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August 2010 Drugs and disordered choicesGene M. Heyman Addiction: A Disorder of Choice, Cambridge, Harvard University Press, 2009 (216 pp). ISBN 9-78067403-298-9 (hard cover) RRP $60.95. Are drug addicts helpless in the face of their addiction, compelled by cravings too strong to resist? Or is drug taking voluntary activity that can be ceased at will? Gene Heyman’s book, Addiction: A Disorder of Choice is a challenge to the dominant medical model of addiction, which in its current form characterises addiction as ‘a chronic relapsing brain disease’ (p. 17). Heyman argues, by contrast, that the behaviour that characterises addiction is voluntary and that the many ill effects of substance abuse result from a series of choices made by the addicted person. Since the cause is voluntary behaviour, the cure is also to be found in voluntary behaviour. Heyman claims that if addiction is a psychiatric disorder it is a very unusual one, given its astonishingly high rate of spontaneous remission (up to 85 per cent). Moreover he argues that recovery from addiction is directly responsive to ordinary social incentives—namely the acquiring of life responsibilities, such as marriage, parenthood, and career, which are incompatible with continued heavy drug use. To support his case, Heyman cites evidence that most people who have ever met the criteria for substance abuse or dependence have ceased using at problematic levels by the age of 30. He thus argues that research on the mechanisms of choice provides a more useful and more optimistic framework than the disease model for understanding what goes wrong in addiction and how to treat it.
The conclusion that many will draw from this work is that if addicts act voluntarily then they must be fully responsible for their state, and for their dereliction of personal, social, and legal obligations. Heyman’s thesis—that the choice to use drugs is fundamentally no different from, and no less voluntary than, a choice of restaurant—risks trivialising the situation of many users. His sweeping claim in the preface that ‘everyone, including those who are called addicts, stops using drugs when the costs of continuing become too great’ (p. vii) will not ring true to families and practitioners who have watched loved ones or patients drink themselves to chronic ill health and death. Heyman does not address issues of moral responsibility or public policy at any length in this book and it would be unfortunate if his work was recruited to increase the stigma attached to addiction and thereby to support punitive attitudes and policies towards those struggling with addiction. A careful reading of the book does not support these conclusions. He acknowledges that the criminal justice approach may be ineffective in reducing illicit drug use (p. 17) and he never suggests that giving up drugs is easy or that treatment should not be available, especially for the hard core of drug users who suffer from co-morbid mental illness. However, his emphasis on voluntariness is potentially very misleading and is likely to be seized upon by those who favour the notion of personal responsibility as a framework for drug policy.
Heyman is certainly correct that drug use by addicts is not literally compelled. Drug use requires voluntary action. The addict must figure out and take the actions needed to procure and administer the drug. So it is not like an involuntary tic or a reflex movement over which individuals have no control. But Heyman fails to appreciate the vast territory which lies between fully autonomous action and compulsion. An action might meet his criteria for voluntariness but fall well short of autonomy. Some drug users might find their cravings too hard to resist in the social or psychological circumstances that they face, and they may also lack the capacity to make meaningful changes in their circumstances. This matters when we are thinking about moral responsibility in addiction and it matters for law, public policy and treatment. LOCAL AND GLOBAL PERSPECTIVES ON CHOICEDespite the title of the book Heyman explicitly denies that addicts choose addiction. Rather addiction is the cumulative result of choices to use drugs on multiple separate occasions. Faced with a choice situation where the immediate cost of refusing drugs is high and the benefits of abstinence lie well in the future the drug user chooses the nearer good—the certain pleasure or relief that drug use offers. Considered from a local perspective where immediate pleasures and pains take centre stage the choice to use drugs right now might well make sense. Considered from a global perspective—the perspective from which we reflect upon how our lives are going overall and make choices in line with our long term values, commitments, and welfare—continued heavy drug use is a very bad idea. The choices made by users threaten their health, their relationships, their education and career prospects and their finances. The problem, according to Heyman, is that drug users are prone to impulsivity and tend to view their options from a local perspective. The conflict between local and global perspectives on choice is familiar to us all. It is difficult to maintain a global view in the face of competing local demands and incentives. We have an empirically well established tendency to apply a discount rate to future pleasures and pains (Ainslie 1975). The pleasures of staying at the bar with friends tonight are usually much more vivid to us than tomorrow’s hangover and many of the bad consequences of drug use are much more remote and uncertain than a hangover. Drug users have been found to apply a steeper discount rate to future pleasures and pains than controls making it even harder for long terms considerations to compete for their attention (Ainslie & Monterosso 2003; Bickel & Johnson 2003). Full rationality requires us to bring local and global perspectives into equilibrium. Most of us are less than fully rational much of the time. Heyman thinks it is clear that behaviour can be both voluntary and irrational and he is surely correct. The dessert lover may be fooling herself that she won’t put on weight and run the risk of heart disease, but she does not eat chocolate layer cake involuntarily. Likewise the addicted person does not consume drugs involuntarily. Heyman points to the planning and versatility, and the responsiveness to circumstances and incentives, of those involved in drug seeking and consuming behaviour as evidence for this. Sustained drug abuse is globally irrational and self-destructive, but it is locally chosen behaviour so if we are to combat it effectively we must target choice and the choice situations that addicts face. As I read Heyman, it is in this sense that addiction is a disorder of choice. THE DISEASE MODEL AND THE NEUROSCIENCE OF ADDICTIONHeyman spends very little time addressing recent findings in the neuroscience of addiction and is, I think, too dismissive of them. He is right that it should come as no surprise to find neural correlates of addictive cravings and so forth in the brain; all behaviour has neural correlates. This would not be enough to establish that addiction is a brain disease. But equally his own diagnosis that drug users tend to adopt a local perspective on choice is hardly news to anyone who has thought about the subject. The issue is surely whether the neuroscience of addiction reveals impairments which would significantly impact on the addict’s capacity to make more rational choices and exercise self-control.
