CHAPTER 5
Drug and Alcohol Use
Scott Krueger was looking forward to balancing the challenging demands of an engineering major at MIT, early-morning crew practice, and an active social life at Phi Gamma Delta, one of the thirty fraternities at MIT. In the fall of 1997, however, the fraternity pledge passed out during a Greek Week celebration after downing sixteen drinks in an hour. When Krueger’s fraternity brothers noticed he was having trouble breathing, they called an ambulance.
By the time rescue workers arrived, Krueger was already comatose. His blood alcohol level was later found to be more than five times the legal driving limit. A few days later, Krueger’s distraught parents had him removed from life support. Krueger is only one of hundreds of college students whose lives are cut short or devastated every year as a result of drug and alcohol abuse.
Krueger’s parents were awarded a $6 million settlement by the university. This unprecedented financial settlement and MIT’s commitment to change the college conditions that contributed to Krueger’s death have spurred other colleges to make similar commitments to create a safer and more secure campus environment for students.
Following Krueger’s tragic death, MIT and several other colleges established stricter alcohol policies including stricter regulations and sanctions for violations of their alcohol policies. Despite these programs and a greater awareness of the dangers of alcohol abuse, over a thousand college students between the ages of 18 and 24 die from alcohol-related injuries every year.1
WHAT IS A DRUG?
Drugs, for the purpose of this chapter, are defined as chemicals that enter the bloodstream and are easily transported to the brain, where they alter the way we feel, with predictable results. Alcohol, by this definition, is a type of drug. Drugs can be smoked, injected, snorted, or swallowed.
Drug abuse is defined as “taking a drug or drugs for purposes other than those for which the drug or drugs were intended, and/or the illicit use of a drug or drugs which can cause harm (not necessarily physical) to oneself and/or others.”2 One of the risks of alcohol and drug use is addiction. Addiction is “a behavioral pattern of drug use, characterized by overwhelming involvement with the use of a drug [compulsive use], the securing of its supply, and a high tendency to relapse after withdrawal.”3
THE HISTORY OF DRUG AND ALCOHOL USE
Alcohol is the most widely used drug in North America. Wine and beer have been used since ancient times for their pleasurable effects, in medicine, with meals, and in religious ceremonies. Even the Mayflower carried a good supply of “bere.”
Distilled spirits were first produced in Europe about 1300 and were often referred to as “aqua vitae” because of their purported powers to prolong life. In 1606, alarmed by the increase in drunkenness, the British government made intoxication a statutory offense with the Act of Repression of the Odious and Loathsome Sin of Drunkedness.
Laws in the colonies were relatively lenient and geared primarily toward controlling drunkenness and disorderly conduct. A Connecticut law prohibited drinking for more than one-half hour at a time. A 1760 Virginia law prohibited ministers from “drinking to excess and inciting riots.”
The temperance movement of the late nineteenth and early twentieth centuries was spearheaded by groups such as the Women’s Christian Temperance Union (WCTU) and the Anti-Saloon League. The WCTU opposed drinking primarily because of its destructive effect on the family. The problem was also blamed on the influx of immigrants from Europe and Ireland, with their decadent drinking habits.
In 1919 the Eighteenth Amendment to the Constitution outlawed the sale and consumption of alcohol. Despite lack of unanimous support for the amendment, most prohibitionists thought that Americans would not violate their Constitution. They were mistaken. Although alcohol189consumption declined during the first few years of prohibition, it began to climb again during the 1920s. Ratification of the Eighteenth Amendment ushered in an era of organized crime and a vast illegal liquor trade, known as “bootlegging,” under the control of such notorious gangsters as Al Capone. The cost of trying to stamp out illegal drinking soared into the millions of dollars. It soon became apparent that prohibition was too unpopular and too expensive to enforce. The Eighteenth Amendment was repealed in 1933 by the Twenty-first Amendment, although some states continued to have local prohibition laws as late as 1966.
Alcohol consumption hit another peak about 1980. Once again the tide of public opinion turned against alcohol. This time it was the medical profession that led the crusade. Rather than denounce alcohol as a moral failing, as had the early prohibitionists, the medical establishment declared alcoholism to be a disease. The disease model continues to dominate attitudes toward alcohol use in the United States today.
Attitudes toward drug use have followed a similar course. Hallucinogenic drugs have been used since antiquity both for pleasure and for religious purposes. Apparently, the techniques of ecstatic trances used by some Hindu yogis involved the use of drugs. The peyote cult of Mexico also used drug-induced ecstasy in mystical and religious rituals. LSD, which was popular in the 1960s, has been similarly credited with helping users get in touch with a deeper mystical wisdom. Marijuana also became popular in the late 1960s and 1970s. Much of the marijuana was imported from Jamaica, where the Rastafarians considered marijuana (ganja) to be the “wisdom weed” and used it in religious rites and for spiritual wisdom.
Drugs have also been widely used for medicinal purposes. Opium was available in a crude form prior to 1800 and was valued by physicians for its calming effect and as a cure for gastrointestinal illnesses. Morphine, a derivative of opium, became a popular painkiller after 1870. When heroin, a derivative of morphine, was introduced into medical practice in the late 1800s, it was actively promoted by the American Medical Association (AMA) and pharmaceutical companies as a cure for many ailments. The easy availability of these drugs in the late nineteenth century was accompanied by a substantial increase in the number of drug addicts.5
Cocaine was first isolated from the coca leaf in the mid-nineteenth century. It became popular as a general tonic and for sinusitis and hay fever. The exhilarating effects of cocaine made it a popular additive in medicine, soda, and wine. In the United States, blacks were blamed by prohibitionists for the “cocaine problem.” Even though studies failed to confirm the widespread use of cocaine by blacks, the fear of an uprising of “euphoric” blacks was used, in part, to justify an era of lynchings and segregation.
LEGAL AND ILLEGAL DRUGS
State laws regulating the use of morphine and cocaine were first enacted in the United States in the 1890s. Federal prohibition of drugs was not attempted initially because it was thought to be unconstitutional. Libertarians, physicians, and the major pharmaceutical societies protested the outlawing of opiates, cocaine, and cannabis, substances they relied heavily on for symptom relief. Despite support for the medicinal use of drugs, by the mid-1920s, the federal government moved to eliminate all heroin use.
The Pure Food and Drug Act of 1906 was the first federal legislation to regulate the use of opium. Because opium was imported from China, opposition to opium was used to reinforce anti-Chinese sentiment and the persecution of Chinese immigrants.
It is sometimes assumed that the division between legal and illegal drugs is based on rational criteria, but this isn’t the case. Alcohol, nicotine (tobacco), and marijuana are currently the three most frequently used drugs in the United States. Yet marijuana, which rarely causes physiological addiction or serious illness, is illegal whereas alcohol and tobacco are not. According to an AMA study, tobacco is the number one “actual cause of death” in the United States; alcohol is number three.
Tobacco kills one out of every three users, ending their lives prematurely by an average of fifteen years. Globally it is responsible for one in every ten deaths, making it one of the leading causes of death in the world.6 More than 80 percent of these deaths occur in the developing world in countries such as China, India, and Indonesia, where tobacco companies are aggressively marketing cigarettes in order to make up for lost revenue due to declining smoking in most industrialized nations.7
Vaping, or the use of electronic cigarettes, has been touted as a safe alternative to regular cigarettes. However, while it has not been linked to cancer, vaping can harm the developing brain. Some of the flavors used in vaping can also damage the lungs.
The abuse of legal over-the-counter or prescription drugs such as painkillers, inhalants, or solvents can also lead to addiction and serious health problems and are responsible for almost twice as many deaths a year as illegal drugs. Marijuana has yet to be directly implicated as responsible in anyone’s death.8
The most recent wave of antidrug laws comes at a time when the public is divided over the wisdom of drug prohibition. Does the state have a right to prohibit or protect adults from using drugs? Is drug abuse a moral, legal, medical, or religious issue? Which drugs should be prohibited and which allowed?
DRUG AND ALCOHOL USE TODAY
More than 25 million Americans currently use illicit drugs. Another 60 million are addicted to cigarettes and 40 million binge on alcohol.9 Sixty-five percent of Americans believe that the drug problem in the United States today is “very” or “extremely” serious, with women and older adults more likely to be concerned about the problem of illicit drugs.10
Overdosing on opiates, both those acquired through legal means for medicinal use and those acquired illegally, kills almost 64,000 people a year, making the current opioid crisis one of the worse addiction epidemics in American history. Indeed, opiate use has been linked to the current decline in life expectancy in the United States.11
The use of illicit drugs by youth peaked in 1981, when 66 percent of American youth under the age of eighteen admitted to having tried illegal drugs.12 When the George H. W. Bush administration declared an official “war on drugs,” it had strong public support. Illicit drug use began declining during the 1980s. However, despite tougher laws and some initial victories, the success of the “war” was short-lived. During the mid-1990s, drug use began rising again, especially among young people. And marijuana has become ten to fifteen times more potent with the use of genetic engineering to alter the plant to make it resistant to attempts by drug agencies to destroy the crop through the use of pesticides.
Marijuana is the most widely used illicit drug in the United States. Support for marijuana is growing. In 2011, for the first time, the majority of Americans supported legalization of marijuana with support being highest among young people.13 Although marijuana was made illegal in 1937, medical marijuana under a doctor’s prescription is currently legal in Belgium, Austria, Great Britain, the Netherlands, and in fifteen states in the United States. In 2005 the U.S. Supreme Court ruled that the federal government can block the backyard cultivation of marijuana, thus greatly limiting its availability for medical use. California and Nevada are also cracking down on growers of medical marijuana.
Canada legalized the use of marijuana for medical purposes in 2001 and legalized marijuana for recreational use in 2018. The new law also allows people to grow their own marijuana, within certain limits, for personal use. This move has created tension between Canada and the United States, where possession of even a small amount of marijuana, unless approved for medical use, is punishable by up to a year in jail. Singapore, where the penalty for trafficking marijuana is death, has some of the toughest marijuana laws.
Possession of small amounts of marijuana has also been decriminalized in Spain, Russia, Greenland, most South American countries, and most parts of Australia. Although marijuana is technically illegal in the Netherlands, possession of less than 5 grams or five plants is not prosecutable. In countries such as Jamaica and India, where marijuana is used in traditional religious rites, its use is generally tolerated, though not legal.
Cocaine is the second most popular illicit drug in the United States. White males are twice as likely to use cocaine as black, Hispanic, and Native American males. African Americans, on the other hand, are more likely to use heroin. Because heroin-related offenses in the United States receive more severe legal penalties than cocaine use or alcohol-related crimes such as drunk driving, blacks bear a disproportionate burden with respect to enforcement of drug laws. Blacks are also more likely than whites to receive convictions for similar drug-related offenses. A study in the state of Washington found that African Americans, who made up only 3 percent of the state’s population, received nearly 20 percent of the drug sentences.14 This disparity was attributed in part to racial profiling.
Tobacco, although legal, is one of the most deadly and addictive drugs. It is responsible for one in five deaths in the United States and one in every three worldwide. Tobacco use has declined by more than 40 percent since 1965, with the largest drop being among college graduates. Less than 8 percent of today’s college graduates smoke compared to 30 percent in 1999.15 People who smoke are also smoking fewer cigarettes, probably because of the greater restrictions on smoking in public places and the workplace as well as increased concerns about the health risks of smoking.
Alcohol is a drug that in moderation may have health benefits. Slightly under two-thirds of Americans drink alcohol—a figure that has remained relatively steady since 1940. Most Americans drink responsibly. Excessive alcohol use, however, has health risks. Alcohol is responsible for more than six times as many deaths—75,000 a year in the United States alone—as all192illicit drugs combined. These include deaths due to accidents, violence, alcohol poisoning, liver disease, neurological disorders, cancer, and suicide.16
DRUG AND ALCOHOL USE AMONG COLLEGE STUDENTS
In 1984 the drinking age was raised from eighteen to twenty-one in the United States in an attempt to curb drunk-driving accidents. However, the drinking-age laws have had little effect on the actual drinking habits of college students. After dropping off from a high in the mid-1980s, drug and alcohol use among college students began to rise again in the 1990s. According to a 2016 survey of college students, marijuana use has almost doubled in the past two decades. One-third of college students also admit to binge drinking in the past two weeks.17
Binge drinking, is defined as five or more drinks in a row for men and four or more for women. Binge drinking is a serious problem on many campuses in both the United States and Canada. According to the National Institute on Alcohol Abuse, almost 2,000 college students die each year from alcohol-related injuries, including automobile accidents. Members of fraternities and sororities are at the highest risk of excessive drinking, because intoxication is viewed as an acceptable aspect of Greek life.18 The use of excessive alcohol has been responsible for the death of several fraternity initiates. (See Case Study 1: Fraternities and Alcohol: The Death of Benjamin Wynne.)
