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Article Excerpt
How a society should direct its resources for treatment of alcohol and drug problems is one of the most difficult and important questions for the treatment system. Should one, for instance, prioritize services to those that have the greatest chance to be rehabilitated or instead to those that have the greatest need for treatment; or should one not prioritize and, in case of a budget cut, just set fewer resources aside for all client groups? In Sweden the municipality has a responsibility for all its inhabitants and should, in principle, not assign priorities. Nevertheless, special efforts can be directed towards special groups and, despite the formal rules, there is room for making priorities at different levels (Socialstyrelsen, 2004a).
Sweden has a long tradition of maintaining a public nonprofit treatment system. This tradition was, however, brought into question in the context of the economic crisis of the 1980s-90s. The criticism led to decentralization of the treatment system, and a re-orientation toward a market basis and differentiation (creating more alternative services designed for different groups) (Oscarsson, 2001). It is also often stated that treatment resources decreased during the 1990s, although this is not supported by official statistics. Oscarsson (2001) explains this divergence by noting that the economic crisis made Swedish society shift focus from marginalized groups to "normal" unemployed groups. When this "normal" group required greater support from society, it meant fewer resources were available for the marginalized groups, especially with privatization diminishing the direct influence of the municipality. In line with this general development, long-term inpatient treatment was to some extent replaced with outpatient treatment and residential services. Support and care services tended to replace pure treatment services, according to Oscarsson (2001). At the same time an individualistic view, stressing the responsibility of the individual, has gained support in society at the expense of a communitarian view focusing on rights and justice (Oscarsson, 2001; see also Giddens, 1994 on individualization of modern society).
According to a report from the Swedish Board of Health and Social Welfare (Socialstyrelsen, 1998) there are greater reasons to worry about "the younger misusers," whom they found were being given less treatment, while the changes that the treatment system had undergone during the 1990s (1) weren't judged as having failed the "group of older, socially and physically worn-down misusers." However, a more recent study indicates the contrary--young drug users are prioritized and older alcohol users are not (Ekendahl, 2004).
In Sweden there are few studies on how priorities are made within the treatment system for alcohol and drug problems, and what the consequences of the priorities are. The aim of this article is to study how different groups of clients or patients are prioritized within the treatment system for alcohol and drug problems in Stockholm County, and how staff thinks priorities should be set. The data-source consists of questionnaire data on staffs' views on how different groups are prioritized, how they should be prioritized, and whether those groups receive the treatment they need. Laws and local guidelines on how priorities should be set are important in understanding the views of staff. Therefore the staff experiences and opinions are contrasted with official documents on how priorities should be set. To gain further understanding of the staff perspectives on priorities, a short theoretical framework will first be presented that will point at different ways of thinking regarding priority setting in treatment. Against this background the staff answers will be analyzed.
Ethical reasoning
Decisions about priorities are for the most part based on ethical principles. A model of describing different grounds on which decisions on priorities can be made has been borrowed from Olsen, Richardson, Dolan & Menzel (2003), and additional thoughts concerning alcohol and drug treatment are added. It should be mentioned that the principles presented are not mutually exclusive; several principles can be used at the same time.
Olsen et al. (2003) suggest three different ways of reasoning, one taking into account future actions by the individual (utilitarian), one focusing on equality (egalitarian), and one taking past actions into account:
Utilitarian
Utilitarian--the more happiness is generated, the stronger the claims for treatment.
* Pecuniary utilitarianism refers to what a treated person is able to produce in terms of wealth in the future.
* Non-pecuniary utilitarianism concerns happiness generated through caring and personal interaction. Priority is given to patients who will return to caring for elderly persons or children.
In alcohol and drug treatment helping those who have the greatest chance of succeeding in treatment and those that are the most socially integrated could be a sign of a utilitarian reasoning.
Egalitarian
Egalitarian reasoning argues for equal shares across individuals. It will give priority to those generally less fortunate to compensate for disadvantages. A secondary objective is to reduce inequalities in life-time well-being across different socio-economic groups. Concerning alcohol and drug problems, an egalitarian principle will give priority to the group that has the most problems and lowest social integration.
Past actions
Past actions can be taken into account when making priorities in two different ways:
* Merit and just deserts is one way in which those who have made the greatest contributions to society will be given priority (e.g. war veterans, charity worker) and those that have done bad things will be given lower priority (e.g. criminals).
* The responsibility of the individual regarding his/her illness can be considered, and for the most part it will lead to a high priority for those whose illness has exogenous causes, for which they could not be blamed, and a lower priority for those whose illness has endogenous causes (smoking, engaging in dangerous sports, etc.).
In alcohol and drug treatment more or less anyone could be seen as having brought their "disease" on themselves, but perhaps some more than others. Some patients might be seen as less culpable and more largely as victims of bad upbringing, etc. These patients would be given priority if past actions are taken into account.
Alcohol and drug problems can, in general, be given different priorities in comparison to other health or social problems depending on the reasoning used. If a utilitarian reasoning is used, those with alcohol or drug problems might be given the same or less priority than other groups, since, because of their alcohol or drug use, they might have less opportunity to get a good job and to have a good social life. Egalitarian reasoning, on the other hand, would give more priority to such individuals, since they have often had misfortune and poor opportunities in life. Judgments from prior actions would give little priority to those with alcohol or drug problems, since they tend to be seen as not having contributed greatly to society, and the causes for illness tend to be seen as endogenous, with the individual thus held responsible for his/her bad health.
Research indicates that alcohol and drug problems have a lower priority and status than other social work assignments, especially child and youth care (Bergmark, 1995; Socialstyrelsen, 2002a) and that alcohol and drug problems are more stigmatizing than most other social problems (Ostun et al., 2001). Past actions and personal responsibility seem to be taken into account.
It should be noted that the discussion above, and this article in general, is predicated on the assumption that treatment is something which will always be sought by those defined as being in need. This assumption is clearly problematic for alcohol and drug treatment. Many clients come into treatment under pressure from families, employers, or others, and there is also a small element of formal compulsory treatment in the Swedish system (Palm & Stenius, 2002). But the discourse about treatment, in Sweden as elsewhere, does not commonly recognize this dimension and its implications, talking instead of priorities for treatment as if all those defined as in need desire it. The materials in the present article--both the official documents and our questionnaire to staff--are framed in a manner consistent with this discourse.
Official priorities
The healthcare system for treatment of alcohol and drug problems accounts for around one-third of the whole alcohol and drug treatment load in Sweden, whereas two-thirds is provided by the social services system (Socialstyrelsen, 2002b). (2) The healthcare system has the responsibility for maintenance treatment, detoxification and other medical treatment, whereas social services have the overall responsibility for residents' material needs, voluntary social treatment, and making decisions about compulsory treatment.
Official statements on how priorities should be made in the healthcare and the social services systems are mostly made in separate documents, and will therefore partly be treated separately in this presentation. However, there is a joint policy document for misuse care and specialized addiction treatment in Stockholm County concerning both systems (Stockholms lans ..., 1998). The...
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