Introduction

In a pamphlet published (1) by the Libertarian Alliance last year, Dr Robert Lefever argued that addiction is a disease. Although Lefever's experience is that the addiction as disease model is a hard sell to other doctors, that is not at all the case in the US, where it is already the prevalent view not only among physicians, but also with the news media, politicians, and the "addicts" themselves. Hardly a day goes by without some prominent public figure going into "treatment" for one addiction or another, whether booze, drugs, sex, or gambling. What was once simply bad or excessive behavior has become sickness to be treated by professionals of one sort or another. But just calling something an illness does not make it so.

The Myth of Addiction

Debating whether addiction is a disease or not begs the question of whether there even is such a thing as addiction. Clearly there are people who use drugs, gamble, or have sex in ways that are harmful to them in some fashion, causing physical problems, financial difficulties, or discord in their sexual and family relationships. Those who would call them addicts, like Lefever, claim that they have some defect, biochemical or psychological, that drives them towards these self-destructive activities, and phrases like impaired impulse control and compulsive use are used to characterize addictive behavior. Such descriptions at least imply that the addict is somehow not in control of their actions, or, in the words of Alcoholics (or Narcotics or Gamblers or Overeaters or Sex and Love Addicts, etc) Anonymous, powerless before their addiction.

This is nonsense. People, when not coerced by others, will generally choose to engage in pleasurable activities and avoid painful ones. But pleasure and pain are in the eye of the beholder. Some people are willing to stop partying to raise children and have a house in the suburbs, while others are willing to sacrifice their relationships and jobs in order to get high whenever they can. But just accepting that we all have different desires and goals doesn't work for everyone. Often the good, upstanding, hardworking citizens find it impossible to put themselves in the place of the party animals, so they are happy to accept what passes for an explanation of such behavior in the concept of addiction. After all, how could anyone choose a crack pipe over the joys of job and family unless they were driven to it by something beyond their control?

The answer from the doctors, that they have an addiction, is really just a label, not an explanation. Naming bad behavior as addiction dresses up people's disapproval of the actions of others in pseudo-scientific garb. It does not explain in what way they are compelled to drink, or how they have lost control of their eating, or why they are powerless before the slot machine. And that is because the concept of addiction is fundamentally flawed.

In order for someone not to be in control of their actions, someone or something else would have to be. For someone's actions to be compulsive, there must be another compelling them. But those who believe in addiction have yet to show who raises the glass to the alcoholic's lips other than the drunk, who injects the heroin into their own vein but the junkie, and who throws the chips on the blackjack table but the gambler. There is no puppet master controlling these people's actions. They are freely choosing to do what gives them pleasure, whether those who seek their satisfaction elsewhere can understand their behavior or not. While most medical professionals would reject the explanation that the devil made them do it, they have accepted a concept just as amorphous and unscientific if they believe that addiction made them do it.

Disease and Difference

Lefever argues that addicts have an inherited biochemical defect that predisposes them to drink, have sex, smoke, or gamble to excess, although the evidence is not at all clear that there is anything that physically sets "addicts" apart from others who engage in such pastimes in moderation. Lefever presents no evidence for this defect other than his belief that it would be "absolutely incredible" if there were not such a defect. Of course such an idea is incredible only to those cannot bring themselves to believe that people can make really bad choices all on their own.

Since one can hardly conclusively demonstrate the existence of a "tendency," Lefever makes no attempt to do so. Instead he muddies the waters by pulling vision problems, contraception, unemployment, and sports injuries into a discussion of what constitutes disease, relieving himself of the burden of proving his case. He claims the conventional view of disease is too narrow, but if it were expanded as much as he seems to argue, it would encompass so much as to be a useless concept. While behavior or relationships or ideas may be viewed as sick, this is so only in a metaphorical way, as when a joke is sick. Taking this designation seriously and diagnosing drunkenness as a genuine illness is to take such a metaphor much too literally.

There is a long history of doctors diagnosing the behavior of others as diseased in some way. With the rise of modern psychiatry, many unusual activities and pastimes were no longer viewed as vices or immoral acts, but as mental illnesses. While mental illness is officially viewed as very much akin to physical illnesses like diabetes, even psychiatrists know this not to be the case. For instance, a disease, like homosexuality, can be created or eliminated from the roster of mental illness simply by the decision of a groups of "experts," based only on whether such activity is socially acceptable or not. This is hardly how medical doctors deal with defining an illness.

In recent years psychiatrists and researchers have attempted to prove that so-called mental illnesses, including addiction, have an anatomic and/or physiological basis in an attempt to prove that they are real illnesses. But the fact that that there are structural or functional changes in the brain associated with some bizarre or anomalous behavior does not in fact prove that the brain anomaly caused the behavior, and not vice versa. It is well-established that mental functions, such as memory and learning, change the brain, and it may be that the brains of people with emotional or mood problems are changed by their mental state instead of the other way around. While there clearly are brain diseases that manifest themselves behaviorally, "disordered" behavior, even in association with changes in the brain, is in no way proof of an underlying disease.

Interestingly, while the experts point to physical changes underlying mental illnesses, many still prescribe and practice talk therapy as at least part of the treatment for them. This alone should highlight the difference between real, physical illnesses and the problems in living that have come to be labeled as mental illnesses. If counseling can really alter the course of disease, perhaps endocrinologists should prescribe psychoanalysis to lower the blood sugars of their diabetic patients.

