Moral Model of Addiction: A Disorder of Choice?

Jase Watford

Department of Social Work, Lakehead University

SOWK – 3415 WDE: Treatment, Drug and Alcohol Abuse

Professor Brenton Diaz

March 12^th, 2021

The Australian Department of Health defines the moral (choice) model of addiction as follows: “During the eighteenth and early nineteenth centuries addiction was viewed as a sin. Drug-dependent people were considered morally weak, and addiction was seen as a fault of one’s character. Under the influence of this model, users were punished with whippings, public beatings, stocks, fines, and public ridicule being relatively common. Spiritual direction was also a common treatment. Jail sentences were another form of punishment and at the turn of the century many more drug users were put in mental hospitals as the jails became full.” (p.1)

Utilizing various perspectives from the realms of social work, psychology and philosophy this paper will define, outline and question the centuries old modality of addiction, where choice sanctions as treatment and how our society is still somewhat loathe in accepting more modern, humane and ethical ideologies for the treatment of addiction and substance abuse disorders. Presently, for the most part, treatment of addiction isn’t uniform, and there are a number of private and public entities invested in determining what route of recovery is administered. For example religious organizations like the Salvation Army have long invested, time and money into addictions; with thousands of facilities all over the world they still use the moral model of addiction. Major Brian Matters from the Sydney based Eastern Command of the Salvation Army who is the former chair of the Australian National Council on Drugs and Drug Advisory Council cited his belief that addiction is sinful and summed up by his comments in Melbourne’s, Age newspaper on 5 January 2000: “I believe addiction is a sin.  I know it’s a medical and psychological problem, but the Bible tells us that sin is falling short of our potential.  It tells us we should not be mastered by things.  It also tells us to keep the body pure as it is the temple of the Holy Spirit.” The Salvation Army is not alone in possessing a very dark aged belief system as there are numerous other organizations around the world which work from that framework, included are “autonomous” groups like Alcoholics Anonymous, where the focus is on a God of your understanding who helps you address your sins and defects of character in their 12 step process. It is evident that religious belief can be used to foregoing science on occasion. To extract an example of the moral model from British history, which ironically is not very different from the present circumstances of our own addiction epidemic, but by 1720, a time that was known as gin madness, a period of intense consumption in Britain. This heavy consumption period of high alcohol percentage gin afflicted the poor and was rife among those who sought relief from their increasingly brutal and alienated lives. British sociologist Jonathan White noted how “Societies that favor structural inequality and uneven access to resources are unlikely to develop a discourse critical of social inequality.  Blaming drunkenness [and other social problems such as poverty, homelessness and child neglect] on the inherent moral weakness [or sinfulness] of the poor was popular right through to the end of the Victorian era.” (White, 2003) Australian journalist Cyril Pearl summarized this failure as the “Keystone of the respectable Victorian’s moral structure. In fulminating about the wickedness of the individual he was able to forget about the wickedness of society; ‘More Prayers’ was a much safer slogan than ‘Less Poverty.’” (Pearl, 1955)

Succeeding the temperance model (of just saying no), was the spiritual model which worked from the axiom that a disconnection from God or a Higher Power was the root cause of addiction. It is in this separation of their connection with a God of their understanding that causes people’s suffering because they fail to live according to God’s will and not thy will. It is because of this belief that recovery consists of establishing or re-establishing a connection with God or a Higher Power. By doing so this removes choice (free will) from the equation, for the exception of a singular choice to give your will over to a higher power and that by doing so God forgives all sins and you once again can walk a righteous path as determined by him. However, society as a whole has become more accepting of deontological thought (moving away from God) creating more free thinkers (philosophers, atheists, agnostics) who reject the idea that we cannot achieve self-mastery and autonomy.

