Clouded Motives and Pharmacological Calvinism: How Recreational Use of a Drug Affects Moral Judgments of Its Medical Use

Abstract

While many drugs are used exclusively for medical reasons, and others are used solely for recreation, some drugs are commonly used for both purposes. For example, cannabis, opioids, benzodiazepines, and stimulants are unique in many ways, but they share the fact that they are regularly consumed both medicinally and recreationally. However, it is not clear how the existence of recreational markets for substances affects moral judgments of their medical use. The current work shows that using a drug for medical reasons is viewed as less morally acceptable if other consumers use the same drug for recreation. This effect emerges because observers infer that medical users are less purely motivated by medical need. Accordingly, the negative effect of recreational drug use on moral judgments of its medical use is mitigated when patients do not have alternative treatment options. These findings have implications for patient stigmatization, drug marketing and lobbying, and policy and legislation designed to regulate the use of medical drugs with recreational benefits.

Keywords

moral judgments recreational drug use pharmaceuticals hedonic consumption

Despite being long relegated to the realm of illicit recreation, cannabis is increasingly being used as a solution for treating or coping with certain medical conditions (Azcarate et al. 2020; Mikulic 2020). Medical cannabis retail sales are expected to generate around 12 billion USD by 2024 (Mikulic 2020), as many consumers rely on the drug to relieve symptoms of chronic pain, epilepsy, multiple sclerosis, anxiety, depression, and more (Martin et al. 2021; Whiting et al. 2015). Both recreational and medical use of cannabis is legal in many states (Huff, Humphreys, and Wilner 2021), and some medical users even buy their cannabis products in the same dispensaries where cannabis is sold for recreational use. At the same time, prescription drugs developed for medical use, such as opioids, benzodiazepines, and stimulants, are regularly consumed recreationally (Drazdowski 2016). In particular, recreational abuse of opioids, and resulting overdoses, has become so widespread it is considered an epidemic in the United States (Compton, Boyle, and Wargo 2015). Thus, although substances like cannabis, opioids, benzodiazepines, and stimulants differ in terms of use occasions, risks of use, and public perception, one feature they share—that also sets them apart from many other pharmacological solutions—is that they are commonly used both medicinally and recreationally (Drazdowski 2016; Huff, Humphreys, and Wilner 2021). However, it is unclear whether or how the presence of recreational markets for these substances impacts judgments of their medical use and downstream consequences.

The current work shows that using a drug for a medical purpose is seen as less morally permissible if other people use the same drug solely for recreational enjoyment. I demonstrate that this effect occurs because the knowledge that some consumers use a drug recreationally leads observers to infer that those who use the drug for medical reasons are less purely motivated by medical need. In other words, the fact that some consumers use a drug for hedonic purposes clouds the perceived motives of those who use it for utilitarian purposes. As a result, observers judge the medical use of the drug as less morally acceptable and, subsequently, more socially stigmatized. In addition, I identify an important boundary condition of this effect, showing that the negative effect of recreational use of a drug on moral judgments of its medical use is mitigated if there are not (vs. are) viable alternative medical options. Further, I show that the negative effect of recreational use of a drug on moral judgments of its medical use persists regardless of whether medical users experience acute pleasure (i.e., get high) when using the drug as prescribed for medical purposes. Consistent with these effects, I also show that people agree to a lesser extent that a person's health insurance should cover the cost of a drug for medical purposes if that drug is (vs. is not) consumed by others recreationally.

These findings offer important insights for explaining and informing state laws and regulation, understanding insurance coverage and provision, and guiding the rules and procedures within health care organizations regarding access to and use of certain medications and treatment options. For example, the ability to buy and access cannabis for medical and recreational purposes differs across states and providers (Garber-Paul and Bort 2021). Likewise, while mid-level practitioners can generally prescribe controlled substances, their authority to prescribe opioids varies as a function of state laws and regulation (National Conference of State Legislators 2019). As a result, patient access to certain medications is subsequently dictated by the state in which patients reside. Moreover, confusion and challenges arise when regulation and policies across entities are not aligned, or when state laws conflict with policies within managed-care companies, corporate pharmacies, or individual practitioners (Bulloch 2019). In Utah, for instance, state laws on opioid prescriptions provide direction, but the state authorizes commercial insurers and the state Medicare program to implement policies for prescribing certain controlled substances (Bulloch 2019). And, as the current work suggests, it is likely the case that stakeholder decisions regarding access to medical drugs with recreational benefits are influenced by moral reasoning, including inaccurate, exaggerated, and/or prejudicial moral judgments. This could be particularly problematic when stakeholders who are more persuaded by moral disapproval or social perception—such as state legislators—have more power over medical treatment decision making than medical entities or professionals who are able to observe different needs on a case-by-case basis. Therefore, understanding whether and how recreational abuse or legitimation of recreational industries for certain drugs affects moral judgments of their medical application is critical for policy makers who determine medical access to certain drugs.

These findings also have meaningful implications for marketers of drugs and for organizations that lobby for (de)regulation of specific substances. For instance, knowing how the coexistence of recreational and medical markets influences perceptions of the latter can help marketers or lobbyists create communication strategies that address issues related to recreational use while combatting perceived immorality or stigmatization of medical use. Moral judgments of medical drugs with recreational benefits could also impact the likelihood of clinicians prescribing or recommending some treatments over others and/or affect biases in treatment recommendations for different patients, for people with certain conditions over others, or both. In addition, feelings of stigma that arise from recreational markets could have negative consequences for patient compliance in using remedies or help-seeking behaviors. Therefore, knowing whether and how recreational markets for drugs affect judgments of medical markets is crucial for informing effective messaging, marketing, and related public policy.

Theoretical Foundations

Drug Use, for Pleasure and Pain

Humans have been consuming psychoactive plants and plant-based substances for both pleasure and healing purposes for millennia (Nichols 2004; Pollan 2021). Nevertheless, such substances have been the cause of significant cultural unrest and legislative controversy for decades in the United States (Farber 2021; Pollan 2021). Yet, despite turbulent histories, medical and recreational markets for psychoactive drugs—such as those for cannabis—have established themselves as legitimate U.S. industries (Huff, Humphreys, and Wilner 2021). At the same time, illicit recreational use of prescription drugs has become increasingly common in the United States, despite nonmedical use of these substances being dangerous and ill-advised (Drazdowski 2016). For example, substances such as opioids, benzodiazepines, and stimulants serve as both essential remedies for many consumers and intoxicating recreational substances for many others (Compton, Boyle, and Wargo 2015; Dowell, Haegerich, and Chou 2016).

