Medical deontology and reporting of drug addicts

Abstract

1. Man has always sought to escape from his miserable condition into some dream paradise. Like Icarus, we all wish to take off for better lands. This has led to early discovery of intoxicating substances which procure an artificial paradise. Alcohol, opium and cannabis are certainly among the most used of these substances. Unfortunately, for certain persons, the use of a drug has the effect of establishing a sort of association which renders it increasingly indispensable. Hence the emergence and development of drug addiction, which is now defined as "a state of periodic or chronic intoxication" produced by the repeated consumption of a natural or synthetic drug. The characteristics of drug addiction include: a desire or need to continue taking the drug and obtain it by any means; a tendency to increase the dose; psychic (or psychological) and generally also a physical dependence on the effects of the drug effects which are detrimental to the individual and to society. This definition, which has been formulated by WHO, adequately sums up the position of drug addicts in relation to their drug and to society. Moreover, it should be remembered that drugs were first not very numerous; with the development of modern chemistry, however, new products have appeared which have an extremely beneficial action in certain cases, but which can also be the source of new forms of addiction.

Details

Author: Professor M. Müller, Dr. P. Müller,
Pages: 7 to 11
Creation Date: 1961/01/01

Medical deontology and reporting of drug addicts

Professor M. Müller
Dr. P. Müller,
University of Lille, France

1. Man has always sought to escape from his miserable condition into some dream paradise. Like Icarus, we all wish to take off for better lands. This has led to early discovery of intoxicating substances which procure an artificial paradise. Alcohol, opium and cannabis are certainly among the most used of these substances. Unfortunately, for certain persons, the use of a drug has the effect of establishing a sort of association which renders it increasingly indispensable. Hence the emergence and development of drug addiction, which is now defined as "a state of periodic or chronic intoxication" produced by the repeated consumption of a natural or synthetic drug. The characteristics of drug addiction include: a desire or need to continue taking the drug and obtain it by any means; a tendency to increase the dose; psychic (or psychological) and generally also a physical dependence on the effects of the drug effects which are detrimental to the individual and to society. This definition, which has been formulated by WHO, adequately sums up the position of drug addicts in relation to their drug and to society. Moreover, it should be remembered that drugs were first not very numerous; with the development of modern chemistry, however, new products have appeared which have an extremely beneficial action in certain cases, but which can also be the source of new forms of addiction.

2. The manner in which our society has developed has also meant that there is an increasing tendency for persons who seek artificial happiness; there can be no doubt that drug addiction threatens to increase, with a parallel increase in a number of addicts.

3. We are not very well informed regarding the number drug of addicts. A few figures will serve to illustrate this mark. The United Nations report for 1958 indicates that of Brazil the areas having the largest number of drug addicts are the cities of Rio de Janeiro and São Paulo. In Brazil drug addicts are, as a matter of course, committed to a psychiatric hospital. Nevertheless, the total number of addicts under treatment at the psychiatric clinics of São Paulo and Botafogo decline.

Of Canada, it is reported that 3,412 addicts have been numbered, and a census carried out in the United States of America has shown that the number of addicts between 1953 and 1958 was 46,256. In India, opium addicts alone were said to the number 432,609. While no doubt considerable differences are from one country to another, we cannot accept without reservation the statistical information given by some countries. To our mind, drug addiction is a world problem which is on the increase in spite of the steps taken in various actions to deal with it.

The particularly serious character of the problem is shown by a more detailed examination of United States statistics We have seen that between 1953 and 1958, 46,256 addicts of various kinds were counted. Their break-down into age groups is as follows:

18 - 21
5,550
21 - 30
27,753
30 - 40
8,328
Over 40
4,625

Fifty-nine per cent of these addicts are negroes, and 80% are males. It will be noted that the great majority of drug addicts are between twenty-one and thirty, and that the number of drug addicts who are minors is considerable. In fact, 72% of the total number of addicts in the United States of America are between eighteen and thirty. In the city of New York, however, 60% of drug addicts are less than twenty. It should be added that in Canada, the number of drug addicts aged under twenty was twice as large in 1958 as it was in 1957.

