The Supreme Court reopens an old question

Alcohol And Free Will

By Robert Wright

“He’s a sick person,” says Jane Wyman for other people’s excesses, as they must in the of Ray Milland. “It’s as though there were numerous states whose legislatures have something wrong with his heart or lungs.” The dictated that group health insurance cover movie is The Lost Weekend, and Milland is Don alcoholism? Should veterans Administration Birnam, an aspiring writer whose potential is hospitals and Medicare, amid present fiscal stifled by his perennial willingness to pawn pressures, spend tax dollars on people who anything, including his typewriter, for enough can’t stay off the bottle? And what is the import money to drink himself unconscious. Wyman, of the Federal Rehabilitation Act, which defines Birnam’s aspiring fiancée, is explaining why he alcoholism as a handicap and prohibits federal deserves forgiveness and patience. It’s not as agencies and federally subsidized institutions though his disintegration were his fault, she’s from discriminating against the handicapped? saying; the man has a disease. On December 7 the Supreme Court is The movie, released in 1945, could hearing the case of two reformed alcoholics who hardly have been better timed. For the previous contend that the VA owes them an education ten years, Alcoholics Anonymous had been because their drinking kept them from pushing the idea that alcoholism is a disease, exhausting educational benefits within the ten and in 1946, about the time The Lost Weekend years of military discharge normally allotted. was winning a fistful of Academy Awards, the They note that the VA grants extensions for idea received the imprimatur of science with the mental or physical problems” not the result of… publication of E.M. Jellinek’s “Phases in the willful misconduct” and maintain that their Drinking History of Alcoholics.” Jellinek (who, drinking wasn’t willful; they were victims of a perhaps not coincidentally, based his study on disease. To withhold these benefits, they say, questionnaires designed and distributed by would be to discriminate against the (A.A.) found that alcoholism follows a roughly handicapped. This may seem like a trivial predictable pattern, from social drinking through matter, but there is a slippery slope here. In a various stages of excess, culminating in secret federal appeals court in Philadelphia, a former drinking, blackouts, and other symptoms. For marine is suing to collect a VA disability pension the true alcoholic, Jellinek found, this grim cycle on grounds that alcoholism rendered him is virtually inexorable, and once he is in its grip, unemployable. a single drink can destroy all self-control. Assuming the Supreme Court doesn’t Salvation lies in accepting that he has a disease duck the disease issue with a narrow ruling (an – that he will never be able to drink like other option left wide open by a tricky jurisdictional people, and complete abstinence is his only issue), the upshot of its decision will probably be alternative to a squalid, perhaps short life. either: (1) that alcoholism is indeed a disease, With the help of A.A. (not to mention powerful enough to extinguish volition; or (2) that Jane Wyman), Jellinek’s model took root. Today drinking, even for an alcoholic, is ultimately a a huge majority of Americans – and of the choice freely made, the consequences of which psychologists, physicians, and other therapists the drinker must bear. Neither of these findings who treat alcoholics – consider alcoholism a is in the interest of enlightenment. If the Court disease. really wants to clear things up, it should Still, when this ideas’s implications are dispense with the concepts of “disease” and of made explicit, the average citizen’s enthusiasm “willful” behavior altogether. The debate over for it may cool. Should the insurance premiums alcoholism’s essential nature is a rime example of teetotallers and moderate drinkers go to pay of how vestiges of the scientific and

