Drugs: Are Addicts Sickorbad?

"We have made criminals out of millions of people who have a disease," said Baltimore Mayor Kurt Schmoke.

It was the first day of the Drug Policy Foundation's International Conference on Drug Policy Reform, and Schmoke was speaking to an overflow crowd at lunch. Smart, articulate, and handsome, he was the hero of the conference, an up-and-coming politician who actually advocates drug-policy reform. His public-health rhetoric was just what I expected to hear for the next three days—calls for more treatment programs and images of drug users as victims of an uncontrollable disease.

I had come to the conference to challenge the medical model. Assigned to a panel with the intimidating title "The Libertarian Alternative: It's More Sophisticated Than You Think," I would argue that a market approach to legalization is more politically feasible than a medical approach. People do not want some kind of government Good Humor trucks roaming the streets dispensing free drugs—the kind of "legalization" drug warriors conjure up to scare people. A drug welfare state, I would contend, is not much better than a drug war. I didn't expect anyone much to agree with me.

I was wrong. True, the 150-plus conference attendees included plenty of social-worker types lusting after federal dollars. One panel was even called "How Will All the New Treatment Funds Be Spent," a reference to the $250 million allocated by the just-passed drug bill. As I sneaked in the room late, one Joanne C. Gampel was droning on in a New York accent that could scratch glass. She was reading an endless list of incomprehensible (and possibly meaningless) statistics—all aimed at showing that both treatment programs and her bailiwick, collecting statistics, need more federal money. She wasn't specific about how much, but an audience member proffered this rule of thumb: "What do they spend now? Double it, triple it, quadruple it." In other words, hand this woman a blank check.

Despite the feeding frenzy, some interesting ideas still got through. William Wilbanks, a criminal justice professor at Florida International University, suggested that the "monkey model" of addiction is preventing sound approaches to drug education. People believe that once someone tries cocaine, for instance, he will become enslaved to the drug, like experimental monkeys that press a lever to get cocaine until they kill themselves.

This concept of human beings as caged laboratory animals, Wilbanks argued, leads to two kinds of drug education: deterrence (scare tactics, "just say no") and treatment (primarily medical programs for addicts). What's missing is "prevention"—strategies to help people who do take drugs control their habits so they don't become addicts.

By telling people they're not responsible for their behavior once they "lose control" to drugs, the monkey model may even encourage addiction. (It also ignores data indicating that about 24 people have tried cocaine for every 1 full-blown addict.) Wilbanks opposes legalization of hard drugs as long as the monkey model holds sway. Legalization would lead more people to try drugs; the monkey model would lead them to interpret the desire to take more drugs as an uncontrollable addiction—a self-fulfilling prophecy.

Wilbanks expected his talk of self-discipline and personal responsibility to arouse suspicion. Hearing his southern accent, he suggested with a twinkle, his audience might even take him for a fundamentalist Christian. He isn't. But he is genuinely offended at the idea that individuals, including drug users, can't make moral choices. "The New Obscenity," he calls it.

If Wilbanks's rough-hewn moral critique represented one wing of the attack on the medical model, Bruce Alexander's decidedly unmoralistic approach was the other. Alexander is a psychology professor at Simon Fraser University in British Columbia and a determined foe of the idea that addiction is a disease.

The medical and moral approaches are not opposites, he argued, but merely manifestations of the same view of addiction: "Sickorbad. It's like it's one word. Either addicts are sick or they're bad." Either way, most people advocate a war on drugs—to contain the plague, stop the evildoers, or both. Despite its scientific patina, the medical model grew up along with the 19th-century temperance movement and reinforced its arguments. Prohibitionists maintained that the only way to avoid succumbing to the disease of addiction was to abstain altogether from drink or drugs.

Indeed, the last-minute drug bill represented the triumph of the sickorbad theory. Without fear of paradox, it split its appropriations equally between law enforcement and education/treatment. And, in a separate bill passed at the same time, Congress even overturned a Supreme Court decision allowing the Veterans Administration to rule alcoholism a form of "willful misconduct." Alcoholism, at least when it comes to veterans' benefits, is officially a disease.

Against this view, Alexander posits an "adaptive" model. Addicts turn to drugs not because they're sick or bad but "as a natural consequence of human distress." Addicts choose to take drugs because, as bad as it is, life with the drugs seems better than life without them. Alexander makes no broad claims about free will. But he does view human actions as purposeful, even if the root causes of those actions lie in a faulty upbringing, unfortunate genes, or an inadequate environment.

As a researcher, he works with real-live addicts as well as rats and monkeys. "I ask them where they'd be without heroin," he told me. "They say they'd be dead."

Wilbanks and Alexander both popped up on several panels. So did other critics of the medical approach. At least in the sessions I attended, nobody seemed very enthusiastic about exchanging the drug war for some kind of addiction maintenance program. (There was, however, a great deal of support for the American Medical Association's very moderate position that physicians should have the legal right to dispense methadone to private patients, outside the bureaucracy of an official government program.)

The audience grumbled when one speaker suggested letting anyone buy drugs—but only from a physician. It would just make the doctors rich, commented the woman next to me. In Britain, she said, one of the heroin-dispensing doctors even set up shop in a subway station. Better to use pharmacists. And even then, she said, "the typical junkie knows more about drug reactions."

Behind many of the arguments against the medical model lies the work of two men: psychologist Thomas Szasz and philosopher Herbert Fingarette. Few people completely accepted Szasz's radical critique of the "therapeutic state," but still fewer discounted it altogether. Szasz's arguments that the disease metaphor is just that, a metaphor, and that the state has no business overseeing its citizens' mental conditions have made a lasting impression.

Fingarette, in his recent book Heavy Drinking, not only made philosophical points but also demolished the empirical evidence that alcoholism is a disease. The Supreme Court drew on his work in its V.A. decision; so did many of the conference attendees. (For a summary of Fingarette's arguments, see the Spring 1988 issue of The Public Interest.)

To change the drug laws, we have to do two things: convince the public that they should be changed and suggest an alternative. In the name of saving people from the disease of addiction, the war on drugs now imposes tremendous costs on nonaddicts—in crime, lost liberties, diverted law enforcement, and tax dollars and cents. Every child shot in gang crossfire and every drug cop killed in the line of duty is a martyr to the idea that the law should protect addicts from themselves.

We have to abandon that idea and to make drug users responsible for their own actions—and their own choices. Drug reformers are beginning to realize that only when we relinquish the medical metaphor and treat addicts not as victims to be cared for or criminals to be punished will we find a way out of the current battle zone.

Virginia I. Postrel is associate editor of REASON.