From Moral Issues that Divide Us
What People Think
Four Arguments for Drugs: Pleasure, Mental Therapy, Artistic Inspiration, Religious Enlightenment
Paley’s Utilitarian Criticism: Harms Outweigh the Benefits
Stoic Criticism: Pleasure should be Avoided
Kant’s Criticism: Intoxication Undermines Autonomous Free Choice
Nietzsche’s Criticism: Intoxication Inhibits Creativity
James’s Criticism: Drug-Induced Mysticism Is Unreliable
Public Policy Issues
Balancing Freedom and Harm
Harm to Others vs. Harm to Oneself
U.S. Drug Laws
Efforts to Relax Drug Laws
State Legalization of Marijuana
U.S. Alcohol Laws
Common Arguments Pro and Contra
The Conservative Position
The Liberal Position
A Middle Ground
Reading 1: Against Marijuana Legalization (by Whitehouse Office of National Drug Control Policy)
Reading 2: For Marijuana Legalization (by The American Civil Liberties Union)
John is a 35 year old drug addict who lives in his mother’s basement. He works on and off in construction but is incapable of holding down a full time job, and whatever he does earn quickly goes into his drug habit, which currently is methamphetamine. His days consist largely of watching TV, hanging around with other meth addicts and getting high. He’s been in and out of jail for drug possession, theft, and disorderly conduct, and he’s been in drug rehabilitation programs 7 times, most of which were part of plea bargain agreements. Since eighth grade he’s been a regular drug user and has sampled most of what’s out there. His exceptional intelligence enabled him to coast through high school and two years of college, but as he became more dependent on drugs he lost interest in even attending class and ultimately dropped out. He was married once, with two children, but after draining the family income and pawning almost everything in their apartment to support his habit, his wife left him with the kids and he hasn’t seen them since. He’s let his appearance go, lost several of his teeth and, now looking almost as old as his mother, it’s been years since he’s been out on a date. In addition to his meth use, he is an alcoholic and smokes heavily, and his prospects for living past his 40s are minimal.
There is nothing particularly remarkable about John’s story, and in fact it is representative of countless people in our society who abuse drugs and alcohol. It is also a very old story. The ancient Greek philosopher Anacharsis (6th cn BCE) was once asked what it would take for someone to lose interest in drinking. His response was all we need to do is observe the evil behavior of intoxicated people. He further stated, poetically, that “the vine produces three types of grapes: the first pleasure, the second drunkenness, the third remorse.” His point is that what begins with pleasure inevitably ends with deplorable conduct that the drinker deeply regrets once sober. In this chapter we will examine the moral issues surrounding drug use, or, more accurately, a subset of drug use specifically involving what are called “recreational drugs”. These are psychoactive drugs (that is, drugs with mind-altering effects) that are taken mainly as a source of pleasure rather than for medical purposes. The most common ones are typically categorized into the following four groups:
- Opiates: drugs formed from the opium poppy and include morphine, codeine, heroin.
- Hallucinogenics: drugs that produce experiences that are qualitatively different from those of ordinary consciousness, and include psilocybin mushrooms, marijuana, LSD.
- Depressants: drugs that diminish the activity in the central nervous system and include alcohol, Methaqualone, Benzodiazepine.
- Stimulants: drugs that increase the activity of the central nervous system and include Cocaine, Caffeine, Nicotine, Amphetamine, Methamphetamine.
While caffeine and nicotine are among the most widely used legal psychoactive drugs, our focus here will be on the use of alcohol and illegal substances such as marijuana, cocaine, heroin, and methamphetamine. For simplicity, in this chapter we will use the term “recreational drug use” in reference to these.
Psychoactive drugs have been used in society for as far back as history provides us with records. Many are naturally produced in plants and easily accessed by human populations in the regions in which they grow. Just as alcohol plays a key function today in social events, psychoactive drugs from plants have also been incorporated into community celebrations, rites of passage, and religious ceremonies. It is impossible to discuss the issue of psychoactive drugs without speaking of the harms associated with them, most of which we all well know from news stories and popular fiction.
One immediate type of harm is that to the users themselves. While many drugs can be taken in limited quantities with no ill effects, the cumulative use of many are particularly harmful. According to the Center for Disease Control, in 2010, 40,000 people in the U.S. died from illegal drug—double of what it was ten years prior. By comparison, in the same year 30,000 were from motor accidents, and 16,000 homicides. Drug-induced included those from overdose, heart attack, organ damage, and even malnutrition. Brain damage is also common. In 2011 around 2.5 million emergency admissions to hospitals were the result of recreational use. In addition to the immediate health risks of extended drug use, there are also secondary harms to users, such as sexually transmitted diseases that result from reduced inhibition and poor precautionary judgment. HIV and hepatitis C commonly result from injection drug use. As with John, a life of heavy drug dependency often derails normal human interests in careers, families, and other activities that we typically consider productive.
In addition to harm that drugs cause to the users themselves, there is also harm caused to others. Drugged driving is a problem where one out of eight weekend nighttime drivers tested positive for at least one illicit drug. Perhaps the most tangible harm to society from drug dependency is its link with crime. A study of arrests in five large cities showed that 63-83% of arrestees tested positive for illegal drugs (ONDCP Fact Sheet). Often crimes are committed by users whose drug habit outstrips their legitimate incomes. Muggings and theft are commonly connected with addiction, and women who ordinarily would never consider prostitution often compromise their convictions to support their drug habits. There are the tragic consequences when people under the influence of drugs get behind the wheel of a car or have their judgments impaired in a job that could put people’s lives at risk, such as with physicians or building contractors. There is also the harm that drugs cause to the user’s family: family resources are depleted, children are neglected and even forced by their parents into prostitution or drug running to boost the family income. Many children of drug-addicted parents end up homeless.
Yet another harm that results from drugs is that involving the illegal drug trade itself. The business of dealing in drugs is a particularly dangerous one, and the high murder rate in large cities owes much to feuding between dealers, such as disputes over distribution territory, payback for dishonest negotiation, or retaliation for the killing of a gang member. The danger also extends to members of the community where dealers do their business. Residents are held hostage to the dangerous drug trade that infiltrates their streets, and pedestrians are often hit with stray gunfire. Young children are routinely recruited for distribution tasks, and weapons make their way into schools. Federal and local governments devote billions in tax dollars to fighting the illegal drug trade, often with minimal success. Prison population is at an all-time high, a large percentage of which is drug related, which, again, burdens taxpayers. Spouses and children of the inmates also suffer as they face new financial and domestic problems.
Alcohol is an unusual drug with a unique set of harms. Alcoholic beverages have been around since ancient cultures, in some places for more than 10,000 years. Its nearly universal availability and acceptance owes in large part to the fact that the alcohol fermentation process occurs naturally in any geographical location. Contrast that with mind-altering drugs, such as marijuana and opium, which grow naturally in only select regions. Although alcoholic beverages have been grandfathered into social acceptance, the harms from alcohol abuse are as severe as those from illicit drugs, and if alcohol was only first discovered today it would likely be banned as a dangerous drug. In fact, one study shows that alcohol use is more likely than marijuana use to lead to violence between partners (tntoday.utk.edu). The harms from alcohol abuse are well known, and they cut across all age and socio-economic groups; it is responsible for around 25,000 deaths per year (ONDCP Fact Sheet). A good example is the harm that results from college drinking. In the U.S., nearly 2,000 students die each year from alcohol-related accidents, and another 600,000 are injured. 700,000 students are victims of assault, 100,000 from sexual assault or rape. Alcohol abuse in colleges leads to unsafe sex, academic problems, drunk driving, suicide attempts, and property damage (www.collegedrinkingprevention.gov).
The above harms with both drugs and alcohol are indicators of what is often called “substance abuse”, and the standard criteria for substance abuse in the mental health counselling industry is this:
A pattern of substance use leading to significant impairment or distress, as manifested by one or more of the following during in the past 12 month period:
1. Failure to fulfill major role obligations at work, school, home such as repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household;
2. Frequent use of substances in situation in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use);
3. Frequent legal problems (e.g. arrests, disorderly conduct) for substance abuse;
4. Continued use despite having persistent or recurrent social or interpersonal problems (e.g., arguments with spouse about consequences of intoxication, physical fights); (DSM-IV)
According to the above, the main indicator of substance abuse is the inability to function normally within society and fulfill one’s basic responsibilities in various social settings.
A hallmark of drug use is that it is addictive. The notion of “addiction” is hard to pin down, and it often varies depending on who you ask. The World Health Organization defines drug addiction as follows:
Drug addiction is the 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.
A standard legal definition of “drug addict” used in U.S. law is this:
The term “addict” means any person who habitually uses any habit-forming narcotic drugs so as to endanger the public morals, health, safety, or welfare, or who is or has been so far addicted to the use of such habit-forming narcotic drugs as to have lost the power of self-control with reference to his addiction. (U.S. Code, 41.201)
A common distinction is drawn between drugs that are physically addictive and those that are only psychologically addictive. Physically addictive ones are accompanied by severe physiological withdrawal symptoms, whereas psychologically addictive ones lack these symptoms.