Accordingly, the coexistence of large recreational and medical markets for substances such as cannabis, opioids, benzodiazepines, and stimulants distinguishes these substances from other drugs. Alcohol, for example, constitutes a legitimate recreational market, but not a medical one. Meanwhile, many prescription and over-the-counter medications constitute legitimate medical markets, but not recreational ones. This is not to suggest there are not consumers who claim to indulge in substances like alcohol for utilitarian or health benefits (e.g., drinking red wine for “heart health”) or people who consume some medications for nonmedical reasons (e.g., enjoying the taste of antacids). However, serious claims that one is treating a health condition with alcohol or that antacids should be consumed for recreation would hardly be met with anything other than justified skepticism or immediate dismissal.

The simultaneous presence of recreational and medical markets for drugs is interesting given the opposing cultural meanings ascribed to medical versus recreational drugs more generally (Huff, Humphreys, and Wilner 2021). Indeed, perceptions of drug use in the United States have long been characterized by an orientation toward “pharmacological Calvinism,” referring to a general distrust of drugs used for nontherapeutic purposes (Klerman 1972).¹ In essence, pharmacological Calvinists assume that if a drug “makes you feel good, it must be morally bad” (Klerman 1972, p. 3). Although it has not been empirically tested, Hecht (2007, p. 119) even suggests that pharmacological Calvinism “causes people to reject any drugs that are used by some people for fun.” Accordingly, I test this notion and elucidate one psychological mechanism—perceived need motives—underlying the moral aversion to using drugs for medical purposes that others use for recreation.

Hedonic Versus Utilitarian Consumption Motives

Utilitarian products are used to accomplish functional tasks, whereas hedonic products are used for enjoyment or recreation (Strahilevitz and Myers 1998). Thus, consumption of hedonic goods is predominantly characterized by affective and sensory experiences of aesthetic or sensual pleasure (Hirshman and Holbrook 1982), while consumption of utilitarian goods is more instrumental and cognitive in nature (Strahilevitz and Myers 1998). Prior research demonstrates that hedonic and utilitarian features can be independent components of product evaluation, such that products can be high or low in both hedonic and utilitarian attributes (Batra and Ahtola 1991).

Nevertheless, consumers tend to categorize purchases generally as either hedonic or utilitarian (Dhar and Wertenbroch 2000; O’Curry and Strahilevitz 2001), with usage and consumption motives being fundamental determinants of whether a purchase is perceived as hedonic or utilitarian (Dhar and Wertenbroch 2000). For example, buying a computer for work purposes is utilitarian, but purchasing the same computer for video gaming is hedonic. Analogously, using cannabis for chronic pain is utilitarian, whereas smoking cannabis just to get high is hedonic. How consumers categorize items matters because it can influence their judgments of prospective purchases and their subsequent experiences of consumption (Khan, Dhar, and Wertenbroch 2005). For instance, utilitarian goods are often thought of as relative necessities, while hedonic purchases are often construed as wasteful and relatively discretionary. As a result, hedonic purchases tend to evoke feelings of guilt (Khan and Dhar 2010), and consumers demonstrate a greater need to justify the purchase and consumption of hedonic versus utilitarian goods (Kivetz and Zheng 2006). Consumers deploy several different strategies to decrease the guilt associated with hedonic purchases, with one strategy being to inflate the value and usage frequency of a utilitarian feature (Keinan, Kivetz, and Netzer 2016). In essence, enhancing or bolstering a utilitarian motive for a purchase can serve as a “functional alibi” to justify indulgent purchases (Keinan, Kivetz, and Netzer 2016).

However, no work that I know of has considered how the presence of hedonic motives for using a product affects evaluations of using the product for utilitarian goals. Likewise, no existing research has examined how the presence of alternative use motives for some other consumers might affect judgments of consumption for other users with different use motives. For instance, drawing on the previous examples, how might the fact that some people purchase a computer primarily for video gaming affect judgments of the decision to purchase the same computer for work purposes? Or, how does the fact that some people use cannabis for recreational purposes affect judgments of those who use it for medical reasons?

Inferred motives

The hedonic consumption motives of some consumers should not have any bearing on judgments of using the same product for utilitarian goals. Such an effect would be inconsistent with the idea that a consumer's personal usage motives dictate evaluations (Dhar and Wertenbroch 2000). Normatively, how some consumers use a good should also not impact perceptions of the extent to which another consumer genuinely needs that good. Nevertheless, I propose that observers will integrate the information that some consumers use a drug for recreational purposes into their evaluations of medical users. In particular, I posit that the knowledge that some consumers have hedonic motives for using a drug will influence the perceived motives of utilitarian users, such that they will seem less motivated by medical need. In other words, the mere presence of alternative recreational motives for using a drug will induce skepticism or uncertainty about the purity of medical users’ motives for using the drug.

I base this proposition on prior work indicating that situational factors and attributes of available choices influence motive assumptions (Ames and Fiske 2013; Barasz, Kim, and Evangelidis 2019). When judging a person's behavior, observers take all available information into account to form inferences about why a person engaged in a particular behavior or made a certain decision (Ames and Fiske 2013). As a result, observers sometimes overrely on irrelevant or extreme attributes when evaluating or inferring the decision motives of others (Barasz, Kim, and Evangelidis 2019; Shoham, Moldovan, and Steinhart 2016). Accordingly, I predict that the knowledge that some consumers use a drug for recreation will be taken into account when people infer the motives of medical users. More specifically, the fact that some consumers use a drug for hedonic purposes will cloud the perceived motives of those who use it for utilitarian purposes, leading observers to infer that medical users are less motivated by medical need.

Moral judgments of consumption

The meaning people infer from an action often depends on their subjective construal of why a person acted in that particular way, or the perceived motives behind a behavior (Griffin and Ross 1991; Malle and Knobe 1997). Moral judgments in particular frequently hinge on perceived motivations (Cushman 2008; Guglielmo and Malle 2010; Reeder et al. 2002). For example, aggression motivated by revenge, rather than personal gain, is seen as relatively more moral (Reeder et al. 2002). Of most relevance to the current investigation, existing work also shows that observers judge purchases by low-income consumers as less morally permissible when they are perceived to be motived by “want” versus by “need” or necessity (Hagerty and Barasz 2020). Drawing on this work, I predict that using a drug for a medical purpose will be seen as less morally acceptable if others use the drug for recreational enjoyment because the presence of recreational use reduces the perception that medical users are motivated by medical need.

