Many people reject the idea that addiction is a disease. The most common objection is that addiction is a “choice” not a disease. It is not difficult to understand this perspective. Using drugs or alcohol is almost always a voluntary act, involving a deliberate decision. The choice to use drugs or alcohol is similar to other decisions motivated by immediate gratification, greed or selfishness, such as having unprotected sex, shoplifting or telling lies. Yet, the consequences of uncontrolled impulses to have unprotected sex, such as unplanned pregnancy, or a felony record resulting from criminal acts are not considered “diseases”. Why should addiction be so labeled?
There seem to be many stark differences between choices and diseases. The first major difference is the role of free will. Choice involves the exercise of free will whereas diseases are things that happen to us without our permission and against our will. Who chooses to get schizophrenia or psoriasis? With diseases ranging from Alzheimer’s disease to kidney stones, patients are blameless victims of disease. On the other hand, free will means we are directly responsible for the consequences of our choices.
Choices are influenced by many factors, including persuasions, incentives, or peer pressure, each of which can encourage certain decisions. Alternatively, threats and punishments can discourage us from making other decisions. For example, political advertisements try to persuade us to vote for one candidate by making promises while negative political advertisements try to scare us from voting for the other candidate. Incentives and punishments also work for addictions. For example, someone applying for a new job might stop using drugs in order to pass a pre-employment urine drug test, while fear of incarceration for repeated drunk driving charges might motivate someone to give up alcohol. On the other hand, no amount of incentives or punishments will stop someone from having a seizure.
Clearly choice plays prominent roles in addictions. However, it would be a mistake to frame “choice” and “disease” as mutually incompatible opposites, suggesting that choice and disease cannot co-exist. In reality, almost every condition we treat in medicine can be strongly impacted by the choices patients make. Most obviously, choices such as smoking, overeating and lack of physical activity contribute immensely to diabetes, heart disease and strokes. In sports, athletes choose to play football aware of the risks of concussions. People also choose dangerous occupations. Should we refuse to treat coal miners with black lung disease because it was their choice to do that kind of work? Should we tell the police officer who got shot on the job that it was her/his own fault for choosing such a dangerous job? Finally, there are also many choices of inaction that lead to health problems. A diabetic with tight finances might choose not to fill an expensive prescription and end up with severe diabetic complications. Fear of medical procedures might cause someone to avoid a colonoscopy, but should we just call the preventable colon cancer that subsequently develops just a “choice”?
Each example of bad health outcomes given above resulted from potentially regrettable choices. We might applaud certain choices, such as serving in the military, or frown on others, such as choosing to ride a motorcycle without a helmet. However, whether or not we “approve” of the choices others make is irrelevant – we do not have the right to judge our patients’ choices. As a physician, I still have the same obligation to treat them with care, compassion and dignity.
The situation with addiction actually gets even more complicated. Just as early stage Alzheimer’s disease specifically affects the brain’s memory functions, the disease of addiction specifically affects the brain’s processing of reward and decision-making. We blame addicted patients for bad choices whereas their disease exactly lies in impaired ability to balance reward with consequences. We blame them for not controlling their urges to use drugs or alcohol when loss of control is the pathology. It is like blaming a blind person for being unable to see – “You wouldn’t be blind if you just used your eyes!”
Yes, addiction clearly involves choice, but choice and disease are not mutually exclusive. If addiction cannot be a disease simply because patients made unwise choices, then diabetes and lung cancer also cannot be diseases because both these conditions also involve poor choices.
This essay merely argues that the involvement of choice does not disprove addiction could be a disease, but does not lay the case for why addiction is a disease. In other essays, I will demonstrate that addiction should be considered not merely as a mental disease or disorder but as a chronic medical disease, just like diabetes, heart disease, Alzheimer’s dementia, etc.