Abstract

Sir—In their editorial, Hall, Carter & Morley [1] present an incorrect interpretation of my central argument. The point of my paper [2] is that there are solid reasons to suspect that the capacity of heroin addicts to consent to heroin therapy is compromised because of their addiction. As one medical commentator on my paper states, if active heroin addicts can give voluntary and competent consent to heroin therapy without any problems, then we need a new conceptualization of addiction: they are not addicted, almost by definition [3]. Yet obviously there are problems and grey zones. The solution is to investigate the issue empirically in order to determine the extent of the problem. (As we have done for consent to research on depression and other mental illnesses.) Ultimately, the question can only be solved on a case by case basis, using standardized assessment tools adapted for this purpose. The MacArthur Competence Assessment Tool (MaCAT‐T) is the particular assessment tool I chose to discuss. [4] It is the most promising candidate available, and it has proved its merits in the areas of depression and schizophrenia. At no point do I condemn heroin therapy and endorse an abstinence model of treatment, as the authors state. On the contrary, I note the success of heroin therapy and make suggestions about how to facilitate the consent process. Ironically, it may be Hall et al . who have oversimplified the issues. What we need here are empirical studies on the decisional capacity of heroin addicts to consent to heroin therapy. Only then will we be able to refute the naive view they have no ‘free will’, or say how much they have; but really my paper is not about ‘free will’ at all. This is a philosophical concept. The topic I chose to discuss is ‘decisional capacity’, also called ‘mental competence’. This is a clinical concept with complex legal and ethical associations that often vary across jurisdictions. My point was that although the Swiss Heroin Trials were approved in Europe, they probably would not be approved in Canada or the United States under existing regulations. Interested readers might want to consider the wide variety of reactions to my paper, published in the same issue [5]. Unfortunately, the editorial by Hall et al . does little to advance this debate.