Bioethics and addiction treatment

(First of two parts)

We all know about codes of ethics. Nearly every clinical profession and organization of clinical practitioners has one. These codes are designed to provide clinicians with general guidelines for ethical conduct in their profession or within the ethical parameters deemed desirable by the professional organization. Ethics codes range in length from one page to hundreds, depending on the profession and organization. Ethics codes attempt to give clinicians a framework within which they can do what is morally right by their patients.

Although they provide general guidance, these codes do little to help clinicians in resolving specific situations involving ethical conflicts. That is the subject of this two-part article. I will attempt to provide one answer to this question: “I'm faced with an ethical dilemma; what should I do, and how do I make decisions about what to do?” I also hope to stimulate dialogue among readers about the ethical foundations of addictions treatments and how we, as a group of professionals, can more ethically serve our clients.

I won't be addressing ethics codes here. Rather, I'll be outlining and demonstrating one method of ethical decision making that has developed over the last 30 years, largely in the context of medical decision making but also applicable to ethical dilemmas faced by clinicians treating other problems. I will argue that if we are truly treating a “disease” as addictions clinicians, we need to begin to think about those it affects and the dilemmas raised by clinical practice in the same way we think about other diseases, such as diabetes, hypertension, and asthma. Addiction has at one time or another been likened to all of these chronic medical diseases, and that makes our clinical practice subject to the same ethics and need for systematic ethical decision making as that associated with other diseases.

In the first part of this article, I'll present a brief overview of the field of bioethics, followed by a closer examination of a particular version of bioethics: pragmatic bioethics. I'll do so in the context of asking readers to consider two very similar case scenarios from clinical bioethics that were developed by a bioethicist from the United Kingdom, Raanan Gillon. These cases highlight some of the difficulties that clinicians faced with ethical dilemmas confront in the interface among clinical practice, bioethics, and the law. Part two will bring the discussion closer to home by presenting and analyzing from a pragmatic bioethical perspective some actual ethical dilemmas in working with clients with addictions. I invite readers to correspond with me about these articles. I hope we can debate these very important issues not only in the context of these two articles, but on an ongoing basis.

Two cases

The two cases are variations on the same theme, and involve a conflict between deeply held values of a patient and recommendations by caring, beneficent clinicians for courses of treatment that conflict with the patient's deeply held beliefs.

In the first case, a competent adult patient who is a devout Jehovah's Witness loses a massive amount of blood from a bleeding ulcer. The best chance of saving his life is an urgent blood transfusion along with surgery to stop the bleeding. The patient refuses blood (consistent with the beliefs of his religion), but asks for an alternative treatment that uses non-blood products (note that this in fact is possible with today's medical technology) and surgery. He accepts the heightened risk associated with this course of action, in that surgery without blood is far less likely to save his life than is surgery with blood. What do his doctors do?

In the second case, a 2-year-old has lost a massive amount of blood as a result of a car accident, and the best chance of saving the child's life is a blood transfusion accompanied by surgery to stop the bleeding. The child's parents are Jehovah's Witnesses and refuse to give permission for a blood transfusion, but ask the surgeons to use the best available non-blood products to restore the child's blood volume and allow surgery to be carried out without blood. They understand the risks involved in this course of action, and that the best course from a medical perspective involves using blood. Nonetheless, they refuse to give permission for their child to receive a blood transfusion. What do the child's doctors do?

As you read the rest of this article, it might be helpful to think about these two cases and how the method I will present might be applied in helping to make ethically sound clinical decisions in each case.

A history of bioethics

Bioethics is an approach to applied ethics that developed in the second half of the 20th century in response to a number of developments, both humanitarian and scientific. Bioethics initially focused on research and the rights of research subjects. This focus grew out of the Nazi concentration camp atrocities, including experiments on inmates that led to their deaths or to lifelong disability. Subsequently it was revealed that similar, apparently exploitive, research also had been going on in the United States (e.g., the Tuskegee syphilis studies). Several national and international commissions issued reports in response to these revelations that detailed the rights of research subjects, specifically to informed consent and to protection from unwarranted risk and harm.

