Article Text

Download PDFPDF
‘First Do No Harm’: physician discretion, racial disparities and opioid treatment agreements
  1. Adrienne Sabine Beck1,
  2. Larisa Svirsky2,
  3. Dana Howard3
  1. 1 The Ohio State University College of Medicine, Columbus, Ohio, USA
  2. 2 Department of Philosophy, Brandeis University, Waltham, Massachusetts, USA
  3. 3 Center for Bioethics, The Ohio State University OSUMC, Columbus, Ohio, USA
  1. Correspondence to Dr Dana Howard, Center for Bioethics, The Ohio State University OSUMC, Columbus, Ohio, USA; howard.1146{at}


The increasing use of opioid treatment agreements (OTAs) has prompted debate within the medical community about ethical challenges with respect to their implementation. The focus of debate is usually on the efficacy of OTAs at reducing opioid misuse, how OTAs may undermine trust between physicians and patients and the potential coercive nature of requiring patients to sign such agreements as a condition for receiving pain care. An important consideration missing from these conversations is the potential for racial bias in the current way that OTAs are incorporated into clinical practice and in the amount of physician discretion that current opioid guidelines support. While the use of OTAs has become mandatory in some states for certain classes of patients, physicians are still afforded great leeway in how these OTAs are implemented in clinical practice and how their terms should be enforced. This paper uses the guidelines provided for OTA implementation by the states of Indiana and Pennsylvania as case studies in order to argue that giving physicians certain kinds of discretion may exacerbate racial health disparities. This problem cannot simply be addressed by minimising physician discretion in general, but rather by providing mechanisms to hold physicians accountable for how they treat patients on long-term opioid therapy to ensure that such treatment is equitable.

  • pain management
  • policy guidelines/inst. review boards/review cttes
  • minorities

Data availability statement

There are no data in this work

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @thedanahoward

  • Contributors ASB and DH worked together to conceive and frame the analysis. ASB wrote the initial draft of the paper, and DH and LS worked collaboratively to revise it critically for important intellectual content. All authors have approved the final version to be published. All coauthors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Other content recommended for you