Ethical Treatment Of A Methadone Client In
A Public Detoxification Facility Essay, Research Paper
In order for a clearer understanding of the content of this paper I will provide the reader with a very brief history of substance abuse treatment in the United States.
The policy of this country, surrounding substance abuse, has always focused on either the illegality of the substance or in the case of alcohol, moralizing the way the substance is used.
There are two basic approaches to treating substance abuse in the United States today. By far the most popular is that in which total abstinence is the primary goal. This approach could be summarized as a confrontational technique. The client is told that their life is out of control due to the abuse and use of a chemical substance. In a harm reduction approach the client would be supported hoping that they would come to the conclusion and realization that their life is out of control due to use of a substance. Secondly that the substance is the central organinizing principle of their lives, meaning that the individuals focus in life has become obtaining and using the substance of their choice.
In the confrontational approach many tools are utilized: detoxification centers, inpatient substance abuse treatment, residential treatments facilities (half-way houses and therapeutic communities), individual and group counseling. Education is the keystone.
Most of these services focus on the Medical Model of addiction and the 12 Step Model of recovery, commonly referred to as Alcoholics Anonymous. The Medical Model encompasses the basic belief of the disease concept, that the alcoholic is biologically different from the non-alcoholic. The alcoholic, it is felt, can never safely drink any alcohol. In the disease concept, the person is viewed as unable to control drinking as opposed to being unwilling or weak. Although the individual is not blamed for his/her disease, he/she is thought to be responsible for behavior. We do not blame diabetics for
their diabetes but we expect them to control their diet and take medication. The alcoholic is seen to have responsibility for managing the disease on a day-to-day basis.
Again it must be emphasized that Alcoholics Anonymous is very closely linked to this model of treatment. Although these principles were first used to treat alcoholism, they have been widely accepted and used in the treatment of all individuals abusing substances.
But the larger question that is not addressed, especially in the United States is what happens to the estimated 90% of the substance abusing population that is not yet ready for the total abstinence approach?
For years now the Europeans have taken a different and less invasive approach. It is called Harm Reduction. The first priority of harm reduction is to decrease the negative consequences of drug use. Harm reduction establishes a hierarchy of goals, with the more immediate and realistic ones to be achieved as first steps toward risk-free use or, if appropriate, abstinence.
Drug-taking behaviors result in one of the three following categories; either beneficial (as in the case of life-saving medication), neutral or harmful. Assigning a positive or negative value – a benefit or a harm – to such effects is subjective and open to controversy, but a harm reduction framework at least offers a pragmatic means by which consequences can be objectively evaluated. It eliminates the anti-user bias when offering services.
These services include street outreach, education, health care services, access to treatment, and HIV risk reduction programs that focus on needle exchange and
methadone treatment of heroin addicts. All of these approaches build bridges between the actively addicted individual and providers of other health services. The hope is that the individual can be kept healthy until he or she is ready to deal with their addiction.
The two most controversial aspects of Harm Reduction are needle exchange programs (NEP’s) and treatment of heroin addicts with methadone. In an earlier paper I noted that the methadone treatment of addicts in a Relapse Prevention program I interned at, caused problems with peers in educational groups and staff members who were in recovery.
I would now like to address this issue from an ethical point of view.
A female client presents herself at a public detoxification facility for the express purpose of detoxifying herself from heroin. She is admitted to the detoxification unit. During her assessment process it is learned that she is also a client of a methadone program that is physically located within the same building. She has been recently relapsed, augmenting her daily methadone dosage with heroin for about 8 weeks. Simply put, she has relapsed to actively using heroin. She also expresses a desire to continue in her methadone program. The detoxification program is based on the Medical Model previously described, with a heavy emphasis on abstention. The Relapse Prevention Program, located within the same building, is also based on the 12-step recovery model based on total abstinence. It is actually an extension of the detoxification unit. It is located on the same floor, just down the hall. Clients such as this, in the past, have been allowed to continue with methadone and complete both programs. My peers on staff, in the past, have not been happy about this approach to treatment. Administration strongly
embraces the idea that this type of treatment be included as an option in the facility. She has been assigned to me for counseling as a client.
