H. Westley Clark, MD, JD, MPH, CAS, FASAM, Anton C. Bizzell, MD, and Anthony Campbell, RPh, DO
CHAPTER OUTLINE
■ CORE ETHICAL PRINCIPLES
■ DEALING WITH DENIAL
■ ESTABLISHING AN ETHICAL STANCE
■ FUTURE DEVELOPMENTS
Practitioners of addiction medicine routinely encounter clinical situations that raise ethical questions. The approach that a practitioner should take has been influenced by the work of Beauchamp and Childress (1), who promulgated the concepts of autonomy, beneficence, nonmaleficence, and justice. These four principles are not exclusive to the practice of medicine, where they are joined by the principle of fidelity, which has at least two subcomponents: confidentiality and veracity. It is well known that the practice of medicine is immersed in ethical precepts, from Hippocrates to the more modern Belmont Report. Operationalizing these concepts in practice is an obligation of all practitioners (2).
In short, ethics amount to the moral principles that govern an individual’s behavior, regardless of whether that person is a clinician or a patient. In this regard, it is important to recognize that what is ethical may exceed what is legal. What is legal is governed by laws or regulations that are codified and published for all to see, whereas what is ethical may be governed by a unique situation that is specific to a particular clinician and patient.
Many people enter the practice of medicine guided by altruism—that is, acting with regard to others. A major complication, and hence an ethical quandary for clinicians in the field, is a practitioner’s attitude toward the disease of addiction and the processes necessary to resolve that disease; this invokes the concept of the duty of the clinician and the clinician’s view of the duty of the patient. Some clinicians view addiction as a self-inflicted moral failing that should respond to the proper exercise of free will. Others view the condition as a biologic disorder that can respond to treatment if the affected individual desires such treatment (3).
The attitudes of individual practitioners and society as a whole can be influenced by the acts of individuals affected by substance use disorders (SUDs). Unlike many medical
conditions—such as diabetes, cerebrovascular conditions, or the loss of an arm or leg—many argue that an individual could have avoided the SUD if he or she had not consumed the alcohol or smoked the cocaine. The complication, of course, is that many acts of harm do occur while an individual is under the influence of alcohol or other drugs. Active substance use is associated not only with physical and psychological problems but also with social problems such as driving under the influence, domestic violence, gun violence, child abuse or neglect, prescription drug diversion, drug dealing, drug trafficking, prostitution, human trafficking, workplace accidents, bad debts, and other negative or criminal acts. The effect of substance misuse on society is both personal (micro) and societal (macro) in nature. Practitioners inevitably are drawn into the tension between these two sets of effects by having to navigate the resulting ethical issues, which also occur at both micro- and macro-levels (4).
For guidance in this process, physicians can turn to groups such as the American Medical Association (AMA), the American Psychiatric Association (APA), the American Society of Addiction Medicine (ASAM), and state boards of medical licensure for information about ethical practices and behaviors that are considered unethical.
CORE ETHICAL PRINCIPLES
As noted earlier, five general principles provide a basis from which to explore the ethical concerns that arise daily in the treatment of SUDs: autonomy, beneficence, nonmaleficence, justice, and fidelity (1,5,6).
Autonomy
A primary principle in modern medicine is that clinicians should respect the right of individuals to determine what course of action is appropriate for themselves. In other words, a person acts in his or her own self-interest as a rational actor. Thus, the clinician must treat the patient as autonomous and avoid actions that would diminish his or her ability to exercise personal liberty in interacting with the clinician, choosing appropriate treatment options, and otherwise determining what is best for himself or herself (2,5).
Customarily, the patient’s capacity to decide is presumed (5). When a patient has an SUD, however, the underlying assumption of competent self-determination may be questioned (6). Psychoactive substances interfere with cognitive processes and decision-making ability. Compromised competence is an important consideration for clinicians because it can influence how the clinician should respond to the exercise of autonomy by a patient. Further, an individual who is competent to exercise decision making under the principle of autonomy also must accept responsibility for the consequences of such decisions as well as accepting the limits of the clinician’s authority under that circumstance.
