Addiction and consent.

In teaching medical students and residents about substance dependence, I often use the phrase " the addiction takes on a life of its own. " This intuitive expression begins to introduce how the severely addicted person becomes merely the " means " for the substance, how the person is displaced within his own body, how there becomes a fundamental separation within the addicted person who himself is diminished as the substance dependence intensiªes. Indeed, the addicted person does not, cannot feel " whole " in the absence of the substance. Understanding substance dependence is to see how an addiction resides within the human person but erodes the things that most deªne his humanity: his sense of self, his aim in life, his actions, his ability to work and love, his capacity to discern and enact choice. These effects are particularly true for opiate dependence , which includes illicit heroin addiction and licit methadone maintenance treatment and directly affects hundreds of thousands of people in the United States and millions worldwide (Franklin and Frances 1999). Speciªcally, in 1998 it was estimated that 2.4 million people in the United States had used heroin during their lives, 130,000 had used it in the prior month, and 81,000 had become new heroin users in 1997 (NIDA 1997). Heroin addiction is unusually powerful and tenacious in its hold on affected persons, is associated with serious comorbid conditions (e.g., HIV, hepatitis, head injury, malnutrition), and mortality rates 13 times greater than the general population. Withdrawal signs and symptoms, although extraordinarily uncomfortable, are generally not life threatening, except in affected babies of addicted mothers (Franklin and Frances 1999; Huse 1999). Opiate dependence has grave psychosocial and societal implications , and is perhaps the most stigmatizing of the addictions. Louis C. Charland's paper, " Cynthia's Dilemma: Consenting to Heroin Prescription " (2002) presents an astute, clear, and courageous analysis of the complexities surrounding informed consent in the context of opiate addiction. Relatively little conceptual work, and no systematic empirical ethics work, has been done in this area, and Charland's paper represents a valuable contribution to an underdeveloped ªeld that is of great importance to public health. I would like to brieºy outline strengths of Charland's well-written paper, argue for greater emphasis on " voluntarism capacity " as well as " decisional capacity " considerations (based on my own work on informed consent and serious illness), and conclude with …