Addiction and medical ethics
I am writing on January 2, 2016. As is currently my habit, following a workout at the gym, I read the Saint Petersburg edition of the Tampa Tribune while I eat breakfast. Sometimes digesting food is not very compatible with reading the morning news. Actually, often it is not compatible. Stories of war, political campaigns, and all the other ways that we humans demonstrate our seeming need to bolster our own sense of worth at the expense of others and frequently in the name of the God of our understanding is not consistent with my body relaxing and digesting whatever food I am eating. In fact much of what we humans do is not consistent with our individual health or the health of the community. On most days there is one particular story or article which commands my attention. This morning it was an article by Keith Morelli of the Tribune staff headlined “Heroin’s surge raises medical ethics issue.” Mr. Morelli does an excellent job of describing an ethical issue faced by surgeons and other health care team members in Florida and, I assume, other states. Mr. Morelli reports:
“Cardiac surgeons are seeing a 50 percent increase in ineffective valvular heart disorders attributed to the use of dirty needles, said Scott H. Bronleewe, a cardiac surgeon practicing in Tampa for the past 26 years.
The cost is staggering: more than $500,000 for the procedure and hospital stay for an uninsured addict, many of whom are back on the operating table within a few months, suffering from the same infection.
Surgeons across the state, already stretched thin by the problem, are stepping back, saying they will operate on an addict once, maybe twice, but will draw the line at a third time.
‘We try to scare them’, Bronleewe said, ‘On multiple occasions we sit with families and read them the riot act. We tell them if you come back with a reinfected condition, you more than likely are going to die.’
Mr. Morelli goes on to report that Dr. Bronleewe goes on to say that the problem is increasing since the state shut down the pill mills ‘which were an easy way for addicts to obtain opiates.’
‘Most of Dr Bronleewee’s patients who fall into this category are opiates addicts, injecting either Dilaudid or heroin, he said.’
Mr. Morelli also talked to Dr. James Orlowski, chief of pediatrics at Florida Hospital Tampa and chairman of the hospital’s ethics committee. Dr Orlowski is also author of the 1999 book “Ethics of Critical Care Medicine.” He quotes Dr. Orlowski as saying, ‘It takes a lot of time, a lot of skill, and it’s expensive. If an individual isn’t going to change behavior and take responsibility for their life, the surgeon really doesn’t have an obligation to replace that heart value a second or third time.
Later in the article Mr. Morelli again quotes Dr. Bronleewee, ‘People have to take responsibility and help themselves and change their destructive lifestyle, he said.’”
First, let me apologize to the reader for so extensively quoting Mr. Morelli’s article. I am perfectly aware that the reader is able to find the article on line and read it for themselves. Even though it may seem like it I did not quote the entire article and do invite the reader to read it in its entirety. I am very appreciative of Mr. Morelli for writing the article and the Tribune for publishing it.
As a certified masters level addiction therapist, I am saddened with what appears to be the lack of understanding of the disease of addiction and the consequent lack of empathy. If I am reading the article with an open mind and if Mr. Morelli’s is accurate in his quotes, there seems to be little to no understanding of this disease and how completely it hijacks the life of the addict and all who care about him or her. This week I have talked with a family whose adult son had again relapsed and was terrorizing his parents. Not long ago this very fine young man had finally surrendered to the need for treatment. He went to a treatment facility and came home the son they loved and who had been missing in action for some time. He was the same kind, loving, smart young man he was prior to the addiction hijacking his mind and body. This young man has been hospitalized with acute kidney distress on more than one occasion. He was happy and proud to be a man of whom he could be proud. Yet, he was unable to allow himself to buy into a 12-step program or some other system which would provide the objective support he needed when the addictive messages returned to again take over his brain. Treatment does not erase the addictive history or messages. When normal life stressors arise, the old messages – the old habits of thinking and behavior – attempt to take over and the addict either runs to the supportive circle of a recovery group or any spiritual support group or he/she relapses. In this case the addict relapsed and now the angry, threating, inconsiderate, potentially dangerous addicted part of his brain has taken over the body of this young man and attempted to, once again, take over the life of the family. For the first time in the years of this young and the family living with this illness, the family knew that the son had to leave, go back to a treatment program, or start using the resources of a recovery program.
One of the problems, of course, is that alcohol and other abusive drugs (1)directly affect how the brain is functioning and (2) aggravate the already difficult condition of attempting to change a habit. There has been much research on the fact that where and how habitual patterns are stored in the brain makes them very difficult for we humans to change. Add to that how particular drugs affect the brain, it is easy to see that we are expecting the addict’s brain to make a rational decision when it is not capable of being rational. There are times when the addict feels so badly (is so sick and tired of being sick and tired) that he or she will follow the direction of another person, but this does not mean the brain of the addict is working in any way approaching normal logic.
In most states and overall in this country, the USA, the addict whose illogical brain wreaks havoc and/or breaks laws, he or she, if they live, go to prison. In a few prisons they may he offered treatment. Often they are not offered treatment. If they have acute medical conditions they may or may not end up in a medical facility before they die. They cannot, in most cases, be involuntarily committed to a treatment facility unless someone is convinced that they are going to commit direct and deliberate suicide in the very near future. Knowing that they are not able to think logically and are being self-destructive to the possible point of death, is not considered legal justification to commit them to treatment.
