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The Human Condition

Can Addicts Help It?

Piers Benn can’t resist finding out.

Are you an addict? Or do you just enjoy a certain substance or activity, and spend a lot of time indulging in it? What is the difference, and how could we tell? And if you are an addict, does that mean you literally cannot resist the things you are addicted to? These are important matters, since they relate to whether you’re responsible for succumbing to the addiction, or the misdemeanours you commit when in its grip. So they are also relevant to questions of legal and social policy.

Take an example. Sometimes you hear of people winning huge damages against tobacco companies for persuading them to smoke, thereby harming their health. But can this be right? The courtroom defence, “Your Honour, I shoplifted because a friend persuaded me to,” would be derided. Even if someone did persuade me, I should not have let him. That is why I am responsible. However, if the tobacco companies had me hooked – addicted – before I knew the risks of smoking, and once I knew, I was unable to give it up, might there not be a case against the companies or their advertisers? I continued smoking, but it wasn’t a free choice… I wanted to stop, but couldn’t. I was addicted. Putting aside the base thought that addiction to money is what makes litigation seem a good idea, is there also a morally defensible case?

Addiction

There is much scientific research on addiction. There are questions about how to diagnose it, whether or how it can be treated, what policies might reduce its harmful effects on society, and so on. But there are philosophical questions as well, which turn upon the concept of addiction and the related problem of free will. If addiction is a fact, is it true that addicts cannot control their addictive behaviour? For example, is there a qualitative difference between a ‘normal’ drinker and an ‘alcoholic’? Many people think there is: the normal drinker can control his drinking, whereas the alcoholic cannot. This belief forms the basis of most treatment programmes. But is it true? To find out, we need to investigate the true nature of addiction, and the assumptions underlying treatment programmes.

I propose that addiction is real, although with fuzzy boundaries. I also propose that addicts possess at least some control over their addictive behaviour. So I need to say in outline what I take addiction to be, since many people think it is part of the meaning of ‘addiction’ that the addict lacks control. We need not go down this route. But addictive desires appear, by definition, to be peculiarly insatiable, and gratifying these desires is central to the addict’s life. In consequence, he often seriously neglects other things that would normally be important to him. Take alcoholism, which involves a chronic and largely insatiable desire for alcohol. Drinking assumes a catastrophic centrality in the alcoholic’s life. However, this doesn’t imply that the alcoholic cannot control his drinking, even if going without it brings intense frustration and disappointment.

Alcoholism is described medically as ‘alcohol dependence syndrome’, and it involves such things as gaining an increasing tolerance to alcohol, and physical withdrawal symptoms if drinking is abruptly stopped, eg, tremors, anxiety, or seizures. But does even physical dependence entail a lack of ability to control drinking? Strictly speaking, no. Stopping without medical detoxification is unpleasant and can be dangerous; but even that doesn’t mean the alcoholic cannot stop drinking. (And if he dies in delirium tremens, then he has to stop. The dead don’t drink.)

Disease and Addiction

So why is it so commonly thought that addicts cannot control their addictive behaviour? One idea is that addiction is a disease. That is to say, the cause of the addiction is some disorder outside of your will which you cannot be expected to control. The ‘disease model’ has been much discussed in research literature. Recovery programmes like Alcoholics Anonymous’ Twelve Step program teach in this way that the addict lacks control over his addictive behaviour. Step One of AA’s Twelve Steps to Recovery reads: “We admitted that we were powerless over alcohol, that our lives had become unmanageable.” (Alcoholics Anonymous, Fourth Edition, Alcoholics Anonymous World Services, Inc, 2001.) This admission is seen as a blessed surrender, often made after many disastrous drinking sprees, mounting medical, legal, familial, social, psychological, financial or professional problems, repeated vows to give up or reduce drinking, and repeated relapse. AA folklore, much of it contained in the fellowship’s ‘Big Book’, Alcoholics Anonymous, contains narratives of desperate individuals who finally accepted that recovery was not possible on their own, but must rest in their turning to a Higher Power – ‘God as we understand Him’ (although nowadays the talk of God tends to be watered down). This can bring alcoholics back to ‘sanity’. AA also believes that alcoholics need to maintain lifelong abstinence, since their disease is literally incurable – as demonstrated by recovering alcoholics who drank again after years of abstinence, and quickly reinstated old behaviours. The disease is always there, waiting to delude them that they can have ‘just the one’ drink. But although there is no cure, recovery is possible – as shown in a re-oriented, abstinent life aided by a Higher Power – God, the ‘room’, sponsors, or, in practice, whatever you choose.

