Decisional Capacity and Addiction The Example of Heroin Prescription

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Decisional Capacity and AddictionThe Example of
Heroin Prescription

• Louis C. Charland Ph.D.
• Departments of Philosophy and Psychiatry
  Faculty of Health Sciences
• University of Western Ontario
• London Ontario Canada N6A 3K7
• Email charland_at_uwo.ca

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Goal

• To inquire into nature of addiction from vantage
  point of decisional capacity
• To focus discussion by adopting example of heroin
  prescription
• To challenge cognitive conceptions of addiction
  by stressing values and feelings
• Better title
• Appreciating the Consequences of Addiction A
  Case Study on the Role of Feelings and Values in
  Decisional Capacity

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Swiss Trials

• 1992-1996, 18 Sites, 18 months, n1146
• Varied cohorts, designs, interventions
• Geneva Trial 1995-1996
• Randomized Design n 51Ms /7352Ms21Fs
• Experimental Group n 27
• Intravenous heroin (oral opiates after 15 days)
• Control Group n 24
• Waiting list and existing alternatives

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Research Question

• whether the experimental programme would
  improve the participants illegal drug use,
  health and social functioning.
• Perneger et al
• BMJ, Vol 317, 4 July 1998, p.13.
• Steps on the road to abstinence
• Declaration de consentement
• HUG 1995

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Targeted Population

• Age ? 20 (Avg 32)
• Heroin dependence ? 2 years (Avg 12)
• Unsuccessful Treatments ? 2
• Low Health Status
• Social Distress
• Perneger et al
• BMJ, Vol 317, 4 July 1998, p.14.

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Mental Health Status

• Experimental Group n27
• 82 severe depression
• 93 severe stress
• 56 hepatitis
• 67 previous suicide attempt
• 15 HIV positive
• 4 with AIDS
• Perneger et al
• BMJ, Vol 317, 4 July 1998, p.14

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Conclusion

• a heroin maintenance program may be a feasible
  and effective treatment option for severely
  addicted heroin users.
• Perneger et al
• BMJ, Vol 317, 4 July 1998, pp.17

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Consent Requirement

• the psychiatrist, confirmed the patients
  eligibility, explained program procedures,
  obtained informed consent,
• Perneger et al
• BMJ, Vol 317, 4 July 1998, p.19

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Informed Consent

• Informed
• Voluntary
• Competent or Capable
• Situation Specific
• Decision Specific
• Threshold Concept

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Competence

• Mental Competence
• Decisional Capacity
• Clinical Concept
• Legal Concept
• Ethical Concept
• Philosophical Concept

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Presumption

• A person is presumed to be capable with respect
  to treatment, admission to a health care facility
  and personal assistance services.
• Health Care Consent Act of Ontario
• 1996, Sec.4(2)

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Models of Competence

• MacArthur Model
• Understanding and Appreciation
• Appelbaum Grisso 1995,1998
• Presidents Commission 1983
• An enduring set of values
• Brock and Buchanan, 1989

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Understanding

• Cognition of relevant facts
• Focus on what questions
• No appeal to values
• Impersonal

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Appreciation

• Legal counterpart called insight
• Significance of decision for oneself
• Ability to weigh risks and benefits
• Requires minimally stable values

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Cynthias Dilemma

• We should not presume that heroin-prescription
  subjects who are active in their addiction are
  capable of competent voluntary consent to
  heroin-prescription research. Quite the contrary,
  we should assume they are incompetent to consent
  unless proven otherwise.
• Louis C. Charland
• Cynthias Dilemma Consenting to Heroin
  Prescription
• American Journal of Bioethics 2(2) 2002, p.37

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Addiction

• characterized by compulsive, at times
  uncontrollable, drug craving, seeking, an use
  that persist even in the face of extremely
  negative consequences.
• Alan Leshner
• Preface, Principles of Drug Addiction
• NIDA 2001

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Dependence

• cluster of cognitive, behavioral, and
  physiological symptoms indicating that the
  individual continues use of the substance despite
  negative consequences. There is a pattern of
  repeated self-administration that usually results
  in tolerance, withdrawal, and compulsive
  drug-taking behavior
• DSM IV, p. 176
• American Psychiatric Association

