Special Senate Committee on Illegal Drugs (37th Parliament, 1st Session)

Past Session:

The Contribution of Ethics

in Defining Guiding Principles for a Public Drug Policy

Expert Report to the
Special Committee on Illegal Drugs of the Senate of Canada
by
Jean-François Malherbe, Ph.D., S.Th.D.
Professor
Applied Ethics Chair
University of Sherbrooke

CH-1454 L’Auberson
May 12, 2002

Introduction

Therapists and Politicians

Prevention programs are most often characterized by the way in which they reduce human existence to the operation of a cybernetic machine, from the bodies we are to the bodies we have, from therapy to biomedical engineering. That is why they are a public menace, one that is better prevented than cured. Medical prevention, far from protecting us from all risk of accident and disease, entails considerable ethical and political risks which aggravate rather than alleviate the crisis of meaning we all face.[1]

The purpose of the first chapters of this paper is to dismantle the dominant logical mechanism of our culture, which, in the health field, is biomedical in nature. We show how a particular vision of disease has, through the technical miracles of modern medicine, managed not only to prevail in the assessment, for the health of individuals, of potential risks "caused" by their behaviour (Chapter 1), but also to establish itself, through a kind of epistemological deception, as the only valid approach to disease (Chapter 2).

In Chapter 3, we show how drug addicts generally strive, through high-risk behaviour, to cope with life anxiety by tending toward death. The message here, in our view, is this: the way in which anyone negotiates a particular way of life in the face of inevitably approaching death is, as a rule, purely individual in nature. And a democratic society has no authority to dictate to its citizens how each of them should cope with the inevitable anxiety related to human existence. On the contrary, society should provide protection for the manner in which all citizens cope with the means they have available. This does not mean it would not be desirable to develop a culture in which life anxiety and the fact of death would be viewed as normal rather than pathological. Nor does it mean it would not be desirable for a democratic society, without renouncing its fundamental rules, to provide its citizens with an assessment of the risks entailed in the various possible ways of living with anxiety. It is not even out of the question that certain inoffensive ways should be favoured, if any exist, though without ever losing sight of that Voltairean statement, which we adapt for our own purposes: Sir (Madam), we detest your ideas and will always fight them, but we will fight even harder for your right to express them.*

Lastly, we examine the basis of a health ethics understood as a capacity for reciprocal autonomization (Chapter 4), then define the role of the therapist, which is to cultivate the individual autonomy of his or her patient, and that of the politician, to guarantee the opportunity to carry on this autonomization work in society (Chapter 5). These two roles cannot be exercised by the same persons because their short-term purposes are opposed, even though their long-term purpose is identical. Ultimately, that purpose, for both the politician and the therapist, is obviously to contribute to the autonomy of their fellow human beings. At first glance, however, therapists cultivate the individual interests of their patients, whereas politicians define the limits of that autonomy. Where the two roles are combined in a single person, patients may lose trust in their therapists and suspect them of imposing arbitrary restrictions, and citizens may always suspect politicians of thinking they know what is best for them.1 For that reason, it is never a good idea for therapists to act as politicians or vice versa.

The purpose of this paper, having regard to this issue as a whole, is to show clearly that the only acceptable reason for the citizens of a democratic state to limit their own autonomy so that they can guarantee it more effectively. And the actual acceptance of this limit of the state's power is the most valid form of disease prevention and the best way of promoting individual health. It is not by restricting citizens through overregulation that they will be in the best position to cultivate their own health.

In the conclusion, we offer five ethical recommendations to guide the formulation of a public drug policy. Those five recommendations are as follows:

1.       That policy makers consider the fact that high-risk behaviours statistically defined as "harmful" are not always in fact harmful for all individuals, but may, on the contrary, in certain specific cases, constitute the least harmful response by those individuals to the difficulty they experience in living in their own circumstances.

2.       That authorities view the question of the legality of drug use and the drug trade in the perspective of an epistemological criticism of biomedical scientific knowledge rather than give in to the illusion of medical scientism.

3.       That a radical distinction be drawn between the need for the adaptive equilibrium of individuals (which in certain cases may involve drug use) and the free trafficking in those harmful substances for the sole purpose of economic gain (which always brings with it strategies designed to create the need for those substances in a population which could create its own adaptive equilibrium through other, less harmful means).

4.       That the fundamental ethical-political principle that the autonomy of individuals in a society cannot be limited by the law except to protect that autonomy more effectively be adhered to.

5.       That a careful distinction be drawn between the role of therapists and that of politicians and that it consequently be constantly recalled that every law is ultimately intended to protect the autonomy of individuals, which presupposes that they are supported in the exercise of their individual critical faculties, and not to standardize ways of living, which is the usual tendency of authorities responsible for enforcing the law.

The following chapters outline and clarify the philosophical and ethical bases of these five recommendations.

Harm and Safety

The concept of "harm" plays a major role in the entire field of public health, but what is strange is that, while the concept itself is purported to be self-evident, there is no clear and distinct definition of it. It is readily apparent from the various ways in which it is used that it is a catch‑all rather than a genuine operative concept. And yet it still has an operative function in that it forms the basis of a significant part of what is said to justify the distribution of public funds for preventive action.

But is that operative function scientific or ideological in nature?1 In other words, does the concept of "harm" have a scientific purpose or is it an ideological representation of social facts that may be interpreted in a scientific manner?

Here we contrast the ideological with the scientific, just as we would distinguish the legitimizing camouflage of particular interests, systems of rebuttable conjecture attempting to open new fields of action to non-transparent interests. The comments below underscore the predominance of ideology in all discourse on "harm" in the hope of revealing, through the purpose of that discourse, a level of intelligibility and operative purpose at which the concept of "harm" could be clearly and distinctly defined and contribute to the designation and search for a new socio-political purpose which the current crises of rationality tend to reject as irrational.

"Harm Entails an Increased Risk of Disease"

The above statement accurately sums up the diverse nature of the most common contexts in which the concept of "harm" is used. Failing a formal definition, it could thus serve as a guide in understanding the concept of "harm". We must therefore define the concepts of risk and disease.

First of all, isn't harm a (more or less complex) aspect of social life entailing a significant increase in risks incurred by our fellow human beings? This first approximation must be clarified, however, with regard to the relevant levels of the social aspects considered, the nature of the risks referred to, and the identity of those who run those risks. Are we to consider essentially individual social phenomena (idiosyncratic behaviour, for example) or merely "statistically significant" social phenomena (but what is "truly significant" in a statistic and relative to what truth?)? Does one consider the risks of death, of disease and also of pleasure or happiness?

Since we are concerned with harm, the risks of happiness appear to be excluded from consideration, even – and this is not the strangest aspect – if they more or less offset the risks of unhappiness! As to potential victims (or beneficiaries) of those risks, who are they: individuals, families, societies or the fragile balance of the biosphere? All these questions (and others as well) are left unanswered in the conventional view. But one thing seems quite clear: the most feared risk is the risk of disease, more particularly the risk of terminal disease.

But what is a disease? Since Claude Bernard,2 every inhibited or exaggerated operation of a physiological function has been considered as disease. These are the phenomena designated by the prefixes hypo- and hyper- in the names of so many diseases. Any organism that ranges too far, for the variable observed, from the average for the population under study is considered sick. Apart from the fact that this statement itself emphasizes the arbitrary nature of this kind of approach (why are citizens 1.60 m or 1.90 m tall pathological in a population in which the average height is 1.70 m?), it will be seen that a singular dysfunction in a complex whole is defined in this manner and that this is no way indicates the potentially positive or negative influence of the part considered on the quality of the whole experienced by the person.

This Cartesian and mechanistic approach to disease proceeds from Descartes' recommendation that problems be reduced to the simplest expression in which they can be solved,3 and not from a comprehensive approach that would indicate at the outset, as Pascal would have it, the significance of each variable in the whole of which it is a part and which defines it.4 In proceeding in this manner, one is prevented from grasping the overall risk of a subject living in his own body and one limits the assessment of it to its influence on one of the parameters defining "an inhabited body, a still living cadaver".5

But not all approaches to disease are as mechanistic or reduce the subject to the objective state of a mechanical body. There are more balanced approaches in which disease is viewed as an adaptive reaction to changes in the environment (external) or the internal environment subject to outside aggression.6 The subtle distinction here is to observe that an individual can "have a disease" simply because he is in good health!

However, this subtlety is further qualified by an arbitrary element because it cannot clearly indicate which of the following three behaviours is the most "adapted" (and, consequently, the healthiest) in the case of a non-smoker who experiences headaches at a particularly decisive political meeting of heavy smokers: leave the meeting, ask his partners not to smoke or take an aspirin while awaiting the end of a meeting that it would be strategically imprudent to leave, even momentarily? This is where some authors have introduced the concept of autonomy in the definition of disease,7 an individual's degree of health being measured by his degree of autonomy in his geo-bio-social environment.

There is no room here to review the definition of the concept of autonomy,8 but suffice it to say that the concept of disease, understood as "a reduction of one's autonomy capability" subsumes "adaptive" (Canguilhem) and mechanistic (Claude Bernard) concepts of disease. There is no autonomy without a minimum of adaptability to the environment or a minimum of "normal" functioning of the mechanistic body. The "autonomy" concept of health thus has the remarkable property of being both very specific (is it not strictly defined by a combination of 12 other concepts?) and very flexible (does it not explain why a one-legged, one-eyed man can be more autonomous than a perfectly "normal" robotized citizen).

However, the "autonomy" concept of disease, as it is currently stated, is still too exclusively linked to the individual's social context and does not expressly take into sufficient account his membership in the system constituted by all interrelated living beings that people the earth and form a thin film of life on the surface of the planet9 or the biosphere. It must therefore undergo, as J.‑M. Pelt asks, new developments expressly including the subject's insertion in this biosphere context. And how could man cultivate the autonomy of others and hope that his own would develop as well, if he neglected to cultivate the biosphere to which he belongs?

Cultivating the biosphere is as necessary a condition of my autonomy as cultivating the autonomy of my fellow human beings. This point need not be developed here, but it was necessary to raise it because it is only in this more global context that one can take the exact measure of "medical uncertainty". In a recent book on a sociological approach to organ transplants, R. Fox shows that, far from being a science or an applied science (as though a physician were an engineer of the human body), medicine is more an art, and in particular the art of detecting, in uncertainty, how best to cultivate patients' health.10 As we have shown elsewhere, medical science is essentially a science of the body which we have, that is to say the cybernetic machine which serves as the material support for the body we inhabit, the body we are. The decisions that doctors are asked to make essentially concern the vicissitudes experienced by their fellow human beings, which are aimed at them, not merely what is wrong with the bodies they have. This is why the greatest care must be taken in extrapolating to the body we are from data gathered concerning the bodies we have. The difference between the two is the subjective significance of the objective dysfunction we are facing: a headache caused by heavy smoking at a meeting one attends does not have the same meaning for the person who is bored to death by that meeting as for the one who intends to participate fully. Which of the two is the sicker: the ardent supporter who takes an aspirin and continues participating in the negotiations or the opportunist who had to be there and slips away on some pretext as soon as he feels the least discomfort? This is a question to which the science of cybernetic machines and mechanistic medicine can only offer arbitrary answers. It can only be answered through lengthy meditation on the purpose of human existence.

What then is "harm"? Nothing seems more unclear to an analyst who is the slightest bit critical. This observation will become even clearer as the concepts of risk, prevention and safety, all three of which appear to be related to that of harm, are critically considered.

Risk Prevention and the Need for Safety

It is a commonly held prejudice that the purpose of medicine is to fight disease and death. However, we all know that there are diseases that help people to live before leading to death (for example, alcoholism, in certain cases) and deaths whose time it is highly desirable not to delay. Thus we know that our vision of the purpose of medicine is false, and yet we continue to talk as though it were clearly true. We have proposed elsewhere to consider the purpose of medicine rather as helping subjects to live with the highest degree of autonomy possible with or in spite of the vicissitudes of the body they have.12 But this vision does not seem to correspond to the necessities of the absolute power over disease and death that we attribute to medicine, or the absolute knowledge it claims to have of what is good for humankind (knowledge that would transmute it into moral knowledge). However these two claims underlie all conventional approaches to prevention, which are all based on concepts of risk, safety, life, death, disease and so on.

