Revive and Refuse: Capacity, Autonomy, and Refusal of Care After Opioid Overdose

Abstract

Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation.

Keywords:

• Decision making
• informed consent
• law
• medicine
• mental health

This article is referred to by:

Revive and Survive: A Critical Lens on the Refusal of Care After Opioid Overdose

Autonomy and Its Constrictive Effects on Our Ethical Lenses and Imaginations

Revive and Respect: Using Structural Competency and Humility to Reframe Discussions of Decision-Making Capacity

Capacity, Rationality, and the Promotion of Autonomy: A Trauma-Informed Approach to Refusals of Care After Opioid Poisoning

Autonomy, Thin and Thick

Law Enforcement Interventionism as Determinant of Decision-Making Among Resuscitated Opioid Users

Hospitals Are Not Prisons: Decision-Making Capacity, Autonomy, and the Legal Right to Refuse Medical Care, Including Observation

Confidence in Care Instead of Capacity: A Feminist Approach to Opioid Overdose

Everyone With an Addiction Has Diminished Decision-Making Capacity

Illuminating the Consequentialist Logic of Harm Reduction After Overdose Through a Hypothetical Randomized Trial

Autonomy-Based Obligations to Patients in the Emergency Department Following Opioid Overdose

Resisting Inadequate Care is Not Irrational, and Coercive Treatment is Not an Appropriate Response to the Drug Toxicity Crises

Opioid Overdose and Capacity

From Opioid Overdose to LVAD Refusals: Navigating the Spectrum of Decisional Autonomy

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

Notes

1 A potential objection is that if a patient can coherently relate a decision to some espoused set of values in order to pursue a choice (e.g., to use heroin, or to refuse observation) that appears to conflict with their more enduring values, then that immediate choice represents what the patient truly wants, and thus, the patient not only has DMC, they act autonomously as well. This objection is similar in spirit to the “liberal view” of addiction, which appears to collapse or deny the distinction between the desires that are produced by addiction on the one hand, and desires that stem from more stable or enduring values on the other (Foddy and Savulescu 2006, 2010). This view has several potential difficulties, two of which are worth pointing out here. First, there are good reasons to doubt the contention that because both OUD-conditioned desires and deeper-held desires are both produced through similar neural circuits, they have indistinguishable moral significance (Foddy and Savulescu 2006 p. 9-11; Foddy and Savulescu 2010 p. 4). Given the way OUD appears to dysregulate the normal interplay between deliberative and impulsive systems for behavioral control, these types of desires are in principle neurobiologically distinguishable (Bechara 2005; Bickel et al. 2018; Koob and Volkow 2010; Noël et al. 2013; Verdejo-García and Bechara 2009).

Second, this view denies what is widely agreed both in the lay and scientific understandings to be a defining feature of SUDs (both for PWOUDs as well as those who treat them or care about them), namely that they involve a struggle for the PWOUD to author their own decisions against the compulsion of addiction, which is a core component of what makes addiction such a vexing affliction.(Levy 2006a p. 18; Levy 2006b p. 433; Racine and Rousseau-Lesage 2017 p. 354).

Additional information

Funding

The authors acknowledge the support of the Greenwall Foundation’s Making a Difference Program for support of this work.