I say the answer should be no. It should make no difference whether we call addiction a disease or a bad lifestyle. (I say “should” because it might matter for insurance purposes.) But it does matter whether addiction is something that can be controlled, or is something that is beyond human control. Most experts I read seem to agree that addiction is at least partly under the addict’s control. This is from a Reason magazine interview of Sally Satel, who spent years helping addicts in Appalachia:
I’m not going to deny any of the neurobiological facts or the very dramatic and eye-catching brain scans that they use—of course the brain has changed in addiction. So that’s all true. But the point is the brain isn’t changed to the point where a person can no longer make decisions.
If my choices are saying addiction is a disease vs. it’s a sin or it’s a crime or it’s evidence of moral failing, well, damn, I’m going to pick disease. But it’s a condition, a behavioral phenomenon that responds to contingencies, that responds to consequences, and that people engage in for reasons.
In Ironton and D.C., there’s not one patient who walked into a clinic and didn’t say that they were there because their wife was going to leave them, their boss is going to fire them, their probation officer is going to punish them, or their kid’s going to hate them. The point is they’re responding to something in their environment. If I had Alzheimer’s disease, which is to me a classic brain pathology, it wouldn’t matter what was going on in the environment or in my cognition or in my view of myself.
If you talk to someone who drinks too much or uses drugs too much—and I emphasize the too much, because that’s the problem—I’d say to them, “Why are you doing that? What’s going on?” That question makes sense. That question can be answered in existential terms. If I said to a person with Alzheimer’s disease, “Why do you have Alzheimer’s disease?” maybe they’ll talk to me about [brain] plaques and tangles and neural pathology. The answer doesn’t come in the form of existential language. That’s very important, because that goes to why people use and how we get them out of it.
I really like this answer. Many people allow words to distort their thinking about various issues. They may say to themselves, “First I need to determine if taxation is theft, and then that will allow me to decide how I feel about taxation.” That’s wrong. The question of whether taxation is justified has nothing to do with the label you decide to attach to the institution.
Similarly, people might say to themselves, “First I’ll decide if addiction is a disease, and then I’ll decide whether to criticize the addict for their behavior.” That’s also wrong. Satel regards addiction as a disease, and yet seems willing to criticize addicts for their behavior. That’s because addicts respond to incentives.
You are free to define words as you choose, but don’t expect society to follow along. If you say, “It’s not a disease if self control can improve the condition”, then diabetes would no longer be a disease.
PS. Mental illness is another problematic term. The issue is not whether mental illness is a disease or a behavioral choice; the question is how should we treat people who behave in unconventional ways. Here’s Tyler Cowen:
I don’t find the term “mental illness” very useful, and very often it is misleading, or even dangerous, or used to restrict the liberties of individuals unjustly.
Tyler doesn’t deny that mental illness exists—the problem is that it’s poorly defined. For instance, we once treated both pedophilia and homosexuality as illnesses. More recently, we’ve changed our minds on homosexuality for (in my view) essentially utilitarian reasons.
READER COMMENTS
Norm Macdonald
Feb 19 2024 at 3:57pm
Alcoholism is the only disease you can get yelled at for having.
steve
Feb 19 2024 at 5:41pm
In general, we try to treat disease and we punish bad lifestyle choices. Lots of people use narcotics at some point. After surgery, back pain, headaches, whatever. Only a small minority go on to become addicted. I think that suggests there is something really different about addicts. At least partially based upon the research turning up in the last 10-20 years I think that is at least partially genetic. There is also Vietnam. As a corpsman at the time the guys were coming back to the US we were very aware fo the high rate of addiction (15%-20% by testing though I think I have seen lowball estimates about 10%). However, when they came back to the US few relapsed after treatment, unlike what we usually see.
That suggests to me that its at least possible, I think probable, that lots of people easily got addicted (there is an actual physical dependence and withdrawal is real) by repeat exposure because they were bored/scared but only those with the correct genetics stayed addicted when returned home.
That doesnt mean they dont have agency. If they do bad stuff trying to obtain drugs or while high they should be punished according to the law. If just trying to treat addiction per se sending them to jail isn’t likely to help.
Agree that we have often defined mental illness poorly. In the past it was often a way to enforce religious beliefs. That said, while mentally ill people can usually still make lifestyle choices the illnesses are rarely a choice.