Why Embrace the Disease Model?

Lefever believes that it is unfair to think that addicts and those who treat them embrace the disease model in order to shirk responsibility for their actions. But it should be no surprise that people who disagree with the disease model of behavior would assume this. The very language used by the addiction industry, words like compulsion, powerless, impaired control, give the impression that addicts are victims of forces greater than themselves. The core of AA and other 12 step programs, which are endorsed by Lefever and are part of virtually all addiction treatment in the US, is that addicts are powerless before their addiction and must rely on god or some other "higher power" to fix them. (Of course the success of such programs requires that addicts in fact demonstrate that they are in control of their urges, so even the 12 steppers don't really believe this stuff.) It certainly sounds like addicts and their therapists are saying it's not their fault.

If the addicts and those that treat them are not trying to avoid responsibility for their situation, what value is there in trying to convince others they are sick, and not just profligate? Well, follow the money: calling addiction a disease means that treatment is covered by health insurance. This is to the advantage of both the addicts and their doctors and has spawned a huge "recovery" industry. And the more things that one can be addicted to, the more money to be made. Now that tobacco users are addicts, drug companies can produce pharmaceutical nicotine. Since obesity is the result of an eating disorder, diet pills and "bariatric" surgery are appropriate treatments.

In addition, classifying addiction as an illness provides job protection for those whose use of chemicals interferes with their ability to come to work or perform their work properly. Laws that proscribe discrimination based on disability are used to keep addicts from being fired, and protect health care workers diverting drugs from patients to themselves from being disciplined. After all, if these people are sick, they shouldn't be punished for manifesting their symptoms. So people who are addicts are allowed to "get away with" behavior that would result in other people getting fired and/or arrested.

Even though the whole medical model of addiction and other mental illness lacks any real scientific basis, this might be overlooked if its application actually helped people change their behavior more effectively than earlier ways of looking at overindulgence. But it doesn't. Anyone familiar with the recovery industry or who knows people who have gone through it has to be aware of the huge "relapse" rate. People who enter rehab and follow up with 12 step meetings or other "therapy" will often keep clean for a while but most (perhaps as many as 90% according to some of the literature2) go back to their favorite activity all too soon. It remains to be shown that medical treatment of addiction is any more effective than simpler (and cheaper) methods, like family and social pressure, which can at times convince people it is time to quit before they totally screw up the rest of their lives.

A Different Approach to Problems in Living

A former US Surgeon General once said that tobacco is more addictive than heroin, and similar statements from others are not uncommon. If this factoid (and no proof is ever offered) were true, it alone would give the lie to the whole medical approach to addiction. Millions of people in the US have quit smoking over the years, the vast majority of them unaided by drugs, therapists, or Tobacco Addicts Anonymous. At some point they decided to stop smoking (or chewing or dipping) and did so. Period. And there are many heroin, cocaine, and alcohol users who have done exactly the same thing.

That is because they have no disease. They simply have chosen to use some drug or engage in some other pleasurable activity to such an extent that it interferes with their jobs, relationships, or other parts of their lives. Sometimes their desire for pleasure ends in disaster for them and their loved ones and sometimes they figure out that their time and money could be better spent in some other way. But in either case they are people making choices, not patients suffering from an illness.

Lefever argues that people who are unhappy (he would say depressed) are more likely to engage in some of the harmful activities which he discusses, and believes that this is further proof that addiction is a disease. While I would agree that people use drugs, gamble, and/or sleep around to make themselves happier, that doesn't mean they were necessarily unhappy to begin with. And even if they were, sadness is no more a disease than drunkenness, despite what the experts and drug companies say. Being sad, trying to make ourselves happy: these are just part of the human condition.

Medicalizing problems in living allows people to turn over responsibility for their lives to the experts, relieving themselves of the burden of trying to figure how to change their lives and circumstances in ways that might maximize their happiness and minimize their distress. It doesn't challenge the social, economic, and religious institutions that breed inequality, poverty, greed, sexual frustration and other social phenomena that lead to unhappiness. It doesn't critique the prohibitionist mentality that creates legal restrictions on drug use, sexual relationships, and even wagering that encourage those who engage in such activities to do so in riskier and more "addictive" ways.

If the addiction professionals cannot bring themselves to give up the medical model, perhaps those they seek to help would be better served by a kind of public health approach. Here, an attempt is made to control a disease by eradicating its causes, such as the mosquitoes which carry malaria or the snails which transmit schistosomiasis. Translating this approach to sadness and overuse of drugs (or depression and addiction as Lefever would have it), perhaps the experts should concentrate on eliminating authoritarian governments and countering puritanical religious sentiments, instead of hospitalizing those who turn to pleasurable but dangerous activities to counteract the misery such institutions can cause.

Notes

(1) Robert Lefever, Some Thoughts on Addictive Disease, Scientific Notes 14, London, Libertarian Alliance, 2006.

(2) Of course, given that Dr Lefever is the sort of person who writes for the Society for Individual Freedom and the Libertarian Alliance, his results are likely to be of the superior sort. This does not alter my view of the basic issue.
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