Addiction and Responsibility: An Inquiry into the Addictive Mind

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Choice reveals preference. Of course, we can make this stipulation if we want. Our claims about the role of reward in addiction will then be unfalsifiable, and so of no interest, since the notion of reward is detached from its ordinary meaning and loses any explanatory value. On this technical reading of the notion of reward to say that some episode of drug use aimed at reward means no more than to say that it was motivated.

This we do not dispute. The interesting question is whether reward in the everyday sense is what motivates drug use in addiction. We see the Liberal View of addiction as arising from the picture of human motivation promulgated by the choice theorists and as gaining some warrant from it. Like the Choice theory the Liberal view says we must start from the assumption that addicts act to satisfy their strongest preferences and the driver for preferences that Foddy and Savulescu nominate is an appetite for the pleasure that drug use offers.

Like choice theorists, Foddy and Savulescu reject the disease model and its claims that addictive action is non-autonomous. They claim that there is nothing special about the choices of those who are addicted — their ordering of values may be different to the non-addict, however, we cannot infer from this that their will is diseased or their choice-making disordered p. But while choice theorists acknowledge the apparent irrationality of addicted choices and seek to explain why addicts choose what appears to be objectively worse for them over the long run, the Liberal View holds that there is no principled reason to think that addictive actions are irrational at all.

Although, some actions performed in the course of addiction may turn out to be non-autonomous, so too may the apparently autonomous actions of non-addicts p.

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We are not entitled to make the judgment that the bad or weak-willed choices of the addicted person are worse or different in kind to bad or weak-willed choices made by the non-addict. Absent the normative assumption that a life devoted to the pleasures offered by drug use is lacking in value we have no reason to suppose that the addict is lacking autonomy. Foddy and Savulescu think that if we adopt a neutral Liberal position on the values at stake we must remain agnostic on the question of the rationality and autonomy of addicts.

The main contours of their argument are as follows:. Neurobiological accounts of addiction that support the Disease model do not sufficiently distinguish the behavior of addicted persons from habitual behaviors for other non-drug-like substances, such as sugar, or activities like gambling p. Addictive behaviors are not irrational, nor can we say that they are non-autonomous p. It is important not to confuse any negative consequences resulting from the consumption of addictive drugs arising from cultural norms and legal sanctions against those practices, with the consequences of consumption of those same drugs absent those norms and sanctions p.

Once we eliminate the errors of the opposing views all we can safely say is that substance addiction involves the seeking and taking of drugs in response to strong, regular, appetitive desires p. Let us now unpack the points above in more detail. Habitual actions that aim at satisfying desires for pleasure, considered as a general category, lead to changes in neural architecture and adaptations which cement new patterns of the same behavior.

The noteworthy thing about illicit drugs, say Foddy and Savulescu, is only that the causal pathway to neural modification is special: certain pleasure-involving receptors are targeted directly, and the intensity of the effect is typically relatively high. But many foods and non-drug-like substances also modify brain biology, they say, as well as practices such as sex or gambling.

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This observation leads to an argument: if these other substances, such as sugar, cause the same kinds of brain changes, and addiction to illicit drugs is a brain disease, then regular consumption of sugar is also a brain disease; but of course it is not. Why single out illicit drugs then? For example, the attribution of compulsion in addiction is generated by a normative bias that is built into philosophical, political, and popular conceptions of what a life ought to contain. In particular it should not contain the selfish and destructive pleasure-seeking that addiction brings about.

But, say Foddy and Savulescu, this is indeed a bias, and it has no place in deciding the criteria for addiction, qua a condition that allegedly compromises rational autonomy. Their view is that we do not know whether autonomy is compromised in addiction. So, they claim, we should be skeptical of claims that addicted persons are compelled in their behavior around the securing and taking of drugs. Why, according to Foddy and Savulescu, should we be skeptical about the claims that the nature of addiction compromises the capacity of persons to be effective in decision-making?

Again, their argument is complex, but two points they make stand out. First, the cultural ideology around the evils of taking illicit drugs provides powerful motivating reasons to internalize a narrative that paints the addicted person as helpless and powerless to control their urges to take mind-altering substances. Indeed, addicted persons themselves utilize this conception of their situation to deflect the stigma and opprobrium attaching to this behavior. They may even be self-deceived. Second, Foddy and Savulescu nominate a heterogeneous set of reasons, particularly from medicine and epidemiology, for doubting the claims of compulsion.

