THE ETHICS COLUMN
Involuntary Rehab Makes A Comeback
By Jacob M. Appel MD JD
Increasing public attention to the nation’s ongoing opioid epidemic has renewed political interest in—and ethical debate about—the merits of involuntary drug rehabilitation treatment. Although a number of states permit forced treatment under very limited circumstances, a form of civil commitment held Constitutional by the United States Supreme Court in Robinson v. California (1962), among the broadest and most well-known laws is a Kentucky statute named after heroin overdose victim Matthew Casey Wethington. “Casey’s law” allows the relatives or friends of an addicted individual to petition a court to mandate up to 360 days of inpatient treatment. Two physicians must concur that the subject is a “danger or threat of danger to self, family or others” and the petitioners must agree both to locate the treatment facility and to pay the bill. Ohio adopted a similar law in 2012. Other state statutes, like Florida’s Marchman Act, permit involuntary drug treatment for shorter periods of time. Over the past year, mandatory rehab bills have gained serious traction in Pennsylvania, New Hampshire and Washington State. But are these statutes good policy?
Opponents of mandatory rehab challenge these laws on both moral and efficacy grounds. First, they argue that substance users have a right to make their own poor choices—and, barring acute incapacity, should not have their freedom restricted. So while it might be ethical to place an intoxicated individual in the proverbial paddy-wagon until sober—to prevent him from injuring himself on the street—once the alcohol has left his system and he is thinking clearly, the state has no business holding him. Second, they question whether involuntary treatment actually leads to sobriety. Some also suggest it is not cost effective.
Rather than addressing the merits of involuntary commitment in a vacuum, one should compare this approach to its alternatives. Even if a year in rehab does not cure the patient, that year is still one year in which he does not drive drunk, stumble in front of a subway car, or clog the emergency rooms of our cities. And a small promise of success is preferable to none. Abridging autonomy is not a decision to be taken lightly, but only a radical view of civil liberties finds value in the right to drink or drug oneself into oblivion.
Safeguards are certainly needed. One might limit this policy to patients who have required emergency services for intoxication on numerous occasions. The patient who orders one too many cocktails with dinner is a far cry from addict who requires weekly evaluation in the ER. Equally important, hospitals should be empowered to petition for such care without family approval in cases where patients are excessive users of services. And most important, mandatory rehab should be imposed without requiring family or friends to pay. If we truly believe addiction to be an illness, we do not want to reserve rehab services for the rich. One would not demand that family members pay for a patient’s chemotherapy or heart transplant. Of course, our society wouldn’t abandon cancer victims or cardiac patients sleep on the sidewalks or to bathe in public fountains, so we may have a long wait before New York adopts an involuntary rehab statute. #