Thus, a clinician should have some means to assess the ongoing competence of a patient in treatment for an SUD. Conditions that cause competence to wax and wane may be especially vexing for both the patient and clinician. Conditions that have a progressively deteriorating effect on competence also can create dilemmas, as it becomes critical to assess the course and rate of the deterioration in order to determine the degree to which the clinician should respect the patient’s autonomy and right to self-determination.
It is essential that the patient have the ability to understand the nature and consequences of the health care issue at stake, the risks and benefits associated with any proposed intervention, and the alternative options for care. The decisions and choices made by the patient should not be distorted by others, including the clinician, or by a medical or psychiatric condition that compromises the patient’s ability to make a free choice.
SUDs can occur across the life span. While there is a peak in prevalence among young adults, no age group is spared the effects. Hence, neurocognitive assessments can be very important in determining the complexity of instructions for care and the nature of recovery-oriented strategies presented to the patient.
It is in the arena of diminished capacity or impairment that the ethical concept of paternalism has currency (5). Here, the clinician or some other authority makes key decisions for the patient. Nevertheless, despite the clinician’s belief that a patient has diminished ability to make appropriate decisions about his or her own care, an effort should be made to explain every aspect of care to the patient, from the results of an assessment to any medications deemed appropriate, to the involvement of family or friends, and to the recovery period.
As the so-called “baby boom” generation ages, more individuals with SUDs and possible cognitive impairment may present for screening, brief intervention, or treatment. As this occurs, the tension between professional paternalism and patient autonomy may become more pronounced. However, baby boomers also may lead the way in maintaining durable powers of attorney for purposes of health and otherwise. Such legal instruments can delegate to friends or family the autonomy that the patient otherwise would exercise. Should a patient’s condition deteriorate dramatically in the absence of a legal instrument that memorializes the patient’s intentions, a court may have to be petitioned to assign a legal guardian for decision making.
The tension between the values of the clinician and those of the patient also may surface in situations where the patient is under the jurisdiction of the criminal justice system or has obligations to the child welfare system or to an employer. For example, in a case where the patient is obligated to report progress to an external agency (such as a court or a child welfare agency) and that report, if accurate, could contain damaging information—such as multiple missed appointments or toxicology screens that are positive for drugs—a patient may ask the clinician to either omit or misrepresent the damaging information. In such a situation, especially in the absence of diminished competency, the clinician could be seen as disrespecting the autonomy of the patient by agreeing to the patient’s request because, as noted earlier, autonomy requires the exercise of responsibility (2).
In many cases, it may be extremely difficult not to “push” the patient toward a decision by emphasizing certain information. If nothing else, such biases should be acknowledged to the patient, who then will be able to listen to the information with an awareness of the bias.
An added benefit is that the patient may be more open to therapies the physician is advocating at another stage of treatment because he or she was not “pushed” early on (6).
Voluntariness versus Coercion
A growing number of patients in addiction treatment have been forced into such treatment by their families, employers, or the criminal justice system. For example, a spouse may give his or her partner an ultimatum: enter treatment “or else.” An employer may require treatment as a condition of retaining a job. A criminal justice agency may require a defendant to enter treatment as a condition of probation, parole, or suspension of charges.
Critics of coerced treatment contend that it is unethical because it violates the principle of autonomy (7). Some critics are particularly concerned when the criminal justice system mandates treatment or offers inducements such as the possibility that a criminal defendant will avoid incarceration, because they view the power imbalance in such circumstances as especially annihilative to autonomy (8).
Proponents of coerced treatment counter that, although such coercion unquestionably impinges on a patient’s autonomy, it does not violate it altogether, even in the context of the criminal justice system (8). The patient may not wish to enter treatment, but always has a choice and retains the right to refuse. He or she may not like the consequences of refusal (losing a spouse, losing a job, or being incarcerated on criminal charges), but still retains the autonomy to make the decision. Proponents also point out that patients who stay in treatment for at least 90 days have better outcomes than those who leave earlier. To the extent that coercion raises retention rates, they argue, it works to improve the chances that the patient will have a positive outcome.