4. We should not lose sight, in this study, of one essential fact: Regardless of whether he is a patient, a former patient, an addict merely indulging in the drug or a doctor, a person who takes drugs will conceal his vice. It is hardly necessary to dwell on the origin of addiction. In our view, there are two groups: that of addicts who first used a drug to quell pain and that of addicts initiated to the drug-taking without any apparent medical reason. For the first group of addicts, medical reasons justified, during a more or less prolonged lapse of time, the use of a beneficial drug; as to the second group, enjoyment alone was sought from the start. The first group consists of occasional addicts who, in principle, appear to be more easily curable; the second group consists of persons who suffer from a veritable psycho-sensorial disease; these persons have constant relapses and tend to become increasingly dependent on the drug. Addicts of the first group will obtain their drugs chiefly by means of medical prescriptions. They will complain of pains which, in their eyes, give them a plausible reason to consult a doctor, or to disturb successive doctors after exhausting, the patience or the tacid complicity of one of them. Addicts of the second group, for their part, will resort to every possible means of obtaining their drug: illicit purchase; medical prescription obtained on the pretext of a chronic disease; fraud; and even false pretences in all their forms.

Among the addicts of the second group, the young must be considered as being in a special class. Among the young, contagion is easier and the effects of contamination more serious, as the figures show; moreover, their lives will be marked by progressive moral and physical degradation unless severe remedial measures are taken in time. This new effect of the non-adaptation of youth is a factor of which there is not yet enough awareness in the old world. It is therefore important to stress it.

5. In order to meet this situation, many countries have organized and regulated the purchase, detention and sale of the various addiction-producing substances. Addiction has thus been placed outside the law in these countries and, in consequence, addicts are deemed engaged in unlawful activities. Most narcotic drugs, however, are still much used in medicine, as is the case of opium derivates, for example, and their manufacture and use could not be prohibited altogether. The regulations enacted have therefore been aimed at ensuring that doctors prescribe these substances only to those of their patients who can or will benefit from them. Doctors can come into contact with drug addicts in various ways. In section 4 above, we have seen how attempts may be made to involve doctors as accessories in the use of drugs. This occurs with patients who claim to suffer from painful diseases and, rightly or wrongly, assert that relief is only possible by means of the use of drugs. A doctor may also be consulted by a patient who does not reveal the connexion between his organic disease and his addiction, which he conceals; in this case, the doctor will, by his examination and interrogation of the patient, be able to discern the precise etiology of the latter's condition. Lastly, a psychiatrist or sociologist working in institutions for the observation and readaptation of children will have the opportunity to diagnose cases of drug addiction of more or less long standing among the young persons admitted to the institution.

In certain countries, it has become apparent for some years that if a doctor in the course of his practice could notify these cases of addiction to the judicial or other competent authorities, these authorities would be better equipped in their struggle against addiction.

6. The rule of medical secrecy debars in principle a doctor from disclosing facts which come to his knowledge in the course of his practice; this rule therefore precludes him from notifying cases of addiction.

The rule of medical secrecy is an old concept; it is now much disputed and has come under fire from different quarters concerned with the study of life in society. Life in society appears to be demanding an increasing interference in the private life of individuals by large administrations which regulate their daily life down to the smallest details; it is a paradoxical fact that our societies appear to be progressively moving towards the ideas of Plato's Republic, in which the citizens' lives were directed towards the general welfare.

The question therefore arises whether, in these circumstances, the principle of professional secrecy can still be upheld in absolute and general terms, and whether those things which Hippocrates regarded as sacred and ranked as mysteries can continue to block "social" needs indefinitely.

7. The rule of medical secrecy is based on the requirements of professional ethics and morality, but it has also been incorporated into the laws of various countries. It has even been raised to the status of an international principle by the International Medical Association. In the code of ethics drawn up by that association, which has been accepted by all member countries, the rule of professional secrecy has held a prominent place from the outset.