Society has viewed drug addiction in largely two ways: the moral model and the disease model. According to the moral model, addiction is ultimately a matter of personal choice, where users have enough control over their actions to continue or not continue with their addictive behavior. It may be difficult to stop, but with the right will power it can be accomplished. Failure to do so is a moral weakness where users know that their actions are wrong but choose to do them anyway. This is the rationale behind traditional religious views that condemn addictive behaviors as sinful, particularly drunkenness and gluttony.
By contrast, the disease model of addiction maintains that addiction is no more a matter of choice than having a mental illness like schizophrenia. Biochemical changes within the brain take place and have a permanent effect on users’ drives. Simple willpower is not sufficient to break free of the addiction, and it must be managed in ways similar to how diseases are treated. Some people are particularly prone to addiction for largely genetic reasons, and are sometimes described as having addictive personalities. Otherwise normal people, without this genetic predisposition, still can become addicts when chemical changes within the brain reach a certain threshold, specifically when the brain’s reward center permanently connects a type of behavior with a pleasure response. In either case, even if users can be reprogrammed to resist a particular behavior, the addictive mechanism within the brain is already fixed and they will forever remain addicts. The disease model of addiction first emerged in the 1940s, and within a few decades it was embraced by both the American Medical Association and the World Health Organization.
Extreme advocates of the disease model sometimes argue that drug addicts who break the law as result of their addiction, such as by stealing to support a drug habit, should not be punished for their conduct, but instead given therapy. They are in essence broken machines that need to be fixed, not punished. However, many mental health organizations that deal with drug dependency incorporate both the disease and moral models. While there are certainly physiological causes of addiction that cannot be over looked, there is nevertheless an element of moral responsibility that users have to control their addiction and to be accountable for the harms that they have caused others through their addiction.
What People Think
While people in the U.S. are reluctant to legalize hard drugs such as heroin, meth and cocaine, attitudes are more lenient when it comes to marijuana, as reflected in the following surveys.
"Do you think the use of marijuana should be made legal, or not?" (Gallup)
Legal Illegal Unsure
10/5-9/16: 60% 39% 1%
10/7-10/10: 46% 50% 4%
8/29 - 9/5/00 31% 64% 5%
"Do you support or oppose allowing adults to legally use marijuana for medical purposes if their doctor prescribes it?" (Quinnipiac)
Support Oppose unsure
5/24-30/16: 89% 9% 2%
“Have you ever tried marijuana?” (CBS)
Yes No Unsure
4/8-12/16: 51% 47% 2%
The issue of drug use has both a moral and legal dimension. On the one hand, even if drug use is legal, we can ask whether the use of such drugs is immoral. Just because the law permits me to do something does not mean that I should do it—such as smoking or riding a motorcycle without a helmet. On the other hand, even if it is immoral to take drugs, we can still ask whether the use of such drugs should be illegal. The law permits us to do a range of immoral activities, such as lying to others or cheating on one’s spouse. While these are things that we should not do morally speaking, at the same time we do not want our laws telling us how to conduct our private lives. For the moment, let us set aside the issue of whether drugs should be illegal and look specifically at whether drug use is immoral. We will consider here arguments both for and against their moral permissibility.
Four Arguments for Drugs: Pleasure, Mental Therapy, Artistic Inspiration, Religious Enlightenment
There are four common arguments given in favor of recreational drug use. First is the argument from pleasure: the main purpose of taking recreational drugs is for the pleasure that they produce, and the pursuit of pleasure comes natural to us.By our very nature we are pleasure-seeking creatures, and much of what motivates us in life is the drive for pleasures of a wide variety. There are pleasures from food, romance, TV, movies, music, art, fashion, literature, travel, sports, games, you name it. Through these activities our brain chemistry is altered in ways that give us unique experiences of pleasure, and through this we step out of our normal routines and escape to a new realm. If we remove pleasures from our lives, then human existence becomes a barren landscape of routine actions that we perform throughout each day as we plod along from birth until death. The Greek philosopher Epicurus (341–270 BCE) argued that pleasure is the centerpiece of human life: “it is from pleasure that we begin every choice and avoidance, and it is also to pleasure that we return, using it as the standard by which we judge every good” (Letter to Menoeceus). Epicurus personally recommended that we only pursue pleasures in moderation and he was against intoxication. Nevertheless, the larger message of his pleasure-seeking philosophy is that, not only is pursuing pleasures morally permissible, but it is something that we should do. Recreational drug use is yet one more of the many pleasures available to us, and if we permit these more normal types of escapism, we should also permit drug use. In this spirit, French philosopher Michel Montaigne (1533–1592)argued that the pleasures that we get from excessive drinking are so rewarding that we should “refuse no occasion nor omit any opportunity of drinking, and always have it in our minds” (Essays, “Of Drunkenness”).
A second argument is that recreational drugs can function as a type of mental therapy by alleviating psychological pain. Studies show that specific drugs reduce anxiety and depression more quickly and effectively than other mental health therapies. These drugs include, marijuana, LSD, psilocybin mushrooms, and ketamine which are hallucinogenic. The mental health benefits come directly from their hallucinogenic properties, and these drugs cannot be synthesized in a way that isolates the therapeutic component from the recreational component. The buzz is the cure. We are all on our own to deal with our personal internal torments, and we are morally justified to find the best relief that we can. While there are indisputable therapeutic benefits to these drugs, the government has unfortunately outlawed them, unjustifiably classifying them as Schedule 1 along with the most dangerous drugs such as heroin and meth. But that just makes the government the moral culprit, not the drug user.
A third argument is that recreational drugs can enhance artistic inspiration. Some of the most creative musicians, painters and writers have sought inspiration through recreational drugs, and the list includes Miles Davis, the Beatles, Salvador Dali, Charles Dickens and Aldous Huxley. The basic idea is not a new one, and Plato argued that the best artists are those that are in some way mentally unhinged. He writes,
If someone approaches the gates of poetry without the madness of the Muses, thinking that he can become an adequate poet solely by means of expert knowledge, he will fail in his purpose. His poetry, being that of a sane man, will be overshadowed by the poetry of those who are mad. [Phaedrus, 245a]
While Plato had in mind a more mystical source of artistic insanity, today we recognize that many great artists had some clinically identifiable mental illness, such as schizophrenia or bipolar disorder. Notable figures are Ludwig van Beethoven, Vincent van Gogh and Ernest Hemingway. Clearly, these artists were at the mercy of their biology and made the best of it by channeling their disorders into a creative outlet. But some recreational drugs have similar neurological effects as these disorders, and can give artists a similar avenue for creativity. Society places a high value on aesthetic beauty and philosophers often rank it as one of life’s greatest intrinsic goods. We also value artistic works regardless of whether drugs were a vehicle of inspiration. It is not like doping in sports which is considered cheating and thus disqualifies the athlete.
A fourth and similar argument is that recreational drugs enhance religious enlightenment. The best case for this is that offered by American philosopher and psychologist William James (1842-1910). He argues that certain types of drugs “stimulate the mystical consciousness in an extraordinary degree” and that they produce “a genuine metaphysical revelation”. He himself experimented with nitrous oxide and was left with the unshaken conviction that our normal waking rational consciousness is only one type of consciousness, and only thin veil separates it from other kinds that are entirely different. His experience was one of mystical oneness in which everything “melted into unity.” He concluded that “No account of the universe in its totality can be final which leaves these other forms of consciousness quite disregarded” (Varieties of Religious Experience, 1902, 16). What James experienced is normal practice in many indigenous religions that use drugs in religious ceremonies, such as Native American ones. While society typically acknowledges the moral right of traditional religions to pursue religious mystical experiences through drugs, it is less generous with isolated religious experimenters who operate outside of traditional religions. According to the user, this bias against the individual mystic is unjustified.
We turn next to moral criticisms of recreational drug use, which take issue with the above four arguments.
Paley’s Utilitarian Criticism: Harms Outweigh the Benefits
The first and obvious objection to recreational drug use is that all of the above four justifications are counterbalanced by the overwhelming amount of harm it produces. We have already looked at the wide range of harms produced by recreational drugs. Philosophers for thousands of years have discussed the moral issue of intoxication, and foremost among their observations is the harm that they cause both to the user himself and to others. British philosopher William Paley (1743-1805) offers this brief list of bad effects of habitual intoxication:
1. It betrays most constitutions either to extravagances of anger, or sins of lewdness.
2. It disqualifies men for the duties of their station, both by the temporary disorder of their faculties, and at length by a constant incapacity and stupefaction.
3. It is attended with expenses, which can often be ill spared.
4. It is sure to occasion uneasiness to the family of the drunkard.
5. It shortens life. [Principles, 4.2]
As a utilitarian philosopher, Paley held that morality is based entirely on whether the consequences of a course of action produce more total good than bad. For him, the pain from habitual intoxication vastly outweighs the pleasure. If we add to this the harms from drugs and alcohol that we have already discussed, a modern-day utilitarian could easily draw the same conclusion as Paley.
