Real Medicine Means Honoring Patient Choice

“Here’s a range of treatment options. What do you want to do?” That, according to Bruce Fuchs, the director of the Office of Science Education at the National Institute of Health, is what physicians today are likely to tell the patient. (Newsweek, Jan. 31 2005, p. 9). Presenting patients with a choice of treatment paths and letting the patient choose reflects the growing sense of responsibility that people have for participating in planning their own medical care. “Medicine is less paternalistic than it used to be,” said Dr. Fuchs in another recent interview. A lot of people “recognize they need to be more active participants in their health care.”

For the contemporary physician, giving the patient a choice is nothing less than an ethical obligation. The American Medical Association’s ethics advisor put it this way:

Each individual has the right to determine what medical treatment he or she will receive, including what life-sustaining treatment will be provided for a terminal condition. It is the physician’s responsibility to advocate for the patient’s right to choose any therapy, including alternative or nontraditional treatments, that reasonably may be expected to improve the patient’s quality of life. Source.

Breach of the doctor’s obligation to give the patient a choice of treatment options may constitute actionable negligence. One current text on the law of medical malpractice puts it this way:

In order to obtain the patient’s informed consent, the doctor must tell the patient not only about the alternatives that the doctor recommends, but also about all medically reasonable alternatives that the doctor does not recommend. A doctor does not comply with the duty of informed consent by disclosing only the treatment alternatives that the doctor recommends. Accordingly, the doctor must discuss all medically reasonable courses of treatment, including non-treatment, and the probable risks and outcomes of each alternative. By not discussing these alternatives, the doctor breaches the patient’s right to make an informed choice and effectively makes the choice for the patient. Source.

Giving the patient a range of alternatives and letting the patient choose is not merely a formal legal exercise. It’s good medicine. Behavioral scientists have long known that treatment which the patient chooses tends to work better than the same treatment when the patient does not choose it. The key is that choice enhances motivation. Source. “A fascinating study found that blood donors perceived significantly less discomfort when they were allowed to select the arm from which the blood would be drawn. The lesson is clear: people are happier and more comfortable when they believe they have some control over a process, particularly an uncomfortable one. Often the control handed over is largely symbolic (as in the choice of arm). In other cases, it’s very real: the medical profession has long recognized the value of allowing the patient to make an informed choice about alternative treatments for cancer and heart disease. These are extremely important, high-stakes decisions, and great value is gained by including the patient in the decision. He or she feels less helpless, less hopeless, and more committed to making the process work.” Source.

What does all this have to do with recovery from addiction? About ninety per cent of the current providers of treatment for addiction in the U.S. subscribe to the teaching that addiction is a disease, on a par with diabetes, heart disease, and cancer. But most of those same addiction treatment providers appear unaware of the basic ethical and motivational approach that real physicians today use in the treatment of patients with real diseases.

Real physicians give patients a choice of treatment options, including options that the physician doesn’t personally recommend. Rare is the addiction treatment program where this principle is observed. In most of them, “range of options” means only the choice between the “Big Books” of AA or of NA. Many treatment providers do not know that there are secular treatment and support group options, and when presented with this information, they do not want to hear it. Such counselors are incapable of conducting the kind of informed discussion of pros and cons of different alternatives that is required today in the real treatment of real diseases.

The real medical model of disease treatment requires obtaining the patient’s informed consent. Few and far between are the addiction treatment programs where informed consent is part of the professional vocabulary. Much more common in the addiction treatment business is the view that the addicted patient does not have the capacity to give informed consent, so that the treatment provider not only may, but must make the choice of treatments for the patient. Therefore, when the addiction patient asks about options or declines to follow the provider’s recommendations, the patient is “in denial” and the provider is justified in applying pressure until the patient “surrenders.”

In real medicine, the authoritarian, nonconsensual approach used in many addiction treatment programs today would be considered unethical, unprofessional, and liable to be prosecuted as malpractice. It’s high time that the addiction treatment field caught up with modern medicine and recognized that patients have rights, including the right to a choice of treatments. Giving patients a choice and involving them as participants in their own treatment yields substantially better results in the treatment of diabetes, heart disease, and cancer. Honoring the addicted patient’s choice among treatment alternatives will yield similar improvement in treating the disease of addiction.

Bush Taking the Axe to Recovery

The Bush Administration is in power for another four years, and the “Christian” right, which claims credit for the electoral win, is pressing to impose its agenda. I put Christian in quotes because I was raised in that religion, but I can’t match up what I learned as a kid with what I see this administration doing. Whom would Jesus bomb?

One of the first patients I met in a local psychiatric hospital ward, where I was doing a LifeRing meeting, was a woman with a nasty bruise in one eye and a bandage over her head. When her husband found out she was using heroin, he bludgeoned her with the family Bible until she collapsed. I’m concerned that the faith-based recovery agenda that the administration is now pushing with renewed vigor is coming from this same kind of moralizing and punitive outlook.

“Drug addiction is not a disease, it’s a SIN” read the sign over the door of a church-based addiction treatment center in Houston, one of the pilot programs established when Pres. Bush was Gov. Bush. Under the 1997 legislation Bush sponsored, church-based treatment programs in the state are exempt from licensing and inspection requirements of traditional centers. Addiction treatment professionals vigorously opposed the program. See May 2000 coverage in Washington Post. Now the faith-based Texas pilot program — despite atrocity stories featuring physical abuse of patients — is going national, under the label “Access to Recovery.”