Actually, the principle of medical secrecy is essentially based on the trust which a patient must be able to place in his doctor. If a patient knows that in certain cases the doctor is entitled to notify his case to the authorities, or even to mention it to other persons, then, if he expects that disclosure to have disagreeable consequences for him, he will prefer to keep his illness secret rather than confide in a doctor. The abolition of medical secrecy, or its relaxation (which would have exactly the same effect) would thus in the long run be harmful to social health.

8. Moreover, as a matter of conscience, a doctor is bound by the trust which is placed in him and, even in the absence of any legislative provision on the subject, he feels very strongly the absolute need not to disclose the information concerned; there can be no doubt that Hippocrates, when he wrote his oath, did no more than codify moral rules known prior to the school of Cos.

9. Lastly, in most countries, the rule of medical secrecy is embodied in legislative provisions which are often very detailed. Jurists are at present seeking to restate the grounds on which these provisions are based. Some believe that the principle of medical secrecy is a matter of public policy, and there can be no doubt that this approach furnishes the easiest, most complete and most satisfactory explanation on the subject. More recently, others have sought an explanation in the existence of a medical contract, a contract originating in the free choice of his physician by the patient; on this basis, a tacit agreement is held to have been reached on a contract by virtue of which the doctor undertakes to place his knowledge and his conscience at the service of his client's health. The fact that the doctor has been freely chosen as a confidant means that whatever the patient confides in him, whether by word of mouth, by allowing the doctor to enter his home, or by permitting him to examine him, must remain secret. It therefore follows that the secret belongs exclusively to the two contracting parties - i.e., the patient and the doctor. There is no possible secrecy between them, and a certificate relating to his illness can always be handed to the patient himself: a doctor cannot invoke medical secrecy in his relations with his patient.

10. Cases, however, often occur in which the patient is not free to select the doctor. The choice of a doctor, instead of being directly made by him, may have been imposed by an administration. The patient may be a minor who does not have full civil capacity, or a mentally deficient person who has lost that capacity; in these cases, there can be no doubt that the secrecy rule remains as binding as ever, although from the legal point of view there can be no question of a contract. Similarly, when the patient dies, the contract is modified, but the secrecy rule persists. It is thus clear that circumstances exist in which the rule of medical secrecy covers a wider field than any contract. Indeed, if the question is probed deeper, it will be seen that unless the rule of medical secrecy exists, no contract will be possible; the patient confides in the doctor precisely because he knows that the doctor will not betray him. The idea of medical secrecy appears well before any contract is entered into.

11. It is thus apparent that there are many instances in which secrecy goes beyond what would be required in a contract, and covers areas which are a matter solely for a doctor's conscience; in our view, it is therefore appropriate to say that secrecy is here a matter of public policy. There have even been cases in which an obligation has been imposed by law on physicians to notify certain cases, and doctors have refused to comply, considering the orders in question unjust. In France, for example, during the German occupation, doctors were required, whenever they attended a wounded person, to report the fact, giving the person's address and explaining the origin of the wounds. Doctors invariably refused to comply with this requirement, which directly conflicted with the law and regulations in force. Medical secrecy is not only consistent with the nature of things, but transcends all other duties.

12. There are, however, exceptions or departures from the rule in all countries. The operation of social legislation, particularly with regard to industrial accidents and occupational diseases, and the military pension machinery provide everyday examples of such departures. These departures, however, do not effect in any way the trust which the wounded or sick patient has in the doctor. In these cases, the doctor obviously gives medical attention, but acts also - and indeed it could almost be said chiefly - as the agent of the administration which provides "raparation" for the condition affecting the patient; it might be possible to carry the argument even further and to say that the cash idemnity given by the administration concerned is part of the treatment, and results from the action of the doctor.

Another much more serious exception is the notification of contagious diseases. In this case, there can be no doubt that the rule of medical secrecy, in spite of all that we have just said, has had to give way before another rule - also of public policy - the protection of public health.

There has been general agreement that it is essential for cases of contagious diseases to be notified in order to prevent the spread of epidemics.

