The following post is part of a special series emerging from Contemporary Issues in Neuroethics, a graduate-level course out of Emory University’s Center for Ethics. Katie Givens Kime is a doctoral student in Religion, with foci in practical theology, psychoanalysis, and neuroethics, and her research investigates the religious and spiritual aspects of addiction recovery methods.
A few years ago, a highly respected and accomplished philosopher at Duke University, Owen Flanagan, surprised everyone when he stood up to speak at Society for Philosophy and Psychology. A garden-variety academic presentation it was not. In “What Is It Like to Be An Addict?” Flanagan revealed to 150 of his esteemed colleagues that he had been addicted to various narcotics and to alcohol for many, many years. Not so long ago, every gruesome morning looked like this:
I would come to around 6:15 a.m., swearing that yesterday was the very last time...I’d pace, drink a cup of coffee, and try to hold to my terrified resolve. But by 6:56—every time, failsafe, I’d be in my car, arriving at the BP station...at 7 a.m. sharp I’d gather my four or five 16-ounce bottles of Heineken, hold their cold wet balm to my breast, put them down on the counter only long enough to be scanned....I guzzled one beer in the car. Car cranking, BP, a beer can’s gaseous earnestness—like Pavlov’s dogs, when these co-occur, Owen is off, juiced...the second beer was usually finished by the time I pulled back up to the house, the house on whose concrete porch I now spent most conscious, awake, time drinking, wanting to die. But afraid to die. When you’re dead you can’t use. The desire to live was not winning the battle over death. The overwhelming need – the pathological, unstoppable – need to use, was. (Flanagan, 2011, p. 77)
Research on addiction is no small niche of medical science. It’s an enormous enterprise. This seems appropriate, since addiction (including all types of substance abuse) is among the top public health crises in the industrialized West. The human suffering and the public (and private) expense wrought by addiction is immense. (See data here, here, and here.)
To that end, two accomplished researchers recently guest lectured here in Atlanta, representing a few dynamic edges of such research. Dr. Mark Gold lectured for Emory University’s Psychiatry Grand Rounds on "Evolution of Addiction Neurobiology and Treatment Over the Past 40 Years,” and Dr. Chandra Sripada lectured for the Neurophilosophy Forum at Georgia State University on "Addiction, Fallibility, and Responsibility.”
However, before we get into the work of Gold and Sripada, let’s establish a big picture for the status quo of addiction research. Nobody debates the severity of the problem of addiction. Views diverge dramatically, however, on the nature and etiology (what is it? how is it caused?) of addiction (Jacobson, 1995). Etiologies and descriptions of addiction vary: addiction as moral failure, as disease, as inherited vulnerability, as pathological attachment, as disordered choice (picking short-term goods over long-term goods), as self-medication…the list continues.
If we can’t agree, at least provisionally, on what addiction is and how it happens, then it’s tough to agree on how best to treat it. It is even tougher to answer the ethical question: “is the addict responsible?” Previous posts on this blog have offered excellent points and counterpoints on various sides of this question. I won’t rehash them. Instead, I think that Flanagan, Gold and Sripada hold different but compelling and practically useful answers that end up reframing the question itself.
Flanagan desperately wanted to use, and desperately did not want to use. He made clear that his philosophical conundrum of “performative inconsistency” – P & ~P – did not take the form of “a calm, Kantian transcendental pose,” but, as Flanagan put it, rather a more wrenching, “how is this f***ing possible?” (Flanagan, 2011, p. 70) Interestingly, Flanagan points out that if you talk with addicts, they speak about being responsible for their past and present actions in the same way the rest of us do -- or perhaps, those of us who are not professional ethicists. This is where I think we mis-frame the question when we ask, “is the addict responsible?” Most of us, in most of our daily living, at various levels of awareness, manage to paradoxically understand our agency as more multifaceted than just “my fault” or “not my fault.”
