Ethical challenges in substance use disorder care: a scoping review of stigma, autonomy, coercion, and decision-making

Background People with substance use disorders (SUD) frequently encounter ethical challenges in healthcare, including stigma, constrained autonomy, coercive dynamics, and difficulties related to decision-making capacity. These challenges may influence access to care, treatment engagement, clinician–patient relationships, and the quality of healthcare delivery.Objectives To map and synthesize empirical evidence on ethical challenges in healthcare delivery for adults with SUD across healthcare settings, with particular attention to stigma, autonomy, coercion, informed consent, and decision-making capacity.Data Sources Web of Science, Ovid PsycINFO, Scopus, and PubMed/MEDLINE were searched from the earliest available indexed records to January 2026. Supplementary citation searches were also conducted.Study Appraisal and Synthesis Methods Primary qualitative, quantitative observational, mixed-methods, and conceptual sources were included. Methodological quality was appraised using CASP, JBI, or MMAT tools, as appropriate for empirical studies. Data were charted using a predefined form and synthesized descriptively and thematically in accordance with the objectives of a scoping review.Results Seventeen sources of evidence met the inclusion criteria. Stigma and discrimination were the most consistently reported ethical challenges across inpatient, outpatient, emergency, and community addiction settings. Ethical tensions related to autonomy and coercion were frequently described, particularly in institutional, acute care, and compulsory treatment contexts. Decision-making capacity and informed consent were less consistently examined and were supported by a smaller and more heterogeneous evidence base.Conclusions Ethical challenges in SUD care are closely linked to treatment environments, clinician–patient interactions, and institutional policies that shape access, engagement, and continuity of care. The evidence base is strongest for stigma and discrimination, while decision-making capacity, informed consent, informal coercion, and ethically complex populations remain underexplored. Future research should address these gaps and support the development of ethically grounded, patient-centered addiction care.