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Complex Illness

• Chronic use and abuse
• Relapsing condition
• Compulsive seeking and using
• Loss of control
• Changes in values
• Changes in lifestyle
• Problems in accountability
• Dishonesty
• Ambivalence

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Argument

• As a matter of principle, heroin addicted
  individuals in these studies are likely to fail
  the appreciation test and the presumption of
  competence should therefore be rejected
• The reason is that addiction is based on
  pathological valuations, which then result in
  pathological decisions, which in turn leads to
  pathological behavior
• Pathological in this case means due to a
  medical condition and not simply the result of
  simple voluntary choice or lifestyle

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Hijacked Brain

• Cognitive Interpretation
• Cognitive loss of control
• Problem in thinking
• Hyman, American Journal of Bioethics 7(1), 2007
• Affective Interpretation
• Affective loss of control
• Problem in feeling
• Charland, American Journal of Bioethics 7(1) 2007

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Feelings in Addiction

• What affective neuroscience brings to the
  understanding of loss of control is above all
  the notion of affect these are internal,
  subjectively experienced, positive and negative
  feelings mental representations that encode and
  reflect goals and values of the organism.
  (Panksepp 1998). These feelings are also
  intimately involved in decisionmaking, where
  their evaluative determinations enable the
  selection of options to guide choice (Damasio
  1994). Thus it is the affective capacities of the
  brain that generate values which then determine
  choice. Addiction disrupts the manner in which
  feelings guide the organism. It is a disorder in
  the evaluative capacities of the brain which
  govern the generation and operation of affect.
  While these disruptions inevitably have cognitive
  consequences, addiction is not primarily a
  cognitive disorder.
• Louis C. Charland
• Affective Neuroscience and Addiction
• American Journal of Bioethics, 7(1) 2007, 21-2

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Moral Emotions in Addiction

• recovery from addiction is not simply a matter
  of thinking or reasoning more clearly. It is,
  quite literally, a physical bodily struggle in
  the realm of affect, where competing feelings
  representing contradictory goals and values in
  the organisms behavioral economy are pit against
  each other. Emotions are also involved. This is
  where morality enters the picture. Emotions and
  their corresponding affects function both as
  precipitates and consequences of thinking and
  behavior. Thus courage and hope may lead to a
  commitment to enter recovery, but then relapse
  follows with associated guilt and shame all
  emotional transitions and transmutations
  (Elster 1998). Or there is success in recovery,
  leading to pride and contentment. Yet if success
  is followed by relapse and that pattern persists,
  probably hopelessness and dejection will set in.
  These emotions, in turn, may soon give way to
  anger and resentment at self and others, creating
  additional barriers to recovery.
• Louis C. Charland
• Affective Neuroscience and Addiction
• American Journal of Bioethics, 7(1) 2007, 21-2

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Conclusion I Addiction

• Examining addiction form vantage point of
  decisional capacity, provides compelling reasons
  for viewing addiction as an affective disorder
  deriving from pathological changes in fundamental
  values guiding the organism.
• This pathology is reflected in the appreciation
  component of decisional capacity assessment,
  through pathologically altered values and
  feelings.

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Conclusion IIAddicted Individual

• The organisms fundamental values are changed in
  addiction. In that sense, the organism is a
  different organism before and during the onset
  of addiction.
• The kind of decisional impairment involved in
  addiction goes beyond simple decisional capacity
  and involves accountability.

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Accountability

• What we really want to know when we ask if a
  person is competent is whether that person is
  able to make decisions for which he can
  legitimately be judged accountable.
• Carl Elliott
• Competence as Accountability
• Journal of Clinical Ethics
• 2(3) 1991, 169.