Neither the addict nor the family of the addict need to be “read the riot act.” If we humans could change behavior by being lectured to as bad people or lectured on our responsibility to take care of ourselves, we would not need change agents – medical doctors, mental health professionals, spiritual guides.
The issues we must address, in my opinion, are:
1. We do have limited health care resources and have to make difficult decision about who gets health care.
2. Health care decisions are currently often made in the context of for profit doctors, hospitals, insurance companies, pharmaceutical companies, and other health care professionals and treatment facilities. We need to revisit a single payer health care system.
3. We need to revisit payment for medical school which will allow us to revisit expectations regarding salaries of physicians.
4. We need independent studies by scientists unrelated to the drug industry to see how new drugs can be created, tested, and made available for a reasonable cost.
5. Families members of those addicted need respectful, loving support. At times, they may have to make difficult choices to protect the health of the other family members. This may include asking the member to leave and going to a treatment facility (assuming health insurance, availability of a bed in that facility) and/or going to a homeless shelter. They may even have to take out a restraining order. This is done out of love for the entire family and is excruciatingly painful. Family members will resist doing this a long as possible. Labeling them as co-dependent is not helpful.
6. Many treatment center are healthy and helpful. Many are not. Insurance companies may dictate what treatment centers are covered and for how long treatment is covered. Many very good treatment centers are not affordable for most people
7. Treatment centers often have long waiting lists.
8. We need to revisit states which dictate who can be committed. Revisiting these laws will not helpful if there are not sufficient beds available when needed, qualified, not compassionate staff who are trained in addiction treatment, and no way to pay for treatment.
9. One does not decide to become an addict. Many people will experiment with drugs, alcohol, or other addictions and will not become addicted.
10. We need to drop the arrogant, self-righteous attitudes which condemn some addiction and laud others. Addiction is the powerful, habitual, and compulsive desire to use power, money, sex, drugs (including alcohol), things, or something else outside ourselves to try to prove our worth and/or to avoid feeling as if we are not enough.
11. We all need to quit acting as if we have or know the answers. At this point none of the answers anyone proposes are working very well. A few individuals, families, and communities do get better in the current system, but most do not.
12. When we have to make choices about who gets care, let’s do so with compassion and deep sorrow.
A lot of the change would be painfully difficult and would require changes in core beliefs and how we think about and design all levels of our communities.
Written on January 2, 2016
I am writing on January 2, 2016. As is currently my habit, following a workout at the gym, I read the Saint Petersburg edition of the Tampa Tribune while I eat breakfast. Sometimes digesting food is not very compatible with reading the morning news. Actually, often it is not compatible. Stories of war, political campaigns, and all the other ways that we humans demonstrate our seeming need to bolster our own sense of worth at the expense of others and frequently in the name of the God of our understanding is not consistent with my body relaxing and digesting whatever food I am eating. In fact much of what we humans do is not consistent with our individual health or the health of the community. On most days there is one particular story or article which commands my attention. This morning it was an article by Keith Morelli of the Tribune staff headlined “Heroin’s surge raises medical ethics issue.” Mr. Morelli does an excellent job of describing an ethical issue faced by surgeons and other health care team members in Florida and, I assume, other states. Mr. Morelli reports:
“Cardiac surgeons are seeing a 50 percent increase in ineffective valvular heart disorders attributed to the use of dirty needles, said Scott H. Bronleewe, a cardiac surgeon practicing in Tampa for the past 26 years.
The cost is staggering: more than $500,000 for the procedure and hospital stay for an uninsured addict, many of whom are back on the operating table within a few months, suffering from the same infection.
Surgeons across the state, already stretched thin by the problem, are stepping back, saying they will operate on an addict once, maybe twice, but will draw the line at a third time.
‘We try to scare them’, Bronleewe said, ‘On multiple occasions we sit with families and read them the riot act. We tell them if you come back with a reinfected condition, you more than likely are going to die.’
Mr. Morelli goes on to report that Dr. Bronleewe goes on to say that the problem is increasing since the state shut down the pill mills ‘which were an easy way for addicts to obtain opiates.’
‘Most of Dr Bronleewee’s patients who fall into this category are opiates addicts, injecting either Dilaudid or heroin, he said.’
Mr. Morelli also talked to Dr. James Orlowski, chief of pediatrics at Florida Hospital Tampa and chairman of the hospital’s ethics committee. Dr Orlowski is also author of the 1999 book “Ethics of Critical Care Medicine.” He quotes Dr. Orlowski as saying, ‘It takes a lot of time, a lot of skill, and it’s expensive. If an individual isn’t going to change behavior and take responsibility for their life, the surgeon really doesn’t have an obligation to replace that heart value a second or third time.
Later in the article Mr. Morelli again quotes Dr. Bronleewee, ‘People have to take responsibility and help themselves and change their destructive lifestyle, he said.’”
