HUX 505: Paternalism and Self-Medication

Rights nor Choices

The Ethics of Paternalism and Self-Medication

By

Eric S. Williams

HUX 505

Defining the Humanities: Philosophy

Dr. Eiichi Shimomisse

February 22, 2001

Drug use in America has cast a shadowy specter of fear into the hearts, minds, and souls of its citizenry. Many Americans honestly believe that drug use, or abuse if you will, is a self-destructive act that harms both the user and their friends, family, and community. It is this track of thought that invariably leads many of us to consider that some sort of direct interaction on the part of either the state or religion must be enforced onto the will of the drug user. By this direct intervention or coercion, the state and religious institutions in America seek to coax users of illicit narcotics away from their self-destructive behavior. This idea of intervention is often referred to in the philosophical world as “Paternalism”.

The term ‘paternalism’ is defined as: “The view that restrictions on individual liberty are legitimate when they are justified by appealing to the values and the welfare of the person being restricted” (Burr and Goldinger 545). This particular belief is rather controversial; it is essentially outright coercion justified by the promise of a benevolent end. That is, paternalism seeks to control the behavior or rights of individuals to preserve the greater good at the expense of personal rights. This coercion is justified in many cases against the user of illicit drugs due to the language or symptoms placed with it. Drug users are often referred to as ‘sick’, their behavior the result of their ‘disease’. This underlying belief that users are ill helps to justify the use of paternalistic intervention in the form of therapy and criminal policy designed to somehow cure them. The arguments for this direct governmental or religious intervention into the lives of private citizens is not without detractors. There are those, such as Dr. Thomas Szasz, who believe that drug use, or self-medication as he calls it, should be available without restriction. His arguments are as equally poignant for a free market of drugs as his state represented opposition works vehemently against it. This paper will seek to understand the essential arguments in support of paternalism in regards to its role against the use of illicit drugs, and report on the arguments opposing said paternalism as presented by Dr. Thomas Szasz and others.

Recreational drug use is seen by many as a victimless crime. On the same token, it seen as a horrifying and self-destructive addiction with victims affected beyond the drug user. There are thousands of Americans that use recreational drugs on a daily basis. This use, however, has been criminalized by a seemingly benevolent state. ‘Paternalism protects people from themselves, as if their safety were more important than their liberty”(Suber). Thusly, as many consider drug use to be a disease, it is logical then that a benevolent state would claim that their intervention in the lives of private citizens to cure them of their drug habits is, in truth, working for the best interest of said user. This glaringly contrasts with the harm principle proposed by John Stuart Mill, who said in his work On Liberty:

“…the sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number is self-protection. That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is harm to others. His own good, either physical or moral, is not sufficient warrant”. (qtd. in Zwolinski)

Is this a logical assumption then? Many oppose this point of view based on a number of differing arguments. Everyone can agree that many people engage in what we consider self-destructive behavior, and that this behavior duly affects those around the offender. In short, a man or woman who drinks to excess and then drives is not only endangering themselves, but the life and liberty of others around them. It’s in this case that we could contend the state has a genuine right to interject into the lives of the common citizen to protect them from the iniquities of the selfish or irrational who may due us injury physically, psychologically, and financially. Isaiah Berlin embellishes this premise by arguing that the state:

“…is in a position to ignore the actual wishes of men or societies, to bully oppress, torture them in the name, and on behalf, of their ‘real’ selves, in the secure knowledge that whatever is the true goal of man (happiness, performance of duty, wisdom, a just society, self-fulfillment), must be identical with his freedom—the free choice of his ‘true,’ albeit often submerged and inarticulate, self”. (qtd. in Zwolinski)

What one must come to accept is that the state often believes that it acts in the best interest of those whom it governs. So too does it feel it is acting in the citizens’ best interest when it prohibits the use, sale, or consumption of recreational drugs. Many claim it is hypocritical of the state to allow the sale of tobacco or alcohol, yet ban potentially ‘safer’ drugs. These critics point to the facts that, “…the total number of deaths caused by misuse of alcohol greatly exceeds the number caused by misuse of drugs, and around 0.9 percent of smokers die each year of smoking-related diseases, compared to only 0.0002 per cent of Ecstasy users”(“Dependence and Addiction”). Paternalists disagree with this notion, saying that if tobacco and alcohol were to be introduced into the market today, they would never be approved for sale or consumption due to their damaging nature (“Dependence and Addiction”). Indeed, alcohol and tobacco have enjoyed a long, prosperous life in the United States; they have become engendered into the very fabric of our society, becoming more or less socially acceptable sins.

