ETHICAL ISSUES SURROUNDING COERCED TREATMENT” OF OPIOID-ADDICTED INDIVIDUALS WITH IMPLANTED NALTREXONE

The following letter was emailed to the well-known and widely respected medical ethicist Dr. Arthur Caplan of the University of Pennsylvania. Dr. Caplan has been invited to respond – and assured that if he does so his response will be posted on this blog with no edits. To date he has not accepted this offer to have the last word.

EMAILED TO DR. CAPLAN ON 17 JANUARY 2007

Dear Dr. Caplan:

Regarding your recent article endorsing coercion of opiate dependent persons to accept naltrexone implants in lieu of incarceration (“Ethical issues surrounding forced, mandated, or coerced treatment,” J Subst Ab Treat, 31:117-120, 2006):

You state at the outset that it is your goal to suggest “a way in which self-determination may not conflict so strongly with the compulsory use of drugs for prisoners.” I believe it is not appropriate for ethicists to help researchers and clinicians climb what you describe as “a very steep ethical hill” by suggesting rationalizations to overcome “… the emphasis that has been placed in American bioethics on the values of personal autonomy and respect for patient self-determination.”

A number of aspects of the proposal to implant “depot naltrexone” through coercion applied by the Criminal Justice System (CJS) are of particular concern:

1. It seeks to force individuals to accept treatment for the explicit reason that it has such limited attraction on a voluntary basis.
2. It would employ a medication whose efficacy is unimpressive, to say the least, even for the limited number of patients who accept it without coercion (and thus, presumably, have some genuine motivation).
3. It would utilize a “delivery system” – implantation of a drug whose pharmacological action persists for months – for the specific purpose of rendering patients incapable of opting out, regardless of the subjective response(s) they may have to the medication.
4. It relies heavily on the CJS (parole and probation officers, and perhaps also judges and prosecutors) to decide who is “sick” and thus qualifies for and needs “treatment” – and this pharmacological treatment in particular. Not only do the criminal justice gatekeepers lack the qualifications needed to make such clinical decisions, the interests they are sworn to represent are first and foremost those of the general society, and not the “patients” (or “subjects”).
5. There is an inherent illogic in this as in all forms of coercion involving the “choice of prison vs treatment.” When clinicians and the care they provide are unsuccessful, it is the subject who pays the price! Ironically, evidence of drug use per se, which merely confirms the existence of the clinical condition being “treated,” is generally what triggers the process leading to incarceration or reincarceration.

Regarding some of the key assumptions underlying your conclusions, you are simply misinformed. Your concept of drug dependent persons being individuals “in the throes of addiction and who [therefore] cannot choose anything . . .” is wrong, as is the implication of the rhetorical question you pose, “Can drug addicted individuals be autonomous when they are addicted . . .?” First, drug dependent people do make decisions all the time – including decisions without legal duress to seek and accept a broad spectrum of treatment services. In fact, lack of treatment availability is probably a far greater deterrent to delivery of care than lack of motivation or decision-making capability on the part of drug users. Furthermore, whatever constraints on autonomy addiction imposes, they are not eliminated by a period of abstinence, whether enforced or voluntary. “Addiction” and the clinical challenge of craving are as much a reality after six months of abstinence (with or without naltrexone) as when an individual is on the streets shooting up with heroin several times a day. Ironically, the undisputed fact is that naltrexone, whatever its degree of efficacy, has no effect whatsoever on the critical phenomenon of craving.

I will not comment on your views concerning methadone, which you contrast with naltrexone by stating, “Breaking the back of addiction is a better moral choice than maintaining addiction at a lower cost,” and your contention that “many [supporters of opiate maintenance] believe that it is better to use substitute drugs that are not as expensive as heroin . . .” I respectfully suggest, however, that you review with some objective experts in the field your perception of addiction treatment that includes the medication methadone.

And finally, an observation concerning one of the premises of your paper - that forcing treatment on people against their will is defensible because it allows them to make choices following “adaptation to the new state of affairs.” Such thinking would allow one to ignore almost any decisions made by patients. Thus, the adamant refusal to have amputation of a gangrenous limb could be overruled with the rationalization that the patient should have the surgery and then be “allowed to adapt” to a prosthesis, with the option of suicide available if adaptation is unsuccessful.

Sincerely,
Robert Newman, MD, MPH