With regard to the ethics in play here, I can’t hope to summarize all that both Dr. Gold and Dr. Sripada presented, but a few relevant elements stood out. Sripada very ably argued that there is overwhelming evidence that addicts lack self-control (cited by the “Irresistibility Defenders”), and there is overwhelming evidence that addicts have substantial self-control (cited by the “Irresistibility Skeptics”).
|Dr. Chandra Sripada, University of Michigan|
To resolve this standoff, Sripada proposed a new model, one based on the idea that addicts’ ability to exert self-control is fallible. He argued that people often fail to realize the obsessionality dimension of addiction—addicts face recurrent urges for drugs throughout the day, and especially when they are stressed. Now suppose the ability to exert self-control is reliable but fallible—sometimes a person makes mistakes in exerting self-control which lead to giving in to the urge. Then given enough time, the cumulative probability that the person will eventually have a relapse rises ever closer to 1. Why should we suppose self-control is in fact fallible? This is an area of active neurobiological investigation, and there are some emerging theories that say the issue might lie with the interaction between certain large-scale brain networks. But even before the neurobiological evidence is in, it seems reasonable to suppose that some amount of fallibility is inevitable. After all, exerting self-control is a highly complex activity and just about any complex activity is going to have a non-zero rate of random failure.
The interesting thing about the Fallibility Model of relapse is that it allows that addicts have substantial control over their drug-directed desires. For any given urge, there is a very high probability that the addict will successfully resist that urge. The problem arises when the person faces a lots and lots of urges. In this context, even a very low rate of fallibility can, over time, lead to a very high probability of relapse.
As for the work of Dr. Gold: his presentation offered an excellent perspective on 40 years of engaging the incredibly complex problem of addiction. (If you don’t know about the Drunk Monkeys of St. Kitts, you really should. This video from BBC is hilarious, disturbing, fascinating, and only about 3 minutes long.) More clinically framed, Dr. Gold recalled the dark days of the 1970’s when, even at Yale Medical Center, addicts (including alcoholics) couldn’t get past E.R., refused hospital admittance due to their “untreatability.” Though far from agreeing, various medical understandings of addiction have at least progressed from the social stigmas that have everything to do with the ethical question at hand: is addiction the addict’s fault?
|Dr. Mark S. Gold, M.D., University of Florida College of Medicine|
From Dr. Gold’s perspective, the question of agency is not as pressing, or is too complex, when questions like “which treatment methods actually work?” are more important in the project of alleviating the destruction and suffering wrought by addiction. Gold pointed out that studies on treatment methods need to be far more rigorous in their longevity – in his view, if a study does not have 5-year data attached, it is not trustworthy. For instance, “unnatural competition between psychiatry and 12-step programs is profoundly misguided,” Gold said, pointing to the “great data for 12-step programs in 5-year studies.”
In the end, my view is that though there is value in the “is the addict responsible” question, we must do the work of viewing human agency with more complexity. As Flanagan points out, “Addicts think they are responsible for what they do. However, it has proved useful for addicts to admit they are powerless over [the addict’s drug of choice]” (Flanagan p. 291). Paradoxically, like millions of recovering addicts everywhere, it has only been by persisting in understanding his lack of agency over the substance-of-abuse that Flanagan has been able to regain a sense of agency over his life.
So it seems that neuroethicists and researchers across disciplines (social and natural sciences, and humanities too!) must engage in the truly difficult task of examining addiction from different epistemological starting points – for what is a person responsible? Is it a change of mind, or a change of biology? Or is a change of mind also a change of biology? Easier said than done. I suggest we head to the beach at St. Kitts!
Flanagan, O. (2011). What is it like to be an addict? In J. S. Poland & G. Graham (Eds.), Addiction and responsibility (pp. 269–272). Cambridge, Mass: MIT Press.
Jacobson, J.G. (1995). Chapter 10: The Advantages of Multiple Approaches to Understanding Addictive Behavior. The Psychology and Treatment of Addictive Behavior, 175-190
Kime, K. (2015). New neuro models for the interdisciplinary pursuit of understanding addiction. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2015/06/new-neuro-models-for-interdisciplinary.html