The HBO Addiction series consists of a 90 minute documentary and 13 other short supplementary films; these are all on the 4 DVD package and are also on the HBO website. The HBO website also lists 4 films which serve as complements to the series, but are not on the DVD, and unfortunately are not commercially available. The 90-minute documentary itself consists of a number of short films made by different people. The whole series has unity of style and content, with Key Messages:
•Addiction is a brain disease.
•Addiction is NOT a moral failure.
•Drugs and alcohol can “hijack” the brain’s natural pleasure pathways.
•The risk factors for addiction include genetic and environmental factors (stress, availability).
•Drug and alcohol abuse usually begins in adolescence, when the brain is still undergoing dramatic changes in both structure and function.
•The younger one starts misusing drugs or alcohol, the greater the chances they will become addicted.
There are a number of talking heads who propound these messages; the most didactic is Nora D. Volkow, director of the National Institute on Drug Abuse, who insists that the medical model of addiction is scientifically proven. The collection of films represents the state of current medical thinking about addiction. It includes the stories of individual people, their families, and their treatments. It's a powerful collection of films that offers people help.
However, in its explicit claims that the medical model has been scientifically proven, this is a fundamentally dishonest work, and it shows its own flaws in the treatments it depicts. The medical "treatment" young people get includes explaining to them the importance of thinking about the consequences of their actions, being considerate of others, and of acknowledging the pain and damage they have caused through their lying and stealing. This is blatantly a form of moral education, trying to repair moral deficiencies.
The central problem in this representation is that is never comes to grips with the distinction between medical and moral problems, and does not acknowledge that in addiction, people may have both. All the emphasis goes on the notion of a brain disease, with scientists pointing pictures of addicts' brains, saying how different they are, as if that proves there is no moral component to addiction. Nora Volkow preaches the medical ideology with passion, returning again and again to the idea that addiction is a disease of the brain, completely akin to heart disease. Yet even Volkow says that the addicted person has to take responsibility for having the disease and must seek treatment.
This emphasis of the medical view over the moral one comes out in the portrayal of treatment. Mostly treatment is described as medical, even though it includes medication, psychotherapy, family therapy, and 12-step programs: the talking heads always describe them as helpful, although they say that they don't work equally well for everyone. Despite all their espousal of a scientific viewpoint, they never say what the success rates are for the different treatments compared with no-treatment. When it comes to moral reactions to addiction, with condemnation, anger, and forgiveness, as well as moral education, there's almost no acknowledgement that these might be effective ways to stop addictive behavior, and the emphasis is all on the fallibility and dangers of such approach. The low success rate of medical and psychological treatments are only really addressed in the persistent claim even if people relapse, we should not consider those treatments a failure. It's an astonishing double-standard: medical treatment that does not solve the problem should not be counted a failure, but moral approaches should never be considered appropriate even if they might succeed.
The basic problem with this medical approach is that is based on an obvious falsehood in its claim that addiction is not a moral failure. If one knows anything about addiction and morality, it is blatantly obvious that addiction often is a moral failure. Addicts frequently knowingly lie, cheat, and hurt others in order to get drugs or alcohol. To deny this counts as a moral failure suggests a lack of understanding of morality. Often the medical scientists who speak to the camera demonstrate their scientific expertise, but they give a strong impression that their grasp of morality is weak. For example, Kathleen Brady says both that childhood abuse can be an instigator of addiction and that it is important that family members not feel guilty for causing addiction: but this is a straightforward self-contradiction. There are clearly cases when bad parenting can cause addiction, and it is entirely appropriate that parents blame themselves for what they have done.
Presumably the urge to deny the moral component of addiction comes from great confidence in the power of science (despite the unimpressive rates of treatment success), and more importantly, a wish to reduce the stigma associated with addiction. The issue of stigma is difficult. Labeling people as bad and shunning them can make their problems worse: we see this in criminal behavior all the time. The American penal system dramatically fails in rehabilitation of criminals, but instead tends to create a self-perpetuating cycle of bad behavior. So the medical experts' sensitivity to the problem of stigma is entirely appropriate. However, there may be non-stigmatizing ways to deal with moral problems; indeed, the seeds of such moral approaches are in some religions, including the teachings of Jesus, which will be familiar to a large proportion of the population of the USA.
Some of the experts in this DVD collection don't place so much emphasis on the medical model. For example, Mark Willenbring, director of the Treatment and Recovery Research Division of the National Institute on Alcohol Abuse and Alcoholism, brings a sensitive and thoughtful perspective. He says that shaming, blaming and expressing is not particularly effective -- although he does not say how effective it is compared to medical approaches. He acknowledges the needs of families and the difficulties of coping with a family member who is abusing drugs or alcohol, but his main recommendation is that they go to Al-Anon, even though the evidence that doing so is helpful is weak, and it isn't clear how much the help it provides is simply educational. Willenbring also says that social support and health insurance is important, and he points to the difficulties of admitting the need for help from others in the highly individualistic culture of the USA. This sort of cultural point is insightful, if rather simplistic, since there are many parts of our culture that do emphasize our mutual needs and the importance of family and community support.
Overall, this Addiction project takes a humanistic and educational stance towards the problem. It is bad at dealing with the moral component of addiction, and may well provide wrong information about the effects of moral disapproval of addictive behavior. Until moral approaches have been scientifically studied, scientists are not in a position to judge whether those moral approaches are appropriate or not, and it is out of their areas of expertise. The addicts and their families show some confusion about the moral components, but they are reluctant to completely give up discussing the moral dimension of addiction. It is a case where the patients seem to have more wisdom than the scientists. It is clear that what families need are a way to combine the medical and the moral, rather than proclamations that addiction is just a brain disease and the only moral responsibility involved is the need to seek treatment. (Do clinicians not hear any alarm bells going off when they say that the addict's moral responsibility consists only in seeing a clinician?) Further, it is also apparent that many treatments do already combine moral and medical components, even if that is not what they say they are doing. This collection of films strongly suggests the need to acknowledge that addiction has both components, and for treatment to explicitly address both of them.
Link: HBO Addiction website
© 2009 Christian Perring
Christian Perring, Associate Professor of Philosophy, Dowling College, New York.