Medical Ethics Follow-up Q&A
The Governor’s Institute held its annual Addiction Medicine conference on April 8-10, 2021. Dr. James Finch, one of the conference Co-Directors, gave a timely and thought-provoking presentation entitled “What Can Medical Ethics Provide Clinicians in a Time of Change and Challenge”. He responds to a participant’s question below.
Q: Autonomy is the right to make poor decisions. If your patients are only free to do what you think is right…and as soon as they make poor choice you step in. Freedom is fundamentally the right to do dumb things. Please speak to this.
A: I believe you are correct to say that autonomy includes the right to make poor choices. Our job is not to convince the person to accept what we think is the right choice for them but to use our knowledge and experience to help them assess the risks and benefits (AKA: “beneficence/non-maleficence”) of the options so they can make a reasoned choice for themselves. Some medical ethicists even take the position that when there is a conflict between these core principles, autonomy takes precedence over the others, partly because of the uncertainties of knowing which choice will actually lead to benefit or avoid harm and partly because the patient is considered to be in the best position to apply those factors to themselves personally.
Applying this clinically, of course, gets tricky at times: It is generally accepted that one limitation on autonomy (or liberty or freedom) is that the person’s choice should not lead to harm for others. This proviso is so strong in medical ethics, that it underlies one of the few exceptions to confidentiality, the expectation that the clinician will notify others if the patient’s choices will put them at direct risk of harm.
Another limitation on autonomy is its reliance on rationality, that is, “reasoned choice” based on a knowledge of risks and benefits and free of “controlling interference”. As I discussed in my presentation, impairment of this aspect of autonomy can be obvious or subtle as we work with individuals with psychiatric or substance use disorders. This proviso is manifest in trying to avoid decisions when the individual is “under the influence” or allowing decisions by surrogates or even forced treatment in settings of clear impairment and danger of harm to self or others. Likewise, coercion, in spite of being criticized for its “controlling interference” is still widely used as a strategy to compensate for the impulsivity and “lack of control” inherent in addictions.
Finally, theoretical constructs aside, I believe your perspective is also clinically pragmatic: We now have plenty of evidence that individuals who are collaboratively engaged in their treatment goals are more likely to be “compliant” and more likely to benefit. We also know that it is more effective to “work through ambivalence” than to try to “break through resistance” and the most consistent association with positive treatment outcome is time in treatment. “My way or the highway” may work for a certain subset of individuals but it doesn’t make clinical sense as a primary mode of operation.
Thanks for the question.
Adapting SUD Models of Care Q&A
The theme of the recent Addiction Medicine 2021 Conference was SUDs and Their Treatment in the COVID Era: Adapting, Transitioning, Learning. Speakers were asked to address, whenever applicable, how COVID has impacted that area: what is the same and what is different and what have we learned that we want to take forward into the post COVID-19 world. Dr Michael Baca-Atlas, a member of the Addiction Medicine Planning Committee, presented on “A Clinician’s Perspective on Adapting and Changing SUD Models of Care”. He responds to a participant’s question that he didn’t have time to address.
Q: Shouldn’t the treatment agreement be structured so there is “a greater balance of power”, i.e. what are the obligations of the prescribing practice other than providing a prescription? Shouldn’t these considerations be part of the written treatment agreement? Things like return of phone calls within a specific time-frame, adjustment of doses in a timely fashion, response to portal communications within a reasonable time, reliable backup coverage when prescriber is off, etc…..basically an agreement by the prescribing practice to treat the patient respectfully and without stigma….instead of “agree to all this or no drug for you”?
A: Thank you for your question. I agree the agreement could/should be better structured to have as you mentioned, “a greater balance of power.” This might include information about not discharging or dismissing patients for unexpected/discordant urine drug screen results or if patients need a higher level of care the provider will assist in arranging the transition. Hopefully, treatment agreements will also include language about virtual care and maybe worth considering changing the name to “treatment plan” instead of agreements or contracts. Language matters and helps reduce stigma!