In addition to such problems as poor concentration, lower grade-point average (GPA), and health risks, binge drinking among college students is linked to intentional violence, including assault, homicide, rape, brawls, vandalism, and burglary, as well as being the victim of aggression, in part because being intoxicated makes the person an easier target for a predator.19
Of students who do not engage in binge drinking, the majority report problems caused by students who do. These problems ranged from unwanted sexual advances and property damage to having sleep or studying interrupted to assault. More than half of all date rapes on campuses are associated with alcohol consumption.20 Alcohol use is also a causal factor in suicide.
College drug use and binge drinking take a huge toll in terms of damage to health and cognitive functioning, violence, property damage, and liability costs to the fraternities and colleges associated with drunken parties. Would lowering the legal drinking age to eighteen make the problem of drinking on campus better or worse?
DRUGS IN SPORTS
Two weeks after the close of the summer 2000 Olympics in Sydney, Australia, the International Olympic Committee medical commission recommended that German wrestler Alexander Leipold be stripped of his gold medal. Leipold had tested positive for the steroid nandrolone after defeating American Brandon Slay in freestyle wrestling. Leipold denied taking the steroid and said he had no idea of how he could have tested positive. He is only one of forty-seven athletes who were suspended from the Sydney games for doping offenses, the highest number ever in the history of the Olympics. Apparently, mandatory drug testing has been ineffective. Despite steps taken to curb drug use in Olympic athletes and the adoption of a “Zero Tolerance for Doping” policy, drug use has continued to plague subsequent Olympics, including the 2016 Olympics. However, there has been a drop in violations since 2000. This has been attributed, in part,193to the development of new technologies or the creation of performance-enhancing drugs that cannot be detected.
Anabolic steroids, such as nandrolone, are testosterone-based drugs that stimulate muscle growth and help athletes recover faster from injuries. However, use of these steroids also increases by fivefold the risk of heart attacks and strokes and may contribute to the development of liver disease.
Although the harms associated with performance-enhancement drugs are well documented, their use in sports continues. Football is the toughest on drug use by professional athletes and hockey the most lenient, with basketball and baseball being somewhere in between the two.21 According to one estimate, between 20 and 40 percent of major league baseball players were using testosterone-based drugs in 2000.22
In addition to steroids, growth hormones, and testosterone, blood doping is used by some athletes in sports that demand great endurance, such as cycling. Blood doping entails injecting a synthetic version of EPO, a hormone that stimulates the bone marrow to produce more red blood cells, which carry oxygen to the muscles. Because EPO is a naturally occurring substance in the body, it is difficult to detect through blood tests. In 2005, French authorities accused American cyclist Lance Armstrong, six-time winner of the Tour de France, of doping practices, an accusation that he denied.
College sports are also plagued by drug use. Peer pressure is a factor in the increased use of steroids by college athletes and young people who want to improve their appearance. The American College of Sports Medicine reports that more than 6 percent of high school and college athletes have taken steroids without a doctor’s permission.23 A policy at Duke University calls for unannounced drug testing, including tests for performance-enhancing as well as recreational drugs, for all college athletes. The first violation is handled by treatment and counseling, the third violation by permanent suspension from the team.
The use of performance-enhancing drugs raises several moral issues. Does the duty of self-improvement require that athletes refrain from using drugs that will harm their bodies over the long run? Is it fair that athletes who use these drugs have a competitive advantage? Should drug testing be mandatory, or does mandatory drug testing violate the autonomy of the athlete? Is the use of performance-enhancing drugs in sports inherently coercive since it puts pressure on athletes to use drugs if they want to win? To learn more about the moral issues involved in the use of performance-enhancing drugs, see Thomas H. Murray’s essay on “Drugs, Sports, and Ethics.”24
In addition to enhancing athletic performance, drugs can also be used to enhance personality. Peole may drink a glass of alcohol at a party to overcome social awkwardness and shyness, or use antidepresants to become a happier, less self-occupied person. (See Case Study 4: Prozac: Enhancing Morality Through Drugs.)
THE DISEASE MODEL OF ADDICTION
The therapeutic revolution in the mid-twentieth century involved relabeling certain behaviors, previously attributed to moral weakness, as diseases. The disease model of addiction views addiction primarily as an individual medical problem rather than a social or moral problem. According to this model, it is not lack of willpower or moral character that separates addicts from nonaddicts. Addiction is a pathological state. Addicts abuse drugs because they are ill; they are biologically different from nonaddicts. People who harm others or break the law while under the194influence of alcohol or drugs should receive treatment, not punishment, because they were no more in control of what they did when “under the influence” than an epileptic having a seizure.
The disease model of addiction was first articulated in the 1940s by Elvine M. Jellinek of the Yale Center of Alcoholic Studies.25 It has since become the official view of both the AMA and the World Health Organization (WHO). In 1956 the AMA recognized drug addiction as a “chemical dependency” and, therefore, a disease like diabetes or cancer. In 1977 the AMA added alcoholism to its list of illnesses, defining it as “an illness characterized by significant impairment that is directly associated with persistent and excessive use of alcohol. Impairment may involve physiological, psychological, or social dysfunction.” Although abstinence may arrest the disease of addiction, the disease itself can never be cured because it is biologically based. Advances in genetics lend weight to the disease model of addiction and the idea of the “addictive personality.” (See Case Study 2: Baseball Star Mickey Mantle: Should Alcoholics Receive Liver Transplants?.)
Alcoholics Anonymous (AA) is based primarily on the disease model. A fundamental assumption of the AA Twelve Steps program is that healing can occur only when alcoholics admit their powerlessness over addiction and turn the healing process over to a “higher power.” The “one disease [addiction], one treatment [abstinence]” approach of AA currently dominates the medical field. (See Case Study 5: The Alcoholics Anonymous Confession of a Double Murderer.)
THE MORAL MODEL OF ADDICTION
Addiction, according to the moral model of addiction, is a freely chosen vice. In his reading at the end of this chapter, Psychiatrist Thomas Szasz, in his reading at the end of this chapter, questions the validity of the medical model and calls for a return to the moral model. Resisting or overcoming addiction is simply a matter of willpower. The religious view that alcoholism is a sin, the prohibition legislation of the early twentieth century, and the “Just Say No” campaign are all based on the moral model of addiction.
Most positions on addiction lie somewhere between the two extremes. Although AA is based primarily on the disease model, accepting moral responsibility for one’s actions is also a key part of the recovery process. Similarly, most supporters of the moral model acknowledge that there are social, personal, and genetic factors that make it more likely that certain people will become addicts. However, unlike predispositions to other diseases, such as breast cancer and diabetes, a person who is genetically predisposed to addiction can avoid it altogether by avoiding the substances that may lead to addiction. Therefore, people who harm others while under the influence of alcohol or drugs should be held morally responsible for their choices and actions. Under the moral model, punishment is an appropriate response to drug-related crime.
THE PHILOSOPHERS ON DRUG AND ALCOHOL ABUSE
Aristotle rejects the disease model of addiction. According to him, virtue entails acting according to reason. People who are drunk are “acting in ignorance.” Thus, addicts give up their essential humanity by giving up control of their actions. We need have no sympathy for a person whose health is destroyed by excessive drinking or drug abuse. Unlike a person whose illness is involuntary, a drunkard is responsible for his ignorance “since it was open to him to refrain from getting drunk.”26 If a person does drink in excess, that person has a responsibility to avoid 195situations, such as some fraternity parties, where he or she might be temped to get drunk or hurt or abuse someone.
Although Aristotle would probably not object to the use of drugs and alcohol in moderation, Buddhists are morally opposed to any use of drugs or alcohol because a “clear and composed mind” is necessary to achieve moral perfection and enlightenment. According to Buddha, all human suffering is caused by people whose minds are confused and their reason dulled.
Muslims are also opposed to the use of alcohol and drugs. Alcohol use is a moral failing. According to Muslim philosophy, “When a person drinks he becomes intoxicated; when he is intoxicated he raves; and when he raves he falsely accuses.”27
Libertarians favor a permissive policy on drug and alcohol use. John Stuart Mill opposed the U.S. prohibition laws of the 1850s as an unjustified interference with people’s liberty. He wrote, “Over himself, over his own body and mind, the individual is sovereign.”28 Although Mill acknowledged that drug or alcohol users can harm others by rendering themselves incapable of working, this does not justify prohibiting drugs, because society can afford to absorb these losses for the sake of liberty.
THE MORAL ISSUES
Virtue Ethics and the Good Life
Virtue ethicists encourage us to improve our character through self-examination and the practice of virtuous behavior. Addiction interferes with our ability to engage in philosophical self-examination and to seek the higher good.
Virtue, in most cases, requires us to seek the mean between excess and deficit. The doctrine of the mean requires that we use our reason to discern where the mean is for us. According to the disease model, the use of any amount of a drug is excessive for addicts. For other people, moderation may be appropriate and consistent with the good and virtuous life. Studies at Harvard University have found that light and moderate drinkers are healthier and live longer than total abstainers. Morphine is another drug where excess for one person may be a deficiency for another. Although it can be addictive, to refuse a dying cancer patient morphine because of fear of addiction is to err on the side of deficiency.
Confucius believed that government bears the primary responsibility for promoting virtue in citizens. The purpose of laws is to make it easier for people to be virtuous. James Q. Wilson argues that if drugs are legal, many people will prefer the pleasure of drug excess over treatment and virtuous behavior. Others contend that it is not the place of government to impose on citizens an ideal of human excellence. It is up to each of us to responsibly determine our own concept of the good life.
Human Dignity and the Categorical Imperative
Kant’s categorical imperative states that we should never use ourselves as a means only. Addicts debase themselves by using themselves as a means only—to get a fix through drugs or alcohol. Addiction is tempting because it “fixes” our disquiet and malaise. Addiction distracts us from our lives and relieves us of the burden, the frustration, the boredom, and the search for meaning in our lives. Addiction becomes the meaning of life. Because drug abuse and addiction prevent us from being fully human, they are incompatible with human dignity.
As rational moral agents, we are responsible for our choices and actions. The disease model is problematic in that it places the burden of “curing” addiction on physicians rather than on the individual, thus allowing addicts to abdicate personal responsibility for their behavior. Passing off responsibility for our destructive and disrespectful behavior is inconsistent with human dignity and freedom.
Autonomy, Liberty Rights, and the Principle of Noninterference
Autonomy involves our ability to make free choices. Szasz argues that prohibiting recreational drug use violates our autonomy. The “right of self-medication,” he writes, is a fundamental right. Enforcement procedures are not only futile, but an infringement on people’s liberty rights. They reject the disease model of addiction. Drug addicts are autonomous, because any person of “reasonable firmness” can stop using drugs.
Not everyone agrees that adult drug users are acting autonomously. Thomas Murray, for example, maintains that the use of performance-enhancing drugs in sports is “inherently coercive.” In sports, in which one’s professional success may ride on using performance-enhancing drugs, the pressure to use these drugs may seriously compromise the athlete’s autonomy. Like Major League Baseball, the National Football League and the National Basketball Association have banned many performance-enhancing drugs, but they balk at mandatory blood testing, saying that making players give blood violates their privacy.
The principle of noninterference states that interference with adults’ free choice must be justified. However, most drug and alcohol addicts begin as children. In the United States, the average age is twelve for the first use of alcohol and thirteen for the first use of illicit drugs.29 Judges in both Massachusetts and Iowa have upheld a school’s right to search students for drugs, ruling in Iowa v. Marzel Jones (2003) that the school’s interest in maintaining “a controlled and disciplined environment” overrules a student’s right to privacy.
Pleasure
Pleasure is the most common reason college students give for using alcohol and drugs.30 According to some utilitarians, the use of drugs for pleasure is not necessarily at odds with the good life and may even contribute to it. However, they draw the line at drug use that interferes with living the good life.
Paternalism and Harm to Self
Paternalism permits interfering with people’s choices for their own good. Drugs and alcohol can be harmful to self. The life of an average alcoholic, for example, is nearly a decade shorter than that of a nonalcoholic.31
The belief that drug and alcohol abuse is a disease promotes a paternalistic approach to drug and alcohol regulation. Indeed, according to the Centers for Disease Control, smoking shortens one’s life by more than ten years. Laws prohibiting alcohol and tobacco use by children are generally based on the principle of paternalism. Given that so many untimely adult deaths involve tobacco and alcohol abuse, however, shouldn’t paternalism extend to adults as well? If adults use these and other drugs in a manner that is harmful to themselves, isn’t their “decision” to do so by definition irrational and, hence, not a free and autonomous choice?
Prohibition based on paternalism can come into conflict with the principle of autonomy. The use of coercion—even “well-meaning” coercion—in an attempt to regulate a person’s 197character is an affront to human dignity and freedom. Should we prohibit drugs for all because drugs seriously impair the autonomy of some? The belief that people use drugs “against their will,” that they have “lost control of their lives,” or that drug users are “morally deficient” is demeaning. It may be better to let addicts continue harming themselves rather than deny them at least some control over their lives.
