The target of Hanna Pickard's very erudite and thought-provoking article is compulsion. She argues that “addiction is not a form of compulsion” and that “addictive desires are not irresistible” (Pickard 2012, 40). However, I fear that compulsion as she presents it is ultimately a metaphysical straw figure, trapped in a false metaphysical dichotomy. What is lacking is a proper attention to specific individual clinical cases, examined over time. At the same time, Pickard's discussion is extremely important because of the manner (...) in which it highlights both the merits and the perils of philosophical inquiry into the nature of addiction... (shrink)

Is it ever possible for people to act freely and intentionally against their better judgement? Is it ever possible to act in opposition to one's strongest desire? If either of these questions are answered in the negative, the common-sense distinctions between recklessness, weakness of will and compulsion collapse. This would threaten our ordinary notion of self-control and undermine our practice of holding each other responsible for moral failure. So a clear and plausible account of how weakness of will and self-control (...) are possible is of great practical significance. Taking the problem of weakness of will as her starting point, Jeanette Kennett builds an admirably comprehensive and integrated account of moral agency which gives a central place to the capacity for self-control. Her account of the exercise and limits of self-control vindicates the common-sense distinction between weakness of will and compulsion and so underwrites our ordinary allocations of moral responsibility. She addresses with clarity and insight a range of important topics in moral psychology, such as the nature of valuing and desiring, conceptions of virtue, moral conflict, and the varieties of recklessness (here characterised as culpable bad judgement) — and does so in terms which make their relations to each other and to the challenges of real life obvious. Agency and Responsibility concludes by testing the accounts developed of self-control, moral failure, and moral responsibility against the hard cases provided by acts of extreme evil. (shrink)

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance (...) directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike. (shrink)

Recent studies reveal some of the neurophysiological mechanisms involved in drug addiction. This prompts some theorists to claim that drug addiction diminishes responsibility. Stephen Morse however rejects this claim. Morse argues that these studies show that drug addiction involves neither compulsion, coercion, nor irrationality. He also adds that addicted people are responsible for becoming addicted and for failing to take measures to manage their addiction. After summarizing relevant neuroscience of addiction literature, this chapter engages critically with Morse to argue that (...) a subgroup of addicted people does meet plausible criteria for compulsion, coercion, or irrationality; that few addicted people are fully responsible for becoming addicted; and that some addicted people can be at least partly excused for failing to manage their addiction. Pickard and Lacey’s “responsibility without blame” approach is also suggested as a fruitful basis for future work in this field. (shrink)

This article critically interrogates contemporary forms of addiction medicine that are portrayed by policy-makers as providing a ‘rational’ or politically neutral approach to dealing with drug use and related social problems. In particular, it examines the historical origins of the biological facts that are today understood to provide a foundation for contemporary understandings of addiction as a ‘disease of the brain’. Drawing upon classic and contemporary work on ‘styles of thought’, it documents how, in the period between the mid-1960s and (...) the mid-1970s, such facts emerged in relation to new neurobiological styles of explaining and managing social problems associated with drug abuse, and an alliance between a relatively marginal group of researchers and American policy-makers who were launching the ‘War on Drugs’. Beyond illustrating the political and material conditions necessary for the rise of addiction neuroscience, the article highlights the productivity of neurobiological thought styles, by focusing on the new biological objects, treatments and hopes that have emerged within the field of addiction studies over the last several decades. (shrink)

There continues to be a debate on whether addiction is best understood as a brain disease or a moral condition. This debate, which may influence both the stigma attached to addiction and access to treatment, is often motivated by the question of whether and to what extent we can justly hold addicted individuals responsible for their actions. In fact, there is substantial evidence for a disease model, but the disease model per se does not resolve the question of voluntary control. (...) Recent research at the intersection of neuroscience and psychology suggests that addicted individuals have substantial impairments in cognitive control of behavior, but this "loss of control" is not complete or simple. Possible mechanisms and implications are briefly reviewed. (shrink)

