Thinking and Acting Ethically

In Part 1 of this two-part article (November 2007 issue) I presented a brief history of bioethics and wrote about how one particular approach to ethical decision-making, pragmatic bioethics, might be applied to help resolve ethical dilemmas in addiction treatment. In Part 2 I want to bring a pragmatic bioethical focus directly to bear on some ethical dilemmas that frequently arise in addiction treatment.

In routine practice we often tend to ignore the ethical underpinnings of what we do. As counselors and therapists with a main aim of helping, we tend to see what we do as good, helpful, and ethically sound, particularly if we are following tenets and principles that our mentors and teachers have taught us. Among these tenets and principles are a focus on 12-Step philosophy as a centerpiece of recovery from addictive disorders, a focus on abstinence as the only acceptable goal for virtually all clients we treat, and a focus on helping people accept that they have a disease that corrupts their ability to make effective life decisions.

This focus on traditional tenets and principles occurs, I believe, because we have been taught that these tenets and principles are the most effective way of helping people resolve addictive behaviors, particularly ones involving substance use. We tend not to question these beliefs because they apparently have withstood the test of time, and besides, we see (at least with some clients, on occasion) that these tenets and beliefs seem to be a key to resolving problems associated with addictions.

I believe, and will argue here, that we should question these tenets and beliefs, not only in the interest of ensuring that we provide the best possible service to as broad a range of clients as we can, but also because ethical and moral practice demands that we do so. Certainly recent years have brought a plethora of research findings that bear on the validity and effectiveness of our strongly held beliefs—sometimes affirming them, but often suggesting that we might be of greater service to our clients by revising or abandoning them. For example, a recent article by William Miller and William White that reviewed the research literature on the use of confrontational techniques in treatment concluded that the evidence overwhelmingly shows no advantage at all for such techniques, and frequent negative consequences associated with their use.1 Yet, in many treatment programs (particularly therapeutic communities), these techniques are still a routine part of treatment. In this article I will present a case that ignoring this and other research not only makes our overall treatment of clients less effective, but is unethical.

Complex scenario

In what follows, I will refer back to the 11 steps proposed by the pragmatic bioethicists Fins, Bacchetta, and Miller to enhance ethical decision-making in clinical settings.2 These are presented in the table. Let's now turn to a case.

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Table. Steps in ethical decision-making (Fins, Bacchetta, and Miller, 1997)

Assess the client's clinical condition. Determine and clarify the clinical diagnosis. Assess the client's decision-making capacity, beliefs, values, preferences, and needs. Consider family dynamics and the impact of care on family members and concerned others. Consider institutional arrangements and broader social norms that may influence client care. Identify the range of moral considerations relevant to the client's case. Suggest provisional goals of care and offer a plan of action, including plausible treatment options. Negotiate an ethically acceptable plan of action. Implement the agreed-upon plan. Evaluate the results of the intervention. Periodically review and modify the course of action, if necessary, as the case unfolds.

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Suppose you are a counselor working in an outpatient substance abuse treatment facility that espouses a 12-Step approach aimed at lifelong abstinence as the primary outcome for clients. The agency has recently adopted Motivational Interviewing and is in the process of incorporating cognitive-behavioral approaches into its overall treatment program. Your program is located in a semi-rural area, and is the only reputable program within 50 miles. For this reason, it is often difficult to refer clients out. There are a few substance abuse counselors in nearby communities. They are all former employees of the program where you work.

Your client is a 30-year-old, married African-American male who reports a history of both heavy alcohol and cannabis use, both stretching back more than a decade. The alcohol use is the prompt for his seeking treatment, which he has done largely at the behest of his wife who, he tells you, has expressed concern to him as a result of several incidents in which he has gotten quite drunk and yelled at both her and their 4-year-old daughter. The client regrets these incidents, and is determined to change, as he loves his family. He also reports an increase in his consumption over the past year, one in which he was laid off from his job as a machinist and during which his family's financial status has been somewhat precarious. His wife has told him that she thinks he should stop drinking altogether.

The client reports that both he and his wife are Rastafarians, and use cannabis regularly both as a part of their religious practice and for their own pleasure and relaxation. He states to you that he is determined to reduce his drinking, but is not interested in quitting altogether, at least not for any prolonged period. Reduction of cannabis use is not a part of his goal for treatment, as it is an integral part of his religious practice and has not contributed, as he sees it, to his recent difficulties in any way. In fact, he asserts to you that his cannabis use has actually been a boon to him—helping him to relax during a time of high stress.

As you complete his intake, it becomes apparent to you that the client meets criteria for a diagnosis of alcohol dependence with physiological dependence, as well as cannabis abuse, and that both diagnoses have been applicable for more than a year. The alcohol dependence diagnosis, while clear, results from his acknowledging only four of the possible seven symptoms in the DSM-IV-TR. He reports family problems, medical issues that may be alcohol-related, and work issues, due largely to his having been laid off. He indicates that he saw a psychiatrist a few months back and was prescribed an antidepressant, but he stopped taking it after a couple of weeks when he did not feel any better.

During the intake interview, the client asks you several questions about your program. He asks what sort of success rates you have, as well as what your dropout rate is. He asks about how goals of treatment are selected, and what sorts of treatment approaches are available. He is particularly interested in whether your program will help him reduce his drinking and what that might entail. He indicates that he has tried on his own, unsuccessfully, but has heard about this organization called Moderation Management and wonders if you can help him connect with it as well as provide some specific tools for reducing his drinking.

