As a pain management physician, I often receive requests to authorize or renew patients’ accessible parking permits. These usually are routine, but not always. One morning, a patient, whom I’ll refer to as Steve, came into my clinic.

Steve was mainly a healthy man in his 40s. He had had chronic pain since an accident on a construction job site several years ago. He had successfully filed for disability, with a ruling that the pain from his workplace injury would not allow him to work in any profession that required prolonged standing, sitting, or lifting. Steve had always been a model patient—consistently polite, pleasant, and compliant with my suggestions for treatment and lifestyle changes to improve his condition.

However, today, something was different. Steve visited me that morning because he decided to renew his accessible parking permit. This request puzzled me because it was not intuitive to my previous recommendations. I knew that Steve had pain, but this had been the case for years. And I also knew that the first law of physical medicine is “use it or lose it.” The less Steve walked daily, the faster he would lose mobility as he aged. This is why I have a policy of only considering handicapped permits for patients over 65 whenever possible. I was in a complex situation, torn between the need to keep Steve mobile and the ethical considerations of issuing a handicapped parking permit. I believed that Steve’s medical condition didn’t warrant a handicapped parking permit, regardless of what previous doctors had determined.

When I explained this to Steve, a change came over him, and he became suddenly irate. His face grew red, then purple. He raised his voice, asking me what kind of doctor I was if I thought he wasn’t disabled. Finally, he stood up. “I’ll sue you for this!” he threatened. He looked ready to do quite a bit more than that.

I confess I began to sweat facing this unprecedented transformation. Steve, a former construction worker, was not a tiny man. Although his injury gave him pain that became unbearable with prolonged standing, it would only take him a few seconds to do damage to me if he wanted to. In addition, I had committed a cardinal sin learned in my psych rotation. Namely, I had let my patient get between me and the door. He could block my exit and trap me in the room.

I quickly excused myself, trying not to show how flustered I was as I walked to my nurse’s station. I assigned Steve to a different doctor—who, I learned through the grapevine, authorized his accessible parking permit to control the potentially volatile situation.

I want to rest on one concern, however. In most states, it is challenging for patients to successfully sue a physician for denying a handicapped parking permit. While disability criteria vary by state, in Florida, only patients with severe lung problems, who are blind, who require permanent use of a wheelchair, and who cannot walk more than 200 feet without stopping to rest must receive a permit.

And therein lies the problem. How do we ensure accessible parking spaces are reserved for those who need them most?

In the end, I am a pain management physician. Virtually all my patients experience chronic pain to some degree. Many have conditions that require them to use wheelchairs, canes, or walkers. Yet, in the parking lot outside my office, there are only two handicapped parking spaces. The ratio of accessible parking spaces to ordinary spaces required by state law is relatively low, and it is almost unheard of for businesses to exceed the required ratio.

So, who should get one of the two accessible spaces outside the pain management clinic? For instance, I was leaving work once when I saw something that stopped me. Parked in one of the handicapped spaces was what I would describe as a monster truck. This massive vehicle was so big that I would have required a ladder to climb into one of the seats. I saw no sliding doors or other obvious equipment, suggesting an occupant in a wheelchair. Yet, upon examination, this truck did have the proper sticker to park in an accessible parking spot.

In my mind, I contrasted this to another patient I had. Penny could not move her legs at all following polio. On one occasion, I asked her to show me how she got in and out of her car to drive. It was a fantastic process that involved using her arms to hoist herself into her car’s back seat, folding up the wheelchair, hoisting the wheelchair up to place it on the back seat beside her, and then using her arms to hoist herself into the driver’s seat, where a unique set of controls allowed her to operate the gas and brakes with her hands. Penny performed this procedure with remarkable speed and a casual attitude.

Surprisingly, she never asked me to authorize an accessible parking permit.

The ethical ramifications of our actions as doctors can be murky. Having a doctor sign off on an accessible parking sticker can make it more likely for states to recognize a patient’s claim of disability—and the accompanying health insurance, housing assistance, and other assistance that can be lifesaving for patients who are too sick or injured to work. Shrewd disability attorneys know this fact. Yet if we authorize handicapped permits for everyone who has pain, what will become of patients who genuinely cannot move more than 200 feet under their own power?

This is one case where I would not advocate for implementing universal standards. If Steve had not already been approved for disability and had needed a permit to help him receive lifesaving assistance, I may have considered his case differently. If Penny had asked for a permit, I would have been required to give it to her. This underscores the importance of individualized assessment in the disability claims process, where each patient’s unique circumstances must be considered.

Still, my goal as a physiatrist is to keep people mobile. If I help my patients avoid physical activity, I may be meaningfully worsening their long-term mobility.

So, how do we, as doctors, decide when this life-changing question comes up? This is a time to practice the human art of medicine, considering all the factors influencing the patient’s physical, economic, and emotional well-being. It’s crucial to strike a balance, ensuring that we don’t hinder our patients’ mobility while upholding the integrity of the disability assessment process.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness.