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The Moral Model, The Medical Model and The Cumulation Fallacy

By Alan Carter-McLemore, Prisoner of the Drug War

It is sad but true that the great majority of Americans support the drug war. Their main reason for doing so is rarely defined specifically, but often goes something like this: If drugs were legalized, then two things would happen: 1) the rate of drugs that are now illegal would drastically and permanently increase; and 2) these new drug users would be in addition to, or cumulative with, those that are presently using legal and illegal drugs. This belief is deeply ingrained in the body politic, and is the chief obstacle to considering and implementing policies that promise to be much more likely to reduce the harm associated with drug abuse.

Everyone recognizes that the costs of the drug war are appalling: billions of dollars spent every year; millions of lives destroyed by arrest and imprisonment; endless - and ever-increasing- military entanglements abroad; the wholesale destruction of essential Constitutional guarantees of liberty; and the transformation of "the land of the free" into the most imprisoned nation on earth. However, if the cumulation effect were true, we would have no choice but to vigorously wage the drug war, since the likely alternative would be the swamping of the country's vital institutions under a tide of nonproductive, medically-needy, and crime-prone drug abusers.

Fortunately (except for the many in government and industry who profit from the drug war), the cumulation effect is most likely a fallacy. Much less fortunate (again, except for the drug war profiteers) is the fact that the cumulation fallacy is solidly grounded, in deeply-held beliefs that involve fundamental conceptions of human nature, and is therefore extraordinarily resistant to change.

Drug policy in this country is based upon the "moral model" of addiction. People with substance- abuse problems are held to be at fault for engaging in "immoral" drug-seeking behavior in direct contravention to a perceived morality which calls for moderation, and preferably abstention, with respect to the use of chemicals for pleasure. Since addicts are thus viewed as being "bad" or immoral people, it follows that traditional social mechanisms for controlling immoral behavior should come into play, the most powerful of which is the criminal sanction. Since immoral behavior is by definition a threat to the basic social morality which defines a culture and holds it together, the application of the criminal sanction is thought to be appropriate in proportion to the perceived threat. The "drug problem" is popularly (though probably erroneously) considered to be at the top of the list of our social problems, and the massive police and military response which constitutes the drug war is the result.

The "moral model" is based upon the tacit assumption that we are all pretty much the same biogenetically, and that one's particular physiological or genetic makeup has little to do with drug-seeking behavior. It follows from this assumption that, since most people can and do control their drug-seeking behavior, those that don't are lacking in will-power or are otherwise morally or socially deficient. Although this belief is still widely held in the U.S., science has undergone a paradigm shift away from the "moral model" and has developed a different conceptualization of substance abuse, called the "medical model" of addiction.

The medical model of addiction had its beginnings in the early 1950's, when it was noticed that alcoholism seems to run in families. Since then, the evidence for a strong, possibly determinative, biogenetic component to addictive behavior has accumulated steadily. Some of the most compelling evidence for the medical model to yet appear came with the publication of an article in the March/April 1996 issue of The American Scientist, entitled "Reward Deficiency Syndrome," by Blum et al.. This study seemed to link a specific genetic anomaly with a deficiency in the number of a particular brain-located dopamine receptor. People with this condition do not experience the ordinary feelings of well-being normally associated with good health and proper bodily functioning; instead, their life consists, to varying degrees, of continuous feelings of generalized pain and dysphoria. Such people are often driven to seek pleasure-producing chemicals and/or behaviors (such as overeating, thrill-seeking, and compulsive gambling) which temporarily provide a measure of the pleasurable feeling they lack, and which normal people take for granted. It is critical here to note that "free will" or "morality" have little to do with these behaviors. Pain itself is compelling, and sufficient pain makes considerations of free will or morality irrelevant. This is why addictive disorders are so intractable, and why treatment programs based upon the "moral model," such as Alcoholics Anonymous-style "12-step" programs, are largely ineffective as methods of permanently stopping drug-seeking behavior (though they do serve other purposes, in particular the reinforcement of dominant ideologies, and thus continue in spite of regularly failing to achieve their stated goal of permanent sobriety).

The medical model of addiction has some very interesting implications. In particular, it means that fears of an ever-increasing number of addicts appearing subsequent to the institution of a policy of drug decriminalization are probably baseless. Since addictive behavior is so strongly influenced by biogenetic and physiological makeup, and since the number of individuals with such biogenetic predispositions is fixed, there is no reason to fear that "normal" people will be widely "corrupted" by the legal availability of presently-illegal psychoactive substances. "Normal" people don't feel the pain that addiction-prone people do, and could reasonably be expected to control their use of substances that are presently illegal just as they now do with the legal but highly-addictive substances alcohol and tobacco. Another implication of the medical model is that police efforts aimed at suppressing drug use through threats of criminal sanctions are doomed to failure because of the largely-involuntary biogenetic nature of drug-seeking behavior; the immediate imperative of relieving pain will practically always override the abstract threat of arrest and criminal punishment. The medical model is the dominant drug-policy paradigm in Canada and in most of Western Europe, and is gaining currency worldwide.

