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On Concepts and Theories of Addiction

Lennart Nordenfelt
Philosophy, Psychiatry, & Psychology, Volume 17, Number 1,
March 2010, pp. 27-30 (Article)
Published by The Johns Hopkins University Press
DOI: 10.1353/ppp.0.0271

For additional information about this article


http://muse.jhu.edu/journals/ppp/summary/v017/17.1.nordenfelt.html

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On Concepts
and Theories of
Addiction
Lennart Nordenfelt

Keywords: addiction, disease, will power, autonomy,


holistic view of health

he article a Liberal Account of Addiction is a good piece of analytic philosophy


applied to psychiatry. It is well-informed
both with regard to empirical matters and philosophical conceptualization. The arguments are
oftenbut, as I will show, not alwaysquite
convincing. The conclusions of the paper also have
crucial consequences for practice, for the treatment
of patients, and for social policy.
The authors argue that current scientific understandings of the problem of addiction are
fundamentally flawed. They distinguish between
two main positions in science: The Disease View
and the Willpower View. According to the Disease
View, drug-seeking behavior is the direct result
of some physiological change in the drug seekers
brain. According to the Willpower View, the addict is no longer rational; he or she uses drugs as a
result of a fundamentally non-voluntary process.
The authors dismiss the Disease View in the
following way. They first note that drug addicts
are in many ways rational planners. The addicts
may have to think a lot to find the best ways to
find the heroin, cigarettes, or alcohol, and they
normally act according to this planning. They
are not in any simple sense caused to act in

2010 by The Johns Hopkins University Press

a particular way. Moreover, referring to recent


neurological literature, the authors note that the
changes caused by drug addictionwhich have to
do with activating reward pathways in the brain
are identical with the outcomes of many other
human activities that we do not call addiction. In
fact, any pleasurable experience causes dopamine
to be released within the brain, activating these
reward pathways (Foddy and Savulescu 2010,
4). These experiences can be the result of coffee
drinking, sexual activity, and physical exercise.
Thus, the physical changes in the brain are not
effects peculiar to the pharmacology of the drugs;
they are instead the effects of the pleasure that the
subject has experienced.
The argument against the Willpower View is
lengthy and more involved. The proponent of the
Willpower View must argue that there is some flaw
in the subjects autonomy. The drug addict is in
some sense unable to avoid taking the drug. The
authors of the present article scrutinize this idea
on the basis of distinguishing between different
senses of autonomy: Substantive autonomy and
procedural autonomy. They state that we must
here be talking about procedural autonomy,
namely, autonomy regarded as dependent only
on our capacity to process information and make
choices in accordance with our preferences. We
cannot, as in the case of substantive autonomy,
require that the preferences themselves be reason-

28 PPP / Vol. 17, No. 1 / March 2010

able. In such a case, many of our ordinary actions


would be judged non-autonomous.
The most reasonable Willpower accounts rely
on the idea that addicted people in some sense lack
self-control. The authors cite different interpretations of the concept of lacking self- control and
they conclude that none of these . . . theories
can say that addicts are necessarily lacking in
self-control unless they also make unreasonable
normative or false factual claims about the nature
of drug- or pleasure-oriented choices (Foddy and
Savulescu 2010, 10). For instance, according to
one interpretation the subject does not endorse his
own desire for drugs, but takes the drug anyway.
According to another interpretation, the addict regrets taking the drug after having done so. Against
such claims the authors claim that many addicts
indeed endorse their desires for drugs and many
addicts do not regret their addictive behavior.
So what is the positive account proposed by
the authors? They put forward what they call a
Liberal View. It contains three claims about addiction: First, we do not know whether an addict
values anything more than the satisfaction of his
addictive desires; second, we do not know whether
an addict behaves autonomously when he uses
drugs; and third, addictive desires are just strong
regular desires.
According to the Liberal View, one has to accept
that the addicts may have drug taking as their highest priority and that they do not have any reduced
procedural autonomy. The authors say: Once we
abandon normative bias, we must accept that there
will be addicts who have this complete, paradigmatic autonomy in their behavior (Foddy and
Savulescu 2010, 15).

