On Concepts and Theories of Addiction

The article "A Liberal Account of Addiction" is a good piece of analytic philosophy applied to psychiatry. It is well-informed both with regard to empirical matters and philosophical conceptualization. The arguments are often—but, as I will show, not always—quite convincing. The conclusions of the paper also have crucial consequences for practice, for the treatment of patients, and for social policy.

The authors argue that current scientific understandings of the problem of addiction are fundamentally flawed. They distinguish between two main positions in science: The Disease View and the Willpower View. According to the Disease View, drug-seeking behavior is the direct result of some physiological change in the drug seeker's brain. According to the Willpower View, the addict is no longer rational; he or she uses drugs as a result of a fundamentally non-voluntary process.

The authors dismiss the Disease View in the following way. They first note that drug addicts are in many ways rational planners. The addicts may have to think a lot to find the best ways to find the heroin, cigarettes, or alcohol, and they normally act according to this planning. They are not in any simple sense "caused" to act in a particular way. Moreover, referring to recent neurological literature, the authors note that the changes caused by drug addiction—which have to do with activating reward pathways in the brain—are identical with the outcomes of many other human activities that we do not call addiction. "In fact, any pleasurable experience causes dopamine to be released within the brain, activating these reward pathways" (Foddy and Savulescu 2010, 4). These experiences can be the result of coffee drinking, sexual activity, and physical exercise. Thus, the physical changes in the brain are not effects peculiar to the pharmacology of the drugs; they are instead the effects of the pleasure that the subject has experienced.

The argument against the Willpower View is lengthy and more involved. The proponent of the Willpower View must argue that there is some flaw in the subject's autonomy. The drug addict is in some sense unable to avoid taking the drug. The authors of the present article scrutinize this idea on the basis of distinguishing between different senses of autonomy: Substantive autonomy and procedural autonomy. They state that we must here be talking about procedural autonomy, namely, autonomy regarded as dependent only on our capacity to process information and make choices in accordance with our preferences. We cannot, as in the case of substantive autonomy, require that the preferences themselves be reasonable. In such a case, many of our ordinary actions would be judged non-autonomous.

The most reasonable Willpower accounts rely on the idea that addicted people in some sense lack self-control. The authors cite different interpretations of the concept of lacking self- control and they conclude that "none of these … theories can say that addicts are necessarily lacking in self-control unless they also make unreasonable normative or false factual claims about the nature of drug- or pleasure-oriented choices" (Foddy and Savulescu 2010, 10). For instance, according to one interpretation the subject does not endorse his own desire for drugs, but takes the drug anyway. According to another interpretation, the addict regrets taking the drug after having done so. Against such claims the authors claim that many addicts indeed endorse their desires for drugs and many addicts do not regret their addictive behavior.

So what is the positive account proposed by the authors? They put forward what they call a Liberal View. It contains three claims about addiction: First, we do not know whether an addict values anything more than the satisfaction of his addictive desires; second, we do not know whether an addict behaves autonomously when he uses drugs; and third, addictive desires are just strong regular desires.

According to the Liberal View, one has to accept that the addicts may have drug taking as their highest priority and that they do not have any reduced procedural autonomy. The authors say: "Once we abandon normative bias, we must accept...