Public Health and personal freedom are frequently in conflict. Public Health is, after all, a branch of government, with an agenda that shares the perspective, the virtues and the vices of government. It is not unusual that individual persons find their liberty, values and aspirations thwarted by governments.
Public Health and personal freedomBruce G Charlton MD
Kings college lecture
Public Health and personal freedom in conflict
I will make a case for greater individual freedom in relation to health. Using examples drawn from psychiatry, I will demonstrate that Public Health often stands in the path of personal satisfaction, fulfillment and creativity; and will argue for greater freedom of access to medications. In particular, I will make the case for the availability on request of potentially life-enhancing psychotropic drugs such as anti-depressants.
The discussion will focus on a specific example: one of the most powerful of psychologically active drugs, a drug that is widely and cheaply available in our society - and a drug which has been used by most of the people who are likely to be reading this. I mean alcohol.
The Public Health perspectivePublic Health involves putting the health of the group as a higher priority than the interests of individuals. Whether or not this is justifiable must be argued case by case (Charlton, 1993).
A classic, and justifiable, Public Health intervention might be quarantining a person suffering from a potentially fatal infectious disease. Individual freedom is sacrificed, but perhaps the whole community may be saved. Even here one can see the potential dangers of Public Health. Its operation is often intrinsically coercive, and the calculus by which the well being of the group is balanced against that of the individual typically leaves considerable scope for disagreement, as well as scope for partiality and prejudice.
In psychiatry a similar argument might be deployed to prevent the availability of a drug which - it was believed - rendered the user a homicidal maniac. In such a situation, the well being of the group would presumably dictate that the freedom of the individual to determine what went into their own body could reasonably be curtailed.
But typically, Public Health issues are much less clear cut. For example, the sacrifice may involve not a minority but the majority of the population - and the benefits may accrue to just a few. Some instances of immunization involve inflicting pain, inconvenience and risk of side effects on the bulk of the population in order that disease be prevented in a minority. This may indeed be justifiable, for instance when immunization led to the eradication of smallpox, but there is a large ethical grey area in which the balance of benefits versus is harm is uncertain.
In sum, there is a tendency for Public Health to be conscripted by politics, and to coerce the citizen - and to become a kind of 'medical police' to enforce the will of the state (Skrabanek, 1994). Public Health policies require continual watching with a skeptical eye.
The Public Health perspective on alcohol
From the Public Health perspective alcohol is a bad thing. Alcohol has - of course - great potential for harm. For instance, in a book entitled Alcohol and the public health, which was issued by the Faculty of Public Health, there is just one sentence on the benefits of drinking (FPHM, 1991)! The dangers of alcohol consumption have been extensively documented in the statistics of road traffic accidents, violence, suicide, and physical disease (Edwards et al, 1994; Plant et al, 1997).
Because of this catalogue of harm, the probable major Public Health benefit of drinking alcohol - a reduced rate of heart attacks - has been denied or ignored by official Public Health channels. However, despite the fact that heart disease was for many decades the major killer in the UK, few Public Health professionals will take the risk of being seen to encourage drinking.
So, to the Public Health branch of government, alcohol is bad and Public Health sees alcohol in terms of diminishing harm eg. by punitive taxation and restrictions on availability (FPHM, 1991). On the other hand, to the fiscal branch of government, the taxes raised by alcohol sales are good. In practice, government policies towards alcohol are the outcome of these and other competing interests. The individual pleasures ands social benefits of alcohol simply do not enter the equation - except insofar as they impinge on electability.
And in this respect, alcohol is representative of the Public Health attitude to psychologically active substances in general. When it comes to defining policy, the overriding goal is to minimize harm (Plant et al, 1997), where harm is defined in terms of preventing positive, objective, quantifiable public consequences such as rates of accidents, suicide and violence. Private 'goods' that may result from psychotropic drugs - goods such as increased happiness, sociability, and human fulfillment in general - these are simply not a part of the calculus since they are private, subjective and incalculable.
Psychiatry and Public Health
The Public Health perspective on alcohol reflects the perspective on psychiatry - which sees mental illness in terms of its objective and interpersonal manifestations such as suicides and assaults, and their implications for expenditure. But a population locked into a negative state of docile low-grade misery would be invisible to Public Health, since such people present no public problem (Pearce, 2000).
