Substance addiction has been historically conceived and widely researched as a brain disease. There have been ample criticisms of brain-centred approaches to addiction, and this paper aims to align with one such criticism by applying insights from phenomenology of psychiatry. More precisely, this work will apply Merleau-Ponty’s insightful distinction between the biological and lived body. In this light, the disease model emerges as an incomplete account of substance addiction because it captures only its biological aspects. When considering addiction as a (...) brain disorder, it will be shown that research fails to account for the contextual, functional, and emotional aspects inherent to subjective health. It is concluded that, while the disease model is fundamental to our understanding of what happens in the brain, its brain-centred approach is cure-oriented. Instead, we suggest a care-orientated approach, which understands and treats the psychological feel as bodily experience situated in an environment, allowing for a more encompassing therapeutic perspective. (shrink)

Although these authors sometimes resort to medical terminology, we strongly agree that addiction is not a disease and that the Brain Disease Model of Addiction captures only one part of the story and distorts the big picture. Yet Satel and Lilienfeld continue to conflate a neurobiological model with a disease model. They also complain that my modeling of addiction reveals a hidden “neurocentric” bias, despite my integration of multiple levels of analysis, exactly as they recommend.

Despite its historical contribution, Heather sees the Brain Disease Model of Addiction as failing to relieve stigma, increasing fatalism, and fundamentally wrong. He also sees “choice” as partly volitional and partly unconscious, implying no moral violation. I agree on all counts. Heather then presents a disorder-of-choice 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.

In this introduction we set out some salient themes that will help structure understanding of a complex set of intersecting issues discussed in this special issue on the work of Marc Lewis: conceptual foundations of the disease model, tolerating the disease model given socio-political environments, and A third wave: refining conceptualization of addiction in the light of Lewis’s model.

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking (...) framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal. (shrink)

Pickard’s contribution reminds me that conceptualizing choice is no simple matter. Pickard sees choice as entirely voluntary, while I argue that choice is only partially voluntary. Choices are based on appraisals of situations, which fluctuate due to external circumstances and internal states such as emotion and mood. Habit itself competes with volition, and all these parameters vary with development. Psychological factors such as delay discounting and especially one's belief in one's agency are critical for volitional choice as well.

Snoek, like other commentators, conflates some of my neural claims with those of the Brain Disease Model of Addiction. But she sees other details of my modeling with precision and depth. I welcome her emphasis on individual and developmental differences in addicts' capacity to recognize and deploy their personal agency. In fact we agree that belief in personal agency is a critical first step to cultivating it. Yet I wish to steer away from the disease nomenclature, to give that belief (...) its best chance to flourish. (shrink)