Marshall and colleagues (2024) bring to broader academic and public attention a genuine and difficult dilemma to which emergency physicians are confronted with. The dilemma could be summarized as:

  1. respecting the autonomy of patients with opioid use disorder at face value, so to speak, when they refuse to stay for a subsequent period of evaluation after taking a fast-acting antidote such as naloxone, or
  2. refusing to take such decisions for genuine expression of autonomous choices and thus envision alternate clinical approaches not solely based on respect for autonomy.

I wish to commend the authors for naming, characterizing, and explaining this important ethical tension since the specific clinical contexts they report are part of our societies. In this sense, these situations, as well as the response to the needs and sufferings of persons with opioid use disorder, concern all of us. The current opioid crisis looms large, and it is notably by exposing the situations it creates in our health institutions, that more of us, including voters and policymakers, will understand the sufferings and challenges created.

To substantiate their concerns about the extent and quality of autonomy and decision-making capacity in this group of patients within this specific clinical context, the authors provide ample evidence from wide-ranging conceptual and empirical literatures, which I will not directly question. Simply put, there is a compelling case to be made about the compromised decisions of persons with opioid use disorder based on evidence from neuropsychology, neuroscience, ethics, and the analysis of the conditions of autonomy and decision-making capacity. My purpose in this commentary is to reflect on the lens adopted by the authors, heavily focused on considerations related to autonomy and decision-making capacity. I want to bring forth the value of building from and extending this descriptive lens, notably in terms of imagining ethical responses.


Racine Eric. Autonomy and its constrictive effects on our ethical lenses and imaginations. American Journal of Bioethics, 2024; 24(5), 25-27, DOI: 10.1080/15265161.2024.2327302.