Denying autonomy in order to create it

The new issue of Addiction has a provocative editorial on mandated treatment. It’s an issue that I’m very interested in and posted about recently.

The writer makes the case that autonomy is usurped by addiction, making it ethically justifiable to coerce treatment for the purpose of restoring autonomy.

The author then goes on to propose naltrexone as a candidate for mandated treatment. He proposes that mandated addicts could regain their autonomy by complying with involuntary treatment. Kafkaesque, no?

Anyone who witnesses the suffering and insanity of addiction first hand can easily find themselves thinking, “If only we could get this person in treatment and make it impossible for them to leave until their addiction is no longer holding them hostage.”

All this might be wonderful if there wasn’t a history of horrific professional abuse of addicts and alcoholics.

Bill White also recently wrote about choice in the context of treatment and recovery and wrestled with the issue of impairment of volitional control and self-determination:

One way to partially reconcile the dilemma between the traditional and emerging views of choice is to first acknowledge that free will in addiction and recovery is not an all or none phenomena. The capacity for volitional control over AOD use and related decisions is variable across individuals (as a function of the interaction between problem severity/complexity and recovery capital) and is dynamic (shifts incrementally on a continual basis within the same individual through both addiction and recovery processes). Recovery can be viewed as progressive rehabilitation or reclamation of the will — the power to reclaim personal choice (Smith, 2005). There are times the recovery process may involve consciously not choosing — relying on resources and relationships outside the self, and times that the next recovery steps require an assertion of self. At a practical level, this means that the first hours of acute detoxification are not the best time to rely exclusively on client choice. And yet, long-term recovery is not possible without choice. If there is no rehabilitation of the power to choose and encouragement of choice, we are left with, not sustainable recovery, but superficial treatment compliance.

To effectively apply a philosophy of choice requires great skill on the part of the addiction professional, particularly where a client’s immaturity, cellular craving, impulsivity, psychiatric symptoms and impaired judgment severely limit choice generation, choice analysis and the capacity to stick with any personal resolution. In such cases, we must carefully plot a path between complete autonomy (total choice and clinical abandonment) and paternalism (no choice and intrusive control). Most clients have a sense of this need as well.

The important question is, if the addict is denied his or her right to choose, who gets to choose? Their family, a doctor, counselor? Under what conditions. What treatments can be involuntarily ordered?

We already accept coerced treatment with the courts and impaired health professional monitoring bodies, but these people still have a choice. They’ve committed a crime or practiced in a way that endangers patients, and they being offered an alternative to incarceration or loss of their license. There is a great distance between coerced treatment as a sentencing alternative and involuntary treatment “for your own good.”

I understand that well-intentioned people might be drawn to this idea, but there is far too much history of abuse and far too much stigma and pessimism among modern professional helpers.

Besides, how could we ever consider such a thing when treatment isn’t even accessible to millions of addicts and alcoholics? We don’t even know what would happen if addicts had access to high quality treatment of adequate duration and intensity. When we offer every addict the same treatments we offer doctors, maybe…maybe we could discuss something like this, but we have a long, long way to go first.

BTW-In the case naltrexone, what happens if the person gets into a car accident or needs emergency surgery and needs opiates for pain management?