Reason Com People Thomas Szasz Article XML

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<entry>
<title type='html'>Malpractice vs. "Malresult"</title>
<link href="http://reason.com/archives/2005/01/10/malpractice-vs-malresult" rel="alternate"/>
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<name>Thomas Szasz</name>
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A new form of insurance for an eternal problem
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<![CDATA[
Doctors and patients both take risks when they do business
together. The physician (for the most part), only puts his wealth
at risk: He protects himself by means of malpractice insurance. But
for the patient, both wealth and physical health are at risk. At
present, the patient can protect himself only against the risk of
incurring a ruinous financial cost for the diagnosis and treatment
of his illness: He protects himself by means of health insurance.
How do we create an insurance regime that provides a form of
protection neither of these policies can provide?
I propose a new form of medical insurance for the patient:
Create PDF in your applications with the Pdfcrowd HTML to PDF API PDFCROWD
protection against the risks of diagnostic and therapeutic
procedures that may or may not be due to bona fide medical
negligence—that is, "malresult insurance."
When a patient suffers an undesirable outcome as a result of
medical care, the harm may or may not be the physician's fault.
More often than not, the "malresult" is an "act of God."
Nevertheless, malresults are now often attributed to and treated as
cases of medical malpractice (negligence). Making medical malresult
insurance available and expecting patients to use it would be a
step toward more fully recognizing the commercial aspects and risks
of the medical situation.
People who choose to buy a house purchase home owner's
insurance. People who choose to drive purchase (are compelled by
law to purchase) automobile insurance. Similarly, people who choose
to undergo diagnostic and therapeutic procedures ought to be able,
and be expected, to purchase medical malresult insurance.
In ordinary commercial relations, premiums for insurance depend
on the demonstrated behavior of the insured. Drivers with a good
record pay a lower premium than drivers with a record of traffic
violations. In medical malpractice insurance, this fundamental
principle is largely inoperative.
Obstetricians and neurosurgeons pay a much higher premium for
malpractice insurance than do ophthalmologists and pediatricians.
Why? Not because they are more prone to practicing medicine
negligently than physicians in other specialties, but because the
procedures they perform are more hazardous than those performed by
ophthalmologists and pediatricians. Accordingly, patients who
submit to high-risk procedures especially need insurance to protect
themselves from malresult, just as physicians who perform such
procedures especially need insurance to protect themselves from
malpractice.
Virtually all medical encounters are risky. The chance of dying
during or after general anesthesia is one in 10,000. The risk of
perforation of the colon during diagnostic colonoscopy is 0.2 to
0.4 percent; it increases to between 0.3 and 1.0 percent if it is
combined with polypectomy; the overall death rate from the
procedure is about one in 12,500. The chance of a pregnant woman
dying as a result of her pregnancy is approximately 1 in 12,000 (in
the U.S.).
The woman who chooses to become pregnant incurs risks similar,
in principle, to the risks an entrepreneur incurs who chooses to
engage in an activity that may be dangerous to others or himself,
say, transporting gasoline. The pregnant woman exposes herself to
the risk of having an abnormal baby or becoming the victim of a
medical complication (for example, a stroke). It is reasonable that
she bear the cost of insuring herself against these
contingencies.
If an obstetrician delivers an abnormal infant, regardless of
whether he is innocent or guilty of malpractice, juries are likely
to find him liable for large damages. If the expectation for the
purchase of insurance for malresult were as firmly established as
is the expectation for the purchase of insurance for malpractice,
pregnant women would be expected to protect themselves by
purchasing such insurance. Obstetricians could then restrict their
practices to women who have such insurance (the cost of which would
be negligible compared with the cost of raising a child). As a
consequence, their exposure to malpractice litigation would shrink
to a fraction of its present size.
The diagnosis and treatment of disease is dangerous for the
patient economically as well as medically. At present, the patient
protects himself from the economic harm of the medical situation by
health insurance, and expects to be protected from the medical harm
by the physician's malpractice insurance. This arrangement fails to
distinguish between injury the patient suffers as a result of the
nature of his illness and treatment, and injury the physician
inflicts on him as a result of improper care.
To the victim of a medical catastrophe, it makes little
difference why such a calamity befalls her or him. Delivering an
infant with spina bifida or becoming quadriplegic as a result of a
hazardous spinal cord operation irrevocably changes the life of the
mother and neurosurgical patient. Perhaps largely for that reason,
tort law does not adequately recognize the difference between
medical "malresult" that happens through no fault of anyone, and
medical malpractice, that is, bona fide medical negligence. The
result is that, in a suit for malpractice brought by a poor,
disabled patient against a rich insurance company (and healthy
physician), the jury is more likely to base its judgment on
compassion for the sufferer than on the merits of the case (that
is, on the question of the physician's culpability or lack of it
for the patient's injury). Awarding a large sum to the
plaintiff-victim "feels" like the "right thing to do" and makes
members of the jury feel better.
Tort litigation cannot restore health irrevocably lost, much
less bring back the dead. All it can do is take money from the
insurance company (and/or the physician) and give it to the victim
or his family (and his lawyers). Adding a market in patient
insurance for malresult to the market in physician insurance for
malpractice would accomplish two important goals. It would
guarantee compensation for the injured patient, more expeditiously
and securely than malpractice insurance does, and it would protect
the physician innocent of malpractice from having to settle claims
against him. (Insurance companies could establish a schedule of
specified diagnostic and therapeutic malresults similar to the
schedule of bodily injuries specified in policies for accidental
bodily injury and death.)
According to the American Medical Association, 20 states now
face a full-blown medical liability crisis. Data from the National
Association of Insurance Commissioners shows a 750 percent increase
nationally in malpractice insurance premiums since 1975. For some
specialists, such as obstetricians, the annual insurance premium
exceeds $200,000.
High malpractice premiums cause physicians to restrict their
practices or retire early, and lead medical students to avoid going
into lawsuit-magnet specialties like obstetrics and neurosurgery.
While the risk of malpractice litigation affects all physicians,
those most affected are specialists whose patients are most likely
to suffer devastating injuries. Similarly, while all patients need
malresult insurance, those who need it most are obstetrical and
neurosurgical patients.
People do not go skiing to break a leg. If they do so, they are,
as a rule, responsible for paying the cost of their treatment or
for having insurance to pay it. People do not consult physicians to
become disabled or die. If they do, they ought to be responsible
for the financial consequences or have insurance to compensate them
for their loss, unless the physician commits demonstrable
malpractice.
Sooner or later, we shall have to confront our inconsistent
expectations from modern medical technology. We demand, as a
"right," the accurate diagnosis and effective treatment of disease;
but when, in the process, we suffer, we feel medically and legally
wronged and take to the courts. Rights and responsibilities cannot
be disjoined forever. It is a delusion to believe that we can
continue to assume medical risks without assuming responsibility
for the harms we suffer as a consequence. The availability of
insurance for malresult would radically change the medical tort
litigation scene: it would place some of the responsibility for
risks inherent in medical diagnoses and treatments on patients,
where it rightfully belongs </div>
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</content>
</entry>
<entry>
<title type='html'>Sins of the Fathers</title>
<link href="http://reason.com/archives/2002/08/01/sins-of-the-fathers" rel="alternate"/>
<author>
</author>
Is child molestation a sickness or a crime?
</div>
</summary>
<![CDATA[
We use words to label and help us comprehend the world around
us. At the same time, many of the words we use are like distorting
lenses: They make us misperceive and hence misjudge the object we
look at. As Sir James Fitzjames Stephen, the great 19th-century
English jurist, aptly put it, "Men have an all but incurable
propensity to prejudge all the great questions which interest them
by stamping their prejudices upon their language."
Consider the ongoing scandal involving Roman Catholic priests
accused of molesting boys. American law defines sexual congress
between an adult and a child as a crime. The American Psychiatric
Association defines it as a disease called "pedophilia."
Crimes are acts we commit. Diseases are biological processes
that happen to our bodies. Mixing these two concepts by defining
behaviors we disapprove of as diseases is a bottomless source of
confusion and corruption.
That confusion was illustrated by a February 8 letter to The
Boston Globe in which the Rev. John F. Burns defended Boston
Cardinal Bernard Law against critics who said he ought to resign.
As an archbishop, Law had transferred the Rev. John J. Geoghan to a
new parish despite allegations of sexual abuse. Geoghan eventually
was accused of molesting more than 100 children over three
decades.
"It should be noted that neither Cardinal Bernard Law nor Father
John Geoghan was aware early on of the etiology or pathology of the
disease of pedophilia," Burns wrote. "The cardinal did what an
archbishop does best. He showed kindness and love to an apparent
errant priest. Father Geoghan also did what more recent knowledge
shows pedophiles do: namely, be in total denial, with hardly any
remembrance or remorse for their diseased acts. Calling for the
cardinal's resignation is absurd. Let the healing begin and the law
take its course."
The law is taking its course not only in the suits filed against
the church by the victims of Geoghan and other abusive priests.
Geoghan himself has been convicted of molestation in one case and
faces trial in another. But if his behavior was caused by "the
disease of pedophilia," a condition that not only compelled him to
fondle boys but erased his memory of those "diseased acts," how can
it be just to punish him? The uncertainty introduced by viewing
sexual abuse as the symptom of a disease played an important role
in the church's failure to protect congregants from priests like
Geoghan. In a May 8 deposition, Cardinal Law was asked how he
approached molestation charges. "I viewed this as a pathology, as a
psychological pathology, as an illness," he said. "Obviously, I
viewed it as something that had a moral component. It was,
objectively speaking, a gravely sinful act." The combination of
these two irreconcilable views, medical and moral, was a recipe for
inaction.
<h4>Medical Penal Establishment</h4>
Today virtually any unwanted behavior, from shopaholism and
kleptomania to sexaholism and pedophilia, may be defined as a
disease whose diagnosis and treatment belong in the province of the
medical system. Disease-making thus has become similar to
lawmaking. Politicians, responsive to tradition and popular
opinion, can define any act, from teaching slaves to read to the
cold-blooded murder of a bank guard, as a crime whose control
belongs in the province of the criminal justice system.
Applied to behavior, especially sexual behavior, the disease
label combines a description with a covert value judgment.
Masturbation, homosexuality, and the use of nongenital body parts
(especially the mouth and anus) for sexual gratification have, at
one time or place, all been considered sins, crimes, diseases,
normal behaviors, and even therapeutic measures. For many years
psychiatrists imprisoned homosexuals and tried to "cure" them; now
they self-righteously proclaim that homosexuality is normal and
diagnose people who oppose that view as "homophobic." Psychiatrists
diagnose the person who eats too much as suffering from "bulimia"
and the person who eats too little as suffering from "anorexia
nervosa." Similarly, the person who has too much sex suffers from
"sex addiction," while the person who shows too little interest in
sex suffers from "sexual aversion disorder." Yet psychiatrists do
not consider celibacy a form of mental illness; celibate persons
are not said to suffer from "anerotica nervosa."
Why not? Because psychiatrists, politicians, and the media
respect the Roman Catholic Church's definition of celibacy as a
virtue, a "gift from God," even though celibacy is at least as
"abnormal" as homosexuality, which the church continues to define
as a grievous sin -- an "intrinsic evil," in the words of Cardinal
Anthony Bevilacqua. Regardless of how unnatural or socially
destructive a pattern of sexual behavior might be, if the church
declares it to be virtuous -- as with celibacy or abstinence from
nonprocreative sexual acts -- psychiatrists do not classify it as a
disease. Thus a religion's moral teachings shape what is ostensibly
a scientific judgment.
Conversely, psychiatric diagnoses affect moral judgments. Fred
Berlin, founder of the Johns Hopkins Sexual Disorders Clinic and a
professor of psychiatry at the Johns Hopkins School of Medicine,
declares: "Some research suggests that some genetic and hormonal
abnormalities may play a role [in pedophilia]....We now recognize
that it's not just a moral issue, and that nobody chooses to be
sexually attracted to young people." Yet an action that affects
other people is always, by definition, a moral issue, regardless of
whether the actor chooses the proclivity to engage in it.
Berlin misleadingly talks about the involuntariness of being
"sexually attracted to young people." The issue is not sexual
attraction; it is sexual action. A healthy 20-year-old male with
heterosexual interests is likely to be powerfully attracted to
every halfway pretty woman he sees. This does not mean that he has,
or attempts to have, sexual congress with these women, especially
against their will. The entire psychiatric literature on what used
to be called "sexual perversions" is permeated by the unfounded
idea -- always implied, sometimes asserted -- that "abnormal"
sexual impulses are harder to resist than "normal" ones.
The acceptance of this notion helps explain the widespread
belief that sex offenders are more likely than other criminals to
commit new crimes, an assumption that is not supported by the
evidence. Tracking a sample of state prisoners who were released in
1983, the Bureau of Justice Statistics found that 52 percent of
rapists and 48 percent of other sex offenders were arrested for a
new crime within three years, compared to 60 percent of all violent
offenders. The recidivism rates for nonviolent crimes were even
higher: 70 percent for burglary and 78 percent for car theft, for
example.
These numbers suggest that pedophiles resist their impulses more
often than car thieves do. In any case, it is impossible to verify
empirically whether an impulse is resistible. We can only say
whether it was in fact resisted. But that doesn't matter, because
the purpose of such a pseudomedical claim is to excuse the actor of
moral and legal responsibility.
Catholic officials took advantage of this psychiatric absolution
to avoid dealing decisively with priests who were guilty of sexual
abuse. What do church authorities do when a priest is accused of
molesting children? They send him to a prestigious psychiatric
hospital -- Johns Hopkins in Baltimore, the Institute of Living in
Hartford, the Menninger Foundation in Topeka -- for "treatment." In
practice, the psychiatric hospital is a safe house for the sexually
misbehaving priest, a place where he can be hidden until he is
quietly reassigned to continue his abuse elsewhere. Berlin claims
such priests are closely watched after being discharged. But a
priest who commits sexual abuse is a criminal who should be
imprisoned, not a patient who should be monitored by psychiatrists
in the church's pay.
<h4>Greek Love</h4>
Sex with minors was not always considered a disease. In ancient
Greece, sexual relationships between men and boys were a normal
part of life. Such relations, called "pederastic," typically
occurred between a 20-to-30-year-old man and a 12-to-17-year-old
boy. The man pursued the boy, and the boy submitted to him as the
passive partner in anal sex. The man also played the role of mentor
to his pupil. With the arrival of heavy pubic hair, usually at age
18, the younger man found a boy to mentor and get sexual
satisfaction from. Sexual relations between men and young children
played no part in Greek pederasty. Judaism and Christianity
redefined same-sex relations as unnatural and condemned them as
sinful. Then, as criminal laws supplemented or replaced
ecclesiastical laws, same-sex relations became crimes as well. That
understanding governed popular opinion until the rise of secularism
and medical science.
The first person to propose redefining "pederasty," which in the
18th century became the term for what we call homosexuality,
appears to have been the French physician Ambroise Tardieu
(1818�1879). In 1857 Tardieu published a forensic-medical study to
assist courts in cases involving pederasty. Tardieu believed that
the penises of active homosexuals were anatomically different from
the penises of passive homosexuals and "normal" men, that the
anuses of passive homosexuals were anatomically different from the
anuses of active homosexuals and normals, and that physicians could
examine individuals and diagnose homosexuality by observing these
alleged markers.
It remained for Karl Friedrich Otto Westphal (1833�1890), a
famous German neurologist, to convert homosexuality from a disease
identifiable by examining the subject's body into a mental illness
identifiable by examining the subject's mind. Westphal renamed
pederasty "sexual inversion" (in German, "contrary sexual
feeling"), a term that was widely used well into the 20th century.
It was also Westphal who popularized the erroneous idea, still held
by many people, that male homosexuals are effeminate and female
homosexuals are masculine. He argued that since sexual inversion
was a disease it should be treated by doctors rather than punished
by law.
<h4>A Return to Athens</h4>
Creating diseases by coining pseudomedical terms was raised to
the level of art by Baron Richard von Krafft-Ebing (1840�1902), a
German-born professor of psychiatry at the Universities of
Strasbourg, Graz, and Vienna. In his Psychopathia Sexualis
(1886), which made him world famous, Krafft-Ebing authoritatively
renamed sexual sins and crimes "sexual perversions" and declared
them to be "cerebral neuroses." Lawyers, politicians, and the
public embraced this transformation as the progress of science,
instead of dismissing it as medical megalomania based on nothing
more than the manipulation of language. "Sexology" became an
integral part of medicine and the new science of psychiatry.
We have come a long way from Krafft-Ebing. In July 1998 Temple
University psychologist Bruce Rind and two colleagues published
their research on pedophilia in the Psychological
Bulletin, a journal of the American Psychological Association.
The authors concluded that the deleterious effects on a child of
sexual relations with an adult "were neither pervasive nor
typically intense." They recommended that a child's "willing
encounter with positive reactions" be called "adult-child sex"
instead of "abuse."
Not surprisingly, this conclusion created a furor, which led to
a retraction and apology. Raymond Fowler, chief executive officer
of the American Psychological Association, acknowledged that the
journal's editors should have evaluated "the article based on its
potential for misinforming the public policy process, but failed to
do so."
Apparently no one noticed that, according to the fourth edition
of the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV,
published in 1994), a person meets the criteria for pedophilia only
if his "fantasies, sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning." In short, pedophilia is a
mental illness only if the actor is distressed by his actions.
Psychiatrists had likewise classified homosexuality as a disease
if the individual was dissatisfied with his sexual orientation
("ego-dystonic homosexuality"), but not if he was satisfied with it
("ego-syntonic homosexuality"). Bending to the wind, the American
Psychiatric Association later backtracked. In DSM-IV-TR,
published in 2000, the requirement of "clinically significant
distress or impairment" was omitted from the criteria for
pedophilia.
Mental health professionals are not the only "progressives"
eager to legitimize adult-child sex by portraying opposition to it
as old-fashioned antisexual prejudice. In a 1999 article, Harris
Mirkin, a professor of political science at the University of
Missouri-Kansas City, stated that "children are the last bastion of
the old sexual morality." As summarized by The New York
Times, he argued that "the notion of the innocent child was a
social construct, that all intergenerational sex should not be
lumped into one ugly pile and that the panic over pedophilia fit a
pattern of public response to female sexuality and homosexuality,
both of which were once considered deviant." Mirkin cited
precedents such as Greek pederasty. "Though Americans consider
intergenerational sex to be evil," he wrote, "it has been
permissible or obligatory in many cultures and periods of history."
He told the Times: "I don't think it's something where we should
just clamp our heads in horror....In 1900, everybody assumed that
masturbation had grave physical consequences; that didn't make it
true."
The analogy is fatally flawed. Autoerotic acts differ radically
from heteroerotic acts. Masturbation is something the child does
for himself; it satisfies one of his biological urges. In that
sense, masturbation is similar to urination or defecation. That is
why we do not call masturbation a "sexual relationship," a term
that implies the involvement of two (or more) persons, one of whom
may be an involuntary participant. Masturbation (in private) is an
amoral act: Strictly speaking, it falls outside the scope of moral
considerations. In contrast, every sexual relationship is
intrinsically a moral matter; medical (or
pseudomedical-psychiatric) considerations ought to play no role in
our judgments of such acts. The religiously enlightened person may
view same-sex relations as evil. The psychologically enlightened
person may view any consensual sex relations as good. Society must
decide which sexual acts are permissible, and individuals must
decide which sexual acts they condemn, condone, or wish to engage
in.
<h4>The Legal Line</h4>
The criminal law defines sex between adults and minors as a
crime. But the law is a blunt instrument. Technically, an
18-year-old male who has a consensual sexual relationship with a
17-year-old female is committing a criminal act (statutory rape),
even though he might be only one day older than his partner. Such
"crimes" generally are not prosecuted.
Sexual contact between a priest and a 10-year-old boy is quite
another matter, and here is where the medicalization of unwanted or
prohibited behaviors hinders our understanding. To impress the
laity, physicians long ago took to using Greek and Latin words to
describe diseases. For example, they called inflammation of the
lung "pneumonia" and kidney failure "uremia." The result is that
people now think that any Greco-Latin word ending in ia --
or with the suffix philia or phobia -- is a bona
fide disease. This credulity would be humorous if it were not
tragic.
Bibliophilia means the excessive love of books. It does
not mean stealing books from libraries. Pedophilia means
the excessive (sexual) love of children. It does not mean having
sex with them, although that is what people generally have in mind
when they use the term. Because children cannot legally consent to
anything, an adult using a child as a sexual object is engaging in
a wrongful act. Such an act is wrongful because it entails the use
of physical coercion, the threat of such coercion, or (what comes
to the same thing in a relationship between an adult and a child)
the abuse of the adult's status as a trusted authority. The outcome
of the act -- whether it is beneficial or detrimental for the child
-- is irrelevant for judging its permissibility.
Saying that a priest who takes sexual advantage of a child
entrusted to his care "suffers from pedophilia" implies that there
is something wrong with his sexual functioning, just as saying that
he suffers from pernicious anemia implies that there something
wrong with the functioning of his hematopoietic system. If that
were the issue, it would be his problem, not ours. Our problem is
that there is something wrong with him as a moral agent. We ought
to focus on his immorality, and forget about his sexuality.
A priest who has sex with a child commits a grave moral wrong
and also violates the criminal law. He does not treat himself as if
he has a disease before he is apprehended, and we ought not to
treat him that way afterward. </div>
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</entry>
<entry>
<title type='html'>Drug Trial</title>
<link href="http://reason.com/archives/1998/03/01/drug-trial" rel="alternate"/>
<author>
<name>Jacob Sullum</name>
<uri>http://reason.com/people/jacob-sullum</uri>
</author>
<author>
</author>
<author>
<name>Jeffrey A. Singer</name>
<uri>http://reason.com/people/jeffrey-a-singer</uri>
</author>
<author>
<name>Dave Fratello</name>
<uri>http://reason.com/people/dave-fratello</uri>
</author>
<author>
<name>John P. Morgan</name>
<uri>http://reason.com/people/john-p-morgan</uri>
</author>
<author>
<name>George D. Lundberg</name>
<uri>http://reason.com/people/george-d-lundberg</uri>
</author>
<author>
<name>Ernest Drucker</name>
<uri>http://reason.com/people/ernest-drucker</uri>
</author>
Is “medicalization” the first step in ending the drug war? Or just the next step in continuing it? Jacob Sullum lays out the
“public health” issues and a panel of experts responds.
</div>
</summary>
<![CDATA[
Washington state's Initiative 685, the "Drug Medicalization and
Prevention Act of 1997," failed by a big margin last November. But
"medicalization" is here to stay. In one form or another, it is the
most frequently endorsed alternative to the war on drugs--far more
popular among reformers than the free market favored by
libertarians. That fact is a source of hope to some, dismay to
others.
In 1988, when Baltimore Mayor Kurt Schmoke helped generate a
surge of interest in drug policy reform by calling for "a national
debate on the merits of decriminalizing drugs," it was
medicalization he had in mind. "Making drugs illegal has not
diminished the American appetite for these substances," he later
explained. "That is because drug abuse is a disease. And like any
other disease, it responds to medical treatment, not criminal
sanctions.... Decriminalization is in effect `medicalization,' a
broad public health strategy--led by the Surgeon General, not the
Attorney General--designed to reduce the harm caused by drugs by
pulling addicts into the public health system. Criminal penalties
for drug use would be removed and health professionals would be
allowed to use currently illegal drugs, or substitutes, as part of
an overall treatment program for addicts....Drugs would not be
dispensed to non-users, and it would be up to a health professional
to determine whether a person requesting maintenance is an
addict."
This general approach--with some important differences in
detail--has played a leading role in criticism of the war on drugs
during the past decade. One cannot attend the Drug Policy
Foundation's annual conference without hearing repeatedly about the
merits of a "medical" or "public health" model. The Lindesmith
Center, a New York drug policy think tank funded by billionaire
philanthropist George Soros, emphasizes "harm reduction," a public
health strategy aimed at mitigating the costs of both drug use and
drug laws through measures such as needle exchange, heroin
maintenance, and the legalization of marijuana for medical use.