Otherwise, how are we to explain such frequent statements as "highway accidents kill more than tobacco." Doesn't that statement lend the illusion that, if all risks related to highway traffic and to smoking were completely under control, no one would die? No, we will all die, and some will die in traffic accidents, others of lung cancer,13 and still others of heart attacks or simply of old age.

The human experience is always complex and multifactorial, and no statement of risk referring to a single factor has any meaning for an individual subject (even though certain correlations appear to be well established).

Even those who do not smoke or drink, eat "right", are moderate in love, do not drive, and so on, ultimately die. It is not even certain that they live longer. It is likely, however, that they find time passes slowly. Perhaps they ultimately die of boredom. Boredom is definitely a risk factor, as the statistic on populations of young retirees suggest. The idea is not to suppress all risks – that would mean suppressing life itself – but to choose one's risks. This is not consistent with conventional thinking. And yet the statement is all the more valid in that it does not confuse statistical risk factors with individual risks, or risks (or a fortiori risk factors) with causes. There is now no need to demonstrate the statistical correlation between excessive tobacco use (but where does the excess begin?) and lung cancer. But it is a serious and common epistemological error to conclude that smoking, for a particular individual, will cause lung cancer in that person. There are some very heavy smokers who never "catch" the cancer they should catch14 and some non-smokers who are not spared. There are even some who "die from stopping smoking" because the weight gain they "catch" as a result of their abstinence is the last straw for their cardiovascular system.

The future cannot be predicted for a singular individual on the basis of statistical information. We can therefore wonder at times about the level of scientific training (or honesty) of doctors who confuse "statistical correlation" with "risk factors" and "causes". It is true, however, that it is more convenient to "preach" to people about the causes of cancer than to support and inform them in the often chaotic advance of their freedom toward fuller responsibility for themselves, for others and for the fragile biosphere to which we belong.

In short, preventive actions are almost always thought out in mechanistic and causalistic terms. They extrapolate unduly to the bodies we inhabit, that we are, from fragile uncertainties derived through statistical analyses of the bodies we have, of the cybernetic machines that serve as the material medium of our singular subjectivity. That is why they most often collide with the irrationality of populations which, even when they know, do not adapt their behaviour to the recommendations made to them by specialists.

Despite all we think we know about addiction, a considerable number of well-informed subjects "happily continue committing suicide" through their dependencies. While health education is largely thwarted, and not only in the field of toxic substances, it is not because human subjects are in fact subjects, that is to say "subjective" beings whose behavioural reactions are linked much more to the meaning they attach to their behaviours than to the objective mechanical-medical consequences which statistical analysis claims to define.

Some risks are no doubt worth taking for life to be worth the trouble of being lived, for it not to dissolve into a maniacal and fearful sequence of endless precautions against all the spices that give it flavour? Lastly, what is most human (the most autonomy, we dare wonder): succumbing to fearful hypochondria and enclosing oneself in a cocoon of universal prevention (to the point of death by asphyxiation and loss of will) or living one's life through risks freely chosen and accepted? To choose the latter, mechanistic medicine must convert and cease to stubbornly refuse to consider disease as a language, a dialogue between the subject and himself in a geo-bio-social environment, the provisional but effective realization of a balance of survival, even an unhappy one.

Why do some patients not want to be cured and seem to cling to the disorders of which they complain and pray their doctors to rid them? It may be assumed that they need them, that their disease is beneficial to them, that the disadvantages they entail are more or less largely offset by the balance they help to strike in their lives. When they "disobey" the prescriptions of preventive medicine, human subjects appear to protest against the anorexia of desire and pleasure to which the logic of health safety at all costs leads. What is ultimately the gravest risk: drinking, smoking, taking drugs, loving or being depressed? We are not unaware that some behaviours (driving, smoking, drinking, eating, loving, taking drugs) are or can be related to risk factors, and we urge no one on to excess and debauchery, but we also know that life is a fragile and dynamic balance of a multiplicity of risks, some of which may no doubt be attenuated (even, in some cases, eventually eliminated), but never without resulting in an at least partial change in others.

True and False Harm in a Convivial Society

It may be hypothesized that every disease, whatever its cause or consequence, is linked to a crisis.16 A disease may be the symptom or consequence of a crisis that, perhaps only for the moment, has found only that outlet. But a disease can only provoke a crisis, for example, by the incapacity it causes. Whatever the case may be, crisis and disease are linked. However, this hypothesis appears enlightening not only for the purpose of analyzing the link between the life of an individual and his or her crises, but also in grasping the potential relationship between a social context, the diseases that correlate with it and the type of crisis conveyed by the context. C. Castoriadis speaks of the collapse of the self-representation of our societies in characterizing the socio-historical crisis which is ours.17 We no longer view the society to which we belong as a project that is worth supporting or promoting, but rather as a chore we are compelled to perform out of habit. In this sense, he emphasizes that our imagination is incapable of projecting into the future a cause that can elicit our individual and collective energies, and he sees this as a cause of socio-historical and individual crisis.

Not knowing what we are fighting for, we lose the desire to live in and through society and timidly retreat into the sphere of our private existence. This phenomenon is extremely common in the West and is gradually spreading to the entire planet; it colours our entire life with an incapacitating scepticism which, in one way or another, whether or not we are aware of it, makes us accomplices in the injustices that structure the social fabric of which we are a part. Thus we find ourselves, whether we like it or not, both victims and accomplices of a society which becomes more totalitarian each day and to which preventive medicine contributes in its own way to the dictatorship of the safety it tends to impose. In view of this development, which inevitably leaves us in crisis as subjectivities bound to become autonomous, the first duty is to resist, to question and to try to understand the profound resilience of the movement that leads us and carries us at the same time.

On this point, the analyses of the ecologist J.‑M. Pelt are extremely enlightening.18 Pelt breaks down the mechanism of our relationship to the biosphere by emphasizing both its predatory character (gradual exhaustion of natural resources) and its destructive character (the extensive industrial and urban pollution which acts as a veritable pathogenic agent infecting the thin film of terrestrial life, gradually making it sick). Without any illusion as to the loss of the paradigm of human nature affecting us, he calls upon all those who can do so to realize the extent to which our species is exhausting and damaging the source of its own life and to invent personal and collective ways of being designed to introduce new types of symbiosis between the species and its environment. This aspect of his views would not be very original if J.‑M. Pelt did not, as H. Jonas does,19 make this call to ecoresponsibility, which must be considered as an indirect responsibility, of course, but one that is increasingly necessary with respect to ourselves and to those who follow us, a project that can drain our energy and enable us to overcome the present collapse of meaning in our societies. This is obviously a utopia, in the original sense of the word, an idea without hearth or home, but a utopia the arbitrary nature of which is only apparent since the idea in fact is to cultivate the conditions of the possibility of our own survival as individuals and as a species.

The project of cultivating the biosphere to make it a habitable garden (which is the original meaning of the ecological movement) now appears to be indissociable from the project of cultivating the autonomy of others (in which ethics consists). And in cultivating both the biosphere and the autonomy of others, the need to respect differences is felt in the most urgent manner.20 Ultimately, the idea is to subscribe to what Michel Serres has recently called "the natural contract", that is to say to accept the fact that our differences enrich us all.21 Whether our differences are cultural differences with "nature" or inter- or intra-cultural differences is of little importance here. From this diversity, a new symbiosis will emerge, if we do not destroy it in ovo. Cultivating nature like a garden inhabited by our fellow human beings whose autonomy we cultivate, while allowing them to cultivate our own: that is the socio-historic project we are bound to carry out.

This indiscernibly personal and collective task is extremely complex and can only be successfully carried out at a cost of apparently deliberate errors and random choices, which, regardless of our conviction as to the final outcome, are extremely difficult to experience and endure.

And in this context, space must be made for disease.22 It falls to us, of course, to respect the sick, but we must also respect ourselves as sick persons, because disease, particularly substance abuse, is also a way of assuming the contradictions of our culture. From a considerable number of trials and errors will emerge the symbiosis we want to cultivate, and no mechanistic medical knowledge can claim to teach us a priori which disorders are productive and which are terminal. It is only by opening up to risk, as freely chosen and accepted as possible, that we can invent a cultivation of the human which is at the same time a cultivation of nature.

In this perspective, what, today, we at times reluctantly agree to call "harm" could well prove to be interim but necessary adaptive behaviours designed not to repress the disorders which are full of solutions which we derive from our wishes. We are entitled to be sick if that is how we best bear and respect the crises we go through which can lead us to new forms of conviviality.

In this regard, a new critique of the preventive cocoon which mechanistic medicine seeks to impose on us is coming to light and concerns the health economy. Etymologically speaking, economy and ecology have a common origin that can be expressed by the category of the habitable. Ecology is the theory of the habitable, economics its management. However, it is essential to prevent management from becoming normative to the point where it makes the common house uninhabitable. Between ecology and economics, the hierarchy of principle is clear: management can never be an end in itself; it is in its essence subordinated to a project which gives it its decision-making criteria. In other words, ecology should be to our purposes what economics should be to our means.23 Reality is still most often very different, but the reason for that must be sought in a kind of hypermechanism which leads us again to consider the biosphere, like the human body, as a cybernetic machine, not as an organism inhabited by desires, resistances, pleasures and aversions specific to a multiform conviviality.

A mechanistic economy ultimately destroys the biosphere, just as mechanistic medicine culminates in a normalization of the human. The error is the same; only the scale differs. Whatever the case may be, just as the human body is not merely a machine, but rather a body inhabited by a specific subjectivity, the biosphere is not merely a vast system of cybernetic interactions, but a body inhabited by what Teilhard de Chardin called the noosphere, the conviviality dimension of which I would like to emphasize.24

If the body as machine is to subjectivity experienced what the biosphere is to our conviviality, one immediately perceives what is profoundly death-causing about the mechanistic model of medicine, like the economy, if it determines its own purposes. It is in this death-causing nature that the principle "harm" we are dealing with consists. Medicine and economy are death-causing mistresses, whereas they could be marvellous servants of a project that must be defined and negotiated step by step by us alone.

In this perspective, what ultimately is true "harm"? There is in fact only one type and it diverts us from our political tasks and from our historical responsibilities by regimenting us, on the pretext of actual but secondary risks of harm, in programs designed to fight against types of pseudo-harm defined with the aid of ideological manipulations of statistics. Intellectual myopia has never helped anyone to live, but only to lose sight of the meaning of life out of a fear of death. It is likely from a new Epicureanism that we will be able to learn to cultivate subtle balances between the many risks of life rather than strive to reduce those risks at the cost of life itself.

The true harm, the worst of all, the most intolerable, the only one that must absolutely be repressed is wanting to make people happy by deepening their fear of disease and death, without asking each individual to make personal choices and realize his or her preferences. The true, the only harm stems from health ideology, from the furor sanandi, which sketches out our happiness without us being able to enjoy it.

Does this mean that everything should be permitted without distinction? Of course not. But the test is still to discover step by step through our trials and errors, and it cannot be imposed on us by experts – doctors or economists – in the name of a prior and death-causing order. The joy of fertile disorder is better for life than the boredom of a type of planning, the arbitrary nature of which equals nothing but sterility.

The Scientistic Temptation of Medicine

How has medicine managed to shape itself in such a way as to dismiss from its field the actual suffering of its subjects and to fall back into a field that is as reduced as it is sterilized? How is it that a genuine preclusion1 of suffering thus appears to be the most dramatic consequence of scientism2 in medicine?

Reduction of the Human to a Machine

The biomedical sciences, which form the basis of modern medicine, view their object as a system, reducing the human being to the organic system which constitutes its material support medium.

Under this methodological approach, it is considered that human beings and their constituent parts can be isolated from their context, that is to say, in particular, from the systems with which they interact. Thus, for example, the circulatory system is considered as separate and different from the respiratory system or from the nervous system. It is also considered that these systems can be broken down into subsystems. The blood, for example, may be considered as a system independent of the heart. However, both fit together as subsystems in the respiratory system. The red blood cells, for example, also form a subsystem of the blood.

Through methodological hypothesis, a system is considered as always fitting into another system and that other systems fit into it. A system is still considered as evolving over time. The circulatory system develops during embryogenesis and deteriorates as the body ages or is attacked by certain diseases such as arteriosclerosis or myocardial infarction. But each stage in the evolution of a system can be characterized by a state. The state of a system at a given time comprises all the information we have about it at the instant considered. Blood pressure or pulse, for example, are elements of the state of the circulatory system of a particular body at a particular time.