Furthermore, because people do not like to be told what to do, paternalism can backfire. There was a dramatic increase in drug use, especially among young people, following President Bush’s declaration of war on drugs. Studies also suggest that raising the drinking age from eighteen to twenty-one throughout the United States may actually have exacerbated the bingeing problem on campuses. In addition to the lure of forbidden fruit, students are now more likely to drink in private places like their dorms and fraternities or in bars that are lax in checking for proper ID.
Nonmaleficence and Preventing Harm to Others
One of the most common arguments for drug prohibition is protection of public health and safety. President Trump, for example, uses this argument in his reading at the end of this chapter. Although restrictions based on paternalism are often considered an affront to personal dignity, most people acknowledge that coercion is justified to prevent people from harming one another.
Wilson, for example, argues that the harms of legalizing drugs outweigh those of prohibition. Drug abuse, he points out, is hardly a victimless crime. It is associated with health problems, reduced job productivity, family violence, crime, fetal alcohol syndrome, drug-addicted newborns, and suicide. Many of these costs are passed on to society. Twenty percent of Medicare funds go to the treatment of problems stemming from alcohol and drug abuse.
Prosecuting and punishing drug-related crimes cost taxpayers more than $30 billion a year. Just over half of the prisoners in federal prisons are drug offenders, and of these, about half are incarcerated for marijuana-related offenses.32
Both Scarlett and Berg, in their readings at the end of this chapter, support legalizing recreational drugs. Harm to others is a powerful argument for working toward decreasing drug and alcohol abuse, but it is not obvious that legal prohibition is the best solution; drug education may be more effective. Making drugs illegal forces up their price, thus encouraging users to resort to crime to pay for their habit. Much of the street violence in our cities is attributable to the illicit sale of drugs rather than to the actual effects of the drugs themselves. In addition, drug prohibition can bring young people seeking drugs into contact with the criminal element.
There are also hidden costs of illegal drug use and alcoholism in terms of domestic violence and the breakup of families. In addition, the cost of health care for alcoholics is more than double that for nonalcoholics; much of this cost is borne by taxpayers and employers. Smokers also use more medical resources and have longer hospital stays than nonsmokers. Indeed, lung cancer is now the leading cause of cancer deaths in both men and women.
CONCLUSION
Drug and alcohol use raises two concerns. The first relates to virtue ethics: We have a personal responsibility to abstain from harmful drugs or drugs that are addictive. If addiction is a disease, virtue dictates that addicts or potential addicts are morally responsible for avoiding drugs and/or alcohol and for seeking a cure, or at least avoiding situations in which they could harm others. On 198the other hand, the moderate use of certain drugs may actually enhance the good life. Knowing the difference between excess and moderation involves the development of wisdom and character.
The second issue relates to social policy. Some philosophers maintain that drugs should be prohibited. Most people agree that harm to others is a strong justification for restricting drug use; however, they disagree over the best means to achieve the objective of minimizing harm.
THOMAS SZASZ
The Ethics of Addiction
Thomas Szasz is a professor emeritus of psychiatry at the State University of New York Upstate Medical Center and author of several books on psychiatry, including The Myth of Mental Illness. In this article Szasz rejects the disease model of addiction. Citing John Stuart Mill’s principle of no harm, Szasz argues that drug laws do not respect the right of citizens to exercise control over their own lives. Therefore, all prohibition laws should be repealed, at least for adults.
Szasz, Dr. Thomas, “The Ethics of Addiction,” Harper’s Magazine, vol. 244, April 1972, 74–79. Used with permission of the author.
AN ARGUMENT IN FAVOR OF LETTING AMERICANS TAKE ANY DRUG THEY WANT TO TAKE
To avoid cliches about “drug abuse,” let us analyze its official definition. According to the World Health Organization, “Drug addiction is a state of periodic or chronic intoxication detrimental to the individual and to society, produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: 1) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means, 2) a tendency to increase the dosage, and 3) a psychic (psychological) and sometimes physical dependence on the effects of the drug.”
Since this definition hinges on the harm done to both the individual and society, it is clearly an ethical one. Moreover, by not specifying what is “detrimental,” it consigns the problem of addiction to psychiatrists who define the patient’s “dangerousness to himself and others.”
Next, we come to the effort to obtain the addictive substance “by any means.” This suggests that the substance must be prohibited, or is very expensive, and is hence difficult for the ordinary person to obtain (rather than that the person who wants it has an inordinate craving for it). If there were an abundant and inexpensive supply of what the “addict” wants, there would be no reason for him to go to “any means” to obtain it. Thus by the WHO’s definition, one can be addicted only to a substance that is illegal or otherwise difficult to obtain. This surely removes the problem of addiction from the realm of medicine and psychiatry, and puts it squarely into that of morals and law.
In short, drug addiction or drug abuse cannot be defined without specifying the proper and improper uses of certain pharmacologically active agents. The regular administration of morphine by a physician to a patient dying of cancer is the paradigm of the proper use of a narcotic; whereas even its occasional self-administration by a physically healthy person for the purpose of “pharmacological pleasure” is the paradigm of drug abuse.
I submit that these judgments have nothing whatever to do with medicine, pharmacology, or psychiatry. They are moral judgments. Indeed, our present views on addiction are astonishingly similar to some of our former views on sex. Until recently, masturbation—or self-abuse, as it was called—was professionally declared, and popularly accepted, as both the cause and the symptom of a variety of illnesses. Even today, homosexuality— called a “sexual perversion”—is regarded as a disease by medical and psychiatric experts as well as by “well-informed” laymen.
To be sure, it is now virtually impossible to cite a contemporary medical authority to support the concept of self-abuse. Medical opinion holds that whether a person masturbates or not is medically irrelevant; and that engaging in the practice or refraining from it is a matter of personal morals or life-style. On the other hand, it is virtually impossible to cite a contemporary medical authority to oppose the concept of drug abuse. Medical opinion holds that drug abuse is a major medical, psychiatric, and public health problem; that drug addiction is a disease similar to diabetes, requiring prolonged (or lifelong) and careful, medically supervised treatment; and that taking or not taking drugs is primarily, if not solely, a matter of medical responsibility.
Thus the man on the street can only believe what he hears from all sides—that drug addiction is a disease, “like any other,” which has now reached “epidemic proportions,” and whose “medical” containment justifies the limitless expenditure of tax monies and the corresponding aggrandizement and enrichment of noble medical warriors against this “plague.”
PROPAGANDA TO JUSTIFY PROHIBITION
Like any social policy, our drug laws may be examined from two entirely different points of view: technical and moral. Our present inclination is either to ignore the moral perspective or to mistake the technical for the moral.
Since most of the propagandists against drug use seek to justify certain repressive policies because of the alleged dangerousness of various drugs, they often falsify the facts about the pharmacological properties of the drugs they seek to prohibit. They do so for two reasons: first, because many substances in daily use are just as harmful as the substances they want to prohibit; second, because they realize that dangerousness alone is never a sufficiently persuasive argument to justify the prohibition of any drug, substance, or artifact. Accordingly, the more they ignore the moral dimensions of the problem, the more they must escalate their fraudulent claims about the dangers of drugs.
To be sure, some drugs are more dangerous than others. It is easier to kill oneself with heroin than with aspirin. But is also easier to kill oneself by jumping off a high building than a low one. In the case of drugs, we regard their potentiality for self-injury as justification for their prohibition; in the case of buildings, we do not.
Furthermore, we systematically blur and confuse the two quite different ways in which narcotics may cause death: by a deliberate act of suicide or by accidental overdosage.
Every individual is capable of injuring or killing himself. This potentiality is a fundamental expression of human freedom. Self-destructive behavior may be regarded as sinful and penalized by means of informal sanctions. But it should not be regarded as a crime or (mental) disease, justifying or warranting the use of the police powers of the state for its control.
Therefore, it is absurd to deprive an adult of a drug (or of anything else) because he might use it to kill himself. To do so is to treat everyone the way institutional psychiatrists treat the so-called suicidal mental patient: they not only imprison such a person but take everything away from him—shoelaces, belts, razor blades, eating utensils, and so forth—until the “patient” lies naked on a mattress in a padded cell—lest he kill himself. The result is degrading tyrannization.
Death by accidental overdose is an altogether different matter. But can anyone doubt that this danger now looms so large precisely because the sale of narcotics and many other drugs is illegal? Those who buy illicit drugs cannot be sure what drug they are getting or how much of it. Free trade in drugs, with governmental action limited to safeguarding the purity of the product and the veracity of the labeling, would reduce the risk of accidental overdose with “dangerous drugs” to the same levels that prevail, and that we find acceptable, with respect to other chemical agents and physical artifacts that abound in our complex technological society.
This essay is not intended as an exposition on the pharmacological properties of narcotics and other mind-affecting drugs. However, I want to make it clear that in my view, regardless of their danger, all drugs should be “legalized” (a misleading term I employ reluctantly as a concession to common usage). Although I recognize that some drugs—notably heroin, the amphetamines, and LSD, among those now in vogue—may have undesirable or dangerous consequences, I favor free trade in drugs for the same reason the Founding Fathers favored 201free trade in ideas. In an open society, it is none of the government’s business what idea a man puts into his mind; likewise, it should be none of the government’s business what drug he puts into his body.
WITHDRAWAL PAINS FROM TRADITION
It is a fundamental characteristic of human beings that they get used to things: one becomes habituated, or “addicted,” not only to narcotics, but to cigarettes, cocktails before dinner, orange juice for breakfast, comic strips, and so forth. It is similarly a fundamental characteristic of living organisms that they acquire increasing tolerance to various chemical agents and physical stimuli: the first cigarette may cause nothing but nausea and headache; a year later, smoking three packs a day may be pure joy. Both alcohol and opiates are “addictive” in the sense that the more regularly they are used, the more the user craves them and the greater his tolerance for them becomes. Yet none of this involves any mysterious process of “getting hooked.” It is simply an aspect of the universal biological propensity for learning, which is especially well developed in man. The opiate habit, like the cigarette habit or food habit, can be broken—and without any medical assistance—provided the person wants to break it. Often he doesn’t. And why, indeed, should he, if he has nothing better to do with his life? Or, as happens to be the case with morphine, if he can live an essentially normal life while under its influence?
Actually, opium is much less toxic than alcohol. Just as it is possible to be an “alcoholic” and work and be productive, so it is (or, rather, it used to be) possible to be an opium addict and work and be productive….
I am not citing this evidence to recommend the opium habit. The point is that we must, in plain honesty, distinguish between pharmacological effects and personal inclinations. Some people take drugs to help them function and conform to social expectations; others take them for the very opposite reason, to ritualize their refusal to function and conform to social expectations. Much of the “drug abuse” we now witness—perhaps nearly all of it—is of the second type. But instead of acknowledging that “addicts” are unfit or unwilling to work and be “normal,” we prefer to believe that they act as they do because certain drugs—especially heroin, LSD, and the amphetamines—make them “sick.” If only we could get them “well,” so runs this comforting view, they would become “productive” and “useful” citizens. To believe this is like believing that if an illiterate cigarette smoker would only stop smoking, he would become an Einstein. With a falsehood like this, one can go far. No wonder that politicians and psychiatrists love it.
The concept of free trade in drugs runs counter to our cherished notion that everyone must work and idleness is acceptable only under special conditions. In general, the obligation to work is greatest for healthy, adult, white men. We tolerate idleness on the part of children, women, Negroes, the aged, and the sick, and even accept the responsibility to support them. But the new wave of drug abuse affects mainly young adults, often white males, who are, in principle at least, capable of working and supporting themselves. But they refuse: they “drop out”; and in doing so, they challenge the most basic values of our society.
The fear that free trade in narcotics would result in vast masses of our population spending their days and nights smoking opium or mainlining heroin, rather than working and taking care of their responsibilities, is a bugaboo that does not deserve to be taken seriously. Habits of work and idleness are deep-seated cultural patterns. Free trade in abortions has not made an industrious people like the Japanese give up work for fornication. Nor would free trade in drugs convert such a people from hustlers to hippies. Indeed, I think the opposite might be the case: it is questionable whether, or for how long, a responsible people can tolerate being treated as totally irresponsible with respect to drugs and drug-taking. In other words, how long can we live with the inconsistency of being expected to be responsible for operating cars and computers, but not for operating our own bodies?
Although my argument about drug-taking is moral and political, and does not depend upon showing that free trade in drugs would also have fiscal advantages over our present policies, let me indicate briefly some of its economic implications.
The war on addiction is not only astronomically expensive; it is also counterproductive. On April 1, 1967, New York State’s narcotics addiction control program, hailed as “the most massive ever tried in the nation,” went into effect. “The program, which may cost 202up to $400 million in three years,” reported the New York Times, “was hailed by Governor Rockefeller as ‘the start of an unending war.’ ”… In short, the detection and rehabilitation of addicts is good business. We now know that the spread of witchcraft in the late Middle Ages was due more to the work of witchmongers than to the lure of witchcraft. Is it not possible that the spread of addiction in our day is due more to the work of addictmongers than to the lure of narcotics?
Let us see how far some of the monies spent on the war on addiction could go in supporting people who prefer to drop out of society and drug themselves. Their “habit” itself would cost next to nothing; free trade would bring the price of narcotics down to a negligible amount….
