Ordinarily we don't suppose that people are to blame for their illnesses. That is, many diseases develop independently of what the sick person does or thinks. This is why the disease model of addiction, widely espoused in the therapeutic community, is so controversial. Common sense suggests that a person's choice to start using an addictive substance is often voluntary, and often made with the knowledge, either vague or specific, of the risks of getting hooked. Of course, some people may have a genetic predisposition to dependence, and some are placed in environments in which turning down that first drink or cigarette is nigh impossible, but nevertheless it's difficult to eliminate voluntary choice in our explanations of why individuals become addicts.
This question is now very much central to the current debate on how we should respond to the problem of addiction. Alan Leshner, director of the National Institute on Drug Abuse, urges that dependence is a chronic, relapsing disease and that, therefore, we should treat addicts as sick and not punish them for their illness. Leshner points out that the addict's brain is radically changed by drugs--"hijacked," as he puts it--so that the ability to resist drugs is severely compromised, if not altogether eradicated. Punishment won't help an addict to get clean, while treatment just might. But Leshner also recognizes that the physical, compelling nature of full-blown dependence does not exonerate an addict from having made the choice to start using drugs.
In a recent interview in The Scientist (12:1, Feb. 2, 1998), he remarked: "What do you say to people who suggest that there's a difference between addiction and other sorts of brain disorders, like Alzheimer's disease or schizophrenia, because the latter conditions don't arise from a voluntary act of will? But lung cancer [caused by smoking] does occur from a voluntary act of will, and we still pay to treat people for it. The question is whether you want to fix it or not. Whether you think the person is evil and you hate them is not relevant. ... You need to deal with it as a health issue, even if you hate them while you're doing it."
Leshner says the issue of responsibility should be outweighed by our obligation to cure. But in reality many feel that the disabilities individuals bring on themselves are their just comeuppance. If an addict is to blame for his addiction, doesn't he deserve to suffer for it? Whether or not someone is "evil" and hated is indeed relevant to whether we feel motivated to help them or punish them. So, we can't duck the issue of moral responsibility when talking about addiction, and the disease model alone won't be enough to deflect the opprobrium many feel toward addicts.
But what accounts for "voluntary acts of will"? Most would say that there is something irreducibly personal driving the initial choice to use drugs, something that derives neither from an individual's environment nor his biological endowment. According to what might be called the "standard model" of free will, we all possess the capacity to act, in some important respect, independently of internal and external conditioning factors. It's that capacity that justifies praise and blame, reward and punishment. If the situation were replayed with all factors the same, the addict could have made a different choice, so he bears an inescapable, originative responsibility for his condition.
The problem, of course, is that the standard model is false. Although it is not yet widely appreciated, this sort of free will seems increasingly implausible given the rapidly growing scientific understanding of human biology and behavior. Acts may be voluntary in the sense that they are not compelled (most nicotine addicts don't start smoking with a gun to their heads), but they are nonetheless fully caused, a function of personality, motives, predispositions, and situations, none of which springs full blown from an uncaused agent within the person. Even if we presently lack the skill to track its causal antecedents, the will--the net vector sum of desire--is just as determined as anything in nature, says science. And you won't find blameworthy free will in the residuum of what's undetermined, since, after all, we are usually only blamed and praised for what we intend to do. Intentional behavior of the sort we can be held responsible for certainly doesn't include random acts that surprise even the actor.
If the standard model of free will is false, it seems as if the addict is completely off the hook and morally blameless; given the governing conditions, things couldn't have turned out otherwise. Indeed, it seems that by challenging the assumption of free will, science threatens the very foundations of moral judgment. In his recent book How the Mind Works (New York, W.W. Norton, 1997, p. 56), cognitive neuroscientist Stephen Pinker confronts this dilemma and reaches a rather startling conclusion, especially for a scientist: We must idealize ourselves as uncaused creatures in order to have morality. In our ethical deliberations we must pretend, contrary to science, that human behavior is in some crucial respect independent of circumstances. For this to work, we must see that, "Science and morality are separate spheres of reasoning. Only by recognizing them as separate can we have them both. ... A human being is simultaneously a machine and a sentient free agent, depending on the purposes of the discussion. ... The mechanistic stance allows us to understand what makes us tick and how we fit into the physical universe. When those discussions wind down for the day, we go back to talking about each other as free and dignified human beings."
