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The 11 papers in this notable collection address the responsibility of addicts for their actions, from moral, legal, and metaphysical perspectives. They use a variety of styles of argument and argue for a number of different points of view. The authors are mainly academic philosophers and psychologists. The work is a helpful contribution to the burgeoning literature on the responsibility of people with mental illness for their actions.
The opening chapter is an introductory one by the book editors, setting out some of the fundamental issues and relating them to the other chapters in the book.
The next three chapters set out different models of explanation of what addiction is or how to explain it. University of Michigan psychologists Kent Berridge and Terry Robinson argue for the incentive-sensitization theory. It's a theory they are now long associated with, and it will be familiar to many who have been following the debates. (A copy of a 2003 paper setting out their view is available here.) The paper in this collection summarizes their ideas that focus on brain circuits involved in addiction, but also addresses issues about the compulsivity and intentionality of addictive action. Here they address work by Stephens and Graham from 2009 ("An Addictive Lesson") which took issue with their claims that addictive action can be compulsive. They take a compromising stance, agreeing with Stephens and Graham that they hadn't proved their claims, but going on to suggest that there is evidence that cue-triggered "wanting" can overpower cognitive wanting. They also argue that "wanting" can occur outside of conscious attention.
Psychiatrist George Ainslie, who is also well known for his work on addiction and breakdowns of self-control, enters into the wider philosophical debate over free will. Ainslie has been associated with the theory that the hyperbolic discounting of future rewards leads to irrational behavior, and that this is a feature not just of humans, but of all organisms. He makes a distinction between self-blame and social blame, and he argues that people base the appropriateness of social blame on that of self-blame; i.e., they blame others if they would blame themselves under similar circumstances. This seems to be not only an empirical theory, but a normative theory about how we should decide issues of moral responsibility. Exactly what Ainslie's final position is remains a matter of uncertainty, and his arguments are not only hard to follow, but involve rather sweeping claims. For example, he claims that "Cause by a disease has always been a gold-standard excuse" (78). He cites evidence that people tend to excuse people whose behavior has a physiological rather than an experiential explanation, which isn't the same distinction. Furthermore, there are plenty of both historical and current cases where people are inclined to blame people who they regard as diseased -- current attitudes towards psychopaths and pedophiles are obvious examples.
Philosopher Neil Levy's position is far more transparent; he has consistently argued that addicts are not morally responsible for their actions, on the basis that they cannot control their actions. He draws on recent work in social psychology on what has been called "ego depletion," which loosely translates to the idea that we only have so much willpower, so after working hard to resist temptation, we eventually get worn out and are unable to resist. It is a revival of a rather old fashioned idea that has plenty of intuitive appeal. He argues that it follows that to blame addicts is irrational. It is a powerful argument, although it goes rather quickly. One wrinkle is that Levy focuses on drug taking itself, and not on the associated behavior of lying, breaking promises, stealing, failing to live up to responsibilities to others, and engaging in drug-seeking behavior. Maybe If one is not free in a relapse, one is also not free in going through all the associated problematic actions, but it needs a bit more argument. More fundamentally, the objection to a view such as Levy's will be from those who put less emphasis on free choice and more on motive and character. Whether they are free or not, some people seem ruined by addiction, and stop caring in any genuine way about those they are affecting; in such cases, the possibility of self-control seems less important in the moral evaluation of what they do.
Gideon Yaffe's article marks a shift of emphasis to moral philosophy; he argues that addicts are not responsible for some of their actions, but they are for some others, which may seem relatively obvious, but he provides a distinctive approach that does not depend much on previous ethical scholarship. Yaffe seeks a way to understand how addiction reduces people's moral responsibility for their actions. He rejects a model of duress, but adopts a related model that focuses on the burdens of compensation: what one needs to do to compensate for one's difficulty in doing what one should. Some people find it harder to do given tasks than others: for example, some people find it difficult to get up on time, and so they need to arrange two or more alarm clocks. When are the burdens too much to expect of a person? Yaffe does not give a full answer to the question, but he does argue that people should not be expected to have to give up their own control of their behavior and just take instructions from someone else. He also argues that a central feature of addiction is the difficulty an addict has in learning from mistakes and changing his or her patterns of action. If the only way an addict has to compensate for their learning deficit is to give up autonomy, that is asking too much of them, and so we should not hold them morally responsible. Ultimately, Yaffe says we don't know enough about addiction to say when addicts are capable of learning and when they are not. It is an intriguing approach, although it puts a great deal of emphasis on addiction as a learning deficit, which is an unusual way to approach the moral responsibility of addicts. It seems a promising start, but much more needs to be worked out, and as ever, it needs to be considered in conjunction with the many other approaches already used.
