Drug Medicalization

Your symposium about national drug policy ("Drug Trial," March) does a service in arguing for more stress on harm reduction and treatment. I agree. Without legalizing any illicit drug, a great deal can be done to achieve demand reduction by prevention and treatment, and by decriminalizing the small-time user.

Voter initiatives to effectively legalize illicit drugs under the pretext of unproved medical benefits are dangerous. Which drugs should be available for medical purposes is a technical question that voters are not qualified to decide.

To allow that would undercut our system of consumer protection through the Food and Drug Administration. This system, of which America can truly be proud, sets scientific–not ideological–standards to ensure that only safe and efficacious medications can be marketed. Drugs like cocaine and morphine, illicit on the street, are nevertheless classified in Schedule II and are available by prescription for legitimate medical purposes.

If convincing evidence shows a real medical value for marijuana (or its active principle, THC), it will certainly pass FDA scrutiny and will then be reclassified and become part of normal pharmacotherapy. My opposition to these medical marijuana initiatives has nothing to do with marijuana per se, but with a concern for not bypassing the FDA procedure.

Avram Goldstein, M.D.
Professor Emeritus of Pharmacology
Stanford University
Stanford, CA

When discussing whether or not "medicalization" is an appropriate way out of the drug war quagmire, it is helpful to agree first on what the word means. "Medicalization" is defined by many as the approach which treats drug use–or abuse–as a public health problem, rather than a criminal justice concern. This seems like a good starting definition. Consequently, I have trouble referring to both November 1996 initiative victories –Propositions 200 and 215 in Arizona and California, respectively–as "medicalization" initiatives.

In Arizona, voters changed the law to remove jail time as an option for people arrested for using illicit drugs. The voters saw the use of cocaine, heroin, LSD, and other drugs as a "problem" where treatment, as opposed to prison, is the more appropriate governmental response.

In California, however, voters didn't see the use of marijuana as the problem. Rather, they saw medicinal marijuana use as the solution to health problems such as cancer, AIDS, glaucoma, and multiple sclerosis.

As we continue to pass good state legislation and win state initiatives, it will be increasingly important for us to develop a more nuanced drug war vocabulary. We are already having problems with this, as evidenced by the confusion over Initiative 685 in Washington state, which was defeated by the voters in November 1997. Advocates, opponents, and the media still refer to that initiative as a "medical marijuana" initiative. In truth, the "medical marijuana" provision was a subset of the "medical marijuana, heroin, and LSD" section–which included all Schedule I drugs–and this was only a small subset of the entire initiative, which was nearly identical to the Arizona initiative.

This confusion has very real policy consequences. Testifying in favor of medicinal marijuana legislation before the Washington state legislature on January 20, I explained that they should pass the bill because, among other things, the voters strongly support it. The chair of the committee responded by asking why the voters had just rejected Initiative 685. I raised my hands in frustration, explaining that they were two entirely different animals. That bill is now dead.

Let us hope that the public discourse is more informative in the months to come, as Washington state voters will have another opportunity to vote on an initiative–this one a pure medicinal marijuana initiative–in November.

Robert D. Kampia
Executive Director
Marijuana Policy Project
Washington, DC

I read with interest your roundtable in the March REASON. My graduate thesis concerns the use of suspicionless drug testing as a "prevention" and "addict identification" tool. (See www.nevada.edu/home/3/gladd/EPS/thesis.html.)

It remains an article of faith among drug war proponents that illicit drug use equals "abuse" and that users are by definition addicts in need of treatment. Under the Americans With Disabilities Act, if you test positive at work and allow yourself to be labeled an addict and remanded to treatment, you are among a protected minority with respect to "employment discrimination." Should you claim to not have a drug problem, on the other hand, your very dissent likewise "proves" you to be an addict "in denial," and your refusal to submit to treatment renders you summarily terminable.

We recently witnessed the ungainly spectacle of L.A. City Councilman Mike Hernandez running off straight away to "rehab" after being caught in a cocaine sting. Until he was caught he wanted drugs, not "treatment." Thomas Szasz has made this sort of point repeatedly.

Just last week Newt Gingrich was at it again, calling for mandatory drug testing of all college athletes, and demanding that all who test positive be remanded to "treatment." This is an apparently untreatable policy tic.

Bobby Gladd

Your roundtable on drug policy reform is a great collection of articles, but there are some aspects of this issue that deserve more attention. One is the fact that–even in the liberal Netherlands–many doctors are ambivalent or plainly unwilling to prescribe methadone, and even more reluctant when it concerns heroin, cocaine, and other illegal psychoactive substances.

Another is the disruptive influence this kind of medicalization has on the patient-doctor relationship, as can be witnessed in many methadone programs around the world. Still, an argument can be made in favor of this kind of medicalization, because it can be an instrument in changing the attitudes of the medical profession and of the general public, and in the development of more rational, nonprohibitionist drug policies.

