So complete is drugs' usurpation of human priorities that what were once semivoluntary actions and reactions become conditioned responses. In an elegant experiment, Volkow and colleagues⁷ measured dopamine(Drug information on dopamine) metabolism in 18 cocaine-dependent patients while they watched a nature video and a video of persons using cocaine. Not only was there a substantial dopaminergic surge in the addicted patients when watching the cocaine film, but even more alarming, it corresponded to their subjective experience of craving, which itself is a measure of the compulsive quality of addiction.

These results obviously underscore the challenge of relapse prevention when even otherwise neutral cues can elicit the intensity of intoxication. But more ominously for free will, what Volkow calls the plastic changes in brain structure and function suggest the entire apparatus of self-determination may have been commandeered.⁸

Philosophically, moral responsibility is the logical, and indeed practical, corollary of free will and is the rational foundation for the attribution of reward and punishment, praise and blame, both in law and daily life. The Encyclopedia of Bioethics expands on this correlation:

Being responsible for our choices and the actions that issue from them just means that we understand the genuinely open alternatives before us, that we desire or intend some of them, and that our final decisions originate with us, rather than being programmed into us by heredity, our physical or social environment, fate, God, or any kind of external causes, however near or remote. These things may influence us, but they cannot completely determine us if we are to be responsible for what we decide and do.⁹

But is he responsible?
It is difficult to answer the emergency department physician's query in the affirmative in light of the research reviewed here. Jack often said to me, "I want to change, I am going to stop." I believe that in the moment he was genuine when he made these promises of reform, but recovery had ceased to be an open possibility. While I would not be so reductionist as to claim that "addiction was controlling him," I do think it is not an exaggeration to say that the neural substrates of his intending and valuing had so strongly been reoriented to substance use that without equally strong alternative reinforcements, Jack could not resist cocaine for long.

My now tempered and much more tentative response when asked about Jack's responsibility is, "he is not responsible but is accountable." Accountability resides with the other moral agents around Jack who retain a greater degree of ethical responsibility: health care providers; his family and friends; social services; and in some cases when he harmed others, the law. Once more, the Encyclopedia of Bioethics explains the idea: "The notion of accountability directs us to revisit all the dimensions of responsibility, though with a focus on our obligation to nurture, model, encourage, cultivate, and teach responsibility to fellow human beings."⁹

Since my realization of Jack's attenuated responsibility, I have responded to each of his emergency department visits with a firm but kind refusal to admit him to the psychiatric unit for his own therapeutic benefit and for the good of the ward. I have in effect held myself accountable for showing compassion and hope for Jack while simultaneously respecting whatever vestiges of self-determination and reason remain. Lo and behold, the frequency of his emergency department admissions dramatically decreased while his attendance at outpatient psychiatric appointments increased.

My last encounter with Jack was in the inpatient medical ward where he was being treated for a life-threatening medical complication, again related to cocaine. For several days he continued the same games of expedient suicidality, provocative behavior with the sitter, and externalization of his problems. Finally, I sat at his bedside and said that all his doctors felt he would die prematurely if he could not stop using the cocaine that was killing him. To my utter amazement, his demeanor completely changed and he asked me to obtain a bus ticket to a neighboring state where his daughter lived, saying, "I will go back to using if I stay here, my daughter loves me and the laws there are much stricter so I will have a chance to start over." The attending physician confirmed that his daughter very much wanted to take care of him and arranged for his transportation. Jack had found a constellation of influences—fear of death, disgust with his lifestyle, and the love of his daughter—powerful enough to at least briefly regain prefrontal freedom.

In my next column, I will explore the ethical implications and clinical applications of the neurobiology of addiction in the very different context of theology and philosophy.