The Supreme Court reopens an old question

by Robert Wright

"He's a sick person," says Jane Wyman of Ray Milland. "It's as though there were something wrong with his heart or lungs." The movie is The Lost Weekend, and Milland is Don Birnam, an aspiring writer whose potential is stifled by his perennial willingness to pawn anything, including his typewriter, for enough money to drink himself unconscious. Wyman, Birnam's aspiring fiancée, 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. E. M. Jellinek (who, perhaps not coincidentally, based his study on questionnaires designed and distributed by

(A. A. ) 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 A.A. (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 tee-totallers 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 rendered 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 rime example of how vestiges of the scientific and philosophical past can impair judicial reasoning and the making of a 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, 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 rubic 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 the 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 on 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 behavior 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 besides 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 their 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 murders? 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 sometime 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 on 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 socio-cultural factors." Can anyone think of a behavior that doesn't fit that description?

My point is that we should not 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 (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. A.A. 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.   À 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 A.A. 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 taking 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.

©New Republic, December 14, 1987

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