Suppose, however, I object to this utilitarian reasoning on the grounds that I personally can regularly take drugs and alcohol without any of these harmful consequences to myself or others. Why, then, would it be immoral for me to get intoxicated when I feel like it? Paley has a response: the harm done by me is multiplied because of the example that I create for others. Drunkenness, he says, “is a social festive vice” where the drinker collects people into his social circle and “the circle naturally spreads.” The habitual desire for intoxicants, he argues, is almost always acquired through connection with “some company, or some companion, already addicted to this practice.” When I consider the full range of consequences of my conduct, I need to include the harmful behavior of those who I have influenced. He writes, “Although you have neither wife, nor child, nor parent, to lament your absence from home, or expect your return to it with terror”, the family situation may be entirely different for your friend who you have influenced.
Is Paley correct that I bear this kind of moral responsibility for the behavior of my friends that I influence? Perhaps not as much as he thinks. It is true that I can be a bad influence on you and others in my social circle. But there is a point at which you bear full responsibility for allowing yourself to go along with the crowd, especially in cases where you know better. From an early age, we are all warned to avoid being influenced by bad examples and not cave in to peer pressure. We are specially warned from an early age about the dangers of drugs and alcohol. If you disregard that advice, join my social circle and follow my example, the fault is your own, not mine. An exception to this is if I intentionally coerce or manipulate you into doing something against your will. That does sometimes happen within social circles of drug and alcohol abuse, but in usual circumstances it is more likely that at some point you became a willing member of my social circle and knowingly set aside the warnings of your youth.
Nevertheless, it may only be a minority of people who are unaffected by the negative effects of drugs, and thus Paley’s larger utilitarian critique remains valid for most people. That is, when the harms of drug and alcohol use counterbalance the goods they produce, then such conduct is immoral.
Stoic Criticism: Pleasure should be Avoided
A second criticism of recreational drug use targets the above argument from pleasure. In contrast with Epicureans, a rival school of ancient philosophy called Stoicism took an opposing position on the pursuit of pleasure. According to Stoics, we should not actively pursue pleasures of any sort, whether normal ones like food and music, or more artificial ones like drug use. Rather, we should exercise restraint through our lives so that we better cope with the unknown and unpredictable tragedies that life invariably gives us. Indulging in pleasure pampers us too much and gives us unrealistic expectations about what life has in store for us. For Stoics, this would be as true for drugs as it is for any other source of pleasure.
But there is a fundamental problem with Stoicism in its most extreme form: it is odd to suggest that we should forego all pleasures to help safeguard us from potential psychological trauma. It is comparable to how a survivalist might devote all of his resources to building and stockpiling a bunker in his back yard, just in case there’s a nuclear war, viral pandemic, or some similar apocalyptic event. He is sacrificing an otherwise normal life to protect himself from a prospect that may not be nearly as likely or tragic as he envisions. The extreme Stoic recommendation seems overly paranoid and would appeal to only a narrow group of loners who are inclined to lead humorless and somber lives.
But while we might for good reason dismiss the extreme Stoic stance against pleasure, a more moderate Stoic view is defensible. Many people do overindulge in pleasures of all sorts. A good example of this is society’s ever-growing credit card debt: desires outstrip financial resources, and disaster results. Also, the rise in obesity shows how challenging it can be to keep our culinary desires in check. Restraint is an important counterbalance to our desires, and restraint often involves learning to completely walk away from pleasures of every type. To combat credit card debt, we may need to throw out the card and use cash only. To combat obesity, we may need to throw out all unhealthy food in the kitchen, and never buy it again. We thus cure overindulgence by eliminating its source, and this rationale applies even more to overindulging in recreational drug because of their addictive nature.
But even when drug use is not addictive, there is something inherently different about drug-related pleasures that may justify Stoic-like restraint. Normal pleasures are very short term, and, if the need arises, we can instantly snap out of our pleasure fantasies to face a more urgent situation. If I am watching a heart-pounding action movie and then remember that I have a research paper due later that day, I can immediately turn away from it and devote my full attention to the project. By contrast, the mind-altering effect of recreational drugs cannot be turned off at will. We are held hostage to the effects as long as the drug is in our system, and this compromises our ability to act rationally and responsibly. The Stoic is right that life is unpredictable and on almost a daily basis we face random situations that require us to be clear headed. The need to be in control of our minds outweighs the pleasure that we get from mind-altering drugs, and thus we should abstain from them. Let us then enjoy in moderation all the normal pleasures that life offers us, but recognize that this one is different because of the grip it has on our cognitive abilities. This does not necessarily mean that all recreational drug use would be morally wrong, but it does suggest that it requires a level of responsibility that rises above the capacities of many if not most people.
Kant’s Criticism: Intoxication Undermines Autonomous Free Choice
A third criticism offered by German philosopher Immanuel Kant (1724-1804) is that intoxication through alcohol or mind-numbing drugs such as opium “blunt the operations of the intellect and reduce the user to the level of an animal” (Doctrine of Virtue, 8). The real damage is the effect that intoxication has on our ability to act freely, which is central to human rationality, and when that is compromised we are no better than animals. College campuses abound with examples of drunk or stoned students being expelled for choices they would never make when sober. For Kant, these are not free decisions made by rational minds, but the result of animalistic impulses. Kant considers one possible benefit from intoxication, which is that it can make us more sociable by enlivening conversation and bringing people together with the openness it produces. But this, he argues, is only the first phase of the intoxication process, and before long the tranquilizing properties of substances make the user “mute, reserved, and unsocial”. Similarly, the possible mental therapy benefit of alcohol and drugs also turns out to be deceiving. They may temporarily create “a dreamy happiness, a freedom from anxiety, or perhaps an imagined strength”, but this soon changes into hopelessness and sadness. It moves from one to the other so imperceptibly that it creates a desire in the user to “repeat and increase the mind-numbing dose.” In short, for Kant, intoxication is an animalistic vice that lures us in with a false promise of happiness, and then strips us of our ability to make rational choices. In this way, it violates a fundamental moral obligation that we have to ourselves to preserve our reason and, thus, our humanity.
Kant is largely correct with everything that he says. Yes, making rational choices is central to what it means to be human. Yes, intoxicated people often lose the capacity to make rational choices. Yes, self-medication through recreational drugs is a bad way to deal with depression, and it can make things much worse. However, the problem with Kant’s analysis is his extremism that allows for no exceptions to his rules. Contrary to what Kant suggests, it is not within our power to make fully rational choices every moment of the waking day. We do not lose our humanity when we occasionally set aside our reason and take a mental vacation by watching a silly movie, going fishing, attending a wild party, or taking a mind-altering drug. Even if we make mistakes by following our animalistic impulses in those situations, we are still human and not entirely reduced to the level of an animal. “To err is human” as the poet Alexander Pope said. Thus, it is an exaggeration to say that we lose our humanity by taking recreational drugs. As to using recreational drugs for mental therapy, it is all about using the right drug for the right problem. You do not take an antibiotic to cure a headache, or take an aspirin to cure an infection. To link the right ailment with the right cure, science is needed. Self-medication is a bad idea since it is done in ignorance of science, and often with substances that are genuinely dangerous. By contrast, the claims today about the mental health benefits of some recreational drugs are backed by science. Once the extremism is taken out of Kant’s theory, what we are left with is no longer a moral mandate, but a word of caution: be careful what you do while intoxicated, and base your drug therapy on science.
Nietzsche’s Criticism: Intoxication Inhibits Creativity
German philosopher Friedrich Nietzsche (1844-1900) specifically addresses the claim that intoxication inspires artistic creativity. His personal use of drugs and alcohol was not always consistent. At certain points in his life Nietzsche took opium, hashish, and chloralto deal with an array of health problems. But he did not drink alcohol since, he said, even moderate amounts turned his life into “a valley of tears”, and he recommended that people with more creative and artistic inclinations abstain completely from alcohol. His reason is that the narcotic effects of alcohol weaken the will, deaden pains that are necessary for growth, and create an attitude of resignation. He notes similar tranquilizing effects of opium. By contrast, he argues, art is a great stimulant of life, and requires ecstasy, frenzy, and an enhanced feeling of power. The true artist needs to break away from the status quo and create a new way of looking at the world. He makes this point when criticizing his own German culture for being so dependent upon beer. Young students devote their whole lives to the pursuit of intellectual ends, yet they sabotage their creative efforts by continually drinking beer. He writes,
The alcoholism of learned youths does not incapacitate them for becoming scholars (a man quite devoid of intellect may be a great scholar) but it is a problem in every other respect. Is there anything that is free from that soft degeneracy which is produced in the spirit by beer! [Twilight of the Idols]
For Nietzsche, then, alcohol and drugs lure the user into being content with their life situations, and inhibit their efforts for both personal improvement and artistic creativity.
But what about the drug-inspired creations of artists like Dali and the Beatles: doesn’t that go against what Nietzsche says? These cases may be misleading in two ways. First, these are world-class artists who typically exhibited extraordinary talent before their drug use, and so the true source of their ability was hard work or natural genius, not drugs. For ordinary artists, it is naive to think that inspiration from drugs or alcohol will magically enhance their creativity and propel them to world attention. Second, just as we are aware of many great artists who were drug-inspired, so too do we know about ones whose drug addictions destroyed their lives and had destructive consequences on their art. Among the devastating effects of drug and alcohol abuse, health professionals today would agree with Nietzsche that a common one is a type of lethargy, sometimes called amotivational syndrome, where a person can lose interest in both normal and creative activities. For ordinary and even world-class artists, this lethargy may counterbalance any momentary flash of creative insight that a drug might induce, and thus prevent the artist from bringing their visions to life in a compelling way. In the case of Dali and the Beatles, it’s possible to do it, but it is a bad gamble. Nietzsche’s advice for struggling artists would be to look for inspiration through one’s internal pain and discontentment, not through mind-altering substances.
