The American Journal of Bioethics

The issue of whether addicts can consent to research that involves giving them their drug of choice is clearly important. If we did not acknowledge it but allowed the research to continue, we would leave addicts vulnerable to exploitation, and they are already seriously vulnerable. Many have poor physical and mental health, and many are marginalized from society—in part because of negative stereotypes that target their moral character.¹ Hence, they deserve our protection, which Louis C. Charland (2002) admirably promotes on behalf of heroin addicts who are enrolled in heroin-prescription studies on the presumption that they are competent to consent. Charland argues that researchers should work with the opposite presumption: that heroin addicts do not have adequate decisional capacity. I have problems with how Charland's argument goes, although I have great sympathy for his project. Let me explain the difficulty I am having.

Using the MacArthur model of competence, Charland claims that in all likelihood, heroin addicts are not competent to consent, because they lack the ability to manipulate information rationally. Such ability goes beyond merely understanding information and appreciating how it applies to one's own life. It is about knowing how to evaluate information and use it efficiently to further one's values. The ability therefore presupposes a set of values, specifically an authentic set: the agent's own. Heroin addiction tends to destroy competence to consent by altering one's personal values so that they are no longer authentic, according to Charland. The addict's brain becomes "hijacked" by the drug.

Charland is actually ambiguous about whether heroin addicts lose their authentic values or whether the value they place on using heroin simply takes precedence over their other values and motivates them to act.² The distinction matters, for only if the former is true does the argument about decisional capacity go through. If heroin addicts maintain authentic values but rarely act on them, then they still may have the ability to weigh information rationally³ and may even exercise that ability; however, the evaluations they make would not govern their behavior. Why would they not do what they rationally decide they should do? Charland's answer is that they are severely compelled to use heroin. Their behavior is not voluntary because of the compulsion that defines their addiction. However, they still might be competent. Charland makes the point about voluntariness and does so convincingly. Should we be equally convinced by his competency argument?

To clarify what is at issue here conceptually, it is helpful to note that the hijacking metaphor works whether the addict retains an authentic set of values or not. Undoubtedly, we have all wondered of late what it would be like to be the victim of a hijacking that threatens to take away everything we hold most dear. It is possible that we would keep our wits about us and constantly think of ways to outmaneuver our hijackers. We would be motivated by what we value most: our own lives, people close to us, and so on. Alternatively, we might be entirely overcome by fear, transformed into a being that feels only fear. We would want only to get out of the horrible situation. These are two extreme responses, and between them are many gradations of response. The question is where do heroin addicts lie on such a continuum? How does the hijacking metaphor apply to them?

I think Charland must be right that with chronic heroin addiction, a person's values become "reoriented" or "overridden" (in this case by addictive cravings, not fear). However, do they become so reoriented that the person no longer values anything authentically; that is, do they no longer have life goals or desires other than using heroin (which is arguably not authentic if the person is addicted)? Are they themselves transformed into beings that feel only a need for heroin? What evidence is there to support such a view? Charland refers in passing to the behavior of addicts: he writes, "They say they really value and desire a life without drugs but usually end up behaving in a manner that shows they really value and desire the opposite." But one's behavior is not always indicative of what one truly values, however, especially when one acts involuntarily, as one does when one acts under compulsion. The main evidence Charland gives to support his position is that heroin addicts constantly experience the cognitive impairment that accompanies the delirium of withdrawal and intoxication. [Begin Page 62] I wonder if the delirium simply masks authentic values rather than destroying them. Still, the result would be the same: the addict no longer has access to authentic values with which to evaluate the option of entering a heroin-prescription research program.

This conclusion about authenticity worries me because it effectively eliminates the category of the "unwilling [heroin] addict" (Frankfurt 1989, 68). Such an addict has a desire to refrain from using heroin and also a desire to consume it; but she only wants the first desire to constitute her will (i.e., to motivate her actions). Therefore, arguably, she has authentic desires and may have the capacity to choose rationally. However, on Charland's model of heroin addiction, such addicts are anomalous. The paradigm of the heroin addict is the "wanton," that is, an addict who has no concern for

whether the desires that move him to act are desires by which he wants to be moved to act. If he encounters problems in obtaining the drug or in administering it to himself, his responses to his urges to take it may involve deliberation. But it never occurs to him to consider whether he wants the relations among his desire to result in his having the will he has. (Frankfurt 1989, 68)

Unless the addict has always expressed such "wanton lack of concern" (Frankfurt, 68), he is no longer himself (as Charland would say). He is like the terrorized victim of a hijacking who is so beside himself that his identity is lost, if only temporarily.

At times, it seems clear that Charland would accept that some heroin addicts are not pure wantons; some maintain real values of their own, which they might wish to constitute their will, but their desire for heroin overrides that wish. At other times Charland suggests that by virtue of being heroin addicts, addicted persons have no authentic values and therefore no competency to consent. Whether Charland's presumption of incompetence is warranted depends on the severity of the effects of heroin- induced delirium. If the effects do not usually negate authenticity, then the presumption will have to be revised. It could still be a presumption against the ability of heroin addicts to consent to heroin prescription; after all, voluntariness is a requirement for consent, and an addict cannot choose such a prescription voluntarily. However, the presumption of incompetence could not be grounded in the blanket assertion that heroin addicts lack authenticity and hence competency to consent.