… free trade in narcotics would be more economical for those of us who work, even if we had to support legions of addicts, than is our present program of trying to “cure” them. Moreover, I have not even made use, in my economic estimates, of the incalculable sums we would save by reducing crimes now engendered by the illegal traffic in drugs.
THE RIGHT OF SELF-MEDICATION
Clearly, the argument that marijuana—or heroin, methadone, or morphine—is prohibited because it is addictive or dangerous cannot be supported by facts. For one thing, there are many drugs, from insulin to penicillin, that are neither addictive nor dangerous but are nevertheless also prohibited; they can be obtained only through a physician’s prescription. For another, there are many things, from dynamite to guns, that are much more dangerous than narcotics (especially to others) but are not prohibited. As everyone knows, it is still possible in the United States to walk into a store and walk out with a shotgun. We enjoy this right not because we believe that guns are safe but because we believe even more strongly that civil liberties are precious. At the same time, it is not possible in the United States to walk into a store and walk out with a bottle of barbiturates, codeine, or other drugs.
I believe that just as we regard freedom of speech and religion as fundamental rights, so we should also regard freedom of self-medication as a fundamental right. Like most rights, the right of self-medication should apply only to adults; and it should not be an unqualified right. Since these are important qualifications, it is necessary to specify their precise range.
John Stuart Mill said (approximately) that a person’s right to swing his arm ends where his neighbor’s nose begins. And Oliver Wendell Holmes said that no one has a right to shout “Fire!” in a crowded theater. Similarly, the limiting condition with respect to self-medication should be the inflicting of actual (as against symbolic) harm on others.
Our present practices with respect to alcohol embody and reflect this individualistic ethic. We have the right to buy, possess, and consume alcoholic beverages. Regardless of how offensive drunkenness might be to a person, he cannot interfere with another person’s “right” to become inebriated so long as that person drinks in the privacy of his own home or at some other appropriate location, and so long as he conducts himself in an otherwise law-abiding manner. In short, we have a right to be intoxicated—in private. Public intoxication is considered an offense to others and is therefore a violation of the criminal law. It makes sense that what is a “right” in one place may become, by virtue of its disruptive or disturbing effect on others, an offense somewhere else.
The right to self-medication should be hedged in by similar limits. Public intoxication, not only with alcohol but with any drug, should be an offense punishable by the criminal law. Furthermore, acts that may injure others—such as driving a car—should, when carried out in a drug-intoxicated state, be punished especially strictly and severely. The right to self-medication must thus entail unqualified responsibility for the effects of one’s drug-intoxicated behavior on others. For unless we are willing to hold ourselves responsible for our own behavior, and hold others responsible for theirs, the liberty to use drugs (or to engage in other acts) degenerates into a license to hurt others.
Such, then, would be the situation of adults, if we regarded the freedom to take drugs as a fundamental right similar to the freedom to read and worship. What would be the situation of children? Since many people who are now said to be drug addicts or drug abusers are minors, it is especially important that we think clearly about this aspect of the problem.
I do not believe, and I do not advocate, that children should have a right to ingest, inject, or otherwise use any 203drug or substance they want. Children do not have the right to drive, drink, vote, marry, or make binding contracts. They acquire these rights at various ages, coming into their full possession at maturity, usually between the ages of eighteen and twenty-one. The right to self-medication should similarly be withheld until maturity.
In short, I suggest that “dangerous” drugs be treated, more or less, as alcohol is treated now. Neither the use of narcotics, nor their possession, should be prohibited, but only their sale to minors. Of course, this would result in the ready availability of all kinds of drugs among minors—though perhaps their availability would be no greater than it is now, but would only be more visible and hence more easily subject to proper controls. This arrangement would place responsibility for the use of all drugs by children where it belongs: on parents and their children. This is where the major responsibility rests for the use of alcohol. It is a tragic symptom of our refusal to take personal liberty and responsibility seriously that there appears to be no public desire to assume a similar stance toward other “dangerous” drugs.
Consider what would happen should a child bring a bottle of gin to school and get drunk there. Would the school authorities blame the local liquor stores as pushers? Or would they blame the parents and the child himself? There is liquor in practically every home in America and yet children rarely bring liquor to school. Whereas marijuana, Dexedrine, and heroin—substances children usually do not find at home and whose very possession is a criminal offense—frequently find their way into the school.
Our attitude toward sexual activity provides another model for our attitude toward drugs. Although we generally discourage children below a certain age from engaging in sexual activities with others, we do not prohibit such activities by law. What we do prohibit by law is the sexual seduction of children by adults. The “pharmacological seduction” of children by adults should be similarly punishable. In other words, adults who give or sell drugs to children should be regarded as offenders. Such a specific and limited prohibition—as against the kinds of generalized prohibitions that we had under the Volstead Act or have now with respect to countless drugs—would be relatively easy to enforce. Moreover, it would probably be rarely violated, for there would be little psychological interest and no economic profit in doing so.
THE TRUE FAITH: SCIENTIFIC MEDICINE
What I am suggesting is that while addiction is ostensibly a medical and pharmacological problem, actually it is a moral and political problem. We ought to know that there is no necessary connection between facts and values, between what is and what ought to be. Thus, objectively quite harmful acts, objects, or persons may be accepted and tolerated—by minimizing their dangerousness. Conversely, objectively quite harmless acts, objects, or persons may be prohibited and persecuted—by exaggerating their dangerousness. It is always necessary to distinguish—and especially so when dealing with social policy—between description and prescription, fact and rhetoric, truth and falsehood.
In our society, there are two principal methods of legitimizing policy: social tradition and scientific judgment. More than anything else, time is the supreme ethical arbiter. Whatever a social practice might be, if people engage in it, generation after generation, that practice becomes acceptable.
Many opponents of illegal drugs admit that nicotine may be more harmful to health than marijuana; nevertheless, they urge that smoking cigarettes should be legal but smoking marijuana should not be, because the former habit is socially accepted while the latter is not. This is a perfectly reasonable argument. But let us understand it for what it is—a plea for legitimizing old and accepted practices, and for illegitimizing novel and unaccepted ones. It is a justification that rests on precedent, not evidence.
The other method of legitimizing policy, ever more important in the modern world, is through the authority of science. In matters of health, a vast and increasingly elastic category, physicians play important roles as legitimizers and illegitimizers. This, in short, is why we regard being medicated by a doctor as drug use, and self-medication (especially with certain classes of drugs) as drug abuse.
This, too, is a perfectly reasonable arrangement. But we must understand that it is a plea for legitimizing what doctors do, because they do it with “good therapeutic” intent; and for illegitimatizing what laymen do, because they do it with bad self-abusive (“masturbatory” or mind-altering) intent. This justification rests on the principles of professionalism, not of pharmacology. Hence 204we applaud the systematic medical use of methadone and call it “treatment for heroin addiction,” but decry the occasional nonmedical use of marijuana and call it “dangerous drug abuse.”
Our present concept of drug abuse articulates and symbolizes a fundamental policy of scientific medicine—namely, that a layman should not medicate his own body but should place its medical care under the supervision of a duly accredited physician. Before the Reformation, the practice of True Christianity rested on a similar policy—namely, that a layman should not himself commune with God but should place his spiritual care under the supervision of a duly accredited priest. The self-interests of the church and of medicine in such policies are obvious enough. What might be less obvious is the interest of the laity: by delegating responsibility for the spiritual and medical welfare of the people to a class of authoritatively accredited specialists, these policies—and the practices they ensure—relieve individuals from assuming the burdens of responsibility for themselves. As I see it, our present problems with drug use and drug abuse are just one of the consequences of our pervasive ambivalence about personal autonomy and responsibility.
I propose a medical reformation analogous to the Protestant Reformation: specifically, a “protest” against the systematic mystification of man’s relationship to his body and his professionalized separation from it. The immediate aim of this reform would be to remove the physician as intermediary between man and his body and to give the layman direct access to the language and contents of the pharmacopoeia. If man had unencumbered access to his own body and the means of chemically altering it, it would spell the end of medicine, at least as we now know it. This is why, with faith in scientific medicine so strong, there is little interest in this kind of medical reform. Physicians fear the loss of their privileges; laymen, the loss of their protections….
LIFE, LIBERTY, AND THE PURSUIT OF DRUGS
Sooner or later we shall have to confront the basic moral dilemma underlying this problem: does a person have the right to take a drug, any drug—not because he needs it to cure an illness, but because he wants to take it?
The Declaration of Independence speaks of our inalienable right to “life, liberty, and the pursuit of happiness.” How are we to interpret this? By asserting that we ought to be free to pursue happiness by playing golf or watching television, but not by drinking alcohol, or smoking marijuana, or ingesting pep pills?
The Constitution and the Bill of Rights are silent on the subject of drugs. This would seem to imply that the adult citizen has, or ought to have, the right to medicate his own body as he sees fit. Were this not the case, why should there have been a need for a Constitutional Amendment to outlaw drinking? But if ingesting alcohol was, and is now again, a Constitutional right, is ingesting opium, or heroin, or barbiturates, or anything else, not also such a right? If it is, then the Harrison Narcotic Act is not only a bad law but is unconstitutional as well, because it prescribes in a legislative act what ought to be promulgated in a Constitutional Amendment.
The questions remain: as American citizens, should we have the right to take narcotics or other drugs? If we take drugs and conduct ourselves as responsible and law-abiding citizens, should we have a right to remain unmolested by the government? Lastly, if we take drugs and break the law, should we have a right to be treated as persons accused of crime, rather than as patients accused of mental illness?
These are fundamental questions that are conspicuous by their absence from all contemporary discussions of problems of drug addiction and drug abuse. The result is that instead of debating the use of drugs in moral and political terms, we define our task as the ostensibly narrow technical problem of protecting people from poisoning themselves with substances for whose use they cannot possibly assume responsibility. This, I think, best explains the frightening national consensus against personal responsibility for taking drugs and for one’s conduct while under their influence….
To me, unanimity on an issue as basic and complex as this means a complete evasion of the actual problem and an attempt to master it by attacking and overpowering a scapegoat—“dangerous drugs” and “drug abusers.” There is an ominous resemblance between the unanimity with which all “reasonable” men—and especially politicians, physicians, and priests—formerly supported the protective measures of society against witches and Jews, and that with which they now support them against drug addicts and drug abusers.
After all is said and done, the issue comes down to whether we accept or reject the ethical principle John Stuart Mill so clearly enunciated: “The only purpose [he wrote in On Liberty] for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will make him happier, because in the opinions of others, to do so would be wise, or even right…. In the part [of his conduct] which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.”
By recognizing the problem of drug abuse for what it is—a moral and political question rather than a medical or therapeutic one—we can choose to maximize the sphere of action of the state at the expense of the individual, or of the individual at the expense of the state. In other words, we could commit ourselves to the view that the state, the representative of many, is more important than the individual; that it therefore has the right, indeed the duty, to regulate the life of the individual in the best interests of the group. Or we could commit ourselves to the view that individual dignity and liberty are the supreme values of life, and that the foremost duty of the state is to protect and promote these values.
In short, we must choose between the ethic of collectivism and individualism, and pay the price of either—or of both.
JAMES Q. WILSON
Against the Legalization of Drugs
James Q. Wilson was a professor of political science at Boston University and former chair of the National Advisory Council for Drug Abuse Prevention. He was also the author of The Moral Sense and Crime and Human Nature. In this article Wilson rejects the libertarian view that 206citizens have the right to use drugs and to drink anything they want. Instead, Wilson argues that the harms of legalizing drugs outweigh the harms of prohibition.
James Q. Wilson, “Against the Legalization of Drugs.” Reprinted from Commentary, vol. 89, no. 2, February 1990 by permission; ©1990 by Commentary, Inc.
In 1972, the President appointed me chairman of the National Advisory Council for Drug Abuse Prevention. Created by Congress, the Council was charged with providing guidance on how best to coordinate the national war on drugs. (Yes, we called it a war then, too.) In those days, the drug we were chiefly concerned with was heroin. When I took office, heroin use had been increasing dramatically. Everybody was worried that this increase would continue. Such phrases as “heroin epidemic” were commonplace.
That same year, the eminent economist Milton Friedman published an essay in Newsweek in which he called for legalizing heroin. His argument was on two grounds: as a matter of ethics, the government has no right to tell people not to use heroin (or to drink or to commit suicide); as a matter of economics, the prohibition of drug use imposes costs on society that far exceed the benefits. Others, such as the psychoanalyst Thomas Szasz, made the same argument….
That was 1972. Today, we have the same number of heroin addicts that we had then—half a million, give or take a few thousand. Having that many heroin addicts is no trivial matter; these people deserve our attention. But not having had an increase in that number for over fifteen years is also something that deserves our attention. What happened to the “heroin epidemic” that many people once thought would overwhelm us?
