Drunks - to treat or to punish?

As the Commons Health Select Committee investigated the adequacy of the NHS response to alcohol problems, the ethical question of how society, including the health service, should respond to people with drinking problems resurfaced.

Alcohol consumption and its consequences for the drinker and others have, of course, been long-standing sources of controversy, mainly because of the range of ethical questions and dilemmas to which they give rise. What are the rights and responsibilities of drinkers in regard to their own health and the wellbeing of others? Are drinkers who get into trouble and experience alcohol problems paying the price of their own irresponsibility or are they the unfortunate victims of a medical condition over which they have little or no control? Is it the duty of the state to deter and punish alcohol misuse or to provide treatment and support for those who experience its effects? Should the person found drunk in the street be picked up by the police car or the ambulance?

The latest round of debates began with the question of the ethics of allocating organs for transplant to people who had damaged their livers by drinking excessively. Then a Think Tank proposed that the costs of being admitted to hospital “to sleep off alcoholic excess” should be met by the drinkers themselves, not the NHS. Meanwhile, former Work and Pensions Secretary, James Purnell, proposed that people dependent on alcohol or other drugs, who refuse to go on a course of treatment, could have their social benefits cut.

Liver Transplants

The argument over who is entitled to a liver transplant was prompted by the publication of figures showing that increasing numbers of the livers available for transplant are being allocated to patients with alcoholrelated liver disease. Whereas in 1997/8, 14 per cent of liver transplants were for alcoholic liver disease, by 2007/8 the proportion had increased to 23 per cent. NHS statistics show that alcoholic liver disease is the main contributor to the 19 per cent increase in alcohol-related deaths between 2001 and 2007. Deaths from alcoholic liver disease rose by 31 per cent during this period.

While the epidemic of alcoholic liver disease is increasing demand for donated organs, not everyone accepts that patients whose need for a transplant is due to their alcohol consumption deserve to receive one. The Observer newspaper quoted the mother of a young woman whose organs helped to keep five people alive after she died objecting strongly to donor organs being given to people with serious alcohol problems.

Eunice Booker, whose 26-year-old daughter, Kirstie, died in a car crash in 2006, was reported as saying:

“I find it offensive that one in four of the livers donated go to alcoholics. If there are two people side by side wanting a liver, and both have the right tissue match, and one is an alcoholic and one isn’t, there’s no contest - you take the one who’s not an alcoholic, they are more entitled.”

Some of the hostility to transplants for alcoholic liver disease arises from alcohol harm being seen as self-inflicted. There is also the George Best problem; patients with drinking problems returning, like the late footballer, to drinking heavily after they have received a new liver.

Dr Tony Calland, Chairman of the British Medical Association’s Medical Ethics Committee, said surgeons are within their rights to refuse transplants to anyone with alcohol-related liver disease if they do not demonstrate a genuine desire to stop drinking.

Don Foster MP, the Liberal Democrat Shadow Culture Secretary, who obtained the figures, commented that his decision to release them “was not an attempt to provoke an argument about who was most deserving of medical resources but rather to highlight the serious consequences of society’s relationship with alcohol.”

Mr Foster said that “as a politician, and a flawed human being,” he found the idea that doctors should make moral judgments about whether a person deserved medical treatment abhorrent. Not least, he said, because he recognised that he had not always lived a blameless life when it came to his own health. However, at the same time, we could not continue to ignore the fact that hospital admissions related to alcohol rose by 57 per cent over the past five years to almost 800,000. Such growth, he said, was clearly unsustainable in the long term.

Mr Foster said the answer was to introduce a system of minimum prices for a unit of alcohol, which, he said, would cut consumption and the numbers of people with alcohol related disease requiring treatment.

Charging drinkers for treatment

The idea of charging drinkers the cost of their hospital stay came from the centre-right think tank Policy Exchange. In a report “Hitting the Bottle” the think tank argued that as the harm from alcohol was now at an epidemic level and costing the NHS nearly £3 billion a year, with hospital admissions for alcohol doubling in a decade, the Government should now commit to a review of its entire strategy for tackling the harms from alcohol. In particular, Policy Exchange recommended that the costs of being admitted to hospital “to sleep off alcoholic excess” should be met by the individuals concerned, not the NHS.

The Think Tank argued that those admitted to hospital for less than 24 hours with acute alcohol intoxication should be charged the NHS tariff cost for their admission, of £532. This amount would be reduced for those paying the costs of their own ‘brief intervention’ alcohol education and awareness course. Such interventions, it said, were proven to reduce both alcohol consumption and future health problems.

There should be a greater focus on policing public drunkenness and the use of Penalty Notices for Disorder (PNDs), so that more people are fined for being drunk. More people suffering with alcoholic excess are now admitted to hospital than are dealt with by the police. The increased use of PNDs should be accompanied by a national roll out of Alcohol Diversion Schemes, moving those issued with PNDs into ‘brief intervention’ alcohol education and awareness courses.

In view of the huge burden placed on the health service by people who are intoxicated, many may be sympathetic to the idea of recovering the costs of a short hospital stay from those whose only real problem is that they are drunk and who are using the facilities of the NHS simply as a soberingup station, courtesy of the tax-payer. However, on the same basis, it could be argued that people should also be charged for using police cells in the same way, and in relation to both police and NHS facilities, the same problem would arise as to where exactly the line was to be drawn. Would a drunk who was kept in hospital for more than 24 hours while the possibility of a head injury was investigated also be charged for their stay? And then there is the problem of enforcement. What would happen if the drunk patient refused to pay, or was unable to pay?

Alas, the Policy Exchange report is not very informative about the practicalities of implementing its recommendations, suggesting that the idea of getting the government to charge drunks for their stay in hospital may not have been wholly serious.

