The Fiction of Affliction in Addiction

by Julian Savulescu

Walter argues that addiction is:

1. a disorder of self-control that comes in degrees. It is essentially pathological self-control, like compulsive hand-washing, where the addict has limited control in some circumstances but not enough self-control.

2. a mental disease.

Bennett Foddy and I have argued that while addicts may have poor self-control and act imprudently, poor self-control and imprudence are not diseases. They are features of the human condition. People become addicted to all sorts of things: heroin, alcohol, nicotine, gambling, sugar, sex, the internet and food. What is common to all these addictions is that involve the reward system. Heroin may be more potent at activating this system than sugar, but they all act in a similar way. There are differences in degree, not kind.

It is true that addicts can come to be driven by cues, want their drug rather than like it, take drugs to relieve distress, boredom, anxiety or loneliness. But so too for all addictions.

People can choose to stop. Addicts offered $100 dollars to stay clean in the Virginia study stayed clean. This is not a disease. You cannot receive $100 and cure your own cancer or schizophrenia. They are diseases; addiction is not.

Many people have poor self control and our ability to exercise self control varies according to our nature and environment. Some people have an uncontrollable temper. They don’t have a disease, even if psychiatrist invent such a category.

There is no doubt that drug addicts harm themselves. But so too do young men who drive too fast and recklessly. Risking harm and poor self control are not diseases.

The reward system drove human learning and development. It is no surprise that this powerful force can run amok. There is no surprise we can become addicted or prey to it. But that is a part of being human, not having a disease.

We should help addicts to lead better lives or realise their goals. But this is an enhancement not treating a disease.

If we accept addiction is not a disease, it is easier to accept harm reduction strategies to enable people to use the pleasure inducing effects of drugs in good life. We would not think we need a war on food because some people become addicted to food. Why then do we need a war on drugs? What we need is a rational approach to addiction and drugs of addiction. The first place to start is to demedicalise addiction and accept its place in normal human behaviour. It may be bad and ruin lives. But that does not make it a disease.

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4 Responses to The Fiction of Affliction in Addiction

  • Peter Wicks says:

    Julian, there seem to be two strands to your argument: firstly, a semantic point concerning whether the word “disease” should be used to refer to addiction; secondly, a practical point about whether such usage is making it harder to adopt a more rational approach to the problem. This in turn raises two question: firstly, what definition of the term “disease” do you have in mind, and secondly do you have any empirical evidence concerning the practical effect of such usage?

    Incidentally, I don’t have children but when I talk to colleagues who do I’m often struck by the extent to which personality features among school-children have become medicalised and “treated”. I am nevertheless inclined to argue that aspects of personality (such as a tendency to addiction) can and should be treated as diseases when they become sufficiently extreme as to pose serious problems.

  • Walter Sinnott-Armstrong says:

    I join Peter in his request for Julian to define disease. Julian admits that some cases of addiction lie at an extreme end of a continuum (far from normal), that addictive desires sometimes “run amok”, that addicts can sometimes be “prey” to their desires, and that addiction can be very harmful, even life-threatening. Consider these paradigm cases rather than the moderate cases that are often misleadingly called “addictions.” About these cases, my question is: Why aren’t these conditions diseases? They are not exactly like cancer in all respects, but who says that all diseases must be like cancer?

    Julian suggests that addicts are like people with “uncontrollable temper” and “young men who drive too fast and recklessly.” But there are crucial differences that are not only differences of degree. Drug addicts often tell stories of one day when they woke up feeling sick and realized that they did not have a cold—they were hooked. Or they abstain longer and feel withdrawal symptoms that sometimes include severe pain, shakes, and even delusions. Nothing like that happens when people go for a long time without explosive temper or without driving fast. If we focus on cases involving such dependency and withdrawal, in addition to extremes on a continuum, then why not see these cases as diseases?

    Of course, not everything that anyone calls addiction is a disease, but that is not the issue. It is the worst cases that cause the worst problems, so let’s focus on those.

  • luosha says:

    “Addicts offered $100 dollars to stay clean in the Virginia study stayed clean.” do you have a reference for this claim? $100/day? It would be surprising if $100 were all it took to get unaddicted, permanently, for everyone. If that were really the case, then sure, addiction is not a disease. But if that were the case, what’s the big fuss? Instead of spending all that money on expensive treatments and research, let’s just pay them all off and save everyone the 250 billion/year figure cited by Sinnott-Armstrong.

    If the claim isn’t true as stated, then it’s not a fair example to use.

  • Peter Wicks says:

    A further thought on this: I don’t think people treating addiction as a disease is the main obstacle to a more rational approach to the problem. It’s precisely people’s tendency to think of it as a moral issue. I’m not saying it’s never appropriate to think of it as a moral issue, but a lot of people don’t even get as far as the concept of hating the sin but loving the sinner.

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