Stripping Addicts of Benefits – Coercion, Consent, and the Right to Benefits

The UK government has announced plans to review the possibility of stripping drug addicts, alcoholics and obese individuals of benefits if they refuse treatment for their conditions. In support of the review, a consultation paper claims that the review is intended to “. . . consider how best to support those suffering from long-term yet treatable conditions back into work or to remain in work.”

One concern that has been raised against the plans is that stripping these individuals of their benefits is unlikely to be effective in getting them to seek treatment, with the Mirror reporting one campaigner as suggesting that “(this strategy) didn’t work in the Victorian times, (and) it’s not going to work now”.

In this post, I shall consider a challenge to the lawfulness of the proposals that is based on the claim that they would coerce individuals into accepting treatment. This is in fact a challenge that Sarah Woolaston, chair of the Health Select Committee has herself raised.

 A central tenet of medical ethics holds that it is permissible to perform a medical intervention on a competent individual only if that individual has given informed consent to that intervention. Correspondingly, in the UK, patients have a long-standing right to refuse consent to medical treatment. This right is grounded by the principle of respect for autonomy, which is understood in most cases to take precedence over considerations of beneficence. This evidenced by cases in which competent individuals’ refusals of life-saving treatment have been respected, even though the treatment is ostensibly in their best interests medically speaking. Consider for example, cases in which doctors have respected Jehovah’s Witnesses’ refusals of blood transfusions. In fact, the right to refuse treatment is considered to have particular force in the UK; for instance, whilst some other jurisdictions permit the non-consensual medical treatment of individuals carrying infectious diseases in the interests of public health, this is explicitly prohibited by the UK’s Health and Social Care Act 2008, Part 2A Orders 45(e).

According to Beauchamp and Childress’ influential account of informed consent, an individual’s decision consent to a medical procedure is valid if it is made:

(1) Intentionally,

(2) With understanding,

And

(3) Without controlling influences that determine their action.[i]

Coercion is one form of controlling influence that can determine action in a manner that invalidates consent. Defining the precise nature of coercion is a somewhat complex issue, as I shall discuss below. Roughly, at this point, we may say that coercing a patient into consenting to a treatment involves a third party threatening to make the patient seriously worse off unless they consent. Further, we may say that for coercion to invalidate the patient’s consent, the main operative reason underlying the patient’s decision to consent must be that they want to avoid the threatened consequences.

It seems that this understanding of coercion could be used to undergird a claim that the UK government’s plans are unlawful. Essentially, we can understand the government’s plans to constitute a coercive threat of the form ‘if you don’t consent to treatment, then you will no longer receive benefits’. If the addict’s operative reason in consenting to treatment is that they want to continue to receive benefits (rather than because they want to receive the treatment because of its health promoting effects), then it seems that we may plausibly describe this as an instance of coerced consent.

Whilst I believe that we should characterize the government’s plans as constituting an unlawful form of coercion, it is important to pre-emptively deal with some other issues surrounding consent in this context they may muddy the waters in our thinking about this issue.

First, whilst I suggested above that it is only permissible to perform a medical intervention on an individual only if that individual has given informed consent to that intervention, I also pointed out that this claim pertains only to competent individuals. If an individual is not competent to make a treatment decision, then it may be permissible to treat them without obtaining their valid consent; the justification for this is that we cannot obtain such consent from the patient in question, and if this is the case, in so far as we can no longer respect the patient’s autonomous wishes, our treatment decisions should be guided by the principle of beneficence.

This is important to acknowledge, since a defender of the government’s proposals might claim that even if the proposal is coercive, it can be permissible to coerce the addicted individuals who are being targeted by the proposal, in so far as addicted individuals are not competent with respect to their decisions not to enter into treatment programmes.

This, however, is an argument that we should reject for a number of reasons. First, it it relies on an inadequate understanding of addiction. As I discussed in a previous post, it is commonly claimed that addicted individuals are not autonomous with respect to their drug taking behaviour because their drug of choice is understood to cause neurobiological changes in the reward pathways in the addict’s brain. However, as Julian Savulescu and Bennett Foddy have pointed out, this view of addiction runs into problems, since any sort of strong reward can result in the same kind (if not degree) of neurobiological change following drug use. Furthermore, this view of addiction ‘hi-jacking the brain’ also overlooks the empirical evidence that suggests that addicts often do end up responding to countervailing reasons that they have to stop taking drugs [ii].

Second, even if addicts are not autonomous with respect to their drug-taking behaviour, this does not entail that they are not legally competent to refuse treatment for their addiction. The legal standards of competence are far lower than the standards that we expect addicts to reach in order for them to qualify as being autonomous with respect to their desires.

Finally, even if we were to assume that addicts were not competent in their decision to refuse treatment, the next guiding biomedical principle that should guide our treatment of addicts is that of beneficience. It is bordering on the absurd to claim that stripping addicts of their benefits is in keeping with this principle. Indeed, if the government’s plans were guided by an intention to get addicts to undergo a treatment that is in their best interests, there are far more effective ways of compelling individuals to undergo treatment than that which is proposed in these plans.