First, let me apologize to the reader for so extensively quoting Mr. Morelli’s article. I am perfectly aware that the reader is able to find the article on line and read it for themselves. Even though it may seem like it I did not quote the entire article and do invite the reader to read it in its entirety. I am very appreciative of Mr. Morelli for writing the article and the Tribune for publishing it.
As a certified masters level addiction therapist, I am saddened with what appears to be the lack of understanding of the disease of addiction and the consequent lack of empathy. If I am reading the article with an open mind and if Mr. Morelli’s is accurate in his quotes, there seems to be little to no understanding of this disease and how completely it hijacks the life of the addict and all who care about him or her. This week I have talked with a family whose adult son had again relapsed and was terrorizing his parents. Not long ago this very fine young man had finally surrendered to the need for treatment. He went to a treatment facility and came home the son they loved and who had been missing in action for some time. He was the same kind, loving, smart young man he was prior to the addiction hijacking his mind and body. This young man has been hospitalized with acute kidney distress on more than one occasion. He was happy and proud to be a man of whom he could be proud. Yet, he was unable to allow himself to buy into a 12-step program or some other system which would provide the objective support he needed when the addictive messages returned to again take over his brain. Treatment does not erase the addictive history or messages. When normal life stressors arise, the old messages – the old habits of thinking and behavior – attempt to take over and the addict either runs to the supportive circle of a recovery group or any spiritual support group or he/she relapses. In this case the addict relapsed and now the angry, threating, inconsiderate, potentially dangerous addicted part of his brain has taken over the body of this young man and attempted to, once again, take over the life of the family. For the first time in the years of this young and the family living with this illness, the family knew that the son had to leave, go back to a treatment program, or start using the resources of a recovery program.
One of the problems, of course, is that alcohol and other abusive drugs (1)directly affect how the brain is functioning and (2) aggravate the already difficult condition of attempting to change a habit. There has been much research on the fact that where and how habitual patterns are stored in the brain makes them very difficult for we humans to change. Add to that how particular drugs affect the brain, it is easy to see that we are expecting the addict’s brain to make a rational decision when it is not capable of being rational. There are times when the addict feels so badly (is so sick and tired of being sick and tired) that he or she will follow the direction of another person, but this does not mean the brain of the addict is working in any way approaching normal logic.
In most states and overall in this country, the USA, the addict whose illogical brain wreaks havoc and/or breaks laws, he or she, if they live, go to prison. In a few prisons they may he offered treatment. Often they are not offered treatment. If they have acute medical conditions they may or may not end up in a medical facility before they die. They cannot, in most cases, be involuntarily committed to a treatment facility unless someone is convinced that they are going to commit direct and deliberate suicide in the very near future. Knowing that they are not able to think logically and are being self-destructive to the possible point of death, is not considered legal justification to commit them to treatment.
Neither the addict nor the family of the addict need to be “read the riot act.” If we humans could change behavior by being lectured to as bad people or lectured on our responsibility to take care of ourselves, we would not need change agents – medical doctors, mental health professionals, spiritual guides.
The issues we must address, in my opinion, are:
1. We do have limited health care resources and have to make difficult decision about who gets health care.
2. Health care decisions are currently often made in the context of for profit doctors, hospitals, insurance companies, pharmaceutical companies, and other health care professionals and treatment facilities. We need to revisit a single payer health care system.
3. We need to revisit payment for medical school which will allow us to revisit expectations regarding salaries of physicians.
4. We need independent studies by scientists unrelated to the drug industry to see how new drugs can be created, tested, and made available for a reasonable cost.
5. Families members of those addicted need respectful, loving support. At times, they may have to make difficult choices to protect the health of the other family members. This may include asking the member to leave and going to a treatment facility (assuming health insurance, availability of a bed in that facility) and/or going to a homeless shelter. They may even have to take out a restraining order. This is done out of love for the entire family and is excruciatingly painful. Family members will resist doing this a long as possible. Labeling them as co-dependent is not helpful.
6. Many treatment center are healthy and helpful. Many are not. Insurance companies may dictate what treatment centers are covered and for how long treatment is covered. Many very good treatment centers are not affordable for most people
7. Treatment centers often have long waiting lists.
8. We need to revisit states which dictate who can be committed. Revisiting these laws will not helpful if there are not sufficient beds available when needed, qualified, not compassionate staff who are trained in addiction treatment, and no way to pay for treatment.
9. One does not decide to become an addict. Many people will experiment with drugs, alcohol, or other addictions and will not become addicted.
10. We need to drop the arrogant, self-righteous attitudes which condemn some addiction and laud others. Addiction is the powerful, habitual, and compulsive desire to use power, money, sex, drugs (including alcohol), things, or something else outside ourselves to try to prove our worth and/or to avoid feeling as if we are not enough.
11. We all need to quit acting as if we have or know the answers. At this point none of the answers anyone proposes are working very well. A few individuals, families, and communities do get better in the current system, but most do not.
12. When we have to make choices about who gets care, let’s do so with compassion and deep sorrow.
A lot of the change would be painfully difficult and would require changes in core beliefs and how we think about and design all levels of our communities.
Written on January 2, 2016
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