The American Journal of Bioethics

One of the difficult issues that emerges from Louis C. Charland's (2002) article is the nature of "addiction." The author cites Leshner on a number of occasions in relation to the effects of addiction—to say that heroin users suffer from an "uncontrollable compulsion to seek and use drugs" (Leshner 1999, 3) and to state that the heroin user's mind "is hijacked" by the drug. Charland summarizes by saying that "addicts are no longer themselves and in that sense can no longer be considered accountable for their decision to use heroin."

I would like to question the legitimacy of the employment of such emotive language in relation to regular users of opiates. I do not suggest that frequent heroin use does not induce physical and psychological dependence, including cravings for the drug. Heroin has major lifestyle impacts for many, but to what extent is its use incompatible with rational decision making in such questions as whether to give up the drug, whether to enter a methadone program, or whether to receive prescribed heroin? Even the extent to which addiction is a useful concept in this context is questionable. As Blau (1996) has argued, addiction is for the most part a lay term and generally a nebulous one:

Although several generations of extensive study have been applied to this area, researchers and practitioners attempting to clarify the concept of addiction do not share a unitary set of rules or standards for understanding or treating the condition. . . . Various definitions have been subject to change and modification, but not to verification. . . . Drug-related research is often inconclusive and frequently contradictory." (90)

The populist notion of addiction encompasses the Leshner notion that a drug takes over a person, depriving them of the capacity for choice and autonomous decision making. Similar unhelpful rhetoric was used for a time in relation to new religious movements "brainwashing" converts and "controlling" their minds. Scientific literature is not so clear on the effects of addiction. Erlich (2001, 40), for instance, recognizes that there is no medically agreed upon definition for addiction. DSM-IV-TR (American Psychiatric Association 2000) also eschews the term, preferring the concepts of substance abuse and substance dependence. This is because the extent to which dependence upon a substance such as an opiate impacts comprehension, decision making, ability to manipulate information rationally, and ability to communicate choice is variable and unfalsifiable. Charland usefully draws attention to the MacArthur model of competence, which addresses each of these indicia. Not surprisingly, he concedes that heroin "addicts" will generally be competent under the MacArthur indicia, but he contends they may not be able to manipulate information rationally.

In this regard his analysis is open to serious doubt. The question perhaps comes down to interpretation of rationality, a matter upon which reasonable people, whoever they are, can and do disagree with a disturbing frequency. Does it really assist the analysis to assert, as Charland does, that everything that addicts decide and do eventually reduces to seeking and using their drug of choice, and that the drug doesn't always have the first say but always has the last say, that decisions are not truly those of addicts and so they cannot be held accountable for them? Interestingly, the law has never subscribed to such notions. The typical response of the courts in most countries has been to acknowledge that drug addiction and substance dependence can explain offending behavior, but they do not excuse it. Addicts make choices. They do not have to buy drugs. They do not have to steal to buy drugs. They do not have to attack people whose houses they break into to get money to sell drugs. They make a range of decisions in relation to their addictions, often bad ones. However, for all those who make dangerous or self-harming choices, there are others who decide to stop using and do so successfully without professional intervention. There are others too who make the choice to enroll in rehabilitation programs.

What impact then can substance dependence be said to have upon the capacity to make choices? First, it is clear that there are dependencies and dependencies, addictions and addictions. There are dependencies that involve only usage that is erratic and not of major proportion. There are dependencies that are intensely physically experienced, and there are others that are principally psychologically [Begin Page 60] felt. It is not helpful to lump all addicts into an extreme category, because there is a substantial continuum of addiction that can be defined in terms of its impact upon what the DSM-IV-TR calls "important social, occupational or recreational activities" (199). In addition, a question thus far unresolved by sound empirical research is the extent to which rational decision-making capacity is impaired by addiction. Often enough opiate-dependent people are able to formulate complex schemes and strategies for procuring more of the substance upon which they are dependent. It is not that they are subject to command hallucinations or anything comparable. They do not break into just any house or car. They generally choose a residence or automobile where their chances of being apprehended are reduced to acceptable levels. This is not to say that they probably would not have engaged in such dishonest behavior if they were not substance dependent and in need of a "fix," but it is to suggest that addiction is considerably more complex than a condition that takes over or quashes rational decision-making capacity. It may well be that the addiction narrows focus and reduces the tendency of persons, for a time at least, to consider prudently other options that might be beneficial to their short- and long-term health interests.

In other words, this reviewer has significant reservations about a central contributor to Charland's concern over Cynthia's dilemma. Cynthia is most likely to give up heroin, probably without medical or other professional assistance. Alternatively, she may well enroll herself more than once in detoxification and rehabilitation programs. Another option is for her to use an opiate antagonist or engage in a methadone program. Still another option in some countries is the kind of heroin-prescription program mooted by Charland. Just as Cynthia has open to her a wide range of means of raising the funds to procure heroin illegally; she too does she have a plethora of choices for how to change her lifestyle and modify or overcome her drug dependence. Many of us would classify many of her potential decisions as ill-considered and even self-harming or constituting a public endangerment until she makes the toughest of choices to stop using heroin, or at least illegally obtained heroin. However, the fact that the options open to Cynthia are difficult and confronting for her does not necessarily deprive her decision making of rationality.

Few of us would wish to discourage Cynthia from exercising her choice as a heroin addict to participate in a methadone program, from taking an opiate-antagonist, or from taking medication designed to ease the stresses of detoxification. The real challenge is to ensure that while Cynthia participates in the heroin-prescription program she is not maintained on heroin for longer than she would want, that she realizes what her other options are, and that she is not otherwise manipulated by researchers with political objectives that are connected to funding or self- advancement. The main objective must be to keep Cynthia alive long enough for her to make the most important choice of all—to decide for herself that she no longer wishes to use heroin, whoever is making it available to her.