Ethical Considerations Related to Stigma in Mental Health Aspects of Treating Substance Use Disorders

Which of the following choices offers legal protections for the confidentiality of medical records related to substance use disorders?

Dr. C confesses that he is being sued in federal court because of the dosing error and fears that you will be compelled to testify against him at trial. You reassure him that such testimony is privileged as a result of which of the following U.S. Supreme Court rulings?

Which of the following next steps is ethically and legally permissible?

The psychiatrist’s obligation to report physicians who practice while under the influence of alcohol reflects the ethical concept of:

The type of psychiatric advance directive described previously is an example of which of the following?

Several states have enacted versions of Casey’s Law, that is, statutes that allow family members to compel individuals to obtain substance use disorder treatment against their will. These statutes reflect the bioethical principle of which of the following?

Dr. Y prescribes a combination of naltrexone and disulfiram to Ms. X and arranges for a follow-up appointment in 2 weeks. Ten days later, Dr. Y receives a subpoena related to Ms. X’s divorce case that requests a copy of her medical records and notes from the visit. What is the appropriate next step?

When Ms. X learns of the subpoena, she asks whether her medical records may be used against her in a future child custody hearing. Which of the following is true regarding medical records that document substance use disorders and child custody litigation?

The answer is C. Title II of HIPAA prevents most health care institutions (known as “covered entities”) from disclosing protected health information except under certain limited circumstances (8). 42 CFR Part 2 is a federal regulation that governs the confidentiality of substance use treatment records in certain federally funded programs (known as “Part 2” programs) (9). Both of these laws protect confidential medical records that are related to substance use disorders, although only HIPAA applies to the records of a patient who is seeing a provider in private practice such as Dr. C. Jaffee v Redmond (1996) is a U.S. Supreme Court decision that guarantees psychotherapist-patient privilege; Powell v Texas (1968) is a U.S. Supreme Court decision that permits the criminalization of public intoxication (choice A). Casey’s Law is a Kentucky statute, replicated elsewhere, that allows family members to petition for relatives with life-threatening substance use disorders to be involuntarily committed (10) (choice D). EMTALA is a federal law that requires hospitals to evaluate and stabilize all patients without regard to ability to pay (choice B). Robinson v California (1962) is a U.S. Supreme Court decision that prohibits states from criminalizing addiction; City of Grants Pass v Johnson (2024) is a U.S. Supreme Court decision that allows states to criminalize sleeping and camping outdoors (choice E).

The answer is E. The U.S. Supreme Court decision in Jaffee v Redmond (1996) extended the psychotherapist-patient privilege to all federal courts. The privilege is said to be held by the patient, who has the right to prevent their psychotherapist from offering testimony regarding confidential disclosures (11). Trammel v United States (1980) is a U.S. Supreme Court decision that affirms spousal privilege (choice D). Branzburg v Hayes (1972) is a U.S. Supreme Court decision that rejects a similar privilege between journalists and sources (choice C). The U.S. Supreme Court decision in Robinson v California (1962) invalidated a California statute that criminalized the status of being addicted to narcotics (choice A). Volk v DeMeerleer (2016) is a Washington State court case that broadly expanded the duty to warn to all foreseeable victims of a psychiatric patient (choice B).

The answer is D. Physicians’ health programs, sometimes known as professional assistance programs, are voluntary programs that offer support and monitoring to physicians who are struggling with substance use disorders, but have not harmed patients (12). Some programs expect a physician to temporarily surrender a license; others do not. Dr. C might be a candidate for such a program. Since Dr. C is not endangering patients at present, no grounds exist to breach confidentiality to either report him to the state licensing authority (choice B) or to warn his employer (choice A). Most states only permit treatment for substance use disorders on a voluntary basis, but those that do permit involuntary commitment do so in limited situations in which the substance use places the user in serious danger, which is not the case here (choice C). Partner notification statutes are mechanisms through which the sexual partners of individuals with certain infectious diseases, including HIV and syphilis, can be anonymously informed of their risk of exposure (13) (choice E); they may also be relevant to the exchange of needles by opioid users, but not to patients with alcohol use disorders.

