Genealogy of the treatment model -- Expert knowledge and encounters with futility -- Treatment plans : mandatory narratives of progress -- Representative payeeships : the deep logic of dependency -- Commitment orders : the practice of consent and constraint -- Coercion, confidentiality, and the moral contours of work.

ABSTRACT I examine the impact of addiction on autonomy in terms of the standard literature on addiction – referred to also as ‘substance dependence.’1 Then in terms of the criteria for substance dependence, by developing a set of practical strategies to help people with addictions think more clearly, I test the idea whether addicts can be helped to become more autonomous. Given that unsuccessful attempts to quit constitute part of the criteria of substance dependence, I look at what goes wrong (...) when people try to quit using a substance. The subjective experience of addiction is an important aid in understanding addiction and first person accounts and literary characterisations of addiction provide insight into the addict's mind and assist us in deciding whether addicts can be helped to become more autonomous. (shrink)

Social representations of addiction and the resulting stigmatization have been widely described and studied in the literature, but their effects are no less problematic. These representations, which also occur in care settings, generate a climate of distrust which damages the therapeutic relationship, and its ethical quality. This article, combining clinical experience and an ethical stance, offers an original, innovating approach to the existence of distrust in care relationships in the area of addiction. Pragmatic approaches deriving from the human sciences and (...) analytical philosophy provide an invitation to escape from the demanding climate of mistrust, and to take the gamble on trust so as to improve the quality of interactions between protagonists in care. In complementary fashion, a sociology of action can combat the disquiet generated by distrust through a new commitment to innovating forms of action. This “poetic” mode of action is legitimized by the reflection that backs it up, and by its presentation to peers qualified to approve it. Finally, continental moral philosophy underlines the importance of a carefully weighed commitment on the part of caregivers and addicted patients towards promises aiming to support a sincere care relationship, without damaging the therapeutic dynamic or the ethical quality by providing too many safety nets. This reflection is intended to achieve better identification of the clinical and ethical issues raised by mistrust, and inclusion of these aspects in the training of personnel and in care provision planning. (shrink)

Research in the field of Empirical Ethics (EE) uses a broad variety of empirical methodologies, such as surveys, interviews and observation, developed in disciplines such as sociology, anthropology, and psychology. Whereas these empirical disciplines see themselves as purely descriptive, EE also aims at normative reflection. Currently there is literature about the quality of empirical research in ethics, but little or no reflection on specific methodological aspects that must be considered when conducting interdisciplinary empirical ethics. Furthermore, poor methodology in an EE (...) study results in misleading ethical analyses, evaluations or recommendations. This not only deprives the study of scientific and social value, but also risks ethical misjudgement. (shrink)

There has recently been interest in applying the techniques of systematic review to bioethics literature. In this paper, I identify the three models of systematic review proposed to date in bioethics: systematic reviews of empirical bioethics research, systematic reviews of normative bioethics literature, and systematic reviews of reasons. I argue that all three types yield information useful to scholarship in bioethics, yet they also face significant challenges particularly in relation to terminology and time. Drawing on my recent experience conducting a (...) systematic review, I suggest that complete comprehensiveness may not always be an appropriate goal of a literature review in bioethics, depending on the research question. In some cases, all the relevant ideas may be captured without capturing all the relevant literature. I conclude that systematic reviews in bioethics have an important role to play alongside the traditional broadbrush approach to reviewing literature in bioethics. (shrink)

In this article we distinguish between philosophical bioethics (PB), descriptive policy orientated bioethics (DPOB) and normative policy oriented bioethics (NPOB). We argue that finding an appropriate methodology for combining empirical data and moral theory depends on what the aims of the research endeavour are, and that, for the most part, this combination is only required for NPOB. After briefly discussing the debate around the is/ought problem, and suggesting that both sides of this debate are misunderstanding one another (i.e. one side (...) treats it as a conceptual problem, whilst the other treats it as an empirical claim), we outline and defend a methodological approach to NPOB based on work we have carried out on a project exploring the normative foundations of paternal rights and responsibilities. We suggest that given the prominent role already played by moral intuition in moral theory, one appropriate way to integrate empirical data and philosophical bioethics is to utilize empirically gathered lay intuition as the foundation for ethical reasoning in NPOB. The method we propose involves a modification of a long-established tradition on non-intervention in qualitative data gathering, combined with a form of reflective equilibrium where the demands of theory and data are given equal weight and a pragmatic compromise reached. (shrink)

