Our society is hooked on harm reduction
We should approach the use and abuse of alcohol and drugs as a moral question, not as a clinical or legal matter.
Dr Michael Fitzpatrick
At the Battle of Ideas in London on 29 and 30 October, Dr Michael Fitzpatrick spoke in a debate titled: ‘Your mind, your high: is recreational drug use morally wrong?’ An edited version of his speech is published below.
I start from the point that it’s much more useful to regard the whole debate around drug use from a moral rather than a medical, legal or criminal perspective, which is the dominant framework within which drugs tend to be discussed. ‘Moral’ in the sense of the question of what sort of standards of behaviour we hold ourselves to as individuals and what sort of standards we wish to prevail in the society in which we live and to determine our relations with other people.
Now, we start with the recognition that the use of intoxicating substances is a universal feature of human society. It’s surrounded with all sorts of rituals, it’s very pleasurable for individuals, and it plays a very important part in all sorts of social life.
And we also recognise that the resort to intoxicating substances in response to the vicissitudes of life is a permanent and ineradicable temptation and a part of the human condition. As Thoreau said, most people lead lives of quiet desperation and the resort to intoxicating substances or altered states of consciousness in response to that experience of life is a constant presence to the human condition.
The problem arises when occasional or episodic use of these substances becomes habitual, customary, compulsive. Then it can become a problem. And, of course, as a society we have existed with this problem in relation to alcohol, which is the predominant substance for creating an altered state of consciousness and intoxication, over hundreds or thousands of years.
The spectrum from recreational to problematic use is something that every individual has got to learn to work out in their own personal relationship to alcohol, because of the way in which it permeates our society. Everybody in this room has had to do that, and has negotiated that, because you can’t live in this society without doing so, and indeed that experience is extending to other sorts of substances which are becoming increasingly familiar.
We only have to look at alcohol to see that problem: alcohol is, on the one hand, a substance which creates great pleasure. It exists in an immense variety of forms. People get tremendous enjoyment from drinking it, making it, sharing it, consuming it at parties; it plays an important part in our lives. We also know the tremendously destructive effect that people’s relationship with alcohol can have and has had. Everybody in this room knows from their personal experience how people’s individual relationship with alcohol can be so damaging and destructive in their own lives, the lives of their families and the lives of people in wider society.
There’s a problem for our society to deal with. The fact that it’s subject to all sorts of political controversies at different times doesn’t detract from the fact that there’s always been a problem there. That problem is in some sense compounded and extended into the whole area of recreational drugs, however they’re defined. Obviously, the problems that those substances create are greater for individuals, and indeed for societies, for whom there is a lack of direction and purpose.
The most striking example of that is the destructive effect of the relationship of alcohol on indigenous or aboriginal societies in various parts of the world – societies which are in a particular state of demoralisation or crisis have a particularly difficult problem with alcohol. It’s a particular problem in our society for people who are poor, demoralised, unemployed, for the immature and the disaffected. These substances are a particular problem for people who are in that state of life. And therefore it’s quite understandable that people should resort to these sorts of substances, and it can become a habitual, customary, addictive part of their life, where the whole process of drug consumption takes over many constructive activities in relation to their personal or social lives.
In response to that, my medical colleague Theodore Dalrymple, one of the most perceptive of medical writers on this subject, takes what you might you say is an extreme view, which is to say that if society is going to stigmatise any activities, these ought to be stigmatised, indeed the addict ought to be stigmatised, because this behaviour is self-centred, self-destructive, self-indulgent and, indeed, socially destructive. I wouldn’t advocate the stigmatising of individuals and the social discrimination of individuals, but it seems to me that it’s an entirely sensible position for society as a whole to take a view of these activities as something that should be regarded with an element of social disapproval or disapprobation. We need to strive for a cultural climate in which these activities are not encouraged, rather than what seems to me to exist at the moment: today, these activities are indulged and in some sense rewarded.
Celebrity culture celebrates this, but it also happens on a smaller scale. It is interesting that a large population now exists that can claim disability benefits on the basis of being addicted to alcohol or drugs. There are 100,000 people in this country in receipt of long-term benefits with a diagnosis of either alcohol or drug dependency. And that’s doubled in the past 10 years.
That’s a very interesting social trend that has been created in our society. This activity is in a sense supported and indulged by the rest of society. One of the striking things – and there’s been some discussion in the medical world about this recently – is of the problem of aging addicts. I’ve got a couple of patients myself who have graduated into old people’s homes, along with their zimmer frames and bottles of methadone. And what that communicates is the extent to which the admission into the category of addiction is a life sentence. It’s a self-fulfilling prophecy which lasts a lifetime – people are condemned to a life in that respect.