The claim that addiction is a brain disease is almost universally accepted among scientists who work on addiction. The claim’s attraction rests on two grounds: the fact that addiction seems to be characterized by dysfunction in specific neural pathways and the fact that the claim seems to the compassionate response to people who are suffering. I argue that neural dysfunction is not sufficient for disease: something is a brain disease only when neural dysfunction is sufficient for impairment. I claim that (...) the neural dysfunction that is characteristic of addiction is not sufficient for impairment, because people who suffer from that dysfunction are impaired, sufficiently to count as diseased, only given certain features of their context. Hence addiction is not a brain disease (though it is often a disease, and it may always involve brain dysfunction). I argue that accepting that addiction is not a brain disease does not entail a moralizing attitude toward people who suffer as a result of addiction; if anything, it allows for a more compassionate, and more effective, response to addiction. (shrink)

People struggling with addiction are neither powerless over their addiction, nor are they fully in control. Lewis vigorously objects to the brain disease model of addiction, because it makes people lose belief in their self-efficacy, and hence hinders their recovery. Although he acknowledges that there is a compulsive state in addiction, he objects to the claim that this compulsion is carved in stone. Lewis argues that the BDMA underestimates the agency of addicted people, and hence hinder their recovery. Lewis’s work (...) offers us a very much to be welcomed neurobiology of recovery. It offers addicted people a hopeful and respectful narrative for their recovery that treats them as agents rather than as damaged brains. However, I argue that overestimating people’s agency can also result in people losing belief in their self-efficacy. Lewis’s strong focus on the agency of addicted people might not match their experiences of struggle, hence reinforcing their feelings of guilt when they fail to control their use. I propose to replace the notion of addiction as a disease with a notion of a disease-like stage in addiction. I call this stage the duress stage in addiction, in which the addictive behaviour is largely impervious to the agent’s values and to available techniques of self-control. However, the agent can overcome this stage by developing new techniques of self-control, by building on their self-concept and belief in self-efficacy, by changing their environments and habits, and by engaging in projects that are meaningful to the agent. (shrink)

A modest opposition to the brain disease concept of addiction has been mounting for at least the last decade. Despite the good intentions behind the brain disease rhetoric – to secure more biomedical funding for addiction, to combat “stigma,” and to soften criminal approaches – the very concept of addiction as a brain disease is deeply conceptually confused. We question whether Lewis goes far enough in his challenge, robust as it is, of the brain disease concept. For one thing, the (...) notion that addiction is a disease is challenging to refute or confirm because the disease concept itself is poorly defined in medical and psychological nosology. More important, quibbling over what kind of disease addiction is unlikely to be productive. The rational response to adjudicating whether addiction is a brain disease is not to engage in potentially fruitless debates over the question of disease classification but rather to view addiction as an enormously complex set of behaviors that operate on several dimensions, ranging from molecular function and structure and brain physiology to psychology, the psychosocial environment, and social and cultural relations. (shrink)

This article reviews scientific advances in the prevention and treatment of substance-use disorder and related developments in public policy. In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned, perhaps because the aberrant, impulsive, and compulsive (...) behaviors that are characteristic of addiction have not been clearly tied to neurobiology. Here we review recent advances in the neurobiology of addiction to clarify the link between addiction and brain function and to broaden the understanding of addiction as a brain disease. (shrink)

I argue that addiction is not a chronic, relapsing, neurobiological disease characterized by compulsive use of drugs or alcohol. Large-scale national survey data demonstrate that rates of substance dependence peak in adolescence and early adulthood and then decline steeply; addicts tend to “mature out” in their late twenties or early thirties. The exceptions are addicts who suffer from additional psychiatric disorders. I hypothesize that this difference in patterns of use and relapse between the general and psychiatric populations can be explained (...) by the purpose served by drugs and alcohol for patients. Drugs and alcohol alleviate the severe psychological distress typically experienced by patients with comorbid psychiatric disorders and associated problems. On this hypothesis, consumption is a chosen means to ends that are rational to desire: Use is not compulsive. The upshot of this explanation is that the orthodox view of addiction as a chronic, relapsing neurobiological disease is misguided. I delineate five folk psychological factors that together explain addiction as purposive action: strong and habitual desire; willpower; motivation; functional role; and decision and resolve. I conclude by drawing lessons for research and effective treatment. (shrink)