Much of the discussion presented here dovetails with the concept of informed consent. A critical component of autonomy, informed consent is the process of communication between a patient and the clinician that allows the clinician to provide specific medical treatments to the patient. As the AMA has pointed out, the communication process associated with informed consent is both a legal requirement and an ethical obligation (9).
Beneficence
The principle of beneficence assumes that an individual wishes to help others pursue their own interests (of course, such interests should be morally correct). As applied to the addiction medical specialist, beneficence implies a moral obligation to act for the benefit of the patient. Inherent in the clinician–patient relationship is an obligation on the part of the physician to aid the patient. However, there are limits to this obligation, and the practitioner should guard against becoming overinvolved with the patient.
Defining the boundaries of what is “good for the patient” also is tied to the notion that a licensed practitioner is, in part, an agent of the state and, as such, an agent of social good. If the “good” in addiction medicine is recovery, then the boundaries of that “good” could become limitless, with the life of the clinician intertwined with the life of the patient. Such an outcome would invoke paternalism and a diminution of patient autonomy. Consequently, beneficence must have natural, ethical limits. While there may not be a natural boundary to the legitimate practice of addiction medicine, involving the patient in shared decision making about his or her care can lead to consensus between the clinician and patient as to the way forward.
Consulting with colleagues in a legally permissible manner broadens the clinician’s insight, so that boundary violations are avoided and the risk of the clinician overidentifying with the patient’s struggles is minimized (1,4).
Nonmaleficence
This ethical principle means “to do no harm.” In treating patients with SUDs, the clinician must not provide ineffective treatments or act with malice toward the patient. This principle is notabout avoiding exposing a patient to the known or unknown risks of a particular therapeutic intervention; in fact, there are risks associated with many effective treatments. Rather, the principle suggests that a clinician’s biases for or against a particular type of treatment should be informed by best practices, scientific research, and/or objective clinical experience (1,4,5).
An example of nonmaleficence is seen in the actions of a primary care physician who prescribes opioid analgesics for the treatment of pain. Because there is an inherent risk of dependence and/or addiction associated with long-term use of opioids, the failure to explain that risk to a patient would be “doing harm.” Further, the physician could be seen as causing harm because he or she lacks the knowledge needed to monitor the patient’s progress and adjust the analgesic as indicated. In another example, if a physician who treats addiction has no registration to prescribe buprenorphine for the treatment of opioid dependence, that could be seen as violating the obligation to do no harm by erecting a roadblock to patients’ access to an important therapy.
It is clear, then, that the intersection of doing good (the principle of beneficence) and causing no harm (nonmaleficence) can produce a conundrum for the addiction medicine specialist. A clinician whose moral values militate against the use of methadone or buprenorphine for the treatment of opioid dependence will be faced with a decision as to whether to limit the options available to patients. While clinicians who hold this view have access to naltrex-one, care must be exercised in discussing clinical options with patients in order to avoid violating the principle of nonmaleficence.
Another example of the intersection between doing good and causing harm can be found in the Housing First paradigm (10), which promotes access to housing for those who are chronically homeless, some of whom also have SUDs or disabling psychiatric conditions. A clinician working within this paradigm may be confronted by the view that a patient should be offered housing without a corresponding requirement to participate in mental health or substance abuse treatment. In such situations, the clinician must find a way to respect the autonomy of the patient while promoting cessation of substance misuse. The “stages of change” model advocated by Prochaska and DiClemente (11) offer the clinician a moral framework within which to operate in such situations.
Nonmaleficence also applies to the selection of therapies, including medications, that have little empirical evidence to support their effectiveness. With the off-label use of medications, the clinician may be relying on studies involving small sample sizes or the idiosyncratic experience of a single program. Where there is limited empirical support for a medication or other therapy, there is insufficient information to educate the patient about the effectiveness of the approach in question; hence, the principle of autonomy is undermined.
The use of psychoactive substances is a source of controversy. A number of states have legalized the dispensing of marijuana, allegedly for therapeutic purposes (12). In those states, clinicians are faced with a dilemma in working with patients who use marijuana, which may be legal under state law but remains a violation of federal law. What is the moral position of the clinician in such a situation? Can the ethical principle of nonmaleficence guide the clinician here?
