Addiction Ethics

July 28, 2011

Although women today make up nearly a third of those persons who abuse substances in the U.S. population, they have often been neglected in research and clinical care. Since the 1970s, increasing academic and governmental attention has been focused on the needs of addicted women. However, significant ethical challenges remain in the effort to provide compassionate, competent, and equitable treatment for women suffering from addictions.

Epidemiological background

In 1994, the United States Department of Health and Human Services estimated that 200,000 women died of illnesses related to drug abuse. The figure was more than quadruple the number of women predicted to die of breast cancer. Large epidemiological studies estimate that 4.4 million women had used an illicit drug in the month prior to being surveyed, and that half of all women 15-44 years of age have used an illicit drug at least once in their lives.

The media have offered often highly stigmatizing accounts of an epidemic of substance abuse among contemporary women. Although the scientific evidence does not support such a dramatic rise in alcohol and drug abuse among women, there are disturbing trends. Heavy drinking is increasing in younger women and students on college campuses, with women in the prime reproductive years of 21-34 having the highest rates of problem substance use. Seventy percent of AIDS cases in women are related to illicit drug use, and at least half are the result of sexual contact with a partner who is an intravenous drug user.

Ethical principles

There is a consensus among Western ethicists that respect for persons, autonomy, veracity, beneficence,

nonmaleficence, and justice are cardinal principles of modern medical ethics. These principles have received wide acceptance and are especially relevant to the ethical issues involved in the treatment and research of women with addictive disorders. Respect for persons requires that health professionals and researchers honor the fundamental dignity of each human being. Autonomy is self-determination, the ability of an individual to make her own medical decisions. Veracity is the obligation of the physician to tell the truth about medical conditions and treatment. Beneficence mandates that health professionals place promoting the good and avoiding harm of a patient or research participant above all other considerations. Nonmaleficence literally means to “do no harm” to the patient through medical care. Justice means that the burdens and benefits of prevention research and treatment must be distributed fairly and impartially.

Stigma

Stigma in the context of addictions has been defined as “a mark that sets a person apart linked to an undesirable characteristic leading to rejection.” Although men in nearly every society are heavier and more destructive users of substances, women have consistently been more highly stigmatized. Historically, women in many cultures have been acculturated to view the use of drugs and alcohol as behavior contrary to their role in society. These cultural expectations play a protective role in discouraging substance use. On the other hand, women who do use substances are disparaged and may be blamed for domestic violence or sexual trauma that befalls them in the context of substance use. In ethical terms, stigmatization fails to respect the intrinsic worth of women suffering from addictive disorders as persons. Stigmatization has contributed to the failure of the medical profession to fulfill the duties of nonmaleficence through adequate attention to issues of domestic victimization and social inequities that contribute to addictions in women.

Ethical dimensions of criminal justice system involvement

Women with addictions are frequently involved with the criminal justice system. Although in many cases this involvement is due to serious criminal behavior, in other cases it is due to the criminalization of addictive behavior. There is a growing trend toward diverting individuals with petty drug-related offenses from incarceration to treatment. However, this progress is opposed by punitive attitudes toward substance abusers, rooted in stigma as described above.

Beyond the stigma attached to substance abuse irrespective of gender, women have been punished for abusing substances under a double standard that treats them differently from men who abuse substances. During the last decade, state legislatures have taken punitive action against women abusing drugs during pregnancy, creating a climate of fear for those seeking help. A 1992 survey found that 150 women in 24 states had been prosecuted for drug use during pregnancy. Ethnic minorities were 10 times as likely to face charges. At least 10 states currently have laws that require mandatory reporting to child protective services of any newborn who tests positive for drugs. It is estimated that thousands of children have been removed from their mothers who were incarcerated rather than sent to drug rehabilitation.

Health professionals often experience ethical dilemmas when treating women who are involved with the criminal justice system. Reporting requirements (e.g., to a probation officer) may create a conflict between veracity (truthfulness) and nonmaleficence (the obligation to do no harm). Mandated treatment compromises autonomy and may seem disrespectful. For clinicians, the ethical mandate is to honestly negotiate with the patient a treatment agreement which acknowledges the constraints imposed by the legal system and professional ethics, and which is on the whole beneficial to the patient. Court-ordered treatment in fact tends to have significant positive consequences for the patient. Since documentation of treatment compliance is often a condition of release, such reporting can literally keep the patient out of jail. Such requirements moreover serve as a strong, albeit coercive, incentive to participate in treatment.

Special features of addiction in women

Fair (just) and effective (beneficent) treatment of substance use disorders in women requires adequate knowledge. In particular, it is crucial to understand how addicted women tend to differ from addicted men, rather than blindly to apply models that were developed for men. Social and environmental influences are strong determinants of addictive behavior in women. Many addicted women are involved with partners who abuse substances and frequently are also perpetrators of domestic violence. Without family system treatment, these women have a poor chance of recovering. Women are often without the job skills, income, or insurance that would enable them to access and afford health care. Many women with addictions are single mothers, yet few programs have childcare available. The highly successful 12-step approach, originally developed by and for white men, emphasizes the surrender of power. This model may be less appropriate and effective for women, and minority women in particular, who have been lifelong victims of exploitation.

Medical and psychiatric comorbidity in women with addictions is different from that found in men. Women become dependent upon substances more rapidly than men even though they tend to consume smaller quantities per body weight. Women also more quickly develop the medical sequelae of alcohol and other drug use for physiological reasons such as lower levels of the enzyme that metabolizes alcohol, and a higher percentage of body fat, which influences how long a drug remains active in the body. Liver disease, hypertension, cardiomyopathy, peptic ulcer, and anemia all have a more severe course in women. Women who abuse substances also have a higher rate of comorbid psychiatric disorders than men. Depression is particularly common and frequently precedes the substance abuse, suggesting that depression may play a causal role. A number of barriers to care have prevented addicted women from receiving appropriate and high-quality care for both addictive and psychiatric disorders.

SEE ALSO: Depression, Domestic violence, Informed consent, Mental illness, Pregnancy, Substance use

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