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SAN FRANCISCO — Thousands of doctors hooked on drugs and alcohol continue to practice medicine while receiving treatment for substance abuse, yet most patients will never know about their physicians' addictions.

This is because of confidential "physician health programs" in nearly every state that allow doctors to keep diagnosing, prescribing and performing surgery as long as they stick with an approved rehab regimen.

Despite some unsettling cases, these arrangements have largely escaped public scrutiny until this summer, when California's medical board outraged physicians across the country by abolishing its 27-year-old program allowing doctors to get help without telling their patients.

A review concluded the state-run program failed to protect patients — or help addicted doctors get better. But the medical community fiercely defends confidential treatment, saying it keeps patients safer.

The emotional debate has revealed bitter differences over how much patients have a right to know, and touches on the unease many Americans feel about defining "addiction" as a medical instead of a moral problem.

"Patients have no way to protect themselves from these doctors," said Julie Fellmeth, who heads the University of San Diego's Center for Public Interest Law and led the opposition to California's so-called diversion program.

Nationwide, more than 5,000 physicians are enrolled in physician health programs, according to the results of an upcoming study obtained by The Associated Press.

But that number is likely much higher, since not all states with programs participated in the survey, said Dr. Greg Skipper, head of Alabama's physician health program and a principal investigator on the not-yet-published Robert Wood Johnson Foundation study. Skipper says between 7,500 and 8,000 doctors are likely in treatment — about 1 percent of all physicians practicing in the United States.

Most addiction specialists favor allowing doctors to continue practicing while in confidential treatment, as does the American Medical Association.

Supporters of such programs say that cases in which patients are harmed by doctors in treatment are extremely rare, and would pale next to the havoc that could result if physicians had no such option.

"If you don't have confidential participation, you don't get people into the program," said Sandra Bressler, the California Medical Association's senior director for medical board affairs. "And if they're out there, you're not going to know about them anyway."

California's program ends June 30. If no alternative program is adopted, the rules could revert back to the zero-tolerance policy in place before 1980, when doctors who were found by the medical board to have drug or alcohol problems were immediately stripped of their licenses.

No other state has followed California's lead. But the president of California's medical board, Dr. Richard Fantozzi, said that behind the scenes, regulators nationwide share his ambivalence toward such programs.

"To hide something from consumers, something so blatant … it's unconscionable today," he said.

Between 10 percent and 15 percent of physicians nationwide will have a substance abuse problem at some point in their lives, a rate similar to that of the general population, according to widespread estimates.

Opponents of such programs are unable to cite any documented cases in which doctors who were confidentially undergoing treatment botched operations.