XIII Some Matters of Perspective (I)
Given a society without unlimited resources, the amount of money and effort that can be invested in an attempt to cope with a problem depends on how grave it is in comparison to other problems which also demand money and effort. As a first approximation of the justifiable investment, we might allocate the available resources proportionately to the, assessment of the gravity of the problems, subject, of course, to the qualification that no problem will be assigned a larger share of the resources than is necessary to cope with it.
It is likely that the resources thus allocated to some problems will be less than adequate. We must then confront the question of whether the returns to be expected from an inadequate investment justify any investment at all. That is, the returns are not necessarily proportionate to the size of an investment, and the expected returns from an inadequate one may be so disproportionately small, either in absolute terms or in relation to the magnitude of the desired effect, that a sound, businesslike approach would compel us to concede failure in advance. We may, of course, hope that the problem will, in time, solve itself, as many problems do; but, in any case, we would delete such problems from our list and either reallocate the available resources to the remaining problems or simply reduce the over-all expenditure.
Let us, for the sake of argument, assume that drug addiction poses such a problem. The per-patient cost of running a hospital facility for teen-aged addicts such as Riverside Hospital is extremely high (especially if we were to include the cost of the special school which is part of the total operation), and the percentage of patients who are "cured" (i.e., who will not relapse) on discharge is extremely small' To a hard-headed businessman, such a state of affairs represents a compelling argument that society must be prepared to live with the problem and to permit the addicts to die with it, without any wastage of society's precious resources.
Such economics are simple. The issue, however, is not quite so simple. There are returns from an investment other than the direct payoff. If the purpose is firm enough, there is the pleasure of tilting at windmills, the excitement of mobilizing one's puny resources against the challenge of seemingly hopeless odds. There is the sure knowledge that the record of human progress is, in large measure, a history of setbacks to the apparently impossible. There is the sense of vitality that comes with the tightening of belts to make available greater resources in the service of dedicated purpose; resources do not come in fixed quantities, but in proportion to the intensity of the will that deploys them. There is the uplift that comes, even in defeat, from the assurance that one has striven nobly and given of one's utmost in the service of a cause one believes in, even though one may have judged the initial entrance to the lists to have been foolhardy.
Conversely, there is the sheer debilitating consequence of a society's readiness to bow to its vision of the dreadful inevitable or to shape its every will according to the decisions of carefully computed coefficients of risk.2 Surely, a society that dares not defy the impossible and that sets numerical values to the lives and essential dignities of human beings is, at least, sick, if not positively moribund. No viable society dares, save under extraordinary circumstances, to set dollars-and-cents or number-of-man-hours values on the lives and dignities of identifiable sectors of its population. Lives may only be balanced against more lives, the dignities of the few against the dignities of the many and even this kind of balancing may only be countenanced in the context of explicit, time-tested governing values and within the limitations of full regard for due process.
Not even the most calloused budget-balancer or meeter-of-payrolls, placed in a position of high public trust, dares abandon human beings to their misery in undissimulated dollars-and-cents terms. If he does make a decision that is, in effect, one of abandonment, the human consequences of this decision are entirely evaded (that is, one talks about anything but the people involved; e.g., "The trampled park grass is a blight on our city"); rationalized in high-sounding terms (e.g., "They will, in the long run, develop greater maturity, responsibility, and happiness if they are compelled to work out their problems by themselves"); justified as proper punitive measures (e.g., "The mother with one illegitimate child may be forgiven her transgression and must be helped; but, if the offense is repeated, she has to be taught to mend her ways"); or supported by some combination of such maneuvers (as, in the last instance, resolutely ignoring the question of what happens to the innocent second or third out-of-wedlock child).
In practice, the degree of investment in a problem of society will be determined by a more-or-less (mostly less) scientific weighting of each need in the total array of competing social needs (the weights being determined, on the one hand, by some kind of scaling of the intensities of the needs and an estimate of the probable effectiveness of the uncommitted resources that can be brought to bear and, on the other hand, by the evocation of the sense of challenge and the arousal of the social conscience). The process is, in essence, a rational one, involving as it does a balancing of competing considerations; but the outcome is not necessarily the most valid.
The scaling of the intensity of competing needs is typically a matter of the number and location of voices raised, of who can shout the loudest (and get the maximum amplification for his voice through the media of communication) and into the most strategically located ears, rather than one of careful diagnosis. The assessment of the probability of success typically rests only on crude impressions gained in the course of experience, and there often is no directly relevant experience on which to base estimates of the probable effectiveness of alternatives of action.