When Henry Thoreau accurately observed that the mass of men lead lives of 'quiet desperation' (Walden, 1971 edition)- he was writing against his background in Puritan New England in the early nineteenth century. Puritanism may be characterized by an over-riding imperative to avoid the risk of harm, specifically the need to avoid public manifestations of sin. The blind spot of Puritanism is to avoid the risk of personal sin at no matter what cost in terms of lost opportunities for personal virtue. In this sense, Public Health psychiatry is almost inevitably driven by that species of Puritanism that Gerald Klerman has astutely called Pharmacological Calvinism.
The general thrust of specifically psychiatric Public Health therefore focuses almost exclusively upon the dangers presented by people suffering psychiatric illness, and the dangers of drugs and other interventions used to treat it. Indeed, since the specialty of psychiatry developed from the need for asylum, this Puritanical deformity affects the whole subject to some extent. The need for treatment is prioritized in terms of its effect of reducing the incidence of these public dangers. For instance, the only numerical target of the UK government's Health of the Nation White Paper of 1992 was reduction of suicide rates (Secretary of State for Health, 1992). Similarly, recent UK debate about 'care in the community' legislation focuses upon whether current rules provides adequate protection to the public, and to a lesser extent protection to the psychiatric patient.
Public Health has no interest in whether a person is leading a fulfilled life - subjective aspect of mental health are invisible. So long as people do not try to kill themselves or others and do not make a nuisance of themselves, that counts a successful outcome. In a nutshell, from the Public Health perspective psychiatry has the Puritanical tendency to sacrifice individual happiness, fulfillment, creativity whenever this sacrifice contributes to the goals of preventing harm - that is, to sacrifice possibility to risk-prevention.
Personal psychiatry has very different priorities, since it is precisely concerned with the fine texture of everyday life seen from within, hence it is dominated by subjective goods and individual satisfactions. From the personal perspective, people seek more from life than the negative benefits of minimizing risk of danger and avoiding being a nuisance. As individuals, we are dissatisfied by lives of 'quiet desperation', and will often take advantage of opportunities offering the prospect of escape from dullness and despondency. Better still, we may seize any realistic chances of the positive goods of happiness and creativity. And many people choose to avail themselves of psychologically active agents in pursuit of this goal.
Alcohol is probably the most powerful of widely available psychotropic drugs. Its effects vary between people and according to dose - in high doses alcohol produces intoxication, stupor, coma and eventually death. In lower doses, its effects may be benign and life-enhancing. Indeed, the great psychopharmacologist Arvid Carllson has said (Healy, 1996): 'Alcohol has done more good than bad to mankind. I am convinced of that. There is so much that has come out of the increased interaction between individuals because of alcohol. Some individuals have had to pay very much for this but mankind has done very well I think.' However the risk of harm is public, objective and quantifiable - while the benefits are typically private, subjective and cannot be given a numerical value.
The psychotropic effects of alcohol
All drugs are double-edged agents in the sense that any treatment capable of affecting the body powerfully enough to do good, is in principle also capable of affecting the body in a harmful way. So that all effective treatments have significant side-effects, and only useless treatments are harmless. But many psychotropic drugs have this quality of objective harms but only subjective benefits - so that from a Public Health perspective it is tempting to limit the availability and usage of these agents.
Opiates are a good example of the phenomenon: opium derivatives such as heroin are at the same time one of the greatest boons to humankind, by virtue of their tremendously powerful pain-relieving action; and one of the greatest and most tragic plagues in history, by their potential for dependence and addiction when abused. The ill-effects of heroin are more objective than its benefits. The puritanical response, adopted in the United States, is to enforce abstinence, therefore make heroin illegal - even for medical purposes.
In other words, the attempt to reduce the Public Health risk of addiction is regarded as more important than the benefits of alleviating the subjectively experienced pain of individual people. The unintended consequence has been that the only people in the USA with access to heroin are drug addicts. Patients suffering extreme pain from terminal disease must make do with often inferior substitutes.
