|
|
| print this
The Supreme Court reopens an old question
Alcohol
And Free Will
by
Robert Wright
"He’s
a sick person," says Jane Wyman of Ray Milland. "It's
as though there were something wrong with his heart or lungs."
The movie is The Lost Weekend, and Milland is Don Birnam,
an aspiring writer whose potential is stifled by his perennial
willingness to pawn anything, including his typewriter,
for enough money to drink himself unconscious. Wyman, Birnam's
aspiring fiancée, is explaining why he deserves forgiveness
and patience. It's not as though his disintegration were
his fault, she's saying; the man has a disease.
The
movie, released in 1945, could hardly have been better timed.
For the previous ten years, Alcoholics Anonymous had been
pushing the idea that alcoholism is a disease, and in 1946,
about the time The Lost Weekend was winning a fistful of
Academy Awards, the idea received the imprimatur of science
with the publication of E.M. Jellinek's "Phases in
the Drinking History of Alcoholics." Jellinek (who,
perhaps not coincidentally, based his study on questionnaires
designed and distributed by (A.A.) found that alcoholism
follows a roughly predictable pattern, from social drinking
through various stages of excess, culminating in secret
drinking, blackouts, and other symptoms. For the true alcoholic,
Jellinek found, this grim cycle is virtually inexorable,
and once he is in its grip, a single drink can destroy all
self-control. Salvation lies in accepting that he has a
disease - that he will never be able to drink like other
people, and complete abstinence is his only alternative
to a squalid, perhaps short life.
With the help of A.A. (not to mention Jane Wyman), Jellinek's
model took root. Today a huge majority of Americans - and
of the psychologists, physicians, and other therapists who
treat alcoholics - consider alcoholism a disease.
Still,
when this ideas's implications are made explicit, the average
citizen's enthusiasm for it may cool. Should the insurance
premiums of teetotallers and moderate drinkers go to pay
for other people's excesses, as they must in the numerous
states whose legislatures have dictated that group health
insurance cover alcoholism? Should veterans Administration
hospitals and Medicare, amid present fiscal pressures, spend
tax dollars on people who can't stay off the bottle? And
what is the import of the Federal Rehabilitation Act, which
defines alcoholism as a handicap and prohibits federal agencies
and federally subsidized institutions from discriminating
against the handicapped?
On
December 7 the Supreme Court is hearing the case of two
reformed alcoholics who contend that the VA owes them an
education because their drinking kept them from exhausting
educational benefits within the ten years of military discharge
normally allotted. They note that the VA grants extensions
for mental or physical problems" not the result of...
willful misconduct" and maintain that their drinking
wasn't willful; they were victims of a disease. To withhold
these benefits, they say, would be to discriminate against
the handicapped. This may seem like a trivial matter, but
there is a slippery slope here. In a federal appeals court
in Philadelphia, a former marine is suing to collect a VA
disability pension on grounds that alcoholism rendered him
unemployable.
Assuming the Supreme Court doesn't duck the disease issue
with a narrow ruling (an option left wide open by a tricky
jurisdictional issue), the upshot of its decision will probably
be either: (1) that alcoholism is indeed a disease, powerful
enough to extinguish volition; or (2) that drinking, even
for an alcoholic, is ultimately a choice freely made, the
consequences of which the drinker must bear. Neither of
these findings is in the interest of enlightenment. If the
Court really wants to clear things up, it should dispense
with the concepts of "disease" and of "willful"
behavior altogether. The debate over alcoholism's essential
nature is a rime example of how vestiges of the scientific
and philosophical past can impair judicial reasoning and
the making of a public policy.
The
rationale for considering alcoholism a disease has evolved
since Jellinek's landmark paper. In the forthcoming book
Heavy Drinking, a formidable critique of alcoholism as a
disease, Herbert Fingarette, a philosopher at the University
of California, Santa Barbara, shows that research in recent
decades has painted a more complex picture than the common
phrase "alcohol dependence syndrome" implies.
Studies suggest that alcoholics do not, in fact, follow
the same route to dissolution, and that some can even learn
to drink moderately; alcoholism, Fingarette argues, is not
a single, binary condition whose course is predictable,
but a grab bag of different kinds of problems.