And, alas, the spirit of high adventure that is ready to take on all corners in a challenging-enough cause and the social conscience that can enlist such a spirit are all-too-readily lulled by superficial activities that are known to be ineffective, but that generate the illusion that society is trying to meet its obligations and that the social conscience is functioning. Or the spirit of high adventure and the social conscience are all-too-readily aborted by the failure to recognize genuine suffering, by the mistaking of some reactions to suffering as wickedness, and by high-sounding formulas that seem to be compelling as long as one does not come into proximity with the areas of suffering. The fortunate can live at peace with themselves, secure in the fiction that that which needs to be done is being done, perhaps even being done to excess.
The problem of drug addiction is a case in point. The gravity of the problem has, to our minds, been grossly misassessed, not so much in terms of the investment in it as in terms of the gains which the investment is calculated to achieve. Judging from the deployment of efforts, from policies adopted, from the emphases and conclusions of legislative commissions of inquiry, from statements made by responsible individuals in testimony before such commissions of inquiry and in the public media of information, the major goal is to suppress the problem, rather than to deal with its causes.
Take one trifling illustration. A highly knowledgeable physician in this field, when asked about the possibility of rehabilitating addicts while maintaining them on drugs, responded that it was his responsibility as a physician "to cure people, not to keep them sick." Knowing something of the background of this man, it is difficult for us to believe that he meant what he said; we must rather assume that he was carried away by the atmosphere of the inquiry. Certainly, no physician would express a similar attitude with regard to diabetic patients, who must be maintained on insulin or on one or another of the recently developed substitutes. Nor would any physician refuse to prescribe a prosthetic device for a physically disabled patient on the ground that such a device maintains the patient with his disability and is in no way calculated to cure him. We are not at the moment concerned with the issue of whether addicts can or should be rehabilitated while maintaining them on drugs; we are concerned with the ease with which knowledgeable and sensible people yield to the forces of unreason in the context of the drug-addiction problem.
It is as though opiate addiction were per se so horrible and menacing an evil that one hardly dares entertain any thought but that of eradicating it by whatever means come to hand. Yet opiate addiction is, in itself, neither so horrible nor so menacing. In Chapter XIV, we shall develop the thesis that by far the most horrible consequences, personally and socially, are directly traceable to its de facto illegality,3 and we shall note, in passing, that the incontinent use of opiates is far less dangerous, both personally and socially, than that of alcohol, a drug the use of which has also been the object of a now-largely-abandoned repressive approach. We are not, of course, saying that drug addiction is a good thing, and we do regard its occurrence as a social problem.
The most rational roots of the image of opiate addiction as a menace are the beliefs that it is a virulently contagious disease and that it is a major cause of crime. Let us first consider the issue of crime. There can be no question but that large proportions of metropolitan-origin jail and prison populations are or have been drug-users; many of these are certainly addicts, although no estimate can be made at this time of how many would meet some specified criterion of drug addiction narrower in scope than "having a history of drug use." Assume the worst, that all who have been called "addicts" actually are addicts in the worst sense of the term. Would this prove that addiction is a major cause of crime? Not at all.
To begin with, for the present purpose, we cannot count those who are in prisons or jails for direct violation of the narcotics laws. The question at issue is not whether violations of these laws occur, but whether those who violate these laws also commit other kinds of crime. Of those left, we must still discount those who would be in prison or jail even if they were not addicts, including those whose history of addiction is related to their inclination to violate the law rather than vice versa. Of those left after this second subtraction, we must again discount those who would not have committed other crimes and who would not have been led into a life of crime if they had had legal access to narcotics under controlled conditions. How many addicts are then left whose addiction may plausibly be interpreted as a significant causal contributor to their crimes? We do not know. It may, however, be recalled that in Chapter III we showed that, for the period 1949— 1952, there was no increase in crimes committed by boys in their later teens in neighborhoods of increasing drug use in Manhattan, although the areas of highest drug use did show a change in the relative incidences of various types of crime.
In brief, we know of no good reason to believe that the use of narcotics per se increases the absolute volume of crime. Its relationship to crime is complex, but not of a kind that justifies panic or the invocation of the rule of "clear and present danger."
