Ethical Issues in Substance Abuse Services

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Ethical Issues inSubstance Abuse Services

• Virginia Summer Institute for
• Addiction Studies

Michael A. Gillette, Ph.D. [phone]
mgillette_at_bsvinc.com http//www.bsvinc.com
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• Part One
• Method In Ethics

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Ethical Theory

• NORMATIVE ETHICS
• Utilitarianism (J.S. Mill) Always act so as to
  bring about the greatest good (happiness) for the
  greatest number.
• Deontology (Immanuel Kant) Always treat people
  as ends in themselves, never as a means only.
• Virtue Theory (Aristotle) Always act
  consistently with the standards of the role you
  play in life.

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Methods of Doing Ethics Theory and Casuistry
Theory Casuistry
THEORY
PRINCIPLES
EASY CASES
EASY CASES
HARD CASE
CASES
CASES
CASES
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The Five Rs REVIEW the situation and identify
the problem/area of need RESPOND to the
issues REDUCE the list of possible responses
RECAST the conflict RESOLVE the dispute and
clarify the confusion
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• Part Two
• The Application to Drug Court

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Ethical Challenges
Self Determination

• Mr. Y has completed his in-patient SA program
  and wishes to move back home where he will live
  with his brother. The family is supportive and
  has indicated that Mr. Y is welcome to return
  home. Mr. Ys brother is a suspected drug
  dealer, however, and staff members are concerned
  that this placement is not in Mr. Ys best
  interest.

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Paternalism

• An intervention is paternalistic whenever the
  justification for the restriction of an
  individuals freedom is calculated to be in their
  own best interest.
• Justified paternalism requires that the
  intervention is autonomy respecting.

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Background Assumptions

• Interferences with clients liberty of action
  are justified only when
• The client lacks the capacity for autonomous
  choice regarding the relevant issue
• There is a clearly demonstrated clinical
  indication for the treatment or restriction under
  consideration
• The treatment or restriction under consideration
  is the least restrictive alternative that is
  reasonably available and capable of meeting the
  clients needs
• The benefits of the treatment under consideration
  outweigh the harms of the interference itself

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Paternalism in Drug Court

• One consequence of respecting an individuals
  autonomy is that he/she must be held responsible
  for the consequences of his/her actions. This
  results in the possibility that an individual
  will be excluded from services if his/her choices
  are inconsistent with the goals of the program or
  create a significant risk of harm to others.

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The Ethics of Disclosure
But Were On The Team

• The CSB has been contracted to provide
  therapeutic supports for non-violent juvenile
  offenders, and as part of that work, two sets of
  charts are kept An Alcohol and Drug Services
  chart that is kept under the strictest of
  confidence, and a second chart to which probation
  officers have access. During a recent meeting, a
  consumers probation officer wanted to know if
  the therapist had information to suggest that any
  rules are being infringed by adolescents in their
  program. The parole officer had a clear
  expectation that information revealed in the
  therapeutic relationship would be shared with the
  parole officer. Should the parole officer have
  access to information relevant to the operation
  of the program?

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ConfidentialityBasic Values

• Privacy
• Honesty
• Identity

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ConfidentialityBasic Concerns

• Who Knows That I Am Receiving Services?
• Who Knows the Details of My Service Plan?
• Who Knows Other Facts About Me That I Reveal
  While Receiving Services?

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ConfidentialityBasic Concepts

• The "Need To Know"
• Defining "Need To Know"
• Obtaining Consent for Disclosure

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The Ethics of Disclosure
Recommendations

• We recommend that a formal understanding of
  the limits of confidentiality should be developed
  in writing.
• We recommend that the CSB should maintain
  strict clinical confidentiality to the limits of
  the law. Appropriate supervisors should
  determine what level of confidentiality applies
  (e.g. ADS standards) so that legal expectations
  may explicitly be communicated.

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The Ethics of Disclosure
Recommendations

• We recommend that while confidentiality
  should be protected to the limits of the law,
  standard justifications for disclosure of
  information should also continue in force (e.g.
  duty to warn third parties of threatened harm,
  reports of communicable diseases to the
  Department of Health, reports to the DMV of
  unsafe drivers, engagement in commitment
  procedures, etc)

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The Ethics of Disclosure
Recommendations

• We recommend that A) CSB staff members do not
  have an ethical obligation to report information
  about past crimes that is revealed during therapy
  and that doing so would likely violate clinical
  confidentiality unless a duty to warn exists, B)
  CSB staff members should not report information
  to parole officers concerning infractions of
  program rules that is derived from a clinical
  exchange unless a clear safety issue exists, and
  C) CSB staff members should not report
  information revealed during a therapeutic
  encounter that indicates staff misconduct unless
  the consumer provides consent for the disclosure.
  If the consumer does not provide consent, then
  the information of staff misconduct must only be
  revealed when a serious safety issue exists and
  then in the most general terms possible so as to
  protect the consumers identity if possible.