Physician Leadership on National Drug Policy, a new group that
includes former FDA Commissioner David Kessler and former Secretary
of Health and Human Services Louis Sullivan, declares that
"addiction to illegal drugs is a chronic illness." Without calling
for decriminalization, the group argues that law enforcement has
been overemphasized, saying "enhanced medical and public health
approaches are the most effective method of reducing harmful use of
illegal drugs."
Washington's Initiative 685, which was modeled after Arizona's
Proposition 200, echoed this theme. "In addition to actively
enforcing our criminal laws against drugs," it said, "we need to
medicalize Washington's drug control policy and recognize that drug
abuse and addiction are public health problems that should be
treated as diseases." Accordingly, it prescribed "treatment" rather
than incarceration for "nonviolent persons convicted of personal
possession or use of drugs." Such offenders would receive
probation, and the sentencing judge could "require participation in
an appropriate drug treatment or education program." If already in
prison, people in this category would be "eligible for immediate
parole and drug treatment, education, and community service,"
provided they were not covered by a "habitual criminal" statute or
serving a concurrent sentence for another crime.
Despite the line about "actively enforcing our criminal laws
against drugs," these provisions would have eliminated jail time
for simple possession--a dramatic change from current policy. But
another aspect of the initiative, authorizing doctors to
"recommend" Schedule I drugs for the treatment of "seriously ill"
patients, got more attention, since it tied into the national
debate over medical marijuana. This section said a physician who
recommended a Schedule I substance, such as heroin, LSD, or
marijuana, would not be prosecuted or disciplined as long as he
cited relevant scientific research, obtained the patient's written
consent, and got a second opinion from another doctor.
Washington's voters did not go for it. Although its backers
spent 10 times as much as their opponents--with infusions of money
from Soros, Phoenix entrepreneur John Sperling, and Peter Lewis,
CEO of Cleveland-based Progressive Insurance--the measure lost by
20 percentage points. Some voters may have felt that out-of-state
organizers with out-of-state money were trying to pull one over on
them. The opposition's ads, funded in part by Microsoft and by
presidential hopeful Steve Forbes's Americans for Hope, Growth and
Opportunity, sought to reinforce that impression. The conservatives
who turned out to oppose the state's highly publicized gun control
initiative probably also helped defeat Initiative 685.
The loss in Washington was a mirror image of the victory in
Arizona, where 65 percent of voters endorsed essentially the same
initiative in November 1996. Since then the Arizona legislature has
passed bills overriding key elements of the proposition. In
response, the initiative's supporters have gathered signatures to
submit those bills to the voters as referendums on the 1998 ballot.
They are also backing the Voter Protection Act, a proposition that
would amend the state constitution to require a three-fourths
majority in each house of the legislature to overturn a
voter-approved initiative.
Unlike the Arizona and Washington measures, initiatives that
deal exclusively with medical marijuana do not explicitly advocate
a "public health" approach to drug policy generally, but they do
represent one aspect of the "harm reduction" agenda. After
California's Proposition 215 passed by a comfortable margin in
1996, Americans for Medical Rights began pushing similar measures
in other states. Activists hope to have medical marijuana
initiatives on the 1998 ballots in Alaska, Colorado, the District
of Columbia, Maine, Nevada, and Oregon.
However medicalization fares on state ballots, it will continue
to shape opposition to the war on drugs for years to come. That is
partly because it offers a sharp contrast to the prohibitionist
approach that has long dominated U.S. drug policy. The stated aim
of the prohibitionists is to eliminate drug use--by which they
generally mean the use of certain drugs, set apart from
accepted intoxicants by custom, superstition, and historical
accident. The stated aim of the public health specialists, by
contrast, is to minimize morbidity and mortality--including the
harm associated with the use of all drugs, whatever their current
legal status.
Thus, the public health specialists are in some ways more
realistic than the drug warriors: They acknowledge that any drug,
licit or illicit, can be harmful under certain circumstances. And
they stress harm rather than drug use per se. This implies that the
consumption of psychoactive substances is not necessarily
problematic. It also suggests a willingness to consider the
undesirable effects of attempts to discourage drug use. This
openness to evidence is probably the most important way in which
public health specialists differ from prohibitionists.
In terms of policy, both prohibitionists and public health
specialists talk a lot about "education." Prohibitionists seem more
willing to bend the truth if they think it will help scare people
away from drugs, while public health specialists are more likely to
insist that drug "education" have a sound scientific basis. They
note that scare tactics tend to backfire in the long run, as people
recognize that they've been misled and learn to distrust the
source. Still, public health messages about drugs, like public
health messages in general, are aimed at changing behavior, not
simply disseminating facts.
Aside from education, the policy prescriptions offered by public
health specialists sound quite different from those offered by drug
warriors. Prohibitionists emphasize interdiction, crop eradication,
and other attempts to reduce the supply of drugs, along with
arrests, fines, property forfeiture, and imprisonment for
producers, sellers, and buyers. Public health specialists emphasize
treatment, taxes, and regulations.
The prohibitionist orientation is basically punitive: Using
certain drugs is a crime; people who do it deserve to be arrested,
humiliated, imprisoned, and divested of their property. The public
health orientation, by contrast, is therapeutic: Drug abuse is a
disease; people afflicted by it need to be treated. From this
perspective, current policy is irrational and inhumane. After all,
you don't lock people up for cancer or diabetes.
But as Thomas Szasz and other critics of contemporary psychiatry
have long argued, the ostensibly liberal policy of treating
behavior like a disease can have profoundly illiberal consequences.
A disease is something inherently undesirable that happens to
people against their will. No one in his right mind wants
to be sick. Furthermore, drug addiction is said to be a disease
that impairs the patient's judgment. Where's the harm, then, in
forcing him to be well? Under the circumstances, it would seem to
be the compassionate thing to do. Presumably, that is the rationale
behind Initiative 685's "court-supervised drug treatment." When the
disease model is combined with the public health imperative to
minimize morbidity and mortality, and to enlist the state's
assistance in that endeavor, the logical result is never-ending
intervention in personal decisions. (See "What the Doctor Orders,"
January 1996.)
Some reformers who are privately skeptical of the disease model
push it because they think that's what the public is prepared to
accept. From their polling and their focus groups, the supporters
of the Arizona and Washington initiatives knew that voters were not
ready for outright decriminalization. They needed to be assured
that somebody would be in charge--if not cops, then
doctors. Given the fate of Washington's initiative, the wisdom of
this strategy is open to question. But even if the measure had
passed, it might have made further reform more difficult by
reinforcing the disease model. If voters believe that people cannot
reasonably be expected to control their drug use, how likely are
they to support the repeal of prohibition?
On the other hand, the war on drugs is not going to end
overnight. Certain piecemeal reforms can mitigate injustice now and
help prepare the public for more radical change later. Reducing the
penalties for marijuana possession in the 1970s was, I think, such
a reform. Making marijuana legally available as a medicine may be
another. By the same token, surely drug users would be better off
if they were never sent to prison, even if they sometimes had to
endure court-ordered "treatment."
Judging from my conversations with reformers, I'm not the only
one who is ambivalent about these issues. To help bring the debate
into focus, REASON invited several prominent critics of the war on
drugs to discuss the pros and cons of medicalization.
Senior Editor <a href="mailto:jsullum@reason.com">Jacob
Sullum</a> is the author of <a href=
"http://www.amazon.com/exec/obidos/ASIN/0684827360/reasonmagazineA/">
For Your Own Good: The Anti-Smoking Crusade and the Tyranny of
Public Health</a>, forthcoming this spring from The Free
Press.
The Political Legitimation of Quackery 
By Thomas Szasz
The Washington State "Drug Medicalization and Prevention Act of
1997" asserts that "we need to...recognize that drug abuse and
addiction are public health problems that should be treated as
diseases." The merits of this claim cannot be intelligently debated
without agreeing on the use of the terms drug abuse,
addiction, treatment, and disease, and
on the kinds of personal conduct that justify coercive state
control by means of public health measures.
From ancient times until recent years, the term public
health, as distinguished from private health, was
used to denote activities undertaken by a government to protect
individuals from disease-causing agents or conditions in the
environment, both physical and human. The principal public health
measures have been sanitation and the control of infectious
diseases, aimed at protecting the community from microbial diseases
such as cholera and typhoid. In this connection, the control of
venereal diseases illustrates an important consideration: The
prostitute's behavior, exposing her client to the risk of
venereal disease, was and is viewed as a public health
problem, justifying the coercive control of her conduct, whereas
the behavior of her client, exposing himself to the risk of
venereal infection, was and is viewed as a private health
problem, not justifying the coercive control of his conduct. By
defining the behavior of the individual who exposes himself to the
risk of "addiction" as a public health problem, we radically expand
the range of legitimate state coercion in the name of health.
Public health measures play a crucial, but neglected, role in
modern political philosophy. Interventions justified in the name of
health--defined as therapeutic, not punitive--fall outside the
scope of the criminal law and are therefore exempt from
constitutional restraints on state coercion. On the contrary, such
measures--promoted as protecting the best interests of "sick
patients"--are viewed as valuable "services" provided by the
Therapeutic State (the polity uniting medicine and state, much as
church and state formerly were united). Presciently, John Stuart
Mill anticipated this insidious tactic: "The preventive function of
government," he warned, "is far more liable to be abused, to the
prejudice of liberty, than the punitory function; for there is
hardly any part of the legitimate freedom of action of a human
being which would not admit of being represented, and fairly too,
as increasing the facilities for some form or other of
delinquency."
Mill could not have put it better had he been addressing
present-day American drug policy. It is self-evident that free
access to a particular drug, like free access to any object,
increases our opportunities for using and abusing it: Freedom of
action means the opportunity to act wisely or unwisely, to help or
harm ourselves. It is also self-evident that, since "no man is an
island," any private act may be viewed as affecting the economic,
existential, or medical well-being of others, and hence be deemed
to pose a "public health problem"; and that if protecting people
from themselves falls within the sphere of public health, then no
private behavior is exempt from being categorized as a public
health problem, subject to control by means of medical
sanctions.
It is ironic that, in 1997, Americans should recommend "drug
medicalization" as a cure for America's drug problem: It
was the "drug medicalization" act of 1914--better known as the
Harrison Narcotic Act--that transformed widely used analgesics and
sedatives into dangerous "narcotics," specially monitored by the
federal government, available only by a physician's
prescription. Horribile dictu, isn't it possible that
defiance of such controls is not a disease, and that coercive state
interference with the free market in drugs--like similar
interference with the availability of other goods--may be the root
cause of the problem we now try to solve by still further
"medicalization"? Aren't we fools if we fail to ask, cui
bono?: Who benefited from drug medicalization in the past and
who benefits from it today?
The die is now cast: Misbehaviors of all sorts are (defined as)
medical problems. Unwanted behavior, exemplified by the
use of illegal drugs, is, by fiat, a disease. The concepts of
disease and treatment have thus become politicized. The World
Health Organization's definition of drug abuse as the "use of a
drug that is not approved by a society or a group within that
society" is illustrative. Thus, doctors, judges, journalists, civil
libertarians, everyone accepts--or pretends to accept--that
self-administering heroin is a disease and that a state agent
administering methadone to an "addict" is a treatment.
Some see the Therapeutic State as an instrument of compassion
and science in the service of "moral progress" and accordingly
support "medicalization" in all its many guises. Others see the
Therapeutic State as an instrument of cruelty and pseudoscience in
the service of a new form of statism and accordingly oppose
"medicalization."
Contributing Editor Thomas Szasz, professor of psychiatry
emeritus at the SUNY Health Science Center in Syracuse, is author
of many books, including <a href=
"http://www.amazon.com/exec/obidos/ASIN/0815603339/reasonmagazineA/">
Our Right to Drugs: The Case for a Free Market</a>
(Praeger).
A New Metaphor for Autonomy 
By Jeffrey Singer
In November 1996, Californians voted to allow possession and use
of marijuana for medical purposes with a physician's
recommendation. Arizonans went further. They permitted patients to
possess and use any illicit drug, provided they receive a written
prescription from a physician, who, in turn, obtains a concurring
second opinion. In addition, the Arizona ballot measure gave drug
users probation and rehabilitation rather than prison time for the
first two convictions. It prohibited incarceration of nonviolent
drug offenders until the third conviction. Finally, the measure
made eligible for release all inmates serving time for simple drug
possession with no other offenses.
Vice President Al Gore, Attorney General Janet Reno, drug czar
Barry McCaffrey, and former Presidents Bush, Carter, and Ford
participated in media events warning voters of the dangers posed by
these initiatives. Despite those efforts, the ballot measures
passed easily, with 56 percent support in California and 65 percent
in Arizona.
From the perspective of some libertarians, most notably Thomas
Szasz, the public health model embodied in these initiatives can be
seen only as a pernicious extension of the meddlesome Therapeutic
State. But when applied to drug policy, medicalization actually
represents a radical rupture with the federal government's
oppressive drug war.
I served as medical spokesman for the group that developed and
promoted the Arizona initiative. Our mission was to seek
alternatives to current drug policy. Accordingly, we commissioned
focus group research to explore how citizens felt about the drug
issue.
Two dispositions were immediately apparent: 1) People
overwhelmingly felt the drug war was a failure, and 2) people
strongly opposed the alternatives of decriminalization and
legalization. But this did not mean they opposed significant
reform. For example, focus group participants firmly rejected the
policy of "do drugs, do time." They believed treatment was much
more appropriate than imprisonment for drug users. This belief was
so strong that they were willing to parole offenders already in
prison. Furthermore, they believed that when it came to prescribing
drugs--even marijuana, heroin, and LSD--the patient/doctor
relationship should supersede government control. Arizona voters
probably did not realize how widely such beliefs were shared:
Tracking polls showed that 60 percent supported the initiative but
only 25 percent thought it would pass.
The focus group and tracking poll results illustrate what
postmodern philosopher Michel Foucault calls "subjugated
knowledge"--an implicit belief that people cannot communicate
unless given the language to do so. The Arizona focus group
research revealed a radical resistance to the drug war that lacked
a narrative with which to express itself. The common "metaphors" of
resistance--legalization and decriminalization--were
unsatisfactory. A new vocabulary took shape as a result of the
focus group experience. Group members repeatedly said drug abuse is
really a "medical" issue. They said drug treatment, even if it
doesn't work, is a more just form of punishment. Thus, a new
discourse on drugs emerged, representing a halfway position between
prohibition and repeal. Years of prohibitionist propaganda made it
impossible to generate popular support for anything more
ambitious.
This new discourse of medicalization is not a top-down narrative
of control written by the government. Instead, the people have
generated a language of resistance to oppressive and ineffective
policies. This discourse is percolating up from citizens who
believe medical authorities can address the drug issue more
effectively than government bureaucrats.
Libertarian critics mistakenly take the term
medicalization to mean the transfer of power from a
political dictator to a medical dictator. To be sure, the
postmodernist would agree that medicalization is a metaphor of
control. But as Foucault argues, there is no way "outside of"
power; all human interactions involve power relations. Therefore,
the only way of conceiving issues of autonomy is through
empowerment. In the context of drug policy, "medicalization" is a
metaphor of empowerment.
In practical terms, the Arizona and California ballot measures
have eased statist drug controls. The federal government responded
by threatening to punish doctors who prescribe illicit drugs to
their patients. This policy prompted federal lawsuits (including
one in which I am a plaintiff) that fundamentally challenge the way
drugs and medical practice are regulated. A recent national poll
found that 69 percent of Americans oppose the federal response to
the medicalization initiatives.
During the Arizona campaign, I had many arguments with
libertarian friends who shared Dr. Szasz's suspicions of
medicalization. But the reaction of the federal government and the
law enforcement community to the measure's approval, coupled with
strong public opposition to that reaction, has led many of them to
re-examine their positions. Any drug policy reform that engenders
so much outrage from the political establishment and incites such
widespread dissent can't be all bad.
<a href="mailto:dr4liberty@aol.com">Jeffrey Singer</a> is a
Phoenix surgeon who served as medical spokesman for Arizonans for
Drug Policy Reform, which ran the Proposition 200
campaign.
The Medical Marijuana Menace 
By Dave Fratello
California and Arizona voters changed the politics of the drug
war when they approved "medicalization" ballot initiatives in 1996.
Both reformers and prohibitionists have had to deal with the
consequences.
On the reform side, as the movement begins to mature and achieve
a tangible success here and there, we are seeing internal debate
and factionalization. For years the movement has functioned
amorphously, with a "big tent" mentality and a lot of preaching to
one another. Nowadays, those of us working on medical marijuana
initiatives for the 1998 ballot seem to catch flak from every
angle. Repeal advocates tell us that medical marijuana does not go
far enough. We are also criticized for how we would permit
medical marijuana--with regulation rather than declarations of
complete freedom for doctors and patients--and for limiting it to
certain medical conditions.
At the same time, the 1996 votes have helped remind reformers of
our common enemies. When an issue like allowing some patients to
use marijuana, seemingly so peripheral to the broader drug policy
debate, causes a panic among the drug war's partisans, it is worth
asking why. One way of addressing that question is to speculate
what might happen if voters approve every state initiative on
medical marijuana (a total of four to six) this November. Could we
expect anything like the over-the-top, multi-agency roar federal
officials let out in 1996? If so, perhaps the drug warriors will
further erode their credibility by fighting public wishes and
denying patients a useful medicine.
Alternatively, the federal drug warriors might give in on
medical marijuana, moving it to Schedule II or III so doctors could
prescribe it, and thereby put a "friendly face" on prohibition,
exactly as Thomas Szasz fears. The multi-state initiative strategy
is designed, in part, to force or facilitate the rescheduling of
marijuana, with the underlying risk of relieving pressure for
reform. If federal officials choose to build a firewall behind
medical marijuana, but in front of legalization, hopes for repeal
of prohibition would dim.
But is it really plausible that the guardians of prohibition
would make that move? The ban on medical use of marijuana is rooted
in the restrictions established by the 1937 law that banned
recreational use, a mistake Congress failed to fix when it rewrote
the drug laws in 1970. Compelling studies of marijuana's
therapeutic potential in the late 1970s and early '80s did not
affect federal policy, so it is difficult to believe today's
proclamations that science will resolve this issue. The evidence
suggests that the drug warriors believe prohibiting medical use is
crucial to the overall policy of intolerance toward marijuana.
If the problem is ideological, it may be impossible to get a
concession. The never-ending frustration of medical marijuana
advocates is that the drug war can't seem to accommodate a modest
reform like making cannabis available by prescription. By the same
token, such a reform could be devastating to the war on the drugs.
That, at least, seems to be the understanding of hard-core drug
warriors.
Whatever the federal reaction, the fight for medical marijuana
offers benefits that abolitionist critics often overlook. In
addition to being a compassionate step in itself, changing state
laws on medical marijuana tends to put the right issues into play
and the right people on the defensive. It raises questions about
the nature of drug prohibition and the rationality of its
enforcers. It enhances the credibility of reformers and attracts
allies who may ultimately be persuaded to support more radical
change.
With those benefits in mind, medical marijuana initiatives
should neither stoke nor calm fears about the medicalization of
drug policy. Permitting the medical use of marijuana does not, as
Thomas Szasz has written in Liberty, endorse the "fiction
that self-medication is a disease" or declare "punishing it a
treatment." The mechanism for allowing medical use is to carve
exemptions into existing criminal laws. That seems to reduce the
power of the state, especially since it forces those charged with
implementation to change their tactics, sometimes fundamentally.
Police in California, for example, are learning that marijuana they
seize may be someone's medicine, in which case they have to give it
back.
If opponents of the drug war want to have an impact, rather than
focusing on the perfect policy or waiting for revolutions in the
public's thinking, we have to reach out to new people, find working
compromises, and advance concrete proposals. Proposals rooted in
medicalization concepts currently have the greatest public appeal,
notwithstanding the recent vote in Washington state. The more
moderate and sensible our proposals seem, the better our chances of
success. At the same time, if it is true that any successful
challenge to the drug war, even on a relatively narrow issue,
threatens an overly rigid paradigm, so much the better. We can't
count on overthrowing the generals with modest peace offerings. But
in the very strange world of U.S. drug policy, it just might
happen.
Dave Fratello, previously with the Drug Policy Foundation,
is communications director for Americans for Medical Rights, a Los
Angeles-based group that ran California's Proposition 215 campaign
and is sponsoring medical marijuana initiatives in several
states.
Medicalization and Scientism 
By John P. Morgan
Medicalization--the idea that drug consumption can be understood
by a scientific assessment of what drugs do in the body and
brain--is not new. Many physicians in the late 19th century tried
to explain heroin or morphine addiction as a kind of allergic
reaction: The repeated injection of opiates permanently changed the
user's physiology, creating an illness requiring lifelong use of
the drug.
Today, medicalization relies on apparently scientific
explanations of the neurobiological mechanisms underlying
addiction. Research in this area is increasingly complex, if not
abstruse, and journalists look to the investigators themselves to
explain how important and revealing it is. These scientists take a
pharmacocentric approach, focusing on the drug as the cause of
behavior and ignoring other factors. Their reports are scientistic,
using the neutral language of neurobiology to disguise value
judgments. Investigators usually assert that results from animal or
cell-culture experiments are clearly relevant to humans. Indeed,
they often claim that a given study "proves" the existence of a
human drug reaction that cannot be found among humans.
Two highly publicized studies reported in the June 27, 1997,
issue of Science illustrate these tendencies. In one,
Fernando Rodriguez de Fonseca and other investigators at the
Scripps Research Institute in La Jolla gave rats daily injections
of a synthetic drug resembling delta-9 tetrahydrocannabinol (THC),
the main active ingredient in marijuana, for two weeks. Then they
gave the rats a cannabinoid antagonist, which stripped the THC-like
drug from its receptor sites. This provoked a withdrawal syndrome
lasting an hour or so, featuring tremors, hyperactivity, and
defensive posturing. The researchers also measured increases in
brain concentrations of corticotropin-releasing factor (CRF), a
neural hormone. Such increases have been seen in rodents undergoing
alcohol and heroin withdrawal.
The study and an accompanying editorial said these findings
confirmed cannabinoid withdrawal in humans and provided
evidence that increases in CRF create anxiety that drives marijuana
users to ingest other drugs. De Fonseca et al. claimed their study
therefore offered support for the "gateway" theory, which says
smoking marijuana leads to the use of cocaine and heroin.
In the second study, Gianluigi Tanda and other researchers at
the University of Cagliari in Italy measured the release of
dopamine in the mesolimbic area of the rodent brain following
injection of THC, a THC-like synthetic, and heroin. Neurobiologists
have long wondered if cannabinoids raise extracellular dopamine in
this brain area because such increases are triggered by many drugs
that humans use for pleasure, including heroin, alcohol,
amphetamine, nicotine, and cocaine. Prior to the Tanda study,
evidence of dopamine release caused by injection of cannabinoids
was equivocal.
In their report, Tanda and his colleagues unhesitatingly
compared marijuana to heroin and, like de Fonseca et al., invoked
their rodent findings as evidence for the much-discussed gateway
theory. They speculated that marijuana use, by increasing dopamine,
"primes" the brain, so the dissatisfied cannabis smoker will be
drawn to heroin for the familiar dopamine rush.
Both studies were widely covered in American newspapers, framed
in just the way suggested by the researchers. Their extrapolations
to humans were reported without qualification, and their results
were described as "new evidence" of marijuana addiction and a
gateway effect.
This unscientific interpretation ignored the findings of prior
research involving both animals and humans. Rodents and primates
will not self-administer THC or other cannabinoids even when they
have been primed with repeated injections and abrupt withdrawal.
Simply put, these animals do not like pot; they find small doses
unappealing and large doses aversive. Hence the de Fonseca study,
in which the researchers went to great lengths to precipitate a
short-lived cannabinoid withdrawal reaction in rats, has no obvious
relevance to animal behavior, let alone human use, which typically
involves smoking small amounts of cannabis episodically, with THC
declining slowly after each session.
