Is addiction a matter of choice or genetics?

The Massachusetts Supreme Court will soon decide whether drugs remove responsibility from addicts

Heather Zeiger | Nov 14 2017 | comment

A courtroom is an odd place to debate philosophical questions which have been kicking around for more than 2000 years. But the Massachusetts Supreme Court will soon decide whether or not drug addicts have free will.

Or, to be more specific, if it is a violation of their constitutional rights to force addicts to be sober. The outcome could have an enormous effect upon US drug policy.

Commonwealth v. Julie Eldred will address a fundamental question about addiction: is it a disease in which a person no longer has control over their actions, or can the addict respond rationally to incentives and reason? This is not the first time that a US court has had to address whether addiction is a disease or a choice. In 1968, however, the US Supreme Court held that "it cannot be asserted that the use of the criminal process to deal with the public aspects of problem drinking can never be defended as rational". After half a century, however, the opiod drug epidemic is a national health emergency, so the question needs to be revisited.

The defendant, Julie Eldred, contends that the court violated her constitutional rights by requiring her to remain drug-free while on probation. Eldred’s lawyers say that she is genetically predisposed to addiction and a drug-free life is impossible. Ms Eldred was adopted and never knew her biological parents. She started abusing prescription pain medicine in high school. She was a cheerleader, had lots of friends, and had good parents, but she turned to drugs because they helped her feel better about herself.

In her 20s Ms Eldred started using heroin. After getting treatment and remaining sober for several years, started using drugs again. Eventually she was arrested for stealing jewelry. As a condition of her probation she was given suboxone to curb her cravings. But ... she had to stay away from illegal drugs. Unfortunately, she didn’t. The judge was not in a mood to be understanding, “This is just a bunch of excuses,” he said. And she went back to jail.

So who is right? Ms Eldred, who says she is powerless to resist the allure of opioids? Or the judge, who says she can?

Two amicus curiae briefs have been submitted to the court. The Massachusetts Medical Society, along with several medical societies and universities, argues that addiction is a chronic disease comparable to diabetes or Alzheimer’s. On the other side, 11 addiction experts contend that addiction is not analogous to other chronic diseases because addiction can be curbed by an act of will. (The disease-model brief can be found here. The choice-model brief is here.)

Disease-model brief

According to the disease-model there is a consensus amongst the medical community that addiction is a disease. There is some compelling evidence from brain studies with addicts. However, one piece of evidence presented in favor of the disease model could just as easily be evidence against it.

Julie Eldred was prescribed suboxone a few days before she tested positive for fentanyl. Suboxone is a type of opioid that practitioners use when treating opioid addiction. It does not produce the high that is associated with heroin or other opioids but it does stave off withdrawal symptoms and cravings. If Julie’s addiction were truly a brain disease, then suboxone should have adequately satisfied the disease cravings. The fact that it didn’t speaks to the complex nature of addiction. She wanted the high and she sought it out even though her brain signaling pathways were technically satisfied.

The brain-disease brief admits that mental health disorders and substance use disorders go hand-in-hand for reasons that are not entirely clear and acknowledges that stress is one of three key stimuli that precipitates relapse. This seems to point to drug use as a coping mechanism rather than as a brain disease.

The appeal to a medical consensus is a red herring. Scientific consensus over nature or nurture has ebbed and flowed depending on the prevailing cultural agenda. In the early 20th Century, the volitional approach did not address how addiction captivates one’s will. More recently the pendulum has swung in the other direction. Now the disease model prevails, but does little to address a person’s responsibility, even in light of a weakened will.

Choice-model brief

The authors of the choice-model brief define their perspective as “the capacity to respond to incentives and reasons, which obviously varies among addicts but which are virtually never entirely lost.” They cite data and personal testimonies that show addicts do retain some capacity to respond to incentives and reason.

The authors support requiring offenders to remain drug free during probation by making them accountable for drug use and providing a strong incentive to stay clean. They can quit. For example, drug use that begins in adolescence usually continues into the 20s. However, by the time a person reaches the early 40s, between 75 and 83 percent addicts no longer meet the criteria for addiction. The authors cite a study that showed the most common explanation for quitting was “It was time to do other things.” And the second most common was “Had no alternative.”

The choice-model brief concedes that that every human action causes changes in the brain. But, brain changes do not mean that actions become involuntary. If that were true, everything we do is involuntary. This kind of biological determinism is a minority view among philosophers of mind.