The facts are clear: a more or less stable pool of heroin addicts has been getting older, with relatively few new recruits. In 1976 the average age of heroin users who appeared in hospital emergency rooms was about twenty-seven; ten years later it was thirty-two. More than two-thirds of all heroin users appearing in emergency rooms are now over the age of thirty. Back in the early 1970s, when heroin got onto the national political agenda, the typical heroin addict was much younger, often a teenager….
Why did heroin lose its appeal for young people? When the young blacks in Harlem were asked why they stopped, more than half mentioned “trouble with the law” or “high cost” (and high cost is, of course, directly the result of law enforcement). Two-thirds said heroin 207hurt their health; nearly all said they had had a bad experience with it. We need not rely, however, simply on what they said. In New York City in 1973–75, the street price of heroin rose dramatically and its purity sharply declined, probably as a result of the heroin shortage caused by the success of the Turkish government in reducing the supply of opium base and of the French government in closing down heroin-processing laboratories located in and around Marseilles. These were short-lived gains for, just as Friedman predicted, alternative sources of supply—mostly in Mexico—quickly emerged. But the three-year heroin shortage interrupted the easy recruitment of new users….
RELIVING THE PAST
Suppose we had taken Friedman’s advice in 1972. What would have happened? We cannot be entirely certain, but at a minimum we would have placed the young heroin addicts (and, above all, the prospective addicts) in a very different position from the one in which they actually found themselves. Heroin would have been legal. Its price would have been reduced by 95 percent (minus whatever we chose to recover in taxes). Now that it could be sold by the same people who make aspirin, its quality would have been assured—no poisons, no adulterants. Sterile hypodermic needles would have been readily available at the neighborhood drugstore, probably at the same counter where the heroin was sold. No need to travel to big cities or unfamiliar neighborhoods—heroin could have been purchased anywhere, perhaps by mail order.
There would no longer have been any financial or medical reason to avoid heroin use. Anybody could have afforded it. We might have tried to prevent children from buying it, but as we have learned from our efforts to prevent minors from buying alcohol and tobacco, young people have a way of penetrating markets theoretically reserved for adults. Returning Vietnam veterans would have discovered that Omaha and Raleigh had been converted into the pharmaceutical equivalent of Saigon.
Under these circumstances, can we doubt for a moment that heroin use would have grown exponentially? Or that a vastly larger supply of new users would have been recruited? …
But we need not rely on speculation, however plausible, that lowered prices and more abundant supplies would have increased heroin usage. Great Britain once followed such a policy and with almost exactly those results. Until the mid-1960s, British physicians were allowed to prescribe heroin to certain classes of addicts. (Possessing these drugs without a doctor’s prescription remained a criminal offense.) For many years this policy worked well enough because the addict patients were typically middle-class people who had become dependent on opiate painkillers while undergoing hospital treatment. There was no drug culture. The British system worked for many years, not because it prevented drug abuse, but because there was no problem of drug abuse that would test the system.
All that changed in the 1960s. A few unscrupulous doctors began passing out heroin in wholesale amounts. One doctor prescribed almost 600,000 heroin tablets—that is, over thirteen pounds—in just one year. A youthful drug culture emerged with a demand for drugs far different from that of the older addicts. As a result, the British government required doctors to refer users to government-run clinics to receive their heroin.
But the shift to clinics did not curtail the growth in heroin use. Throughout the 1960s the number of addicts increased—the late John Kaplan of Stanford estimated by fivefold—in part as a result of the diversion of heroin from clinic patients to new users on the streets. An addict would bargain with the clinic doctor over how big a dose he would receive. The patient wanted as much as he could get, the doctor wanted to give as little as was needed. The patient had an advantage in this conflict because the doctor could not be certain how much was really needed. Many patients would use some of their “maintenance” dose and sell the remaining part to friends, thereby recruiting new addicts. As the clinics learned of this, they began to shift their treatment away from heroin and toward methadone, an addictive drug that, when taken orally, does not produce a “high” but will block the withdrawal pains associated with heroin abstinence.
Whether what happened in England in the 1960s was a mini-epidemic or an epidemic depends on whether one looks at numbers or at rates of change. Compared to the United States, the numbers were small. In 1960 there were 68 heroin addicts known to the British 208government; by 1968 there were 2,000 in treatment and many more who refused treatment. (They would refuse in part because they did not want to get methadone at a clinic if they could get heroin on the street.) Richard Hartnoll estimates that the actual number of addicts in England is five times the number officially registered. At a minimum, the number of British addicts increased by thirtyfold in ten years; the actual increase may have been much larger….
The United States began the 1960s with a much larger number of heroin addicts and probably a bigger at-risk population than was the case in Great Britain. Even though it would be foolhardy to suppose that the British system, if installed here, would have worked the same way or with the same results, it would be equally foolhardy to suppose that a combination of heroin available from leaky clinics and from street dealers who faced only minimal law-enforcement risks would not have produced a much greater increase in heroin use than we actually experienced. My guess is that if we had allowed either doctors or clinics to prescribe heroin, we would have had far worse results than were produced in Britain, if for no other reason than the vastly larger number of addicts with which we began. We would have had to find some way to police thousands (not scores) of physicians and hundreds (not dozens) of clinics. If the British civil service found it difficult to keep heroin in the hands of addicts and out of the hands of recruits when it was dealing with a few hundred people, how well would the American civil service have accomplished the same tasks when dealing with tens of thousands of people?
BACK TO THE FUTURE
Now cocaine, especially in its potent form, crack, is the focus of attention. Now as in 1972 the government is trying to reduce its use. Now as then some people are advocating legalization. Is there any more reason to yield to those arguments today than there was almost two decades ago?*
I think not. If we had yielded in 1972 we almost certainly would have had today a permanent population of several million, not several hundred thousand, heroin addicts. If we yield now we will have a far more serious problem with cocaine.
Crack is worse than heroin by almost any measure. Heroin produces a pleasant drowsiness and, if hygienically administered, has only the physical side effects of constipation and sexual impotence. Regular heroin use incapacitates many users, especially poor ones, for any productive work or social responsibility. They will sit nodding on a street corner, helpless but at least harmless. By contrast, regular cocaine use leaves the user neither helpless nor harmless. When smoked (as with crack) or injected, cocaine produces instant, intense, and short-lived euphoria. The experience generates a powerful desire to repeat it. If the drug is readily available, repeat use will occur. Those people who progress to “bingeing” on cocaine become devoted to the drug and its effects to the exclusion of almost all other considerations—job, family, children, sleep, food, even sex. Dr. Frank Gawin at Yale and Dr. Everett Ellinwood at Duke report that a substantial percentage of all high-dose, binge users become uninhibited, impulsive, hypersexual, compulsive, irritable, and hyperactive. Their moods vacillate dramatically, leading at times to violence and homicide.
I do not take up the question of marijuana. For a variety of reasons—its widespread use and its lesser tendency to addict—it presents a different problem from cocaine or heroin.
Women are much more likely to use crack than heroin, and if they are pregnant, the effects on their babies are tragic…. Cocaine harms the fetus and can lead to physical deformities or neurological damage. Some crack babies have for all practical purposes suffered a disabling stroke while still in the womb. The long-term consequences of this brain damage are lowered cognitive ability and the onset of mood disorders. Besharov estimates that about 30,000 to 50,000 such babies are born every year, about 7,000 in New York City alone. There may be ways to treat such infants, but from everything we now know treatment will be long, difficult, and expensive. Worse, the mothers who are most likely to produce crack babies are precisely the ones who, because of poverty or temperament, are least able and willing to obtain such treatment. In fact, anecdotal evidence suggests that crack mothers are likely to abuse their infants.
The notion that abusing drugs such as cocaine is a “victimless crime” is not only absurd but dangerous. 209Even ignoring the fetal drug syndrome, crack-dependent people are, like heroin addicts, individuals who regularly victimize their children by neglect, their spouses by improvidence, their employers by lethargy, and their coworkers by carelessness. Society is not and could never be a collection of autonomous individuals. We all have a stake in ensuring that each of us displays a minimal level of dignity, responsibility, and empathy. We cannot, of course, coerce people into goodness, but we can and should insist that some standards must be met if society itself—on which the very existence of the human personality depends—is to persist. Drawing the line that defines those standards is difficult and contentious, but if crack and heroin use do not fall below it, what does? …
HAVE WE LOST?
Many people who agree that there are risks in legalizing cocaine or heroin still favor it because, they think, we have lost the war on drugs. “Nothing we have done has worked” and the current federal policy is just “more of the same.” Whatever the costs of greater drug use, surely they would be less than the costs of our present, failed efforts.
That is exactly what I was told in 1972—and heroin is not quite as bad a drug as cocaine. We did not surrender and we did not lose. We did not win, either. What the nation accomplished then was what most efforts to save people from themselves accomplish: the problem was contained and the number of victims minimized, all at a considerable cost in law enforcement and increased crime. Was the cost worth it? I think so, but others may disagree. What are the lives of would-be addicts worth? I recall some people saying to me then, “Let them kill themselves.” I was appalled. Happily, such views did not prevail.
Have we lost today? Not at all. High-rate cocaine use is not commonplace. The National Institute of Drug Abuse (NIDA) reports that less than 5 percent of high-school seniors used cocaine within the last thirty days…. Medical examiners reported in 1987 that about 1,500 died from cocaine use; hospital emergency rooms reported about 30,000 admissions related to cocaine abuse….
In some neighborhoods, of course, matters have reached crisis proportions. Gangs control the streets, shootings terrorize residents, and drug-dealing occurs in plain view. The police seem barely able to contain matters. But in these neighborhoods—unlike at Palo Alto cocktail parties—the people are not calling for legalization, they are calling for help. And often not much help has come. Many cities are willing to do almost anything about the drug problem except spend more money on it. The federal government cannot change that; only local voters and politicians can. It is not clear that they will.
It took about ten years to contain heroin. We have had experience with crack for only about three or four years. Each year we spend perhaps $11 billion on law enforcement (and some of that goes to deal with marijuana) and perhaps $2 billion on treatment. Large sums, but not sums that should lead anyone to say, “We just can’t afford this any more.”
The illegality of drugs increases crime, partly because some users turn to crime to pay for their habits, partly because some users are stimulated by certain drugs (such as crack or PCP) to act more violently or ruthlessly than they otherwise would, and partly because criminal organizations seeking to control drug supplies use force to manage their markets. These also are serious costs, but no one knows how much they would be reduced if drugs were legalized. Addicts would no longer steal to pay black-market prices for drugs, a real gain. But some, perhaps a great deal, of that gain would be offset by the great increase in the number of addicts. These people, nodding on heroin or living in the delusion-ridden high of cocaine, would hardly be ideal employees. Many would steal simply to support themselves, since snatch-and-grab, opportunistic crime can be managed even by people unable to hold a regular job or plan an elaborate crime. Those British addicts who get their supplies from government clinics are not models of law-abiding decency. Most are in crime, and though their per-capita rate of criminality may be lower thanks to the cheapness of their drugs, the total volume of crime they produce may be quite large. Of course, society could decide to support all unemployable addicts on welfare, but that would mean that gains from lowered rates of crime would have to be offset by large increases in welfare budgets.
Proponents of legalization claim that the costs of having more addicts around would be largely if not entirely offset by having more money available with which to treat and care for them. The money would come from the taxes levied on the sale of heroin and cocaine.
To obtain this fiscal dividend, however, legalization’s supporters must first solve an economic dilemma. If they want to raise a lot of money to pay for welfare and treatment, the tax rate on the drugs will have to be quite high. Even if they themselves do not want a high tax rate, the politicians’ love of “sin taxes” would probably guarantee that it would be high anyway. But the higher the tax, the higher the price of the drug, and the higher the price the greater the likelihood that addicts will turn to crime to find the money for it and that criminal organizations will be formed to sell tax-free drugs at below-market rates. If we managed to keep taxes (and thus prices) low, we would get that much less money to pay for welfare and treatment and more people could afford to become addicts. There may be an optimal tax rate for drugs that maximizes revenue while minimizing crime, bootlegging, and the recruitment of new addicts, but our experience with alcohol does not suggest that we know how to find it.
THE BENEFITS OF ILLEGALITY
The advocates of legalization find nothing to be said in favor of the current system except, possibly, that it keeps the number of addicts smaller than it would otherwise be. In fact, the benefits are more substantial than that.
First, treatment. All the talk about providing “treatment on demand” implies that there is a demand for treatment. That is not quite right. There are some drug-dependent people who genuinely want treatment and will remain in it if offered; they should receive it. But there are far more who want only short-term help after a bad crash; once stabilized and bathed, they are back on the street again, hustling. And even many of the addicts who enroll in a program honestly wanting help drop out after a short while when they discover that help takes time and commitment. Drug-dependent people have very short time horizons and a weak capacity for commitment. These two groups—those looking for a quick fix and those unable to stick with a long-term fix—are not easily helped. Even if we increase the number of treatment slots—as we should—we would have to do something to make treatment more effective.
