In this essay I will discuss a new vaccine that can treat and prevent cocaine addiction. I will explain why a hypothetical public policy of compulsory inoculation of infants against the effects of cocaine would be paternalistic. I will then present some reasons why the paternalistic policy should not be implemented for ethical and pragmatic reasons, while considering rebuttals to these objections in a largely point-counterpoint fashion.
The cocaine vaccine
Celtic Pharma is a company that specialises in ‘novel’ pharmaceutical products in ‘the late stages of clinical and regulatory development’.[1] TA-CD is a new vaccination is being developed by Celtic Pharma. The molecular structure of TA-CD is designed in such as way that it mimics a certain class of antibodies that attach to cocaine molecules as they pass through the blood stream, making them, at this stage, too large to pass into the Central Nervous System. Subsequently the user does not gain any pleasure from ingesting cocaine. This is because the mechanism that creates a surge of dopamine in the brain is short-circuited. Due to the negation of pleasurable effects that usually accompanies cocaine addiction, Celtic Pharma foresee that the implementation of TA-CD into a patient management program can improve the chances that cocaine abusers will kick their habit and become valuable members of society.[2]
A separate study, in this field has been undertaken by a group of medical researchers not related to Celtic Pharma's research effort. This study has shown promising results for a vaccine which stimulates the subject’s immune system to produce a store of actual antibodies that similarly prevents cocaine from actually reaching the brain.[3] In light of these recent and dramatic developments, it seems that the reality of cocaine ‘vaccination’ is not very far away.
Considering the social impact of cocaine addicts, vaccines like TA-CD seems destined to be a valuable tool towards their rehabilitation when it is released. While cocaine isn’t as prevalent a drug as it once was (for instance, the crack cocaine epidemic that swept America in the 1980s and early 1990s), it is still a problem on our streets and it is likely that this vaccine would be welcomed by many to help deal with the issue.
Vaccination against the threat of disease is an important defence against morbidity. Immunization is a remarkably successful and cost effective strategy of preventing infectious diseases by preventing contraction and slowing contagion. Infant immunization has resulted in a decline in and, in some cases, eradication of previously common contagious diseases, such as: polio, smallpox, rubella, tetanus, and measles. Infant immunization programs have had such success that Sir Sandy Macara, the former chairman of the British Medical Association has called for them to be compulsory.[4]
So, why not a compulsory cocaine vaccine? To see the potential public policy implications of this vaccine, we have to place ourselves in the realm of (plausible) hypotheticals. Imagine that the TA-CD vaccination clears clinical trials and is approved by the medical authorities as a treatment and preventative medication. Now imagine that a state puts forward a bold policy proposal which makes if compulsory for all children to be vaccinated against the effects of cocaine, therefore mitigating future potential cocaine addiction in these individuals.[5]
Why a compulsory narcotics inoculation policy for infants would be paternalistic
The Stanford Encyclopedia of Philosophy describes paternalism as the interference of a state or an individual with another person, against their will, and justified by a claim that the person interfered with will be better off or protected from harm.[6] Paternalism can draw justification from Mill’s Harm Principle which states that, “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.”[7] Typical examples of paternalistic policies are seatbelt laws to prevent road deaths, laws against suicide (eg. forfeiture of insurance benefits), and high taxes on cigarettes to incentivise healthy living. [8]
Paternalism mimics a parent’s relationship with their child by applying a ‘Mother (father?) knows best’ policy framework. What then are the relevant moral considerations, in this situation? Do parents who inhabit a certain social-class or live in a certain social environment have a duty to vaccinate themselves and their kids from cocaine?[9] Would to not get the vaccine be reckless endangerment? What role should the state play? Does the state have extra special obligations to protect its citizens from potential harm?
It could be questioned whether compulsory inoculation against the effects of cocaine would actually be a paternalistic policy. Feinberg argues that when most of the individuals affected by a policy actually approve of the policy then the policy cannot be called paternalistic. If popular support endorses a policy then Feinberg states that the law can be construed as, “…fair or unfair, wise or unwise, but in either case, it will not be ‘paternalistic’.”[10] This upsets the view of compulsory inoculation as paternalistic. This is because most of the public could hypothetically endorse a government that implemented this policy. However, it must be remembered that the individuals who are the subject of this policy are infants and so do not have any say in democratic deliberation or procedure. For this reason, it would be a stretch to say that they consent to the policy. Therefore, the policy may be classified as paternalistic. But which type of paternalism?
There are two types of paternalism, hard and soft. A policy is said to be hard paternalistic if it asserts that it is legitimate to interfere with individuals’ actions even if the person is fully aware of the repercussions of those actions. Inversely, a policy is said to be soft paternalistic if it asserts that it is legitimate to interfere with individuals’ choices only if it is unclear if the person is fully aware that they are acting contra to their best interests.