In response, defenders of the disease concept say that there
may be several kinds of disease under the rubic of alcoholism,
just as there are various strains of flu. And, they add,
some problem drinkers whose patterns diverge from the norm
aren't " real" alcoholics anyway. Still, even
as they dismiss Fingarette's criticisms, these people are
also doing some strategic repositioning. They are staking
their case less to the supposed clinical coherence of alcoholic
behavior and more to the fresh evidence of that behavior's
biological underpinnings.
For instance, some people appear to be genetically predisposed
to problem drinking. Alcoholics' children who are adopted
by non-alcoholics are several times more likely to become
alcoholic than the adopted children of non-alcoholic parents.
And studies of identical twins reared apart also point to
a genetic factor. Further, there are physiological abnormalities
- in biochemistry, and in brain wave patterns under certain
laboratory conditions - that occur disproportionately in
alcoholics. In fact, some occur disproportionately in the
children of alcoholics, even children who have never had
a drink. All of this, the argument goes, underscores the
soundness of the disease label and the fallacy of blaming
alcoholics for their problems. Since the biological deck
is stacked against them, it is wrong, as one researcher
at the National Council on Alcoholism put it, to label them
"Moral weaklings."
It
is hard to attack this line of argument, because it is hard
to discern it clearly in the first place. Some alcoholism-as-disease
advocates talk as if the physiological correlates of alcoholism
might be causes of the disease, whereas others seem to view
them more as biological labels, identifying alcoholics as
fundamentally different from the rest of us. To the extent
that a unifying theme exists, it is the belief that the
more "biological" a given behavior is, the less
control the behavior has over it.
This
belief does not exactly belong along the frontiers of modern
thought. To talk as if some behaviors (the free-will kind)
have a purely psychological basis while others (the disease
kind) have a partly physiological basis is like distinguishing
between election victories due to a candidate's popular
support and victories due to the number of votes received.
It is a basic, if usually unspoken, tenet of modern behavioral
science that physiological and psychological processes are
not alternative explanations of behavior but parallel explanations.
We presume that all aspects of subjective experience - ideas,
emotions, epiphanies, cravings - have physiological counterparts;
that every behavior, while explicable in terms of thoughts
and feelings, could also be explained as the result of a
particular flow of neuronal, hormonal, and other biochemical
information; that all behavior is in the deepest sense physically
compelled. This is just an assumption, of course, but it
is an assumption central to science, and research in neurology,
psychology, and genetics has tended to substantiate it.
Indeed,
so has the very fact that many alcoholics have a characteristic
brain-wave pattern; they have characteristic patterns of
behavior and sensation, so any good scientific materialist
would suspect the existence of characteristic physiological
patterns. Granted, if the physiological patterns were neater
and cleaner than the behavioral patterns, then the alcoholism-as-
disease crowd could take heart; if there were a physiological
abnormality that all alcoholics and no non-alcoholics possessed,
then the claim that alcoholism is a single, coherent syndrome
would be in some measure strengthened. But so far the physiological
evidence is fragmented, just like the behavioral evidence:
some alcoholics have this unusual trait, others have that
one, and others' have none. And all of these physiological
traits can be found, with less frequency, in the non- alcoholic
population.
Alcoholism-as-disease proponents may think this sermon about
the philosophy of behavioral science pedantic and besides
the point. The point, they will say, is that the physiological
correlates of alcoholism, like the alcoholic behaviors themselves,
appear to be, in some cases, hereditary. Alcoholics, in
other words, are born, not made. Strictly speaking, of course,
this isn't true. To say that alcoholism has a heritable
component is not to say that alcoholism is ever preordained
by the genes. It is to say that some people who inherit
alcoholics' genes have a genetic predisposition toward heavy
drinking, that the range of circumstances that will lead
to alcoholism is broader for them than for most people.
Now,
it may be that this fact should deepen our compassion for
alcoholics. But if it qualifies them as disease victims,
and leaves them blameless for their behavior, then for the
sake of consistency we are going to have to begin cutting
down on the use of blame generally - and of credit. For
their is now evidence that genes can similarly predispose
people toward violent behavior, stellar intellectual achievement,
and various other things. So should we consider violence
a "disease" and exonerate murders? Should we withhold
praise from great mathematicians because their genes gave
them a head start?
