Satel on Addiction

Wow. It's not just us crackpot rational choice economists who take choice seriously.

Now comes an important and provocative book called Addiction: A Disorder of Choice by the psychologist Gene Heyman, a research psychologist at McLean Hospital and a lecturer at Harvard. Heyman mounts a devastating assault on the brain-based model of addiction. Not that he views addiction as independent of the brain—no serious person could even entertain such a claim. What he rejects, however, is the notion that excessive drug or alcohol consumption is an irresistible act wholly beyond the user’s control, as the term “addiction,” commonly understood, implies. If anything, Heyman writes, “[a]ddiction … helps us understand voluntary behavior.” How so? “[B]ecause,” he explains, “it is not possible to understand addiction without understanding how we make choices.”

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Good intentions aside, is the “brain disease” of addiction really beyond the control of the addict in the same that way that the symptoms of Alzheimer’s disease or multiple sclerosis are beyond the control of the afflicted? Showing how the two differ is an important theme of the book. If, as Heyman says, “drug-induced brain change is not sufficient evidence that addiction is an involuntary disease state,” then how are we to distinguish between voluntary and involuntary behavior?

Heyman’s answer is that "voluntary activities vary systematically as a function of their consequences, where the consequences include benefits, costs, and values.” Take, for example, the case of addicted physicians and pilots. When they are reported to their oversight boards they are monitored closely for several long years; if they don’t fly right, they have a lot to lose (jobs, income, status). It is no coincidence that their recovery rates are high. Via entities called drug courts, the criminal justice system applies swift and certain sanctions to drug offenders who fail drug tests—the threat of jail time if tests are repeatedly failed is the stick—while the carrot is that charges are expunged if the program is completed. Participants in drug courts tend to fare significantly better than their counterparts who have been adjudicated as usual. In so-called contingency management experiments, subjects addicted to cocaine or heroin are rewarded with vouchers redeemable for cash, household goods, or clothes. Those randomized to the voucher arm routinely enjoy better results than those receiving treatment as usual.

Contingencies are the key to voluntariness. No amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing an Alzheimer’s patient to keep her dementia from worsening, or threatening to impose a penalty on her if it did. This is where choice comes in: choosing an alternative to drug use. Heyman realizes how odd this might seem. How can otherwise rational people choose self-destruction unless they are diseased? This question was raised in colonial America. Dr. Benjamin Rush, also known as the father of American psychiatry, was among the first to promote the notion that alcoholism was a disease. And he did so not on the basis of medical evidence, Heyman reminds us, “but rather [upon] the assumption that voluntary behavior is not self-destructive.”

Sounds like a mix of Becker-Murphy on rational addiction and Szasz-Caplan on disorder as extreme preference; will have to add the book to the pile....

HT: Arts & Letters Daily.