There are many people who swear by Twelve Step movements and who believe their lives were saved by them. And it is wise not to argue with them when they are so happy no longer indulging their previous addiction. Nevertheless there remain some real philosophical difficulties with this approach. I shall discuss some of these problems after briefly looking at some reasons why the disease model of addiction is so appealing.

The Appeal of the Disease Model

One reason why the disease model of addiction became popular is that it seemed to remove moral blame from addicts. It is no more a person’s fault that she is alcoholic than it is her fault that she has leukaemia. It is therefore more compassionate to treat addicts as ill rather than felons. Additionally, alcoholism doesn’t only afflict people who show other undesirable traits, such as fecklessness or self-indulgence. The disease can afflict anyone, regardless of character, status, education, profession or sex.

Secondly, the disease model seemingly gains support from genetics. There is at least one study which concludes that children born to alcoholic parents, but brought up from birth by non-alcoholic adoptive parents, are more likely to become alcoholic than the norm (cf W. Goodwin, F. Schulsinger, L. Hermansen, S.B. Guze, and G. Winokur, ‘Alcohol Problems in Adoptees Raised Apart from Alcoholic Biological Parents’, Archives of General Psychiatry 28, no. 2, pp.238-43, 1973). If a disposition to chemical dependency is rooted in a physical disorder in the brain, a genetic explanation seems appealing.

Thirdly, the disease model gains support from personal testimony. Many recovering alcoholics relate how they endlessly swore they would never drink again, only to relapse sooner or later. For them, that depressingly familiar cycle demonstrates powerlessness. If you desire an end to suffering and are able to bring it to an end, then you do so. If you don’t end it, then either you don’t really want to, or else you can’t (or both). Hence if you do want to end the cycle, yet do not do so, it follows that you are powerless to end it, at least on your own.

Fourthly, the idea that addiction entails lack of control is encouraged by the language we often use to describe it. We speak of powerful urges, overwhelming desires, irresistible temptations, the grip of addiction, the force of habit. Let’s call this ‘force vocabulary’: it’s about people struggling against powerful desires, and losing the fight. I shall later suggest that there are other expressions which capture the phenomenology of addiction, but avoid the suggestion of overwhelming power.

But Where’s The Philosophy?

The above points combine causes of the disease model’s popularity with purported justifications of the model. I shall argue that although addiction is a real phenomenon, there is no justification for regarding it as a disease. (In fact, it is not totally clear what it means to say it is a ‘disease’, and this is partly because the concept of disease is philosophically difficult.) But it is important to examine some other philosophical notions first. The disease model depends upon the idea that addicts suffer from an impairment or a lack of responsibility. But what, generally speaking, is necessary for responsibility? And is there something special about addictive behaviour by which addicts are unable to resist their addictions, even if they have free will in other areas of their lives? Problems about free will and responsibility are deep, controversial and quite possibly unsolvable. But clarifying some things about these ideas may lead us towards a sensible view of addiction. So let me make some brief remarks.

There are broadly speaking three positions concerning free will in contemporary philosophy. One is libertarianism. This says that we are free with respect to at least some of our actions, and causal determinism with respect to human action is not absolute: free will and determinism are incompatible. Another position is hard determinism, the doctrine that all human behaviour, thoughts, feelings and so on, are necessitated by their causal history, and that therefore free will is an illusion. A third popular position is compatibilism. This is the view that free will is compatible with determinism: determinism may or may not be true, but this doesn’t matter for free will, which operates in any case. You do freely make choices according to your reasons, even though your thoughts and actions have causes. Compatibilism essentially defines freedom not in terms of the absence of causation, but in terms of the absence of compulsion. The issue remains controversial, but my tentative inclination is that compatibilism is probably right. It is interesting that radical, ‘hard’ determinism commands little support among philosophers, though it may command more in other disciplines. Why is this? Largely because we experientially recognise that there is something that we call free will.

