A type of alcoholic beverage, to be specific, red wine, according to some researchers contains a substance known as resveratrol, an antioxidant that was shown to be protective against heart diseases, if consumed in moderate amounts. Take too much red wine, and it isn’t too good for the heart either. In most societies, the problem comes about when too much alcohol is taken. According to studies by the World Health Organisation (WHO), alcohol resulted in greater cost to life and longevity than tobacco, and has a similar impact in terms of mortality, disability, financial costs and other measurable impact (the combination of these is known as burden) as unsafe sexual practices. Excessive alcohol consumption results in a whole host of problems – health issues such as heart and liver diseases, motor vehicle crash deaths and injuries from violence. According to 1990 estimates by WHO, alcohol accounted for 3.5% of the years of life lost due to disease and disability. Estimates showed that alcohol caused a total of 1.1 million deaths, but also has health-protective effects in that it prevented 470,616 deaths. However, on the overall, alcohol has resulted in net worldwide deaths of 773,594. International reviews have shown that 37 – 43% of male deaths and 18 – 43% of female deaths due to motor vehicle accidents are attributed to alcohol. In addition to the health impact, alcohol abuse also results in negative social impacts, e.g. absenteeism from work, law enforcement issues.
As such, the alcohol problem is an issue that lawmakers and policy-makers will inevitably grapple with. Last month, a Singaporean Member of the Parliament, Indranee Rajah announced her intention to push for a “no alcohol zone” in an area that is within the vicinity of a popular nightspot. The issue was that the nightspot, popularly known to Singaporean locals as Zouk was situated close to residential areas. Residents highlighted their concerns of drunken revelry, and another major issue was the effects of drunkenness where drunk revellers vomit and pee at the bridges which are popular hangout areas. A no alcohol zone is possibly effective in alleviating an alcohol problem within one area, but the possibility of the problem shifting to another location cannot be ruled out, and this can be illustrated with an example of a major Australian hospital which declared a “no smoking zone” within the hospital compounds as part of a drive to promote a healthy lifestyle. Those who smoke within the “no smoking zone” will be slapped with an on-the-spot fine. So what happened in the end? Smokers congregated at one of the hospital’s entrance, which was considered outside the perimeter of the “no smoking zone”, and smoked. The problem was that this produced a cigarette smog, which patients entering the hospital from that particular entrance will be exposed to, much to the irritation of their lungs. The same possibility cannot be ruled out for a no alcohol zone, the problem may migrate to somewhere else.
Regardless of which angle one comes from in dealing with the negative effects of alcohol consumption, there is arguably no running away from addressing the problem itself. It is a little bit like how doctors address the symptoms (whatever manifest on our body, such as skin itchiness that is caused by a liver problem), but more importantly zero in on the source of problems. The alcohol problem necessitates a multiple angle approach in the form of medico-legal processes and fiscal policy intervention. These two major areas will be discussed here, though there are other forms of interventions, e.g. social interventions that can be explored in tackling the alcohol problem.
The medico-legal processes and fiscal policies discussed here is applicable to the following scenarios. First scenario, a patient who is repeatedly hospitalised for the bad side effects of alcohol and is diagnosed as having alcohol dependency. The second scenario, a woman presents to the police station with bruises and wounds in different stages of the healing (inflicted on her constantly over a period of time), and upon questioning reveals that she has been abused by her husband who consumes alcohol excessively. The third scenario is an alcohol addict with liver disease who is awaiting a liver transplant. He has not been up to date with his medical appointments, and did not adhere to treatments aimed at quitting drinking. The fourth scenario, a man who is arrested outside for violent conduct or damaging public properties while under the influence of alcohol, as determined by breathalyser tests.
The first medico-legal issue that has to be addressed is the status of alcohol dependency. In certain major healthcare systems, there are a series of diseases known as notifiable diseases in which the authorities must be informed of should any patient contract them. They are usually infectious diseases, which can spread from person to person, and if left unchecked, have the potential to escalate into an outbreak. Hence, authorities have to be informed when cases of patients harbouring signs or symptoms of such diseases emerge. This is to allow them to monitor the situation and take preventive action. The downside to notification is the sacrifice of patients’ confidentiality from the ethical perspective. However, that is justified in the name of protecting the community’s interest. The interesting question is whether alcohol dependency or addiction should be made a notifiable condition, i.e. when clinics or major hospitals diagnose a patient with alcohol addiction, should there be a law that requires medical practitioners to notify authorities whenever a diagnosis of alcohol addiction crops up?
Alcohol dependency is unlike an infectious disease which can spread from person to person, but the very act of notifying authorities, if there is such a law sacrifices the patient’s confidentiality. However, the motivation for notifying authorities and for action to be taken is done in the name of protecting the community’s interest. The argument that justifies a law making alcohol dependency a notifiable condition is that alcoholism is first and foremost a condition which can result in the individual affecting the community, and there is much evidence for it as discussed earlier in the form of violence, property damage and motor vehicle accidents. The fact is that alcoholism is a more common problem than a number of notifiable diseases, some of which are rare and exotic, e.g. Ebola virus. Furthermore, infectious diseases outbreaks is periodical whereas alcoholism is an ongoing problem that the society has to grapple with. Hence, for the reasons highlighted, alcohol dependency or addiction should be made a notifiable condition.
