I got some really great feedback on the inaugural post on the ethics of forced/mandated treatment. I readily admit that I am not an authority on substance abuse disorders—the last few years I have been far more focused on health care and homelessness. This is evidenced by the fact that I am not up on the current terminology. So let me address some of the comments sent to me by colleagues and students of mine who work int he field
A few folk pointed out that in current policy and treatment environments, the term “substance use disorder” is the preferred nomenclature as per the newest edition of the Book of Human Troubles, the DSM-5. For clarification, here is how the DSM defines the issue:
“…a problematic pattern of use of an intoxicating substance leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
- The substance is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
- A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
- Craving, or a strong desire or urge to use the substance.
- Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
- Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
- Recurrent use of the substance in situations in which it is physically hazardous.
- Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
- A markedly diminished effect with continued use of the same amount of the substance.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for each substance).
- The substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.
Complicating things is the fact that some agencies and organizations are still using use, abuse, and addiction and the manner in which we measure the rates in a population may not yet have caught up with the new DSM criteria. Nevertheless, my colleague Elspeth Slayter points out that this terminology is important “…the use of the term “substance use disorder” is favored to “substance abuse” in the addiction treatment community – as they are trying to move society towards the understanding of addiction as a disease vs. a choice. Same holds true for “substance user” vs. “substance abuser.”” I often scoff (as Elspeth pointed out to me) at language policing. In this case I think that she is correct in that it is simply a more precise term that fits with the current science of addiction. So, I stand corrected and will keep this in mind for future posts.
Questions of Effectiveness
In my initial post, I argue that the moral justification for involuntary treatment was premised in no small part of being able to answer the effectiveness question. Not an easy task. My colleague Elspeth pointed out, and I agree, that there are weaknesses in the literature. The biggest weakness is the tendency to lump all substances and/or settings together when making claims about the effectiveness of mandated treatment. However, further look at the literature indicates that there is evidence to show that mandated treatment for opioids can be effective as can mandated treatment for alcohol use. It should be noted that much of the data comes from programs that were connected to the criminal justice system. When the clients were operating within a system that had greater coercive power (they could be hit with a technical violation of probation or parole if they failed to complete a treatment program) there were stronger outcomes. Some studies of programs that do not have that degree of legal coercion were also found to be effective but only within certain narrow outcomes. There are also a few studies that show a negative relationship between coercion and treatment outcomes. So how do we make sense of this?
The effectiveness of mandated treatment is situational. Type of substance, criminal justice involvement, treatment setting, and treatment goals are all key factors in determining the likely success of a program. Again, there is also a need for better research; the authors of the systematic review I recently read indicate consistent issues in the research: “variation in coerced treatment outcomes is due to (1) inconsistent terminologies, (2) neglected emphasis on internal motivation, and (3) infidelity in program implementation.” As I have mentioned, there is also the tendency to lump together different substances. But this also brings me to another weakness in my original post: I emphasized opioid use as the issue that prompted me to reconsider my position on mandated treatment. However, my former student Kate Taylor who is also an experienced practitioner in substance use treatment pointed out that the social, economic, and medical toll of alcohol use disorders is far greater than that of opioid use and that it is folly to consider mandated care for one while ignoring it for the other.
Having spent more time in the treatment literature, specifically looking at mandated care I still maintain that on balance the evidence indicates it is probably as effective as voluntary treatment, though we must acknowledge the contingencies above. I am also anxious to see new research with programs that employ cutting edge pharmacological interventions. I maintain my initial position that mandated treatment is ethically justified insofar as it it effective and I maintain that under the proper conditions it is probably as effective as voluntary treatment. However, Kate as well as other former students of mine in the field as well as colleagues with expertise in this area point out another problem with mandated care: implementation. The original purpose of my post was so answer an ethics question and develop an ethical position. It is however worth mentioning the problem of feasibility.
Policy and Infrastructure Challenges
The system we have in place (I am speaking of Massachusetts here) for treating persons who have been mandated under Section 35 is, as the kids like to say, a hot mess. In short, there is a lack of beds in treatment facilities. A few choice observations from friends and former students working in the field.
“treatment and lack of beds is deplorable and lack of solid sober accredited housing for women is practically non existent. My clients beg for opportunities, only to be rejected because of underlying mental health issues. Not many with serious addictions lack mental health problems”
“There’s also a huge gender discrepancy in MA. With section 35, when the treatment beds are full men were sent to Bridgewater, minimum security with built in addiction services. Women however were sent to Framingham, medium security with no addiction program in place. I know they passed legislation last year to increase women’s services and resources in this regard but I’m not too sure of how that has panned out. Of my female patients who have been put on section 35s in the past 5 years, all but one went to prison for 90 days.
So, there is obviously a serious policy and implementation problem here. The issue of policy and implementation comes after the question of whether mandated care is even morally justified. And hey, policy problems are easy to fix, right? In all seriousness, I would like to see a case made that invokes the right to treatment. If the state is going to abridge the liberties of an individual then the state must provide the kinds of services and therapeutic milieu that could be reasonably expected to help an individual regain the ability to exercise personal autonomy. Absent that, mandated treatment becomes, as my colleague Michael Melendez points out, punishment and custodial care rather than treatment. If the state cannot provide the solicitous care individuals mandated to treatment require then the state is violating the basic premises of mandated care that undergird its moral justification. If the state cannot or will not make the necessary policy, infrastructure, and economic commitments that allow for effective interventions then the state no longer has the moral foundation to continue the practice of “sectioning” persons with substance use disorders.
Further Issues to Consider
There are three other points that folks brought up that I was going to address in this post. The first is the misreading of J.S. Mill. My friend and colleague Dom Sisti made mention of this, and I am in agreement that Mill’s thoughts on individual rights are not as libertarian as is often supposed. The other issue that was brought up by two people who really know the substance use literature (my colleague Michael Melendez and my doctoral classmate Maayan Schori) is the issue of harm reduction policies and programs. I have been thinking about these two things a lot and think they each deserves its own stand alone post. The ethics of harm reduction are quite complex and require some space to discuss.
Lastly, Dom Sisti challenged me on the fact that I have thus far justified my argument in favor of mandated care based on the scale of the public health problem. Are we justified in mandating care even if the problem is demographically small? What if it is only one person? To be sure, I couched a lot of my argument in the social welfare and public health implications of substance use disorders. This makes sense in light of how we have generally conceptualized individual rights, especially in the United States–“do what you want so long as you don’t interfere with others.” We tend to think of our rights as negative, that is, we have a right to be free from interference. For instance, my freedom of speech means that the government may not censor me, however, it does not mean that the government must provide me the means or mechanism for personal expression (like this blog). I have a freedom from rather than a right to. As such, we can partly justify mandated treatment on public health grounds since the scale of the public health issues and the accompanying transgression of the rights of others trump an individual’s right to non-interference. However, I think that implicit in the idea that we curtail freedom in order to promote freedom (Caplan’s argument) is a different conceptualization of rights and the role of the state. There is an implicit notion that the state has a part to play in actively promoting the exercise of rights and autonomy. If we conceptualize the state as having a role in promoting human flourishing then it follows that mandating treatment for persons with substance use disorders is morally justifiable on teleological grounds apart from the public health implications. I think that virtue ethics may provide a foundation for a more nuanced approach to this issue. I have an inclination toward virtue ethics and will be exploring in future posts the role of virtue ethics in social work and how they are a remedy to the kind of shallow, bureaucratic decision making and enforcement of political orthodoxy that are engendered by the current NASW code.