James’s Criticism: Drug-Induced Mysticism Is Unreliable
Let us assume that traditional indigenous religions, such as Native American ones, are morally justified in using mind-altering drugs within their religious ceremonies. The question is whether private individuals who are not part of these religious traditions are also justified, and we have seen William James’s defense for this. However, he follows up is discussion with an equally compelling criticism: attempts at drug-induced mystical experiences are an unreliable source of mystical knowledge. He says that, while he indeed experienced the unity of all things when under the influence of nitrous oxide, his attempt to write down his insights during that state resulted in “tattered fragments” that, to the sober reader would appear to be “meaningless drivel”. In that moment, he explains, all opposites seemed to connect together, such as “God and devil, good and evil, life and death, I and thou, sober and drunk”. He says that the most coherent sentence that he wrote down was this: “There are no differences but differences of degree between different degrees of difference and no difference.” Further, he maintains, the longer he explored the drug-induced experience of unity, his initial feeling of rapture shifted to horror. For, if opposites are intertwined, there is no reason to choose any one side or the other, such as God vs. devil, good vs. evil, life vs. death. His insight that started out as “rosy bright” collapsed into a “pessimistic fatalism” (“On some Hegelisms”).
This, of course, was just one man’s experience with drug-induced mysticism. But the larger point is that, if you go it alone without the guidance of an established religious tradition, there is no telling whether your experience will even be mystical, rather than just an incoherent bad trip. If James attempted a drug-induced experience within the setting of a traditional indigenous religion, his mind would not likely have drifted off to see an identity between God and the devil, or good and evil. The religious context would define his experience through the shared beliefs of its members, and they could correct his wayward interpretations. For that matter, without being in the setting of a traditional religion, there is no reason to expect that the user’s drug experience would even be either mystical or religious. Like the millions of hallucinogenic experiences that take place each year among drug users, it would probably be a mind-boggling and pleasurable experience. But without the context of a traditional religion, there is no reason to expect that it would rise to the level of being either religious or mystical. There is thus no clear moral justification for individuals outside of traditional religions to use drugs for mystical purposes.
PUBLIC POLICY ISSUES
Let us set aside the moral issue of drug use and focus now on the public policy issue. Regardless of whether recreational drug use is moral or immoral, we next want to ask, which drugs should be legalized and which banned? What kinds of legal penalties should be imposed on offenders? How aggressive should law enforcement be in catching drug users and dealers?
Balancing Freedom and Harm
The key issue regarding the legality of recreational drugs concerns finding the right balance between people’s civil liberty to make personal choices without governmental interference, and the government’s responsibility to protect society from harms. If I want to eat a sandwich or hop around on one foot, and there is no serious harm in either of these activities, then the government has no business preventing me from doing them. Clearly, the situation with drugs is different because of the harms that result.
To better understand how the laws need to balance between freedom and harm regarding drugs, consider this thought experiment. Imagine that there was a town called “Buzzville” in which scientists and the local government worked together to eliminate the harmful effects of drug use. Drug companies developed a new generation of recreational drugs that were not harmful to take, and were not addictive—at least no more so than craving some comfort food such as chocolate ice cream. The drugs were also designed so that they would have no physiological effect when taken by people under 21 years old, thus completely eliminating the risk that the drug trade could pose to minors. If drug users found themselves in situations where they needed to sober up quickly, the mind-altering effects of these drugs could be immediately reversed by swallowing an antidote pill. Cars, heavy machinery and other potentially dangerous things were equipped with safety switches that would disable the unit if it detected the presence of drugs in the user’s breath or sweat. In short, all of the harms of drug use, both to society and the individual, were completely eliminated. Contrast this, now, with a rival town called “Overdoseville” that has only one recreational drug, but it is as addictive and deadly as heroin. Virtually everyone in the town is addicted to the drug, and society can barely function. Citizens cannot hold down regular jobs, muggings and theft are commonplace, and life-expectancy is age 35 because of the high rate of overdose and health-related problems.
On the one hand, if an environment like Buzzville ever did become a reality, there would be no obvious grounds for legally prohibiting drugs. The freedom to use drugs would outweigh the harms, since all the harms have been eliminated. On the other hand, if an environment like Overdoesville existed, the harms from drug use would overwhelmingly outweigh individual freedom, and there would be compelling grounds to legally prohibit drugs. In fact, if governments did nothing, they would be in violation of its social contract to keep society from collapsing into the state of nature. Our actual society is somewhere in between Buzzville and Overdoseville in terms of the freedom-harm balance of drug use. The critical question is how close must we get to Buzzville before we should legally permit drugs? There is at least some harm that we can tolerate if the benefits are great enough. A good example of this is our use of automobiles: we enjoy the mobility that our cars give us, but driving is one of the riskiest activities there is and results in around 30,000 deaths per year in the U.S. However, our society has judged that the personal benefits of automobile use outweigh their harms. Similar reasoning might apply with drug use: if the personal benefit that we derive from recreational drug use is great enough, we may be willing to accept some harms.
Some European countries have substantially relaxed their drug laws, and the Netherlands is a case in point. While recreational drugs technically remain illegal there, the Dutch have a policy of non-enforcement with “soft drugs” such as marijuana, and users are typically not prosecuted. At the same time, though, the Dutch strictly enforce laws prohibiting drug importation-exportation, and driving under the influence. The U.S. is not as lenient as this, and its current assessment is that the harms of drugs outweigh the importance of our freedom to choose.
Harm to Others vs. Harm to Oneself
We have seen that some harms from drug use affect mainly the individual user, while others affect society at large. When balancing freedom and harm with drug use, should we take into account both individual and social harm, or only social harm? British philosopher John Stuart Mill argued that governments are only justified in restricting the social harm of anyone’s conduct, regardless of the harm that comes to the individual. His general principle is this:
The only purpose for which [governmental] 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. [On Liberty, 1]
This is also his position with intoxication even when the user is an addict: if he does not harm others, then he should have the freedom to become intoxicated regardless of the harm he does to himself. Mill writes that drunkenness “in ordinary cases, is not a fit subject for legislative interference” but that “the making himself drunk, in a person whom drunkenness excites to do harm to others, is a crime against others” (On Liberty, 5). The addict’s behavior may be immoral, and his friends are entitled to encourage him to change, but the government should not punish him. The American Civil Liberties Union (ACLU) makes the same argument:
In trying to enforce the drug laws, the government violates the fundamental rights of privacy and personal autonomy that are guaranteed by our Constitution. The ACLU believes that unless they do harm to others, people should not be punished -- even if they do harm to themselves. [“Against Drug Prohibition”]
In short, for the staunchest defenders of personal freedom such as Mill and the ACLU, the issue of drug illegality hinges on harm to others, not harm to oneself. The U.S. Government, however, does not go this far and factors in both harm to others and harm to oneself. This is most evident in statements made by U.S. Government agencies, which, when defending the illegality of drugs, regularly list harms to the user as well as harms to society. At least for now, the question of drug legalization hinges on balancing personal freedom against the harm from drugs, both to society and the user.
U.S. Drug Laws
All countries have laws that classify and prohibit specific recreational drugs. In the U.S. this is accomplished with the Controlled Substances Act, first created in 1970, which defines five categories or “schedules” of drugs. The first schedule is the most restrictive and pertains to drugs that meet the following three criteria:
- The drug or other substance has a high potential for abuse.
- The drug or other substance has no currently accepted medical use in treatment in the United States.
- There is a lack of accepted safety for use of the drug or other substance under medical supervision.
The remaining four categories differ based on their potential for abuse, their legitimate use in medical practice, and their addictive nature. The fifth schedule is the least restrictive and includes drugs that have minimal potential for abuse, accepted medical use, and a low risk of addiction. A good example is cough medicines with small amounts of codeine. In total, over 200 drugs are listed among the five schedules.
Many morally-charged legal issues in the U.S. are left to individual states to resolve for themselves, such as assisted suicide and capital punishment. With recreational drugs, though, the Federal government has a strict anti-drug policy that umbrellas over the whole country and, with the recent exception of marijuana, this allows for little wiggle room for individual states. The Federal government’s position on drugs is characterized by what it calls the “war on drugs,” a phrase coined in 1971 by President Richard Nixon who described drug abuse as "public enemy number one in the United States."
The White House Office of National Drug Control Policy (ONDCP) is responsible for establishing “policies, priorities, and objectives for the Nation's drug control program” (www.whitehousedrugpolicy.gov). They identify possible points of disruption along the drug supply line, seek out drug dealers, establish treatment programs for drug users, and have ad campaigns that discourage drug use. One of their most memorable ad campaigns was one depicting an egg in a frying pan. A hot frying pan was displayed, and the narrator said “This is drugs.” Next, an egg placed in and began sizzling, and the narrator said “this is your brain on drugs. Any questions?” A particularly controversial ad campaign during the late 1990s involved secretly funding television networks to include anti-drug messages within the plot lines of some of the most popular primetime sit-coms and dramas. The ONDCP would examine the scripts beforehand and suggest changes that would qualify the network for funding. The ONDCP argued that these embedded messages were more effective than normal anti-drug public service commercials, but denied that they dictated any script changes in those programs to the show’s producers. They have since abandoned these ad campaigns.
