Choice and free will: beyond the disease model of addiction

The causal story behind addiction, backed up by neuroscience, is playing an increasing role in how addicts are portrayed. According to a recent ad campaign designed to build support for treatment, addiction is a disease process that corrupts the brain, so addicts shouldn't be stigmatized as having a character flaw or moral deficiency. It features a man saying: "It'd be better if I had cancer; then you wouldn't tell me what I'm going through is just a phase. You wouldn't see my condition as a lack of willpower, but the disease that it truly is."

But as reported by Benoit Denizet-Lewis in the New York Times Magazine, people remain skeptical about the disease model of addiction:

A series of recent surveys sponsored by the National Council on Alcoholism and Drug Dependence and by Faces and Voices of Recovery, a recovery advocacy group, found that half the public called addiction a personal weakness. Among those who did see addiction as a disease, most put it in a special category of diseases that people get by making poor choices.

These findings aren’t surprising. Poor choices (taking that first, second or third hit of cocaine) certainly figure in the onset of addiction, and choices aren’t ordinarily considered part of a disease process. Moreover, poor choices can indeed result from what might be called “personal weaknesses,” for instance a genetic susceptibility to addiction related to a particular type of dopamine receptor, or a penchant for risk-taking, whether learned, inherited, or both.

But of course what’s meant by personal weakness and bad choices, when stigmatizing addicts, is that the addict should have risen above his weakness; he could have chosen otherwise at the time addiction took hold. There’s an implicit assumption of contra-causal agency: no matter what influences and factors came to bear, the addict could have done otherwise, but simply chose not to. It’s that supernaturalist assumption which the disease model of addiction is meant to counter, which it does, but only to a limited extent. To combat stigmatization effectively, we must go further and show that there’s deterministic story behind sane, voluntary choices, as well as the drug-damaged brain. Otherwise, stigmatizers will always have a ready target: the supposedly non-physical moral core of a person, his freely willing soul-essence which rises above natural causality when making decisions.

On the other hand, just because this core doesn’t exist (on a naturalistic view of ourselves) doesn’t mean that there isn’t a moral component to addiction. Whenever voluntary choices are involved, as they are to some extent even in highly addictive behavior, moral concepts potentially apply. We want to minimize behavior that’s harmful, either to the addict or others, and the social judgment that such behavior is wrong is among the first lines of defense. To the extent that someone has a functioning “normative operating system,” the anticipation of censure or other social sanctions helps to keep bad choices in check. Most addicts retain some capacity to be influenced by social norms, and thus they remain moral agents.

The key point, though, on an enlightened understanding of the moral dimension of addiction, is that it’s specific behavior that’s the potential target of sanctions, not the mythical moral core. Once bad choices are seen as outcomes of causes and conditions, not free will, then we won’t imagine that there’s any virtue in the blanket condemnation of the addict as a bad person, even though we must still judge some behavior as wrong. We replace the moral essentialism of the soul with the moral consequentialism of making sanctions contingent on particular choices.

Of course, the threat of sanctions is just the punitive side of behavior control, and there’s much that can be done on the positive side to cure addiction, for instance to consistently and strongly reward productive, non-addictive behavior (as for instance in what’s called contingency management therapy). Punitive policies on addiction are often premised on the underlying notion that, as a moral failure, the addict deserves opprobrium, whether or not it does any good. Seeing that there is no freely willing agent to blame therefore makes it difficult to justify mere stigmatization, and easier to undertake programs that, on the moralistic view, might seem to coddle bad actors.

Conservatives about addiction such as Stanton Peele (quoted here) and Sally Satel (and many moderates too, no doubt) often worry that addicts will “escape responsibility” for their choices should the disease model carry the day. To go beyond the disease model, and portray addiction as a fully determined behavioral disorder might seem to obliterate the basis for responsibility altogether, but we’ve seen this isn’t the case.

What is the case, however, is that accountability is just part of the cure for addiction, and we shouldn’t be any tougher on addicts than necessary: accountability should be tempered with compassion. Understanding that addicts, like the rest of humanity, are fully caused phenomena shifts the focus from punishing the blameworthy soul to creating conditions under which they can learn new, successful behavior. And holding out rewards, not just threats, plays an essential role in that process.

Who counts as a naturalist?

The death of god, it seems, is always deferred. He’s been kept alive - robust, in fact - despite what might be called explanatory displacement: the tendency of science to displace supernatural explanations with natural explanations. What god used to get credit for (lightning bolts, creating humans) can now be chalked up to unintentional, non-purposive, and more or less mechanical processes. The more we can explain in this fashion, the less there is for god to do and the less reason to believe he exists, one would suppose. After all, what rationally motivates belief in things, to a large extent, is the role they play in good explanations, those that permit prediction and control. Things that cease to play a role (e.g., phlogiston, the ether, élan vital, protoplasm, cold fusion) usually get dropped from our ontology - our catalog of what exists.

