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date: 27 November 2020

Alcohol and Other Drugs: Public Health Ethics Issues

Abstract and Keywords

This chapter examines ethical principles that guide public health intervention to reduce the harms of alcohol and other drugs, including justice-based concerns regarding intervention. While many egalitarian moral theories support public health measures to reduce these harms, and thereby protect individual capability and opportunity, there are opposing arguments to limit public health intervention based on either individual liberty or personal responsibility. The chapter also reviews ethical issues related to prevention, treatment, harm reduction, and decriminalization/legalization. Prevention through education is politically appealing, but is not always evidence-based and can be stigmatizing. Treatment can be highly cost-effective, but some approaches are controversial, such as legally coerced treatment. Harm reduction approaches, such as needle exchange, can reduce many of the negative health consequences of alcohol and drug use, but they require a more direct government role in illicit behaviors. Marijuana legalization is a growing movement in the United States, but it poses complex regulatory challenges.

Keywords: alcohol and other drugs, public health ethics, justice, treatment, prevention, harm reduction, decriminalization, public health intervention, personal responsibility, needle exchange, marijuana legalization

(p. 511) Introduction

The consumption of alcohol and other drugs (AODs) generates widespread health harms. Alcohol alone contributes 4.6 percent of the global burden of disease (Rehm et al., 2009), and illicit drugs contribute an additional 0.8 percent (Degenhardt et al., 2013). In the United States, drug overdoses (mainly due to opioids) are now the leading cause of injury death (Levi, Segal, and Kohn, 2012), and they are growing. Overdose deaths have been rising in other countries as well (Martins et al., 2015). AODs also contribute to, or exacerbate, health conditions such as cancer. Harder to quantify is the emotional anguish related to harmful AOD use, which affects people using substances as well as their families and communities. For example, children raised by individuals with a serious drug or alcohol problem are at elevated risk for educational and health problems (Lander, Howsare, and Byrne, 2013). Heavy AOD use also contributes to unemployment, homelessness, criminal activity, and poverty (Kasunic and Lee, 2014).

This chapter reviews the ethics of public health approaches designed to reduce the harmful effects of AOD use. These efforts take many forms, including preventing harmful use, reducing the adverse consequences of harmful use, encouraging treatment utilization, and changing the social conditions that give rise to harmful use. Public health approaches extend beyond traditional prevention campaigns or treatment programs to include regulatory policy, criminal justice programs, and social services. This wide reach produces tensions regarding the appropriate scope of public health intervention, especially when such programs encroach on personal choice or privacy.

The chapter examines the normative foundations for public health intervention in AOD use, and then focuses on two types of ethics concerns: those related to the (p. 512) appropriate goals of public health, and those related to the means used to pursue those goals. These concerns prompt key ethical questions, such as the following: What is society’s responsibility to prevent, mitigate, or eliminate harms related to AODs? What burdens can reasonably be imposed on society and on affected individuals in pursuit of these goals?

The chapter will begin by providing an epidemiologic overview of AOD use and presenting broad ethical perspectives. It will then focus on justice-based concerns as they relate to prevention and treatment programs, law enforcement, harm reduction, and legalization. While the primary focus is on the United States, the discussion has relevance to other developed countries as well. Perspectives on AOD policy in low- and middle-income countries can be found elsewhere (WHO, 2014; Degenhardt and Hall, 2012).

The Epidemiology of Harmful AOD Use

About 8.1 percent of US adults have a current AOD disorder, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (CBHSQ, 2015). The large majority (two-thirds) of these individuals have a problem solely with alcohol rather than illicit drugs. An even larger population engages in harmful behaviors that may not meet clinical criteria for a disorder, such as misuse of prescription medications or occasional binge drinking (CBHSQ, 2015). The burden of harmful AOD use is more prevalent among men and, with a few exceptions, among individuals of lower socioeconomic status (Compton et al., 2007). Mental illness prevalence is higher among individuals with an AOD disorder (Compton et al., 2007). A common misconception is that minority populations use AODs more often than do whites; in fact, rates are comparable or lower among minority populations, but they are disproportionately likely to be arrested or incarcerated due to an AOD-related offense (Cook and Alegría, 2015).