From a twenty-first century partnership between bioethics and neuroscience, the modern field of neuroethics is emerging, and technologies enabling functional neuroimaging with unprecedented sensitivity have brought new ethical, social and legal issues to the forefront. Some issues, akin to those surrounding modern genetics, raise critical questions regarding prediction of disease, privacy and identity. However, with new and still-evolving insights into our neurobiology and previously unquantifiable features of profoundly personal behaviors such as social attitude, value and moral agency, the difficulty of (...) carefully and properly interpreting the relationship between brain findings and our own self-concept is unprecedented. Therefore, while the ethics of genetics provides a legitimate starting point - even a backbone - for tackling ethical issues in neuroimaging, they do not suffice. Drawing on recent neuroimaging findings and their plausible real-world applications, we argue that interpretation of neuroimaging data is a key epistemological and ethical challenge. This challenge is two-fold. First, at the scientific level, the sheer complexity of neuroscience research poses challenges for integration of knowledge and meaningful interpretation of data. Second, at the social and cultural level, we find that interpretations of imaging studies are bound by cultural and anthropological frameworks. In particular, the introduction of concepts of self and personhood in neuroimaging illustrates the interaction of interpretation levels and is a major reason why ethical reflection on genetics will only partially help settle neuroethical issues. Indeed, ethical interpretation of such findings will necessitate not only traditional bioethical input but also a wider perspective on the construction of scientific knowledge. (shrink)

There continues to be a debate on whether addiction is best understood as a brain disease or a moral condition. This debate, which may influence both the stigma attached to addiction and access to treatment, is often motivated by the question of whether and to what extent we can justly hold addicted individuals responsible for their actions. In fact, there is substantial evidence for a disease model, but the disease model per se does not resolve the question of voluntary control. (...) Recent research at the intersection of neuroscience and psychology suggests that addicted individuals have substantial impairments in cognitive control of behavior, but this "loss of control" is not complete or simple. Possible mechanisms and implications are briefly reviewed. (shrink)

ABSTRACT This article attempts to show a way in which social science research can contribute in a meaningful and equitable way to philosophical bioethics. It builds on the social science critique of bioethics present in the work of authors such as Renée Fox, Barry Hoffmaster and Charles Bosk, proposing the characteristics of a critical bioethics that would take social science seriously. The social science critique claims that traditional philosophical bioethics gives a dominant role to idealised, rational thought, and tends to (...) exclude social and cultural factors, relegating them to the status of irrelevancies. Another problem is the way in which bioethics assumes social reality divides down the same lines/categories as philosophical theories. Critical bioethics requires bioethicists to root their enquires in empirical research, to challenge theories using evidence, to be reflexive and to be sceptical about the claims of other bioethicists, scientists and clinicians. The aim is to produce a rigorous normative analysis of lived moral experience. (shrink)

This volume was initiated to meet the challenges of the increasing contemporary trend to "treat" substance users (in the broadest sense of this concept), whether in institutional settings, ambulatory programs, or even controlled environments such as prisons. Although several essays concentrate more particularly on some of the ethico-moral problems encountered by juridico-moral interventions--problems relating to criminalization, decriminalization, legalization, and interdiction--the main focus is on broadly medical or therapeutic responses to drug use, and in particular on problems encountered within the domain (...) of drug user counseling. Codes of ethics for drug user counselors can be found as an appendix. (shrink)