Option one; this client could be transferred to another facility that specializes in heroin withdrawal using methadone exclusively. This would be the most expedient solution, and it is their specialty.
Option two; the client could be kept through her detoxification process and then discharged back to her previous program. This would allow them to deal with her relapse. Again this is their specialty.
Option three; the client could be kept an allowed to complete the entire program at our facility. This would allow us to provide basic education to her about other choices of treatment modalities.
I want to keep this client at our facility for our entire program. I want to be sure that she is completely aware of the choice she has made regarding her treatment. I would like her to be exposed for a period of time to other addicts that have decided on different choices. This will happen through advanced educational groups that are provided on the unit and provide a safe place for her to be confronted by her peers with regards her treatment choice. Also education would be provided through interaction with peers in informal settings. I would provide her with support through this process. And will let her know that she has a right to decide on her own treatment plan, I will support her in this choice, be respectful of her decision, and advocate for her around this choice.
The Golden Rule
Confucius said, “What you do not want done to yourself, do not to others.”
Aristotle said, “We should behave to others as we wish others to behave to us.”
Jesus said, “As ye would that men should do to you, do ye to them likewise.”
Kantian ethics focus’s on this approach; doing what is right and establishing a universal standard or code of ethics and morals. Right must be done whether it brings happiness or not. Damn the consequences. Kant would admit her to the program. It is the right thing to do.
Now my peer counselors are up in arms. They perceive her to be a risk factor to some of the other clients who are committed to total abstinence. They are Utilitarians most definitely. Their ethics focuses on what brings happiness to the masses. (Even slavery was O.K. using this model because it maximized the good.) The Utilitarians want this client denied treatment in our facility and sent packing. They feel that her very prescience in the facility threatens the maximization of treatment for other clients.
So now there is an Ethical Dilemma. There is a clash between those members who strongly believe treating addiction according to principles that are accepted by most staff members. These are utilitarian beliefs. I embrace a Kantian philosophy and opt for the Harm Reduction Model. This agency is a public detoxification facility and the client has been admitted, an implied contract for treatment has been established. The agency now has an obligation to provide equal treatment to this client without discrimination. I have made a commitment to the agency to provide a service to its clients. I have been trained in ethics during my educational process and been provided with the Program Code of Ethics. I have an obligation to work within that code and treat all clients equally.
I feel strongly that about allowing this client to remain in this treatment setting using Methadone. I am hoping to create a bridge to the 12 Step Model if she is ready. I do not
dismiss lightly the fact that this will probably create some emotional issues for the direct care staff as well as for some of the clients.
All clients have a right to treatment. My client has a right to choose her treatment mode. She has a right to continue with her previously established treatment regimen. I will to the best of my ability provide a safe environment for my client. I will insist that the client is treated fairly. I must advocate for my client. She has a right to expect that advocacy. She has a right to confidentiality. The client is the single most important person involved in this transaction. I have examined my feelings surrounding this issue and I feel comfortable advocating for this client. If I was not comfortable and my issues began to impact I would ask my supervisor for help.
The Utilitarians see my client’s inclusion in the entire program as detrimental. They anticipate their personal discomfort. That discomfort comes from the fact that they are in recovery and believe only in the 12 Step Model. They believe they have the right to feel good and that my client is a threat to that feeling. Even though they know that all clients should be treated equally they feel that the greater good of the community supercedes that belief. They also feel that my client will threaten the comfort of their groups and this in and of itself is a good enough reason to deny participation. They feel strongly that for the good of the vast majority, themselves and their clients, this client should go someplace else for treatment. And for that purpose they feel that they have a right to impose their preferred values on the client and dismiss her right to treatment.
In applying Kantian ethics to this situation a breath of fresh air is allowed to blow through the treatment facility. By allowing the client to stay in treatment at this facility the professional staff is given an opportunity to grow. Valuable lessons about all clients
rights hopefully will take root. This should make it easier for the next client with circumstances of treatment that are viewed as different to gain help at this facility. Hopefully the staff will gain insight into their own feelings.
Most of all I think this will benefit the client also for the reasons previously listed on page 4.
Brown, S. (1985). Treating the Alcohlic: a developmental model of recovery New York, New York, Wiley Press