"Jack" has been in our emergency department at least 100 times in the 4 years I have worked at the Veterans Affairs Hospital. I first encountered him in the medical ICU, where he was hospitalized multiple times with chest pain and ECG changes after cocaine binges.
"Jack" has been in our emergency department at least 100 times in the 4 years I have worked at the Veterans Affairs Hospital. I first encountered him in the medical ICU, where he was hospitalized multiple times with chest pain and ECG changes after cocaine binges. He was often admitted to the inpatient psychiatric unit when we could not sort out his accidental overdoses from suicidal behavior or when he feigned self-harm to escape legal consequences or to have a warm, safe place to stay. Once in the psychiatry ward, Jack was sexually inappropriate and would exploit other, more vulnerable patients and was quickly discharged.
As long as I have known Jack, he has had both psychotic and mood disorders secondary to long-term and heavy cocaine use and has often displayed real suffering. Yet, when someone would suggest that the voices and depressions troubling him were related to his drug use and that we would like to help him with his addiction, he would reject the suggestion and ask for either benzodiazepines, a sack lunch, or to be admitted, depending on how naive or resentful the clinician caring for him seemed. One week when Jack had been a particularly "frequent flier," the exasperated emergency department physician asked me if "this guy was responsible."
During the first years I dealt with Jack, my answer was decidedly yes, and this presumption guided my dispositions, which were in general fair, if not overly kind, in that if I felt he was suicidal or in danger from drug dealers I would usually admit him. Once I learned of his acting out on the ward and his manipulation became more transparent (or perhaps my experience-worn judgment grew more cynical), I confess I occasionally had a streak of punitiveness when I wished for a criminal justice rather than a mental health solution based on a presumption of his ethical culpability.
In psychiatry, when concerns are raised about responsibility, the real issue is frequently one of decisional capacity. The bread and butter of psychosomatic physicians such as my-self is evaluating whether patients can consent or refuse treatments, can leave against medical advice, or can care for themselves or handle finances.1 Jack would be considered essentially decisionally capable: he had consented several times to cardiac interventions; even when craving cocaine, he would usually remain in the hospital until he was safe for medical discharge; and he appeared to have street smarts sufficient to obtain regular supplies of drugs and stay alive.
And yet, as I come up to my fifth year as an attending consultation psychiatrist, I am increasingly convinced that patients like Jack are actually not responsible--but that they are accountable. In the rest of this column, I hope to make practical sense of this paradoxical statement, and in my next column I will suggest how several ancient philosophers and theologians may offer us unexpected insights regarding the status of the freedom of thousands of patients like Jack who populate emergency departments and hospitals across the country.
In bioethics, autonomous choice requires two kinds of freedom: freedom from external coercion, such as financial constraints or social pressures, and freedom for internal resources, such as motivation, intentionality, discipline, discernment, evaluation, memory, learning, reasoning, and decision making used to achieve voluntary goals.1 Brilliant neuroscience researchers such as Stephen Hyman2 and Nora Volkow3 are uncovering a dynamic representation of the neurobiology of addiction that is far more nuanced and complex than the old models of the dopamine-driven reward pathway.
In the early stages of addiction, the free will of someone like Jack is relatively intact. I say relatively because emerging research suggests that Jack probably had a decreased number of D2 dopamine receptors, and this state of hypodopaminergic function increased his risk to excessively respond to the suprathreshold dopamine stimulation of drugs of abuse.4 As the addiction progresses, the main brain engines of free will are damaged and begin to malfunction, including the attentional and self-control mechanism of the anterior cingulate gyrus; the crucial orbital prefrontal cortex that associates emotional and motivational valence with environmental stimuli and cues; and the dorsolateral prefrontal cortex, the seat of executive function and as such, the true decision maker.
In the later stages of addiction, Volkow cautions, free will may be virtually devastated: "We have come to see addiction as a disease that involves the destruction of multiple systems in the brain that more or less are able to compensate for one another. When the pathology erodes the various systems, you disrupt the ability to compensate, and the addictive disease erodes and destroys the life of the individual."5
In the new conceptualization, addiction is not so much a matter of dysregulation of the pleasure systems but of a distortion of goal direction expressed by the term "salience." Evolution has wired the brain to seek out and respond to environmental factors, such as sex, food, money, and affection, that improve the chance of the survival and even thriving of the species. All of these natural incentives release dopamine, not so much to satisfy desire as once thought but as a way of neurochemically cementing the salience of these stimuli (ie, potentiating learning).
Tragically, drugs and alcohol have a massively more potent dopaminergic action than even the best gourmet meal, a good run on a beautiful fall morning, or the devotion of a wife and children. These new neurobiological explanations of addiction give molecular weight to the phenomenological DSM-IV-TR criteria for "continued [substance] use despite adverse consequence" by a dependent person.6 Given the extreme biological response to drugs of abuse compared with daily life and work, it is no wonder that "time spent in obtaining the substance replaces social, occupational or recreational activity."6 Jack had a family who loved him, and he was resourceful enough to have been successful had he only employed the immense energy he spent on substance use in the service of more productive aims.
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 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.9But 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.
Stern T, Fricchione G, Cassem N, et al, eds.
Massachusetts General Hospital Handbook of General Hospital Psychiatry
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Hyman SE. The neurobiology of addiction: implications for voluntary control of behavior.
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Kalivas PW, Volkow ND. The neural basis of addiction: a pathology of motivation and choice.
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Volkow ND, Wang GJ, Fowler JS, et al. Decreased striatal dopaminergic responsiveness in detoxified cocaine-dependent subjects.
Moran M. Drug addiction erodes "free will" over time.
American Psychiatric Association.
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Fourth Edition, Text Revision (DSM-IV-TR).
Washington, DC: American Psychiatric Publishing; 2000.
Volkow ND, Wang GJ, Telang F, et al. Cocaine cues and dopamine in dorsal striatum: mechanism of craving in cocaine addiction.
Volkow ND, Baler R. The neural substrates of addiction.
Ogletree T. Responsibility. In: Post SG, ed.
Encyclopedia of Bioethics.
Vol 4. 3rd ed. New York: Macmillan Reference; 2004:2379-2385.