A preventive ethics approach to methadone maintenance programmes

In New Zealand opioid users obtain their drugs by extraction from codeine-based products, prescribed medication and poppies (in season) as geographical isolation and efficient border protection mean that street heroin is expensive and irregularly available. Hospital run methadone programmes have a virtual monopoly on the provision of opioid substitution programmes leaving clients with limited options if they want to leave methadone programmes. This leads to high client retention rates and provides an opportunity to explore the characteristic conflict that occurs between clients and providers of these programmes. Methadone providers are open to charges of paternalism as they exercise power in what they perceive as the best interests of their clients. Paternalism can be justifiable in treatment where a patient faces serious risks that can be reliably predicted, where these risks are irreversible and where patients have impairment in their autonomy. There may be a degree of impaired autonomy in clients entering a Methadone Maintenance Programme (MMP) as a product of the desperate circumstances of clients on entry to the programme and as a result of opioid dependency. However the risks of not participating in the programme cannot be reliably predicted for an individual client and the impairment in autonomy is of a temporary nature, making paternalism unjustifiable in these programmes. It is suggested that paternalism may be more than a perception in methadone programmes and that it may contribute to conflict between providers and clients. Aspects of MMPs that may indicate paternalism are: confusion between the long term and short term aims of the programmes, assumptions regarding client autonomy on entry and after clients stabilise on the programme, confusion over the application of harm minimisation aims and the inflexibility and social invasiveness of programmes. Preventative ethics is a process whereby programme structures are examined to identify and eliminate those which may lead to unacceptable treatment for clients. This paper examines aspects of MMPs that have the appearance of paternalism and suggests a number of programme design strategies that might assist in eliminating unjustifiable paternalism from MMPs.