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Medical Ethics in Addiction Medicine
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Introduction
The American Society of Addiction Medicine (ASAM) has adopted the American Medical Association’s (AMA) Principles and Code of Medical Ethics (“the Principles”) that guide physicians in the ethical practice of medicine.1 In prefacing the Principles, the AMA describes the complex relationship between ethical values and legal principles, and acknowledges that laws sometimes permit or even mandate ethically unacceptable conduct.2 Given that criminal-legal consequences can be associated with substance use, and that stigma and discrimination surround addiction and its medical treatment, addiction specialist physicians (ASPs)3 face unique and difficult professional ethical challenges that are not addressed by the Principles, specifically. Thus, this statement elucidates the Principles to help guide ethical decision-making in the clinical practice of addiction medicine. In general, ASAM believes many of these recommendations can apply to any physician or other healthcare professional engaged in addiction treatment, even if not an ASP.
Principles and Recommendations
AMA Principle of Medical Ethics 1: A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
1.1. ASPs should provide high-quality, evidence-based care that is respectful of and responsive to individual patient preferences, needs, and values.4 Such person-centered care requires engaging in shared decision-making with patients about their care, which should be holistic, empowering, trauma-informed, and culturally safe.5,6 This includes acknowledging individuals’ preferences when abstinence is not a goal. Therefore, ASPs should refrain from abruptly discontinuing treatment based solely on disagreement with the patient over the treatment plan, patient lack of progress, or return to use. Instead, continuation of a patient’s treatment should be based on careful consideration of its benefits and risks, including the safety of the patient and clinical staff, and possible legal consequences.
1.2. Drug testing is one component of evidence-based addiction care that assists ASPs in assessing, diagnosing, treating, and supporting patients’ remission from addiction. The appropriate use of drug testing as part of evidence-based medical care requires specific training and consultation with relevant, current medical society guidelines. ASPs should not use drug testing or its results as a punitive measure, including to discontinue a patient’s treatment or to remove a patient’s access to medication for addiction treatment, based on the result from any drug test alone.
1.3. Sometimes addiction treatment is offered as an alternative to criminal-legal or other sanctions or provided to individuals on an involuntary basis; nevertheless, ASPs should seek to engage such patients in decision-making and to respect patient preferences. In addition, ASPs should oppose civil commitment proceedings for a patient with substance use disorder (SUD), unless a) the ASP personally conducts an individualized, clinical assessment of the patient and determines that civil commitment is in the patient’s best interest, consistent with the AMA Principles and Code of Medical Ethics; b) judicial oversight is present to ensure that the patient can exercise their right to oppose the civil commitment; c) the patient will be treated in a medical or other health care facility that is staffed with medical professionals with training in the field of substance use and mental health disorders, and the patient’s treatment in such facility includes access to continuous treatment with all Food and Drug Administration-approved medications for SUD, including withdrawal management, as prescribed by the ASP; and d) the facility is separate and distinct from a correctional facility.7
1.4. Before an ASP discloses a personal history with addiction to their patient, they should decide whether self-disclosure, and what degree of self-disclosure, would be beneficial to the patient. In addition, ASPs should consider that the self-disclosure creates risk of adverse consequences to the patient, for instance, by undermining the clinician-patient therapeutic alliance.8–11
AMA Principle of Medical Ethics 2: A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to advocate for patients, even when that involves reporting a colleague who is not competent, is impaired or engages in fraud or deception.
2.1. As a general principle, ASPs should seek to be free of conflicts of interest, especially those that are financial in nature, and should independently set clinical service fees, striving to ensure such fees are not exploitative. ASPs should prioritize improving patients’ wellbeing over improving their own or their employers’ financial status, including refraining from soliciting testimonials from patients actively undergoing addiction treatment (to limit the risk and impact of coercion) for use in marketing and for referrals.
2.2. As a general principle, patients’ clinical needs should guide ASP’s approval of any treatment plans, including in court-mandated settings. ASPs should decline to approve any plans that are unreasonable, unnecessary, or do not align with the evidence, including inappropriate use of ancillary services, such as neuroimaging, toxicology, and genetic testing.
2.3. ASPs should perform drug testing only when clinically necessary. ASPs should strive to make independent and autonomous clinical decisions to perform drug testing, including in fear-inducing, high-pressure criminal-legal contexts. Drug testing has been overused in addiction treatment for the purposes of profiteering; thus, ASPs should consider the costs of different testing methods and their financial burden on insured and uninsured patients. ASPs should also be cognizant that billing trends for certain covered benefits can provoke insurers to implement restrictions in coverage of such benefits. Additionally, excessive drug testing can be burdensome, stigmatizing, and can reduce treatment participation.
2.4. ASPs should report patients’ treatment outcomes accurately, whether for use in marketing, scientific research, or quality measurement, thereby providing valuable data to inform evidence-based practice and promote social good.
