Choice and Compulsion
The Myth of the Victimless High
I concede without reservation that medical concepts play a legitimate role in drug use. Physical dependence is a real pathophysiological phenomenon with well-described neurochemical mechanisms. Withdrawal syndromes can be dangerous, and in some cases lethal, if unmanaged. Alcohol withdrawal, in particular, can precipitate seizures, delirium tremens, and death, and often requires medically supervised tapering with GABAergic agents. These facts are not controversial, and denying them would be unserious.
What is mischaracterized is the claim that drug use is primarily a medical problem rather than a moral or criminal one.
Drug users are not innocent victims struck by a disease that arrives unbidden. Using heroin is not analogous to developing leukemia or being struck by lightning. The presence of neurochemical reinforcement does not negate agency. It explains why drugs are pleasurable and why stopping is difficult, but difficulty is not the same as involuntariness.
Addictive substances act primarily through dopamine. That is not incidental. Dopamine is the neurochemical correlate of reward, motivation, and reinforcement. Drugs are addictive because they feel good. They produce pleasure, relief, or escape, and the brain learns to pursue those effects. But dopamine is not a master that enslaves the will. Every human being is driven by dopamine to some extent. We still make choices. We still prioritize. Dopamine is what underlies every temptation, but what determines whether one gives in is character.
Drug addiction reveals priorities. It demonstrates that the pleasure derived from the drug has been elevated above competing goods: family, work, health, dignity, legality, and often the well-being of others. Addicts routinely show a willingness to sacrifice all of these in pursuit of the high. That willingness is not imposed externally. It is revealed in the choices the addict makes, repeatedly, over time.
Once addicted, stopping is undeniably hard. Cravings are powerful. Withdrawal is miserable. Relapse is common. None of this converts drug use into an involuntary act. We routinely expect people to resist powerful biological drives when acting on them would harm others. Hunger, anger, sexual desire, and fear all have biological substrates. They do not absolve behavior.
The modern insistence that addiction is a disease functions less as a scientific insight than as a moral anesthetic.
Labeling addiction as a disease replaces moral language with clinical euphemism. Words like vice, self-indulgence, irresponsibility, and neglect are displaced by phrases such as substance use disorder, maladaptive coping, and chronic relapsing illness. The effect is not greater understanding but moral evasion. Behavior that would once have been condemned is now viewed with clinical neutrality.
This reframing allows physicians, policymakers, and institutions to feel compassionate while avoiding uncomfortable truths about choice, self-control, and obligation. Yet judgment does not disappear. It is merely displaced. Someone must still decide whether behavior is tolerated, subsidized, punished, or restrained. The disease model simply denies that these decisions are moral decisions at all.
The disease framing also depends on a striking asymmetry in how agency is treated. Drug users are routinely portrayed as incapable of responsibility when harms occur. Theft, assault, child neglect, impaired driving, and public disorder are attributed to compulsion. Responsibility is attenuated or erased. Yet the same individuals are assumed to possess full autonomy when demanding services, housing, legal leniency, or even continued access to narcotics through substitution programs. Agency vanishes when blame is at stake and reappears when entitlements are demanded.
This inconsistency is politically useful. It permits endless provision without accountability. But it is incoherent. Either drug users possess agency or they do not. Acts cannot be involuntary only when convenient.
Perhaps the most corrosive effect of the medicalized narrative is the inversion of victimhood it produces. The addict is centered as the primary victim, while those harmed by drug use fade into the background. Families endure theft, violence, neglect, and emotional devastation. Children are placed into foster care. Neighborhoods decay under the weight of open drug use, vandalism, and disorder. Small businesses absorb losses. Pedestrians and drivers are killed by impaired operators. Taxpayers fund remediation for damage they did not cause.
These victims are diffuse and anonymous. They lack advocacy organizations and sympathetic media narratives. The addict, by contrast, is visible and endlessly foregrounded. Compassion is concentrated toward the person causing harm, while those bearing the harm are rendered invisible.
If addiction were primarily a medical disease, outcomes should improve as treatment expands. Instead, despite unprecedented investment in harm reduction, pharmacologic substitution, public health outreach, and social services, morbidity, mortality, homelessness, and drug-related crime have worsened. Treating addiction as a disease encourages management rather than resolution. It assumes chronicity, normalizes relapse, and lowers expectations. The goal shifts from cessation to mitigation, and damage accumulates accordingly.
Policies designed to avoid stigma often entrench addiction by removing consequences that historically constrained destructive behavior. Decriminalization, permissive enforcement, and unconditional tolerance are framed as humane but in practice are indistinguishable from abandonment. Consequences are not merely punitive but instructive and corrective. They communicate boundaries, and removing these boundaries does not liberate people from their addiction. It leaves them alone with it.
Medicine is not a neutral participant in this process. Expanding the disease label enlarges medicine’s jurisdiction, budgets, and authority. Every behavior reclassified as pathology becomes an opportunity for billing, research funding, and institutional relevance. Pathologizing behavior is safer than confronting it. It avoids moral controversy while expanding professional control.
I did not always hold these views. I once favored legalizing drugs and treating drug use as a primarily medical rather than criminal problem. I believed drug use was largely a victimless crime. That belief eroded when states began legalizing a drug widely regarded as benign: cannabis.
The consequences have been impossible to ignore. Cities now smell constantly of skunk. Drug use has skyrocketed. Otherwise functional adults have been encouraged to use cannabis products under the assumption that they are safe. Meanwhile, the product itself has changed dramatically. Cannabis is no longer a low-potency plant grown by amateurs. It has been industrialized, concentrated, and optimized by corporate and pharmaceutical interests. THC concentrations have risen far beyond anything historically typical.
With this shift has come pathology that was once rare or essentially unknown. Cannabinoid hyperemesis syndrome is now a routine diagnosis. I see multiple patients with this condition every day in the emergency department. It was virtually unheard of prior to legalization. What was marketed as harmless, marketing which I admit had previously fooled me, has produced immense harm.
The philosophical justification for drug legalization rests on the claim that drug use is a legitimate lifestyle choice rather than a moral failure or a crime. That claim, in turn, rests on the idea that drug use is victimless. Our society increasingly believes that anything consenting adults engage in cannot be immoral, that consent alone is sufficient for moral permissibility.
This belief emerges from a deeper cultural shift. We are no longer religious. We no longer believe that life has a given purpose or trajectory, or that we are accountable to anything beyond our own preferences. Instead, we believe our lives exist for our own fulfillment and pleasure. So long as we do not directly violate the rights of others, all choices are treated as morally equivalent. Working or playing video games, raising children or not, pursuing excellence or chemical escape. These are all regarded as interchangeable lifestyles. We owe nothing to the future. We owe nothing to each other beyond noninterference.
This is a deeply flawed vision of human life.
A life spent pursuing chemical pleasure is a life poorly lived. I do not concede that an act must have a direct victim to be immoral. Some choices are better than others even in isolation. A society that refuses to make such distinctions cannot sustain itself.
Even if one accepts the premise that there are no victimless crimes, drug use still fails the test. The image of a solitary individual harming no one in private is a fantasy. In reality, the effects of drug use inevitably spill outward. Even highly functioning users compromise their ability to meet obligations to their families, employers, colleagues, and communities. A society with widespread drug use becomes unreliable, disordered, and brittle.
Drug use is not something that merely happens to people. It is something people do, again and again, with foreseeable consequences, to themselves and more importantly, to others. We must stop pretending otherwise.