Addiction as compulsion

The health sciences have long viewed addiction as a compulsion. But a body of psychological evidence shows that addictive decision-making is often reason-responsive, and epidemiological studies suggest that many addicts recover from addiction on their own. Prominent philosophers and social scientists take this to mean that addiction is a matter of free choice rather than compulsion. The stakes of the disagreement are high. The compulsion view reduces stigma and facilitates treatment. The free choice view attributes to addicts a high degree of responsibility, potentially empowering them but also risking re-stigmatization. I argue that addiction is a compulsion because it compromises the ability to reliably abstain. While much addictive behavior is under agential control, much is not; addiction undermines control in several ways. And while studies show that substance misusers often stop on their own, psychiatry distinguishes addiction from less severe disorders. Evidence suggests that the ability to reliably abstain in addiction has to be regained, usually with professional help. The action-theoretic distinction between first- and second-order ability–i.e. between the ability to φ, and the ability to become able to φ–enables us to say that addiction universally compromises the first-order ability to reliably abstain, while the second-order ability depends largely on access to scarce societal resources, like effective treatment. Addiction undermines the ability to reliably abstain by undermining control over some individual behaviors. Neil Levy and Chandra Sripada identify several cognitive processes that undermine resolution adherence in addiction, but the case for addictive compulsivity is strengthened when we account for the role of affect. While Hanna Pickard convincingly denies one form of emotional compulsion in addiction, I develop an original account centering on the emotional distress of withdrawal. I argue that the ability to intentionally abstain requires belief in one’s ability to attempt abstinence, and that in what I call “pathodoxastic compulsion,” this belief is precluded by sufficiently intense distress. A foundation of my arguments for addictive compulsivity is the view that addiction is a condition with particular control-impairing aspects. A predictable criticism of this view from the social sciences is that addiction is not a condition at all, apart from being a pattern of otherwise normal behavior. I therefore provide two arguments against the reduction of addiction to a behavioral pattern. For one, addiction informatively explains addictive behavior, and it is viciously circular to explain a behavior φ in terms of behavior φ. Moreover, addiction persists long after addictive behavior ceases, and this is hard to account for if addiction is nothing but a behavioral pattern. The compulsivity of addiction has important bioethical implications. The fact that addicts cannot reliably abstain means that putative treatment options for addiction must be compared not to abstinence but to nonmedical use in consequentialist analysis, including medical risk-benefit analysis. As such, harm reduction measures that have been shown to improve health outcomes for addicts by enabling medically supervised drug use accord with both widespread moral intuitions about when drug use is immoral, and the ethical principles governing the healthcare professions. We ought to proliferate even the most controversial evidence-supported harm reduction measures, including the medical provision of drugs of addiction.