De Fonseca et al.'s most egregious extrapolation was their
speculation that cannabis smokers move to other drugs because of
the "anxiety" seen in withdrawal. It is difficult to show any
marijuana withdrawal phenomenon in humans, and I know of no study
that links cessation of cannabis use with the use of other drugs.
Yet somehow the release of a neural hormone in rats signaled to the
researchers that human cannabis users suffer abstinence anxiety
that they try to alleviate with cocaine or heroin.
Similarly, it's hard to know what to make of the dopamine
increases found in the Tanda study, since rats do not actually like
cannabinoids. Earlier research in this area was based on the theory
that reinforcing drugs raise dopamine levels. Now we have
an experiment linking increased extracellular dopamine with a
compound that is not reinforcing in rodents and has not
been shown to be an important drug of dependence in humans. There
are many drugs that increase extracellular dopamine which humans do
not find attractive, including levodopa, tricyclic antidepressants
(Elavil, Tofranil), and anticholinergics (atropine, Artane).
These attempts to scare people about marijuana through animal
studies, because actual human experience with the drug is not
alarming enough, suggest the pitfalls of the biological
reductionism on which medicalization depends. Where medicalization
is the practice, scientism is the theory.
<a href="mailto:drjpm@scisun.sci.ccny.cuny.edu">John P.
Morgan</a>, a physician and professor of pharmacology at the City
University of New York Medical School, is co-author of
<a href="http://www.amazon.com/exec/obidos/ASIN/0964156849/reasonmagazineA/">
Marijuana Myths, Marijuana Facts</a> (Lindesmith
Center).
Show Me the Data 
By George D. Lundberg
My personal activities in the field of substance abuse go back
about 30 years to my time as a faculty member at the University of
Southern California in Los Angeles. I am, by training and
experience, a forensic pathologist and a toxicologist. The 1960s in
Los Angeles were the early heyday of our modern drug abuse epidemic
and provided a natural laboratory for studying voluntary human
street drug experimentation, informing the academic and clinical
fields, albeit with great pain and sadness.
I define drug as any chemical which, when administered
to a living thing, produces an effect. I define drug abuse
as the use of a drug in a manner that is likely to cause harm. This
definition deliberately ignores law and medical practice because
most drug abuse is legal (alcohol and tobacco) or within the bounds
of medical practice (e.g., prescription sedatives). For practical
purposes, drug abuse is confined to psychoactive drugs, which are
chemicals that affect the way a person thinks, feels, or behaves.
Drug use is not necessarily a problem; harm from drug use is the
problem. Of course, you cannot have drug harm without drug use, but
you can have drug use without drug harm.
We in the new group called Physician Leadership on National Drug
Policy (PLNDP) believe that scientific evidence should drive
American drug policy and that up to this point it has not. The
PLNDP is a group of leading physician activists and pragmatists who
intend to work with the public and with policy makers to improve
the lives of our patients and our communities by reducing drug
harm.
Chronic psychoactive drug use can lead to addiction, which is a
chronic illness. Addiction does not go away. Physicians don't
always strive for cures. We generally don't cure hypertension,
arthritis, diabetes, or asthma, for example, but we can medically
manage them quite well. The same is true with chronic chemical
addiction. We cannot cure it, but we can manage it, often
successfully, at a reasonable cost to society.
We in the PLNDP believe that when one considers the tens of
billions that our federal and state governments spend each year on
drug control, we should be getting better results. We should be
applying principles of scientific evidence to the various methods
available to intervene in the drug field--for primary prevention,
secondary prevention, treatment, and rehabilitation. Available
evidence strongly suggests that emphasizing source control,
interdiction, and domestic enforcement--methods that account for 75
percent of drug control spending--is a very inefficient strategy.
It is clear that the government is throwing large amounts of
taxpayer money away each year. We don't have all the answers yet,
but we do know that proven treatment methods offer a more
cost-effective alternative.
Drug law enforcement has a place, but not necessarily the
premier place, because the evidence does not support that approach.
Now that the U.S. military (of which I was a loyal full-time member
for 11 years) has run out of real wars to fight, it is getting
involved in phony wars on marijuana fields in Mexico and coca
fields in Bolivia. Let's stop playing drug war games. They are no
longer entertaining, and they don't work.
George D. Lundberg is editor of The Journal of the
American Medical Association.
Defending the Public Health Trademark 
By Ernest Drucker
Public health is concerned with the well-being of populations
and therefore shares with medicine the goal of reducing suffering
due to disease. But its "patient" is the community and its measure
of successful "treatment" is the reduction of collective morbidity
and mortality, usually measured in terms of prevention. Indeed,
clinical medicine exists as a function of public health's failure:
It treats the casualties of unhealthy social policy and poor public
health practice.
The problem with public health comes from its close historical
association with clinical medicine, i.e., an over-reliance on the
disease model. While a perfectly appropriate way of understanding
the course and characteristics of individual illness, the disease
model is only a small part of what is required to appreciate the
complex biological and social circumstances that contribute to
morbidity and mortality. Many critics of the public health
perspective fail to distinguish its perspective from that of
medicine. Workplace injuries, highway accidents, and home
poisonings are not diseases, but they are well understood (and
prevented) using a public health model.
When it comes to drugs, public health data usually focus on the
most negative outcomes (disease and death) and the "hard realities"
of drug use: addiction, overdose, AIDS, crime, domestic violence.
But this is only part of the picture. In the vast majority of
cases, the positive aspects of drug use, such as psychological
benefits and social involvements, outweigh any harm. Because of the
stigma attached to illegal drug use, these "soft realities" are
largely ignored in public discourse. But they can be inferred from
public health data.
While tens of millions of Americans have used illicit drugs--70
to 80 million marijuana, 40 million cocaine, and 20 million
heroin--the number of heavy or problematic users is only 5 percent
to 10 percent of those figures, similar to the proportion seen with
alcohol. Public health data on moderate alcohol use (one or two
drinks per day) suggest it is not only harmless but actually
beneficial. I suspect a similar case could be made for other drugs,
which are often used (successfully) to "self-medicate" anxiety,
depression, and attentional difficulties.
Through public health data we can also see that, despite an
overall reduction in the number of drug users during the most
vigorous prosecution of the war on drugs, from 1972 on, the
consequences of drug use have generally gotten worse:
There has been an absolute increase in drug-related health problems
such as AIDS and overdose deaths. Meanwhile, the huge economic and
social costs of massive incarceration and criminalization
associated with drug prohibition generate a cascade of adverse
consequences in the targeted communities. These are consequences
not of drug use but of drug policy. And it is public health methods
that make them visible to the naked eye.
So who could be against public health? Well, for a start, our
gracious editorial host, Jacob Sullum. His forthcoming book about
America's current "war on tobacco" bears the subtitle The
Tyranny of Public Health. The phrase is provocative,
suggesting that public health could operate contrary to the public
interest, and possibly oxymoronic, since most of us who work in the
field are impressed by our relative powerlessness to affect
policies. But it does capture something of the battle for the right
to use the "trademark" of public health: One can cite many
moralistic (and often useless) restrictions imposed on victims of
past epidemics in the name of public health, or the contemporary
use of imaginary or overblown health risks to exert social control,
as in bans on smoking in outdoor spaces.
On the face of it, any public which is fully and accurately
informed of a serious risk to its collective well-being may fairly
decide that it wishes to protect itself and restrict the freedom of
some individuals to achieve that goal. But if the advocates of drug
prohibition want to justify their position on public health
grounds, why do they consistently overlook public health data
suggesting measures that might actually save lives? The continued
ban on the use of federal funds for needle-exchange programs, for
example, defies a large body of scientific literature demonstrating
their efficacy and ignores the recommendations of multiple expert
commissions. As a consequence of this failed policy, my colleague
Peter Lurie and I estimate, 10,000 to 20,000 preventable AIDS cases
have occurred in the United States.
The message of history is that most people are willing to forgo
some individual freedom for the larger good if the threat is real,
the process is fair, and the response is effective at saving
lives--as with confining or isolating carriers of easily infectious
diseases such as typhoid or bubonic plague. These examples seem to
me the opposite of tyranny. But current attempts to justify our
demonstrably unhealthy drug policies in public health or medical
terms make a mockery of both professions, whose best efforts are
sorely needed to deal with our all-too-real drug problems.
<a href="mailto:drucker@aecom.yu.edu">Ernest Drucker</a> is
professor of epidemiology and social medicine at Montefiore Medical
Center/Albert Einstein College of Medicine, a senior fellow of the
Lindesmith Center, and editor-in-chief of the journal
Addiction Research. </div>
]]>
</content>
</entry>
<entry>
<title type='html'>The Law: Killing Kindness</title>
<link href="http://reason.com/archives/1994/05/01/killing-kindness" rel="alternate"/>
<author>
</author>
Jack Kevorkian believes we can solve moral problems by medicalizing them.
</div>
</summary>
<![CDATA[
The act of killing may be deemed good or bad, depending on who kills whom and why. When a man shoots an intruder about to attack
him, we condone the killing as self-defense. When a bandit shoots a bank teller, we condemn the killing as murder. However, when a
person kills himself, we are confused about whether to regard his act as good or bad and instead classify it as mad.
Although priests no longer consider suicide a mortal sin, and lawmakers do not punish it as an offense against the state and
hence a crime, psychiatrists now diagnose it as a symptom of a mental illness and hence incarcerate the unsuccessful or would-be
suicide as a "dangerous" mental patient. Regardless of our moral judgment of the act, suicide is by definition a type of homicide.
Like any homicide, we may judge suicide to be justified or unjustified, virtuous or wicked, sane or insane, depending on the
circumstances and on our own values.
It is against this background that we must view Dr. Jack Kevorkian's crusade for physician-assisted suicide as a state-approved
"right" and "treatment." Since Kevorkian's recent announcement that he has abandoned his campaign of law defiance, and instead has
undertaken a campaign of "law reform," he is more dangerous than ever. His aim is ominous because it taps into one of our most
powerful popular delusions, namely the belief that we can solve moral problems by medicalizing them. Maintaining that the so-called
right (of a terminally ill patient) to physician-assisted suicide is more fundamental than our established constitutional rights,
Kevorkian wants it encoded in the constitution of the state of Michigan. And because this right is, in fact, a service, he wants it
guaranteed--that is, provided--by expanding the medical profession's legally recognized repertoire of treatments to include doctors
helping patients to commit suicide.
To grasp the threat of Kevorkian's purported compassion and the seemingly widespread popular support for it, it is necessary to
remember the long history of medicine's war on freedom and self-determination. In Plato's Republic, he explained "that our
rulers will have to make considerable use of falsehood and deception for the benefit of their subjects. We said, I believe, that
the use of that sort of thing was in the category of medicine."
Before approving physician-assisted suicide as a treatment, we need to confront the ethical challenge of suicide itself. As
matters stand, suicide is in a moral-legal limbo. It is a right: The act is not prohibited by the criminal law. It is not a right:
Expressing the intention to commit suicide or attempting to do so is prohibited and punished by the mental-health laws (by
psychiatric incarceration and involuntary "treatment"). In other words, suicide is a right in principle, but not in practice: The
"right" is annulled by mental illness, a condition now attributed virtually automatically to the suicidal person as well as the
successful suicide (which is why he is no longer refused religious burial in consecrated ground).
Next, we must distinguish between a person's assertion that he wants to die and the act of ending one's life. Speech is richly
nuanced, especially in emotionally charged situations. In the final analysis, actions alone count. Unless a person kills himself--
by his own hand, preferably alone--we cannot be certain he wanted to die. The potential abuses of a tax-supported service of
physician-assisted suicide--especially for old people--are too obvious to require detailing.
Finally, we must decide whether we want to retain or reject the time-honored moral principle that the physician, qua physician,
should not kill or assist in killing another person. If abstaining from such behavior--like abstaining from having sex with
patients, except more so--is an integral part of the physician's role, then physician-assisted suicide is a contradiction in terms.
On the other hand, if such behavior is deemed permissible or even praiseworthy--because of the patient's consent or request--then
it is not unreasonable to entrust doctors with the task of assisting persons who want to kill themselves.
It is important to keep in mind in this connection that Kevorkian rejects the view that suicide is a basic human right. He
believes that suicide is justifiable only when a person experiences intense suffering caused by a fatal illness, both the nature of
the illness and the severity of the suffering being judged by the doctor. Even then, Kevorkian does not support the sufferer's
right to kill himself--say, by having access to lethal drugs. Instead, he advocates giving doctors the professional privilege--and,
by implication, the professional duty--to help persons kill themselves.
But the fact is that neither killing another, nor killing oneself, nor helping a person kill himself requires medical expertise.
Giving a person a drug to help him commit suicide is like giving him liquor to help him become drunk. Actually, Kevorkian's
proposed practice of "medicide" closely resembles the execution of a death-row inmate by lethal injection. Both interventions
depend on the use of drugs, the main difference between them being that one form of drugging is carried out with the subject's
consent (ergo, it is a treatment), and the other is carried out without his consent or against his will (ergo, it is a punishment).

Although this is an important distinction, it does nothing to resolve our dilemma. The desperate plea of a person in pain,
deprived by drug laws of adequate analgesics, is a poor imitation of consent. Conversely, an individual may commit a capital crime
because he wants his life to end, may not experience death as a punishment, and may request execution. Moreover, we accept
treatment without consent as legally proper (typically in psychiatry), and we do not accept consent as sufficient justification for
transforming an ordinary act (such as sexual intercourse) into a medical treatment.
Judging by the published reports, the persons whom Kevorkian has "assisted" could have ingested a fatal dose of a lethal drug,
had they had access to such a drug and the courage to use it. The fact that drugs useful for committing suicide are now available
by prescription only is a cultural-legal artifact. Prior to 1914, lethal drugs, like other consumer products, were available in the
free market. Not by coincidence, suicide was then considered to be the act of a moral agent, not a symptom of a mental disorder or
a treatment for an agonizing illness.
Kevorkian deserves credit for his candor: He wants physician-assisted suicide to be a new medical specialty, "medicide." This
gauche neologism should serve as a warning. Terms such as herbicide, insecticide, and infanticide illustrate the
linguistic rule that, by adding to a noun the Latin suffix -cide, we identify the living thing killed. Medicide
therefore means "killing doctors" or "killing medicine" (in Latin, doctor is medicus, and medicine is
medicina). Nomen est omen.
Contributing Editor Thomas Szasz, professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse, New York,
is the author of numerous works on drug and mental-health policy. His forthcoming book is Cruel Compassion (Wiley).
 </div>
]]>
</content>
</entry>
<entry>
<title type='html'>Know Thy Enemy</title>
<link href="http://reason.com/archives/1993/12/01/know-thy-enemy" rel="alternate"/>
<author>
<name>David Kelley</name>
<uri>http://reason.com/people/david-kelley</uri>
</author>
<author>
<name>Peter Huber</name>
<uri>http://reason.com/people/peter-huber</uri>
</author>
<author>
<name>William A. Niskanen</name>
<uri>http://reason.com/people/william-a-niskanen</uri>
</author>
<author>
<name>Steven Hayward</name>
<uri>http://reason.com/people/steven-hayward</uri>
</author>
<author>
<name>Gary S. Becker</name>
<uri>http://reason.com/people/gary-s-becker</uri>
</author>
<author>
<name>Cathy Young</name>
<uri>http://reason.com/people/cathy-young</uri>
</author>
<author>
<name>Bruce Ames</name>
<uri>http://reason.com/people/bruce-ames</uri>
</author>
<author>
<name>Thomas Jukes</name>
<uri>http://reason.com/people/thomas-jukes</uri>
</author>
<author>
<name>Fred L. Smith</name>
<uri>http://reason.com/people/fred-l-smith</uri>
</author>
<author>
</author>
<author>
<name>Robert Higgs</name>
<uri>http://reason.com/people/robert-higgs</uri>
</author>
<author>
<name>Donald N. McCloskey</name>
<uri>http://reason.com/people/donald-n-mccloskey</uri>
</author>
<author>
<name>William H. Mellor , Ill</name>
<uri>http://reason.com/people/william-h-mellor-ill</uri>
</author>
<![CDATA[
In past book issues, REASON has asked people to recommend edifying books—books that are significant because of the good they can
help accomplish. But a well-rounded person should be familiar with pernicious books as well. So this year we asked each contributor
to suggest a book published in the last 50 years that is significant because it has helped promote wrongheaded ideas with serious
consequences. We suggested that the contributors might want to recommend antidote books as well. Here are their responses.
<h2>David Kelley</h2>
In the 19th century, liberals worked to limit the role of government in economic matters, under the banner of free trade,
laissez-faire, and the rights of property and contract. But around the turn of the century, in England and America, liberalism
changed its course. As against the classical liberals, modem liberals wanted to expand government's power to regulate private
economic activity and transfer wealth among its citizens.
Liberalism as a doctrine may be out of favor, but we still live in a liberal regime, with all the programs that liberals argued
and lobbied for successfully: regulation of the economy as a whole through fiscal and monetary policy; regulation of individual
sectors through regulatory agencies; welfare programs for the poor; and "social insurance" programs—unemployment benefits,
Medicare, Social Security—for the entire population. Even conservative politicians now take these programs for granted.
It is therefore useful to know the arguments, the political philosophy, that made modem liberalism so successful. The best guide
to this philosophy is L.T. Hobhouse's little book Liberalism (Oxford University Press, 1964). During his career, Hobhouse
taught at Oxford and the University of London, was a journalist at the Manchester Guardian and other papers, and lectured
widely in England and America. Liberalism is his attempt to justify the growth of the state by appealing to the
individualist ideals of classical liberalism. Though the book was first published in 1911, it might have been written yesterday by
the editorialists of The New York Times, if they took the time (and had the ability) to formulate the principles behind
their positions.
Hobhouse thought that the ultimate good is the self-realization of the individual: "the development of will, of personality, of
self control, or whatever we please to call that central harmonizing power which makes us capable of directing our own lives."
Self-realization is the product of the individual's own voluntary initiative and choice; it cannot be compelled. But he claimed
that the individual is not fully autonomous. His nature is shaped by society, and his exercise of choice depends on certain
conditions that society must provide, including the provision of goods like education as well as the exercise of coercion by the
state to regulate economic production and exchange.
Liberalism discusses the standard programs liberals sought, the standard rationales for them, and—most importantly—the
redefinitions of classical-liberal concepts (freedom, rights, and equality, among others) that made the rationales seem plausible.
The writings of later liberals, from John Dewey to John Rawls, contain little that one cannot find in Hobhouse, usually stated more
clearly and economically.
As a counterpart to Liberalism, I would recommend the writings of Ayn Rand, especially her essay "What is Capitalism?"
in Capitalism: The Unknown Ideal. Point for point—on human nature, on coercion and rights, on wealth and equality—Rand
engages the issues on the same philosophical level as Hobhouse. Because she defends laissez-faire capitalism on moral grounds, she
comes to grip with Hobhouse's arguments in a much fuller way than a purely economic critique could do.
David Kelley is executive director of the Institute for Objectivist Studies.
<h2>Peter W Huber</h2>
Published in early 1949, George Orwell's 1984 is the most important piece of political satire of our times. To this
day, Orwell's one truly great book impels us to launch giant antitrust suits against companies like AT&T and IBM. Big Brother.
The Thought Police. Newspeak. Doublethink. These are all Orwell's words, Orwell's ideas. In fact Orwell has added his own name to
the English language: OrweIlian—the word is filled with chilling power.
The future that Orwell describes in 1984 is a future of an evil machine controlled by an evil ministry. Orwell calls
the machine "the telescreen"—a sort of two-way television set. Telescreens are bolted to every wall, they hang on every street
comer, and in every living room, even in the toilets. There is no way to shut them off. The telescreen connects to a huge Ministry
that towers over central London. The machine is evil because it serves as the eye and ear of the Ministry. And the Ministry is
powerful because it is master of the machine. Indeed, Big Brother, the omniscient, omnipotent leader of the state, has never been
seen in the flesh. He is nothing more than a face and a voice on the telescreen. And every minute of the day and night, Big Brother
is watching...you.
Technology has taught us otherwise. If you want to transmit large amounts of information, to and from large numbers of people,
efficiently, flexibly, and reliably, you must use many switches, many points of interconnection. Unless you disperse the power, the
system just won't perform. Thus, the centralized mainframe computer is being broken apart and spread out into hundreds of desktop
machines. The large, central telephone exchange is being replaced by distributed switches with multiple levels of interconnection
among them. We are building networks of networks—one for conventional telephone, several for cellular telephone, several for data
transport, several for video transport, all interlinked and interconnected like the ribs and spines of a geodesic dome.
In a world of really advanced communication—the world now unfolding before us—people will be able to form communities,
collaborations, alliances, almost at will, over any distance, from San Francisco to Singapore. The telescreen gives a man eyes and
ears that can see and hear at any distance, and a tongue that can speak to anyone on the planet. The telescreen frees a man's
senses, and his voice, and thus frees his intellect and his conscious mind. The telescreen gives man the power to hear, see, and
speak, to be heard and seen, in the company of his own choosing, wherever it may be found. With the telescreen, men can create new
cities whenever they need them, in the capacious light beams of the network and the airwaves of the stratosphere. For the first
time in history, it is becoming possible to have brotherhood without Big Brother.
Orwell imagined the world of Stalin filled with Apple computers and concluded that it would be more horrible than any world ever
seen before. Orwell was wrong. As Ithiel de Sola Pool would explain in his landmark 1983 book by that title, telescreens are, in
fact, Technologies of Freedom.
Peter W. Huber is a senior fellow at the Manhattan Institute and a columnist at Forbes.
<h2>William A. Niskanen</h2>
My candidate for one of the most wrongheaded books of the last 50 years is the 1982 book by Ira Magaziner and Robert Reich,
Minding America's Businesses. I chose this book not because the authors are evil or the book is awful but because the book
promotes the profoundly pernicious view that the government can and should have a "rational" industrial policy to guide the
allocation of labor and capital. Moreover, the authors are now in positions of substantial responsibility, Magaziner as the major
architect of the Clinton health plan and Reich as secretary of labor, so there is reason for concern that they may have maintained
this perspective.
As I mentioned, this book is wrongheaded but not awful. The authors were careful about the facts. The analysis was plausible to
most people other than economists; the authors, for example, do not understand comparative advantage or the causes of inflation,
but neither do most people. And the book provides a useful summary of our government's messy de facto industrial policy.
The conceptual case for industrial policy is that the returns to some investments are higher than the returns to the investor.
The primary weakness of this case is that the government does not have either the information or the incentive to support these
investments. The information necessary to identify a promising technology, product, or firm is decentralized and often contrary to
the conventional wisdom. The characteristic incentives of government are to support old technologies, failing firms, and
technological fads. Magaziner and Reich have a perception that is either naive or arrogant—that appointing the right people to high
office is sufficient for a rational industrial policy. The Clinton administration promises to be an interesting if costly test of
this perspective.
The most effective early responses to this book were an article by Charles Schultze in the Fall 1983 Brookings Review
and Chapter 3 of the 1984 Economic Report to the President. More interesting, perhaps, the 1990 book by Robert Reich,
The Work of Nations, makes the case that government's primary focus should be on improving the skills of the labor force,
not on the allocation of investment.
One's ability to identify great heroes and villains is much enhanced by the telescope of time. My pantheon of heroes probably
includes many of the same men and women that most REASON readers honor. And our lists of great villains probably also share such
names as Rousseau, Marx, Nietzsche, and Freud. Proximity, in contrast, clouds the analytic senses. Greatness, for either good or
ill, is difficult to discern among people one has met or seen on television. My tentative judgment is that Magaziner and Reich have
done only little harm as authors but that they have the potential for great mischief as government officials.
William A. Niskanen is chairman of the Cato Institute.
