Addiction: Brain Disease or Moral Failing

In the past we had our suspicions. Now neuroscience has demonstrated that many mental illnesses, especially addictions, are brain diseases. By this theory, the human mind is powerless to change brain chemistry.

The theory appeals because it is completely non-judgmental. It provides a foolproof pseudo-scientific absolution.  It tells the patient that there is nothing he can do on his own to change his addictive behavior. What better for an alcoholic than the message that his brain chemistry is making him do it.

Such is the way people today have learned to think about addictions. Such is the way that Michael Botticelli, the Director of the Office of National Drug Control Policy explained it on 60 Minutes the other day.

In a Forbes article Dr. Sally Satel takes Botticelli to task for his conceptual errors.

She begins by summarizing his opinion:

 “We’ve learned addiction is a brain disease,” he said, echoing an increasingly prevalent view. But especially coming from such a visible spokesperson, that theory does harm to addicts, their families and policymakers. “You know the hallmark of addiction is that it changes your brain chemistry. It actually affects that part of your brain that’s responsible for judgment,” he goes on. “We don’t expect people with cancer to stop having cancer.”

True enough, Satel writes, addiction does change brain chemistry. But the analogy is simplistic and misleading:

Comparing drug addiction to cancer is misguided in profound ways. Of course drugs change the brain, but the neural changes that occur in the brains of addicts do not necessarily disable their capacity to reason and to respond to rewards. Indeed, a vast literature shows that addiction is an activity whose course can be altered by its foreseeable consequences. By contrast, no amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing a patient with breast cancer to keep her tumor from spreading, or threatening to impose a penalty on her if it did. It won’t work.

The important treatment point is that addicts respond to rewards and punishments. When the moral cost of their addiction becomes too high they can exercise judgment and stop. They also respond to moments of self-awareness. When they see the horrors they are visiting on themselves and others, they can choose, voluntarily, to change their behaviors. Brain chemistry notwithstanding, they retain free will and can use it to direct their behavior.

It isn’t always about rewards and punishments:

Many autobiographical accounts by former addicts reveal that they were startled into quitting by a spasm of self-reproach. In The Night of the Gun, the late New York Times columnist David Carr movingly recounts how he decided to kick his habit after he realized how profoundly irresponsible he’d been when he locked his twin baby girls in his car while he met with his dealer to score crack.

The same paradigm, Satel remarks tellingly, does not apply to cancer. The analogy is specious. You cannot talk a patient out of cancer. Bribes and punishments have no appreciable effect on the growth of a tumor. Self-awareness has no impact on the progress of the disease.

It is vitally important that we understand the distinction Satel is making. Mainly, because making addiction purely a brain disease deprives us of one of the most important treatment factors: the patient’s free will and his ability to choose to act differently.

Satel offers an example:

A classic example comes from heroin-soaked Southeast Asia in 1971. When President Nixon decided to drug test Vietnam veterans as a condition of returning stateside, the vast majority of those using heroin on a regular basis managed to stop (detox was offered to them as well). An important goal – coming home – was at stake, and most men controlled their behavior accordingly. Notably, within the three years after they returned, only 14 percent of men who were addicted in Vietnam resumed regular use in the U.S.

If 86% of a sampling of heroin addicts were able to overcome their addictions within three years of returning to the United States, surely that argues against the notion that they are victims of their brain chemistry and that they cannot, of their own volition, pursue effective treatment.

The moral of the story is that neuroscience has its limits, even when dealing with conditions that do have a physiological component. If we take addiction to be a brain disease we deprive the addict of moral agency and absolve him of responsibility for treating his addiction.

This ends up sounding judgmental, but we do best to respect addicts enough to have confidence that they can undertake actions that will help them to overcome addiction. By trying to pretend that they are not responsible we are counseling inaction, and even suggesting that they cannot possibly resist temptation.

And yet, each moment when addicts choose to shoot up or to take another drink they could have done otherwise. Surely we will never say the same about people who suffer from cancer.

Keep in mind that 12 Step programs only work for those who participate in them actively. The same applies to many other mental health treatments.