Also in the late 20th century, debates in the medical and wider communities about abortion, end-of-life issues, and allocation of scarce organs for transplantation resulted in a further development of bioethics that focused not only on research but on the right both to access and to refuse medical treatment—even treatment that could be life-saving.

Prior to the development of bioethics, clinical practitioners were governed by codes of ethics that were often based on a combination of historical tradition (e.g., the Hippocratic oath taken by medical school graduates) and ethical philosophy. Two major, and often conflicting, ethical approaches have dominated ethical philosophy since the 19th century: duty-based and consequentialist ethics.

Duty-based (or deontological) ethics was systematized by German philosopher Immanuel Kant. Kant's position, summarized in a maxim that has been called the “categorical imperative,” has two components. First, take no action that you would not want to be the basis of a universal law of how to behave in that type of situation. Second, never use human beings as a means to achieve an end.

Kant's approach quickly came under criticism, as indicated by the following case. You are standing on a street corner minding your own business, and a man carrying a new boom box runs up to you saying he is being chased by the police. He asks that when the police arrive you tell them he has gone in the opposite direction from the one toward which he now runs. You suspect he stole the boom box. Do you tell him you will follow his wishes? Do you tell the police the truth? If you tell the man you will follow his wishes and then you don't, you have lied—and lying, even for noble social purposes, is problematic at any time, according to the categorical imperative.

The second ethical approach that developed in part in response to Kant is consequentialist (often called “utilitarian”) ethics. Consequentialist ethics, as proposed by the English philosophers Jeremy Bentham, John Locke, and John Stuart Mill, holds that ethical decisions can be known by their consequences. Bentham's maxim that we should strive to have our decisions produce the “greatest good for the greatest number” exemplifies this position. The consequentialists have come under fire by those who believe in universal ethical principles and laws, as well as those who ask how “good” is to be determined—and by whom.

Attempting to base clinical ethical decisions on these two abstract ethical philosophies proved quite difficult, and these two approaches are largely relegated to academic philosophy today. The advent of bioethics resulted in clinicians and ethicists beginning to think about how these rather esoteric and often vague philosophical ideas could be effectively incorporated in day-to-day ethical decision making.

In the early 1970s, two ethicists at the Kennedy Institute of Ethics at Georgetown University, Thomas Beauchamp and James Childress, developed an approach to resolving clinical ethical dilemmas that has been called “principlism.” Principlism has grown into the dominant paradigm in bioethics, and has become central to clinical ethical decision making in medicine. Beauchamp and Childress, reacting against the vagueness and lack of practical utility in the dominant ethics approaches, suggested that all ethical dilemmas could be subsumed under one of four principles: autonomy (respect for the individual person's autonomy as a human being and decision maker), beneficence (trying to do good), nonmaleficence (avoiding doing harm), and justice (fairness and equity in providing care).1

Principlism represented a major shift in ethical decision making because it provided a framework within which clinicians could understand and address ethical dilemmas. However, principlism, like most approaches to ethics, came under fire from applied ethicists who advocated different but also practical approaches to clinical ethical decision making.

Casuists, represented most prominently by Albert Jonson and Stephen Toulmin,2 suggested that ethical decision making was best done by attempting to relate particular ethical dilemmas and situations to paradigm cases (the name “casuistry” refers to “cases”) and then adapting the paradigm case to the particular case as a way of making an ethical decision. Casuistry very much resembles the law, where decisions are often made by referring to prior court decisions or precedents and then applying the findings in those older cases to the current case.

