led to tight restrictions on their use, and clinicians are not trained to provide them when they are needed.

While opioids can be harmful and addictive, as America’s current crisis demonstrates, the fact that something can be dangerous is not sufficient reason to impose extreme restrictions on its clinical use. Risks are justified when the expected benefits clearly outweigh the expected harms. Policymakers in the developing world are making a choice to impose what the WHO calls “overly restrictive regulations” on morphine and other essential palliative medicines. Low or zero access is neither medically nor morally justified.

Designing a system that provides adequate access to morphine without encouraging over-prescription or leaking drugs onto the black market is tricky but not impossible. The Lancet Commission draws attention to the Indian state of Kerala, where trained volunteers are at the center of community-based palliative care, bolstered by international collaboration with the WHO, university researchers, and non-governmental organizations. There is no incentive to over-prescribe, and no evidence of opioid diversion.

Another model worthy of study, the Commission says, is Uganda, where a hospice run by an NGO supplies the national public health-care system with oral morphine.

Laura Plummer’s smuggling of painkillers was doubtless foolish; her experience in an Egyptian jail will be a personal tragedy. But if her story is true, she is also a victim of the excessively tight restrictions on opioids that prevented her boyfriend from obtaining tramadol legally.

Plummer’s case thus highlights a broader misfortune: that so many citizens of developing countries are denied effective pain relief by governments in the grip of opiophobia. This is not merely foolish; in the words of the Lancet Commission, it is also a “medical, public health, and moral failing and a travesty of justice.”


Peter Singer is Professor of Bioethics at Princeton University, Laureate Professor at the University of Melbourne, and founder of the non-profit organization The Life You Can Save. His books include Animal Liberation, Ethics in the Real World and, with Katarzyna de Lazari-Radek, Utilitarianism: A Very Short Introduction.

Copyright: Project Syndicate, 2018.
www.project-syndicate.org

 


This article is brought to you by Project Syndicate that is a not for profit organization.

Project Syndicate brings original, engaging, and thought-provoking commentaries by esteemed leaders and thinkers from around the world to readers everywhere. By offering incisive perspectives on our changing world from those who are shaping its economics, politics, science, and culture, Project Syndicate has created an unrivalled venue for informed public debate. Please see: www.project-syndicate.org.

Should you want to support Project Syndicate you can do it by using the PayPal icon below. Your donation is paid to Project Syndicate in full after PayPal has deducted its transaction fee. Facts & Arts neither receives information about your donation nor a commission.

 

 