So I think we need to move away from that sort of support for the culture of drugs, from indulging it in those ways, and we should not celebrate this way of dealing with the experience of modern society as being in some way interesting or creative. As the slogan goes, ‘A drunk is a drunk, every heroin addict is a philosopher’. Pete Doherty is a cult hero of our era and that seems to me a morbid aspect of contemporary society that we have these sorts of folk heroes, people who celebrate this condition or the idea of creativity being enhanced by these substances – which is one of the great illusions that is well discussed by Theodore Dalrymple, going back to the romantic poets and de Quincy and Coleridge and that whole tradition. I haven’t got the space here to go into that now, but what a myth and a delusion that is.
I’m not saying that any of these activities should be banned or clamped down on. Instead, I’m talking about the sort of cultural climate we ought to seek to foster around them, and that seems to me to be consistent with this wider notion of bringing the morality of issues into focus.
The alternatives are to regard drug use as a medical or as a legislative issue. However, the consumption of drugs, it seems to me, cannot be construed as a medical problem; this idea that it’s a disease is a fatuous notion. The problem is not about a medical condition, but that people have not learned how to live their lives in a real and meaningful way. And that is a problem for which doctors have nothing to offer. I can tell you as I’ve worked in this area for 30 years. A doctor cannot tell you how to live your life, though many may be tempted to do so. The futility of this idea is eloquently confirmed by the complete ineffectiveness of medical treatments for drug use. But what I object to is not the fact that the treatments are useless, but how dehumanising they are.
Reducing the drug addict to a physiological system that can be blocked with some drug, detoxed by replacing one drug or another, or reducing the addict to some sort of automaton which will behave in a criminal way if the drug is not replaced with something else, is ultimately dehumanising. It construes the human being as something without any control or volition over their own behaviour, without any capacity to change their behaviour, without any control over how they live their lives. The paradox of this is the sort of warm glow of benevolence on the part of doctors and health professional who believe that they are being helpful in these relationships, when in fact they’re removing all humanity from the people that they’re treating.
The concept of harm reduction is very interesting in this regard; the idea that you have a state policy which reduces the harm associated with the activities that individuals undertake. That is an inherently infantilising concept: ‘We, the state, will take over from you the individual the judgement of what is safe for you to engage in.’ It takes responsibility away from you for determining your own behaviour. Nothing could be more reinforcing to irresponsible behaviour than the philosophy of harm reduction.
The usual alternative to the medical view of drug use is the legislative one. There’s much discussion of the decriminalisation of drugs which tends to be extremely simplistic. One of the issues about it is when people talk about decriminalisation what they usually mean is some change in the legislative framework, some different form of regulation rather than the current one. Anybody who wants to make out that it’s a simple problem doesn’t understand the complexity of it. And you only have to look at the history of alcohol to see that. Western societies have struggled with how to regulate alcohol for 200 years, manifestly unsuccessfully, and a triumph in that area doesn’t seem to be anywhere near coming around. It’s simple if you argue it from a basic principle – one that many people, including myself, hold dear – namely, Mill’s idea of non-interference in private behaviour. What the individual does is up to the individual and the state should not interfere in it. That is a very sound principle to which I strongly adhere. But you also can’t ignore the fact that there is a cost to be paid for that, which you can’t just entirely dismiss.
You can look at it entirely pragmatically and say, look, the harmful consequences of the war on drugs are even more than those caused by the drugs themselves. I think you can make a persuasive argument for that and people will be familiar with the discussion around that. But I would say, yes, there’s a case to be made there, but can you really be sure that the removal of all legislation would not create even bigger problems than we already have in relation to the flow and, in particular, the commodification of these drugs which are becoming increasingly widely available, and the promotion of them on the market? Would that indeed do less harm than the current regulation? Maybe, maybe not. It seems to me open to discussion.
On balance, many people, including my colleague Theodore Dalrymple, come down in favour of continuing the criminalisation of drugs in the current form. On balance I come down on the opposite position because it seems to me that the principle of individual autonomy, particularly in the current climate of more coercive and repressive state legislation, is a more important principle to stand by. The danger of the infantilisation of social policies in all areas and the dangers of intrusive social and public-health policies are greater than the dangers of drug use. Indeed, there’s a sort of soporific, stupefying effect of all those sorts of policies which is nearly as bad as methadone.
But more important than that discussion is a wider question. It’s not really a question about laws. It’s a question of the moral, cultural, social climate that we create around it, and I think that’s what we really need to tackle – the baleful effects of the drug culture and the drug-treatment culture. And we should make a start, I would say, by repealing the laws, closing the clinics, stopping the benefits. The take-home message from that is ‘take responsibility for your own actions’.
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