(Open Court, Chicago, paper, 179 pages including references and index, ISBN 0-8126-9403-1, 2000)
In the tobacco wars, smokers and states seeking compensation for smoking-related health costs are now in the ascendant, having won big court settlements against tobacco companies in California and Florida. Juries now seem to buy the argument that 1) heavy smokers are addicted, 2) cigarette makers concealed evidence that nicotine was addictive even as they aggressively marketed their product, and therefore 3) tobacco companies share a proportion of the responsibility for the illness and death that results from heavy smoking.
On the other side, lawyers for Philip Morris and other tobacco giants argue that smokers were well aware of the risks of smoking and could have chosen to quit anytime. After all, the Surgeon General’s report publicizing the danger of cigarettes came out in 1964, and many people do quit, some even after years of heavy smoking. Since the smokers bringing these lawsuits presumably knew the risks, it was their informed, uncoerced decision to continue smoking which explains the huge toll of tobacco-related sickness and death, not anything tobacco companies did.
At issue, then, is the nature of addiction, choice, and responsibility. Do substances such as nicotine, or alcohol, or heroin have the power to usurp self-control, such that those who purvey drugs (whether legal or illicit) should be held at least partially accountable for the bad behavior, and bad health, of addicts? Why do some heavy substance users simply stop, or outgrow their habit, while others find it impossible to extricate themselves from addiction? If I end up an alcoholic, even though I’m knowledgeable about the risk of imperceptibly increasing dependence, is this only my doing? Should we regard compulsive drug takers (and perhaps compulsive gamblers) as sick, or as morally deficient, or perhaps both?
As summed up by Alan Leshner, head of the National Institute on Drug Abuse, the prevailing view of addiction disseminated by treatment and prevention professionals is that of "a chronic, relapsing disease that results from the prolonged effects of drugs on the brain".[1] Leshner and others capitalize on the recent explosion of neuroscientific research to make the case that addiction is less a moral failing than a neurological disorder, albeit one that originates in the choice to use drugs. Perhaps the addict is responsible for his behavior in the early stages of substance abuse, but not once the neural "switch" of addiction has been thrown. This so-called "disease model" of addiction prompts us to treat addicts as sick individuals with a chemically-induced compulsion instead of punishing them as willful transgressors of social norms. It also suggests that those who profit from the distribution of addictive drugs, such as liquor and tobacco companies, might share some responsibility for the costs associated with their use.
There is little question where Jeffrey Schaler’s sympathies lie in the tobacco wars, or in the larger debate over addiction. Schaler’s objective in this rather intemperate volume is nothing less than to destroy, root and branch, the disease model of addiction, and his motive is clear: he believes that if we give in to a physiological account of addiction as a brain disease, our status as autonomous and morally responsible individuals is at risk. But even though he scores some good points against those who suppose addiction is literally a disease, his fear of physiology drives him to an even more dubious proposition: that addiction, even in its final compulsive stages, is simply a personal choice. Those who choose to be addicted do so, he says, because they choose to avoid coping with stressful life situations. Those who drink heavily do so not because they are weak willed, but because they have an "iron will" to keep drinking despite the negative consequences (p. 7). And it is only the exercise of willpower, Schaler contends, that can allow someone to overcome addiction. In short, it is basically up to you whether or not you get addicted, and whether you recover.
Of course Schaler isn’t suggesting that anyone sets out, consciously and deliberately, to become an alcoholic, compulsive smoker, or drug addict. He means simply that the behavior which leads to and maintains an addiction – acquiring and actually ingesting substances – is usually voluntary, and often involves thinking, planning, and other rational capacities. All these are hallmarks of choice.
Fair enough, but to call choices voluntary, and not look further into why various choices are made, is to cut short the explanation of addiction at the crucial juncture. The individual’s decision to engage in behavior that puts him or her at risk for addiction is left unexplained, in which case the temptation (which Schaler can’t resist) is to hold the person alone responsible for their situation. This, combined with the "fact" that only willpower can extricate us from addiction, underlies Schaler’s moralistic, derisive stance towards addicts and those who would presume to heal them. It also motivates his contention that providing drug treatment, housing, education, skills training, and employment assistance are unnecessary intrusions into the addict’s life. Such a radical conclusion is congenial to libertarians, among whom Schaler is conspicuously eager to be counted.
