**5. Conclusions**

Unless physicians treat the chronic and acute illnesses in patients with IE due to IVDU, their ethical duties toward their patients remain unfulfilled, and they fail to provide just care. This issue becomes more precarious when considering patients who require additional valve replacements due to continued IVDU.

The American Medical Association's *Code of Medical Ethics* states that is the physician's ethical obligation "to place patients' welfare above their own self-interest and above obligations to other groups and to advocate for their patients' welfare" [23]. It is the duty of physicians to promote the health of their patients through comprehensive, beneficial treatment based on evidence-based medicine, and to respect them as persons with dignity, uninfluenced by social stigma and clinical bias. For patients with IE secondary to IVDU, it is important to treat both the psychiatric, social and infectious etiologies: the substance use disorder, homelessness, and food insecurity, as well as the IE, along with any additional comorbidities that are present. Although every patient with IE secondary to IVDU differs in the severity of presentation and comorbid conditions, patients with a positive prognosis should have the opportunity to achieve health and life with medical assistance.

Unfortunately, it is not unusual for patients with recurrent IE secondary to IVDU to experience social stigmatization and bias at the hands of the healthcare system and to be denied the comprehensive care that is needed in such cases. While some patients are justifiably denied due to a significant medical risk over benefit, patients are also denied simply because they are perceived as non-compliant, or because their potentially risky surgical treatments may negatively affect the health reviews and ratings of the surgeons performing the valve replacements. It is not ethically just to penalize viable surgical candidates when their addiction has neither been addressed nor treated. Citing high rates of treatment failure and non-compliance is not a valid excuse when the substance use disorder has not been treated as aggressively as the IE, especially when taking into considerations the lack of resources available for these patients to seek and maintain recovery.
