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Addiction: Medical Disease or Moral Defect?

Scientific theories that addiction hijacks the brain have just increased the stigma that they were meant to stop. At least in the moralistic bad old days, addicts were still viewed as having free will. Here's an alternative to both of these no-win approaches.


What's wrong with this picture?: brain scans and mug shots photos via

By Maia Szalavitz


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Do people with addictions have free will? Or are we, while using, virtual automatons with no control over our behavior? This is the fundamental question that divides those who see addiction as a sign of an irrationally “hijacked” and “diseased” brain—and those who see it as some type of choice.

And it’s a question that matters deeply to people in recovery. Some of us were so filled with self-hatred during our active addictions that it was a relief to learn that it wasn’t all our fault, a relief without which recovery seemed impossible. Others, however, note that those who are seen as powerless in the wake of a disease are also often seen as lesser beings to whom almost anything can be done—including using force and humiliation—in order to "help."

I’d like to propose something of a “third way” to defuse some of the heat around this no-win debate. Most people familiar with addiction can agree that while using, otherwise rational people typically make some profoundly stupid choices. If not, they would hardly qualify for the diagnosis. On the other hand, there’s a huge amount of research data—and no shortage of anecdotes—that suggest that this is not the whole story.

Anecdotally, virtually no one shoots up in front of the police, suggesting that at least some control over behavior clearly occurs. Researchwise, dozens of studies find that offering addicts alternatives like money reduces, with surprising frequency, the amount of drugs they will self-administer in the lab. Even seasoned crack users with long histories of arrest will, in order to receive as little as $5, turn down free government crack after they’ve taken the first hit if the dose isn’t high enough. (And no, they’re not just using the money to buy street crack: they live in a lab monitored during the experiments.)

Other studies show that paying people for drug-free urines can dramatically improve treatment outcomes. In rats, the choice to take drugs such as morphine—even after physical dependence has been established—is sharply reduced simply by providing them the opportunity to socialize with other rats and have a stimulating living environment.

Clearly then, while addiction can affect free will, it doesn’t completely eliminate choice. So, does this mean it’s not a disease, merely a moral weakness that can be overcome by good character?
Whichever way you slice it, addicts lose. Either we are deliberately making bad choices and must be locked up…or we are mindlessly driven by compulsions and must be locked up. The middle way offers an alternative—that it is not your fault that you are at high risk but you are responsible for dealing with it.
Not exactly. Just because an addict’s choices around drugs aren’t completely determined by craving doesn’t mean that they are completely free, either. It’s quite possible for addiction to produce a more subtle alteration in a person’s preferences that biases—but does not force—decisions in favor of using.

This seems to me closer to the truth of my own experience. My control was imperfect, but not nonexistent—and it was not predictable in its strength. For example, I once stayed off of heroin while I was supplying some to a famous rock star whom I idolized, because i had vowed to take a month off and was only at day 29. In contrast, however, the first thing I did when I got bailed out of jail after being arrested was to find and shoot the hidden dilaudid (a strong opioid) that I knew the cops hadn’t found.

My middle view may help resolve a difficult conundrum that relates to the stigma of addictive disorders. Here’s the problem. Several studies find that teaching people that addiction is a brain disease increases rather than reduces stigma. Why should the “scientific” or “medical” model trigger such a seemingly irrational response? Basically, it's because people see those who are “brain diseased” as permanently damaged and scarily out of control. As a result, they want to lock them up (whether or not they get treatment) even if the problem “isn’t their fault.”

The fewer “aspects of mind” you attribute to someone—like being able to freely make choices, feel pain and pleasure, and form intentions and plans—the more you dehumanize at person, research finds. And the more you dehumanize a certain group of people, the more you support measures like incarceration or treatment that is coercive and infantilizing. After all, the treatment is intended to fix those whose behavior is child- or animal-like in being uncontrollable.

Media images of crack-, meth- or heroin-crazed criminals who kill for no reason in grotesque ways do not help. While crack, meth and alcohol can increase the risk of violence, the vast majority of drug-related crime is linked to the drug trade, not to use of a drug—and a recent CDC study showed that even most gang violence isn’t drug related.

Ironically, viewing addiction as a moral issue doesn’t pose this particular problem because it sees active addicts as capable of making choices but deliberately making bad ones. This at least has the virtue of maintaining their humanity, even if it imposes an “otherness” on them—and, of course, it still justifies punitive measures and carries other types of stigma.

However way you slice it, it seems, addicts lose. Either we are deliberately making bad choices and must be locked up…or we are mindlessly driven by compulsions and must be locked up. The middle way offers an alternative to this dead end—the idea that it is not your fault that you are at high risk for addiction but you are responsible for dealing appropriately with the issue. 

To the extent that addiction lies somewhere between completely free choice and robotic slavishness, the condition is an exaggerated instance of the human predicament. None of us make choices without constraints—but few are utterly incapable of good decisions. Recognizing this duality could allow us to acknowledge both the humanity of people with addiction and the reality that our choices aren’t always the best. To fight stigma, we can’t insist that we’re mere victims of a “hijacked brain,” but nor are we calculatingly and deliberately doing wrong at every turn.

As the slogan goes, we’re just like everyone else—only more so.

Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, and co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006). 
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