Schaler contrasts two views of addiction, the now popular disease model and his candidate for a more enlightened view, the "free will" model. The former, as Schaler describes it, understands addiction as a progressive loss of control over substance use, and sees treatment and other outside help as essential to regaining control. In contrast, the free will model holds that control is never lost but is simply willfully misused. Addiction ends when the addict decides on the basis of his or her internal resources – willpower – to stop misusing substances.
These models diverge, obviously, on the nature of control, and in particular the locus of control. Schaler’s book mostly consists of illustrating this difference in various contexts, while ridiculing those who imagine that the capacity to exercise one’s will is ever significantly compromised. In the disease model, the addict is understood as the victim of overpowering urges generated by significant physiological changes caused by substance use, but Schaler points out that over time the consumption of alcohol and drugs is often moderated or ceases entirely, even without treatment. How can addicts properly be thought of as "out of control" victims of a substance when many succeed, seemingly on their own, in cutting down or stopping their compulsive behavior?
Addicts sometimes do moderate their substance use without any obvious outside assistance, and Schaler is right that the disease model paradigm of loss of control is at least an incomplete and possibly misleading account of addiction. But in mounting his critique, Schaler is wrong on two counts: first, in his adamant dismissal of the role of physiology in addiction, and second, in divorcing personal choices from any clear determinants, whether in biology or environment. The result is a "theory" of addiction far worse than that he seeks to supplant. The disease model, after all, gets at least half the story – the biology – more or less right, even if it sometimes ignores the role of external factors in shaping addictive behavior. But Schaler, in order to defend his free will model and the inviolable status of personal willpower, must discount both biology and environment as determinants of choice.
Schaler is quite direct, and quite mistaken, in dismissing what he calls the "far-fetched, scientifically worthless fantasy about ‘physical addiction’" (p. xvii). He insists that "no identifiable pathology has been found in the bodies of heavy drinkers and drug users" and further, that if any changes were found, these would not count as signs of addiction, but merely the effects of addiction, which is best understood, he says, as a self-inflicted psychological condition (p.16). However, the evidence from neuroscience is overwhelming that the prolonged use of opiates, for instance, results in structural and functional changes in the brain which produce the intense craving and withdrawal symptoms reported by addicts. Assuming opiates are available, these changes dramatically increase the probability of future opiate use – they are central in explaining paradigmatic addictive behavior and therefore likely to play a central role in a scientific account of addiction.
More evidence for the physiological basis of craving, notably ignored by Schaler, can be found in research on the genetic contribution to susceptibility to drug abuse. Twin studies have shown that for some substances, notably heroin and other opiates, biological endowment plays as much a role as social and family environment in determining the risk of dependence.[2], [3] This means that some physical attribute of the brain, perhaps a heightened sensitivity to chemical reinforcement stemming from a lack of endogenous enkephalins (opiate analogs produced by the body), increases the risk of addiction. Similarly, the burgeoning pharmacopoeia of drugs to treat substance abuse testifies to the physical basis of compulsive drug-taking. That the euphoria of heroin can be blocked by compounds operating at the neural level leaves no doubt about the chemical basis for addiction. But such considerations go unmentioned in Schaler’s book.
To imagine at this late date, as Schaler does, that physiology plays little if any role in addictive behavior is to be gripped by the libertarian creed of radical autonomy, to which any evidence of biological determinism is an affront. Such ideology explains Schaler’s second major error in this book, which is to credit individual choice with an originative power independent of either biology or environment. This mistake is slightly more subtle, since Schaler seems to recognize, sometimes explicitly, that environment does make a difference in the course of addiction. For instance, in outlining the "credo" of the free will model he writes "Addiction has more to do with the environments that people live in than with the drugs they are addicted to" and "People become addicted to alcohol and other drugs when life is going badly for them" (p. 9). Although both of these points aren’t indisputable (biology might sometimes play a bigger role than environment; people with what seem good lives sometimes end up addicted) at least they recognize that life circumstances play a role in the addictive process.
But in Schaler’s analysis the power of environmental conditions to shape behavior always gets reinterpreted as, or trumped by, the power of personal choice. For instance, he complains that when trying to help Native Americans with addiction, "treatment providers advocating the disease model…ignored the social, political, and economic context within which drug use occurs" (p. 121). Yet he also writes that Native Americans "choose to drink too much alcohol and consume drugs excessively to avoid coping with their experience of life…in a predominately racist, that is, anti-Native American society" (emphasis added, p. 120). So although Schaler seems on the one hand to admit the contribution of social conditions to drug abuse, on the other he minimizes this by suggesting that individuals freely choose addiction as a response to such conditions. The inviolable core of personal choice ultimately owes nothing to biological or social factors, so the conclusion is that addicts can and should cure themselves.
