It should be obvious by now, but somehow it is not: Physicians are not immune to the same emotions that govern human behavior everywhere else. We like to imagine that our white coats and years of training somehow grant us a protective immunity to fear, to shame, to the raw surge of emotion that can stop us in our tracks. The truth is, physicians and other medical professionals are just as subject to the power of affect as anyone. And nowhere is this more clear (or more damaging) than in the way chronic pain is treated in the shadow of the opioid crisis.

This is not to make matters worse by admonishing and shaming physicians from a new angle. At the onset, I attest that the problems we are facing lie principally, and in some respects, solely, at the feet of disingenuous private actors and government overreach. Without these actors, there would be no problem. Until very recently, physicians have, in the main, been given deference as far as their judgment. Despite medicine being more grounded than ever before in objective science, that very science is not being followed. What I am offering is a moment of ethical reflection. That reflection needs to involve an emotional inventory. Is our fear, anger, and shame influencing our actions more than our interest in treating our patients to the best of our ability?

It is more than understandable when the profession has more or less systematically ignored the teaching of pain care. This slighting of the subject and the attendant ignorance engendered a long-term, now baked-in, bias against opiates. This has left a vacuum that has been filled by anti-opiate zealots and given law enforcement a target to punish and extract millions from those prosecuted, despite science that supports the use of opiates and a Supreme Court ruling, XIULU RUAN v. UNITED STATES, to the contrary. And even more understandable when, on a weekly basis, there are reports of doctors and associates being given life sentences for practicing compassionate care.

Yet letting our emotions, our affect, override our reasons ends in betraying all the principles of medical ethics.

• Beneficence: Compromised.
• Non-maleficence: By not using the best tools at hand, we harm patients.
• Autonomy: Patients are denied full participation in their care, knowing full well that there is medication that can alleviate pain and make them, if not whole, functional.
• Fealty to our oath: We betray our oath to ourselves and our patients to do our very best, and some claim we must act in congruence with our oaths even to our detriment.

Are these principles outdated and naive? If so, what replaces them? Although these guides do not often come to mind, they are like any other moral code we live by. Articulating them is not necessary because we have internalized them. They need to be brought back into consciousness in times like these. Without them, we are in danger of losing our north star and autonomy. We are in danger of moral injury to ourselves, our colleagues, and society.

In many ways, many of us have already lost our way. Several generations of students and residents have been co-opted by the false anti opiate narrative. Many others have lost autonomy through employment. They have to follow the no opiate corporate line. This is to say nothing of looking over our shoulders for regulators and prosecutors.

Yet the problem does not go away. Patients are in pain. They are not being treated or, worse yet, removed from their medication and offered poor and often more dangerous alternatives. There it is. And what do we do about it?

My original idea in formulating this piece was and is to say that a way forward is to start recognizing the power of fear, and other emotions such as distress and shame. No one wants to lose a license, spend time in jail, and lose family, friends, and assets. But when reason and emotion are at odds, it rarely ends well. Reason and emotion need to work together to come to the best solution for society. Granted, this situation, if we are honest, might seem insolvable barring some sudden discovery of a safer pain medication that is acceptable to all. But I must insist this is chasing our tail, and it doubles back, implying that we do not have a safe way to treat pain. But we do have such a medication, existing opiates. Current research shows addiction rates below one in one hundred, if not one in one thousand, when opiates are taken as prescribed.

Have we reached a point of no return? I hope not. At the end of the day, we are the healers. When push comes to shove, people come to us for care. It is an existential issue. The buck stops with us. That is not an arrogant statement. It is, as they say, simply a fact. Ultimately, what judge, legislator, prosecutor, or DEA agent is not going to want the best care, including relief of pain when needed?

If we can start anew. We do that by not withdrawing and hiding from fear. We lobby for every patient we have in pain. We support legislation such as that passed in Illinois. We redouble our efforts to make the Ruan decision viable and the law of the land. We do these things by recognizing an unappreciated emotion, and that is interest. Interest is a powerful force. It is what makes everything possible. It pushes through shame and fear. Reason coupled with interest brings courage to find solutions and overcome adversaries that base their actions on misguided narratives but also on the quicksand of pseudoscience, greed, and power.

Brian Lynch is a family physician.