"A Liberal Account of Addiction" is a major contribution to the discussion of addiction, its treatment, and the social and policy issues which arise from it. Questioning as it does many generally accepted assumptions about addictive behavior, particularly the use of hard drugs, it will provoke even those who do not agree with it to rethink their positions. Many of its suggestions are relevant also, in my opinion, to thinking about other areas of psychiatric interest. Nevertheless, I want to argue that its authors have perhaps not freed themselves sufficiently from some common assumptions, in particular about the nature of mental disorder, and that their argument might benefit from such liberation.
The central assumption that I have in mind is that understanding human actions is nothing but understanding the brain activity that accompanies them. If so, then a pattern of behavior can count as a 'mental disorder' in any clinically or legally relevant sense only if it is the result of a brain disease, causing a breakdown in normal brain functioning. Starting from this assumption, the authors seek to show, by means of evidence from neuroscience, that addiction to drugs does not have a unique 'neural substrate,' distinct from that of any other kind of pleasure-seeking behavior. When we have a pleasurable experience of any kind, as they point out, dopamine is normally released within the brain. This, they say, activates the 'reward' pathways, making the person more likely to repeat the behavior that gives rise to the pleasurable experience in question—whether it is eating, sex, or injecting heroin. Addiction, they argue, is therefore just a tendency to repeat an intensely pleasurable experience, whatever the nature of that experience might be. The particular chemistry of the substance involved in this particular form of pleasure is, they argue, irrelevant—all that matters is that the experience it gives someone is pleasant. Addiction, they conclude, is not in itself a symptom of disorder, in need of medical treatment, but just a particular example of normal human pleasure seeking (if perhaps more 'wanton' than some others).
A slightly different, although connected, line of argument is that addiction cannot be a sign of disorder because it does not undermine normal autonomy. The fact that addiction can cease when circumstances change, or simply as a person gets older, for instance, is cited as evidence that addicts are not the victims of irreversible neurological adaptations that make them incapable of responding to reasons to change their behavior. Therefore, they conclude, addiction is not the same as compulsion or involuntary movement, but a perfectly rational and chosen way of behaving. Addicts do not lack willpower: They are capable of giving up their addiction, but choose not to. They are different from non-addicts, or even from those 'addicted' to weaker pleasures, like chocolate, in [End Page 23] that they prefer to pursue their addiction even at the expense of social and family responsibility, or of a prudent concern for their own long-term selfinterest. But that does not make them irrational: It means only that they have a different, but equally valid, hierarchy of goods from other people. Addicts do not act 'robotically'; it is just that drugoriented desires are peculiarly strong. And even if they do regard their addictive behavior as morally undesirable, their continuance in it in the face of their own moral objections is not a sign of abnormality or disorder: Most human beings do things sometimes that they find pleasurable, even if they also see them as morally objectionable.
Underlying these arguments, and also the view which they oppose, is a certain philosophical picture of human beings and their behavior. According to this picture, human psychology is simply the reflection of human neurophysiology. Thus, for instance, although the authors claim that their account of addiction is relatively 'skeptical,' and has less explanatory power than that of their opponents, they nevertheless seem to accept at least the possibility of a complete account, which will only come about as a result of 'further advances in biological and psychological science.' But that seems to imply that a more complete understanding of why addicts behave...