I just read an interesting review of a new behavioral psychology book, “Addiction: A Disorder of Choice,” by Gene Heyman. As the review states, the key theme of the book is “that the idea [of] addiction [as] a disease has been based on a limited view of voluntary behavior.” As a remedy to this limited view, the author draws out the distinction between addiction and diseases such as Alzheimer’s or multiple sclerosis, the course of which cannot be altered by voluntary behavior. In contrast, he argues that the success of treatment programs which provide reinforcement for sobriety demonstrates that a key element of addiction is choice- if it were not, incentives just wouldn’t work. Of course, this suggests that the move toward viewing addiction as a disease rather than a choice is problematic in light of what we normally mean by “disease.” But, what’s far more interesting to me is the implication that the “disease of choice” thesis has for our concept of “choice.” This is the issue I will explore further.
The person snorting her first line of coke or dabbing a little bit of heroin does not want to become a hopeless crackwhore or junkie anymore than the person diagnosed with Alzheimer’s wants to lose her memory. In this way addiction resembles a disease more than a choice. Most rational people don’t want to destroy themselves, and most addicts start out as rational people who want to feel better. Addiction is the sum of incremental choices made on an ever-sliding scale of rewards and negative consequences. It feels good and doesn’t seem that bad the first time, it might seem worse the next time, but it feels even better, and so on and so forth until it is a serious, life-swallowing problem that you just can’t resist. Except of course, you can resist it, and if and when you do resist it, the negative symptoms of addiction get better. The same can’t be said of Alzheimer’s.
The possibility of resisting addictive behaviors is what makes addiction a “choice,” but no addict manages to resist indulging unless he has stronger incentives to refrain than to continue. Of course, as anyone who has studied the philosophy of David Hume can tell you, this isn’t just the way choice works with addicts. A choice is always determined by competing desires. This is as true of the martyr debating whether a vow of silence is more important than a cry for help as it is for a junkie debating between one more hit and passing his court-appointed drug test. We are all slaves to our desires, some of us just have crueler masters.
The fact that actions are determined by desires, and desires themselves are, on some basic level, unchosen, raises a serious question about ultimate moral responsibility. I’m not going to offer an opinion on that question, but I mention it because this is clearly the issue that motivates the move toward viewing addiction as a disease rather than a choice. If addiction is a choice and addicts do terrible things, then they are morally responsible for those terrible things. If addiction is a disease, then addicts shouldn’t be blamed for the “symptoms” of their disease. Intuitively, I think most of us want to carve out some sort of middle position in between these two extremes. What’s troubling about addiction is not the content of the desire. Wanting a line of coke is not like wanting to rape a child. The problem is the overwhelming force of the desire: Addicts privilege their fix over all other competing desires, including the desire to fulfill moral obligations to other people. So, to preserve the intuition that addicts can be responsible for bad things but not be bad people, we are intentionally opaque in the use of terms like “disease”- which addiction really isn’t- and “choice” -which addiction really is, but which implies a level of freedom and self-determination that nobody really has.
I think Heynman is right to characterize addiction as a “choice,” but the word needs to be trimmed of its metaethical weight. Addicts have a choice because their behavior is determined by one desire, and that behavior could be altered if competing desires become more powerful. Treatment programs are designed to strengthen the motivational force of these competing desires by focusing the addict’s attention on all of the things that they can keep or get by staying sober and all of the things which they stand to lose if they don’t. These programs also offer incentives that tip the balance of competing desires by making some desire-fulfillment much easier than other desire fulfillment. All of this suggests that addiction- both the active problem, and the process of recovery- is not a singular, moral choice. Choice is never-ending sequence of battles between competing desires. The fact that treatment programs work by reinforcing certain desires and disincentivizing others should not suggest to us that addicts have much in the way of power or freedom to change on their own. It simply means that, given the right support and opportunities, they can change. Of course, the same description of choice is equally applied to non-addicts as well.