We will address these questions in two ways: first, we will examine the Choice account of motivation that we take to underlie the LiberalView to test the status of the claim that addictive motivation can be explained in terms of pleasure-seeking. What is meant by this claim and what would count as evidence against it? Second, we will probe the role that pleasure plays in addictive actions via evidence sourced from addicted persons themselves. In a recent study

1All 2010 in-text references to Foddy and Savulescu will be to this work.

(*n* = 69), semi-structured interviews were undertaken to explore the effects of substance use on what addicted persons value, specifically in relation to the ways addiction has impacted on the course of their lives. During these interviews many of our subjects offered accounts of the phenomenology of addiction and addictive motivation. Our research indicates that there are important nuances to the role that pleasure plays in addiction; that changes in motivations for substance use occur over the course of addiction; and that there is variation in how pleasure itself is evaluated by the individuals concerned. We hope in these two ways to supply a richer and more informative account of motivation in addiction than is currently accepted by holders of either the Lay or Liberal view. Our results, together with other evidence, suggest that addictive motivation is complex, and make it doubtful that severely addicted persons' consumption can be subsumed under the category of ordinary weakness of will.

# **CHOICE MODELS OF ADDICTION**

Recently, models of addiction which arise from behavioral economics and the psychology of choice have taken center stage in the ongoing debate over how best to characterize what goes wrong in addiction. Choice theorists see this model as breaking the impasse between Medical models (including the brain disease model), which remove or diminish, perhaps unacceptably, the agency of those who are addicted, and Moral or Lay models which condemn them. Disease models claim that the behavior of addicts is substantially involuntary – that it is caused by processes which bypass deliberation and choice or that are impervious to them. Moral models deny this and claim that the goals and values of the addicted person are bad or their choices and actions are weak in ways which reflect poorly on them.

By contrast, prominent choice theorists such as George Ainslie (24) and Gene Heyman (25) argue that the universal principles of choice that underlie ordinary behavior also explain the drugseeking behavior of addicts. If we want to explain what people choose and do we must understand it in terms (broadly speaking) of satisfactions sought or pains avoided. George Ainslie claims that an economic theory of action must assume that the "individual is constrained to choose the option with the greatest expected reward of all those she considers." [(2), p. 116] It is impossible for the agent to be more motivated to pursue a lesser perceived reward over a greater reward when both are available to her. The addicted person follows this pattern: her choices, like all other choices, aim at reward and are responsive to incentives. She uses drugs because they offer her more in the way of pleasure or reward than the available alternatives. Seen like this we may think that her choices are, in themselves, no more to be condemned than those of people who are preoccupied with exercising, work, stamp-collecting, or gourmet food – though like these other choices they may be criticized if they impose unacceptable costs on others or are pursued by unlawful means. Drug users, including those who are called addicts, choose to use drugs, and upon examination the explanation for what they do is of a piece with explanations of the voluntary behavior by non-addicts. This, we take it, is central to the Liberal View.

Models of addiction which propose that the user aims at the highest reward on offer face an obvious problem that choices in other domains usually do not: that of the not infrequent cases in which continued drug use incurs heavy costs, such as loss of employment, damaged relationships, legal penalties, and poor health. Additionally the initial intense pleasure that drug use delivers tends to fade over time and so it is hard to see the pleasure gained as outweighing the obvious costs. Ainslie and Heyman explain the addicted person's chronic drug-seeking in the face of diminishing rewards and higher costs in the following way. Activities that are initially extremely highly rewarding set up inflated expectations of future reward. The promise of drug rewards in the immediate future combined with overly steep discounting of the value of other more distant rewards is further exacerbated by the toxic effects of addictive rewards on other natural rewards which drain them of the pleasure which could normally be expected from them. Drug use thus continues to promise, and they claim to deliver, more reward than the *immediately* available alternatives, even though the amount of pleasure on offer is substantially reduced and even though, were the drug user to delay gratification for long enough they would reap greater long-term rewards. This model is argued to provide a more useful and more optimistic framework than the disease model in providing directions for treatment based on positive incentives that can out-compete drug rewards.