It is notable that we don’t find significant disagreement between Heyman and addiction neuroscience about the facts. They agree that drug taking is hard to quit and is so both because drug pleasures undermine other pleasures and because drug users find it difficult to adopt and maintain a reflective stance. The disagreement is one of interpretation. Addiction neuroscientists focus on evidence of neurological dysfunction and impairment to support the view that addiction is rightly conceptualised as a brain disease. Heyman focuses on the voluntary nature of drug use and high rates of recovery to argue that it is not. His reasoning appears to go like this. If the behaviour of addicts is voluntary (and it is), it cannot be the product of a disease or disorder. In my view this is simply a mistake as I hope the following examples indicate. Behaviour that is generally accepted as the product of psychological disorder can still be voluntary, as practices such as cutting and starving reveal. Self-harm, for example, is symptomatic of post traumatic stress disorder but the young woman who engages in cutting rituals does not act involuntarily in relieving her distress in this way. Usually she takes great care to keep her activities secret, which suggest a high degree of voluntary control. The anorexia sufferer engages in very high levels of conscious control and planning of actions surrounding food. Would Heyman argue that PTSD and anorexia are not genuine disorders? The choices made by drug users could be both voluntary in Heyman’s sense, and substantially shaped by psychological disorder or impairments to brain function. Further, while high rates of spontaneous recovery may not be common among psychiatric disorders they are common enough in bodily illness. Think of the common cold or the flu. Heyman’s arguments don’t establish that the disease model is misplaced. However, drug abusers are not all alike and a more fine grained approach is needed to distinguish between those who respond to ordinary incentives and those who cannot. The neuroscience of addiction is beginning to make these distinctions (Bechara 2005) and may in the future be able to predict which approaches to treatment have the best prospect of success for particular individuals. Heyman acknowledges that adopting, maintaining, and choosing from a global perspective is cognitively demanding. It requires the individual to exercise executive control over their impulses and attention. Addiction neuroscience strongly suggests that many addicts have impaired executive function making them especially vulnerable to impulses or drug cravings. According to Antoine Bechara, an expert in the neurobiology of decision making, brain scans of addicts have revealed structural abnormalities in components of the reflective system. For example the ability to resist the intrusion of unwanted thoughts or memories is an important mechanism of impulse control, but addicts show deficits in this mechanism (2005, p. 1460). Bechara found that ‘substance related cues trigger bottom up mechanisms in substance abusers, influencing top-down mechanisms such as impulse and attentional control’ (2005, p. 1461). They can ‘hijack the top down goal-driven cognitive resources needed for the normal operation of the reflective system and exercising the willpower to resist drugs’ (2005, p. 1461). Heyman is correct that such impairments do not make drug abuse inevitable, but it is surely the case that individuals with impairments to higher cognitive functions will be less able to adopt the global perspective from which better choices can be made.