Steve
Mactoul
Feb 19 2024 at 7:36pm
Sotel finds herself in a bit of self-contradiction. The decision to take drug is free-willed but she doesn’t want to use the word “moral failing”.
Diabetes isn’t a instance of the same. You accept uncritically the framing gluttony/sloth for obesity/diabetes for what is a hormonal disorder.
Indeed, the current blockbuster drug ozempic is a hormone analog.
Scott Sumner
Feb 20 2024 at 12:25pm
Both diabetes and addiction are partly genetic and partly lifestyle choices.
Ryan M
Feb 26 2024 at 12:25pm
The whole concept of lifestyle choices is pretty difficult, too. Obesity is maybe an even better example than diabetes (and if you have diabetes as a result of lifestyle, you are almost guaranteed to be obese).
But obesity is a result of a great many things, many of which are under your control, many of which may be genetic, whether it be your personal choices, life circumstances, depression, body type, job … whatever it is, the final result is undoubtedly bad, and it could be corrected through major changes in lifestyle, but there are very likely too many contributing factors to even be counted.
Michael Sandifer
Feb 19 2024 at 7:54pm
Both addiction and Alzheimer’s are conditions that involve genetics, epigentics, and environmental exposure factors.
There is signifcant evidence that a minority of people have very strong genetic/epigentic predispositions to certain addictions, such as opioids, alcohol, gambling, etc. Then, there are those with such predispositions for addiction more generally. These are people who are nearly guaranteed to become addicted to certain susbtances or situations to which they’re exposed.
Then, there are those with weaker inborn predispositions, but who develop epigentic and/or psychological predispositions to addiction. These can be people from high-stress homes, military veterans with PTSD, etc. There can also be people with other mental health conditions, such as bipolar disorder or major depressive disorder, who in addition to the afore-mentioned vulnerabilities, may also be self-medicating.
There can be vast differences in the way different people respond to the same drugs. The opioids I’ve been prescribed for minor surgeries don’t make me high, but just kill the pain and make me drowsy. Hence, I never take them except right after surgery, and even then I often don’t take them. However, opioid addicts in my family describe a deep high and relaxation that comes from the same drugs, and some of them have stolen my opioids in the past.
I agree that semantics shouldn’t matter, but the word “disease” could be seen to apply to at least some addicts. The important point is that addiction is actually very complex, as is Alzheimer’s Disease. We shouldn’t forget that life choices can greatly increase the odds of having the latter disease for some people too. These two “diseases” are much more similar than disimiliar, at least for many patients.
Philo
Feb 19 2024 at 9:01pm
Suppose there were a pill that, if taken daily, would make the experience of dosing oneself with heroin, alcohol, or whatever quite unpleasant (perhaps painful). Would the addict–of heroin, alcohol, or whatever–take the pill every day? If so, his addiction has considerable similarity to disease; if not, not.
Mark Bahner
Feb 19 2024 at 10:32pm
Would the addict take the pill that makes heroin painful, but still take the pill and the heroin? That seems extremely unlikely…that a person would take both the pill that makes the heroin painful and the heroin.
Philo
Feb 20 2024 at 12:25am
I was assuming that.
Peter
Feb 20 2024 at 3:45am
You are making the classic mistake of confusing the tool with the behavior, i.e. “banning guns will stop murder”. Our addict will simply move to another drug, compulsively so, because the need is get high. They would prefer less harmful perfect substitutes but if they have to resort to huffing gasoline, drinking methanol, or burning themselves while self asphyxiating, they will. And like anorexics, they will kill themselves in that search if we make them.
Philo
Feb 20 2024 at 9:30pm
If you easily abandon heroin by switching, say, to cocaine, you are not addicted to heroin.
Peter
Feb 21 2024 at 1:34am
Drug addicts aren’t addicted to a specific drug, sans niche cases of physical dependency, they are addicted to drugs. That is the problem. Drugs, like means to murder, are fungible. There is no such thing as a heroin addict outside extremely niche black swans. There are drug addicts whose current drug of the now is heroin and will remain so until it isn’t and a new drug replaced it.
Scott Sumner
Feb 21 2024 at 1:15pm
Addiction is a term like disease, so vague as to be of limited use.