The answer is B. Dual loyalty refers to the simultaneous duty of physicians to serve the interests of their patients and society at large (14). The concept of dual loyalty emerged in the early 20th century in relation to public health and safety concerns. Boundary crossings are acts by a provider that transcend the normal professional roles of physicians (choice A). The ethical principle of autonomy refers to the right of the patient to make their own decisions and control their own care (choice D). The ethical principle of justice requires that similar individuals be treated similarly and emphasizes the importance of equity in the delivery of medical services (choice C). Strict liability is a standard in both civil and criminal law that judges an act independent of the intention behind that act or the fault of the perpetrator (choice E) (15).

The answer is A. A Ulysses contract or Ulysses pact is a document that allows individuals “to commit themselves now to a particular course of treatment at a future time if they suspect they will not be willing or able to follow that course of treatment at that future time” (16). These documents take their name from an episode in Homer’s Odyssey. Res ipsa loquitur is a legal concept under which negligence can be automatically inferred from certain actions (choice B). Bargaining down is a phenomenon in which patients state prior to becoming ill or disabled that they would never wish to live in a particular condition, but once they find themselves in that condition, they decide they do wish to live (choice C). Habeas corpus, a Latin term meaning to have the body, is a concept in criminal law used to challenge unlawful detentions (choice D). Unconscionability is a concept in contract law that prevents the enforcement of contractual agreements that defy modern social norms or public policies (17) (choice E).

The answer is B. Beneficence, one of the four principles of medical ethics proposed by Thomas Beauchamp and James Childress, is the duty that physicians must serve the well-being of their patients. It is often considered a corollary to the principle of nonmalfeasance (“do no harm”) (18). Justice is another concept in medical ethics that requires each individual to be treated fairly and equitably (choice B). Informed consent is a requirement in both clinical care and human subject research that patients receive a reasonable disclosure of relevant information prior to any intervention and then offer voluntary agreement to proceed (choice C). Respect for persons is a concept proposed by the Belmont Report (1979) that includes both upholding patient autonomy and protecting individuals with diminished autonomy (choice D). Utility is a philosophical principle that seeks to achieve the most widespread positive outcomes for the largest number of individuals (choice E).

The answer is B. The next appropriate step for Dr. Y is to discuss the subpoena with Ms. X and ask whether she wishes to comply with the subpoena. Dr. Y may also wish to consult an attorney at this juncture. Different types of subpoenas exist and Dr. Y may have legitimate grounds, such as physician-patient or psychotherapist-patient privilege, not to provide the medical records. Complying without Ms. X’s consent before raising these issues with the court runs the risk of a lawsuit for breach of confidentiality (choice C). Although HIPAA distinguishes between medical records and psychotherapy notes, it does not mean that medical records should automatically be released (choice D). Quashing the subpoena may be the ultimate aim, but privilege is held by the patient and Ms. X should be involved in the decision regarding how to proceed (E). A subpoena should never be ignored because it is a legal summons and disregarding it can result in serious legal consequences for the physician (choice A) (19).

The answer is B. Judges in most states have broad latitude regarding what evidence to consider in rendering determinations of child custody. Since active substance use may raise questions that are related to parental fitness, judges may choose to subpoena such records. Substance use disorders are diseases, but as with other serious medical conditions, that does not mean they cannot be used in child custody hearings (choice C). Whether the substances used are legal or illegal is not likely to be a relevant factor in such decisions (choice D). 42 CFR Part 2 shields only substance use treatment records in certain federal centers (i.e., “Part 2” programs) and not more broadly (choice E). Some form of psychotherapist-patient privilege does exist in all 50 states; however, no privilege is absolute, and exceptions do exist in certain areas in which the mental well-being of the party is at stake; child custody cases are often among these exceptions to the general principle of psychotherapist-patient privilege (choice A) (20).