H₁: Using a drug for medical reasons is perceived as less morally acceptable if other consumers use the drug primarily for recreational purposes.

H₂: The negative effect of others’ recreational use of a drug on perceived moral acceptability of its medical use is mediated by observers’ perception that medical users are less motivated by medical need.

In addition, I hypothesize that the negative effects of recreational use of a drug on moral judgments of its medical use will have downstream consequences on perceived social stigma of using the drug for medical purposes. Stigma often stems from beliefs about the lesser “moral status” of a behavior, group, or condition (Goffman 1963). Moreover, knowledge of public stigma can often result in self-stigma, wherein individuals feel fearful of enacted stigma that results from identification with a stigmatized group (Luoma et al. 2008). Thus, I hypothesize that the negative effect of recreational drug use by some consumers on moral judgments of its medical use by others will also increase feelings of stigma for medical users.

H₃: The negative effect of a drug’s recreational use on the moral acceptability of its medical use subsequently increases perceived social stigma of using the drug for medical purposes.

Availability of alternative options

I investigate whether the negative effect of some consumers’ recreational use of a drug on moral judgments of others who use it for medical reasons is attenuated when there are no alternative viable medical treatments. I predict that knowing that a medical user has tried other available medical options without success—and that the focal drug is therefore the only remaining viable medication option—will reduce the negative effect of recreational use of a drug on moral judgments of its medical application. I base this prediction on the notion that knowledge that a drug is a last resort for medical users will serve as a signal of medical need, thereby attenuating the clouding effect of recreational use on perceived motives for medical use.

H₄: The negative effect of recreational use of a drug on moral acceptability of its medical use is attenuated when there are no alternative viable medical options.

Pleasure Versus Recreational Use

Importantly, some drugs produce comparable pleasurable effects when used recreationally and medically, whereas others do not. This may be a result of dosing, medical supervision, means of ingestion, and/or changes to chemical composition for medical application. Accordingly, it is unclear whether the recreational use of a drug will negatively impact moral judgments of its medical use if medical patients do not reap the same pleasurable highs associated with recreational use. Because I hypothesize that the negative effect of recreational use of a drug on moral judgments of its medical use is due to a clouding effect of perceived motives, and not simply experienced pleasure, I expect that the presence of recreational use of a drug will reduce perceived moral acceptability of its medical use regardless of whether medical users experience comparable pleasure—or get high—from using the drug. Even if users do not get high from medicinal use, the knowledge of alternative recreational use motives will still adulterate the perceived medical need motives and subsequent moral judgments of medicinal use of the drug.

H₅: Using a drug for medical reasons is perceived as less morally acceptable if other consumers use the drug primarily for recreational purposes, regardless of whether users experience acute pleasure when using the drug medically.

Overview of Studies

Six studies demonstrate that using drugs for utilitarian (i.e., medical) purposes is perceived as less morally acceptable if other people use the same drug for hedonic purposes. Study 1 tests whether consumers perceive the use of drugs for medical purposes as less morally acceptable, and subsequently more socially stigmatized, when they are used by others for recreational purposes (vs. a control condition). Study 2 builds on the first study by showing that the negative effect of alternative uses of a medical drug on moral judgments emerges when the drug is used by others for recreational purposes, but not when it is used by others for alternative medical purposes. Study 3 delves into the underlying mechanism, showing that the effect of others’ recreational use of a drug on moral acceptability of its medical use is mediated by observers’ perception of the extent to which medical users are motivated by medical need. Next, Study 4 explores a moderator of the effect, showing that the negative effect of others using a drug for recreational purposes on judgments of its medical use is attenuated when alternative viable medical options are unavailable. Study 5 then shows that the negative effect of others using a drug recreationally on moral judgments of its medical use persists regardless of whether medical users experience acute pleasure when using the drug medicinally. Finally, Study 6 examines an implication of moral judgments of medical drugs with recreational benefits by showing that people agree to a lesser extent that a person's health insurance should cover the cost of a drug for medical purposes if that drug is (vs. is not) consumed by others for recreational purposes.

Study 1: The Effect of Recreational Use of a Drug on Moral Judgments of Its Medical Use

The goal of Study 1 is to test the hypothesis that using a drug for medical purposes is viewed as less morally acceptable if the drug is used by some consumers for purely recreational enjoyment. I also assess whether the negative effect of recreational use on perceived moral acceptability of its medical use increases feelings of stigma when the drug is used for medical reasons.

Method

Three hundred participants (52.3% female; M_age = 40.63 years) were recruited from Amazon Mechanical Turk (MTurk) for a paid online study. I randomly assigned respondents to either the recreational use or control condition. Participant in both conditions read an excerpt from a hypothetical news article describing a fictitious drug called Abannoral that can be used to treat chronic pain. Participants in the recreational use condition were told that the drug is also used for recreational purposes. For a complete description of stimuli, see Appendix A.

In random order, participants rated the moral acceptability of taking the drug to treat chronic pain and the perceived social stigma of taking the drug for medical purposes. Moral acceptability was based on the average of participants’ responses to seven items. Participants indicated the extent to which they thought taking Abannoral to treat chronic pain seems immoral, moral, permissible, virtuous, healthy, unhealthy, and indulgent.² Responses were based on seven-point Likert scales (1 = “Not at All,” and 7 = “Very”; α = .79). Ratings of immoral, unhealthy, and indulgent were reverse coded so that higher scores reflect higher moral acceptability. I assessed perceived social stigma by asking participants—as separate questions in random order—how comfortable they would feel telling their colleagues, friends, and family that they were taking the drug. Responses were based on seven-point Likert scales (1 = “Very Uncomfortable,” and 7 = “Very Comfortable”; α = .90). Finally, in this and all subsequent studies, participants provided their age, gender, and comments for the researchers.

Results

Moral acceptability

As predicted, participants in the recreational use condition perceived the medical use of the focal drug as less morally acceptable (M = 4.57, SD = 1.05) compared with those in the control condition (M = 4.94, SD = .91; t(298) = 3.25, p = .001, d = .38).

