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The noncompliant substance abuser.

The Noncompliant Substance Abuser

JR is a combative, young white female who presents in the Emergency Room disoriented, with a fever, chills, and a cough productive of yellow sputum. She complains of chest pain and shortness of breath.

JR is well known to the medical staff. She has had three previous admissions with endocarditis and interrupted her clinical course on two of those admissions by leaving the hospital against medical advice. On her most recept previous admission, her mitral valve was replaced with a porcine prosthesis. She also tested HIV positive (but was and remains asymptomatic for AIDS).

JR's social history includes occasional prostitution, IV substance abuse (cocaine), and needle-sharing. Although JR had been referred repeatedly to the substance abuse shelter, she refused counseling.

With a diagnosis of pneumonia, Staphylococcus aureus bacteremia, and a mitral valve vegetation and mild insufficiency, JR is placed on appropriate IV antibiotics and hospitalized.

On the third hospital day, JR is much improved. She is calmer, less combative, and seems resigned to the clinical course as outlined to her by her attending physician (four to six weeks of IV antibiotic therapy).

On hospital day 10 JR has a low-grade fever but otherwise feels much improved. She begins to show signs of irritability. She quarrels with her medical resident and nurse about the necessity of remaining in the hospital.

On hospital day 11 JR objects to receiving medical direction from the medical resident and demands to see her "real doctor." The attending physician is called. JR tells him that she can't stand being confined to the ward. She says that she feels well enough for discharge. The attending points out that the growth on her prosthetic heart valve, while reduced in size, remains. He explains that the bacteria growing in her blood is especially dangerous and that a more extended clinical course is medically indicated. He warns JR that she risks death if she cuts off her clinical course prematurely. JR trivializes his warnings, saying, "I'm under a death sentence anyhow." On day 12, JR walks out against medical advice.

Two days later, JR again presents to the Emergency Room with a fever, shortness of breath, and a rapid heart rate. A repeat echocardiogram shows worsened mitral valve incompetence and heavier regurgitation. Replacement of the prosthetic valve is recommended. JR's attending physician points out the contraindications of JR's poor surgical risk status and her record for recidivism. A consultation with the hospital ethics committee is sought. After a thorough review, the committee offers the opinion that it would not be unethical to replace JR's damage heart valve. Surgery is scheduled.

JR tolerates surgery better than expected. Her course of antibiotics is resumed. In hope of achieving better compliance, JR is fitted with a PRN adapter (an indwelling catheter permitting direct IV access) and given instructions for self-administering her antibiotics at home. On the fifteenth day after surgery, JR is discharged, scheduled for a follow-up clinical appointment in two days. JR misses her appointment.

Four weeks after discharge, JR presents yet again in the Emergency Room, with a fever and shortness of breath. Clinical signs indicate that her second valve replacement has failed. (JR admits to using the PRN adapter for cocaine). An echocardiogram shows heavy mitral regurgitation and a perivalvular abscess. She is growing Pseudomonas aeruginosa in her blood. JR demands another valve, saying it would violate her civil rights to be refused. Would it be wrong to refuse her?


Patients like JR frustrate doctors and nurses no end. These patients are pejoratively referred to as "dirtballs," especially by residents. Sometimes attending physicians tell their residents that the best they can hope for in caring for such a patient is to learn how to insert a subclavian line when her blood pressure drops.

JR was an "undesirable" or "hateful" patient for several reasons: (1) she had a serious illness that would require prolonged hospitalization and intensive use of services; (2) she is HIV positive, for which there is no highly effective treatment; (3) she evidenced continued self-destructive behavior; and (4) she was medically indigent and inadequately insured.

The decision to operate on JR has been made twice, on the basis of medical distinctions: mitral valve rupture is a life-threatening complication of endocarditis. A decision not to operate on JR would be made on the basis of someone's, presumably the attending physician's, assessment of socioeconomic and cost/benefit considerations in her care.

Faced with arguments about limited resources, it is always important to clarify whose resources are being considered and whether and to what degree there is a scarcity of those resources. Here, the valves themselves are plentiful. Porcine valves are easily available, and not in fixed supply, as are human blood or human donor organs. A valve shortage does not limit JR's care.

What might limit it is the shortage of financial resources. First, the Medicaid payment for JR's care comes from a limited public purse, now faced with increasing numbers of poor people needing medical care, combined with state resistance to raising taxes to pay for this care. Funds spent on JR are likely to diminish availability of care for other needy people.

Second, concern exists about the overall amount of society's money that goes to health care. This concern is an important reason not to waste health-care resources, but the definition of waste is complex in a fragmented reimbursement system like ours. Since most health-care providers are not working within a defined capitated system and are not asked to make actual tradeoff decisions between two different services, or even two different patients, how can we argue that a lifesaving procedure is a waste unless we believe that this specific patient's life is worth less than the average patient's life?

A scarcity of institutional resources may mitigate against valve replacement. But hospital beds are not scarce: low daily censuses have already forced many hospitals to close.

Yet, physicians are trained (and paid) to make medical distinctions, not social ones. Medical indications are different from issues of cost containment. We wonder if a physician would consider refusing the request of an impaired substance-abuser colleague--a young anesthesiologist, for example--who needed another valve replacement. Is there something morally different about the yougn physician's request? Is it primarily the young physician's means and peer group--our own--that separates his case from JR's? In one study of 100 impaired physicians treated in Georgia, all were compelled to complete an in-patient training program; most went into remission and many returned to work after treatment.

What JR needs is treatment of two diseases, not one: prosthetic valve endocarditis and drug dependence. Successful treatment of one depends on the other. A recent national study documented a woeful shortage of drug treatment programs, many of which have been proven effective.