One of us has argued elsewhere (3, 4) that the choice model and the reward account of motivation on which it rests fails to provide an adequate explanation of the actions of a small but significant subset of those who are called addicts and so fails to set aside the possibility that the disease model applies to this group. We will not rehearse all of those arguments here but we flag our concern that disease theorists and choice theorists may not be applying the term "addict" to the same group and thus that conclusions that may be warranted for the larger group of substance abusers who mature out of harmful drug use upon acquisition of new interests and responsibilities do not transfer to those hard core users with whom clinicians are concerned.

Another concern with the Choice account centers on the meaning of the term "reward" in the theory. According to this account, even where it is difficult or impossible for us or for the person concerned to identify the reward that drug-taking offers – as for example in some cases of chronic alcoholism where the physical ill effects of use are immediate and severe – ex hypothesis there must be such a reward or the person would not keep choosing to use drugs. In our view this claim is either trivial or false. We address the triviality claim here; we will provide reason to think that any substantive claim is false in a later section.

If we stipulate that *all* action aims at some reward (or relief), then the conclusion that drug users are motivated by the rewarding properties of their substance of choice follows from the fact that their behavior is intentional. Choice reveals preference. Of course, we can make this stipulation if we want. Our claims about the role of reward in addiction will then be unfalsifiable, and so of no interest, since the notion of reward is detached from its ordinary meaning and loses any explanatory value. On this technical reading of the notion of reward to say that some episode of drug use aimed at reward means *no more* than to say that it was motivated. This we do not dispute. The interesting question is whether reward in the everyday sense is what motivates drug use in addiction.

# **THE LIBERAL ACCOUNT OF ADDICTION**

We see the Liberal View of addiction as arising from the picture of human motivation promulgated by the choice theorists and as gaining some warrant from it. Like the Choice theory the Liberal view says we must start from the assumption that addicts act to satisfy their strongest preferences and the driver for preferences that Foddy and Savulescu nominate is an appetite for the pleasure that drug use offers. They say "we should accept that many addicts may be choosing to use drugs because they desire drug use more than any other thing" (2010: p. 14).

Like choice theorists, Foddy and Savulescu reject the disease model and its claims that addictive action is non-autonomous. They claim that there is nothing special about the choices of those who are addicted – their ordering of values may be different to the non-addict, however, we cannot infer from this that their will is diseased or their choice-making disordered (2010: p. 14). But while choice theorists acknowledge the apparent irrationality of addicted choices and seek to explain why addicts choose what appears to be objectively worse for them over the long run, the Liberal View holds that there is no principled reason to think that addictive actions are irrational at all. Although, *some* actions performed in the course of addiction may turn out to be nonautonomous, so too may the apparently autonomous actions of non-addicts (2010: p. 15). We are not entitled to make the judgment that the bad or weak-willed choices of the addicted person are worse or different in kind to bad or weak-willed choices made by the non-addict.

Foddy and Savulescu's target is the normative framework and assumptions that surround drug use and inform both the Disease and Moral Models. Absent the normative assumption that a life devoted to the pleasures offered by drug use is lacking in value we have no reason to suppose that the addict is lacking autonomy. Foddy and Savulescu think that if we adopt a neutral Liberal position on the values at stake we must remain agnostic on the question of the rationality and autonomy of addicts. The main contours of their argument are as follows:

Let us now unpack the points above in more detail. Habitual actions that aim at satisfying desires for pleasure, considered as a general category, lead to changes in neural architecture and adaptations which cement new patterns of the same behavior. The noteworthy thing about illicit drugs, say Foddy and Savulescu, is *only* that the causal pathway to neural modification is special: certain pleasure-involving receptors are targeted directly, and the intensity of the effect is typically relatively high. But many foods and non-drug-like substances also modify brain biology, they say, as well as practices such as sex or gambling.

This observation leads to an argument: if these other substances, such as sugar, cause the same kinds of brain changes, and addiction to illicit drugs is a brain disease, then regular consumption of sugar is also a brain disease; but of course it is not. Why single out illicit drugs then? Foddy and Savulescu suggest that the reason illicit drugs are thought addictive and deserving of the disease tag, is that the category emerges from "unjustifiable factual claims" based on cultural prejudices. For example, the attribution of compulsion in addiction is generated by a normative bias that is built into philosophical, political, and popular conceptions of what a life ought to contain. In particular it should not contain the selfish and destructive pleasure-seeking that addiction brings about. But, say Foddy and Savulescu, this is indeed a bias, and it has no place in deciding the criteria for addiction, *qua* a condition that allegedly compromises rational autonomy. Their view is that we do not know whether autonomy is compromised in addiction. So, they claim, we should be skeptical of claims that addicted persons are *compelled* in their behavior around the securing and taking of drugs.