The way in which we characterize the structural and functional differences between psychopath and normal brains – either as biological disorders or as mere biological differences – can influence our judgments about psychopaths’ responsibility for criminal misconduct. However, Marga Reimer (Neuroethics 1(2):14, 2008) points out that whether our characterization of these differences should be allowed to affect our judgments in this manner “is a difficult and important question that really needs to be addressed before policies regarding responsibility... can be implemented (...) with any confidence”. This paper is an attempt to address Reimer’s difficult and important question; I argue that irrespective of which of these two characterizations is chosen, our judgments about psychopaths’ responsibility should not be affected, because responsibility hinges not on whether a particular difference is (referred to as) a disorder or not, but on how that difference affects the mental capacities required for moral agency. (shrink)

Heroin prescription involves the medical provision of heroin in the treatment of heroin addiction. Rudimentary clinical trials on that treatment modality have been carried out and others are currently underway or in development. However, it is questionable whether subjects considered for such trials are mentally competent to consent to them. The problem has not been sufficiently appreciated in ethical and clinical discussions of the topic. The challenges involved throw new light on the role of value and accountability in contemporary discussions (...) of mental competence. (shrink)

Addiction of the variety discussed in this chapter, is a condition that by its very nature compromises decision-making capacity across the decisional spectrum. The impairment is present not only at moments of withdrawal and intoxication, but at all stages of the active addictive cycle, as long as the pathological dispositions to overvalue addictive drugs remain entrenched and operative. In light of this entrenched and pervasive reorientation in pathological values, it seems reasonable to question the unilateral presumption of capacity for cases (...) of this sort. The reason is that there is an important, but restricted, sense in which the addicted individuals in question are not ‘responsible’ for their decisions regarding drug use. The high likelihood of relapse means that, as a clinical matter of fact, they are usually not accountable. At the same time, clinical experience also suggests that we should treat addicted individuals as if they are responsible because that empowerment is crucial to their recovery. In the end, there is probably only one safe course of action to take when faced with such a difficult situation. This is to suspend the unilateral global presumption of capacity and instead assess decision-making capacity on a case-by-case basis, with careful monitoring and encouragement. (shrink)

This book examines core issues related to legal insanity, integrating perspectives from psychiatry, law, and ethics. Various criteria for insanity are analyzed and recommendations for forensic psychiatric and legal practice are offered. Many legal systems have an insanity defense, in one form or another. Still, it remains unclear exactly when and why mental disorders affect a person’s moral or criminal responsibility. Questions addressed in this book include: Why should insanity be a component of our legal system? What should be the (...) criteria for an insanity defense? What would be the reasons for abolishing it? Who should bear the burden of proof? Furthermore, the book discusses the impact neurosciences may have on psychiatric and psychological evaluations of defendants as well as on legal decisions about insanity. (shrink)

The current dominant perspective on addiction as a brain disease has been challenged recently by Marc Lewis, who argued that the brain-changes related to addiction are similar to everyday changes of the brain. From this alternative perspective, addictions are bad habits that can be broken, provided that people are motivated to change. In that case, autonomous choice or “free will” can overcome bad influences from genes and or environments and brain-changes related to addiction. Even though we concur with Lewis that (...) there are issues with the brain disease perspective, we also argue that pointing to black swans can be important, that is: there can be severe cases where addiction indeed tips over into the category of brain disease, but obviously that does not prove that every case of addiction falls into the disease category, that all swans are black. We argue that, for example, people suffering from Korsakoff’s syndrome, can be described as having a brain disease, often caused by alcohol addiction. Moreover, the brain changes occurring with addiction are related to choice-behaviour, habit formation and insight, hence essential mental abilities to break the addiction. We argue for a more graded perspective, where both black swans and white swans are rare, and most cases of addiction come as geese in different shades of gray. (shrink)