<h2>Steven Hayward</h2>
For a while during the late 1960s and early '70s, it was a rhetorical fashion to say, "Any nation that can land a man on the
moon can [fill in the blank]." My own contribution to this cliche was, "Any nation that can land a man on the moon can abolish the
income tax." But mostly this nostrum was deployed by Sens. Humphrey and McGovern or the editorial writers of The New York
Times in relation to poverty or some other intractable social problem.
Because Marxist-inspired class warfare has never resonated very well in American politics (as President Clinton found out to his
surprise in the tax bill fight), establishing and enlarging the redistributionist state required a more nuanced justification
rooted in the nation's middle-class "can-do" spirit, which was best exemplified in the moon-landing crusade. The breakthrough book
that provided this rationale was Michael Harrington's The Other America, published in 1963. Together with J.K. Galbraith's
The Affluent Society, Harrington's book supplied the intellectual basis for the Great Society's vast expansion of the
welfare state beyond its previous New Deal borders. President Kennedy read The Other America shortly before his death and
is said to have been moved by it to order his New Frontiersmen to begin drawing up policy blueprints based on the book.
Harrington contended that the number of Americans living in poverty was much larger than the usual statistics showed. But the
most important part of his argument was a new conception of the nature of poverty. Harrington attempted to debunk the common view
that poverty was chiefly the result of defects in character and initiative among poor people, arguing instead that the poor were
victims, trapped in a culture that was structurally sealed off from economic progress and expanding prosperity. A rising tide
wouldn't lift boats with holes in their hulls.
Appealing to the American can-do spirit, Harrington argued that an institutional attack on poverty could help produce the moral
regeneration necessary to end poverty. "There is only one institution in the society capable of acting to end poverty," Harrington
concluded. "That is the Federal Government." The War on Poverty was declared.
The obvious antidote book is Charles Murray's Losing Ground: American Social Policy, 1950-1980 (though one
should not overlook the early challenge to the poverty warriors from Edward Banfield's 1969 book, The Unheavenly City).
Murray copiously documents the perverse results of this misbegotten crusade so effectively that today's poverty warriors either
accept or must take account of his arguments and evidence. For example, Mickey Kaus's recent tract, The End of Equality,
which rehearses many of Harrington's old themes about the structural nature of poverty, contains several discussions of Murray but
not a single reference to Harrington. And central to Kaus's book is the admission that big-spending "money liberalism" won't work.

The War on Poverty is destined to continue for a long while yet, but thanks to Murray and the growing recognition that social
problems aren't engineering tasks to be tackled like moon landings, we can hope that perhaps it won't end up being a fruitless
Hundred Years' War.
Contributing Editor Steven Hayward is research and editorial director for the Pacific Research Institute in San
Francisco.
<h2>Gary S. Becker</h2>
In 1942 Joseph Schumpeter, the outstanding Austrian economist, published Capitalism, Socialism, and Democracy,
a collection of loosely connected essays. The book is justifiably considered a classic. His analysis of political democracy in
terms of competition for political leadership was profound, and it influenced my approach and that of many others to this important
subject. The book also contains many other insights.
But two major themes not only have turned out to be wrong but have had a pernicious influence on subsequent discussions of
capitalism. The more important is Schumpeter's claim that capitalism was doomed—not by its failures, as in Marxian analysis, but by
its successes. For according to Schumpeter, capitalism alienated intellectuals, who were unhappy because they are not important
players in a decentralized free-market system. Moreover, intellectuals do not like the profit motive that drives this system. But
Schumpeter greatly exaggerated the long-run influence of intellectuals on public policy.
Schumpeter joined his pessimism about the future of capitalism with unwarranted optimism about the economic potential of
socialist and communist economic systems. That a great economist believed socialism might work successfully gave much reassurance
to the many intellectuals attracted to socialism during the middle of this century.
He apparently believed that weak individual incentives under socialism would be compensated for by stronger group incentives:
"The socialist order presumably will command that moral allegiance which is being increasingly refused to capitalism"; "there might
be more self-discipline and more group discipline in socialist society, hence less need for authoritarian discipline than there is
in a society of fettered capitalism"; "the vested interest in social unrest may be expected to disappear in part"; and "
socialism might be the only means of restoring social discipline" (italics in original). He even claimed that
"intellectuals as a group will no longer be hostile" and that trade unions will develop "into exponents of the social interest and
into tools of discipline and performance, acquiring an attitude so completely different from that which is associated with trade
unions in capitalist countries." These comments on socialism now seem quaint and naive, although, in Schumpeter's defense, he wrote
before most of the evidence about socialism and communism was readily available.
Fortunately, Schumpeter's forecast of capitalism's future was dead wrong. Capitalism has especially thrived in the 1980s and
'90s because public opinion has been far more impressed by the success of the Asian Tigers and other free-market economies, and the
economic failure of socialist and communist countries, than by theories about capitalism's performance, including Schumpeter's
sophisticated form of negativism.
Capitalism, Socialism, and Democracy was both a great book and a dangerous one. The danger came from
the support his subtle but flawed analysis of the future of capitalism and socialism gave to intellectuals who did not need further
reasons to dislike a decentralized, free-market, profit-oriented system.
Gary S. Becker, a winner of the Nobel Memorial Prize in Economic Science, is University Professor of Economics and
Sociology at the University of Chicago.
<h2>Cathy Young</h2>
No book since The Feminine Mystique has had a greater impact on contemporary American feminism than Carol Gilligan's
In a Different Voice: Psychological Theory and Women's Development (Harvard University Press, 1982). A Harvard psychology
professor, Gilligan challenges the "masculine bias" of theories that stress the development of an autonomous self as a prerequisite
to mature intimacy.
Psychologists such as Erik Erickson, Gilligan complains, acknowledged that psychological development was different for the young
woman (who must "attract the man...by whose status she will be defined" and for whom, therefore, self is defined through
relationships) yet canonized the "male" process of individuation as the norm, disregarding values rooted in female experience.
Through interviews with male and female children and young adults, she seeks to demonstrate that whereas men base their moral
judgments on individual rights and abstract principles of right and wrong, women's moral understanding is "contextual," emphasizing
human needs, empathy, and interdependence.
Many feminists were disturbed by Gilligan's apparent validation of sex stereotypes and traditional feminine virtues, yet she was
championed by such prominent female commentators as Ellen Goodman, and Ms. put her on the cover as Woman of the Year in
January 1984. Although, in contrast to legal scholar Catharine MacKinnon, Gilligan sees women as moral agents rather than passive
victims of patriarchy, her brand of feminism opens the way to fresh charges of male oppression: Institutions are sexist not only if
they exclude women but if they include them on "male" terms (expecting them to be as competitive and individualistic as men) and
fail to incorporate "female" values. In the past decade, Gilligan's influence has surfaced in educational theories that call for
more cooperative, intuitive learning styles attuned to "women's ways of knowing," in claims of women's distinct "caring" political
agenda (more social programs), and in feminist jurisprudence, which derides individual rights and objective rules as male
fixations.
To a degree, Gilligan corrects the oversights of earlier feminists who seemed to think that liberated women would just assume
male roles and life would go on as if the traditionally female nurturing tasks weren't even needed. Yet she is especially irked by
the view (espoused by some of the male psychologists she takes on) that "female" moral judgments are appropriate primarily in the
personal sphere. While In a Different Voice steers clear of explicit politics, Gilligan's assertion that "male" ethics are
based on the obligation not to hurt others and "female" ethics on the obligation to help others ("a morality of
rights and non-interference may appear frightening to women in its potential justification of indifference and unconcern")
engenders a nagging suspicion that "female values" may be a code word for socialism.
Gilligan's methods and conclusions have been challenged by a number of social scientists and writers, including feminists Susan
Faludi and Katha Pollitt. The most thoughtful critiques can be found in A Fearful Freedom: Women's Flight From Equality,
by Wendy Kaminer (Addison-Wesley, 1990), which shows the dangers of constructing legal norms based on the presumption that women
are more nurturing and "connected" than men, and The Mismeasure of Woman, by Carol Tavris (Simon & Schuster, 1992).
Tavris argues that Gilligan tends to absolutize often small statistical differences between the sexes, minimizing the female desire
for autonomy and the male desire for intimacy.
Indeed, reading In a Different Voice, one often feels that Gilligan is arbitrarily interpreting the subjects'
statements to fit her theory of sex differences. Responding to the hypothetical dilemma of Heinz, whose dying wife needs a drug
that he can't afford and for which the druggist won't reduce the price, a male subject says Heinz is justified in stealing the drug
because "human life is worth more than money," while a female subject says he should steal the drug because his wife "is another
human being who needs help." In Gilligan's view, the male response appeals to an abstract hierarchy of priorities and the female
response to an actual person's needs; yet aren't both really saying the same thing?
Recent studies have offered at best slim support for Gilligan's findings, showing that male and female college students, at
least, are much more alike than they are different in balancing intimacy and autonomy. In politics, Bill Clinton is far closer to
Gilligan's "female" model than is Margaret Thatcher. Generally, Tavris's conclusion that both men and women sometimes act in
"feminine" ways (when caring for a sick relative) and sometimes in "masculine" ways (when competing for a promotion) seems to be
solidly grounded in common sense. Yet, at least in academic feminism, the Gilligan model—often framed in terms of much more
absolute gender division that Gilligan herself proposed—reigns supreme.
In the 1950s, women with overly individualistic personal values were often stigmatized as masculine. In the '90s, women with
overly individualistic political values are often stigmatized as "male-identified." Have we really come a long way?
Contributing Editor Cathy Young is a writer in Middletown, New Jersey.
<h2>Bruce N. Ames & Thomas Jukes</h2>
Rachel Carson's Silent Spring (1962) became the inspiration for the environmental movement. Its elegant prose expressed
passionate outrage at the ravaging of beautiful, unspoiled nature by man. Its frightening message was that we are all being injured
by deadly poisons (DDT and other pesticides) put out by a callous chemical industry. This message was snapped up by intellectuals,
and the book sold over a million copies. Many organizations have sprung up to spread Carson's message.
Rachel Carson set the style for environmentalism. Exaggeration and omission of pertinent contradictory evidence are acceptable
for the holy cause.
The book starts with a romanticized vision of a world in harmony, followed by a horror story of an "evil spell that settled on
the community: mysterious maladies swept the flocks of chickens; the cattle and sheep sickened and died....Children...would be
stricken and die within a few hours....The few birds seen anywhere were moribund...and could not fly...a white granular
powder...had fallen like snow upon the roofs and the lawns, the fields and the streams."
The powder was DDT, which actually saved tens of millions of lives, more than any substance in history, with the possible
exception of antibiotics. The benefits of DDT were omitted from the book. Silent Spring said the American robin was "on
the verge of extinction," yet Roger Tory Peterson (the dean of American ornithologists) said it was the most numerous bird on the
continent. DDT was highly toxic to mosquitoes but of very low toxicity to honey bees and higher animals. In the Third World, DDT
saved the lives of millions of children who otherwise would have been exposed to malaria and other insect-borne diseases.
DDT displaced the more toxic and persistent lead arsenate. DDT was the first of a series of synthetic agricultural chemicals
that have advanced public health by increasing the supply and reducing the price of fruits and vegetables. People who eat few
fruits and vegetables, compared to those who eat about four or five portions a day, have about double the cancer rate for most
types of cancer and run an increased risk of heart disease and cataracts as well. Thus, pesticides lead to lower cancer rates and
improved health. Life expectancy has steadily increased in our era of pesticides. Pesticide residues in food are trivial in terms
of cancer causation or toxicity. There has never been any convincing evidence that DDT (or pesticide residues in food) has ever
caused cancer in man or that DDT had a significant impact on the population of our eagles or other birds.
Carson's fundamental misconception was: "For the first time in the history of the world, every human being is now subjected to
contact with dangerous chemicals, from the moment of conception until death." This is nonsense: Every chemical is dangerous if the
concentration is too high. Moreover, 99.9 percent of the chemicals humans ingest are natural. For example, 99.99 percent of the
pesticides humans eat are natural pesticides produced by plants to kill off predators. About half of all natural chemicals tested
at high dose, including natural pesticides, cause cancer in rodents. People determined to rid the world of synthetic chemicals
refuse to face these facts. Risk assessment methods build in huge safety factors for synthetic chemicals, while natural chemicals
are ignored. Current policy diverts enormous resources from important to unimportant risks.
Bruce N. Ames is a professor of biochemistry and molecular biology and Thomas Jukes is a professor of biophysics at the
University of California, Berkeley.
<h2>Fred L. Smith Jr.</h2>
Ralph Nader's Unsafe At Any Speed: The Designed-in Dangers of the American Automobile, a blistering attack on the
Chevrolet Corvair and the whole American auto industry, was the first assault of the consumerist movement. Published in 1965, this
book had an immediate impact on the American political scene. General Motors was immediately placed in the spotlight, and within a
year Congress enacted the Motor Vehicle Safety Act. Spurred on by his victory, Nader redoubled his assaults against America's
producers and innovators, pushing a spate of regulatory initiatives. Congress, in turn, passed the Wholesome Meat Act, the
Comprehensive Occupational Health and Safety Act, the National Gas Pipeline Act, the Radiation Control for Health and Safety Act,
and more. For the next three decades, American automobiles, as well as other consumer products, would increasingly be designed by
politicians rather than corporate engineers.
The significance of Nader's book goes beyond its direct political ramifications. Nader's work profoundly changed the way risk
and safety were viewed in the American polity. Regulators and consumer activists were immediately cast as noble crusaders who
sought a safe, clean, healthy world—thwarted by those willing to place a price tag on a human life, to assign a dollar value to a
clean environment. Health, safety, and environmental risks, Americans came to believe, could only be addressed by pervasive
political controls. Laws mandating "safety" at any cost have accounted for much of the growth in government for the last three
decades.
Aaron Wildavsky in Searching for Safety sought to reframe this debate—to reexamine the argument that the choice was one
of safety vs. profits. A safer world, he noted, often reflects the adoption of "unsafe" products that are safer than the products
they displace. Fire was—and remains—a highly risky technology, but a fireless world faces even greater risks. Society must create
institutions that balance risks against risks—the risks of allowing a certain product or technology to be used versus the risks of
banning that product.
Wildavsky pointed out that societies cannot anticipate all the possible risks that an uncertain world entails, and rather should
strive to increase wealth and knowledge so as to become more resilient, more able to overcome dangers of whatever sort. Wealthier
societies, Wildavsky also noted, are safer (and healthier and cleaner) societies. Political regulators aren't engaged in easy
morality plays but rather complex risk-balancing tasks in which the risks reduced by their regulations must be contrasted with the
direct and wealth-reduction risks stemming from their actions. This is a fact that Nader and his followers have yet to learn.
Unlike Nader's book, Wildavsky's writings have not yet led to massive changes in the political landscape, but his work provides
the intellectual basis for current risk reform efforts. Sadly, Aaron died earlier this year at the age of 63. His Searching for
Safety is one of the most important, and tragically under-read, books of the post-war period.
Fred L. Smith Jr. is the founder and president of the Competitive Enterprise Institute in Washington, D.C.
<h2>Thomas Szasz</h2>
My candidate is The Crimes of Punishment, by Karl Menninger (Viking, 1968). The gist of Menninger's message is
illustrated by the following excerpt: "The word justice irritates scientists. No surgeon expects to be asked if an
operation for cancer is just or not....Behavioral scientists regard it as equally absurd to invoke the question of justice in
deciding what to do with a woman who cannot resist her propensity to shoplift, or with a man who cannot repress an impulse to
assault somebody." Heaping praise on the book, the reviewer for The New York Times wrote: "As Dr. Menninger proves so
searingly, criminals are surely ill, not evil." The book made the Times bestseller list.
If crime is sickness and punishment is crime, then punishment too is a sickness. The self-contradictory character of Menninger's
thesis did not diminish its appeal to the liberal-psychiatric mind set, determined to replace penal sanctions with involuntary
psychiatric "treatments." Indifference to fundamental rights to liberty and property, rejection of personal responsibility, and a
pervasive erosion of justice and order are just some of the obvious consequences of this wrongheaded view.
Actually, in The Crime of Punishment Menninger systematically articulated a set of ideas and policies that had long
been integral to psychiatric doctrine, namely the proposition that crime is a mental illness that should be controlled by means of
coercive psychiatric interventions ("hospitalization" and "treatment"), rather than penal sanctions. Menninger himself had advanced
these ideas in his earlier writings.
I hope it does not violate the canons of modesty appropriate for this occasion to suggest that the best "antidotes" against
The Crime of Punishment are my own writings, in which I defend the case for treating so-called mental patients as moral
agents, entitled to liberty if they obey the law and deserving of punishment if they violate it. The books in which I present this
view most fully are Law, Liberty, and Psychiatry (1963), Ideology and Insanity (1970), and
Insanity: The Idea and Its Consequences (1987).
Contributing Editor Thomas Szasz is professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse.

<h2>Robert Higgs</h2>
Like most graduate students in economics during the last 40 years, I spent many painful hours plowing through Paul Samuelson's
Foundations of Economic Analysis (Harvard University Press, 1947). From that sacred text we novices learned how to prove
many specific theorems. Far more important, we learned how neoclassical economics—"modem economic science"—was supposed to be done.

We built mathematically specified "models," sets of equations describing the relations of selected economic variables. Model in
hand, we proved that it had a stable equilibrium, then characterized the relations of the variables in that blessed state. Altering
the "data" or the "parameters" of the model, we ascertained how a new equilibrium differed from an initial one. In its advanced
form this protocol rendered most older economists instantly obsolete, but for young math wizards like Samuelson it opened up the
prospect of "new realms of aesthetic delight." Eventually most economists entered those realms. Playing increasingly clever
mathematical tricks with the models constituted "scientific progress."
Samuelson fashioned his models, which set the standard, after 19th-century physics. Functions were assumed to be smooth and
continuous. Economics was reduced to various types of the same calculus problem: finding a constrained extremum. The economist's
job was to state the objective function and the constraints, then grind out the solutions. This required considerable mathematical
ability and stomach for tedium but little imagination and no familiarity with economic reality.
By the 1960s, if not earlier, academic economists who quarreled with this way of doing the job were, as Roy Weintraub put it,
"regarded by mainstream neoclassical economists as defenders of lost causes or as kooks, misguided critics, and anti-scientific
oddballs." By aping 19th-century physicists, neoclassical economists convinced themselves and others that they were doing science,
but the effort was basically misguided, not so much scientific as, in F. A. Hayek's term, "scientistic." Human beings, purposeful
and creative, are not like atoms; nor is a market analogous to a physical or chemical system. In the view of Hayek and his teacher
Ludwig von Mises, neoclassical economics is, in critical respects, pseudo-science.
James Buchanan's What Should Economists Do? (Liberty Press, 1979) presents a telling critique of mainstream economics.
"Its flaw lies in its conversion of individual choice behavior from a social-institutional context to a physical-computational
one," he writes. Further, the obsession with equilibrium gives rise to "the most sophisticated fallacy in economic theory, the
notion that because certain relationships hold in equilibrium the forced interferences designed to implement these relationships
will, in fact, be desirable." Mainstream economists cannot move the earth with a mathematical lever, because they have no place to
stand—no "given" information about property rights, consumer preferences, resource availabilities, and technical possibilities.
What neoclassical economics takes as given is, in reality, revealed only by competitive processes. "Most modern economists,"
Buchanan aptly concludes, "are simply doing what other economists are doing while living off a form of dole that will simply not
stand critical scrutiny."
Robert Higgs is a visiting professor of economics at Seattle University.
<h2>Donald N. McCloskey</h2>
The brothers Polanyi, Karl (1886-1964) and Michael (1891-1976), raised in the sunset of the Austro-Hungarian Empire, cover the
range of reasonable responses to the 20th century. One response is to think of the market as the problem and the government—
reinvented, of course—as the solution. Thus Karl's book published in 1944 about the rise and decline of modem capitalism, The
Great Transformation.
People love it. Though hardly beach reading, it's well written, a piece of higher journalism. The theme is that the market was a
recent invention, a mere novelty that has spoiled life. "The origins of the cataclysm lay in the utopian endeavor of economic
liberalism to set up a self-regulating market system....Leaving the fate of soil and people to the market would be tantamount to
annihilating them." That theme is an old one, of course, echoed by greens and reds down the decades since 1848. But Polanyi put it
well, giving three generations of English-speaking intellectuals a story to warrant the welfare state.
In other words, you have to give the book its intellectual due. Most fields of history have gone through a (Karl) Polanyi
Period, in which the master's notion that the market is new and nasty has been applied afresh. Someone in African history or
Mesopotamian history or American colonial history or (I am not making this up) Viking history runs across Polanyi's book, from
which he discovers that he does not have to learn economics to sneer at markets. Eventually a reaction sets in, when the historians
realize that the market is forever. The cycle takes about 20 years. New fields keep falling into it, 50 years on.
The book has never gone out of print. Professors still assign it. Intellectuals who want to learn about economics, but are
afraid to ask, still pick it up and devour it. No book on the half century past has had more influence on social thinking.
The antidote? Any of the books by Karl's smarter brother, Michael. Michael was a famous chemist before turning to philosophy and
public policy and therefore knew that proving something about the world is tough. He was not a consistent libertarian and even on
occasion sounds like Congressman Kelly of Florida: "The free enterprise system is absolutely too important to be left to the
voluntary action of the marketplace." But by the standard of the time, and certainly by the standard of the Polanyi family, he was
a veritable Hayek.
Like his brother, he wrote well in his adopted language. Find his book Personal Knowledge (1958), an exploration of
how, really, we know. Or, directly after sipping Karl's book, take a long drink from Michael's The Logic of Liberty
(1951). In The Logic he argues, for example, "there exists no fundamental alternative to the system of money-making and
profit-seeking" and "the social management of polycentric tasks requires a set of free institutions." Michael's response to the
20th century was to think of government as the problem and the market as the solution. Neither brother so much as mentions the
other in his writings. It's no wonder. Karl was the poison and Michael the cure.
Donald N. McCloskey teaches economics and history at the University of Iowa. His latest book is Knowledge and
Persuasion in Economics (Cambridge University Press).
<h2>William H. Mellor III</h2>
John Wesley Powell's exploration of the Grand Canyon in 1869 required mental and physical heroism of Randian proportions. The
one-armed Civil War veteran led expeditions down the uncharted Green and Colorado rivers, overcoming torrential rapids, near
starvation, and hostile Indians. In the process, he mapped thousands of miles of unexplored territory and gained dramatic insights
into the challenges confronting the Western United States, challenges that remain today. Sadly, one of the best American writers of
this century, Wallace Stegner, uses Powell's exploits as the foil to showcase his radiant defense of Progressive Era policies as
the way to meet these challenges.
The first half of Beyond the Hundredth Meridian: John Wesley Powell and the Second Opening of the West (Penguin, 1954)
is devoted to the gripping account of Powell's two trips through the beautiful canyon country. Stegner chronicles the action and
natural grandeur to potent effect. The excitement builds as one appreciates how the explorers confront disaster and death countless
times. Yet Powell, with his quiet resolution to advance scientific understanding of the West, never wavers in the face of
staggering adversity.
As a result, one begins the second half of the book with great admiration for Powell and his vision of the West. Stegner
carefully plays on this to draw the reader into sympathetic agreement with Powell as he turns his vast energy into forming one of
our first Progressive Era bureaucracies, the U.S. Geological Survey. Powell envisioned an agency run by well-informed,
scientifically trained elites who would ensure that the fragile ecology of the West would be managed to provide the greatest public
good for his and future generations. The USGS served as the model for many later government agencies and the training ground for
countless bureaucrats who staffed these new agencies. Powell, "both the bureaucrat and the idealist knew that private interests,
whether they dealt in cattle or sheep, oil, mineral, coal, timber, water, or land itself, could not be trusted or expected to take
care of the land or conserve its resources for the use of future generations. They could be trusted or expected to protect neither
the monetary nor the nonmonetary values of the land."