On Definitions of Terms
Versus Theories of Phenomena
I think that the reasoning provided by the authors of this article is highly interesting and clarifying. However, in my view there is one serious
weakness in their argument. This has to do with
the authors failure to clearly distinguish between
the meaning of the word addiction and a theory
of addiction as a phenomenon.
The authors say that they argue that the generally understood meaning of the term addiction is

scientifically and philosophically flawed (Foddy


and Savulescu 2010, 1). But do the authors primarily discuss the meaning of the term? The most
plausible interpretation to me is that they discuss
certain theories about the nature of addiction,
including its etiology. The Disease View entails
a theory of addiction as a phenomenon. According to this theory, drug addiction is caused by a
neurological impairment. The Willpower View
entails another theory, namely that addiction is
constituted by certain non-autonomous behavior.
(This view does not entail any specific etiology.)
But if these theories of addiction are flawed
and if the authors propose a theory that is more
correct, then for such a proposal to be meaningful
all the theories must concern the same group of
people. And how is this group of people singled
out? What is the common basic definition of addiction or drug addiction? It is not clear that the
earlier theorists provide such a definition. Nor do
the present authors, and this mars their reasoning. It could be the case that they and the earlier
theorists refer to partly different groups.
Consider the following minimal definition: A
drug addict is a person who regularly seeks drugs.
Such a minimal definition includes a lot of people,
including myself. I drink alcohol regularly, but
I doubt that anybody would include me among
drug addicts. Try then the following still quite
minimal definition: A drug addict is a person
who regularly seeks drugs because he or she takes
pleasure in this and thus has a strong desire for
it. This again applies to many people, not all of
whom would normally be called addicts. But it
seems as if the present authors do not require
more of their class of drug addicts. In the concluding sections, when they present the Liberal
View of addiction, they seem to be talking about
a group roughly corresponding to this definition.
(Observe that the authors sometimes talk about
drug users in general, e.g. on p. 3.) And if this is
the way they single out the class of drug addicts,
then it is salient that many drug addicts need not,
for instance, have reduced autonomy, and then
they need not fulfill the conditions indicated by
the Willpower theorists.
But assume instead that the basic definition
made by the willpower theorist is the following: A
drug addict is a person who regularly seeks drugs,

Nordenfelt / Addiction 29

takes great pleasure in them, has an extremely


strong desire for them, and has, partly for this
reason, reduced autonomy with regard to the
drug-seeking behavior. A peculiar feature of the
drug addict, they may claim, is that he or she has
to some extent lost control over the drug-seeking
behavior. The addict is to some extent compelled
to do what he or she does. Then the Willpower
theorist has by definition limited the class of
addicts compared with what is assumed by the
present authors.
The authors themselves concede that it might
turn out that some particular cases of addictive
behavior are in fact not autonomous. The Liberal
account does not deny this (Foddy and Savulescu
2010, 15). This means that the smaller group of
non-autonomous drug seekers need not be an
empty class. The Willpower theorists can then
claim that this smaller class is precisely the one we
call drug addicts. Thus, the different theories do
not refer to the same class. Hence, the view of the
Willpower theorist need not contradict the view
of the present authors in substance. They disagree
instead in the choice of basic definitions.
But to stop here would be to simplify things.
The present authors do not intend to talk just
about semantics. They intend to say something
substantial. Therefore, let me try the following
interpretation: There is in practice a fairly welldefined group of persons (although I have not explicitly defined it here) that most ordinary people
and psychiatrists label as drug addicts. These
persons continuously seek drugs, and they do so
because they find drug taking extremely pleasant,
and most of them claim that they cannot give up
this habit. It seems that it is at least quite difficult
for them to give up their habit.
This is the class of people that we wish to understand, the present authors may claim, and we
want to understand the nature of their dispositions
in a deeper way. Earlier theorists have proposed
explanations of these dispositions. The present
authors think that these explanations are flawed
and they propose a different account.
Are the present authors correct in this opinion? Is there an implicit, common to the various
theorists, definition of drug addiction that would
make a comparison between the different theories meaningful? I must here raise my hands and

confess that I cannot judge. I am not a specialist


in the field of addiction. Given the contents of the
authors paperincluding their oscillation between expressions such as drug users and drug
addictsthis seems at least to be doubtful.