Is addiction a virulently contagious disease? All of the evidence that we have and that we have reviewed in Part One indicates that it is not. The spread of drug use is associated with human misery, not with any intrinsic contagiousness. To be sure, where misery is widespread and narcotics are freely available, addiction may be said in a sense to be contagious, that is, to individuals whose resistance is extremely low. Even so, there was only one census tract (a few square blocks) in New York City where as many as 10 per cent of the late-teen-aged boys became involved, in one way or another, with narcotics in the course of a four-year period.4 Ninety per cent of the boys did not become noticeably involved with narcotics in the four-year period. Even if we were to interpret all of the cases in the tract as due to contagion, the degree of contagion is obviously limited.
Does this constitute a threat of a contagion that threatens to engulf society? Additional perspective may be provided by statistics from an earlier period. In 1915, the most responsible estimate5 sets the total number of addicts in the United States at somewhat less than 215,000. This was the year that the Harrison Act went into effect and some years before any serious efforts at enforcement had begun. Up to this time, with the minor exception of smoking opium, opiates could be obtained without prescription at any apothecary's shop. Opiates in significant dosages were common ingredients of widely used proprietary medications. Many physicians prescribed opiates as readily and as lavishly as contemporary physicians prescribe recently developed tranquilizers and other "wonder drugs." If ever the availability of narcotics could threaten a plague, this was the period; and alarmists were numbering addicts in the millions. Against this background, 215,000 addicts does not sound quite so bad as it otherwise might.
Moreover, even this figure must have been based on a fairly loose usage of the term "addicts." The same study reports that, by 1922, a year or two after fairly vigorous efforts at enforcement of the Harrison Act had begun, the number of addicts had declined to about 110,000. In other words, even if one were to make the obviously unreasonable and far-fetched assumption that, for some mysterious reason, there was not a single new case in this entire period in all of the United States, almost half the addicts of 1915 had died or were cured in less than ten years. The figure is simply not credible of addicts with full-blown cravings. It is to be noted, moreover, that at no time subsequent to the passage of the Harrison Act or to the beginnings of its vigorous enforcement was there any evidence of an epidemic of serious withdrawal sickness (and, probably because of the customary dosage levels, the withdrawal syndromes of that period were typically far more severe than they are today), of hordes of desperate addicts descending on beleaguered physicians and pharmacists, of a tremendous upsurge of illegal entry into pharmacies and physicians' offices, or of vast numbers of "dope fiends" turning to fanatical criminal efforts to satisfy their suddenly illicit cravings.
No, drug addiction is not so grave a menace that we can hardly entertain any thought but that of exterminating it. Not, that is, unless we were to anticipate an enormous expansion in human misery and a sense of hopelessness at being able to do anything about the misery; with respect to such a prospect, alarm about the possible spread of drug addiction would seem to be misdirected.
Let us, however, for the sake of argument, assume that the only conceivable approach to the problem of drug addiction is the suppression of traffic in narcotics. On this assumption, is it a good business practice to make the effort? Or would it be sounder to direct the resources that would be utilized in such an effort into efforts to ameliorate other social ills or even not to mobilize the resources at all so that we may achieve the general benefits of a somewhat lessened tax burden?
The issue thus raised is one of the probable effectiveness of measures that may be taken to suppress the traffic in narcotics. Highly relevant here is the economic law of supply and demand. Given large numbers of addicts, we start with a fairly high level of demand. The effectiveness of law enforcement measures lowers the supply. The selling price, and hence the potential level of profit that accompanies the successful evasion or corruption of law enforcement efforts, rises. To the unprincipled traffickers in narcotics, this counterbalances the increased risk and justifies an increased countermobiization effort to evade and corrupt the law enforcement efforts and to increase the market by expanding the number of addicts. The investment in law enforcement then rises, the counterinvestment goes up, and the vicious cycle rolls merrily along. There are, of course, ups and downs along the way—the ups being hailed by those who believe in the law enforcement approach as evidence of the effectiveness of the approach and the downs as evidence of the need for increased effort.
The suppression approach is, of course, not simply one of increasing the number of police officers devoted to catching offenders. It also includes a demand for increasing police powers (which always carries with it increased infringement of the guaranteed constitutional liberties) and increasingly severe penalties (with special emphasis on the death penalty, the exaction of which is not only conventionally considered the supreme deterrent, but is also so much more economical than long prison terms).
