The right to refuse medical treatment is a fundamental human right recognised in our uncodified constitution. The protection of our autonomy is deeply embedded into our health system. Yet, there are situations when we, if unwittingly, expect patients to simply give up their right to the freedom of consent to being treated. Worse, being treated with medication that potentially ruins their life.

The College hosted an excellent Webinar on Drug Misuse last month. It started with a brief summary of our current understanding of the neurobiological basis of addiction. There was a powerful statement that got me thinking about a very interesting but also very concerning aspect of drug dependence that goes all the way to a fundamental principle of our healthcare culture, the principle of informed consent.

Loss of Autonomy

By becoming drug-dependent, a person loses the ability to control their behaviour in relation to that drug. This includes making an informed choice about being treated with the medicine they are addicted to.

Addiction is fundamentally a condition of loss of cognitive control of substance-related behaviour

Sellman, 2009

In this paper the authors explain that drug-addiction completely changes a person’s behaviour as they become compulsive and lose their conscious control over their actions. This happens not only with strong, illicit drugs such as heroine or methamphetamine, but with milder prescription medicines, such as benzodiazepines or opioids. We see this too often in the pharmacy. It’s literally the pharmacist’s nightmare to deal with some of these patients as they struggle to invent stories that explain why they need their repeats early, or just simply get offended and irritated if there is the slightest chance that they aren’t going to have their drug immediately. I can only imagine what goes down at the GP visit.

Clearly, obtaining the medicine becomes paramount for the addict, while other things in their day-to-day life progressively become less and less important. At that point they no longer have the power to decide whether or not to be treated with the drug, as a non-cognitive compulsion takes control. So, under these circumstances, how can a person be expected to give informed consent to treatment?

Informed Consent

It is a fundamental principle in the New Zealand health care system that patients have the right to make informed decisions about their treatment. Under the Code of Rights, treatment can only be provided with the patient’s consent unless some exception applies. However, the roots of the principle of informed consent are found in the New Zealand Bill of Rights Act, which is one of the most important parts of New Zealand’s uncodified constitution. Our right to autonomy in deciding what happens to our body is crucial in our society. And the law recognises this, therefore, if a person is capable of making an informed choice, it must be respected.

So what about a person who becomes unable to make an informed choice due to the treatment itself? People may consent to a temporary loss of consciousness, for example before general anaesthesia, but nobody is going to ask for informed consent in relation to further treatment while the person is under the influence of the anaesthetic drugs. The idea sounds ridiculous.

Yet, when somebody goes to hospital with a broken bone, and, on discharge, opioid pain relief is prescribed which happens to cause dependence, we don’t immediately see an issue with a GP prescribing further opioid pain relief to the person, because we may not realise that, in the meantime, the patient has become unable to make a level-headed decision whether or not to accept the treatment.

A Fundamental Human Right

An alarming number of people become addicted to prescription drugs, which has been recognised by the Medical Council a long time ago, and the profession is strongly pushing back on this global issue. But I wonder how many of the people that become drug-dependent truly appreciated the probability of dependence and the consequential loss of autonomy before starting the treatment. Would they have chosen to take the medicine anyway? This question is, or ought to be, dealt with by the prescribing doctor before initiating the treatment, but I trust that doctors follow their professional judgement and guidelines in good faith. So, I’m not going to question that the patients’ consent is properly sought before starting medication that carries a relatively high risk of addiction.

But it is an interesting question whether, and under what circumstances, we should accept the patients’ consent to lose their autonomy and their ability to refuse treatment at a later stage, as a matter of law. The right to refuse medical treatment is one of our most fundamental, shall we say, constitutional rights, on par with the right not to be subjected to torture or not to be deprived of life. And as a matter of criminal law, we definitely do not allow a person to consent to their own death. Of course, in health-related decision making there are circumstances when the potential benefits outweigh the risks, but as a health professional, you really have to make the case when the risk involves losing a fundamental human right.  Therefore, we cannot lightly say that drug-dependence is an acceptable risk of the treatment, just as we cannot lightly say that continuing excruciating pain or death is an acceptable risk of the treatment.

Conclusion

I believe that there is more work to be done in recognising the true consequences of addiction induced by prescription drugs. More weight needs to be given to the risk of losing the ability to refuse further treatment. Further, the Code of Rights recognises that a person may have diminished competence, in which case treatment decisions can be made on behalf of the person, in their best interests. In addition, no law gives right to a person to demand a particular treatment, therefore it can be discontinued by the prescriber. In fact, the Medical Council unambiguously prohibits doctors from prescribing drugs with abuse potential to patients who are addicted to such drugs.

And, on the positive side, by helping a person fight their addiction, one helps to restore their freedom of choice, their autonomy, their right to live free from a compulsive and harmful behaviour that was forced on them by an addictive drug.