Theories are, of course, all well and good, but the important thing is how they work in practice. So how do the "moral model" and medical model compare in the real world? Consider the following:

1). The United States is by far the most hawkish drug-warring nation in the world with regard to money spent, force brought to bear, and body count (prisoners). Holland and the Scandinavian countries of Western Europe are at the opposite extreme: the medical model is firmly established, and drugs of all types are largely decriminalized (although the more dangerous ones are often only dispensed under medical supervision). If the "moral model" is correct, the U.S. should have a much lower rate of drug abuse than that prevailing under the "immoral" medical model of the Dutch and Scandinavians. In fact, the precise opposite is true: the U.S. has the highest rate of drug abuse in the Western world and the Dutch and Scandinavians have the lowest overall.

2). What about collateral costs of drug use? The United States government, like a stern parent dealing with an errant child, tells its citizens to "just say no", and will not countenance any policy or program that may "send a signal" that illegal drug use is permissible to any extent at all. This has resulted in the near-total prohibition of officially-sanctioned ameliorative measures such as needle-exchange and methadone-maintenance programs, and the gutting of treatment programs of all types to feed the burgeoning drug war effort. Additionally, drug-treatment programs that do exist are under great pressure to conform to prevailing "moral model" ideology which drastically limits the consideration of other options. (Side note: It is a measure of the scientific solidity of the medical model that even "moral model" programs usually give lip service to medical-model concepts while ignoring most of their practical implications.) The Dutch and Scandinavians, in contrast, are much more tolerant of drug experimentation and use, even to the point of making highly-addictive drugs directly available on demand, with the drug abuser having no reason to avoid treatment because of fear of criminal sanctions.
The "moral model", with its demonization of the effects of illegal drugs on the behavior of their users, predicts that the inflexible, punitive approach of the U.S. would be much more successful in reducing the collateral costs of drug abuse, while the tolerant medical model would lead to an ever-increasing range of drug-related social damage. The reality? Once again the real world supports the medical model. Rates of AIDS and criminal activity associated with drug use are at opposite extremes for the U.S. as opposed to the Dutch and Scandinavians, with the U.S. having the highest and the Dutch and Scandinavians the lowest in the Western world. The fact that is apparent to the Dutch and Scandinavians, and increasingly to the rest of the world, is that it's not the pharmacological effects of drugs that cause most of the crime, violence and disease associated with drug use; rather, it's drug prohibition that's overwhelmingly responsible. (The U.S. learned this lesson with its disastrous experiment with alcohol prohibition, but has apparently forgotten it.)

3). Okay, but what about the children? Push a drug warrior into a corner, and s/he invariably predicts dire consequences for children if the drug war is de-escalated. The pious proclamation that the drug war "protects children" is the most powerful and effective weapon in the drug warrior's propaganda arsenal. So what are the facts? Is the "moral model" superior to the medical model in keeping people of preadult ages from using drugs?
Strike three: In Holland where marijuana use is decriminalized and marijuana can be openly purchased in hundreds of shops, the lifetime prevalence of marijuana is lower than in the United States where hundreds of thousands of people are arrested each year for marijuana possession. The collateral costs of the drug war for U.S. children are even worse in terms of the destruction of families and neighborhoods wreaked by police actions and by the criminal gangs who thrive on the illegal drug market, not mention the fact that the billions wasted on the futile and counterproductive drug war could be much more felicitously spent on things that help children, such as bolstering the truly-desperate public school systems. The "moral model" is a disaster for America's children.

It seems apparent from these examples that the "moral model" is as flawed operationally as it is scientifically, and that the dreaded cumulation effect is indeed a fallacy: wherever the medical model is tried, the rates of drug abuse go down, and the collateral damage associated with drug use goes down drastically.

One other point to consider: It's logical to believe, in light of the apparent validity of the medical model, that people who feel compelled to use a mind-altering substance will use the substance that satisfies them with the least economic, social and medical damage to themselves and their loves ones. If this is true - and reason and the evidence suggests that it is - the legal availability of a wide range of psychoactive substances might paradoxically serve to lower the damage associated with drug use. People without a compelling biogenetic problem are not likely to use any substance immoderately; and those with such a problem will find the substance they can most easily live with. One wonders whether or not this probable fact has anything to do with the heavy financial support given to the drug war-supporting Partnership for a Drug-Free America (of the egg-in-the-frying-pan notoriety) by the manufacturers and sellers of those deadliest of drugs, alcohol and tobacco...

The medical model of addictive behavior is cause for hope that we as a nation can find our way out of the Vietnam-style morass of the drug war. There is nothing inherently inferior about America as a nation or a people that would indicate that the medical model won't work here as well as it is working in the growing number of nations that are trying it. Maybe we'll soon give it a try.

I hope so. The alternative is too grim to contemplate.

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