Moreover, as a general rule, in spite of the unpleasantness involved, patients understand very well the reasons which compel the authorities to make the notification of contagious diseases compulsory. In most cases, compliance with that requirement by the doctor will not lead to any adverse comment by patients.

13. In a growing number of countries there is increasing recognition of the need to treat the drug addict as a patient, and drug addiction as a kind of illness. This does not mean that such an attitude replaces entirely penalties for acts resulting from or related to addiction which violate the laws. But it means that the addict cannot be weaned away from his addiction and rehabilitated in society unless medical, health and social measures are jointly applied. Several countries have advanced well in that direction, and others are commencing to take the first steps. Some of the important measures taken by countries with a view to the control and treatment of an addict as a patient are the obligatory declarations required to be made in respect of addicts by medical practitioners, the registration or licensing of addicts and the compulsory treatment of addicts. In some countries even, all citizens are required to report addicts. The measures taken by countries for the reduction and suppression of addiction are within the framework of the international treaties on narcotic drugs, and particular reference may be made in this connexion to article 15 of the 1931 Convention.

14. In this struggle against drug addiction, the need is apparent to resort to all possible means in order to eradicate this social evil, or at least reduce it in extent, since none of these means by itself can eradicate drug addiction altogether. The control of the manufacture, trade and international traffic in drugs, police measures to check illicit traffic, the control of pharmacies, and the legislation governing the prescription of narcotic drugs have so far proved useful but quite insufficient.

The system introduced on 9 December 1959 in Thailand provides an example of an attempt at a complete system of control and treatment:

  1. Abolition of the use of smoking opium and of the sale of opium throughout the country as from 30 June 1959;

  2. Notice to opium smokers requiring them to submit an application for registration not later than 31 December 1958;

  3. As from 1 January 1959, introduction of a more strict system of control for smoking opium, so as to make it impossible for non-registered drug addicts to use this opium;

  4. Abolition of licensed premises for the supply of opium as from 30 June 1959;

  5. Establishment of clinics and convalescent centres for opium addicts by the Ministries of Public Health and the Interior;

  6. Treatment of drug addicts, whether licensed or not, for six months as from 1 January 1959, and measures connected with the convalescence of these addicts;

  7. Enforcement, as from 1 July 1959, of the penalties specified by the legislation on opium against offenders, provision being made for their after-care in a clinic or convalescent home for a period of not more than ninety days upon their release from prison.

On 9 December 1958, the Ministry of Finance issued a notice requiring opium addicts to apply for registration before 31 December 1958, and ordered the owners of premises licensed to issue opium to sell it only to authorized addicts.

No doubt a small additional contribution would be made towards the solution of this grave problem if doctors were required to notify cases of drug addiction. A measure of this kind, however, would not greatly affect the character of the struggle against addiction. Very few cases of drug addiction become known to doctors as a direct result of their ordinary practice. The only cases which they detect in this manner are those of patients who invoke a painful disease as an excuse for using a drug, and endeavour to obtain prescriptions to procure it from a pharmacy. In their case, however, a notification by the doctor would be quite unnecessary. These cases are soon apparent to the authorities because of the numerous prescriptions, the large number of doctors consulted, the progressive increase in the doses, all of which can be traced by the operation of legislation along the lines of the French law on the prescription and issue of substances included in schedule B. Since the prescriptions are issued in the name of the patients, they constitute in fact compulsory notifications. The majority of drug addicts, however, are unknown to the doctors. This is particularly true of the most dangerous addicts - i.e., those whose addiction is not of pathological origin and who are active in propagating addiction; these addicts obtain their drugs by illicit means. Equally dangerous are those persons who live on the drug traffic and the profits derived from it, and who may or may not be addicts themselves.

In our view, the latter category of addict is the most dangerous and the most numerous. There is no comparison between the number of these addicts and the few isolated cases which may become known to doctors in the course of their practice.

We have cited above some alarming statistical figures in section 3 and, in section 5, we have mentioned the cases in which a doctor in charge of a social service can contribute to the detection of addicts, particularly minors and adolescents.

