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The American Journal of Bioethics, Volume 2, Number 2, Spring 2002, pp. 55-56 (Article) 3XEOLVKHGE\7KH0,73UHVV

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Open Peer Commentaries References

Charland, L. C. 2002. Cynthia’s dilemma: Consenting to heroin prescription. American Journal of Bioethics 2(2):37–47.

Cynthia’s Dilemma

Walter Ling, Integrated Substance Abuse Programs/UCLA

Louis C. Charland’s paper “Cynthia’s Dilemma” (2002) opens with a recovering addict’s remark, but the basis for the argument is the Swiss heroin trial. “Cynthia’s dilemma,” according to the author, is that heroin addicts cannot adequately consent to participate in research where heroin is provided. The source of the dilemma, as the author sees it, is the nature of heroin addiction itself. Two points are offered to buttress this argument. First is that the offer of free heroin makes it impossible for addicts to give consent because they love the drug too much and this love so impairs their judgment that they cannot give voluntary consent. The compulsive need to seek and use heroin, the author says, impairs the addict’s decisional capacity to make choices about it. Second, the author contends that even if voluntary consent were possible, heroin addicts are mentally incompetent to make such a decision. Since competence, as the author sees it, must involve some sort of accountability, or value set, a competent choice must minimally reºect a person’s real likes and dislikes (what the addict likes is to get high, and what he dislikes is to get sick). To the author, being dependent means that every ªber of an addict’s being is bent on seeking heroin. Addicts no longer seek heroin to get high but rather to avoid withdrawal; therefore an addict cannot “just say no” to heroin. The author equates inability to say “no” with being incompetent. This misses the point. Compulsion is a matter of degree and so is its inºuence on an addict’s decision. Few heroin addicts would attempt to take heroin from an armed dealer without the means to pay for it, and most would readily give up their “stash” to a law enforcement ofªcer rather than risk getting shot. Surely they are not giving it up incompetently. And so the argument that a strong desire, or loving too much, renders one incompetent to make a decision with respect to an object of desire simply does not hold. If it did, all marriages would have to be considered for annulment because they involve persons who are incompetent at the time of proposal. True enough, there are instances where wrongly proposed marriages have led later to murder, but it cannot be said as a general

Spring 2002, Volume 2, Number 2

statement that people who are too much in love make marriage proposals incompetently. The Swiss trial is used as a substrate for the author’s second argument that even if voluntary consent is possible, addicts are mentally incompetent to give it. The adequacy of the consent procedure in the Swiss trial is not the issue here, however, but rather it is the general competency of those who gave consent. The author points to concerns about the competence of alcoholic subjects giving consent in alcohol trials and laments that similar reservations have not been expressed in heroin studies. In his view heroin and alcohol are alike, but of course they are not. Here the author confuses heroin intoxication and withdrawal with delirium from alcohol withdrawal; but whereas delirium may be a feature of alcohol intoxication and withdrawal, it is not with heroin. The author asserts that heroin addicts vacillate between a state of intoxication and withdrawal and that the state of physiological and psychological compulsion nulliªes voluntary choices. He takes literally Alan Leshner’s metaphoric comments that an “addicted brain is a hijacked brain” and that “addicts are no longer themselves” to support his argument that chronic heroin addiction results in radical changes in personal values. Such values are related to a person’s genuine likes and dislikes, which give rise to accountability, which in turn relates to competence. A competent choice, he argues, must reflect a persons’ real likes and dislikes, based on his or her set of personal values. A choice that does not reflect a person’s real likes or dislikes, according to the author, cannot be said to be a real choice. But do addicts under the influence of heroin or in withdrawal know what they like or dislike? Of course they do. Every heroin addict knows that without heroin he will get sick and that an injection of heroin will offer relief. As noted earlier, an overriding desire for something neither excuses a person from being accountable nor renders his decision incompetent. If addicts are considered incompetent, then virtually all addicts who are arrested cannot offer pleas of guilt or innocence, make decisions about their own future, or conduct any other form of business,

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The American Journal of Bioethics

since their general competence would be considered impaired. If one argues that this incompetence is speciªcally related to heroin, then addicts cannot be charged with any crime related to the procurement or use of the drug. But if a heroin addict murders his dealer, is he mentally incompetent at the time of the murder? Further, if one gives in to the author’s argument, then one must assume that a heroin addict’s incompetence is permanent, since, as in all clinical trials, consent can be withdrawn at any time and there is no evidence that this happened in the Swiss trial. This brings us not to Cynthia’s dilemma but to the di-

A “Fix” of Reality

Dana Katz, University of Pennsylvania

lemma of Cynthia. Was Cynthia competent to enter into a discussion with the author? Would we all be in a state of incompetence because we love something too much? Mea culpa. The lesson here, it would appear, is that it is generally a bad idea to enter into a philosophical discussion with an addict whose competency may be in doubt. ■ Referneces

Charland, L. C. 2002. Cynthia’s dilemma: Consenting to heroin prescription. American Journal of Bioethics 2(2):37–47.

J. R. Neuberger, Delaware Chapter, National Alliance of Methadone Advocates

We applaud Louis C. Charland (2002) for raising for bioethics debate the provocative and underdiscussed subject of heroin-prescription trials. He does an excellent job of discussing informed consent and subject competency. Charland does not, however, adequately contextualize his discussion within the world of heroin addiction and thereby overlooks certain practical aspects of research participation. This ultimately leaves many of his concerns illplaced. Charland argues that, in the absence of empirical evidence, it cannot be presumed that heroin addicts are competent to consent to a trial that offers heroin at no cost, because they “have an impaired decisional capacity to make choices about heroin.” Their addiction, he asserts, compromises their values such that they are likely to exaggerate the beneªts of participating while undervaluing the risks so that they “can hardly be considered mentally capable of rationally weighing the risks and beneªts.” Charland speciªes only one beneªt of participation (free heroin) and never speciªes any risks. So, ironically, like his imagined subjects, he does not exhibit full appreciation of the risks and beneªts of participation. In light of the absence of empirical evidence to support Charland’s claim, we cannot agree with his presumption that addicts or, more speciªcally, the subject population of heroin-prescription trials, would likely exaggerate the beneªts of participation. Addicts are extremely knowledgeable about heroin, its availability, its illegality, its social stigma, and its composition—addicts frequently have a sophisticated understanding of chemistry. Within the context of single-arm heroin-prescription trials, addicts

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may very well weigh the risks and beneªts of participation very rationally. About the Subject Population

Heroin prescription is being evaluated as a treatment for severely and chronically dependent treatment-refractory abusers who are socially disintegrated. They need to “ªx” three to four times a day and ªnd their way into “the system” through social, legal, or economic crisis (Bammer et al. 1999). To begin, it is important to note that the main harms associated with heroin addiction stem ªrst from its illegality and second from its impurity, both of which are minimized in the medical research model. The illegality of heroin deªnes the culture of its use and treatment. Direct harms of use come in many forms: 1. reluctance to seek emergency medical attention out of fear of police intervention; 2. exacerbated economic hardship as a result of arrests, incarceration, and, for some, imposed, state-sponsored treatment programs that are inconsistently effective; and 3. increased health risk. Numerous studies conªrm that heroin addicts are at increased risk to experience violence and/or contract HIV/ AIDS and hepatitis (Darke and Zador 1996). Addicts also tend to concomitantly use central nervous system depressants such as alcohol and benzodiazepines (prescription tranquilizers such as Valium, Halcyon, and Xanax), which some argue are the leading cause of respiratory failure and death among heroin users (Darke and Zador 1996).

Spring 2002, Volume 2, Number 2