595: Decision-making autonomy in chronic pain: ethical implications and a pilot MacCAT-T study

Topic: Education, Societal Impact, and Others
Subtopic: Ethics

Background and Aims: Patient decision making autonomy (DMA) is a cornerstone of medical ethics [1], yet is rarely evaluated in chronic pain care. Chronic pain, now recognized as a disease [2], requires complex multidisciplinary management, which presupposes adequate decisional capacity. However, persistent pain may alter cognitive, emotional and judgment processes, potentially limiting DMA. This pilot study examined whether first‑time patients attending a tertiary pain center possess sufficient DMA to consent to proposed treatments, comparing clinicians’ subjective assessments with a standardized tool while identifying potential autonomy deficits with implications for clinical practice, personalized care, and ethical decision‑making [3].

Methods: We conducted a monocentric prospective cohort study over two months in a French tertiary pain center. Adult patients consulting for chronic pain for the first time were included. DMA was assessed using two approaches: clinicians’ routine clinical judgment and the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) considered the benchmark tool for decision-making capacity [4]. Demographic and pain-related variables were collected to explore differences between DMA profiles. Analyses examined concordance between clinician assessments and MacCAT-T scores, as well as feasibility and patient satisfaction.

Results: Twenty-seven patients (77.7% women, median age 49 years, median pain duration 5 years) were included. Physicians considered 88% fully autonomous, whereas MacCAT-T revealed deficits in 52%: 26% mild and 26% major, mainly affecting reasoning and expression of choice. Concordance between clinical and tool-based assessments was poor (p < 0.0001), with physicians frequently overestimating autonomy. Nociplastic pain was significantly associated with lower autonomy (p = 0.036). Interview duration was 20 minutes, and 92% of patients reported high satisfaction, supporting feasibility for routine practice.

Conclusions: This pilot study shows that DMA is frequently impaired in chronic pain, challenging the pre-assumed full competence. Divergences between clinician judgment and standardized assessment highlight the need for structured tools to ensure ethically sound, patient centered care. Beyond measurement, supporting autonomy should include health literacy enhancement (clear information, teach back, decision aids) and shared decision making embedded in pain care pathways. Because DMA may fluctuate with symptoms, emotions and context, reassessment is warranted. The exploratory finding linking nociplastic pain with lower autonomy should be confirmed; if replicated, it would justify reinforced therapeutic education and tailored decision aids for these patients.

References: [1] Beauchamp TL, Childress JF. Respect for autonomy. Principles of biomedical ethics. Eighth edition, New York, NY: Oxford University Press; 2019, p. 100–2.
[2] Treede R-D, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain 2019;160:19–27.
[3] Durand G. La médecine des désirs. Pour une médecine minimaliste [The Medicine of Desires: Toward a Minimalist Medicine]. French. Vrin; 2023
[4] Grisso T, Appelbaum PS, Hill-Fotouhi. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv 1997;48:1415–9.

Presenting Author: Julien NIZARD
Submitting Author: Marguerite d'Ussel

Senior Author: Julien Nizard

IASP 2026 Global Year theme of Neuropathic Pain: No

• Nathan MOREAU: DDS, PhD - Equipe Neurosciences oro-faciales, UMR-S 1333, INSERM, Université Paris Cité, France
• Guillaume DURAND: PhD - UMRS INSERM-Oniris 1229-RMeS, Regenerative Medicine and Skeleton, Nantes Université, Nantes, France
• Anne COUTAUX: MD - Centre douleur chronique – Hôpital Saint-Joseph, Paris, France
• Julien NIZARD: MD, PhD - UMRS INSERM-Oniris 1229-RMeS, Regenerative Medicine and Skeleton, Nantes Université, Nantes, France