Benefit cuts for alcohol and drug patients?

Another proposal which looks much more serious, partly because it emanates from the Government itself, is the idea of encouraging people dependent on alcohol or other drugs to seek treatment by threatening to cut their welfare benefits if they refuse. Certainly the proposal looked sufficiently serious for some of the major players in the alcohol and drug fields, such as Alcohol Concern, to lobby vigorously against it.

The plan to cut the social benefits of unemployed drug and alcohol addicts appeared as part of the Welfare Reform Bill, introduced into the House of Commons by then Work and Pensions Secretary, James Purnell.

The Bill constitutes the latest instalment of the Labour Government’s New Deal Programme. Essentially, the concept is that, as a key part of the commitment to promote full employment, the benefit system will be turned from a passive provider of financial support to the unemployed and others suffering hardship, into a tool to promote engagement in the labour market. The intention is that the benefits system will offer support tailored to the particular individual to help them move back into work.

One of the features of the present situation, however, is the high number of what have been called the ‘invisible unemployed’, people of working age who are out of work, but who are not registered as unemployed but, rather, as unable to work through sickness or disability and who thus receive incapacity benefit.

The number of people receiving incapacity benefit has grown substantially, mainly, some critics have suggested, because it is a convenient way for the Government to disguise the true level of unemployment.

The system has also been attacked for being open to abuse and exploitation. In 2008, one of the Government’s own welfare advisers alleged that fewer than a third of the 2.7 million people claiming incapacity benefits were legitimate claimants. Many, he said, were actually working illegally while receiving the benefit. In response, a spokesman for the Department of Work and Pensions said “…we agree … that there are many more people who could and should be supported to move off benefits and into work. We … have already committed to replacing incapacity benefit and introducing a new medical test that places the emphasis on what work a person can do, rather than what they can’t.”

This is where the Welfare Reform Bill and the proposal to cut benefits of people dependent on alcohol and other drugs come in, for, as the White Paper on the Bill explained, for a number of people the biggest barrier to participating in the labour market is their use of drugs. The provisions of the Bill were then extended also to cover people whose drug of choice was alcohol. In recent years, around 40,000 – 50,000 people have been receiving incapacity benefits on the basis of a primary diagnosis of alcohol dependence, with a similar number receiving benefits on the basis of drug dependence.

The package of incentives and disincentives aimed at drug and alcohol misusers, to encourage them back into the workforce, includes requiring compulsory drugs tests and compliance with a rehabilitation plan for problem users receiving benefits, with the threat that failure to comply may result in loss of benefit.

Opposition to proposals

The Government’s plans to encourage drug and alcohol misusers back into work prompted a generally hostile reaction from the major alcohol and drug agencies.

For Alcohol Concern, Don Shenker condemned the proposal to make receipt of benefit conditional on seeking treatment or work as “counterproductive”.

He said:

“People with alcohol dependency issues require financial stability to seek, undergo and move away from treatment. Any threat that welfare benefits will be cut simply adds to the risk of relapse. In addition, requiring someone to undergo treatment requires that treatment services are available and the latest research shows only 1 in 18 alcohol dependents are able to access treatment, making these plans potentially unworkable. While the Secretary of State is right to want to support alcohol dependents into treatment, making welfare benefits conditional on treatment or work is misguided.”

The Royal College of Psychiatrists and the civil rights lobby group ‘Liberty’ also joined the attack, protesting that the proposals amounted to a gross intrusion into privacy and jeopardised patient confidentiality, and in any case were based on a fundamentally flawed understanding of the nature of drug dependence.

In a briefing on the Bill to the House of Lords, the Royal College and Liberty stated that the proposals would

“discourage many problem drug users from applying for benefits and may mean a number of people will withdraw from the system to ensure that their dependency does not become public. Many people dependent on drugs hide the problem from their friends and family and, indeed, do not even admit their addiction to themselves. Imposing what, in effect, amounts to forced treatment also shows a failure to understand the fundamental nature of addiction and the method by which it is treated. These provisions are likely to act as a further barrier to employment; may increase the risk of social exclusion; and risk increasing crime rates and entrenching the cycle of dependency.”

Some, however, may wonder if it is not actually the Royal College and other critics of the Bill who have a questionable understanding of the nature of addiction and of the other issues involved. The arguments about patient confidentiality and alcohol and drug dependents being in denial may be thought to be strange ones, given that the question arises in relation to people claiming benefits precisely on the basis of a medical diagnosis of alcohol or drug dependence. And forcing people to confront their dependence on alcohol and other drugs and to do something constructive to overcome the problem is normally accepted as a legitimate, indeed indispensable, element of the social response to alcohol and drug dependence.

In the criminal justice system, for example, the return of the driving licence to drink drive offenders with a serious alcohol problem is conditional upon their providing convincing evidence to the authorities that they have overcome their problem and are fit to drive.

The same principle of conditionality applies in workplace alcohol and drug programmes. Crudely expressed, these programmes normally offer substance abusing employees a hobson’s choice between agreeing to overcome their dependence by, for example, undergoing a treatment programme, or accepting normal discipline, which would often mean being fired. Far from being attacked as counterproductive intrusions into privacy, likely to entrench dependence and bring about relapse, workplace programmes are promoted by bodies such as Alcohol Concern as highly desirable responses to alcohol and drug problems. Indeed, in one of its major reports on alcohol, the Royal College of Psychiatrists itself claimed that “in companies where such policies exist and are genuinely operated, the extra motivation provided by the opportunity to remain employed greatly enhanced treatment outcome.”

On the face of it, it is difficult to see why the proper approach to treatment for dependence should take not just different, but exactly opposite forms in the employed compared with the unemployed.