In my last column, "Accountable but Not Responsible" (April 2008), I suggested that long-term substance use could lead to a state in which the addiction had so co-opted a person's neurobiology that the individual could no longer exercise free will to any meaningful degree. I argued that a substance use disorder could advance to the point that the patient could only choose not to use the substance with enormous difficulty and effort. At this nadir of self-determination, the concept of responsibility as generally understood was no longer applicable. I instead presented the idea that patients with severe substance use disorders, while not "responsible" in terms of free choice and the attendant praise and blame we normally associate with autonomy as consequences, remained accountable. I delineated accountability as the obligation of the moral shareholders in the surround of the patient to continue earnest efforts to assist the individual in his or her struggle with addiction.
I ended the column with a pledge in the next essay to further explore this distinction using the insights of ancient philosophy and theology rather than the discoveries of modern neuroscience. Specifically, I will explore Aristotle's concept of the incontinent will and Augustine's concept of the captive will. I will end the column with some initial thoughts on ways in which contemporary substance use treatment can assist these patients to regain a measure of self-mastery and autonomy.
Aristotle's incontinent will
Whether persons who know what is good can rationally choose behavior against their own best interest is a debated topic in Greek ethics and epistemology that is beyond our task here. Suffice it to say that Aristotle departs from his masters Plato and Socrates in thinking that at least some categories of persons can know what is right and good and still act in ways opposed to that knowledge. Anyone who has ever been personally or professionally involved with a person with an addiction has in frustration asked similar questions. Why does the mother with a devoted husband and children, who readily admits her alcohol(Drug information on alcohol)ism is ruining her health and family, continue to drink? How can an intelligent attorney suddenly binge on cocaine for days, wreaking havoc on his practice and relationships?
Aristotle's explanation is 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.1 Aristotle distinguished 2 types of akrasia: "Impetuosity and weakness. Some people deliberate and then under the influence of their feelings fail to abide by their decision; others are carried away by their feelings because they have failed to deliberate."2 The mother with alcohol dependence in the example above displays akrasia of the weakness type while the lawyer exhibits impetuous akrasia. No one who has ever lived has failed to experience conflicts between reason and emotion; the difference is that the akratic person lacks the character trait required to discipline desire. The Stanford Encyclopedia of Philosophy emphasizes that Aristotle anticipated the modern recognition of addiction as a relapsing or lifelong condition. "It is important to bear in mind that when Aristotle talks about impetuosity and weakness, he is discussing chronic conditions."1
From a 21st-century perspective, the cause of akrasia is multifactorial and can be illustrated through the case of "Bill." Everyone who knows him agrees that Bill is a nice guy with strong Christian beliefs and a kind heart. He was once a successful craftsman with a reasonably stable life until the tragic loss of a child catalyzed his own childhood trauma, eventuating in years of cocaine and heroin addiction, homelessness, minor crimes, and family dysfunction. In the 10 years I have treated him, I have become convinced that Bill truly does comprehend the deleterious ramifications of his addiction and that his values are antithetical to the lifestyle in which he is submerged. Akrasia for me reconciles these seeming inconsistencies: Bill's will is so akratic that he is unable to choose differently. Bill's incontinence has overpowered his responsibility, and I am no longer surprised when the results of his toxicology screening turn out positive despite his protestations that he is clean or when he leaves the treatment program several days after admission despite imploring me to arrange an intake. I continue to hold him and myself and the other clinicians involved in his care accountable, which means, in practical terms, that I will confront him with the toxicology results but will write another prescription for his mood stabilizer. We will try to arrange housing so he does not live on the streets but will not rescue him when his drug use leads the property managers to evict him.
There is a tendency in Greek philosophy, although less so in the biologically oriented Aristotle, to associate akrasia with moral opprobrium. This contradicts and is the converse of my application of the concept. Aristotle wrote, "Thus it is evident that incontinence is not a vice (except perhaps in a qualified sense), because it is contrary to the agent's choice, whereas vice is in accordance with choice."1 Genetics, trauma, personality, poverty, peers, and mental illness—the contributors to akrasia are plenty and their interactions are complicated and yet all undermine the 19th century (and sadly, the all-too-current) stigmatization that persons with addic- tion disorders are licentious or morally flawed. These terms not only imply, but in fact require, a measure of intact choice, and I argue that the akrasia so commonly encountered in persons with addiction is, as Aristotle taught, a defect of free will.