Social stigma

Participants in the recreational use condition reported that they would feel greater social stigma, as indicated by a lesser willingness to tell others that they were taking the focal drug for chronic pain (M = 4.22, SD = 1.75), compared with those in the control condition (M = 4.81, SD = 1.54; t(298) = 3.12, p = .002, d = .36). A mediation analysis (PROCESS Model 4; Hayes 2013) also showed that the effect of condition (control = 0, recreational = 1) on social stigma was mediated by perceived moral acceptability of using the drug for medical reasons. Specifically, the effect of recreational use condition (vs. control) on moral acceptability was negative and significant (B = −.18, t(298) = −3.25, p = .001), the effect of moral acceptability on comfort telling others about taking the drug was positive and significant (B = .92, t(298) = 11.42, p < .001), and the indirect effect was negative and significant (indirect effect = −.17; 95% confidence interval [CI_95%] = [−.28, −.07]). See Figure 1.

Discussion

The results of this study provide support for the hypothesis that knowing that some consumers use a drug recreationally negatively affects perceived moral acceptability of medical use of the drug. This study also shows that the effect of recreational use on perceived moral acceptability of its medical use subsequently influences perceived social stigma of using the drug for medical purposes. Specifically, participants reported that they would feel less comfortable telling others (namely, friends, colleagues, and family) they use a drug for medical purposes if some people use it recreationally.

It is tenable to theorize that the negative effect of recreational use of a drug on moral judgments of its medical use stems from a more general dilution effect, wherein the ability to use a product for multiple goals reduces its perceived efficacy for serving any single goal, rather than from a specific effect of outside recreational use (Zhang, Fishbach, and Kruglanski 2007). Accordingly, to test this alternative explanation, in the next study, I compare the effect of knowing that a drug is used by some people for alternative recreational reasons with the effect of knowing that it is used for alternative medical reasons on moral judgments of using the drug for chronic pain.

Study 2: The Specific Effect of Recreational Use on Moral Acceptability of Using a Drug for Medical Purposes

In Study 2, I aim to replicate and extend the results of Study 1 by testing whether there is a specific effect of knowing that others use a drug for recreational purposes on judgments of its medical use, or if the presence of any alternative use motive negatively impacts moral judgments of its medical use. To do this, I compare the effect of alternative recreational use motives with both a control condition (i.e., no alternative use motives mentioned) and a condition that notes alternative medical uses for the focal drug.

Method

Four hundred fifty-one participants (47% female; M_age = 39.85 years) were recruited from MTurk for a paid online study. Respondents were randomly assigned to one of three conditions: recreational use, medical use, or control condition. Similar to Study 1, all participants read a hypothetical news excerpt about a fictitious drug, Abannoral, that could be used to treat chronic pain. Those in the recreational use condition also learned that the drug has been used recreationally as a “club drug” for years, while those assigned to the medical use condition were told that Abannoral has also been used for years for other medical purposes (to reduce symptoms of Crohn's disease). For complete description of the stimuli, see Appendix B. After reading the excerpt, participants rated the moral acceptability of using the focal drug to treat chronic pain using the same seven-item index as in Study 1 (α = .86).

Results

A univariate analysis of variance (ANOVA) indicated a significant main effect of drug use condition on the perceived moral acceptability of using the drug to treat chronic pain (F(2, 448) = 34.42, p < .001, η² = .13). Post hoc comparisons showed that participants thought that using the drug for chronic pain was significantly less morally acceptable in the recreational use condition (M = 4.22, SD = 1.32) compared with the control condition (M = 5.01, SD = 1.00; p < .001, d = .67) and the medical use condition (M = 5.22, SD = .95; p < .001, d = .87). However, there was no significant difference in moral judgments of using the drug for chronic pain between the medical use and control conditions (p = .30).

Discussion

The results of Study 2 provide evidence for the specific effect of the presence of alternative hedonic motives for using a good on moral judgments of using the same good for utilitarian reasons. Compared with a control condition, participants judged the medical use of a drug as less morally acceptable if others use the drug recreationally, but not if others use the drug for different medical reasons. This study helps rule out the possibility that the observed effects are the result of a more general dilution effect (Zhang, Fishbach, and Kruglanski 2007) wherein any alternative use motive has negative effects on evaluations, as opposed to being specific to the negative effect of the presence of hedonic motives for using a good on moral permissibility of using the good for utilitarian reasons.

Study 3: Mediation by Perceived Medical Motives

The goal of Study 3 is to test the hypothesis that the effect of recreational use of a drug on judgments of its medical use is mediated by the perception that medical users are less motivated by medical need.

Method

Three hundred participants (62.7% female; M_age = 35.53 years) were recruited from Prolific Academic for a paid online study. Participants were randomly assigned to the recreational use or control condition. All participants read about a drug, “Drug A,” that can be used to manage symptoms of chronic pain. Those in the recreational use condition also learned that some people use the drug for recreation. For complete description of stimuli, see Appendix C.

In random order, participants rated the extent to which they thought medical users of the drug are motivated by medical need and provided their judgments of the moral acceptability of using Drug A to treat chronic pain. Specifically, to judge perceived medical motives, participants answered the question, “For people who choose to take Drug A to manage chronic pain symptoms, to what extent do you think their decision to do so is motivated by medical need?” Responses were based on a nine-point Likert scale (1 = “Not at All,” and 9 = “Entirely”). Moral acceptability was based on the same seven-item index used in the previous studies (α = .79).

Results

Perceived motives

Independent t-tests showed that participants in the recreational use condition thought that medical users were less motived by medical need (M = 7.15, SD = 1.33) compared with those in the control condition (M = 7.57, SD = 1.31; t(298) = 2.80, p = .005, d = .32).

Moral acceptability

Independent t-tests showed that participants in the recreational use condition thought that using the focal drug for medical purposes was less morally acceptable (M = 4.95, SD = 1.05) compared with those in the control condition (M = 5.24, SD = .88; t(298) = 2.59, p = .01, d = 1.04).

Mediation

A mediation analysis (PROCESS Model 4; Hayes 2013) indicated that the effect of condition (control = 0, recreational = 1) on the moral acceptability of using the drug for medical reasons was significantly mediated by perceived need motives. Specifically, the effect of use condition on perceived medical need motives was negative and significant (B = −.43, t(298) = −2.80, p = .005), the effect of perceived medical need motives on moral acceptability was positive and significant (B = .33, t(298) = 8.58, p < .001), and the overall indirect effect was negative and significant (indirect effect = −.14; CI_95% = [−.26, −.04]). Further, the direct effect was no longer significant when the indirect effect was controlled for (B = −.15, t(298) = −1.48, p = .14). See Figure 2.

