Disease and choice

A NY Times philosophy blogger challenges the hijacked brain metaphor for addiction:

It might be tempting to claim that in an addiction scenario, the drugs or behaviors are the hijackers. However, those drugs and behaviors need to be done by the person herself (barring cases in which someone is given drugs and may be made chemically dependent). In the usual cases, an individual is the one putting chemicals into her body or engaging in certain behaviors in the hopes of getting high. This simply pushes the question back to whether a person can hijack herself.

There is a kind of intentionality to hijacking that clearly is absent in addiction. No one plans to become an addict.

My problem with this is that it assumes the hijacking occurs only after the first dose is consumed. AA insightfully broke the problem of loss of control into two parts, a physical allergy that causes loss of control once one takes the first drink and a mental obsession that leads to the first drink. She is only addressing the physical allergy. Of course, if the physical allergy were the only problem, jails and detoxes would be churning out recovered alcoholics and addicts.

She seems to operate from the premise that the addict is in control at the time of the first dose. But it’s a little like a person who is in full control who loves and craves strawberries with rare intensity but is allergic to them. AND, they have some sort of memory impairment that periodically interferes with their ability to recall the misery and danger of their allergic reaction and while the craving for strawberries is greatly intensified. Is that person in control?

Her solution is to reject the binary choice we’re so often presented with. It’s not choice or disease, it’s choice and disease.

A little logic is helpful here, since the “choice or disease” question rests on a false dilemma. This fallacy posits that only two options exist. Since there are only two options, they must be mutually exclusive. If we think, however, of addiction as involving both choice and disease, our outlook is likely to become more nuanced. For instance, the progression of many medical diseases is affected by the choices that individuals make. A patient who knows he has chronic obstructive pulmonary disease and refuses to wear a respirator or at least a mask while using noxious chemicals is making a choice that exacerbates his condition. A person who knows he meets the D.S.M.-IV criteria for chemical abuse, and that abuse is often the precursor to dependency, and still continues to use drugs, is making a choice, and thus bears responsibility for it.

Linking choice and responsibility is right in many ways, so long as we acknowledge that choice can be constrained in ways other than by force or overt coercion. There is no doubt that the choices of people progressing to addiction are constrained; compulsion and impulsiveness constrain choices. Many addicts will say that they choose to take that first drink or drug and that once they start they cannot stop. A classic binge drinker is a prime example; his choices are constrained with the first drink. He both has and does not have a choice. (That moment before the first drink or drug is what the philosopher Owen Flanagan describes as a “zone of control.”) But he still bears some degree of responsibility to others and to himself.

The complexity of each person’s experience with addiction should caution us to avoid false quandaries, like the one that requires us to define addiction as either disease or choice, and to adopt more nuanced conceptions. Addicts are neither hijackers nor victims. It is time to retire this analogy.

The concern I have is that she reduces addiction to being like any other chronic illness that may require difficult to make lifestyle changes, like diet and exercise.

The hijacked brain metaphor may be flawed, but it’s attempting to communicate that the addiction uses the addict’s own self-preservation instincts, desires and will to maintain addiction. For the active alcoholic who is sober at the moment and wishes to stay that way, it might be thought of as a struggle between a present self and a future self. He knows and fears that his future self will drink and will, once again, be off to the races. The question is who or what is in control of his future self’s taking of that drink?