It is often claimed that the autonomy of heroin addicts is compromised when they are choosing between taking their drug of addiction and abstaining. This is the basis of claims that they are incompetent to give consent to be prescribed heroin. We reject these claims on a number of empirical and theoretical grounds. First we argue that addicts are likely to be sober, and thus capable of rational thought, when approaching researchers to participate in research. We reject behavioural evidence purported (...) to establish that addicts lack autonomy. We present an argument that extrinsic forces must be irresistible in order to make a choice non-autonomous. We argue that heroin does not present such an irresistible force. We make a case that drug-oriented desires are strong regular appetitive desires, which do not compromise consent. Finally we argue that an addict’s apparent desire to engage in a harmful act cannot be construed as evidence of irrational or compulsive thought. On these arguments, a sober heroin addict must be considered competent, autonomous and capable of giving consent. More generally, any argument against legalisation of drugs or supporting infringement of the liberty of those desiring to take drugs of addiction must be based on considerations of harm and paternalism, and not on false claims that addicts lack freedom of the will. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which shows that some ways (...) of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, by developing innovative clinical programmes that employ harm reduction, and thereby changing the standard of care to include routine use of these evidence-based approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations. (shrink)

A plethora of ethical issues in livestock agriculture has emerged to public attention in recent decades, of which environmental and animal welfare concerns are but two, albeit prominent, themes. For livestock agriculture to be considered sustainable, somehow these interconnected themes need to be addressed. Ethical debate on these issues has been extensive, but mostly started from and focused on single issues. The views of farmers in these debates have been largely absent, or merely figured as interests, instead of being considered (...) morally worthwhile themselves. In this paper the relevance for ethical debates of the ways farmers discuss and engage with moral concerns is explored. The variety of norms that figure in contemporary farming practices is sketched in its multifarious complexity, illustrated by ethnographic fieldwork, and systematized in terms of “orders of worth.” Reviewing the practical arguments and commitments of farmers within this framework reveals that farming practices are subject to mixed motives, in which an amalgam of types of concerns play a role. Recognition of the peculiarly entangled nature of the ethics of farming practices could counter the tendency in policy making, technological innovation, and ethical thought to compartmentalize our moral landscape. Understanding farming practice as the integration of a mosaic of concerns in the light of a variety of moral experiences would foster public appreciation of positions of farmers in debates on improving the sustainability and societal acceptability of livestock agriculture. (shrink)

Despite the increased prevalence of bioethics research that seeks to use empirical data to answer normative research questions, there is no consensus as to what an appropriate methodology for this would be. This review aims to search the literature, present and critically discuss published Empirical Bioethics methodologies.

Recent research in epidemiology has identified a number of factors beyond access to medical care that contribute to health disparities. Among the so-called socioeconomic determinants of health are income, education, and the distribution of social capital. One factor that has been overlooked in this discussion is the effect that stigmatization can have on health. In this paper, I identify two ways that social stigma can create health disparities: directly by impacting health-care seeking behaviour and indirectly through the internalization of negative (...) interpersonal judgments. I then argue that social arrangements that foster self-respect can reduce the impact of stigmatization on health disparities. I conclude by showing how John Rawls' conception of justice can be used to address the intersection of stigma, health, and self-respect, in contrast to critics of his position, who have seen him as excessively focused on the allocation of material goods. (shrink)

This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which shows that some ways (...) of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, by developing innovative clinical programmes that employ harm reduction, and thereby changing the standard of care to include routine use of these evidence-based approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

This trailblazing book provides a comprehensive view of the ethical issues that cut across the addiction field, from Employee Assistance Programs to treatment and aftercare. By addressing probing questions that illuminate today's complex ethical landscape, LeClair Bissell and James Royce explore how standard guidelines for professional conduct benefit counselors and clients alike.

The definitive book on ethics for chemical dependency treatment professionals.

Substance use and misuse occurs at a very high rate among people with mental health problems and the relationship between the two conditions is complex. In this paper we argue that treatment of substance use in dual diagnosis clients must begin from an understanding of the losses suffered by those with mental illness. We outline the fundamental condition of effective agency, unified agency, which is disrupted in mental illness and show how this is needed to secure access to central social (...) and moral goods such as continuing employment and satisfying relationships. We argue that drug use will be disvaluable primarily in so far as it too prevents access to this set of agential goods and focuses the agent on synchronic well-being to the exclusion of diachronic well-being. The goals and methods of treatment for dual diagnosis patients should thus reflect the primary impairment to unified agency. (shrink)