1. Ethics and Clinical Harm Reduction Frederick Rotgers, PsyD, ABPP Associate Professor of Psychology Philadelphia College of Osteopathic Medicine

2. Overview Framework for discussion Current trends in bioethics Ethical basis for clinical harm reduction Objections to clinical harm reduction Discussion

3. Framework for Discussion Veatch, 2003 Metaethics Normative Ethics Rules and Rights (Codes of Ethics) Cases (Casuistry)

4. Two people disagree on how to handle a case Each cites cases to support a particular course of action Reliance on “paradigm” cases=casuistry

5. Rules and Rights (Codes of Ethics) Grounded in moral system Rights claims, e.g. “patient should always give consent to a treatment.” Question of how rigidly rules apply –Antinomianism—no rules/rights ever apply –Legalism—Specific rules/rights for every situation

6. Normative Ethics Three Questions –Action theory: “what principles make actions morally right?” Beneficence Non-maleficence –Value theory: “What kinds of consequences are good or valuable?” –Virtue theory: “What kind of character traits are morally praiseworthy?” Benevolence Respect

7. Metaethics Meaning and justification of ethical terms How people know which principle or virtues are the “correct” ones How we can know we have the “right” answer Religious Answers –Divine will –Divine Law Secular Answers –Universal Natural law Hypothetical contract –Relativist One’s culture One’s Personal preferences Actual Social contract

8. Current Trends in Bioethics Deciding what constitutes “benefit” and “harm” Shift from Conservative to Liberal values Traditional Hippocratean Approach –Physician/clinician decides what is best using own best judgment—paternalistic –Focus either on limited “health” or broader “well-being” –Benificence/Nonmaleficence

9. Current Trends in Bioethics Shift in focus from physician/clinician to patient –Autonomy –Personal choice –Rights To refuse beneficial treatment To choose treatment other than that recommended by a particular clinician To place a higher value on aspects of well-being other than health

10. Current Trends in Bioethics Balancing Benefits and Harms –Bentham: arithmetic summing--utilitarianism –Comparing ratio of benefits to harms –“Primum non nocere” Who should do the balancing?

11. Current Trends in Bioethics Deontological (duty-based) models emphasize “respect for persons” –Respect for autonomy –Fidelity to promises –Veracity –Avoidance of killing (but not always—e.g. legal euthanasia) Duty based: formal obligation to act in certain way towards others regardless of the consequences

12. Ethical Basis for Clinical Harm Reduction Follows from the most universal deontological ethics –Emphasis on personal choice and autonomy –Fidelity—loyalty to the patient Sometimes produces dilemmas: loyalty to patient sometimes does not produce best outcomes –Veracity—informed consent

13. Objections to Clinical Harm Reduction Over-borne will –Being addicted itself reduces personal autonomy –Raises questions about the nature of addiction—is addictive behavior voluntary or involuntary? Competency –Being addicted renders one incapable of making certain decisions –“Cynthia’s Dilemma: Consenting to Prescription Heroin” Charland, 2002 Social obligation –Responsibility to family members of addict and society at large

14. Discussion What should be the basis for clinical decision-making and clinician recommendations? –Subjective –Religious –Objective research How do we factor in the interests of both the individual and society?