Why, according to Foddy and Savulescu, should we be skeptical about the claims that the nature of addiction compromises the capacity of persons to be effective in decision-making? Again, their argument is complex, but two points they make stand out.

First, the cultural ideology around the evils of taking illicit drugs provides powerful motivating reasons to internalize a narrative that paints the addicted person as helpless and powerless to control their urges to take mind-altering substances. Indeed, addicted persons themselves utilize this conception of their situation to deflect the stigma and opprobrium attaching to this behavior. They may even be self-deceived. This would not be surprising, say Foddy and Savulescu, for this reason: "[g]iven that the average person subscribes to some version of the Lay View, the worst thing an addict could say is that she used drugs because she wanted to or because she enjoyed it." (2010: p. 9)

Second, Foddy and Savulescu nominate a heterogeneous set of reasons, particularly from medicine and epidemiology, for doubting the claims of compulsion. Again, they say, there is a stereotypical view of drugs as causing withdrawal, but this is overstated and cannot be generalized from the key case, heroin addiction. In addition they note, with the choice theorists that most people ultimately give up their drug habit by the age of 35. And many base their drug-taking behavior or abstention around rational considerations, e.g., life choices such as pregnancy (2010: pp. 12–14). If their behavior was compelled it would not be responsive to rational considerations and ordinary life incentives.

In the light of all this, Foddy and Savulescu sum up their own view this way:

The Liberal View contains only three claims about addiction. First, we do not know whether an addict values anything more than the satisfaction of his addictive desires. Second, we do not know whether an addict behaves autonomously when they use drugs. Third, addictive desires are just strong, regular appetitive desires. (2010: p. 14)

The conclusion is that we should err on taking at face value the behavior of drug addicts – that they are rational choosers who value drugs for their rewarding properties more than they value the alternatives. Avoiding "normative bias" they say, we should accept that on face value addicts are autonomous. The Liberal account says that non-autonomy is not a *defining* condition of addiction, even though some cases of addictive behavior might turn out not to be autonomous. Addiction on the Liberal View is a matter of acting on one's strong appetitive desires for pleasure, and that is all.

The Liberal view developed by Foddy and Savulescu can escape the charge of triviality directed at the choice account, insofar as it assumes that what motivates drug use in addiction is pleasure and it characterizes pleasure as "[a] conscious sensation produced by the brain that has the quality of being pleasant, satisfying, or enjoyable" (2010: p. 19). Central to the Liberal View, is the claim that addicted persons respond to incentives – that is what justifies the *prima facie* assumption of autonomy – and the driving incentive much of the time is pleasure (Foddy and Savulescu do agree that drug use may fail to deliver on its aim of fulfilling pleasure.). We will return to the question of responsiveness to incentives in addiction later in this paper. Our main interest here is the role of pleasure in addiction. Let us be clear: we do not question the claim that a life devoted to pleasure-seeking may be autonomously chosen. Nor do we deny that some of those who are called addicts are autonomously choosing a life centered on drug pleasures or that many of the harms suffered by drug users are the result of illiberal social and legal policies which stigmatize such pleasures (though we note this does not apply to the very significant harms caused by legal and socially approved drugs like alcohol). What we do deny is that pleasure or reward plays the central motivating role assigned to it by Choice theorists and by Liberal accounts in an important set of cases and these are precisely the cases where we have most reason to question the autonomy of the addict.

Our self-report data suggest strongly that we should construe the role of pleasure somewhat differently to how the choice accounts would have it, especially when it is conceived as part of a narrative dynamic. The role of pleasure in addiction must be understood as changing over time. While a strong desire for pleasure plays a crucial role for many, perhaps most, people in establishing addiction, it is not so clear that pleasure or the expectation of pleasure plays this role in maintaining addiction. If it does not and we cannot easily construe the behavior of the addict as aiming at reward then there will be reason to question each of the three claims made by the Liberal View.

In Section "The Diachronic Value of Pleasure in Addiction" we present our self-report data to support our claims around the more nuanced understanding of pleasure in addiction. Before that, however, we respond to the claim made by Foddy and Savulescu that the self-report data from those with addiction problems is unreliable.

