Richard J. Bonnie

Public Health Ethics: Mapping the Terrain

Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics.Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics. We begin by briefly defining public health and identifying general features of the field that are particularly relevant for a discussion of public health ethics.Public health is primarily concerned with the health of the entire population, rather than the health of individuals. Its features include an emphasis on the promotion of health and the prevention of disease and disability; the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors — biological, behavioral, social, and environmental in developing effective interventions.

Responding to requests from adult patients for neuroenhancements: Guidance of the Ethics, Law and Humanities Committee

In the last decade, persons who have no diagnosed medical or mental health condition are increasingly seeking and utilizing, for the ostensible purpose of enhancing their memory or cognitive skills, prescription drugs that were originally developed to improve executive function or memory in persons diagnosed with disorders such as attention deficit hyperactivity disorder or Alzheimer disease. Evidence suggests that this practice, now known as neuroenhancement, is gathering momentum. As a result, neurologists may be encountering patients without a diagnosed illness asking for medications with the goal of improving their memory, cognitive focus, or attention span. Strong arguments have been made for and against this practice, often reflecting strongly held convictions concerning the appropriate practice of medicine. The purpose of this report is to provide neurologists with an overview of the ethical, legal, and social issues surrounding the use of pharmaceuticals prescribed to enhance or augment normal cognitive or affective functioning, as well as practical guidance for responding to an adult patient’s request for neuroenhancement.

The MacArthur adjudicative competence study: development and validation of a research instrument.

Assessment of competence to stand trial is a common evaluation that can have substantial consequences for defendants and the criminal justice system. Despite a voluminous literature, much remains unknown. An obstacle to progress in understanding what is better termed “adjudicative competence” is the absence of structured, standardized research measures for assessment of defendants. This article presents the legal framework, assessment strategy, instrument description, psychometric properties, and construct validation of the MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The measures meet or exceed accepted indices of internal consistency, and interscorer agreement. Observed patterns of correlations among measures support the underlying theoretical structure of competence-related abilities. Moreover, the MacSAC-CD distinguishes groups of competent and incompetent defendants; reflects changes in competence status; and correlates positively with clinical judgments, negatively with psychopathology and impaired cognitive functioning, and negligibly with cynicism toward the justice system

Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders

BACKGROUND Extended-release naltrexone, a sustained-release monthly injectable formulation of the full mu-opioid receptor antagonist, is effective for the prevention of relapse to opioid dependence. Data supporting its effectiveness in U.S. criminal justice populations are limited. METHODS In this five-site, open-label, randomized trial, we compared a 24-week course of extended-release naltrexone (Vivitrol) with usual treatment, consisting of brief counseling and referrals for community treatment programs, for the prevention of opioid relapse among adult criminal justice offenders (i.e., persons involved in the U.S. criminal justice system) who had a history of opioid dependence and a preference for opioid-free rather than opioid maintenance treatments and who were abstinent from opioids at the time of randomization. The primary outcome was the time to an opioid-relapse event, which was defined as 10 or more days of opioid use in a 28-day period as assessed by self-report or by testing of urine samples obtained every 2 weeks; a positive or missing sample was computed as 5 days of opioid use. Post-treatment follow-up occurred at weeks 27, 52, and 78. RESULTS A total of 153 participants were assigned to extended-release naltrexone and 155 to usual treatment. During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to relapse than did those assigned to usual treatment (10.5 vs. 5.0 weeks, P<0.001; hazard ratio, 0.49; 95% confidence interval [CI], 0.36 to 0.68), a lower rate of relapse (43% vs. 64% of participants, P<0.001; odds ratio, 0.43; 95% CI, 0.28 to 0.65), and a higher rate of opioid-negative urine samples (74% vs. 56%, P<0.001; odds ratio, 2.30; 95% CI, 1.48 to 3.54). At week 78 (approximately 1 year after the end of the treatment phase), rates of opioid-negative urine samples were equal (46% in each group, P=0.91). The rates of other prespecified secondary outcome measures--self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration--were not significantly lower with extended-release naltrexone than with usual treatment. Over the total 78 weeks observed, there were no overdose events in the extended-release naltrexone group and seven in the usual-treatment group (P=0.02). CONCLUSIONS In this trial involving criminal justice offenders, extended-release naltrexone was associated with a rate of opioid relapse that was lower than that with usual treatment. Opioid-use prevention effects waned after treatment discontinuation. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00781898.).