Another example of conflicting interpretations of the principle of nonmaleficence is found in the debate over abstinence versus harm reduction approaches to the treatment of SUDs. For example, advocates of abstinence argue that a harm reduction approach is dangerous because it allows a patient to continue using alcohol or other drugs and communicates a mixed message about the dangers of their use. In contrast, advocates of harm reduction argue that the abstinence-based model does not allow for compassion or for meeting the basic needs of individuals who are in the throes of addiction (4). Some advocates for harm reduction also assert that the abstinence-based model actually prevents recovery because it does not permit the patient to progress through the stages of change envisioned by theorists such as Prochaska and DiClemente, but instead imposes a rigid clinical philosophy on the patient. Given that there are many pathways to recovery, each of these arguments creates an ethical dilemma for the clinician at both a personal and professional level.
A final issue related to the principle of nonmaleficence can be found in the context of the so-called difficult patient. Such a patient may miss appointments or violate the treatment agreement or otherwise fail to cooperate with the clinician. Some clinicians might be inclined to discharge such a patient or to transfer him or her to another clinician for care. While the patient has a personal responsibility under the ethical principle of autonomy to honor the therapeutic agreement, the clinician has a professional obligation to do no harm. In tort law, there is a corollary to this situation, in that a clinician must not abandon a patient in the patient’s hour of need. While neither nonmaleficence nor the tort concept of nonabandonment binds the clinician to the patient in perpetuity, both concepts recognize that the clinician has a duty to work with the patient to achieve the best outcome.
In order to avoid violating the principle of nonmaleficence, clinicians should establish clear guidelines with every patient at the beginning of treatment, renew the understanding of those guidelines periodically, and address the clinical issues associated with noncompliance during the course of treatment.
Finally, because patients suffering from SUDs are vulnerable through their medical instability, psychological unsteadiness, and, in some cases, suggestibility, they are at risk for exploitation. In an ideal world, no clinician would be involved in such machinations, but in the “real” world, such behaviors do occur, however, rarely. Most state boards of medicine, psychology, social work, and counseling have regulations that address (and provide penalties for) sexual or financial exploitation of patients and other unacceptable behaviors on the part of practitioners.
Justice
This ethical principle requires that, at a macrolevel, society distributes goods and services—including medical goods and services—fairly. At the microlevel, it means that clinicians will treat patients with equal conditions equally. In a normative sense, the principle of justice would require that medical needs are determined according to (a) the benefit that would accrue to a patient from the services offered, (b) the acuity of the patient’s need, (c) the potential enhancement of the patient’s quality of life, and (d) the duration of the benefit (5).
In an ideal world, nonmedical criteria would not limit the services that a patient would receive. The AMA’s Code of Ethics affirms that “Non-medical criteria, such as ability to pay, age, social worth, perceived obstacles to treatment, patient contribution to illness, or past use of resources should not be considered” (5). Despite these views, there are wide disparities in the ability of patients who suffer from addiction to pay for services, just as there is a wide difference in the cost of services offered by addiction treatment providers. Fortunately, a wide spectrum of treatment facilities and services are available, from volunteer nonprofit-run organizations to government-financed programs to privately operated facilities.
A larger issue may be the absence of demand for services. Data collected by the Substance Abuse and Mental Health Administration (SAMHSA) show that more than 90% of those who meet the clinical criteria for treatment services for SUDs perceive no need for treatment and hence do not seek or receive such treatment (13). Moreover, enactment of the Affordable Care Act and the Mental Health Parity and Addiction Equity Act will allow an estimated 62 million more people to access to mental health and addiction services (14). However, having financial access to services and perceiving a need for services are two different things.
It has been argued that health care practitioners have a responsibility to advocate for their patients and to be involved in establishing humane policies of resource allocation at both the institutional and societal levels (15). Thus, in order to give meaning to the principle of justice in the context of addiction, practitioners should make efforts to educate their colleagues and patients and to promote societal awareness of the need for addiction treatment. Otherwise, the lack of demand for treatment services will create distortions in the marketplace by shifting the allocation of scarce resources toward services that are in greater demand, leaving low-demand services such as addiction treatment without sufficient resources. Thus, clinical strategies such as screening, brief intervention and referral to treatment (SBIRT) and integration of primary medical care with behavioral health care can help give greater weight to the principle of justice by educating patients about their situation and by educating members of the clinical team about the importance of SUD treatment.