Why Averting Harmful AOD Use Promotes Justice

Because of the negative effects of AODs on health and well-being, most accounts of justice support the importance of averting harmful AOD use (the emphasis on harmful is important, because some forms of AOD use may be neutral or, in fact, provide health benefits). John Rawls (1999, 2001) has argued that a just society would incorporate a principle of fair equality of opportunity, which ensures that people from disadvantaged backgrounds are able to pursue opportunities on equal terms with equally talented people from more advantaged backgrounds. Extending this account, Norman Daniels (2008) argues that fair equality of opportunity requires the use of social resources to meet health (p. 513) needs, since failing to meet these needs would lead to unequal opportunity stemming from disease or disability. Health needs may be met by health care or by interventions addressing social determinants of health such as housing and nutrition (Daniels, Kennedy, and Kawachi, 2004). Amartya Sen (1980, 1993) has argued that a just society should be ultimately concerned with a fair distribution of individual capabilities, or the range of things that a person can “be or do.” Similarly, Powers and Faden (2006) argue that public health intervention helps provide a basis for a more just society in part by achieving a level of wellness that enables people to be active and included as participants.

Harmful AOD use diminishes people’s ability to participate in valued activities and to pursue opportunities in normatively important ways. First, it increases the risk of premature death and chronic illness (Whiteford et al. 2013), thus shortening the time individuals have to pursue life projects, while also causing physical limitations that may interfere with meaningful activities and self-care. Second, intoxication and addiction impair the capacity of individuals to exert self-control, make decisions, and express their preferences. Impulsive choices—such as stealing from family to support an addiction—may contradict people’s own deep desires (e.g., the desire to maintain healthy relationships). Third, harmful AOD use often leads to conditions of social disadvantage and marginalization (Room, 2005), which can reduce the ability of individuals to sustain themselves financially and to maintain valued social connections.

AOD use not only affects those using the substance. A pedestrian may be fatally struck by a drunk driver. Family members are harmed when a family breadwinner loses his or her employment due to addiction. Widely diffused harms include medical spending and losses in economic activity due to reduced productivity.

As described below, harmful AOD use can be prevented or mitigated, which can improve individuals’ capabilities and prospects of pursuing opportunities. To the extent that justice requires improving individuals’ capabilities and prospects, individuals who would benefit from policies that reduce AOD harms—either caused by their own or others’ use—have a justice-based claim to social assistance. Efforts to avert harms from AODs include preventing people from initiating harmful use, treating harmful use once it arises, enforcing laws that keep others safe, and creating a legal environment that supports public health goals.

The Role of Personal Responsibility

Arguments framed in terms of personal responsibility contend that harmful AOD use is to some extent voluntary, and that this voluntariness limits individual claims to social assistance. Hard-line versions of this argument would argue that society should not “bail out” individuals who make unwise choices, even when the stakes are life or death (Miller, 2016). Others argue that while society should not entirely abandon those suffering from addiction, it may take personal choice into account when deciding how to confront addiction or prioritize scarce public health resources (Satel and Lilienfeld, 2014).

In a classic argument, Richard J. Arneson (1989, 2004) distinguishes inequalities arising from the “natural lottery” and those arising from personal preferences or choices, judging (p. 514) inequalities due to choices to be acceptable. For luck egalitarians such as Arneson, justice only requires ameliorating disadvantages that stem from unchosen bad luck (such as having a congenital disability that requires use of a wheelchair), but does not require societal amelioration of disadvantages that result from individuals’ judgments, preferences, or free choices.

If the luck egalitarian position argues that assistance is limited for diseases or injuries that occur because of lifestyle free choice (Roemer, 1993, 1995), this raises into question the degree to which AOD use is voluntary and to which individuals can control whether their use will harm themselves or others. Related, even if initiating AOD use is voluntary, becoming addicted surely limits free choice and, on some accounts, calls into question whether this limited choice also limits personal responsibility.

