Skip to main content

Advertisement

SpringerLink
Log in

Addiction is a Disability, and it Matters

  • Original Paper
  • Published:
Neuroethics Aims and scope Submit manuscript

Abstract

Previous discussions of addiction have often focused on the question of whether addiction is a disease. This discussion distinguishes that question – the disease question – from the question of whether addiction is a disability. I argue that, however one answers the disease question, and indeed on almost any credible account of addiction, addiction is a disability. I then consider the implications of this view, or why it matters that addiction is a disability. The disease model of addiction has led many to see addiction as primarily a medical problem, and to make medical treatment of the addicted person the first priority in addressing addiction. Once addiction is viewed as a disability (whether or not it is also a disease), different concerns are foregrounded. The problem of addiction resides not only in the addicted person, but also in the social environment in which the addicted person finds herself. The fundamental ethical question about addiction is not how addicted persons can be treated or otherwise changed, but how a just society can make reasonable accommodations for addicted persons.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. See [10] for further discussion of terminological issues around ‘disease’ and ‘disability’. The boundary between these concepts becomes more complicated when we consider more theoretical accounts of disease. For example, the the influential account of disease proposed in [11] will hold that deafness does in fact count as a disease. I will leave the concept of disease at an intuitive level, as do most advocates of the disease model of addiction.

  2. Compare ([15], pp. 852–853): ‘The question we must therefore ask is: Which purposes should a precising definition of addiction serve? The answer is: several . . . As a result, there may be multiple definitions of addiction, each appropriate to different purposes and contexts.’

  3. The appeal to dispositions is not novel, especially in philosophical accounts. Thus, for example, ([14], p. 35) define addiction as a ‘strong appetite,’ and define an appetite in turn as ‘a disposition that generates desires that are urgent, oriented toward some rewarding behavior, periodically recurring, often in predictable circumstances, sated temporarily by their fulfillment, and generally provide pleasure.’

  4. What is it for a disposition to be powerful? At first approximation, a powerful disposition is one that wins out when it conflicts with some ordinary habit or disposition. I leave open the question this process is a rational or an arational one – that is, whether these dispositions tend to win out because of their rational force, or whether they in some sense compel their subjects to act as they do.

  5. Since this is a minimal definition, it will be subject to objections from over-inclusiveness. [15] consider the case of someone who has a strong appetite to play golf and argue – as an objection to [14] – that such a person does not have an addiction to playing golf. The account offered here is sympathetic with the idea that golf-playing might be an addiction. But this is a reasonable judgment once we take seriously the reality of behavioral addictions. There is considerable evidence that video-game addiction, for example, is a pervasive and devastating condition [20].

  6. This claim may appear to conflict with the aspect of the definition of addiction on which the activity in question is ‘excessive.’ After all, to judge someone’s use of a substance (for example) to be excessive seems to make an evaluative judgment: namely that they are using more than they ought to. In response, it is important to understand the sense of ‘excessive’ in question as a subjective one, relativized to the goals of the person in question. The language of the DSM-5 is helpful in capturing this sense of excessiveness: one engages in activity excessively, in this sense, when one does ‘in larger amounts or over a longer period than was intended’ [19].

  7. This point turns on a crucial if contentious point about dispositions, namely that a disposition (such as addiction) is not to be identified with its causal basis (such as, on the ASAM account, a certain disease) [21]. This distinction is what allows us to make claims about addiction while remaining neutral about its underlying grounds.

  8. This definition of addiction also does not settle the disability question: this definition is compatible with the claim that addiction is a disability, and also with the claim that it is not. The question of whether addiction is a disability is a further, substantive question. I will argue for a positive answer to that question in what follows, but that is a distinct argument, which will depend on additional claims about both addiction and the nature of disability.

  9. The WHO has subsequently updated their account of disability to be, among other things, more sensitive to the environmental contribution to disability [23].

  10. The points made here against the simple impairment account echo the points developed with great force by advocates of the ‘social model of disability’ [24, 25]. The subsequent discussion remains aims to remain neutral on whether the social model is correct, and indeed on how to understand what counts as a ‘social model’ of disability.

  11. I therefore defend a pragmatic approach to definition both for addiction and for disability. The proposals offered, however, are different. For addiction, I offered a broad and minimal definition. For disability, I will only state several platitudes. It may be that disability is too contested to even admit of a minimal definition; see [26] for some of the challenges for defining disability.

  12. The method here is inspired by the approach to philosophy of science suggested in [27].

  13. One important account of disability that would reject this platitude is that of Elizabeth Barnes [28]. Barnes thinks we should be skeptical of the idea of impairment itself ([28], p. 26). As it happens, addiction nonetheless may count as a disability by Barnes’s lights, as it plausibly counts as the kind of condition that disability rights advocates are seeking to promote justice for ([28], p. 46; this is an extrapolation, as Barnes explicitly restricts her discussion to physical disabilities).

  14. I therefore do not claim that addiction must be a disability, or that it is a disability on any possible account. Fingarette’s account, for example, may be one on which addiction is not a disability. My claim is instead that advocates of almost every credible account of addiction should, by their own lights, accept that addiction is a disability.