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Again, they say, there is a stereotypical view of drugs as causing withdrawal, but this is overstated and cannot be generalized from the key case, heroin addiction. In addition they note, with the choice theorists that most people ultimately give up their drug habit by the age of And many base their drug-taking behavior or abstention around rational considerations, e.

If their behavior was compelled it would not be responsive to rational considerations and ordinary life incentives. The Liberal View contains only 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 they use drugs. Third, addictive desires are just strong, regular appetitive desires.

The conclusion is that we should err on taking at face value the behavior of drug addicts — that they are rational choosers who value drugs for their rewarding properties more than they value the alternatives. The Liberal account says that non-autonomy is not a defining condition of addiction, even though some cases of addictive behavior might turn out not to be autonomous.

Central to the Liberal View, is the claim that addicted persons respond to incentives — that is what justifies the prima facie assumption of autonomy — and the driving incentive much of the time is pleasure Foddy and Savulescu do agree that drug use may fail to deliver on its aim of fulfilling pleasure. We will return to the question of responsiveness to incentives in addiction later in this paper. Our main interest here is the role of pleasure in addiction. Let us be clear: we do not question the claim that a life devoted to pleasure-seeking may be autonomously chosen.

Nor do we deny that some of those who are called addicts are autonomously choosing a life centered on drug pleasures or that many of the harms suffered by drug users are the result of illiberal social and legal policies which stigmatize such pleasures though we note this does not apply to the very significant harms caused by legal and socially approved drugs like alcohol.

What we do deny is that pleasure or reward plays the central motivating role assigned to it by Choice theorists and by Liberal accounts in an important set of cases and these are precisely the cases where we have most reason to question the autonomy of the addict. Our self-report data suggest strongly that we should construe the role of pleasure somewhat differently to how the choice accounts would have it, especially when it is conceived as part of a narrative dynamic.

The role of pleasure in addiction must be understood as changing over time.

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While a strong desire for pleasure plays a crucial role for many, perhaps most, people in establishing addiction, it is not so clear that pleasure or the expectation of pleasure plays this role in maintaining addiction. If it does not and we cannot easily construe the behavior of the addict as aiming at reward then there will be reason to question each of the three claims made by the Liberal View.

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Before that, however, we respond to the claim made by Foddy and Savulescu that the self-report data from those with addiction problems is unreliable. This echoes a similar observation by Dalrymple 5 who has said that when working as a psychiatrist, he was always struck by how differently users described their addiction to him in terms of suffering and involuntariness compared with what they would say to their peers in the hallway in terms of pleasure.

The claim is that addicted persons will be reluctant to express to professionals and others the pleasure-incentive that is really driving their addictive actions. This claim presupposes that addicted persons are being honest and truthful with their peers and not with professionals. While it is plausible to suppose that socially available narratives of addiction influence what users say to clinicians, courts and other concerned parties about their drug use, we think that the claim that it is impossible to obtain from them honest accounts of their motivations for use is overstated, unfair to those who seek help for their drug use or who participate in research projects, and lacking a solid evidential basis.

We suggest that: i Addicted persons may be ambivalent about their using and this will be reflected in differing accounts given to different groups. First, we think that insofar as users express different attitudes to different groups this may reflect genuine ambivalence about their drug use, as different considerations are brought to the fore. When with family the damage done to family relationships and the hurt suffered by those near to them will be more salient than it is with peers. With professionals damage to health and to long-term prospects comes to the fore. With peers, the pleasures induced by the drug and its social aspects will be most prominent. The question, then, is not whether the individual is lying to one of these groups.

The question is, of the accounts they give, which, if any, should be privileged in providing reliable testimony concerning what motivates their drug use. Given the expression of different attitudes to different groups, attitudes underpinned by a rationale responsive to that context, there is no a priori reason for thinking one of these groups is privileged as the group to receive the truthful account.

Second, the responses to our own study provide reasons to doubt that addicted persons are honest with their peers a context where the taboo of taking drugs for pleasure does not operate and not with those professionals with whom they are engaged. Our questionnaire reflected none of the normative biases Foddy and Savulescu identify, and we made clear to the participants that our role as philosophers not treatment professionals , oriented us to an interest in their story, and their experiences.

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Respondents repeatedly stated that they wanted to be honest with us, that they enjoyed the conversation and felt listened to. Sometimes they asked us directly if we wanted the socially accepted explanation or if we wanted to hear what they really thought.