Cynthia's Dilemma
Authors: Walter Ling
Journal: The American Journal of Bioethics (2002)

Louis C. Charland’s paper “Cynthia’s Dilemma” (2002) opens with a recovering addict’s remark, but the basis for the argument is the Swiss heroin trial. “Cynthia’s dilemma,” according to the author, is that heroin addicts cannot adequately consent to participate in research where heroin is provided. The source of the dilemma, as the author sees it, is the nature of heroin addiction itself. Two points are offered to buttress this argument. First is that the offer of free heroin makes it impossible for addicts to give consent because they love the drug too much and this love so impairs their judgment that they cannot give voluntary consent. The compulsive need to seek and use heroin, the author says, impairs the addict’s decisional capacity to make choices about it. Second, the author contends that even if voluntary consent were possible, heroin addicts are mentally incompetent to make such a decision. Since competence, as the author sees it, must involve some sort of accountability, or value set, a competent choice must minimally reoect a person’s real likes and dislikes (what the addict likes is to get high, and what he dislikes is to get sick). To the author, being dependent means that every aber of an addict’s being is bent on seeking heroin. Addicts no longer seek heroin to get high but rather to avoid withdrawal; therefore an addict cannot “just say no” to heroin. The author equates inability to say “no” with being incompetent. This misses the point. Compulsion is a matter of degree and so is its inouence on an addict’s decision. Few heroin addicts would attempt to take heroin from an armed dealer without the means to pay for it, and most would readily give up their “stash” to a law enforcement ofacer rather than risk getting shot. Surely they are not giving it up incompetently. And so the argument that a strong desire, or loving too much, renders one incompetent to make a decision with respect to an object of desire simply does not hold. If it did, all marriages would have to be considered for annulment because they involve persons who are incompetent at the time of proposal. True enough, there are instances where wrongly proposed marriages have led later to murder, but it cannot be said as a general statement that people who are too much in love make marriage proposals incompetently. The Swiss trial is used as a substrate for the author’s second argument that even if voluntary consent is possible, addicts are mentally incompetent to give it. The adequacy of the consent procedure in the Swiss trial is not the issue here, however, but rather it is the general competency of those who gave consent. The author points to concerns about the competence of alcoholic subjects giving consent in alcohol trials and laments that similar reservations have not been expressed in heroin studies. In his view heroin and alcohol are alike, but of course they are not. Here the author confuses heroin intoxication and withdrawal with delirium from alcohol withdrawal; but whereas delirium may be a feature of alcohol intoxication and withdrawal, it is not with heroin. The author asserts that heroin addicts vacillate between a state of intoxication and withdrawal and that the state of physiological and psychological compulsion nulliaes voluntary choices. He takes literally Alan Leshner’s metaphoric comments that an “addicted brain is a hijacked brain” and that “addicts are no longer themselves” to support his argument that chronic heroin addiction results in radical changes in personal values. Such values are related to a person’s genuine likes and dislikes, which give rise to accountability, which in turn relates to competence. A competent choice, he argues, must reflect a persons’ real likes and dislikes, based on his or her set of personal values. A choice that does not reflect a person’s real likes or dislikes, according to the author, cannot be said to be a real choice. But do addicts under the influence of heroin or in withdrawal know what they like or dislike? Of course they do. Every heroin addict knows that without heroin he will get sick and that an injection of heroin will offer relief. As noted earlier, an overriding desire for something neither excuses a person from being accountable nor renders his decision incompetent. If addicts are considered incompetent, then virtually all addicts who are arrested cannot offer pleas of guilt or innocence, make decisions about their own future, or conduct any other form of business,