15. It is, however, possible to classify into two groups those addicts who resort to doctors: the first group includes those who come to a doctor for treatment, asking help to overcome addiction.

These cases are of great interest to a doctor. The patients concerned are certainly entitled to secrecy, provided that the doctor takes a personal interest in their treatment and its results, and endeavours to entrust the patient to a medico-social institution for after-care. There can be no doubt that in no event must the doctor notify these cases.

The second group is that of addicts who consult an unknown doctor purely in search of a prescription which will serve to obtain by licit means the drugs which they need, or which they are unable to obtain by the usual illicit means. These persons cannot be regarded as patients; nor are they mental cases. They consult a doctor purely because of the power he has to issue prescriptions; they are law-breakers who are more or less openly seeking the willing or unwilling complicity of a doctor.

In the case of this group of drug addicts, and this group alone, a doctor would not appear to be absolutely bound by the normal rules of professional secrecy; it would seem that, in these cases, the doctor can make a notification without that implying, strictly speaking, any conflict with medical ethics.

Lastly, the same will be true of minors and adolescents taken to the doctor by their families or by the police authorities. These cases are especially important from the social point of view; they are also the most dangerous ones, because of the addicts' age and their tendency to proselytize.

16. It is naturally a delicate matter to suggest some new departure or exception, but there are reasons to believe that a scheme along the lines of the French legislation on the struggle against venereal disease, embodied in title II of book II of the French Public Health Code, and on the organization of the treatment of dangerous alcoholics (title V of the same book) might well prove useful.

It is, however, necessary first to make disintoxication - i.e., the treatment of drug addiction - compulsory. If this were done, it could be made likewise compulsory to notify cases of drug addiction, with or without the name of the addict. Cases would be reported to the public health authorities by the doctor, omitting the name of the patient if he accepts treatment; a full report would, however, be filed if the patient refused treatment, or if the social conditions of the addict's life lead the doctor to the conclusion that he is a contagious addict.

These provisions could be supplemented, as in the case of the legislation against venereal diseases and dangerous alcoholics, by general provisions enabling the public health or judicial authorities to order the committal of an addict to hospital as a matter of course. It would be a question of reporting not drug addicts as such but those addicts who are dangerous to others, or who refuse treatment.

17. It is perhaps possible to obtain an idea of the results which could be expected from such an amendment of the relevant legislation by examining the manner in which cases of syphilis and tuberculosis, for example, are notified.

In France, these two diseases are classified as contagious diseases subject to compulsory notification. However, such notifications are very rarely made because, in spite of the explicit provisions of the law and the heavy penalties to which doctors are liable, they are reluctant to report cases of these two diseases, which, because of their chronic character and their profound social implications, make patients reluctant to disclose their exact nature.

The progress of medical science, however, has made it possible to cure certain types of tuberculosis, and this has brought about some change in the general outlook; doctors are now more concerned with the protection of young children against contamination by a patient who refuses to undergo treatment, for example.

A similar progress has become apparent in regard to syphilis, and the same would appear to be true of drug addiction when treatment is given in truly specialized centres. However, with regard to syphilis, because of its normally venereal origin, the number of notifications by doctors has not altered materially; physicians seem to prefer to treat their patients themselves and try to persuade them directly to take steps not to contaminate others. The position is different with regard to drug addiction: the doctor is generally not in a position to provide treatment himself, because that treatment requires admission to a hospital. Nor can the doctor himself ensure prophylaxis.

In cases of drug addiction, it would appear that the possibility of notifying the names of addicts, if necessary, can in certain cases serve to allay the conscience of a doctor who considers certain types of addict dangerous.

18. From this study, a number of facts emerge which appear to us fundamental in the progress of the struggle against drug addiction.

The total number of known or suspected drug addicts is still very large, but a new group of addicts has emerged which is very rapidly increasing, particularly in certain highly developed countries. This is the group of children, minors, adolescents and young adults. Their emergence as consumers of drugs is particularly alarming. They can form, in the rising generation, an active nucleus of drug addicts ready to replace those whom certain countries are endeavouring to suppress by legislative measures; they can become a source of moral and intellectual degradation.

