Comment: Involuntary treatment labels addiction as moral failure

By Peg O’Connor / For The Herald

The calls to invoke civil involuntary commitment laws for people with Substance Use Disorders (SUDs) are getting louder in communities with a marked increase of overdose deaths. Preliminary data suggest nearly 108,000 people died from an overdose in 2021. At present 35 states, including Washington state, have laws that allow for a civil commitment of an individual for a SUD.

Civil commitment is a legal mechanism that allows family members, health care practitioners, police or others to go to court asking for legally mandated substance abuse treatment for an individual who poses a significant threat of harm to self or others. The process often involves assessment by professionals of the harm an individual poses. These assessments may result in mandates for hospitalization, in- or out-patient treatment or participation in other community-based resources for specified periods of time.

While SUDs are included in the fifth edition of the “Diagnostic Statistical Manual of Mental Disorders,” some of these states’ laws exclude SUDs from their legal definition of mental illness or disorder. The exclusion of SUDs from this category in legal statutes may be a consequence of the overlap of two considerations.

The first is the vestiges of the view that addiction is on some level, a moral failure. Moral failings in general are not taken to be the sort of thing that absolve a person of responsibility. To the contrary, people tend to think we are most responsible for our moral failings and the acts that issue from them.

Moral failings most certainly can lead to illegal activity, which is the second consideration. Some addictions are to illegal substances or to legal substances used illegally, such as prescription medications used not as prescribed or alcohol consumption by minors, for example). Put another way, these laws enshrine the view that mental illnesses may involve a diminished capacity that is different in kind from the diminished capacity from a SUD. The former may mitigate legal responsibility but the latter does not.

There are few studies about the efficacy of mandated treatment for SUDs. One reason for this is the significant variation between states in what may be mandated or what is even possible to mandate. Rural areas, for example, are treatment deserts for both in- and out-patient services. Some areas have no in-patient treatment facilities but may be richer in other community-based programs. How can one compare an experience where medication assisted therapies are available from those that are not, for example? How does mandated treatment in an unused building at a correctional facility affect outcome as is the case in Massachusetts? This points to the deeper and even more troubling question of efficacy. There is no shared standard or benchmark for successful treatment in general.

Treatment centers that primarily use the 12-Step Model see abstinence as the success. But how long after the completion of treatment must one remain abstinent in order to count as a success? That is never specified. Treatment centers that use medication-assisted therapies aim at harm reduction by using medications that may reduce cravings or replace an illegal drug with one medically prescribed such as methadone or naltrexone. While a more rigid 12-stepper might say this isn’t true abstinence, a person who drastically reduces their cravings lowers the chances of overdosing, which is a significant reduction of harm. Should reduction of harm as opposed to abstinence be the guiding consideration in judging efficacy?

The increase of laws for civil commitment continues a long-established practice of making individuals bear the responsibility for problems that have systemic or structural dimensions. Addiction is a condition of an individual most surely; it is individuals who are addicted. But that is not all it is; addiction has social, political and economic dimensions. The production and aggressive marketing of oxycontin to targeted communities, for example, shows some of these dimensions.

Communities that had high disability claims were singled out; these were people in physical and psychological distress. These considerations made people especially vulnerable to developing addictions. This is especially true in the state of West Virginia, which has the highest overdose rate of 81.4 deaths to 100,000 people. That vulnerability is linked to the absence of accessible and affordable health care, treatment options, other forms of social services, and viable employment opportunities. The drug companies were apex predators.

The sharp increase in overdose deaths is driven by a multitude of causal factors; some of which are deeply personal and others of which are social, political and economic. No amount of focus on the personal will ever be enough to counteract the power of the broader considerations. Involuntary commitment laws keep the focus on individuals who are seen as hopeless, intractable or utterly defiant. To reduce the great harms of addiction, we need better health care, treatment options, social services and employment options.

Peg O’Connor, doctor of philosphy, is a recovering alcoholic of 34 years and has been a professor of philosophy at Gustavus Adolphus College in St. Peter, Minn., for 27 years. She is the author of “Higher and Friendly Powers: Transforming Addiction and Suffering.” (Wildhouse Publications, 2022) and “Life on the Rocks: Finding Meaning in Addiction and Recovery” (Central Recovery Press, 2016).