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The Battle Over Addiction

To read Sally Satel's response, click here.

In her review of Gene Heyman’s book, Addiction: A Disorder of Choice, Sally Satel performs an impressive feat of sophistry, simultaneously advancing a false dichotomy while acknowledging its flaws but nevertheless picking one side. Confused? So were we. But let us try to explain.    

The review—and apparently the book itself (we confess we’re not inclined to read it)—relies for its argumentative power on drawing a distinction between the roles that biology and personal responsibility play in how we understand drug and alcohol abuse. Regrettably, modern medicine, Satel argues, has come to see addiction as a “disease” when it is, as Heyman puts it, “a disorder of choice.” Setting up one’s argument as a much-needed corrective to conventional wisdom is of course a classic trope of punditry, but it is a far less effective and honest device when no one actually believes the alleged conventional wisdom. Then it is known as a straw man. And that is the first problem with Satel’s piece. Addiction, after all, is a function of both biology and behavior; and both addicts and those who treat them acknowledge as much.   

Drawing a bright line between brain and behavior allows Satel to adopt an air of politically incorrect bravery—“It may strike some as insensitive to insist that addiction is a disorder of choice”—but unfortunately it leads only to silly observations. For example, Satel notes that addiction cannot be a disease because, unlike, say, Alzheimer’s, one can choose to stop using drugs whereas one cannot choose to stop having Alzheimer’s. “Showing how the two differ,” she writes, “is an important theme of the book.” Only someone who considered that bit of obviousness to be some sort of intellectual thunderbolt would feel the need to argue, as Satel does, that, because addiction is different than Alzheimer’s, society must hold addicts accountable for their actions—as though drunk drivers and crack heads were currently treated with the same gentle sensitivity as cancer patients.   

True, Satel admits, medical imaging technology has allowed us to see that an addict’s brain behaves differently: if you show a crack addict an image of a crack pipe, his brain will light up like a Christmas tree. But this, she says, does not make addiction a “disease” because, as philosopher (!) Daniel Shapiro notes, “You can examine pictures of brains all day, but you’d never call anyone an addict unless he acted like one.” Except that participants in recovery programs do so all the time, referring to themselves as “addicts” regardless of their present abstinence in recognition of the fact that theirs is a condition they will be battling for a lifetime. Contra Satel, there is no such thing as an “episode of addiction”; a crack addict is not cured just because he’s put down the pipe.  

Satel herself seems to recognize the flaws of brain-vs.-behavior dualism, noting, “Not that [Heyman] views addiction as independent of the brain—no serious person could even entertain such a notion.” Indeed not. But given that Satel repeatedly uses formulations that emphasize dichotomy—applauding Heyman’s “devastating assault on the brain-based model of addiction”; approvingly noting that Heyman “pits himself squarely against” those who believe addiction is a brain disease; and herself writing that “addiction is not a brain state, it is a behavior”—this acknowledgment is difficult to understand. Her point—and Heyman’s—seems to be that the biological component of addiction is the result of incremental choices that were voluntarily made but that led to “drug induced brain change.” Thus if addiction is a disease, it is a disease of the addict’s choosing. That argument is certainly more nuanced, but it is no less wrong for being so.   

Addiction can take hold in a variety of ways, including simple repeated use, but many addicts are born with a greater propensity to abuse drugs and alcohol and to succumb to the brain changes that result. This genetic influence on behavior is clearly demonstrated by the fact that addiction runs in families, meaning that the biological difference between an addict and a non-addict is not simply the effect of abuse, it is a cause as well. A person who is predisposed to addiction will respond differently to drugs or alcohol than a person who is not—beginning perhaps with his first drink. (Peter’s brother, an addict who has been sober for two years, recalls that his first experience with alcohol was revelatory, leaving him thirsty for more; or, in his words, “Whoa! When can I do that again?”) One could, of course, argue that the user decided to take that first drink, and therefore the resulting addiction, biological propensity or no, is his fault. And yet how many people have never tried alcohol—and how many made it through college without at least one drunken experience? The vast majority of them did not become alcoholics, and yet their salvation is not simply a function of superior decision-making skills. After all, at some point they did choose to drink.  

The repeated use of alcohol then induces structural changes in the brain. Satel seems to say that such changes are insignificant unless they “block the influence of the factors that support self-control.” Whatever the results of a brain scan, can we really say that addiction undermines free will? Well, actually, we can. Satel mentions how addict brains light up at images of drugs and alcohol, but what she does not mention is that the part of the brain that lights up is the limbic system—and that it lights up before the frontal cortex, which handles decision-making, has even had time to process the image. That is, the unconscious mind of an addict begins clamoring for drugs before he or she even has the opportunity to exercise control. This does not obviate the role of choice, but it certainly reduces “the factors that support self-control.”   

Regardless, Satel approvingly cites Heyman’s suggestion that addicts can be cured if only we can alter the cost-benefit analysis they conduct every time they use. (Here, we're going to venture that neither Satel nor Heyman has spent much time with addicts.) “This can be achieved through treatment, imposing credible threats…or the development of new modes of gratification that compete with drugs.” Putting aside the “new modes of gratification that compete with drugs”—because, as Sacha, a recovering alcoholic, responded, “Where can I get some?”—the suggestion that treating addicts is as simple as imposing “credible threats” elides the devastation that addicts are willing to endure. Sure, you can (perhaps successfully) threaten an addict with the end of his career if he doesn’t stop drinking, and yet how do you threaten the thousands who were willing to lose their jobs and still suffer? The threat of jail time, meanwhile, is apparently so successful that one-half to two-thirds of all inmates in the United States are drug or alcohol abusers. And what do we say of the addicts who kill themselves, to whom even the most credible and devious of threats might not have seemed so threatening?   

Now, let us repeat, choice clearly plays a large role in addiction, and, patronizing tone aside, there is truth to Satel’s and Heyman’s argument that the road to sobriety begins when an addict decides that the costs of addiction have simply grown too steep. But this point is obvious—not bold, not counterintuitive, not paradigm-shifting or -correcting. That is why you’ll hear members of Alcoholics Anonymous talk about addicts “finding their bottom.” Every recovering addict had a turning point where he or she decided that addiction had simply become too painful. In other words, the members of AA—some two million people—already understand that addiction is partly a function of choice. Admittedly, AA’ers also say that they are “powerless” over the disease, but that is not an elision of personal responsibility; it is a crucial way of circumnavigating one of the problems that bedevil addicts: the illusion that they can somehow keep their use under control. In fact, one of AA’s mantras is “Just do the next right thing.” AA’s is an argument that the good life is the sum of many little choices; its philosophy seems the very epitome of personal responsibility.  

Of course, the first and most important choice that any addict can make is to get help. All we can say is that when they do perform that feat of willpower, we hope the person they turn to isn’t Sally Satel. 

Sacha Z. Scoblic’s book, My Fantasy Relapse, will be published next year. Peter Scoblic is TNR’s executive editor.

To read Sally Satel's response, click here.