Resolving these questions in practice is murky because many (but not all) key risk factors for AOD use are outside of individuals’ control. Low-resource neighborhoods and poverty increase risk factors for harmful AOD use and increase the stakes of harmful use (such as incarceration or job loss) (Caton et al., 2005; Fergusson, Horwood, and Woodward, 2001; Alexandre and French, 2004). Much of the variance in risk of addiction can also be explained by genetic factors; in studies of twins adopted into different family environments, shared genetics accounted for as much as 60 percent of the risk of developing alcoholism (Kendler et al., 1992; Prescott and Kendler, 1999). Finally, as mentioned earlier, addiction is an illness characterized by a loss of personal control. A growing body of research in psychology and behavioral economics emphasizes that addiction may be literally irrational—in the presence of intense cravings, individual decision-making may be substantially dominated by a “hot” reactive self rather than a “cool” deliberative and reasoning self (Kalivas and Volkow, 2005; Everitt and Robbins, 2005; Hyman, Malenka, and Nestler, 2006). Thus, even if it were determined that there is some element of personal choice in initiating AOD use, people who have addictions may have diminished control over when, and how much, they use.

Fully withholding assistance to those harmed by AOD through their own choices may seem overly harsh, or indeed counter to principles of justice such as social solidarity. Following Shlomi Segall (2010), some luck egalitarians may adopt a pluralistic view that does not entirely withdraw support from those with AOD-related disadvantage, but rather assumes that personal responsibility is one of several bases that can be used to determine resource allocation, and could therefore assign less (but at least some) priority to people who are harmed through their own choices.

Prevention through Screening, Education, and Awareness

Preventing harmful AOD use can take many forms—including taxation, broad-based social programs, and other drug control policies (described further in subsequent sections)—but the focus in this section is on prevention through educational and (p. 515) awareness campaigns. For an intervention to be ethically justified, it should be (among other things) effective (Childress et al., 2002). Many prevention campaigns, however, have been shown to be ineffective. For example, the DARE (Drug Abuse Resistance Education) campaign aimed at US school children had little positive effect on preventing AOD initiation (Pan and Bai, 2009). By contrast, other prevention strategies have shown effectiveness, including programs to build psychological skills such as resilience to resist harmful use (Griffin and Botvin, 2010).

Screening, often used as a means of identifying individuals to receive education or other prevention programs, poses its own ethical challenges. One challenge is that screening—outside of the doctor-patient relationship—can intrude into individual privacy. For example, workplace screening may involve collecting information on illegal behaviors that could raise concerns of bodily privacy (to obtain urine or blood samples) or informational privacy. In some cases, such screening can result in dismissal from a job. Finding ways to implement screening in settings where individuals may benefit while assuring necessary privacy is a critical challenge. Relatedly, there are challenges to making participation in prevention programs confidential, especially when these programs occur in workplaces or schools. Individuals may also be reluctant to participate in prevention programs if their status as “high risk” is visible to others. While these concerns may be mitigated in practice, concerns about privacy and stigma could constrain how policymakers target high-risk populations.

Treatment

Most people with current AOD disorders do not receive treatment (CBHSQ, 2015). While a large segment of people recover without any treatment (“spontaneous remission”), treatment can be a highly effective tool for reducing harmful use (Price, Risk, and Spitznagel, 2001). Indeed, some have demonstrated that treatment can “pay for itself,” with every dollar invested in treatment resulting in several dollars of reduced social spending (Ettner et al., 2006). However, treatment programs are difficult for many people to access and are largely disconnected from the medical system, a legacy of the historical marginalization of treatment. Outside of medically oriented programs, many people access treatment through self-help programs or the criminal justice system (Smith and Strashny, 2013).