  15. See [35] for further discussion of the significance of a ‘well-managed’ addiction.

  16. Compare ([1], p. 45): ‘The more common view is that drug addicts are weak or bad people . . . To the contrary, addiction is actually a chronic, relapsing illness.’

  17. An interesting question is how the disability view might diminish (or fail to diminish) the stigma associated with addiction. See [38] for a thoughtful discussion of how disability is stigmatized, as well of strategies for resisting stigmatization of disabled persons.

  18. This condition may not be met, for there may well be substantial costs to legalization, perhaps including its intangible impacts on families and on society generally. My aim here is not to assess these costs (see [44] for an attempt to do this), or to assess whether the advocate of the disability view should, all things considered, endorse legalization. I also bracket the question of whether the advocate of the disability view might instead advocate more modest alternatives, such as decriminalization. Rather, my aim is simply to give an example of how the disability view might have far-reaching implications for social policy.

  19. This is a morally sensible view to take, for instance, of HIV. For a thoughtful discussion of the intersection between HIV and disability, see [45].

  20. In this way, the disability-only view will tend to coincide with what David Wasserman calls the ‘radical’ version of the view that addiction is a disability, while the disease-disability view will tend to be closer to the ‘moderate’ version of that view ([7], pp. 475–476).

  21. Compare the discussion in ([7], pp. 474–476), which considers several ways of endorsing the idea that addiction is a disability without necessarily holding that addiction is evaluatively neutral.

References

  1. Leshner, A.I. 1997. Addiction is a brain disease, and it matters. Science 278 (5335): 45–47.

    Article  Google Scholar 

  2. Levy, N. (2013). Addiction is Not a Brain Disease (and it Matters). Frontiers in Psychiatry 4: 24.

  3. Lewis, M. 2015. The biology of desire: Why addiction is not a disease. NY: PublicAffairs.New York.

  4. Lewis, M. 2018. Brain change in addiction as learning, not disease. New England Journal of Medicine 379 (16): 1551–1560.

    Article  Google Scholar 

  5. Heyman, G.M. 2009. Addiction: A disorder of choice. Harvard University Press.

  6. Pickard, H. 2012. The purpose in chronic addiction. AJOB Neuroscience 3 (2): 40–49.

    Article  Google Scholar 

  7. Wasserman, D. 2004. Addiction and disability: Moral and policy issues. Substance Use & Misuse 39 (3): 461–488.

  8. Flacks, S. 2012. Deviant disabilities: The exclusion of drug and alcohol addiction from the equality act 2010. Social & Legal Studies 21 (3): 395–412.

    Article  Google Scholar 

  9. Pickard, H., and S.H. Ahmed, eds. 2018. The Routledge handbook of philosophy and science of addiction. UK: Routledge. Abingdon.

  10. Scully, J.L. 2004. What is a disease?: Disease, disability and their definitions. EMBO Reports 5 (7): 650–653.

    Article  Google Scholar 

  11. Boorse, C. 1977. Health as a theoretical concept. Philosophy of Science 44 (4): 542–573.

    Article  Google Scholar 

  12. Pickard, H. (2018). The Puzzle of addiction. In Pickard & Ahmed (Eds.), The Routledge Handbook of Philosophy and Science of Addiction, 9–22. Abingdon, UK: Routledge

  13. Berridge, K.C. 2017. Is addiction a brain disease? Neuroethics 10 (1): 29–33.

    Article  Google Scholar 

  14. Foddy, B., and J. Savulescu. 2010. Relating addiction to disease, disability, autonomy, and the good life. Philosophy, Psychiatry, and Psychology 17 (1): 35–42.

    Article  Google Scholar 

  15. Sinnott-Armstrong, W., and H. Pickard. 2013. What is addiction? In The Oxford Handbook of Philosophy and Psychiatry, ed. K.W.M. Fulford, et al., 851–864. Oxford UP.Oxford: UK.

  16. Wallace, R.J. 1999. Addiction as defect of the will: Some philosophical reflections. Law and Philosophy 18 (6): 621.

    Google Scholar 

  17. Herron, A., and T.K. Brennan. 2019. The ASAM essentials of addiction medicine. Philadelphia, PA: Lippincott Williams & Wilkins.

  18. Becker, G.S., and K.M. Murphy. 1988. A theory of rational addiction. Journal of Political Economy 96 (4): 675–700.

    Article  Google Scholar 

  19. American Psychological Association. 2013. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychological Association.

  20. Gentile, D. 2009. Pathological video-game use among youth ages 8 to 18: A National Study. Psychological Science 20 (5): 594–602.

    Article  Google Scholar 

  21. Prior, E.W., R. Pargetter, and F. Jackson. 1982. Three theses about dispositions. American Philosophical Quarterly 19 (3): 251–257.

    Google Scholar 

  22. World Health Organization. 1980. International classification of impairments, disabilities, and handicaps. Geneva, Switzerland: World Health Organization.

    Google Scholar 

  23. World Health Organization. 2001. International classification of functioning, disability, and health. Geneva, Switzerland: World Health Organization.

