Article Text

Download PDFPDF
Paper
Scientific and conceptual flaws of coercive treatment models in addiction
  1. Susanne Uusitalo1,
  2. Yvette van der Eijk2
  1. 1Department of Behavioural Sciences and Philosophy, University of Turku, Turku, Finland
  2. 2Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  1. Correspondence to Susanne Uusitalo, Department of Behavioural Sciences and Philosophy, University of Turku, Turku 20014, Finland; susuus{at}utu.fi, susanne.uusitalo{at}gmail.com

Abstract

In conceptual debates on addiction, neurobiological research has been used to support the idea that addicted drug users lack control over their addiction-related actions. In some interpretations, this has led to coercive treatment models, in which, the purpose is to ‘restore’ control. However, neurobiological studies that go beyond what is typically presented in conceptual debates paint a different story. In particular, they indicate that though addiction has neurobiological manifestations that make the addictive behaviour difficult to control, it is possible for individuals to reverse these manifestations through their own efforts. Thus, addicted individuals should not be considered incapable of making choices voluntarily, simply on the basis that addiction has neurobiological manifestations, and coercive treatment models of addiction should be reconsidered in this respect.

  • Substance Abusers/Users of Controlled Substances
  • Autonomy
  • Coercion
  • Competence/incompetence
  • Decision-making

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

The coercive treatment of addictioni is not widely advocated for in the literature, but is still practiced.2 Drug-addicted criminal offenders, for example, are part-coerced into therapy as a restrained option, with prison as the alternative. Countries such as Norway and Finland have compulsory commitment to care of substance misusers in their mental health and social legislation.3 In China, addicted opiate users can be referred by family or a doctor into rehabilitation centres where they are forced into abstention and medical treatments.4 Such approaches may be justified on retributive grounds, or the basis that they will bring better or more cost-effective treatment outcomes or improved public health outcomes; notwithstanding the fact that they represent a blatant intrusion on patient autonomy. However, the integrity of one's autonomy in addiction has also been called into question. Caplan, for example, advocates for a coercive treatment model in which autonomy that is ‘lost’ as a result of the addiction is restored through medical therapy.5 Though this reasoning is rarely used in practice, there is a possibility that some will use it as an ‘ethical’ justification for the coerced treatment of addiction. It is on these treatment models, then, that this paper will focus: models that operate on the assumption that autonomy in addiction is sufficiently impaired to justify the coerced medical treatment of addicted drug users in their ‘best interests’.ii

In our discussion about ‘autonomy’ and the notion of control as a part of ‘agency’, we simply mean that an agent is one who acts and not merely a subject to which things happen, and this action requires certain abilities and capacities from the agent.iii7 ,8 In other words, to have agency is, among other things, to have control over one's own actions that is partly constitutive of autonomy, which is here defined as the ability to act in accord with one's own reasons, motives and values.9 In addiction, agency is sometimes thought to be impaired beyond a point at which autonomous actions related to the addiction are no longer possible.iv Consequently, addicted individuals are considered incapable of making decisions regarding their addiction or its treatment, and coercive treatment may be considered ethically justified.

The aim of this paper is to critique the scientific and conceptual basis of coercive treatment models of addiction in the context of their description of ‘autonomy’, and in light of neurobehavioural research, to nuance our current understanding of ‘agency’ in addiction.v We ultimately argue that brain disease theories of addiction—used as the scientific basis for coercive treatment models5—employ too narrow an empirical and conceptual scope in explaining human action; a risk which, when actualised, has unwelcome implications on addiction treatment. We proceed with suggestions on how a more nuanced conceptual understanding of agency in addiction should be used to develop less ethically problematic treatment approaches.

The conceptual basis of coercive treatment models

The idea that addicted individuals lack the ability to make decisions concerning their addiction-related actions and treatment—and should therefore be subjected to coercive treatment—may be arrived at via several conceptual routes. Threat to one's autonomous decision-making may come from alleged features of addiction that undermine one's competence for decision-making;12 ,13 a questionable influence of addiction that affects the individual's agency;14 or from the individual's social and psychological circumstances, limiting the acceptable options she has, for example.15 While not all of these views have been used for endorsing coercive treatment models, insofar as they argue for addicted individuals’ incapacity to make treatment decisions they may be applied to these models.