Sacrificing clinical medicine to Public Health
At a 'milder' level of pain, recent legislation in the UK has meant that aspirin and paracetamol are sold only in packs of 32 tablets maximum, and in 'blister' packaging in order to deter overdosing and reduce the national statistics of attempted suicide.
This strategy of reducing the availability of drugs (less than three days supply of aspirin can be purchased in one go) and enormously increasing its cost (due to expensive packaging and larger overheads) appears to have been successful. Some good has come of it: paracetamol overdosages are indeed less common, and the pharmaceutical companies and pharmacists have had their profit margins enhanced. But the consequences in terms of increased pain (and reduced wealth) experienced by the tens of millions of people who use these drugs has not been taken into account. The problem is that these consequences cannot be taken into account - no matter how real and intrusive they are to the people who experience them.
This raises the dilemma of public health in its starkest form: tens of millions of people have suffered preventable pain in order to deter, lets say, some hundreds or thousands of people from taking overdoses with paracetamol or aspirin. Taken to its logical conclusion, access to painkillers should be made so inconvenient and expensive that overdoses are impossible. Even as things stand, the Public Health imperative to prevent harm has overwhelmed the clinical imperative of medicine to do good - and the reason that this has been allowed to happen is that the harm is statistical (and a Health of the Nation managerial target) while the benefit is subjective.
The uses of alcohol
Alcohol is yet another double-edged pharmacological agent. Indeed, it is a mistake to regard alcohol as one drug. More accurately, it can be regarded as several drugs - according to dose and context, and the purpose for which it is taken.
Alcohol is not just a drug, since it is a flavoring element in some of the most complexly enjoyable foods and drinks: beer, cider, wine, whisky and so on and on. Indeed, almost all complexly enjoyable drinks contain psychoactive drugs, for instance the caffeine in tea and coffee. I do not know why this should be, but adult humans seem to get a particularly refined pleasure from 'acquiring the taste' for mild toxins which children reject. For example mouldy 'Blue Stilton' is perhaps the finest of cheeses, 'well-hung' game such as pheasant or venison is actually putrefying by the time it is cooked, and bitter dark chocolate is regarded as more sophisticated than the white or milk varieties. So, one major reason for drinking alcohol is that people like the taste of alcoholic drinks.
Another reason that people drink alcohol is - of course - to become intoxicated as a positive objective in its own right. When intoxication is the object, people don't mind much what the drink tastes like. I have spoken with Scandinavians who distilled a brew made from a fermented solution of sugar, yeast and tomato ketchup. Some people from Central Europe will even drink schnapps.
In other words, some of the people, some of the time, drink alcohol to produce a delirious state of brain impairment, arriving at which they find pleasant to be a gratifying process. Intoxication of this sort may be a kind of happy holiday from the real world - albeit the happiness is short-lived, and usually followed by that holiday-in-hell we call a hangover.
Benefits of alcohol
But aside from its effects in flavoring and as a pleasurable intoxicant, there are at least three other reasons for taking alcohol as a psychoactive drug; and all of these reasons have the objective of enhancing life. The first is as is as a hypnotic, to promote sleep. The second is to take alcohol as a kind of 'antidepressant' or painkiller. The third an anti-anxiety agent particularly to reduce shyness, increase confidence and lubricate social intercourse.
From a narrowly Public Health perspective, these psychopharmacological benefits of alcohol are almost invisible. Whether someone is shy, has a good nights sleep, or is miserable are matters of supreme indifference to the government - except insofar as a population of shy, insomniac miseries are probably easier to control than a population of confident, well-rested and motivated people.
The first point to emphasize is that sleep, happiness and confidence are perfectly reasonable attributes for people to seek - we are not talking about drug-crazed ecstasies. So, we need to avoid the easy option of Pharmacological Calvinism and advocating abstinence, since this would only diminish dangers by eliminating the possibility of benefit.
The benefits of alcohol can be examined and evaluated. If people want to achieve these benefits, and it is decided that alcohol is a suboptimal or excessively dangerous strategy for achieving them; then it behooves us to suggest some other alternatives to alcohol which achieves the desired effect either with better efficacy or at lower risk.
