AMA Journal of Ethics^®

My hands started to shake and I could feel the beads of sweat form on my forehead and trickle down to my brow. I looked up at the clock—10:27. I had been sitting in this meeting for over an hour without a break and my body was screaming for its 10:00 cigarette. At least give me the 10:15 Diet Coke, it pleaded with me. Being stuck in this meeting without so much as a cup of coffee was making me cranky and I was no longer able to focus on the meeting or what was going on around me. I looked at the clock again. It was only 10:28. Maybe this self-denial was a good thing, I thought. I could prove to myself that I didn't need nicotine. I looked down and saw my leg trembling nervously under the table.

And so it goes for the addicted person. Cravings that will not quiet until fed—repeatedly and with greater and greater quantities; discomforts that manifest physically when the craving for a "drug" of choice—be it a legal or illegal substance or even a behavior—is not satisfied; an inability to focus on anything except for the next fix. These are all common characteristics of an addiction. It is to this complicated confluence of problems—the ethical issues associated with diagnosing and treating addiction—that we dedicate this issue of Virtual Mentor.

Addiction to alcohol and drugs has long been recognized as a medical condition, complete with physical and psychological components, but treating it successfully has continued to elude many of the best doctors and health experts. The ethical quandaries raised by addiction include the degree to which it can be said to compromise patient autonomy, patient access to appropriate medical care, and how the perceptions that physicians—often subconsciously—have of addicts affects treatment. Many of us are familiar with "traditional" substance abuse, like alcohol or drug use. Indeed, based on a 2006 poll, there are "roughly 40 million American adults with a spouse, parent, sibling or child battling addiction" [1].

In two of our clinical cases, we explore these more well-known addictions. The clinical pearl looks at fibromyalgia, a disease in which addiction can more readily occur due to the constant pain that patients endure and the lack of effective treatment for this syndrome. Recently, and more controversially, gaming (both video and online) has been recognized as potentially addicting and is examined in a third clinical case and the journal discussion.

Although the word "addiction" conjures up many images—some individual, some stereotypic—it can be difficult to define, much less teach about effectively. With over 50 years of combined teaching experience, our medical education authors share the wisdom of their long careers researching and teaching this topic. Health law examines some of the punitive measures that states have tried to levy against pregnant women who have addictions to drugs or alcohol.

The policy forum questions the usefulness and fairness of insurance-sponsored wellness programs that reward certain health markers such as weight control and smoking cessation. While smoking and overeating have traditionally been considered to be within a patient's control, if they are now medically recognized as rooted in addictions, then are the insured being punished for conditions over which they have little to no control? Following this policy discussion, the medicine and society article explores the two-fold problem of pain. If physicians are too concerned with people becoming addicted to medication they may fail to prescribe affective treatment. Yet physicians tend to neglect these same risks of addiction for certain categories of patients including the rich and famous.

Finally, amid all of this talk of medicine and ethics and the language used to describe addiction, the op-ed takes a more philosophical view, and questions whether we all—doctors, health professionals, and society as a whole—have got carried away with medicalizing what has been traditionally viewed as a vice—a sin—to be overcome. While the author does not advocate condemning or abandoning the addict, he does urge the reader to not be so quick to label everything with a medical tag, recommending instead that we consider ourselves as the human beings that we are, in need always of redemption, but not always of prescription.

In one issue of Virtual Mentor we could not cover the entire field of addiction medicine, but it is our hope that you find it informative and thought provoking. I invite you to consider your own ethical quandaries in your clinical or research ventures and if these articles inspire a reaction, we urge you to share your thoughts with us.