by Craig Klugman, Ph.D.
Pilots do it. Train conductors, air traffic controllers, TSA agents, police offices, fire fighters, Olympic athletes and long haul truckers do it. In eleven states, some recipients of public aid even have to do it. So shouldn’t health providers have to do it?
“It,” of course is drug testing, often random and sometimes for suspicion of use. Jobs that are charged with taking care of the safety of the public (or sometimes that benefit from the public dole) are often drug tested throughout their careers to ensure that they are not using drugs. The presumption is that drug use means placing the public in danger. According to the Society for Human Resource Management, 84% of employers in private industry require pre-employment drug testing and 39% conduct random screenings of their workers. National surveys estimate that nearly 14.1% of adult workers use illicit drugs.
Physicians and nurses have a sacred trust to directly protect the lives of their patients and the public. This concept is nonmaleficence in action—do not create a situation or be in a state that could put people in danger. A new proposition in California is being put before voters in November. If passed, California’s Prop 46 would require random drug testing of doctors. The proposal also requires physicians to check a central patient database before prescribing controlled substances and would lift the present liability cap of $250,000 in medical malpractice pain and suffering lawsuits.
The call for testing of health care providers is not new. In 2008, Massachusetts General Hospital and the Cleveland Clinic mandated anesthesiologists to be drug tested because of the high rate of abuse in that discipline. One reason for this high rate is workplace exposure.
The current call for drug testing is based on a fear of patient safety. A few case studies in the news have elicited concern that health care workers are putting people at risk. For example, the California bill—known as the Troy and Alana Pack Act—is sponsored by Bob Pack after his children were killed in a car crash. The at-fault driver was under the influence. He had been given multiple prescriptions for narcotics. Such proposals seek to criminalize drug use instead of providing treatment for an addiction. They encourage drug users to stay on the down low for fear of jail time or losing a job, instead of getting the help he or she needs.
Why focus on doctors? A New York Times editorial says that all health care workers should be screened. After all, emergency medical technicians have to pass drug screens but licensed physicians and nurses do not. Perhaps the California bill is not broad enough.
There are many reasons to support drug testing. Among them are perceived safety of self and others, regulations that require it, health insurance providers may encourage it, and it may act as a deterrent. Some organizations may drug test as part of their public relations campaigns. They are saying: “We’re drug free so we can be trusted.” Bioethicist Art Caplan has come out in favor of testing health care providers in part because peers rarely report on impaired professions. Plus, like the anesthesiologist, access to drugs is part of the work environment.
Claims that such screening is a violation of privacy and denies professionalism are often tossed aside as unimportant. In today’s world privacy is often viewed as quaint and from a bygone era. Also consider that few people mention that unreliability of the tests: In 5-10% of cases there are false positives and in 10-15% of cases there are false negatives.
How does testing welfare recipients protect public safety? It doesn’t but it does further demean the most vulnerable in our society and stigmatizes them for being in need of a helping hand. And the same will happen for health care providers.
The shortcoming of these presumptions and assumptions is that the data does not back them up. Cases that make sensational headlines, non-peer-reviewed articles, and massive marketing campaigns have shown that this danger lurks. But the peer-reviewed articles on this “danger” are few and far between. Searches for this information lead to official websites expounding on the danger through hyperbole more than facts. The hype is not necessarily supported by the reality. When dealing in fear and a now multi-billion dollar testing industry, real data is merely an inconvenience. (For more on the failure of the War on Drugs click here)
Some will argue that if you have nothing to hide then you have nothing to fear. This logically fallacy simply brushes aside concerns about false positives, false negatives, violations of privacy and protection from baseless searches (Fourth Amendment).
Legally, California and other states to follow may end up mandating random drug testing and pre-employment drug testing of physicians, nurses and other health care professionals. But ethically, balancing the loss of privacy, dignity, and whether patient safety is actually improved against the perception of public protection does not support the idea of testing everyone. For those who show signs of abuse or are suspected of abusing, testing can be helpful if the goal is to get them help and support their recovery. But subjecting everyone is unjust. And testing to punish is unconscionable.