Tuesday, January 10, 2012

Addiction, Philosophy--and Science

A number of bioethics twitterers were calling attention to this piece on addiction and philosophy from the New York Times's online Opinionator page. I enjoyed it, but thought that at its core it was more the application of a metaphor drawn from philosophy to the problem of addiction, rather than a philosophical treatment of the problem of addiction. So I googled around for a philosophical treatment of addiction and found this piece by Piers Benn. It is a genuinely philosophical treatment of the issue, but one which fails for lack of familiarity with contemporary addiction science.

In the piece, Benn asks whether addiction is properly termed a disease. (He speaks mostly about alcohol addiction, and so shall I.) Benn entertains and rejects four reasons why we might consider it a disease. The first is people sometimes argue that it would be more humane for us to talk about it that way, and thus to relieve addicts from blame and stigma. But Benn rejects that argument, favoring a "tough love" approach. (In another portion of the essay, he rejects the idea that addicts can't control themselves, essentially by pointing to the fact that some addicts can and do.) The second reason he considers for the disease model is that "the disease model seemingly gains support from genetics;" on this point, he cites a study from 1973 that showed that children of alcoholics, raised by non-alcoholic parents, are more likely to become alcoholic. Benn rejects this on grounds that genetic predispositions to drink don't actually force anyone to drink, and don't keep everyone from quitting. The third justification for the disease model is that addicts often talk about their own experience of powerlessness--inability to quit their habit even though they want to; Benn rejects this as self-deception. Addicts, he implies, aren't powerless, they just think they are. The fourth reason is that ordinary language often describes addiction in terms of irresistible forces and compulsions; Benn recommends that we simply think about addiction differently, as involving powerful forces, but not irresistible ones.

The underlying theme seems to be that addiction can only be a disease if it implies complete lack of control and therefore supplies addicts with a moral excuse for their conduct. If some addicts can control their behavior, then addiction doesn't imply complete lack of control, and therefore isn't a disease, and therefore supplies no moral excuse.

This won't do. First, it implicitly regards "addiction" as uniform, such that the ability of one person to kick an addiction is proof that all others could have done so as well, but for their weakness of will. Second, as Benn comes close to admitting at the close of the essay, the whole essay maps the idea of disease onto an idea of powerlessness which doesn't make sense. Some Type II diabetics can bring their insulin and blood-glucose under control with diet and exercise. Does this imply that the others aren't really sick?

Most unfortunate, though, is the fact that the whole article proceeds without any investigation into the current science of addiction. Scores of studies since 1973 have confirmed genetic predispositions to addiction, not only in humans but also in rats and monkeys. And contemporary brain-scan science has firmly established that the brain's reward-triggers are physically altered by substance use among addicts, in a way that they are not among mere "social users" of the same substances. (These results, too, have been duplicated in other species.) Recent brain-imaging studies have show that addicted alcoholics, unlike social drinkers, drink less for pleasure than for stress-relief; and that alcohol abuse among those with the correct genetic predisposition sensitizes the brains to stressors. This sensitization lasts well after detoxification, both in humans and in other species, and may help explain high rates of relapse. And finally, it's been shown that judgment centers of the brain (in the prefrontal cortex) are physically inhibited by alcohol intake, so that when (as Benn puts it) the tenth drink seems "highly alluring" to the alcoholic, that is not because (as Benn argues) the alcoholic is being akratic, and lacks the resolution to act on his better judgment, but because the portion of the brain which might normally supply better judgment has literally been shut down.

Someone, somewhere, might mount a philosophical argument against the disease model of addiction. But such an argument cannot be based only on armchair reflections about how we use language, about the Greek view of weakness of will, or about whether medicalization of addiction would or would not be kind. It must, also, deal with the science of the last four decades.

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