The promise of broader insurance coverage for addiction services also carries with it other derivative themes as part of the principle of justice. For example, health care practitioners may find that their comfort level is being challenged as increasing numbers of persons with SUDs seek care (and thus constitute a larger portion of their caseloads). While it is normal to have biases, it is important to recognize when and how such biases affects one’s ability to practice within the principle of justice, so that no patient is discriminated against or denied access to treatment that other patients receive. Staff training is an important component of efforts to give currency to the principle of justice because such training can help prevent discrimination against patients with SUDs. This helps to ensure a general level of fairness regardless of an individual clinician’s personal feelings about SUDs and can help promote an atmosphere of impartiality and equality in the treatment setting (6).
Fidelity
The principle of fidelity focuses on the quality of being faithful or loyal to the duties and obligations of a caregiver to a patient. It encompasses telling the truth and keeping actual and implicit promises to the patient, that is, veracity. It also involves not representing fiction as truth. In establishing a relationship with a patient, the clinician creates a set of expectations. These include honoring the treatment agreement, adhering to professional codes of ethics, maintaining an acceptable level of competence through training and continuing education, and following the policies and procedures of the treatment organization and all applicable laws. It also means that the information provided to the clinician will remain confidential to the extent permitted by law (4).
Among other things, fidelity invokes the Hippocratic oath: “What I may see or hear in the course of the treatment or even outside of treatment of the patient in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things to be shameful to be spoken about (16).”
Although 42 CFR Part 2 (17) provides a legal framework for confidentiality that governs federally funded treatment programs, it is not the law alone upon which the patient relies in his or her relationship with the clinician. Confidentiality is both an implicit and explicit promise by the clinician not to divulge a patient’s personal information without that the patient’s permission (see Chapter 110 for more information).
If a physician is going to maintain fidelity by keeping promises, it is essential to be clear in advance about which promises may have to be broken and the circumstances under which that might occur. Federal regulations offer a limited list of exceptions to confidentiality in the context of addiction treatment. For example, if a patient appears to be suicidal or homicidal, confidentiality may need to be breached. Or if a patient violates certain aspects of the treatment agreement, the relationship between the clinician and the patient may be terminated. It is important that the clinician be very clear about the limits to fidelity, so there are no surprises at a later date (4).
Fidelity and its two subcomponents, veracity and confidentiality, create a level of trust in the therapeutic relationship that is necessary for the patient to make progress in treatment. Such trust can be tested in situations involving group therapy or family therapy. While the patient is always the principle focus of the clinician, information must be shared in the group or with family members if they are to be useful as resources. Thus, the patient should have a clear understanding of the limits of confidentiality in the situation of group and family therapy. Ideally, written information would be provided to the patient, describing the boundaries of confidentiality in those situations, so that the patient can make an informed judgment as to whether to participate.
As noted earlier, the principle of fidelity requires that the clinician be as knowledgeable about addiction treatment as possible so that the patient can rely on the clinician to recommend specific treatment modalities or programs. There should be no financial, clinical, or philosophical conflict of interest on the part of the physician in terms of the recommended course of treatment. For example, a patient who is dependent on opioids might benefit from medication-assisted treatment, but if the clinician recommends only nonpharmacologic therapies, he or she may be violating the principle of fidelity. Such a situation also represents a breach of the principle of autonomy, because the patient is not being provided with critical information to make a decision about which course of treatment is the most likely to be beneficial.
Fidelity and veracity do not apply only to the relationship between the clinician and the patient; they also apply to the relationship between the clinician and society as a whole. For instance, a patient might ask a clinician to withhold critical information in a report to a judge, child welfare agency, or employer. While the patient can opt not to ask the clinician to file a report, he or she should not ask the clinician to misrepresent or withhold information that would appear in such a report.
Fidelity and veracity also militate against dual relationships, as in situations where the patient and clinician have either a past social relationship or contemplate a future social relationship. It is difficult for the clinician to act in the best interests of the patient if either the clinician’s or the patient’s emotional or mental processes are distorted by the dynamics of such a social relationship (4).
