Letters to the Editor The journal publishes both invited and unsolicited letters. It is at the editor’s discretion whether such letters are sent out through peer review.
ADDICTIONS, AUTONOMY AND SO MUCH MORE: A REPLY TO CAPLAN Caplan argued recently [1] for treating someone with an addiction against her will by administering naltrexone involuntarily. Denying her right to refuse treatment is defended ethically by a seemingly contradictory or paradoxical reason: it is expected to restore her autonomy. In our view, the article’s justification of forced treatment is debatable for three reasons. First, only the biological component of addictions is examined. Psychological and social factors and their complex interactions with the biological are omitted; so naltrexone’s actual and sustained ability, regardless of involuntary/voluntary use, to curb addiction may be much less than presumed. Second, cravings are described as coercive. Coercion is defined typically as involving threats. While telling a client ‘swallow this pill or no afternoon pass’ constitutes a threat and thereby coercion, how do neuropsychological processes threaten someone? Cravings can be difficult, but coercive? Addiction is also described as involving ‘compulsion’ and overriding free will. However, many people manage their cravings and stop using substances on their own, so cravings are not entirely compulsive [2]. The concepts of coercion and compulsion are not as fitting as needed. Similarly, the portrayal of people with an addiction seems extreme. It is important to remember that tobacco and alcohol are the most harmful and common addictions, not illegal drugs. Phrases such as ‘truly addicted’ and ‘in the throes of addiction’ can imply that people either are or are not addicted; yet addiction is about degrees. Autonomy is presented in extreme ways, too. To say ‘an addict cannot be a fully free, autonomous agent’ presumes that people usually are. This is questionable. Recent debates about autonomy as a ‘hypervalue’ [3,4] and the corrective of relational autonomy [5] warrant more contextualized use of autonomy in discussions about addictions. Third, we believe that Caplan argues for a provocative conclusion because he knows that successful recovery can be an exhausting series of successes and relapses. However, social justice considerations are overlooked. Many addicted people are multiply disadvantaged: unemployed, poor, inadequately housed, medically untreated, isolated and stigmatized. Social justice demands increased caution if rights (i.e. refusal of medical treatJournal compilation © 2009 Society for the Study of Addiction
ment) may be denied. As per the precautionary principle [6], unless there is credible, convincing evidence of the effectiveness of ‘denying autonomy to create it’, the proposed practice is unsupportable. Furthermore, what could be needed to administer a medication involuntarily has been overlooked. Oral forms have choking risks. Injectable forms may require physical restraints. Damage to therapeutic alliances demands very cautious use of forced therapies. The paper accepts that addicted people still have capacity for all types of decisions. Instead of involuntary treatment, some type of advance directive or Ulysses contract is more respectful of autonomy [7]. Also, a harm reduction approach for successful, sustainable treatment and intervention, as demonstrated by opioid agonist maintenance therapy [8] and supervised injection sites, is more balanced. Reliable health, social and outreach services plus non-coercive drug use expectations typify these programmes. They help to empower a person to be more autonomous in terms of enjoying the freedom of decision-making, accepting attendant responsibilities and pursuing what is personally meaningful. Declaration of interest None. Acknowledgements Daniel Z. Buchman is funded by NIH/NIMH R01 #MH 9R01MH8482-04A1 (J. Illes, Principle Investigator), Vancouver Coastal Health Research Institute, Michael Smith Foundation for Health Research DANIEL Z. BUCHMAN 1 & BARBARA J. RUSSELL 2,3 1
National Core for Neuroethics, The University of British Columbia, 2211 Wesbrook Mall, Koerner S124, Vancouver, BC V6T 2B5, Canada. E-mail:
[email protected] 2 The Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J 1H4 and 3Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada. E-mail:
[email protected] References 1. Caplan A. C. Denying autonomy in order to create it: the paradox of forcing treatment upon addicts. Addiction 2008; 103: 1919–21. Addiction, 104, 1053–1055
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2. Levy N. Addiction and autonomy. Can J Philos 2006; 36: 427–47. 3. Gaylin W., Jennings B. The Perversion of Autonomy: Coercion and Constraints in a Liberal Society. Washington: Georgetown University Press; 2003. 4. Frank A. Ethics as process and practice. Int Med J 2004; 34: 355–7. 5. Sherwin S. A relational approach to autonomy in healthcare. In: Sherwin S., editor. In: The Politics of Women’s Health: Exploring Agency and Autonomy. Philadelphia, PA: Temple University Press; 1998, p. 19–47. 6. Resnick D. B. The precautionary principle and medical decision making. J Med Philos 2004; 29: 281–99. 7. Andreou C. Making a clean break: addiction and Ulysses contracts. Bioethics 2008; 22: 25–31. 8. Carter A., Hall W. Informed consent to opioid agonist maintenance treatment: recommended ethical guidelines. Int J Drug Policy 2008; 19: 79–89.