A closer investigation into the nature of coercion suggests a moral issue that might covertly lie at the heart of this matter. I suggested above that coercion involves the use of threats to make someone worse off. In the philosophical literature, there has been a great deal of debate over how we should distinguish threats (which can coerce) from offers (which, many allege, cannot). We need not go into the details of this debate here. For our purposes here, we need only consider the following ‘rights-based’ account of coercion that has been highly influential in this area. One of its main proponents, Alan Wertheimer, suggests that the way in which coercion is used in law reveals that coercion is understood by the law in the following way:

A coerces B to do X in a way that invalidates B’s consent only if A proposes or threatens to violate B’s rights or not fulfil an obligation to B if B chooses not do X [iii].

The phrase in italics is key for the issue that I am considering here. By virtue of this phrase, on this sort of account of coercion, it would not be coercive to threaten to strip benefits from addicts who do not consent to treatment, if it is not the case that addicts have a right to those benefits (or that the state has the obligation to provide them). Accordingly, this account provides defenders of the government’s proposals with a philosophical basis for defending the lawfulness of the proposals. However, it does so only by opening up a political Pandora’s box – to what extent do individuals have a right to benefits, and if they do have such rights, to what extent are these rights conditional on the right-holder’s agreeing to act in certain ways? It might be suggested that these are the actual moral issues at the heart of this matter, even if they are reached via the accusation that the government’s proposals are coercive, and a consideration of what that accusation amounts to.

[i] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 6th ed.. (New York ; Oxford: Oxford University Press, 2009), 59.

[ii] Bennett Foddy and Julian Savulescu, “A Liberal Account of Addiction,” Philosophy, Psychiatry, and Psychology 17, no. 1 (2010): 1–22.

[iii] A. Wertheimer and F. G. Miller, “There Are (STILL) No Coercive Offers,” Journal of Medical Ethics 40, no. 9 (September 1, 2014): 592, doi:10.1136/medethics-2013-101510.

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2 Responses to Stripping Addicts of Benefits – Coercion, Consent, and the Right to Benefits

  • Paul Treanor says:

    This is written from an insular perspective, and that can obscure the issues. Britain is not the only country with a welfare system, and other EU countries have already taken a position on the obligations of those who claim benefit. Germany already has a policy to require obese claimants to lose weight, and in the Netherlands there is a routine obligation on claimants to accept any medical treatment as specified by the local authority (benefit is decentralised). In both the Netherlands and Germany there has in the past been an obligation on claimants to work as a prostitute: the law in the Netherlands was amended at the insistence of Christian parties. (I don’t know the current policy in Germany, which has large-scale legal prostitution).

    The obligation with most impact on claimants is, of course, that they must accept work, including all kinds of workfare projects. So far there is no definitive judgement by the European Court of Human Rights on the issue of workfare as ‘servitude’ or ‘involuntary labour’. It is probable that such a judgement will address the issue of whether denial of benefits can be regarded as coercion, and that would also be relevant for cases where medical treatment is a condition of benefit. Very probably the Court would say that there is no coercion, since no-one is obliged to apply for benefit.

    I think this whole issue must be seen in the light of political developments, and the changing nature of the welfare systems. When they were introduced, the memory of mass unemployment was still fresh. The general opinion was that anyone could lose their job in hard times, and the state should then save them from destitution. That is very different from the current situation in prosperous north-western Europe. In countries such as Britain, Germany and the Netherlands, benefit has become a permanent income for an unemployable underclass. That no longer has the support of public opinion, and there is general resentment against this ‘scrounger class’, as the tabloid media in those countries clearly show.

    It is this resentment, rather than the hope that the claimants will find work, which motivates the increasing demands on the claimants. Benefit authorities themselves know that the underclass is unemployable: employers won’t even take them when their labour is offered for free, and have to be bribed with subsidies to provide workfare places. That has consequences for the ethics.

    I think we have to accept that an underclass of vulnerable people has no claim on support by the state, against the general will of the taxpayer. If the taxpayer (the ‘hard-working families’ and so on) was happy to pay for their support, then there would be no workfare, and nothing to discuss. The government could simply exempt them from work and grant them a Basic Income. But that’s not the ways things are: the majority despises the underclass, and will not concede them anything.

    It seems clear to me that the solidarity, which we presume in a political community, certainly in a national community, is absent. Claimants are not ‘us’, they are ‘them’. That is reinforced by the real differences between the underclass and the ‘normal’ citizen – mental illness, addiction, obesity, long criminal records, and sometimes political extremism. Given that the ‘scroungers’ don’t belong to the community, why should they have any claim on its collective resources? We should think about this as an issue of political community, rather than as an individual rights issue. The claimant underclass in western Europe is suffering because it is a hated minority, and the historical options for ethnic minorities offer more appropriate policy options, than for instance medical ethics.

  • Dan Dennis says:

    Remember that the money being given to the addict etc is coerced from the taxpayer. They have to pay the tax or go to jail. So there will be coercion going on either way. The question is whether to coerce the taxpayer or coerce the addict. The options of pay tax or go to jail seem much more demaning than the option of receive money for nothing or get treatment for a debilitating addiction where getting that treatment is likely to improve your life, be better for you and others.

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