The authors acknowledge the importance of drugs like suboxone to curb cravings but treatment should address the complex nature of addiction. Addition is more than merely biological. There are environmental, social, cultural, motivational, and other factors.

The problem with modern model

A helpful book on the subject of addiction is Addiction and Virtue by Kent Dunnington. He turns to classics such as Aristotle, Aquinas, and the Bible. The addict has a corrupted will yet maintains some responsibility; the addict is an embodied being but he or she is also more than the sum of his physical parts, genetic, neurological or otherwise.

“…we cannot determine whether human behavior is voluntary by examining bodily constitutions, whether genetic or neuronal. That is because genetic predispositions and brain configurations influence both voluntary and involuntary behaviors…If we wish to determine whether or not a certain sort of human behavior is voluntary, we must look elsewhere”.

Dunnington suggests looking at classical thinkers.

“We cannot, therefore, pretend that the will is unconstrained by the body. This is why Aquinas says that habits of the will, although primarily habits of the soul, are secondarily habits of the body…Like the intellect and the sense appetite, practical reason—the ‘rational appetite’—is subject to alteration, corruption, and exhaustion”.

For addicts like Julie Eldred, contemporary models of addiction do not address the root problem. The choice model addresses only half of the equation. The addict needs to learn how to cope with the hardships of life. The severity of these hardships depend on experience, genetics, personality, and many other factors. However, a person is still responsible for how he or she responds to those hardships. Addiction feels like a solution, but really it only serves to remove the person, not the problem.

Dennington describes drug addiction as a habit that arose from practicing an activity (i.e., drug use) over and over with an “inward intensity of intent and focus.” By “habit” he means something so ingrained that the person seemingly cannot act against it even if he or she wants to; it is second nature.

The authors of the choice-model brief point out that no one sets out to become an addict, just as no one sets out to become obese. But sometimes undesirable outcomes happen from incremental action. Whether or not addicts have a choice now, they did have a choice the first time and the second time. With each successive use, they create “ruts” in their brain. With each high those ruts become so deeper and harder to escape from.

But as research with people who have obsessive-compulsive disorder shows, no matter how deep those ruts are, a person can resist them, and in time, they can actually change their brain. Pre-modern notions of an immaterial mind and material brain are helpful for understanding how this happens. The mind and brain can affect each other. Similarly, classical thinkers believed that no matter how habituated a person was, that person can build different habits that are direct toward different ends.

Many people who have struggled with addiction find that one of the best descriptions of their plight is in the New Testament. The apostle Paul writes in his letter to the Romans: “For I do not understand my own actions. For I do not do what I want, but I do the very thing I hate… For I have the desire to do what is right, but not the ability to carry it out. For I do not do the good I want, but the evil I do not want is what I keep on doing.”

Addiction is philosophically, ethically, socially, and medically complex. An addict is not completely helpless, but the habit he has created has made it extremely difficult to choose the good. In Aristotelean terms, this is “incontinence”. Addiction is both a moral and physical sickness.

Modern vocabulary seems to have lost the words to describe this. Old words like “habit” or “incontinence” have been trivialized or medicalized. Classical thinkers had a way to talk about nature and will, flesh and spirit, volition and providence that seems to better capture the paradoxical nature of addiction:

“What is important to see in all of this is that habit genuinely stands midway between both determined disease and unconstrained choice, and therefore acts as an important corrective in both directions. To say ‘addiction is a habit’ is to say something genuinely different from either ‘addiction is a disease’ or ‘addiction is a choice’ because habit mediates between determinism and voluntarism”.

Heather Zeiger is a freelance science writer with advanced degrees in chemistry and bioethics. She writes on the intersection of science, culture, and technology.

November 14, 2017

We have heard a lot about dastardly deeds lately, so it is refreshing to read Francis Phillips' review of Suzanne's Children -- the biography of a Belgian society woman who was living in Paris during the Nazi occupation and decided that "Something must be done" for the children of Jewish adults being deported wholesale to concentration camps. An inspiring glimpse of a woman who suffered her own hardships but put them aside to help others.

Also today: Tracey O'Donnell interviews Mark Regnerus about reactions to his book, Cheap Sex. Heather Zeiger analyses a case in which an American court will soon decide whether or not drug addicts have free will. Marcus Roberts writes that Canada is to admit nearly one million immigrants over the next three years to compensate for low fertility and meet social security commitments. And Michael Cook has an update on euthanasia in The Netherlands, where, "If there was any taboo, it has gone."