Augustine's captive will
Similarly, as I turn to Augustine, I wish to make clear at the outset that I am detaching his formulation of the captive will from its moorings in his controversial doctrine of original sin and predestination: I am examining it as a perceptive paradigm of addiction. The platonically influenced Augustine taught that the will is only truly free when it chooses the good for which it is intended. The will can still exercise autonomy in choosing lesser goods, but freedom is correspondingly attenuated as it moves away from what is its right and, in this theological version, divinely ordered purpose. The Stanford Encyclopedia of Philosophy calls this a volitional theory of self-mastery or rightly ordered appetite.
Some theorists are much impressed by cases of inner, psychological compulsion and define freedom of will in contrast to this phenomenon. For such thinkers, true freedom of the will involves liberation from the tyranny of base desires and acquisition of desires for the Good. Plato, for example, posits rational, spirited, and appetitive aspects to the soul and holds that willings issue from the higher, rational part alone. In other cases, one is dominated by the irrational desires of the two lower parts. This is particularly characteristic of those working in a theological context—for example, the New Testament writer St Paul, speaking of Christian freedom (Romans vi-viii; Galatians v), and those influenced by him on this point, such as Augustine. (The latter, in both early and later writings, allows for a freedom of will that is not ordered to the good, but maintains that it is of less value than the rightly ordered freedom.)3 "Mary" is a perfect example of the captive will. A social worker, she continued to drink at work, while driving, and at home with disastrous consequences. In all these actions she was responsible in the conventional sense that it was the individual personality "Mary" who purchased the alcohol, kept working enough to pay for it, drove the car while intoxicated, and so on. But in a real psychological sense, Mary no longer could choose outside the confines of the alcoholic existence: the sphere of her will was constricted by the perpetuation of her addiction. In Augustine's words, "The man who does not act rightly although he knows what he ought to do, loses the power to know what is right; and whoever is unwilling to do right when he can, loses the power to do it when he wills to."4
Augustine himself will admit that this is a theological mystery, one that neurobiology and cognitive psychology have both partially illuminated in our time through their discoveries and descriptions of compulsion, craving, learning theory, and habituation discussed in my last essay. But whatever the cause, Mary is no longer responsible for choosing the good; that is, she cannot not drink but is accountable for the aftermath of her limited choices. Aristotle is less clear on how that accountability can be actualized, but Augustine's ultimate answer in all senses of the word ultimate is grace. Here I ask the reader to separate grace from a specifically religious context and to conceive of it existentially as a radical intrusion of freedom that strengthens and restores the will to full power and true orientation to the good. For some, that freedom comes through the paradoxical surrender of power in the 12 steps of Alcoholics Anonymous and other self-help organizations. For others, that release is realized through motivational interviewing or cognitive-behavioral therapy. We have seen remarkable liberations in our own substance abuse program with the use of medications such as buprenorphine(Drug information on buprenorphine) (Subutex), which has allowed patients bound to and by opioids for decades to live free of their addiction and not die. Nor should the traditional understanding of grace in religion and spirituality be discounted as a strong means of redeeming the will. Even for Aristotle, incontinence can be cured, and although he does not provide an explicit method, the implication is that through abstinence from the substance, self-control can be developed, not unlike the skills taught through contemporary relapse prevention.
The astute reader of this essay and its predecessor has likely been pondering the corollaries of the responsibility/accountability differentiation for the ethical, social, political, and even forensic aspects of addiction treatment. A worthy initial effort from a much more clinically based perspective than presented in these 2 columns is the white paper, "Responsibility and Choice in Addiction," from the Committee on Addictions of the Group for the Advancement of Psychiatry.
If we are to develop effective treatment strategies for persons with substance use disorders, we must understand that these patients cover an entire spectrum, ranging from those whose abstinence is considerably related to personal responsibility to those whose abstinence will require intensive psychiatric and rehabilitative treatment. If we recognize that an individual with an addiction may not be fully able to exercise free will, then society's obligation to intervene becomes stronger.5