Alcohol is sometimes used as a hypnotic to promote sleep. There are two ways in which this is commonly done - one benign, the other harmful. In low doses, and when getting off to sleep is the problem and staying asleep once you are asleep is not a problem, occasional use of alcohol as a hypnotic is reasonable - for example the hot whiskey toddy when suffering from a cold.
But alcohol is quite rapidly eliminated from the body so will seldom produce a full night's sleep (Leonard, 1997). If taken in a large dose to 'knock you out', alcohol does not so much promote sleep as produce anaesthesia - and anaesthesia does not yield the restorative benefits of true sleep. Indeed, when the alcohol begins to wear off there is usually a rebound characterized by shallow sleep with vivid and unpleasant dreams and early awakening. Poor sleep is a very common complaint - probably due to the noisy, tense, crowded lives we lead that require so much planning and worrying, and where we are ruled by the clock rather than the spontaneous rhythms of the body. For instance, recordings of brain waves indicate that an early afternoon siesta is programmed into humans, yet how many people are able to fit a post-lunch nap into their working schedule?
Humans can get by on just a few hours sleep per night and can struggle through a lifetime of low-grade fatigue. But if we are not talking about mere survival, but instead about the possibility of leading a fulfilling and creative life, then it may be that sustained and satisfying sleep is necessary for that personal goal.
If alcohol is a relatively ineffective and potentially addictive hypnotic, then we need to consider the alternative. Sleep can be promoted by a wide range of drugs, but a natural-feeling, restorative and satisfying sleep is much harder to obtain, even when the full range of modern pharmacology is available. The standard sleeping tablets are not strikingly good at providing a satisfying sleep except in the short term, probably because they distort the natural pattern of brain waves which seem to be needed to produce the benefits of sleep. My hunch is that some of the unusual antidepressants, like trazodone or mianserin; hormones such as melatonin, or the new atypical neuroleptic drugs, like risperidone and olanzepine, may produce a better quality of sleep than the currently used agents - although all have significant side effects (Charlton, 2000).
In the longer term, more studies need to be done in which sleeping medications are evaluated by people's subjective satisfaction at the quality of their night's sleep, rather than by objective measures of how many hours of unconsciousness they produce. Until then, each individual would need to try different agents in different doses to discover what best suited them.
2. Antidepressant painkiller
Alcohol is sometimes - implicitly - used as a kind of antidepressant; its function being to allow the drinker to escape from a state of misery. This antidepressant use of alcohol is equivalent to using it as a psychological 'painkiller' or analgesic. Indeed, alcohol is sometimes used as a physical painkiller. Before the invention of anaesthetics, alcohol was taken prior to painful operations, and even nowadays, some people with chronic, intractable pain or depression end-up by drinking to excess as a way of seeking relief.
Unfortunately, to achieve the effect of dulling the mind to pain, alcohol must be taken in large enough doses to produce a significant degree of intoxication. Substantial impairment of mental function is inevitable, and physical damage and addiction are probable in the long term.
This is how alcohol is traditionally used, or abused, in high latitude Northern European societies such as Finland, Scotland and Newcastle-upon-Tyne - drink is taken to the point of intoxication, or not at all. The population is divided into teetotal abstainers and binge drinkers. My hunch is that this bingeing versus abstention pattern of alcohol use may be related to the fact that high latitudes have a high incidence of Seasonal Affective Disorder caused by the short hours of daylight in winter producing episodes of winter and spring depression. This high prevalence of depression is 'self-treated' in a sub sector of the population by dulling the mental pain through escaping into a state of intoxication or oblivion. But because of the social harms produced by this pattern of alcohol consumption, drinking becomes stigmatized and attitudes to it become polarized with the development of powerful temperance movements (Levine, 1992).
But abstinence, although safer, is not necessarily a very happy alternative. In Protestant Northern Europe, especially before the era of modern psychopharmacology, the majority of the population who abstained from alcohol tended to be introverted, dour and miserable - leading lives of Puritanical self-denial and 'quiet desperation'. When alcohol is the only available antidepressant, a person's choice usually simplifies to a short, wild, violently emotional life of intermittent intoxication; or a life of over-controlled low grade misery and watery pleasure. The abstinent alternative is associated with a longer life - and it certainly feels like a longer life.