The ONDCP determines how much of the nation’s drug control efforts should go towards prevention, or treatment, or enforcement. Liberal administrations typically emphasize prevention and treatment more than conservative administrations do, as exemplified in the following statement from the ONDCP during the Obama administration:
Preventing drug use before it begins is a cost-effective, common-sense way to build safe and healthy communities. Research on adolescent brain development shows the value of focusing prevention on young people: those who reach the age of 21 without developing an addiction are very unlikely to do so afterward. [National Drug Control Strategy, 2010]
The ONDCP also states that, for many addicts, “brief interventions are not sufficient to promote recovery,” and addiction treatment is effective “only if it is readily available and of high quality” (ibid).
Efforts to Relax Drug Laws
Amidst governmental efforts to reduce and punish drug use, various organizations advocate the legalization of at least some drugs. A notable example is Law Enforcement Against Prohibition (LEAP), which consists of police officers and government officials whose mission is “to reduce the multitude of unintended harmful consequences resulting from fighting the war on drugs and to lessen the incidence of death, disease, crime, and addiction by ultimately ending drug prohibition” (www.leap.cc). One of their advertising slogans is “Drug abuse is bad. The war on drugs is worse.”
The ACLU also takes this view. On balance more public harm is done through criminalization than would occur through a responsible system of decriminalization. It is costly and ineffective; it creates public health problems, gangsterism, an explosion in the number of nonviolent prisoners. It also as a devastating effect on African-American and Latino communities. “Black males have a 29% chance of serving time in prison at some point in their lives, Latino males have a 16% chance, and white males have a 4% chance,” and much of this is drug-related. The criminal justice system itself contributes to the racial disparity. The DEA has helped train police to profile highway travelers for potential drug couriers, which includes associating such activities with people of color. Minority women, they argue, are especially vulnerable to the drug war, who “are coerced into the drug trade by a boyfriend or husband, often play only a small role, but then receive the same harsh prison terms.” Supreme Court ruled that “public housing authorities could evict an entire family if someone in the household or a guest used drugs, even if the others knew nothing about it or tried to stop it.” In short, according the ACLU, “These are the grim realities of the War on Drugs. They are staged on a battlefield where the heaviest casualties are people of color. Instead of continuing these destructive policies that ultimately tear the fabric of our society, it is time to rethink and reassess the effectiveness and purpose of our current drug policies” (“Race and the War on Drugs”).
Other organizations support the strategy of harm reduction: recognizing the inevitability of drug use within society, as a public health policy we should attempt to lessen its harmful effects, rather than wage a war against it. Some harm reduction recommendations include reducing criminal penalties for marijuana use, using methadone to treat withdrawal symptoms from opiate addiction, needle exchange programs, and programs that test the safety of users’ drugs. Switzerland, one of several European countries with harm reduction initiatives, has a legalized heroin program whereby registered heroin addicts can go to government clinics twice a day for injections of the drug, along with required counseling. The program aims to reduce drug crimes, remove addicts from the street and make them more functioning members of society. The U.S. government consistently rejects the adoption of these types of harm reduction strategies.
Yet another strategy for drug-leniency is the legalization of marijuana for medical purposes. Some medical benefits associated with marijuana are alleviation of chronic pain, alleviation of nausea for chemotherapy patients and others with AIDS, tremor relief for people with multiple sclerosis, and reduction in epileptic seizures. The U.S. government’s position on this, though, is twofold. On the one hand, they acknowledge that there is some proven medical benefit to the chemical THC, the active ingredient in marijuana, and this drug is currently available by prescription in pill or patch form under the brand name “marinol”. On the other hand, though, they maintain that smoking marijuana is not an effective delivery system for THC since dosage cannot be controlled and marijuana smoke has dangerous secondary chemicals. Medical marijuana advocacy, they argue, is just a ploy to help legalize marijuana for recreational use.
State Legalization of Marijuana
State and Federal governments have had a long history of cooperation with drug laws and enforcement. But while the Federal government has held a hard line position, several states have recently enacted marijuana laws that conflict with Federal ones. In 1996 California voters passed a state-wide ballot initiative called the “Compassionate Use Act” which allows patients, with their physician’s approval, to possess or grow small amounts of marijuana for medical purposes. In the years following, 22 other states have legalized medical marijuana. But the U.S. government did not back down in their stand against such medical use, and twice the U.S. Supreme Court sided with the federal government against California. In one of these, Gonzales v. Raich (2005), the Court stated that the federal government has a reasonable basis for believing that locally grown medical marijuana could be channeled into the illegal drug trade. However, one Supreme Court Justice, in a dissenting opinion, argued that California’s Compassionate Use Act is a justifiable social experiment to test the viability of medical marijuana within the confines of that particular state, without causing risk to the rest of the country.
In 2012 Colorado and Washington became the first states to enacted laws that legalize marijuana for recreational use, and since then several other states have done the same. Like medical marijuana, this also places these states in direct conflict with the U.S. government’s ban on any sale or possession of marijuana. However, in response to state legalization of marijuana for medical and recreational use, the Federal government indicated that it would change its priorities and not target individual users and even marijuana suppliers in these states where there is a “strong and effective regulatory system” (DOJ memo, August 19, 2013). The bottom line is that marijuana use and distribution is still illegal in Federal law, but the Federal government will not prosecute in those states where it is controlled responsibly.
U.S. Alcohol Laws
The manufacture, sale and consumption of alcoholic beverages are restricted in some measure in every country throughout the world. Some conservative Muslim countries have outright bans. Those that permit alcoholic beverages typically regulate their sale and distribution, and restrict consumers based on age, public usage, and motor vehicle operation. The story of alcohol prohibition in the U.S. is well-known. Under pressure from the temperance movement to reduce crime, poverty and disease from drinking, in 1919 Congress ratified the Eighteenth Amendment to the U.S. Constitution which prohibited the sale, manufacture, and transportation of alcoholic beverages nationwide. While consumption of alcohol was not banned, per se, the aim of the legislation was to severely curtail it by making such beverages difficult to obtain. The effect of the law, though, was catastrophic, with increases in drinking, bootlegging, violent crime, and law enforcement corruption. In a 1926 Senate committee hearing on the effects of prohibition, one witness stated the following:
Nothing is and nothing could be more certain, from all the evidence, than that prohibition is an unqualified failure and a colossal calamity to the Nation. Whatever promotes drunkenness and drug addiction and all forms of intemperance also promotes crime of every kind. We have the unimpeachable evidence of our senses that certainly more than half the crimes and misdemeanors perpetrated throughout the land and sensationally featured and headlined in the newspapers are crimes which are the result of prohibition. [Hiram Maxim, Senate Judiciary subcommittee on “The National Prohibition Law” April 5-24, 1926]
Prohibition ended in 1933 with the ratification of the Constitution’s twenty-first amendment, which repealed the eighteenth amendment. In spite of the end to prohibition, the twenty-first amendment grants broad powers to states regarding the distribution and sale of alcoholic beverages, and until 1966 Mississippi remained a completely dry state. Today 33 states delegate authority to local counties or municipalities to ban or restrict the alcohol sale.
Since the end of prohibition, all states follow what is called the three-tiered system of alcohol distribution: alcohol producers can sell only to licensed alcohol distributors, and, in turn, only the distributors can sell to licensed retailers. Producers such as breweries cannot sell directly to grocery retailers or to individual consumers. The system’s purpose is to provide limited access to alcoholic beverages and thus promote moderation in drinking. It also helps ensure that alcoholic beverages are not sold to minors, and it provides a simple method for alcohol tax collection. As a whole, the system helps set the price of alcoholic beverages at the right level: if the price is too cheap, then people will drink too much, and if too expensive they will bootleg. As one alcohol distributor puts it, “The best method of regulating alcohol does not necessarily come at the greatest convenience or lowest cost for individual consumers. However, it does ensure that consumers have appropriate access to alcohol at the lowest cost to society and with the least harm to its members” (www.mndistributors.com).
The three-tiered system has recently come under attack from thousands of small wineries and microbreweries throughout the country who feel that their businesses could be improved by selling directly to retailers and consumers, skipping entirely the restrictive distribution process. Ending the system, they argue, would result in increased jobs for the small businesses, and lower costs and greater variety for consumers. The system benefits no one but the alcohol distributors who want to retain a monopoly over the country’s supply of alcoholic beverages. Critics of the three-tiered system have sued many states for discriminatory regulations: such states allow in-state wineries to distribute directly to retailers, but do not allow this for out-of-state wineries. These States in essence set aside the three-tiered system for their own wineries, but impose the three-tiered system on out of state ones. What would happen if we completely eliminated the three-tiered system that we have today, just as these small wineries would prefer? According to Pamela S. Erickson, a defender of the three-tiered system, we have only to look at the United Kingdom to see how alcoholic beverage deregulation has affected them. Over a four-decade period, the U.K. has incrementally deregulated alcohol to where it is available any time of day during the week in all varieties of bars and stores. It is now 70% more affordable and “the marketplace is flooded with cheap alcohol that has encouraged people to drink.” The social consequences of this deregulation, she argues, have been particularly bad:
Hospital admissions for alcohol liver disease and acute intoxication have doubled over just 10 years. Underage drinking rates are twice what ours are. Problems around bars and clubs are so severe in London that London has two buses equipped as field hospitals to take care of people who have been victims of alcohol-fueled violence or alcohol intoxication every weekend. [“Legal Issues Concerning State Alcohol Regulation,” U.S. House Judiciary subcommittee hearing, 2010]
In the U.S., changing the three-tiered system is a multifaceted issue. It puts the interests of small wine producers against distributors, private industry against governmental regulation, and, most importantly, profit against public health.
