InfoTrac Web: Expanded Academic ASAP.
 

Source: The New Republic, Dec 14, 1987 v197 n24 p14(3).

Title: Alcohol and free will: the Supreme Court reopens an old question.
Author: Robert Wright

Subjects: Alcoholism counseling - Laws, regulations, etc.
Alcoholism and crime - Laws, regulations, etc.
People: Jellinek, E.M. - Research
Fingarette, Herbert - Research
Gov Agncy: United States. Veterans Administration - Cases

Magazine Collection: 42D1787
Electronic Collection: A6172649
RN: A6172649
 

Full Text COPYRIGHT 1987 The New Republic, Inc.

ALCOHOL AND FREE WILL

"HE'S A SICK PERSON,' says Jane Wyman of Ray Milland. "It's as though there
were something wrong with his heart or his lungs.' The movie is The Lost
Weekend, and Milland is Don Birnam, an aspiring writer whose potential is
stifled only by his perennial willingness to pawn anything, including his
typewriter, for enough money to drink himself unconscious. Wyman, Birnam's
aspiring fiancee, 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 AA) 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 AA (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 idea's implications are made explicit, the average citizen's
enthusiasm for it may cool. Should the insurance premiums of teetotalers 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 renders
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 prime example of how
vestiges of the scientific and philosophical past can impair judicial
reasoning and the making of 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, all 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 rubric 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 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 of 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 behaver 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 beside 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 there 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 murderers? 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 sometimes 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 of
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, environmental, and sociocultural
factors.' Can anyone think of a behavior that doesn't fit that description?

My point is not that we should 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 of (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. AA 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 AA 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 talking 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.

-- End --