Disability is primarily a social phenomenon -- a way of being a minority, a way of facing social oppression, but not a way of being inherently or intrinsically worse off. This is how disability is understood in the Disability Rights and Disability Pride movements; but there is a massive disconnect with the way disability is typically viewed within analytic philosophy. The idea that disability is not inherently bad or sub-optimal is one that many philosophers treat with open skepticism, and sometimes (...) even with scorn. The goal of this book is to articulate and defend a version of the view of disability that is common in the Disability Rights movement. To be physically disabled is not to have a defective body, but simply to have a minority body. (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)

The cochlear implant controversy involves questions about the nature of disability and the definition of “normal” bodies; it also raises arguments about the nature and significance of culture and the rights of minority cultures. I defend the claim that there might be such a thing as “Deaf culture” and then examine how two different understandings of the role of culture in the lives of individuals can lead to different conclusions about the rights of Deaf parents in relation to their children, (...) and about the ethics of public funding for research on cochlear implants. An argument asserting the rights of minority cultures to equal respect and consideration within a multicultural society, informed by communitarian political philosophy, offers the best prospect for the defence of the unique culture(s) of the Deaf. (shrink)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

Where does normal brain or psychological function end, and pathology begin? The line can be hard to discern, making disease sometimes a tricky word. In addiction, normal ‘wanting’ processes become distorted and excessive, according to the incentive-sensitization theory. Excessive ‘wanting’ results from drug-induced neural sensitization changes in underlying brain mesolimbic systems of incentive. ‘Brain disease’ was never used by the theory, but neural sensitization changes are arguably extreme enough and problematic enough to be called pathological. This implies that ‘brain disease’ (...) can be a legitimate description of addiction, though caveats are needed to acknowledge roles for choice and active agency by the addict. Finally, arguments over ‘brain disease’ should be put behind us. Our real challenge is to understand addiction and devise better ways to help. Arguments over descriptive words only distract from that challenge. (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. Causal Thesis: Dispositions have a causal basis. II. Distinctness Thesis: Dispositions are distinct from their causal basis. III. Impotence Thesis: Dispositions are not causally active.

It is both common and natural to think of addiction as a kind of defect of the will. Addicts, we tend to suppose, are subject to impulses or cravings that are peculiarly unresponsive to their evaluative reflection about what there is reason for them to do. As a result of this unresponsiveness, we further suppose, addicts are typically impaired in their ability to act in accordance with their own deliberative conclusions. My question in this paper is whether we can make (...) adequate sense of this conception of addiction as a volitional defect. In particular, I want to focus on some philosophical assumptions, from the theory of action, that bear directly on the very idea that addiction might impair the agent’s volitional capacities. Understanding this idea, I shall argue, requires that we start out with an adequate conception of the human will. Only if we appreciate the kinds of volitional capacities characteristic of normal agents can we conceptualize properly the impairment of those capacities represented by addiction, and assess the implications of such impairment for questions of responsibility. (shrink)

Variation in addiction suggests that a good definition will be précising: it should serve a purpose. The authors canvass the various purposes served by a definition of addiction in psychiatric, social, legal, economic, interpersonal and scientific contexts. They argue that addiction is a strong and habitual want that significantly reduces control and leads to significant harm. What counts as significant varies relative to purpose and context. The authors offer a basic account of the nature of control and how and why (...) it can be reduced. The chapter explores the nature of harm and why it is part of the definition. And it concludes by suggesting that progress in understanding addiction depends on bearing in mind the various purposes and contexts of enquiry, together with the common-sense but often neglected point that both control and harm come in degrees. (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)

Drug use and drug addiction are severely stigmatised around the world. Marc Lewis does not frame his learning model of addiction as a choice model out of concern that to do so further encourages stigma and blame. Yet the evidence in support of a choice model is increasingly strong as well as consonant with core elements of his learning model. I offer a responsibility without blame framework that derives from reflection on forms of clinical practice that support change and recovery (...) in patients who cause harm to themselves and others. This framework can be used to interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and instead maintaining care and compassion alongside a commitment to working for social justice and good. (shrink)

Concepts We thank all three commentators for extremely constructive, insightful, and gracious commentaries. We cannot address all their valuable points. In this response, we elucidate and relate the concepts of addiction, disease, disability, autonomy, and well-being. We examine some of the implications of these relationships in the context of the helpful responses made by our commentators. We begin with the definitions of the relevant concepts which we employ: ¥? ? ? Addiction (Liberal Concept): An addiction is a strong appetite. ¥? (...) ? ? Appetites: An appetite is a disposition that generates desires that are urgent, oriented toward some rewarding behavior, periodically recurring, often in predictable circumstances, sated temporarily by their fulfillment, and generally provide pleasure. ¥? ? ? Disease (Naturalistic Concept): A disease is some biological or psychological state that results in subfunctioning of the organism in a given set of environmental and social circumstances, C. The reference class is a natural class of organisms of uniform functional design; specifically, an age group of a sex of a species. A normal function is a part or process within members of the reference class and is a statistically typical contribution by it to their individual survival and reproduction (Boorse 1977, 1997). ¥? ? ? Disability (Welfarist Concept): A disability is a relatively stable biological or psychological state that tends to reduce the amount of well-being that this person will enjoy in a given set of environmental and social circumstances (Savulescu and Kahane 2009; Kahane and Savulescu, 2009). ¥? ? ? Autonomy (Rationalist Concept): A person rationally desires or values some state of affairs if and only if he or she desires that state of affairs while (1) being in possession of all relevant. (shrink)