We would tell JR and her treating physicians that she should have the valve replacement, if she promised to complete an in-patient substance abuse program, just like the young anesthesiologist. If JR leaves the hospital AMA again, or breaks her promise, efforts at saving her life with intensive medical and surgical treatment will have been unsuccessful. Palliative care, with a limited treatment plan (symptomatic treatment for the discomfort of dyspnea and fever) is what we can and should offer then. BUt until we're willing to offer real treatment for JR's underlying disease of drug dependence--and a routine referral to the city shelter is barely a start--treatment of her valve disease cannot be considered futile.


This case challenges our capacity to control prejudicial impulses regarding unpopular forms of self-abuse. Our much-publicized war on drugs has created a social climate which selectively stigmatizes illicit drug use, making it respectable--no, laudable--to be especially harsh with refractory IV substance abusers. Having said this, however, it does not follow that we must never refuse heart valve replacements to substance abusers for fear of indulging prejudice. At some point, any reasonable person must begin to doubt the wisdom of additional heart-valve replacements for a patient like JR. But when? Does it come only at the point where the expectable patient benefit from an additional surgical intervention equals zero? Somewhere short of this? Does the patient's extraordinary record of noncompliant, self-destructive behavior make a difference?

If a tissue graft may be withheld from an otherwise eligible heart transplant candidate partly because of expected noncompliant postoperative behavior, may a valve replacement be withheld on similar grounds? Presumably, the shortage of suitable organs and a determination that they do as much good as possible explains in part why noncompliant postoperative behavior matters in transplant cases. Resource scarcity does not present itself so dramatically in patients with substance-abuse-related endocarditis but it remains an issue nonetheless. Costs average $14,000 for treating endocarditis medically. Uncomplicated surgical replacement of affected valves averages $24,800. Since few substance abusers with endocarditis have full insurance coverage, their treatment expenses tend to be cost-shifted to others. Some observers may think that this provides another argument for socially guided health-care rationing. For present purposes, I leave questions of rationing aside, noting only in passing that some hospitals seem to have adopted a two-valve limit for IV substance abusers.

I think it would not be wrong to refuse JR's demand for another heart valve. In general, health-care professionals have no obligation to offer treatment options that have proven to be ineffective in a patient. An otherwise effective therapeutic effort can be rendered ineffective by non-compliant patient behavior. A pattern of noncompliant, self-abusive behavior can justify a belief that otherwise effective therapy will be rendered ineffective by it. When such evidence exists, it is not wrong to withhold otherwise effective therapy until there is good evidence that it will be successful. JR's history of noncompliance and drug-abuse count as sufficient evidence to believe that her future behavior probably would destroy any prosthetic valve that might be placed. Therefore it would not be wrong to refuse JR's demand for another valve until and unless a change in her behavior makes a reassessment appropriate.

One might object that JR's underlying medical problem, chemical dependency, is a chronic disease which, like diabetes, can be managed, but not cured. Refusing to offer surgery for the foreseeable complications of substance abuse is no different from refusing amputation of a gangrenous limb to a noncompliant, insulin-dependent diabetic. Since it would be wrong to refuse amputation of a gangrenous limb to a noncompliant diabetic, so it would be wrong to refuse heart valve replacement to JR. To refuse her amounts to punishing her for suffering from a common complication of her chronic disease. This is medically inappropriate.

Although the thrust of the objection does not rest on the analogy with diabetis, it is worth pointing out that there is an important difference between the moral resources of diabetics and substance abusers. No insulin-dependent diabetic can cure her disease by an act of will, yet at least some substance abusers do, by appropriate acts of will and perhaps with help, discontinue substance abuse.

The relevant part of the objection seems to rest on the claim that even an impressive record of noncompliance cannot justify refusing a surgical intervention which will likely be undermined by just that sort of noncompliance. This strikes me as a dubious claim. Smokers are not candidates for heart transplantation. This is not because smokers are stigmatized socially, but because their addiction creates an unacceptable additional risk of allograft failure. JR's record of noncompliance is similar in this respect.

The suggestion that refusing to offer JR a third valve replacement is punitive requires classification. It likely means that regardless of the stated, justificatory reason for refusal, the real reason is punitive and discriminatory. Substantiating this claim would require showing that the reasons offered for refusal in JR's case are inherently weak and that despite their applicability in similar cases they are invoked only here. It would then be reasonable to explain JR's treatment as motivated by widely held prejudices against substance abusers.

Everything important hangs on showing that the justification is inherently weak. I think JR's record makes it permissible to refuse to offer her a third valve on the grounds that there is no obligation to offer patients interventions that will be ineffective. The controversial part of the argument concerns whether noncompliant, self-destructive behavior can be a relevant causal factor in judging efficacy. If it can, how much evidence must one have before the principle justifies refusal? Some ethicists think that a patient's noncompliant, self-destructive behavior can never serve in an argument to justify refusing an intervention. I think this absolutist position is too strong.

Christine Cassel is chief, Section of General Internal Medicine, University of Chicago Medical Center, Chicago, Ill.; John La Puma is director, Center for Clinical Ethics, Lutheran General Hospital, Park Ridge, Ill.

Lance K. Stell is a medical ethicist at Charlotte Memorial Hospital and Medical Center, Charlotte, N.C., and chairman of the Philosophy Department, Davidson College, Durham, N.C.
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Title Annotation:includes commentaries
Author:Cassel, Christine; La Puma, John; Stell, Lance K.
Publication:The Hastings Center Report
Date:Mar 1, 1991
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