Beneficence (Benefit)

According to Beauchamp and Childress (2001), the medical principle of beneficence emphasizes that treatment providers should act for the benefit of patients by providing competent, timely care within the bounds of accepted treatment practice. The principle of beneficence is satisfied when treatment providers make proper diagnoses and offer evidence-based treatments, that is, treatments drawn from research that provides statistical data about outcomes or from consensus-based standards of care. Beneficence is compromised when diagnoses are questionable or when outcome data do not validate a diagnosis or treatment. When MAT is carried out according to best-practice standards, the principle of beneficence is satisfied (Bell and Zador 2000).

Autonomy

Autonomy, like beneficence, springs from the ideal of promoting patients' best interests. However, whereas beneficence emphasizes the application of provider knowledge and skills to improve patient health, autonomy emphasizes respect for patients' rights to decide what treatment is in their best interests (Beauchamp and Childress 2001).

Standard medical practice places great value on patient autonomy. Usually, patients' and physicians' goals for treatment are identical, but, when they differ, physicians generally accord patients the right to make their own choices and accept the fact that patients' values may differ from physicians' values. For example, a physician might focus on extending a patient's life, whereas the patient might be more concerned with the quality of that life.

Exceptions to the principle of autonomy in standard medical practice are limited to circumstances in which patients' decisions might endanger themselves or others or in which patients may lack the capacity (because of physical or mental impairment) to make rational choices. Normally, standard medical practice does not permit an exception when patients make the “wrong” choice and the physician “knows better.” The physician may educate or perhaps attempt to persuade a patient but may not make decisions for the patient.

Nonmalfeasance—“First, Do No Harm”

The principle of nonmalfeasance emphasizes that health care providers should not harm or injure patients (Beauchamp and Childress 2001). Opioid treatment programs (OTPs) are on strong footing in terms of this principle. Before entering MAT, patients have been ingesting illicit opioids (and often other substances) and exposing themselves to serious health risks. Patients entering MAT are also at risk of arrest and imprisonment for illegal activities to support their addictions.

Once enrolled in OTPs, patients begin ingesting medications that have been manufactured in a regulated setting. The risks associated with injecting or otherwise ingesting substances of abuse produced under unknown conditions are gradually eliminated. Patients come under the care of professionals who monitor adverse drug reactions and attend to other health care needs. However, MAT carries risks of its own, including an increased risk of death in the induction phase of pharmacotherapy if medication dosage is not adjusted carefully (see chapter 5).

Justice

The principle of justice emphasizes that treatment providers should act with fairness (Beauchamp and Childress 2001). Sometimes this principle is expressed as the duty of providers to treat patients in similar circumstances equally and to use resources equitably. When treatment resources are limited, it may be unclear how to apply this principle in MAT. The principle of justice also applies when treatment providers consider the involuntary discharge of patients.

Besides emphasizing that clinicians should act fairly toward patients, the principle of justice imposes a responsibility to advocate politically and socially for resources (including adequate funding and better treatment by other medical providers) to meet the needs of patients in MAT.

Conflict Between Beneficence and Autonomy

A conflict arises between the principles of beneficence and autonomy when a treatment provider and a patient disagree about what is in the patient's best interest and how treatment should progress. Exhibit D-1 describes such a clash in which a provider believes that stopping all illicit drug use is feasible and in the patient's best interest but the patient disagrees or cannot comply. One or both of the following questions express the source of controversy:

• What is the proper balance between respect for a patient's autonomy and a provider's responsibility for that patient's health?
• Should the patient or the clinician decide what is in a patient's best interests?

Patients in MAT who stop their opioid abuse but not their abuse of other substances (i.e., “noncompliant” or “nonresponding” patients) are a major research focus. The literature is replete with studies of strategies, such as contingency contracting (see chapter 8), that use patients' dependence on their treatment medication to compel their compliance with treatment-related mandates. These strategies “are based on the assumption that patients have the necessary skills to produce drug-free urine samples but often lack sufficient motivation” (Iguchi et al. 1996, p. 315). Examples of mandates enforced by contingency contracting include adoption of and adherence to a drug-free lifestyle (Iguchi et al. 1997), attendance at additional therapy-related sessions (with or without a significant other) (Iguchi et al. 1996; Kidorf et al. 1997), and performance of employment-related tasks (Kidorf et al. 1998). Training in substance abuse treatment provides treatment providers with an awareness and understanding of patients' tendencies toward denial, minimization, and rationalization of their substance use. A working familiarity with such studies provides treatment providers with a reasonable basis to choose beneficence over autonomy when they conclude that they know better than patients what is in patients' best interest.

The conflict between beneficence and autonomy is not unique to MAT, but it is especially acute in MAT because of the fundamental power imbalance between treatment providers and patients. Patients in OTPs depend on their medication and may fear the effects of withdrawal from it. That dependence gives providers (and the principle of beneficence) the upper hand. Patients who refuse to comply with provider views of what is in their best interests risk administrative discharge or other sanctions. Until recently, only an OTP could provide patients with medication, ensuring the OTP's hold over patients. Often no other facility exists from which to obtain MAT.

Why do treatment providers in OTPs lean toward the principle of beneficence and away from the principle of autonomy in their approach to patients? The following factors may apply:

• A longstanding, complex regulatory system that favors a rule-governed perspective in OTPs
• Belief that patients in denial cannot act in their best interests
• Disagreement about goals between patients and treatment providers
• Attention to community concerns
• Effects of noncompliant patients on staff, patients in compliance, and new patients
• Discomfort with the disease model (see below)
• View of patients in MAT as failures
• Limited research examining the precept that complete abstinence is in patients' best interests.

Clinicians Who Are Uneasy With the Disease Model

MAT providers generally embrace the concept of addiction as a chronic relapsing disease; however, unlike medical professionals treating other chronic illnesses, some providers appear uncomfortable with the idea of alleviation of symptoms without cure (Hunt and Rosenbaum 1998, p. 202). These providers might draw on lessons from physicians caring for patients with other chronic diseases. How do they deal with noncompliant patients who fail to alter their diets or lifestyles, for example? Based on the disease model underlying comprehensive maintenance treatment, total abstinence may be unrealistic in the short run for some patients. When OTPs refuse to recognize that immediate abstinence is unrealistic and punish patients for the continuing but reduced presence of symptoms, they are not defining addiction as a disease. The long-term goal is always reducing or eliminating the use of illicit opioids and other illicit drugs and the problematic use of prescription drugs; but, in the short run, patients should be supported as they reduce their substance use.

Research suggests that many patients are aware that they may relinquish their autonomy when they enter MAT. A study about the attitudes of patients receiving methadone found that many see OTPs as institutions that control and punish more than they help—OTPs are agents of conventional society (Hunt and Rosenbaum 1998).

In the opinion of Bell (2000, p. 1741), “Patients need protection because many are reluctant to complain because they have a sense of powerlessness and do not want to jeopardize their treatment.” Providers at OTPs should be aware of any bias toward the principle of beneficence and away from the principle of autonomy. Rather than assuming that the tilt toward beneficence is always correct, treatment providers and administrators should ask themselves in each case whether they are striking a proper balance between these two fundamental principles.

Other Conflicts Among the Four Principles of Medical Ethics