Has this always been true of just alcohol and tobacco? No. According to Dr. Thomas Szasz, a free market of drugs was enjoyed by the United States from 1776 till 1914 (Szasz, “The War on Drugs”). Szasz opposes any state-sanctioned restrictions in the case of drug use. Yet paternalists assert that certain restrictions or controls must be placed on illicit drugs to protect people from doing harm to themselves. The Christian Medical Fellowship is quoted as saying:

“Telling people not to take drugs is often seen as authoritarian. However, the Christian view is that it is damaging to become a slave to anything, and addiction to drugs is a form of slavery. Intriguingly, it is today’s demand for freedom of choice that can lead to addiction….We are intended to depend on Him [God] and relate to Him…in contrast to the restrictions imposed by addiction to drugs, dependence on God is the route to real freedom. (“Dependence and Addiction”)

Mark Kleinman presents a slightly more secular point of view. In his book, The New Paternalism: Supervisory Approaches to Poverty, Kleinman asserts that paternalism must be introduced in society to quell use and addiction to illicit drugs. He defends intrusion of paternalistic practices by the state on the individual for a variety of reasons listed herein:

n The assumption that healthy adults are capable of acting rationally in their own interests matches reality only imperfectly

n The 3 million or so persons who are both heavy users of expensive drugs and involved in the criminal justice system account for large proportions of criminal offenses and consumption of expensive drugs.

n Continued use of expensive drugs among offenders is linked with continued high rates of criminal activity.

n Illicit street markets cause enormous social damage.

n The probation and parole systems are the key to managing the population of drug using offenders. Abstinence from drug use ought to be made a condition of continued liberty, and that condition ought to be enforced with frequent drug tests and predictable sanctions. (Kleinman 184)

Kleinman’s arguments for paternalistic coercion in the realm of drug addiction go beyond these facts. Kleinman also contends that, “the assumption that healthy adults are always or almost always the capable stewards of their own well being” is also flawed (Kleinman 187). This assumption, Kleinman believes, leaves no role for authoritative restrictions designed to govern such behavior as it may be seen as dangerous or destructive (187). Further, Kleinman goes on to contend that rational minds may “demand(s) calculation, (and that) someone who gets that calculation wrong may act in ways not conducive to his goals” (188). It assumed by most paternalists that the rational human seeks to live a long and healthy life, and that acting retrograde to that end is both counterproductive and unnatural. Criminals, as Kleinman calls them, use drugs to degrade his own judgement. We assume, then, that all people wish to do right by the law and that no individual seeks to injure themselves or others on purpose. But someone acting in public either intoxicated on liquors or drugs can potentially injure themselves through irrational actions, or others through poor judgement (as in the case of driving drunk or falling off a ledge while high).

Thomas Szasz argues against the basic premises of paternalism, claiming that, “In an open society, it is none of the government’s business what idea a man puts into his mind; likewise it should be none of the government’s business what drug he puts into his body”(qtd. in Burr and Goldinger 366). Szasz defends this premise by saying that, “drug addiction or drug abuse cannot be defined without specifying the proper and improper use of pharmacologically active agents”, and further goes on to add, “…these judgements have nothing whatever to do with medicine, pharmacology, or psychiatry. They are moral judgements” (365). Essentially then, what Szasz is defending here isn’t the unilateral use of drugs, it is the misconceptions surrounding it’s labeling.

Drugs are often labeled as ‘dangerous’ to the user in a variety of ways. It is claimed by paternalist Gerald Dworkin that drug users are unable to understand the consequences of their own actions, particularly “decisions which involve taking drugs that are physically or psychologically addictive and those which are destructive to one’s own mental and physical capacities” (qtd. in Burr and Goldinger 383). Following this train of thought, a drug user may not be in total control of their faculties when contemplating self-destructive behavior such as suicide. Dworkin says “decisions, such as that to commit suicide, …are usually made at a point where the individual is not thinking clearly and calmly about the nature of his decision” (383). By this judgement, a paternalist may assume that drugs may somehow be responsible for suicide, as it was the drug that robbed the user of the rational mind…keeping them from knowing better.

Szasz refutes this claim while still accepting some modicum of paternalistic truth. Szasz agrees that indeed some drugs are dangerous, such that heroin is more deadly than aspirin, etc. Yet he also claims it is ludicrous to blame drugs for suicide or accidental deaths. Szasz claims that self-destructive behavior “may be regarded as sinful and penalized by means of informal sanctions. But it should not be regarded as a crime or (mental) disease …it is absurd to deprive an adult of a drug (or of anything else) because he might use it to kill himself. To do so is to treat everyone the way institutional psychiatrists treat the so-called suicidal mental patient” (qtd. in Burr and Goldinger 366).