Neither abstinence nor binge drinking is an ideal response to depression. There are superior substitutes for alcohol as an antidepressant: agents that are both safer and more effective (Pearce, 2000a). Indeed alcohol is a pretty lousy antidepressant: short-acting and only relieving misery at the price of significant brain impairment.
My understanding of depression is that it is not so much a mood, as a physical state (Charlton 2000, 2000a). Depression is a feeling of malaise - of fatigue, heaviness, dull diffuse aches and pains and the demotivating inability to experience or to anticipate long term pleasurable emotions. This physical state prevents a person from feeling gratifying emotions and gradually drags their mood down. True antidepressants therefore probably work rather like a painkiller or analgesic, to relieve these physical sensations of fatigue, heaviness and pain.
So the traditional antidepressant painkillers, such as imipramine and amitriptyline, which are powerful and long-acting analgesics, are a much better option than alcohol for treating depression without impairing mental function - and they also tend to improve appetite and sleep. These traditional antidepressants do, however, produce unpleasant side effects in some people that outweigh their beneficial effects. It may be that other pain killers could be used to treat some of the malaise state of depression. For instance simple analgesics, available over the counter, such as aspirin, paracetamol or ibuprofen, and the mild opiate analgesics such as codeine may turn out to have a role as antidepressants (Charlton, 2000).
All antidepressants have side effects that may be troublesome, and there is always the problem of deliberate overdose. But they are probably a safer, more effective and less addictive alternative to alcohol. An individual person may decide that the subjective benefits outweigh the risks, and may find that life while taking antidepressants is more fulfilling than life without the drug (Kramer, 1994). In my opinion, whether or not to take antidepressants should generally be a matter of choice for the patient. The doctor would adopt an advisory role - except when treatment would be dangerous, when a veto may be exercised (Charlton, 1998).
3. Alcohol as an anxiolytic social-lubricant
When used in small frequent doses, especially when taken with food, alcohol reduces anxiety and promotes sociability in many people (Leonard, 1997). Broadly speaking, this is how alcohol is used in Southern European countries such as Spain. In Spain, drinks may taken frequently but moderately throughout the day, with food (which slows alcohol absorption), and the drinker never shows signs of intoxication. Indeed traditionally, Spanish men would regard slurring their words, uncoordinated action or uncontrolled behavior as shameful, un-masculine behavior leading to loss of reputation. So, in Spain most people drink, most of the time, yet very few get drunk. The contrast with Northern European patterns of drinking is extreme.
Small frequent doses of alcohol are an effective treatment for shyness. And debilitating shyness - even the extreme form of social phobia - are very common in our mass industrial society populated largely by masses of strangers. Hence the use of alcohol as a social lubricant is, by and large, life-enhancing - especially since social relations are probably the single major source of human satisfaction.
So long as proper precautions are taken, this style of alcohol usage promotes a fulfilling human life. However, although it is quite different from euphoric intoxication, nevertheless even modest alcohol consumption does produce a measurable impairment of some mental functions, and frequent doses are necessary to produce a sustained effect. In the long term, physical damage is a possibility - and liver cirrhosis is common in countries such as Spain. So what are the alternatives?
The most straightforward alternative to alcohol are the benzodiazepine drugs such as diazepam or Valium (Healy, 1997). These share many of the disadvantages of alcohol in terms of being potentially addictive and prone to abuse, but they have the advantages of being longer acting and safer than alcohol - safer both in acute intoxicating doses, and in the long term. It seems clear that there are some people, although perhaps not very many, who are neither addicted to nor dependent on benzodiazepines - but whose lives are more satisfying when taking a small or occasional dose of these drugs.
