The American Journal of Bioethics

ISSN: 1526-5161 (Print) 1536-0075 (Online) Journal homepage: http://www.tandfonline.com/loi/uajb20

Balancing Beneficence and Autonomy Claire D. Clark & Michael F. Weaver To cite this article: Claire D. Clark & Michael F. Weaver (2015) Balancing Beneficence and Autonomy, The American Journal of Bioethics, 15:7, 62-63, DOI: 10.1080/15265161.2015.1042717 To link to this article: http://dx.doi.org/10.1080/15265161.2015.1042717

Published online: 06 Jul 2015.

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Date: 15 October 2015, At: 14:42

The American Journal of Bioethics, 15(7): 62–68, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2015.1042717

Case Commentaries

Balancing Beneficence and Autonomy

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Claire D. Clark, University of Texas Health Science Center at Houston Michael F. Weaver, University of Texas Health Science Center at Houston The disagreement between the psychiatric consultant and orthopedic team arises from their conflicting interpretations of the ethical principles of patient autonomy and physician beneficence in treating Mr. Huggins, a surgical patient with alcohol use disorder (AUD). Should a health care provider’s beneficent motivation to address Mr. Huggins’s AUD take precedence over the patient’s desire to drink beer in the hospital? Rather than strictly privileging patient autonomy—an approach that would support both the continuation of the beer service and uncritically honor Mr. Huggins’s initial disinterest in alcoholism treatment—we argue that the relative importance of physician beneficence and patient autonomy should ideally evolve over the course of the patient’s treatment. In our opinion, beneficence (the physician’s responsibility to act in ways that provide the greatest benefit for the patient) is initially more important than Mr. Huggins’s autonomy during this hospitalization. Allowing Mr. Huggins to continue to drink beer in the hospital poses short- and long-term health risks, as we describe in the following. Beneficence dictates that the patient should receive appropriate monitoring and medication for treatment of alcohol withdrawal, due to both the serious consequences of alcohol withdrawal and the acute risks of receiving beer during the hospitalization. Later in Mr. Huggins’s hospitalization, after the more immediate issues of the prevention or treatment of alcohol withdrawal have been appropriately addressed, the issue of autonomy becomes more important. After stabilization, Mr. Huggins’s autonomy can be appropriately respected and he can be given the choice to decide whether to resume drinking alcohol after he has been discharged from the hospital, or to seek additional help for treatment of his AUD. The orthopedic team might argue that, in addition to upholding Mr. Huggins’s desire to continue drinking during his hospitalization, the beer prescription prevents alcohol withdrawal syndrome (AWS), a potentially fatal condition. But there are safer and more effective alternatives to beer. Both benzodiazepines and barbiturates, which are different classes of sedative–hypnotic medications, are cross-dependent with alcohol and effectively treat alcohol withdrawal, even in patients who also have

other surgical or medical illnesses (Weaver 2007). There are no controlled trials evaluating the safety or relative efficacy of using ethyl alcohol itself—either compared to placebo or benzodiazepines or barbiturates—for management of alcohol withdrawal. Given the proven efficacy and safety of benzodiazepines, the use of alcohol for detoxification is strongly discouraged by authorities such as the American Society of Addiction Medicine. The best available research suggests that benzodiazepines or barbiturates, not beer, provide the greatest medical benefit to patients at risk for AWS. The ethical principle of nonmaleficence (the duty to avoid doing harm to a patient) is closely related to beneficence. While the orthopedic team believed that continuing the beverage service would not significantly interfere with the outcome of the surgery, beverage alcohol in the form of beer, even when administered in a hospital setting, causes multiple detrimental effects. It is an intoxicant that can impair judgment and interfere with the capacity to make health care decisions, especially at higher doses. Alcohol is a gastrointestinal irritant that can cause gastritis or peptic ulcers, which can lead to surgical complications if Mr. Huggins develops vomiting or gastrointestinal bleeding. Acute and chronic alcohol ingestion causes immune system dysfunction through a variety of mechanisms, which also increases Mr. Huggins’s risk of postoperative complications such as infection or poor healing. Surgical patients with AUD are more likely to have postoperative complications or even require repeat surgery. In this case, nonmaleficence dictates that harm can be avoided by not providing beer to Mr. Huggins. While Mr. Huggins may not initially express interest in substance abuse treatment, AUD is a serious health condition that may complicate both his surgery and quality of life. When AUD is identified by a clinician, it is often accompanied by medical/surgical or mental health problems as well as social consequences. Behavior problems may occur in hospitalized patients with AUD, including surgical patients, and manifest as agitation, sleep disturbances, and verbal abuse (Williams et al. 2008). Addressing drinking behavior in a hospital setting can prevent additional consequences for the

