Abstract
Background and Objectives: Australia is in the midst of an epidemic of deaths due to overdose of heroin. More than 700 young Australians die each year because they use too much heroin, often after taking other drugs as well as heroin. A recent review of mortality among heroin users suggested that up to 25% of heroin overdose deaths could be suicides. While hundreds die each year from overdosing on heroin thousands of heroin users overdose and recover, either without specific medical help or after being treated by medical or paramedical staff or both. A common story from ambulance officers and emergency department staff is that after being treated for overdose of heroin, many, perhaps most patients, abruptly leave the scene of their treatment. This outcome means that a comprehensive assessment and management of their heroin and other drug use, and mental state is very difficult. The purpose of this paper is to review ethical arguments for detaining heroin users who overdose to enable a comprehensive assessment of them and to discuss treatments with them.
Method: The approach we use in this paper is that which some philosophers adopt to develop their own foundational principles in ethics. This method posits a process in which deliberators move back and forth between general principles and considered judgements-in this case about particular circumstances of heroin overdose and addiction as a mental illness in general-modifying each in the light of an appraisal of the other using empirical information about outcomes where possible.
Overall we ask:
What choices do we need to make?
What information is enough for us to make reasoned choices?
We met as a group to consider this question and asked the Treatments Ethics Committee of the Royal Adelaide Hospital to examine the question also, thereby enhancing the deliberative process. We analysed data on presentations of overdose on heroin to the Royal Adelaide Hospital
Results: While intoxicated with heroin to the point of overdose, heroin users are not able to make rational judgements about their wellbeing. While experiencing an acute withdrawal syndrome from heroin, heroin users may not be able to make rational judgements about their wellbeing. It follows that there can be adequate ethical grounds for paternalistic treatment of heroin users in such circumstances. The justification for such paternalism includes our duty of care to them. But, it also follows that we should judge carefully how we reverse the effects of heroin with naloxone. We should aim to avoid precipitating an acute withdrawal reaction that renders heroin addicts vulnerable to impulsive and ill-considered actions. We suggest strategies for the best ethical and clinical treatment of heroin overdose.