Studying a system consists in describing it in its successive moments and attempting to formulate the laws it obeys. If those laws are correctly stated, they enable us to predict how the system will evolve based on the parameters which determine that state at each instant. Without this set of methodological hypotheses, it would be impossible to know how a system functions.

In considering the human being as a system, the biomedical sciences, and physiopathology in particular, have grasped the operation of this system since they can predict its evolution based on the variation in the parameters that define it. This methodological conquest, the result of Cartesian dualism, has proven to be of considerable influence, which it is not our intention to denigrate. However, the operationality thus acquired comes at a heavy cost, because it reduces the human being to a cybernetic machine, abstracting from its particular history, specific subjectivity and actual existence.

The objectivation of the human being by the biomedical sciences consists in disregarding certain aspects of the subject in order to highlight others. Measurable time is removed from duration, geometry from qualitative space, the entropy of the body from the aging of the person, biological metabolism from personal existence. In short, the biomedical sciences cut into human flesh to extract an abstraction called "cybernetic machine". Objective observation is emphasized at the cost of the subject's self-understanding. Common determinisms are removed from the actual exercise of personal freedoms.

The Preclusion of Suffering

In short, the scientific approach to the human being abstracts the body from the person, the body we have from the body we are. However, this operation, although necessary, often goes unperceived, and medicine, by unduly extrapolating knowledge acquired about the body we have for the care of the body we are, becomes scientistic. It believes it can regulate the bodies we are like a mechanic controls cybernetic machines. It is thus, in particular, the suffering experienced by the subject and the words he uses to express it that scientistic medicine views as negligible.

And yet, those words stem from the suffering of a subject seeking his own identity in the heart of the crisis he is experiencing, in the heart of the body-rending experience that makes him cry out. However, for his cry to become words, he must be heard by others for what he is. One may, moreover, wonder whether the objectivation of the human being by the biomedical technosciences is not used in large part to protect the caregivers from the cries of patients who, if they heard them, would refer them back to their own mute cries of their own anguish.

Through a strange reversal of their methodology, the caregivers, practitioners of objectivation, are supposed not to suffer, and this makes them deaf to the cries of those they care for. Those cries thus do not make themselves heard. Their message is confused by the expression of pain. The patient's pain triggers the technical action of the caregiver, who tries to rid him of it. The patient is transformed into an object of pain, his cry immediately reduced to the expression of a technically controllable pain.

But the suffering his cry signifies is implicitly considered contemptible precisely because it cannot be warded off by a technical act. However, not to hear the cry of a suffering man as the cry of a subject facing death in his desire to live is to sentence him to silence, to exclude him from the true conversation that instructs us in our humanity.

However, there are many ways to repress the word that would be spoken if the suffering were heard for what it is. The most effective way is to consider that the human being is not the subject of such suffering or, a fortiori, of such speech. This is what scientism leads to.

Suffering is inevitable. It is part of life, the sign of the maieutic* history of human beings, who are, or at least should be alternately midwife and patient in their relations with each other. Becoming a man or a woman means allowing others to deliver us in a relationship which never spares us suffering. That is why medicine, which should be the art of encountering, together with others, one's true suffering, rather than masking it behind the technical treatment of pain and its causes, should be a philosophical art, a maieutic art, an intersubjective art.

Suffering remains inevitable even when we try to reject it, but if it is denied, if it does not find in speech the expression which makes it possible to meet it face to face, the subject will try constantly, but always in vain, to recover his previous health of which he is now forever deprived, to restore his irremediably lost previous state, to reverse irreversibly elapsed time.

And in this illusory attempt, indefinitely repeated, he will find the medical establishment participating each time he meets a practitioner who will not hear his suffering in the expression of his pain, but also each time he leads a practitioner astray, off the beaten paths of his art, each time the practitioner allows himself to be deterred by an express request from his patient.

The secret complicity that is established between patient and caregiver, combining their efforts to avoid encountering suffering, that of the patient referring the caregiver back to his own, always ultimately culminates in a loss of speech in both. It is as though the illusory wish to restore health as it is defined by current social standards, drained in its realization all the energy which the parties in fact most need to allow their suffering to be expressed in speech, to mourn their illusions and to open up to a future that remains to be invented.

The health professions, and the medical corps in particular, appear to behave most often as though their mission were to guarantee and promote a normalcy which is in fact merely the condensed expression of the screen we raise between our suffering and ourselves in the illusory hope of not suffering. But make no mistake: we do not intend to argue for the rehabilitation of pain. Medicine has a duty to fight against and overcome pain through appropriate care, but it must also not conceal the fact that pain is both symptom and cause: the suffering involved in being a man, a woman, who is going to die.

When the human being is reduced to the scientistic image which our scientific culture makes of it, that being is lying to himself while believing he is telling the truth. When medicine is an accomplice in this lie or, even worse, cultivates it, it renounces its purpose and transforms into a death-causing ideology. From that lie results the death of the subject, under the responsibility of the caregiver, and of the patient. Lastly, and paradoxically, it is through technical and scientific development that it cultivates, and that question society precludes for itself – and consequently precipitates – the very thing it sought to correct: suffering.

Scientism thus consists precisely in behaving or thinking as though the scientific approach was not reductive. In other words, it is wanting to apply to the entire dynamic of the human knowledge which is valid only in respect of the cybernetic machine that serves as its material medium.

This abusive extrapolation more or less deliberately disregards everything the scientific approach has had to disregard in order to represent itself as operative knowledge, in particular all phenomena relating to the meaning or non-meaning of individual human existence. Lastly, preventive medicine digs its own grave each time it allows itself to be directed by the scientistic siren song.

The Failure of Scientistic Medicine

The medical approach to drug addiction is based on the possibility of prevention, which itself is based on the rationality of citizens. In actual fact, however, this type of prevention does not appear to work so easily.

The preventive approach is not really understood by citizens. It presupposes that an individual's behaviour is clear to that individual, that he can consciously alter it based on the rational perception proposed to him of the threat that stalks him.

Moreover, advertising puts individuals in an agonizing situation of indecision by bombarding them with contradictory messages. For example, on the one hand, the "health warning" on each package of cigarettes tells him "You are in danger," while, on the other hand, even very indirect commercial advertising reassures him, "Enjoy without fear." In fact, individuals are torn in their daily lives between their desire to relieve their anxiety and the role assigned them by the technical approach conveyed by anti-risk campaigns. This tearing causes anxiety which they attempt to resolve through drug use and rejecting the health message.

An individual's subjectivity fades away under this technical approach which claims to support it. For lack of a principle of reality, a principle of otherness, the individual is reduced to the role assigned him by social discourse. Prevention campaigns based on citizens' rational decisions fail because they rely on responsible subjects who scarcely exist and whom they, paradoxically, help to anesthetize. Those campaigns fail because they raise in the minds of those they are aimed at a question which they do not want to face and which they are incapable of answering: why are we so attached to our so‑called "high-risk" habits?

The decision to stop smoking, drinking or taking drugs could be a rational decision. But if that were the case, the individual would defy the deep meaning of the advertising messages aimed at him. His decision would appear as the result of a genuine questioning of himself and of his relations with others. If it were to be exercised, such responsibility would soon be threatened because the individuals who would have exercised it would need to continue carrying on the social roles assigned them by conventional discourse. That is why successful detoxification is so difficult.

Ultimately, scientistic discourse causes the solutions it advocates to fail precisely because it reduces the human to the organic. The only way to overcome this difficulty is to begin a real debate on the place of anxiety and anxiety-relieving medication in social life. But this project faces considerable barriers.

The User Game

The scientific approach to the human body, its diseases and disease prevention measures is characterized by a disregard for the aspects of human existence related to meaning. The objectivation of human existence opens the field of medicine's operationality, but, at the same time, shuts off its access to what is ultimately its sole purpose: relieving human suffering or, to say it otherwise, helping human beings live in the body they are despite the vicissitudes of the body they have.

A smoker's* body is a more or less docile cybernetic machine whose evolution, that is to say aging, takes a particular turn as a result of his or her living habits. The process is extensively described in all preventive medicine textbooks and in medical books on pneumology, cardiovascular diseases and other pathologies linked to the smoking of toxic products. It is beyond the scope of this paper to discuss the merits of the hypotheses advanced on the issue or to develop others. However, a philosopher is not prohibited from taking an interest in the question of what a "joint" means to those who use it.

If one wishes to understand this phenomenon from the inside, it is even necessary to conduct a phenomenological analysis of the use of cannabis derivatives, that is to say to advance as rigorous an interpretation as possible from the standpoint of the psychological make‑up and relationship of the smoker to himself, to others and to the world in general.

Our hypothesis is that smoking is a specific way of being in the world and that it is worth the trouble to try to elucidate it. We do not claim to psychoanalyze smokers; we are not qualified to do so. However, we will rely on certain psychoanalytical studies in sorting out the many threads that make up the fabric of the smoker's existence in his relationship to the "joint".

Symbolic Versatility of the "Joint"

The singular body of a smoker is moulded in particular by the entire symbolic system of which the act of smoking is a part. From that standpoint, the "joint" is characterized by its surprising symbolic versatility. "It can be alternately and in a rich and nuanced way, breast, feces, phallus, transitional object, structuring mother and tranquillizer, all powerful father..."2 The evocative power of this symbolism is quite strong: a "joint" can be sucked like the nipple of a breast, hot and perfumed; it usually ends its ephemeral existence in an ashtray, where it joins other malodorous butts; it stands between the fingers, glows red and exudes a hot, whitish fluid; its use often marks the transition from one activity to another or the interval between two editions of a repetitive act;... "The extreme availability of the cigarette, the permissiveness that surrounds it, the simplicity of its use and even its moderate price make lighting a cigarette an act almost as simple as a child putting his finger in his mouth, and it affords the same pleasure."3 Sucking one's thumb or the end of a "joint" provides a minor pleasure substituting for a missing pleasure which would be complete. Freud, himself a heavy smoker, moreover described the habit of smoking as a regressive equivalent of masturbation.

The symbolic versatility of the "joint" is likely rooted in "the extreme complexity of the elements that come into play in the act of smoking: motor skills (picking up a cigarette, lighting it, smoking it, extinguishing it), the impact on the senses (taste, smell, heat, coenesthesia, kinesthesia), changes in internal chemistry and inside the body, the social relationship (the fact that a cigarette can be smoked in front of or with others), the consumption aspect, in the economic as well as food sense. The purpose and use that can be made of it can reproduce most objects, fantasies, desires and mechanisms that marked a person's psychological life in his or her formative childhood years."4

Thus one can understand the fascination adolescents may have with the "joint". In an autobiograhical work, Quebec novelist Roger Lemelin deftly describes his first steps as a smoker:

One day, circumstances arise that lead you to smoke, as though you had decided to join a sect. First contacts with the tobacco monster vary with each individual. Mine were extraordinary and made me a cigarette fanatic. As a result of that event (Editor's note: the spectacle of a very young woman in the neighbourhood whose some hoods were encouraging to hold a smoking cigarette between her labia), I waited so long before committing my first puff that, if I had waited a little longer, I would have been relegated to the camp of the "sissies" (...) One day, fed up with my friends calling me a sissy, I decided to take the plunge. (...)One evening, I was suddenly very troubled to see my friends smoking with sheer pleasure, while I contented myself with an ice cream cone. I took a cigarette in my fingers and tried to inhale the smoke. Everything began to turn, I had trouble getting home and, flattened with a stomach ache, I vomited so much that I swore I would never do it again. (...) Surrounded by advertising, by the smells arising from public places, by the example of my friends, who chainsmoked with obvious arrogance and pleasure, I felt my defences fall one by one. At the movies, when I saw the seducer tap two cigarettes on a table (to pack the tobacco, I suppose), put them between his lips to light them with a gold-plated lighter, then put one between the open lips of his prospective prey, I was fascinated. Then, when he elegantly clicked his lighter shut under the woman's chin, I felt I belonged to a race of men unknown to these distinguished people.5

This passage leads us to the heart of the subject of this chapter because it emphasizes that one becomes a smoker to reassure oneself as to the validity of one's existence. Roger Lemelin clearly states it: "You become a smoker through all kinds of ways and a heavy smoker out of a fever that stems from chronic insecurity about the difficulties of existence."6 Annie Leclerc, also a novelist, writes, even more explicitly:

Cigarettes offer nothing, or nearly nothing. But don't they give something all the same? Yes, a dizziness of the essential, which fails most when, at 15 or 16 years of age, you want to enter the fray of life, the look, the countenance, the form of a person who resembles a person, and not a slug, a pustule, a cauliflower, an affirmation of virility for boys, a mark of emancipation for girls, membership in the elite clan of independent, autonomous and self-sufficient adults. The worst is that, in some way, it works. It's very hard to be able to think you can exist, and cigarettes sometimes managed that trick.7

What smokers or former smokers say of the smoking habit always refers more or less explicitly to the difficulty of living.