Address correspondence to Michael F. Weaver, MD, Department of Psychiatry, University of Texas Medical School at Houston, 1941 East Road, Houston, TX 77054, USA. E-mail: [email protected]

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Prescribing Beer for Hospitalized Patients With AUD

patient. The American College of Surgeons Committee on Trauma mandates routine screening for AUD at trauma centers because interventions for alcohol problems can reduce subsequent alcohol-related injury and are cost-effective (Gentilello et al. 2005). A psychiatric consultant can address acute issues of intoxication and withdrawal in the inpatient setting. Additionally, hospitalization presents an opportunity for advising patients to decrease their substance use and for engaging them in treatment. A health crisis that makes the externalities of AUD evident may be a “teachable moment” for patients who were previously resistant to treatment. Screening, brief intervention, and referral to treatment (SBIRT) with trauma patients can reduce their future alcohol intake and risk of trauma recidivism. A nonjudgmental attitude is essential to SBIRT, and increases the likelihood that the patient will answer honestly and consider recommendations. Motivational interviewing (MI) is an effective, client-centered counseling technique that can be employed during a brief intervention. Many people with substance use disorders are deeply ambivalent about their behavior and its consequences (e.g., although Mr. Huggins expressed no interest in alcoholism treatment at the time of the surgery, he had made several previous attempts to moderate his alcohol use without medical help). MI is a nonconfrontational method in which counselors help clients articulate and resolve ambivalence and gauge their own readiness for behavioral change. Acute and long-term treatment is necessary once the diagnosis of AUD is made (McLellan et al. 2000). A strong and clear recommendation from the clinician to change drinking behavior is essential. A sample statement might read: “Based on the information you have provided, you are at high risk of having or developing an alcohol use disorder. It is medically in your best interest to stop drinking.” This can be followed up by specific medical reasons to quit drinking before problems (or more problems) develop (Weaver 2013). To fulfill the ethical responsibility to the patient, the clinician should not only raise the patient’s drinking as an issue, but also provide appropriate information and engage the patient in discussion. This may include discussion of various treatment options

available to the patient. Hospitalized patients identified with AUD should be provided with information linking them to local community addiction treatment resources. In the United States, physicians certified in treatment of addictive disorders can be found through the American Society of Addiction Medicine (www.asam.org) or the American Academy of Addiction Psychiatry (www.aaap. org). At times it may be more expedient and cost-effective to refer the patient to a nonphysician counselor, which can be found through the National Association for Alcohol and Drug Abuse Counselors (www.naadac.org). Recovery from AUD is possible, and those who are treated have less disability than those who remain untreated. If the patient is resistant to changing drinking behavior, the clinician should not engage in a debate or argument with the patient, but can continue to offer clear advice to abstain. Such clear and strong advice, however, is best done using an empathic, nonjudgmental approach that respects patient autonomy. &

REFERENCES Gentilello, L. M., B. E. Ebel, T. M. Wickizer, et al. 2005 Alcohol interventions for trauma patients treated in emergency departments and hospitals: A cost benefit analysis. Annals of Surgery 241(4): 541–550. http://dx.doi.org/10.1097/01.sla.0000157133.80396.1c. McLellan, A. T., D. C. Lewis, C. P. O’Brien, et al. 2000. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association 284: 1689–1695. http://dx.doi.org/10.1001/jama.284. 13.1689. Weaver, M.F. 2013. Choices for patients and clinicians: Ethics and legal issues. In Addressing unhealthy alcohol use in primary care, ed. R. Saitz, 195–205.New York, NY: Springer. Weaver, M.F. 2007. Dealing with the DTs: Managing alcohol withdrawal in hospitalized patients. Hospitalist 11(2): 22–25. Williams, G., M. Daly, E. M. Proude, et al. 2008. The influence of alcohol and tobacco use in orthopaedic inpatients on complications of surgery. Drug and Alcohol Review 27(1): 55–64. http://dx. doi.org/10.1001/jama.284.13.1689.

A Problem with the Evidence Base Jason D. Keune, Saint Louis University School of Medicine Surgeons’ relationships with their patients differ substantially from the relationships that form between patients and physicians in other specialties. Charles Bosk, an

ethnographer of surgeons, wrote, “When the patient of an internist dies, the natural question his colleagues ask is, ‘What happened?’ When the patient of a surgeon dies, his

Address correspondence to Jason D. Keune, MD, MBA, Saint Louis University School of Medicine, 3635 Vista Ave. @ Grand Blvd. Department of Surgery, 3FDT, St. Louis, MO 63110, USA. E-mail: [email protected]

July, Volume 15, Number 7, 2015

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Balancing Beneficence and Autonomy.

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