Many individuals in treatment are legally required to participate, which also raises ethical concerns. First, individuals in court-ordered programs have constrained treatment choices compared to other medical patients. However, coerced treatment has been justified on the basis that most individuals with severe addiction would like help achieving sobriety, but need an extra “nudge” to stay committed to a program. Receiving treatment in an outpatient program is less disruptive, and ultimately more productive, than the alternative of incarceration. Second, physicians who care for patients legally coerced into treatment can be asked to report on a person’s progress and to divulge sensitive (p. 516) information about drug use, such as the results of urinalysis drug screens. Physicians must ordinarily obtain patient consent to cooperate with law enforcement before initiating care, but the ability to obtain truly free consent can be limited since that consent is obtained under coerced conditions (i.e., where the alternative is jail). In extraordinary circumstances, where obtaining consent may be impossible (e.g., a patient with drug-induced psychosis), some treatment may be justified in order to reduce risk to the patient or to others.

There are also deep philosophical disagreements about how best to help individuals with harmful AOD use. These disagreements concern not only scientific debates about which treatments are effective, but also about whether it is appropriate to focus on the character of a person in recovery. “Tough love” treatment programs, in which patients are asked to inform upon, and sometimes punish, fellow patients who deviate from rules, were once popular, but they have now fallen into disrepute. Self-help programs are much less controversial, but some people object to the perspective that people are powerless in the face of their “disease” and must submit to a higher power to overcome addiction. These ideas are not grounded in the medical understanding of addiction, but they may nevertheless be valuable to some people (Humphreys et al., 2004). On the other end of the spectrum, methadone maintenance for opioid use disorder—which has very strong medical evidence—is rejected by many in the self-help community as an addiction by other means (Stancliff et al., 2002). Individuals in methadone maintenance do become physically dependent upon methadone (an opioid), but such treatment is appropriately described as “normalizing” because it helps individuals to maintain functioning and reduces cravings for harmful drugs like heroin. Since restoring normal functioning is a key goal of treatment, this trade-off should be viewed as more than acceptable.

Coercion and Law Enforcement

The United States’ legal response to AOD use has led to an increase in imprisonment, the most significant restriction of liberty. The rise in imprisonment is a direct consequence of the “War on Drugs,” with a surge in incarceration, including mandatory sentences for possession of small quantities of drugs, since the 1970s (Chanenson and Berman, 2007). Incarceration has serious and wide-reaching negative health consequences. African Americans in particular are at substantially greater risk of imprisonment (Western and Pettit, 2010). Prison is bad for the health of the prisoner (increasing the risk of infectious diseases and mental health problems) and often bad for the health of the prisoner’s family (Massoglia, 2008; Turney, 2014; Schnittker et al., 2015). The racial disparities resulting from mass incarceration, on their own, raise questions about the fairness of criminal justice policies (Alexander, 2010).

The many health harms of incarceration raise questions about whether there is any public health justification for incarcerating people for low-level AOD offenses (as distinct from those who distribute drugs). Renewed calls for decriminalizing drug possession (p. 517) are motivated by a desire to reduce the ill effects of incarceration. It is important to note that decriminalization—reducing or eliminating criminal sanctions for drug possession—is different from legalization (discussed further below). For example, marijuana has been decriminalized in twenty-one US states (as of 2016) (NCSL, 2016), but it is illegal to possess marijuana in most of these states. Countries such as Portugal have decriminalized harder drugs. Keeping people out of correctional settings and mitigating the harmful effects of a criminal record are positive effects of decriminalization.