In the struggle against drug addiction, certain measures should no doubt play a prominent part, such as those adopted by Thailand in regard to opium smoking; sources of drug supply must be stopped; the production, storing, trade and use of drugs must be brought under control; drastic measures must be taken, or those in force must be strengthened, against the illicit possession and sale of addiction-producing drugs, whether they are old drugs or new synthetic drugs; it is also necessary to organize everywhere, on a scale comparable with the relative importance of the evil in each country, specialized social and medico-social services capable of detecting and controlling cases of addiction, and providing addicts with treatment and after-care; it is necessary to compel addicts to undergo disintoxication and to punish recidivists, provided that the penalties are served in special penitentiary sections where treatment and after-care are provided.

To our mind, however, it is necessary to resort to every possible method of attack. The system of the registration of drug addicts makes it possible to get a picture of the progress of addiction in the various countries and to note with satisfaction the recession of the evil, or else detect any deficiencies in the system of the control in force. Registration also makes it possible to take appropriate individual measures.

The compulsory notification of cases of addiction by doctors, which proceeds from the same idea, can only make a small contribution to the solution of this grave problem. This fact, however, should be no reason to neglect it. Any attempt to make such a notification compulsory would, however, conflict in principle with the International Code of Ethics and with the rule of professional secrecy which we have examined in its various aspects; if, therefore, it is desired to introduce it, the manner must be examined very closely. To our mind, such a notification cannot be imposed indiscriminately in all cases.

A drug addict is undoubtedly an individual whose psychic faculties are affected. His willpower is lessened, as is his moral sense, which may even be completely paralysed. He cannot defend himself alone against his disease. Such a person is not always an ordinary patient. In certain cases, when a doctor detects addiction on examining the patient, or when a patient confides his condition to a doctor and asks for his professional assistance, there can be no question of the doctor reporting him to the authorities; this, however, is subject to the explicit condition that the doctor should not become an accomplice of the addict by prolonging his addiction, but should guide him rapidly and firmly to the weaning process and lead him to the specialized bodies which can provide him with the necessary moral after-care.

In other cases, it would appear that the drug addict should not be placed on the same footing as an ordinary patient, in regard to whom the doctor is under a duty to observe absolute secrecy. We believe that the answer to this difficult problem can be sought in measures similar to those adopted in the French legislation on the subject of drugs, contagious diseases and alcoholism.

As stated in section 14 above, although there is no obligation laid down in France to notify cases of a drug addiction by name, such a notification is in effect imposed in connexion with the prescription of narcotic drugs; the doctor is under obligation to make use of a special drug-prescription book in which the names and addresses of the patients must be entered. This is a form of indirect compulsory notification. The doctor does not commit a direct breach of medical secrecy; he records a treatment, and not a diagnosis. It is for the pharmacy inspection services to detect cases of drug addiction with the aid of the information thus given.

To our mind, however, these measures can be supplemented by the study of a new social legislation. Such legislation would impose the compulsory notification of cases of drug addiction, without disclosure of the names of addicts, if the latter consent to be treated and do not seem to present any danger to themselves and others. On the other hand, in the case of dangerous individuals capable of active proselytism, of addicts who refuse treatment, and of minors, the notification would specify the name. The same would be true, of course, in all cases coming to the knowledge of doctors in observation and treatment centres for delinquent minors.

19. The reply to the question embodied in the title of this article must therefore be an extremely complex one: it is not consistent with the ethics of the medical profession to notify cases of addicts who come to a doctor for treatment or of addicts detected in the course of somatic examination following a consultation with a view to treatment, provided that the addict concerned accepts disintoxication treatment; on the other hand, a doctor may report to the authorities those who, without any medical reason, seek to obtain from him a prescription which will enable them to continue to take drugs more or less legally or who, because of their age or their propensities to active proselytism, constitute a serious moral danger.