Resolving Life Anxiety, While Fuelling It

"Like all civilized beings," psychoanalyst Gérard Pommier writes, "I sometimes feel a kind of anxiety, and, I admit, I often don't know why. My dreams, which I will continue to have probably until the end, suggest to me that my appetites are unsatisfied, that I need more of everything, more love, more power, more money. My small glories remain less than what I make them out to be. My thirst for beauty is unslaked. In short, I have every reason to be on edge. What to do? I could undoubtedly take it out on my fellow humans on the ground that it's they who have blunted this demanding libido. What could be more tempting (...)? (But) if I were more reasonable, I would have to take other steps to calm down, and I would do what all my civilized brothers have always done, in all weathers and in all climates, no matter how far advanced their culture. There isn't one that offers any remedy for these kinds of torments: coffee, tobacco, wine and so on, all so many drugs conducive to a calming of these libidinal twitchings, and thus beneficial to thought and action. (...) It is therefore more reasonable to smoke than to attack one's neighbour, and to consider, for example, smokers' "tobacting out" as a solution for the future.8

The polemic nature of this statement should not prevent one from considering the following hypothesis: might not smoking be "a way of channelling anxiety so it does not cause a crisis"?9

"Yes," Annie Leclerc writes, "with every new cigarette. To do away with cares, boredom, the cacophony of so many pointless, absurd words, to put off until later the disgust with so much contamination, to erase death."

And elsewhere: "When living one day became very difficult, I gave in to this minor mania, I dreamed of erasing everything, of forgetting and catching fire, immediately, and I said to myself that it would help me to live if I believed that what was impossible was possible..."

And again: "If one smokes, even while aware of the irreversible, terrible, degrading damage that tobacco can cause, it's not out of an obscure penchant for decline and decay, for suffering, for an end to life. You smoke in order to live, not to die."11

And Roger Lemelin, in his own way, shows how, after his boat exploded, as a result of his smoking while refuelling it, tobacco helped him to live, to get through the crises of his life.

I've been bragging, bragging since the start of this tale, and I realize that, after the explosion, I felt I was forced to admit my problem to myself: words no longer meant anything to me. I couldn't read, let alone write. (...) I had revolted, like a locomotive under full steam, lost in a maze of mocking rails, seeking a station which some evil engineer had hidden in a distant forest, I launched into a series of trips on which I sought in vain what an inner voice, telling me to persevere, urged me to find: my happiness as a writer.

But the more I searched, the less I found, and the more I smoked. Like an enraged bull, the smoke shooting out my nostrils. I became the most intoxicated smoker in Canada. Travelling for 15 days, I had to take a full arsenal in a special suitcase. I was a slave travelling with his chains. I can still see the marble-top dresser in the hotel, covered with 50 packs of Player's, a bundle of fifty Havanas, a box of pipe tobacco, a tobacco pouch, a cigar cutter, various lighters, disposable lighters, luxury items, butane and gas lighters, reserves of each type of lighter fluid, plastic tops for the various lighters, touchwood, special reserves for the Dunhill, a lighter for high wind (the one I used on fishing trips), six pipes, pipe cleaners, a cleaning knife, alcohol to disinfect my pipes, a portable humidor for my cigars, breath mints, wood matches for cigars and pipes and cartons of matches for an emergency, also useful for noting telephone numbers, and a miniature chemical extinguisher found at the Paris flee market.12

It is not uninteresting to note that, following this accident caused by careless smoking, Roger Lemelin did not for an instant consider stopping smoking. On the contrary, it was his passion for tobacco that enabled him to make the "desert crossing" that followed the explosion: doesn't smoking help "to lull dull worries to sleep"?13

But the process whereby a smoker dams up his anxiety tends to escape him and ultimately makes him suffer to the point of feeling the anxiety it was supposed to alleviate. It's because a "joint" is always disappointing.

To be back on the fire of pure presence. To awaken blazing, delighted. To join this darting naked flame; in a single breath, to live...

But no one stays on the threshold of birth. The spring flows. The cigarette burns and, in its smoky wake, underscores our obscure, although always disappointed joy in living. Ultimately, it's not really a cigarette, it's a mutilated member, a disfigured remain, a scrap; we call it "a butt" in the corner of the mouth and we stamp it out. An ugly little shapeless remain of a minuscule party that never really took place, or of which, in any case, we have no trace or tangible memory. It all went up in smoke, in impalpable ashes. Nothing left but this funny stillborn fetus huddled in its shame of not having known, not having done better.14

Ultimately, the "joint" appears as a necessarily illusory attempt to suspend the flight of time, to remain on the threshold of life, the flow of which leads to death. The "joint" is paradoxically both chronic suspension and acceleration of the work of entropy in us: suspension in the sense that we are our bodies, acceleration in the sense that we have bodies.

It all appears as though, for the smoker, all of life is anxiety-causing. "The heavy smoker is suffering from diffuse anxiety, unrelated to any object, omnipresent, constantly renewing itself and constantly relieved by cigarettes. Any situation triggers the 'anxiety signal' which in turn triggers smoking."15

At least one of the causes of this anxiety is discernible, although it is virtually always denied: knowledge of the risk of cancer and heart disease related to smoking often associated with cannabis. This fear of disease is all the more anxiety-causing since it is repressed. Annie Leclerc writes, "We know that, when smoking, we retain the charred, irritating traces of our disappointment."16 But it's as though smokers were unreachable, invincible. The fear of a fatal outcome related to their habit is "intellectualized and detached from the smoker's daily, corporal experience".17 "In not 'believing' in cancer, smokers not only defy the bad object, but also insist on the playful or symbolic nature of their habit: it is impossible that something 'pretend' they do can be counted as 'real'."18

It is the lack of proportion between the minor act and the curve it helps to describe that permits this cleavage between present and future.

Lastly, smokers engage in a paradoxical fight against the anxiety at the idea of dying and, more profoundly, against death itself. That at least is how one is tempted to interpret the attitude of certain smokers who, like Freud, and most of them no doubt unconsciously, seem to find "a way of introducing death into life in the form of an 'internal foreign object', a bad object, increasingly invasive and a harbinger, but for which one is solely responsible and over which one has control." Freud consciously wanted "not to let himself be taken by death, as occurs in a heart attack, but to allow it to enter him slowly and methodically so as to control it and observe its effects."19

Playing with Fire

Smokers are thus faced with a deadly dilemma:

- take the side of death in order to preserve control over their lives as long as possible,

- accept, while increasing, the void which the "joint" gives them the illusion of filling.

The latter choice seems possible only at the cost of a profound reorganization of the libidinal economy. That at least is what the writers who were questioned say and was emphasized by the analyses that Odile Lesourne offers of the most often sudden and radical phenomenon of stopping smoking. Consider what Annie Leclerc has to say:

When I tell myself I will "never smoke again", it's as though I'm saying I will never go home again, that I will have to live out in the open, exposed, without ever being able to go back.. (...) Sometimes I feel discouraged, at having to desire, later, tomorrow, or 10 years from now, this absurd thing, I know, a cigarette, which never gives you what you ask of it, because it's EVERYTHING. Everything, immediately, the flaming conflagration of the self in contact with the world. All pleasure. Splendour of the hottest point in the self, combined with the exquisite presence. Life and death intertwined. Ultimate - first, only and final - consumption.

Perhaps I'll have to die with this desire. I can get used to that. But not to the idea of dying of it, of smoking, like an empty dream strangled by its own illusions. Perhaps the emptiness of the dream will stay there, in the heart of the heart. And it's precisely because I found there was meaning in the fact that nothing could fill it that I was able to stop smoking. I want to remain an empty smoker forever. I saw someone, a friend, die of it; it was too awful. (...) No, no, I prefer to keep that wound in my chest forever, that emptiness of which I can even say, in a sense, yes, that I love it...

That's obviously very difficult. It's scarcely possible. It means indefinitely desiring the impossible without allowing yourself to believe it's possible. Remaining in that wound. Because it means living, for real, and that's what I want the most. For it to be real, not false. (...)

It's only possible if a higher need to live came to risk itself, to fly into a new sky, an even more difficult desire to exist, and when it jumped, without a net, without show, naked. In short, it's impossible if you do that simply armed with a "no". It's only possible with a more demanding, even more brilliant "yes", yes beyond, yes...20

After finally regaining the desire to write and long hoping that a misfortune would occur that would force him to stop smoking without him having to make the solitary decision by himself, Roger Lemelin still suffered from living.

My pain in living woke me several times a night, shaken by a hollow cough. I got up and lit a Player's. I poured myself a glass of gin, then another, and smoked more cigarettes. I not only gave my lungs no rest, I threatened myself with alcoholism. It couldn't last.

I wasn't the same man after a nightmare from which I woke in a sweat in which I saw Dr. Lemieux, with a Davidoff in his mouth, doing an autopsy of me as I watched him in a mirror on the ceiling, like those in certain refined bedrooms. I was stupefied by what I saw in the mirror. The entire inside of my trunk was criss-crossed with vines gracefully intertwining and falling apart, forming here and there blond and brown locks framing the unfocused and beautiful faces of Marilyn Monroe, Brigitte Bardot, Catherine Deneuve, Gina Lollobrigida, Sophia Loren, Martine Carol, the snake charmer from my childhood, Viviane Romance. The vines imprisoned little Margot from long ago and avoided, as though laughing, the scissors brandished by my mother and my wife, pushed from behind by Mrs. Plouffe and Mrs. Cotroni. These beautiful demons chanted in a soft languid voice, while their flying hair brushed a keyboard, the Virginia tobacco velvet keys of which invited me to smoke. The traitorous woman-shaped spirals whispered to me: we are your charming and obscene cancer. We owe you everything, you owe us everything, we have accompanied you in all your trials and all your pleasures. We are Siamese, inseparable, you cannot flee us. We have lived together, we will die together." So I understood that the most beautiful women are those who kill us most perfectly. Then there arose in me a desire as strong as the desire for suicide, irreversible, the desire to live! I screamed: "I'll get you, you bitches!" And I woke up. Immediately, standing on my bed before my dumbfounded wife, I appointed myself captain of a fighting unit to put an end to my smoking. I had had enough.21

I chose Thursday, February 11, 1985, at noon. In the morning, as recommended, I smoked nearly 30 cigarettes. Then I took a pack from the stock I had left, put it in my wife's hands and told her simply, "Soak it in the sink and throw it in the garbage." Before her incredulous eyes, I took one last puff from the butt that hung from my lips, put it out in the ashtray and gravely announced: "Starting a noon, I will never smoke again." She had heard that many times, didn't mock me and merely answered: "I wish that for you with all my heart."22

I'm now convinced of it. I'll never smoke again! I escaped! The first three days of withdrawal were hard, the others somewhat less so. But during those six days, I learned a lot about myself and my own body.

As I swore to do, following that gradually less painful period, I stopped using the pills. Of course, I wasn't completely out of danger, but the pride I exuded, the conscience cleared because I had started a new life, would become formidable defences for me.23

You have to stop suddenly, just like you take your last breath. The most powerful pill is in us.24

The comprehensive interpretation Odile Lesourne offers of the smoker's passion is based on a number of testimonials gathered through a lengthy series of interviews with smokers and former smokers. It is striking to see the extent to which her conclusions are illustrated by the passages I have cited from Annie Leclerc and Roger Lemelin. In my view, this convergence is an excellent argument in support of the hypothesis that smokers play with life. Ms. Lesourne expresses, better than I could do, this very enlightening point of view.

