(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.
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.