ADHD and the ethical aspects of treatment

Attention deficits and forms of hyperactivity are extremely common in children, especially in boys. Despite further differentiation, both symptoms - lack of focus and excessive, sometimes disorganised and impulsive activity - only provide indications of the illness, but not a definite diagnosis.

A precise diagnosis is therefore necessary in order to be able to assign those symptoms to a clear disease. If this is the case and it is therefore ADHD, different stages of comprehensive therapy become apparent.

These range from changing the diet and establishing a regular daily routine to drug treatment. Accordingly, the latter may only be used if all options below the administration of methylphenidate have been exhausted and there is also a severe degree of ADHD.

Despite side effects, drug intervention can be necessary and beneficial, especially as it is important to realise the urgency that is caused by the lifeworld context of this disease: on the one hand, it can severely hinder the social life of these children and have a detrimental effect on their education and thus their future.

Drug intervention may be necessary and beneficial despite side effects.

Both aspects can obviously delay, hinder or even damage further biographical development. It is important to weigh things up very responsibly here.

Decision making

In the following, only the case in which all non-drug therapies have been exhausted will be considered in more detail. The alternative is then: either to administer methylphenidate (usually in the form of Ritalin and subject to further conditions and restrictions), but accepting possible side effects, or to avoid these with the risk of not being able to reduce the symptoms and accepting negative consequences for the learning and social behaviour of the affected children.

A decision must be made by doctors, parents and the children concerned, but also in the context of a comprehensive therapeutic strategy. In this context, decision-making is determined to a certain extent, as not all options are available at all times. As mentioned above, a drug intervention should only be started after more cautious medical alternatives have been trialled and have proved unsuccessful or unsuccessful.

However we decide to deal with dilemmas, we have to accept negative results.

Decisions require alternatives, and there must be reasons in favour of each of these alternatives. If we were dealing with a clear-cut situation, there would be nothing to decide. And if we were confronted with different options, even though the reasons speak unequivocally in favour of one of these options, the necessary decision would be made. Decisions in the narrower sense are therefore trade-offs between similarly good options (or options considered to be similarly good).

Moreover, these are situations in which a decision must be made because postponement is ruled out; postponement itself would be nothing other than a decision. This decision is made with a view to alleged reasons, so that a random or spontaneous choice is ruled out. In this narrower sense, decisions are rational considerations.

And yet: the real or supposed reasons only point in one direction and still allow for alternatives. Decisions are therefore made with reasons, while we find ourselves in a situation in which the «deciding» person is under-supplied with reasons. Having reasons does not rule out the risk of being wrong, but minimises it.

Moral dilemmas

Finding ourselves in a dilemma is the extreme case of the situation just described. Here, too, we are faced with alternatives, whereby dilemmas are characterised by the fact that the reasons in favour of both options weigh equally heavily.

There are two additional aspects: firstly, even dilemmatic arrangements do not allow the decision to be postponed. Waiting any longer is not an option, if only because it represents a decision in itself - with corresponding, possibly negative consequences. Here, too, we encounter the aforementioned urgency of the decision, the omission of which does not release us from the scenario outlined, but rather entangles us further in it.

On the other hand, dilemmas are inherently ambiguous: Whatever we decide, we have to accept negative outcomes. In other words: dilemmas don't know any «happy endings» without «bad ones». Both of the possible options entail negative effects, and like the positive ones, these negative ones also weigh equally heavily. A balance of negative consequences remains unavoidable.

ADHD confronts sufferers, parents and doctors with far-reaching decisions.

We are dealing with genuinely moral dilemmas when we are confronted with a morally significant situation. This in turn means two things: not all dilemmas are moral, as there are of course personal or emotional dilemmas; moral dilemmas, on the other hand, concern the integrity of a person and/or the social context, so that the lives of fellow human beings are fundamentally affected by an action.

The classic example in moral philosophical discourse is the so-called trolley scenario, in which n people are to be killed in order to save n+x people. A very similar scenario is currently being staged on several stages in the theatre play «Terror» by Ferdinand von Schirach.

In both cases, the question arises as to whether these are dilemmas and how we ourselves would decide. Schirach's play, for example, envisages the audience becoming jurors and making their own judgement in a vote, so that - depending on the result - the play is performed to the end.

ADHD and its treatment - a moral dilemma?

Let's come back to the starting point: ADHD confronts us - the sufferers, parents and doctors - with far-reaching decisions. These decisions with regard to therapy, also with regard to drug therapy or its rejection or suspension, cannot be avoided. And there may be good reasons in favour of all options - but there may also be weighty reasons against them.

If all conservative options fail, ADHD can be treated with an active substance to effectively increase attention and learning behaviour, although this effect is not safe and carries risks. These, in turn, can be avoided by not administering methylphenidate, although it is then accepted that the children may be at a disadvantage in biographically decisive respects, as their learning behaviour and lack of concentration could make higher education very difficult.

Decisions can be moral because you take responsibility for a person.

Let us summarise: Do ADHD and its treatment really present a moral dilemma? Usually not - but sometimes and in borderline cases they do. Because the case of a fundamentally ambivalent decision-making situation described above, which can be called moral, can certainly occur, because responsibility for a person has to be taken carefully and sensitively.

And the second question: why should we look at ADHD and its treatment from the dilemmatic borderline case (which therefore remains the exception)? Quite simply because the escalation and intensification of a particular scenario allows its internal difficulties and challenges to emerge much more clearly.

ADHD and its treatment is not a dilemma per se, but it can become one. And this morally significant circumstance clarifies analytically and conceptually how carefully all those involved have to weigh up an upcoming decision, but also what this weighing up actually looks like, what forms it can take in practice and what options are open - or even necessarily remain closed.