Charland, for example, argues that addictive behaviours involve a shift in values which casts doubt to individuals’ abilities to evaluate the risks and benefits concerning their addictive behaviours or treatment related to it, as addiction makes them overrate the benefits of drug use. In Charland's view, the role of value in competence is not the only problem in addiction; competence for decision-making is also affected by two kinds of compulsions, one which results in volitional impairment and another in cognitive impairment.vi Henden, in contrast, argues that addictive actions may be involuntary, not because addiction is compulsive but because voluntariness requires alternatives that are acceptable in terms of an objective standard of well-being.15

Going further, Caplan argues that in addiction one does not lack the competence for decision-making; rather, addicted individuals are—as a result of drug use—subjected to coercion from within. This coercion, then, may be removed by subjecting the individual to involuntary medical therapy.5 Though this argument remains widely disputed, it shares a common thread with the other views: because addicted individuals are unable to make autonomous addiction-related decisions, coercive treatment may be considered a viable means of restoring autonomy that is lost as a result of the addiction.

The scientific basis of coercive treatment models

Coercive treatment models of addiction share a common scientific foundation: evidence demonstrating the neurobiological changes in addiction that impair the ability to avoid drug use.16 More specifically, addictive drugs are known to alter activity in dopaminergic pathways (mesocortical, mesolimbic and mesostriatal pathways).17 These changes, put together, result in neurobiological shifts in which behaviour become increasingly cue-driven, habitual and orientated towards immediate rather than long-term reward.

The conditioning of drug-related cues involves reward and memory circuits in dopaminergic mesocortical and mesolimbic pathways (including structures such as the prefrontal cortex, amygdala and nucleus accumbens). In the prefrontal cortex, an excessive reward value is assigned to the drug. Upon cue exposure, this activates the amygdala, where memories of an emotional, subconscious nature are formed.18 The amygdala directly innervates the nucleus accumbens, where rewards are processed. Put together, when the individual is exposed to a drug-related cue, dopaminergic activity in these structures and pathways increases, which also corresponds to cravings: a desire or drive to use the drug. When the craving is satisfied (by taking the drug), activity again decreases.19 Cue exposure is a potent trigger and often sufficient for relapse even after long periods of abstinence.vii 20 ,21

Non-rewarding compulsions in addiction are mediated primarily through the mesostriatal pathway (basal ganglia). When a behaviour is reinforced through this pathway, it becomes increasingly automated, and significant conscious efforts may be required in order to change it. Similarly, in obsessive compulsive disorder (OCD), behaviours that are not necessarily rewarding are repeatedly enforced in the basal ganglia.22 Meanwhile, the ability of the prefrontal cortex—a structure involved in inhibiting risky behaviours and rationalising long-term goals—to inhibit addictive behaviours is impaired.23 Studies, for example, repeatedly show that the activity in the prefrontal cortex is reduced in addiction, and that this reduced activity is proportional to the severity of the addiction.24

Put together, this evidence has led to interpretations of addiction as a chronic and relapsing ‘brain disease’.25 In this view, drug use is initially voluntary, after which neurobiological processes gradually ‘take over’; the degree to which neurobiological processes are usurped being proportional to the severity of the addiction.26 The neurobiological changes described here are therefore not categorical; they are of degrees, and they translate to degrees in the constraints on competence and autonomy. Caplan, for instance, is willing to grant that.27

However, brain disease theories have been widely criticised,28 and tend to ignore a growing body of evidence indicating that it is possible to reverse neurobiological ‘faults’ and overcome a disorder through one's own efforts. This idea is well-demonstrated in a study on people with OCD.29 In this study, positron-emission tomography (PET) scans were done before and after an intervention on 18 patients off medication with moderate to severe OCD. For the intervention, the patients were shown a PET scan of their brain and told that the compulsive behaviours characteristic of OCD were a result of neurobiological ‘faults’. They were taught to overcome these faults by becoming aware of them, actively resisting them and shifting their attention elsewhere. 12 of the 18 patients had significant improvements in their symptoms, which was accompanied with reduced activity in various brain regions including the prefrontal cortex and basal ganglia. A similar phenomenon has been observed in repeat studies with OCD,30 as well as in similar studies with other disorders including depression,31 phobia,32 schizophrenia, anxiety and stress.33 Although extensive work in this field has not yet been done for addiction, there is evidence that when addicted individuals successfully exercise self-control over their cravings, this reduces hyperactivity in the prefrontal cortex.34

This research suggests that, though addictions are characterised by various neurobiological ‘faults’, these can be overcome without necessarily requiring medical help or, indeed, coercive treatment.viii Neurobiological changes that result from this effort are termed ‘top-down plasticity’, as they originate in one's own high-order functions.35 This has resulted in explorations into a new therapeutic approach, neurobehavioural therapy, in which individuals are taught to ‘reverse’ neurobiological processes that underlie the disorder through behavioural methods. These may include cognitive behavioural therapy, awareness training, and/or harnessing the will and resolve to overcome the disorder.31

