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Denying autonomy in order to create it: the paradox of forced treatment

Posted Nov 09 2009 10:00pm
I was on the great Neuroscience and Society website at the University of Pennsylvania, looking up more information on the 2010 Neuroscience Boot Camp (which I really hope to attend, provided I can snag both an admission spot and a scholarship), when I checked out their full-text research articles published by members of the program. One, titled Denying autonomy in order to create it: the paradox of forcing treatment upon addicts, immediately caught my eye.

(Just to warn you: the article is full-text, but it's really blurry. It appears they scanned in printed pages to create the . pdf files, so you can't copy and paste the text into word to get a better look. And no, printing it doesn't help either. I apologize if there are any errors in my transcription of the text.)

The author, Arthur Caplan, writes:

People who are truly addicted to alcohol or drugs really do not have the full capacity to be self-determining or autonomous. Standard definitions of addiction cite loss of control, powerlessness and unmanageability. An addiction literally coerces behavior. And addict cannot be a fully free, autonomous agent precisely because they are caught up in the behavioral compulsion that is addiction. If this is so, at least for some addicts, then it may be possible to justify compulsory treatment involving medication or other forms of therapy, if only for finite periods of time, on the grounds that treatment may remove the coercion causing the powerlessness and loss of control.

Addicts, just as many others with metal illnesses and disabilities, are not incompetent. Indeed, to function as an alcoholic or cocaine addict one must be able to reason, remember complex information, set goals and be oriented to time, place, and personal identity; but competency by itself is not sufficient for autonomy. Being competent is a part of autonomy, but autonomy also requires freedom from coercion. Those who criticize mandatory treatment on the grounds that an addict is not incompetent and thus ought not to be forced to endure treatment are ignoring this crucial fact. Addiction, bringing in its wake as it does loss of will and control, does no permit the freedom requisite for autonomy or self-determination.

The parallels to eating disorders are striking and, to me anyways, rather obvious. I believe that legal coercion should be a last resort measure. No one wants this- not the sufferer, not their family, and typically not society either. Buy-in is important in a therapeutic relationship, but if you never get sober, down from your Mt. Everest-level highs or begin a normal pattern of nutrition, "buy-in" is kind of irrelevant.

Coercion, even if it's not of the legal variety, is a commonly used tactic in both addiction treatment and eating disorders treatment. Done right, it can be seen as beneficial, even to the sufferer. Loving coercion could be financial ("I'm not paying for college if you're not healthy"), practical ("I don't think you should drive the car until you are doing better"), and even emotional (refusing to engage the person's disordered behaviors). Most sufferers, myself included, typically don't respond to these efforts with joy and praise, but that doesn't mean that they're not necessary. Many ED sufferers who felt they were coerced into inpatient treatment ultimately admitted they needed to be hospitalized.

In the end, what's worse: a few months of coerced treatment or a lifetime of an eating disorder?
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