By Dr David Laing Dawson
One of the foundations of a civilized, organized society is the assumption that each member is personally responsible for his or her behaviour and will be held accountable. Then, over time, we cautiously make some exceptions through our laws and courts.
Before the western disease model developed as a way of understanding illness, most cultures, in different ways and to different degrees, held individuals morally responsible for their illnesses, especially, of course, mental illness.
Though we understand the western model of disease as an assumption of biological causes and pathways, of equal importance historically was the removal of moral culpability from the sufferer. (the illness was no longer ascribed to moral lapses that allowed the devil in).
Even so, if the sufferer committed a crime he or she was still held morally and legally accountable until the M’Naghten trial in 1840. Since then each western country has developed variations of the three factors that could, through due process, allow a judge or jury to arrive at a finding of not guilty by reason of insanity or mental defect, or, now in Canada, Not Criminally Responsible. These are: labouring under the influence of a defect or illness of the mind, and did not appreciate the nature or consequences of his actions, and could not distinguish right from wrong.
It is also a relatively recent development that we do not hold children accountable for crimes they commit, or some mentally handicapped or demented citizens, and adolescents are given a modified pass.
It is certainly compassionate to consider an established addiction an illness, and at least from that point, not consider the addict’s seeking and using of drugs a moral failure, quite apart from the assumption of biological determinism. But as for crimes an addict might commit he or she would have to satisfy all three of the precepts listed above for a finding of “not criminally responsible”.
The assumption of free will and personal responsibility is in itself a determinant of human behaviour. What happens when we remove that responsibility?
I think it fair to say that the incidence of schizophrenia or serious depression would not increase. But what about addiction? No matter how you slice it, the addict must do something (seek out, ingest, inject, snort) to continue being addicted. Of course not doing that thing brings about illness and suffering as well.
The general wisdom often voiced in the therapy world is that addicts and alcoholics will only change or engage in a rehab process when they are ready to, or have decided to. But that wisdom has always struck me as too generous. Experience indicates they will enter treatment and try to stay clean when they have to. When they have to or else face some serious legal, employment, medical, or social consequences. As I have written before this is not a particularly strong condemnation of addicts, for all humans mostly engage in the hard work of changing behaviour when they “have to”. (the wake up call of a heart attack eg)
Addicts also have certain striking personality traits. They are not tolerant of delayed gratification. They tend to ascribe cause and responsibility to someone else or some factor beyond their control, and they lie. True of all humans I suppose but definitely traits that make helping addicts problematic.
Now before you think I am being harsh on the illness of addiction please note that the treatment, rehab, and recovery programs for alcoholism and addiction all tacitly acknowledge these traits. They do so in their forms of group therapy that all emphasize taking personal responsibility, in the lie detector urine test before methadone is handed out, in the AA twelve step program.
It is definitely more compassionate to think of addiction as an illness rather than a moral failing deserving our scorn and condemnation. But to do this naively will help no one.
We have already made the mistake of administratively blending addiction services with those for the mentally ill with the consequence of attitudes toward each, models of care toward each, models of security and protection for each bleeding both ways, helping neither.