More promising alternatives to alcohol as a social lubricant are some of the newer drugs marketed under the 'antidepressant' label, drugs such as fluoxetine (better known as Prozac); or paroxetine (Seroxat) which was recently licensed specifically for the treatment of social phobia and which has been shown in trials to improve social confidence even in normal non-depressed people (Knutson, 1998). When they work, and when side effects (which may be severe) are not significant, such drugs may diminish shyness and promote social interactions. Lives have been transformed for the better by diminishing pointless anxiety and allowing the emergence of a more relaxed and sociable personality and lifestyle (Kramer, 1994). This is not a dumb intoxication, but a new set of positive possibilities that can be life-enhancing - even profoundly so.
My belief is that drugs such as Prozac and Seroxat work as emotional buffers (Charlton, 2000).They do not alter normal emotions, but prevent extreme swings of emotions - they are a kind of 'safety net', that guard against overpowering negative emotions. This is often reassuring to the shy person who knows that they will not be overwhelmed by panic or loss of control in a social situation. On the down side, extreme positive emotions may be buffered as well as negative ones - so the up-swings of euphoric feelings that most of us get from being in love, and some of us get from exercise, may be diminished. And this may be unpleasant, or too big a price to pay for many people.
Again, it is a matter of individual constitution, individual responses and preferences. Hence the decision whether or not to take the drug should be individual - since only the individual can judge whether the benefits compensate for the side effects and risks.
Alcohol is a drug of abuse, but not just a drug of abuse; nor is the use of alcohol necessarily an inappropriate exercise of human freedom. People use alcohol for good reasons as well as bad - to produce effects that are life-enhancing, as well as the more familiar life-escaping effects.
But there are potentially superior alternatives to alcohol, even where is it being used appropriately, for instance to reduce shyness. These alternatives may be safer and more effective - as well as cheaper. Yet typically alternative psychopharmacological agents are not readily available, except on prescription, and only then when indicated by a formal psychiatric or medical diagnosis. Because of this link to mental illness, even when they are available and appropriate, the use of psychotropic drugs is stigmatized compared with alcohol (Healy, 1998). The drug comes with the label of suffering a mental disorder - despite the fact that people without any detectable psychiatric disorder may benefit from taking such drugs - as is the case for antidepressants.
At present, people lack the freedom to optimize their personal health, largely because of the constraints of Public Health. The Public Health principle is to avoid harm, which implies restricting the access and availability of powerful psychotropic drugs because of their potential dangers - and these restrictions apply even when such agents may enhance life. This conflicts with the personal goal of maximizing individual well being.
In effect, we as individuals are not allowed to make the decision to take the risk of consuming - say - Prozac unless we are judged by a professional to be at some greater risk of harm because we are suffering from a formal psychiatric illness (Healy, 1998). In other words, the risk benefit analysis is made for us, by other people - despite the radically incomplete information they have of potential and actual benefits, due to these being subjective. These scales are weighted in favour of abstinence. The Public Health perspective has a blind spot exactly where health matters most to each of us - our own subjective sense of well being.
The consequence is a invisible plague of avoidable misery. Invisible, because it constitutes psychiatric symptoms with mainly private significance - malaise, misery, free-floating anxiety, social phobia, insomnia. Avoidable because these symptoms are left untreated for fear that their treatment may cause Public Health problems such as side effects, overdoses, addiction or other causes of excessive health service expenditure. And a plague because there are millions of people whose lives subjectively feel blighted, who might - although there is no guarantee - find a pharmacological agent that would enable them to lead significantly happier, more creative lives (Charlton, 2000).
So we are not talking about using drugs as euphoriants, we are talking about drugs that may increase the chance of human fulfillment through a diminution of pain and malaise, a more satisfying social life, more restorative sleep, and more energy and motivation to tackle the projects that make life worth living (Charlton, 1998). Such agents do not make someone happy - any more than taking aspirin makes you happy. Taking aspirin to treat a headache does not make you happy - but it is difficult to lead a fulfilled life when suffering a headache, and easier to be happy when the pain has been relieved. So our concern is with agents that do not induce happiness - rather they remove obstacles to happiness.
What applies to psychiatric disease and psychotropic drugs applies generally to other diseases and other therapeutic agents. When health services are focused on Public Health they become dominated by objective factors, such as the statistics of morbidity and mortality. In such a framework it is likely that the personal and subjective aspects of health are neglected. Individual freedom is often overwhelmed by Public Health because it is so easy to ignore another person's misery or thwart their aspiration. Against each person's own misery is stacked the ignorance and indifference of the majority who are not so afflicted.
