How Many Life-Saving Surgeries Should Addicts Have?

Infections from injecting drugs can ruin a heart.

Posted Dec 17, 2019

Intravenous drug users are susceptible to developing endocarditis, an infection of the heart valves from bacteria entering the blood stream. Endocarditis can be treated by replacing the infected valves, though it can re-occur from continued intravenous drug use. This presents a complicated set of related ethical dilemmas for physicians, patients, family members, and hospital officials.

Consider the following scenario:

A young woman has endocarditis. Prior to the procedure, the surgeon informs her he will operate this one time. If she develops a subsequent infection, he will not perform the surgery again. The young woman admits she has an addiction and wants to live for her own sake and for the sake of her children. This admission, along with the strong support of her family ,is part of the reason why the surgeon agrees to perform life-saving surgery.  The young woman has the surgery, remains sober, and is doing well. However, the infection from her endocarditis had been so severe that it causes another of her valves to start leaking. It was unclear whether she would need another surgery. Her physician told her if she did require another surgery because of that first infection, she would be eligible.

This is not a hypothetical thought experiment but one discussed in an article in The New York Times. There are a variety of initial responses to this situation. They range from believing everyone should have a second chance to forfeiting the right to surgery because of drug use. Some claim that drug users risk their lives so much that they must not want to live. Why perform surgery? Others are critical of a doctor who would make the pronouncement about “one and done” while some feel enormous empathy for a physician caught in this position. Some wonder about the costs of surgeries and ask who pays. “Costs shouldn’t matter,” say some while others say, “Someone has got to pay and we taxpayers are footing the bill. We’d rather have money go to someone who is more deserving or needs it more.”

Some relevant factors to consider

Many patients who develop endocarditis have no health insurance and live in states where Medicaid was not expanded with the Affordable Care Act. As a result, the costs of these lifesaving surgeries are shouldered locally either by hospitals, municipalities, or counties. Local not-for-profit hospitals operate with limited budgets: Helping Person A means there is less money to help Person B. Further, many local municipalities and counties are wary of needle exchange programs that would cut down on rates of infection. Finally, in many areas of the United States, there is little to no access to affordable addiction treatment. With few physicians available to provide medication-assisted therapies (MAT) such as Suboxone or methadone, and the wariness of officials about MAT (prescribing opioids to treat opioid dependence), active addicts have little access to what the government recommends as best practices.

Other issues

The view of The National Institute of Drug Abuse (NIDA) is that addiction is a “chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control, and those changes may last a long time after a person has stopped taking drugs.” If infection occurs as part of another medical condition (addiction), is a person being penalized and made to forfeit his life for having this condition? Are there other medical conditions whose patients might be similarly penalized?

Should a patient having a strong family or support network factor into a physician’s decision to operate? If a strong support network increases the likelihood of success in treatment, which would reduce the chances of a new infection, then this is arguably a justified factor. However, many people lack such a network, so this becomes a strike against them. In what other medical cases is looking at a patient’s support network justified?

If we start to look at some external considerations in worthiness of surgery determinations, then we need to specify the range of those considerations. Should one’s economic class status be a consideration? That makes many uneasy because it is mostly poor people lacking adequate insurance who find themselves in this position. Even when patients do have insurance, insurance companies may make the decision not to cover the procedure over the protests of the surgeon.

Some might object all these external considerations merely confuse the issue. Others will say that these external considerations are or make the issue. Individual physicians are finding themselves in ethical dilemmas they never imagined. The best hospital administrators find themselves in Catch-22 or double-bind situations. People struggling with addiction are caught in the worst situations, with their lives hanging in the balance. How should the scales tip?