"Heavy smokers do not believe that cancer will happen to them, even if their smoking is based to a certain degree on the possibility of that outcome. They play with their lives rather than risk them. Smoking too much, as much as risking cancer, means engaging in innumerable symbolic acts of putting to death a small, unimportant object. It can be said that all smoking falls between these two things, in the essentially playful space, in this "playing with fire", in the literal sense of the expression. While smokers do not believe in cancer, it is both and contradictorily out of negation of their unconscious wishes and because their entire activity remains in the field of pretend. If they kill a false mother represented by an object as negligible as a "joint", even thousands of times, how could this little game be turned against them? Here again, smokers have one foot in the symbolic world and the other in the real world: the intoxication is quite real, even though cancer is not, but each of the units of which it is constituted remains symbolic, even though in an utterly minimal sense."25

"If smokers manage over time to separate the two images of death from another, if they construct, beside that of the unconscious, an image of death as real, over which they have no power, which cannot in any case be controlled and must be accepted, it is likely that they will stop smoking. The work of accepting death by means of a detour from the real can make smoking, which continued because of the unconscious wish to overcome the death-causing, death-giving object, pointless, vain and unnecessary."26

What conclusion can be drawn from this essay on the profound experience of the smoker and any person who consciously takes a risk? One can of course attempt to justify prevention campaigns on the basis of the above considerations. Knowledge of the "mechanisms" of tobacco/pot/marijuana/hash use could help to improve prevention messages. However, we do not think this is the best lesson to draw from these explorations in the areas of individual existence isolated through scientific objectivation.

The reason is that all of us, smokers, non-smokers, ex-smokers and future smokers, face death, which none of us will escape, and from which no prevention campaign will protect us. The psychological work each of us must do with regard to impending death is not part of any pre‑established mode of operating. It is up to each of us to negotiate or wager our lives. And we must accept the truth that this effort is always painful and difficult and entails its share of anxiety and suffering. Tobacco, alcohol and cannabis derivatives, together with the use of gadgets and fast driving in particular, are among the most obvious derivatives our society knows. All these derivatives are dangerous. I very much doubt that cannabis is the most dangerous of all. But all provide their share of momentary relief. And I don't dare imagine what the statistical distribution of cancers, heart and venereal disease, suicide and stroke would be if all those derivatives were, for one reason or another, put permanently beyond our reach.

In other words, the fundamental problem of our civilization is not whether it is acceptable to prohibit the trade in cannabis derivatives or even their use, but rather not to repress the expression of anxiety when it arises and, even better, to invent new ways of taming it. On this point, it is useful to recall that every unjustified restriction, which adds to the already heavy burden of civilized individuals, can only increase their sense of being the object of some form of totalitarianism rather than the subject of their own destiny. From this standpoint, anti-drug campaigns seem decidedly like attempts to deny death rather than recognize its presence in collective and individual life. Isn't their message ultimately received as a conditional promise of eternal life? In this respect, we agree with N. Bensaïd, who says that preventive medicine conceals our fear of death by making us die of fear.

However, the question as to whether it is tolerable to smoke in our society is a question that arises for each individual, each person being free to choose his or her diversions with respect to oncoming death. Obviously, this statement must be qualified because individual freedom cannot be expressed in society without a minimum of restrictions which guarantee that it can be exercised. The last chapter of this paper will be devoted to that discussion.

Ethics

The Path of Subjectivation

If we want to get a clear idea of the question of a non-reductive approach to disease and suffering, it is necessary to consider carefully what is commonly called "human nature". This is not a pointless detour or a surreptitious restoration of some model of "humanity" which it is our purpose to faithfully copy. On the contrary, the idea is to effect an exceptional opening of human beings to what they as yet are not, to creatively continue the story already begun by their predecessors.

"Autonomy" in American Bioethics

American bioethics is particularly attentive to respect for the autonomy of individuals. As Hubert Doucet has written, "The theme of autonomy, as it has frequently been stated, is at the heart of the American bioethics movement and even gives it its meaning."[2] Autonomy in the American sense of the term is the opposite of paternalism. It is understood as "the right to be protected from decisions which an authority imposes of its own initiative".[3] According to the English philosopher John Locke (1632‑1704), on which American bioethics draws to a large degree, the individual has four inalienable rights, which exist prior to the formation of any political order: the right to life, liberty, health and property.[4] In its deepest root meaning, the concept of autonomy in American bioethics is a negative concept of autonomy: to protect the individual from the arbitrary action of others. This perspective may be seen in various, particularly important official texts, such as the Belmont Report and the Bill of Rights, for example, which assert the sovereignty of the individual and prescribe the provisions necessary to protect him from "the undue encroachment of the state or of others".[5] According to this conception, autonomy is the fundamental principle of ethics and its only limit is the autonomy of others. In this perspective, the use of drugs should be authorized as long as it harms no one else. However, it is this concept of harm that is the problem because, as has just been shown, it is most often largely dependent on a scientistic conception of the human body and of medicine, a conception which results in genuine harm as a result of the ideological nature of the standards it claims to base on scientific knowledge. That is why we find it impossible to base the American concept of autonomy on principles designed to guide a public drug policy.

The considerations of this report are thus based on another concept of autonomy: reciprocal autonomy. This concept first expresses the conviction that humans are first and foremost heirs who receive from others what they are as much as what they have. It is not until we have received life that we are entitled to require that it be respected. So there is no radical opposition between the American concept of autonomy and the concept of reciprocal autonomy. They are compatible with each other. However, they do not at all designate the same reality. Reciprocal autonomy is more fundamental than the sovereign autonomy of American bioethics which may be derived from it. In the human condition, the reciprocity of ties pre‑exists the autarchic affirmation of the individual. It is thus on this fundamental reciprocity that we want to base eventual guiding principles for a public drug policy, not solely on the individual claim to autonomy. However, this concept is quite complex and needs to be introduced.

The Critical Concept of Autonomy

All human beings are genetic, relational and cultural heirs. Our heritage is spread over the three categories of the biological, the psychic and the symbolic. Of course, our heritage is not a prison; we can make it productive, manage it (at least in part) and redirect it, but we would not be heirs if others had not lived before us. Without genitors, we have no genetic heritage, without protectors in social life, no "specific" heritage, without linguistic initiators, no cultural heritage. Accordingly, the fact that we find ourselves heirs is indeed the sign that, deep within us, we find traces of others, of others as a condition of the possibility of our own existence as part of humanity. The existence of others is the condition of the possibility of our own existence. We would not exist if others did not exist, if there were no "others".

In other words, if we want to flourish and develop through human existence, it is not ourselves we should cultivate but others, simply because "others" are our gardener. This means that we find, written deep within ourselves, this fundamental law of humanity that we would not exist if others had not caused us to exist. This law is written at the very centre of our most intimate being, even if we have not yet understood it. And moral education consists, at least in part, in being guided or at least accompanied in our progress toward this fundamental discovery that, at the heart of our personal singularity, we can read the universal requirement that is instructive of our humanity. It is thus a principle of fundamental reciprocity that constitutes the essence of the law that we can read deep within ourselves. It is the fundamental moral law.

The principle of reciprocity we have just stated is entirely contrary to the principle of autonomy of American bioethics, which is that "I cultivate my own autonomy because that's what I want." To erect as a standard the arbitrary nature of one's pleasure is a destructive principle because its implementation would separate us from our roots and cut us off from others to the extent that they are the condition of the possibility of our own existence. That would make us impervious to those who cultivate us and allow us to live.

The true principle for autonomy tells us that it is written within us that we must cultivate the flower that every other person represents because that is how we ourselves will be able to continue surviving. Translated into philosophical language, this means: a human being who has become aware of what he is in his humanity cultivates the autonomy of others and his own develops as a result. If we strive to cultivate the autonomy of others, others cannot not fail to discover at one point that their own purpose is to cultivate our own autonomy, which, too, is the condition of the possibility of their own.

The fundamental ethical principle is to cultivate the autonomy of everyone we meet, including oneself because, as Paul Ricoeur has noted, we are always other, as well, for ourselves.[6]

But what does "cultivating the autonomy of others" mean? The adjective "critical" modifying the noun "concept" in the title of this section indicates that it is a concept defined after an effort of discernment (the Greek word "krinein" means, in particular, to discern) is not simply a normal concept. The definition we offer here is thus a technical definition which does not necessarily include its common usage.

The word "autonomy" comes from the Greek auto, meaning self, and nomos, meaning law. In that sense of the word, a person or institution is said to be autonomous if it gives itself its own law, if it is in fact its own legislator. In this sense, a democracy is said to be autonomous since, by definition, it creates its own laws.

"Who gives himself his own law." This does not necessarily mean "who erects as a standard what one arbitrarily wants as an individual." That would be false autonomy. The reality is different: a truly autonomous person learns to read the law written within himself which defines his membership in humanity. That law is the same for everyone since it defines our common humanity. It may be, of course, that we read it somewhat differently from a neighbour. However, what is this law which philosophical reflection enables us to read deep within our identity and which makes us mutually supportive human beings?

To answer that question, we think it useful to take a brief philosophical detour which non-philosophers are undoubtedly not very accustomed to taking, but which nevertheless has its charms. To conduct the analysis, we must start with a hypothesis and test its validity.

That hypothesis is that, throughout the history of humanity, there has been at least one act of communication which was at least partly successful between two human beings. This hypothesis is irrebuttable. Any person who would speak or write to dispute it would prove its validity by simply wanting to assert the validity of his argument in the eyes of others. The person who communicates to say that it is impossible to communicate proves, by simply intervening in the debate, that his objection is not valid since he communicates his objection. No one can dispute this point of departure, whatever his philosphical or religious convictions; otherwise he would not be speaking to us.

We therefore take as our point of departure the dialogue, even highly imperfect, between two persons. This point of departure is irrebuttable. Our work then consists in stating the conditions that must be met for that point of departure to be possible. We state a fact and then ask ourselves on what conditions that fact is possible. For reasons that would be too long to set out here in detail, we state 12 conditions in the form of a double-entry table (three times four). This table contains three lines because every human act has three dimensions: organic, psychic and symbolic (see reference above to the three dimensions of human beings as heirs). It also contains four columns because every human act, according to an Aristotelian approach (so‑called theory of four causes), which is standard in philosophy, can be exhaustively analyzed by successively adopting four points of view, those of material cause, formal cause, efficient cause and final cause.

Concept of Autonomy Matrix
Recognizing	Complying with the prohibition from	Assuming	Cultivating
presence	homicide	one's solitude	solidarity
difference	incest	one's finitude	dignity
equivalence	lying	one's uncertainty	liberty

This table represents what we call the "concept of autonomy matrix". What then are the conditions that must be met for a dialogue that is at least half successful to exist?

Condition 1 - For a dialogue to be established between two persons, two persons must be present. The presence must be ensured through a medium such as a telephone, fax machine, mail and so on, but each of the interlocutors must ensure that the other is present. It is moreover only in a highly derivative, and as it were fictional, sense that we can speak to ourselves. Consequently, there must first be the mutual presence of the interlocutors.

Condition 2 - It is because another person than I, different from me, one day spoke to me that I entered into the social conversation. It is necessary for there to be a difference between the interlocutors for there to be a dialogue between them. There can be no dialogue without otherness. A thousand and one differences make us different beings and make each of us a singular being. The idea is to recognize as a difference of law these differences of fact between the other and me, difference of law meaning that he does not belong to me, that he is not my utensil. One cannot really communicate with a slave, that is to say with an inferior being whom one considers as a slightly more developed machine than the others.

Condition 3 - Difference is not enough. There must also be a certain equivalence between interlocutors. Let us avoid any misunderstanding here by stating at the outset that the difference, in the sense I intend here, is a difference of fact: we are male, our interlocutor female, we are older or young than they, etc. Equivalence, however, exists in the order of values: whatever differences there may be between us, we acknowledge that our interlocutors have the same moral value as we do: if we were to choose between their lives and ours, the choice could only be arbitrary since, as members of the same humanity we, in principle, have the same dignity and, accordingly, the same respect is owed both of us.

Another way to express the same thing is to emphasize the fact that we cannot truly communicate with someone whom we do not take seriously, with someone to whom we do not speak seriously and who we think does not speak seriously with us. We must consider the other person with whom we communicate as on the same moral footing as us, despite all the differences of fact that distinguish or even separate us.

Presence, difference and equivalence are the first three conditions of the possibility of dialogue.

How could we claim to recognize the existence of the other person if we felt free to kill him? If we could choose those we would keep and those we would kill, we would not recognize the presence of the other person. Without complying with the prohibition against homicide, we cannot claim to recognize the presence of the other person or dialogue with him.