# **CAN WE RELY ON SELF-REPORT DATA TO UNDERSTAND THE ROLE OF PLEASURE IN ADDICTION?**

Foddy and Savulescu claim that because of the taboo nature of addiction, it becomes, according to those who reject self-report data, ". . .*impossible* to obtain *honest* accounts from addicted persons themselves. . ." (2010: p. 3, our italics). They say, "[t]here is enormous social pressure for addicts to provide an alternative explanation for their drug use" [(1): p. 9]. This echoes a similar observation by Dalrymple (5) who has said that when working as a psychiatrist, he was always struck by how differently users described their addiction to him (in terms of suffering and involuntariness) compared with what they would say to their peers in the hallway (in terms of pleasure). The claim is that addicted persons will be reluctant to express to professionals and others the pleasure-incentive that is really driving their addictive actions.

While it is plausible to suppose that socially available narratives of addiction influence what users say to clinicians, courts and other concerned parties about their drug use, we think that the claim that it is impossible to obtain from them honest accounts of their motivations for use is overstated, unfair to those who seek help for their drug use or who participate in research projects, and lacking a solid evidential basis.

We suggest that: (i) Addicted persons may be ambivalent about their using and this will be reflected in differing accounts given to different groups. (ii) What they say to peers is not obviously more reliable than what they say to professionals from whom they have sought help, but even if it is, the data that we have collected is not subject to these biases. (iii) There is also social pressure on many people struggling with addiction to *remain* users when they would prefer to quit, or to use more than they want to, and this social pressure plausibly influences what they say to peers. (iv)We should distinguish between the heat of the moment and the cool reflective moment in determining what it is that people really prefer.

First, we think that insofar as users express different attitudes to different groups this may reflect genuine ambivalence about their drug use, as different considerations are brought to the fore. When with family the damage done to family relationships and the hurt suffered by those near to them will be more salient than it is with peers. With professionals damage to health and to long-term prospects comes to the fore. With peers, the pleasures induced by the drug and its social aspects will be most prominent. The question, then, is not whether the individual is lying to one of these groups. The question is, of the accounts they give, which, if any, should be privileged in providing reliable testimony concerning what motivates their drug use. Given the expression of different attitudes to different groups, attitudes underpinned by a rationale responsive to that context, there is no *a priori* reason for thinking one of these groups is privileged as the group to receive the truthful account. In particular we do not know whether an addicted person's statement to a fellow user misrepresents their understanding of what motivates them.

Second, the responses to our own study provide reasons to doubt that addicted persons are honest with their peers (a context where the taboo of taking drugs for pleasure does not operate) and not with those professionals with whom they are engaged. Our questionnaire reflected none of the normative biases Foddy and Savulescu identify, and we made clear to the participants that our role as philosophers (not treatment professionals), oriented us to an interest in their story, and their experiences. Our open style of questioning was designed to avert any sense of being judgmental and the semi-structured nature of the interviews meant that we maximized the possibility of eliciting clear and reflective accounts of respondents' understandings of the role pleasure played in their addictive experiences. Respondents repeatedly stated that they wanted to be honest with us, that they enjoyed the conversation and felt listened to. Sometimes they asked us directly if we wanted the socially accepted explanation or if we wanted to hear what they really thought. It became clear that respondents were not reluctant to express to us the nature of their using, its extent, and the kinds of incentives that drove this behavior, including pleasure. We will explore their reflections on pleasure in the next section.

Third, some of the responses we collected suggest that we should be cautious about privileging what they say to their peers over professionals and others, in seeking to explain their behavior. Social pressure cuts both ways and many long-term addicts live in a social milieu in which using is expected and abstinence is seen as a threat, an implied criticism, or socially unacceptable.

The other addicts aren't really . . .they don't want to see someone get on with their life "cause then. . . oh this is what I think, then. . . it's saying to them, may be you can do this but they don't want to. . . they're comfortable. I don't know, it's kind of like misery loves company. . . you can have so many friends when you're miserable and everybody wants to hear all your problems and they're all so consoling you know but sometimes I wonder if they're not being patronizing and they really like to. . . "cause I notice when I'm going well, noone's that happy and it's like no-one wants to give you a shot when you're hanging out but when you've been clean for six months everyone wants to give you a shot, it's things like that I've noticed, you know. (R67)"