This book should be read by anyone concerned with liberty or the American West. Stegner writes with authority and sensitivity
about real problems that to this day plague the West: water allocation, political control over resources that leads to exploitation
or misuse, and the myths and realities of economic existence in this arid region. Though the book was written in 1954, it offers a
persuasive case for why Powell's vision should still be pursued. Stegner subtly validates the basic premises of enlightened rule by
scientific experts, premises all too popular in Washington today.
This book is an excellent example of how the case for activist government can be successfully advanced using romance, history,
adventure, and human interest. Until classical liberals are able to bring similar forces to bear in support of our arguments, we
will lose more often than we will win. With respect to the West, a good start has been made in Free Market Environmentalism,
 by Terry Anderson and Don Leal, and Visions upon the Land, by Karl Hess Jr. But the ultimate refutation of Stegner
is yet to be written.
William H. Mellor III is president and general counsel of the Institute for Justice in Washington, D.C.
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<entry>
<title type='html'>The Law: Death By Prescription</title>
<link href="http://reason.com/archives/1993/04/01/the-law-death-by-prescription" rel="alternate"/>
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In November, a "right to die" proposition in California was defeated by a narrow margin. Washington voters rejected a similar
bill last year. In other countries too (especially Holland), many people support the idea to which this phrase alludes. But there
is something fundamentally wrong with the notion that we have "a right to die" and hence with everything based on that notion.
Right, a political concept, refers to the relationship of the individual to the state. Death, a biological
concept, refers to a property that is inherent in, and the final destiny of, all complex living things. Since death is a fact of
nature, like the setting of the sun, it is foolish to speak of a "right to die." Today, the phrase usually functions as a euphemism
for "physician-assisted suicide"—or, in plain English, granting doctors the right to kill patients.
Having a right to kill, under certain circumstances, may be deemed either morally good or morally bad. But killing, even if it
is legally permissible, cannot be morally neutral, as the controversy about abortion illustrates. Furthermore, like any moral agent
who commits an act, a person who kills (himself or others) may be considered competent or incompetent. In a society based on Anglo-
American principles of political liberty and personal responsibility, every adult is presumed to be competent until proven
incompetent, just as he is presumed to be innocent until proven guilty. And like innocence, incompetence is a legal concept that
must be based on a judicial determination.
Potentially, everyone can kill others or himself (or both). There are certain well-defined instances in which a person has the
legal right to kill another—for example, the enemy in war, a criminal condemned to death, an aggressor in self-defense (when no
other option would avail), a fetus during the first trimester of pregnancy. Paradoxically, the right to kill oneself is a murkier
matter. Although suicide is no longer a criminal offense, most people find the idea of a "right to kill oneself" offensive, or at
least distasteful. One reason for this is that the Judeo-Christian ethic condemns suicide. For centuries, it was treated as both a
sin (an offense against God) and a crime (an offense against the sovereign), with harsh punishments visited on both the corpse and
the family of the "offender."
Suicide is now considered to be the cardinal symptom, and the preventable result, of a treatable mental illness called "clinical
depression." The medical view of suicide rests on an analogy with a disease, such as acute appendicitis, that if left untreated
results in death but if properly treated does not. An inflamed appendix has a disposition to rupture, an outcome likely to be fatal
(in the days before antibiotics, it always was). Timely removal of the inflamed appendix saves the patient's life. Similarly,
depression is a disease that makes the patient disposed to try to take his own life, an "outcome" (what we call it is crucial) that
may be fatal. Timely treatment of the depression saves the patient's life.
This analogy is persuasive to the extent that we accept the supposed similarities between the inflammation of a vestigial part
of the intestine and the intention of a decision-making individual and ignore the differences between depriving a voluntary patient
of his appendix and an involuntary nonpatient of his liberty. Regardless of the absurdity of viewing suicide as a disease (with a
fatal outcome) rather than as a decision (one we may deem "irrational"), however, the fact remains that most people seem more
terrified of the human potential for suicide than of the human potential for murder. As a result, although suicide is not illegal,
a person diagnosed as "suicidal" may legally be deprived of liberty by confinement in a mental hospital.
In short, we entertain two mutually incompatible views of suicide. One is political: The decision to end one's life is an
integral part of our fundamental right to control our fate. The other is medical: The decision to end one's life is a symptom of a
mental disease, justifying coercive psychiatric intervention. Instead of confronting the conflict between these two views, we
prefer to expand our repertoire of medical procedures, adding to it the acts of doctors "assisting" patients who want to kill
themselves (and also those of doctors killing patients at their request).
Let us assume that the suicidal person is physically capable of swallowing a handful of pills. Why does such a person need a
doctor to kill him or to help him kill himself—any more than he needs a doctor to give him a drink? One reason might be that he
finds the task of killing himself distasteful or does not want to take responsibility for the act. Another is that the trade in the
necessary instrument—in this case, the drug—is illegal. Hence we wish to grant physicians the privilege to prescribe, for
psychiatrically approved patients, the drug useful for committing suicide.
Thus, the citizen needs the doctor not so much to kill him as to give him legal access to an otherwise illegal product. In an
article offering "proposed clinical criteria for physician-assisted suicide," published last year in The New England Journal of
Medicine, Rochester, New York, physician Timothy E. Quill and two colleagues write: "For a physician, assisting with suicide
entails making a means of suicide (such as a prescription of barbiturates) available to a patient who is otherwise physically
capable of suicide." This is reminiscent of Prohibition, when doctors were in the habit of prescribing whiskey.
Policy makers in Western societies say they are struggling to contain medical costs. Yet they endorse the medicalization of one
of mankind's most basic moral choices, the choice to end one's life. Typically, physicians classify a person who wants to kill
himself (or who they think wants to kill himself) as mentally ill, define his decision as a symptom of mental illness, and justify
the use of psychiatric incarceration and coercive drugging as treatments. When physicians deem a person to be suffering from an
incurable illness and intense pain, however, they define physician-assisted suicide, in the words of Quill et al., as an
"extraordinary and irreversible treatment."
Preventing suicide is psychiatric treatment. Facilitating suicide is medical treatment. Viewing suicide as a moral choice, and
the physician's participation in it as medical meddling, is professional heresy.
Contributing Editor Thomas Szasz is professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse. He is
the author, most recently, of Our Right to Drugs: The Case for a Free Market (Praeger).
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<entry>
<title type='html'>The Law: The Socrates Option</title>
<link href="http://reason.com/archives/1992/05/01/the-socrates-option" rel="alternate"/>
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Before he was sentenced to 15 consecutive life terms in prison last February, Jeffrey L. Dahmer told Milwaukee County Circuit
Judge Laurence C. Gram Jr. that he had gained insight into his crimes. "I wanted to find out just what it was that caused me to be
so bad and evil," he said, groping to explain why he had tortured, murdered, and dismembered 15 boys and young men. "The doctors
have told me about my sickness, and now I have some peace."
Dahmer's trial highlights our deep-seated unwillingness to face the basic facts of human nature and our eagerness instead to
conceal the moral agency and personal responsibility of evildoers behind an impenetrable screen of legal fictions and literalized
medical metaphors. Dahmer pleaded both guilty and insane. This is a contradiction in terms. Since at least the 18th century in
English and American legal usage, to label a person "insane" has meant that he lacks mens rea, the guilty mind, which is
what distinguishes an impersonal event, such as a hurricane, that results in injury or death from a personal act that causes injury
or death and that may, therefore, constitute a criminal offense.
Michael Moore, professor of law at the University of Pennsylvania and a recognized authority on mental health and the law, puts
it this way: "Since mental illness negates our assumptions of rationality, we do not hold the mentally ill responsible.…being
unable to regard them as fully rational beings, we cannot affirm the essential condition to viewing them as moral agents to begin
with."
This rationale explains why the traditional insanity plea is framed as "not guilty by reason of insanity." In other words,
lawyers and psychiatrists view insanity—at least when it suits their purposes—as a condition that annuls personal responsibility.
This model of insanity rests on an analogy with the following scenario: Unbeknown to himself or anyone else, a previously healthy
person suffers from a developing brain tumor. He has a seizure while standing at the top of a stairway, collapses, and knocks down
an elderly person standing next to him, who rolls down the steps, hits his head, and dies. Although the person who suffered the
seizure has, as a physical agent, caused the death of another, he is not criminally liable for any offense whatsoever.
The plea of "guilty but insane" is thus a strategic, legal-psychiatric fiction whose aim is to secure the incarceration of the
defendant in a building called a "hospital" rather than in one called a "prison." Indeed, Dahmer's attorney emphasized that he did
not seek freedom for his client, only storage in a mental hospital where he could be "studied"—as if Dahmer were a material object
rather than a moral agent. Most Americans do not seem bothered by the fact that we live in a society in which physicians have
state-delegated powers to incarcerate murderers in "hospitals" and to "treat" them, against their will, for nonexistent diseases.

Before his sentencing, Dahmer told the judge, "I didn't ever want freedom. Frankly, I wanted death for myself." If ever there
was doubt about Dahmer's sanity, this statement should dispel it. Since each of us has but one life, sentencing Dahmer to 15 life
sentences is still another legal fiction, one that we seem to prefer to sentencing him to death (Wisconsin has no death penalty) or
simply to life without parole. And we prefer it as well to giving him the option of dying by his own hand.
Many people now indulge in the effortless exercise of enhancing their self-esteem by opposing the death penalty. Because many
people now want to impose this sentence on drug dealers rather than on real criminals, I usually avoid debating the issue. But I
well remember engaging in one such debate with a young woman who objected to executing criminals because, she said, she could not
bring herself to carry out the execution. When I reminded her of Socrates' sentence, she changed the subject.
I submit that the Hemlock Society and "death doctor" Jack Kevorkian are side shows in our shadowboxing with the true contours of
our own moral agency, whose ultimate symbol is the right to suicide—not for the terminally ill, not with the assistance of doctors,
but in principle. A prisoner has a right to a lawyer, a Bible, and visits by relatives, among other things. If we overcame our
phobia about drugs and suicide, we could add to this list the right to a bottle of barbiturates for every prisoner who requests it
(or perhaps only for those sentenced to life). Instead, we put prisoners such as Dahmer on "suicide watch" and interpret their own
Lady Macbethian self-destruction as evidence of "untreated mental illness."
We have a right to deprive persons convicted of serious offenses of liberty but not of dignity. For convicts, the Socrates
Option would restore some of their lost dignity. For the rest of us, it would help dispel some of the psychiatric fog in which we
have shrouded our legal system.
Contributing Editor Thomas Szasz, professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse, is the
author most recently of Our Right to Drugs: The Case for a Free Market (forthcoming from Praeger).
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<entry>
<title type='html'>The Law: Hinckley and Son</title>
<link href="http://reason.com/archives/1991/07/01/the-law-hinckley-and-son" rel="alternate"/>
<author>
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Ten years ago, in a well-planned and brilliantly executed attempt to murder Ronald Reagan, John Hinckley, Jr., shot the
president, inflicted permanent brain damage on Press Secretary James Brady, injured two of the agents guarding the presidential
entourage—and committed existential suicide. The anniversary of Hinckley’s crimes was marked by agitation for the so-called Brady
Bill, which would establish a national seven day waiting period for the purchase of handguns. The fate of Hinckley himself was
virtually ignored. Yet although Hinckley is as good as dead, his case demonstrates that psychiatry remains our society’s most
fearsome and most despicable instrument of punishment.
Ostensibly, Hinckley is the beneficiary of the best judicial and medical systems in the world. But let’s not forget that
Hinckley wanted to plead guilty to his crimes, was forced to plead insanity, and was “acquitted” against his will. Hence, because
of the diabolical fictions of law and psychiatry, Hinckley is as innocent of shooting President Reagan as the readers of this
column; his deed was not a crime but a symptom of illness; and he is not incarcerated in a prison but is treated in a hospital.
As the symptoms of pneumonia are cough and fever, so the symptoms of Hinckley’s schizophrenia were buying a gun, loading it,
locating President Reagan, taking good aim, and firing. Since Hinckley is sick, he is in a hospital. The fact that he cannot leave
his doctors, just as Saddam Hussein’s “guests” in Iraq could not leave their host, casts not the slightest doubt in the minds of
many Americans on the validity of the psychiatric fiction that Hinckley is a “patient.” Housed in the nation’s premier madhouse,
Hinckley must be receiving the best treatment for schizophrenia that American psychiatry has to offer. However, his disease must be
difficult to treat, as he shows no sign of improvement. Maybe Clozapine will cure him, though I doubt it. I think it is more likely
that he will be discharged via the morgue.
Lest my argument be misunderstood as a defense of Hinckley, let me say that I consider him to be guilty of one of the gravest
crimes in law, the attempted assassination of a head of state. He should have been tried, convicted, sentenced to death, and
executed—or, perhaps, allowed to kill himself, which is what he wanted and had attempted but was prevented from doing. Perish the
thought. After all, every educated person knows that Hinckley’s desire to kill himself expiating his guilt and ending a life
wrecked beyond hope of repair—was also a symptom of his schizophrenia. Indeed, thanks to the efforts of John Hinckley, Sr., and the
National Alliance for the Mentally Ill (actually, the National Alliance for the Parents of the Mentally Ill), most Americans now
also know that schizophrenia is a brain disease—indeed, “one of the most treatable” diseases. What is the treatment? Psychiatry’s
magic bullets: the so-called neuroleptic drugs.
The elder Hinckley’s participation in his son’s life, especially since the tragic events of March 1981, have raised psychiatric
charlatanry to unprecedented heights of journalistic, judicial, and medical legitimacy. It was Hinckley père who, when his
son experienced difficulties making the hazardous journey from adolescence to adulthood, chose to interpret the problem as a
symptom of mental illness, dispatched him to see a shrink, and thus pinned the ineradicable stigma of mental illness to his tail.
This critical, initial psychiatric stigmatization had predictable consequences: The youngster’s progress toward achieving the
powers and privileges of adulthood was further obstructed. But not to worry. The cure was right at hand. It consisted of Valium
dispensed by Hinckley père’s psychiatrist to Hinckley fils.
After submitting to what everyone believed was the best medical treatment for his “illness,” John Hinckley, Jr., proceeded to
flunk life more dramatically than ever. But, smart kid that he was, he soon saw the handwriting on the wall and apparently decided
to stop the charade: He decided (as I see it) to avenge himself against his father by bringing shame on his head and, at the same
time, to end his own parasitic and pathetic existence. Everything worked as planned, except for one thing. The hail of bullets from
the guns of Secret Service agents, in which he expected to die, did not materialize.
So Hinckley did the next best thing: After being taken into custody, he tried to kill himself. When that effort was thwarted, he
wanted to be tried and to plead guilty to the crimes with which he had been charged. Hinckley, Sr., and his lawyers (who are always
identified as his son’s lawyers) foiled that effort, too.
I shed no tears for John W. Hinckley, Jr. But, to borrow from Thomas Jefferson, I do tremble for my country when I think that
God is honest and will therefore not look kindly on a nation that classifies its lawbreakers as sick, its most fearsome prisons as
hospitals, its psychiatric jailers as doctors, and some of its most toxic chemicals, forced by the “doctors” on their prisoners, as
treatments for nonexistent diseases.
Contributing Editor Thomas Szasz is professor of psychiatry emeritus at the SUNY Health Science Center in Syracuse.
</div>
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</content>
</entry>
<entry>
<title type='html'>Psychiatry in the Age of AIDS</title>
<link href="http://reason.com/archives/1989/12/01/psychiatry-in-the-age-of-aids" rel="alternate"/>
<author>
</author>
The doctors see a new chance to be jailers.
</div>
</summary>
<![CDATA[
Happiness and sadness, elation and depression are the emotions we normally experience in response to the good and bad cards life
deals us. Suppose that a person of modest means desperately trying to win the lottery hits the jackpot. Suddenly he is rich, and he
feels happy, even elated. Or suppose that a young and hitherto healthy person develops a debilitating and fatal illness. Suddenly
he is sick and dying, and he feels sad, even depressed.
Obviously, one need not be a psychiatrist, or any other kind of expert, to think this way. That is exactly what is wrong with
such a commonsensical formulation: It is too simple, and hence useless for the physician who wants to meddle—or forcibly intervene—
in the elated or depressed person's life. To enable professional meddlers to engage in their specialty, it is necessary to define
"extreme moods" as diseases. Consider how easy this is.
Experts at one of our leading medical institutions, the Johns Hopkins University Medical School, recently studied four patients
suffering from AIDS who felt depressed. Did they view the patients' depression as a normal response to dying from AIDS? No. They
interpreted it as itself a symptom, a psychiatric manifestation of AIDS. Why? To rationalize treating the patients with "electro-
convulsive therapy" (ECT).
"Although major depression is not the most frequent psychiatric manifestation of infection with human immunodeficiency virus
type I (HIV), it does occur in many patients," the researchers say in the June issue of The American Journal of Psychiatry.
 "Delusional depression has also been described in such individuals. The effectiveness of ECT for individuals with severe
depression, especially those who do not respond to medication or who have delusions, is well established.…We report here the
successful treatment with ECT of four patients with major depression, three of whom were HIV-seropositive and one of whom had
AIDS."
The technical details of this report need not concern us. What should concern us is that the authors do not mention whether any
of their patients were involuntarily hospitalized and treated against their will. Since one of the patients tried to kill himself
while in the hospital and another "had persistent suicidal ideation," it seems possible, if not likely, that some or all of these
patients were the beneficiaries/victims of psychiatric coercion.
One patient was "a 35-year-old gay white man with AIDS [who] was transferred to our psychiatric ward after attempting suicide.
He had tried to hang himself with pajamas while receiving inpatient psychiatric treatment in another hospital. The patient had a
successfully treated episode of Pneumocystis carinii pneumonia four months before admission. He believed he was a bad
person and had persistent suicidal ideation.…The patient received twelve ECT treatments, after which all of his depressive symptoms
resolved.…Response to treatment for depression: No relapse (patient died four months after discharge)."
This approach to the unhappiness of a young man mortally ill with AIDS nicely illustrates my old contention that conventional
psychiatrists, especially those with a biological bent, perceive their task as exactly the opposite of the psychoanalyst's task as
Freud defined it: "making the unconscious conscious." Obviously, this metaphoric process can flow in both directions: It is
possible—indeed, easy enough—to make what is conscious unconscious, to repress, deny, obscure what is self-evident. When patients
do this, psychiatrists call their reinterpretation of reality a delusion. When psychiatrists do it, they call it the successful
treatment of depression with ECT.
Psychiatrists have latched onto the problems of AIDS patients as their ticket to renewed respectability within the medical
profession. Says Dr. Stuart E. Nichols, Jr., chairman of the American Psychiatric Association's National AIDS Commission: "The AIDS
epidemic presents unparalleled opportunities for psychotherapeutically oriented psychiatrists to rejoin the mainstream medical
community.…I think there are real opportunities with this illness for our profession to rejoin medicine and be a really valued,
respected, esteemed medical specialty.…This is a chance to demonstrate that psychotherapy can make a difference in people's lives.…
Every psychiatrist needs to be involved in this."
This is an absurd and arrogant assertion. Freud, Jung, Adler, and the other pioneer psychotherapists did not look to syphilis or
gonorrhea or the many other devastating infectious diseases untreatable in their days as "a chance to demonstrate that
psychotherapy can make a difference in people's lives." What makes Nichols believe that psychiatrists are able to relieve the
perfectly realistic anxieties, depressions, and suicidal inclinations of AIDS patients? Or that doing so is, prima facie,
morally praiseworthy?
Psychiatric involvement with AIDS does not stop here. Having no legitimate subject matter of their own, psychiatrists are ever
eager to fill any vacuum that arises in the medico-social atmosphere. Such a vacuum now exists with respect to the management of
the AIDS patient who knowingly—even deliberately, with malice aforethought—exposes others to infection. Psychiatrists and their
lackeys have rushed to fill it.
In this case, as in many others, the psychiatrist's offer of help is simply a Trojan horse concealing the real agenda: coercion
in the name of therapy. Indeed, psychiatrists are already offering their services as jailers. In the June issue of The
Psychiatric Times, Dr. Lise Van Susteren describes a depressed patient who told her he had tested positive for the AIDS
antibody but was continuing to engage in sexual activity without using condoms. Van Susteren suggested that he be admitted to a
psychiatric hospital, and the patient agreed. But before long he was discharged.
Now Van Susteren became alarmed: "Soon he was back in my office.…I asked him again about his sexual activities. I was devastated
by his words—his threat to use his disease to 'conquer the world.' He told me that sometimes when he got angry with someone, an
inner voice told him, 'Let's get this guy,' and he would try to have sex with him.…I was convinced—by my understanding of his
illness, by his history, by his demeanor, and by the details of his sexual encounters—that he was telling the truth.…In a sweaty
moment, I called a magistrate in Virginia to have the patient involuntarily hospitalized, in a forensic ward.…He refused to swear
out a warrant."
Van Susteren seems to have no doubt that such a person ought to be deprived of liberty and that the best place in which to
imprison him is a psychiatric hospital. Not surprisingly, she has had no trouble finding support for her idea. Noting that there is
a widespread belief that AIDS patients should be "quarantined," she laments: "However, there is no 'good' place to put such
people." She then quotes a medical ethicist who further laments that "it is extremely difficult to have a patient who is not
psychotic committed to a psychiatric hospital. And even if it is done, hospitals must ensure that other patients are not
endangered."
Lest one dismiss this particular "ethicist" as just another justifier of legal expediency and psychiatric power, Van Susteren
cites support for the psychiatric coercion of AIDS patients from a more impressive authority—the World Medical Association: "Many
health officials believe that quarantining is the only effective answer for those few HIV patients who, despite attempts to educate
or pressure them, cannot or will not stop putting others at risk. The World Medical Association recommends that authorities be
notified of irresponsible patients in order to have them 'placed in a psychiatric hospital.'"
We must now ask: Exactly what sort of danger does an AIDS patient represent and to whom? Is his very freedom a threat to the
community? Or does he endanger only some persons—for example, those who choose to share a needle or sexual favors with him? Van
Susteren implicitly opts for the former view and cites a legal authority's reasoning to support her position: "Robert Goldstein, a
law professor at the University of California at Los Angeles and a specialist in the law and psychiatry, asked, 'How is this
patient different from the psychotic person who walks down the street with a gun, threatening to kill everyone?"' I find it
shocking that Goldstein and Van Susteren, supposedly experts on psychiatry and law, see no difference between these two situations.

In the first place, the gunman displays a lethal weapon; Van Susteren's AIDS patient does not. Second, the gunman publicly
proclaims his intention to harm others; the AIDS patient does not. Third, the gunman commits an overt act that clearly violates the
criminal law; the AIDS patient does not. Fourth, and perhaps most significant, the gunman's potential victims are passive, innocent
bystanders vulnerable simply because they happen to be near him. By contrast, the AIDS patient's potential victims are active,
vulnerable because, and only because, they have decided to engage in a sexual act with him. It is hard to say whether the analogy
between the gunman and the AIDS patient is stupid or scheming, or both. But there is no valid analogy between the two at all.
Of course, this is not to say that Van Susteren's AIDS patient is not dangerous. Obviously he is. But not randomly. If one were
looking for an analogy for the danger Van Susteren's "irresponsible" AIDS patient poses to society, it would not be the danger that
a "gun-toting psychotic" poses; instead, it would be something rather like the danger a careless skydiver poses. Clearly, if a
sensible person wished to engage in skydiving, he would not want such an unreliable individual to pack his parachute. Indeed, any
self-respecting sky diver would want only someone whom he knew well and who had merited his trust to pack his parachute. Sex,
especially, between males, is a similarly dangerous sport.
The encounter between the AIDS patient and the psychiatrist is thus another example of psychiatry's denial of moral agency and
its war on responsibility. That, after all, is the bottom line in the analogy between the gunman and the AIDS patient: Since, in
the psychiatric view, the AIDS patient endangers others regardless of their conduct, he is a threat to the general community who
deserves to be incarcerated—for the protection of society and the treatment of his illness.
