Questions of Medical Ethics

Ethical and epistemological quandaries examined

Addiction and the 91%

What the nonabusing majority can do to help abusers.

About 23 million people in the U.S.—about 9% of us—suffer direct physical, mental, and social harm from drug or alcohol overuse or addiction. Many millions more experience secondary consequences from a loved one’s illness, disability, imprisonment, or death. I’m among the millions who have watched as a dear family member gradually lost himself, his promise, and his life to substance abuse. It feels hopeless sitting beside a loved one dying of cirrhosis, or waiting for a child, parent, or friend to finally go too far, winding up dead alone. Lacking training, power, and resources, individuals usually are helpless to intervene. But at a society-wide level, our typical responses to substance abuse have let us avoid responsibility for what we could do.

Think of three common perspectives on addiction. There’s the AA-derived perspective: the addict has to hit bottom, take responsibility for herself, accept her own helplessness. There’s the common medical ethics worry that mandating treatment would override the addicted person’s autonomy. And there’s the perpetual observation that the effectiveness of substance abuse treatment is low.

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The first two obviously give us reasons (excuses, I’m suggesting) to butt out. The rationale for turning aside is that although addicted people may need help from a treatment center, a sponsor, or a higher power, they are—and should be—responsible for seeking out and holding onto their own sobriety. In light of the first two perspectives, we have tended to blame addicted people for the third as well, again letting everyone else off the hook. In a recent shift, we now increasingly view addiction as disease. This reframes the low treatment efficacy as a treatment failure, not as the addict’s failure. But if it’s treatment failure, there’s obviously plenty of room for improvement: Much available treatment has a limited scientific basis, despite the ongoing illnesses, deaths, and widespread social consequences. And even if treatment were effective, access is sharply limited. At present, only 1 in 10 people harmed by substance use gets treatment. Forty percent of counties have no outpatient substance abuse facility that accepts Medicaid, thus abandoning many who are poor.

Consider a contrasting case. We urgently combated breast cancer, bringing the death rate down by a third since 1990. Breast cancer now kills about 40,000 people, mostly women, per year. (The death rate in black women, however, remains shockingly higher than that in white women.) In comparison, non-tobacco substance abuse kills about 120,000 annually, and tobacco still kills about 400,000—ten times the number breast cancer does. And of course, the suffering associated with substance overuse ripples way beyond the death rate.

One way to reduce the toll would be to double down on the disease model of addiction. This route would involve investing much more money and intensive research in a range of treatment modalities—not just a search for anti-addiction pharmaceuticals, but studying biological, psychological, and social approaches that might help people build or rebuild satisfying lives. The other route would be social support beyond the “treatment” mode for people at risk of addiction, struggling with addiction, or working to maintain sobriety. Communities could do much more, for example, to reduce stigma, promote prevention, and to offer education, skill building, housing, and care for complicating psychic and physical illnesses.

Whichever route we take—or if, ideally, we choose both—we need to do something uncomfortable: we need to accept that a large part of the responsibility for addiction and recovery is not on those who are addicted, but on the other 91%. 

Susan C. C. Hawthorne, Ph.D., is an associate professor of philosophy at St. Catherine University.

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