Lowenstein sees a role for soft-paternalism in influencing health behaviour because the aim is to reinstate the individual’s autonomy by ‘protecting them from themselves’.[11] A soft-paternalistic policy would be, for instance, a €500 tax rebate if you agreed to have your blood checked at a clinic every three months and were found to have no traces of cocaine in your system. Incentivising individuals to stop them from making the harmful decisions that are associated with cocaine is one way of decreasing the burden on scarce public resources while mitigating the chance that the individual will make compromised choices that they wish they would not make.
However, soft-paternalistic policies can be cumbersome to implement. For instance, the monetary and productivity costs associated with setting up checking-up systems are not trivial. Take for example the German healthcare system which is set up with nudge elements. There is much disgruntlement among doctors in Germany who are made to supervise their patients’ push-ups in order for them (the patients) to claim an insurance rebate.[12] A cocaine blood-test tax-rebate scheme is likely to put similar ‘policing’ burdens on social institutions.
Hard paternalism, on the other hand erects greater boundaries to a choice set. The idea is that a hard paternalistic policy tries to place a choice completely out-of-bounds, rather than needing constant incentivisation, coercion, deception, supervision, and policing. Compulsory infant inoculation against the effects of cocaine would be a hard paternalistic policy as it will lead to adults being constrained against their will.
When framed like this, it seems that a policy of inoculating babies at birth against cocaine addiction may seem to be a worthy paternalistic policy.
Why this paternalistic policy may not justified
There is something intuitively discomforting about the thought of inoculating babies against cocaine addiction, in this author at least. While paternalism may have a role to play in broader health policy, it seems that this is taking paternalism too far. There are a number of reasons that this is the case, which I discuss below in no particular order.
Firstly, infants should not be the primary targets of policy-makers’ concern. They are not yet making the sub-optimal decisions that would have harmful effects on their own lives and the lives of others. They are a blank slate when in terms of decision-making. In contrast, cocaine addicts should be the targets of paternalistic policies as they have established themselves in a position where they are making sub-optimal decisions by being unable to break their habit. A policy which stipulates that criminals that are found to be cocaine addicts should be involuntarily inoculated would be more ethically acceptable, as it is easy to identify them as a direct harm to themselves and to others.
A possible retort to this objection to this could be based on intergenerational justice grounds. It could be claimed that it is unfair to future generations to leave them to deal with problems when we currently have the medical knowledge to prevent them from happening. However, I do not think that this is a strong argument for two reasons: firstly, because we are leaving future generations no worse off than we are now – i.e. every generation has to deal with addicts so our inaction is defendable (though admittedly weakly) on egalitarian terms; and secondly, for the further reasons explored below.
Secondly, it has been argued that, in some cases, paternalism can be interpreted as problematic because it does nothing to build moral character. Bovens’ argues that such policies may not increase our capacity for self-control. For instance, he reminds us of the paradox that capital punishment may contribute to a more violent culture and may increase violent crime in the long run.[13] In the hypothetical case of TA-CD inoculation of infants, if we have manipulated people’s bodies to make them immune from the effects of cocaine when they come-of-age does this mean that we are creating more moral people with self-control. No. We might have strong reasons to believe that these people will seek their thrills elsewhere and may instead substitute cocaine for heroin, crystal-meth, ecstasy, ketamine, or others. They might even be more psychologically disposed to rebellion and counterculture. By vaccinating with TA-CD we are shifting the problem around, failing to see the bigger picture, and not enhancing individuals’ moral character and perhaps contribute to the deterioration of future generations morality.
A possible response to this rejection is that perhaps those inoculated infants will grow up to be less inclined to try addictive substances and would be inspired by their government’s moral heavy-handedness to be morally virtuous and abstain from a wider array of drugs. This is unsubstantiated conjecture and strikes this author as intuitively problematic.
Thirdly, even if such a policy of inoculations at birth were ethically defensible, it would not be a pragmatic policy decision. While there are no solid figures on addiction rates, according to the European Monitoring Centre for Drugs and Drug Addiction that monitors drug use in the EU, only 3% of Britons between 15-65 had tried cocaine between 2007-2008, a fraction of which would experience complications or become addicts.[14] The amount of money that would need to be spent on infant inoculation would seem to be an extravagantly wasteful measure for marginal benefit.
A possible objection to this is that inoculation could be cost-effective if it were mandatory for those born into a particular social class or borough where the prevalence of cocaine use is high. However, this is an even less appealing policy prospect. Those in these groups would likely be humiliated and insulted for being singled out for treatment. This policy is likely to be received as offensive to the integrity of the individuals of these groups and the perceived presumption of future akrasia of their children. The consequences for the ‘marked’ person of being singled out by others, even in their infancy, may be both socially disruptive and psychological in nature for the individual concerned, leading to a significant potential for negative externalities.