That's another big step because all my so-called friends are down here and to leave them is going to be hard, but they're not really friends anyway, they're just acquaintances through pubs and drugs, that's pretty much it. So, yeah, to leave them it's going to hurt them, but it's probably not going to hurt me as much as it's going to hurt them, but what can you do, you've got to get rid of the old people, you know what I mean? (R5)

He's [his boss, who also has a drinking problem] always ringing up to come to work, even if I have a day off – "Are you going to come tomorrow? I'll even come and get you." "Yeah I'll be there, I'll be there." And he'd say "You got any beers in your bags?" and I say "No." I know I got beers in the bags; as soon as I get to work I'll open a beer, [and] by lunchtime he's looking at me going "fuck it," let's go and get a beer, and I've already had six by then and I'm thinking oh, I don't really need another one but I go with him and then I might have another six that afternoon. (R6)

Finally, and in response to the preceding considerations, it is common in philosophy and in common-sense, to distinguish between what people want and what they "really want" or value and the differential responses may in part reflect this distinction. GaryWatson describes a person's values as: ". . .that set of considerations which he – in a cool and non-deceptive moment – articulates as definitive of the good,fulfilling, and defensible life" [(6), p. 105]. However, as Watson points out, our valuational system and our motivational system may come apart. Another related distinction is between people's experiential interests and their critical interests [(7): p. 201]. The former are satisfied when a person's present inclination for certain kinds of felt experiences is met. Desiring a warm bath and lying in it, having a wish to smell roses and smelling them, having a yen to hear Bach and listening to it, all count as examples. Critical interests, by contrast, are not tied either to the present, or to any kind of feeling. That one's treasured antique violin is passed down to a grandchild, or that one's standing in the community as a decent citizen is recognized would count as examples of critical interests.

These distinctions provide an alternative explanation to selfdeception or pressure to adopt socially acceptable narratives of addiction where there are instances of different content or emphasis in what is said to professionals and what is said to peers. When addicted persons are with their drug using peers, attentiongrabbing drug cues abound. Their experiential interests or immediate urges dominate their attention and what they say about drug use then is much more likely to be, as it were, in the heat of the moment. In a more reflective moment when their critical interests come to the fore, such as when they are with a therapist or a researcher, they are likely to express a measured assessment of their drug use which encourages them to describe how it impacts on their life extended over a longer period than the time it takes to make the next score.

Foddy and Savulescu's reason for dismissing the possibility of reliable first hand reports is the taboo nature of drugs and pleasure that supposedly prevents the addict from delivering an honest appraisal of their drug-related activities to those outside their peer group. As we've shown there is reason to think that this assessment is unduly pessimistic – especially surely as applied to alcohol. If that is right then any claim that we should privilege what users say to their peers over what they say to professionals and others must turn on privileging experiential interests and synchronic desires for pleasure over critical interests and diachronic values, and this is a matter on which the Liberal view must remain agnostic. While both perspectives must be taken seriously, and are equally important in understanding addiction, in our view the persistence of grief, regret, and internal conflict in many of our subjects (including many alcoholics) provides at least a *prima facie* reason for privileging their critical interests.

# **THE DIACHRONIC VALUE OF PLEASURE IN ADDICTION**

While the self-reports of those who are addicted cannot tell the whole story of the role of pleasure in addiction, self-report data provides a valuable insight into the changing role of pleasure over the course of addiction. In this section we will draw on material from qualitative interviews with 69 opioid and alcohol-dependent subjects in order to counter what we think is the overly narrow understanding of pleasure in addiction assumed in the choice accounts. As we have said, we agree that a life of pleasure could be autonomously preferred and that some user's lives may be autonomously structured around the pursuit of drug-related pleasures. Most of our subjects did not characterize or experience their lives or their drug-seeking as autonomous in this way. However, our interviews revealed a nuanced and changing role for pleasure across the course of addiction.

On the basis of our interviews we can distinguish three subgroups of users: the first group said that pleasure was their main motivation for using substances. On the Schwartz Value Questionnaire they scored "hedonism" as their most important value. But this simple nomination disguised an important aspect of their self-understanding in relation to the incentive pleasure gave them. Pleasure was, for them, intensely motivating, but they realized that in the long run the damage their drug use caused had the effect of hindering their goal of a hedonistic life. They were disposed to stop their consumption for hedonistic reasons, and yet found doing so beyond them. The Liberal account argues that even in these cases where pleasure is the only value at stake, there is no reason to think one's short term appetites must align with one's longterm hedonistic project to maximize the rewards of consumption over time. What they say is in line with the Choice model: at the moment of consumption, it is the appetitive reward the person most wants, and that although this may count as weak-willed it is not *prima facie* non-autonomous. Our view is that, on the contrary, the extraordinary difficulty some subjects face in orienting themselves toward the pleasure they both want and value most signifies an important loss of control – of self-authorship. We make good on this claim in a later section.

