Bryan Caplan  

The Spread of Szaszian Economics

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I was thrilled to publish "The Economics of Szasz" in Rationality and Society, and even more thrilled to win a Szasz Prize as a result.  But I can't say the paper had much influence on the economics profession.  I'm very pleased, then, to see that behavioral economists like Laibson are giving a lot of love to Gene Heyman's Addiction: A Disorder of Choice.  Here's the gist from Sally Satel's sympathetic review:
If, as Heyman says, "drug-induced brain change is not sufficient evidence that addiction is an involuntary disease state," then how are we to distinguish between voluntary and involuntary behavior?

Heyman's answer is that "voluntary activities vary systematically as a function of their consequences, where the consequences include benefits, costs, and values."

In "The Economics of Szasz," I gave many examples of this point.  Here are some of Heyman's, as filtered through Satel:

Take, for example, the case of addicted physicians and pilots. When they are reported to their oversight boards they are monitored closely for several long years; if they don't fly right, they have a lot to lose (jobs, income, status). It is no coincidence that their recovery rates are high. Via entities called drug courts, the criminal justice system applies swift and certain sanctions to drug offenders who fail drug tests--the threat of jail time if tests are repeatedly failed is the stick--while the carrot is that charges are expunged if the program is completed. Participants in drug courts tend to fare significantly better than their counterparts who have been adjudicated as usual. In so-called contingency management experiments, subjects addicted to cocaine or heroin are rewarded with vouchers redeemable for cash, household goods, or clothes. Those randomized to the voucher arm routinely enjoy better results than those receiving treatment as usual.

The lesson:

Contingencies are the key to voluntariness. No amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing an Alzheimer's patient to keep her dementia from worsening, or threatening to impose a penalty on her if it did.

Thus Heyman reinvents my "Gun to the Head Test."  Sweet.

My main quibble with Satel's review is that she's overly charitable to promoters of the view that addiction is a brain disease.
In fairness, the scientists who forged the brain disease concept had good intentions. By placing addiction on equal footing with more conventional medical disorders, they sought to create an image of the addict as a hapless victim of his own wayward neurochemistry. They hoped this would inspire companies and politicians to allocate more funding for treatment. Also, by emphasizing dramatic scientific advances, such as brain imaging techniques, and applying them to addiction, they hoped researchers might reap more financial support for their work. Finally, promoting the idea of addiction as a brain disease would rehabilitate the addict's public image from that of a criminal who deserves punishment into a sympathetic figure who deserves treatment.
Frankly, I see nothing good about the intentions of the scientists who "forged the brain disease concept."  While I think that addictive behavior should be legal, it's still irresponsible and emotionally abusive towards the people who care about you.   The addiction-as-disease story shifts the blame from where it belongs - the self-destructive addict - to family, friends, co-workers, employers, tax-payers, and other victims.  Calling bad behavior a "disease" may be merciful, but it's unjust.


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COMMENTS (9 to date)
hacs writes:

Off topic, an interesting empirical research.

LM DeBruine, BC Jones, JR Crawford, LLM Welling & AC Little. The health of a nation predicts their mate preferences: Cross-cultural variation in women's preferences for masculinized male faces. Proceedings of the Royal Society of London B.

Tom West writes:

No amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition.

I'd bet a $1,000 (even odds) that we could increase the 6 month survival rates of terminal cancer by credibly announcing the intention to execute the children of anyone who died before the sixth month mark.

Well, okay, I wouldn't, but not because I'm afraid I'd lose.

Doc Merlin writes:

'Calling bad behavior a "disease" may be merciful, but it's unjust.'

Agreed on this point.

JLA writes:

I'm a little puzzled. Previously, you've argue that we should defer to the experts.

I would bet, at even odds, that the percent of PhD psychologists who believe that schizophrenia is an disease is at least as high as the percent of PhD economists who believe that farm subsidies are bad.

Why should we defer to expert economists but not expert psychologists?

Tom West writes:

The main problem is that reality is not nearly so elegant as to make things either "voluntary" or "involuntary".

Instead we have a continuum that goes from completely voluntary to completely involuntary.

While pretending that such ambiguity doesn't exist might make for a nice airtight moral philosophy, just like economics, it's important not to mistake model for reality.

Kurbla writes:

Gun into head - situation of extreme danger causes involuntary changes of ones physiology - some of them are easily observable, like increased blood pressure, heart beat etc. Effect is the same like you forced one to take some pill that increased his heart beat rate three times. There is no reason to believe that everything one can do in such gun or pill enhanced situation, he can do without gun or pill as well. As any punishment or reward works on similar way, we have little reason to say that change in behaviour due to punishment or reward is voluntary.

I believe that it is opposite: no one is guilty. All people are innocent, our behaviour is just result of physical processes out of our control. But we have to punish criminals, not because they are guilty, but because that works in practice. We do not punish people rationally - we punish them instinctively. So, we feel pleasure while punishing criminals, just like we do if we eat or have sex ... And we do not punish only criminals, we punish everyone, our friends, spouses, children ... all of them are innocent. However, if we admit that we punish innocent people, we'll be confused, and become ineffective. Because of that we invented free will, just like we invented other religious ideas. Now we believe that murderer made his own, voluntary decision, and we do not think twice about punishing him.

Brian writes:

@Tom West,

I would take the bet against you. All evidence at lest with breast cancer shows that people who fight hard and are positive have no higher survival rates than though’s who are not (that is not to say they, their friends, and their families are not better off during the treatment). There is indication it is true across the board. However, there might be a slight increase in survival rates due to people not giving up on treatment and choosing to die.

This evidence tends to prove Bryans point that addiction is not a disease.

Nate writes:

"I believe that it is opposite: no one is guilty." And I believe the exact opposite of that. If you can't help it because of the flow of matter and energy through you, it means the problem is with your very being. So culpable, it's in your blood.

Or as my brother told the overweight person that blamed their genes, "while I believe research shows you are wrong, do you really prefer to claim yourself an inferior model?"

Ben Kalafut writes:

Honored by this? Isn't Szasz still ranting about "lesions" in the age of imaging and neuroscience?

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