Discussion

The results of Study 3 provide evidence in support of the hypothesis that the negative effect of recreational use of a drug on perceived moral acceptability of its medical use is mediated by medical users’ perceived need motives. The presence of recreational use has a clouding effect on the perceived need motives of medical users, which detrimentally affects moral judgments of its medical use. In the next study, I test whether information that reinforces the perceived need motives of medical users attenuates the negative effect of recreational use of a drug on moral judgments of using it for medical purposes.

Study 4: Moderation by Available Medical Alternatives

The goal of Study 4 is to test H₄’s prediction that the effect of recreational use of a drug on moral acceptability of its medical use is moderated by the availability of viable medical alternatives. I predict that the negative effect of others’ recreational use of a drug on moral judgments of its medical use will be attenuated in situations wherein medical users do not have viable alternatives. More specifically, I predict that a lack of viable alternatives for medical users will bolster the perception that medical users are motivated by medical need, thereby reducing the negative effect of outside recreational use on the moral acceptability of using a drug for medical purposes.

Method

Four hundred fifty-four undergraduate students (40.8% female; M_age = 19.51 years) were recruited to participate for course credit. This experiment uses a 2 (recreational use vs. control) × 2 (viable alternatives vs. no viable alternatives) between-subjects design. I randomly assigned participants to either the recreational use or control condition. All participants read about a hypothetical drug, Ketarate, that can be used to treat chronic pain. Participants in the recreational use condition also read that Ketarate can be used for recreation. For a complete description of stimuli, see Appendix D.

Next, I randomly assigned participants to the viable-alternatives or no-viable-alternatives condition. Those assigned to the viable-alternatives condition read, “Some people choose to use Ketarate before trying other medical treatments. In these cases, Ketarate is one of several viable medication options they could choose from.” Those assigned to the no-viable-alternatives condition read, “Some people choose to use Ketarate only after they have tried other medical treatments without success. In these cases, Ketarate is the only viable medication option left for them to choose from.” Participants then rated the perceived need motives and moral acceptability of these consumers using the focal drug. For need motives, participants responded to the question, “For these people, to what extent do you think the decision to use Ketarate is motivated by medical need?” Responses were based on a nine-point Likert scale (1 = “Not at All,” and 9 = “Entirely”). Moral acceptability was measured by the average of six items (immoral, permissible, moral, healthy, unhealthy, and indulgent), all rated on seven-point Likert scales (1 = “Not at All,” and 7 = “Very”; α = .79).

Results and Discussion

Moral acceptability

A two-way ANOVA indicated no significant main effect of use condition (M_recreational = 4.91, SD = 1.22; M_control = 5.00, SD = 1.06; F(1, 450) = 1.09, p = .30, η² = .002), but there was a significant main effect of viable-alternatives condition (M_NVA = 5.13, SD = 1.14; M_VA = 4.78, SD = 1.12; F(1, 450) = 10.89, p = .001, η² = .02) and a significant interaction of use condition and viable-alternatives condition on moral acceptability (F(1, 452) = 6.76, p = .01, η² = .02). Contrasts showed that the negative effect of others using a drug recreationally on moral acceptability of its medical use was significant in the viable-alternatives condition (M_recreational = 4.58, SE = .11; M_control = 4.97, SE = .10; F(1, 450) = 6.64, p = .01), but not in the no-viable-alternatives condition (M_recreational = 5.20, SE = .10; M_control = 5.04, SE = .11; F(1, 450) = 1.21, p = .27).

Perceived motives

A two-way ANOVA indicated no significant main effect of use condition (M_recreational = 7.07, SD = 1.78; M_control = 7.24, SD = 1.56; F(1, 450) = 2.38, p = .12, η² = .005), but there was a significant main effect of viable-alternatives condition (M_NVA = 7.81, SD = 1.36; M_VA = 6.51, SD = 1.71; F(1, 450) = 82.49, p < .001, η² = .16) and a significant interaction between use condition and viable-alternatives condition on perceived medical motives for using the drug (F(1, 450) = 7.71, p = .006, η² = .02). Contrasts showed that the negative effect of others using a drug recreationally on perceived need motives was significant in the viable-alternatives condition (M_recreational = 6.18, SE = .15; M_control = 6.81, SE = .14; F(1, 450) = 9.33, p = .002), but not in the no-viable-alternatives condition (M_recreational = 7.89, SE = .14; M_control = 7.71, SE = .15; F(1, 450) = .76, p = .38).

Moderated mediation

To better evaluate the underlying mechanism of the observed effect, I examined the indirect effect through a moderated medication analysis (with independent variable [IV] = control vs. recreational use condition, moderator = viable-alternatives vs. no-viable-alternatives condition, mediator = perceived medical need motives, and dependent variable [DV] = moral acceptability, where the moderator moderates the A path between the IV and the mediator; Hayes 2013, Model 7, 5,000 bootstrapped samples). The analysis showed that the mediating effect of perceived motives was conditionally dependent on whether medical users have available medical alternatives. That is, the effect of recreational use of a drug on moral acceptability of its medical use was mediated through perceived motives when medical users had alternative viable medical options (conditional indirect effect = −.22, CI_95% = [−.39, −.06]) but not when they did not have alternative medical options (conditional indirect effect = .06; CI_95% = [−.06, .20]). An index of moderated mediation further confirms successful moderated mediation (CI_95% = [.07, .50]).

Discussion

The results of Study 4 provide evidence for moderation by the presence or absence of viable medical alternatives. Specifically, when medical users have available medical alternatives, there is a negative effect of other people using the drug for recreational purposes on the perceived motives of medical users, which subsequently reduces the perceived moral acceptability of using the drug for medical reasons. However, when medical users do not have available medical alternatives, the negative effect of others’ recreational use on perceived need motives for and moral judgments of medical use is attenuated.

