No Need for the Disease Label: Choice is Complicated. Reply to Heather
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LETTER
No Need for the Disease Label: Choice is Complicated. Reply to Heather Marc Lewis
Received: 20 February 2017 / Accepted: 22 February 2017 / Published online: 4 May 2017 # Springer Science+Business Media Dordrecht 2017
Abstract Despite its historical contribution, Heather sees the Brain Disease Model of Addiction (BDMA) as failing to relieve stigma, increasing fatalism, and fundamentally wrong. He also sees Bchoice^ as partly volitional and partly unconscious, implying no moral violation. I agree on all counts. Heather then presents a disorder-of-choice (DOC) model of addiction, highlighting the failure of self-regulation with respect to immediate goals. Not only do I endorse such modeling, but the neural mechanisms I describe may help to explicate it more thoroughly. Keywords BDMAvs. blame . BDMA and scientific legitimacy . Biology and badness . Differentiating developmental models . Agreement with Ainslie and Lewis . Biology of dual processing . Loss of selfregulation not from disease . Alternatives to Btreatment^ . Harm done by BDMA
Nick Heather's commentary [1] makes its first contribution by specifying a false dichotomy: that addiction is either a moral failing – because addicts voluntarily choose actions that cause harm – or it's a disease. No, in fact, choice is simply not that simple, but more on that later. His second contribution is to expose how NIDA and other prominent organizations and funders, M. Lewis (*) Developmental Psychology, University of Toronto, 27 King’s College Cir, Toronto ON M5S, Canada e-mail: [email protected]
especially in the US, have exploited this false dichotomy by "guilting out" their opponents. If you don't take our word for it when we say addiction is a disease, then you are blaming addicts for their addiction. Since, over the last century, blaming, disparaging, and punishing addicts has only led to more suffering, and since it clearly has not helped "fix" the problem, then it would be wrong-headed at best, and "intellectually dishonest" or even cruelly punitive otherwise, to reject the disease model and accept the choice premise in its place. On both these points Heather and I agree. It is indeed a strange logic: choosing to cause harm is blameworthy, blame is bad for everyone, so a model that does not blame is a good model, and our model is a model that does not blame, and so – the last term in the algorithm is the assumption that the Brain Disease Model of Addiction (BDMA) is the only alternative. I agree with Heather that it's almost painfully obvious that there are many other models that do not blame individuals for the problem of addiction. Indeed, some are behavioral or psychosocial, and others, such as mine, are based on biological science. Since there are clearly other models that absolve the addict from blame, Heather asks whether the disease model is the only scientific model the public is likely to understand. That might salvage the logic. But he shows this to be untrue as well. Many other models would fit what educated adults are likely to understand. So
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