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Thank You

• Louis C. Charland Ph.D.
• Departments of Philosophy and Psychiatry
  Faculty of Health Sciences
• University of Western Ontario
• London Ontario Canada N6A 3K7
• Email charland_at_uwo.ca

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Historical Sketch

• From Addiction to Dependence
• and
• Back Again

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Definition of Addiction

• Addiction
• Inherently a moral problem
• Habituation
• Not inherently a moral problem
• Dependence
• A medical problem
• Addiction
• A chronic medical and psychosocial illness

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Drug Addiction

• A state of chronic or periodic intoxication
  produced by repeated consumption of a drug
• Overpowering desire (or compulsion) to continue
  taking the drug and to obtain it by any means
• Tendency to increase the dose
• Psychic (or psychological) and sometimes a
  physical dependence
• WHO Tech Rep Ser 1957, 7, Sec 8

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Drug Habituation

• A condition resulting from repeated consumption
  of a drug
• A desire (but not a compulsion) to continue
  taking the drug
• No tendency to increase dose
• Some degree of psychic dependence, but absence of
  physical dependence
• WHO Tech Rep Ser 1957, 7 ,Sec 8

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Drug Dependence

• a state arising from repeated administration
  of a drug on a periodic or continuous basis. Its
  characteristics will vary with the agent involved
  and this must be made clear by designating the
  particular type of drug dependence in each
  specific case for example drug dependence of
  the morphine type
• WHO Tech Rep Ser 1964, 13, Sec 4

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Degrees of Compulsion

• Morphine
• overpowering desire
• Barbiturates
• strong desire
• Cocaine
• overpowering desire
• Amphetamine
• a desire
• WHO Tech Rep Ser 1964, 13, Sec 4

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Alcoholism

• Phases of disease or disorder
• Symptomatic drinking
• Coping and self-medicating
• Addictive drinking
• Uncontrolled drinking
• Organic disease
• Brain damage
• WHO Tech Rep Ser 1951, 42, Sec 2

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Medical Approach

• Aid without moral censure
• Detoxification
• Psychotherapy
• Social Work
• Pharmacology
• WHO Tech Rep Ser 1964, 42, Sec 5

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Substance Dependence

• cluster of cognitive, behavioral, and
  physiological symptoms indicating that the
  individual continues use of the substance despite
  negative consequences. There is a pattern of
  repeated self-administration that usually results
  in tolerance, withdrawal, and compulsive
  drug-taking behavior
• DSM IV, p. 176

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Dependence

• Physiological Dependence
• Tolerance
• Withdrawal
• No Physiological Dependence
• Compulsive use
• DSM IV p.179

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Illness Model

• Drug addiction is a complex illness. It is
  characterized by compulsive, at times
  uncontrollable drug craving, seeking, and use
  that persist in the face of extremely negative
  consequences. For many people, drug addiction
  becomes chronic, with relapses possible after
  even long periods of abstinence.
• A. L. Leshner
• Principles of Drug Addiction and Treatment
• NIDA 2001

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Essence of Addiction

• Compulsive drug seeking behavior, and use, in
  the face of negative consequences
• Physical dependence is not that important
• Drug Abuse and Addiction Research
• The Sixth Triennial Report to Congress from the
• Secretary of Health and Human Services 1999, p.2.

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Loss of Control

• uncontrollable compulsion to seek and use drugs
  
• continued repetition of voluntary drug taking
  begins to change into involuntary drug taking
• Leshner, Alan.
• Science-Based Views of Drug Addiction and its
  Treatment
• Journal of the American Association. 1999, 282,
  no. 14 1315.

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Intoxication and Withdrawal

• states that resemble delirium
• National Bioethics Advisory Commission 1998
• Research Involving Persons with Mental Disorders
  That May Affect Decisionmaking Capacity

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A Hijacked Brain?

• Implications for personal values
• A.L. Leshner
• Addiction is a Brain Disease
• Science Vol 278, 3, 69-71.

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A Selfish Brain?

• Implications for personal care
• Denial, rationalization
• Implications for interpersonal relationships
• Lying, manipulation
• Robert L. Dupont
• The Selfish Brain 2001

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Argument

• Compulsion.
• Loss of control over drug use.
• Agency.
• Agency severely compromised.
• Integrity.
• Breakdown in integrity

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Implications for Treatment

• Must restore
• Medical integrity
• Personal integrity
• Social integrity