When many addiction professionals think of informed consent the first thing that comes to mind is a likely a research protocol. Clients often associate informed consent with a form signed before a surgical procedure. Yet, informed consent is one of the most central ethical and legal principles and processes of clinical care and is especially important in addiction treatment.

Informed consent is a practical means of honoring the more abstract concepts of the rights and dignity of the human person. The practice of informed consent actualizes and protects one of the most central values in modern bioethics: autonomy defined as the right and ability of the client to make his or her own medical decisions. However, patients cannot exercise full and authentic self-determination in health-care decision making without receiving adequate information from the addiction professional treating them.

Clinicians often wonder how much and what kind of information to convey to patients in order to meet not just the letter, but also, the collaborative spirit of informed consent. Most ethics experts would recommend that several broad areas be discussed with a client before beginning a specific form of treatment, or if there are substantial changes in the therapy. The first is the diagnosis for which the patient is being treated, such as alcohol abuse or cocaine dependence. The second is the prognosis — what the client can expect to happen during the course of his illness. The third is the nature of the proposed treatment — for example cognitive-behavioral therapy.

Talking to your clients

An often-overlooked element of informed consent is discussion of the alternatives to the proposed treatment, such as other forms of therapy and/or medications. A description of alternatives also is not complete without mention of the likely outcome with no treatment; whether that means the client attempts to change his substance use on his own, or continues his current pattern of addiction. Review of risks and benefits associated with the proposed treatment are an essential factor in the informed consent process, one on which legal action often focuses.

Which risks and in what detail should be disclosed to the client can often be confusing to addiction professionals as they try to balance not overloading the client with facts, versus failing to mention significant aspects of the treatment. A good rule of thumb is to discuss the most common and the most serious risks of a treatment. For instance, if you were working with a client who had been prescribed disulfiram (Antabuse) you would want them to know they could have an unpleasant reaction if they consumed alcohol while on the medication including flushing, nausea, vomiting, flushing and palpitations among other symptoms. Besides the dramatic consequences of drinking alcohol on Antabuse, you would also want the client to know that they may develop an unpleasant aftertaste on the drug, which though not medically concerning, could worry a client and thus, affect adherence

A question that often comes up in addiction treatment is whether informed consent is required for psychotherapy and counseling or only for medication treatments. The ethical codes for the American Psychological Association, The National Association of Social Workers and the National Association for Alcoholism and Drug Abuse Counseling, among many other professional associations of non-prescribers, all include informed consent provisions in their ethical guidance to their members.

Unfortunately, despite the recommendation of these organizations and others that explicit informed consent be obtained and documented for assessments and ongoing therapy, this ethical and legal obligation is frequently ignored or inadequately executed. Part of the reason for this inattention to the informed consent process is that it is too often seen as being a static and formal requirement that the law, regulatory agencies or institutional policy imposes and interposes between client and therapist. Informed consent is more appropriately viewed as a dynamic inter- personal collaboration between addiction professional and patient that is integral to the successful therapeutic relationship. Informed consent is sometimes misunderstood as being equivalent to a treatment agreement or contract, and certainly there is some ethical overlap. The treatment agreement is, however, a statement of the mutual responsibilities and obligations of patient and professional within the treatment relationship, while informed consent focuses on the process of shared-decision making regarding the treatment plan.

Fostering that shared decision making with individuals who have addictions may be a challenge for several reasons unique to our patient population, especially if the clinician works in the public health sector. Many of our clients may come from diverse ethnic backgrounds where language is a barrier to informed consent, warranting the services of an expert interpreter or translator rather than relying on untrained staff, or even worse, family members.

Clients who begin using substances as adolescents, or who come from disadvantaged circumstances, may be illiterate or have little education, making it incumbent on the professional to use language that is understandable, and perhaps, to employ audio-visual aids to convey information. Clients with heavy and prolonged use of stimulants, alcohol or inhalants may have cognitive impairments that require special educational approaches to informed consent or the use of a surrogate decision-maker. Many persons with addiction are disenfranchised or from cultures where individual autonomy is not the prevailing value. This merits the counselor take therapeutic steps to empower the patient on the one hand; or to incorporate family or community autonomy into treatment planning, on the other.

Finally, the all too prevalent stigma attached to addiction in our society, as well as the criminal status of the use of illicit substances, means that patients may have issues of trust and voluntarism that will need empathic and reflective attention if true informed consent is to be fostered. Despite these formidable obstacles, addiction professionals who see informed consent as primarily an opportunity to clarify and codify the ethical aspects of treatment expectations and therapeutic objectives can not only enhance their relationship with their patient, but obtain the secondary goals of improved outcomes, professional responsibility, legal safeguards and regulatory compliance.

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