COMMON ARGUMENTS PRO AND CONTRA
The Conservative Position
The conservative position on recreational drugs is that their use is both immoral and should remain illegal. The chief arguments for the conservative position are these.
1. Harm to society. There are serious harms to society from drug use, as we have already seen, including increases in murder, theft and prostitution. It is, in fact, one of the leading sources of crime in society. A criticism of this argument is that much of the harm associated with recreational drug use is the result of it being illegal to begin with. If drugs were made legal, the illegal drug trade and the evils associated with them would disappear, as happened with organized crime in the U.S. when alcohol prohibition was repealed in 1933. While some of the harder drugs would have other harms associated with them, social harm from softer drugs would likely be very minimal.
2. Harm to user’s health. Drugs adversely affect the user’s health, and we have an obligation to avoid unnecessary harm to our bodies, such as that which is caused by regular drug use. A criticism of this argument is that harm to oneself is often a byproduct of exercising one’s freedom, such as with playing dangerous sports or simply driving in a car. While it’s good to reduce harms to oneself when we can, eliminating all such harms would seriously curtail our freedom to act as we like and try out different hobbies, careers and lifestyles.
3. Decrease in user’s motivation. Drugs adversely affect the user’s motivation to be a productive citizen. We have an obligation to ourselves and society to develop our talents and be productive citizens in some way. But the pleasures of drug use, even with less addictive ones, often eclipse the ordinary sense of enjoyment and satisfaction that we might get from learning new skills and creating a better society. A criticism of this argument is that the same rationale applies to other recreational diversions, such as watching mindless TV shows that waste huge amounts of time and sap our motivation to do something more useful. We all can’t be obsessively high-energy and productive people, and there is something to be said for living a relaxed and laidback life, if that’s what we so choose.
The Liberal Position
The liberal position on recreational drugs is that the less harmful and addictive ones are morally permissible and should be legalized. Here are the main arguments for that position.
1. Autonomy: drug use should be a matter for individuals to decide for themselves, so long as their use of drugs does not negatively impact others. In a free society, the presumption is that individuals should be at liberty to make their own choices, even when their decisions are not always the smartest or safest ones for themselves. The only restriction should be whether the individual’s actions cause significant harm to others. The use of recreational drugs is a case in point. A criticism of this argument is that most recreational drug use does have a serious negative impact on society. Marijuana and perhaps a few others might be exceptions, but the most addictive ones result in great harms. Further, addiction to drugs compromises a person ability to make free choices, and thus undermines autonomy.
2. Pleasure: recreational drugs provide a great source of pleasure to people, and this counterbalances the harm to themselves. Many of the decisions that we make in life involve balancing pleasures with potential pains. If the pleasure is great enough, we will accept the risk. So too with recreational drugs: while users might be at risk of some harm, they may accept this in exchange for the pleasure benefits. A criticism of this argument is that few peoples’ lives are completely isolated, and there are almost always family members who are secondary victims to the harm that drug users bring on themselves. Children are particularly vulnerable to this. Because of drug use, parents might have less money for their children’s needs and be less motivated to focus on their children’s wellbeing than their own happiness. Even drug-using college students with no kids might negatively impact their future careers by squandering their present educational opportunities, which ultimately affects their future families.
3. Cultural tradition: the use of mind-altering substances has been an important part of human culture. This is particularly evident with the role that alcohol has played throughout history: it pacifies us when sad, heightens enjoyment when happy, and is incorporated into many of our celebrations. While alcohol is the poster-child for the value we place on mind-altering substances, recreational drugs can and do perform that same function. A criticism of this argument is that society needs to draw a line somewhere regarding the various mind-altering substances that it will embrace as acceptable parts of cultural tradition. Heroin and meth, for example, will never gain acceptance because of how addictive and harmful they are. While other mind-altering drugs are similar to alcohol in their effects, they nevertheless do not have a long history of acceptance, and society appears reluctant to move the line of acceptance beyond alcohol.
A Moderate Compromise
There is a famous expression attributed to Voltaire that “I may not like what you say, but I will defend your right to say it.” To some extent this intuition applies to how we behave as well as what we say. We may not always like the choices that people make in their lives, but we should acknowledge a person’s freedom to make those choices. We already grant this when it comes to alcohol use. So why not with other drugs too? There are good reasons for society to restrict the use of highly addictive drugs because of the harm they cause to society (independent of the harm that results from the illegal drug trade itself). If there is any room for compromise, it would be to legalize softer drugs, which some states have already done with marijuana. In states where this is not possible, an alternative would be to replace criminal penalties with civil ones, such as a fine similar to a traffic offense.
READING 1: AGAINST MARIJUANA LEGALIZATION (by Whitehouse Office of National Drug Control Policy)
The Health Risks of Marijuana
Marijuana is classified as a Schedule I drug, meaning it has a high potential for abuse, no currently accepted medical use in treatment in the United States, and lacks accepted safety for use under medical supervision.' The main active chemical in marijuana is delta-9- tetrahydrocannabinol, more commonly called THC. THC acts upon specific sites in the brain, called cannabinoid receptors, starting off a series of cellular reactions that ultimately lead to the “high’ that users experience when they Smoke marijuana. Some brain areas have many cannabinoid receptors; others have few or none.
Research has shown that marijuana use can have implications for learning and memory and effects can last for up to one week after the acute effects of the drug wear off Heavy (used on average 18,000 times and a minimum of 5,000 times in their lives) marijuana users reported that the drug impaired several important measures of health and quality of life, including physical and mental health, cognitive abilities, social life, and career status."
Marijuana is the most commonly used illicit drug in the United States. In 2012 alone, nearly 32 million people ages 12 and older reported using the drug within the past year. A Substantial portion of these Americans were using marijuana nearly every day in the past 12 months. In 2012, 17.0 percent of Americans 12 or older who had used the drug in the past year did so on 300 or more days within the past 12 months." This translates into 5.4 million people using marijuana on a daily or almost daily basis over a 12-month period. In fact, approximately 4.3 million people met the diagnostic criteria for abuse or dependence on this drug, more than any other drug.
While significantly lower than the peak use year in 1979, overall marijuana use rates in the United States have increased in the last decade. Since 2002, prevalence of past month marijuana use among Americans 12 and older has increased more than a full percentage point (from 6.2 percent in 2002 to 7.3 percent in 2012). This is also true among young adults aged 18 to 25, with rates of past month use increasing from 17.3 percent in 2002 to 18.7 percent in 2012. There may be some positive news among young people ages 12 to 17. According to national survey data, youth use rates have decreased from 8.2 percent in 2002 to 7.2 percent in 2012; however, this overall trend masks recent year-to-year increases in use among young people, particularly between 2008 and 2011. These variations indicate that use by America's youth should remain a key focus for policymakers, law enforcement, and public health leaders.
Marijuana poses considerable health and safety implications for the users themselves, their families, and our communities. Decades of research into the use and effects of the drug have found an array of negative consequences. Research finds that approximately 9 percent (1 in 11) of marijuana users become dependent, and the younger a person starts using it, the more likely he or she is to become dependent on marijuana or other drugs later in life. These are not the only problems connected to marijuana use. For example, marijuana use can have implications for learning and memory, and its effects can last for days to weeks after the acute effects of the drug wear off, particularly in chronic users. Researchers have also found that adolescents' long-term use of marijuana begun during adolescence is associated with an average eight-point lower IQ later in life.
One study found that people who smoke marijuana frequently but do not Smoke tobacco have more health problems, including respiratory illnesses, than nonsmokers.' The harms of marijuana use can also manifest in its users' quality of life. In one study, heavy marijuana users reported negative effects of their marijuana use on several important measures of health and quality of life, including physical and mental health, cognitive abilities, social life, and career status.
The consequences of marijuana use are particularly acute in our health care and Substance abuse treatment system. In 2011, marijuana was involved in nearly 456,000 emergency department (ED) visits nationwide, representing approximately 36 percent of all ED visits involving illicit drugs. And in 2012, approximately 314,000 Americans 12 or older reported receiving treatment for marijuana use in the past year, more than any other illicit drug, and trailing only alcohol and pain relievers.' These figures present a sobering picture of this drug's very real and serious consequences.