All this is music to the ears of libertarians. Dispense with treatment and other community-funded interventions and simply spread the word about willpower. What could be less intrusive, and less costly? If someone doesn’t extricate themselves from addiction, they simply haven’t chosen to get better and that choice, after all, is theirs alone to make. Although circumstances might increase one’s risk of addiction, we can all rise above circumstances, right?
But if such is true, how explain why some rise and others don’t? If addiction is indeed a choice, precisely why do some choose addiction? Schaler’s "explanation," if it can count as such, is to point to the individual and his free will, and to look no further. He won’t look further, of course, because to do so would challenge the libertarian credo that our freedom, ultimately, transcends both biology and culture:
"Most of us know people who smoked for years and then quit abruptly. Their bodies had adapted to nicotine and since they chose to quit, they did. Question: What do we attribute that behavior to? Answer: the exercise of free will.
"And what of people who do not want to quit? Why explain their behavior using terms such as weak will and physiological addiction? Those people simply choose to continue smoking, even if a doctor or loved one has suggested they quit. They aren’t suffering from a weak will. They have an iron will: they choose to continue smoking against medical advice." (p. 59, emphasis added)
At one point, Schaler suggests that even a complete determinist could accept his free will model, as long as the distinction between voluntary and involuntary behavior is acknowledged (p. 69). But nothing in the rest of his book suggests he could seriously countenance a thorough-going determinism. After all, from a scientific explanatory perspective, the voluntary is just as determined as the involuntary, it’s just a matter of the causes involved: reflex arcs or complex interactions of biology and culture. This means that an "explanation" of addiction as a function of free will, willpower, or an ultimately personal choice (see quote above) is a patent evasion of any factual account of how the voluntary choice to use addictive substances actually arises. And Schaler’s book is a litany of such evasion, despite his occasional lip service to science. Held hostage by libertarianism, Schaler gives very short shrift to plausible explanations of addictive behavior, and ultimately does the field a grave disservice by denying the reach of science into the realm of choice.
Nevertheless, many will find something deeply attractive about Schaler’s thesis, since it stakes out a moral dimension to addiction which a full blown disease model seemingly lacks. By insisting that addiction is a choice within the control of the addict, Schaler joins other libertarian psychologists such as Herbert Fingarette, Stanton Peele, and Thomas Szaz in their appeal to the common sense notion of personal responsibility: no one starts drinking or smoking with a gun to their head, so if addiction ensues, who’s to blame? Not society or biology, surely.
But surely it is possible to view addicts as responsible, moral agents (albeit agents who are severely compromised in the late stages of addiction) without resorting to obscure notions of libertarian free will which deny that choices have causal histories. Individuals, to be held accountable, don’t have to be free in some ultimate, contra-causal sense as Schaler so often implies, they just have to have the capacity to respond to, and anticipate, social rewards and sanctions. We are justified in assigning a certain measure of blame to the addict for his condition, not because his choice wasn’t determined by biology and environment, but because assigning blame (e.g., stigmatizing excessive drug use, withholding certain privileges) can help to modify future choices, both of the addict and those who witness his predicament. Libertarians imagine that only the radically autonomous core of self can be the proper object of praise and blame, but such a self, if it existed, would actually be immune to such influences. Only a self which is fully a function of biology and culture is the sort of self that moral injunctions could modify, and it’s all we need to ground a robust sense of moral agency.
Such a naturalistic conception of responsibility – one that places the addict entirely within a causal context – means that insisting on personal accountability is just one of many resources available in attacking addiction. Holding addicts primarily to blame for their situation may work in some cases, but is justified only to the extent it produces change without unnecessary collateral damage: in the late stages of addiction emphasizing personal failings may have little effect, and might well be counterproductive in piling shame on shame. While Schaler and other libertarians would have us largely ignore biological and environmental factors, and focus primarily on the blameworthy free will of the individual, a causal model of addiction encourages an ecological approach to treatment which can simultaneously address the neurobiology of the addict and his family and social circumstances, while justifying the judicious application of personal sanctions.