    Google Scholar 

  24. Shakespeare, T., and N. Watson. 2001. The social model of disability: An outdated ideology? In Exploring Theories and Expanding Methodologies: Where we are and where we need to go, ed. S.N. Barnartt and B.M. Altman, 9–28. Bingley, UK: Emerald Group Publishing.

  25. Oliver, M. (2013). The social model of disability: thirty years on. Disability & Society 28 (7): 1024–1026.

  26. Wasserman, D., Asch, A., Blustein, J., and Putnam, D. (2016). Disability: definitions, models, experience. The Stanford Encyclopedia of Philosophy. ed. E.N. Zalta. Stanford, CA: Metaphysics Research Lab, Stanford University.

  27. Lewis, D. 1970. How to define theoretical terms. The Journal of Philosophy 67 (13): 427–446.

    Article  Google Scholar 

  28. Barnes, E. 2016. The minority body: A theory of disability. Oxford University Press.

  29. Wakefield, J. (2018). The harmful dysfunction analysis of addiction: normal brains and abnormal states of mind. In Pickard & Ahmed (Eds.), The Routledge Handbook of Philosophy and Science of Addiction, 90–101. Abingdon, UK: Routledge.

  30. Fingarette, H. 1988. Heavy drinking: The myth of alcoholism as a disease. Berkeley, CA: University of California Press.

  31. Barry, C.L., E.E. McGinty, B. Pescosolido, and H.H. Goldman. 2014. Stigma, discrimination, treatment effectiveness and policy support: Comparing public views about drug addiction with mental illness. Psychiatric Services 65 (10): 1269–1272.

  32. Volkow, N.D., G.F. Koob, and A.T. McLellan. 2016. Neurobiologic advances from the brain disease model of addiction. New England Journal of Medicine 374 (4): 363–371.

    Article  Google Scholar 

  33. Hall, W., A. Carter, and C. Forlini. 2015. The brain disease model of addiction: Is it supported by the evidence and has it delivered on its promises? The Lancet Psychiatry 2 (1): 105–110.

    Article  Google Scholar 

  34. Pickard, H. 2017. Responsibility without blame for addiction. Neuroethics 10 (1): 169–180.

    Article  Google Scholar 

  35. Watson, G. 1999. Excusing addiction. Law and Philosophy 18 (6): 589–619.

    Google Scholar 

  36. Meurk, C., A. Carter, B. Partridge, J. Lucke, and W. Hall. 2014. How is acceptance of the brain disease model of addiction related to Australians’ attitudes towards addicted individuals and treatments for addiction? BMC Psychiatry 14 (1): 373.

    Article  Google Scholar 

  37. Trujols, J. 2015. The brain disease model of addiction: Challenging or reinforcing stigma? The Lancet Psychiatry 2 (4): 292.

    Article  Google Scholar 

  38. Susman, J. 1994. Disability, stigma and deviance. Social Science & Medicine 38 (1): 15–22.

    Article  Google Scholar 

  39. Connery, H.S. 2015. Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions. Harvard Review of Psychiatry 23 (2): 63–75.

    Article  Google Scholar 

  40. Volkow, N.D., T.R. Frieden, P.S. Hyde, and S.S. Cha. 2014. Medication-assisted therapies—Tackling the opioid-overdose epidemic. New England Journal of Medicine 370 (22): 2063–2066.

    Article  Google Scholar 

  41. Marlatt, G.A. 1996. Harm reduction: Come as you are. Addictive Behaviors 21 (6): 779–788.

    Article  Google Scholar 

  42. Wilson, D.P., B. Donald, A.J. Shattock, D. Wilson, and N. Fraser-Hurt. 2015. The cost-effectiveness of harm reduction. International Journal of Drug Policy 26: S5–S11.

    Article  Google Scholar 

  43. Szott, K. 2015. Contingencies of the will: Uses of harm reduction and the disease model of addiction among health care practitioners. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 19 (5): 507–522.

    Article  Google Scholar 

  44. MacCoun, R.J., and P. Reuter. 2001. Drug war heresies: Learning from other vices, times, and places. New York, NY: Cambridge University Press.

  45. Hanass-Hancock, J., and S.A. Nixon. 2009. The fields of HIV and disability: Past, present and future. Journal of the International AIDS Society 12 (1): 28.

  46. Sparrow, R. 2005. Defending deaf culture: The case of Cochlear implants. Journal of Political Philosophy 13 (2): 135–152.

  47. Miller, N.S., and M.S. Gold. 1998. Comorbid cigarette and alcohol addiction. Journal of Addictive Diseases 17 (1): 55–66.

Download references

Availability of Data and Material

Not applicable.

Code Availability

Not applicable.

Author information

Authors and Affiliations

  1. Simmons University, Boston, MA, USA

    John T. Maier

Authors
  1. John T. Maier
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John T. Maier.

Ethics declarations

Conflict of Interest

Not applicable.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Maier, J.T. Addiction is a Disability, and it Matters. Neuroethics 14, 467–477 (2021). https://doi.org/10.1007/s12152-021-09466-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12152-021-09466-8

Keywords

Search

Navigation