"Addiction" and Autonomy

OK, i'm going to take the plunge here. Over the past few years there have been a number of discussions, particularly among bioethicists, but also (very rarely) among addictions treatment professionals about the impact of "addiction" (whatever THAT means) on personal autonomy, defined as the ability to make decisions about issues relating to the substance(s) to which the person is "addicted."

For example, Louis Chartrand published a paper in 1999 entitled "Cynthia's Dilemma" in which he argued that by virtue of being "addicted" to heroin the titular focus of the paper, Cynthia, was incapable of giving informed consent to participate in a prescription heroin trial. In a similar vein, Arthur Caplan, a bioethicist at the University of Pennsylvania, has argued in favor of coerced administration of buprenorphine to opioid dependent persons because their "addiction" made them incapable of exercising appropriate autonomy in deciding whether or not to seek treatment for their opioid dependence. Kaplan justified his position this way: "addiction" by definition means that the person's free will is overborne, buprenorphine and similar medications (in Kaplan's view) restore this free will. By forcing the opioid dependent to take the medication we violate personal liberty in order to restore the individual's free will.

These two positions raise a number of questions in my mind that I don't have answers to, but that I hope folks who read this blog will ponder and comment upon.

1) Is it true that being "addicted" eliminates decisional capacity, or does being addicted simply add in a factor to decisions that non-addicted persons don't consider?

2) How do we reconcile the positions of Chartrand and Kaplan with the evidence of the many addicted people who make the decision, on their own, without pressure or coercion, to take steps to change or eliminate their addictive behavior? Certainly, the founders of AA made many health enhancing decisions while they were still "addicted".

3) Is "addiction" an all or none phenomenon within the individual (eg. is the individual who has not "overcome" his/her addiction always and totally incapable of making certain kinds of decisions until the "addiction" is overcome) or is it a variable phenomenon within the individual (eg. at times the person IS incapable of making certain decisions, perhaps when actually intoxicated, while at other times the individual is capable of making many of the same decisions?) such that if we were, for example, to catch the person in a "less addicted" moment or window of time, he/she would be capable of making decisions that at other times he/she may not be?

4. How do we determine whether or not an "addicted" person is capable/competent to make particular types of decisions? Do we utilize the legal definition of decisional capacity? How do we assess capacity, or do we assume that by virtue of being "addicted" certain types of decisions are off limits? What about "addicted" persons who make decisions we believe are appropriate ones? Are they incapacitated in that case? Or do we then assume they have suddenly become "competent" because their decision is what interested others believe is the best one?

I have some views on these questions which I will post over the next few days, but would be interested to hear from others about your thoughts.