If we permitted ourselves to use others as a simple extension of ourselves, if we allowed ourselves to incorporate them, to assimilate them, to merge them with us, how could we claim to recognize the difference between them and us, which difference is necessary to dialogue?

Complying with the prohibition against incest, which we below call the prohibition from domination, is a condition of the possibility of dialogue. Here we are not using the term incest in the same sense as in social surveys, but in the archetypal sense in which it is used by psychoanalysts and anthropologists, in the sense that it means that, for each member of a given community, there is at least one potential sexual partner to whom access is strictly prohibited (usually his mother and nurse and, by extension, his sisters and certain cousins), not because sexual relations would necessarily be a merger, an incorporation of the other into me, an instrumentalization, but precisely because, for us to be able to enter into communication, potentially sexual communication, with the other person, there must be a prohibition placing a limit on our desire to incorporate that person. This is thus the prohibition from merging with the object of my desire which opens the way for me to a relationship stamped with a seal of autonomy. No known culture is exempted from this rule.8

However, if we did not comply with the prohibition against idolatry, which can also be called the prohibition from alienation or lying, how could we claim to respect the moral equivalence without which we and others could never dialogue? How indeed could we truly dialogue with someone we despise to the point of lying to him or who despises us to the point of lying to us? In all idolatry, as in all alienation, there is a lie. As the psalm goes:

The idols of the nations,

are silver and gold, ...

They have mouths, and speak not:

eyes have they, and see not.

They have ears, and hear not:

noses have they, and smell not.

They have hands, and handle not;

feet have they, and walk not:

neither speak they through their throat.

They that make them are like onto them; ...

This last line, from which Hegel, Feuerbach and Marx derived their entire theory of alienation, perfectly encapsulate the perverse mechanism of idolatry: take an object made by man and invest it with one's humanity to the point of losing one's subjectivity and becoming in turn an object. Idolatry and alienation are specific cases of lying. One cannot dialogue with someone to whom one lies. One can dialogue with someone to whom one has lied, provided one admits it and asks to be pardoned. (We will leave aside here cases of moral impasse in which one could potentially consider lying to avoid a greater evil.)

When we define true autonomy as the ability not to erect our own arbitrary will as a standard, but rather to read the instructive law of humanity deep without ourselves, we anticipate, as it were, the more detailed statement of the three prohibitions we have just described. Humanity would not be humanity if it were not structured by these three prohibitions which define it. They are not imposed on us from the outside by any superior authority. They express the conditions of possibility of our existence as members of humanity, as singular individuals and as a group.

Some philosophers feel these three prohibitions can be reduced to the first: the prohibition against homicide. It is plausible that lying to the other person or incorporating him as an instrument are two ways of killing him. We prefer, however, to explain the three levels.

However, this work of complying with the three fundamental prohibitions which define humanity cannot be done all alone. It is done over a long process of maturing, in which each human being is invited to accept his own singular condition. What does this mean?

Each of us is invited to accept his solitude. Each of us is alone and permanently alone. None of us can take the place of another. Each of us, as it were, transports his place with him. We can be in sympathy with another person, but we can never take his place. When we receive a power of attorney to conduct a banking transaction, how do we sign the form we hand the employee? Do we sign our own name or that of the person for whom we are acting? Our own; otherwise we commit a forgery. Each of us is alone is being able to say "I", in his own name. If you tell someone, I love you, or, I don't hate you at all (which ultimately means the same thing), only you can say that in truth; only you are bound by it. Theatrical conventions enable one person to take the place of another or, rather, to play a role, but what is involved precisely is a role, not something actual. Each of us is alone in having fingerprints that are one's own. This is what we call the solitude inherent in all of human existence.

But we are not only solitary; we are also finite. We are being actuated by infinite desire and equipped with very limited ability to realize those desires. We must therefore choose, and choosing means renouncing. That is the mark of our finitude. One cannot be both teacher and student. One cannot ply all trades at the same time. Sometimes we do not know our limits, which may be higher or lower than we think. But that does not alter the fact that we are, in essence, limited. If we do not at least accept the principle that there are limits, that means that we merge, that we deny differences, precisely because our limits are never exactly the same as those of others. It is not by taking on more every day that we are not God (or the devil) that we can ultimately be born to ourselves. And this labour – in the sense of the labour of a woman in childbirth – in always a labour done with another who facilitates it or impedes it, but without whom the labour itself could not take place. We therefore always read the trace of the other person in us.

But we are also called upon to assume our own uncertainty. From the moment we agree to wage war on lies, we realize that nothing much is certain. Many certainties appear to be illusions to which we have become attached, to which we at times adhere so much that we do not want to recognize them for what they are or cannot do so. Courage is required to detach ourselves from them because it is too often our illusions which hold us together, as though they formed a second, immaterial and often unconscious skeleton. And yet it is by taking this path of uncertainty, of detachment from the illusions that keep us that we are ultimately able to find the most intimate place within us, the trace of the other and the law which instructs us in humanity, the call that invites us to cultivate the autonomy of every human being and of the entire human being.

It does not prevent the fact that we always exist in uncertainty, because, in a difficult situation, we never know whether the least evil is what we thought we could consider as such. We may not be guilty of having made a decision, even if we are not assured that it is the best, provided we can say in truth that we did everything we could to make the best decision. In these matters as in so many others, what are considered the objective decisions are most often those dictated by the person who has the long end of the stick. We can not be guilty of being uncertain, but especially we can be guilty of believing we are certain when we have not really examined the entire question in a critical manner.

However, our human condition is not characterized solely by negative aspects. It also involves positive aspects which can be expressed in the form of values which we are called upon to cultivate.

Only I can occupy my own place, but I would occupy no place if others had not put me there. The fact that we occupy a personal position implies that there are other personal positions and thus that there are already others. We would not say "I" if there were no "you" and "he". Our solitude itself implies that there is solidarity among us. We would not be solitary if we were not in need of solidarity, and we would be incapable of solidarity if we were not solitary.

Furthermore, our finitude is also what confers our dignity on us. We are not God, of course, but we are not nothing. We are ourselves and we are worth the trouble as such. We know people who are so worthy that they become impervious to any call to solidarity, and others who have so much solidarity that they lose their dignity. We are summoned to solidarity but not at the cost of our dignity. We are called upon to ensure our dignity is respected, but not at the cost of our freedom.

Because, ultimately, here is the twelfth condition of the possibility of dialogue: freedom. Isn't our uncertainty the condition of our freedom? How would we be free if we were not uncertain? If there were no uncertainty, there would be no choice or responsibility. "Responsibility" is the duty to account for one's choices, for the exercise of one's freedom, but it should be emphasized here that freedom is not autonomy, but only one of the components of autonomy. The arbitrary exercise of freedom is the contrary of autonomy, but freedom fairly balanced by dignity and solidarity is autonomy.

Ultimately, the law that is instructive of humanity, moral law, the one called "natural law" in certain schools of thought, the law which we can read deep within ourselves in dialogue with others which accompanies this progress to our inner self is precisely to acknowledge the presence, difference and equivalence of others, to respect the prohibitions of homicide, incest and lying, to assume our solitude, finitude and uncertainty, to cultivate the values of solidarity, dignity and liberty. Autonomy is all that. And an autonomous person is a being who strives day after day to live in accordance with the law which he discovers deep within his humanity. Autonomy is thus not a question of all or nothing, but a question of more or less of progression or regression. This law is not a sign of our heteronomy. It comes to us from elsewhere. It is the expression of our very humanity, which we read in the trace of the other in us.

An "Operative" Definition of Ethics

This approach of reciprocal autonomy enables us to define an operative concept of ethics. This is the ethics of the step-by-step, drop-by-drop; it is an ethics of finitude which accepts, once and for all, its powerlessness to produce a perfect world without renouncing the idea of perfection in the world.

I define ethics as "the labour which we agree to perform with each other to reduce, as far as possible, the inevitable difference between our values as practised and our values as stated". All the words of this definition carry meaning. For that reason, it is useful to comment on them one after the other.

Ethics is a labour …

The word "labour" is understood here in the very strong sense of a "woman in labour". It is an act that gives birth to something, an inaugural act, a personal act, not simply a labour of execution which one undertakes more or less mechanically and without much creativity.

… which we agree

Every person is invited to take part in this labour, but each person also has the opportunity to refuse to make the commitment it requires. There will always be out and out individualists who will put their subjectivity above the rule, and there will always be legalists who will protect their fragility behind the letter of the rule, but this is not a sufficient reason to refuse to contribute to the search for a third way between subjectivism and legalism.

… to perform with each other

Of course, each person may perform a personal labour to refine his judgment, but the most productive way to transform one's own "common sense" into "refined common sense" is still critical discussion between peers, discussions which are characterized by what the philosopher Karl Popper called "critical intersubjectivity".

… to reduce the inevitable difference

There is always a difference between the ideal and reality. There is no reason to be scandalized by this fact because the human condition is made in such a way that we are never completely equal to the task of achieving our ambitions, even the most legitimate. However, our challenge is not so much to be perfect as to be on a positive path toward perfection.

… between our values as practised and our values as stated

Some deny the existence of this difference: the idealists who see only what is stated and consider it sacred to the point where they form a screen which lends them the illusion of being protected from reality, and the cynics, who consider that practices disregard all statements or even use them in a Machiavellian way to conceal their dubious practices from the eyes of others. To deny the difference by holding one of the two up as an absolute is to refuse to undertake the labour of ethics (even if one puts one's stated values on display). Positively accepting the tension of this difference while working to reduce it, that is the labour of ethics.

… "as far as possible"

This labour is endless. The reason for this is that we do not control everything. Many realities remain beyond the scope of our ability to transform them. What Aristotle called necessity characterizes what cannot be otherwise than what it is. And yet he distinguished from necessity contingency, which characterizes what could be other than what it is, and he recommended that we not expend our energy in vain attempts to change necessity, but to accept what we cannot change, while concentrating our strength on changing what is within our power to alter. This humble determination amounts to accepting the finitude of our human condition. This discourages some who, like capricious adolescents, "want everything, right now, and more". But it is a sign of true maturity to know what is possible and what is not and, as the saying goes, to avoid "biting off more than you can chew".

Therapy and Politics

The therapeutic relationship is a particular form of fundamental human relationship (a mutual procreation) characterized by the fact that one of the parties to the relationship requests help from the other, who is supposed to have competence and experience which the former is usually lacking. A therapeutic relationship is thus an expressly asymmetrical relationship the particular characteristic of which is sanctioned by the compensation paid to the expert by the person requesting assistance or his protectors.

In this perspective, we will first attempt to sketch a general picture of the therapist or, as it were, define the qualifications he should have to properly play his role without confusing it with that of the politician. Then, we will consider the paradox created by the concept of reciprocal autonomy which has just been defined. Lastly, we will outline the true task of the politician with regard to public health.

Therapy, or the Art of the Possible

Change meets many types of resistance. There is resistance within us, because we are afraid of knowing who we in fact are, but there is also very strong resistance around us. It is as though we had to copy models, that is to say precisely not change but reproduce stereotypes, repeat blocked and blocking situations. However, there are many resistance strategies: one can also attribute the crisis to the social situation or other situations, thus blaming scapegoats for the actual question of what one is for oneself. These are stillborn crises, which abort because everything is arranged around those who go through them so that they are not expressed in language, so that they are repressed, denied. Repressing successive crises in which human existence necessarily consists precipitates that existence toward a death worse than death; it is to kill it before it is born.

It must moreover be recognized that medicine, particularly where it confines itself to biomedical engineering, appears in many crises as an authority ultimately repressing the fundamental questioning of human beings faced with the question of the truth of their existence. Wishing at all costs to bring to light the organic cause of a "metaphysical" malaise is an attitude which, so as to be neither deliberate nor conscious, is no less murderous.

The request of a patient is always, if only implicitly, the request of a body experienced in the labour of becoming a subject. To this labour of procreation responds the obstetrical or maieutic meiotic work of the therapist.2

A crisis is a situation in which one is called upon to discern the facts in order to change. But what conditions must be met for a crisis to be actually an opportunity for change? In theory, the answer is simple: the crisis must be expressed in language.

For a crisis to be able to open up to change, for a disease to become a positive experience, we must manage, with the aid of a doctor or other persons, to find in ourselves the strength to overcome. The first condition is thus for us to have a defence mechanism within ourselves in order to exercise some creativity. We must still be able to think of ourselves as persons capable of one day writing the next chapter in our own history, whatever the road blocks that now appear to be in the way.

