Why the Disease-Choice Paradigm Doesn’t Work

Is addiction a choice or a disease?  There are proponents on both sides with research to back their claims.  Is it possible that addiction is neither?  Kent Dunnington argues for another model in his book, Addiction and Virtue: Beyond the Models of Disease and Choice.

addiction and virtueDunnington begins by stating, “If addictions are diseases, then they are not the sorts of thing that humans do but rather the sorts of thing that humans suffer.  And, if this is so, then it would be simply misguided to ask – as I propose to ask – how we should understand and describe addiction as a type of human action.” (15)

Alcoholism is commonly defined as a “chronic, relapsing, brain disease” characterized by “compulsive use of drugs.” (17)  Being a philosopher, Dunnington takes their definition to task.  There are several arguments made by proponents of the disease model supporting their claim that addiction is in fact a disease.

Argument 1 – Tolerance and Withdrawal

“Drug addiction is a brain disease because the abuse of drugs leads to changes in the structure and function of the brain”, and those changes are accompanied by what is known as tolerance and withdrawal.  Therefore, addiction must be accompanied by tolerance and withdrawal and all cases of tolerance and withdrawal must be considered addiction.  However, tolerance and withdrawal really are not necessary and sufficient conditions for addiction.  People without addiction can experience tolerance and withdrawal and plenty of people with addictions have communicated that upon stopping they did not experience the negative side effects of tolerance and withdrawal.

Argument 2 – Brain Changes Result in Involuntary Behavior

It is often noted that drug abuse leads to changes in the structure and function of the brain.  It is assumed that these changes then result in involuntary behavior, therefore making addiction more like a disease than a type of human action.  Dunnington argues that the first premise is correct, but not the second premise.  He writes, “if it [the second premise] were true, it would turn out that all sorts of activities that we consider voluntary are in fact involuntary.  For instance, studies show that the brain structure and function of skilled musicians are transformed by years of practice.” (20)

Argument 3 – Addiction is Genetic

This argument holds that if an activity is influenced by genetics it is therefore involuntary.  The problem with this position is that we now know that our genes shape everything we do.  Research has shown that cheerfulness, religiosity and the like are genetically influenced, yet we do not consider these to be diseases.  “Why, then, should we conclude that addiction is a disease simply because addiction has genetic underpinnings?  Unless we are content to reduce all human behavior to pathology, we must reject the assumption that genetic influence entails biological determinism.” (24)

Argument 4 – Medical Treatment is the Best Option

Dunnignton agrees that if medical intervention is the best option for treatment then it may be appropriate to speak of addiction as disease.  “The disease concept of addiction maintains, first, that addiction is a chronic physiological disorder, and second, that it therefore can be most adequately treated through medical intervention.” (24)  The problem with this is that most addicts do stop without medical intervention.  While studies of addiction relapse indicate a 10-40% remission rate in those treated they do not take into account that those who have willingly entered into treatment most likely “exhibit comorbidity”, possibly influencing their recovery rate.  However, recent studies of the general public indicate up to an 82% remission rate of addiction without medical treatment.  Addiction, by these results, is neither chronic nor best treated medically.

Next Post – Addiction as Habit


3 thoughts on “Why the Disease-Choice Paradigm Doesn’t Work

  1. So where are his arguments against choice? My Step-son’s father has been in and out of medical treatment constantly and is currently one day out of his 6th medical treatment….

    I believe it’s both. It is genetically influenced (brain and personality are wired in such a way as the drug of choice “works” to alleviate the symptoms the person is experiencing (anxiety, doubt, etc..) Which is why for some people alcohol does the trick and for others heroin and others pot, others sex, both hetero and homosexuality and others no one talks about because they are applauded, though they ruin their lives and families just as devastatingly workaholics. They (workaholics) don’t get a negative rap because they are productive citizens, but they leave a wake of family and relationship destruction.

    I believe it’s a choice, but not like the choices we make rationally. By it’s very nature it is irrational. But i believe it’s a learned behavior, modeled first and then copied. Usually by parents, but can be by peers as well.

    So in the beginning it’s a choice, albeit naive, but still a choice, then once it works it’s magic and allows one to escape from the difficulties of life, it begins to take hold and then once the tolerance/withdrawal cycle is well under way, it is complicated by physiological cravings apart from the psychological ones.

    The only exception I know of is homosexuality (specifically male homosexuality) there is a lot of research that points to them being abused during the hard wiring phase of their childhood, when their brain is recognizing it’s male-ness..

    Anyway, that’s my take on it.

    1. Dunnington doesn’t address the choice paradigm directly in the same way he does the disease paradigm. I think he would argue, along with Aristotle and Aquinas, that addiction is different from the initial act of picking up a drink or injecting some substance, etc. I think all agree that addiction begins with a willful choice. What Dunnington argues against from the habit perspective and proponents of the disease model from the disease perspective is that one does not remain in addiction simply because they choose to do so. In fact, the testimony of many addicted persons is that they watch themselves making decisions they do not want to make. I would agree that addiction begins with a willful decision, not necessarily to become addicted, but willful nonetheless. However, I would agree with Dunnington that addiction is habit, not disease, and habit moves beyond the mere realm of willfully choosing each and every time. I’ll post more on this later. Thanks for the interaction.

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