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?
answer is that "voluntary activities vary systematically as a function
of their consequences, where the consequences include benefits, costs,
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.
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.
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
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.