Don’t Let the Good Life Pass You By

What is the "good life" though? Does it involve sobriety or drinking/drugs in moderation or is it drowning out all sorrows/stress/worries using other stimulants? What is alcoholism? What is addiction? What causes them?

This discussion is an interesting, complex one that has probably either directly or indirectly affected everyone that will read this. Chapter 19 of Medical Ethics is on the ethical issues inn treating alcoholism and addiction. There are three different viewpoints presented by the author, and I think that the reality is most likely a mix of all of them.

The first question--is alcoholism/addiction a disease? If the answer to this question is yes, and the disease model of alcoholism is correct, then alcoholics fall down a 'rabbit hole' to alcoholism, and after taking their first drink their fate is sealed. Alcoholics Anonymous and Narcotics Anonymous believe strongly that, "alcoholism is an illness...which can never be cured. The concept of Alcoholics Anonymous is that alcoholics are sick people who can recover if they will follow a simple program" (Pence 462). The AA/NA model has developed a few distinct claims:

1. some people are more susceptible to alcoholism because it's a disease

2. a specific pattern develops during alcoholism, one of inevitable descent to rock bottom

3. the pain of withdrawal makes alcoholics so miserable that they continue drinking (or using drugs) to avoid their misery

4. victims lose all control over their use of substances (alcohol or drugs)

5. the damage of the above steps in the process escalates until victims hit the proverbial bottom, when they either die or reach out to others for help

They also adopt the stance that substance-abusers shouldn't be blamed for being sick and to do so would be to blame the victim. If it is a disease, these patients should also be treated as patients and should receive the same attention and care that other healthcare provides.

Next up is neuroscientists, who take a different stance. They claim that alcoholism/addiction is better considered and treated as an acquired disease of the brain (Pence 463). This is based initially on the fact that the first release of dopamine in the first exposure to the stimulant is higher than it will be in any subsequent high, thus leading to a pursuit of euphoria but never again achieving it to the same extent. There is also the matter of the antireward system being overactive in addicts, where an overwhelming feeling of uneasiness or general malaise follows the drug wearing off. So, even when the drug is no longer pleasurable and addicts no longer understand why they're taking the drug, this scientific specialty field claims that the brain has changed and now impairs many processes, leading to continued addiction.

Another hypothesized understanding of alcoholism/addiction comes from genetics. These scientists claim that alcoholism is a polygenic disorder (caused by an assortment of genes), as demonstrated in ~60% of alcoholism cases between 2004-2009 (Pence 464). Much of this is thought to be due to the underproduction of dehydrogenase (breaks down alcohol) and/or a genetic predisposition to alcohol resistance which leads to drinking larger amounts of alcohol without feeling as intoxicated. For some genetic diseases, a genetic mutation leads directly to a disease regardless of other factors; this is not the case for alcoholism. This fact raises some doubt, but geneticists say that "alcoholism is gene-based" and a person may be predisposed to a higher likelihood of becoming addicted, but isn't guaranteed to see that as part of their life. It is interesting to note though, that at this point much of the research is not yet able to definitively declare reasons as to why specific groups or cultures of people are more or less susceptible to becoming addicted (e.g. Native Americans and alcoholism) (Pence 465). 

When it comes to the ethics of alcoholism and addiction, there are again many different ideas. According to Kantian ethics, humans can give up on themselves and treat themselves as things--voluntarily destroying part of their essence (Pence 466). Humans are also "special" and that generates ethical considerations. Therefore, the disease model is flawed in treating people as things because it takes away their free will. Ethics based on Kantian models claim that AA and NA contradict themselves, because their programs assumes that the addict has the power to choose to be sober as well as claiming that people should be treated as objects (with a disease). 

Another philosopher, Herbert Fingarette, looked at studies and statistics and concluded that alcoholics have free will over their drinking, choose to be heavy drinkers, and make drinking a main focus of their lives (Pence 469). He also denied that alcoholism involves a progression of the disease, finding that many alcoholics learn to control their drinking and/or change their behavior if it begins to accelerate out of control. Fingarette said that many people who do not consider themselves alcoholics actually meet the criteria for alcoholism, therefore invalidating the disease model. Another contradiction (to AA/NA) pointed out here was that if the patient has a disease over which he has no control, what's the point of therapy or trying to live clean?

Sociologists focus elsewhere. From this vantage point, social factors explain a person's behavior better than anything else (Pence 468). Aspects such as ethnicity, socioeconomic status, social background, family structure/stability, etc. contribute directly to a variety of behaviors and explain many part of a person's life. 

Another approach, harm reduction, is in direct contrast to a moralistic approach by focusing on reducing bad consequences of deviant behavior rather than eliminating the behavior (Pence 469). This philosophy can be applied to many other moral issues like gun control, teen pregnancy, smoking, and, medical malpractice, among others. Harm reduction suggests that the addict controls some of the consequences of other actions and reducing some consequences of deviant behavior would allow them to have more control over their life.

The social justice model seeks answers to issues such as the thousands of addicted people living on the streets and using a wide variety of drugs (Pence 472). This can be compared to the Rawlsian ideas of justice, where a society is only just if the poor are better off than under a different system, which is currently false. Rawlsian justice also requires the basic structure of a society to discourage addictions rather than allow corporations to create addicted people and profit off of them, which is also not currently the case. There are many flaws with the current social and economic systems in place, and much must change before things can be considered just.

So, what? In my personal opinion, there are certain approaches that make more or less sense than others, but again, everyone's experiences are different. There's a lot to consider here, but I think it's important to look at the bigger picture and recognize that alcoholism and addiction are not positive conditions and that changes need to be made before there will be a just society that doesn't prey on people who may be more susceptible to these diseases/conditions/whatever you to call them.

Textbook reference:

Pence, Gregory. Medical Ethics: Accounts of Ground-Breaking Cases. 9th ed., McGraw Hill, 2021.