However, there are legitimate concerns about increasing the scope of decriminalization—including normalizing the use of illegal drugs and reducing deterrence. Decriminalization also may eliminate the legal enforcement that leads many people to receive treatment. Many AOD users on their own will not be motivated to seek treatment for their harmful drug use, and individuals in coerced treatment are more likely than others to complete treatment (Saloner and Cook, 2013). That said, coerced treatment involves deprivations of liberty and may not be cost-effective when delivered in a broad, untargeted manner (Kleiman, Caulkins, and Hawken, 2011). One promising model for coerced treatment involves programs that place offenders into programs with swift and certain criminal sanctions for violating drug-testing requirements, but that limit jail time to short periods (such as weekends) for violators. Those successfully meeting sobriety benchmarks can receive reduced judicial supervision, until they are finally released from the program. This model has been successfully implemented in Hawaii (the HOPE program) (Hawken and Kleiman, 2009) and in South Dakota for drunk drivers (the 24/7 program) (Kilmer et al., 2013). Such approaches are ethically appealing because they involve a more delicate and contextually specific use of incarceration while preserving individuals’ ability to pursue meaningful lives outside of the criminal justice system.

Harm Reduction

Harm reduction encompasses a broad range of approaches to reducing the harmful effects of AOD use and may overlap with the goals of treatment. The most visible and controversial strategies include needle exchange programs, safe consumption sites, and supervised administration of clinical-grade heroin (now provided on a limited basis in Switzerland, Canada, and other countries).

Other programs that permit AOD use among people participating in employment or housing programs are also controversial. The more moderate examples are “work first” and “housing first” policies that do not require individuals to be abstinent to participate in subsidized housing or employment programs (Collins et al., 2012). Many of these approaches have been shown to be effective (Lurie et al., 1993; Padgett, Gulcur, and Tsemberis, 2006). On the other end of the continuum, Amsterdam has a program that employs individuals with alcohol use disorders to work as street sweepers and pays them in beer (Holligan, 2014). Such a program is ostensibly justified in that it reduces idleness in this group, provides them with a sense of self-worth, and may substitute (p. 518) beer for other even more harmful alcoholic beverages, but the effectiveness of such approaches is not well-evaluated.

In whatever form they take, harm reduction efforts can be justified on straightforward consequentialist terms—providing these programs increases the well-being of AOD-using individuals, and society more broadly, by preventing the bad health outcomes that accompany AOD use (without necessarily reducing substance use). These programs, it is argued, have little downside, since they improve the well-being of people who are not otherwise willing or able to fully abstain from use. If someone is not prepared to stop injecting heroin, their health trajectory can still be improved by ensuring that they have access to safe needles and to naloxone, the medication to reverse an overdose. To reduce stigma and increase acceptance, harm reduction programs often deliberately refrain from making any moral judgments about the “badness” of AOD use, although most are deliberately linked with treatment programs and provide education about treatment. Nonetheless, making commitments to quitting is not a requirement of harm reduction. Moreover, harm reduction programs can have secondary benefits through reduced disease transmission and prevention of other harms to others, and thus may advance other justice-based concerns.

One objection to harm reduction is that it creates conditions that enable continued AOD use and do not necessarily improve an individual’s productivity or quality of life. By reducing the health costs of using drugs—such as blood-borne infections or the risk of overdose—one concern about harm reduction is that it neutralizes risks that otherwise encourage quitting (MacCoun, 1998). Harm reduction could also reduce the perceived harms of initiating drug use for children and adolescents to the extent that harm reduction normalizes the behavior. There is some evidence that this may be true for marijuana decriminalization (Pacula, 2010), but research is scarce for “harder” drugs. Moreover, harm reduction as provided in public health interventions generally includes counseling and referral to treatment programs. Even if concerns about normalization were well founded, the government—and affected individuals themselves—arguably has a strong interest in reducing the harmful social ills related to illegal drugs, especially in reducing the transmission of human immunodeficiency virus (HIV), hepatitis C virus, and other costly infectious diseases, and harm reduction could be integrated with treatment to foster long-term health improvement.