Mactoul
Feb 20 2024 at 4:31am
Well, there is such a drug–Antibuse that alcoholics take. If they then consume alcohol, they become seriously ill. So they avoid drinking.
Philo
Feb 21 2024 at 1:39am
If it worked for everybody, and was not too expensive, that would suggest that alcoholism is a choice, not a disease.
Peter
Feb 21 2024 at 11:34am
Peter
Feb 20 2024 at 3:09am
So as a person who suffers from mental illness arm chair definitions are generally the problem. What separates the illness from armchair is the lack of choice / life impact.
An addict in the throws of addiction is incapable of seeking treatment, people seeking treatment are simply users, albeit generally heavy ones. A major depressive who is wasting away in bed dying in their own feces from starvation because they can’t even motivate themselves to get out of bed isn’t seeking treatment because their wife is leaving them, they are unable to have that rational conversation. I suffer from bouts of severe ruminations leading to catatonia and when I’m episodic my brain isn’t thinking correctly leading to irrational decisions and behavior that you can’t escape out of or avoid as your brain is interpreting everything including it’s own thoughts wrong. I’m on disability for life as a result after medically retiring. I knew a meth addict that compulsively washed their hands to to the point she eventually got necrosis and had to have both partially amputate partially, she simply had no ability to stop the meth or hand washing. She was found dead a months later emaciated bed bug sores covering her entire body dead from an OD in a trap house.
Asking my dead friend why she did it makes as much sense as the Alzheimer person, she doesn’t know, she can’t trust her own thought processes, and it’s compelled. The same as asking me why I can’t stop ruminating in the middle of a rumination cycle but yeah “mental illness is a choice”. Not everything is a cognitive disorder or more accurately, responds to cognitive therapy, especially one where the cognition itself is the problem.
People that trivialize actual mental illness and addiction, which is really a compulsive disorder fundamentally, simply have no real experience with it around it and are armchairing heavy non-addicted users or fashionable mental illnesses. Drunks and alcoholics are not synonyms though we like to pretend the are in modernity. One can seek treatment, the other can’t.
Andrew Clough
Feb 20 2024 at 9:46am
Another Scott wrote a very good piece quite a while ago on just this topic. https://www.lesswrong.com/posts/895quRDaK6gR2rM82/diseased-thinking-dissolving-questions-about-disease
Alabamian
Feb 20 2024 at 11:21am
Misunderstandings of maps and territories are at the bottom of many many cultural and social debates.
SSC: Categories were made for man, not man for the categories.
spencer
Feb 20 2024 at 12:26pm
LOL. People confuse addicts with users. With the addict, the car drives itself to the dope house. But both will quit when they finally encounter enough pain.
Scott Sumner
Feb 20 2024 at 12:35pm
Everyone, Andrew Clough linked to an excellent Scott Alexander post that presents a much more in depth discussion of the position I’m taking here:
https://www.lesswrong.com/posts/895quRDaK6gR2rM82/diseased-thinking-dissolving-questions-about-disease
TGGP
Feb 20 2024 at 9:03pm
I’m with the late Mark Kleiman: the “disease model of addiction” was falsified by the effectiveness of Mao’s campaign against opium addiction. Beliefs should help you make accurate predictions and achieve your goals. The disease model of addiction did not do that.
No, type 1 juvenile diabetes is an autoimmune disease not resulting from poor self-control.
Scott Alexander said “You Don’t Want A Purely Biological, Apolitical Taxonomy Of Mental Disorders” but his “You” didn’t apply to people like Greg Cochran (who looks to Darwinian fitness as one of his criteria for identifying pathogens, and wrote my second link in my first paragraph) and Emil Kirkegaard. A consistent stance is possible, even if many others will have strong reasons to reject such stances.
Scott Sumner
Feb 21 2024 at 1:14pm
“No, type 1 juvenile diabetes is an autoimmune disease not resulting from poor self-control.”
Obviously, that’s not the type I was referring to.
Ryan M
Feb 26 2024 at 12:18pm
Having worked in a field directly related to addiction (and the consequences of addiction) for the past 15 years, I very much agree with the quote from Ms. Satel.
The problem with the “addiction is a disease” model is that it removes human culpability from the equation; in fact, it is specifically designed to remove human culpability from the equation. I have heard addiction described as a spiritual problem, and I think that is far closer to the truth.
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