In so-called contingency management experiments, subjects addicted to cocaine or heroin are rewarded with vouchers redeemable for cash, household goods, or clothes. Those randomized to the voucher arm routinely enjoy better results than those receiving treatment as usual.
Contingencies are the key to voluntariness. No amount of reinforcement or punishment can alter the course of an entirely autonomous biological condition. Imagine bribing an Alzheimer’s patient to keep her dementia from worsening, or threatening to impose a penalty on her if it did. This is where choice comes in: choosing an alternative to drug use. Heyman realizes how odd this might seem. How can otherwise rational people choose self-destruction unless they are diseased? This question was raised in colonial America. Dr. Benjamin Rush, also known as the father of American psychiatry, was among the first to promote the notion that alcoholism was a disease. And he did so not on the basis of medical evidence, Heyman reminds us, “but rather [upon] the assumption that voluntary behavior is not self-destructive.”
In all, Addiction should be required reading for anyone who treats patients, researches addiction, or devises policy surrounding drug-related crime. All should benefit deeply from Heyman’s key idea: “that the idea [of] addiction [as] a disease has been based on a limited view of voluntary behavior.”
Finally, Heyman uses the phenomenon of addiction to make a profound point about neuroscientific progress in general. “The implication is that as we learn more about a disorder,” he writes, “the more likely it is to be thought of as a disease”—and, consequently, as a condition whose course cannot be modified by its foreseeable consequences.
Progress in brain science will also force a confrontation with the fact that the common interpretation of pathological behavior is often informed by a primitive form of dualism. If biological roots can be found, then we reflexively think “disease”—as in the obliteration of choice-making ability. The mechanical “brain disease” rhetoric is a symptom of the growing tendency to privilege neuroscientific explanations as the most authentic way of understanding human behavior.