It is, however, only a tribute to the integrity of our courts that judges, confronted by the misery involved in individual cases, become extremely reluctant to impose the most severe available penalties and that, the more severe the minimum penalties and the more dictatorial the police powers, the more the judges lean over backward in imposing the traditional burden of proof on the prosecuting attorneys. In other words, the more severe these measures, the more difficult it becomes to obtain convictions. Yet it may be taken as axiomatic that the effectiveness of the punitive aspects of law enforcement depends on three factors: the severity of the punishment, its immediacy, and its certainty. If an increase in one of these factors is offset by a decrease in another, then where are we?
There is another aspect of the law enforcement approach to narcotics which tends to be self-defeating. The structure of the illegal narcotics business is that of a pyramid, or a series of interlocking pyramids resting on the same base. At the bottom of this structure and constituting the vast majority of individuals involved in the business are the addict-pushers. These are usually people impelled to narcotics by their own uncontrollable cravings who would otherwise be unable to support their habit. Consider an enforcement unit which has to justify its existence in the results it can show. Going after higher levels of the narcotics business pyramid, to say nothing of the apex or apexes, is a long, hazardous, and at best uncertain affair. To be sure, a monthly raid or so, netting a large supply of more-or-less pure heroin (measured in ounces or pounds, but impressively valued on the illegal market in thousands or even millions of dollars) and a half-dozen or so culprits is assured of its half-colunm or so in the daily press (but, save when there is a paucity of other news, there is no assurance of a mention in radio or television newscasts). Even so, an annual record of a few score convictions can hardly be impressive when violators of the law are numbered in the thousands.
By contrast, the addict-pusher is a sure bet. All that is needed is to keep an eye on him once he has been released from serving his sentence and, sooner or later, usually sooner, he will be caught selling or at least in possession. This poor wretch does not command the services of high-priced legal talent, and the case is quickly processed through the courts with a minimum of waste of police time. The result is an impressively large record of arrests and convictions for the individual officer and for the enforcement unit as a whole. Inevitably, a large share of the activities of the enforcement unit goes into this kind of revolving-door enterprise—a revolving door for the police as well as for the addict. It is our impression that being caught in a revolving door is not an effective way of going somewhere.
The latest development in the approach that takes as its central goal the suppression of the evil is that of compulsory therapy. The idea is to sentence addicts to indefinite terms of psychotherapy in prisonsturned-hospitals, discharge being contingent on a certificate of cure. Judges, it is expected, should not be reluctant to hand out such sentences, since they are for the benefit of the prisoner-turned-patient. Hardly any thought is given to the question of where the needed therapeutic personnel are to be recruited. Even less thought is given to the question of whether psychotherapy is something that can be administered by force. Or to the question of whether even the willing 'addict patient can benefit from continuous psychotherapy uninterrupted by bouts with the responsibilities and temptations of freedom. Or to the implications of releasing the cured patient to the very conditions in which he succumbed in the first place. Or, for that matter, to the meaning of "cure."
It may be inferred that we do not believe that this method of dealing with the problem has great likelihood of achieving even its own professed goals. No one seems to have yet thought of the possibilities of setting aside sizable territories—separate ones for males and females, of course—bounded by concrete walls and surrounded by shark-infested moats. Anyone suspected of illegal involvement with narcotics could be dropped into such a territory by parachute, as could all of the necessities and comforts of living, including large supplies of tranquilizers (other than heroin, of course) and anaphrodisiacs. Medical care could be provided easily through the physician and nurse addicts. These areas could be patrolled by automated radar and target-finding missile bases to prevent the intrusion of unauthorized aircraft. We could then be certain that there would be no possible spread of contagion from within the pale. Who knows but that such a humane procedure might even work, and it might incidentally contribute to the solution of such other social problems as the population explosion. It might even prove comparatively inexpensive and eventually recommend itself for application to sex deviants, multiple offenders, and witches.
Pending the adoption of such a procedure, however, the suppression approach is not good business. But what of the challenge of the problem, the do-or-die attitude, and the social conscience? Great challenge does not emanate from fear, nor do great causes emerge from panic; people who are seen as being led into trouble by their own weak characters and wicked choices do not enlist the social conscience. To be sure, one of the great dangers of addiction is commonly taken to be contagiousness, and it is necessary to protect the good citizens from this menace; but somehow those who do become infected do so of their own volition and because of their willingness to enter into a compact with evil.