But why in a mental hospital? Whatever controversy there may be about the psychiatrist's proper social role, one thing is clear:
It is not his job to forcibly isolate people who suffer from contagious diseases. Accordingly, the proposal that "irresponsible"
individuals infected with AIDS be psychiatrically imprisoned ("mentally hospitalized") is both absurd and abhorrent. Nevertheless,
the fact that so important an international organization as the World Medical Association endorses this policy should be a warning—
as if the role that psychiatrists played in Nazi Germany and the Soviet Union were not warning enough—of how prone the psychiatric
profession is to moral corruption by social and political fashions.
How is the psychiatrist's zeal to quarantine "irresponsible" AIDS patients to be reconciled with his behavior when he or a
colleague is (potentially) HIV-positive or actually suffers from overt manifestations of the disease? In the hypocritical way
typical of involuntary psychiatric interventions: They are for patients only!
A report in the June 2 issue of American Medical News describes a physician-patient whose psychiatrist helped him "find
a hospital for AIDS-related treatment because the trainee did not want his colleagues and supervisors to learn of his condition."
After the patient died, the head of his department complained that "the patient's analyst was colluding" in keeping the illness
secret. The analyst justified his behavior by explaining "how closeted the patient felt he had to be." Was that responsible
behavior on the part of the physician-patient? Or his analyst?
The inconsistency between the psychiatrist's recommendation that the "irresponsible" AIDS carrier be quarantined and the
psychiatrist's own behavior gets even more glaring. The American Medical News article quotes Nichols, chairman of the
APA's National AIDS Commission: "'I've chosen not to get tested,' added Dr. Nichols, 'and I have to defend that position' to
patients who ask his status. A number have asked him if he is facing reality by not undergoing an antibody test. 'Probably not,' he
tells them, 'but it's my decision.'" Another psychiatrist "who said he also chose not to undergo HIV antibody testing said he can
cope with the anxiety of not knowing his status more easily than he could with the knowledge that he was infected."
Are these psychiatrists behaving irresponsibly? Would they meet Van Susteren's and the World Medical Association's criteria for
commitment to a mental hospital as "irresponsible" AIDS carriers? Or is this another case illustrating the Indian adage that it all
depends on whose ox is gored?
So we see psychiatrists electroshocking AIDS patients to cure their depression and save them from suicide; giving AIDS patients
psychotherapy to prove that psychiatrists are real doctors; seeking to incarcerate AIDS patients in mental hospitals to protect
others from being infected by them, and, last but not least, just posturing to show what good guys they are. Declares Dr. Herbert
Pardes, president of the APA: "At the least, mental health professionals must be prepared to do the following: help patients cope
with the tremendous adversity associated with their disease…support partners and families…help strengthen community prevention
efforts…fight discrimination against AIDS patients on all levels—local, state, national."
The last pronouncement is especially persuasive coming as it does from the president of a group with a special interest in
stigmatizing people. But when it comes to breast-beating and self-congratulation, the psychiatrists are hard to outdo. Concludes
Pardes: "Thus, the first step for all of us is to decide that AIDS is everybody's problem and that no one shall be left to suffer
alone. I have already made my decision."
Unctuously parodying Mother Teresa, Pardes unwittingly betrays the psychiatrist's incurable propensity to meddle—not only in the
AIDS patient's misery, but in everyone's life. For what business of Pardes is it to declare that "AIDS is everybody's problem"? In
fact, nothing is a particular person's problem, unless he assumes responsibility for it or someone else forcibly imposes
responsibility for it on him.
For centuries psychiatrists waged war on the homosexual, notwithstanding their sudden peace overture of 1973, when they repealed
the classification of homosexuality as a disease. In AIDS the psychiatrists may have found the reinforcements needed to mount a
new, even more promising crusade. With an estimated one million Americans testing positive for HIV waiting in the wings, happy days
are here again for psychiatry.
Mad doctors once claimed that homosexuality was a disease and offered their services to protect the community from it by
stigmatizing and segregating the so-called patient. Now they claim that depression experienced by a person suffering from AIDS is a
symptom of the HIV infection and offer their services to cure the depression with electroshock treatment.
As a bonus, they generously throw in their willingness to imprison ("hospitalize") the "irresponsible" AIDS patient (who often
happens to be a homosexual). How many psychiatrists currently agree with this position is uncertain. How many will agree with it in
the future will clearly depend on how fashionable and lucrative it turns out to be.
We live in remarkable times, politically as well as psychiatrically. In the communist world, people clamor for democracy and
freedom but seem not to have the least inkling that the term democracy refers to a type of social organization based on
respect for private property and the rule of law, and that the term freedom is meaningless if it does not include the
freedom to own, save, invest, and inherit property. We, in the free West, are similarly confused, not about the relationship
between private property and individual liberty, but about the relationship between private health and individual liberty. We have
lost sight of the fact that the term freedom is meaningless if it does not include the freedom to be sick, to remain sick,
and to die in one's own way. The relationship developing between AIDS patients and the psychiatric profession is a case in point.

Clearly, plus ça change, plus c'est la même chose. Should we celebrate the reliability of the psychiatric
physician, so loyally and eagerly rallying to society's every passing need to rid itself of its unwanted members? Or should we fear
it as an ever-present danger built into this alleged medical specialty at its creation, against which we must always guard
ourselves? Perhaps we should even consider the possibility that the actual and potential evils of psychiatric coercion so outweigh
its alleged benefits as to justify the abolition of psychiatric slavery altogether.
Contributing Editor Thomas Szasz is a professor of psychiatry at the SUNY Health Science Center in
Syracuse, New York. </div>
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</content>
</entry>
<entry>
<title type='html'>Psychiatric Self-Defense</title>
<link href="http://reason.com/archives/1983/05/01/psychiatric-self-defense" rel="alternate"/>
<author>
</author>
A new kind of "living will" would protect people from involuntary psychiatric intervention
</div>
</summary>
<![CDATA[
In the last two decades there has been a widening public recognition that much of psychiatric practice rests on or involves
coercion and violence. As this recognition grew, there emerged a concern, not least among former psychiatric patients, with
"patient's rights," especially the right to reject psychiatric treatment.
Since politics, however, is the art of saying one thing and doing another, the mental health establishment—which is nothing if
it isn't political—lost no time in coopting the patients' rights issue. Whereas formerly the code phrase in the mental health
reform business was mental illness, now it became the rights of mental patients. The phrase the right to
treatment has become a formidable new weapon in the psychiatrists' perennial struggle to oppress and control the "mental
patient."
Today, coercive psychiatrists themselves freely admit that in the past mental patients were deprived of liberty by being
involuntarily "warehoused." But that is no longer true, they say. Now mental patients are guaranteed their "right to treatment,"
especially with so-called antipsychotic drugs.
The enormous importance of the right-to-treatment rhetoric is illustrated by Kenneth Donaldson's famous appeal to the Supreme
Court in 1975. The appeal was brought on Donaldson's behalf by a group of mental health reform lawyers on the ground that
Donaldson's rights had been violated when he was deprived of treatment during incarceration in a mental institution. The appeal was
supported by every major mental health group in the country, including such traditional enemies of the involuntary mental patient
as the American Psychiatric Association and the American Orthopsychiatric Association.
It is important to emphasize and recognize that the mental health establishment's sudden concern with patients' rights has thus
left completely untouched the age-old problem of what to do with the "mental patient" who refuses treatment. The stubborn fact is
that ever since the birth of psychiatry, people have been deprived of the right to reject the ministrations of mad doctors. For 200
years or more, people were deprived of this right on the grounds that they were "insane" or "psychotic" and hence were incompetent
to manage their lives. For the past 15 years or so—since the advent of the patients' rights rhetoric—people have been deprived of
this right on the ground that their "true interests" require that they receive "life-saving psychiatric treatment." Although some
of the legal protections provided to mental patients might have worked to their temporary advantage, I believe that, on balance,
the added legal attention lavished on the so-called rights of mental patients has served only to authenticate further the
legitimacy of depriving them of the only right that counts—the right to reject treatment, the right to reject being cast in the
role of mental patient; in short, the right to reject psychiatric authority.
<h2>ENDING THE REIGN OF THE PSYCHIATRIC INQUISITION</h2>
Whenever force is an established method of resolving an ideological conflict, it is likely that the proponents and opponents of
force do not speak the same language. For example, during the waning days of the Inquisition, the advocates of clerical tortures
feared heresy and the imaginary terrors of eternal damnation and embraced the Inquisition as a protection against these dangers;
whereas the critics of such torture feared the Inquisition and its very real terrors and embraced the ideas of the Enlightenment as
a protection against these dangers. Today, the proponents of psychiatric coercion fear psychosis and the dire consequences of
psychiatric neglect; whereas the opponents of such coercion fear psychiatry and the dire consequences of involuntary psychiatric
interventions.
Recently, a report on "patients' rights" in Psychiatric News, the American Psychiatric Association's official
newspaper, explained that psychiatrists no longer think "in terms of physical restrictions on freedom but of the shackles of
[psychiatric] illness itself and the patient's right to freedom from this mental restraint." The report cited the views of two
"experts" on patients' rights according to whom involuntary mental hospitalization and "treatment" actually increase the
involuntary mental patients' freedom:
<blockquote>
We would submit that commitment can be justified on the grounds of enhancing the individual's future freedom. If society
insisted that freedom be the only purpose of commitment, commitment to achieve a real lack of unnecessary constraints from mental
illness and to increase a patient's options could be justified.…Such an approach…would place psychiatry fully behind the principle
that psychiatric institutions be utilized for increasing the freedom of the mentally ill.
</blockquote>
This rhetoric of "psychiatric slavery in the name of mentally healthy freedom" explains a seeming paradox: the professional
advocates of the rights of mental patients are the most determined adversaries of former mental patients' groups that are lobbying
for mental patients' right to reject treatment.
Sadly, but not surprisingly, psychiatric reformers have sought and continue to seek to improve the mental health system by doing
even more for the patient, for society, or for both. Thus, they have tried to protect the patient from himself or from those who
might exploit or mistreat him; they have tried to protect society from the "dangerous" patient and his "illness"; and, most
recently, they have tried to restore the "sick patient" to "mental health." Each of these efforts is paternalistic in principle and
coercive in practice.
The individualist approach to the core problem of psychiatry—namely, coercion in the name of mental health-is radically
different. Viewing psychiatric coercion as essentially similar to religious coercion, the individualist solution to it is also
similar. That solution, exemplified by the Founding Fathers' position on clerical power, was to protect the free practice of
religion but to abolish coercion in the name of God. The individualist solution to clinical coercion is the same: to protect the
free practice of psychiatry but to abolish coercion in the name of mental health.
Simple? Of course. Why, then, are so few people interested in it? The answer to that question is not so simple. I shall point
here only to one of the reasons for it.
When the United States went through its birth pangs, violence in the name of God was an accepted political and legal principle
throughout Europe and indeed the whole world. What justified this practice? We know the answer only too well: an alliance between
church and state that made the use of force in the service of God as legitimate as the use of force in the service of Caesar. The
soldier protected the commonwealth from external enemies. The inquisitor protected it from internal enemies, especially heretics.

The problem of religious coercion, like the problem of psychiatric coercion, could be approached in two ways. One way would be
to look to the state to protect the victims of clerical power. This would generate a rhetoric about the rights of heretics and
demands for guaranteeing the heretic's right to proper (that is, orthodox) worship. The other approach would be to recognize that
the source of clerical power lies in an alliance between church and state. This realization would generate (as it did in the United
States) a rhetoric about the separation of church and state and demands for making worship the private affair of the worshipper.

We can easily see how the first course only aggravates the problem. By guaranteeing the absurdity of the heretic's right to
embrace the true faith, it further authenticates the legitimacy of religious coercion. Similarly, coercion, being the result of an
alliance between psychiatry and the state, can be ended only by a separation of psychiatry and the state. Any other course,
particularly the state's "guaranteeing" the absurd right of mental patients to receive treatment can lead only to reauthenticating
the legitimacy of psychiatric coercion. The history of mental health reform in the United States during the past 15 years
illustrates and supports the validity of this interpretation.
Psychiatrists, however, contend that insane persons—out of touch with reality, misinterpreting therapy as torture—cannot
competently consent to or reject psychiatric interventions. And many people, perhaps the majority of the population, believe that
this is true. So some special legal mechanism is necessary for realistically implementing a separation of psychiatry and the state.
Such a mechanism is prefigured in procedures that people in Western societies have developed for coping with other situations in
which a moral agent's capacity to act competently is diminished or destroyed. There are two typical situations of this sort: death
and incapacitating terminal illness. And there are two legal instruments that have been developed to cope with them: wills (last
wills and testaments) and so-called living wills. I propose that we create a third type of will—the "psychiatric will."
<h2>SECURING THE RIGHT TO AN UNMOLESTED MIND</h2>
Many of us are eager to exercise our desires over the distribution of our property after we die. The purpose of the last will is
to assure this by extending our control into a situation in which we cannot otherwise exercise any control at all.
While the use of last wills is an ancient practice, the use of living wills, in anticipation of a lingering, painful, and
expensive terminal illness, is of more recent origin. Executed while the person is not disabled by illness, a living will directs
those responsible for caring for its author to abstain under certain circumstances from administering to him or her life-sustaining
measures. The legal philosophy underlying this practice is illustrated by the following opinion of a Kansas court: "Anglo-American
law starts with the premise of thoroughgoing self-determination. It follows that each man is considered to be the master of his own
body, and he may, if he be of sound mind, expressly prohibit the performance of life-saving surgery."
The psychiatric will I propose rests on the same principle and seeks to extend it to "mental treatment." It asserts, in effect,
that competent American adults should have a recognized right to reject ahead of time involuntary psychiatric interventions that
they may be deemed to require in the future when they are considered incompetent to make decisions concerning their own welfare. My
model for the psychiatric will is the so-called living will and, more specifically, the rejection by Jehovah's Witnesses of blood
transfusion as a medical treatment.
A frequently cited opinion concerning the constitutionality of allowing Jehovah's Witnesses to reject blood transfusion, even
when the transfusion may be lifesaving, was formulated in 1964 by Chief Justice (then Circuit Judge) Warren Burger. In this
opinion, Burger recalled Justice Brandeis's famous words about our "right to be let alone." "The makers of our Constitution," wrote
Brandeis, "sought to protect Americans in their beliefs, their thoughts, their emotions, and their sensations. They conferred, as
against the Government, the right to be let alone—the most comprehensive of rights, the right most valued by civilized man." To
which Burger added these (for my present purposes, decisive) words: "Nothing in this utterance suggests that Justice Brandeis
thought an individual possessed these rights only as to sensible beliefs, valid thoughts, reasonable
emotions, or well-founded sensations. I suggest he intended to include a great many foolish, unreasonable, and even absurd
ideas which do not conform, such as refusing medical treatment even at great risk."
As we have seen, then, where the person is conscious and rational, the courts have tended to accept the principle that a person
has a right to refuse medical treatment even if the result is death. "Even in an emergency situation," an article in the
Journal of Medical Ethics recently explained, "where death would ensue if treatment were not administered, the court
upheld a patient's refusal of treatment."
Since involuntary psychiatric intervention is rarely lifesaving (and even if it were, that would not be enough under the
foregoing ethical-legal principles to justify its forcible imposition on unwilling clients), the parens patriae rationale
for psychiatric coercion is fatally undermined. The psychiatric will would implement the right to reject psychiatric treatment for
people deemed to be fully competent and rational at the time they made their decision. On what constitutional, moral, or political
grounds could Americans be denied this right?
<h2>ESTABLISHING THE FORM OF THE PSYCHIATRIC WILL</h2>
Many people (and virtually all psychiatrists and other mental health experts) fear the danger of a "nervous breakdown" or
"psychotic illness." These people believe that mental illness exists, that it is like any other illness, that it is amenable to
modern psychiatric treatment, and that the effectiveness and legitimacy of such treatment do not depend on the patient's consent to
it. Accordingly, such people seek protection from "life-threatening" mental illness and support the use of involuntary psychiatric
interventions.
On the other hand, there are other people (including a few psychiatrists and other mental health experts) who fear the danger of
compulsory psychiatry or involuntary "therapy." Some of these people also believe that mental illness does not exist and
that psychiatric coercion is torture rather than treatment. Accordingly, these people seek protection from the powers of psychiatry
and advocate the abolition of involuntary psychiatric interventions.
Let us now apply the principles underlying the last testament and the living will to the psychiatric contingency some people
might want to anticipate and control, such as "sudden madness" or "acute psychosis." Since involuntary psychiatric confinement is a
tradition-honored custom in modern societies, these people are wise to anticipate the possibility of their own sudden madness
managed by others by means of commitment and coerced treatment. To forestall that happening, we need a mechanism permitting anyone
who has reached the age of maturity to execute a "psychiatric will" prohibiting his confinement in a mental hospital or his
involuntary treatment for mental illness. Those failing to execute such a document before an actual encounter with coercive
psychiatry would, of course, have the opportunity to do so as soon as they "recovered" from their first episode of "mental illness"
or otherwise regained their competence.
Since commitment entails the loss of liberty, the foregoing mechanism for its protection is relatively weak. It requires the
affirmative assertion of a desire to do without involuntary psychiatric care, and in the absence of such a declaration, the person
would remain a potentially defenseless victim of psychiatric coercion. So even though this kind of psychiatric will would be a
great improvement over the present situation, a more powerful document could be fashioned by shifting the presumptive rights. In
this stronger version, a person would be free from psychiatric coercion unless he executed a psychiatric will in advance that
asserted his right to such coercion should the "need" for it arise. This arrangement would leave most of us free from psychiatric
coercion, much as we are free, without having to go to such troubles, from religious coercion.
The second version of the psychiatric will is stronger and theoretically more attractive than the first. But because the
paternalistic perspective on involuntary psychiatric interventions is now so prevalent, the weaker version may be more acceptable
to most people and to their elected representatives. Of course, the rejection of psychiatric interventions need not be total in
either version of such a will. For example, some persons might wish to authorize coerced hospitalization and to forbid treatment by
drugs or electroshock, while others might wish to authorize coerced drug therapy and to forbid confinement. Only through a
mechanism such as this could the responsibilities as well as the rights of the "severely mentally ill" be expanded.
The use of psychiatric wills might put an end to the dispute about involuntary psychiatric interventions. Earnestly applied,
such a policy should satisfy the demands of involuntary psychiatry's proponents (the psychiatric protectionists) and its opponents
(the psychiatric voluntarists). Surely, the psychiatric protectionists could not in good faith object when people who were
competent to make binding decisions about their own future chose to prohibit personally unauthorized psychiatric assistance. Nor
could the psychiatric abolitionists really complain when other people who were competent to make binding decisions about their
future chose to permit their own temporary (or not-so-temporary) psychiatric "enslavement."
Finally, it should be noted that although the main purpose of the psychiatric will would be to protect potential patients from
unwanted psychiatric interventions, such a document would also protect would-be therapists from the risks they now face in their
relations with involuntary mental patients. This dual function of the psychiatric will is inherent in its being an instrument for
transforming a status relationship into a contractual relationship.
As matters now stand, psychiatrists faced with the task of having to care for "seriously ill mental patients" often find
themselves in a Catch-22 situation. They are in danger of being sued both for confining and for failing to confine the "patient,"
for using coercive treatment as well as for failing to use it. The psychiatric will, prospectively requesting or refusing
involuntary psychiatric interventions, would constitute a contract between potential future psychiatric patients and their
potential future psychiatrists. Hence, while it would protect the former from psychiatric coercion or psychiatric neglect (as the
case may be), it would protect the latter from charges of unauthorized treatment or unprofessional neglect.
Contributing Editor Thomas Szasz is a professor of psychiatry at the State University of New York College of Medicine. He is
the author of many books, including Psychiatric Justice and The Myth of Mental Illness. </div>
]]>
</content>
</entry>
<entry>
<title type='html'>Drug Prohibition</title>
<link href="http://reason.com/archives/1978/01/01/drug-prohibition-ill-conceived-laws-have" rel="alternate"/>
<author>
</author>
Ill-conceived laws have created today’s drug problem.
</div>
</summary>
<![CDATA[
<img alt="" height="384" src="https://media.reason.com/mc/2014_06/prohibition_jan1978reason.jpg?h=384&w=250"

title="|||Reason" width="250" style="float: right;">
Americans regard freedom of speech and religion as fundamental rights. Until 1914, they also regarded freedom of choosing their
diets and drugs as fundamental rights. Today, however, virtually all Americans regard ingesting certain substances—prohibited by
the government—as both crimes and diseases.
What is behind this fateful moral and political transformation, which has resulted in the rejection by the overwhelming majority
of Americans of their right to self-control over their diets and drugs in favor of the alleged protection of their health from
their own actions by a medically corrupt and corrupted State? How could it have come about in view of the obvious parallels between
the freedom to put things into one's mind and its restriction by the State by means of censorship of the press, and the freedom to
put things into one's body and its restriction by the State by means of drug controls?
<h2>CENSORSHIP</h2>
The answer to these questions lies basically in the fact that our society is therapeutic in much the same sense in
which medieval Spanish society was theocratic. Just as the men and women living in a theocratic society did not believe in
the separation of church and State but, on the contrary, fervently embraced their union, so we, living in a therapuetic society, do
not believe in the separation of medicine and the State but fervently embrace their union. The censorship of drugs follows from the
latter ideology as inexorably as the censorship of books followed from the former. That explains why liberals and conservatives—and
people in that imaginary center as well—all favor drug controls. In fact, persons of all political and religious convictions, save
libertarians, now favor drug controls.
Liberals tend to be permissive toward socially disreputable psychoactive drugs, especially when they are used by young and hairy
persons; so they generally favor decriminalizing marijuana and treating rather than punishing those engaged in the trade of LSD.
They are not at all permissive, however, toward non-psychoactive drugs that are allegedly unsafe or worthless and thus favor
banning saccharin and Laetrile. In these ways they betray their fantasy of the State—as good parent: such a State should restrain
erring citizens by mild, minimal, and medical sanctions, and it should protect ignorant citizens by pharmacological censorship.
Conservatives, on the other hand, tend to be prohibitive toward socially disreputable psychoactive drugs, especially when they
are used by young and hairy persons; so they generally favor criminalizing the use of marijuana and punishing rather than treating
those engaged in the trade of LSD. At the same time, they are permissive toward nonpsychoactive drugs that are allegedly unsafe or
worthless and thus favor free trade in saccharin and Laetrile. In these ways, they too betray their fantasy of the State—as the
enforcer of the dominant ethic: such a State should punish citizens who deviate from the moral precepts of the majority and should
abstain from meddling with people's self-care.
Viewed as a political issue, drugs, books, and religious practices all present the same problem to a people and its rulers. The
State, as the representative of a particular class or dominant ethic, may choose to embrace some drugs, some books, and some
religious practices and reject the others as dangerous, depraved, demented, or devilish. Throughout hisory, such an arrangement has
characterized most societies. Or the State, as the representative of a constitution ceremonializing the supremacy of individual
choice over collective comfort, may ensure a free trade in drugs, books, and religious practices. Such an arrangement has
traditionally characterized the United States. Its Constitution explicitly guarantees the right to freedom of religion and the
press and implicitly guarantees the right to freedom of self-determination with respect to what we put into our bodies.
Why did the framers of the Constitution not explicitly guarantee the right to take drugs? For two obvious reasons. First,
because 200 years ago medical science was not even in its infancy; medical practice was socially unorganized and therapeutically
worthless. Second, because there was then no conceivable danger of an alliance between medicine and the State. The very idea that
the government should lend its police power to physicians to deprive people of their free choice to ingest certain substances would
have seemed absurd to the drafters of the Bill of Rights.
