Monday, 27 February 2017
Thoughts on the surgeon general’s report on addiction
by Theodore Dalrymple
Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health begins with the modern American equivalent of the Catholic Church’s nihil obstat, the ecclesiastical certification that the book to which it attaches contains nothing morally or doctrinally objectionable:
Apart from the fact that this leaves open the possibility of discrimination on grounds of religion, and mistakes the aspiration for the achievement, the HHS then proceeds to discriminate on the very next page after this ritual incantation. It provides a list of languages with which readers may seek, free of charge, help in translation of the report: Spanish, Chinese, Vietnamese, Korean, Tagalog, Russian, Arabic, Haitian Creole, French, Polish, Portuguese, Italian, German, Japanese, and Farsi. But why not Somali, Amharic, Tigrean, Tamil, etc.? It can only be because someone has chosen to discriminate.
It is hardly to be expected that difficult thoughts will follow the report’s unctuous beginning. The Secretary for Health and Human Services during whose term of office the report was written, Sylvia Mathews Burwell, provides a preface to it, in which she writes:
In other words, there is no relevant moral or typological difference between, say, Parkinson’s disease and addiction: a point of view that, implicitly and without recognition perhaps, is contradicted by much of what follows in the report itself. The secretary continues:
It seems rather curious, then, though not strictly contradictory, that in the next preface, by Kana Enomoto, Principal Deputy Administrator of the Substance Abuse and Mental Health Administration (a somewhat Owellian-sounding organization), we are told that:
In other words, the greater our understanding and the more tools we have, the worse the problem grows. Of course, it might be that we fail to use our greater understanding and tools effectively, but it might also be that our greater understanding is nugatory and that the tools are not as useful as supposed. The HHS secretary makes one further point:
That the Act might be wrong in principle (though right in point of political correctness), and be in practice an open invitation to endless fraud, does not enter the secretary’s mind even as a possibility. As for addiction equity, might it not boil down to “I take the drugs, you pay for the consequences”? The surgeon general himself, Vivek H. Murthy, says in his preface:
I note in passing Murthy’s belief that to recognize a character flaw in others is automatically to deprive them of compassion, though it is also possible that the recognition of flaws in others is essential to our recognition of their humanity, that is to say, their likeness to us. Treating others as moral beings is not the same as unfeeling censoriousness. But even worse is the surgeon general’s totalitarian project to make us all think alike, even though the content of what we must think is highly disputable. Here, for example, is a quotation from an article titled “The brain disease model of addiction,” written by three eminent researchers in the field, published in 2015 in the Lancet Psychiatry:
In other words, we must all be led, according to the surgeon general, to think what might not be true, could possibly be a lie, and can certainly be disputed; and it is the job of the surgeon general to lead the leaders in this dubious enterprise. A quick reading of J S Mill’s On Liberty might prophylactically have curbed his imperative mood.
After the prefaces come the acknowledgements. According to my quick count, there were 169 contributors to, and editors of, the report. This is probably more contributors than to Diderot’s and d’Alembert’s Encyclopédie. The sheer number of experts involved in compiling the report acts, whether intentionally or not, to intimidate potential critics: for how could one casual reader stand against so many of the great and good?
It is not that the report contains no useful information or makes no sensible suggestions. But it sometimes misses, or avoids commenting on, interesting things even in its own data. A graph shows that the only drug that has seen increased use proportionate to population in America is marijuana, and that this increase started with President Obama. We must remember, though, that it does not follow that a caused b because b came after a.
There is much evidence in the report that its own basic outlook is mistaken. For example, alcoholism and binge drinking in America have not become less prevalent since the 1980s, but the number of fatal road accidents caused by alcoholics and binge drinkers has halved. It is possible that factors such as better brakes or roads have played a part; but it seems to me likely that the most important factors have been consistent propaganda and police enforcement, factors that prove that alcoholics and binge drinkers continue to be moral agents who make decisions, their drinking notwithstanding.
Many people with what the authors call substance-use disorders do not seek treatment. The reason why 40 percent of them fail to do so is as follows:
But it is a frequent occurrence that such people do eventually seek treatment (or give up their drug use spontaneously), after further abuse that might, on the argument above, have been expected to induce yet more changes in the brain circuits that control impulses, motivation, and decision-making. And unless we suppose that there is no connection at all between between man as a purposeful, thinking being and man as a physical being, all behavior whatsoever—for example, being nice to one’s favorite aunt—must have at least a neurobiological correlate. But there is no being-nice-to-one’s-favorite-aunt disorder, whatever changes to the brain being nice to one’s favorite aunt might entail.
In the last three years alone, almost as many Americans have died as a result of opioid overdose as have been killed in all American military actions since the end of the Second World War. The evidence suggests to me that this “epidemic” started with, and has been maintained by, the irresponsible, incompetent, and sometimes corrupt prescribing of opioids by a portion of the American medical profession. But this does not altogether absolve the patients themselves of responsibility for their predicament—unless no one is ever responsible for anything.
Toward the end of the surgeon general’s preface to his report, Murthy writes:
The analogy, alas, is far from exact. It is as if I were to write a play about a man’s inability to make up his mind and say that 400 years ago, Shakespeare wrote Hamlet.
First published in City Journal.
Posted on 02/27/2017 5:53 AM by Theodore Dalrymple
27 Feb 2017
Portugal decriminalized personal drug use and the result has been a huge decrease in HIV, addiction and has freed up the cops to go after bigger fish. One tool has been the use of dissuasion panels. As John Sturart Mill once said, no government has the right to protect a man from himself, but maybe it can talk him out of it.
28 Feb 2017
The only moral judgment now permissible is to be against moral judgment. But judge we do. Man is a moral animal and our ability to make moral judgments makes us human. Compulsive, immoderate use of substances is inherently a moral issue, whether or not it is permissible to say so.