Finally, there is a potential social, artistic, and intellectual value to the euphoria that cocaine produces that potentially outweighs the costs of treating those who become addicted. Sir Arthur Conan Doyle, Sigmund Freud, U.S. President Ulysses S. Grant[15], and Brian Wilson of the Beach Boys[16] were all cocaine users and, because of the nature of the drug, likely addicts. Counter-culture revolutions such as those experienced in the United States in the 1960s owe a debt to the mind-altering addictive drugs. Addictive substances inspired a wealth of music and literature, from Dylan’s seminal album ‘Bringing It All Back Home’ to Kerouac’s ‘On The Road’, both directly or indirectly. In a sense, we may push that they weren’t making sub-optimal decisions at all. Do we really want to neuter such a rich nectar of artistic inspiration that has inspired millions of non-drug-abusing individuals?
A possible objection to this is that, there are numerous artists, writers, and musicians who have been successful without the aid of strong narcotics. Surely, it would be non-virtuous to praise those whose creative powers were artificially stimulated. I think that this is disputable. The effects of cocaine allow access to something which acts as the muse of creativity and stirs passions. Our society praises those who create works and ideas that are ‘authentic’ and create value through entertainment and education, regardless of drug influence. Western society seems, at least to this author, to extend a somewhat relaxed attitude by ignoring, excusing, or celebrating drug-culture’s association with the arts and important social movements.
Conclusion
I have shown that, given new medical developments, it is possible to imagine a hard paternalistic policy of compulsory TA-CD vaccination for infants. Despite its face-value virtue (eradication of future cocaine addicts), I have shown that a number of ethical and pragmatic concerns make this hard paternalistic policy unwise to pursue and is not a satisfying solution to the problem of cocaine addiction.
[1] Celtic Pharma, “The Firm – Overview”, Accessed at: http://www.celticpharma.com/thefirm/index.html
[2] Celtic Pharma, “The Portfolio – TA-CD”, Accessed at: http://www.celticpharma.com/theportfolio/ta-cd.html
[3] Weill Cornell Medical College, “Press Release - Vaccine Blocks Cocaine High in Mice”, (Jan. 4, 2011) Accessed at: http://weill.cornell.edu/news/releases/wcmc/wcmc_2011/01_04_11.shtml
[4] Smith, R., “Childhood vaccinations should be compulsory, says former head of BMA”, The Telegraph, (Jun. 4, 2009), Accessed at: http://www.telegraph.co.uk/health/children_shealth/5436636/Childhood-vaccinations-should-be-compulsory-says-former-head-of-BMA.html
[5] Note that a cocaine vaccination would appear have close-to-no implications for the effectiveness of on any established medication. The use of cocaine based treatments for medical purposes is very rare. It is only approved as a local anaesthetic in rare cases and has been almost fully replaced nowadays with synthetic alternatives.
[6] Dworkin, G., “Paternalism”, in The Stanford Encyclopedia of Philosophy, Accessed at: http://plato.stanford.edu/entries/paternalism/
[7] Mill, J.S., “On Liberty”, (1859)
[8] Kleinig, J., “Paternalism”, Manchester: Manchester University Press, (1983)
[9] This does not imply a low socio-economic background. Because of its cost, cocaine is a drug often associated with affluent socio-economic backgrounds also.
[10] Feinberg, J., “The Moral Limits of the Criminal Law, Volume 3: Harm to Self”, Oxford: Oxford University Press, (1989), pg. 19
[11] Loewenstein, G., “Asymmetric Paternalism to Improve health Behaviours”, Journal of the American Medical Association, Vol. 298, No. 20, (2007)
[12] Schmidt, H., “Draft PhD. Dissertation - Chpt. 2: Responsibility, ‘Carrots’ And ‘Sticks’ In Health Care Policy in Germany and the USA”, pg. 33, Accessed at: http://moodle.lse.ac.uk/mod/resource/view.php?id=197150
[13] Bovens, L., “The Ethics of Nudge”, in Grüne-Yanoff, T. & Hansson, S.O., “Preference Change: Approaches from Philosophy”, Berlin and New York: Springer, Chapter 10, (2008)
[14] European Monitoring Centre for Drugs and Drug Addiction, “Country Overview: United Kingdom”, Accessed at: http://www.emcdda.europa.eu/publications/country-overviews/uk/data-sheet
[15] Radenkova–Saeva, J., “Review Article: Recreational Drugs and its Impact on Music, Literature, and Art”, Biotechnology & Biotechnological Equipment, Vol. 22, No. 2, (2008)
[16] Levine, B., “Brian Wilson: A Cork on the Ocean”, Scientific American Mind, (Dec. 2005)
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