The American Journal of Bioethics

Adil E. Shamoo and Jonathan D. Moreno (2004) have certainly hit many of the key reasons why the proposed SATURN (Student Athlete Testing Using Random Notification) study is highly problematic from an ethical perspective. However, a few other issues can usefully be mentioned in the service of an even more complete critique. As a psychiatric clinician who has worked with many substance abusing patients and who has also been involved in training to prevent sexual exploitation of patients, these issues were immediately salient as I read the paper.

First, it is not uncommon in both professional and lay writing about intoxicating substances to confuse, or conflate, "use" and "abuse" of same. From a clinical perspective substance use and substance abuse are distinct categories. The mere presence in a body fluid such as urine or blood of an intoxicant or one of its breakdown products does not allow the clinician to distinguish use of that substance from its abuse. Of course, in a situation—such as the transportation industry or possibly even high school sports—where a "zero tolerance" policy is promulgated, this difference is not relevant so long as the individuals gathering this information do not go beyond their specific mandate and draw some unwarranted conclusion regarding the (possible false positive) presence of a specific clinical syndrome (e.g., substance abuse, or even dependence—which is yet another distinct category).

Therefore, when in the stated purpose of the SATURN study mention is made of intent both "to assess the use of drugs and alcohol" and "to determine the influence of drug testing on risk of substance abuse," I am left with a lack of clarity as to how "use" and "risk of abuse" will be correlated, and I am concerned about their possible confusion. Similarly, when Shamoo and Moreno comment that "There can be no disagreement that adolescent drug use is a serious problem, both in its magnitude for society and in its consequences for the drug user," I think what they mean to refer to—for this would afford them a more cogent statement—is that "adolescent drug abuse" is a serious problem. This is not a trivial difference, especially when we consider that inevitably with most youth there will occur a "learning phase" with regard to their initial trial states of intoxication with various substances. Some minority of group members will go on to develop true substance abuse and an even smaller portion to develop true substance dependence. Much current research, as both Shamoo and Moreno and the authors of the SATURN study are no doubt well aware, is being conducted in an effort to determine risk factors for progression along this clinical continuum from abstinence to dependence (and even death).

An important potential problem with a zero-tolerance approach to substance use (e.g., "Just say No to drugs") by an adolescent population (as opposed to airline pilots) is that it denies the reality of what might well be reasonable degrees of experimentation and learning. This very learning might be precisely what is needed for some—or even many—individuals to develop their own safe usage pattern (including, but not limited to, controlled drinking, occasional use of marijuana, or zero use of any substance). In fact, as we know, reasonable arguments can be made for controlled, socially-more-or-less-safe exposure to substances (e.g., wine with dinner at home with one's parents; smoking a joint at home with a parent) as an effective way to learn safe usage or nonusage practices. If we take this hypothetical a step further, we could argue that high school athletes who have dutifully complied with a mandatory testing program for four years while at home in a safe, secure environment might be placed at higher risk of less safe alcohol/drug experimentation when they leave home and go off to college or to work or to the military, and perhaps then might be even more vulnerable to less safe substance-use...