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I read a post on a forum about two years ago that some schools in the US preform routine drug tests, and failing those, more long-term tests (fat samples, hair samples etc) on incoming medical students. It had me thinking about the ethical implications of this scenario and what it meant for barriers of medical education (for instance, targeting populations of those who have recovered from substance abuse but suffered in the past). I have a hard time seeing this be allowed in Canada but has anyone ever heard of this happening here? 
 

For the record: I’m a complete square, I do not use recreational (or prescription for that matter!) drugs. This is simply a thought provoking issue that I came across.

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I think it's not a straight-cut answer. You are right that it does not necessarily respect the best interests of medical students, but keep in mind that beyond the respect for the basic human rights of students (which are of course allotted to all indivdiuals), the schools actually have an obligation to carry out these sorts of tests if they believe that they would help respect the best interests of patients (who are the principle parties we must consider as health care professionals). In the case where patient beneficence would be compromised (and I discuss below whether I think it could), it is totally fair to expect such tests.

Now, if substance abuse occurred a long time ago and is unlikely to occur going forward into medical school or residency (as designated by a health care professional), then I think it is a non-issue. So, if a drug test came back positive, it is going to be testing for drug abuse that occurred recently, and I think we can all agree that having a med student snorting cocaine before electives or a resident high on nitrous would not be what we call a "high standard of care". Now I won't comment on marijuana because I think there is a variable cultural context to consider there. In Canada, it would be no big deal as long as it's on your own time and you don't show up high when you're supposed to be working with patients. But in the US, I know they still take it very seriously. 

Of course, there is always the argument that even if a person isn't taking drugs, drug testing them is an invasion of privacy/autonomy. But I think we can draw parallels here to mandatory police/vulnerable sector checks that are required for health care professionals. I don't see much debate in that realm, and I think largely the same arugment applied: that patient interests come first. I would think that any medical school with a such a policy would have a responsibility to disclose it to student before they apply, and certain before they accept an offer to enrol there (and it wouldn't be ethical to subject already enrolled students to a recently enacted policy if they didn't agree to it when enrolling). But I've never heard of such a policy being enacted anywhere. 

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3 hours ago, zxcccxz said:

I think it's not a straight-cut answer. You are right that it does not necessarily respect the best interests of medical students, but keep in mind that beyond the respect for the basic human rights of students (which are of course allotted to all indivdiuals), the schools actually have an obligation to carry out these sorts of tests if they believe that they would help respect the best interests of patients (who are the principle parties we must consider as health care professionals). In the case where patient beneficence would be compromised (and I discuss below whether I think it could), it is totally fair to expect such tests.

Now, if substance abuse occurred a long time ago and is unlikely to occur going forward into medical school or residency (as designated by a health care professional), then I think it is a non-issue. So, if a drug test came back positive, it is going to be testing for drug abuse that occurred recently, and I think we can all agree that having a med student snorting cocaine before electives or a resident high on nitrous would not be what we call a "high standard of care". Now I won't comment on marijuana because I think there is a variable cultural context to consider there. In Canada, it would be no big deal as long as it's on your own time and you don't show up high when you're supposed to be working with patients. But in the US, I know they still take it very seriously. 

Of course, there is always the argument that even if a person isn't taking drugs, drug testing them is an invasion of privacy/autonomy. But I think we can draw parallels here to mandatory police/vulnerable sector checks that are required for health care professionals. I don't see much debate in that realm, and I think largely the same arugment applied: that patient interests come first. I would think that any medical school with a such a policy would have a responsibility to disclose it to student before they apply, and certain before they accept an offer to enrol there (and it wouldn't be ethical to subject already enrolled students to a recently enacted policy if they didn't agree to it when enrolling). But I've never heard of such a policy being enacted anywhere. 

That's an excellent point! One of the few reason why I assumed that it was fair to subject student's to this would be the fact that it is potentially acting in the best interest of the patient (say if someone was found to have tested positive). A great parallel as well with respect to the vulnerable sectors check. Upon a brief google of the situation as well I found that in most cases this was being done by the hospitals that are affiliated with the schools and thus it seemed to be more of a policy of the hospital itself to clear them of any liability issues later on down the line. Thank you for your thoughtful response!

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There are some major flaws in the arguments here.

1.     You assume that if someone uses illicit drugs they are inherently less safe for patients than someone who does not use drugs. That is a big leap, someone could be high all the time in their personal life and still provide great care. If we were to follow your logic process to its end point should we not also screen for alcohol? It is one of the most widely abused drugs even though it is legal, and has a far great societal impact than most drugs https://www.economist.com/graphic-detail/2019/06/25/what-is-the-most-dangerous-drug .

2.     I am confused by the attempt to draw parallels between vulnerable sectors check and substance use. There is a world of difference between someone who assaults an old lady, or commits pedophilia and an individual using recreational drugs in their own personal time at no harm to anyone else than themselves.

