Authenticity and the Hijacked Brain

Carolyn McLeod

The American Journal of Bioethics, Volume 2, Number 2, Spring

2002, pp. 62-63 (Article)

Published by The MIT Press

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The American Journal of Bioethics
Authenticity and the Hijacked Brain
Carolyn McLeod, University of Tennessee, Knoxville
The issue of whether addicts can consent to research that
involves giving them their drug of choice is clearly impor-
tant. If we did not acknowledge it but allowed the research
to continue, we would leave addicts vulnerable to exploita-
tion, and they are already seriously vulnerable. Many have
poor physical and mental health, and many are mar-
ginalized from society—in part because of negative stereo-
types that target their moral character.1 Hence, they de-
serve 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 capac-
ity. I have problems with how Charland’s argument goes,
although I have great sympathy for his project. Let me ex-
plain the difªculty I am having.
Using the MacArthur model of competence, Charland
claims that in all likelihood, heroin addicts are not compe-
tent to consent, because they lack the ability to manipu-
late 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 efªciently to further one’s
values. The ability therefore presupposes a set of values,
speciªcally an authentic set: the agent’s own. Heroin ad-
diction 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 “hi-
jacked” 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 distinc-
tion matters, for only if the former is true does the argu-
ment about decisional capacity go through. If heroin ad-
dicts maintain authentic values but rarely act on them,
1. As Leshner (1997) writes, the most common view of drug addicts
is that they are “weak or bad people, unwilling to lead moral lives
and to control their behavior and gratiªcations” (45). Some evidence
for this lies in frequent calls for punitive measures against welfare
recipients who abuse drugs, and in statements by addicts claiming
that they are treated disrespectfully in such contexts as healthcare
clinics (see Sterk 1999, 126).
2. He writes, “chronic heroin addiction results in radical changes in
personal values that make seeking and using heroin the overriding
goal of the addict’s life” (my emphasis); but he later implies that
heroin addicts have “no minimally stable real values of their own”;
that is, values that could be overridden.
62 ajob
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 deªnes 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 argu-
ment?
To clarify what is at issue here conceptually, it is help-
ful to note that the hijacking metaphor works whether the
addict retains an authentic set of values or not. Undoubt-
edly, we have all wondered of late what it would be like to
be the victim of a hijacking that threatens to take away ev-
erything 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 her-
oin 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 evi-
dence Charland gives to support his position is that heroin
addicts constantly experience the cognitive impairment
that accompanies the delirium of withdrawal and intoxica-
3. They do not necessarily retain that ability, because having it in-
volves more than having a set of authentic values. See Charland.
Spring 2002, Volume 2, Number 2

tion. I wonder if the delirium simply masks authentic val-
ues rather than destroying them. Still, the result would be
the same: the addict no longer has access to authentic val-
ues 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 con-
sume it; but she only wants the ªrst 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 prob-
lems 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.
Ethical Evaluation of Heroin-Prescription Research:
An Insider’s View
Dominique Sprumont, Institute of Health Law, University of Neuchâtel and Fribourg (Switzerland)
In exploring Cynthia’s Dilemma, Louis C. Charland
(2002) argues that heroin addicts should be treated as in-
competent unless proven otherwise. He concludes that
heroin-prescription research violates existing North
American ethical standards for clinical research. Yet, rec-
ognizing that there is a strong need for investigating the
medical prescription of heroin as a treatment alternative,
he suggests two strategies for conducting such research:
ªrst, the use of a surrogate decision-making procedure;
second, a focus on the notion of risk that builds on the
idea that competence should be assessed using a sliding
scale.
The fact that Charland refers exclusively to North
American ethical standards in his conclusion should be
Spring 2002, Volume 2, Number 2
Open Peer Commentaries
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 over-
rides 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 war-
ranted depends on the severity of the effects of heroin-
induced delirium. If the effects do not usually negate au-
thenticity, 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, volun-
tariness is a requirement for consent, and an addict cannot
choose such a prescription voluntarily. However, the pre-
sumption of incompetence could not be grounded in the
blanket assertion that heroin addicts lack authenticity and
hence competency to consent. ■
References
Charland, L. C. 2002. Cynthia’s dilemma: Consenting to heroin pre-
scription. American Journal of Bioethics 2(2):37–47.
Frankfurt, H. 1989. Freedom of the will and the concept of a per-
son, in The inner citadel: Essays on individual autonomy, ed. John
Christman. New York: Oxford University Press; ªrst published in
1971 in the Journal of Philosophy 68.
Leshner, A. 1997. Science 278:45.
Sterk, C. Fast lives: Women who use crack cocaine. Philadelphia:
Temple University Press, 1999.
underlined. Indeed, the context in which the heroin and
cocaine prescription-research program was launched in
Switzerland is crucial to understanding how it was evalu-
ated at the time. In 1992 large cities such as Zurich were
confronted with an acute drug problem. The situation was
growing out of control, in both a sociocriminal and a pub-
lic-health perspective. Thus it was ªrst a political decision
to prescribe heroin and cocaine under medical supervision
as an alternative treatment for drug addicts. The purpose
of the program was to investigate heroin and cocaine pre-
scription as a prevention and assistance measure, with the
understanding that abstinence was the ªnal goal. The Eth-
ical Review Commission of the Swiss Academy of Medical
Science was invited to evaluate the ethical acceptability of
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