In this symposium we bring together four papers which consider novel approaches to the use and response to what are popularly known as “drugs”. The language available here is not altogether helpful—the drugs discussed (cannabis, tobacco, cocaine) have very different pharmacological effects, social acceptability, long and short term psychological effects, medical uses, and legal status.¹ Arguably, the way these three drugs (together with others, such as opiates) are considered as constituting a unified medical field can only be understood as a rather specific social and historical phenomenon, rather than being based on a coherent concept of “drugs”. Nevertheless a major part of international health and foreign policy turns on this social construction, and as doctors, ethicists, or policy makers we are obliged to work within this social reality, even as we criticise its basis.²

A central consideration in all four papers is the role of autonomy. This is a particularly vexed issue in the context of psychoactive drugs, in that both the use of particular drugs and becoming addicted to such drugs have a direct effect on our ability to be autonomous, and colours our conception of the meaning of autonomy.³ Tobacco, for example, may be used by some smokers to enhance their sense of autonomy through assisting in focussing their attention, whereas addiction to tobacco smoking is a very visible mark of the limits of the autonomous will’s ability to act on itself. Cannabis, on the other hand, is often used precisely to disinhibit the will and to get “out of it”, as a mark of our dissatisfaction with the nagging demands of autonomy, particularly in an era in which we are meant to be “responsible” all the time.^4,5

At a deeper level, this curiosity about the relation between drugs and autonomy can lead us to a whole series of worries about the extent to which our human capacities of rationality and choice are malleable to (if not determined by) physical interventions in our physical being, the ways in which third parties may for various reasons want to weaken or alter our physical or social bodies, and the ways our present choices may bind our future selves.⁶ No wonder public policy is so concerned with drugs!

This concern manifests itself in a whole panoply of decisions, strategies, policies, and regulatory activities, some of which appear to be manifestly irrational. Matti Hayry argues that banning the medicinal use of cannabis is an irrational and indefensible restriction of freedom [see page 333]. His argument could readily be extended to the non-medicinal use of cannabis, or to considerations of the injustice of this type of restriction on freedom. A drug which is thought to be far more addictive is tobacco, and it would be interesting to apply Hayry’s arguments to tobacco.⁷ Hasman and Holm examine the merits of a type of treatment which could prevent people from becoming addicted to the nicotine component of tobacco—a nicotine conjugate vaccine [see page 344].⁸ Like Hayry, Hasman and Holm are concerned with freedom, in this case the right to an open future. Although some commentators, following the nineteenth century philosopher T H Green, might argue that this sort of restriction on freedom is actually autonomy enhancing, Hasman and Holm are unconvinced by this argument.⁹ Carter and Hall, and Ashcroft and Franey examine in more detail another vaccine approach to a drug of addiction, cocaine [see page 337 and page 341].^10,11 In these two papers, the authors evaluate the likely social impact of using such a vaccine as either a therapeutic or preventive measure, and concentrate mainly on questions of social justice, rather than individual liberty.

This suite of papers gives a taste of some of the current debates at the cutting edge of drug policy. The UK Government’s Foresight Programme recently initiated a study on “Brain Science, Addiction and Drugs” which will take a 20 year look into the future, examining trends in drug development and other new technologies, to take an informed guess at what the policy issues will be concerning the regulation of drugs and the treatment of addictions.¹² This debate is likely to run and run. As ethicists, two central challenges face us: how far can we be rational about drugs, basing our arguments on autonomy and freedom, when drugs are a standing challenge to the conceptual and empirical basis of those concepts? And how far do our concerns with consistency and rationality help us untangle the curious social worlds of drugs and of drug policy?