The second group consisted of people who cited pleasure as the initial reason for consuming; over time, however, after repeated use, the pleasurable effects of the substances they were taking faded out and pleasure was no longer their main motivation for use. The third group claimed to have never really experienced pleasure from using. For both the second and third group their ongoing motivation to use drugs was something of a mystery to them. They explained it by reference to addiction – which they seemed to experience as a motivating force distinct from any interest in or expectation of pleasure.

# **PLEASURE ALL THE WAY THROUGH, BUT A PLEASURABLE LIFE IS MORE THAN USING**

We identified a sub-group of users who acknowledged they were motivated primarily by pleasure. Still, even for this group our data shows that the Choice model may be too simplistic. Those who valued hedonism did so based on an understanding of that notion that was broader than just the "instant pleasure" derivable from substance use; their sense of the value of pleasure was *diachronic* in nature.

A hedonistic lifestyle, as understood by many of those we interviewed, is not reducible to a narrowly focused pleasure-seeking or seen in terms of the aggregation of a set of pleasurable experiences. Only a minority of the respondents described themselves as pleasure seekers in this narrow sense, and even they were skeptical about the contribution of substance use to their hedonistic lifestyle in the long run. One person, who described himself as hedonistic, made clear that substance use was only part of a hedonistic life. Other users described how drug use can conflict with other primarily hedonistic values, such as holidays and material goods, which nevertheless require planning and a diachronic perspective at odds with the synchronic focus induced by substance use.

I just enjoyed life and work but life more than work (. . .). I think I wanted to be successful. I was very hedonistic. You know I wanted the right clothes; I wanted to eat in the right restaurants and be with the right people,go to the right parties and that sort of thing. (MHE 001)

When you're drinking you're just thinking of the moment, you're not thinking of anything else sort of thing, anyone or anything in particular you know, you're just thinking about having a good time and a laugh and a joke maybe with a couple of friends that you're with or something like that, but you're not. . . it's not as if you're sitting there talking about planning and buying a house or what are we going to do. . . plan a holiday to go overseas next year or something like that. (R32)

One young female alcoholic stated that although she was doing many nice things in her life (including a job she enjoyed, and frequently attending festivals), due to her excessive alcohol use, she was not able to remember many of those enjoyable things and that her alcohol use was also frequently spoiling enjoyable occasions. Another user described herself as a "willing addict"; she claimed that all she had ever wanted to become in life was an addict. However this seemed tightly connected with a kind of status she had within her using and dealing family gained by her ability to be able to get every prescribed medication she wanted from the time she was a minor, rather than from the pleasures of use itself.

Additionally most of our respondents were highly skeptical about the possibility of long-term use without significant negative consequences.

Well don't get me wrong, I love using mate. If I could use successfully I would. I'd still be using.  (R50)

Another respondent described it as follows:

Heroin is an astonishing thing. I will never. . . regret taking heroin. In fact those two years I took heroin are actually one of the best two years of my life. (P1)

Yet this respondent did decide to stop because of the negative consequences of his use. He describes the experience of coming off heroin as an extra bill he had to pay for his use, an extra hard time. Adherents to the Choice model will say that such cases make their point. It shows that people *will* stop using when the costs become too high – and of course many of those costs are a result of the unjustified normative bias which stigmatizes drug use.

In response we agree that many people do stop using when the costs rise and this may be particularly true of this hedonistic sub-group.

But others don't even when, from their own point of view the costs are manifestly enormous – including impending death – and the hedonistic benefits are invisible. If the Choice and Liberal theorist's claim that addicts will stop when the costs become too high amounts to the truism that addicts will stop using when their momentary drives to use no longer outweigh competing motivations they have done no more than reiterate their own account of motivation. The important issue for us is *why* some individual's motivations are unresponsive to massively increasing costs and decreasing rewards and whether this calls into question the Liberal *prima facie* assumption of rationality or autonomy in these cases.