I discussed this argument in an article in the Dutch medical journal Medisch Contact in 1994, which in English translation is titled "The Medicalization of (Problematic) Intoxicant Use and the Medical Provision of Psychoactive Drugs." It can be found online at www.drugtext.nl/articles/freek2.html.

Freek Polak, M.D.
Amsterdam, Netherlands

I have a difficult time understanding the comments of Thomas Szasz regarding the recent drug medicalization initiative that was rejected by voters in the state of Washington. Szasz refers to the World Health Organization's definition of drug abuse as the use of any prohibited drug, and then seems to apply that faulty definition to drug addiction. I agree that drug use is not a disease, but drug addiction most certainly is. Improper diet (which can include the ingestion of drugs) is not a disease either, but it can lead to any number of diseases.

If Szasz is simply pointing out that it would be idiotic to arrest people for possession of drugs and force them into treatment for drug abuse, I have no problem with his reasoning. At the same time, however, it would be more compassionate to force them into treatment than to continue putting them in prison. Does Szasz think the drug war is just going to end overnight?

Carl Olsen
Des Moines, IA

Thomas Szasz replies: I wish to thank Mr. Olsen for his comment. Having a chance to reply gives me an opportunity to clarify some important points.

Mr. Olsen says that drug addiction "most certainly" is a disease. I disagree. Habits–whether deemed bad by others or the self–are not diseases.

Mr. Olsen believes that it is "more compassionate" to force so-called drug abusers to submit to what he calls "treatment" than to imprison them. I disagree. Imposing an indefinite, legally unregulated treatment on a person (especially one who has no disease) is not, ipso facto, more compassionate–meaning, I assume, preferable for the subject–than imposing a finite, legally regulated prison sentence on him. In any case, that choice would have to be made by the subject, an option Mr. Olsen doesn't mention.

Mr. Olsen accepts that forced treatment is a treatment. I do not. In medicine, the law regards treatment without consent as assault and battery. I regard forced "treatment" (rationalized as serving the "patient's" own best interests) as torture disguised and justified as treatment, a contention supported by the 300-year history of the psychiatric holocaust and its denial by the victors who write history. Using the coercive apparatus of the state to force people to submit to the ministrations of doctors of medicine is persecution in the name of health, exactly as using the coercive apparatus of the state to force people to submit to the ministrations of doctors of divinity was persecution in the name of God.

Neither Mr. Olsen nor I knows how the drug war will end, but end it will. We do know that alcohol Prohibition did not end by giving some Americans booze by prescription and others involuntary treatment for booze abuse. I feel confident that drug prohibition will not end by giving some Americans marijuana by prescription and others involuntary treatment for marijuana abuse. Indeed, I fear that compounding the prohibitionist zeal of the drug warriors with the therapeutic zeal of the drug medicalizers will only intensify our flight from reason and responsibility.

Subsidizing the Family

In his article on the Parental Bill of Rights ("Family Planning," March), Walter Olson is as critical of the proposal as George Will and James Q. Wilson are enthusiastic about it. As one of the two authors (along with my son, Grandon) of the Parental Bill concept, I welcome the enthusiasm and take the criticism seriously–alas, more seriously than I believe this particular criticism warrants. Olson's arguments, such as they are, make sense only for a world that no longer exists, certainly not in late 20th-century America.

I could go on at length about dozens of details in Olson's article–for example, I wonder how he feels about the World War II GI Bill of Rights on which our program is ultimately modeled and to which many of his criticisms would equally apply. Let me, however, go directly to the main issues involving this long-since-departed world where his arguments might have some relevance. That world is one in which a) there is a strong interest in the future and especially the future that will be inherited by one's children and grandchildren; and b) governmental policies are either minimal or at least neutral with respect to the institution of the family. I argue that neither of these assumptions is accurate in today's America. The failure of these assumptions is exactly why the Parental Bill program and other similar programs are (unfortunately) necessary.

I have recently written a book on the decline of what was once a very strong interest in the future, Posterity: Progress, Ideology, and the Decline of the American Family. In this book, I try to explain why the balance between self and posterity has shifted so sharply in the direction of self over the past several decades. The notion that, in this very present-minded world of ours, the family can be counted on to give adequate attention to our children–to "regulate itself" as Olson puts it–is largely wishful thinking

Certainly it becomes wishful thinking when we add the second point–the expansion of governmental programs whose main effect, intended or unintended, is to undermine the traditional American family. There are hundreds of examples, one obvious one being the expenditure of billions of dollars in public subsidies for various out-of-home day care arrangements. Olson undoubtedly wishes that such programs did not exist. But they do exist, and every indication (for example, Clinton's recent State of the Union message) is that these subsidies will be expanded in the future.