One thing that can often make it more effective is compulsion. Douglas Anglin of UCLA, in common with many other researchers, has found that the longer one stays in a treatment program, the better the chances of a reduction in drug dependency. But he, again like most other researchers, has found that drop-out rates are high. He has also found, however, that patients who enter treatment under legal compulsion stay in the program longer than those not subject to such pressure…. If for many addicts compulsion is a useful component of treatment, it is not clear how compulsion could be achieved in a society in which purchasing, possessing, and using the drug were legal. It could be managed, I suppose, but I would not want to have to answer the challenge from the American Civil Liberties Union that it is wrong to compel a person to undergo treatment for consuming a legal commodity.
Next, education. We are now investing substantially in drug-education programs in the schools. Though we do not yet know for certain what will work, there are some promising leads. But I wonder how credible such programs would be if they were aimed at dissuading children from doing something perfectly legal. We could, of course, treat drug education like smoking education: inhaling crack and inhaling tobacco are both legal, but you should not do it because it is bad for you….
Again, it might be possible under a legalized regime to have effective drug-prevention programs, but their effectiveness would depend heavily, I think, on first having decided that cocaine use, like tobacco use, is purely a matter of practical consequences; no fundamental moral significance attaches to either. But if we believe—as I do—that dependency on certain mind-altering drugs is a moral issue and that their illegality rests in part on their immorality, then legalizing them undercuts, if it does not eliminate altogether, the moral message.
That message is at the root of the distinction we now make between nicotine and cocaine. Both are highly addictive; both have harmful physical effects. But we treat the two drugs differently, not simply because nicotine is so widely used as to be beyond the reach of effective prohibition, but because its use does not destroy the user’s essential humanity. Tobacco shortens one’s life, cocaine debases it. Nicotine alters one’s habits, cocaine alters one’s soul. The heavy use of crack, unlike the heavy use of tobacco, corrodes those natural sentiments of sympathy and duty that 211constitute our human nature and make possible our social life. To say, as does [Ethan] Nadelmann [Executive Director of Drug Policy Alliance], that distinguishing morally between tobacco and cocaine is “little more than a transient prejudice” is close to saying that morality itself is but a prejudice.
THE ALCOHOL PROBLEM
… Alcohol, like heroin, cocaine, PCP, and marijuana, is a drug—that is, a mood-altering substance—and consumed to excess it certainly has harmful consequences: auto accidents, barroom fights, bedroom shootings. It is also, for some people, addictive. We cannot confidently compare the addictive powers of these drugs, but the best evidence suggests that crack and heroin are much more addictive than alcohol.
Many people, Nadelmann included, argue that since the health and financial costs of alcohol abuse are so much higher than those of cocaine or heroin abuse, it is hypocritical folly to devote our efforts to preventing cocaine or drug use. But as Mark Kleiman of Harvard has pointed out, this comparison is quite misleading. What Nadelmann is doing is showing that a legalized drug (alcohol) produces greater social harm than illegal ones (cocaine and heroin). But of course. Suppose that in the 1920s we had made heroin and cocaine legal and alcohol illegal. Can anyone doubt that Nadelmann would now be writing that it is folly to continue our ban on alcohol because cocaine and heroin are so much more harmful?
And let there be no doubt about it—widespread heroin and cocaine use are associated with all manner of ills. Thomas Bewley found that the mortality rate of British heroin addicts in 1968 was 28 times as high as the death rate of the same age group of non-addicts, even though in England at the time an addict could obtain free or low-cost heroin and clean needles from British clinics. Perform the following mental experiment: suppose we legalize heroin and cocaine in this country. In what proportion of auto fatalities would the state police report that the driver was nodding off on heroin or recklessly driving on a coke high? In what proportion of spouse-assault and child-abuse cases would the local police report that crack was involved? In what proportion of industrial accidents would safety investigators report that the forklift or drill-press operator was in a drug-induced stupor or frenzy? We do not know exactly what the proportion would be, but anyone who asserts that it would not be much higher than it is now would have to believe that these drugs have little appeal except when they are illegal. And that is nonsense.
An advocate of legalization might concede that social harm—perhaps harm equivalent to that already produced by alcohol—would follow from making cocaine and heroin generally available. But at least, he might add, we would have the problem “out in the open” where it could be treated as a matter of “public health.” That is well and good, if we knew how to treat—that is, cure—heroin and cocaine abuse. But we do not know how to do it for all the people who would need such help. We are having only limited success in coping with chronic alcoholics. Addictive behavior is immensely difficult to change, and the best methods for changing it—living in drug-free therapeutic communities, becoming faithful members of Alcoholics Anonymous or Narcotics Anonymous—require great personal commitment, a quality that is, alas, in short supply among the very persons—young people, disadvantaged people—who are often most at risk for addiction.
Suppose that today we had, not 15 million alcohol abusers, but half a million. Suppose that we already knew what we have learned from our long experience with the widespread use of alcohol. Would we make whiskey legal? I do not know, but I suspect there would be a lively debate. The Surgeon General would remind us of the risks alcohol poses to pregnant women. The National Highway Traffic Safety Administration would point to the likelihood of more highway fatalities caused by drunk drivers. The Food and Drug Administration might find that there is a nontrivial increase in cancer associated with alcohol consumption. At the same time the police would report great difficulty in keeping illegal whiskey out of our cities, officers being corrupted by bootleggers, and alcohol addicts often resorting to crime to feed their habit. Libertarians, for their part, would argue that every citizen has a right to drink anything he wishes and that drinking is, in any event, a “victimless crime.”
However the debate might turn out, the central fact would be that the problem was still, at that point, a small 212one. The government cannot legislate away the addictive tendencies in all of us, nor can it remove completely even the most dangerous addictive substances. But it can cope with harms when the harms are still manageable.
SCIENCE AND ADDICTION
One advantage of containing a problem while it is still containable is that it buys time for science to learn more about it and perhaps to discover a cure. Almost unnoticed in the current debate over legalizing drugs is that basic science has made rapid strides in identifying the underlying neurological processes involved in some forms of addiction. Stimulants such as cocaine and amphetamines alter the way certain brain cells communicate with one another….
When dopamine crosses the synapse between two cells, it is in effect carrying a message from the first cell to activate the second one. In certain parts of the brain that message is experienced as pleasure. After the message is delivered, the dopamine returns to the first cell. Cocaine apparently blocks this return, or “reuptake,” so that the excited cell and others nearby continue to send pleasure messages. When the exaggerated high produced by cocaine-influenced dopamine finally ends, the brain cells may (in ways that are still a matter of dispute) suffer from an extreme lack of dopamine, thereby making the individual unable to experience any pleasure at all. This would explain why cocaine users often feel so depressed after enjoying the drug. Stimulants may also affect the way in which other neurotransmitters, such as serotonin and noradrenaline, operate….
Tragically, we spend very little on such research, and the agencies funding it have not in the past occupied very influential or visible posts in the federal bureaucracy. If there is one aspect of the “war on drugs” metaphor that I dislike, it is its tendency to focus attention almost exclusively on the troops in the trenches, whether engaged in enforcement or treatment, and away from the research-and-development efforts back on the home front where the war may ultimately be decided.
I believe that the prospects of scientists in controlling addiction will be strongly influenced by the size and character of the problem they face. If the problem is a few hundred thousand chronic, high-dose users of an illegal product, the chances of making a difference at a reasonable cost will be much greater than if the problem is a few million chronic users of legal substances. Once a drug is legal, not only will its use increase but many of those who then use it will prefer the drug to the treatment: they will want the pleasure, whatever the cost to themselves or their families, and they will resist—probably successfully—any efforts to wean them away from experiencing the high that comes from inhaling a legal substance.
LYNN SCARLETT
On the Legalization of Drugs
Lynn Scarlett is the Co-Chief External Affairs Officer at the Nature Conservatory. She also served as Acting Secretary of the U.S. Department of the Interior in 2006. In her letter to the editor, written in response to James Q. Wilson’s article, “Against the Legalization of Drugs,” Scarlett presents arguments regarding the benefits of legalizing drugs.
James Q. Wilson’s article, “Against the Legalization of Drugs”, perpetuates several myths about drug use and drug legalization. Moreover, the substance of his empirical arguments—that the drug war has curtailed drug use and that legalization would result in significant increases in drug abuse—is open to serious dispute. Finally, his philosophical argument—that a specific category of drugs is immoral—is based on misrepresentation of the effects of the drugs in question and a narrow conceptualization of morality.
Lynn Scarlett, “On the Legalization of Drugs, Round 2,” Reprinted from Commentary, June 1990 by permission; ©1990 by Commentary, Inc.
At the outset, Mr. Wilson suggests that legalization is akin to raising the white flag of surrender. This is an 214oft-repeated but inaccurate piece of rhetoric. Proponents of drug legalization do not suggest that we “give in” to drug use. Most proponents view legalization as having two beneficial consequences: first, legalization would remove the drug trade from the hands of organized crime and children, thereby eliminating much of the attendant violence; and second, legalization would enable us to focus our attention on education (as we have done with nicotine) regarding the health and other hazards of drug use.
Mr. Wilson then moves on to suggest that the drug war caused the decline, or at least stabilization, that we have seen in the use of heroin. He points to price increases for heroin in the 70’s as evidence that prohibition worked…. Mr. Wilson has some of his facts right. Heroin use did stabilize in the early 1980’s (though it may be climbing). However, it is difficult to attribute this to the drug war, since, in fact, the price of heroin declined in the 80’s by 20 percent, while purity rose some 33 percent. Clearly, factors other than the drug war and its price effects were at work here. Moreover, while heroin use stabilized, the use of cocaine climbed during the 80’s, to peak in the mid-80’s. Over the past several years, cocaine use has declined despite rapidly falling prices and more plentiful supplies…. In other words, drug use—whether of heroin or cocaine—has fluctuated under a regime of prohibition in patterns apparently unrelated to price or illegality….
Mr. Wilson’s own arguments undermine some of his assertions. Many proponents of legalization argue that most drug users, despite popular conceptions to the contrary, exhibit controlled consumption, whether of heroin, cocaine, or marijuana. And those who curtail consumption report that they do so primarily for health reasons and not because of fear of the law or of rising prices. Mr. Wilson himself notes a survey that showed that two-thirds of a group of blacks in Harlem claimed that they stopped their drug use for health reasons. A survey of high-school students nationwide showed that 21 percent stopped their use of cocaine for health reasons, 12 percent due to pressure from family and friends, 12 percent due to cost, and none due to fear of law enforcement. These surveys bode well for a scenario of legalization, since they suggest that an educational campaign about the health effects of drugs accompanying legalization can, as education has done with nicotine, help to curtail use….
After dismissing the health effects of cocaine as grounds neither for supporting nor opposing prohibition, Mr. Wilson gets to the real heart of his argument. He believes that certain categories of drugs are immoral. They are immoral because they are mind-altering, and this, he says, is why nicotine is legal and cocaine, heroin, and marijuana are not.
First, the facts. While heroin, cocaine, marijuana, and other illicit drugs have varying impacts on the body and brain, this does not mean that their use necessarily impairs one’s ability to lead a successful life. Indeed, the vast majority of individuals who use marijuana on a casual basis are productive citizens with healthy emotional lives. The same is true for the recreational users of cocaine and even heroin. Dr. Arnold Trebach of the Drug Policy Foundation and others have amply documented that casual use does not necessarily lead to mental, emotional, or physical impairment…. Mr. Wilson’s characterization of drug use in general is simply false….
Mr. Wilson is correct that for some users cocaine, heroin, or marijuana, like alcohol, can be highly debilitating (though, incidentally, on this score Mr. Wilson overplays the differences between legal drugs like nicotine and illegal ones). Most proponents of legalization share Mr. Wilson’s concern over this debility. But to acknowledge that some individuals suffer enormously from their drug addiction and do harm to others as a result does not lead automatically to the conclusion that all drug users manifest immoral, inhumane, unsympathetic behavior. In short, drug use does not, as Mr. Wilson contends, “destroy the drug user’s essential humanity.” This being the case, Mr. Wilson’s moral argument falls apart….
Mr. Wilson writes that “human character is inconceivable without society, and good character is less likely in a bad society.” But what is a bad society? Here, Mr. Wilson overlooks the enormous harm to basic principles of due process of law now being wrought by the drug war. These principles, which are designed to protect us against arbitrary authority, serve as the foundation for a society based on responsible and free individuals. Such a foundation allows for a pluralistic climate in which families, churches, and social groups can prosper. That, I would argue, is what makes a “good society.”
A genuine concern about legalization is that it would lead to significant increases in the numbers of people 215using (or abusing) drugs. Mr. Wilson, with little but gut feelings to back his views, firmly insists that drug use would increase. While any discussion of the effects of legalization on use is necessarily speculative, one can point to evidence that suggests Mr. Wilson is wrong. For example, decriminalization of marijuana in the Netherlands and in a number of U.S. states has not been accompanied by increased use; in fact, use has declined in these areas. And in Finland, too, there was no increase in the use of alcohol after prohibition was repealed, to the accompaniment of a public-education campaign.