But you don't tell a story to the walls; you tell it to someone. And the most essential condition for a crisis to be an opportunity for change is that someone be there to hear the other person in crisis and try to tell his or her story, someone who listens without moralizing or trivializing and is attentive to the meaning of the story.

The third condition for a crisis to be an opportunity for change is that we be able to reread our pasts in order to reopen the future. This obviously means that we must recognize the crisis for what it is and that we do not allow ourselves merely to put our head in the sand. The idea is to recognize that something has been irremediably lost and that it can now only be a memory. In a way, we must give up a flattering but false image of ourselves.

A crisis is a dramatic moment: a moment of judgment, of reassessment of life and restructuring of our hierarchy of values. No one has ever stopped changing or ever been immune from crisis. The last crisis is death. And it is our reactions to crises that build the major stages in life, that prepare us to be solid or fragile, open or closed until the day we die.

A crisis will only be an opportunity for change if we are already fully prepared for change and creativity. Listening to the other person in crisis may mean agreeing to enter tactfully into the inner conversation that person is relating to us for a moment, and, after offering a few words to maintain that conversation, tactfully withdrawing from it as well.

It is in this way, and this way alone, that medicine can each day become more of a human service than an oppression. It is this type of listening, which has nothing organic about it, although it does not at all preclude the possibility of physical change, that the physician can perform his true social function, which is to help his fellow beings live in the body they are despite the vicissitudes of the body they have.

But this Socratic effort, to be properly carried out, requires qualities that are worth briefly stating here.

Accepting that we ourselves are suffering from anthropic separation, that is from the insurmountable difference between the body we have and the body we are. This means accepting the anxiety inherent in all of human existence, naming it, taming it and even using it as energy, the considerable force of which can become creative rather than destructive. It also means, at least for doctors, accepting in advance a twofold failure in the fight against suffering and death: the failure of the patient's death and the failure of the physician's death. To state it in more positive terms, it means giving up a scientistic conception of medicine, according to which the purpose of medicine is to overcome suffering and death. This task is so far out of reach that it is better to pull back and contemplate more modestly the purpose of one's profession as a therapist as being to help one's patients live with the pleasure of the body they are despite the vicissitudes of the body they have.

Recognizing that they need their patients. In order to "earn a living" and achieve rewarding social status, of course, but also simply in order to live. There is true pleasure in providing care that can be very deep and perfectly legitimate: the pleasure of a resonance between the search for personal balance conducted by a therapist and the attempt to provide aid and support to one's patient. In one sense, the patient is a kind of mediation in the inner labour of the therapist. It is not unusual that, in a good therapeutic relationship, the patient unknowingly cultivates the autonomy of his therapist, as the latter methodically strives to cultivate the patient. Knowing how to show one's patients gratitude for their trust is an appreciable quality in a therapist.

Knowing how to train the ear to hear the patient's existential crisis through the words used to express his request, but, at all times, training the mouth not to speak too quickly, never to force open the door or increase the patient's pace. Agreeing not to be, above all, scientifically effective at all costs. Knowing how to wait for the right moment, while helping the patient avoid predictable and avoidable catastrophes. Allowing the other person to take the initiative is a great art. Consequently, in our view, it is up to the patient to conduct the dialogue and not to the caregiver, particularly since the truth is not in any case a content which the caregiver can pour more or less completely from his brain into that of the patient.

In medicine, truth is always a manifold entity. There is statistical truth, which is most often quite well established, but has little to do with the patient who is focused on his personal fate. There is diagnostic truth, which may be relatively sure in certain cases. There is prognostic truth, which most of the time is not very sure; what can be said to a patient about his future that is absolutely sure and certain? Nothing specific: the probability of developing such and such a condition is high but not certain and so on. And yet, what really interests a patient is his prognosis, much more than his diagnosis. What gross human errors could be avoided by distinguishing clearly between a biomedical truth concerning the body I have and a therapeutic truth concerning the body I am.

Acquiring enough autonomy, however, to allow oneself to be guided by the patient, without allowing oneself to be imprisoned in his discourse or attitude. A therapist is not only an attentive ear. A therapist is a person who must be able to mobilize his or her skills and experience appropriately. Some patients unconsciously choose the language of the body and of disease rather than the language of words. In such cases, the therapist must know how to resist words which most often say precisely the contrary of what the body is saying. The therapist must also know, for example, how to read differently the sentences written by the body of a woman and by the body of a man because, as Norbert Bensaïd aptly notes, women experience their bodies as objects they know thoroughly, which they take care of and which they offer to varying degrees to the view of others, whereas men experience their bodies as more or less docile instruments in work and in love.

Acquiring enough autonomy not only to avoid the traps consciously or unconsciously laid by patients, but also to resist any form of institution subjected to the temptation of totalitarianism. Using necessary critical judgment always to distinguish clearly between biomedical knowledge and its use for the specific benefit of each patient. In other words, ensuring that the therapist is not reduced to an agent of applied biomedical science. But the closest institution most likely to succumb to the totalitarian temptation is the therapist himself, who will have to pay particular attention to avoiding the traps of paternalism and perfectionism. Ultimately, doesn't the therapist always run the risk of being taken for a god?

The Paradox of Autonomy

The basis of ethics as therapy is the moral imperative to cultivate the autonomy of others. However, for moral life to be possible, the conditions for the possibility of that life must be met. It is the task of politics to define the minimum restrictions necessary so that individual autonomy can flourish in a society. This is a paradoxical task since the idea is to restrict in order to render autonomous. However, the paradox is nothing but that of autonomy itself.

The conditions for the possibility of dialogue stated in the chapter on the path of subjectivation include the statements of three prohibitions. Those prohibitions represent a severe restriction which life in society imposes on the arbitrary exercise of individual freedom. And yet it is compliance with those "limitations on liberty" which transforms liberty into autonomy.

This is the first paradox of autonomy: there can be no autonomy without a minimum of heteronomy. The art of politics, moreover, is to formulate that minimum, ensuring that it remains a true minimum. This is a difficult task because, among other things, there are always citizens or groups of citizens who try to develop to their own advantage the minimal constraint system which makes life in their society possible. It is the role of the politician to resist them on behalf of the autonomy of all.

But the paradox of autonomy does not stop at the political definition of the minimum restrictions necessary for its exercise. Moral autonomy also consists in the individual prerogative to ascertain situations in which it is more human, within the spirit of the law, to transgress the letter of the law than to adhere to it blindly.

Where the individual finds himself at a moral impasse, that is to say in a situation in which, whatever he does, including refraining from acting, he will violate or allow to be violated the principles underlying autonomy itself, what should he do? First of all, he should obviously check to see whether the situation really offers no positive outcome, that is to say no possibility of resolution that would be consistent with the founding principles of autonomy. After making that check, in the desired critical spirit, the individual will have to attempt to define the "lesser evil", that is to say the decision that will result in the least possible regression in the autonomy of the persons concerned by the situation and its resolution. This is precisely the nature of the "prudential judgment" described at the end of Chapter 6.

Obviously, the decision to make such a transgression is always a subjective decision, that is to say the decision of a subject in a particular situation. In this sense, there is no objectivity in ethics, and, when someone appeals to objectivity, it is because he is raising his own subjective assessment as an absolute standard. Moral objectivity is never the subjectivity of the person holding the long end of the stick. It is precisely the task of the politician to resist such a person.

Accepting our human condition, our finitude, our solitude and our uncertainty, also means accepting that we are "incarnate", that, for better or for worse, we are subjects, and thus beings who can never completely abandon our subjectivity. This means that human beings never really have clear access to the reality of things and that it is normal that their practical judgments always remain marked by a margin of uncertainty related to the fact that they are firmly rooted in the history of humanity.

In other words, no practical judgment is ever absolutely assured of its own moral rectitude. This does not mean that human beings are entitled to decide arbitrarily; it merely means that they are never immune from error because each of their judgments contains an invincible share of uncertainty.

But is it enough for someone to claim that he has deemed in good conscience that such a decision is the lesser evil for it in fact to be so? No one, as I have just emphasized, has absolutely objective access to the reality of things. However, that is not a sufficient reason to hold one's own subjectivity up as objective. That is why it is necessary to shape and inform one's conscience every day and to enlighten it as much as possible when making a serious decision.

This is why, as well, the subject who has taken responsibility for a transgression he considers life-giving, when blind obedience would have been death-causing, may be called to account for his decision before the authorities established by society to deal with potential instances of arbitrary exercise of individual freedom. Isn't accounting for one's decisions the true meaning of the word "responsibility"?

How can the subject protect himself from risks that could lead his fellow beings and himself to exercise his own liberty arbitrarily? Only a decision reached intersubjectively, that is to say through dialogue with others, wiser and more competent than us (who do not necessarily think like us), may be considered sufficiently enlightened. This intersubjective dialogue is the only method for avoiding arbitrary decisions. This is a tough requirement, but it is essential if we want to avoid the arbitrary exercise of liberty.

Moral judgment is thus always, essentially and not accidentally, eminently subjective. Does this mean morality is absolutely subjective? No, since every person can read the moral law within himself. However, the high moral deeds of human beings are always outlined by actual, singular individuals in unparalleled historical situations.

We should moreover emphasize the essential distinction between subjectivity and arbitrariness. Every moral decision is subjective. There is no objective moral decision. Why? Because a moral decision is always made by a subject dealing alone with the question of the meaning of existence. It is a trace of our condition: solitude, finitude and uncertainty. There is no reason to feel guilt. In the same thorny situation, two subjects of equal competence could "in good conscience" make two different decisions. But that does not mean that every moral decision is arbitrary. We must not hold up our own subjective assessment as a so‑called objective standard. We must avoid subjectivism, but subjectivity is unavoidable.

What is morally true is also true in science. One of the most critical and most authoritative philosophers of science of the twentieth century, Karl Popper, demonstrated this when he emphasized that the surest scientific knowledge is never anything but the provisional result of the critical intersubjectivity of learned men and women.1

But how do we avoid raising our unavoidable subjectivity as an arbitrary standard? The only way is to submit our decision hypothesis to the intersubjectivity of dialogue with a few trusted persons capable of listening and understanding and saying what they think. Comparing our own subjectivity to that of others known for their profound humanity (and not only for their technical qualifications) is the way to go, and one profoundly consistent with the philosophy outlined in this paper.

The idea is to expose one's own subjectivity to the risk of comparison with other subjectivities, not in the hope of establishing an artificial consensus, but of avoiding arbitrariness. Does this mean sharing responsibility? Not at all because each person remains responsible for his own decisions. The idea is simply to check through an intersubjective approach whether one is being too subjective, to check whether our sense of humanity in this difficult situation is not too singular, to check whether our necessarily personal way of reading and applying the instructive law of our humanity is not too arbitrary.

It is intersubjective dialogue that serves as a buffer to guarantee that we do not raise our singular subjectivity to the level of a universal standard. If others agree with us, we will still make our decision in solitude, but we would at least have a guarantee that we have not made it outside any form of solidarity. The ultimate purpose is to sharpen our critical sense, our ability to discern faithfully our desire not to deceive ourselves.

Ultimately, however, the concept of the "lesser evil" is merely an additional indication that we do not control everything and that all control, no matter how desirable, inevitably entails a share of non-control which is the mark of our human condition. The fact that we are never completely masters of our own destiny should not prevent us from striving to achieve greater mastery, but simply protect us from any claim that would spring from some totalitarian approach. And misunderstanding this principle of reality, which is related to our finite, solitary and uncertain condition, could merely result in a proliferation of the untoward effects inevitably caused by any blind rush to realize our desires. Ultimately, human autonomy consists in desiring the impossible, while recognizing that the impossible is not possible.

Politics and Concern for the Necessary

The ethical challenge in the fight against addiction is simply to know why and how far to resist this furor sanandi which has come over most Western governments in recent years.

From the outset, we clearly assert that we are not opposed to preventive medicine. Quite on the contrary. However, we intend to resist the various forms of totalitarianism which are readily concealed behind the ideals of public health.

When prevention is designed and practised as the political task of cultivating the autonomy of citizens by making them accept their health responsibilities and helping them to achieve their potential desire to discharge those responsibilities properly, it is the essence of true democratic civic spirit.