FDA Approval of New Drugs
Since 1996, 20 states and Washington, D.C., have passed laws allowing Smoked marijuana to be used for a variety of medical conditions. Many of these state laws originated in order to create a legal defense to state criminal possession laws or to remove state criminal penalties for purported medical use of marijuana. Since then, many have evolved into state authorization for production and distribution of marijuana for purported medical purposes. These laws vary greatly in their criteria and implementation, and many states are experiencing vigorous internal debates about the safety, efficacy, and legality of their marijuana laws.
State marijuana laws do not change the criteria or process for Food and Drug Administration (FDA) approval of new drugs. The FDA, as the authority charged with approving new drugs based on a finding of Safety and efficacy, has noted that Smoking marijuana is a potentially harmful method for delivering the constituent elements of marijuana. The FDA has not found smoked marijuana to have an accepted medical use in treatment in the United States and has not approved smoked marijuana for the treatment of any disease. These State laws are not the primary test for declaring a substance a recognized medication. Marijuana should be subjected to the same rigorous clinical trials and Scientific scrutiny the FDA applies to all other new medications, a comprehensive process that ensures the highest standards of safety and efficacy.
The FDA has approved drugs containing synthetic compounds similar to naturally occurring delta-9-THC. Dronabinol is one such synthetically produced compound, used in the FDA-approved medicine Marinol, which is already legally available for prescription by physicians whose patients suffer from nausea, vomiting, and appetite and weight loss. Another FDA-approved medicine, Cesamet, contains the active ingredient Nabilone, which also has a chemical structure similar to THC. And SativeX, an oromucosal spray approved in Canada, the United Kingdom, and other parts of Europe for the treatment of multiple sclerosis spasticity and cancer pain, is currently in late-stage clinical trials to support FDA approval.’" In November 2013, the FDA granted orphan drug designation to Epidiolex, an oral liquid formulation of a highly purified extract of plant-derived cannabidiol (CBD), a non-psychoactive molecule from the cannabis plant, for treating Dravet syndrome, a rare and severe form of infantile-onset epilepsy.
Physicians routinely prescribe medications with standardized modes of administration that have been shown to be safe and effective at treating the same conditions that marijuana proponents claim are relieved by Smoking marijuana. The biomedical research and medical judgment that guide the FDA approval process should continue to determine what are safe and effective medications.
State Legalization Efforts
The Administration continues to oppose attempts to legalize marijuana and other drugs. This opposition is driven by medical science and research. Above all, though, it bears emphasizing that the Department of Justices (DOJ) responsibility to enforce the Controlled Substances Act (CSA) remains unchanged. As DOJ has historically noted in its guidance to prosecutors, Federal drug enforcement resources prioritize and target the serious crimes of drug dealing, violent crime, and trafficking. The law enforcement officials who have sworn an oath to uphold Federal law will continue to pursue drug traffickers, drug dealers, and transnational criminal organizations that weaken our communities and pose serious threats to our Nation. The Department of Justice has not historically devoted resources to prosecuting individuals whose conduct is limited to possession of small amounts of marijuana for personal use on private property.
In 2012, voters in the states of Colorado and Washington passed initiatives legalizing marijuana for adults 21 and older under state law. In establishing the CSA, Congress determined that marijuana is a dangerous drug and that the illegal distribution and sale of marijuana is a serious crime. DOJ is committed to enforcing the CSA consistent with these determinations. On August 29, 2013, DOJ issued guidance to Federal prosecutors concerning marijuana enforcement under the CSA. In this guidance, DOJ stated that it expects states and local governments that have enacted laws authorizing marijuana-related conduct to establish and enforce strict regulatory schemes that protect eight public health and safety interests, including preventing the distribution of marijuana to minors, preventing revenue from going to criminal enterprises, and preventing the diversion of marijuana to other states. All of these interests are critical, and we will work closely with DOJ and other Federal and state partners to monitor the implementation of these state laws.
Calls for legalization often paint a misleading picture. Although state legalization efforts include taxes on marijuana, costs associated with legalization may far exceed any additional tax revenue. For example, the tax revenue collected from alcohol pales in comparison to the costs associated with it. Federal excise taxes collected on alcohol in 2009 totaled around $9.4 billion.” state and local revenues from alcohol taxes totaled approximately $5.9 billion. Taken together (S15.3 billion), this is just over six percent of the nearly $237.8 billion (adjusted for 2009 inflation) in alcohol-related costs from health care, treatment services, lost productivity, and criminal justice.” These figures present a much more complicated picture of the potential revenue streams and costs that marijuana legalization might bring to states and localities.
The existing black market for marijuana likely will not disappear if the drug is legalized and taxed. Research by the RAND Corporation noted that “there is a tremendous profit motive for the existing black market providers to stay in the market, as they can still cover their costs of production and make a nice profit.'
It is for these reasons and others that the National Drug Control Strategy focuses on drug prevention, treatment, Support for recovery, and innovative criminal justice strategies to break the cycle of arrest, incarceration, and re-arrest.
Driving under the influence of drugs or alcohol continues to pose a significant threat to public safety. A systematic review of the literature indicates that acute marijuana consumption is associated with an increased risk of motor vehicle collisions resulting in serious injury or death, compared with drivers not consuming marijuana. Sadly, this is too frequently being demonstrated on America's roads. In 2009, marijuana accounted for 25 percent of all positive drug tests for fatally injured drivers for whom drug-test results were known and for 43 percent among fatalities involving drivers 24 years of age and younger with known drug-test results. Moreover, approximately one in eight high School seniors responding to the 2013 Monitoring the Future survey reported driving after Smoking marijuana within two weeks prior to the Survey interview, more than the number who reported driving after consuming alcohol.
In response to this problem, four years ago, ONDCP identified drugged driving as a national priority in the 2010 National Drug Control Strategy and set an ambitious goal of reducing drugged driving in America by 10 percent by the year 2015. In the four years since we started, we have made progress in addressing this issue.
Drugs are important in prevention and treatment of disease and health complaints. The increasing number of available drugs and drug users, as well as more complex drug regimens lead to more side effects and drug interactions, and complicates follow-up. Drug-related problems (DRPs) lead to substantial morbidity (1) and mortality (2), as well as increased health care expenditure (3), which in turn affect both patients and society. Norwegian and international studies show that nursing homes (4, 5), hospitals (6, 7) and general practices (8, 9) have a high prevalence of such problems, and professionals agree that there is substantial room for improvement. The Ministry for Health and Care Services has requested industry-independent research in this area in a Governmental White Paper (10).
Systematic review of patients’ total drug use, in the light of clinical information, is an effective method to identify DRPs and start interventions (4, 5, 11, 12). This is a method currently used in research and clinical practice, especially by clinical pharmacists in hospitals and nursing homes. Definitions and classifications of DRPs differ (13 - 16), and modified versions of these are often used when documenting clinical interventions. It would be an asset to have a common classification system in research and clinical practice.
We aimed at developing and validating a Norwegian classification system for DRPs based on internationally published systems, clinical experience and a consensus procedure. The classification should be based on unambiguous definitions, be useful in different settings (general practice, hospitals, nursing homes, pharmacies) and contexts (research, clinical practice) and with varying access to relevant clinical information (from patients, medical records, drug charts and prescriptions).
Material and method
Development of a classification system
The process started with a seminar for ten physicians and pharmacists who had experience with medication reviews from research or clinical practice. A working group (authors) developed a draft for classification with a hierarchical structure based on a European system (15), to ensure comparability with international studies.
Elements from a modified Delphi technique were used to further develop the classification. By this method consensus is obtained between independent experts through several rounds of «silent brainstorming» where participants in a «panel» produce ideas individually without discussing them. The ideas are communicated to a group of decision makers who discuss the ideas, adjust the draft and subsequently submit a revised draft to the panel participants. The panel participants and decision makers communicate through e-mail (17). Contrary to classical Delphi technique, the panel participants in this study did not prioritize the various elements according to relevance.
The draft classification was sent to medical and pharmaceutical groups in Norway (October 2005). The receivers were: Norwegian Society for Pharmacoepidemiology, special interest group of clinical pharmacists in the Norwegian Association of Hospital Pharmacists, the e-mail list EYR for general practioners, the five regional Drug Information Centres, the Norwegian Pharmaceutical Association, the Pharmacy Association and the Norwegian Society for Pharmacology and Toxicology. The review group was requested to comment on structure, content, clinical relevance and the wording of the classification, as well as suggest changes. The authors assessed all comments and suggestions from the panel and thereafter adjusted the draft for classification. A revised draft was returned to all respondents (March 2006), but no further comments came up during the second review.
Validation of the classification
Relevant professional groups were invited to participate in validation of the classification. The purpose was to assess whether the panel used the classification system in the same way with respect to allocating various DRPs to relevant categories. The panel consisted of 26 pharmacists and 13 physicians working in hospitals, nursing homes, general practice or pharmacies. Twenty-six short, real case reports were sent to the panel (Box 1). Each report contained at least one specific DRP that the participants were asked to assign the most relevant main or subcategory in the classification. All categories in the classification system were represented in the case reports. If a panel participant had suggested more than one category for one single case report, the result was shown in decimals; for example 0.5 for classification in two categories and 0.3 for three categories. A large Australian study used a similar procedure (16).