Study 5: Pleasurable and Nonpleasurable Medical Use

In Study 5, I examine the interplay between pleasurable side effects and recreational use of a drug on moral judgments of using a drug for medical purposes. I independently manipulate whether a drug is used by some consumers recreationally and whether medical users experience acute pleasure (i.e., get high) from the drug. I hypothesize that knowledge of recreational use motives reduces the moral acceptability of medical use of the drug because it clouds the perceived need motives of medical users; thus, I predict that the negative effect of general recreational use of a drug on moral judgments of its medical use will persist regardless of whether medical users experience pleasurable side effects when using the drug medically. In other words, even if medical users do not experience acute pleasure—or get high—from using a drug medicinally, knowledge of alternative recreational use motives for a substance will still have a negative effect on perceived moral acceptability of using the drug for medical purposes.

Method

Six hundred participants (47.7% female; M_age = 40.29 years) were recruited from MTurk for a paid online study. I used a 2 (recreational use vs. control) × 2 (pleasurable vs. not pleasurable) between-subjects design. I randomly assigned participants to either the recreational use or control condition. All participants read about a drug that can be used for chronic pain management. Those in the recreational use condition also learned that the drug is used recreationally. For complete description of stimuli, see Appendix E. I also randomly assigned participants to either the pleasurable or nonpleasurable condition. The description in the pleasurable condition stated, “When taken in low doses to manage chronic pain, Drug A has been shown to have slight positive effects on mood and produces general positive psychological effects, such as feelings of pleasure and calm,” while the description in the nonpleasurable condition stated, “When taken in low doses to manage chronic pain, Drug A has not been shown to have any effects on mood or to produce any psychological effects.”

Next, participants rated the perceived need motives of medical users and moral acceptability of using the drug for symptoms of chronic pain. Moral acceptability was based on the same seven-item index as used in the prior experiments (α = .79). Perceived need motives were based on responses to the question, “For people who choose to take Drug A for chronic pain symptoms, to what extent do you think their decision to do so is motivated by medical need?” (nine-point Likert scale: 1 = “Not at All,” and 9 = “Entirely”).

Results

Moral acceptability

There was a significant main effect of use condition (M_recreational = 4.98, SD = 1.19; M_control = 5.52, SD = .92; F(1, 596) = 38.35, p < .001, η² = .06), no significant main effect of pleasure condition (M_pleasurable = 5.23, SD = 1.08; M_{nonpleasurable} = 5.27, SD = 1.12; F(1, 596) = .15, p = .70, η² = .000), and a trending interaction of recreational use condition and pleasure condition on moral acceptability of using the drug for medical purposes (F(1, 596) = 3.47, p = .06, η² = .01). However, contrasts indicated that the marginally significant interaction was driven by the fact that the effect of recreational use on moral judgments was larger in the no-pleasurable-side-effects condition (M_recreational = 4.91, SE = .09; M_control = 5.61, SE = .09; F(1, 596) = 32.67, p < .001) than in the pleasurable-side-effects condition (M_recreational = 5.04, SE = .09; M_control = 5.42, SD = .09; F(1, 596) = 9.31, p = .002), but it was significant in both conditions.

Perceived motives

There was a significant main effect of use condition (M_recreational = 7.07, SD = 1.54; M_control = 7.74, SD = 1.27; F(1, 596) = 35.13, p < .001, η² = .06), a significant main effect of pleasure condition (M_pleasurable = 7.26, SD = 1.44; M_{nonpleasurable} = 7.56, SD = 1.44; F(1, 596) = 6.82, p < .001, η² = .01), and a significant interaction between recreational use and pleasure condition on perceived need motives of medical users (F(1, 596) = 7.52, p < .001, η² = .01). However, contrasts indicated that the interaction was driven by the fact that the effect of perceived motives of recreational use was larger in the no-pleasurable-side-effects condition (M_recreational = 7.06, SE = .11; M_control = 8.05, SE = .11; F(1, 596) = 37.83, p < .001) than in the pleasurable-side-effects condition (M_recreational = 7.08, SE = .11; M_control = 7.44, SD = .11; F(1, 596) = 5.04, p = .03), but it was significant in both conditions.

Mediation

A mediation analysis (PROCESS Model 4; Hayes 2013) collapsed across pleasurable conditions³ indicated that the effect of recreational use of a drug on moral acceptability of its medical use was significantly mediated by the perceived need motives of the medical users. Specifically, the effect of use condition (control = 0, recreational = 1) on perceived medical need motives was negative and significant (B = −.68, t(298) = −5.88, p < .001), the effect of perceived need motives on the moral acceptability of using the drug for medical reasons was positive and significant (B = .46, t(298) = 18.45, p < .001), and the overall indirect effect was negative and significant (indirect effect = −.31, CI_95% = [−.44, −.20]).

Discussion

The results of this experiment elucidate the roles of pleasure and recreational use of a drug on perceived motives and moral judgments of using a drug for medical purposes. The negative effect of recreational use of a drug on the perceived need motives of medical users and moral acceptability of using the drug for medical reasons persists regardless of whether medical users experience acute pleasurable side effects from the drug. Pleasurable side effects from the medicinal use of a drug are not necessary to produce a significant negative effect of knowledge of the drug’s recreational use on perceived motives and moral judgments of using the drug for medical purposes.

Study 6: The Effect of Recreational Use of a Drug on Beliefs That Costs for Medical Use Should be Covered by Health Insurance

In Study 6, I test for a consequential outcome of the effect of recreational use of a drug on moral judgments of using the drug for medical purposes. In particular, I assess whether consumers are less likely to believe that a person's health insurance should cover the cost of a drug used for a medical purpose if the drug is also used by others recreationally. I predict that because people judge the medical use of a drug as less morally permissible if the drug is used by some people recreationally (vs. not), they will also agree to a lesser extent that a drug with (vs. without) recreational benefits should be covered by a patient's health insurance when used medicinally.

Method

Two hundred participants (53% female; M_age = 40.96 years) were recruited from MTurk for a paid online study. Participants were randomly assigned to either a recreational use or control condition. For a complete description of stimuli, see Appendix F. Participants then responded to the following question: “In your opinion, if someone took Drug A for chronic pain, to what extent do you think their health insurance should cover the cost of the drug?” (nine-point Likert scale: 1 = “Should Definitely NOT Be Covered,” and 9 = “Should Definitely Be Covered”).

