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8. CONCLUSION AND IMPLICATIONS FOR HEALTH POLICY

by a genetic screen as being vulnerable or at risk is potentially
disadvantaged by that identification in a number of ways. In the first place,
the person’s self-esteem may be reduced; as a minimum requirement, a
substantial tangible benefit from the identification would be needed to
balance this risk. The person’s financial and status interests may be
adversely affected if the identification is available to anyone else; for
example, an insurance company may refuse insurance, an employer may
choose not to employ, a person may refuse to marry. At present, in many
countries, these adverse effects of such identification are not at all
theoretical: for instance, insurance companies may have routine access to
health records, or may require such access as a condition for issuing an
insurance (thereby coercing consent).
There is an urgent need to consider the ethical issues raised by such genetic
identifications in the course of providing health services in an international
context, as well as at national and local levels. The issue is not limited to the
field of psychoactive substance use and dependence, and WHO has given
general consideration to these issues in the context of genetic counselling.
For instance, “proposed ethical guidelines for genetic screening and testing”
(WHO, 1998) provide that “results should not be disclosed to employers,
insurers, schools or others without the individual’s consent, in order to avoid
possible discrimination”. However, as the genetic research improves its
predictive power, the stigmatization of and discrimination often associated
with psychoactive substance use make it a particularly urgent issue that
requires action beyond such general guidelines, as the genetic research
improves its predictive power.
As discussed in Chapter 5, the use of immunotherapies and other
neurological interventions, especially to the extent that they are irreversible,
would raise difficult ethical issues. The neuroscience findings that the use of
psychoactive substances shares many pathways in the brain with other
human activities raise the question of what other pleasures or activities might
be adversely affected by such interventions. The application of genetic
modifications, particularly if heritable, would raise many of the same ethical
issues currently being discussed in the context of human cloning.
The main ethical issues concerning therapies which interfere with the
psychoactive effects of substance use, or which are aversive, are the
requirement for patient consent to treatment, the patient’s ability to give it,
and the ethics of coerced treatment (see Chapter 7). The medications or other
biological interventions at issue here are only one aspect of the means by
which societies or groups coerce individuals regarding unwanted behaviours,
and all such means are subject to similar ethical considerations. One
additional consideration for prescription medications and medical
procedures is the special ethical injunctions and constraints by which the
medical profession and other health professions are guided (e.g. Declaration
of Helsinki, see Box 7.1). Moreover, any treatment modality which is coerced
should presumably have been shown to be effective.

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