A review of Vaccines against vice: A constructive technology assessment of immunotherapies for addiction, by Abbi Hobbs.
In her intelligent and thoughtful dissertation, Abbi Hobbs uses Constructive Technology Assessment (CTA) to examine the potential impact of immunotherapies against addiction and drug use. CTA emphasises a participatory approach to technology assessment and development in which technology, society, and environment co-evolve. Central to this approach is an engagement with those most affected by the technology.
In the first chapter, Hobbs, influenced heavily by the “biopolitics” of Nikolas Rose, reviews the historical construction of “addiction” from an immoral behaviour to illness requiring treatment. In doing so, she provides the contexts in which immunotherapies are likely to be used.
In chapter 2, Hobbs outlines CTA and the research methods employed in her dissertation. Her focus is on the use and development of vaccines against two drugs – one licit (nicotine) and the other illicit (cocaine). Hobbs uses qualitative methods to examine the views and attitudes of a range of stakeholders in the US and UK, including scientists, medical professionals and policy makers involved in the development of drug vaccines, drug users (smokers and ex-smokers, social cocaine users, and drug users in treatment), and parents.
In chapter 3, Hobbs questions whether increased pathologizing of addiction as a “brain disease,” particularly by the National Institute on Drug Abuse which funds much of the research on vaccines, will facilitate the marketing of a ‘technological fix’ to a growing number of individuals whose behaviour falls outside socially constructed norms. She asks whether the neuroscientific turn may also draw attention away from social drivers of drug use and policy approaches for reducing drug-related harm or the social construction of problematic drug use and addiction.
In chapter 4, Hobbs examines the coerced use of vaccines to treat addicted individuals for their own good. Others, including myself, have raised concerns about whether the construction of addiction as a “brain disease” that “hijacks” a person’s volition may justify their use under coercion. Others, such as the bioethicist Art Caplan, argue that technologies that provide a prophylaxis against relapse to drug use could be seen as enabling autonomy (Caplan (2008). “Denying autonomy in order to create it: the paradox of forcing treatment upon addicts.” Addiction, 103(12): 1919-1921.).
Experts and most drug users Hobbs interviewed were highly critical of the coerced use of drug vaccines, which they contended would be ineffective and potentially harmful if individuals attempted to override the blockade with higher doses or switched to using other potentially more harmful drugs. Most social drug users disagreed with the biological model of addiction, seeing their drug use as a choice that served various, often positive, uses. In contrast, drug users in treatment were more enthusiastic about the use of drug vaccines. They understood addiction in biomedical terms as a “loss of volition.” Whereas smokers and casual drug users thought that coercive use of drug vaccines decreased autonomy, those in treatment thought vaccines increased an individual’s autonomy by freeing them from the constraints of drug use and making choices available to them.
While drug vaccines are being developed primarily as adjuncts to addiction treatment, some discourses suggest that they may also be employed as part of a wider public health campaign to prevent addictive drug use in the general population. In chapter 5, Hobbs provides an historical analysis of the aims of public health. Public health was originally conceived as an effective way of creating social structures and processes that minimized harm in the environment. Hobbs charts the emergence of a new model of public health that places the burden upon individuals to manage their own health risk to maximize their economic value to society. Drug vaccines, she argues, serves both needs.
In chapter 6, Hobbs examines the views of stakeholders toward the use of drug vaccines as part of mass childhood immunization (MCI) programs. Experts believed that MCI introduced unnecessary risks and were skeptical about the ability of vaccines to provide the necessary blockade. Those closely involved in the development of vaccines were most supportive of MCI, particularly for nicotine, which was seen as most harmful and addictive. Hobbs rightly notes the apparent contradiction in favoring MCI for a legally available substance. Lay participants rejected MCI believing that it violates the free choice of individuals to take drugs. They also rejected biomedical models of addiction used to justify MCI, constructing more prosocial accounts of drug use.
In chapter 7, Hobbs examines the views of stakeholders to the off-label use of drug vaccines by parents. Following Rose, Hobbs argues that it is not state-imposed vaccination of at-risk individuals that is the real concern, but the social promotion of healthy lifestyles and the “activation of guilt, anxiety, envy and disappointment” (p. 197) that will drive the possible uptake of childhood vaccination (Nikolas Rose. The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century. Princeton: Princeton University Prress, 2007.).
Hobbs examines the history of attitudes towards the use of vaccines and the role of the parent or guardian in making decisions on a child’s behalf in their best interests. Parents viewed the preventative use of drug vaccines as inappropriately curtailing child’s “right to an open future” (p. 204) echoing Joel Feinberg. Parents emphasized the importance of freedom-of-choice in self-determination, self-governance, and moral learning. Vaccines were also seen as undermining the role of the parent as teacher and carer. In contrast, both experts and parents in treatment for drug use saw nicotine vaccines as “keeping options open” for the child (p. 211), more in line with the views of Louis Charland and Art Caplan (Charland (2002). “Cynthia’s Dilemma: Consenting to heroin prescription.” American Journal of Bioethics, 2(2): 37-47). As the author explains, “drug use was not typically put forward as an active choice but constructed more as the default option, where autonomy was already constrained” (p. 219).
Hobbs concludes that neurobiological models of addiction have helped cast vaccines as “magic bullets” that meet modern public health goals: vaccines have “the ability to permanently return the compromised subject to the hypothetical social contract” (p. 225) and make “addicts” into good contributors to the economic well-being rather than a burden on public resources. She believes that this has the potential to undermine broad and varied social responses to treating addiction and the social drivers of drug use.
Hobbs’ research demonstrates that context is important to how vaccines are used and understood by drug users, clinicians, and the broader public. Hobbs sees the failure of current vaccines as “an opportunity for real-world learning” (p.235) to assist in the development of next-generation vaccines that meet both user requirements and social needs. Such a process requires a critical neuroscience that is more cognizant of the social worlds that lead to drug use and construct our understandings of addiction.
31 semi-structure interviews with professionals involved in the research and development of drug vaccines in the US and UK
8 focus groups (total 36 participants) with 4 sets of potential users of drug vaccines: parents/ legal guardians of children under 16; smokers and ex-smokers; socially integrated cocaine users; and (ex)cocaine users in treatment facilities
University of York. 2011. 343 pp. Primary Advisor: Nik Brown.
Image: Image of vaccine. Freerangestock.com.