ADDICTION IS A PSYCHIATRIC DISORDER – WHAT HAVE WE LEARNED FROM HISTORY?

Lucke & Hall raise important questions in their report on project ‘prevention’, a US-based project 1, whose approach raises grave ethical concerns from a European historical viewpoint. The surgical sterilization of women at a reproductive age for a cash incentive is more than a sensitive issue, especially when it involves psychiatric patients. An additional consideration must be that, for a substance-dependent woman, cash incentives are not the same as they would be for a healthy proband. From a historical perspective, the proceedings described are in the neighbourhood of so-called ‘treatment intervention’ of psychiatric patients in the past. They are remindful of the ‘sterilization legislation’ implemented during the Nazi regime in Germany 2. Many countries had sterilization policies executed in the past, including the United States and Canada. Mainly, patients in mental hospitals were subject to involuntary sterilization in numerous states and provinces. In Sweden, the Sterilization Act of 1934 affected 62 000 people, among them mental patients. It was supported by the Lutheran church, the government and the majority of the medical profession and was not disestablished until 1975 3, 4. In the Czech Republic, more than 50 Roma women were sterilized unlawfully as recently as 2003, after misunderstanding informed consent 5. In our view, sterilization should not be recommended in such a manner to substance-dependent women, just as it would not be to other psychiatric patients. The legislation on sterilization has not yet been harmonized in Europe. Nevertheless, in the European context Austria can serve as an example of how an appropriate regulation is structured. It requires informed consent and special safeguards in order to protect mentally disabled people. The performance of a long-acting form of contraception can be judged under the statutory offence of severe bodily harm with permanent impact. The crime is threatened with an imprisonment sanction of up to 5 years (Art. 85 Austrian Criminal Code). However, the respective activity is not punishable if the patient consents, but the statute itself determines the preconditions of consent, indicating that the consenting person has to be aged at least 25 years. If this requirement is not fulfilled, sterilization is permitted if there are certain reasons which are not violating moral principles (Art. 90 paragraph 2 Criminal Code). Additionally—considering the patient's physical and mental capability— it has in any case to be assessed that the consenting person is able to understand the consequences of the intervention. Finally, case law decides if there are appropriate reasons for intervention. Aiding and abetting sterilization can also lead to punishment. The perpetrator will be subject to a stronger sanction. This is an intrinsic principle of the Austrian statute: e.g. it is not permitted to put pressure on someone to consent to sterilization. It is also generally forbidden to sterilize imprisoned sex offenders to reduce their libido, even though this might facilitate an early release from imprisonment 6. The group of opioid-dependent women is a particularly vulnerable target population who need a special professional approach, empathy and care. A difference between North America and Europe may be that in Europe addiction is always seen as a psychiatric disorder, whereas in North America addiction medicine is seen partially as a medical speciality of its own. Patients with an addiction disorder should be provided with the same clinical treatment and approach as other patients with a mental disorder. An additional consideration is the high rate of psychiatric comorbidities, in particular of affective disorders, where proper decision-making can be influenced 7. A lower level of education can facilitate misunderstanding of medical information 8. In addition, decision-making processes occur under the influence of psychoactive substances—therefore, any of the addressed decisions should be made only if a stable mental condition is given. A comprehensive care setting with a multi-professional team approach should include the possibility to address issues such as family planning with the women on the same level as it would be with a woman suffering from an episode of major depression or other mental disorder. We agree that inter-uterine devices (IUDs) should be the first choice for opioid-maintained women. Oral contraceptives are not suitable, as more than 90% of opioid-dependent women are heavily dependent on nicotine 9, placing them at additional risk of thrombosis and pulmonary embolism 10. Behavioural measures such as non-cash incentives have been effective in promoting abstinence from drug use 11. Optimal results are achieved when contingency management models with escalating regimes are used. For provision of birth control measures it seems most appropriate to provide free access through a fund, optimally with easy reversible methods. This has been practised successfully at the Addiction Clinic of the Medical University of Vienna.

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