Do patients addicted to drugs truly have capacity?

“Capacity” is one of those words that sounds like it belongs on the side of a moving box:
Fragile. Handle with care. Do not assume. And when addiction enters the chat, people often
jump to one of two extremes: either “They can’t make choices at all,” or “They chose it, so everything
is on them.” Both takes are… convenient. Both are also usually wrong.

In clinical ethics and health law, decision-making capacity is not a vibe. It’s a specific,
assessable set of abilities that helps answer a practical question: Can this person make this decision
right now? Not “Are they a good person?” Not “Do we like the decision?” Not “Have they ever made a mess
of things?” (If “past mistakes” were disqualifying, humanity would be out of business.)

So, do patients with drug addiction truly have capacity? The evidence-based answer is:
often yes, sometimes no, and always: it depends on the decision and the moment.
Let’s unpack thatwithout turning your brain into a legal textbook or your conscience into a pretzel.

What “capacity” means (and what it doesn’t)

Capacity vs. competence: cousins, not twins

Capacity is a clinical determinationtypically made by a treating clinicianabout whether a person
can make a particular healthcare decision. Competence (often called “legal capacity” in some contexts)
is a legal determinationmade by a courtabout whether someone can make decisions in a broader domain.
In plain American English: doctors evaluate capacity; judges decide competence.

Capacity is decision-specific and can change (sometimes quickly)

Capacity isn’t an all-or-nothing badge you wear forever like a “Hello, I’m Capable” sticker. It’s
task-specific and time-specific.
Someone might have capacity to choose between two medications, but not to manage complicated finances that day.
Someone might be able to consent to treatment in the morning, then lose capacity during acute intoxication in the afternoon,
and regain it after stabilization.

Clinicians also use a common-sense principle sometimes described as a “sliding scale”:
the higher the stakes (riskier decision, bigger consequences), the more confidence we need that the person’s
decisional abilities are intact. That’s not discrimination. That’s the ethical equivalent of checking the parachute twice.

Why addiction makes people worry about capacity

Addiction can affect judgment and self-controlwithout erasing personhood

Modern medicine describes addiction (often diagnosed as a substance use disorder, or SUD)
as a complex condition involving compulsive use despite harms. Research and clinical guidance also recognize that
addiction can involve changes in brain systems related to reward, stress, and executive functionareas linked to
decision-making and behavioral control.

But here’s the crucial nuance: difficulty resisting a craving is not the same thing as inability to understand information,
appreciate consequences, reason about options, or communicate a stable choice. Addiction can narrow someone’s “decision bandwidth”
(especially under stress), yet many people with SUD still perform complex jobs, care for families, and make thoughtful medical decisions.

Capacity can be impaired by the “usual suspects” around addiction

When capacity problems show up in addiction care, they often come from factors that can occur with addiction
rather than from the diagnosis alone, such as:

• Acute intoxication (temporarily clouding cognition, attention, and memory)
• Withdrawal (pain, anxiety, agitation, or autonomic symptoms that can overwhelm focus)
• Delirium or severe medical illness
• Co-occurring psychiatric conditions (e.g., severe depression with psychosis, mania, acute paranoia)
• Neurocognitive disorders or brain injury
• Extreme sleep deprivation (yes, it countsyour brain is not a phone you can run on 1% forever)

The takeaway: if someone lacks capacity, the “why” is often treatable or temporary. And if it’s temporary,
the most respectful move is frequently to pause, support, and reassessnot to label the person permanently incapable.

The honest answer: addiction doesn’t automatically remove capacity

A diagnosis is not a capacity verdict

Ethically and clinically, it is inappropriate to assume incapacity solely because a person has a substance use disorder.
Research on consent and addiction has repeatedly warned against diagnosis-based assumptions. Many individuals with SUD demonstrate
intact decisional abilities unless there is acute cognitive impairment, severe intoxication/withdrawal, or other destabilizing factors.

If you remember only one sentence from this article, make it this:
Capacity is assessed, not presumedespecially not presumed absent because of stigma.

When capacity is usually intact

Many people with SUD have capacity for many healthcare decisions most of the time, including:

• Consenting to treatment for infections, injuries, chronic conditions, or mental health care
• Choosing among evidence-based treatment options for SUD (including medications, counseling, or both)
• Accepting or refusing a specific intervention after demonstrating understanding and reasoning
• Participating meaningfully in shared decision-making (values, goals, trade-offs)

In these cases, the best practice is to treat the person like… a person: provide clear information, check comprehension,
respect preferences, and document the discussion. Revolutionary, I know.

