Cynthia's Dilemma: Consenting to Heroin Prescription

Abstract

Heroin prescription involves the medical provision of heroin in the treatment of heroin addiction. Rudimentary clinical trials on that treatment modality have been carried out and others are currently underway or in development. However, it is questionable whether subjects considered for such trials are mentally competent to consent to them. The problem has not been sufficiently appreciated in ethical and clinical discussions of the topic. The challenges involved throw new light on the role of value and accountability in contemporary discussions of mental competence.

Addiction, Autonomy, and Informed Consent: On and Off the Garden Path

“…Leshner himself has claimed that what begins as voluntary behavior gradually becomes involuntary "ultimately to the point that the behavior is driven by a compulsive craving for the drug" (Leshner, 1999(Leshner, , 1315. With facts like these in mind, critics of research and treatment programs that involve giving drugs to addicts have suggested that the programs are (prima facie) unethical, because addicts cannot give autonomous informed consent to participation (Charland, 2002;Elliott, 2002;Woods, 2002). As Charland puts it, addicts can't say "no" to the offer of heroin, and for that reason they cannot give their informed consent.…”

Opiate Addicts` Attitudes Towards Heroin Prescription~!2009-07-31~!2010-05-28~!2010-07-14~!

“…In this ethical dispute the competence of opiate addicted patients regarding their decision to participate in heroin prescription was challenged by the assertion that opiate addicts have a distorted evaluation of heroin use and therefore have a pathological bias in favor of heroin prescription. This view has been advanced academically by Charland [10], but was also driving a widespread public debate. The diagnostic definition (ICD-10; DSM IV) is that opiate addicts suffer from a pathological and often irresistible craving for heroin as a core symptom of their disease.…”

“…According to Charland [10] the decision of an opiate addict to participate in heroin prescription might be considered to be driven exclusively by his pathological urge to consume heroin, overriding any rational deliberation which normally would be expected to precede and prepare such a decision. In contrast, key features of a competent decision making are understanding the relevant information, appreciation of the treatment options in respect to the situation of the individual patient, and achieving a decision consistent with one´s own premises [18,19].…”

“…If the urge to consume heroin indeed overruled any reasoning, this is a situation clearly in conflict with the notion of the autonomous patient. None of the controlled trials have been accompanied by attempts to elucidate the decision-making processes preceding the participation in these studies, thus the presentation of the dilemma created by the juxtaposition of personal autonomy and an overwhelming urge to consume heroin [10] as well as the numerous commentaries of this exposition could not rely on more than diagnostic considerations, anecdotal evidence and general clinical reasoning.…”

Valoración de la capacidad para participar en investigación en población adicta: mitos, barreras y beneficios

“…La evaluación debe referirse a una tarea y un nivel de riesgo concreto: la comprensión para consentir participar en un estudio simple debe ser menor que la requerida para un estudio complejo con mayor riesgo. La bibliografía recomienda que se evalúe de forma rutinaria la capacidad de decisión en aquellos estudios con riesgo superior al mínimo (Morán-Sánchez et al, 2016).…”