This conjecture is strongly supported by a casual remark by Thomas Jefferson, clearly indicating that he regarded our freedom to
put into our bodies whatever we want as essentially similar to our freedom to put into our own minds whatever we want. "Was the
government to prescribe to us our medicine and diet," wrote Jefferson in 1782, "our bodies would be in such keeping as our souls
are now. Thus in France the emetic was once forbidden as a medicine, the potato as an article of food."
<h2>A THERAPEUTIC STATE</h2>
Jefferson poked fun at the French for their pioneering efforts to prohibit drugs and diets. What, then, would he think of the
State he himself helped to create, a State that now forbids the use of harmless sweeteners while encouraging the use of dangerous
contraceptives? that labels marijuana a narcotic and prohibits it while calling tobacco an agricultural product and promoting it?
and that defines the voluntary use of heroin as a disease and the legally coerced use of methadone as a treatment for it?
Freedom of religion is indeed a political idea of transcendent importance. As that idea has been understood in the United
States, it does not mean that members of the traditional churches—that is, Christians, Jews, and Mohammedans—may practice their
faith unmolested by the government but that others—for example, Jehovah's Witnesses—may not. American religious freedom is
unconditional; it is not contingent on any particular church proving, to the satisfaction of the State, that its principles or
practices possess "religious efficacy."
The requirement that the supporters of a religion establish its theological credentials in order to be tolerated is the hallmark
of a theological State. In Spain, under the Inquisition, there was, in an ironic sense, religious tolerance: religion was
tolerated, indeed, actively encouraged. The point is that religions other than Roman Catholicism were considered to be heresies.
The same considerations now apply to drugs.
The fact that we accept the requirement that the supporters of a drug establish its therapeutic credentials before we tolerate
its sale or use shows that we live in a therapeutic State. In the United States today, there is, in an ironic sense,
pharmacological tolerance: approved drugs are tolerated, indeed, actively encouraged. But drugs other than those officially
sanctioned as therapeutic are considered worthless or dangerous. Therein, precisely, lies the moral and political point:
governments are notoriously tolerant about permitting the dissemination of ideas or drugs of which they approve. Their mettle is
tested by their attitude toward the dissemination of ideas and drugs of which they disapprove.
The argument that people need the protection of the State from dangerous drugs but not from dangerous ideas is unpersuasive. No
one has to ingest any drug he does not want, just as no one has to read a book he does not want. Insofar as the State assumes
control over such matters, it can only be in order to subjugate its citizens—by protecting them from temptation, as befits
children; and by preventing them from assuming self-determination over their lives, as befits an enslaved population.
<h2>CONTROLLING DANGER</h2>
Conventional wisdom now approves—indeed, assumes as obvious—that it is the legitimate business of the State to control certain
substances we take into our bodies, especially so-called psychoactive drugs. According to this view, as the State must, for the
benefit of society, control dangerous persons, so it must also control dangerous drugs. The obvious fallacy in this analogy is
obscured by the riveting together of the notions of dangerous drugs and dangerous acts: as a result, people now "know" that
dangerous drugs cause people to behave dangerously and that it is just as much the duty of the State to protect its citizens from
dope as it is to protect them from murder and theft. The trouble is that all these supposed facts are false.
It is impossible to come to grips with the problem of drug controls unless we distinguish between things and persons. A drug,
whether it be heroin or insulin, is a thing. It does not do anything to anyone unless a person ingests it or injects it into
himself or administers it to another. Obviously, a drug has no biological effect on a person unless it gets into his body. The
basic question—that is logically prior to whether the drug is good or bad—is, therefore: How does a drug get into the person's
body? Although there are many ways that that can happen, we need to consider here only a few typical instances of it.
A person may take an accepted nonprescription drug like aspirin by way of self-medication. Or, he may be given an accepted
prescription drug like penicillin by way of medication by his physician. Neither of these situations disturbs most people nowadays.
What disturbs the compact majority is a person taking a drug like LSD or selling a drug like heroin to others.
The most cursory attention to how drugs get into the human body thus reveals that the moral and political crux of the problem of
drug controls lies, not in the pharmacological properties of the chemicals in question, but in the character-properties of the
persons who take them (and of the people who permit, prescribe, and prohibit drugs).
The true believer in conventional wisdom might wish to insist at this point—not without justification—that some drugs are more
dangerous than others; that, in other words, the properties of drugs are no less relevant to understanding our present-day drug
problems than are the properties of the persons. That is true. But it is important that we not let that truth divert our attention
from the distinction between pharmacological facts and the social policies they supposedly justify.
<h2>PROHIBITION</h2>
Today, ordinary, "normal" people do not really want to keep an open mind about drugs and drug controls. Instead of thinking
about the problem, they tend to dismiss it with some cliche such as: "Don't tell me that heroin or LSD aren't dangerous drugs?"
Ergo, they imply and indeed assert: "Don't tell me that it doesn't make good sense to prohibit their production, sale, and
possession!"
What is wrong with this argument? Quite simply, everything. In the first place, the proposition that heroin or LSD is dangerous
must be qualified and placed in relation to the dangerousness of other drugs and other artifacts that are not drugs. Second, the
social policy that heroin or LSD should be prohibited does not follow, as a matter of logic, from the proposition that they are
dangerous, even if they are dangerous.
Admittedly, heroin is more dangerous than aspirin, in the sense that it gives more pleasure to its user than aspirin; heroin is
therefore more likely than aspirin to be taken for the self-induction of euphoria. Heroin is also more dangerous than aspirin in
the sense that it is easier to kill oneself with it; heroin is therefore more likely to be used for committing suicide.
The fact that people take heroin to make themselves feel happy or high—and use other psychoactive drugs for their mind-altering
effects—raises a simple but basic issue that the drug-prohibitionists like to avoid, namely: What is wrong with people using drugs
for that purpose? Why shouldn't people make themselves happy by means of self-medication? Let me say at once that I believe these
are questions to which honest and reasonable men may offer different answers. Whatever the answers, however, I insist that they
flow from moral rather than medical considerations.
For example, some people say that individuals should not take heroin because it diverts them from doing productive work, making
those who use the drugs, as well as those economically dependent on them, burdens on society. Others say that whether individuals
use, abuse, or avoid heroin is, unless they harm others, their private business. And still others opt for a compromise between the
total prohibition of heroin and a free trade in it.
There is, however, more to the prohibitionist's position than his concern that hedonic drugs seduce people from hard labor to
happy leisure. If prohibitionists were truly motivated by such concerns, they would advocate permission to use heroin contingent on
the individual's proven ability to support himself (and perhaps others), rather than its unqualified suppression. The fact that
they advocate no such thing highlights the symbolic aspects of drugs and drug controls.
<h2>DRUGS, FUN, AND SIN</h2>
The objects we now call "dangerous drugs" are metaphors for all that we consider sinful and wicked; that is why they are
prohibited, rather than because they are demonstrably more harmful than countless other objects in the environment that do not now
symbolize sin for us. In this connection, it is instructive to consider the cultural metamorphosis we have undergone during the
past half-century, shifting our symbols of sin from sexuality to chemistry.
Our present views on drugs, especially psychoactive drugs, are strikingly similar to our former views on sex, especially
masturbation. Intercourse in marriage with the aim of procreation used to be the paradigm of the proper use of one's sexual organs;
whereas intercourse outside of marriage with the aim of carnal pleasure used to be the paradigm of their improper use. Until
recently, masturbation—or self-abuse, as it was called—was professionally declared, and popularly accepted, as both the cause and
the symptom of a variety of illnesses, especially insanity. To be sure, it is now virtually impossible to cite a contemporary
medical authority to support the concept of self-abuse. Expert medical opinion now holds that there is simply no such thing: that
whether a person masturbates or not is medically irrelevant, and that engaging in the practice or refraining from it is a matter of
personal morals or life style.
On the other hand, it is now impossible to cite a contemporary medical authority to oppose the concept of drug abuse. Expert
medical opinion now holds that drug abuse is a major medical, psychiatric, and public-health problem: that drug addiction is a
disease similar to diabetes, requiring prolonged (or life-long) and medically carefully supervised treatment; and that taking or
not taking drugs is primarily, if not solely, a matter of medical concern and responsibility.
Like any social policy, our drug laws may be examined from two entirely different points of view: technical and moral. Our
present inclination is either to ignore the moral perspective or to mistake the technical for the moral.
<h2>A MEDICAL PROBLEM?</h2>
An example of our misplaced over-reliance on a technical approach to the so-called drug problem is the professionalized
mendacity about the dangerousness of certain types of drugs. Since most propagandists against drug abuse seek to justify certain
repressive policies by appeals to the alleged dangerousness of various drugs, they often falsify the facts about the true
pharmacological properties of the drugs they seek to prohibit. They do so for two reasons: first, because many substances in daily
use are just as harmful as the substances they want to prohibit; second, because they realize that dangerousness alone is never a
sufficiently persuasive argument to justify the prohibition of any drug, substance, or artifact. Accordingly, the more they ignore
the moral dimensions of the problem, the more they must escalate their fraudulent claims about the dangers of drugs.
To be sure, some drugs are more dangerous than others. It is easier to kill oneself with heroin than with aspirin. But
it is also easier to kill oneself by jumping off a high building than a low one. In the case of drugs, we regard their potentiality
for self-injury as justification for their prohibition; in the case of buildings, we do not. Furthermore, we systematically blur
and confuse the two quite different ways in which narcotics can cause death: by a deliberate act of suicide and by accidental over-
dosage.
I maintain that suicide is an act, not a disease. It is therefore a moral and not a medical problem. The fact that suicide
results in death does not make it a medical problem any more than the fact that execution in the electric chair results in death
makes the death penalty a medical problem. Hence, it is morally absurd—and, in a free society, politically illegitimate—to deprive
an adult of a drug because he might use it to kill himself. To do so is to treat people like institutional psychiatrists treat so-
called psychotics: they not only imprison such persons but take everything away from them—shoelaces, belts, razor blades, eating
utensils, and so forth—until the "patients" lie naked on a mattress in a padded cell, lest they kill themselves. The result is one
of the most degrading tyrannizations in the annals of human history.
Death by accidental overdose is an altogether different matter. But can anyone doubt that this danger now looms so large
precisely because the sale of narcotics and many other drugs is illegal? Persons buying illicit drugs cannot be sure what they are
getting or how much of it. Free trade in drugs, with governmental action limited to safeguarding the purity of the product and the
veracity of labeling, would reduce the risk of accidental overdose with so-called dangerous drugs to the same levels that prevail,
and that we find acceptable, with respect to other chemical agents and physical artifacts that abound in our complex technological
society.
In my view, regardless of their dangerousness, all drugs should be "legalized" (a misleading term that I employ reluctantly as a
concession to common usage). Although I recognize that some drugs—notably, heroin, amphetamine, and LSD among those now in vogue—
may have dangerous consequences, I favor free trade in drugs for the same reason the Founding Fathers favored free trade in ideas:
in a free society it is none of the government's business what ideas a man puts into his mind; likewise, it should be none of its
business what drug he puts into his body.
<h2>"HERESY"</h2>
Clearly, the argument that marijuana—or heroin, methadone, or morphine—is prohibited because it is addictive or dangerous cannot
be supported by facts. For one thing, there are many drugs, from insulin to penicillin, that are neither addictive nor dangerous
but are nevertheless also prohibited: they can be obtained only through a physician's prescription. For another, there are many
things, from poisons to guns, that are much more dangerous than narcotics (especially to others) but are not prohibited. As
everyone knows, it is still possible in the United States to walk into a store and walk out with a shotgun. We enjoy that right,
not because we do not believe that guns are dangerous, but because we believe even more strongly that civil liberties are precious.
At the same time, it is not possible in the United States to walk into a store and walk out with a bottle of barbiturates or
codeine or, indeed, even with an empty hypodermic syringe. We are now deprived of that right because we have come to value medical
paternalism more highly than the right to obtain and use drugs without recourse to medical intermediaries.
I submit, therefore, that our so-called drug-abuse problem is an integral part of our present social ethic that accepts
"protections" and repressions justified by appeals to health similar to those which medieval societies accepted when they were
justified by appeals to faith. Drug abuse (as we now know it) is one of the inevitable consequences of the medical monopoly over
drugs—a monopoly whose value is daily acclaimed by science and law, State and church, the professions and the laity. As formerly
the church regulated man's relations to God, so medicine now regulates his relations to his body. Deviation from the rules set
forth by the church was then considered heresy and was punished by appropriate theological sanctions, called penance; deviation
from the rules set forth by medicine is now considered drug abuse (or some sort of "mental illness") and is punished by appropriate
medical sanctions, called treatment.
The problem of drug abuse will thus be with us so long as we live under medical tutelage. That is not to say that, if all access
to drugs were free, some people would not medicate themselves in ways that might upset us or harm them. That, of course, is
precisely what happened when religious practices became free. People proceeded to engage in all sorts of religious behaviors that
true believers in traditional faiths found obnoxious and upsetting. Nevertheless, in the conflict between freedom and religion, the
American political system has come down squarely for the former and against the latter.
If the grown son of a devoutly religious Jewish father has a ham sandwich for lunch, the father cannot use the police power of
American society to impose his moral views on his son. But if the grown son of a devoutly alcoholic father has heroin for lunch,
the father can, indeed, use the police power of American society to impose his moral views on his son. Moreover, the penalty that
that father could legally visit on his son might exceed the penalty that would be imposed on the son for killing his mother. It is
that moral calculus—refracted through our present differential treatment of those who literally abuse others by killing, maiming,
and robbing them as against those who metaphorically abuse themselves by using illicit chemicals—which reveals the depravity into
which our preoccupation with drugs and drug controls has led us.
<h2>SELF-MEDICATION</h2>
I believe that just as we regard freedom of speech and religion as fundamental rights, so we should also regard freedom of self-
medication as a fundamental right; and that, instead of mendaciously opposing or mindlessly promoting illicit drugs, we should,
paraphrasing Voltaire, make this maxim our rule: "I disapprove of what you take, but I will defend to the death your right to take
it!"
Sooner or later we shall have to confront the basic moral dilemma underlying the so-called drug problem: Does a person have the
right to take a drug, any drug—not because he needs it to cure an illness, but because he wants to take it?
The Constitution and the Bill of Rights are silent on the subject of drugs. That would seem to imply that the adult citizen has,
or ought to have, the right to medicate his own body as he sees fit. Were that not the case, why should there have been a need for
a constitutional amendment to outlaw drinking? But if ingesting alcohol was, and is now again, a Constitutional right, is not
ingesting opium or heroin or barbiturates or anything else also such a right?
It is a fact that we Americans have a right to read a book—any book—not because we are stupid and want to learn from it, nor
because a government-sup-ported educational authority claims that it will be good for us, but simply because we want to read it;
because, that is, the government—as our servant rather than our master—hasn't the right to meddle in our private reading affairs.

I believe that we also have a right to eat, drink, or inject a substance—any substance—not because we are sick and want it to
cure us, nor because a government-supported medical authority claims that it will be good for us, but simply because we want to
take it; because, that is, the government—as our servant rather than master—hasn't the right to meddle in our private dietary and
drug affairs.
It is also a fact, however, that Americans now go to jail for picking harmess marijuana growing wild in the fields, but not for
picking poisonous mushrooms growing wild in the forests. Why? Because we, Americans, have collectively chosen to cast away our
freedom to determine what we should eat, drink, or smoke. In this large and ever-expanding area of our lives, we have rejected the
principle that the State is our servant rather than our master. This proposition is painfully obvious when people plaintively
insist that we need the government to protect us from the hazards of "dangerous" drugs. To be sure, we need private voluntary
associations—or also, some might argue, the government—to warn us of the dangers of heroin, high-tension wires, and high-
fat diets.
But it is one thing for our would-be protectors to inform us of what they regard as dangerous objects in our
environment. It is quite another thing for them to punish us if we disagree with them.
Dr. Szasz, a contributing editor to REASON, has written widely in books and articles on the subjects of
psychiatry, involuntary mental hospitalization, drug laws, and suicide. Another version of this article appeared in Skeptic
in 1977.
</div>
]]>
</content>
</entry>
<entry>
<title type='html'>The ACLU & Involuntary Commitment</title>
<link href="http://reason.com/archives/1974/04/01/response" rel="alternate"/>
<author>
<name>Aryeh Neier</name>
<uri>http://reason.com/people/aryeh-neier</uri>
</author>
<author>
</author>
<![CDATA[
Response Aryeh Neier 
I have long believed that Dr. Thomas Szasz performs a great service for civil liberties by his opposition to the incarceration of
persons accused of mental illness. However, I think that the service he performs is substantially diminished by his reckless
assaults on those who do not agree with him on every matter. His attack on the ACLU ["The ACLU's 'Mental Illness' Cop-Out,"
REASON, January 1974] is a case in point.
Here are some examples of his recklessness:
(1) Dr. Szasz notes that Ramsey Clark and Karl Menninger are officers of the ACLU's National Advisory Council. He then proceeds
to attack their views on mental commitment. The reader is meant to infer that their views are those of the ACLU.
In fact, while Mr. Clark and Dr. Menninger are members of our 80 person National Advisory Council, the views on mental
commitment attributed to them by Dr. Szasz are not those of the ACLU. The ACLU's policies are determined by an 80 member Board of
Directors. In the more than a decade that I have worked for the ACLU, I do not recall any occasion in which either Messrs. Clark or
Menninger participated in the very extensive discussions on mental commitment that have taken place within the ACLU.
The ACLU National Advisory Council and Board of Directors are both bodies composed of people with diverse points of view. What
any of those people say in their private capacities is not necessarily to be taken as the position of the ACLU. If, for example,
Dr. Szasz happened to serve on the ACLU Board or Advisory Council, I would hope that his support for Richard Nixon in the last
presidential election were not taken as the position of the ACLU and I hope it is not taken as the position of any association with
which Dr. Szasz is affiliated unless the association itself has taken the position.
(2) Dr. Szasz refers to Charles Markmann's book on the ACLU, THE NOBLEST CRY, as an "official history." He then
proceeds to quote this "official history" as the gospel on ACLU activities.
It is not an "official history." In fact, when Markmann's book appeared, I wrote an unflattering review of it objecting both to
its philosophy and to some slipshod treatment of factual material.
(3) Dr. Szasz says that the ACLU has participated in drafting legislation for the civil commitment of persons accused of being
mentally ill. What he does not say is that the ACLU role, in every instance with which I am familiar, is one of trying to
limit civil commitment by seeking more precise criteria for commitment and by establishing due process protections for persons
facing commitment.
There is a school of thought which believes that one legitimizes institutions which should be eliminated by encumbering them
with procedural safeguards. I have some sympathy for that point of view. However, reading Dr. Szasz, one would infer that the
purpose of ACLU participation in drafting mental commitment legislation was to put more people in institutions. The opposite is
true.
(4) Dr. Szasz attacks the ACLU for being enthusiastic about Robinson v. California (1962). He then tells us that in
Robinson the U.S. Supreme Court ruled that "addiction is a disease, whose cure is imprisonment in a mental hospital." The
decision says no such thing. Rather, it says that addiction is a disease and that to put some one in prison for being sick is cruel
and unusual punishment in violation of the Eighth Amendment. The Court noted in passing that compulsory treatment of addiction
might be constitutionally valid.
The ACLU applauds the Robinson decision for its holding that the status of being an addict cannot be criminally
punished. However, the ACLU is opposed to involuntary civil commitment of narcotics addicts; deplores the dictum in
Robinson which tolerates civil commitment; has challenged civil commitment in court; and has testified and lobbied against
civil commitment of addicts before state and national legislative bodies. I personally have testified for the ACLU in flat
opposition to civil commitment of narcotics addicts before at least 8 legislative hearings in the past 7 years.
(5) With respect to alcoholism, the ACLU has opposed both criminal sanctions and involuntary commitment. While we have supported
the creation of rehabilitative facilities, we have insisted that they be voluntary.
(6) Dr. Szasz states that "the ACLU is actually an ideological, and perhaps in part also an economic, captive of the 'liberal'
medical-psychiatric establishment.…" I cannot imagine what he means by that statement. It seems to be impossible for Dr. Szasz to
believe that anyone does not share all his views unless something like financial corruption is involved.
(7) Dr. Szasz refers to an Alabama case, Wyatt v. Stickney. That case established a constitutional right to treatment
for persons incarcerated in mental hospitals.
The ACLU decision to enter that case united two strands of thought that exist within the ACLU. Those who oppose all involuntary
incarceration supported the case in part because it would make incarceration on grounds of mental illness expensive for the state
and, thereby, reduce the number of persons incarcerated. They were also concerned that as long as involuntary incarceration has not
been abolished, inmates of institutions should at least get showers, decent food, changes of laundry, and the like.
Support for the case also came from those who believe that involuntary incarceration can, in certain circumstances, be justified
by dangerousness to self and/or others. They believed that if people are incarcerated it must be with treatment reasonably designed
to lead to their being freed. In addition, they share the elementary humanitarian concern that people held in institutions should
be adequately fed, bathed and clothed.
These two points of view on "right to treatment" are both very well represented on the ACLU Board of Directors. Despite years of
debate on the issue, neither side has been able to command the support to enable it to make its point of view the ACLU's
definitive policy. I am very much troubled by this, as are the members of the ACLU Board. Unfortunately, I do not see the deadlock
being broken at an early point.
However, both sides in the ACLU agree that involuntary commitment should be at most a last resort. In practice, it is
generally a first resort. Therefore we have been able to engage in wide-ranging opposition to involuntary commitments. They
virtually never meet the standards of even those on the ACLU Board who would support some forms of commitment. I am pleased with
what the ACLU has been able to do against involuntary commitment, though I hope we can do a lot more.
Aryeh Neier is Executive Director of the American Civil Liberties Union.
Reply Thomas Szasz 
In my article, I wrote that the ACLU has supported, and continues to support, involuntary mental hospitalization. I did not write
that every one of the 80 members of the ACLU's Board of Directors, or that Mr. Neier himself, personally support psychiatric
incarceration. By asserting that some members of this Board and that Mr. Neier himself oppose such incarceration, Mr. Neier makes
it appear as if I were wrong and "reckless." By this sort of reasoning, one could equally well assert that the American Psychiatric
Association opposes involuntary hospitalization—when in fact it does not—because some of its members oppose it.
Further examples of my "recklessness" are that I failed to mention that the ACLU is seeking "more precise criteria for
commitment" and believes that psychiatric incarceration should be used only as "a last resort." Seeking criteria for commitment
implies that commitment is a morally and legally valid imposition of loss of liberty. As to advocating commitment only as a "last
resort," the American Psychiatric Association also advocates it only as a last resort. I don't know anyone who advocates it as a
first resort. Here, then, Mr. Neier himself supplies the most damaging evidence in support of the thesis of my article—namely, that
the ACLU is intimately wedded to the prevailing psychiatric ideology which seeks to legitimize and regulate procedures for
depriving persons of liberty who have been neither charged with nor convicted of any offense whatsoever.
What I have called the ACLU's "betrayal of civil liberties for mental health" is further illustrated by Mr. Neier's attempt to
justify the ACLU's support of civil commitment in Wyatt v. Stickney on the grounds that the victims of psychiatric
incarceration "should at least get showers, decent food" and so forth. No decent person can oppose such amenities for the victims
of any kind of oppression. But Mr. Neier is working and writing for the American Civil Liberties Union, not the American Red Cross!
I can only regret that Mr. Neier and the ACLU cannot see or do not agree that when a person is unjustly deprived of his liberty,
the moral mandate of an organization ostensibly devoted to the protection of civil liberties is to fight for his release from
captivity, rather than for his comfort in it; and that when it fights over the conditions of his confinement, it inevitably
authenticates the validity of that confinement. When Japanese-Americans were confined in "relocation camps," was it the duty of the
ACLU to fight for their freedom, or for their showers?
Perhaps it would have been more accurate if I had described THE NOBLEST CRY not as an "official history" of the ACLU,
but as an "adulatory history" of it. However, the facts I have quoted from this book are not is dispute. Is this, then,
"recklessness" on my part, or is Mr. Neier's mentioning it—not to mention his mentioning my support of Mr. Nixon in 1972—an attempt
to discredit me when he cannot dispute my evidence?
