You are a psychologist, drug treatment counselor, and program manager in a mid-sized city, in an otherwise rural area, in a region devastated by the opioid epidemic.
You work at an outpatient center that administers daily doses of methadone that tempers withdrawal symptoms for those trying to end opioid addiction. Patients must come in each morning to get a supervised daily dose of medication and attend a group therapy session. There is more need than available treatment slots, so many patients have waited significant time while addicted before getting this chance for help.
This morning you have an appointment with 40-year old Jerome. Jerome is from the small minority African-American community in this otherwise heavily white area. Community advocates have complained that the African-American community is being ignored in the area’s response to addiction.
Formerly a plumber, husband of a school-teacher wife, and father of two, Jerome became addicted to prescription pain killers following a temporary back injury, eventually moving on to a variety of “street” opioids. He got off the waitlist into your program after losing his job, his marriage, and his child visitation rights to addiction. He was participating in your program until two weeks ago, seemingly doing well, when one morning he failed to report and did not return. Now he has been sent back to you after hospital emergency room treatment for an opioid overdose. Jerome begs for a second chance: “I almost made it; I almost made it. This time I will. I want my life back.”
In general, your program has about a 25% drop-out rate and a stated one-chance only policy, given the waiting list. You feel torn about what your response to Jerome should be. In fact, you have been inconsistent responding to patients who have dropped out and tried to come back, denying some and allowing others, depending on your view of chance for success. Given certain facts in Jerome’s history, you believe Jerome really needs inpatient addiction treatment for a reasonable chance of success. But the waiting list for the nearest in-patient facility is even longer; it is farther away geographically; and it disfavors patients with his minimalistic insurance. You feel pained that medical professionals contributed to Jerome’s initial slide into addiction. You also have the impression that racial discrimination may have played a role in delayed medical response earlier in the addiction process, although you can’t be sure of that. At the same time, you feel torn about how much to consider such factors, given that you have denied re-entry to otherwise very similarly situated white people desperate for treatment.
What should you do?
Discussion of Case: Confidentiality and duty to warn
Get the facts.
- How might you explore with Jerome what, specifically, triggered his recent return to opioids and overdose?
Identify ethical tensions.
- Different conceptions of justice may seem in tension with each other: consistent application of program rules for each participant, versus recognition of and desire to mitigate racial injustices that contribute to health inequities.
- Deny program re-entry consistent given with the stated one-chance-only policy and your lack of confidence in odds for success.
- Allow program re-entry, while making clear that any future relapses will result in permanent expulsion of the program.
- Refer Jerome to the waitlist for inpatient care despite your doubts about length of waitlist and financial disincentives to accept him, independently of decision on program re-entry.
Practice preventive ethics/systems issues --potential responses:
Reconsider the one-chance-only policy as a triage strategy in light of all available evidence about how people enter the program, and what factors contribute to ultimate success in addiction treatment. (For example, are people applying to the program with differential levels of previous treatment? What percentage of people seeking addiction services have relapses on the journey to complete recovery?) On balance, is the one-chance-only policy fair? The answer to that question determines whether one considers this as a case about considering exceptions to rules, or a case about something else.
Support health reform proposals that reduce disparities in insurance and access to care.
Participate in health professional/community-engagement with the local African American community regarding addiction support to bolster advocacy for addicted members of that community.