Results and Discussion

An independent t-test indicated that participants in the recreational use condition believed to a lesser extent that the drug should be covered by health insurance (M_recreational = 7.58, SD = 1.74; M_control = 8.09, SD = 1.40; t(198) = 2.82, p = .02, d = .32). This result is consistent with the prior studies showing that people judge the medical use of a drug as less morally permissible if it is used by other consumers for purely recreational reasons. This study further implies that moral disapproval of using drugs with recreational benefits for medical purposes has downstream consequences on consumers’ willingness to endorse means of more easily or cheaply accessing such drugs for medical reasons, such as by having the cost of these substances covered by one's health insurance.

General Discussion

Although some drugs are used exclusively for medical reasons, and others are consumed solely for recreation, a number of drugs are commonly used for both purposes. For example, while cannabis, opioids, benzodiazepines, and stimulants are all unique in their specific uses, benefits, and risks, they share the fact that they are regularly consumed both medicinally and recreationally. The simultaneous existence of recreational and medical markets for these substances and others like them presents important questions in terms of how the presence of each market could affect judgments of the other. Answering these questions has meaningful implications for marketing and brand management decisions as well as for legislation, policy, and regulation.

The current work shows that using a drug for a medical purpose is seen as less morally acceptable if other people use the same drug solely for recreation. This negative effect of recreational use of a drug on moral judgments of its medical application is driven by users’ perceived medical need motives. In other words, the fact that some consumers use a drug for hedonic purposes clouds the perceived motives of those who use it for utilitarian purposes. As a result, drugs that have recreational markets are seen as more socially stigmatized medical solutions. Moreover, the negative effect of recreational use of a drug on moral acceptability of using it for medical purposes persists regardless of whether medical users experience acute pleasure (get high) when using the drug for medical purposes. Further, I show that people agree to a lesser extent that insurance should cover the cost of drugs for medical purposes when those drugs are consumed by some people for recreational reasons (vs. are not consumed by others recreationally).

This work offers several theoretical contributions. First, existing research investigates how hedonic versus utilitarian consumption motives affect one's categorization and evaluations of purchases (Dhar and Wertenbroch 2000) and demonstrates that consumers often engage in strategies to justify hedonic purchases (Keinan, Kivetz, and Netzer 2016). Here, I shift the focus of analysis and explore the consequences of some consumers using a product for hedonic purposes on observers’ judgments of other consumers using the same product for utilitarian purposes. In doing so, I also contribute to the bodies of work on motive inferences (Ames and Fiske 2015; Barasz, Kim, and Evangelidis 2019) and moral judgments of behaviors (Cushman 2008; Newman and Cain 2014) by demonstrating that the mere knowledge that other people consume a product for hedonic purposes clouds the perceived motives and subsequent moral acceptability of using the same product for utilitarian purposes. Furthermore, I contribute to research on market legitimation, showing how the presence of multiple markets for the same product can influence consumer perceptions of product use (Huff, Humphreys, and Wilner 2021; Humphreys and Latour 2013). In addition, I add to existing work on perceptions of pharmaceuticals and medical technologies (Riis, Simmons, and Goodwin 2008; Williams and Steffel 2014).

Future Research and Policy Implications

Future research should explore how knowing that a good can be used for hedonic purposes affects judgments of utilitarian usage outside the domain of drugs and pharmaceuticals. For instance, many products and new technologies in fitness, health, beauty, and productivity can serve either hedonic or utilitarian purposes, and use motives often vary among consumers. For example, a fitness tracker could be construed as a predominantly utilitarian product for people who use it to track health metrics, such as heart rate or sleep, or as predominantly hedonic for people who use it to engage in fun fitness competitions with friends. Similarly, Botox could be used for primarily medical utilitarian reasons, such as reducing headaches or treating overactive sweat glands (Eckardt and Kuettner 2003), or for discretionary cosmetic purposes, such as preventing and eliminating wrinkles. Accordingly, it would be interesting to investigate whether the knowledge that some consumers use these goods hedonically affects judgments of people who claim to use them for utilitarian purposes, particularly if they claim that consumption is based on need.

Equally, it would be interesting for future research to investigate how knowledge of alternative motives for behavior influence moral judgments more generally. For instance, as mentioned previously, when observers learn that an act of aggression is motivated by revenge, they evaluate it as relatively more moral than if they were told that the aggression is motivated by desire for personal gain (Reeder et al. 2002). However, what if observers learned that a person's act of aggression is out of revenge but also learned that other people behave the same way for personal gain? It is possible that knowledge of alternative potential motives adulterates perceptions of the motives of a focal actor in a similar manner as observed in the current work, which would be interesting to explore.

The negative effect of recreational use of a drug on moral judgments of its medical application also suggests multiple policy implications. First, state legislators and health care organizations may be influenced by moral reasoning when creating and enacting policies and regulation that limit access to drugs with recreational benefits. For example, in response to the opioid crisis, several states have introduced prescription limitation laws to attempt to reduce opioid-related morbidity and mortality. However, the specific laws are highly variable across states. For instance, states including Connecticut, New York, Pennsylvania, and Massachusetts have passed laws limiting opioid prescriptions to a seven-day supply (Bulloch 2019). Meanwhile, Florida limits opioid prescriptions to three days for acute pain but allows prescribers to extend to a seven-day supply if they document an exception (Hincapie-Castillo et al. 2020). By contrast, a few states have granted authorization to other entities, such as the U.S. Department of Health, a state health official, or provider regulatory boards, to direct opioid prescription limits (National Conference of State Legislators 2019). Similarly, laws regarding access and use of cannabis for medical or recreational purposes also vary from state to state. Whereas any cannabis consumption is currently illegal in some states, using it for medical purposes is legal in other states, and using it for either medical or recreational purposes is legal in another set of states (Garber-Paul and Bort 2021).

Indeed, among other drivers, moral condemnation of recreational drug use often leads to the introduction of policy guided by the unidimensional goal of use reduction (Reuter and Caulkins 1995), such as the aforementioned legislation limiting the dosage, duration, or amount of opioid prescriptions that physicians can issue (Nicholson and Mills 2019). However, although this type of legislation may be well-intended in focusing on reducing drug dependence and related fatalities, such one-size-fits-all approaches can also have harmful effects on people who rely on these drugs for legitimate medical reasons (Nicholson and Mills 2019). Overly strict legislation, combined with moral stigma on users, can also make physicians apprehensive to prescribe opioids—or worse, uninterested in treating patients with pain management issues altogether (Nicholson and Mills 2019). Thus, prescription limits and other restrictive legislation can make necessary access to prescription drugs more difficult, leaving patients with genuine medical needs stuck without sufficient medical treatments or palliative care.

