Advocates for the disease model of addiction say their arguments are evidence-based, and that their opponents are driven by ideology. But the closer you look, the shakier is the evidence for the disease model of addiction. The most cogent critique comes from Gene Heyman, a research psychologist and lecturer at Harvard Medical School. His book Addiction: A Disorder of Choice makes a convincing case that choice plays a much more important role in addiction than in other psychiatric disorders. And it demolishes the current “enlightened” picture of addiction as a chronic, relapsing illness with a bleak prognosis for recovery.
She concludes, against the general medical consensus (those elitists!) that
[d]rug addiction is a set of self-destructive impulses that are out of control – just like all the other impulses that lead us to choose short-term pleasure at the price of long-term pain.
The thing I always find remarkable about Wente is that under the guise of being contrarian, she almost always ends up confirming popular prejudices. Addiction is not a disease! Addicts deserve everything they get! Addiction is a moral choice! Conventional treatment enables addicts! Helping addicts by providing harm reduction strategies is wrong! Punish addicts for their addiction! And so on.
Wente nods (very) briefly to the benefits of the disease model of addiction, and the need to treat addicts with empathy and compassion. But how many people actually remember the real reasons we treat sick people, including substance abusers, in the rush to judgement?
“A disease is a condition,” Wente says, “that’s beyond your power to control.” Well, no. I would define disease, and I think I would get nods of agreement from my health professional colleagues, as any condition that prevents an individual from functioning with optimal social, mental or physical well-being. Unfortunately Wente thinks disease is always something entirely random, like bacterial meningitis or ALS. What I would like to ask Wente is this: if addiction is not a disease, and if addicts are entirely responsible for their condition, what about non-insulin dependent diabetics and those suffering from heart disease, which have strong links to lifestyle choices and, some would say, self-destructive impulses? Why should we treat them any differently than drug addicts?
The point is we all make choices, good or bad, for our health. Choice, however, often implies a moral value judgement and the assignment of blame: two things clinicians should avoid in treating patients. But choice — whether it’s your 80-year-old diabetic grandmother or the homeless substance abuser down the street — shouldn’t be confused with disease.