In terms of health insurance coverage, neither the patient nor the clinician should misrepresent the patient’s eligibility for certain benefits or utilization of those benefits. In situations in which a patient may be eligible for disability benefits, neither the patient nor the clinician should misrepresent findings relevant to a determination of eligibility.
DEALING WITH DENIAL
Historically, practitioners in primary care settings did not inquire about a patient’s substance use unless it was directly related to the presenting complaint, and annual physical examinations rarely included questions about alcohol or drug use. In fact, guidelines from the U.S. Preventive Services Task Force (USPSTF) recommend only that primary care physicians should screen for depression and alcohol misuse (18). The USPSTF guidelines state that “screening in primary care settings can accurately identify patients whose alcohol consumption does not meet criteria for alcohol dependence, but places them at risk for increased morbidity and mortality. Brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6 to 12 months or longer” (18). In contrast, the USPSTF concluded that current evidence is insufficient to support recommended screening of adolescents, pregnant women, and other adults for drug misuse.
Nevertheless, when a physician suspects that a patient who arrives at the office with another presenting complaint also is misusing alcohol or drugs, he or she must take the initiative if the patient does not raise the issue. In such a case, the physician has an ethical duty to act if there is reason to believe that the patient’s use of alcohol or misuse of drugs is affecting his or her health.
The difficulty is that raising the issue sometimes is not enough. Denial is an integral part of addictive disorders. Individuals in denial fail to recognize or are reluctant to acknowledge their problem, or they find ways to deny or minimize the extent of their alcohol or drug use because they are ambivalent about giving up that use. In such situations, what is the proper balance between respect for the principle of autonomy and the physician’s responsibility for the patient’s health? Should the physician raise the issue and then drop it if the patient is resistant?
As discussed earlier, fidelity and veracity must be bidirectional in order to give substance to autonomy. Nevertheless, denial may be about shame, guilt, and substance-induced distortions of memories. While shame and guilt can be attenuated through good clinical care and solid therapeutic relationships, distortions of memory are another matter.
Talking to the Patient
To fulfill the ethical responsibility to the patient, the clinician must do more than simply raise an issue. He or she should provide relevant information, engage the patient in discussion, and, if the patient shows resistance, follow up during future visits. In such a scenario, how far the clinician can intrude on the patient’s autonomy depends a great deal on the strength of his or her relationship with the patient. Unless a firm foundation of trust and understanding has been established, persistent questions or a forceful confrontation can backfire and ultimately reinforce the patient’s resistance. It also may become clear that the patient does not have an accurate memory of his or her substance use, in which case a “surrogate historian” in the person of a family member or a friend may be helpful, but only with the patient’s express consent (4).
Ordering Laboratory Tests
Must, or should, a patient’s consent be obtained before a drug screen is ordered? It is likely that the law does not require the patient’s consent. Ordinarily, a clinician does not ask a patient to sign a consent form before sending blood or urine for other types of testing. However, ordering laboratory tests to screen patients for SUDs has different implications, and failing to consult the patient can damage the physician–patient relationship and undermine efforts to induce the patient to acknowledge his or her problem.
Further, screening urine or blood for drugs is not a routine practice in primary care settings. Patients expect to be screened for blood sugar and cholesterol, but they do not expect to be screened for drug use. A patient confronted with the results of a test he or she did not know was being conducted and for which he or she did not give consent may feel betrayed by the clinician and is likely to be angry that the physician did not show respect for his or her autonomy (4,19). As a result, the patient may refuse to participate in further discussions about alcohol or other drug use. Tactically, therefore, the better practice is to obtain the patient’s permission for blood or urine tests for alcohol or other drug use (19).
A second reason the physician should obtain the patient’s permission before ordering laboratory drug screens has to do with the patient’s right to privacy. If the physician orders a test, the patient’s insurance company or other third-party payer will know about the test and perhaps even its result, so even the decision to order a drug screen discloses a good deal, regardless of whether the test result is positive or negative. Therefore, it is the patient, not the physician, who should decide whether it is appropriate and necessary for the health insurer to have that information.