The American chemical dependency treatment industry — more or less the only place where a person hooked on addictive substances has a hope of getting clinical therapy — is already in disarray. The Journal of Substance Abuse Treatment reported last year that about 40 per cent of the nation’s substance abuse treatment facilities had either gone out of business or reorganized during the previous two years, and that the turnover among treatment staff at all levels had reached the level of “extreme instability.” More than half of program directors surveyed nationwide had served in their positions less than one year.

Now add to this unstable mix a legion of well-meaning churchmen and women unsullied by clinical experience with addiction, and fueled by $100 million in federal vouchers. That’s the initial price tag of the administration’s faith-based “Access to Recovery” program; the projected total is $600 million. Thousands of people looking for recovery will be getting “treatment” in church basements and parish halls instead of in licensed clinics and counseling centers. Chances are that much of that “treatment” will consist of getting bludgeoned with the Bible — metaphorically, at least. At taxpayer expense.

NAADAC, the National Association of Addiction Professionals, rightly lobbied the administration to require that the new legions of faith-based providers be held to “the same set of licensure and certification requirements that secular counselors have adhered to for decades.” Those are the words of Jonathan Westin, NAADAC’s Director of Government Relations, writing in Addiction Professional. At last report, that won’t happen nationwide, any more than it happened under Gov. Bush in Texas. There will be no comparable licensure and certification requirements. For addiction professionals who have been struggling to raise the level of the field, including the compensation and status of counselors, the administration’s “Access to Recovery” has to be a bitter pill. “Taking the Ax to Recovery” is a more fitting name.

The backstory is that most addiction treatment programs have done little to deserve the label “secular” or to elevate the professional level of the field. About 90 per cent of the programs in the U.S. dispense the faith-based 12-step model. Too many treatment programs are happy to hire staff whose main professional qualification is their own recent recovery, and whose only professional reference is a phone call from their sponsor. They work cheap, and it’s unclear why they should be paid at all. The other month a counselor was telling me about the wonderful step study meeting he and his patients attended, and how step study would be the focus of their recovery work in the weeks ahead. That may be fine, but in what sense is this a “secular counselor”? Why should people pay for step study in treatment programs, when they can get it for free in AA?

In trying to take a stand on secular professionalism, NAADAC’s lobbyists are on slippery ground. There’s just not that much secular professionalism in evidence. If the administration’s legions of subsidized vendors of faith-based addiction “treatment” end up laying waste to the already shaken industry, as seems possible, it will be because the industry’s unhealthy dependency on the faith-based 12-Step paradigm has left the door open to precisely this kind of invasion. Cynics would say that “Access to Recovery” is nothing more than a $600-million government subsidy for the most Bible-thumping wing of the 12-step movement, which has never seen much value in clinical treatment anyway, other than as a funnel to fill the rooms.

The core reason for the disarray in the treatment industry, in my opinion, is that its dominant paradigm doesn’t work well enough to earn solid, sustaining public trust. You don’t have to parse the outcome statistics — deplorably scarce as they are — to see the pall that hangs over the industry. Prof. George Vaillant of Harvard, who is a Trustee of Alcoholics Anonymous, reported in his book The Natural History of Alcoholism that the success rate of his 12-step based model treatment clinic in Boston was no better than the spontaneous recovery rate among the untreated. Prof. Alan Marlatt of Seattle found that the most common outcome of treatment — which 90 per cent of the time means 12-step treatment — is relapse. That’s not to say there aren’t treatment success stories. I’m one of them. There are laudable islands of quality treatment, and I was lucky enough to have access to one. But the Big Picture is not confidence-inspiring. Faith-based treatment and faith-based support groups have had a virtual lock on the American recovery scene for about fifty years, but they haven’t made a dent in the addiction problem. If anything, substance abuse is more widespread, more severe, more costly, and more notoriously out of control than when the 12-step movement started.

In a sense, every addict can relate to what the Bush administration is doing here. The faith-based approach isn’t getting us off, so what’s needed is a stronger dose of the same thing. The “God as you understand Him” of the 12 steps is too wishy-washy; what addicts need is the God of the Ten Commandments. Recovering addicts aren’t straightening other addicts out fast enough; what’s needed is staff who’ve never given in to sin and can provide stern moral examples. The experiment has led to the same negative result ten thousand times, so we need to repeat the experiment again, but harder. And if that leads to terrible consequences, too bad. We’ve all been there.

It’s too early to predict the shape of treatment in 2008. But one thing is certain: in the next four years the case for a caring, rational recovery path such as LifeRing will become more compelling than ever. Wherever there is an action, there is a reaction. The comparatively mild faith-based approach of the 12 steps has always driven thousands of people away in search of an alternative. The hard faith-based approach that may dominate the next four years under Bush will drive away many more. They will be looking for another road, and we need to be there for them. In the treatment profession, the progressive crumbling of the dominant paradigm will lead some individuals to put their heads into the sand, hoping that change won’t occur if they don’t see it. Many others will be jostled into awakening, rethinking old assumptions, and looking for new ideas. This may be a bumpy period, but it will also be a period of great opportunity for moving forward and reaching larger numbers.