Published in Sacramento Medicine, December 1995

An ethical policy toward drug use or availability should produce consequences that promote the greatest good, or the least harm, for the greatest number of citizens. Drug use allows citizens autonomy over their own states of pain, stress or enjoyment. This benefit must be balanced against the harms of drug side effects or abuse. However, attempts to prohibit drugs also create serious social problems, such as black market crime, violence and corruption of law enforcement. Furthermore, money spent on enforcing prohibition must come from other public communal resources. These harms must all be weighed in developing an ethical policy on legalization.

In spite of undeniable harms from drug abuse, virtually all societies have permitted access to some psychoactive, intoxicating drugs. The choice of drug has been based on geographic and cultural features. Norms and rituals were developed which determined when, where, by whom and in what form the drug was allowed for "relatively safe" use. Thereby, different cultures have allowed use of marijuana, coca, opium, alcohol, caffeine, and tobacco, with formal or informal rules to prevent abuse. A fundamental ethical dilemma of current legislation choices is their arbitrariness. We permit aggressive marketing of legal tobacco and alcohol, which contribute to 600,000 deaths per year in the US alone, and order long prison terms for dealings in other, less harmful drugs.

Use of a drug can certainly become more problematic when introduced into cultures where its use is foreign and not controlled by cultural norms. Even coffee was apparently problematic when first introduced into Europe. Three-hundred year-old descriptions of caffeine abuse resemble current descriptions of cocaine abuse. Prohibition provides an important element of safety, giving cultures time to evaluate harms and develop appropriate controls and norms for integrating relatively safe substances from other cultures.

However, potential benefits from prohibiting drug use are counteracted by unintended, yet harmful, consequences. Illegal trade in prohibited drugs predictably moves toward the most potent and toxic forms which can be smuggled easily. Toxic hard liquors replaced safer beer and wine; IV heroin replaced safer opium smoking and fueled the AIDS epidemic. Successful interdiction of marijuana, as easy drug to seize, has contributed to the cocaine epidemic. In each case, dealers moved to a less risky drug to smuggle, and exposed society not only to drug forms more dangerous to the public health but to a more violent drug trade. Tough incarceration policies for drugs have meant going easy on non-drug crimes of violence and victimization, which are ignored or punished less severely, usually leading to early release from prisons overcrowded with drug users. Afro-Americans make up only 13 percent of drug users but 77 percent of those imprisoned for drug use, exacerbating racial tensions. In some cities, minority incarcerations have been so widespread as to seriously disrupt both the family and the community, hurting millions of children. In addition, the innocent public is victimized by property crimes committed to obtain money for illegal drugs. The billions of dollars that flow into international narco-terrorist organizations have destructive consequences worldwide. Thus, prohibition can significantly reduce the total amount of use yet produce an ethically unacceptable level of secondary harms that endanger innocent people all over the planet.

There are also ethical dimensions to resource utilization. Possession of tiny amounts of an illegal drug can now bring 25 years in prison at a cost of a million dollars. More than a million drug users are incarcerated each year, most of them marijuana users, a less harmful drug not associated with either criminal behavior or violence. In our age of "no new taxes," the billions spent on interdiction and incarceration diverts resources from other services critical to healthy communities: schools, health care, TB and HIV control, services for the elderly. Poorer quality education places our children at higher risk for drug use, exacerbating the problems prohibition is supposed to prevent. The fiscal priorities of prohibition create significant short- and long-term ethical problems.

Finally, there are human rights issues in drug policy. For hundreds of years, governments have imprisoned and, at times, killed users of tobacco, alcohol, caffeine, opiates, cocaine and marijuana. Today, drug violations are punished more harshly than most violent crimes. The demonizing of drug use by politicians and media has been one way of obscuring the humanity of drug users, subverting the golden rule of ethics, the "What if it were I?" test.

Is there a human right to have access to "relatively safe" substances that reduce pain or stress, enhance sociability, and even expand mental capacities? What weight should this right have as against society’s right to protect citizens from the harms of drug use? Chronic pain patients, routinely denied appropriate pain relief out of a misguided fear of "creating addiction," often feel pushed to street drugs or suicide. However, society is now rapidly asking whether such denial of pain relief is itself unethical. The slow progress on individual rights vis-a-vis drugs continue as some of us now ask whether the right to medicinal use of marijuana might also be legitimized.

In summary, given the complexity of the harms from both legalization and prohibition, an ethical policy must assure that the innocent majority is not exposed to greater harms from attempts to prevent lesser ones. An ethical policy on illegal drugs demands a commitment to a scientific evaluation of innovative policies and their effects, similar to our ongoing experimentation in regulating and reducing harms from alcohol and tobacco. If legalization of relatively safe, low potency forms of certain drugs were experimentally shown to reduce use of more dangerous drugs, reduce crime and reduce the costs of enforcement and incarceration, then legalization or decriminalization would be ethical and prohibition immoral.