When a patient wants their cake and wants to eat it too

When a patient wants their cake and wants to eat it too

Samuel Vorster

Introduction: The dilemma:

A male patient of 38 years, alcohol dependent, currently working as a pilot, for a airline in Southern Africa, asks you to help him with his problem. He also asks of you to keep his diagnosis confidential, as he would immediately lose his job should his diagnosis be made known.  This ethical dilemma involves a value dispute1, where the patient sees his medical condition and the possible effects, for his work, as being separate.

The patient has an alcohol dependency. It has known effects and concerns.  There is a concern with the patient’s ability to conduct his work whilst in the intoxication and withdrawal symptoms of his use.  There is a risk of harm to others, property and to himself.

According to online discussions of the usage of alcohol in the aviation environment, there is an importance of the use of strict restrictions to safeguard passengers and persons living on each flight path2,3.  According to SA Labour law and the airline’s policies, it is advised to conduct regular medical checks on its personnel4 and have strict protocols on how employees are monitored and treated whom use substances4,5,6.

Moral principles:

  • Autonomy

The patient’s capacity to make decisions.  The patient of legal age, but the question would be his possible incapacity, by his alcohol dependence.   The concern is the patient’s right to confidentiality and its limits.  According to the HPCSA, this would be deemed as harm to others and we have a duty to report7.

2) Beneficence

The treatment should benefit the patient’s life.  Initially, a breach of confidentiality would cause harm for the patient.  For example, he might incur disciplinary action but could be a valuable change factor in his treatment.

3) Non- Maleficence

Causing harm to others the patient is at risk through his intoxication, withdrawal or physical/ mental effects, of his alcohol use, during his responsibilities as a pilot.  The patient could struggle to claim “temporary non-pathological incapacity” as a defense8.  There is also the risk that the patient could lose his job.

4) Justice

The patient has a legal right to be treated fairly (and equally) by their employer in respect of treatment for alcohol dependence.  However these same rights would dictate that other parties need for protection8,9.  Hence the patient would have to avoid harming others through his medical condition, for eg his passengers etc.

Moral theories

The patient’s ethical problem can be further understood, and guidance can be attained, by using various ethical/ moral theories.

  • Consequentialism and Utilitarianism

Negative outcomes are determinates of moral judgment and action needs to increase global long term happiness1.  With the potential risk verses the rare frequency of airline incidents2, reporting would only cause consequences towards the patient.

  • Deontology/Rule morality

Any action could later be accepted into law1.  In the above scenario the rare airline incident could have detrimental consequences to the lives of many and could lead to trauma.  Zero tolerance should be strictly adhered to.

  • Virtue Ethics

Take remedial action that the lay person would accept and could show sympathy in the patient’s situation1.  Regardless if the patient has had a past of bad decision making regarding his use of alcohol and working, we can not predict his future actions. The patient has requested treatment and attempting to protect his career.

  • Liberal Individualism

The patient has a right to his life, freedom, basic needs and to own his own property according the bill of rights1.  These rights are not unconditional and need to be assessed on an individual case basis1.

  • Social Contract Theory

All persons should be treated equally.  Persons whom are tasked and qualified to conduct work must do it to its fullest extent1.  The pilot needs to transport the passengers to their destination, in a manner that safeguards all parties and their property.


  • Communitarianism

The common good practices should take place, that benefits everyone1.  In this matter there is a community of passengers and pilots, should they be treated differently?  So would it benefit the community as a whole to punish one and not the other?  Therefore if persons should be treated equally, the pilot should be treated for his illness and if he transgresses the rules set out in his job description, be disciplined accordingly.


  • Ethics of care

Alcohol dependence is a medical condition with a bio-psycho-social understanding and is treatable with an evidence based treatment.  “Best interests for the patient” principle, dictate that this patient is treated for his addiction in a manner to increase the patient’s overall functioning in a way which would reduce the risk of relapse.  This is our duty of care and not to punish the patient for having a treated disease.

  • Casuistry

Investigation into case history and the facts of the patient’s case in the above matter should shed light in the best way to proceed in the matter1.  As above, the incidents of airline disasters where pilots were found to be intoxicated are highly rare2, due to the operating actions of personal being tested prior to taking duty.  With consulting with experts in the field of aviation, in this case, via online search, it is found that airline companies have strict protocols with the assessing, monitoring of the personnel, that the possibility of a “intoxicated” pilot being on duty would only be possible by human error4,5.  In this case the patient has no history of poor work performance of incidents of harm to others.  This would be a factor in outcome of the case.



By keeping the above points in mind, should the pilot be treated differently because he has the status of a pilot or because of the responsibility that he, and his company, has to the public as a whole?  Should we take the benefit of the doubt and only report if the patient relapses into alcohol use?  The patient could be in treatment, stay sober and no incident(s) could take place.    However the patient has a right to treatment, could protect him from any disciplinary action.  This would only be considered if this medical condition is conveyed to the employee in a timely fashion.  Should the right for this patient, to keep operating his job with the risks of impeding the rights of others?  Our duty is to uphold human rights as a whole and not to benefit one over another.   If the patient/ pilot can not fulfill this contracted role he would have to be suspended until he can.   Would this be practical for the company? For the aviation industry? Would this action be accepted into law. What impact would this have for future pilots in the field of aviation?


In considering the concepts of autonomy, beneficence, non – maleficence, justice and above-mentioned moral theories in conjunction with the above case, the following moral judgment his been considered. The patient works in an industry with strict conditions when consuming substances at any time and the above alcohol dependency does pose major risks for the patient, the company’s property, its reputation, the users of the company’s service and persons living on it’s flight path.  The above risks, with the use of relevant legislation and case law, can draw a picture to illustrate to the patient that it would be in his best interest to allow the practitioner to act on his behalf to mediate with his work to secure his treatment and limit any disciplinary towards him.

Word Count [1231]


  1. Prof Pienaar W. Solving bioethical issues in the treatment of addicted patients.
  2. Askthepilot.com [Internet]. Pilots and alcohol. [updated 2019 Aug 15; cited 2019 Sep 15]. Available from:  https://www.askthepilot.com/pilots-and-alcohol/
  3. Chambers, D, Times live [Internet]. Cape Town pilot jailed after arriving drunk for Mauritus flight.  [updated 2018 Jun 13; cited 2019 Sep 15].  Available from:  https://www.timeslive.co.za/news/south-africa/2018-06-13-cape-town-pilot-jailed-after-arriving-drunk-for-mauritius-flight/
  4. South African Airways Group. Integrated Report for the year ended 31 March 2017. 2018.
  5. South African Civil Aviation Authority. Revised cross functional accident reduction plan 2016/17- 2018/19 Implementation plan (Drug and substance abuse in the aviation maintenance environment). 2017
  6. Erasmus, N, Claassen, A & du Toit, J. [Internet].  Alcoholism and the workplace. [cited 2019 Sep 15]. Available from: https://www.labourguide.co.za/alcoholism-in-the-workplace
  7. HPCSA. Guidelines for good practice in the health care professions: National patient’s rights charter, Booklet 3. 2008.
  8. Nelson, D. Non-Pathological Criminal Incapacity in South Africa – a disjunction between Legal and Psychological Discourse? A Case Study. 2012
  9. HPCSA. Guidelines for good practice in the health care professions: Confidentiality: Protecting and providing information, Booklet 10. 2008.