Louis Charland attempts the old solution to the thorny philosophical problem of free will of avoiding it by taking an empirical, practical approach. He does not pretend to be able to avoid all philosophy, but he does hope to make the problem tractable. He argues that we should use the operationalized criterion of decision-making capacity as used in medical ethics to determine when a person is able to make a choice. With addiction, in contrast to other mental illnesses, he argues that decision-making capacity has not been carefully measured or made the subject of research, and that it needs to be. He suggests that there are political forces at play, resisting this kind of research, because it may turn out that addicts are not competent to make decisions about their involvement in addiction studies, which would mean that those studies would have to end. There is so much invested in addiction research that researchers are reluctant to call into question the competency of their experimental subjects. Charland draws attention to the contrast between thoughts and feelings: he claims that addiction is primarily a disorder of feeling or affectivity rather than cognition. Further, he argues that the concept of decision-making competence should include the criterion of values, and that addicts, because of their liability to relapse, and their difficulty in sticking to their plans to abstain from their addictive substances, may have disordered values. It would follow then that because of these disordered values, which he argues are not really theirs, but are due to the addiction, that addicts are often not competent to make decisions about whether they should be in addiction research, even when they are in a state of remission from addictive behavior.
Charland is clear that his proposals are tentative; he suggests that there needs to be much more research into these issues. He is right about this, although the problem he is pointing out may extend to the research program he is proposing, and it may be difficult to accomplish. There are some problems with how he has expressed his ideas, however, because he assumes a rather simple distinction between thoughts and feelings, while at the same time admitting that feelings can take propositional objects: one can have a strong feeling that one wants heroin. It isn't so clear to what extent one can make any useful distinction between problems of cognition and problems of affectivity, because they are so closely intertwined. Further, Charland paints with a broad brush when discussing responsibility, and does not do much to distinguish competence from moral responsibility. Even if his arguments that it is frequently unethical to allow addicts to participate in addiction research are right, it does not follow that they lack moral responsibility for their actions -- not that he ever says that it does follow, but noting this highlights the fact that this approach will not be able to answer some of the most pressing issues addressed by other authors in this volume.
Stephen Morse's article "Addiction and Criminal Responsibility" is largely a repetition of many ideas he has set out previously, especially in his article "Medicine and Morals, Craving and Compulsion," published in Substance Use & Misuse, 2004, Vol. 39, No. 3, pp. 437–460. He argues that most standard approaches that absolve addicts of moral or criminal responsibility are not well argued, and that it is reasonable to hold them responsible in many cases. This article is a somewhat updated version of his arguments, which are extremely plausible, so it is a useful contribution to this collection.
It's less immediately clear that Nancy Potter's chapter on understanding self-injury is a good fit for the book, but the idea that people can become addicted to cutting or similar forms of behavior is worth exploring. Potter argues that it is not helpful to explain SIB (self-injurious behavior) as an addiction in the medical model. This is not really a surprising conclusion, but the argument sheds light on a troubling kind of behavior, and so the article is illuminating. Potter gives a useful overview of the narrative of addiction, and shows why it is problematic in creating false dichotomies between disease conditions and behavior for which people are morally responsible. She shows how we should look for a model for describing SIB that not only will be accurate, but will have a beneficial effect on the treatment of those who engage in SIB.
Petry, Alessi and Rash set out the benefits of contingency management (CM) treatments. These provide people with substance abuse disorders with rewards for not using prohibited substances and penalties for using them. They say that despite being a highly effective and inexpensive form of treatment, it is rarely used. The authors do not say much about the relevance of CM to moral responsibility, but they do mention that it shows the problems with the idea that addicts just lack self-control.
The book finishes with two chapters by self-professed addicts who are also philosophy professors. Richard Garrett discusses his food addiction and Owen Flanagan discusses his alcoholism and benzo addiction. Garrett's contribution is notable for his discussion of religious approaches to understanding addictive behavior, paying special attention to Buddhism. Flanagan describes what it is like for him to be an addict, from his point of view. He explains he is doing a form of phenomenology. He also relates addiction to his theories in philosophy of mind; he emphasizes his expanded natural method as a way of integrating the first person experience with the scientific understanding of the mind. When it comes to understanding self-control, he recommends Aristotle, Dewey and Dennett, and expresses great skepticism about the whole modern literature on free will. He also argues that a disease model of alcoholism is not appropriate to the phenomenon, but it can be useful for addicts to profess that they are powerless over the drugs they use. Neither of these papers goes deep into issues of responsibility, but they will be thought provoking for those who are interested in the issues they raise.
© 2013 Christian Perring
Christian Perring, Professor of Philosophy, Dowling College, New York