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The Ethics of Disclosure
Recommendations

• We recommend that legal issues are relevant
  to this discussion as well as ethical issues.
  Therefore, we recommend that legal counsel should
  be involved. We believe that if parole officers
  want access to our confidential records, they
  should be required to generate a legal
  justification for access. The CSB should
  continue to protect confidentiality as
  extensively as it can, consistent with current
  standards of practice and Federal, State and
  Local laws.

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BoundariesGive Him Another Chance

• Supervisor W was recently reviewing information
  regarding a number of students who are being
  dismissed from the program for failing to keep
  required appointments. Supervisor W realized
  that one of the students who is about to be
  dismissed is the grandson of old family friends.
  Supervisor W considers the possibility that he
  might be able to approach the student on a
  personal level, revealing his friendship with the
  students family, in order to encourage the
  student to become more engaged in services. Is
  there an ethical problem with using a personal
  relationship in this case to attempt to secure a
  good outcome for the student?

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SAS Dual RelationshipsI Thought You Were My
Sponsor

• Staff person S has agreed to be Staff person Ts
  sponsor. They have known each other for a long
  time, and the relationship seems to work well.
  On one occasion however, Staff person T confides
  in his sponsor and tells him that he recently
  relapsed. Staff person T is confident that he
  can overcome this setback, and he is asking Staff
  person S for support. After discussing the
  experience fully, Staff person S is concerned
  that Staff person T might have been high while at
  work. Worse yet, Staff person S is worried that
  Staff person T might be tempted to divert
  medications from some consumers for his own
  benefit. Although Staff person T does not have
  any evidence of medication diversion or dangerous
  work habits, he feels that he is in a moral
  dilemma. Does the duty of confidentiality as a
  sponsor outweigh the duty to maintain a safe work
  environment? Should Staff person S be more loyal
  to Staff person T, or to the facility in which he
  works?

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Dual RelationshipsThe Definition

• Dual relationships may be defined as situations
  in which care providers (staff persons) and
  consumers of services simultaneously maintain a
  therapeutic (or agency related) relationship and
  a conflicting outside relationship. A
  therapeutic (or agency related) relationship and
  an outside relationship shall be considered to
  conflict whenever the following two conditions
  exist (1) the care provider (staff person)
  plays the role of provider or supervisor of
  services to the consumer that involves access to
  information about or the exertion of control over
  the provision of services (2) the care provider
  (staff person) and consumer are involved in a
  hierarchical, dependent or influential
  relationship that is not part of the consumer's
  service plan.

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Dual RelationshipsThe Dangers

• Dual Relationships are dangerous because they
• Create the opportunity for the erosion of
  objectivity on the part of service providers
• Create pressure on consumers to act in accordance
  with staff wishes (loss of autonomy). This loss
  of consumer freedom may be the result of
  intentional manipulation or unintentional
  influence
• Create the opportunity for secondary gain on the
  part of staff, and thus create real or apparent
  conflicts of interest
• Create situations in which the authority of care
  providers may be eroded
• Create opportunities for the loss of
  confidentiality
• Support the development of double standards
  (other consumers lose trust or their care
  deteriorates)

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Dual RelationshipsSome Questions To Ask

• Is the consumer voluntarily engaged in this
  activity?
• Is this activity consistent with my role as a
  care/service provider?
• Is this activity available equally to all the
  capable consumers whom I serve?
• Do I experience secondary gain by engaging in
  this activity?
• Does the facility experience secondary gain by
  engaging in this activity?
• Is there significant opportunity for this
  activity to negatively impact on my ability to do
  my job?
• Is there a reasonable chance that the consumer(s)
  involved in this activity may misconstrue the
  nature of our relationship as a result of the
  activity?
• Is this activity something that I would rather
  other staff and consumers not know about even in
  general terms?
• Is this activity a reasonable part of the
  consumer's treatment/service plan?
• Have I spoken about this activity with my
  supervisor?

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Dual Relationships
But Im In Recovery Too

• Staff person W works in a small town in
  Virginia. He has been in recovery for three
  years, and recently attended an AA meeting where
  he planned to share his struggle to deal with the
  fact that his brother, who has only been in
  recovery for three months, has just moved in with
  him and created a disruption at home. Staff
  person W is concerned that the presence of his
  brother may hinder his own recovery. When Staff
  person W begins to share, however, he notices
  that a client from his program is at the meeting.
  What should Staff person W do?

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The Ethics of Patient RefusalThe Limits of
Provider Support
Optimal Care
Sub-Optimal/Super-Standard Care
Sub-Standard Care

• Staff never have an obligation to commit
  malpractice