Sound, ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for difficult or especially complex patients, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice.
Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, autonomous, responsible, developing, and fulfilled. Furthermore, the conditions we treat often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate such tremendous adaptation and strength as well. If all work by physicians is ethically important, then our work is especially so.
As a service to Focus readers, in this column we endeavor to provide ethics commentary on topics in clinical psychiatry. We also proffer clinical ethics questions and expert answers in order to sharpen readers’ decision-making skills and advance astute and compassionate clinical care in our field. This column focuses on ethical considerations in the care of people living with addictions.
Laura Weiss Roberts, M.D., M.A.
More than 23 million people in the United States suffer from addiction to alcohol or drugs, including abuse of illicit and prescription medications. Recent estimates suggest that an additional 1.2 million adults in the United States experience addictive gambling, a disorder just recently recognized in DSM-5. The National Institute on Drug Abuse estimates that the annual overall costs associated with abuse of tobacco, alcohol, and illicit drugs exceed $600 billion, including costs related to crime, lost work productivity, and health care expenditures. In addition, roughly 100 million adult Americans are affected by chronic pain, placing these individuals at risk for addiction to prescription medications and worsened disability.
Because addictions, by their very nature, interfere with an individual’s ability to resist a substance or negative behavior, many ethical issues related to autonomy, motivation, and personal agency arise in the care of people living with addictions. Because addiction is profoundly stigmatized, special issues surrounding confidentiality and truth-telling are also salient in the treatment of addiction. Because addiction treatment models have evolved from abstinence-oriented to harm reduction–oriented approaches, knowledge and attitudes about addiction care are not universally supported. This heterogeneity in expertise creates additional challenges in upholding clear and consistent standards of care across diverse settings and communities. Finally, because insufficient scientific attention has been given to addiction and because services are limited and inadequate, many social justice issues are inherent to addiction treatment at this point in history. Taken together, addiction care is more ethically complex than many other areas of medicine.
Questions
| 1–8. | Match the principle with the clinical ethics standard or goal in the treatment of addictions. | | A. | Autonomy | | | B. | Beneficence | | | C. | Compassion | | | D. | Justice | | | E. | Nonmaleficence | | | F. | Privacy | | | G. | Veracity | | | | _______ 1. Informed consent | | | | _______ 2. Certificate of Confidentiality | | | | _______ 3. Equitable access to treatment | | | | _______ 4. Mandatory random drug testing | | | | _______ 5. Pain relief | | | | _______ 6. A community-based program that provides sandwiches to patients | | | | _______ 7. Avoidance of drug-drug interactions | | | | _______ 8. Honoring a patient’s preference to decline HIV testing |
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| 9–12. | Match the ethics term with each clinical scenario provided below. | | A. | Therapeutic boundary crossing | | | B. | Therapeutic boundary violation | | | C. | Neither a therapeutic boundary crossing nor a violation | | | | _______ 9. A 46-year-old physician with alcohol dependence, now in remission, speaks with his patients about his past addiction issues. He tries to build rapport and an empathic connection, even with his most difficult patients, through this careful practice of self-disclosure aimed solely at advancing therapeutic goals. | | | | ______ 10. A 46-year-old physician talks with his patients about his observation that spirituality has been important in recovery from addiction for many of his patients. | | | | ______ 11. A 46-year-old physician tries to find out how to obtain illicit narcotics from his patients who present for buprenorphine treatment. | | | | ______ 12. A 46-year-old physician, with the patient’s permission, invites the patient’s spouse to an appointment to discuss the impact of addiction on their marriage. |
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| 13–14. | Identify the correct response for each of the following questions. | | | ______ 13. A 35-year-old woman comes to a new patient appointment requesting narcotic pain medication for chronic lower back pain, migraines, and menstrual cramps. She also requests antianxiety medications for panic attacks and, as she says, for “the posttraumatic.” The patient appears distressed and irritable. The physician performs a comprehensive history and physical examination and thoroughly reviews the patient’s medical records. The physician provides a 1-week supply of an anxiolytic and nonnarcotic analgesic medication. She offers emotional support, orders some additional laboratory tests, and requests to see the patient again in 1 week. Which of the following pairs of ethics principles best characterizes this physician’s approach? | | | A. | Beneficence, confidentiality | | | B. | Beneficence, justice | | | C. | Beneficence, nonmaleficence | | | D. | Beneficence, veracity | | | | ______ 14. A 72-year-old woman with a long prior history of addiction is hospitalized, awaiting transfer to the hospice unit. She has advanced cancer, which is now metastatic, and her physician has arranged for the patient to self-administer narcotic medication frequently and with an escalating dosage. The patient is at risk for respiratory compromise because of the medication aimed at pain relief. A member of the hospital treatment team is worried that the patient is “addicted” to the narcotic medication and that the patient could “kill herself,” placing the team at risk “for a big, big lawsuit.” An ethics consultation is requested. Which of the following is a likely response from the ethics consultant in this scenario? | | | A. | Pain relief, even with the risk for respiratory compromise, is ethically acceptable if the patient has consented to her end-of-life treatment and is decisionally capable. | | | B. | Pain relief, even in end-of-life care, can cause addiction and the self-administration of narcotic should be discontinued. | | | C. | Pain relief, in the presence of prior addiction, should be restricted to nonnarcotic medications. | | | D. | Pain relief using self-administered narcotics is always correct in the care of cancer. |
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| 15–17. | Match the term with the ethically salient goal in the treatment of addictions. | | A. | Harm reduction | | | B. | Zero tolerance | | | C. | Controlled use | | | | ______ 15. A strategy informed by the principles of respect for persons and nonmaleficence that seeks to minimize harm resulting from risky behavior associated with addiction | | | | ______ 16. A strategy anchored in autonomy in which the aim is to alter the use of a substance to a level that will minimize the likelihood of the most serious effects | | | | ______ 17. A strategy emphasizing paternalism in which only adherence to an absolute standard, such as total abstinence, is accepted and is supported in the clinical care model |
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| 18–20. | Indicate whether each statement pertaining to the care of patients with addictions is correct or incorrect. | | A. | Correct | | | B. | Incorrect | | | | _______ 18. Malpractice claims against psychiatrists can be related to negligent misdiagnosis of their patients living with addiction. | | | | _______ 19. Malpractice claims against psychiatrists can be related to inappropriate prescriptions for addictive medications to patients known to be susceptible to substance dependence. | | | | _______ 20. Accurate and complete documentation of informed consent for treatments, including medications with potential addictive properties, is important clinically and legally when caring for patients living with addiction. |
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Answers
1, A; 2, F; 3, D; 4, G; 5, C; 6, C; 7, E; 8, A; 9, A; 10, C; 11, B; 12, C; 13, C; 14, A; 15, A; 16, C; 17, B; 18, A; 19, A; 20, A.
Laura Weiss Roberts, M.D., M.A., Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
Address correspondence to Laura Weiss Roberts, M.D., Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5717; e-mail:
[email protected]Dr. Roberts reports that she is the owner of and investigator for Terra Nova Learning Systems.
Resources
Geppert CMA, Roberts LW (eds): The Book of Ethics: Expert Guidance for Professionals Who Treat Addiction. Center City, MN, Hazelden Publishing, 2008Google Scholar
Roberts LW, Hoop JG: Professionalism and Ethics: A Q & A Self-Study Guide for Mental Health Professionals. Arlington, VA, American Psychiatric Publishing, 2008Google Scholar
Roberts LW, Reicherter D (eds): Professionalism and Ethics in Medicine: A Study Guide for Physicians and Physicians-in-Training. New York, Springer, 2015Crossref, Google Scholar
