Irony is not the first quality one looks for in a medical journal, but when I read an editorial in the August issue of the British Journal of Psychiatry by Nancy Petry, a National Institute of Health-funded psychologist at the University of Connecticut School of Medicine, I thought I was reading satire. But I wasn’t, of course.
The editorial concerned a technique called contingency management treatment. In essence, it consists of bribing drug abusers to stop taking drugs. I quote verbatim:
Contingency management treatments are interventions in which substance misusing people receive tangible, positive reinforcers for objective evidence of behaviour change. For example, patients receive a voucher, exchangeable for retail goods and services, whenever they submit a urine sample that tests negative. . . .
No doubt readers (and taxpayers) will feel reassured to learn that among the goods not exchangeable for such vouchers were liquor and weaponry.
The author seems completely unaware of the implications of her method of “treatment.” Leave aside for the moment the ease with which drug-takers have traditionally deceived doctors with their urine samples, and the fact that some drugs disappear swiftly from the urine, so that absence of evidence is not evidence of abstinence; what does the rationale of the “treatment” tell us about the supposed “disease” of addiction?
It presupposes, of course, that the consumption of drugs is under voluntary control; a person can stop taking drugs if he wants to. But if this is true, then addiction is not a disease in any reasonable sense of the word; and if it is not a disease, there can be no treatment for it, only “treatment.”
In corrupt countries where officials take bribes as a condition of doing anything, is bribery a form of treatment of the terrible diseases of prevarication and procrastination?
The argument in favor of contingency management treatment is that some addicts respond to it. Indeed, you will probably be astonished to learn that a “dose-response relationship” exists: in Petry’s words, “studies that provide lower voucher amounts demonstrate less positive results.”
I have little doubt that if you gave sufficient money to habitual housebreakers and other acquisitive criminals, they would stop their illegal activities. The more money you gave them, indeed, the more effective and long-lasting your “treatment” would be. On the other hand, I would not necessarily expect such “treatment” to reduce the total amount of acquisitive crime in society; rather the reverse.
The author dismisses possible moral objections to bribery dressed up as medical treatment with a rhetorical flourish. “Politics and ideology will clearly impact on the expansion of this technique in practice.” That her own presuppositions are ideological—that addicts are diseased and in need of treatment, and that the end justifies the means—escapes her entirely, and leads to an astonishing moral blindness.