From my understanding of your post, I think you are talking about recreational drug users, and not individuals suffering from addiction. Something to consider, is that by punishing individuals for using substances, a system makes them less likely to seek help if they are suffering from addiction. Most province's medical associations have physician health programs which can assist students/residents/physicians in getting treatment for addiction, with a focus on rehabilitation. Focusing on harm reduction and rehabilitation rather than punishment, is a more effective route to promote patient safety by encouraging those in need to engage in care. As opposed to hiding their problems for fear of reprimand where they can spiral and worsen.

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3 hours ago, drdean said:

There are some major flaws in the arguments here.

1.     You assume that if someone uses illicit drugs they are inherently less safe for patients than someone who does not use drugs. That is a big leap, someone could be high all the time in their personal life and still provide great care. If we were to follow your logic process to its end point should we not also screen for alcohol? It is one of the most widely abused drugs even though it is legal, and has a far great societal impact than most drugs https://www.economist.com/graphic-detail/2019/06/25/what-is-the-most-dangerous-drug .

2.     I am confused by the attempt to draw parallels between vulnerable sectors check and substance use. There is a world of difference between someone who assaults an old lady, or commits pedophilia and an individual using recreational drugs in their own personal time at no harm to anyone else than themselves.

From my understanding of your post, I think you are talking about recreational drug users, and not individuals suffering from addiction. Something to consider, is that by punishing individuals for using substances, a system makes them less likely to seek help if they are suffering from addiction. Most province's medical associations have physician health programs which can assist students/residents/physicians in getting treatment for addiction, with a focus on rehabilitation. Focusing on harm reduction and rehabilitation rather than punishment, is a more effective route to promote patient safety by encouraging those in need to engage in care. As opposed to hiding their problems for fear of reprimand where they can spiral and worsen.

Fantastic post. Discouraging those who have a substance issue from seeking help is not in the best interests of patient safety and drug testing would contribute to stigma, which is already a major barrier in helping people with substances. Great point about alcohol as well, many seem to conveniently overlook substances that are social acceptable in these conversations. 

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4 hours ago, drdean said:

There are some major flaws in the arguments here.

1.     You assume that if someone uses illicit drugs they are inherently less safe for patients than someone who does not use drugs. That is a big leap, someone could be high all the time in their personal life and still provide great care. If we were to follow your logic process to its end point should we not also screen for alcohol? It is one of the most widely abused drugs even though it is legal, and has a far great societal impact than most drugs https://www.economist.com/graphic-detail/2019/06/25/what-is-the-most-dangerous-drug .

2.     I am confused by the attempt to draw parallels between vulnerable sectors check and substance use. There is a world of difference between someone who assaults an old lady, or commits pedophilia and an individual using recreational drugs in their own personal time at no harm to anyone else than themselves.

From my understanding of your post, I think you are talking about recreational drug users, and not individuals suffering from addiction. Something to consider, is that by punishing individuals for using substances, a system makes them less likely to seek help if they are suffering from addiction. Most province's medical associations have physician health programs which can assist students/residents/physicians in getting treatment for addiction, with a focus on rehabilitation. Focusing on harm reduction and rehabilitation rather than punishment, is a more effective route to promote patient safety by encouraging those in need to engage in care. As opposed to hiding their problems for fear of reprimand where they can spiral and worsen.

I think this is also an interesting take. I believe the assumption that someone who recreationally uses illicit drugs is more unsafe for patients than someone who does not is not an unfair opinion. I suppose it hangs on someone’s interactions with people who are dependent on substances; be it alcohol or any other substance. In my experience, people who I have had personal relationships with who also have a dependent relationship on a substance often cannot perform their daily tasks (work, school, life activities etc) without using regularly. Of course this is not every addict’s experience and is only my experience of what I have viewed, but I would struggle to see how a doctor who is dependent on a substance could provide quality care while actively using or experiencing the effects of said substance. I completely agree with what you’re saying about someone who uses drugs recreationally and that is probably what is more likely to be the case for medical students. I think the point about parallels between vulnerable sector checks and drug tests was that both are requirements that some students have to pass to be deemed appropriate to practice medicine. Should a mature applicant who did something foolish in their late teens or early twenties be barred from ever entering medicine 10-15+ years later? Should someone who recreationally uses drugs safely and on their on time be penalized? I think the major point was that both of these possibilities could be revealed by a test the student has to take. 
 

I completely agree as well that punishment is never the way to go as it perpetuates the cycle of fearing help and not getting better. I’m not sure what the punishments would be for failing these drug tests (not being granted admission, most likely?). As for the alcohol commentary, again; you’re very correct. Alcohol has always seemed to remain untouched in most professions and medicine doesn’t seem to differ. I think the alcohol issue is rooted in deeper more political and economical reasons and is thus sort of shunted into its own category. 
 

Thanks so much for your take! Everyone is very insightful and respectful! 

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