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As clinical ethicists, we read with interest the recent commentary of Pilarinos et al Secure Care: More Harm Than Good [1]. In British Columbia, discussion is ongoing regarding secure care legislation for youth involved in high-risk substance use (HRSU) [2], and we commend these authors for bringing their concerns forward. We encourage application of an ethical lens, incorporating ethical principles and consideration of a range of ethical issues, in development of policy and treatment programs for this population.
Prior to consideration of intervention contrary to individual’s wishes, a significant risk of harm must be established. Harms of HRSU by youth can range from decreased school performance to death by overdose [3]. Longer term, yet less clearly documented effects, such as impacts on the developing brain, are also of serious concern [3,4].
Overriding autonomy by means of involuntary treatment should never be taken lightly, as this can cause significant harms. Many youths possess the capacity and legal authority to make health care decisions [5,6]. However, some scholars posit that individuals with severe substance use disorders may struggle to follow through on decisions to reduce or abstain from substance use due to the neurobiologic effects of addiction—leading to actions that go against their authentic values or best interests [7]. The question of whether an individual with a severe substance use disorder can be capable of making autonomous decisions with respect to their substance use and treatment is unsettled. Decision makers must therefore balance the potentially coercive effects of addiction against the authoritative act of involuntary treatment.
Given the risk of significant harm and potentially compromised capacity related to HRSU, intervening against a youth’s wishes to compel treatment could be ethically justifiable in some cases. However, ethical justification for such intervention must meet the following criteria [8,9]:
1. Intervention is effective (beneficence). While intervening to ‘do something’ may be tempting, the intervention must have documented efficacy to be justifiable. Pilarinos et al acknowledge that “addiction treatment programs are effective for some” [1] (p. E1219) but before secure care should be considered, the nature and goal of the intervention, as well as individuals for whom it is likely to be effective, must be identified. If evidence does not support effectiveness of secure care in meeting treatment goals, such infringement on youth autonomy is ethically problematic. Given the paucity of evidence, research into such interventions may be acceptable providing it is methodologically sound, as well as scientifically and ethically justified.
2. Intervention is the least intrusive yet effective option (autonomy). As well as being effective, an intervention should be the least intrusive. The intervention must be proportional to possible harms and benefits. Desperate situations may justify significant intrusions on freedoms while less serious situations do not. It would be ethically problematic to design a system in which youth were routinely involuntarily placed in secure care when less restrictive approaches would likely be effective. Therefore, it is important to provide a continuum of care to ensure access to the least intrusive services.
3. Intervention does not cause greater harm than it seeks to prevent (non-maleficence). Mandating secure treatment may be ethically justifiable given the duty to protect youth from harm, for example, when a youth has overdosed multiple times over a short period and is likely to experience severe harms or die. However, this duty is not license for involuntary treatment for all youth who use substances. A range of potential harms related to secure care must be considered including risks in over-riding autonomy (e.g., distrust in providers and ‘the system’), destabilising effects, and increased risk of overdose after treatment [1]. It is critical to individually assess whether risks of treatment are outweighed by benefits, such as detoxification, assessment, and stabilization (including improvement of decisional capacity) [10]. Appraisal of risks and benefits associated with substance use from the youth’s perspective is necessary to understand why they are using (e.g. to cope with trauma) and the alternatives available to them [3].
4. Intervention is non-discriminatory (justice). Secure care for some youth must not hold them to a higher standard than others who are similarly situated. There must be clear criteria for those who would be treated involuntarily in secure care such that like cases are treated alike.
5. Intervention is fair (justice). High-risk substance use may be linked to social determinants of health that have been inadequately addressed through current systems (e.g., poverty, racism). It is important to address the root causes of substance use, and provide culturally safer care, particularly for underserved communities (e.g. Indigenous youth). This discussion needs to be placed in a larger social context, as the intersections with systemic inequities and injustices are numerous.
Justice also requires that we address issues of resource allocation and procedural justice. We must leverage current resources to target gaps to create an accessible system of care for all youth with substance use challenges. Similarly, if secure care is implemented, procedural justice requires appropriate stakeholder engagement, (including youth, parents, and communities impacted by substance use) and robust safeguards to protect the rights of youth in secure care (e.g., fair appeal process).
Finally, the state has a special duty to care for and protect minor youth. For youth with severe substance use disorders, decisional capacity regarding substance use may be compromised or absent. Involuntary treatment for this population may be justifiable if the demonstrated benefits outweigh the potential harms and if issues of autonomy and justice are fully taken into account.
In conclusion, numerous ethical issues arise when developing policy and treatment programs for the subgroup of youth with HRSU, and we strongly support the inclusion of ethicists in these discussions. Approaches such as secure care have potential to cause harm, however that reality cannot lead to inaction. Instead, evidence, risks, and benefits need to be comprehensively evaluated, with thorough consideration of youth autonomy, cultural safety, fair process, resource allocation, and stakeholder consultation. Swift action and adequate funding are needed to ensure youth with HRSU have access to the most effective and least restrictive services that can meet their needs.
References
1. Pilarinos A, Kendall P, Fast D, DeBeck K. Secure care: more harm than good. CMAJ. 2018;190(41):E1219-E1220. doi:10.1503/cmaj.180700
2. Hogg G. Safe Care Act.; 2017. https://www.leg.bc.ca:443/parliamentary-business/legislation-debates-pro.... Accessed November 6, 2018.
3. Turpel-Lafond, M. E. A review of youth substance use services in B.C. May 2016. https://rcybc.ca/substanceuse. Accessed November 6, 2018.
4. Volkow ND, Koob GF, Croyle RT, et al. The conception of the ABCD study: From substance use to a broad NIH collaboration. Developmental Cognitive Neuroscience. 2018;32:4-7. doi:10.1016/j.dcn.2017.10.002
5. Infants Act. Vol c 223.; 1996.
6. Canadian Paediatric Society. Medical decision-making in paediatrics: Infancy to adolescence. Paediatrics & Child Health. 2018;23(2):138-146. doi:10.1093/pch/pxx127
7. Volkow ND, Koob GF, McLellan AT. Neurobiologic Advances from the Brain Disease Model of Addiction. Longo DL, ed. New England Journal of Medicine. 2016;374(4):363-371. doi:10.1056/NEJMra1511480
8. Browne A, Blake M, Donnelly M, Herbert D. On liberty for the old. Can J Aging 2002; 21:283-293
9. Young, J. M & Everett, B. (2018) When patients choose to live at risk: What is an ethical approach to intervention? BCMJ 60 (6):314-318)
10. Charles G. Secure Care Summary Report (Part One): Secure Care Legislation. September 2016. doi:http://dx.doi.org/10.13140/RG.2.2.17514.52164