The casuists presaged another emerging group of bioethicists who call themselves “pragmatic” bioethicists. Pragmatic bioethics, whose main proponents are Glenn McGee, a bioethicist at the University of Pennsylvania,3 and Franklin G. Miller, a bioethicist at the National Institutes of Health, is based on the American philosophy of pragmatism, which defines “truth” as being “what works” in a particular context or setting. Taking this idea of truth as a starting point, pragmatic bioethicists have developed a method for clinical ethical decision making that takes into account the four principles, as well as the specific facts of the case at hand, and examines them in the context within which that case is being decided. As a result, it is possible in pragmatic bioethics that two apparently similar cases might be ethically resolved in different ways. This happens because the pragmatic bioethicists have also adopted another idea from pragmatic philosophy: that community and decision maker consensus leads to the best understanding of truth (as what works) and gets closest to the best outcome in ethical decision making.

The method of pragmatic bioethics

Miller and colleagues have outlined a systematic method, based on the pragmatism of philosopher John Dewey, for making ethical decisions in clinical settings. A key assumption of their method is that there are probably no universally acceptable ethical principles that apply equally well in all clinical circumstances. They recommend that ethical decisions be made in a somewhat tentative and experimental fashion. That is, after using the method they outline, clinicians should then assess the effects of the decision, and be open to revising it if the outcome warrants it. This approach places them squarely in the consequentialist camp of ethicists, who evaluate the adequacy of ethical decisions based on their outcomes, as opposed to the duty-based ethics camp in which universal duties to others form the central core of ethical behavior.

This approach has led to criticism that pragmatic bioethics leads to situational ethics—that is, ethics that shift with the situation. However, pragmatic bioethicists point out that not every clinical situation is like every other. They also state that in today's multicultural world, clinicians are increasingly likely to encounter clients whose fundamental beliefs differ dramatically from the clinician's. Pragmatic bioethicists argue that because of the incredible diversity of religious and cultural views, attempts to apply universal principles—even if we could define what they are—are doomed to failure. Rather, they suggest that “the aim of moral problem solving is to reach a consensus solution that can withstand moral scrutiny with respect to the decisions made and the process of reaching and implementing them.”4

Miller and colleagues suggest that clinicians go through the following steps when addressing ethical dilemmas that arise in practice. This will lead to an ethically appropriate process that increases the likelihood that the ultimate decision will withstand “moral scrutiny”:

1. Assess the client's clinical condition.

2. Determine and clarify the clinical diagnosis.

3. Assess the client's decision-making capacity, beliefs, values, preferences, and needs.

4. Consider family dynamics and the impact of care on family members and concerned others.

5. Consider institutional arrangements and broader social norms that may influence client care.

6. Identify the range of moral considerations relevant to the client's case.

7. Suggest provisional goals of care and offer a plan of action, including plausible treatment options.

8. Negotiate an ethically acceptable plan of action.

9. Implement the agreed-upon plan.

10. Evaluate the results of the intervention.

11. Periodically review and modify the course of action, if necessary, as the case unfolds.

Several characteristics of the pragmatic method for ethical decision making bear highlighting. First, this is a collaborative decision making process in which the clinician, client, and concerned others collectively discuss and attempt to arrive at ethical decisions that are acceptable to all. Second, this approach is experimental, in that it leaves open the possibility that, as a course of action is implemented, the individuals involved may change and necessitate a revision of the plan derived from the initial negotiation.

In the second part of this series, I will attempt to show how the pragmatic method I've outlined can be applied first to the two cases I presented at the beginning of this article and then to two other cases involving ethical dilemmas frequently encountered in addictions treatment. I would urge you to think about the two cases I've presented in this article using the pragmatic method I've outlined. If you'd like to share your effort or discuss the cases further, please don't hesitate to contact me. I can be reached most easily by e-mail at fredro@pcom.edu.

References

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics ( 5th Edition ). New York City:Oxford University Press; 2001.
2. Jonsen AR, Toulmin S. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley, Calif.:University of California Press; 1988.
3. McGee G (ed.). Pragmatic Bioethics. Cambridge, Mass.:The MIT Press; 2003.
4. Fins JJ, Bacchetta MD, Miller FG. Clinical pragmatism: a method of moral problem solving. Kennedy Inst Ethics J 1997; 7:129–45.