Chapter 115 – Ethical Issues in Addiction Practice

Introduction
- Addiction medicine professionals routinely encounter clinical situations that raise ethical questions
and concerns
- Beauchamp and Childress: autonomy, beneficence, nonmaleficence, and justice
- recognize that what is deemed to be ethical may sometimes conflict with what is deemed to be legal

Core Ethical Principles

- Autonomy - right of individuals to determine what course of action is appropriate for themselves
Patients have the right not to do well.

- Patients have presumed capacity. However, this is can be questioned in SUD patients because
substance can interfere with cognitive processes and decision-making ability
Ex. Patients who want to leave AMA

- Voluntariness
Often compelled by families, employers, criminal justice system
Critics say unethical because it violates principle or autonomy
Proponents say:
We acting in the patient’s best interest in light of lack of capacity
Those who stay in treatment for 90 days have better outcomes
Patients retain the right to refuse but may not lie the consequences (losing a spouse,
losing a job, or being incarcerated on criminal charges)

Indomitability of the human spirit

You can’t make a horse drink from the well

- Beneficence: moral obligation to act for the benefit of the patient; however, there are limits and
important to define boundaries
- Nonmaleficence: “to do no harm”
- must not knowingly provide ineffective treatments or act with malice toward a patient; not
about avoiding exposing a patient to the known or unknown risk, rather, the principle
suggests that a clinician’s bias for or against a particular type of treatment should be
informed by best practices, scientific research, and/or objective clinical experience.
- Nonmaleficence also applies to the selection of therapies, including medications that have
little empirical evidence to support their effectiveness.
- “the difficult patient” - Some clinicians might be inclined to discharge such a patient or to
transfer them to another clinician. While the patient has a personal responsibility, 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.

- Fidelity: being faithful or loyal to the duties and obligations of a caregiver to a patient, telling
the truth, keeping promises, confidentiality, be knowledgeable about addiction treatment, no
financial, clinical, or philosophical conflict of interest
 - Justice
 Society distributes goods and services—including medical goods and services—fairly.
 Clinicians will treat patients with equal conditions equally.

Dealing with Denial

Individuals in denial fail to recognize or are reluctant to acknowledge their problem or find ways to deny
or minimize the extent of their substance use because they are ambivalent about changing that use.
Denial may be about shame, guilt, and substance-induced distortion of memories

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 a compassionate and nonconfrontational manner.

Ordering Laboratory Tests

Must, or should, a patient’s consent be obtained before a drug screen is ordered?

- Patients expect to be screened for blood sugar and cholesterol, but they do not expect to be
screened for drug use.
- Ordering SUD labs has different implications
- Patient’s right to privacy. If the physician orders a test, the patient’s insurance company 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 necessary and appropriate for the health insurer
to have that information.

Older Age
- As we age, we become more sensitive to perceived threats to our autonomy.
- 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.
- 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 that they consume, thus interfering with the
therapeutic effects of the medications.

Resources for Resolving Ethical Dilemmas

- Consultation can involve peers, senior staff, or other providers within the community.
- Professional Standards or Codes of Ethics
- Legal Consultation with your malpractice insurer, hospital risk management, lawyers in state
addiction boards, pro-bono law groups or bar associations.