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Debating Medical Utility, Not Futility: Ethical Dilemmas in Treating Critically Ill People Who Use Injection Drugs

Published online by Cambridge University Press:  01 January 2021

Stephen R. Baldassarri ,
Ike Lee ,
Stephen R. Latham  and
Gail D'Onofrio
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Extract

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal.

Type
Symposium Articles
Information
Journal of Law, Medicine & Ethics , Volume 46 , Issue 2: Law and the Opioid Crisis: An Inter-Disciplinary Examination , Summer 2018 , pp. 241 - 251
Copyright
Copyright © American Society of Law, Medicine and Ethics 2018

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References

“National Institutes of Health Consensus Development Conference Panel Statement: Management of Hepatitis C,” Hepatology 26 (September 1997): 2S–10S, available at <https://doi.org/10.1002/hep.510260701> (last visited April 6, 2018).CrossRef+(last+visited+April+6,+2018).>Google Scholar
Edlin, B. R. et al., “Is it Justifiable to Withhold Treatment for Hepatitis C from Illicit-Drug Users?,” New England Journal of Medicine 345 (July 19, 2001): 211–214, available at <https://doi.org/10.1056/NEJM200107193450311> (last visited April 6, 2018).CrossRefGoogle Scholar
American Association for the Study of Liver Diseases, “When and in Whom to Initiate HCV Therapy | HCV Guidance,” available at <https://www.hcvguidelines.org/evaluate/when-whom> (last visited April 6, 2018).+(last+visited+April+6,+2018).>Google Scholar
Martin, P. et al., “Evaluation for Liver Transplantation in Adults: 2013 Practice Guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation,” Hepatology 59 (2014): 1144–1165.Google Scholar
Hull, S. C. and Jadbabaie, F., “When Is Enough Enough? The Dilemma of Valve Replacement in a Recidivist Intravenous Drug User,” The Annals of Thoracic Surgery 97, no. 5 (May 2014): 1486–1487, available at <https://doi.org/10.1016/j.athoracsur.2014.02.010> (last visited April 6, 2018).CrossRefGoogle Scholar
Hoffmann, J. P., “The Historical Shift in the Perception of Opiates: From Medicine to Social Menace,” Journal of Psychoactive Drugs 22 (1990): 53–62.CrossRefGoogle Scholar
Ballantyne, J. C. and Mao, J., “Opioid Therapy for Chronic Pain,” New England Journal of Medicine 349 (November 13, 2003): 1943–1953, available at <https://doi.org/10.1056/NEJMra025411> (last visited April 6, 2018).CrossRefGoogle Scholar
Heather, N., “Q: Is Addiction a Brain Disease or a Moral Failing? A: Neither,” Neuroethics 10, no. 1 (April 1, 2017): 115–124, available at <https://doi.org/10.1007/s12152-016-9289-0> (last visited April 6, 2018).CrossRefGoogle Scholar
Volkow, N. D., Koob, G. F., and McLellan, A. T., “Neurobiologic Advances from the Brain Disease Model of Addiction,” New England Journal of Medicine 374 (2016): 363–371.CrossRefGoogle Scholar
Baddour, L. M. et al., “Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications,” Circulation 132 (2015): 1435–1486.CrossRefGoogle Scholar
Garfein, R. S. et al., “Viral Infections in Short-Term Injection Drug Users: The Prevalence of the Hepatitis C, Hepatitis B, Human Immunodeficiency, and Human T-Lymphotropic Viruses,” American Journal of Public Health 86 (1996): 655–661.CrossRefGoogle Scholar
Westbrook, R. H. and Dusheiko, G., “Natural History of Hepatitis C,” Journal of Hepatology 61 (2014): S58–68.Google Scholar
Mattick, R. P. et al., “Methadone Maintenance Therapy versus No Opioid Replacement Therapy for Opioid Dependence,” The Cochrane Library (2009).Google Scholar
Kakko, J. et al., “1-Year Retention and Social Function after Buprenorphine-Assisted Relapse Prevention Treatment for Heroin Dependence in Sweden: A Randomised, Placebo-Controlled Trial,” The Lancet 361 (2003): 662–668; J. M. Soeffing et al., “Buprenorphine Maintenance Treatment in a Primary Care Setting: Outcomes at 1 Year,” Journal of Substance Abuse Treatment 37 (2009): 426–430; D. A. Fiellin et al., “Counseling Plus Buprenorphine–naloxone Maintenance Therapy for Opioid Dependence,” New England Journal of Medicine 355 (2006): 365–374.CrossRefGoogle Scholar
Mathew, J. et al., “Clinical Features, Site of Involvement, Bacteriologic Findings, and Outcome of Infective Endocarditis in Intravenous Drug Users,” Archives of Internal Medicine 155, no. 15 (1995): 1641-1648.CrossRefGoogle Scholar
Hubbell, G. et al., “Presentation, Management, and Follow-up Evaluation of Infective Endocarditis in Drug Addicts,” American Heart Journal 102, no. 1 (1981): 85-94.CrossRefGoogle Scholar
Østerdal, O. B. et al., “Cardiac Surgery for Infective Endocarditis in Patients with Intravenous Drug Use,” Interactive Cardiovascular and Thoracic Surgery 22, no. 5 (2016): 633-640.CrossRefGoogle Scholar
Rivoisy, C. et al., “Prosthetic Valve Candida Spp. Endocarditis: New Insights into Long Term Prognosis - the ESCAPE Study,” Clinical Infectious Diseases 66, no. 6 (2017): cix913-cix913, available at <https://doi.org/10.1093/cid/cix913> (last visited April 6, 2018).Google Scholar