Mr. Neier also cites my claim that "the ACLU is actually an ideological, and perhaps in part also an economic, captive of the
'liberal' medical-psychiatric establishment," and says that he "cannot imagine" what I mean by it. Had he read the next sentence,
he would have seen just what I mean by it. It reads: "In other words, the ACLU is, in effect, a lobby for the American Medical
Association and the American Psychiatric Association: it is in the interests of these medical guilds that ever-more human
conditions and problems be defined and treated as diseases—and it is this interest that the ACLU serves." This, then, is what Mr.
Neier's rhetoric of "recklessness" comes down to: I am reckless toward the ACLU in making this perfectly valid charge against it,
but he is not reckless towards me in calling the first half of my criticism meaningless, omitting the second half, and topping it
off with a gratuitous slur on my character.
Repeatedly, Mr. Neier refers to what he thinks and what, he did. But my essay was about the ACLU, not about Mr. Neier. I am glad
that Mr. Neier's view on psychiatry and civil liberties are closer to mine than to the ACLU's. This hardly invalidates my criticism
of the ACLU. But it raises a question: Why does Mr. Neier write this letter for the ACLU?
It seems to me, in short, that what I have written about the ACLU is not reckless but embarrassing. The ACLU has no hesitation
in publicizing embarrassing facts about persons whose political policies it opposes; I have none in publicizing embarrassing facts
about the ACLU whose psychiatric policies I oppose. Is this recklessness on my part, or evidence that the ACLU can dish it out but
can't take it?
Thomas S. Szasz is Professor of Psychiatry at the State University of New York at Syracuse. </div>
]]>
</content>
</entry>
<entry>
<title type='html'>The ACLU's "Mental Illness" Cop-Out</title>
<link href="http://reason.com/archives/1974/01/01/the-aclus-mental-illness-cop-o" rel="alternate"/>
<author>
</author>
<![CDATA[
REASON is pleased to present an important new article by Dr. Thomas S. Szasz, one of America's most forthright advocates of
individual liberty. During most of the 1960s Dr. Szasz was the lone voice speaking out in defense of the individual
against the oppression of what is now becoming known as the "Therapeutic State." Beginning with his book THE MYTH OF MENTAL
ILLNESS/A 1961, Szasz advanced the controversial view that what is commonly called mental illness is merely conduct which the
majority finds distasteful and wishes to suppress. Szasz argued that bizarre conduct, so long as it does not interfere with the
rights of others, is no grounds for restricting a person's liberty. From there he proceeded to catalogue the abuses of State
psychiatry in such books as LAW, LIBERTY, AND PSYCHIATRY; PSYCHIATRIC JUSTICE; and THE MANUFACTURE OF MADNESS.
One of the most important civil liberties issues involved in "mental health" cases is the State's unlimited power to commit
people, involuntarily, to institutions. Yet a jail is still a jail, argues Szasz, even if it is called a "mental hospital" and the
guards are called "staff. "It is on this vital issue that Dr. Szasz here takes the American Civil Liberties Union to task.
George Orwell's ANIMAL FARM was rejected by four publishers, mainly because it made Stalin look bad. Since the
watchword among modern liberals, especially in Europe, had long been ''Pas d'ennemis agauche" ("There are no enemies on
the left"), this was simply not done. In a hitherto unpublished preface to ANIMAL FARM, Orwell flailed against this
hypocrisy, and concluded with this ringing denunciation:…it is the liberals who fear liberty and the intellectuals who want to do
dirt on the intellect: it is to draw attention to that fact that I have written this preface." [1]
Orwell's criticism was directed against England, not the United States, where the situation is, indeed, somewhat different,
especially today. Although liberals here too see the mote on the right through a microscope and the beam on the left through
inverted opera glasses, the object of their greatest hypocrisy is not Communism but Psychiatry. Thus, civil libertarians, and
especially the ACLU, refuse to confront the attack upon liberty by institutional psychiatry, and hence cannot take a clear stand
against it. The upshot is that they hedge and fudge and, in the end, come down squarely against liberty and for
psychiatry.
My purpose here is to present a brief history of the American Civil Liberties Union's betrayal of civil liberties. This betrayal
is prompted,in my opinion, by a stubborn effort to avoid direct confrontation and conflict with the psychiatric ideology and
industry.
<h6>THE COP-OUT</h6>
During the first few decades of its existence, the ACLU took no notice of psychiatry and involuntary mental hospitalization.
Once it did, however, it was love at first sight: the Union's immediate response to psychiatric incarceration was to embrace it as
a heaven-sent—nay, science-sent—answer to the problem of social deviance and social control.
In his official history of the ACLU, Charles Markmann relates, with unconcealed pride, how, toward the end of the Second World
War, "The Union…began to draft model statutes for the commitment of the insane.…Twenty years after the first Union draft of a model
bill for commitments to mental hospitals, Congress enacted for the District of Columbia a law closely following the Union's
proposals." [2]
In short, the Union has a fairly long and unqualifiedly disastrous history of uncritically accepting the concept of "mental
illness," whose "treatment," by imprisonment, is then casually delegated to the psychiatric profession.
There were, of course, many reasons for this cop-out then, and why it continues, in attenuated form, now. The popularity and
scientific legitimacy of psychiatric principles and practices is one. The lure of a paternalistic approach to troublemakers, which
sees the psychiatric as against the penological approach to law enforcement as "humane" and "progressive," is another. The third,
the one to which I want to call attention here, is more personal. We know, after all, that organizations do not move by themselves.
They are moved, this way or that, by individuals who have strong convictions and the will to see their convictions prevail. Two
persons who meet these criteria are Dr. Karl Menninger and Mr. Ramsey Clark. These men are not merely defenders, but enthusiastic
advocates, of involuntary mental hospitalization. Dr. Menninger has long been, and Mr. Clark now is, prominent in the ACLU. Their
established positions on commitment, and the historic position of the ACLU on this issue, are, however, now coming into ever
sharper conflict with the opinion of those members of the Union who are no longer afraid to recognize psychiatry's threat to civil
liberties.
<h6>MENNINGER'S VIEWS</h6>
Dr. Karl Menninger is generally recognized as the professionally most respected and politically most influential psychiatrist of
our time. He is a founder of the famed Menninger Clinic and Foundation, a former president of the American Psychoanalytic
Association, the recipient of countless psychiatric awards and honors—and he has long been a Vice-Chairman of the National
Committee of the ACLU.
I summarize below, in the form of paradigmatic citations, Menninger's views on mental illness, crime, justice, and involuntary
mental hospitalization.
<blockquote>
We insist that there are conditions best described as mental illness.…All people have mental illness of different degrees at
different times, and sometimes some are much worse, or better. [3]
From the standpoint of the psychiatrist, both homosexuality and prostitution—and add to this the use of prostitutes—constitute
evidence of immature sexuality and either arrested psychological development or regression. Whatever it may be called by the
public, there is no question in the minds of psychiatrists regarding the abnormality of such behavior. [4]
The very word justice irritates scientists. No surgeon expects to be asked if an operation for cancer is just or not.…
Behavioral scientists regard it as equally absurd to invoke the question of justice in deciding what to do with a woman who cannot
resist her propensity to shoplift, or with a man who cannot repress an impulse to assault somebody. This sort of behavior has to be
controlled; it has to be discouraged; it has to be stopped. This (to the scientist) is a matter of public safety and
amicable co-existence, not of justice. [5]
Eliminating one offender who happens to get caught weakens public security by creating a false sense of diminished
danger through a definite remedial measure. Actually, it does not remedy anything, and it bypasses completely the real and unsolved
problem of how to identify, detect, and detain potentially dangerous citizens. [6]
[In a society properly informed by'behavioral science',] indeterminate sentences will be taken for granted, and preoccupation
with punishment as the penalty of the law would have yielded to a concern for the best measure to insure public safety, with
rehabilitation of the offender if possible, and as economically as possible. [7]
When the community begins to look upon the expression of aggressive violence as the symptom of an illness or as indicative of
illness, it will be because it believes doctors can do something to correct such a condition. At present, some better-informed
individuals do believe and expect this. [8]
Do I believe there is effective treatment for offenders.…? Most certainly and definitely I do. Not
all cases, to be sure.…Some provision has to be made for incurables—pending new knowledge—and these will include some offenders.
But I believe the majority of them would prove to be curable. The willfulness and the viciousness of offenders are part of the
thing for which they have to be treated. They must not thwart our therapeutic attitude. It is simply not true that most of them are
'fully aware' of what they are doing, nor is it true that they want no help from anyone, although some of them say so. [9]
Some mental patients must be detained for a time even against their wishes, and the same is true of offenders. [ 10]
</blockquote>
As these passages show, Menninger divides social sanctions imposed on offenders or alleged offenders into two types:
"punishments" administered with "hostile intentions," and "treatments" administered with "therapeutic intentions." The former are
bad and should therefore be abolished; the latter are good and should therefore be used as widely as possible. Menninger thus urges
that we abandon the legal and penological system with its limited and prescribed sanctions called "punishments," and replace it
with a medical and therapeutic system with unlimited and discretionary sanctions called "treatments." In short, he proposes the
destruction of law and justice—in the name of science and therapy.
In a recent article in THE NEW YORK TIMES MAGAZINE entitled "A Model, Clockwork- Orange Prison," Phil Stanford reported
on the Patuxent Institution in Maryland, an institution which combines the most repressive, anti-civil-liberties aspects of both
prison and mental hospital—the sort of thing Dr. Karl Menninger has advocated throughout his entire professional life. Menninger
knows Patuxent, and he knows what he likes. "Dr. Karl Menninger, perhaps the country's most honored psychiatrist, thinks Patuxent
is a 'great idea'," writes Stanford. "He [Menninger] says,'It's the only one of its kind.…Patuxent is a progressive step forward.'"
[11]
<h6>RAMSEY CLARK'S POSITION</h6>
The other prominent civil libertarian and a leading figure in the ACLU to whose views on psychiatry I wish to call attention is
Ramsey Clark. Mr. Clark is a former Attorney General of the United States, and the Chairman of the National Advisory Council of the
ACLU. I list below a few passages from his best-selling book, CRIME IN AMERICA, which illustrate his views on crime,
mental illness, the indeterminate sentence, and involuntary mental hospitalization.
<blockquote>
Most people who commit serious crimes have a mental health problem. [12]
Poor mental health, alcoholism and drug addiction are present in most crime.…It finally has become clear to the public that
alcoholism is a health problem.…Drug addiction is an illness. Medical science can discover cures and provide care.…Drug users
should be placed in correctional programs that cure and provide the opportunity to stay cured. The user's crime, until it causes
him to commit other crimes, is against himself. When an individual is first found to be a user, criminal sanctions are neither
necessary nor desirable. Where commitment is necessary, civil commitment of a contractual nature offers the opportunity for
physical control over the addict without the stigma of a conviction for crime—and therefore the best chance for rehabilitation.
Voluntary participation, which is the basis for civil commitment, creates an attitude helpful in achieving a cure. [13]
Punishment as an end in itself is itself a crime in our time. The crime of punishment, as Karl Menninger has shown through his
works, is suffered by all society.…The use of prisons to punish only causes crime.[14]
If rehabilitation is the goal, only the indeterminate sentence will be used.…The sentence to a fixed term of years injures
beyond its irrationality.…Indeterminate sentencing affords the public the protection of potentially long confinement without the
necessity that long sentences be served.…The day of the indeterminate sentence is coming.…If we release persons who have the
capacity for further crime, only temporary safety has been afforded. [15]
Behavioral scientists can tell us how to condition violence from our personal capability. Psychiatry, psychology, anthropology,
and sociology hold the key.…We can do this. It is more important than the ABM system to our personal safety. [16]
Malnutrition, brain damage, retardation, mental illness, high death rates, infant mortality, addiction, alcoholism—these are the
principal causes of crime. [17]
</blockquote>
In my opinion, these passages constitute some of the purest and most concentrated extracts of mistake, misinformation, and just
plain bunk that the reader is likely to find in the literature on crime and mental illness! However, it does not really matter
whether the reader agrees with me that these passages constitute Mr. Clark's genuflections before the altar of modern institutional
psychiatry, or whether he regards them as true facts and sound judgments. What matters is that we recognize Mr. Clark's
enthusiastic endorsement of involuntary psychiatric interventions, and especially involuntary mental hospitalization; that we face
the fact of his unqualified support of indeterminate sentences as "rational" sanctions, and of his uncompromising opposition to
fixed sentences as "irrational" sanctions; and that we not deceive ourselves about his utter neglect of the deprivations of civil
liberties inherent in the kinds of confinements he advocates. In short, in a conflict between civil liberty and mental health, Mr.
Clark comes down squarely on the side of mental health—that is, on the side of psychiatric totalitarianism.
<h6>ADDICTION</h6>
The ACLU's position on "alcoholism" and "drug addiction"—these terms being themselves misleading metaphors, implying that the
self-determined uses of certain substances are, by their very nature, diseases requiring diagnosis and treatment by physicians!—is
still another act in the drama of the Union's systematic sellout of liberty for "health."
When it first encountered alcoholism, the Union thought it had met the devil; however, it soon "recognized" that alcoholism was
not really an "evil," but an "illness." "In the preoccupation with loftier matters that characterized its first decade," writes
Markmann, "the ACLU hardly noticed the daily violations of civil liberties and law by which Prohibition was enforced. It has been
suggested that in part this blind spot might well have arisen out of the fact that so many of the Union's early leaders were social
workers, clergymen, and reformers to whom, at least in the abstract, Prohibition seemed genuinely desirable because of the manifold
evils of drink."[18]
This is justifying the ACLU's position on Prohibition, not explaining it. It might be well to recall, in this
connection, that while the ACLU tacitly supported Prohibition, many others—for example, that "arch-reactionary," H. L. Mencken—
valiantly opposed it.
The Union's position on what it calls the problem of drug addiction—but what I think civil libertarians should call the right to
self-medication—leaves one no option but to conclude that the ACLU has never been, and is not now, primarily concerned with civil
liberties at all; but that it seeks instead, under the banner of civil liberties, to transform our relatively open society into one
that is completely closed—that is, into a Therapeutic State.
A landmark decision regarding addiction, supported by one of the most admired civil libertarians in America, and hailed by the
ACLU with unrestrained enthusiasm, is Robinson v. California (1962): The United States Supreme Court here ruled that
addiction is a disease, whose proper cure is imprisonment in a mental hospital.[20] In his concurring opinion, Justice William 0.
Douglas asserted that "the addict is a sick person. He may, of course, be confined for treatment or for the protection of society.
Cruel and unusual punishment results not from confinement, but from convicting the addict of a crime.…A prosecution for addiction,
with its resulting stigma and irreparable damage to the good name of the accused, cannot be justified as a means of protecting
society where a civil commitment would do as well.…If addicts can be punished for their addiction then the insane can also be
punished for their insanity. Each has a disease and each must be treated as a sick person." [21 ]
Evidently neither Justice Douglas nor the ACLU is willing to consider the possibility that neither the "addict" nor the "insane"
is sick, and that—especially from the point of view of civil liberties—the best way to "treat" them would be by leaving them alone.
Furthermore, neither Justice Douglas nor the ACLU is willing to face the inconsistency inherent in their prescription—namely, that
if the addict and the insane are sick, then the proper remedy is to offer treatment to them, rather than to
impose it on them. For surely Douglas and the ACLU must know, as nearly everyone knows, that persons with cancer and heart
disease—and even with gonorrhea and syphilis!—cannot be forced to submit to treatment they do not want. How, then, does the mere
claim of some "civil libertarians" that certain persons are sick justify their further claim that these persons
should be detained against their will? and their still further claim that the persons so incarcerated should be forced to
submit to interventions which they call treatments but which the "patients" call tortures?
The sad tale of the ACLU's support of health, as defined by medical authorities and the society they serve—rather than its
support of civil liberty, as defined by those deprived of it and by common sense—goes on and on and shows no signs of abating.
Summarizing the ACLU's stand on alcoholism, Markmann concludes, in 1965, as follows: "Having made an initial inroad on
entrenched ignorance by the overthrow of the California law making narcotics addiction a crime [referring here to the
Robinson decision], the Union, however belatedly, has begun a similar campaign against the parallel callousness that
treats the alcoholic as the criminal he is not rather than as the sick man he is.…The Union will attempt to bring the law abreast
of medicine and justice. Individual judges in considerable number have long recognized that alcoholism is a disease, but they have
been hobbled not only by the prevailing lack of facilities for its treatment but particularly by the middle-class stupidity that
keeps on the statute books laws that require men of good will on the bench either to violate their oaths by ignoring evidence or to
behave, against all their principles, like Puritan witch-hunters." [21 ]
This, then, is some of the evidence that makes me conclude that the ACLU is actually an ideological, and perhaps in part also an
economic, captive of the "liberal" medical-psychiatric establishment, rather than an independent defender of civil liberties. In
other words, the ACLU is, in effect, a lobby for the American Medical Association and the American Psychiatric Association: it is
in the interests of these medical guilds that ever-more human conditions and problems be defined and treated as diseases—and it is
this interest that the ACLU serves. As such a lobby, it is hardly surprising that the ACLU cannot recognize, much less fight, the
enemies of civil liberties who wear not brown shirts but white coats—who are members not of the Ku Klux Klan, but of the American
Psychoanalytic Association!
<h6>THE ALABAMA CASE</h6>
The latest incident in this brief account of the history of the betrayal of liberty for lunacy by the ACLU which I want to
mention is a suit in which the ACLU and Dr. Menninger met in court.
In the fall of 1970, following the dismissal of a group of employees from an Alabama mental institution, the dismissed workers
and the guardians of the patients sued the State, contending that the staff reduction made effective treatment impossible. This
suit has become something of a cause celebre in legal-psychiatric circles, many civil libertarians celebrating, I think
once again quite mistakenly, the court's support for their claim that hospitalized mental patients have a "right to treatment." I
mention this case here, however, only because it brought together Dr. Karl Menninger and the ACLU in court-testifying against each
other! This scene—and the boundless confusion and hypocrisy concerning psychiatry in the top echelons of the ACLU which it
signifies—deserve, I think, more public exposure than they have received.
The case was tried in the Federal District Court in Montgomery, Alabama, in 1971. the ACLU Foundation was authorized by the
Court to participate as amicus curiae to the same extent as the plaintiffs and defendants, and thus played a major role in
all aspects of the case, including oral arguments. The State of Alabama, the defendant in the case, invited several experts to
testify in its behalf, among them Dr. Karl Menninger. Although Menninger must have known that the ACLU was supporting the
plaintiffs, he chose to testify for the defendants. Here is how his participation is described in CIVIL LIBERTIES, the
official organ of the ACLU:
<blockquote>
Menninger appeared as a witness for Alabama. 'I am very much in disagreement with computer medicine/ he announced. 'Boy scouts
can give treatment.' Menninger claimed, 'Patients need love more than psychotherapy.' He said he would rather have 'more clergymen
than psychiatrists and psychologists.' "
On cross-examination, Attorney Dean revealed that at the Menninger Clinic in Topeka, there is one psychiatrist for every eight
patients. Menninger justified this by the difference in 'economic base', the difference in type of patients and the difference in
services offered. Nobody asked him why persons who are involuntarily incarcerated in state mental institutions should get less
professional care than those who decide to pay their own way in private institutions. [22]
</blockquote>
From the same report we learn that "The ACLU Board of Directors is still polishing its policy on mental commitments. However,
most of the Union's leaders appear to agree on certain minimal standards: Involuntary commitment should be the last resort to which
society turns in dealing with the mentally impaired. Before commitment there must be clear demonstration that the individual is a
danger to himself or herself or to others.…And there must be assurance that the individual who is committed will, in fact, be
treated adequately." [23]
In other words, while the victims of institutional psychiatry are perishing, the ACLU is "polishing." How reassuring. And how
very reassuring that the ACLU no longer refers to mental illness or mental patients! But if there is no illness-
and none is mentioned in the paragraph I here excerpted—then what is there to treat? And how much more reassuring still
that the ACLU insists on "adequate treatment"—for involuntary patients! Would electroshock do? Or is that inadequate, and
would nothing less than lobotomy satisfy the "minimal standards" of the ACLU?
I say: Enough! If the ACLU is still unprepared to defend the civil liberties of Americans accused of "mental
illness," the least it could do is get out of the way—that is, stop justifying and supporting involuntary mental hospitalization—
and let others, not so confused or corrupted or both, defend the victims. If it doesn't, then its acronym should be clearly
understood to stand for the American Civil Lunacy Association—an association for the defense of lunacy, the privileged territory of
the psychiatric mafia.
The masthead of the September 1972 issue of CIVIL LIBERTIES, from which I quoted above, perhaps explains further the
ACLU's consistently confused position of psychiatric matters and its subtly hostile attitude towards the victims of institutional
psychiatry. Among the officers of the ACLU listed on this masthead, the first is its Chairman of the Board of Directors; and the
second is its Chairman of the National Advisory Council: Ramsey Clark. [24]
<h6>CREATIVE PARANOIA</h6>
Zola accused the General Staff of the French Army of deliberately incriminating an innocent Jew as a traitor. Dreyfus's enemies
were, of course, in a bind: since they knew that Dreyfus was innocent, they could be fair to him only by admitting that they were
guilty.
The same considerations hold for the American Civil Liberties Union's relationship to the involuntary mental patient. Since
civil libertarians believe that, within the bounds of the criminal law, people should be legally free to behave as they like, the
Union could be fair to the mental patient only by admitting that it has been wrong or wicked or both.
The moral is that the enemies of civil liberties are to the right—and yes, to the left, also—and above and below, and before and
behind. They are everywhere.
Psychiatrists call such fear for liberty paranoia.
Those who love liberty call it eternal vigilance.
<h6>NOTES AND REFERENCES</h6>
[1] George Orwell, "The Freedom of the Press," THE NEW YORK TIMES MAGAZINE, October 8, 1972, p. 76.
[2] Charles L. Markmann, THE NOBLEST CRY: A HISTORY OF THE AMERICAN CIVIL LIBERTIES UNION (St. Martin's Press, 1965),
pp. 400-401.
[3] Karl Menninger, THE VITAL BALANCE: THE LIFE PROCESS IN MENTAL HEALTH AND ILLNESS (Viking, 1963), p. 32.
[4] Karl Menninger, "Introduction," in THE WOLFENDEN REPORT: REPORT OF THE COMMITTEE ON HOMOSEXUAL OFFENSES AND
PROSTITUTION (Stein & Day, 1964), p. 6.
[5] Karl Menninger, MAN AGAINST HIMSELF (Harcourt, Brace, 1938), p. 69.
[6] Karl Menninger, THE CRIME OF PUNISHMENT (Viking, 1968), p. 17
[7] Ibid., p. 108.
[8] Ibid., p. 207.
[9] Ibid., pp. 260-61.
[10] Ibid., p. 265.
[11] Phil Stanford, "A Model, Clockwork-Orange Prison," THE NEW YORK TIMES MAGAZINE, September 24, 1972, p.71.
[12] Ramsey Clark, CRIME IN AMERICA: OBSERVATIONS ON ITS NATURE, CAUSES, PREVENTION, AND CONTROL (Simon and Schuster,
1970; Pocket Books, 1971; page numbers refer to Pocket Books edition), p. 43.
[13] Ibid., pp. 75-6.
[14] Ibid., p. 199.
[15] Ibid., pp. 202-205.
[16] Ibid., p. 245.
[17] Ibid., p. 322.
[18] Markmann, op. cit., p. 348.
[19] Robinson v. California, 370 U.S. 660, 1962.
[20] Ibid., p. 674.
[21 ] Markmann, op. cit., p. 406.
[22] "The First Landmark: Mental Patients' Rights," CIVIL LIBERTIES, No. 289, September 1972, pp. 5-6.
[23] Ibid., p. 5.
[24] Ibid., p. 4. </div>
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