But as Thomas Szasz and other critics of contemporary psychiatry have long argued, the ostensibly liberal policy of treating behavior like a disease can have profoundly illiberal consequences. A disease is something inherently undesirable that happens to people against their will. No one in his right mind wants to be sick. Furthermore, drug addiction is said to be a disease that impairs the patient's judgment. Where's the harm, then, in forcing him to be well? Under the circumstances, it would seem to be the compassionate thing to do. Presumably, that is the rationale behind Initiative 685's "court-supervised drug treatment." When the disease model is combined with the public health imperative to minimize morbidity and mortality, and to enlist the state's assistance in that endeavor, the logical result is never-ending intervention in personal decisions. (See "What the Doctor Orders," January 1996.)
Some reformers who are privately skeptical of the disease model push it because they think that's what the public is prepared to accept. From their polling and their focus groups, the supporters of the Arizona and Washington initiatives knew that voters were not ready for outright decriminalization. They needed to be assured that somebody would be in charge--if not cops, then doctors. Given the fate of Washington's initiative, the wisdom of this strategy is open to question. But even if the measure had passed, it might have made further reform more difficult by reinforcing the disease model. If voters believe that people cannot reasonably be expected to control their drug use, how likely are they to support the repeal of prohibition?
On the other hand, the war on drugs is not going to end overnight. Certain piecemeal reforms can mitigate injustice now and help prepare the public for more radical change later. Reducing the penalties for marijuana possession in the 1970s was, I think, such a reform. Making marijuana legally available as a medicine may be another. By the same token, surely drug users would be better off if they were never sent to prison, even if they sometimes had to endure court-ordered "treatment."
Judging from my conversations with reformers, I'm not the only one who is ambivalent about these issues. To help bring the debate into focus, REASON invited several prominent critics of the war on drugs to discuss the pros and cons of medicalization.
Senior Editor Jacob Sullum is the author of For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health, forthcoming this spring from The Free Press.
The Political Legitimation of Quackery
By Thomas Szasz
The Washington State "Drug Medicalization and Prevention Act of 1997" asserts that "we need to...recognize that drug abuse and addiction are public health problems that should be treated as diseases." The merits of this claim cannot be intelligently debated without agreeing on the use of the terms drug abuse, addiction, treatment, and disease, and on the kinds of personal conduct that justify coercive state control by means of public health measures.
From ancient times until recent years, the term public health, as distinguished from private health, was used to denote activities undertaken by a government to protect individuals from disease-causing agents or conditions in the environment, both physical and human. The principal public health measures have been sanitation and the control of infectious diseases, aimed at protecting the community from microbial diseases such as cholera and typhoid. In this connection, the control of venereal diseases illustrates an important consideration: The prostitute's behavior, exposing her client to the risk of venereal disease, was and is viewed as a public health problem, justifying the coercive control of her conduct, whereas the behavior of her client, exposing himself to the risk of venereal infection, was and is viewed as a private health problem, not justifying the coercive control of his conduct. By defining the behavior of the individual who exposes himself to the risk of "addiction" as a public health problem, we radically expand the range of legitimate state coercion in the name of health.
Public health measures play a crucial, but neglected, role in modern political philosophy. Interventions justified in the name of health--defined as therapeutic, not punitive--fall outside the scope of the criminal law and are therefore exempt from constitutional restraints on state coercion. On the contrary, such measures--promoted as protecting the best interests of "sick patients"--are viewed as valuable "services" provided by the Therapeutic State (the polity uniting medicine and state, much as church and state formerly were united). Presciently, John Stuart Mill anticipated this insidious tactic: "The preventive function of government," he warned, "is far more liable to be abused, to the prejudice of liberty, than the punitory function; for there is hardly any part of the legitimate freedom of action of a human being which would not admit of being represented, and fairly too, as increasing the facilities for some form or other of delinquency."
Mill could not have put it better had he been addressing present-day American drug policy. It is self-evident that free access to a particular drug, like free access to any object, increases our opportunities for using and abusing it: Freedom of action means the opportunity to act wisely or unwisely, to help or harm ourselves. It is also self-evident that, since "no man is an island," any private act may be viewed as affecting the economic, existential, or medical well-being of others, and hence be deemed to pose a "public health problem"; and that if protecting people from themselves falls within the sphere of public health, then no private behavior is exempt from being categorized as a public health problem, subject to control by means of medical sanctions.
It is ironic that, in 1997, Americans should recommend "drug medicalization" as a cure for America's drug problem: It was the "drug medicalization" act of 1914--better known as the Harrison Narcotic Act--that transformed widely used analgesics and sedatives into dangerous "narcotics," specially monitored by the federal government, available only by a physician's prescription. Horribile dictu, isn't it possible that defiance of such controls is not a disease, and that coercive state interference with the free market in drugs--like similar interference with the availability of other goods--may be the root cause of the problem we now try to solve by still further "medicalization"? Aren't we fools if we fail to ask, cui bono?: Who benefited from drug medicalization in the past and who benefits from it today?
The die is now cast: Misbehaviors of all sorts are (defined as) medical problems. Unwanted behavior, exemplified by the use of illegal drugs, is, by fiat, a disease. The concepts of disease and treatment have thus become politicized. The World Health Organization's definition of drug abuse as the "use of a drug that is not approved by a society or a group within that society" is illustrative. Thus, doctors, judges, journalists, civil libertarians, everyone accepts--or pretends to accept--that self-administering heroin is a disease and that a state agent administering methadone to an "addict" is a treatment.
Some see the Therapeutic State as an instrument of compassion and science in the service of "moral progress" and accordingly support "medicalization" in all its many guises. Others see the Therapeutic State as an instrument of cruelty and pseudoscience in the service of a new form of statism and accordingly oppose "medicalization."
Contributing Editor Thomas Szasz, professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse, is author of many books, including Our Right to Drugs: The Case for a Free Market (Praeger).
A New Metaphor for Autonomy
By Jeffrey Singer
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