Mr. Wilson’s description of the British system of drug regulation is also misleading. For forty years that system worked without entailing increases in heroin use. The increases in use since the 60’s are very likely attributable at least in part to changes in the system. At the very least, one can conclude that legalization per se did not lead to increased use, since increased heroin use did not occur during the first four decades that the system was in place.
We cannot know for certain what the effects of legalization would be on use. But we can direct our policy efforts toward implementing legalization measures that attempt to address this risk through education, restrictions on use by minors, and so on. Before we can construct such policies, however, we need to discard the kind of moralistic arguments set forth by Mr. Wilson that are largely based on hyperbole about drug use, drug abuse, and the human soul.
JEFF BERG
The Logic of Drug Legalization
Jeff Berg was born in Montreal, Quebec, Canada. He attended Humber College, Dalhousie University, and the University of Western Ontario where he studied philosophy, political science, and business. In addition to the legalization of drugs, which he argues for in the following reading, his interests include prison reform, the reduction of military spending, and early childhood education and welfare. He is also a regular contributor to Counterpunch, Countercurrents, and Dissident Voice.
Jeff Berg, “The Logic of Drug Legalization,” CounterPunch, November 15, 2017. Copyright ©2017 CounterPunch. All rights reserved. Used with permission.
The Drug Lords of today exist because of the extraordinary profits resulting from criminalization. Estimates run in the half a trillion range globally per year. By way of comparison there are only twenty or so countries with a national economy of that size. The situation is exactly analogous to the prohibition era. When gunfights, beatings, murders and firebombs were the business strategy of choice for the pushers of alcohol. Once booze was legalized the bootleggers were immediately driven out of business. Alcohol is heavily taxed today there are however no Bootlegging Lords on the playground pushing cheaper booze on our children.
Nor would such pushers exist for any other drug that we might choose to legalize. Sure the criminals could evade the cost of taxes on their product but there are enormous costs incurred by criminal enterprises that don’t apply to legal ones. This is why marijuana today is sold for hundreds of times what it costs to grow. Our legal producers will not be faced with those costs and so can sell to us below current prices on the street. With profit margins cut to the bone the ‘dread lords and masters’ that control the illegal drug market today will simply melt away like the last snow before the advancing spring.
If you are worried about our kids as relates to the issue of the legalization and/or decriminalization of marijuana and other harder drugs then know this. The only reason that there exists so many pushers on our playgrounds is the direct result of drug prohibition. Legalize them and the profit goes away. The profit goes away and the pushers go away. Just as they did after the end of the Prohibition Era. Do we see pushers on the playground with bottles of vodka or moonshine or wine pushing them to our kids on the street today? No we do not. Why? Because there’s no money in it.
Legalize all drugs and for the same reason the pushers go away not only from the playground but from every street corner in America. The violence between the pushers goes away. Our streets would instantly become so very much safer we would barely be able to recognize them. Policing would become so much safer we could reasonably go to the ‘Bobby’ model of them not having to carry guns. Community policing would become the norm as opposed to the exception. The police today are the adversary of communities in the inner cities because they threaten the flow of money from the activity of the sale of illegal drugs. Take away that flow of money and you take away that adversarial dynamic.
Can I tell you that no drugs will end up in the hands of our youth? Of course not. Just as I can’t tell you they won’t smoke and drink. While we are on the subject. Cigarettes kill more people per month than all hard drugs combined in a year. I can’t count the number of families that have suffered from alcoholism but I can count my childhood family among them. If we were going to criminalize any drug on the basis of social harm then nicotine would be #1 and alcohol #2. Would that be the right course of action? Of course not. What we have done instead is one of the most remarkable success stories in the history of social engineering. We publicized the science at our disposal, we expelled smoking from social spaces, we created treatment methods for overcoming the addiction. Still there are smokers. Still there are alcoholics. Just as there are overeaters and people that do not exercise. Such is life. Such is the nature of freedom. Such is the outcome when we preference freedom of the individual over the harm that prohibition causes to society. As long as we widely publicize the information of the harm, as long as we provide help for 217the addicted, freedom is the only road to be chosen for this voyage.
What I can tell you is the pushers will leave the playground and children will no longer be used as pushers. What I can tell you is the murder rate and the overdose rate will be massively reduced. No small gains.
As importantly would be the results if drug use and addiction were treated as a medical issue and not a criminal one. We would empty our prisons to an extraordinary degree, unclog our judicial system, and reduce our policing needs. The savings would be massive. To this would be added the money made from the sale of the drugs. Just as it has with booze and cigarettes and every other drug we currently sell. Not to mention every other thing we buy that has a sales tax. Why should we exempt these drugs? In Colorado the revenues raised for the State are higher with pot than they are with booze. After one year!
With all of this money, and we are talking billions here in Canada, and orders of magnitude larger in the U.S., we could afford a program for every single addict. Every addict could get their fix and the best treatment medical science can provide. And still we would be billions of dollars ahead. Not even including the intangible effect of our much safer streets and homes.
For addicts the result would be a massive reduction in misery for the blighted lives of these unfortunates. Our streets and homes would become instantly safer as they would no longer need to steal to feed their habit. As I say we wouldn’t even recognize the place. It would be like we had been asleep and awoke to a dream, and for a real change of pace one that wasn’t a nightmare. Don’t we deserve in this day and age of climate change and ecological collapse at least one dream upon awakening that isn’t a nightmare?
To this we can add reducing the corruption of our police, politicians and judiciary. Today corrupted all over the world by the hundreds of billions directly resulting from this prohibition. All of this is of course far more than enough but to it we can add something equally important. The end of our complicity in the destruction of entire societies. Peasant farmers rained on with Agent Orange and other chemical warfare. Our complicity in mass murders as the Drug Lords fight the police and the Army over the profits. Mexico’s murder rate is second only to war torn Syria! Think on that. The only country worse than Mexico is one in the midst of a protracted and utterly disastrous civil war.
In addition to this is the mass violence in societies throughout Latin America and other places like Afghanistan that are disastrously corrupted from the cop on the beat, to their military command, to the President of their countries. Attorney Generals have been assassinated, journalists, judges, lawyers, politicians, cops, and uncounted scores of innocent bystanders. All because of the profit that we supply to this trade by our consumption. We are the fuel for this fire. Our consumption is burning their societies to the ground. Take away that profit and the problem instantly becomes a tiny fraction of what it was here and there.
After the prohibition of alcohol was ended so too was the reign of the Capone’s, and the Luciano’s and the Lansky’s. Guns and graft was replaced by quality control and marketing. The mobsters however simply moved their operations to those drugs that remained illegal. Any sane society with a modicum of rationality would recognize the parallel. Recognize that the taking of drugs is a question of personal choice. Like cigarettes and alcohol. Yes it comes with a medical cost, without a doubt. It need not however come with the corruption, the crime, the murders, the oppositional relation to the ‘popo’, the astronomical costs of incarceration, and the militarization of the police. All of those are avoidable.
The indisputable problems that will remain are treatable in the main, and those that are not are tragic. As is mortality. They are however tragedies on a personal level as opposed to calamities on a societal one.
DONALD J. TRUMP
Speech by President Donald Trump Declaring the Opioid Crisis a Public Health Emergency
In the following speech given before Congress in 2017, President Trump declares opioid addiction, whether to legal or illegal drugs, to be an epidemic and a public emergency. He offers several suggestions for dealing with the crisis, proclaiming that “we can be the generation that ends the opioid epidemic.”
Thank you all to members of Congress, my cabinet, governors, members of Congress, state, local leaders, first responders and health care professionals gathered here today. We have some truly incredible people in this room that I can tell you.
Speech delivered before Congress, October 26, 2017.
Most importantly, we acknowledge the families present who have lost a cherished loved one. As you all know from personal experience, families, communities and citizens across our country are currently dealing with the worst drug crisis in American history….
Drug overdoses are now the leading cause of unintentional death in the United States by far. More people are dying from drug overdoses today than from gun homicides and motor vehicles combined.
Think of it, motor vehicle crashes, gun homicides, more people by far from drug overdoses. These overdoses are driven by a massive increase in addiction. To prescription pain killers, heroin, and other opioids. Last year almost one million Americans used heroin. And more than 11 million abused prescription opioids.
The United States is by far the largest consumer of these drugs using more opioid pills per person than any other country by far in the world. Opioid overdose deaths have quadrupled since 1999, and now account for the majority of fatal drug overdoses. Who would have thought. No part of our society, not young or old, rich or poor, urban or rural, has been spared this plague of drug addiction and this horrible, horrible situation that’s taking place with opioids.
In West Virginia, a truly great state, great people, there is a hospital nursery where one in every five babies spends its first days in agony because these precious babies were exposed to opioids or other drugs in the womb, they endure nausea, pain, anxiety, sleeplessness, and have trouble eating, just as the same adults undergoing detox.
Some of these children will likely lose one or both of their parents to drug addiction and overdose. They will join the growing ranks of America’s opioid orphans. Such beautiful, beautiful babies. Beyond the shocking death toll, the terrible measure of the opioid crisis includes the families ripped a part, and for many communities, a generation of lost potential and opportunity.
This epidemic is a national health emergency. Unlike many of us, we have seen and what we have seen in our lifetimes, nobody has seen anything like what’s going on now. As Americans, we cannot allow this to continue. It is time to liberate our communities from this scourge of drug addiction. It’s never been this way. We can be the generation that ends the opioid epidemic. We can do it.
That is why effective today my administration is officially declaring the opioid crisis a national public health emergency under federal law. And why I am directing all executive agencies to use every appropriate emergency authority to fight the opioid crisis….
As part of this emergency response, we will announce a new policy to overcome a restrictive 1970s-era rule that prevents states from providing care at certain treatment facilities with more than 16 beds for those suffering from drug addiction.
A number of states have reached out to us asking for relief, and you should expect to see approvals that will unlock treatment for people in need…. Ending the epidemic will require mobilization of government, local communities and organizations. It will require the resolve of our entire company.
The scale of this crisis of addiction is why soon after coming into office I convened a presidential commission headed by governor Chris Christie that has consulted with experts across America to listen, to learn, and report back on potential solutions….
After we review and evaluate the commission’s findings, I’ll quickly move to implement approximate and appropriate recommendations.
But I want the American people to know the federal government is aggressively fighting the opioid epidemic on all fronts. We are working with doctors and medical professionals to implement best practices for safe opioid prescribing.
… We are requiring federally employed prescribers to receive finally special training. The Centers for Disease Control and Prevention has launched a prescription awareness campaign to put faces on the danger of opioid abuse. I want to acknowledge CVS Caremark for announcing last month that it will limit first-time opioid prescription among seven day supplies, and I encourage others to help stop this epidemic to do their part.
The FDA is now requiring drug companies that manufacture prescription opioids to provide more training to prescribers and to help prevent abuse and addiction and has requested that one especially high risk opioid be withdrawn from the market immediately….
The U.S. Postal Service and the Department of Homeland Security are strengthening the inspection of packages coming into our country to hold back the flood of cheap and deadly fentanyl a synthetic opioid manufactured in China and 50 times stronger than heroin.
… The justice department is aggressively and really valiantly pursuing those who illegally prescribe and traffic in opioids both in our communities and on the internet.
And I’ll be looking at the potential of the federal government bringing … major lawsuits against people and against companies that are hurting our people…. And that will start taking place pretty soon….
I’ll be pushing the concept of non-addictive pain killers very, very hard. We have to come up with that solution. We give away billions and billions of dollars a year, and we’re going to be spending lots of money on coming up with a non-addictive solution.
We will be asking Dr. Collins and the NIH for substantial resources in the fight against drug addiction. One of the things our administration will be doing is a massive advertising campaign to get people, especially children, not to want to take drugs in the first place, because they will see the devastation and the ruination it causes to people and people’s lives….
The fact is if we can teach young people, and people generally, not to start, it’s really, really easy not to take them. And I think that’s going to end up being our most important thing. Really tough, really big, really great advertising. So we get to people before they start so they don’t have to go through the problems of what people are going through.
We are already distributing nearly $1 billion in grants for addiction prevention and treatment. And over $50 million to support law enforcement programs that assist those facing prison and facing addiction. We have also launched an $81 million partnership to research better pain management techniques for our incredible veterans.
… For too long we have allowed drugs to ravage American homes, cities, and towns. We owe it to our children and to our country to do everything in our power to address this national shame and this human tragedy. We must stop the flow of all types of illegal drugs into our communities.
For too long dangerous criminal cartels have been allowed to infiltrate and spread throughout our nation. An astonishing 90% comes from across the border which we are building a wall which will help in this problem. We’ll have a great impact. My administration is dedicated to enforcing our immigration laws, defending our maritime security, and securing our borders.
We also have to work with other countries to stop these drugs where they originate…. Whether that country is China, whether it’s a country in Latin America, it makes no difference. We are going to be working with all of them. We are taking the fight directly to the criminals in places that they are producing this poison.
Here in America we are once again enforcing the law, breaking up gangs, and distribution networks, and arresting criminals who pedal dangerous drugs to our youth. In addition, we understand the need to confront reality right smack in the face that millions of our fellow citizens are already addicted. That’s the reality.
