Is it time to rethink how we determine capacity for patients suffering from substance use disorders? We began debating this question after taking care of a young woman with endocarditis. Endocarditis is an infection of part of the heart, frequently associated with IV drug use, and fatal if not properly treated. This patient had a long history of IV drug abuse. She had been admitted one week earlier and was being prepared for surgery, but she left against medical advice. Perhaps not surprisingly, she came back to the emergency room and, stated that “this time” she was ready for treatment. She was admitted to the hospital, but quickly left against medical advice for a second time. We are not sure if she ever came back again but we both feel fairly confident that her untreated endocarditis will end her short life.

The sad truth is those of us in healthcare see stories like this every day. “Why not just force them to stay in the hospital?” You may ask. Unfortunately, it is not that simple. In the United States, people have a right to make decisions for themselves. In the medical field, as long as a patient has “capacity”, we cannot force them to stay in a hospital or accept medical treatment, unless they lack the ability to clearly and consistently communicate a choice and tell us the risks, benefits and alternatives of treatment. If a patient can participate in this conversation, we cannot legally hold them for medical treatment.

Nearly all of the patients we see with severe substance use disorders have capacity in the strictest definition of the medical term. They are not intoxicated while seeing us and they can understand and verbalize the risks of their decision to leave. By legal standards, they have the capacity to refuse care even if it will ultimately lead to significant impairment or even death. Yet, we think it’s worth asking if these patients are truly making rational decisions. While they may verbalize the consequences of their choices, we question whether they truly have the ability to understand them. Drug addiction changes the brain chemically and structurally. It creates cravings that are more debilitating than acute intoxication. In fact, the word “addiction” comes from a Latin term that means “enslaved by.” These patients may not be intoxicated when they see us, but that does not mean that the substances are not exerting their influences. We would not let a patient who was intoxicated refuse medical care. Why then do we allow these patients who are being driven by a chemical dependency walk out of our hospitals?

Other countries have recognized that patients suffering from severe addiction lack the capacity to make informed decisions. New Zealand passed the Substance Addiction (Compulsory Assessment and Treatment) Act of 2017. This legislation allows for the involuntary hospitalization and treatment of patients who are considered to have a severe substance addiction. While the main focus is on drug addiction treatment, the bill also allows for involuntary treatment of medical conditions for patients suffering from substance use disorders. The bill does note, however, that this option should be the last resort after other less coercive options have failed.

We are not sure if what New Zealand's actions are replicable in the United States, but something has to be done. These patients are one of the most vulnerable populations that we treat, and yet we are often forced to watch as addiction drives them to ruin. We need to rethink whether these patients truly have capacity to act in their own best interests, because the hard truth is, the medical field is failing them.

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