In the context of the current work, policy guided solely by use reduction goals is also problematic because restricting or limiting access to drugs will likely only increase the perceived immorality of using the drugs for medical reasons. Specifically, placing onerous restrictions on access to drugs will likely amplify the perception that substances are taboo, thereby fomenting moral disapproval of using them for medical purposes. Likewise, limiting access to drugs through medical channels will also probably not reduce illicit use of these drugs (Chen et al. 2019). In fact, patients and recreational users may be more likely to rely on illegal markets for accessing these and related substances, which could be more harmful and undermine the primary goal of use reduction. Therefore, state legislators should focus on crafting policy guided by harm-reduction goals in addition to use-reduction goals. Integrating considerations of aggregate public harm with considerations of reducing recreational use would lead to more nuanced policy that could help states better calibrate legislation intended to reduce misuse of drugs while still enabling necessary access to drugs with medical benefits. Of course, taking a harm-reduction approach also requires more research to understand and quantify the specific benefits and risks of drugs for different applications and from different perspectives. Thus, increasing government-funded research on the medical benefits of substances in addition to the risks of medical or recreational use would help policy makers craft more tailored and informed legislation surrounding recreational and medical use based on aggregate harm-reduction goals. Therefore, while states should consider crafting policy guided by both use and harm reduction, the federal government should consider directing more federal funding into research on substances with medical and recreational markets to help guide such policy decisions.

States should also consider investing in educational initiatives for drugs that have both medical and recreational benefits. Educational programming would be useful at all levels of consumption—from clinicians who can prescribe or recommend these drugs, to lawmakers, to drug distributors, end users, and communities more generally. Education designed to provide balanced perspectives on recreational use of substances in addition to their medical efficacy and necessity for certain groups of people could help reduce stigma. In the cannabis industry, consumer education on the various benefits and risks of consumption largely falls either onto consumers themselves or onto cannabis brands, distributors, and ancillary providers with vested interest in growing the category. States could supplement these efforts with education specifically oriented around the medical benefits of substances with the goal of reducing the stigma of medical use. This would benefit providers and users alike.

Organizations lobbying for the (de)regulation of medical drugs with recreational benefits should also consider how to effectively frame or reframe messaging around such substances to subvert moral disapproval or increase the likelihood of moral acceptance. For example, prior to the use of antiretroviral treatments for AIDS patients in the 1990s, significant support for using cannabis for medical purposes was garnered by framing the drug as a compassionate palliative for those suffering with and dying from AIDS (Dioun 2017). Such framing shifted the perception of cannabis as an immoral drug just used for recreation to a moral solution to help suffering people. Indeed, much of the societal support for the medical use of cannabis in recent decades is due to its reframing as a compassionate palliative substance versus as an intoxicating vice (Dioun 2017). Of late, the positive moral framing of cannabis has expanded further into being a substance to support general wellness, whatever that may mean for each individual user (Dioun 2017, 2018; Huff, Humphreys, and Wilner 2021). As such, organizations lobbying for legalization and rescheduling (i.e., recategorization) of cannabis should continue to consider how to frame cannabis generally in a morally positive light and then how to stretch those framings to encompass a broader continuum of users. Meanwhile, in the domain of substances like opioids, benzodiazepines, or stimulants, organizations lobbying for less strict regulation or governmental intervention on usage and access should focus on emphasizing the continuum of users and the framing of such substances as morally positive or compassionate solutions for those with legitimate medical needs.

Marketers selling drugs for medical purposes that also have recreational users would benefit from highlighting the extent to which patients genuinely need or rely on such treatments to function in order to alleviate moral judgments and stigmatization of medical use. Similarly, the current work suggests that greater separation between solutions used for medical versus recreational purposes could also benefit the medical market by decreasing stigmatization of medical use. In the cannabis market, for example, many dispensaries serve both medical and recreational users in the same location and with the same brand of products. However, creating more distance between recreational and medical markets would likely benefit medical providers and users (e.g., separate physical dispensaries and digital sites for medical and recreational consumers, more distinct branding, regulation on packaging and verbiage in communications and on products, less marketing touting both benefits in a single message or campaign). Thus, as the markets for recreational and medical cannabis grow, it would be useful for regulatory bodies to consider how to facilitate or mandate greater separation between the medical and recreational markets to reduce blurred boundaries and subsequent moral disapproval of medical use. Indeed, pharmaceutical companies that sell drugs for both medical and recreational purposes should consider how they can create greater separation between the marketing of these products and their distribution as well as enhance provider, patient, and consumer education on the various uses of such substances.

Furthermore, while the explosive growth of the medical and recreational markets for substances like cannabis is exciting, this work suggests that caution should be exercised as these markets continue to develop to ensure that they are maximally beneficial to consumers—both recreationally and medically. Although there is obvious appeal in allowing both markets to continue to advance on their current trajectories, this research suggests that it is possible that if cannabis becomes as popular and normalized for recreation as, say, alcohol, this could have adverse effects on moral judgments of its medical use. Accordingly, this work elucidates the importance of thoughtfully navigating the expansion of recreational drug markets, particularly with regard to marketing communications, brand management, policy design, and distribution strategies. In the case of prescription drugs such as opioids, benzodiazepines, and stimulants, this work illuminates how the growth of recreational markets could have negative spillover effects onto moral perceptions of using the drugs for legitimate medical reasons. Policy makers need to keep this in mind when crafting legislation so as to strike the right balance between reducing recreational use of these drugs while still allowing appropriate, nonstigmatized medical access to prescription drugs.

Conclusion

In conclusion, the current work sheds light on how recreational use of a drug can affect moral judgments of other consumers who use the same substance for medical reasons. I show that using drugs for medical purposes is viewed as less morally acceptable if others use the same drug for hedonic purposes, an effect that emerges due to a reduction in observers’ inferences that medical users are motivated to consume the drug because of medical need. These findings contribute to literature on hedonic versus utilitarian consumption and suggest marketing and lobbying implications for reducing the stigma of using these drugs for medical purposes and creating legislation and policy that balance aggregate public harm reduction with enablement of appropriate access to drugs.

Footnotes

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Appendix F

Joint Editors in Chief

Kelly D. Martin and Maura L. Scott

Special Issue Editors

Matthew E. Sarkees, M. Paula Fitzgerald, and Cait Lamberton

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

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