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Thinking and Acting Ethically

January 1, 2008
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Case scenarios uncover ethical dilemmas that haven't been given due attention in the field

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.

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

  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.