I started working as an addiction counselor in 1994 and I cannot recall any time since then that has been characterized by such polarization in the responses being proposed and implemented.
At one pole, multiple states are proposing and passing legislation to allow for involuntary treatment. We’ve long had mandated treatment in criminal courts, but these new bills and laws create a civil process for people with addiction who have committed no crime, based on a finding of grave disability, or danger to self or others.
At the other pole, we see advocates framing drug use as a human and civil right that government should protect and facilitate. A good example of this is Carl Hart’s recent book, which has been popular among advocates.
The philosopher John Locke once noted that pursuing happiness is “the foundation of liberty.” This idea is at the core of the Declaration of Independence, the document that gave birth to our nation. The Declaration asserts that each of us is endowed with certain “unalienable Rights,” including “Life, Liberty and the pursuit of Happiness,” and that governments are created for the purpose of protecting these rights. The use of drugs in the pursuit of happiness, in my view, is arguably an act that the government is obliged to safeguard.
Hart, C. L. (2021). Drug use for grown-ups: chasing liberty in the land of fear. Penguin Press.
Also at this pole, the philosophy of harm reduction centers autonomy and frames policy and program decisions as a choice between liberation and stigma, with liberation representing freedom from external forces infringing on liberty and dignity, plus freedom from harmful traditions and orthodoxies.
So… we’re seeing simultaneous efforts to infringe on personal autonomy and assert individual liberties.
autonomy: self-directing freedom and especially moral independence
Merriam-Webster Dictionary
But does using drugs actually represent autonomy? For most users, yes.
What about the minority with addiction? Which is characterized by episodes of impaired control and distortions in salience and the valuation of drug use relative to relationships, jobs, material possessions, moral values, life goals, etc.?
Does suicide represent self-directed freedom for a person experiencing a severe depressive episode?
Do relationship-damaging hypersexual behavior or debt-incurring spending represent self-directed freedom for a person experiencing a severe manic episode?
Does neglect of self-care and severing relationships with support systems represent self-directed freedom for a person with schizophrenia experiencing a psychotic episode?
When a person with addiction commits a crime related to their addiction (say, drunk driving or theft), do we want courts to view that behavior as self-directed freedom? Or, do we want the court to recognize their addiction and treat it as a mitigating factor that requires assistance?
It would be easy to dismiss these competing efforts and views as completely incoherent and choose to embrace one while rejecting the other. However, I’m not so sure the tension between them should be dismissed as incoherence.
Isaiah Berlin suggested that we can think of liberty in two ways — positive liberty and negative liberty.
Negative liberty can be thought of as freedom from — the “absence of obstacles, barriers or constraints.”
Positive liberty can be thought of as freedom to — “possibility of acting… in such a way as to take control of one’s life and realize one’s fundamental purposes.”
This notion has been recognized and explored in the context of public health.
For decades, there have been 2 major competing political definitions of freedom: “positive” and “negative.” Negative freedom is characterized by the absence of external constraints on personal decision making, and positive freedom is portrayed as the exposure to conditions necessary to pursue desired opportunities.
Ackerson, L. K., & Subramanian, S. V. (2010). Negative freedom and death in the United States. American journal of public health, 100(11), 2163–2164. https://doi.org/10.2105/AJPH.2009.179259
Libertarians and harm reduction advocates seem to be primarily concerned with negative freedoms. (Though, not exclusively. There is attention to social factors that may limit positive freedoms.)
On the other hand, efforts to establish processes for involuntary addiction treatment are often driven by family members who are primarily concerned about negative freedoms — that their loved one’s freedom to make decisions about the course of their life is severely limited by their addiction — much like a person with a severe mental illness.
These arguments about positive freedom invite questions about whether there is a “true self” and whether the addicted person’s behavior represents a freely chosen act of their true self, or a manifestation of their illness. Attending to positive freedom also raises concerns about paternalism — that impaired decision-making can be used to justify infringing on some freedoms in the name of increasing other freedoms.
Some of these decisions can also be framed as “hands-on” vs. “hands-off.” Harm reduction favors a hands-off approach, while involuntary treatment represents an aggressive hands-on approach.
These situations often pit negative freedom against positive freedoms where negative liberties are limited in the hope of increasing positive freedoms.
Many advocates and PWUD are rightly concerned that opening this door puts us on a slippery slope that can easily lead to abuse. Others are rightly concerned that ignoring limited positive freedom in the context of addiction can constitute neglect.
One of Recovery Review’s contributors, Alexandra Plante, offered an interesting distinction in an article for Stat.
Autonomy in engagement is very different from the autonomy of the individual, as we know that drug use has very real effects on families, how individuals experience their communities, and even broader implications if we examine the heavy burden of drug use on the U.S. health care system. Attaching ideas of personal autonomy and the right to use drugs to harm reduction suddenly implies that “the harm my drug use does to others is not my problem.”
Plante, A. (2023, November 6). There’s a real risk that harm reduction could be a fad. Retrieved November 9, 2023, from STAT website: https://www.statnews.com/2023/11/06/harm-reduction-drug-use-substance-disorder-addiction-research/
I’m not certain I fully understand the distinction between “autonomy in engagement” and “the autonomy of the individual” but I think she may be encouraging us to think about service models that approach client engagement in ways that respect their autonomy but also recognize that their autonomy might be limited by the impact of their behavior on others and, in the case of addiction (not all SUDs), that symptoms of addiction may limit autonomy.
None of this leads us to easy answers. In fact, these considerations undoubtedly complicate things for us.
One major barrier is the lousy job we do in distinguishing addiction from other drug use. And, it’s important to note that this problem isn’t confined to poorly trained practitioners. I routinely see scholarly work that fails to specify the kind of substance use problems it’s addressing or uses SUD and addiction interchangeably.
However, thoughtful consideration of these factors could help mitigate conflict among advocates and providers with different priorities and goals. It also may help us develop policies and systems of care that maintain ambitious goals and maximize liberty.
recoveryreview.blog 
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