If hard determinism were true, then no actions would be free, addictive or not. Although addictive behaviour may be phenomenologically different to other behaviour, this is not relevant to the issue of whether it is fundamentally free. Since hard determinism excludes any kind of free will, on this position the ‘normal’ drinker or gambler is ultimately no more free or responsible than the ‘addict’. But if we are defending some conception of free will, what shall we say about addiction? I am assuming that we need not try to settle the issue between compatibilists and libertarians. Instead, the question is, Is addictive behaviour special in being compulsive?

What might ‘compulsive behaviour’ be? If it exists, it is behaviour over which you are powerless. But we’ll get a better purchase on powerlessness if we approach it negatively, as a state of not being able to do something, however hard you try. Thus, if Bill Gates offers you ten million dollars to push a truck up a hill, you will not be getting that money. You are powerless over the truck. Speaking of ‘compulsion’ admittedly sounds awkward here – as if saying that you’re compelled not to get the vehicle up the hill – but the idea is reasonably clear.

Then there are other, more difficult sorts of compulsion. Duress is one. Consider a bank teller who hands over cash at gunpoint. She does not merely calculate that her life is more important than the bank’s not losing the money, she acts as she does because she is terrified – under duress from an intense emotion. Does intense emotion, in general, make for compulsion? We possibly want to say that in such cases, actions are neither completely free nor entirely compelled. Emotions like extreme fear or anger can cloud rational judgement (hence English law allows a ‘provocation’ defence against a charge of murder), but even this does not make for literal compulsion. There is still a choice.

What, then, of addiction? I have suggested that there is room for the concept of addiction even if its boundaries are fuzzy. I suggest that addiction is more a disorder of desire than of will. Typically, acting on an addictive desire creates more desire rather than satisfies it. Additionally, addicts find it more distressing to resist their desires than do non-addicts. This could have some relevance for the attribution of moral blame; we could say that addiction is similar to duress in some respects. But this is not equivalent to the powerlessness argued for by Twelve Step programmes. People can and sometimes do resist intense impulses by themselves, without outside help. And if Bill Gates offered a group of alcoholics a million dollars each if they could prove six months abstinence in the midst of normal opportunities to drink, I would be surprised if none succeeded. (“But then, surely they weren’t true alcoholics?” To this, the proper answer is: beware of slippery re-definitions.)

Disease Again

Now we can return to the considerations that made the disease model tempting. What is right, or wrong, with them?

The first consideration was that it is more compassionate to ‘medicalise’ addiction than to ‘moralise’ it. This attitude opposes the one shown, for example, by a tough Soviet psychiatrist in 1972:

“We would not call a smoker ill, who says he cannot give up smoking. It is a matter of will for him to give up smoking. It must be explained to the broad masses of the population that alcoholism is not a disease, that to treat the alcoholic as an ‘unfortunate, tormented by his ailment’ is not only incorrect but harmful to the alcoholic himself, since it cultivates a dependent state of mind in him. The alcoholic should be surrounded by universal censure and contempt, not by universal solicitude.” (N. Troyan, quoted in a BBC External Services broadcast on alcoholism, 6th November 1972.)

This view will seem intolerant to many people, even plain nasty. Doubtless the psychiatrist was mindful of the widespread vodka problem in the then Soviet Union. But was he wrong? Is it really more compassionate to deal with addicts as if they were ill? Advocates of ‘tough love’ would dispute this. And even if it is more compassionate to regard addiction as a disease, this doesn’t solve the question of whether it is one. We have seen that the idea that addicts completely lack control is very doubtful.

The second argument concerned genetics. As the aforementioned study suggested, there is some empirical evidence that genetic factors are implicated in some cases of alcohol addiction (although not that there a single gene for alcoholism).