This research implies that brain disease theories of addiction employ concepts in a manner that risks simplifying human agency to neurobiological processes that solely express ‘bottom-up determinism’ in contrast to the top-down plasticity just described.ix Brain disease theories and coercive treatment models, then, fail to accommodate the possibility of an account of human agency that involves a reciprocal interaction between one's cognitive high-order functions and neurobiologically driven behaviours that in turn interact with the social and physical environment.36

In other words, agency does not necessarily depend on normally functioning neurocircuitry, and, in addiction, the differing neurobiological manifestations do not automatically deprive individuals of their capacity for autonomous decision-making and control over their action. It should be noted that the notion of control is, however, ambiguous. Proponents of coercive treatment models locate the impairments of agency in addiction to ‘voluntary behavioural control’.6 ,26 Control here does not refer to the agent's mastering of physical movements nor to any alien forces taking over the self, but more on how the agent conducts her life.

Further conceptual hazards

The coercive treatment models described typically refer to innate compulsion as a reason why addiction is problematic, and draw on brain disease theories of addiction for empirical support. However, a philosophical review on the various kinds of evidence of compulsion in addiction—such as regret, strong desire or imprudent choice—illustrates problematic argumentation in these kinds of models.37

In the context of healthcare ethics and legal issues, common criteria for decision-making capacity require the person to communicate a choice, understand the relevant information, appreciate the situation and its consequences, and demonstrate reasoning regarding treatment options.36 In light of the neurobiological research described above, the criterion of communicating one's choice is not at issue, nor the criterion of grasping ‘the fundamental meaning of information communicated by physician’.38 It also seems reasonable to regard addicted individuals as capable of acknowledging their medical condition and likely consequences of treatment options.x Their actions remain intentional and are probably goal-oriented. What, then, is problematic in addiction is a lack of capacity to appreciate and be motivated to have a life without addiction. Caplan, for example, implies that while some addicted individuals may be competent, addiction coerces the individual and thus it is a question of voluntariness rather than competence.5 We agree that addiction most likely does not always undermine addicted individuals’ competence for decision-making; rather this is reversible and dependent on the severity of addiction.

The key for understanding lost control in addiction, then, lies in the notion of voluntariness and not in one's rational abilities. Voluntariness refers to the agent's willingness to act and this willingness also ought to be free from controlling influences. Involuntariness, then, involves ‘the possibility of coercion and undue influence’ at the moment of decision.38 In our opinion, it is unlikely that cue-driven drug cravings would force the agent to choose drugs instead of treatment in the healthcare setting. Furthermore, the idea that a desire for drugs is so causally efficient that it takes over the agent's actions is conceptually problematic and an inaccurate description of human behaviour.37 This suggests that an addicted individual's brain is static in the sense that desire-related mechanisms determine the agent's actions without the agent's possibility to intervene or veto these processes. In habitual behaviour, automated processes may dictate the agent's action; but to infer that she is unable to change the resultant behaviours is inaccurate in light of the evidence that supports neurobehavioural treatment approaches.xi

Towards a more ethical treatment approach

Coercive treatment models do not empower addicted individuals; they disempower them by violating the right to consent and disrespecting individual autonomy. The evidence illustrated in this paper indicates that individuals, no matter how severe their addiction, retain a capacity to overcome addiction-related compulsive urges. Thus, the coercive treatment of addiction cannot be ethically justified on the grounds that autonomy has been negated by addiction. A non-coercive and more ethical treatment, then, should entail helping individuals to identify reasons to quit drug use, helping them to find ways to become more aware of drug-related cues and training their capacity to control addictive behaviours. The latter may consist of cognitive and/or behavioural therapies, or neurobehavioural therapies. Developing an awareness of drug-related triggers may include making a record of the circumstances in which cravings are felt, and learning to avoid those circumstances. Together, these can help to identify and suppress addictive drives. Motivational training is also necessary, since the addicted individual herself has to be willing to engage in these positive changes. Willingness translates into change, other things being equal. It has been argued elsewhere that, in addiction, the mobilisation of one's will and resolve is one of the best indicators of therapeutic success.36

The options we choose are influenced by the options we have. A supportive environment can therefore have a powerful effect in facilitating these changes. For example, it was mentioned that drug-related cues in the environment can act as potent triggers for cravings. An environment free of drug-related cues thus helps addicted individuals to avoid cravings and overcome the addiction.40 A supportive environment is also important in helping individuals to identify reasons to quit drug use. Having meaningful opportunities in life, a supportive community or positive pressure from loved ones (eg, friends and family) can make the option of living with an addiction less desirable in light of better alternatives. Motivation may also be enhanced by the (consented) administration of medicines or a harm-reductive approach, as this can bring individuals closer to treatment services. Incentive programmes and the promotion of better social support systems can also facilitate change in more severe cases who might otherwise not respond to interventions such as neurobehavioral therapy, and should therefore be an integral aspect of addiction therapy. In other words, in acknowledging the dynamic nature of agency, not only in terms of top-down plasticity but also the contextual influences that are in play in addiction and in all action, treatment approaches should place more emphasis on the circumstances of addicted individuals as well as their innate abilityxii to resist addictive behaviours.