We may have exaggerated somewhat. There are people who see the core of human misery at the root of the problem and more who see the misery associated with addiction. There are, consequently, scattered and woefully inadequate efforts to provide help. More and more voices are saying that basically the problem is not one for the police and the criminal courts to solve, that it is only compounded by existing law, and that it is likely to be only more confounded by current proposals to strengthen the law toward the goal of suppression. Few indeed, however, even among these are ready to face the issue of whether drug addiction is itself the ultimate evil. In any case, the great body of aroused public opinion and the bulk of public effort to do something about the problem seems to have foundered in a morass of irrationality. Our reservations are no less with regard to voluntary self-commitment for a prescribed minimum period, an idea that is commonly included in compulsory therapy plans. The considerations involved are exactly the same as those raised in the preceding paragraph, on therapy.
That the basic concern of compulsory therapy plans is suppressive rather than therapeutic and that ideologies of suppression and of therapy do not easily mix is most evident in the qualifications that are generally introduced as to which addicts are to be eligible for compulsory therapy as an alternative to jail sentences. Apart from the restriction that addiction cannot relieve an individual from responsibility for major crimes, the qualifications generally have the effect of making the most seriously affected cases ineligible. Thus, there is generally a limit set on the number of times a patient may avail himself of the therapeutic alternative, and a self-committed addict who seeks discharge before his time is up renders himself ineligible forever. It is as if one were to declare that an easily cured patient is sick, but a hard-to-cure patient is a scoundrel. A parallel instance would be to rule that a chronic ulcer patient is eligible for hospitalization only twice (and only once if he has left the hospital prematurely the first time) and thereafter must seek his own remedies.
1 Cf. M. A. Alksne, R. E. Trussel, J. Ellinson, and S. Patrick, "A Follow-up Study of Treated Adolescent Narcotics Users" (Columbia University School of Public Health and Administrative Medicine, 1959). In an earlier study of our own, we had found that twenty-nine of thirty selected patients on whom we followed up after discharge were back on drugs within six months, and the thirtieth had entered the army during this interval, so that we were unable to keep track of him. Actually, such evaluation is hardly to be taken as conclusive, even in its own terms. Some psychiatric experience suggests that patients become more amenable to psychotherapy after several discharges. No critical study of this has, however, been done. It is also known that some addicts (and this is also true of alcoholics) apparently spontaneously stop using drugs at some time during their maturity (the alcoholics somewhat later than the opiate addicts). Again, no critical study has been done of the selective factors involved in these remissions, and it is not known whether early hospitalization experience, with or without efforts at psychotherapy, increases, decreases, or leaves unaffected the likelihood of later remission. That is, the payoff on hospitalization may not be detectable until long after discharge.
2 The coefficient of risk may be described as the ratio of the product of the net worth of an outcome and the probability of achieving it to the product of the net cost of an alternative outcome and the probability of the latter. Thus, if one stands to win $100 and sets the worth of the pleasure of the play and of winning at $50, the net worth of success is $150. Similarly, if one must invest $10 to stand a chance of winning the $100 and he sets the pleasure of the play at $5 and the negative worth of the frustration of losing at $15, the net cost of failure is 10 + 15 — 5 = $20. If, now, the probability of winning is 1 in 5 and the probability of losing is 4 in 5, the coefficient of risk is
(150 X 1/5) / (20 X 4/5) = 30/16.
Since the ratio is greater than one, the game is worthwhile and, if the calculation has not taken all of the pleasure out of the game, one should join the play if he is fortunate enough to encounter such opportunities. Both the concept and the illustration have been oversimplified, inasmuch as provision has only been made for two discrete, mutually disjunctive, and collectively exhaustive alternatives. The reasoning employed can, however, be adapted to much more difficult decision situations. For instance, if there are many discrete alternative outcomes, the coefficient can be defined as the ratio of the sum of the worth-probability products for each favorable outcome to the sum of the corresponding products for each unfavorable outcome.
3 It will be recalled that it is the possession of the drug which is illegal, not its use.
4 This was a tract with an exceptionally small over-all number of boys in the age range under study. Because of the small denominator, a slightly higher or lower detection rate than usual would markedly affect the drug rate. Since this is an extremely deviant high-rate tract, it is likely that the high drug rate is in part due to an unusually high detection rate. Assuming that failures in detection are unlikely in the most seriously involved cases, it is not unlikely that an unusually high detection rate means that an exceptionally high proportion of less seriously involved cases were caught. In other words, the extremely high drug rate in the census tract referred to above may well exaggerate the true situation.
5 Lawrence Kolb and A. G. Du Mez, "The Prevalence and Trend of Drug Addiction in the United States and Factors Influencing It," Public Health Reports, 39 (1924), 1179-1204.