Self-destructive behavior poses different legal and ethical problems depending on whether it is legal behavior, such as alcoholism, or illegal behavior, such as cocaine use. The AMA policy statement suggests that the physician should provide information and document consent. Beyond this, physicians must decide how far they are willing to accommodate a patient who is unwilling to modify medically destructive behavior. Is there a point where the physician’s continued treatment of complications of self- destructive behavior becomes an impediment to the patient’s commitment to changing the behavior? Is refusing to continue to treat the patient ethically justifiable if the patient does not have access to appropriate treatment programs? Should the physician’s role differ for illegal activities such as cocaine use?

Every self-destructive patient poses these questions. They are more urgent when the patient is pregnant and her behavior threatens to injure her fetus. Absent a state law requiring the reporting of the behavior in question, the physician has no duty to report a patient’s illegal drug use to the police or public health authorities. If the state offers only jail to illegal drug users, it is difficult to argue that reporting such a patient is in the patient’s interest. A physician’s ethical duty is more difficult to determine if the state offers appropriate rehabilitation services. Given the current knowledge of addictive behavior and the effects of drugs such as cocaine, it is difficult to speak of a knowing and voluntary refusal of care by an addicted patient. If the patient cannot make an informed choice, the physician’s duty may be to seek judicial intervention to determine the patient’s best interests.