Can the Harmful Dysfunction Analysis Explain Why Addiction is a Medical Disorder?: Reply to Marc Lewis
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LETTER
Can the Harmful Dysfunction Analysis Explain Why Addiction is a Medical Disorder?: Reply to Marc Lewis Jerome C. Wakefield
Received: 29 March 2017 / Accepted: 2 April 2017 # Springer Science+Business Media Dordrecht 2017
In a target article [1] in a previous issue of this journal, Marc Lewis argued that addiction is a manifestation of the brain’s normal capacities for pleasure-seeking and habit formation, and therefore is not a brain disorder as is commonly claimed but rather a learning-developmental phenomenon. In two papers in that issue [2, 3], based on my evolutionary Bharmful dysfunction^ conception of disorder, I argued that addiction is a medical disorder because addictive sensitization is to substances or other stimuli that the brain was not biologically designed to handle. (In [1], I explained why, given Marc’s goals and the semantics of disorder and disease, it is justified to shift the focus from the question of whether addiction is a brain disease to the broader question of whether it is a medical disorder.) In his reply [4] Marc posed fundamental questions about the viability of an evolutionary approach to the concept of disorder and raised provocative issues about the disorder status of various sexual practices and orientations, and these points require comment. Marc notes that my evolution-based argument that addiction is a disorder depends on being able to differentiate Bwhat are ‘naturally selected adaptations’ and what are not.^ True, and this is exactly what the science of evolutionary biology routinely provides, namely, an identification of what functions the various features of an organism were naturally selected to perform. Such
J. C. Wakefield (*) School of Social Work, Department of Psychiatry, and Center for Bioethics, New York University, 1 Washington Square North, New York, NY 10003, USA e-mail: [email protected]
facts are often difficult to establish and fallibly inferred from circumstantial evidence due to lack of direct knowledge of evolutionary history and underlying mechanisms, and there is a lot of room for ambiguity and fuzziness and indeterminacy in such judgments. However, answers are still possible, as the science of evolution demonstrates. Marc denies such knowledge, restating his response to another paper that raised an evolutionary argument: BIt’s very tricky to specify what evolution intended, but the functions of human neural systems are magnificently general. The dopaminergic system evolved to pursue goals, jack up motivation, and narrow attention to those goals by demoting the salience of other goals. So it seems to be working well in addiction.^ Note that evolution of course has no intentions, so Marc’s phrase Bwhat evolution intended^ is simply a metaphorical way of talking about the fact, recognized in biological theory since antiquity starting with Aristotle’s notion of Bfinal causes^ and finally explained by Darwin’s theory of evolution through natural selection, that natural features of biological systems are structured in ways that are not accidental but co
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