This column will focus on ethics in treating substance use disorders. To begin, let's discuss a little bit about ethics. Every provider has a moral compass. Just as a compass can point one in the correct direction, a person's moral compass allows them to do certain acts and not do others.

My belief is that our moral compass develops throughout our life, beginning in childhood, with the environment that we are raised in. For example, I was raised Roman Catholic. I had to go to mass every Sunday and Holy Day, and my mother really wanted us to go to confession weekly. I learned the 10 commandments as a young child. When I look back at the way in which I was raised and my parents' beliefs and values, which were certainly instilled into me, there are certain beliefs and principles that I have. My moral compass was developed from this upbringing.

In practice settings, a person's moral compass can certainly be challenged, which creates what is termed moral distress.

Moral distress is defined as "knowing what to do in an ethical situation, but not being allowed to do it" (Jameton, 1984). Institutional constraints are most frequently the etiology of why the provider cannot do what is morally correct.

Moral distress creates pain and anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, makes a moral judgment about the correct action, and yet, as a result of real or perceived constraints, participates in perceived moral wrongdoing when it is against what they want to do (Nathaniel, 2002).

Moral distress can affect any type of healthcare provider. It certainly impacts all major areas of nursing practice, inclusive and not limited to clinical practice, administrative practice, educational practice, and research practice.

The impact of moral distress can cause loss of provider's moral integrity, emotional detachment, moral residue (builds up and retains moral distress), and a crescendo effect where repeated moral distress is cumulative.

Executives have the responsibility to create an ethical practice environment where every individual provider is valued and is not placed in a situation that creates more distress for them.

The following two scenarios provide examples of moral distress:

1. An operating room nurse is hired at a new facility. This facility performs elective abortions. This nurse does not believe in abortion and believes that every fetus has the right to life. She is asked to participate as a nurse in the abortion of an incoming patient. If the facility truly believes in not creating moral distress for this provider, then this nurse has the right to refuse in participating in this procedure.

2. Several states have now enacted assisted suicide legislation for terminally ill patients. Some providers may not believe in assisted suicide; thus, a terminally ill patient requesting this would create moral distress for a provider who does not believe in assisted suicide.

I will never forget a patient that we had in an acute care hospital in New Jersey. I was the Chief Nursing Officer at the hospital. We had implemented a nurse-driven bioethics committee that was multidisciplinary. Members of this committee served in an advisory capacity for physicians who consulted the committee. We would review the patient's medical record. We would speak to the attending physician and any family members, as well as the patient if they were coherent. There was a patient that the committee was consulted on. This patient had a cerebellar infarction, was dying with no hope of recovery, was cognitively impaired, and was not capable of making a decision. The patient had a clearly executed advanced directive. His wife was listed as the decision maker if he became incapacitated in decision-making. The wife of the patient requested that intravenous (IV) fluids be discontinued. Under case law in New Jersey, we could do this. The advice of the ethics committee was to discontinue IV fluids. When the physician was advised of this, he stated that he had never withdrawn IV fluids on a dying patient and he felt that he would be "murdering the patient." The ethics committee met with the patient's wife and explained the dilemma with the physician and that we could not compromise on how the physician felt as that created moral distress and an ethical dilemma for the physician. The patient was transferred to the care of another physician who could comply with the wife's wishes. The initial attending physician was in agreement with this plan.

A major item that also impacts moral distress and ethical decision-making is the focus on controlling costs and reimbursement for care. The reality is that every type of healthcare facility is a business.

There is no doubt about it that there is declining reimbursement rates. The financial aspects of any organization can create ethical dilemmas for providers.

Examples of such dilemmas, which can potentially lead to moral distress in substance use treatment centers, are inclusive but not limited to the following:

* The provider believes in an abstinence model-Patients want medication-assisted treatment.

* The provider believes in the 12 steps-The patient states that 12 steps do not work for him.

* The provider orders Penicillin IM for a patient with Stage I syphilis-The cost of the injection is $97.00. Patient's insurance will not cover the medication, and she does not have cash to pay for it.

* The patient is a self-pay patient, and the facility administrator authorizes the patient to use their cell phone while in treatment. This is normally against the facility policy.

* The patient has overdosed multiple times on opioids and wants to sign out against medical advice.

* The patient is on three medications required for medical conditions. The patient lives 4 hours way and did not bring in his medication. The pharmacy will not fill the medication as the patient just had it refilled prior to coming into treatment.

* The patient was sent into treatment by a family member because the family member wants the patient to have treatment. The patient arrives in an intoxicated state. The next day when the patient is coherent, they are adamant about leaving treatment as they are not yet ready for treatment.

Ethical dilemmas and challenges to ones' moral compass will continue. Health care is becoming more and more complex. Patient autonomy is the primary ethical principle that providers try to follow as long as it is ethical and legal.

The key, from my perspective, is having an ethical practice environment, listening to patients and their concerns, and always trying to do the right thing for both the patient and the provider.

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