However, this undertaking cannot be conceived of without or, particularly, against citizens. What we resist are precisely the forms of prevention that seek, without saying so, to achieve the happiness of citizens in spite of themselves. This paternalism, even legalized (where that is the case), is an enormous perversion of ethics which is found in anti-drug, anti-tobacco, anti-AIDS and anti-alcohol campaigns.

Three main pillars appear to support the house of prevention: a scientistic conception of the human being, a rationalistic vision of medicine and a strictly biostatistical science. Unfortunately, none of these stands up to critical analysis.

The so‑called scientific conception of the human being proceeds from our reduction of human existence to its quantifiable aspects. The bodies we have are a substitute for the bodies we are through the isolation of the specifically human aspects of cultural symbolism.

The so‑called rational vision of medicine proceeds from the same reduction and holds that its ultimate purpose is to return all organic dysfunction to the norm, that is to say to prevent the biological parameters of the human being which might have strayed from the norm from continuing to lean to the left or to the right, to remain in their hyper- or hypo- state, to remain too much or too little.

And the biostatistical science which serves as an argument for preventive medicine is too often characterized by gross, monumental epistemological errors such as, for example, the common confusion of causes and risk factors, the formation of individual prognosis based on a statistical correlation not particularly well established in an observed population, confusion of proximate causes and first causes in the etiological analysis of pathologies and the reduction of a range of multifactorial influences to a single cause.

When, for example, the government of a major democratic state requires tobacco companies doing business in its country to print one of the following "health warnings" on every pack of cigarettes:

"Use of tobacco reduces life expectancy"

                "Use of tobacco is the main cause of lung cancer"
                "Tobacco use is a significant cause of heart disease"
                "Tobacco use during pregnancy can be harmful to the baby's health",1

there is every reason to believe that it has never been concerned about demonstrating that it is not diffuse life anxiety, when it becomes disproportionate, that causes premature death, lung cancer, heart disease or complications in pregnancy or, for some, the irrepressible desire to smoke, to find an endless stream of sexual partners or to drink too much alcohol.

It is as though it had been proven once and for all that no individual had ever displayed dangerous behaviour in the hope, conscious or otherwise, of avoiding even greater danger. And yet we all know people who, at one time or another in their lives, sometimes ourselves, have fallen ill or are still ill in order to adapt to their conditions of existence.

These diseases are not merely diplomatic in the superficial meaning of the word; they are properly speaking adaptive. If it seems so clear to most prevention professionals that such adaptive diseases can only be poor intellectual fantasies, it is no doubt because the scientific conception of the body and the rational view of medicine exclude any such causal relationship between human being and the unconscious.

And yet their error is proven every day, and they themselves daily lament: if no unconscious motivation arose in our behaviour, all of us would long since have complied with the rational injunctions of prevention and none of us would smoke, not even that "joint" or slim Havana we occasionally like to enjoy at the end of an excellent meal with friends.

This paper is necessary, not because of the originality of its argument – others stated it 20 years ago2 – but because of its philosophical approach. It is by questioning the type of human beings and the type of conviviality between human beings conveyed by totalitarian prevention that we intend to resist it and offer instead a form of prevention that cultivates autonomy. And we have mainly focused our attention on the issues of tobacco, alcohol and AIDS simply because of the present circumstances in which anti-tobacco, anti-alcohol and anti-AIDS campaigns of an entirely unheard of scope flourish.

Ultimately, it is ethics we are concerned with here once again, since, in the name of all that is good, an attempt is being made to impose a truncated vision of humanity. From a logical standpoint, this paper was written in the perspective of the ethics of autonomy, which, over the past 15 years, has formed the basis of our work in the philosophy of the biomedical sciences. Lastly, are we not entitled to wonder whether prevention, at least in its totalitarian form is not to society what substance abuse is to the individual: a drug used to relieve the diffuse anxiety inevitably caused by existing without ever really proving that that existence has meaning, to avoid the inevitable confrontation with the solitude, finitude and uncertainty that leave their indelible mark on our human condition?

Conclusion

The Contribution of Ethics in Defining Guiding Principles for a Public Drug Policy

Briefly stated, ethics, understood as the labour patiently done to reduce the discrepancy between what we say and what we do, recommends that the following principles serve as guidelines in defining a public drug policy:

1.       That policy makers consider the fact that high-risk behaviours statistically defined as "harmful" are not always in fact harmful for all individuals, but may, on the contrary, in certain specific cases, constitute the least harmful response by those individuals to the difficulty they experience in living in their own circumstances.

2.       That authorities view the question of the legality of drug use and the drug trade in the perspective of an epistemological criticism of biomedical scientific knowledge rather than give in to the illusion of medical scientism.

3.       That a radical distinction be drawn between the need for the adaptive equilibrium of individuals (which in certain cases may involve drug use) and the free trafficking in those harmful substances for the sole purpose of economic gain (which always brings with it strategies designed to create the need for those substances in a population which could create its own adaptive equilibrium through other, less harmful means).

4.       That the fundamental ethical-political principle that the autonomy of individuals in a society cannot be limited by the law except to protect that autonomy more effectively be adhered to.

5.       That a careful distinction be drawn between the role of therapists and that of politicians and that it consequently be constantly recalled that every law is ultimately intended to protect the autonomy of individuals, which presupposes that they are supported in the exercise of their individual critical faculties, and not to standardize ways of living, which is the usual tendency of authorities responsible for enforcing the law.

In my view, these recommendations express the potential contribution of ethics to defining guide principles for a public drug policy.

Jean-François Malherbe

L’Auberson

May 2002

* This report is based on my book, Autonomie et prévention. Alcool, tabac, sida dans une société médicalisée, Fides, Montréal, 1994, 189 pages. In fact, that study, which I summarize here, does not concern cannabis directly, but rather alcohol and tobacco. However, scientists now consider that the harmful effects of cannabis derivatives and the risks of dependence involved in their use are no more serious than those of tobacco and alcohol. The ethical considerations developed here for the purposes of public drug policies may thus be extrapolated to cannabis derivatives without any other reservation than the prudence we should always exercise with respect to all scientific findings.

1 This does not mean that a person cannot be both therapist and politician in one lifetime, but rather that therapists and politicians are clearly separate for each patient. This moreover is the practice, for example, in certain psychiatric teams in which one doctor is designated as therapist (and will defend his patient's interests on principle) and another who plays the role of politician (defending the interests of society on principle).

1 On this distinction, see Paul Ricoeur, "Science et idéologie", in Revue Philosophique de Louvain, tome 72, n° 14, mai 1974, pp. 328-356.

2 Claude Bernard: Introduction à l'étude de la médecine expérimentale, (1863), Paris, Flammarion, 1984.

3 René Descartes: Discours de la Méthode, "La Pléiade", Paris, Gallimard, 1953.

4 Blaise Pascal: Provinciales, Paris, Gallimard, 1987.

5 Norbert Bensaïd, La lumière médicale, Seuil, Paris, 1981, p. 233.

6 G. Canguilhem, Le normal et le pathologique, PUF, Paris, 1966.

7 Erich Fromm: Société aliénée et société saine, Le Courrier du Livre, Paris, 1971. Ivan Illich: Némésis médicale, Seuil, Paris, 1975.

8 J.-F. Malherbe : Pour une éthique de la médecine, Larousse, Paris, 1987; 3rd edition revised and expanded: Fides, Montreal, 1997. German, Italian and Spanish translations.

9 Jean-Marie Pelt, L'homme re-naturé, Seuil, Paris, 1990.

10 Renée Fox, L’incertitude médicale, Artel, Louvain-la-Neuve, 1988.

12 Pour une éthique de la médecine.

13 Of which it remains to be shown in each specific case that it is the direct consequence of a cause called smoking.

14 To be consistent with the conventional medical morality, which predicts that punishment for their misconduct.

16 Pour une éthique de la médecine, pp. 89 et seq.

17 Cornélius Castoriadis: L'institution imaginaire de la société, Seuil,Paris, 1975.

18 L'homme re-naturé.

19 Hans Jonas: Le principe responsabilité, une éthique pour la civilisation technologique, Cerf, Paris, 1990.

20 Albert Jacquart: Eloge de la différence, Seuil, Paris,1978.

21 Michel Serres : Le contrat naturel, Fr. Bourin, Paris,1990.

22 François Laplantine, Anthropologie de la maladie, Payot, Paris, 1986.

23 Jean-Pierre Dupuy: La critique de la raison à l'intérieur des sciences de l'homme et du social, in "Colloque Grand Orient de France, Raison-rationalisme-rationalité, 1 and 2/3/1986, pp. 65-71.

24 Pierre Teilhard de Chardin: Le phénomène humain, Seuil, Paris, 1970.

1 By "preclusion", I mean, in borrowing the term from Jacques Lacan, the operation of the unconscious whereby individuals or societies effectively prevent themselves from achieving the goal they sincerely desire.

2 By "scientism", I mean an attitude, and the corresponding doctrine, in which science is considered as having the last word on everything.

* Translator's Note: Maieutics (from the Greek word "maia", or "midwife") is the branch of philosophy relating to the Socratic method. According to Plato, Socrates viewed knowledge as something all human beings have in them and which can be elicited from them by means of question and answer, much as a baby can be delivered from its mother by a midwife. This explains the otherwise obscure metaphor used in this sentence.

* By "smoker", we mean here both users of pot/hash/marijuana and tobacco smokers, not to mention the fact that the two substances are very often smoked together. Most of the studies cited here concern tobacco. The word "cigarette" is thus frequently used in the works here referred to. I use the word "joint" wherever the context allows to show that I am extending my comments to include smokable cannabis derivatives.

2 Odile Lesourne: Le grand fumeur et sa passion, P.U.F., Paris, 1984, p. 211.

3 Id. p. 120.

4 Id. pp. 109-110.

5 Roger Lemelin: Autopsie d'un fumeur, Ed. Alain Stanké, Montréal, 1988, pp. 13-16.

6 Id. p. 11.

7 Annie Leclerc: Tabacreux, in L'esprit des drogues, Autrement, Paris, ,p. 131.

8 Gérard Pommier: Il est plus raisonnable de fumer!, in Passages N° 44, février 1992, pp. 20-21.

9 Op. cit. p. 22.

11 Op. cit. pp. 131, 132 et 133.

12 Id. pp. 95-96.

13 Id. p. 151.

14 Leclerc, op. cit. p. 131

15 Lesourne, p. 179.

16 Op. cit. p. 132.

17 Lesourne, p. 51.

18 Id. p. 143.

19 Id. p. 22.

20 Leclerc, op. cit. p. 135.

21 Lemelin, p. 151-152.

22 Id. p. 160.

23 Id. p. 163.

24 Id. p. 167.

25 Lesourne, p. 218-219.

26 Id. p. 219.

[2] Hubert Doucet, Au pays de la bioéthique. L’éthique médicale aux Etats-Unis, Labor et Fides, Genève, 1996, page 64.

[3] McCullough and Wear, in Theoretical Medicine, 6 (1985), p. 296, cited by H. Doucet p. 65.

[4] Hubert Doucet, op. cit., page 67.

[5] Idem.

[6] Paul Ricoeur, Soi-même comme un autre, Éditions du Seuil, Paris, 1990.

8 It should be noted that this prohibition has a positive aspect since it implies that the partner must be sought in another family, in another clan, which has the consequence of reinforcing social cohesion through inter-family alliances.

2 On this point, the reader will benefit and enjoy the remarkable book that Norbert Bensaïd published nearly 30 years ago, in 1974, with Éditions Denoël/Gonthier under the title, La consultation - Le dialogue médecin/malade, which I have used so extensively here that it should be cited on nearly every page.

1 Karl R. Popper, La logique de la découverte scientifique, Payot, Paris, 1974. This is the French translation of Logik der Forschung, Springer Verlag, Wien, 1934. However, it was the various English editions, published under the title, The Logic of Scientific Discovery, that have been authoritative in the scientific and philosophical worlds. See on Popper's work my book, La philosophie de Karl Popper et le positivisme logique, P.U.F., Paris, 1976, 1979.

1 Cf. sections 10 to 16 of the Tobacco Products Regulations (SOR/89-21 amended by SOR/89-248) made by the Government of Canada under the Tobacco Products Act, assented to in 1988 and entered into force on January 1, 1989.

2 Cf., par example, Norbert Bensaïd, La lumière médicale, les illusions de la prévention, Seuil, Paris, 1981, to which I owe a great deal.

Illegal Drugs (Special)