Compulsory detention in addiction treatment


In their recent editorial, Hall et al. [1] argue that ‘compulsory detention, forced detoxification and enforced labour’ are ethically unacceptable as well as ineffective ways of treating addiction. The authors also claim that Russia and Sweden are two of the few developed countries that still detain addicted people compulsorily and that this has been done ‘in the absence of rigorous evaluations of the efficacy or safety of this approach’. Israelsson & Gerdner [2] recently published a paper on international trends in compulsory commitment of substance abusers. Based on data from 104 countries and territories, they conclude that the existence of compulsory commitment to care of substance misusers was more common than not at all three times of observation (1986, 1999, 2009). There has, indeed, been a slight net reduction in the existence of compulsory care after the millennium, but the main shift has been from civil compulsory care to compulsory care within criminal justice legislation. Moreover, within civil compulsory care there is a clear trend from social to mental health legislation, suggesting a shift from openly acknowledged compulsory care to hidden compulsory care. The claim that hardly any (developed) country practises compulsory care for addicted individuals is, then, highly questionable. Furthermore, we would like to challenge the claim that Sweden practises compulsory detention of substance abusers without rigorous evaluations of efficacy or safety. Obviously, more can always be conducted in terms of evaluation and scrutiny but Sweden does, in fact, produce statistics, perform follow-ups, finance research and evaluations of substance abusers in compulsory care. Performing, for example, randomized clinical trials to ascertain the efficacy of compulsory detention is, however, not feasible or ethically defensible.

What is more worrying in this editorial is the tendentious link made between compulsory detention, forced detoxification and enforced labour. Hall et al. more or less equate compulsory detention to lack of independent review or appeal processes, centres run by the military, hard physical labour, unmedicated detoxification, physical and psychological abuse and withholding of food as punishment for non-compliance. If this were an apt description of all compulsory detention it naturally ought to be abolished as soon as possible. However, the conditions described in the editorial cannot be seen as an inherent part of compulsory detention/care of addicted individuals per se. Swedish compulsory care institutions are, for example, run neither by military nor police, and are inspected regularly by independent authorities. Clients can only be withheld after a court ruling which may be appealed, and clients do not perform any labour. What the authors describe are inhumane institutions found in countries where we are likely to find a widespread absence of human rights at large, including appalling conditions in, e.g. mental hospitals, orphanages and prisons. Hall et al. would hopefully agree that there is a slight difference between being detained in a developed country where rule of law reigns compared to the clearly non-democratic regimes depicted in this editorial.

Compulsory detention, in any way or form, is always a tough question and needs to be challenged and debated. Unfortunately, this editorial is more about misleading and insinuating than about challenging and debating.

Declarations of interest