At the heart of Szasz’ queries is the underlying anger of addicts being labeled as ‘sick’ or ‘diseased’. Szasz dictates that people take drugs for two very different reasons. One is to allow the user to conform and function in society; the other is an outright refusal to prescribe to social conformity (qtd. in Burr and Goldinger 367). Szasz claims the stigma of fear placed on drug users is the result of societal inability to understand that users are not “’addicts’…unfit or unwilling to work and be ‘normal,” and that the general public is more comfortable “to believe that they [addicts] act as they do because certain drugs…make them ‘sick’” (367). Indeed the Christian Medical Fellowship clearly writes, “addiction leads to illness, accidents, unemployment, family breakdown, child neglect and violence” (“Dependence and Addiction”). Kleinman takes it a step further, claiming that even drug dealers are irrational in that they themselves do not fully understand the repercussions of their actions, that dealing is “less than rational behavior” (194).

Szasz replies that an easy way to end the social and psychological problems associated with drugs is to allow a free trade market for drugs. Szasz claims that a free trade market would be “more economical for those of us who work, even if we had to support legions of addicts [via taxation], than is our present program of trying to ‘cure’ them” (qtd. in Burr and Goldinger 369). The paternalistic fear that free market trade would result in scores of addicts is also scrutinized by Szasz, who says that laziness and industriousness are more engendered in our cultural patterns. This is why, Szasz points out, the Japanese haven’t been on a sexual free for all since the introduction of free trade abortion (368).

Should drugs then be available to everyone without limitations? Paternalists claim that their essential function is to protect children who are “generally held not to possess the full range of liberties open to adults and…state intervention seems sometimes warranted” (Zwolinski). Szasz agrees with this, stating that some measure of maturity, or at least age, is needed in order to become fully possessed of the right to self-meidcate (Burr and Goldinger 370). That notwithstanding, what about accountability for injury inflicted onto others while under the influence? Is Szasz permitting the free use and indulgence of drugs at any time and place? No. Szasz believes that drugs should be treated more or less in the same fashion as alcohol. Governmental controls on drugs would allow for more responsibility to be placed on the parent to educate and control their children in regards to drug use as minors (370). Furthermore, as we “prohibit by law the sexual seduction of children by adults…”pharmacological seduction” of children by adults should be similarly punishable” (371). Finally, self-medication should be carried out in private or designated locations in public. “Public intoxication, not only with alcohol but with any drug, should be an offense punishable by criminal law. Furthermore, acts that may injure others—such as driving a car—should, when carried out in a drug intoxicated state, be punished strictly and severely” (370).

Szasz, in the end, finds himself in agreement with some paternalistic practices as they relate to children and limited accountability. That is where the similarities close. Szasz feels that self-medication should be a right enjoyed by all and protected by the Constitution much the same way in which we regard freedom of speech and religion (Burr and Goldinger 369). The arguments for paternalistic insurrection or coercion by the state have been well documented in this text. Furthermore, the arguments against paternalism, as presented by Thomas Szasz and his contemporaries, have similarly been presented. Is one side right or wrong? No. The simple fact is that issues of paternalism and drug-legitimization/decriminalization, are far too complex to be truly analyzed in anything less than a fully rendered tome. Self-medication and the role of the state in the general welfare and protection of its’ citizens is a testy subject with opinions offered from the religious perspective, political perspective, and psychological perspective. Szasz himself sees his argument for the decriminalization of illicit drugs as not so much a question of paternalism so much as a question of labeling. “By recognizing the problem of drug abuse for what it is—a moral and political question rather than a medical or therapeutic one—we can choose to maximize the sphere of action of the state at the expense of the individual, or of the individual at the expense of the state” (374). Only through this understanding may some compromise be reached and drug policy in the United States finally change from ‘curing’ the sickness to correcting the ‘labels’.

Works Cited

Burr, John R. and Milton Goldinger. Philosophy and Contemporary Issues. 8^th ed.

Prentice-Hall Inc. 2000.

“Dependence and Addiction.” CMF Files No. 8. Christian Medical Fellowship, 1997.

15 February 2001 http://www.cmf.org.uk/ethics/brief/addict.htm.

Kleinman, Mark A. R. “Coerced Abstinence: A Neopaternalist Drug Policy Intitaive.”

The New Paternalism: Supervisory Approaches to Poverty. Ed. William Mead. 1997. 182-195. 19 February 2001 .

Suber, Peter. “Paternalism.” Philosophy of Law: An Encyclopedia. 2nd Edition Ed.

Chistopher B. Gray. Garland Publishing Co. 1999. 19 February 2001

http://www.earlham.edu/~peters/writing/paternal.htm.

Szasz, Dr. Thomas. “The War on Drugs is Lost.” November Coalition.

15 February 2001 http://www.november.org/Szasz.html.

Zwolinski, Matt. “The Perils of Paternalism: A Reply to Goodin.” 19 February 2001

http://www.u.arizona.edu/~mattz/paternal.html.