Some people may object that harm reduction is problematic despite its potential to improve health. On this view, social programs (especially those funded with government resources) have a duty not only to promote health, but also to represent the values of a good society, including respect for the law and concern for individual dignity. This public role is incompatible with harm reduction programs, which, it is argued, do not go far enough in rejecting behaviors that diminish individual dignity or condone criminality. This view presupposes both that there exists a sufficiently well-developed conception of public morality to draw a bright line between acceptable and unacceptable practices, and that the government has a more compelling interest in advancing that public morality than it does in protecting the public’s health (Keane, 2003). In response, it might be argued that public sentiment is contaminated by prejudices that make it unreliable—for example, (p. 519) lesser criticism of alcohol compared with other drugs is interwoven with racial and socioeconomic biases, and does not necessarily reflect clear or objective moral standards.

Legalization, Taxation, and Regulation

Long seen as a utopian (or dystopian) fantasy, drug legalization is no longer hypothetical. As of this writing, growing, selling, and consuming marijuana for recreational purposes is permitted by eight US States and the District of Columbia and is legal for medical purposes in most states, though it remains illegal under federal law. Many arguments are raised in favor of legalizing at least some drugs: legalization provides a framework for regulating the safety and supply of drugs, imposing age requirements for buyers, maintaining standards for purity and potency, mitigating violence in illicit markets, and the collection of revenue through taxes, which can be used to fund treatment programs.

Legalization can encourage use and misuse of AODs, however. While prohibition of alcohol in the United States was a complete failure, alcohol also provides a cautionary tale about the dangers of low taxes and a weak regulatory framework. Despite clear evidence that advertising increases demand among underage consumers (Saffer and Dave, 2006), marketing restrictions have remained weak. Taxes on alcohol products are low relative to the costs their misuse imposes on society (Kleiman, Caulkins, and Hawken, 2011), and the most harmful products are the least expensive. Moreover, there are well-known problems of enforcement, including rogue retailers that continue to sell to underage buyers. Such concerns could be abated, but not entirely avoided, with higher taxes and greater enforcement. However, the regulatory frameworks guiding legalization are not substantially guided by public health evidence, as other stakeholder groups and industries eager to profit play an important role in maintaining an environment with easy access.

Legalization thus requires balancing very different harms and benefits. As mentioned, one purported benefit of legalization is that it enables greater control over price, supply, safety, and access than exists in illicit markets. The health benefits of regulation could be varied and include reducing environmental harms that arise through illegal cultivation, curbing street-level violence, and discouraging heavy use through quantity or place of sale restrictions. Health benefits aside, many see legalization as desirable because it gives more people something that they want—just as responsible adults experience pleasure from consuming cocktails, there are welfare gains to allowing responsible adults to engage in moderate marijuana use. How to weigh these benefits against the compelling interest in protecting the most vulnerable—children, people with a propensity for addiction, and those residing in communities that will be adversely affected by legalization—is unlikely to be a settled question on many theories of justice. In the absence of a clear answer from the standpoint of justice, there is value in pursuing some cautious and (p. 520) controlled experiments in legalization, but these experiments should be evaluated with strong monitoring of unintended health consequences.

Conclusion

Much to the disappointment of temperance crusaders, there will almost certainly never be a future free of AOD use. AOD use is deeply embedded in current social practices, and drugs and alcohol are a source of great pleasure for many individuals. This chapter has surveyed a variety of approaches that could be used to either constrain the spread of harmful use or treat individuals with AOD use problems.

Most strategies involve some regulation of individual choices, and rarely is the government able to remain entirely neutral in its approach to determining which AODs are permitted. This is not a new problem. For example, governments have, for some time, expressed a greater tolerance toward alcohol and its associated harms than toward other addictive substances. The public health perspective is valuable within these debates because it draws policymakers’ attention toward the objective impact of different AODs on population health, and particularly on the health of vulnerable subgroups. Public health research also demonstrates the dangers that come with stigmatizing addiction or the unintended consequences of driving certain behaviors underground. Though health impacts alone will not resolve social debates, public health provides one of several valuable voices in a fractious and impassioned public discourse.

Acknowledgments

Excellent and extensive comments were provided by Nancy Kass, Govind Persad, and Kenneth Stoller. Christian Morales provided additional excellent comments and editorial assistance. Any errors or omissions are the author’s sole responsibility.

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