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philosophical past can impair judicial reasoning It is hard to attack this line of argument, and the making of a public policy. because it is hard to discern it clearly in the first place. Some alcoholism-as-disease advocates The rationale for considering alcoholism talk as if the physiological correlates of a disease has evolved since Jellinek’s landmark alcoholism might be causes of the disease, paper. In the forthcoming book Heavy Drinking, whereas others seem to view them more as a formidable critique of alcoholism as a disease, biological labels, identifying alcoholics as Herbert Fingarette, a philosopher at the fundamentally different from the rest of us. To University of California, Santa Barbara, shows the extent that a unifying theme exists, it is the that research in recent decades has painted a belief that the more “biological” a given behavior more complex picture than the common phrase is, the less control the behavior has over it. “alcohol dependence syndrome” implies. This belief does not exactly belong along Studies suggest that alcoholics do not, in fact, the frontiers of modern thought. To talk as if follow the same route to dissolution, and that some behaviors (the free-will kind) have a purely some can even learn to drink moderately; psychological basis while others (the disease alcoholism, Fingarette argues, is not a single, kind) have a partly physiological basis is like binary condition whose course is predictable, but distinguishing between election victories due to a grab bag of different kinds of problems. a candidate’s popular support and victories due In response, defenders of the disease to the number of votes received. It is a basic, if concept say that there may be several kinds of usually unspoken, tenet of modern behavioral disease under the rubic of alcoholism, just as science that physiological and psychological there are various strains of flu. And, they add, processes are not alternative explanations of some problem drinkers whose patterns diverge behavior but parallel explanations. We presume from the norm aren’t ” real” alcoholics anyway. that all aspects of subjective experience – ideas, Still, even as they dismiss Fingarette’s criticisms, emotions, epiphanies, cravings – have these people are also doing some strategic physiological counterparts; that every behavior, repositioning. They are staking their case less to while explicable in terms of thoughts and the supposed clinical coherence of alcoholic feelings, could also be explained as the result of behavior and more to the fresh evidence of that a particular flow of neuronal, hormonal, and behavior’s biological underpinnings. other biochemical information; that all behavior For instance, some people appear to be is in the deepest sense physically compelled. genetically predisposed to problem drinking. This is just an assumption, of course, but it is an Alcoholics’ children who are adopted by non- assumption central to science, and research in alcoholics are several times more likely to neurology, psychology, and genetics has tended become alcoholic than the adopted children of to substantiate it. non-alcoholic parents. And studies of identical Indeed, so has the very fact that many twins reared apart also point to a genetic factor. alcoholics have a characteristic brain-wave Further, there are physiological abnormalities – pattern; they have characteristic patterns of in biochemistry, and in brain wave patterns behavior and sensation, so any good scientific under certain laboratory conditions – that occur materialist would suspect the existence of disproportionately in alcoholics. In fact, some characteristic physiological patterns. Granted, if occur disproportionately in the children of the physiological patterns were neater and alcoholics, even children who have never had a cleaner than the behavioral patterns, then the drink. All of this, the argument goes, alcoholism-as- disease crowd could take heart; if underscores the soundness of the disease label there were a physiological abnormality that all and the fallacy of blaming alcoholics for their alcoholics and no non-alcoholics possessed, problems. Since the biological deck is stacked then the claim that alcoholism is a single, against them, it is wrong, as one researcher at coherent syndrome would be in some measure the National Council on Alcoholism put it, to strengthened. But so far the physiological label them “Moral weaklings.” evidence is fragmented, just like the behavioral evidence: some alcoholics have this unusual

