The need for everyday ethics in clinical practice with people who are substance dependent

David A Silkoff1

1 Centre for Health Equity, Melbourne School of Population and Global Health, 207 Bouverie Street, The University of Melbourne, Victoria 3010,

This paper argues for a richer understanding of how ethical challenges are embedded within the everyday practice of practitioners within the field of substance misuse. This will benefit both thinking regarding ethics and clinical practice. I describe my own experiences of ethical and legal grey areas in routine clinical practice as an experienced clinician in the field. Examples include decisions such as what to do in respect to prescribing a medication for opioid dependence when any beneficial impact appears negligible; and addressing hazardous mixing of prescribed and non-prescribed drugs.

To assess whether research in ethics could assist with these challenges. I conducted a systematic review of 20 high ranking journals in bioethics, using the terms drug dependen* OR substance dependen* OR alcohol*; and of 20 high ranking substance misuse journals using the terms ethic* OR moral*. I also examined textbooks in the field of ethics in substance use work.

Within published research, representation of clinicians’ everyday ethical challenges was almost absent. Most work concerning ethics and substance use concentrates on research ethics, or applying ethical theory to specific interventions or policy. Studies using empirical data at all were a minority. Textbooks concentrate on applying ethical principles to hypothetical situations. I will argue that to help with ethical reflection within practice, research should focus on the everyday work and experiences of practitioners. Ethical challenges may benefit from a detailed empirical approach to everyday ethics within the substance use field. This will also broaden the currently narrow study of ethics within a complicated area of healthcare.


David Silkoff is a PhD student in the Centre for Health Equity at the University of Melbourne. He is studying the everyday ethics of practitioners working with people who have problematic substance use. David is also a nurse practitioner in the Alcohol and Other Drug sector, and he prescribes pharmacotherapy within this field. His interest in ethics within daily practice grows from his own experience of ethical challenges, and exploring possible frameworks to assist with these.