We want them to get help they need. We have no choice but to help these people that are hooked and are suffering so they can recover and rebuild their lives with their families. We are committed to pursuing innovative approaches that have been proven to work, like drug courts.
Our efforts will be based on sound metrics and guided by evidence and guided by results. This includes making addiction treatment available to those in prison and to help them eventually reenter society as productive and law-abiding citizens. Finally, we must adopt the most common sense solution of all to prevent our citizens from becoming addicted to drugs in the first place.
We must and are focusing so much of our effort on drug-demand reduction. We must confront the culture of drug abuse head on to reduce the demand for dangerous narcotics. Every person who buys illicit drugs in America should know they are risking their future, their families, and even their lives. And every American should know that if they purchase illegal drugs, they are helping to finance some of the most violent, cruel, and ruthless organizations anywhere in the world.
Illegal drug use is not a victimless crime. There is nothing admirable, positive, or socially desirable about it….
Each of us have a responsibility to this effort. We have a total responsibility to ourselves, to our family, to our country, including those who are struggling with this addiction. Each of us is responsible to look out for our loved ones, our communities, our children, our neighbors, and our own health. Almost every American has witnessed the horrors of addiction, whether it’s through their own struggle, or through the struggle of a friend, a coworker, a neighbor, or, frankly, a family member. Our current addiction crisis, and especially the epidemic of opioid deaths will get worse before it gets better.
But get better it will. It will take many years and even decades to address this scourge in our society. But we must start in earnest now to combat national health emergency. We are inspired by the stories of every day heroes who pull their communities from the depths of despair, through leadership and through love….
We will work to strengthen vulnerable families and communities, and we will help to build and grow a stronger, healthier, and drug-free society. Together we will face this challenge as a national family with conviction, with unity, and with a commitment to love and support our neighbors in times of dire need. Working together, we will defeat this opioid epidemic. It will be defeated. We will free our nation from the terrible affliction of drug abuse. And, yes, we will overcome addiction in America.
We are going to overcome addiction in America. We have fought and won many battles and many wars before. And we will win again. Thank you. God bless you. And god bless America. Thank you.
CASE STUDIES
1. FRATERNITIES AND ALCOHOL: THE DEATH OF BENJAMIN WYNNE35
Much of the criticism of binge drinking on college campuses is focused on the Greek system. A Harvard study found that 86 percent of fraternity-house residents are binge drinkers. Binge drinking can be deadly.
In August 1997 twenty-year-old Benjamin Wynne of Louisiana State University was accepted as a pledge with the Sigma Alpha Epsilon fraternity. To celebrate, Wynne and the other pledges got rip-roaring drunk. The festivities started with an off-campus keg party in which beer was funneled through a rubber hose into the drinker’s mouth. Following this, the Sigma Alpha Epsilon brothers headed to Murphy’s Bar, which was near the campus, and drank “Three Wise Men,” a 151-proof drink made from rum, whiskey, and a liqueur. The festivities ended with the brothers wheeling the pledges back to campus in shopping carts because they were too drunk to walk.
Police were called to the fraternity house several hours later. They found almost two dozen men passed out on the living-room floor, including Wynne who was dying of alcohol poisoning. The autopsy showed that Wynne had consumed the equivalent of twenty-four drinks the night 222before. When rescue workers arrived, he was already comatose. A few days later, his distraught parents had him removed from life support. This was not an isolated event. According to the National Institutes of Health, alcohol drinking by college students is a contributing factor in almost 2,000 student deaths each year.36
2. BASEBALL STAR MICKEY MANTLE: SHOULD ALCOHOLICS RECEIVE LIVER TRANSPLANTS?
In 1995 sixty-three-year-old Yankee baseball star and Hall-of-Famer Mickey Mantle lay critically ill in a Dallas Hospital, his liver destroyed by forty years of alcohol abuse.
Alcoholism is associated with a liver disease known as alcohol-related end-stage liver disease (ARESLD). According to the National Institutes of Health, about half of all deaths from liver disease are related to chronic alcoholism.38 Mantle was given two to five weeks to live. The only hope for people with end-stage liver disease is a liver transplant. Livers are very scarce, however, and the waiting list is long. Only a fraction of those who need liver transplants ever get one.
The night after Mantle was hospitalized, a suitable donor was found. Mantle was moved to the top of the recipient list and soon received a new liver, even though the American Medical Association has proposed that patients with alcohol-related liver disease should not compete equally with other people who need liver transplants.39 Mantle died shortly after of a failed liver transplant.
3. WINNING AT ALL COSTS: DRUGS IN SPORTS
You are the captain and star player on your college basketball team, which has made the finals. A wealthy entrepreneur, who is an avid basketball fan and alumnus of your college, has promised to make a $60 million donation to your school if your team wins the finals. Your college desperately needs the money. It is currently in serious financial trouble and has been forced to lay off faculty and cut back on academic programs.
A few weeks before the game, the wealthy entrepreneur offers you a banned performance-enhancing substance. He assures you that you will not get caught, because the substance has been slightly altered so that it cannot be detected. He also tells you that he will make a $60 million donation even if your team loses, but only on the condition that you take the drug for the next two weeks. The team you are playing in the finals is better than yours and has won the finals the past two years in a row. According to a noted sports analyst, the odds against your team are eight to one.42
4. PROZAC: ENHANCING MORALITY THROUGH DRUGS43
Although the role of drugs in lowering inhibitions against immoral behavior is widely acknowledged, there is considerable resistance to the similar idea that certain drugs may actually enhance moral behavior. People who suffer from depression can become self-preoccupied to the point of seeming indifferent to the consequences of their actions for others. According to Peter Kramer, author of Listening to Prozac, treatment with a drug such as Prozac can in some cases “turn a morally unattractive person into an admirable one.”44 Prozac can also numb feelings, however.
Kramer cites the case of Phillip, an undergraduate who was undergoing psychotherapy because of humiliation he had received from his parents. Initially, Phillip resisted the use of medication. As his depression became more severe, however, Phillip agreed to try Prozac. Although he felt better on the Prozac, he also hated it. He felt phony. Why? Because he had been robbed of his disdain, resentment, and rage without having to first work through it.
Prozac is used not only by people who feel depressed or overwhelmed by the challenges of life; many use it as a means of self-transformation. According to Kramer, using Prozac can increase autonomy and life choices by “lend[ing] people courage and allow[ing] them to choose life’s ordinary risky undertakings.”45
5. THE ALCOHOLICS ANONYMOUS CONFESSION OF A DOUBLE MURDERER47
On New Year’s Eve 1989, Donald Cox broke into a couple’s bedroom and slashed their throats. The murder remained unsolved until Cox confessed his brutal crime at an AA meeting. Following the confession, one of the AA members called the police. Should this confession be admitted as evidence in a court of law?
According to Cox and his lawyers, the rules of AA obligate members to confess their transgressions. Because confession is part of the recovery process in AA, it should remain confidential, like confessions made to a priest or a psychiatrist. “It doesn’t seem right,” his lawyer Adele Walker argued. “It’s like he’s being punished for recovering.” Furthermore, if confessions made during AA meetings did not remain confidential, AA would not be nearly as effective in helping alcoholics.
On the other hand, it is also an AA principle that alcoholics must accept responsibility for their actions, even when they are drunk. Although Cox claimed that he was drunk at the time of the murders and tried the “drunken stupor–temporary insanity” defense at his trial, he had no trouble recalling what had happened on that tragic New Year’s Eve.
NOTES
1. National Institute on Alcohol Abuse and Alcoholism, “College Drinking,” https://
2. Global Health Research, Drugs and Beyond (Alberta, Canada: Global Health, 1995), 7.
3. Jerome Jaffe’s definition, quoted in Francis F. Seeburger, Addiction and Responsibility (New York: Crossroad, 1996), 48.
4. Listed are the effects of small or moderate amounts of these drugs. Excessive amounts may be accompanied by other, sometimes harmful, effects.
5. For an excellent history of drug and alcohol use in the United States, see David R. Musto, The American Disease (New Haven: Yale University Press, 1973), and his article “Legal Control of Harmful Substances,” in the Encyclopedia of Bioethics, vol. 5 (New York: Simon & Schuster, 1995), 2439–2443.
6. World Health Organization, Report on the Global Tobacco Epidemic, July 19, 2017.
7. Michael Bloomberg, “The Way to Save Millions of Lives Is to Prevent Smoking,” Newsweek, September 29, 2008.
8. “The Opioid Diaries,” Time Magazine 191, no. 9, March 5, 2018, p. 11.
9. For the most recent statistics on deaths due to drug use go to DrugWarFacts.org.
10. “Use of Selected Substances,” 2010. www.cdc.gov/
11. Gallup Poll, “In U.S. 65% Say Drug Problem ‘Extremely’ or ‘Very Serious’”, October 25, 2016, http://
12. “The Opioid Diaries,” 2018,
13. Gallup Poll, October 6–9, 2011.
14. John Iwasaki, “Forum Tackles Race and Drug Use,” Seattle Post, December 6, 2002, http://
15. For the latest statistics on tobacco use go to the American Lung Association website at www.use.org.
16. Centers for Disease Control, www.cdc.gov/
17. Office of Applied Statistics, U.S. Department of Health and Human Services, http://
18. Ibid.
19. Jürgen Rehm et al., “The Relationship of Average Volume of Alcohol Consumption and Patterns of Drinking to Burden of Disease: An Overview,” Addiction 98 (2003): 1220–1221.
20. Robin Hattersley-Grey, “Sexual Assault Statistics,” Campus Safety Magazine, March 5, 2012.
21. Kenneth Jost, “Are Stronger Anti-Doping Policies Needed?” Congressional Quarterly Researcher, July 23, 2004.
22. “Steroid Cloud Mars Baseball,” Milwaukee Journal Sentinel, October 15, 2000, p. 1C.
23. ACSM, “Position Statement: Senate Hearing on the Abuse of Anabolic Steroids,” July 2004.
24. Thomas Murray, “Drugs, Sports, and Ethics,” in Feeling Good and Doing Better: Ethics and Nontherapeutic Drug Use, eds. Thomas H. Murray, Willard Gaylin, and Ruth Macklin (Clifton, NJ: Humana Press, 1984), 107–126.
25. See E. M. Jellinek, The Disease Concept of Alcoholism (Highland Park, N.J.: Hillhouse Press, 1960).
26. Aristotle, Nicomachean Ethics, bk. 3, ch. 5.
27. Encyclopedia of Religion, vol. 12, ed. Mircea Eliade (New York: Macmillan, 1987), 129.
28. John Stuart Mill, On Liberty (Indianapolis: Hackett, 1859/1978), 9.
29. H. Thomas Milhorn, Drug and Alcohol Abuse (New York: Plenum, 1994), 3.
30. E. Webb, C. H. Ashton, P. Kelly, and F. Kamali, “Alcohol and Drug Use in UK University Students,” Lancet 348, no. 9032 (1996): 922–925.
31. Brent McCluskey, “Alcoholism Shortens Lifespan by Nearly a Decade, Study Finds,” April 9, 2015, www.thefix.com.
32. Sam Taxy, Julie Samuels, and William Adams, “Drug Offenders in Federal Prisons”: U.S. Department of Justice, Bureau of Justice Statistics, October 2015.
33. For a description of who is eligible to possess marijuana for medical purposes, see the Health Canada website: www.hc-
34. http://
35. For more on this and similar incidents see Cohen, “Binge,” 54–56.
36. “Discussing Drinking,” NIH News in Health, September 2006.
37. H. Wesley Perkins and Henry Wechsler, “Variation in Perceived College Drinking Norms and Its Impact on Alcohol Abuse: A Nationwide Study,” Journal of Drug Issues 26, no. 4 (1996): 961–974.
38. National Institutes of Health, “Fungi in the Gut Linked to Alcoholic Liver Disease,” June 13, 2017.
39. Alvin H. Moss and Mark Siegler, “Should Alcoholics Compete Equally for Liver Transplants?” Journal of the American Medical Association 265, no. 10 (1991): 1295–1297.
40. “Liver Transplant: Treating End-Stage Liver Disease,” December 15, 2006, MayoClinic.com.
41. John Taylor, “Live and Let Die: In Praise of Mickey, Jerry, and the Reckless Life,” Esquire, December 1995, p. 120.
42. This case study is based on questions used in a 1995 poll of U.S. Olympians or aspiring Olympians as reported in Michael Bamberger and Don Yaeger, “Over the Edge,” Sports Illustrated, April 1997, pp. 60–67.
43. Case study adapted from Judith A. Boss, Perspectives on Ethics (Mountain View, Calif.: Mayfield, 1998), 222–223.
44. Peter D. Kramer, Listening to Prozac (New York: Viking, 1993), 294.
45. Ibid., 258.
46. Ibid.
47. This case study is adapted from “AA Made Me Confess,” in Alan Dershowitz, The Abuse Excuse (Boston: Little, Brown, 1994), 69–71.