Over at The New Republic, Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute, recen
tly 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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Neuroethics at the Core 
This is an interesting discussion. I’ll try to get to read the background material.
There are two problems with this whole discussion:
1. what is voluntary behavior? You can’t really address this question without approaching the big ‘consciousness’ issue, where everyone gets stuck.
2. What is “a disease”? As I see it, the term disease is meant for clinicians, not for patients. They help in categorization and treatment. But the term falls apart really quickly. There has been some attempt to define ‘diseases’ by causes. This works for some, but falls down badly for others. For example, before measles was understood, the concept grew out of a cluster of symptoms. Once the measles virus was understood, measles was defined not by the cluster of symptoms, but by a unifying causal vector. This notion grew, I believe, out of the success of the ‘germ theory’, and works well for viral and bacterial diseases.
What about something like ‘heart disease’? Doesn’t work there. As I roughly understand most heart diseases they are state problems. For example, a proclivity to a certain type of arrhythmia. There may, in fact, be several routes to going from a normal rhythm to an abnormal rhythm. A brain example is epilepsy, a state disorder. Psychiatric diseases have not been reduced to single vector causes. Rather, they seem to be state disorders.
Can an individual voluntarily control a state disorder, or even a vector? Sometimes. Image you have epilepsy and know that a certain activity leads to seizures, for example, staring at moving stripes. To the degree that we understand voluntary behavior, then, you have some voluntary control over your disease. Does that make it not a disease? You could even choose, or not choose, to take your meds. Does that make the disease not a disease because it is under voluntary control?
Seems like and apples and oranges situation. Voluntary control does not affect whether you call something a disease. On the other hand, I’m not sure labeling addiction a disease is really useful.
Jkubie, you raise an important point: the concept of disease is not well defined and the necessary and sufficient conditions for a disease is still yet to be universally agreed upon upon. Additionally, is there a difference – or is it even necessary to distinguish – between illness, disease, and disorder? If so, what are the differences (see some of Jerome Wakefield and Alan Horowitz’s work regarding mental illness)? The ordinary language concept of disease is a value-laden term full of social meaning. Historically, a disease was something that should to be resisted or controlled. Is that how society ought to think about addiction? Despite incredible advances in recent years, since the science behind addiction is still in its nascent phases, I am skeptical in conclusively calling addiction a (brain) disease at this time.
Diseases are’t found of course, they are announced.
“Disorder” heralds disease absolutism. A failure to challenge the term is an admission that disease, like phlogiston, is real and that it only takes time and effort to find it. We use the term “disorder” to ferry us from the hidden, value-laden judgement that something is wrong to the judgement that something is, therefore, physically wrong. We have no idea, of course, how disorder can be a wrong substance, energy or structure, but we like to think that we will know it when we see it because it flags itself up…somehow.
Neurobiology works to the model that the cause of mental distress is physically causal and so can, ultimately, be “found” by the brain scientist. This is bad logic on many levels. Some of the arguments used can be circular: we know that a person’s experiences are symptoms because there is a brain disorder and we know that there is a brain disorder because there are symptoms. Here, the word “disorder” is the other member of the priviliged binary “disorder/order” both of which fall in the scale of social acceptance, with the latter privileging “order” over “disorder”.
The real danger, with us now, is that some physical states are cashed as diseases rather than social judgements of disease. Such a currency buys guilt-free genetic tinkering. But this danger wouldn’t arise if the scientists didn’t promote the now popular perception that diseases can be found, whether mental or physical.
I had a chance to speak to the head of genetic research at Cardiff University Hospital. He defered to my observation that neither genetics nor brain studies can determine whether something is an illness or not, but then I shouldn’t have had to make a point of asking.
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