This way of viewing addiction has its benefits: if addiction is a disease then addicts are not to blame for their plight, and this ought to help alleviate stigma and to open the way for better treatment and more funding for research on addiction. This is the main rationale of a recent piece in the New York Times, which describes addiction as a disease that is plaguing the U. S. and stresses the importance of talking openly about addiction in order to shift people’s understanding of it. And it seems like a welcome change from the blame attributed by the moral model of addiction, according to which addiction is a choice and, thus, a moral failing—addicts are nothing more than weak people who make bad choices and stick with them.
In 1974 sociologist Lee Robins conducted an extensive study of U. S. servicemen addicted to heroin returning from Vietnam. While in Vietnam, 20 percent of servicemen became addicted to heroin, and one of the things Robins wanted to investigate was how many of them continued to use it upon their return to the U. S. and how many remained addicted.
What she found was that the remission rate was surprisingly high: only around 7 percent used heroin after returning to the U. S. , and only about 1 2 percent had a relapse, even briefly, into addiction. The vast majority of addicted soldiers stopped using on their own. Taking a different line, in his book Addiction: A Disorder of Choice, Harvard University psychologist Gene Heyman also argues that addiction is not a disease but sees it, unlike Lewis, as a disorder of choice.
Heyman presents powerful evidence not only that just about 10 percent of people who use drugs get addicted and only around 15 percent of regular alcohol drinkers become alcoholics but also that around 80 percent of addicts overcome their addiction on their own by the age of 30. They do so because the demands of their adult life, like keeping a job or being a parent, are incompatible with their drug use and are strong incentives for kicking a drug habit. The difference in these cases, between people who can and people who can’t overcome their addiction, seems to be largely about determinants of choice. Because in order to kick substance addiction there must be viable alternatives to fall back on, and often these are not available. Many addicts suffer from more than just addiction to a particular substance, and this increases their distress; they come from underprivileged or minority backgrounds that limit their opportunities, they have histories of abuse, and so on. So although choices are in principle available, viable choices for people are largely dependent on determinants of choice beyond their control, and this can mitigate their responsibility.
It is for this reason that philosopher and mental health clinician Hanna Pickard of the University of Birmingham in England offers an alternative to the dilemma between the medical model that does away with blame at the expense of agency and the choice model that retains the addict’s agency but carries the baggage of shame and stigma. Both these models, Pickard claims, place the responsibility away from us: it is either the addict’s fault or the disease’s. But if we are serious about the evidence, we must look at the determinants of choice, and we must address them, taking responsibility as a society for the factors that cause suffering and that limit the options available to addicts. To do this we need to distinguish responsibility from blame: we can hold addicts responsible, thus retaining their agency, without blaming them but, instead, approaching them with an attitude of compassion, respect and concern that is required for more effective engagement and treatment. And the two, responsibility and blame, can come apart if we realize that responsibility is about the person who makes choices, but blame is about our choice of how to respond to them. In this sense, the seriousness of addiction and the suffering it causes both to the addicts themselves but also to the people around them require that we take a hard look at all the existing evidence and at what this evidence says about choice and responsibility—both the addicts’ but also our own, as a society.
We can call addiction a disease because the concept of a disease is not clearly defined, but if by “disease” we mean that there are brain changes that lead to lack of choices, then there is ample evidence to dispute this view. In the end, we cannot understand addiction merely in terms of brain changes and loss of control; we must see it in the broader context of a life and a society that make some people make bad choices.