On Disease as the Cause of


Drug Addiction
So far in my comparative analysis I have only
referred to the Willpower View. Let me now, from
a different angle, focus on the Disease View. I then
focus on it as a theory of the nature of drug addiction. Let me for the moment assume that we
agree on definitions.
The authors are quite convincing with regard to
the special neurological hypothesis. I have faith in
their presentation of facts. Drug addicts do not in
general have a neurological impairment such that
their addictive behavior is (partially) caused by it.
Some neurological changes may have taken place
(in terms of activated reward pathways) as a result
of the drug use but such changes can be the result
of all kinds of pleasant experiences, including
those of exercise, food, and sex. I therefore accept
their rejection of this particular theory.
However, a disease hypothesis can be of a different kind. First, there need not be a question
of a neurological, or in general somatic, disease.
Second, the hypothesis may be embedded in a
theory of health that is different from a conventional, medical one. I am referring to the kind of
holistic theory that has been developed by, for
instance, Fulford (1989), Prn (1993), and myself
(Nordenfelt 1987/1995, 2000). Space prevents me
from giving a full characterization of such a theory
here. Let me just make the following remarks,
which mainly reflect my own views.
The basic concept in a holistic theory is health.
Health is defined as a persons ability to realize
his or her vital goals, given standard or otherwise reasonable circumstances. The negative
medical conceptsnamely disease, defect, and
impairmentare defined as such bodily or mental
processes as tend to reduce the subjects ability to
realize their vital goals, that is, their health.
The question can now be put: Do drug addicts
have a reduced health? Are they partially prevented
from realizing their vital goals as a result of their

30 PPP / Vol. 17, No. 1 / March 2010

addiction? Assume for the sake of argument that


we are talking about addicts with some degree of
reduced autonomy. (I quite agree with the authors
that autonomy is a matter of degree. I would say
that a person already has a somewhat lowered
autonomy when it is just difficult for him or her
to do something vital.) It seems to be plausible to
say that (some) addicts have developed a mental
disposition that is such that it is difficult, even
extremely difficult, for them to quit their drug
habits. This disposition makes them forget about
other, vital matters such as cultivating their social
relations, running their household, or even sustaining their basic hygiene. Therefore I would say that
the health (in this holistic sense) of these addicts
is somewhat reduced. It is a matter of stipulation
when we would say that it is reduced to the extent
that we would call it an illness.1
Now this reduced health must of course have
some cause. In this case, we would say that there
is at least a mental disposition of the subject which
is a (partial) cause of the addiction. This mental
disposition probably ultimately has a neurological
base, although not in terms of a salient neurological lesion or impairment. The base can be subtle
and complicated. The mental disposition can be
the result of a conglomerate of neurological factors, including activated reward pathways. This

conglomerate may well, in terms of a holistic


theory, be called a disease or an impairment. It
may be called so because it is responsible for the
reduced health of the addict.
Thus, via the introduction of a holistic theory
of health we can argue for a disease view of (some
types of) addictions. Such a disease view, however,
is radically different from the one under attack by
the present authors.

Note
1. I have elsewhere (2007) developed an actiontheoretic model for the understanding of such mental
illness as entails acting under compulsion.

References
Foddy, B., and J. Savulescu. 2010. A liberal account
of addiction. Philosophy, Psychiatry & Psychology
17, no. 1:122.
Fulford, K. W. M. 1989. Moral theory and medical
practice. Cambridge: Cambridge University Press.
Nordenfelt, L. 1987/1995. On the nature of health.
Dordrecht: D. Reidel Publishing Company.
. 2000. Action, ability and health. Dordrecht:
Kluwer.
. 2007. Rationality and compulsion. Oxford:
Oxford University Press.
Prn, I. 1993. Health and adaptedness. Theoretical
Medicine 14:295304.

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