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trait, others have that one, and others’ have of volition altogether. It is redundantly true that none. And all of these physiological traits can be the more we understand about the mechanics of found, with less frequency, in the non- alcoholic behavior, the more deterministic behavior will population. seem. (And it is worth noting that, Alcoholism-as-disease proponents may notwithstanding the aversion of free-will think this sermon about the philosophy of aficionados to genetic explanations of behavior, behavioral science pedantic and besides the it won’t really matter whether the determinism point. The point, they will say, is that the appears to be mostly genetic or mostly physiological correlates of alcoholism, like the environmental. When it comes to the question of alcoholic behaviors themselves, appear to be, in free will, determinism is determinism is some cases, hereditary. Alcoholics, in other determinism.) words, are born, not made. Strictly speaking, of The alcoholism-as-disease advocates course, this isn’t true. To say that alcoholism has sometime show encouraging signs of a heritable component is not to say that understanding all this, but they never seem to alcoholism is ever preordained by the genes. It grasp its generality. In its friend-of-the-court brief is to say that some people who inherit alcoholics’ in the Supreme Court case, the National Council genes have a genetic predisposition toward on Alcoholism argues, “Whether any particular heavy drinking, that the range of circumstances individual who drinks will become an alcoholic is that will lead to alcoholism is broader for them largely the result of forces beyond his or her than for most people. control. Extensive research has demonstrated that the disease of alcoholism is produced by a Now, it may be that this fact should confluence of genetic/biochemical, environdeepen our compassion for alcoholics. But if it mental, and sociocultural factors.” Can anyone qualifies them as disease victims, and leaves think of a behavior that doesn’t fit that them blameless for their behavior, then for the description? sake of consistency we are going to have to My point is that we should not abandon begin cutting down on the use of blame the concepts of blame and credit. Whatever generally – and of credit. For their is now science seems to say about the deterministic evidence that genes can similarly predispose nature of human behavior, the inescapable fact people toward violent behavior, stellar is that no society can function well without intellectual achievement, and various other holding people responsible for their actions. This things. So should we consider violence a is one of life’s four or five great ironies; we are “disease” and exonerate murders? Should we all victims (or beneficiaries of) an extremely withhold praise from great mathematicians complex conspiracy between our genes and our because their genes gave them a head start? environment, yet all of us must be held And these questions are just the accountable for the results; otherwise, things fall beginning of the trouble. Science appears to be apart. So as the march of science yields more on the verge of perceiving a host of obscure and more evidence that people are basically connections between genes and behavior. machines, we are going to have to get used to Fingernail biting, reading Pulp novels, altruism, the idea of blaming robots for their malfunctions. entrepreneurship – thousands of such behaviors, It feels strange at first, but you get used to it some trivial and some consequential, may well after a while. turn out to vary according to genes. And even There are those who concede that the those behaviors not linked in this way will turn disease conception of alcoholism doesn’t out to be under short-term physiological control, withstand scientific or philosophical scrutiny yet as the complex network of biochemical insist on preserving it as a “useful fiction.” They influences comes into focus. So if we are going say that (a) by absolving alcoholics of blame, to follow the alcoholism-as-disease logic, and this fiction keeps them from being saddled with equate genetic inclinations and physiological “irrational guilt feelings,” and (b) the word influences with the surrendering of volition, then “disease” underscores the importance of we are going to have to give up on the concept abstinence. The obvious responses are:(a)

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What’s so irrational about feeling guilty when recovery statistics often mean less than meets you’re flushing your life down the toilet and the eye. bringing your family along for the ride? For every None of this is to say that corporations alcoholic who is immobilized by guilt, there are and insurance companies should stop pouring probably several who use the “disease” idea to money into alcoholism treatment, or that insulate themselves from the guilt that might alcoholic veterans shouldn’t receive free otherwise incite a recovery; (b) People have therapy. Perhaps objective analysis – that is, been known to abstain completely from things – analysis performed by someone other than the coffee, for example –without first concluding that treatment industry’s hired guns – would show they had a disease. A.A. could drop the word that, given the costs and the benefits, it’s often “disease” without appreciably altering its cheaper in the long run to subsidize certain prescription for recovery. kinds of treatment. (And certainly a socially Perhaps the most common “useful inexpensive effort like A.A. is worth the trouble.) fiction” argument is that the disease conception But this analysis shouldn’t be short-circuited by of alcoholism keeps the treatment funds (now the groundless presupposition that alcoholism is totaling an estimated $1 billion a year flowing – a disease in the sense that cancer is or a from the government, from health insurance handicap in the sense that blindness is. companies, from paternalistic corporations. Of The treatment-industry spokesmen who course, the people most vociferously advancing are always waving around those suspiciously this argument pay their rent with these funds, large estimates of the societal costs of untreated thus casting some doubt on their objectivity. alcoholism like to maintain that they’re not trying Moreover, in Heavy Drinking, Fingarette shows to tug at anyone’s heartstrings. “We’re taking that the efficacy of treatment programs, remains dollars and cents,” the director of the National unclear; because many treatment centers deal Association of Addiction Treatment Providers with precisely those patients who are most likely told me. “We want to get beyond the to recover on their own – the affluent, employed, compassion issue.” Well, fine; let’s get beyond it. and well-educated – seemingly impressive The first step is to quit using the word “disease” – which, all told, is just a crutch.

Source: New Republic, December 14, 1987.

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