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Accountable but Not Responsible

Accountable but Not Responsible

"Jack" has been in our emergency department at least 100 times in the 4 years I have worked at the Veterans Affairs Hospital. I first encountered him in the medical ICU, where he was hospitalized multiple times with chest pain and ECG changes after cocaine binges. He was often admitted to the inpatient psychiatric unit when we could not sort out his accidental overdoses from suicidal behavior or when he feigned self-harm to escape legal consequences or to have a warm, safe place to stay. Once in the psychiatry ward, Jack was sexually inappropriate and would exploit other, more vulnerable patients and was quickly discharged.

As long as I have known Jack, he has had both psychotic and mood disorders secondary to long-term and heavy cocaine use and has often displayed real suffering. Yet, when someone would suggest that the voices and depressions troubling him were related to his drug use and that we would like to help him with his addiction, he would reject the suggestion and ask for either benzodiazepines, a sack lunch, or to be admitted, depending on how naive or resentful the clinician caring for him seemed. One week when Jack had been a particularly "frequent flier," the exasperated emergency department physician asked me if "this guy was responsible."

During the first years I dealt with Jack, my answer was decidedly yes, and this presumption guided my dispositions, which were in general fair, if not overly kind, in that if I felt he was suicidal or in danger from drug dealers I would usually admit him. Once I learned of his acting out on the ward and his manipulation became more transparent (or perhaps my experience-worn judgment grew more cynical), I confess I occasionally had a streak of punitiveness when I wished for a criminal justice rather than a mental health solution based on a presumption of his ethical culpability.

In psychiatry, when concerns are raised about responsibility, the real issue is frequently one of decisional capacity. The bread and butter of psychosomatic physicians such as my-self is evaluating whether patients can consent or refuse treatments, can leave against medical advice, or can care for themselves or handle finances.1 Jack would be considered essentially decisionally capable: he had consented several times to cardiac interventions; even when craving cocaine, he would usually remain in the hospital until he was safe for medical discharge; and he appeared to have street smarts sufficient to obtain regular supplies of drugs and stay alive.

And yet, as I come up to my fifth year as an attending consultation psychiatrist, I am increasingly convinced that patients like Jack are actually not responsible--but that they are accountable. In the rest of this column, I hope to make practical sense of this paradoxical statement, and in my next column I will suggest how several ancient philosophers and theologians may offer us unexpected insights regarding the status of the freedom of thousands of patients like Jack who populate emergency departments and hospitals across the country.

Freedom's dimensions
In bioethics, autonomous choice requires two kinds of freedom: freedom from external coercion, such as financial constraints or social pressures, and freedom for internal resources, such as motivation, intentionality, discipline, discernment, evaluation, memory, learning, reasoning, and decision making used to achieve voluntary goals.1 Brilliant neuroscience researchers such as Stephen Hyman2 and Nora Volkow3 are uncovering a dynamic representation of the neurobiology of addiction that is far more nuanced and complex than the old models of the dopamine-driven reward pathway.

In the early stages of addiction, the free will of someone like Jack is relatively intact. I say relatively because emerging research suggests that Jack probably had a decreased number of D2 dopamine receptors, and this state of hypodopaminergic function increased his risk to excessively respond to the suprathreshold dopamine stimulation of drugs of abuse.4 As the addiction progresses, the main brain engines of free will are damaged and begin to malfunction, including the attentional and self-control mechanism of the anterior cingulate gyrus; the crucial orbital prefrontal cortex that associates emotional and motivational valence with environmental stimuli and cues; and the dorsolateral prefrontal cortex, the seat of executive function and as such, the true decision maker.

In the later stages of addiction, Volkow cautions, free will may be virtually devastated: "We have come to see addiction as a disease that involves the destruction of multiple systems in the brain that more or less are able to compensate for one another. When the pathology erodes the various systems, you disrupt the ability to compensate, and the addictive disease erodes and destroys the life of the individual."5

In the new conceptualization, addiction is not so much a matter of dysregulation of the pleasure systems but of a distortion of goal direction expressed by the term "salience." Evolution has wired the brain to seek out and respond to environmental factors, such as sex, food, money, and affection, that improve the chance of the survival and even thriving of the species. All of these natural incentives release dopamine, not so much to satisfy desire as once thought but as a way of neurochemically cementing the salience of these stimuli (ie, potentiating learning).

Tragically, drugs and alcohol have a massively more potent dopaminergic action than even the best gourmet meal, a good run on a beautiful fall morning, or the devotion of a wife and children. These new neurobiological explanations of addiction give molecular weight to the phenomenological DSM-IV-TR criteria for "continued [substance] use despite adverse consequence" by a dependent person.6 Given the extreme biological response to drugs of abuse compared with daily life and work, it is no wonder that "time spent in obtaining the substance replaces social, occupational or recreational activity."6 Jack had a family who loved him, and he was resourceful enough to have been successful had he only employed the immense energy he spent on substance use in the service of more productive aims.

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