Some people hate genetic explanations of behaviour, as they think this undermines personal responsibility. But a partly-genetic explanation does not imply that people with ‘alcoholic’ genes are compelled to drink. At most, it explains why some people are more inclined than others to become alcoholics: why they want alcohol more than others. For instance, genetic factors may cause alcohol to abnormally boost the brain’s production of the pleasure-enhancing hormones dopamine and serotonin. But this is not compulsion. It just means that some people find it abnormally uncomfortable to resist alcohol, or stop drinking once started. If an alcoholic drinks because he badly wants to, then even though causal factors like genes might underlie this destructive desire, he still drinks because he decides to act on the desire; and roughly, decision is the essence of free action.

Thirdly for the ‘disease’ idea, there was the appeal to personal testimony. Addicts who want to change often report a subjective feeling that they cannot. They go through repetitive cycles of heavy drinking, its nasty consequences, resolution to change, and eventual relapse. Some of them eventually reach Step One of the Twelve Steps. For them, the proof of their powerlessness is this apparently endless cycle of failure.

There is a similarity between this and the phenomenon called ‘weakness of will’, or akrasia as the Greeks called it, meaning ‘lack of power’ – although the Greek word can mislead us: I think it is more accurate to describe the phenomenon as lack of resolution to act on your better judgement, rather than literal lack of power. Anyway, addictive behaviour often exemplifies akrasia.

The problem with weakness of will can usefully be divided into two. First, is it possible for someone both to believe that he ought to do A rather than B, and to be able to do A, yet still do B instead? Second, if this is possible, how is it explained?

Some philosophers think it isn’t possible. It is an intractably paradoxical situation. If the person ends up doing B, then either he doesn’t really think he should do A (at the moment of decision) and/or he is unable to do A. A similar line is possible for addictive behaviour: either the desire to resist isn’t really there, or the ability to resist is not there (or both). If the problem is with a lack of desire to resist, then maybe he has deceived himself – genuinely forgetting, while drinking, how horrible the consequences of drinking can be. If the problem is with the inability to resist, then we are dealing with an inability of a special, psychological kind, rather than an inability comparable to lack of physical strength. (Compare this with R.M. Hare’s discussion of weakness of will in Freedom and Reason, Ch 5, 1963.) But I think this line of argument is mistaken. We often do things that we think are wrong, and that we could resist doing, including actions that manifest an addiction.

But how do we explain this situation philosophically? When it comes to addictive drinking, for instance, it’s best to say that qua providing a short-term buzz, alcohol is desirable; but qua the cause of later withdrawal horrors, it is not. Of course, realising the extent of the horrors, it would be rational to do some thinking and stop drinking. But for an alcoholic, the tenth drink is highly alluring, which itself is a good reason to drink it – not good in the ‘all things considered’ sense, but good in the sense that qua pleasurable, it is to be drunk.

There is nothing surprising about humans knowingly acting irrationally. Why suppose a priori that we are always most influenced by reason? ‘Insightful irrationality’ is part of the human condition; this is surely confirmed by everyone’s experience. It is the failure to grasp this that leads so many addicts in Twelve Step programmes to declare their ‘powerlessness’.

Fourthly, I suggested that the language we use to describe the experience of addiction can misleadingly bolster the idea of utter powerlessness. What I called ‘force vocabulary’ – talk of overwhelming desires, irresistible urges, etc, reinforces this thinking. But if we choose, we can describe these things differently. What about: an intense urge, a vivid desire, and so on? Such phraseology can help us see that pleasurable yet harmful activity can be both intelligible and avoidable.

Conclusion

In this article I have somewhat run together the ‘powerlessness’ idea and the ‘disease’ idea. This may be unduly simple, but it captures enough truth. I have not gone into the knotty question of what exactly ‘disease’ is. What I have suggested is that the subjective phenomena that lead people to regard addiction as disease – for example, insatiable cravings and nasty withdrawals – can be explained in other terms. Thus although addiction is perfectly real, the ‘disease of addiction’ is not.

Piers Benn has been a Lecturer in Medical Ethics & Law at Imperial College London, and in Philosophy at other universities. He is currently writing Commitment for the Art of Living series, Acumen Press.