Examples of case reports used in the validation of the classification
A 62-year-old man complains of fatigue. Treatment with mirtazapine was started last week and he now takes 30 mg in the evening. He was already using diazepam 10 mg × 3, as well as zopiclone 5 mg to sleep. Classify this case (case 1: 36 % agreement).
An 87-year-old woman complains of heavy breathing and swollen legs. She has been diagnosed with atrial fibrillation and post infarction failure. She uses warfarin, ramipril 10 mg and furosemide 40 mg × 2. Previously she has also used a beta-blocker and spironolactone, but these drugs were discontinued because of bradycardia and hypotension. You are not sure about which changes in the patient’s medication regimen would be appropriate. Classify this problem (Case 5: 51 % agreement).
80-year-old woman living in a nursing home. The patient has arthritis and complains regularly of pain in her back and hips. She uses paracetamol 500 mg × 2. Classify this case (Case 20: 92 % agreement).
60-year-old man with diabetes and ischemic heart disease presents a prescription on sildenafil 50 mg to a pharmacy. He also uses isosorbide mononitrate, metformin, glipizide, aspirin, enalapril and metoprolol depot. You point out that sildenafil should not be used with nitrates. Classify this problem (Case 22: 74 % agreement).
Definition and classification of drug-related problems
The expert panel agreed on adapting the definition of DRPs provided by the Pharmaceutical Care Network Europe: «An event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes» (15). In this context, a potential problem means a condition that may cause drug-related morbidity or death if no action is undertaken; an actual problem is manifested with signs and symptoms.
DRPs are divided into six main categories and 12 subcategories (tab 1). The categories are given in an order consistent with drug therapy evaluation in clinical practice.
Table 1 Classification of drug-related problems
1. Drug choice
1a Need for additional drug
One or more drugs are missing according to established national/international guidelines. Deviations from guidelines that are based on the patient’s individual treatment goals and risk factors are not considered to be DRPs.
Statins after a myocardial infarction.
Aspirin after a cerebral stroke.
ACE¹ -inhibitor for heart failure.
Calcium supplements when using corticosteroids.
1b Unnecessary drug
A drug that is seen as unnecessary if the indication is no longer present, with lack of discontinuation or double prescription of two or more drugs from the same therapeutic group
Antibiotic treatment finalised.
Ibuprofen and diclophenac concomitantly.
Methenamine in a patient with a permanent catheter.
1c Inappropriate drug choice
Not given reason for deviation from concordance between drug and diagnosis/indication or absolute/relative contraindication because of for example age or comorbidity. Deviations that are based on the patient’s individual treatment goal and risk factors are not considered to be DRPs.
NSAID² with reduced renal function.
Broad-spectred antibiotic for simple infection.
Antipsychotic drug for restlessness in dementia.
Amitryptiline and other drugs with anticholinergic effect in elderly.
ACE¹ -inhibitor with aortic stenosis.
2a Too high dose
2b Too low dose
2c Sub-optimal dosing scheme
2d Sub-optimal formulation
Suboptimal dosing (including dosing time and formulation) according to established national/international guidelines. Deviations that are based on the patient’s individual treatment goal and risk factors are not considered to be DRPs.
Too high ACE¹ -inhibitor dose in relation to kidney function.
Too low paracetamol dose in relation to symptom-giving arthritis. Nitrates given without nitrate-free period. Diuretics given in the evening.
Should receive a slow release formulation rather than a direct release tablet, e.g. diuretic or analgesic.
3 Adverse drug reaction (ADR)
Any noxious, unintended, and undesired effect of a drug, which occurs at doses in humans for prophylaxis, diagnosis, or therapy (WHO)
Orthostatic hypotension, instable/falling with use of blood pressure lowering drug.
Rhabdomyolysis with use of statin.
Rash with use of penicillin.
An interaction is occurring when the effect of a drug is changed by the presence of another drug, food, drink or some environmental chemical agent. Drug combinations with intended overall effect are not considered to be DRPs.
SSRI³ and TCA⁴ (increased S-concentration of TCA).
Furosemide and NSAID² (reduced diuretic effect).
Furosemide and digitalis (increased effect/toxicity of digitalis with hypokalemia).
Drugs and various natural drugs/additives/health products, e.g. St John’s wort and warfarin.
5. Drug use
5a Drugs administered by health personnel
5b Drugs administered by the patient
Patients’ real drug use deviate from the doctor’s prescription with respect to type of drug, dose or scheme. It is a prerequisite that prescriptions are based on a common understanding (concordance) between prescriber and patient (exception: patient with dementia, emergency situation etc.) Problems with logistics are not considered to be DRPs.
The patient had taken a wrong drug or dose or to the wrong time.
Crushing of slow release tablet or opening of capsule.
Practical problems with opening tablet box, difficulty swallowing, nausea/vomiting. Misunderstanding the instructions for use - need for information/guidance. Problem with generic exchange.
6a Need for/lack of monitoring of effect and toxicity of drugs.
Monitoring with respect to effect and toxicity of drugs is not done or does not adhere to guidelines.
Clinical examination, e.g. blood pressure, weight with heart failure.
Blood tests, e.g. regular counting of Hbc with clozapine treatment.
6b Lack of or unclear documentation of the drug chart/prescription
Drug chart / prescription lacks information about drug strength or formulation, as well as instructions for use (dosing scheme etc.).
Mistakes in transferring between sources.
In general therapy discussions that include several problems and do not belong in any other category.
Discussions on appropriate drug therapy for individual patients, e.g. change dose or add a new drug.
Validation of the classification system
On average, 70 % (median 70 %, variation 36 - 99 %) agreement was obtained on the DRP category (tab 2). For 10 of the 26 cases, at least 75 % of the respondents chose the same category and for 24 cases more than half were classified as the same. For 22 cases one or more respondents classified them into different categories. There were no differences between physicians and pharmacists in general, but some of the cases were associated with a more varied classification and for these we found a larger difference both within and between professional groups.
Table 2 Validation of the classification system: The panel’s (n = 39) assignment of DRP category for 26 cases¹
1. Drug Choise
3. Adverse Drug Reaction
5. Drug use
Total number of respondents²
A Norwegian system for defining and classifying DRPs is proposed. The system builds on cross disciplinary agreement between physicians and pharmacists from various clinical and scientific positions. The classification is a tool to handle challenges in relation to drug treatment and the system could contribute to improved documentation of various problem areas.
The panel’s professional and geographical heterogeneity contributes to the classification system’s relevance for various aspects of the drug treatment (prescription, monitoring, use, documentation), for various aims and for different parts of the health services. Although it was a goal to include all Norwegian experts in the field, and it should be simple enough to get an overview of the professional environment in the country, it is possible that not all have been included.
Consensus-based procedures are suitable for integration of research-based and experience-based knowledge. The modified Delphi technique is an established method for development of clinical guidelines and quality indicators (17). This method ensures that various meanings are promoted, independent of the participants’ relations, position and status. Communication by e-mail enables participation of experts who are geographically far apart. On the other hand, the method is demanding and lack of discussion may prevent identification of good ideas and elimination of bad ones.
Van Mil and collaborators have assessed 14 published classification systems of DRPs (18). The group points out that classification systems should be validated and also that the results of this procedure should be published. However, only a few of the classifications have been validated. We have gone through a case-based validation procedure among a heterogeneous review panel to assess the content of the classification and to reveal validity (face).
The classification system has an open hierarchical structure that can be adapted and expanded with several categories according to need, setting and access to clinical information. The intention was to construct a general model that comprises many different problem areas and at the same time prioritize simplicity and flexibility rather than in depth detailed descriptions. Previously published classifications have been considered to ensure comparability with international models.
We have chosen to include both actual and potential problems in the definition of DRPs (15). This choice is founded in our understanding of the importance of identifying problems before they have become manifest and thereby prevent a possible negative outcome, as for example lack of effect or increased morbidity. Both potential and actual problems can be identified by conducting regular systematic reviews of patients’ total drug use.
The participants in the hearing group agreed that undertreatment («need for additional drug») would be part of the classification system. This problem is not strictly associated with one or more specific drugs, but rather to a presumption of effective treatment or to adherence to guidelines to prevent disease; e.g. anticoagulation after a heart attack. Our view coincides with that of Van Mil and collaborators. They criticize the lack of undertreatment as a category in several published classification systems and point at evaluation of treatment effectiveness of a certain condition as a crucial part of medication reviews (18). However, this presumes access to relevant clinical information such as symptoms and laboratory tests, which in some settings will be inadequate, for example in pharmacies.
Validation of the classification system showed an average of 70 % agreement on choice of category. Limit values had not been predefined as there was not sufficient published material to base such definitions on. Our findings are however in agreement with an Australian validation procedure for classification of DRPs; they found an agreement of 69.9 % (16). For some cases there was a larger variation in the classification. Some were relatively heterogeneous and it was challenging to classify these as one single problem in one single category. It is known that such validations render partition between processes difficult, i.e. problem perception and classification in itself (18). Belonging to a professional group did not affect the choice of category and this is in favour of the categories’ lack of ambiguity and the system’s robustness.
We considered the agreement to be sufficient to use the classification in research projects and clinical practice, for example in communication between physicians, pharmacists working in clinical settings or pharmacies and with patients. An evaluation and possible revision of the classification should be done after it has been used for a while.