Wilkinson, D. J. C. and Savulescu, J., “Knowing When to Stop: Futility in the Intensive Care Unit,” Current Opinion in Anaesthesiology 24 (2011): 160.CrossRefGoogle Scholar
La Puma, J., Cassel, C. K., and Humphrey, H., “Ethics, Economics, and Endocarditis: The Physician’s Role in Resource Allocation,” Archives of Internal Medicine 148, no. 8 (August 1988): 1809–1811, available at <https://doi.org/10.1001/archinte.1988.00380080087023> (last visited April 6, 2018).Google Scholar
See Hull, supra note 5.Google Scholar
Gansera, L. S. et al., “High-Risk Cardiac Surgery in Patients with Intravenous Drug Abuse and/or Active Hepatitis C or HIV Infection: An Ethical Discussion of Six Cases,” The Thoracic and Cardiovascular Surgeon 64, no. 1 (January 2016): 2–5, available at <https://doi.org/10.1055/s-0035-1551682> (last visited April 6, 2018).CrossRef+(last+visited+April+6,+2018).>Google Scholar
Kirkpatrick, J. N. and Smith, J. W., “Dilemmas in Dual Disease: Complexity and Futility in Prosthetic Valve Endocarditis and Substance Use Disorder,” The American Journal of Bioethics 18, no. 1 (January 2, 2018): 76–78, available at <https://doi.org/10.1080/15265161.2017.1401160> (last visited April 6, 2018).CrossRefGoogle Scholar
Pope, T. M., “Medical Futility Statutes: No Safe Harbor to Unilaterally Refuse Life-Sustaining Treatment,” Tennessee Law Review 75 (2007): 1.Google Scholar
National Conference of Commissioners on Uniform State Laws, “Uniform Health-Care Decisions Act,” Issues in Law & Medicine 22, no. 1 (2006).Google Scholar
Pope, T. M., “Dispute Resolution Mechanisms for Intractable Medical Futility Disputes,” New York Law School Law Review 58 (2013): 347.Google Scholar
H.B. 1403, 54th Leg., 1st Reg. Sess. (Okla. 2013) at 3.Google Scholar
. Prob. Code § 4735 (West 2000).Google Scholar
Nishimura, R. A. et al., “2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines,” Circulation 129, no. 23 (June 10, 2014): e521–643, available at <https://doi.org/10.1161/CIR.0000000000000031> (last visited April 6, 2018).Google Scholar
See Pope, No Safe Harbor, supra note 24 at 117.Google Scholar
See Pope, No Safe Harbor, supra note 24.Google Scholar
Marsala v. Yale-New Haven Hosp., Inc., 166 Conn.App. 432.Google Scholar
Pope, T. M., “Involuntary Passive Euthanasia in US Courts: Reassessing the Judicial Treatment of Medical Futility Cases,” Marquette Elder’s Advisor 9, no. 2 (2007): 229-268.Google Scholar
“Results from the 2016 National Survey on Drug Use and Health: Detailed Tables” (Substance Abuse and Mental Health Services Administration, September 7, 2017), available at <https://www.samhsa.gov/samhsa-data-outcomes-quality/major-data-collections/reports-detailed-tables-2016-NSDUH> (last visited June 1, 2018).+(last+visited+June+1,+2018).>Google Scholar
“National Survey on Drug Use and Health, 2015,” Government, Substance Abuse and Mental Health Services Administration public online data analysis system, available at <http://pdas.samhsa.gov/#/survey/NSDUH-2015-DS0001/crosstab/?column=CHMNDLREC&results_received=true&row=INCOME&weight=ANALWT_C> (last visited April 6, 2018); “National Survey on Drug Use and Health, 2002,” Government, Substance Abuse and Mental Health Services Administration public online data analysis system, available at <http://pdas.samhsa.gov/#/survey/NSDUH-2002-DS0001/crosstab/?column=NEDLRECR&results_received=true&row=INCOME&weight=ANALWT_C> (last visited April 6, 2018).+(last+visited+April+6,+2018);+“National+Survey+on+Drug+Use+and+Health,+2002,”+Government,+Substance+Abuse+and+Mental+Health+Services+Administration+public+online+data+analysis+system,+available+at++(last+visited+April+6,+2018).>Google Scholar
Merrill, J. O. et al., “Mutual Mistrust in the Medical Care of Drug Users,” Journal of General Internal Medicine 17 (2002): 327–333.Google Scholar
Buchman, D.Z. and Lynch, M.-J., “An Ethical Bone to PICC: Considering a Harm Reduction Approach for a Second Valve Replacement for a Person Who Uses Drugs,” American Journal of Bioethics 18, no. 1 (2018): 79-81.CrossRefGoogle Scholar
Shrestha, N. K. et al., “Injection Drug Use and Outcomes After Surgical Intervention for Infective Endocarditis,” The Annals of Thoracic Surgery 100, no. 3 (September 1, 2015): 875–882, available at <https://doi.org/10.1016/j.athoracsur.2015.03.019> (last visited April 6, 2018).CrossRefGoogle Scholar
“ASCO Plans to Release Conceptual Value Framework to Assess the Value of New Cancer Treatment Options,” American Society of Clinical Oncology, January 27, 2016, available at <https://www.asco.org/advocacy-policy/asco-in-action/asco-plans-release-conceptual-value-framework-assess-value-new-cancer> (last visited April 6, 2018).+(last+visited+April+6,+2018).>Google Scholar
Ruchika, M., “Does Blame Trump Benefit in Treatment Decisions? Nonadherence and Cardiac Surgery,” The American Journal of Bioethics 18, no. 1 (January 2, 2018): 81–83, available at <https://doi.org/10.1080/15265161.2017.1401158> (last visited April 6, 2018).Google Scholar