Addiction neuroscience has also found greater intensity of response to drugs in addicts, and abnormally low responsiveness to natural rewards. Research by Nora Volkow, the director of the US National Institute on Drug Abuse indicates that addicts have fewer dopamine D2 receptors, which are found in parts of the brain involved in motivation and reward behaviour. They are thus more vulnerable to the effects of addictive drugs, which send dopamine surging, while having a muted response to other pleasures (McGowan 2004). Heyman also emphasises these abnormal patterns of response to pleasure and pain, though he describes them as properties of addictive substances rather than of addicted persons’ brains. He says that addictive substances are those which are intoxicating, instantly rewarding, ‘specious in that their costs are delayed or uncertain’ and ‘behaviourally toxic’ (p. 147). According to Heyman ‘A substance is behaviorally toxic when it poisons the field making everything else relatively worse’ (p. 145). The ordinary pleasures of eating, socialising, exercising, planning a holiday or achieving at work no longer seem rewarding. Giving up drugs is hard because all other options have been drained of value. It requires the individual to choose unrewarding options for a considerable period of time, maybe weeks or months, before they experience any benefit from abstinence. Given that the global perspective is cognitively more demanding to maintain than the local perspective and that drug users are less well equipped to take a global perspective, it is little wonder that relapse is common, at least in the early stages of quitting. VOLUNTARY BEHAVIOUR, CHOICE AND REPONSIBILITYOrdinarily we think that if some action is voluntary then the person can be held responsible for it. However, if it can be shown that a person suffers a mental impairment which affects their decision making and control capacities, then we think that the person may have some excuse for their actions. Heyman insists that addicts act voluntarily and that their choices are responsive in the ordinary way to their choice situation. So the conclusion many will draw is that drug users are fully responsible and thus blameworthy for their actions. When Heyman talks of voluntary action he means action that is under the intentional control of the person performing it. But intentional control isn’t enough to establish responsibility. After all many actions performed by animals and small children are voluntary and responsive to incentives but we don’t think that animals and small children are morally responsible for their actions. Responsible action requires that we also have the capacity to adopt and choose from a global perspective. That is what it is to be autonomous. The evidence from neuroscience suggests that at least a significant sub-group of drug users are impaired in the cognitive capacities necessary for adopting a more reflective global perspective and the exercise of self-control. Thus, members of this group lack autonomy and so may not be fully responsible for their actions. However, even if we set this evidence, and the disease hypothesis, to one side it seems clear that drug use remains a forced choice for many.
Most decisions surrounding drug use fall somewhere on the spectrum between fully autonomous action and action which is compelled. The environment inhabited by many drug users, particularly the ‘hard core’ who will not cease using by their late thirties is worth highlighting in any debates over responsibility and policy. Poverty, abuse, and trauma as well as cravings, depression or other mental illness, may all work to deprive the addict of feasible alternatives to drug use, placing them in a situation not dissimilar to that of the service station attendant who is offered a choice between opening the till and getting his arm broken. Models of addiction which fail to set drug use in a wider social context, instead focusing on individual choice or individual brains, miss much that is important. Listening to the voices of users drives this point home.
These people are not unreflective; they challenge the claim that failure or incapacity to take a global perspective or to exercise self-control is always the key to understanding the choice to use drugs. They suggest that we need to focus on the life stories of addicts and on their options as well as their choices. Middendorp (2009b) provides a happy ending to Robbie’s story. Helped into supported housing and with new social outlets Robbie found that his need for, and use of, alcohol decreased. Heyman would argue that his theory predicts this result and provides reasons for optimism about the prospects for recovery in even the hardest cases. Insofar as his book encourages such optimism among drug users themselves and insofar as it motivates further exploration of programs which focus on providing positive incentives to quit and alternatives to drug use (p. 168ff) it is welcome. Nevertheless his focus on voluntariness and choice obscures the bleakness of the options faced by many addicts as well as the often coercive nature of their own unwanted desires, moods, and emotions. It is to be hoped that it does not lead to simplistic or moralised policy solutions for what is often a complex and difficult to treat disorder. REFERENCESAinslie, G. 1975, ‘Specious reward: A behavioral theory of impulsiveness and impulse control’, Psychological Bulletin, vol. 82, pp. 463–496. Ainslie, G. & Monterosso, J. 2003, ‘Hyperbolic discounting as a factor in addiction: A critical analysis’, in Choice, Behavioural Economics, and Addiction, eds R.Vuchinich & N. Heather, Pergamon, Oxford. Bechara, A. 2005, ‘Decision making, impulse control and loss of willpower to resist drugs: A neurocognitive perspective’, Nature Neuroscience, vol. 8, no. 11, pp. 1458–1463. Bickel, W.K. & Johnson, M.W. 2003, ‘Delay discounting: A fundamental behavioral process of drug dependence’, in Time and Decision, eds G. Loewenstein, D. Read & R.F. Baumeister, New York, Russell Sage Foundation. Middendorp, C. 2009a, ‘Heroin: A curse or a source of meaning?’, The Age, 22 June. Middendorp, C. 2009b, ‘Being homeless does not mean being hopeless’, The Age, 4 August. McGowan, K, ‘Addiction: Pay attention’, Psychology Today [Online], Available: http://www.psychologytoday.com/articles/200411/addiction-pay-attention?page=2 [2010, Aug 7]. Weinberg, D. & Kogel, P. 1995, ‘Impediments to recovery in treatment programs for dually diagnosed homeless adults: An ethnographic analysis’, Contemporary Drug Problems, vol. 22 no. 2, pp. 193–236. Jeanette Kennett is a professor in the Department of Philosophy at Macquarie University. She has published widely on philosophical and ethical issues related to moral responsibility, the self and mental disorder. She is lead investigator on an interdisciplinary Australian Research Council funded project titled ‘Addiction, moral identity and moral agency: integrating theoretical and empirical approaches’. |
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