Sunday, February 27, 2011

Alcoholism and Personal Responsibility

I'll soon be consulting about a fascinating clinical situation involving an elderly person with alcoholism, other medical problems, and a VERY disruptive behavior pattern. (For reasons of confidentiality, I'm presenting very limited details.)

The patient develops recurrent alcohol-related medical problems, leading to repeated hospitalization. The person has refused placement in any kind of nursing home, but a pattern of belligerence drives away household help and has made agencies reluctant to get involved. Remaining at home will almost certainly lead to recurrent medical emergencies or even death, but a psychiatric hospital concluded that the person could not be committed on an involuntary basis.

From the perspective of clinical ethics, what should the care team do? What can it do?

Alcoholism is a hugely important global health issue and a fascinating philosophical paradox. Society has moved from a purely moralistic view of alcoholism to seeing it as a disease for which management strategies can be devised. The first of AA's twelve steps embodies this view - "We admitted we were powerless over alcohol—that our lives had become unmanageable." The first step in dealing with any condition is acknowledging that the problematic condition is really present!

The clinical team feels caught. Without abstinence from alcohol the patient is likely to spiral downward, causing ever more havoc for self and others as the process unfolds. As caring clinicians they want to prevent harm and promote health, but the patient doesn't cooperate. As clinicians who are out and about in the community, they are also pressured to deal with the patient's socially problematic behavior. And as citizens in a society strongly devoted to liberty, they don't have recourse to forcing any form of intervention unless the patient were to meet the high bar for psychiatric commitment.

Medical benefit - restoration of health to the maximum possible degree is and should be the primary goal. But there are also social control concerns, since the patient's behavior has caused significant problems, including physical injury (luckily relatively minor so far), to others.

Given the valid social control components of the situation, I was struck by the absence of reference to the law in the clinical material. Medical policy and medical ethics directs us to be "patient centered," but patient-centeredness can include serious attention to patients' responsibilities for their own behavior. The tenth step moves from the powerlessness of the first step to asking the person "to take personal inventory and when we [are] wrong promptly admit it."

I'll bring up this this issue of personal responsibility and the role of the legal system when I meet with the team, and may write about the situation again after that.

(Evaluating the degree to which a person is competent to make his own decisions and should accordingly be held responsible for his actions is especially difficult with elderly folks who have alcoholism, since both aging and alcoholism can be associated with declining mental function and capacity for self governance. A 2003 article in General Hospital Psychiatry on "Decision-making capacity and alcohol abuse: clinical and ethical considerations in personal care choices" provides helpful useful insights.)

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