The assumption of the Liberal and Lay views that addicts freely choose to take addictive substances for their rewarding properties certainly has application *to a sub-group of addicted persons*. However we see that even in this group people are quite skeptical about the contribution of substances to a pleasurable lifestyle in the long run. Although they don't necessarily regret their use and still like the effects of the substance, they acknowledge the ways in which repeated consumption for instant pleasure ultimately undermines other diachronic values and reasons that they endorse. The Liberal view accepts this latter nuance, but insists that individuals among this group remain motivated by their appetite for the rewards of their preferred substance and that we have no special reason to suppose they lack autonomy. To do so is unjustifiably to privilege their reflective preferences over their first order preferences. We think that there is an important difference between the initial motivational profile of the hedonist drug user who smoothly translates her pleasure-oriented values into action and the same person later on, utterly disabused of the belief that drug use will promote her hedonistic ends, but who is nevertheless episodically motivated to consume drugs when the cues pressuring her to do so become overwhelming – a difference relevant to the assessment of autonomy.

### **INITIAL PLEASURE**

This group of respondents said they used substances for their pleasurable effects, but only, or especially, at the start of their addiction. They described their initial use as a honeymoon period, until their lives began to fall apart, a period in which substance use ceased to be pleasurable:

that's the love-hate thing I have with. . . when I first started, I liked the feeling but then once I got addicted I didn't like it. And I always wanted to quit because of that. (FHE 041)

This group, for whom drug use no longer produces pleasure and who want to quit, divides between those who end up using to ameliorate the negative effects of craving and withdrawal and those for whom pleasure or relief ceases to play a useful explanatory role.

I mean some people will say oh, the drugs stopped working for me. I don't agree, you know, I don't believe that. . . I mean I think if they weren't working you wouldn't do them. They do.  (MHE 9)

While it sounds odd to portray those who use substances to relieve unpleasant sensations as living a hedonic existence, drug use for such individuals might still be the most rewarding option. The relief described by this user is indeed fully consistent with the choice model and can be accommodated by Foddy and Savulescu. Yet even where our users' stories are consistent with the claims of the choice account we think these accounts miss something important in the phenomenology of addiction. The idea of drug use "taking on a life of its own" recurs throughout our interviews. It is the point at which drug use ceases to serve its original hedonic function and becomes detached from the user's perceived interests, values, and desires.

We think that for a significant sub-group of users pleasure ceases to have the explanatory value attached to it by Foddy and Savalescu, and that at some point neurobiological models, such as that proposed by Robinson and Berridge (8); Berridge et al. (9), and Koob and Volkow (10), are a better fit with their reported experiences. The fit between the neurobiology, the phenomenology, and the behavior may be thought to constitute converging lines of evidence for the view we present. We do not suggest that the neurobiological evidence could be sufficient on its own.

These neurobiological models do however purport to provide an explanation of the *shifting* role of pleasure in different stages of addiction that our subjects and others describe. Although initial substance use can release a large amount of dopamine in the brain, causing intense feelings of pleasure, repeated substance use has quite a different effect. Because the brain is over-fueled with dopamine, neural changes in the reward pathways occur to restore the balance, such as the decrease of post-synaptic dopamine receptors, to overcome the effect of the substance. This results in tolerance for the substance (with less pleasure experienced), but also a higher threshold for experiencing those rewards obtained from normal rewarding activities, like food, sex, and social cooperation. Koob andVolkow (10) call this the"motivational withdrawal syndrome," roughly, the emergence of a negative emotional state – anhedonia – that occurs after abstinence [(10), p. 217]. This state can persist for months or even years after abstinence.

But that is not the only change caused by the huge surges in dopamine release by substance use. Dopamine's function is twofold: it primes us on the circumstances or cues in which the pleasurable event occurs, and it reinforces behavior that is directed to those goals. These effects occur because the intensity of a drug experience provides a learning signal that this reward was better than expected. On the next occasion when the same cues appear we will be more sensitive in our recognition of the type of activity generating what we have learnt, and we will be disposed to pay attention and direct our behavior accordingly (11, 12). The huge amount of dopamine release works as a Trojan horse that overtakes the reward-related learning process and creates long-term associative memory processes directing a person to further substance use [(13). p. 575]. Becoming hypersensitive for drug-associated cues then occurs mostly in the absence of subjective feelings of pleasure. Thus the increasingly addicted person continues to want a substance they no longer have a strong liking for. Repeated substance use increases compulsive wanting, or craving, and at the same time diminishes experienced pleasure. Normally we want what we like, and we like what we want, but Berridge (14) has shown that these systems operate through different neural pathways. It is not so much the pleasurable effect (the liking) that drives the addicted person, but the reinforcing, conditioned learning aspects of dopamine driving the behavior (15).