Browse articles by author

More Essays

Jun 17th 2021
EXTRACT: "Confronting our complex history and ultimately embracing a more equitable, balanced, and humble culture may be a tall order in these fractious times. But that makes it even more imperative that we fully reckon with who we are and who we are capable of becoming."
Jun 11th 2021
EXTARCT: "A further health benefit of hiking is that it’s classed as “green exercise”. This refers to the added health benefit that doing physical activity in nature has on us. Research shows that not only can green exercise decrease blood pressure, it also benefits mental wellbeing by improving mood and reducing depression to a greater extent than exercising indoors can."
Jun 10th 2021
EXTRACT: "“The greatness of a nation and its moral progress,” Mahatma Gandhi said, “can be judged by the way its animals are treated.” If we apply that test to the world as a whole, how much moral progress have we made over the past two millennia? ...... That question is suggested by The Golden Ass, arguably the world’s earliest surviving novel, written around 170 CE, when Emperor Marcus Aurelius ruled the Roman Empire. Apuleius, the author, was an African philosopher and writer, born in what is now the Algerian city of M’Daourouch."
Jun 4th 2021
EXTRACT: "Research we’ve done, which looked at 37 adults with type 2 diabetes, found that over two weeks, prolonged sitting was associated with high blood sugar levels. But we also found that when people stood up or walked around between periods of sitting, they had lower blood sugar levels. Other studies have also had similar results."
May 28th 2021
EXTRACT: "Paul Van Doren's legacy lies in a famous company, and in his advice to young entrepreneurs to get their hands dirty, and to know what goes into making what they are selling."
May 19th 2021
EXTRACT: "May 7th marked three hundred and ten years since the philosopher David Hume was born. He is chiefly remembered as the most original and destructive of the early modern empiricists, following John Locke and George Berkeley." .... " Shocking as it may (and should) sound, Hume is implying nothing less than that the next time you turn the key in your car ignition, you are as justified to expect the engine will start as you are in believing it will turn into a pumpkin. For there is a radical contingency that pervades all our experience. We could wake up tomorrow to a world that looks and behaves very differently to the one we are in now. Matters of fact are dependent on experience and can never be known a priori — they are purely contingent, and could always turn out different than what we expect."
May 1st 2021
EXTRACT: " The sad reality is that the Mizrahim (Jews of Middle Eastern and North African descent) were discriminated against from the day of Israel’s inception, whose Ashkenazi (European Jewish) leaders viewed them as intellectually inferior, “backward,” and “too Arab,” and treated them as such, largely because the Ashkenazim agenda was to maintain their upper-class status while controlling the levers of power, which remain prevalent to this day." ..... " The greatest heartbreaking outcome is that for yet another generation of Israelis, growing up in these debilitating conditions has a direct effect on their cognitive development. A 2015 study published in Nature Neuroscience found that “family income is significantly correlated with children’s brain size…increases in income were associated with the greatest increases in brain surface area among the poorest children.” "
Apr 25th 2021
EXTRACT: "We all owe Farah Nabulsi an enormous debt of gratitude. In a short 24-minute film, The Present, she has exposed the oppressive indecency of the Israeli occupation while telling the deeply moving story of a Palestinian family. What is especially exciting is that after winning awards at a number of international film festivals​, Ms. Nabulsi has been nominated for an Academy Award for this remarkable work of art. " 
Apr 25th 2021
EXTRACT: "When I crashed to the floor of my home in Bordeaux recently after two months of Covid-19 dizziness, I was annoyed. The next day I collapsed again. Now I was worried. What I didn’t know was that my brain was sloshing around inside my skull, causing a mild concussion. Nor did I know that I was in for a whole new world of weird and wonderful hallucinations."
Apr 13th 2021
EXTRACT: "Overall, our review has found that there isn’t evidence to back up the claims that veganism is good for your heart. But that is partly because there are few studies ....... But veganism may have other health benefits. Vegans have been found to have a healthier weight and lower blood glucose levels than those who consume meat and dairy. They are also less likely to develop cancer, high blood pressure and diabetes. "
Apr 8th 2021
EXTRACT: "Pollock’s universe, the universe of Mural, cannot be said to be a rational universe. Nor is it simply devoid of all sense. It is not a purely imaginary world, although in it everything is in a constant state of flux. Mural invokes one of the oldest questions of philosophy, a question going back to the Pre-Socratic philosophers Parmenides and Heraclitus – namely, whether the nature of Reality constitutes unchanging permanence or constant movement and flux. For Pollock, the only thing that is truly unchanging is change itself. The only certainty is that all is uncertain."
Apr 8th 2021
EXTRACT: "Many present day politicians appear to have psychopathic and narcissistic traits too. It’s easy to spot such leaders, because they are always authoritarian, following hardline policies. They try to subvert democracy, to reduce the freedom of the press and clamp down on dissent. They are obsessed with national prestige, and often persecute minority groups. And they are always corrupt and lacking in moral principles."
Apr 6th 2021
EXTRACT: "This has led some to claim that not just half, but perhaps nearly all advertising money is wasted, at least online. There are similar results outside of commerce. One review of field experiments in political campaigning argued “the best estimate of the effects of campaign contact and advertising on Americans’ candidates choices in general elections is zero”. Zero!"
Mar 30th 2021
EXTRACT: "The Father is an extraordinary film, from Florian Zeller’s 2012 play entitled Le Père and directed by Zeller. I’m here to tell you why it is a ‘must see’." EDITOR'S NOTE: The official trailer is attached to the review.
Mar 28th 2021
EXTRACT: "Picasso was 26 in 1907, when he completed the Demoiselles; de Kooning was 48 in 1952, when he finished Woman I.  The difference in their ages was not an accident, for studies of hundreds of painters have revealed a striking regularity - the conceptual painters who preconceive their paintings, from Raphael to Warhol, consistently make their greatest contributions earlier in their careers than experimental painters, from Rembrandt to Pollock, who paint directly, without preparatory studies."
Mar 26th 2021
EXTRACT: "Mental toughness levels are influenced by many different factors. While genetics are partly responsible, a person’s environment is also relevant. For example, both positive experiences while you’re young and mental toughness training programmes have been found to make people mentally tougher."
Mar 20th 2021

The city of Homs has been ravaged by war, leaving millions of people homeless an

Mar 20th 2021
EXTRACT: "There are two main rival models of ethics: one is based on rights, the other on duties. The rights-based model, which traces its philosophical origins to the work of John Locke in the 17th century, starts from the assumption that individuals have rights ....... According to this approach, duties are related to rights, but only in a subordinate role. My right to health implies a duty on my country to provide some healthcare services, to the best of its abilities. This is arguably the dominant interpretation when philosophers talk about rights, including human rights." ........ "Your right to get sick, or to risk getting sick, could imply a duty on others to look after you during your illness." ..... "The pre-eminence of rights in our moral compass has vindicated unacceptable levels of selfishness. It is imperative to undertake a fundamental duty not to get sick, and to do everything in our means to avoid causing others to get sick. Morally speaking, duties should come first and should not be subordinated to rights." ..... "Putting duties before rights is not a new, revolutionary idea. In fact it is one of the oldest rules in the book of ethics. Primum non nocere, or first do no harm, is the core principle in the Hippocratic Oath historically taken by doctors, widely attributed to the ancient Greek philosopher and physician Hippocrates. It is also a fundamental principle in the moral philosophy of the Roman statesman Marcus Tullius Cicero, who in De Officiis (On Duties) argues that the first task of justice is to prevent men and women from causing harm to others."
Mar 18th 2021
EXTRACT: "Several studies have recently compared the difference between antibodies produced straight after a coronavirus infection and those that can be detected six months later. The findings have been both impressive and reassuring. Although there are fewer coronavirus-specific antibodies detectable in the blood six months after infection, the antibodies that remain have undergone significant changes. …….. the “mature” antibodies were better at recognising the variants."
Mar 15th 2021
EXTRACT: "Like Shakespeare, Goya sees evil as something existing in itself – indeed, the horror of evil arises precisely from its excess. It overflows and refuses to be contained by or integrated into our categories of reason or comprehension. By its very nature, evil refuses to remain within prescribed bounds – to remain fixed, say, within an economy where evil is counterbalanced by good. Evil is always excess of evil." ....... "Nowhere is this more evident than in war. Goya offers us a profound and sustained meditation on the nature of war ........ The image of a Napoleonic soldier gazing indifferently on a man who has been summarily hanged, probably by his own belt, expresses the tragedy of war – its dehumanization of both war’s victims and victors."