Stuart Gitlow, MD
| October 16, 2012
The September issue of our Journal of Addiction Medicine features an article by JW Boyd and JR Knight discussing ethical dilemmas confronting state physician health programs (PHP's). Within the article, the authors show concern regarding the coercive nature of the system, specifically indicating that "physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine." There is also concern that when such treatment is recommended, cost may be prohibitive for the standard 90 day length of rehabilitation, notably longer than the 20-28 day stay typical for other patients undergoing substance abuse treatment, despite what they describe as a lack of evidence that healthcare professionals require longer treatment.
The Federal Aviation Administration has similar rules applying to aircraft pilots identified as having addictive illness. These pilots have little choice but to cooperate with FAA standards and regulations if they wish to obtain a special issuance medical certificate, under which they may continue to fly either privately or commercially. They too have to pay sometimes prohibitive amounts for their treatment, which as it happens is also a 90 day length of rehabilitation as a starting point. The questions which Boyd and Knight pose for physicians could therefore also be posed for pilots. A quick literature search reveals there to be no evidence that pilots require longer treatment.
But there's a problem with this line of thinking. Both pilots and physicians have been demonstrated to do well with these treatment programs. Recovery rates over 80% appear to be rather consistently identified both by PHPs and by studies of pilots conducted by the FAA and by independent airlines. These long term recovery rates appear dramatically superior to the recovery rates obtained within the general population, which, depending on what literature you believe, seems to lie somewhere in the 40-50% area. Further, one could easily argue that many of our patients have little choice but to cooperate with recovery programs if they are to regain their physical health, their financial status, custody of their children and their legal freedom. It would seem that these measures of coercion would often be at least equal to one's desire to simply regain access to one's chosen occupation or avocation.
Given that recovery rates are demonstrably higher with pilots and physicians going through these well-defined recovery programs, I would flip the question as posed by Boyd and Knight: is there any evidence that the general public requires less treatment than do healthcare professionals and pilots? I would further ask, given the excellent outcomes generally obtained by PHPs and pilot recovery programs, why there have been no studies in which members of the lay public go through identical programs to determine what their long term outcome would be. Indeed, what happens when a non-healthcare professional or non-pilot goes through 90 days of rehab, and is then followed regularly by an addiction specialist physician while simultaneously attending twelve-step or similar self-help groups and being subject to random urine drug testing, all as the FAA requires of pilots requesting a special issuance medical, and as state medical boards generally require of physicians wanting to return to practice? Would they too have an 80-90% recovery rate?
Before we go after a successful set of programs, perhaps we should first ask the question as to whether we should direct our attention toward less successful approaches. This is not meant in any way to undermine the ethical dilemmas addressed by Boyd and Knight; such dilemmas are legitimate and deserving of focus and attention so as to ameliorate the inherent conflicts of interest as best we can. The authors have done an expert job at pointing out the major issues to be considered. But as with all ethical dilemmas, there are valid arguments on both sides that need to be considered closely, and each argument needs to be considered from an opposing direction to determine if the stage is set properly for any investigation to follow.