Schaler further objects to the disease model on grounds that it encourages passivity on the part of the addict. This it might well do if one imagined addiction to be a disease just like cancer, with a more or less inexorable progression. Indeed, it is this sort of simplistic, literal disease model that Schaler sets up for the kill. But it’s a straw man since few, if any, of Schaler’s opponents actually take such a view; they understand full well that playing an active role in one’s own recovery can dramatically affect the prognosis.
The question, though, is what conditions will foster taking such a role? Schaler leaves the addict on his own with bootstraps and willpower, suggesting that the internal capacity to change can always be mustered independently of one’s circumstances. Those not wedded to the ideology of radical autonomy will instead look carefully at the factors which can reliably sustain the desire to change and an internal locus of control (that is, the belief that there are things one can do to recover). Such factors will include advising the addict about his own brain chemistry so that appropriate medications can be tried, and helping to create a social environment which offers incentives to become, and remain, sober. Skillful treatment recognizes that both the desire and power to change are a function of the addict’s internal and external circumstances, not simply willed into existence.
Schaler’s libertarian blinders put him well behind the curve of addictions theory, which has begun to combine an increasingly detailed neurobiological understanding of the brain’s response to drugs with a deeper appreciation of the role of social networks in facilitating or curbing addictive behavior. Along these lines, Harvard psychologist Gene Heyman has developed a bio-behavioral model which shows promise in reconciling what he calls the "contradiction of addiction": that excessive substance use is often subjectively felt and described by addicts as out of control, yet it’s clearly responsive to environmental contingencies.[4], [5] Being out of control, Heyman suggests, is a function of how some extremely reinforcing substances (or even activities, such as gambling) can subvert the normal, rational tendency to avoid self-destructive choices. Like Schaler, Heyman recognizes that such choices are often voluntary and therefore not accounted for by a disease model, but unlike Schaler he develops a detailed (and fairly technical) theory of behavioral choice to explain why and under what conditions bad choices are made. Not surprisingly, free will and willpower play no role in his analysis. And unlike Schaler, Heyman’s theory suggests policies that might actually help addicts, as he puts it, "make better decisions": limit the availability of drugs and alcohol, increase the salience of the long-term consequences of excessive substance use, and provide reinforcing alternatives. None of this will completely eradicate addiction, of course, but it’s a far better bet than the libertarian prescription of laissez-faire self-cure.
A bio-behavioral model of addiction, whatever its final shape, will still leave room for personal accountability even as it provides the theoretical underpinnings for interventions by doctors, therapists, families, communities, and government. To hold ourselves and others responsible for substance use in a reasonable and useful fashion, we must recognize that voluntary choices arise within a determining context of biological and social factors, and that the direct application of praise and blame to the individual is one among many strategies available, and not always the best. As part of the social context of drug abuse, the suppliers of addictive substances, tobacco companies included, are as legitimate targets for reform as are the addict’s bad habits. And seeing that choices arise as a function of circumstances will tend to dampen retributive and punitive attitudes toward addicts, while helping to pinpoint where and when the imposition of limited personal sanctions actually helps.
With luck, Schaler’s book will turn out to be among the last hurrahs of those who imagine that responsibility and dignity inheres in some undetermined, inviolable core of self. In reality, someone in the grip of full blown addiction has little capacity for either responsibility or dignity, and both must be restored to him. That these are restored by virtue of outside help, and not by willpower, does not in the least render them less valuable. It does, however, distribute the responsibility for their restoration to those who have the means to shape policy on addiction prevention and treatment – that is, to nearly all of us.
TWC, August 2000
Notes
[1]. Leshner, A. Addiction is a brain disease, and it matters, Science, 278, October 3, 1997, pp. 45-47.
[2]. Kendler, K., Karkowski, L., Neale, M., Prescott, C. Illicit psychoactive substance use, heavy use, abuse, and dependence in a US population-based sample of male twins. Arch Gen Psychiatry, 2000, 57:261-269.
[3]. Tsuang, M., Lyons, M., Meyer, J., Doyle T., Eisen S., Goldberg J., True W., Lin N., Toomey R., Eaves, L. Co-occurrence of abuse of different drugs in men: the role of drug-specific and shared vulnerabilities. Arch Gen Psychiatry, 1998; 55:967-972.
[4]. Heyman, G., Resolving the contradictions of addiction. Behavioral and Brain Sciences, 1996 19, 561-610, with open peer commentary.
[5]. Heyman, G., Is addiction a chronic relapsing disease? Relapse rates, duration estimates, and a theory of addiction. Forthcoming in Defining Addiction and Making Policy, Philip Heymann, ed., Harvard University Press.