When capacity is more likely impaired (and what that looks like)

Capacity concerns become more likely when the person cannot perform one or more of the core decisional abilities.
Examples of situations where clinicians should be especially cautious include:

• Severe intoxication where the person cannot track information, stay awake, or communicate coherently
• Severe withdrawal where distress prevents understanding or deliberation
• Delirium or major medical instability (confusion, disorientation, fluctuating attention)
• Acute psychosis or mania where beliefs prevent realistic appreciation of consequences
• Severe cognitive impairment affecting memory and reasoning

Notice what’s missing: “They are making a decision I disagree with.”
Disagreement is not a diagnostic test.

How clinicians assess capacity in real life

The four abilities model (simple enough to remember, serious enough to use)

A widely used approach evaluates whether the person can:

1. Communicate a choice (a clear, consistent decision)
2. Understand relevant information (what’s going on, what’s proposed, risks/benefits/alternatives)
3. Appreciate the situation and consequences (how this applies to them, not “people in general”)
4. Reason about options (compare, weigh trade-offs, explain a rationaleeven if you wouldn’t choose it)

Clinicians often weave these checks into conversationthen document the patient’s responses.
When a case is complex, structured tools (like the MacCAT-T or the VA’s ACCT) can support a more formal evaluation.
Tools don’t replace judgment; they organize it.

Capacity-support is part of respecting autonomy

Ethical care doesn’t stop at “pass/fail.” A core principle in medical ethics is to involve patients as much as possible,
even when capacity is partly impaired. In addiction care, that often means reducing barriers and
strengthening understanding, for example:

• Using plain language and teach-back (“Tell me in your own words what you heard.”)
• Breaking choices into smaller steps (today vs next week vs long-term plan)
• Addressing treatable drivers of confusion (pain, dehydration, low oxygen, withdrawal symptoms)
• Revisiting the decision when the patient is more stable
• Inviting a trusted support person (with the patient’s permission) to help process information
• Offering low-barrier, patient-centered options that align with the patient’s goals

This is where good addiction care quietly becomes great ethics:
you’re not “granting” autonomyyou’re making it easier to exercise.

Consent, coercion, and the “helping by overriding” dilemma

Involuntary treatment exists, but it’s ethically complicated

In the U.S., some states allow forms of civil commitment or involuntary treatment for severe substance use disorders.
These policies are often justified as life-saving during overdose crises. But ethical justification is not automatic:
removing autonomy demands strong evidence of benefit, fair procedures, and humane care settings.

Real-world outcome data are limited and mixed, and some studies raise concerns about relapse rates and medical morbidity after commitment.
Professional discussions (including in addiction medicine circles) emphasize caution, the importance of evidence-based treatment during and after any commitment,
and the ethical necessity of respecting patient dignity and preferences whenever possible.

Shared decision-making and low-barrier care: capacity-friendly by design

Many experts argue that the best way to “solve” capacity concerns in addiction is to reduce the circumstances that undermine capacity:
fear, shame, unstable housing, untreated mental illness, and care systems that require patients to leap over flaming hoops while juggling paperwork.

Low-barrier models emphasize meeting people where they are, offering effective treatment options, and using shared decision-making to support engagement.
Counterintuitively, a system that treats patients with more respect often gets more cooperationand fewer ethically messy showdowns.

Practical takeaways (for clinicians, families, and anyone trying to be helpful)

1) Don’t confuse “impaired control” with “no capacity”

Addiction can involve compulsive behavior, but capacity is about specific decisional abilities.
Many people with SUD can understand, appreciate, reason, and chooseespecially when stable.

2) Check the moment: intoxication, withdrawal, delirium, or crisis can temporarily impair capacity

If the person can’t stay focused, can’t repeat back the plan, can’t connect consequences to themselves,
or can’t communicate a consistent choice, that’s when clinicians should slow down and reassess.

3) Support capacity before you override it

If a person seems “not capable,” ask: what’s in the way right now? Pain? Panic? Withdrawal symptoms?
Confusion? Lack of sleep? Fix the fixable, then revisit the decision.

4) Document the reasoning, not just the conclusion

In clinical practice, the strongest capacity work isn’t “Patient lacks capacity.” It’s:
“Patient could not explain risks/benefits, could not appreciate consequences despite teach-back, and reasoning was disorganized.”
In other words: show your math.

5) Use person-first language and reduce stigma

“A patient with a substance use disorder” is not political correctness; it’s precision.
Stigma can bias capacity judgments. Bias isn’t just rudeit’s clinically dangerous.

