Treating addicts for self-inflicted conditions: the ethical dilemma

WHEN 28-year-old Jerika Whitefield’s mitral valve was damaged by endocarditis, she needed life-saving surgery to repair it.

Before performing the surgery, doctors in her native Tennessee gave her a blunt warning: if she repeated the behaviour that had caused the infection in her heart, they would not save her again.

Whitefield, mother of three young children and a survivor of childhood abuse, had begun taking prescription opioids for endometriosis as a teenager, according to The New York Times.

In 2015, she went through a period of postpartum depression and began injecting crushed opioid pills and occasionally methamphetamine. One of those injections introduced the infection that nearly cost her life.

Increasing rates of opioid and methamphetamine addiction, especially in disadvantaged areas such as rural Tennessee, have led to an explosion of injection-related endocarditis, Knoxville cardiothoracic surgeon Dr Thomas Pollard told The New York Times.

Dr Pollard is a vocal advocate for improved addiction services but, like Jerika Whitefield’s doctors, he has made the decision not to perform a second operation on patients whose endocarditis returns as a result of continued drug misuse.

He is haunted by the case of a 25-year-old man whose heart valve he had replaced, only to see him return a few months later with two badly infected valves, including the new one, and a positive test for illegal drugs. Dr Pollard refused to operate a second time and the man died in hospice care.

The doctors interviewed by The New York Times acknowledged that financial issues can factor into a decision not to treat.

In the US, where many of the most disadvantaged individuals may not have access to health insurance, the costs can end up falling back on the hospital. Treatment for endocarditis can cost more than US$150 000, Dr Pollard told The New York Times.

Australia’s universal health insurance means that the issues are not quite as stark here, but the question of who “deserves” treatment can still be a live one.

Faced with a shortage of donor organs, many of us would instinctively feel that a non-smoker should get priority over an individual who smokes for a new lung, or an abstainer over a person with alcoholism for a new liver.

Australian guidelines are firm on this point, saying that “the fact that an individual may require a transplant due to lifestyle choices they may have made in the past is ethically irrelevant”.

But it isn’t always that simple. The guidelines go on: “However, ongoing substance abuse – including excessive alcohol consumption, cigarette smoking and illicit drug use – are generally considered contraindications to transplantation. These lifestyle factors increase the risk of poor transplant outcomes”.

For example, patients in need of a liver transplant as a result of alcohol consumption are generally required to be sober for 6 months before they will be accepted on to the transplant waiting list, the guidelines say. Their risk of recidivism will also need to be assessed.

It seems inevitable that some of those patients will die before they can complete the 6 months of abstinence. This has certainly happened in the US, where similar rules apply.

The guidelines do allow some latitude, but it’s worth considering how much such restrictions are influenced by our judgment of people struggling with substance misuse, and our reluctance to see addiction as a disease rather than a failing of character.

Would our moral outrage be triggered in the same way by somebody whose devotion to skiing led them to keep hitting the slopes, despite repeated injuries and against medical advice?

Where medical resources are scarce, as they are with donated organs, we obviously want them to go to those most likely to benefit, but working out just who that is will never be easy.

There’s no foolproof way to assess somebody’s risk of recidivism and, just because somebody has relapsed before, that doesn’t mean they will again.

I’m grateful that we don’t live under the American system, where lack of insurance can be the deciding factor, but we do face some of the same ethical dilemmas, especially when you consider the shortage of addiction services in many areas.

Jane McCredie is a health and science writer and editor, based in Sydney. You can find her on Twitter at @janemccredie.

 

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