NYT ponders if IV drug users should get ‘second chance’ at heart surgeries, triggering outcry from addiction experts

An article published Sunday in the New York Times has triggered an impassioned social media response — mostly from addiction experts — expressing frustration over how people with addiction are stigmatized by the medical community, and how media coverage can perpetuate the problem.

Here’s the headline:

Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get?

The story focuses on the challenges doctors face treating heart valve infections (aka “endocarditis”) that are a result of people using intravenous drugs with unsterile needles. In particular, the story raises the question of how doctors should manage people who continue to inject drugs after having surgery, placing their hearts at risk of further damage.

“Would we ask that question of people with medical conditions other than addiction?” said Maia Szalavitz about the story’s headline. Szalavitz is a reporter and author of “Unbroken Brain: A Revolutionary New Way of Understanding Addiction.”

“Would we take insulin away from diabetics who don’t follow their diet or exercise program? If we accept addiction as a disease then this kind of treatment —  and this sort of framing of an article — are both completely unacceptable,” she said.  “It’s a ubiquitous, default sort of approach. Reporters rarely stop to ask themselves this question: ‘If I were covering another disease, would I still frame it this way?’ If the answer is ‘no’ then you to need to fix it. Otherwise, you’re just reinforcing the prevailing stigma.”

Article sheds light on important topic, but needed more voices

“I think the article did address some of the ethical issues, but it would have benefitted from additional voices,” said Leigh Turner, PhD, a bioethicist at the University of Minnesota. “I think bringing these often-hidden decisions into the public light is itself an ethical act, and a reminder that journalism is a moral practice.”

But Turner also thought delving deeper into the issue of stigmatization was something that might have added balance to the article.

“Additional voices could have more forcefully challenged some of the clinical decisions involved,” he explained. “Some of these decisions appear to put the hospital’s financial interests ahead of the expressed preferences and best interests of patients. Other decisions have to do with whether to provide or withhold care. These decisions are not necessarily justifiable, but can instead represent overt discrimination and stigmatization of patients who become ill from drug use.”

Of all the consequences of stigmatization, one of the most insidious may be that it turns people into “others,” or as writer Szalavitz puts it, “we stop valuing the life of someone and then we stop seeing them as human.”

For example, how would you feel about headlines — or doctors — that asked these questions:

• When should we stop treating emphysema in people who continue to smoke?
• How many heart bypass surgeries should a sedentary, junk food “user” be allowed?

Who would dare write those headlines?

No addiction experts were included

“This is a troubling article with a contribution to stigma that goes beyond the headlines,” says Michael Bierer, MD, a primary care physician who’s also the president of the Massachusetts Society of Addiction Medicine.

“There’s no inclusion of an expert on addiction. And several things are left unchallenged–such as the source who dismisses the evidence-based treatment of opioid addiction as simply ‘trading’ one vice for another,” said Bierer, who is also a contributor to HealthNewsReview.org. “And there’s no consideration that the heart damage that requires surgery may be more a symptom of a larger medical issue: the untreated addiction.

“Tell me this: When is it justified to deny a life-saving procedure?”

The ethics

I thought the ethical dimensions of the story — which were partially implied in the article, but not fully explored — deserved more scrutiny. I asked Turner, the bioethicist, if there were other ethical issues that he felt strongly about highlighting. Here’s a few he mentioned:

• The decisions to ration or limit care (to patients with addiction) seem to take place with little explicit guidance from the institutions employing the physicians, the societies to which they belong, or evidence-based practice guidelines. One risk associated with physicians making such consequential decisions without explicit, publicly debated and defended ethical standards, is that personal prejudices of individual physicians can have deadly consequences for patients who might — if provided care by different physicians — survive and recover.
• Physicians can act as financial gatekeepers for their institutions when they refuse needed medical care to those who lack insurance. “Bottom-line” economic interests then fuse with stigmatizing attitudes towards those who have used drugs. Prejudice and publicly unaccountable rationing of health care then masquerade as prudent clinical judgment.
• Such stigmatizing responses typically fail to grasp the nature of addiction, and frame such patients as blameworthy and personally responsible for suffering such heart damage. We also tend to neglect the routine underfunding of addiction programs, as well as the broader social and economic contexts within which people become addicted to particular drugs.

This broader social and economic context was, for the most part, well rendered in the article.

Anger and dissenting opinion

If the Twittersphere is any indication, this article stirred up plenty of anger and dissenting opinion. To be fair, much of the anger I came across had more to do with the topic itself. Not the writing.

Many expressed concern that some providers seem to value the lives of those with addiction differently than those with other diseases. Others expressed discomfort with doctors acting as arbiters of morality … or even mortality.

But a point could be made that if there were that many alternative views on this topic, why weren’t those voices included in the article? At the very least, including voices that address the issues of ethics and stigma as mentioned above. Here are some of those voices we found on Twitter:

Important coverage of realities people w/ #addiction face in getting equitable care, eg valve repair. Valves aren’t a scarce resource; we don’t deny angioplasty to person w/ 3rd heart attack. Worse still effective addiction treatment rarely offered #Stigma https://t.co/Fablh1A03k

— Sarah Wakeman (@DrSarahWakeman) April 29, 2018

Is there anything we can do to get through to journalists 1. What stigma looks like when baked into "objective" reporting, and 2. That by perpetuating stigma, they are complicit in death and suffering from substance use and bad policy? https://t.co/I31Ys4xy9Z

— Leo Beletsky (@LeoBeletsky) April 29, 2018

This is just one of a multitude of articles touching on this complex topic. Not only is it a compelling one, but maybe it serves as an important reminder for all of us — writers and readers alike — to ask two questions of any piece we approach on drug addiction: What are the ethical considerations at play here? Does this writing challenge or contribute to stigma?

More: How to write about addiction without promoting stigma and bias: 4 tips for journalists