Consent and coercion in addiction treatment

Abstract

Addictive behaviors clearly undermine individual and population health (Ezzati, Lopez, Rodgers, Vander Hoorn, & Murray, 2002), and exact an enormous economic cost on societies across the world (Lewin Group, 2004; Rehm, Baliumas, & Brochu, 2006). Clinicians, researchers, policy makers and the public at large are thus eager to implement effective policies and programs to reduce the social, health and economic burdens of addiction. Treatment is one important response to these burdens. Addiction treatment programs have traditionally adopted the view that clients are sufficiently impaired and concerned by their problems to seek help voluntarily. However, the case-mix has shifted over time, and mandatory treatment pathways are becoming increasingly entrenched in addiction treatment programs and policies around the world (Wild, 2006). The rationale for mandatory addiction treatment has recently been broadened to emphasize findings from neuroscience research. Evidence of impairments in decision making (Bechara, 2005; Bechara, Dolan, & Hindes, 2002) and behavioral control (Goldstein & Volkow, 2002) in people with histories of substance abuse and gambling disorders has been used to argue that people with such neurocognitive deficiencies cannot reasonably be assumed to be capable of informed consent. Some have extended this argument further by proposing that mandated addiction treatment should be used to restore patient autonomy (Caplan, 2008) and is therefore justifiable on humanitarian grounds. In this chapter, it is suggested that any proposals in favor of mandatory treatment policies and programs must provide reasonable evidence that: (1) people experiencing addictions are incapable of making treatment decisions; (2) treatment provided under mandates is effective; (3) there are no iatrogenic effects of mandatory treatment; and (4) negative effects of not providing mandatory treatment are likely. In the following sections, it is argued that neuroscientific findings are currently insufficient to support (1), and that neuroscience cannot, in principle, provide compelling evidence with respect to (2), (3) and (4). Moreover, addiction research outside the neuroscience area has not provided sufficient evidence to support criteria (2), (3) and (4). Consequently, it is concluded that mandatory addiction treatment policies and programs-despite their appeal as a useful approach for reducing the health, economic and social costs of addiction-do not currently warrant widespread support.

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