Service, advocacy and adjudication: balancing the ethical challenges of multiple stakeholder agendas in the rehabilitation of chronic pain.

PURPOSE To highlight potentially conflicting roles of the rehabilitation professional in the treatment of clients with persistent pain conditions. In assisting clients requiring rehabilitation, the role of the rehabilitation professional is usually fairly clear and unambiguous. If however questions about the authenticity of the client's presenting disability have been raised, then a major role conflict can arise. Many clients present with symptoms of pain and disability yet there is no objectively discernible disease, and in these cases, the authenticity of the condition may be questioned. As rehabilitation professionals we may thus find ourselves acting in different roles: (i) We might be a clinical service provider working to reduce the client's suffering, (ii) We might become the client's advocate working to protect the client in conflicts with an insurer, (iii) We might become an adjudicator working to help the insurer detect evidence of our client's fraudulent behaviour. The principal objective of this paper is to distinguish these roles, and highlight their incompatibility. It is stressed that accreditation for and competence in clinical intervention does not guarantee or legitimize competence in advocacy or adjudication. CONCLUSIONS AND RECOMMENDATIONS The paper concludes by suggesting that the primary role of the rehabilitation professional should be the provision of clinical service and that the adoption of the role of advocate or adjudicator may cross unacceptable ethical boundaries resulting in bringing harm, intentionally, or unintentionally, to the client.