A third reason is financial. The patient’s benefits plan may not cover drug screens. In such a case, the patient should have the opportunity to decide whether he or she is willing to pay for the test out of pocket, which is a decision that should be made before the test is ordered.
Unfortunately, if the physician consults the patient, there is a good chance that the patient will refuse permission to perform a drug test. However, this leaves the door open to further discussions with the patient about possible drug problems. The patient likely will appreciate the clinician’s concern for his or her autonomy and privacy and thus may be more open than would be the case if the physician was perceived as acting “behind the patient’s back” and therefore not to be trusted. The clinician might begin such a discussion by asking, in a neutral way, why the patient does not wish to have a drug screen performed.
The clinician is less likely to encounter problems if he or she orders a test of liver function. Patients are less likely to be surprised that such a test has been ordered, yet the test results still provide an opening for a conversation about the health effects of alcohol and other drug use.
When the Patient Is an Older Adult
The physician who suspects an older adult patient is misusing alcohol or other drugs should proceed with caution. As individuals age, most become more sensitive to perceived threats to their autonomy (20). Because of the stigma surrounding SUDs, a patient whose physician suggests that he or she may be drinking too much or misusing drugs (legal or illegal) may conclude that the physician is suggesting that whatever brought him or her to the office for a medical visit has an emotional basis or that the patient’s functioning or capacity is diminished. If an older adult thinks that his or her autonomy is being threatened, the patient may point to the “normal” infirmities of old age as the source of the difficulty, rather than acknowledging a problem with alcohol or other drugs (20).
Most older adults are unaware that the way their bodies metabolize alcohol and other drugs (including prescription medications) changes as they age and that the amount of alcohol or drugs they consumed without obvious adverse consequences when they were younger can harm their health and even incapacitate them as they grow older (20). Moreover, many older adult patients take multiple prescription drugs to control their cholesterol, blood pressure, diabetes, depression, or anxiety. They may not be aware that their prescription medications can interact with each other and with any alcohol or over-the-counter or illicit drugs they consume, thus interfering with the therapeutic effects of their medications. An approach that emphasizes these issues provides an opportunity to engage an older adult in a discussion about SUDs without posing a threat to his or her autonomy.
ESTABLISHING AN ETHICAL STANCE
Ethical principles that apply to addiction research and practice are similar to those that apply to general medical care. The long tradition of Western medicine that evolved from Hippocrates in the 5th century has matured through the activities of various professional organizations such as the American Medical Association, the American Hospital Association, the American Nurses Association, the American Psychiatric Association, the American Psychological Association, and the National Association of Social Workers, to name a few. These organizations have promulgated codes of conduct and behavior predicated on the imperative that clinicians must behave in an ethical manner in their interactions with patients and in the conduct of health-related matters.
Physicians can avoid or minimize potential ethical dilemmas if they remain aware of the sources of potential conflicts of interest, keep the purposes of the ethical principles in mind, discuss potential conflicts with patients at the beginning of treatment, and take steps to reduce the potential for conflicts (19).
Resources for Resolving Ethical Dilemmas
Resources for obtaining professional guidance on ethical issues can be found through consultation with colleagues, accessing professional standards or codes of ethics, and obtaining legal consultation. Each has strengths and drawbacks, and each is more relevant to some types of ethical dilemmas than others (4,19).
Consultation
Consultation can involve peers, senior staff, or other providers within the community. Confidentiality needs to be assured in seeking consultation. If there is a chance that information cannot be shared without divulging confidential information, the provider might find a consultant in another geographic locale. Without the patient’s consent, identifying information must not be shared.
Professional Standards or Codes of Ethics
Professional standards are another resource. Many medical organizations have adopted professional standards and codes of ethics, as have organizations in social work, nursing, and psychology. While such standards do not provide answers to every ethical dilemma, they do provide useful parameters for acceptable and unacceptable professional behavior. They also may help the professional frame questions that clarify the underlying issues and thus move the situation toward a decision. Professional standards can be accessed by contacting the association’s headquarters office or accessing its Web site.