Greater access to pharmacological agentsAt present, access to drugs is largely restricted to 'prescription-only', except where it can be demonstrated that a drug's benefits in practice outweigh its dangers by a substantial margin. The onus of proof lies on those who wish to give the public access, and the default position is that access is denied. In other words, the public are denied direct access to modern pharmacology - under the present system a sufferer has no right of access to agents that may relieve his or her suffering. For instance, a person in severe pain must convince a doctor of their condition in order to gain access to powerful pain killers. If the person in pain does not convince a doctor, or the doctor judges that the risk of providing pain relief outweighs the probable benefits, then the patient must continue to suffer.
But the principle can be reversed. The public could have access to all pharmacological agents except where it could be shown that this would be inappropriate. In other words, the public might demand the right to determine their own treatment - perhaps choosing making exceptions where this right is suspended - for example is children, for agents that are highly dangerous or toxic, or for highly addictive substances.
This situation is, of course, the one that existed until about a hundred years ago (Healy, 1998). Restricted public access to drugs is a relatively recent phenomenon. Prescription-only drug restrictions were originally introduced purely for controlling access to dangerously addictive agents such as cocaine and morphine. Now, all drugs are treated as if they were dangerously addictive, and all adults treated as if they were dependent addicts.
Some people may wish to take the chance of the benefits of a drug, even when the odds are against them. For instance, a person in severe pain or other distress may choose to take considerable risks to escape this situation. Such a person might want pain relief even when this brought with it a small chance of addiction, since they may judge that a life dominated by pain is no life. The same applies to shyness, malaise, anxiety… these negative emotions may dominate a person's life, thwart their aspirations, and they may feel that even a significant risk is worth taking in order to obtain relief.
Of course such a policy would present significant dangers - all freedoms present dangers. Of course, it would be wise for patients to seek expert advice about before ingesting powerful chemicals - it is easier to harm oneself than help oneself, and there is significant potential for injury from all agents that may do good. And of course there is the question of who pays for all this. But at the end of the day, the principle must surely be that each individual should be responsible for what they put into their own body, since that person bears the brunt of both risks and benefits - and if people wish to take risks with their bodies then they should be able to do so. The rest is logistics.
From the example of alcohol, it is overwhelmingly obvious that many people wish to use pharmacological means of shaping their lives, and indeed do so within the constraints of available and acceptable agents. Too often a question is framed about whether people should or should not avail themselves of psychotropic drugs in shaping their lives. But this is a mistaken emphasis, and it assumes that 'we' have a right to decide what drugs other people take and whether they 'deserve' to take them. The onus of proof needs to be reversed: what right do 'we' have to determine which chemicals other people put into their bodies? And why are people prevented from using drugs which they believe may benefit them?
In a world where psychiatric symptoms are endemic, and where there are treatments that offer a significant chance of significant benefit - then the proper question should not be whether humans should use psychotropic drugs, but how humans should use psychiatric drugs (Charlton, 2000). This presupposes that people have access to such agents.
Not all drugs should be available on request, nor should all drugs be available unrestrictedly. But given the vast potential for subversion of Public Health by goals of expediency (Skrabanek, 1994), the essentially political nature of Public Health, and the way in which it can so easily be made to serve the interests of government against both individuals and populations - then individual freedom seems the best starting point for rational policy. Protection of freedom should be the fundamental postulate, and restrictions on freedom should require specific justification in each instance of restriction. The primary safeguard against the abuse of Public Health is personal freedom.
It follows that the primary decisions in medicine should be based on criteria of personal health, not Public Health. And, at the bottom line, subjective experience is more important than objective statistics.
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Bruce G Charlton MD
Department of Psychology
University of Newcastle upon Tyne
also by Bruce Charlton
Cargo Cult Science
The Malaise Theory of Depression
Psychiatry and the Human Condition
Pharmacology and Personal Fulfillment
Awareness, Consciousness and Language
Psychopharmacology and The Human Condition
Injustice, Inequality and Evolutionary Psychology