Tolerable Cruelty

If you want to read a sad, sad story of how miserably our standard approaches to drug addiction have fared, check out this long investigation into the lives and deaths of heroin and prescription opioid users in Kentucky. It takes a long time to get through; I think I needed an uninterrupted hour, at least, to finish reading it. The picture painted therein is not so much grim as nearly hopeless. I will spare you the suspense: we have in our toolbox drugs that could, very possibly, eliminate the threat of relapse and subsequent deaths from overdose for most addicts, and we refuse to use them on preposterous “moral” grounds.

There’s simply too much too good reporting in the linked piece for me to be able to summarize it in a way that does it justice, but a basic theme keeps emerging again and again: there’s a conflict between what we know works from a scientific and medical standpoint, and what facilities and people who are nominally charged with caring for addicts are actually dispensing. What we know works is something that blocks the withdrawal symtoms and eliminates the cravings, preferably without making the user sick. That something is called suboxone, and it is, as the article notes, pretty much the “standard of care” for treating opiod addiction.

What gets meted out to addicts, on the other hand, is best described as moralistic bullshit. Interview after interview cited in the article has people saying things like suboxone is “not sobriety… it’s being alive but you’re not clean and sober.” Or: “[treatment] is a drug-free model. There’s kind of a conflict between drug-free and suboxone.” Or, and this for me is maybe the worst of all because not only is it scientific ignorance but in my view actually judicial malpractice, the case of Judge Karen Thomas, who literally orders addicts off suboxone if they want a sentencing reduction. It’s hard to imagine the callousness required to utter the following:

“I understand they are talking about harm reduction,” Thomas said. “Those things don’t work in the criminal justice system.” In a subsequent interview, the judge added, “It sounds terrible, but I don’t give them a choice. This is the structure that I’m comfortable with.”

This is where we are as a society: the comfort of a judge taking precedence over medical standards of care.

Our model of thinking about addiction is, unfortunately, skewed because, as the article points out, addiction treatments got under way before we really understood anything about how it affects the brain. But the problem goes deeper than that. Consider the language used by those who speak negatively of suboxone, and you find the same words and phrases making an appearance across the board: “clean”, “abstinence”, “drug-free.” Why do these particular locutions have any moral weight? After all, we would not say that a cancer patient must remain “clean” or “drug-free.” We understand that cancer is a disease and that those who have it are not morally culpable for it[1]. We generally accept that treatment of diseases frequently involves the consumption of various drugs; all the talk about purity goes out the window when you come down with pneumonia.

Unfortunately, we routinely fail to extend this understanding to mental illness. Our folk theory of mind is terribly suited for talking about mental illness as actual illness. Or, if you prefer, the scientific image is not nearly as appealing as the manifest image. To suggest that an addict is sick rather than wicked seems to remove the possibility of condemnation, and if there’s one thing we’re desperately attached to in this country, it’s the ritual of condemning people for moral laxity. To use Judge Thomas’ terms, we just aren’t comfortable with a medical model of the brain, and our comfort clearly should take precedence over people’s real lives.

Cleanliness, purity, abstinence: whence the moral valence of these terms? They suggest a kind of “natural” state, uncorrupted by external influences. The mind as unsullied Eden, so to speak. Where the moral valence of that comes from, I don’t need to tell you. Out of this obsession with the rhetoric of the purge comes the idea that if addicts fail, it’s because they want to fail; if they had wanted to succeed, they would have. A circularly self-justifying chain of reasoning that admits no breaks into which some notion of medical effectiveness could penetrate. Cheap moralism, all the cheaper for the fact that the moralists never need justify themselves, operating as they do against a backdrop of erroneous assumptions about the nature of health and illness and about the mind’s relation to the body. Cartesian dualism is a hell of a drug, as deadly in its own way as any opioid.

It’s not an accident, of course, that blue Minnesota has seen successes where red Kentucky has failed. As usual, liberal states are much more willing to move from moralistic scolding to an attempt to actually do something about the problem[2]. Massachusetts and Maryland have had some success as well.

Ever since I learned about it from Rorty’s Contingency, Irony, and Solidarity, I’ve loved Judith Shklar’s definition of a liberal as someone who thinks that being cruel is the worst thing that one can do. And what is the denial of medical treatment but the most abject cruelty, visited by the state on some of its most vulnerable members, in service of a misguided attachment to a moral language it can barely articulate? This is the damage that the short-circuiting rhetoric of purity can do, measured in actual human lives.

[1] Or, at least, most of us understand this. There’s no shortage of people in the world more than happy to take to task a cancer patient for not having lived an approriately “clean” life, but they tend to occupy the fringe rather than the mainstream.

[2] Although, unfortunately, not as willing as they should be: far too many liberals ascribe unnecessary moral properties to “purity” and “cleanliness,” as the anti-vax and anti-GMO movements readily demonstrate.

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