In July Government announced an independent review into the impact on employment outcomes of drug or alcohol addiction or obesity .
One well-publicised option is to make acceptance of treatment a condition of receiving benefit. This was met with horror from curiously diverse quarters:
· UKIP said threatening those at the bottom of society with penury if they ‘do not do what they are told’ shows a fixation on finding people to blame – rather than lifting burdens from everyone 
· Alistair Campbell called the Prime Minister’s statement on this ‘embarrassing’ and ‘pathetic’ at the very time that leaders like Angela Merkel were leading debate on Ukraine and Greece 
· GP leaders said it could lead to GPs becoming probation officers and inspectors 
· Conservative Health Select Committee Chair Sarah Wollaston called the plan unworkable and illegal – describing consent as central to health treatment 
· Slimming World said alarmist headlines that overweight people face losing their benefits will make the problem worse; and that blame will perpetuate a cycle of despair and loneliness 
What has any of this got to do with disabled people?
In the very first sentence the Review talks of how best to support claimants with ‘potentially treatable conditions’ - like obesity or addictions to drugs or alcohol - into work. So the overt reason for selecting obesity and addictions is that they are treatable conditions. But maybe the (not so) covert reason is that both are easily stigmatised experiences, where people can be blamed for their life choices. Hence headlines like ‘Is it right to use benefits to pay for addiction?’  or - slightly more paternalistically – ‘A welfare system that buys drink for alcoholics, drugs for addicts and sweets for the obese is cruel, not compassionate’
If it’s really just about targeting people with treatable health conditions, then where is the limit? Any treatable health condition?
If it’s about people whose choices impact on health conditions/impairments, then what about rock climbers or hang-gliders? Should anyone engaging in risky activities have their benefits stopped?
It is worth disabled people setting out clear principles to guide discussion in this arena – both because so many have multiple impairments (would the person who is obese due to adverse effects of psychiatric medication, or steroids taken for asthma, or chemotherapy have their benefits stopped?); and because it’s worth getting principles clear when ideas like this are first consulted on, to influence the debate from the outset.
So here are some principles, to start a debate:
1. In general, it is perfectly fair for society to have expectations of people living with health conditions and impairments (for instance, to pursue education or to bring up children effectively) – as long as society’s obligations to them are met - ie as long as the world is becoming more inclusive, based on universal design, with an enabling state getting education/transport/support right. Indeed to have no expectations of disabled people leads to rank paternalism: expecting nothing of people is a sure way of keeping them subservient
2. But it is not fair for those expectations to be turned into an injection of fear – the fear of loss of benefits – because fear is not an effective behavioural incentive. Positive motivators - engendering hope, offering support when you need it, peer support from others who have been through similar challenges – simply work better than fear-based ones. For instance, sanctions for non-participation in the Work Programme employ fear and have patently not led to growing numbers of disabled people on ESA going on to the Work Programme and getting jobs (see http://www.disabilityrightsuk.org/news/2015/august/high-success-rate-esa-sanction-challenges)
3. Still less is it fair to link fear of loss of benefits to requirements to accept treatment. In England we are witnessing a steep rise in coercive treatment – for instance, 53,136 uses of Mental Health Act compulsion (in 2012-13), 30% higher than in 2003-4. See http://www.cqc.org.uk/sites/default/files/monitoring_the_mha_2013-14_report_web_0303.pdf.pdf . Making treatment a requirement to get benefits would exacerbate this trend. Legally it is an assault to medically treat someone without consent, except in highly specified circumstances – and under the UNCRPD these circumstances should be further narrowed (our current mental capacity and mental health laws permit too much treatment without consent). ‘Consent’ is not consent if made under threat of poverty.
4. It is not fair to view impairments and health conditions just as ‘illnesses’ that require ‘treatment’. If, for instance, you experience significant anxiety due to life events (from abuse to unemployment), drink alcohol to mitigate it, become dependent on alcohol, face social rejection due to your problems, which exacerbates your anxiety – then just ‘treating addiction’ is missing the point. A social understanding of both the multiple causes of addiction and the social consequences – rejection, unemployment – are needed. We need to move away from narrow medical models in which the problem is seen as an illness, the solution as a ‘treatment’. It is particularly abhorrent to require people to accept treatments that may not even work (the success rate of treatments for addiction is not brilliant – even when people are motivated to use them; it is likely to be lower for people dragged in for fear of poverty)
5. It is not fair to set different requirements to accept treatment on people who have long-term health conditions than other citizens. For most people with long-term health conditions it is also illegal, under the Equality Act 2010
6. It is not fair to set different requirements to accept treatment on people who have ‘chosen’ activities that have impacted on their health (like people who drink above safe limits of alcohol). Whilst it is fair to employ positive incentives to encourage and support people to build healthier lives and look after and manage their own health, it is unfair to use negative motivators for 2 reasons. Firstly, who really does ‘choose’ to be dependent on alcohol? People ‘choose’ in a context of social and economic stresses and cheaply priced drinks. And secondly a founding principle of the NHS is a health service available to all, based on consent – not a differential service with one approach for people who behave according to some societal ‘norm’ and another for people who ‘choose’ drinking or rock climbing.
Dame Carol Black, who is conducting this independent review, should think long and hard about which types of incentives actually work (not just what treatments work, in the classic clinical sense); and base her review on principles of fairness, equality and human rights.
By Liz Sayce