2.5. It is ethical to use contingency management (CM), an evidence-based behavioral therapy based on operant conditioning principles that provides or removes rewards from patients – sometimes based on the results of drug tests – to incentivize and sustain behavior change in addiction treatment.12,13 While some policy barriers exist to implementing CM, ASPs that use CM should strive to implement it with fidelity.14
AMA Principle of Medical Ethics 3: A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
3.1. To reduce stigma associated with substance use and SUD (a treatable, chronic health condition), ASPs should advocate to shift laws and regulations regarding personal substance use away from approaches based on assumptions of criminality and towards public health approaches prioritizing treatment, health and wellness, including supporting changes to increase patients’ access to evidence-based treatment and harm reduction interventions.15
3.2. ASPs should advocate to shift laws so that abstinence from drugs or engaging in counseling for SUD or SUD treatment is not a precondition to access medical care; social benefits, including education, food and housing; or support services.15
3.3. ASPs should have knowledge of applicable state laws where they live and practice that may require reporting of the results of drug tests of the birthing parent-infant dyad who use substances for criminal-legal or otherwise punitive purposes,16 and advocate to change such policy and practice, as it discourages pregnant people from seeking addiction, prenatal, and other care, and can lead to worse pregnancy as well as health outcomes for the birthing parent-infant dyad.
AMA Principle of Medical Ethics 4: A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
4.1. As with all medical records, ASPs should protect addiction treatment records, including the identification of a person as a patient receiving addiction treatment, with extreme care. Confidentiality is critical to a trusting and successful clinician-patient treatment relationship.
4.2. ASPs should base decisions about a patient’s treatment, referral, and reporting on medical evidence, in accordance with applicable laws; such decisions should not be influenced by a patient’s race, ethnicity, legal/justice system involvement, religion, immigration status, age, sex, gender identity, sexual orientation, socioeconomic status, or other personal or demographic characteristics that are independent of a patient’s medical status or treatment needs. ASPs should work to dismantle existing, significant structural barriers to accessing care.
4.3. ASPs should assist patients as they deem appropriate, for example, with social benefits. However, ASPs should neither give legal advice, nor act as legal counsel, to patients. ASPs should support patients in seeking legal counsel if appropriate.
4.4. ASPs should perform drug testing on birthing parent-infant dyad after obtaining written, informed consent, during which the ASP should disclose existing reporting requirements to the patient, prior to drug testing. ASPs should take appropriate steps to ensure that the results of such drug tests remain confidential to the extent permitted by law. Ethical dilemmas arise when governmental entities require clinicians to share drug testing results without a patient’s consent, especially when laws require reporting of drug test results from the birthing parent-infant dyad to child welfare agencies or criminal justice-legal personnel. In these fear-inducing, high pressure situations, ASPs should strive to make independent and autonomous clinical decisions. ASPs should be fully cognizant of the adverse consequences of such reporting to the birthing parent-infant dyad. Moreover, in such cases, ASPs should only disclose the minimum amount of information necessary under law. Furthermore, ASPs who disclose such results under statutory mandates should advocate for their patient when third parties take adverse actions against the patient based on drug test results, especially from samples that were not collected or handled according to procedures that meet forensic standards.
AMA Principle of Medical Ethics 5: A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
5.1. ASPs should be aware of subtle and overt sponsorship of continuing medical education (CME) courses and should seek professional training opportunities that are free from conflict and other bias.17,18 ASPs should not rely solely on accreditation as evidence of freedom from commercial bias.
5.2. ASPs should ensure patients are supplied with up-to-date information about the full range of evidence-based treatments for each clinical indication and SUD.
AMA Principle of Medical Ethics 6: A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
6.1. While recognizing the value of long-term clinician-patient relationships that have developed mutual trust, ASPs are often called on to maintain therapeutic boundaries in the treatment relationship. Therefore, ASPs should be cautious when considering providing treatment to someone they know personally. While such dual relationships are not categorically unethical, such as when patients have no other option to access treatment, the potential harm that could be caused to patients (and clinicians) in treatment that is provided within the context of dual relationships should be openly acknowledged and discussed.
AMA Principle of Medical Ethics 7: A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
7.2. ASPs should consider and support interventions that reduce risk and morbidity for the wider community and support public health measures that reduce substance use-related harm in a community (e.g., naloxone distribution, syringe service programs and overdose prevention sites19 where permitted by law).
7.3. ASPs should widely support evidence-based prevention interventions to improve communities and better public health.20
AMA Principle of Medical Ethics 8: A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
8.1. ASPs should consistently base assessments of patients on multiple indicators of their stability and wellbeing. While drug testing may seem like a straightforward and efficient means of assessing patients, drug tests provide only limited information on substances a patient may have used in a brief window of time, and an overreliance on drug testing of patients, especially over the long-term, can undermine trust and the therapeutic alliance in the clinician-patient relationship. ASPs should use drug testing as one monitoring tool among many, which is especially important in fear-inducing, high-pressure criminal-legal contexts where drug testing may be prioritized over more holistic assessments of stability and well-being.
AMA Principle of Medical Ethics 9: A physician shall support access to medical care for all people.
9.1. ASPs should advocate for their patients and policies that make evidence-based addiction care, including the use of medications for addiction treatment, available as a component of medical care, to all in need, including individuals in prisons, jails, drug courts, child protection systems, on probation or parole, and those without health insurance.15 ASPs should advocate against laws, regulations, organizational policies, and health plans’ coverage that place arbitrary or non-evidence-based restrictions on how addiction care is delivered.
9.2. ASPs should not make patients’ access to evidence-based addiction care contingent on participation in other activities, such as counseling or peer support groups, including the use of medications for addiction treatment.
Adopted by the ASAM Board of Directors on April 3, 2024.
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