The diagnosis of disability. Treating and rating disability in a pain clinic.

Medical diagnosis sanctions illness and directs physicians toward effective treatment. In chronic illness, these two functions of diagnosis can come into conflict. Nowhere is this conflict more striking than in the case of disability ratings for those with chronic pain. An institutional case study examining the relation between a pain clinic and a worker's compensation program is presented and analyzed in terms of two questions: (1) Is it ethical for one physician to both treat pain and rate disability in patients with chronic pain? (2) Is physician rating of disability due to pain scientifically valid? Ethical and conceptual analyses support a negative response to each of these questions. The roots of the ethical and scientific problems concerning disability ratings are identified in society's demand to differentiate medical and nonmedical distress. We propose a system of time-limited compensation for pain as a therapeutically superior alternative to disability ratings.