The next question is what the authorities can do once they are notified of a person with alcohol dependency? A registry can be created that captures the particulars of such an individual. This registry can be made accessible to outlets selling alcoholic beverages and also by the transport or traffic authorities. Thus, when this person goes to an outlet to purchase alcohol, the outlet should ask to sight his identity card and check his particulars against this database. If his name is inside the database, he should not be allowed to purchase alcoholic beverages. Of course, one way around it is to ask a proxy to purchase alcohol on his behalf. However, a law that deters proxies from purchasing alcohol on behalf of alcohol addicts can be put in place, e.g. a charge or conviction for helping an addict procure alcohol. The transport or traffic authorities can also access this registry and identify drivers of normal and heavy vehicles and take appropriate action to temporarily suspend the driver from operating a vehicle until his alcohol problem has been resolved, and that its resolution is medically certified.
Entry into this registry should not only come from a medical diagnosis of alcohol dependency, since a limited number of such people end up getting diagnosed. Situations where law enforcement agencies apprehend individuals guilty of causing damage or harm to people and property whilst under the influence of alcohol upon conclusion of investigations should also prompt entry of particulars into this registry. First-time offenders will be placed into the registry for a definite period of time, and if this window period remains incident-free, their names can be struck off. Multiple offenders will be on the registry for a longer period of time, and in some cases, require a referral to a drug and alcohol service of a medical institution for evaluation of possible alcohol dependency. This legal procedure addresses the issues in scenarios one (patient diagnosed with alcohol dependency), two (a wife who was abused by her alcohol addict husband) and four (man arrested for violent conduct whilst under the influence of alcohol).
This leaves us with the third scenario, that of a patient with advanced liver disease caused by his excessive alcohol consumption and is awaiting a liver transplant, but he refused to adhere to medical treatment for his alcohol dependence. The policy options that we can explore here come in the form of fiscal policies. An inspiration is drawn from Article 62 of the German Social Security code which reduces the amount of treatment subsidies for conditions that one could initially prevent or seek treatment to prevent, but fail to do so. The German Security Code was originally implemented as a “stick” approach to ensure that cancer patients attend their screening and treatment programmes faithfully, failing which will result in a reduction in co-payment for their cancer treatment. The ethical perspective behind such a law is the issue of whether the public should finance the treatment of diseases that are self-induced, for example in this scenario where liver disease is caused by alcohol consumption, and furthermore, the patient refuses to adhere to treatment for alcohol dependency. However, tax revenues are finite, and subsidising self-induced diseases will deny resources from being diverted to other important areas. Thus, reducing subsidies for patients who do not adhere to treatment for otherwise preventable diseases if they had been more adherent is a “stick” approach that “arm-twists” them into changing their lifestyle or seeking treatment to change their lifestyle, e.g. reduce alcohol consumption to prevent diseases from arising in which they may not get subsidies for treatment, e.g. liver transplantation as a result of not being adherent.
The second fiscal policy worth considering is sin taxes. Such are taxes levied to discourage partaking in social vices. It is worth noting that according to a WHO document, it is poor families who usually spend on alcohol. A sin tax will elevate the prices of alcohol products, and thus, reduces access to them by addicts who do not have the financial power. Based on information from the WHO document, drinkers especially from the developing world come from poor households, which is why a sin tax for alcohol is a possible tool to reduce their access.
Although moderate intake of alcohol as demonstrated by research is healthy for our hearts and is perfectly acceptable, what is not acceptable is when the drinking goes beyond reasonable limits, and on a regular basis. That is when the safety of persons and property are possibly endangered. To protect both public and community interests, medico-legal procedures can be put into place; especially those which require notification of alcohol dependency by the medical establishment to the authorities or law enforcement agencies establishing that damage to personal and public interests was committed under the influence of alcohol, both of which result in the capture of alcohol users’ particulars into a central registry. The point of this registry is to list individuals who should not have access to alcohol and should not operate normal or heavy vehicles. This is a double safety net in that even if such addicts gain surreptitious access to alcohol, example in a gathering, their ban from operating vehicles will at least eliminate the risk of motor vehicle accidents. Lastly, besides medico-legal procedures, fiscal policies that can be considered is one that operates as a “stick” approach in reducing subsidies for self-induced disease, specific for those caused by excessive alcohol intake in cases of those who do not adhere to treatment for their addiction, and secondly, a sin tax that reduces the access among those who cannot afford the elevated prices of alcohol products.
Thus, drinking safely, especially in moderate amounts is everyone’s responsibility, failing which necessititates actions dedicated towards protecting public interests.
**Note: Even though this article contains a Singaporean example, it is aimed at an international audience
Part of the P-K4 project series, strategic thinking towards a safer future
Photo courtesy of Iguanasan, Flickr Commons