Addiction: A Disorder Of Choice? : 13.7: Cosmos And Culture To understand addiction, we must view it against the background of the dynamic pattern of values, preferences and choices that real people make. This is the argument of Gene M. Heyman's worthwhile book on the topic.
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Addiction: A Disorder Of Choice?

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A Chinese chef demonstrates his cooking skills to visitors during the 12th Asian International Exhibition of Food and Drink, Hotel, Restaurant & Foodservice Equipment Supplies & Services (HOFEX) at the Hong Kong Exhibition Center in 2007.
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"Shall I have Chinese food tonight, or Italian?

I like Chinese more, but I had it last night, and I find that I enjoy it less if I have it two nights in a row. And anyway, I guess I'm kind of in the mood for Italian."

This imagined interior dialog brings out an interesting fact about values, preferences and choices. I may prefer one thing to another (Chinese food to Italian), but the current value of my preferences fluctuates dynamically as a response to my actions and past choices. If I eat Chinese food every night, the value to me of those meals will gradually reduce to zero.

This is a general truth about life and choice. Exercise is wonderful, until you get tired; rest is wonderful, until you get bored, and then restless. In a good life — if I can be permitted such a phrase — there is a kind of interplay and balance in the dynamic of shifting values, preferences and choices. What we like and want affects what we do; what we do in turn affects what we like and want.

The Chinese food example comes from Gene M. Heyman's 2009 book on addiction; Heyman makes an interesting observation in this connection. It isn't only the case that our choices and actions bring about dynamic fluctuation in the values we place on things; it is further the case that there are always different ways of framing the choice problems that we face.

So consider the dining example again and notice that there are two different ways I might reason about the question what should I eat? According to the first way, I say to myself: what do I want to eat now? Chinese, or Italian? If I take this local approach, I am likely to tend, over time, to alternate nightly between Chinese and Italian cuisine (perhaps, given my antecedent preference for Chinese food, with a slight tendency to eat Chinese more often).

But there is also a global approach available to me. Instead of thinking of the choice I face on a meal-by-meal basis as a choice about what to eat right now given what I want right now, I might ask myself: how can I get the most out of my meals by planning a series of meals? And if take up this global perspective, I am likely to be led to a very different conclusion about what to do. After all, from this perspective it may become immediately clear that the way to get the most out of my meals is by eating fewer Chinese than Italian meals, not because I like Chinese less, but because I like it more, and because I realize that I can enhance my pleasure in the Chinese food I do eat by eating it less often. The local perspective leads me to eat approximately equal amounts of Chinese and Italian food; the global perspective leads me to eat more Italian than Chinese. And even though I like Chinese food more, by eating it less, I maximize my overall eating pleasure.

There's a lot to be said for the global perspective. It's smart. It's rational. And, as Heyman lays out convincingly, it may lead to an outcome which is better over all (that is, I get more pleasure from what I eat). Of course, the local perspective is much easier to take up. On the local perspective, we simply respond perceptually to the options before us here and now. What do I want to eat, now? Taking up the global perspective requires discipline; we need step back and think about the best course of action. We need to abstract away from present impulse.

Whatever we say about the relative merits of local versus global perspectives, the critical thing is this: values are dynamic and the choices we make affect not only what we do but the pleasure we take in what we do.

When Heyman says that addiction is a disorder of choice — this is the title of his book, Addiction: A Disorder of Choice — he does not mean that addicts are weak willed or that they make dumb choices. This is not a blame-the-victim book. He means something different, something subtle. His point: the distinctive hallmark of addiction is the fact that in addiction the normal interplay we've just been contemplating between choice, value and preference breaks down.

And this is because addictive substances are, in Heyman's phrase, behaviorially toxic. They neutralize the value of everything else. Work, sex, food, friendship, children — looked at locally, nothing outweighs the value the addict places on his desired substance. If I take up the local perspective on whether I should consume my drug or go to sleep, or exercise, or make love, the drug will win out every time. Addictive behavior is the natural outcome of taking up the local perspective in the presence of behavioral toxicity.

Of course the more I use my drug, the more I come to tolerate its effects, and so the less pleasure an episode of drug use can afford me. This suggests that if I were to take up the global perspective, it would lead me in the direction of abstinence. After all, from the global perspective I'd realize that by using the drug less, the pleasure of using drugs would go up; abstaining from drug use would also enhance the pleasures of non-drug activities. From the global perspective it becomes clear that I'd be a happier drug user to the extent that I minimized my use of drugs.

Why doesn't the addict take up this global perspective? And why doesn't this give him or her a route to abstinence? Why can't the addict manage this? This is an interesting and important question. And it is, of course, tantamount to the question: Why is the addict addicted? What is it to be addicted?

And now we come to the main upshot of Heyman's discussion, an upshot which is as provocative as it is, in a way, modest. The idea is this: if we are to understand addiction, we must view it precisely in this setting where wants, values, preferences and choices are in play. Addiction is in this sense a disorder of choice.

To say this is not to deny that addiction is a disease, although it is to put pressure on what we mean by disease. Nor is it to deny that addiction has critical neurological aspects. Indeed, as we discussed last week, it is doubtless that the mechanism whereby addictive substances produce their behaviorally toxic effects are in part neurological. What Heyman's proposal does rule out, though, is the idea that we can understand addiction apart from the setting of a person's dynamic life as an agent. And for this reason, I believe, it rules out the now familiar reductive dogma that addiction is a disease of the brain.

Here is a remarkable yet rarely remarked fact about addiction. Only a very small portion of drug users are drug addicts. About 15 percent of people who drink develop alcoholism; about 10 percent of those who experiment with drugs become drug addicts. (See Heyman's book for the references.) Why is this? What governs these outcomes?

Genetic and neurological factors may play an important role. But perhaps there are other choice-related factors that play a role as well. Here's a possibility: as Heyman informs us, the majority of addicts are single; moreover, no one is better positioned and more motivated to resist the addict's problem than his or her spouse. Having a spouse raises the costs of addiction and may be a factor, a choice-pertinent factor, in predisposing someone to avoid the trap of addiction.

It may even help the addict break free from addiction. For there is a second remarkable but rarely noticed fact about addiction (again, see the book for the details). Despite the oft-chanted dogma that addiction is a chronic incurable disease of the brain — "once an addict always an addict" — the best data available clearly demonstrates that more than 75 percent of hardcore drug addicts will eventually cease to take drugs and that they will do so without having received treatment. How can this be? What could explain this? And what determines who breaks free from the trap of addiction and who fails to do so?

If Heyman is right, we might hope to find the answer to these questions by turning our attention not to the nervous system of the addict, to his or her internal life, but rather to the pattern of needs, options, values, preferences and pressures that structure the person's ongoing life in a community with others.

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