It is very understandable that parents would want these subsidies increased. For despite Olson's open-mindedness about current day care arrangements, there is overwhelming evidence that many, if not most, of them are exceedingly bad for children, especially infants and toddlers. An extensive 1995 study of day care centers reports that "child care at most centers in the United States is poor to mediocre with almost half of the infants and toddlers in rooms at less than minimal quality" (italics in original). This report, mind you, came from authors who strongly support an increase in day care subsidies. Olson's view that, once parents recognize that day care is inadequate, they will want to raise their young children themselves, is the exact opposite of the truth. It is almost certain that they will then demand higher subsidies so that they can count on so-called "quality" care.

Social Security, Medicare, tax-protected pensions, and similar programs also distort parental choice. The past several decades have seen a dramatic shift in the composition of our labor force: a massive withdrawal of older men and a massive infusion of young mothers. It used to be that the overwhelming majority of 65-year-old men remained in the labor force; now only a small fraction do. Similarly, it used to be that only a small fraction of mothers with children under 6 in intact families were in the labor force; now two-thirds are.

Thus, the main drift of the Parental Bill of Rights program would be to shift subsidies from retirement years to young parenting years. It is an extraordinary misapplication of public funds when we heavily subsidize older men so that they can retire earlier than ever when they are living much longer and when work in the service economy is much easier on the elderly than in the past.

I agree with Olson in being for a general reduction of government programs that impact the institution of the family. Most such programs tend to undermine the family, not strengthen it. However, I do not believe that governmental action is by any means the sole cause of American family decline. Rather, I would suggest that this governmental action is, to a great degree, a reflection of the same underlying cultural attitudes that are weakening the family on their own. Were these cultural attitudes to change, there would probably be no need for a Parental Bill of Rights or any other significant government intervention in this area.

But that world does not exist now. Until it does, it seems to me that we must try to support all efforts to increase the care and attention parents give to their children and to raise the flag of "family values" (that abused term!) whenever we can. This is exactly what the Parental Bill of Rights would attempt to do.

Richard T. Gill
Ft. Lauderdale, FL

Walter Olson replies: One extraordinary, and highly unconservative, premise underlies the mass of prolix condescension that here issues from Mr. Gill's pen. Human nature, he contends, has in our own times undergone a radical change, with the result that ordinary middle-class parents no longer care overmuch about the future that faces their children. (The world in which they once did care, his second paragraph announces, is "long since departed.") I find this premise unlikely in itself, inconsistent with both the behavior and the expressed sentiments of nearly all middle-class (or, for that matter, poor) parents I see around me, and at odds with survey data concerning what adults worry about and what motivates them to work overtime, move to suburbs distant from their work, give up leisure time, or forgo present consumption.

Nowhere in his long letter does Mr. Gill respond to my prediction that steeply subsidizing later college education for mothers who stay home with children would cause many to postpone college attendance strategically to take advantage of the subsidy; would unfairly penalize taxpayers who decline to arrange their lives in the prescribed patterns (including women who persist in the now-common pattern of postponing childbearing until they finish their education); and would actually encourage some illegitimacies (if subsidies were made available to out-of-wedlock mothers, as is apparently contemplated). I hope this doesn't mean that Mr. Gill has not devoted much thought to whether these results will occur, or that he does not much care.

As for the facile invocation of the GI Bill to justify any ill-conceived social program that one might come up with, I can only say that, yes, I do see a very real difference (as regards the sorts of public services that might engender a claim on the taxpayer fisc) between being conscripted and sent into the Battle of the Bulge on one hand and looking after one's own child on the other.

Law vs. Law

While generously applauding Steven Landsburg's remarkable book, Fair Play, Nicholas Schulz criticizes Landsburg's call to disobey bad laws. ("Out of the Mouths of Babes," March.) Schulz is particularly worried about Landsburg's proposal to teach children "that all laws are bad" as well as Landsburg's admonition that the attorney general should be someone who "believes that bad laws are bad and should be ignored."

Landsburg's advocacy of solipsistic lawlessness is only apparent. This confusion is caused by our regrettable habit (slipped into by Landsburg) of equating government dictates–especially statutes–with law. But law and statutes are entirely different things. Genuine law grows spontaneously out of the decentralized interactions of countless people.

This "common law" must be discovered in the actual practices of those affected–such as how commercial law grew through the centuries not from governments but from the actual practices of merchants. Government can no more centrally plan the law than it can centrally plan industrial outputs and prices. Attempts at either sort of central planning generate perverse results.

Statutes, in contrast to genuine law, are almost always arbitrary commands imposed upon citizens by the sovereign with threats of violence. That the sovereign is elected by a majority of voting citizens does little to render more law-like that sovereign's statutory commands. Legal central planning, like economic central planning, is no less absurd when practiced by democratic governments than when it is practiced by totalitarian thugs.

Landsburg is correct if he is read–as I think he should be read–to say that statutes are often bad, and that any decent attorney general should refuse to enforce bad statutes. Indeed, because modern legislatures are largely in the business of supplanting spontaneously evolved law with statutes, refusing to enforce bad statutes may well be an exercise in upholding the law.

Donald J. Boudreaux
Foundation for Economic Education
Irvington-on-Hudson, NY