Over at The New Republic, Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute, recently reviewed the controversial book Addiction: A Disorder of Choice by psychologist Gene Heyman. Heyman’s thesis is that conventional wisdom about addiction being a ‘disease’, or perhaps a ‘brain disease’, is incorrect. Satel quotes Heyman by saying, “that the idea [of] addiction [as] a disease has been based on a limited view of voluntary behavior.” Accordingly, addiction is not an “irresistible act”, as he claims the term ‘addiction’ implies, and is in fact a “disorder of choice”. [Note: I have not read Heyman's book, so I will not comment on the book directly]. Indeed, Satel conveys Heyman’s position as one that is in opposition to perspectives from powerful public figures that support the view that “Addiction is a Brain Disease, and it Matters.” Satel agrees with Heyman’s position, namely that if addiction is a disease, it is a disease the person chose for herself.
Satel’s review of Addiction prompted a response from writer Sascha Z. Scolbic and Peter Scolbic (TNR’s executive editor), who argued that Satel was puting up a “straw man” argument. [See Satel's reply to the Scolbic's here].
Satel’s critique of “the mechanical ‘brain disease’ rhetoric” focuses on what the addiction-as-brain-disease concept means for voluntary control. Despite her critique, Satel does make an important observation:
In fairness, the scientists who forged the brain disease concept had good intentions. By placing addiction on equal footing with more conventional medical disorders, they sought to create an image of the addict as a hapless victim of his own wayward neurochemistry. They hoped this would inspire companies and politicians to allocate more funding for treatment. Also, by emphasizing dramatic scientific advances, such as brain imaging techniques, and applying them to addiction, they hoped researchers might reap more financial support for their work. Finally, promoting the idea of addiction as a brain disease would rehabilitate the addict’s public image from that of a criminal who deserves punishment into a sympathetic figure who deserves treatment.
People who live with addictions face stigma, discrimination and barriers on a daily basis, whether it be for employment, healthcare, housing, or the brunt of society’s gaze. Since the concept of addiction has deep ties to a history of morally problematic behaviour, promoting a view of addiction that intends to reduce these injustices is morally praiseworthy. However one area in particular where Satel’s critique is limited, IMO, is what a “brain disease” view means beyond the debate of voluntary control, personal responsibility, and human agency. In Satel’s review, there is virtually no discussion on possible unintended consequences of a brain disease perspective, such as an increase in social stigma or social distance towards addicted persons. For example, by equating addiction with other medical conditions, the stigma and/or discrimination commonly associated with pathology may be increased – as opposed to reduced - for those considered ‘brain diseased’; addicted persons may be construed as neurobiological others. Thinking about, understanding, and construing addicted persons as neurobiologically different may, paradoxically, increase unintended harm on the group the brain disease term is intended to benefit. [Sociologist Jo Phelan has done some excellent work in this area, particularly around genetics and mental illness].
In this way, the addicted person and her brain are one of the same, and, through the exuberance of popular media sources, and the ‘regimes of knowledge’ that govern “scientifically acceptable” statements (Foucault), we may see the emergence of the addicted brain as, what Ian Hacking calls, a human kind. Hacking states that human kinds are classification systems that can be applied to groups of individuals that form the idea of a specific kind of person. Speaking about addiction and the emergence of a folk neurology, Scott Vrecko refers to this as “neurobiological human kinds.”
True, understanding the ‘addicted brain’ as a natural kind does have implications for voluntary control, and how both moral and legal responsibility is attributed. But the debate needs to move beyond voluntary control and requires some empirical backing. The way scientific knowledge, power, technology, and culture intersect and how they are involved in the governance of social problems, has an impact on the way we see the world. If anything, Satel’s review invites reflection on how the words we use to describe each other have impact on our relations, and how certain terms, despite their laudable intentions, may come with a hefty price.
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