The MacArthur adjudicative competence study: diagnosis, psychopathology, and competence-related abilities

A set of measures assessing abilities related to legal standards for competence in the adjudicative process were administered to mentally-disordered criminal defendants with diagnoses of schizophrenia, affective disorder, other psychiatric disorders, and to criminal defendants without diagnosed mental disorder. Mentally-disordered defendants were recruited from two groups: those who had been committed for restoration of competence and those who had been identified by jail personnel as mentally ill. Significant impairments in competence-related abilities were found for approximately half of the defendants with schizophrenia. Defendants with schizophrenia scored lower on measures of understanding, reasoning, and appreciation related to the adjudication process. The association between symptoms and competence-related abilities was explored within diagnostic groups. Conceptual disorganization was found to be inversely correlated with performance on all measures in both defendants with schizophrenia and those with affective disorders. For other psychotic symptoms, differing patterns of correlations were found in the two major diagnostic groups. The implications for policy designed to safeguard the rights of defendants to be tried while competent are discussed.

Dilemmas in administering the death penalty

This article critiques ethical arguments against conducting forensic evaluations of capital defendants or condemned prisoners and against treating prisoners found incompetent for execution, and considers the impact of widespread professional abstention on the legal system. It concludes that arguments for abstention by forensic evaluators are grounded mainly in personal moral scruples against capital punishment, rather than in tenets of professional ethics, but that abstention would be ethically required if the evaluators scruples preclude objectivity. It also concludes that treatment of incompetent prisoners known to want treatment is ethically permissible but that treatment for the sole purpose of readying the prisoner for execution is not.

The marihuana conviction : a history of marihuana prohibition in the United States

RICHARD J. BONNIE and CHARLES H. WHITEBREAD II, The marihuana convinction. A history ofmarihuana prohibition in the United States, Charlottesville, University Press of Virginia, 1974, 8vo, pp. xiv, 368, illus.,

When Is an Adolescent an Adult? Assessing Cognitive Control in Emotional and Nonemotional Contexts

12.50. One of the outstanding problems of twentieth-century Western society has been, and still is, addiction to drugs of plant and chemical origin. This book deals with only one of them, and is apparently the first full-scale history of the use, abuse and prohibition of marihuana, also known as Indian hemp or Cannabis sativa, in the United States. It has a very long history and over the centuries has provided man with a tough fibre used to make rope, twine, and cloth, with an oil and bird-seed, and with a psychoactive agent used for medicinal, religious, and for intoxicant purposes. The modern problem relates to the last of these properties. Marihuana was taken into the States early in the present century and since then a continual war has been waged against its addictive use. The extent of present-day involvement, a quarter-million persons arrested annually for marihuana violations and twenty-six millions having smoked it illegally, is a measure of the problem and the need for increasing vigilance. The authors trace this story in detail with careful documentation and judicious selecting from masses of material. Altogether it makes fascinating reading. But, more importantly, it presents the history of a social problem of outstanding significance. Although the actual drug may be less of a problem in this country, the underlying theme is the same as for other habit-forming agents. And also the historical approach, if carried out objectively as is the case with Professors Bonnie and Whitebread, is a most valuable one. As a contribution to the recent history of social medicine, welfare and legislation it deserves a wide audience.

Integrating Supply and Demand Reduction Strategies for Drug Abuse Prevention

An individual is typically considered an adult at age 18, although the age of adulthood varies for different legal and social policies. A key question is how cognitive capacities relevant to these policies change with development. The current study used an emotional go/no-go paradigm and functional neuroimaging to assess cognitive control under sustained states of negative and positive arousal in a community sample of one hundred ten 13- to 25-year-olds from New York City and Los Angeles. The results showed diminished cognitive performance under brief and prolonged negative emotional arousal in 18- to 21-year-olds relative to adults over 21. This reduction in performance was paralleled by decreased activity in fronto-parietal circuitry, implicated in cognitive control, and increased sustained activity in the ventromedial prefrontal cortex, involved in emotional processes. The findings suggest a developmental shift in cognitive capacity in emotional situations that coincides with dynamic changes in prefrontal circuitry. These findings may inform age-related social policies.

Mental Health System Transformation After The Virginia Tech Tragedy

Historically, demand and supply reduction approaches to the prevention and control of tobacco, alcohol, and other drug abuse have been treated as independent efforts in the United States, vying for public attention and funding. Separate reviews of research suggest that the more effective components of each approach can reduce potential drug use by 20% to 40% for 3 years and sometimes longer. Review of theories relevant to behavior change suggest that integrating the two approaches could increase this proportion to 40% to 50% for longer periods by synergistically affecting community anti-drug use norms and compliance. This article briefly reviews demand and supply reduction approaches to drug abuse prevention and presents hypothetical models of change in drug use behavior based on program and policy interventions that are introduced sequentially into communities.