Since Pinker thinks that the "machine" view of ourselves undermines moral agency, naturally he is forced to keep science and morality in separate spheres. But is this dramatic and artificial disconnection of our explanatory powers and our ethical intuitions really necessary? The example of addiction will show that it is not.
First, it's clear that knowing that the voluntary choice to start using drugs is not a matter of uncaused free will doesn't invalidate our judgment that such a choice is bad. After all, addiction destroys lives, rendering addicts unproductive and unhappy. We have excellent reasons for expressing disapproval of drug abuse, since such disapproval can help dissuade those who aren't in the grip of nicotine or alcohol or heroin from taking that first, second, or nth hit. Precisely because the decision to drink or smoke or shoot up is, at first, voluntary--not internally compelled by addiction--stigmatizing that decision can reinforce the resolve to abstain or cut back.
Second, seeing that the traditional notion of free will is false may have an effect on just how much stigma we want to dispense, as well as its timing. Knowing that voluntary choices are just as determined as knee jerks undercuts the moralistic self-righteousness of those who suppose that they would never have succumbed to the temptations of crack or speed: there but for the contingency of life go I. Our anger at moral failure might be tempered, and seeing the causal necessity behind choices to use drugs might lead us to de-emphasize punitive measures with little or no utility (e.g., cutting welfare and health benefits for addicts) and increase our commitment to prevention, treatment, and outreach programs that actually reduce addiction and its harms. At the very least, seeing through the fiction of free will should lead us to re-evaluate the effectiveness of punishment, since it isn't deserved in the traditional sense.
We all know the power of stigma; just ask any youngster if he or she wants to grow up to be a junkie or a crackhead. But, as investigations of what works in treatment have shown, direct shaming of addicts is usually counterproductive: they need to learn that, despite the mistakes they have made, they are worthy of rehabilitation. What brings them and keeps them in treatment is knowing that someone cares, that they possess some kernel of dignity that merits praise and support, not continued condemnation. Stigma may play a useful corrective role in the early stages of drug abuse, but not after addiction has taken hold.
Although a thorough understanding of what causes addiction may lead us to reconsider the utility of stigma, it doesn't change our basic moral stance toward addicts and potential addicts: your choices were bad; do better next time or suffer the consequences. But such an understanding can significantly fine-tune the practical ethics of blame. To repeat: the vehemence of stigmatization will be kept in check by understanding that the choice to use drugs isn't a matter of uncaused free will, and its timing will be informed by how far along in the addictive process the individual has progressed. Such are the virtues of not compartmentalizing science and morality.
The growing scientific consensus that all human behavior lies within the natural realm has implications far beyond the study of addiction, of course. Whenever individuals are given all the blame or take all the credit for who they are and what they do, we can defeat such claims by pointing out the causal antecedents of their faults and virtues. Responsibility for good and bad doesn't inhere within some special, uncaused internal agent, but is distributed over the influences that create character and motive. Nevertheless, we must still praise or condemn an individual's behavior, because that, in part, is how people are shaped. Even though we can't any longer suppose that rewards and sanctions are deserved, in the pre-scientific sense of that word, they must still be applied, judiciously and compassionately. People are moral beings that should be held accountable--that is, be subject to rewards and sanctions--just to the extent that they have the capacity to anticipate and be influenced by them.
This model of morality ensures that, in the event a naturalistic, scientific self- understanding takes hold, excuse-mongering will not flourish. It will be generally conceded that we are all, in all respects, products of environment and heredity, but for that very reason social sanctions (and some hurt feelings, unfortunately) will be deemed essential to bring out the best in us, and inhibit the worst. On the other hand, it is likely that this same understanding will moderate the excesses of our all-too-punitive culture, transmuting our zeal for punishment into a concern for changing the conditions that produce destructive behavior in the first place. In a culture more fully informed by science, it will be a good deal more difficult to become an addict, and a good deal easier to find help, not rejection, should the unfortunate choice to abuse drugs arise.
Thomas W. Clark is a research associate at Health and Addictions Research Inc. in Boston. The views expressed here are strictly his own. He can be contacted at www.naturalism.org.