And
these questions are just the beginning of the trouble. Science
appears to be on the verge of perceiving a host of obscure
connections between genes and behavior. Fingernail biting,
reading Pulp novels, altruism, entrepreneurship - thousands
of such behaviors, some trivial and some consequential,
may well turn out to vary according to genes. And even those
behaviors not linked in this way will turn out to be under
short-term physiological control, as the complex network
of biochemical influences comes into focus. So if we are
going to follow the alcoholism-as-disease logic, and equate
genetic inclinations and physiological influences with the
surrendering of volition, then we are going to have to give
up on the concept of volition altogether. It is redundantly
true that the more we understand about the mechanics of
behavior, the more deterministic behavior will seem. (And
it is worth noting that, notwithstanding the aversion of
free-will aficionados to genetic explanations of behavior,
it won't really matter whether the determinism appears to
be mostly genetic or mostly environmental. When it comes
to the question of free will, determinism is determinism
is determinism.)
The
alcoholism-as-disease advocates sometime show encouraging
signs of understanding all this, but they never seem to
grasp its generality. In its friend-of-the-court brief in
the Supreme Court case, the National Council on Alcoholism
argues, "Whether any particular individual who drinks
will become an alcoholic is largely the result of forces
beyond his or her control. Extensive research has demonstrated
that the disease of alcoholism is produced by a confluence
of genetic/biochemical, environ- mental, and sociocultural
factors." Can anyone think of a behavior that doesn't
fit that description?
My
point is that we should not abandon the concepts of blame
and credit. Whatever science seems to say about the deterministic
nature of human behavior, the inescapable fact is that no
society can function well without holding people responsible
for their actions. This is one of life's four or five great
ironies; we are all victims (or beneficiaries of) an extremely
complex conspiracy between our genes and our environment,
yet all of us must be held accountable for the results;
otherwise, things fall apart. So as the march of science
yields more and more evidence that people are basically
machines, we are going to have to get used to the idea of
blaming robots for their malfunctions. It feels strange
at first, but you get used to it after a while.
There
are those who concede that the disease conception of alcoholism
doesn't withstand scientific or philosophical scrutiny yet
insist on preserving it as a "useful fiction."
They say that (a) by absolving alcoholics of blame, this
fiction keeps them from being saddled with "irrational
guilt feelings," and (b) the word "disease"
underscores the importance of abstinence. The obvious responses
are:(a) What's so irrational about feeling guilty when you're
flushing your life down the toilet and bringing your family
along for the ride? For every alcoholic
who is immobilized by guilt, there are probably several
who use the "disease" idea to insulate themselves
from the guilt that might otherwise incite a recovery; (b)
People have been known to abstain completely from things
- coffee, for example –without first concluding that
they had a disease. A.A. could drop the word "disease"
without appreciably altering its prescription for recovery.
Perhaps
the most common "useful fiction" argument is that
the disease conception of alcoholism keeps the treatment
funds (now totaling an estimated $1 billion a year flowing
– from the government, from health insurance companies,
from paternalistic corporations. Of course, the people most
vociferously advancing this argument pay their rent with
these funds, thus casting some doubt on their objectivity.
Moreover, in Heavy Drinking, Fingarette shows that the efficacy
of treatment programs, remains unclear; because many treatment
centers deal with precisely those patients who are most
likely to recover on their own - the affluent, employed,
and well-educated - seemingly impressive recovery statistics
often mean less than meets the eye.
None
of this is to say that corporations and insurance companies
should stop pouring money into alcoholism treatment, or
that alcoholic veterans shouldn't receive free therapy.
Perhaps objective analysis - that is, analysis performed
by someone other than the treatment industry's hired guns
- would show that, given the costs and the benefits, it's
often cheaper in the long run to subsidize certain kinds
of treatment. (And certainly a socially inexpensive effort
like A.A. is worth the trouble.) But this analysis shouldn't
be short-circuited by the groundless presupposition that
alcoholism is a disease in the sense that cancer is or a
handicap in the sense that blindness is.
The
treatment-industry spokesmen who are always waving around
those suspiciously large estimates of the societal costs
of untreated alcoholism like to maintain that they're not
trying to tug at anyone's heartstrings. "We're taking
dollars and cents," the director of the National Association
of Addiction Treatment Providers told me. “We want
to get beyond the compassion issue." Well, fine; let's
get beyond it. The first step is to quit using the word
"disease" - which, all told, is just a crutch.
(Source:
New Republic, December 14, 1987)
|
|
GO
BACK
GO
BACK