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.