Unless, that is, they have independent means of ontological support. For god, this support comes from historically entrenched religious traditions that vigorously meme supernaturalism. These traditions, of course, take advantage of evolved human psychology: our disposition to read intention into the world, our distaste for death, and our tribal tendency to form in-groups built around shared ideology. All of these supply fertile ground for belief in a supervisory creator who has special concern for our tribe (not the other guy’s), and in an immaterial soul that survives to join him in the hereafter. So explanatory displacement notwithstanding, supernaturalism lives on.

Still, as science advances, believers feel the heat of god’s explanatory irrelevance. Writing in the New York Times about Pope Benedict’s seminar on evolution, Ian Fisher reports that

…Father Fessio and others say the pope, based on his statements and writings, remains deeply concerned specifically about the contention among some supporters of modern evolution that the theory refutes any role of God in creation.

‘Given this ideology, the temptation or danger is real to say that you don’t have any need of God, that the spirit doesn’t exist,’ said Msgr. Fiorenzo Facchini, an Italian priest and paleoanthropologist. ‘And the church should keep guard against this and denounce it.’

So how do we keep god in the picture? Well, by claiming he’s needed to get the ball rolling. After that, material, mechanical processes, such as natural selection, take over. We won’t find god’s intention written directly in the fossil record or in our DNA, but he still gets the credit. Not bad for a day’s work.

This move, of course, begs the question of where god came from. For those seriously interested in explanations, this question spikes god, since positing a further mystery (a creator) to explain a more proximate mystery (the origins of life and the universe) simply multiplies mysteries. But for those wanting a fig leaf of explanatory relevance for god, his role as Very Remote Controller is just the ticket. It gives him at least a bit part to play, and thus (if we don’t ask too many questions) a quasi-rational reason to believe in him, apart from wanting to be reassured about death and our privileged place in the universe.

The same sort of dynamic, curiously enough, is being played out in a discussion among a group of religious naturalists (RNs) associated with the Institute for Religion in an Age of Science (I'm a member and a participant in the discussion). The issue, essentially, is about the scope of religious naturalism itself. All parties to the debate count themselves as naturalists insofar as they all claim that nature is all there is – there’s no additional supernatural realm. But the question that divides them is: What is nature? What is its ontology? This question has bite, since if we can’t agree about the nature of nature, then the designation “religious naturalist” may not be particularly informative.

Some RNs think that nature is, in some sense, benevolent or purposive. It has a direction - a teleology - that we participate in, for example in having evolved to become intelligent creatures. Among the most florid expressions of natural teleology is the belief in “evolutionary enlightenment” and “conscious evolution” as championed by New Age gurus Andrew Cohen and Ken Wilbur. But there are less specific, milder versions as well, in which nature includes a force for good, such that things are working out for the best. We live, perhaps, in a Panglossian universe.

What’s happened here, of course, is that god’s role as intentional creator, supervisor, and protector has been transmuted into an aspect of nature. Nature has us and our interests in mind, so to speak. But just as there is no good scientific explanatory justification for god, there’s no good scientific justification, at least not yet, for imputing to nature either benevolence or purpose. Such notions play no role in currently accepted scientific theories; they have no explanatory relevance. Instead, the same human psychology that drives belief in god is driving belief in a cosmos that has a purpose we can latch onto. People very much want there to be something more beyond chance and necessity, and even those who’ve abjured traditional theistic consolations will sometimes read into nature what they’re so strongly motivated to find.

All sorts of comforting beliefs about nature are consistent with science, since science can’t prove that nature has no purpose, just as it can’t prove the non-existence of god. Just as Francis Collins in his new book The Language of God can confidently assert that his belief in a Remote Controller is consistent with his belief in natural selection, so too can self-described religious naturalists assert that their belief in cosmic benevolence is consistent with science. There may not yet be hard evidence for benevolence, but it can’t be categorically ruled out.

The defense against what’s very likely wishful thinking is to stick to the ontology science positively supports. Without the constraint of having positive evidence for an existence claim, then there’s almost no limit to what we can claim about nature, in which case the concept of the natural becomes too loose to distinguish it from the supernatural. To count yourself meaningfully as a naturalist, as opposed to supernaturalist, therefore requires you to cite good evidence for your conception of nature. Empiricism and naturalism go hand in hand.