FAQ: questions people ask out loud (and questions they ask in their heads)

Can someone with addiction refuse treatment and still have capacity?

Yes. Capacity does not require choosing what clinicians or family members prefer.
A person can have capacity and still refuse treatmentsometimes even treatment that could save their life.
That can be heartbreaking, but heartbreak isn’t a capacity criterion.

Does “wanting to leave” mean they lack capacity?

Not automatically. People leave hospitals for many reasons: fear, responsibilities, past trauma, withdrawal discomfort, stigma,
or feeling talked down to. Clinicians should assess whether the patient understands risks and alternatives and whether symptoms
(like withdrawal) are interfering with reasoning.

Does addiction make people “incapable of consent” for research or care?

Broadly labeling people with SUD as incapable is ethically risky and not supported as a blanket rule.
Many demonstrate decisional capacity unless acutely impaired. The right approach is individualized assessment.

If capacity is impaired, what happens next?

Typically, clinicians look for ways to restore capacity (treat symptoms, wait for sobriety/stability) and involve the patient as much as possible.
If urgent decisions must be made and the patient truly lacks capacity, clinicians may rely on emergency standards, surrogates, or legal frameworks
depending on the situation and jurisdiction.

Experiences related to the question (composite vignettes, ~)

Real-life capacity questions rarely arrive with a neat bow. They show up as messy human moments.
The experiences below are compositescommon patterns described across clinical ethics discussions, addiction medicine, and patient narrativesdesigned
to illustrate how capacity can look in the wild.

Vignette 1: “I’m leaving. Right now.”

A patient hospitalized with a serious infection says they want to leave immediately. Staff assume “noncompliance,” but a slower conversation reveals a simpler truth:
the patient is terrified of withdrawal symptoms starting overnight. Once clinicians acknowledge that fear and offer symptom relief, the patient can engage.
The capacity question wasn’t “Does addiction erase autonomy?” It was “Can this person think clearly while panicking about imminent suffering?”
When distress decreased, decisional abilities improvedand the plan shifted from a standoff to a partnership.

Vignette 2: The patient who can explain everything… except the part that matters

Another patient repeats back the risks and benefits flawlesslylike someone memorizing lines for a play. But when asked, “What do you think happens to you
if we do nothing?” they respond with a shrug or magical thinking: “I’ll be fine. I always am.” Here the stumbling block is appreciationnot intelligence.
Clinicians might use teach-back focused on personal consequences, explore denial versus delusion, and check for delirium or intoxication.
Sometimes the fix is medical (treat an underlying condition); sometimes it’s communicative (use concrete examples, visuals, timeframes).

Vignette 3: “You’re not going to judge me, are you?”

A patient with opioid use disorder avoids eye contact and gives short answers. A rushed team interprets this as incapacity.
But when a clinician explicitly states confidentiality limits, asks permission before sensitive questions, and uses non-stigmatizing language,
the patient opens up and participates in shared decision-making. The patient’s capacity didn’t magically appearaccess to respectful communication did.
This is the quiet way stigma distorts capacity judgments: when people feel threatened, they stop thinking expansively.

Vignette 4: Recovery doesn’t mean “perfect,” and capacity doesn’t require perfection

A person in recovery considers restarting medication for addiction after a relapse. They express guilt and shame, but they also articulate clear goals:
“I want to keep my job. I want to repair relationships. I need something that reduces cravings.” They weigh options, ask about side effects, and choose a plan.
This vignette highlights a truth families often miss: capacity isn’t measured by whether someone has struggledit’s measured by whether they can
deliberate in a meaningful way right now.

Across these experiences, a pattern emerges: the most ethical care doesn’t start by asking, “Do they deserve choice?”
It starts by asking, “What support makes choice possible?”

Conclusion: capacity is real, nuanced, and worth the effort

Patients with drug addiction are not automatically “without capacity.” Capacity is a decision-specific, time-specific clinical assessment.
Addiction can influence decision-makingespecially under intoxication, withdrawal, or crisisbut many patients retain the ability to understand,
appreciate, reason, and communicate choices. When capacity is impaired, best practice is to support and restore it when possible, involve the patient
to the greatest extent, and use coercion only with extreme caution and strong justification.

If you want an ethical north star, try this: assess capacity carefully, reduce stigma aggressively, and support autonomy relentlessly.
It’s harder than a hot take, but it’s also how you respect humanityespecially when humanity is having a rough week.