A classic philosophical argument of Akrasia is “Aristotle’s explanation that such people are incontinent of will. ‘Akrasia’ is translated as “incontinence” or even more literally, “lack of mastery.” The akratic person cannot master his passions; he lacks that continence, which in Greek philosophy requires that reason control the emotions.” (Geppart, 2008) Aristotle doesn’t doom the akratic person, but instead pleads for them to adopt reason over emotion (Apollonian over Dionysian) which is the classic rational philosophical dialectic used to support the moral model of addiction. Where a moral failure (a failure to do what is right) causes addiction. Therefore, recovery consists of strengthening one’s will or motivation to behave in an upright manner. The concern however is that when will and choice is applied from a macro lens “The medical concept of disease has been disputed mainly by those advancing the role of choice in addiction. The difficulty in evaluating claims and viewpoints advanced by both parties is that many of those who participate in the discussion (therapists, researchers, policy makers) have either fiscal interests or a strong, often preconceived and thus mostly ideological, personal opinion about the status of the disease model.” (Nordic Study on Alcohol and Tobacco, 2013)  Normative thinking about addiction traditionally is divided between choice and compulsion especially regarding addiction, identity, and morality. American bioethicist, philosopher, and interdisciplinary researcher Brian D. Earp asks “Are persons with addiction free moral agents, for example, who are responsible for their behavior while under the influence of drugs, or for becoming addicted to drugs in the first place? Or are they passive victims of a “brain disease” and thus deserving of social support and medical treatment rather than stigma or moral censure?” (p.3) The question however, is it possible for a free moral agent to be a victim? If all people are free to choose, is it possible that their choices could make a victim of another? This form of questioning automatically assumes the agent has an intrinsic sense of self morality (what is good) and that it is shared as a universal truth with the other. According to Earp “Recent literature on addiction and judgments about the characteristics of agents has focused on the implications of adopting a ‘brain disease’ versus ‘moral weak-ness’ model of addiction.” (Earp, et al, 2019) However, in the field of addiction (most recently utilizing upstream ways of thought), Earp and the other authors had concerns that societal perceptions are still stuck in the past and that “Typically, such judgments have to do with what capacities an agent has (e.g., the ability to abstain from substance use). Much less work, however, has been conducted on the relationship between addiction and judgments about an agent’s identity, including whether or to what extent an individual is seen as the same person after becoming addicted.”  (Earp, et al, 2019)

Identity has long been used within addiction and recovery circles. Whether it is “I am an addict/alcoholic” or “I am 20 years clean/sober” the person’s identity is generally tethered to the narrative that they have given up all previous sense of self and are remaking themselves in the mould of the other. This makes it problematic, should that person stumble and relapse everything they had invested into that identity gets shattered and ceases to exist. Even though that person had 20 years of recovery, they are forced to start over at day one. This is the cause and effect of choice, but choice in accordance to a certain set of rules within the belief system

It is that the illusion of choice in this system works on the premise that there are free choices when in actuality all choices are manifested by the inherent system/model. How can you freely choose the direction for yourself when the paths provided are selected in advance by a biased arbiter or pre-existing pattern? This is where the problem of the disease model comes into play “Being in control of one’s action is constitutive of that person’s agency. If we accept, for the time being, that addiction is compulsate, a disease that the person seems to have no control over, we need an under-standing of that compulsion.” (Uusitalo, S. 2013)

So let’s take into context the phrase, the disease of addiction, there is no such thing as the disease of cancer. Compulsions with addiction, the individual is generally conscious of their choice, ergo consequences. A disorder is the appropriate definition of addiction behaviour. It is a drinking or drugging disorder. Similar compulsions exist with eating, gambling, high risk behaviour, often correlating with anxiety and OCD etc. Uusitalo maintains that “Affects are capable of influencing rational choices in at least two ways. First, anticipated positive affect raises the probability of choosing types of behaviour that yield such affect to the agent. In this way, anticipated reward motivates addictive behaviour. Second, existing negative affects such as depression, anxiety, restlessness, irritability or shame raise the expected utility of behaviours that offer the agent an escape from the present misery. In this way, psychological withdrawal symptoms and other negative affects motivate addictive behaviour, including relapses.” (p. 9) With compulsions, or other various behaviours. There has to be a sense of ownership. “Addicts, whether or not we say they have a disease, are often said to be characteristically ‘out of control’. When we say that someone is ‘out of control’ or acting ‘compulsively’, it is more than an abstract scientific claim used to identify a disorder. Like the claim that addiction is a disease, it is a claim with extensive practical and moral repercussions. Perhaps the most important repercussion is that if a person acts truly compulsively they are excused of moral responsibility for their drug‐seeking behaviour, either partially or in full.” (Bennett. 2010)

This isn’t to say that we return to the Draconian measure of shame and punishment. But to have an individual acknowledge how a person’s behaviour impacts themselves and society as a whole is a step in recognizing the other. Thusly, allowing for a measure of awareness which ultimately could constitute a step of change within the continuum

In a perfect world it would allow us to remove a certain view point, to make it less myopic, or to remove the blinders. We have to understand that for centuries, as civilizations formed and its people evolved, we as a society have clung to a widespread belief in free will, both philosophically and theologically. It is in that origin, one which is rooted in the possibility that if you lost this belief that it could become catastrophic. We must be conscious of that fact and be aware that there are governing forces which determine what we do, as an individual and as a people. That isn’t to say we do not have a choice, in our present society and using a North American lens, our code of ethics for example assumes that we can freely choose between right and wrong. By Christian norms this “moral liberty” allows for us to discern and pursue the good, instead of merely being compelled by appetites and desires.