Legal Consultation
For many providers, obtaining legal advice may seem unrealistic given limited resources, but there are low-cost strategies for obtaining advice in some situations. Most bar associations have a pro bono legal component that may provide consultation at no charge or at a reduced rate. Legal service agencies that operate as a social service to the community may have expertise regarding certain ethical dilemmas. In addition, every state has a department of substance abuse and/or mental health that is charged with funding and regulating addiction treatment. Such an entity may have an attorney available who can assist with legal issues related to treatment.
Although ethical issues usually are complex enough to require a case-by-case evaluation, hospitals, addiction treatment programs, and other organizations should formally articulate practices that establish a process for approaching ethical issues. Given the ambiguous nature of ethical dilemmas, it is helpful to clarify the process for resolving them, even if the actual resolution may differ from case to case (19).
Summary: A Step-by-Step Model for Making Ethical Decisions
By following the steps outlined below, health care professionals can move to a more rational level of decision making about ethical issues (4,6,19).
Identify the Ethical Issue
What is the clinician’s reaction to the situation? Ethical issues often are revealed when the practitioner has a “gut instinct” that something is not right. Confusion, anxiety, and uncertainty about what to do next also are indicators that an ethical issue may be involved. If basic principles seem to be compromised, the clinician should stop and evaluate further. A significant step is to examine one’s own feelings about the situation.
Review the Principles at Stake
What is the true dilemma? So much can be occurring with a patient that it is difficult to see the real issue as well as to assess how significant the issue may be.
Consider Possible Solutions
At this point, the next step—or at least several options— may be clear. If there are multiple choices, it is useful to list the options and carefully examine each one. A further step is to list the pros and cons of each option.
Take Action
Having arrived at this point, the clinician should be ready to make a decision. Sometimes, the decision may not be one that everyone is comfortable with, but it may be the least objectionable plan. The patient should be helped to understand the rationale for the decision.
Follow Up and Evaluate the Outcome
The outcomes of ethical decisions should be evaluated and their impact on patients carefully monitored, both as a form of resolution of the current situation and as a reference point for addressing similar dilemmas in the future.
FUTURE DEVELOPMENTS
The coming decades promise exciting breakthroughs in the treatment of SUDs. Yet if the past is any guide to the future, each new discovery will bring with it new challenges to the core ethical obligations of honoring informed consent, protecting confidentiality, and respecting justice, while also protecting the public from harm and ensuring good care of individual patients (6).
As pointed out by Ashcroft et al. (21) in their review of ethical issues raised by progress in addiction research, “There is significant potential for great social and individual benefit from developments in this area, but these need to be evaluated alongside some potentially significant risks of harm or limitations on individual freedom that might undermine the value or acceptability of these developments.” The authors point out that concerns about the ethical implications of scientific developments are given greater urgency by the stigma and discrimination still attached to addiction and to the persons who suffer from this medical disorder.
For example, with the growth of managed care, the physician and patient no longer have an exclusive relationship. Third-party payers have intruded into the relationship in multiple ways, as by shifting some financial risk to the physician or awarding bonuses to physicians whose patients do not use expensive (or extensive) services. Under other plans, contracts limit the services for which a physician will be reimbursed. (Note that such contracts do not limit the services the physician can provide—only those for which he or she will be paid.) In this way, many managed care plans create incentives that can impinge on medical judgment.
If a clinician allows financial incentives or disincentives to influence his or her treatment recommendations, or leads him or her to discharge a patient who has exhausted benefits under a health insurance contract, that clinician has placed financial interests before his or her obligation to the patient, which is a clear ethical violation.
Because health insurers and other third-party payers place (often hidden) limits on certain forms of treatment, ethicists have begun to suggest that the physician should inform the patient about any economic issues that could influence either the physician’s recommendation or the patient’s decision. Providing an opportunity for the patient to give “economic informed consent” ensures that the patient knows about such limitations before making a decision about the proposed course of care.
If physicians and other caregivers can adapt to the “new normal,” these unprecedented paradigm shifts can influence health care decision making in a reasoned and balanced fashion, and there is real hope that the cultural stigma and disenfranchisement underlying health disparities in addiction treatment may move in the direction of compassionate and competent care for all those who suffer from addiction (4,19,21).
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