Conclusion

Addiction is notoriously challenging to treat. Coercive treatment models attempt to restore addicted individuals’ abilities to decide and act autonomously regarding addiction-related issues, but they rely on too narrow a view of agency. The conceptualisation of agency in this context should reflect the reciprocal nature of higher cognitive states and functions with the functions of pathways and circuitries; currently excluded from reasoning that supports coercive treatment models. With a proper understanding of these, we hope that more effective treatment measures will be achieved, as the studies with patients having OCD suggest. Our critique, then, supports a conceptual approach in which addiction is not viewed as autonomy-negating, and treatments in which addicted individuals are not forced into therapy but supported in identifying and training their own will and capacity for self-control.

Acknowledgments

We would like to thank Barbara Broers, Ben Capps, Adrian Carter, Juha Räikkä and two anonymous referees for their helpful comments on an earlier draft.

References

Footnotes

  • Contributors Both authors conceptualised and wrote this paper: Both authors discussed and agreed on the focus of the paper. Both authors drafted and revised the text, and agreed on the final draft.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i ‘Addiction’ is a clinically recognised disorder with clear psychological, behavioural and neurobiological characteristics—see, for example, ref. 1. For the purpose of this paper, ‘addiction’ refers to drug addictions and not behavioural addictions (eg, gambling disorder).

  • ii We focus on mandated medical therapy in the best interests of addicted individuals, so other justifications for coerced therapy, such as those mentioned, are not discussed further. Refer to ref. 6.

  • iii Note that this definition does not strictly conflict with the idea that environmental cues affect agents’ actions.

  • iv We use notions of ‘control’, ‘agency’, and ‘autonomy’ in a somewhat interchangeable matter though the terms are not strictly synonymous. For instance, agency is not restricted to self-control, but self-control is used in one's agency. Further, an agent can make decisions and act in ways that are not autonomous, that is, that are not in accordance with the agent's own reasons, motives and values.

  • v Criticism towards the brain disease theories of addiction and mandatory medical therapy for addicted individuals has been raised before. See, for example, refs. 10 ,11. Nevertheless, insofar as we are aware, there has not been a detailed conceptual and scientific criticism of these issues with a specific focus on the notion of agency.

  • vi Compulsion here refers to ‘uncontrollable’ behaviour that is driven by powerful cravings for the drug. See ref. 12.

  • vii It should be noted at this point that, since addictive practices are often cue-triggered, there is a link between human action and the environment so addictive actions should not be considered as isolated from the context in which they take place. This point is returned to later, in the discussion on more ethical treatment approaches.

  • viii In other words, by using mental efforts that originate from the person's will, for example an active resistance to drug cravings. Taking medicines partly falls under this scope, as it is an effort on the part of the individual to overcome the addiction. In this case potential neurobiological changes that result from medicine-taking would be a result of the individual's decision to take those medicines.

  • ix By ‘bottom-up determinism’ we refer to a reductivist view in which the neurobiological changes resulting from drug use determine the ways in which the addicted individuals act, without direct influence originating in higher order cognitive functions.

  • x One may argue that very severe addictions may result in cognitive impairments; for example impairments that result from oxygen depletion in the brain as a result of respiratory depression in heavy heroin use, or Wernicke–Korsakoff as a result of severe alcoholism. However, cognitive impairments would then be a direct result of these syndromes and an indirect consequence of the addiction, but not strictly a direct consequence of the addiction in itself.

  • xi If, on the other hand, the addiction-driven behaviour is considered be motivated by obsessive thoughts, the situation changes to the extent that the discussed mandatory medical treatments become even less warranted as they target the desire-related mechanisms and not the obsessive thoughts—see ref. 39.

  • xii ‘Innate ability’ in this context refers to an individual's ability to self-control behaviours, such as addictive cravings and actions. As discussed above, this ability may be enhanced through treatments such as neurobehavioural therapies, medicines or a supportive social environment.

Other content recommended for you