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Key points
- The moral model seems to encourage prohibition, while the medical model seems to discourage it.
- Addiction is a condition that may benefit from medical treatment but should not be defined by it.
- Policy decisions should take what is best for addicted people and those prone to addiction seriously and put their accommodations first.
It is not a good era for prohibitionists. Cannabis – which has frequently been the object of unsound laws and discriminatory enforcement – is increasingly being decriminalized or legalized in many US states. Psychedelics such as psilocybin have been the target of extensive academic research because of their potentially profound effects on the treatment of mental health disorders. Changes like these suggest a pathway to the gradual reintroduction of drugs whose use has long been severely prohibited.
Alcohol, the original target of prohibition, has not enjoyed a similar renaissance. The mental health effects of alcohol, at least in the medium to long term, are almost universally held to be neutral at best and deeply destructive at worst. Nonetheless, there has been no serious attempt to revive the prohibition of alcohol, a movement that enjoyed widespread support in the United States less than a century ago.
It is worth wondering, at this moment, why anyone was ever drawn to the peculiar institution of prohibition in the first place.
A recent book, Smashing the Liquor Machine by Mark Lawrence Schrad, reminds us that the reputation of prohibition as a fundamentally conservative movement is mistaken. In fact, prohibition and the temperance movement that motivated it was a global progressive movement against those who would profiteer off the misfortune of others. If the practice of prohibition did not always match these lofty ideals, it is worth remembering these motivations. (Some have recalled the impact of prohibition in the United States as far more beneficial than we remember.)
It is also worth considering when evaluating the history of drug and alcohol policy, the place of addiction in these discussions. Different understandings of addiction can yield very different perspectives on these policy debates.
One traditional view is that addiction is a kind of moral failing. Unlike most people, who moderate their use of substances such as alcohol, the addicted person uses these substances immoderately, seemingly without regard for the harm that he may cause to himself or others. Such behavior has struck many people as a form of immorality and has led them to view addiction through a moral lens.
If one thinks of addiction this way, prohibition can seem like a natural policy measure. After all, one of the activities of the state is to prohibit and impose criminal sanctions on immoral behavior such as murder and theft. If substance use is, at least for some people, just another form of immoral behavior, then it could seem to make sense to prohibit it as well.
Nearly all experts now reject this moral model of addiction. In its place, many favor a medical model of addiction, on which addiction is understood as a chronic disease. From this point of view, the prohibition of alcohol or other drugs can seem perverse. If drug or alcohol use is the symptom of a disease, then it seems senseless to prohibit it, just as much as it would be senseless to prohibit the symptoms of diabetes.
Thus the medical model of addiction has tended to be associated with hostility to prohibition. In the medical model, the proper places for responding to addictions are hospitals and clinics, not courtrooms and jails. Prohibition, on this view, is based on an outmoded and unhelpful understanding of addiction.
So the moral model seems to encourage prohibition, while the medical model seems to discourage it. I have argued that both models are wrong: addiction is not a moral failing, but neither is it a purely medical condition like a disease. Rather, addiction is a disability – like blindness or deafness – a condition that may benefit from medical treatment but should not be defined by it.
People with addiction confront certain sorts of limitations – due both to their own acts and also to social discrimination – and the aim of addiction policy should be to accommodate them, just as we provide accommodations for people who are blind or deaf.
When addiction is understood in this way, what should we say about prohibition? I believe the answer is not clear. On the one hand, prohibition can be extraordinarily harmful to people with addictions, especially when it is accompanied by harsh criminal penalties. Certainly, a disability model suggests that the decriminalization of substances, at least for those who use them, is the sensible approach.
On the other hand, prohibition does curtail consumption and the worst consequences of addiction. People with addictions are no less rational than anyone else, and they reduce their use when drugs or alcohol are not available. (This, incidentally, is another reason to be suspicious of the idea that addiction is a disease or compulsion). From this perspective, prohibition is actually a form of accommodation: it makes the world a more livable place for people who are disposed to substance use disorders.
As an advocate of the disability model of addiction, I am less concerned to advocate any particular answer to the question of prohibition than to making a proposal about how these debates should be decided. In deciding drug or alcohol policy, we cannot simply look to what would be best for most people, on average. For disabilities often mandate policy choices that impose costs on the majority in order to respect the rights of a few.
Discussions about whether to prohibit the sale of alcohol should prioritize the fact that a share of the population is prone to an alcohol use disorder and first ask what policy would be best for them.
Similarly, current debates about cannabis legislation should take seriously the idea that cannabis use disorder can be a severely limiting condition and consider what measures would best accommodate it.
Arriving at sensible policy decisions on drug and alcohol use means taking seriously what is best for addicted people or people prone to addiction and putting their accommodation first.