In summary, you are faced with the following challenges in working with this client: 1) He wants to know more detail about your program than most clients ask about at intake; 2) He is adamant that abstinence is not his goal, yet your program adopts this goal as a requirement for all clients, and every counselor of whom you are aware in the area does as well; 3) There are indications that his alcohol use has affected members of his family sufficiently to prompt his wife to pressure him into treatment; 4) He asks about Moderation Management, a support group that has no face-to-face meetings in your area and about which you know only a bit (e.g., that it supports moderation for problem drinkers); 5) A child may be at risk from the client's behavior; and 6) His wife supports abstinence from alcohol, but not cannabis.

What are the ethical issues involved in this case? Before you read on, it might be helpful to put this article aside and jot down the ethical issues you believe this case raises. Then return to the article to see my discussion.

As you think about this client, it might be helpful also to think about how you will go about addressing the 11 points of the Fins, Bacchetta, and Miller process for ethical decision-making. How would you go about gathering information and talking with the client about the dilemmas involved? Would you invite his wife to participate? How would you address any legal responsibility in your state toward the client's child and the possibility of psychological or physical abuse?

As you think about these questions, let's examine the ethical issues I see in this case. Please note that I am not saying these are the only ethical issues, just ones that emerge from a bioethical analysis of the case based on the bioethical approaches I outlined in Part 1 of this article. I believe there are several important ethical dilemmas confronting any clinician who might see this client:

• Informed consent. Traditionally, addiction treatment providers (along with mental health providers who use largely psychotherapeutic approaches) have provided only a bare minimum of detail about important pieces of information such as what will happen in treatment, what the success and failure rates of the program are, what alternatives are available, and what happens if the program available is not what the client wants. In a recent informal survey of treatment programs that I have done, more than 80% of respondents indicated that they provided no information of this sort to clients seeking help at their programs. Given the fact that it is now well-documented that substance abuse treatment can both help and harm clients,3,4 ethical practice requires us to expand the degree of information we provide to clients before they begin treatment in order to allow them to make an informed decision as to whether to pursue treatment with us or to seek help elsewhere.

• Goal choice and client autonomy. It has been traditional in substance abuse treatment in the United States for the treatment provider to choose the goal of treatment with respect to substance use, and that goal is almost always lifelong abstinence. But what if a competent, non-intoxicated, non-confused client such as the one just described states that he needs help but that his goal with respect to his substance is moderation? What happens when a client who uses multiple substances wishes to address only one of them in treatment? In modern bioethics, the preeminent approach to such issues has been to respect a person's autonomy and right to make his/her own choices if the patient has not been deemed legally incompetent to make such decisions. This is certainly the case with respect to consenting to medical procedures that carry a risk of harm in addition to the possibility of benefit. Is a person seeking substance abuse treatment competent to make such decisions? How do we know?

• Clinician knowledge. How much responsibility rests with the clinician to be able to connect a client to services that are not among those the clinician believes are effective, or that the clinician is not familiar with or knows do not exist in the region where the client resides? Is it ethical, for example, for a clinician to insist over a client's objections that he attend 12-Step meetings for support if the client objects that he is not comfortable with the spiritual aspects and mentions of “God” in the meetings?

• Impact of treatment decisions on others—do they have a right to know? Clearly this client's family has been affected by his substance use. There has been risky behavior directed at both spouse and child, readily acknowledged by the client. Child protection reporting laws aside for a moment, what responsibility does the clinician have to this client's family? To what extent should the clinician become involved in addressing family members’ interests in the client's goals?

• Sociolegal concerns. The client uses and wishes to continue using, albeit for religious reasons, a drug that is illegal. Does the clinician have any obligation to the larger society in this respect? Is it a part of the clinician's role to attempt to convince the client to stop using cannabis, even though it is a part of his religious practice? This raises an even larger issue: How much of the clinician's role ethically involves protecting or attempting to protect the client from his own potentially harmful behavior?

More questions than answers?

I've outlined a number of ethical issues that I believe confront clinicians when they see a client such as the one I have described. I have not provided answers, only questions—questions I hope each reader will think about and address using the steps outlined in the table.

By implication, in writing this article, I am suggesting that as a field we have too long neglected the issues I am raising. I believe that, in this age of increasingly evidence-based practice, we do ourselves and our clients a disservice by failing to question both the scientific and ethical basis for our practice. I hope we can do better!

Frederick Rotgers, PsyD, ABPP, is an Associate Professor of Psychology at the Philadelphia College of Osteopathic Medicine. His e-mail address is fredro@pcom.edu.

References

1. Miller WR, White W. Confrontation in addiction treatment. Counselor 2007.
2. Fins JJ, Bacchetta MD, Miller FG. Clinical pragmatism: a method of moral problem solving. Kennedy Inst Ethics J 1997; 7:129-45.
3. Ilgen M, Moos R. Deterioration following alcohol-use disorder treatment in Project MATCH. J Stud Alcohol 2005; 66:517-25.
4. Moos RH. Iatrogenic effects of psychosocial interventions for substance use disorders: prevalence, predictors, prevention. Addiction 2005; 100:595-604.