"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.

Ethics and substance use(rs)

We've spent billions on enforcement of drug laws, yet few (particularly few in government and policy positions) seem to ask the question, "is this the right thing to do?" Nor is the question, "is our approach genuinely making the world a better place" ever asked. In this blog I want to provide a forum for both my thoughts and yours about these questions and others that address the intersection between ethics, bioethics and substance use. Questions abound not only about policy, but about how we as private persons and as clinicians (if you share a commitment to healthcare, as I do) think about and interact with people who use psychoactive substances, whether or not that use is "excessive". I use quotation marks because one of the ways I hope this blog will unfold is to serve to question many of our definitions in this field, the assumptions underlying them, and the uses to which those definitions are put.

Some initial questions that are near and dear to my heart at this point, because I'm writing a book about them:

1. Informed consent to treatment is de riguer as a pre-treatment practice in medicine, particularly where there is evidence that a treatment can cause harm, either because it is not effective, or because it may produce iatrogenic negative effects. What does informed consent to treatment look like in most treatment programs for substance users? Is the practice of informed consent in most treatment programs or by most treatment providers ethically sound?

2. Can addicted persons give truly informed consent to treatment, and especially are they capable (in the sense of decision-making capacity) of refusing a particular treatment or treatment goal in favor of one the clinician might not see as being the best course of action? This is a debated topic in both the addictions treatment and bioethics fields in the U.S.

3. What should the components of a informed consent to treatment for substance use disorder be in order for the informed consent to pass ethical muster?

4. Is the "war on drugs" ethical? What arguments are there for and against?

5. How do the moral and ethical views of individuals play into the war on drugs?

I could come up with many more, but I invite you to comments with your answers to any or all of these questions. Happy writing!

the prof speaks out: Time to speak out

the prof speaks out: Time to speak out

I agree that this is very important. I hope that people will take advantage of David Clark's blog as well as mine on Bioethics and Substance Use.