DOESN’T ETHICS REQUIRE KEEPING ALL OPTIONS OPEN IN THE NAME OF PERSONAL AUTONOMY? Buchman & Russell take issue with my argument that it may be ethical to infringe temporarily upon a person’s right to refuse treatment. I argued, specifically, that it might be ethical to administer involuntarily a drug such as naltrexone for a short period to a person with an addiction to alcohol if the goal of such treatment is the restoration of more or greater autonomy to the addict [1]. Buchman & Russell are surely right to note that addicted people do have the capacity to make many types of decisions. That, however, is precisely why it does not make sense to argue that compelling treatment upon an addict is justified because they are, as a class, incompetent. Some addicted to alcohol or drugs may well be incompetent, but the reason I did not try to frame my argument around incompetency is that for a large number of addicts one must override a competent refusal of treatment in order to provide a drug such as naltrexone. That is why there is, in my words, a paradox raised—in order to salvage greater autonomy it may be necessary to ignore or override temporarily some degree of autonomy that is present. Buchman & Russell wonder if naltrexone has the ability to curb addiction. I would not know. I am relying upon published reports and claims I have heard at professional meetings that it can. My only point in invoking this drug as an example was that it seems to have many prominent advocates who, contrary to Buchman & Russell, believe it to be effective. This leads to Buchman & Russell’s second point— cravings may not be coercive and some addicts manage their cravings. Yes, cravings for alcohol or drugs may not be coercive of autonomous judgement but those who Journal compilation © 2009 Society for the Study of Addiction
treat addicts at my own institution assure me that for some addicts they are. In a world in which hundreds of millions of lives are ruined by chronic alcoholism it seems implausible to maintain that many otherwise competent individuals are not compelled, coerced or otherwise driven to drink and that they cannot ‘manage their cravings and stop using substances on their own’ [2]. If it is true that addiction can be compelling or coercive of behavior then, even if an addict retains a great deal of autonomy, would it not make sense to try to restore more of their autonomy? There is a hint in Buchman & Russell’s letter that they think it might be better to use willpower rather than a drug. Why? If the temporary use of a drug can allow an addict to be free of cravings, compulsion and coercive pressures faster and more effectively, then why is willpower preferable to pharmacology? Which leads to the last source of their disagreement— justice demands caution when the vulnerable have their rights restricted. I would agree. However, the temporary use of a drug to remove the psychological burdens of addiction, if an effective drug does or were to exist, would not be inherently unjust. It would be unjust if given only to the poor or disadvantaged; or, if it were used without monitoring and safety precautions; or, if its use were continued beyond an agreed-upon minimal period after which the patient would have to consent to continued administration. The idea of ignoring autonomy temporarily in the service of creating more autonomy is hardly unknown in medicine. In rehabilitation medicine requests from competent people who have been horribly disfigured by burns or left paralyzed by trauma to be allowed to die or to stop all treatment are ignored routinely [3]. Could it not be and should it not be also a part of the options used in addiction treatment? Of course, caution is in order in administering treatment that has been declined, but the ethical fight ought to be about what constitutes a reasonable period of time before such efforts must be abandoned. Those worshipping at the altar of patients’ rights may find it hard to let their faith broaden to permit some intrusion into patient autonomy, no matter how limited, temporary, monitored or effective that intrusion is, but is that either right or good?
Acknowledgement The Scattergood Foundation of Philadelphia provided support for this letter.
Declaration of interest None. Addiction, 104, 1053–1055