German philosopher Immanuel Kant’s categorical imperative defined and aligned freedom and goodness. Kant argued that if we are not free to choose then we cannot choose the path of righteousness. Meaning Kant’s imperative is that free is an example that we are a means to an end, we are the means to our end, ours and ours alone and not the other way around. This paradox is at the centre and the crux of addiction and substance abuse disorders. By definition “the choice model holds that addictive behaviors are governed by universal principles of choice and motivation. (Rise & Halkjelsvik, 2019) Choice, according to our present society believes an individual or group of people make the choice to actively use substances. However, under the same school of thought and applying Kant’s imperative on free will, would/should these individuals not also be allowed (through client self-determination) to select their method of recovery? After all we are the means to our own end.

Norwegian psychologists Jostein Rise and Torlief Halkjelsvik highlight that “The scientific discourse about addiction has been dominated by two models: the disease model and the choice model. The former considers addiction as following a disease-like course, with behaviors that have taken control of the person–so-called compulsive actions.” (p.2) Summarily Rise states “Because free will is held to be a prerequisite for an agent to be punished for wrongdoing and praised for doing well, a number of scholars have posited a close relation between free will and moral responsibility. The main debate in philosophy revolves around whether free will and moral responsibility are compatible with determinism–the idea that whatever happens is fully determined (caused) by previous events and the laws of nature.” (p.4)

It is unfathomable that society is unable to collect in lock step and agree uniformly. Cast aside cultural and religious/spiritual beliefs because addiction does not segregate and isn’t selective. It has a single goal, to get you alone and kill you. It fools the mind into believing that it can survive without the body. That would be the behaviour of a disease and “The Disease View states that there is some “normal” process of motivation in the brain and that this process is somehow changed or perverted by brain damage or adaptation caused by chronic drug use.” (Foddy & Savulescu 2010) Addiction within people in today’s world is surrounded by choice, in that it is less about right or wrong and the good and bad, but about the choices in life that you have to make to survive. This places the emphasis on environmental predisposition, choices lead to consequences, and those consequences open a person up to greater or lesser risk of substance abuse. Just like any other disorder, or level of health an individual’s mental wellness, or the quality of life, stable income, etc. is based on their environment which is dictated by the social status and the system in which it dwells.

References

Australian Department of Health (2004). Models that help us understand AOD use in society. Medium. https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-front5-wk-toc~drugtreat-pubs-front5-wk-secb~drugtreat-pubs-front5-wk- secb-3~drugtreat-pubs-front5-wk-secb-3-4

Bennett, F. (2010). Addiction and its sciences—philosophy. Addiction Volume 106, Issue 1  January 2011 Pages 25-31. https://doi.org/10.1111/j.1360-0443.2010.03158.x

Earp, B. D., Skorburg, J. A., Everett, J., & Savulescu, J. (2019). Addiction, Identity, Morality.     AJOB empirical bioethics, 10(2), 136–153.       https://doi.org/10.1080/23294515.2019.1590480

Edmund, H., & Melberg, h. (2013). Addiction: Choice or Compulsion. Front. Psychiatry, 07        August 2013 | https://doi.org/10.3389/fpsyt.2013.00077

Foddy, B., & Savulescu, J. (2010). A Liberal Account of Addiction. Philosophy, psychiatry, &        psychology : PPP, 17(1), 1–22. https://doi.org/10.1353/ppp.0.0282

Geppart, C. (2008). Aristotle, Augustine, and Addiction., Psychiatric Times Vol 25 No 7,             Volume 25, Issue 7. https://www.psychiatrictimes.com/view/aristotle-augustine-and-  addiction

Halpern, J. (2002). Addiction Is a Disease., Psychiatric Times Vol 19 No 10, Volume 19, Issue      10. https://www.psychiatrictimes.com/view/addiction-disease

Rise, J., & Halkjelsvik, T. (2019). Conceptualizations of Addiction and Moral Responsibility.       Frontiers in Psychology., 28 June 2019. https://doi.org/10.3389/fpsyg.2019.01483 https://journals.sagepub.com/doi/pdf/10.2478/nsad-2013-0004

Uusitalo, S., Nikkinen, J., & Salmela, M. (2013) Addiction, agency and affects – philosophical perspectives. Nordic Studies on Alcohol and Drugs Vol. 30. 2013. https://journals.sagepub.com/doi/pdf/10.2478/nsad-2013-0004

White, J. (2003). The “Slow but Sure Poyson”: The Representation of Gin and Its Drinkers, 1736–1751. Journal of British Studies, 42(1), 35-64. doi:10.1086/342685