Summing up, there is a major strand of research that argues that the neurobiological effects of sustained drug use help to understand and characterize the function of pleasure for this group. This group learns to continue wanting a drug that has ceased to generate for them the pleasure it originally had. This is not just a "very strong appetite" for pleasure as this is normally understood. It has compulsive elements divorced from any person-level expectation of pleasure, in that it captures and monopolizes the addicted person's attention making it extremely difficult for them to focus on and pursue other more valued activities.

We acknowledge that the science is far from settled, so it pays to be cautious in recruiting data to support philosophical theorizing. Philosophers lack the expertise to adjudicate between positions within the neuroscience of addiction. But we do not in any case claim what Foddy and Savulescu are especially keen to deny – that this research establishes that addiction is a brain disease or that addictive action is somehow not intentional. We take no position here on whether addiction is a brain disease (We think that some of the common arguments against the disease claim are bad arguments, but that's another story.). We do not think that an argument that the autonomy of addicts is impaired depends on establishing a disease model or upon showing that addicts do not intend and choose those of their actions that are motivated by their drug-related urges.

While it is clearly true, as the choice model emphasizes, that the particular actions an addicted person undertakes in procuring and consuming drugs are responsive to a variety of contingencies, we think this flexibility is not as significant as proponents of such models have it. In particular it does not show that drug consumption is not in some sense compelled, or that it must be the most rewarding synchronic option available, at least on any ordinary understanding of the notion of reward [see (3) on this point]. On a view which sees wanting and liking as dissociable and dissociated in many long-term users, drug use ceases to be chosen in the sense proposed by the choice models, that is, as *rationally responsive*, either globally or locally, to an evaluation of the rewards on offer. The *means* taken to drug use may indeed be flexible and responsive to local contingencies and so drug use can be delayed or moderated in some circumstances, but the *goal* itself seems to be a stubborn feature of their psychology. In the hard core user it is relatively impervious to reflection, choice, and control, even when it is clearly highly dysfunctional.We think that this is an important feature of addiction. Drug use becomes, as one of our respondents put it, like a chore or an "obligation." It becomes something they have to do but that they no longer enjoy or understand themselves doing. Here is a representative sample capturing this idea:

Yeah but now it's just. . . it's not even fun anymore really,it just sort of becomes a. . . I don't know, more or less like a chore I suppose but yeah I just. . . I want to get away from it. (R29)

It's. . . there was reason, early part, until I came to understand why I was behaving the way I was behaving. So in. . . no, not now. No. There's no reason. (R39)

[W]hen I was 20, 30, when I was 40 my drinking was good, I had good times on the drink, from when I was 50 to 60 just. . .I'm just drinking for nothing (. . .) I'm just drinking for drinking sake now. (R24)

Now Foddy and Savulescu may counter that we see the same phenomenon in the other kinds of cases they give. Perhaps repeated high consumption of sugar or repeated gambling has the same effects in some people and so they feel driven to consume or to gamble even though they say they no longer enjoy it, and even though it has disastrous consequences which they certainly do not enjoy. If this were to be the case we would not see it as reason either to reject those neurobiological or phenomenological accounts which accept the liking/wanting dissociation in addiction, or to become skeptical about the category of addiction. The relevant behavior is addictive even if it responds to substances or stimuli which do not usually pose a risk of addiction2 .

### **NEVER EXPERIENCED PLEASURE**

Summing up, the groups we have described so far report that although the drug use fulfilled a certain role for a period of time, at some point this ceased to be the case. It ceased either because tolerance led to a loss of pleasure, or because,for more complicated reasons, their drug use could no longer be rationally or successfully incorporated as part of a more sophisticated hedonistically motivated lifestyle.

We can now distinguish a third group who don't describe any feelings of pleasure or hedonism when using drugs. Some within this group emphasized the strong physical dependency that came with their consumption:

[A] lot of people talk about a honeymoon period on drugs. I can't remember a time like that, I can remember starting

2We think that behavioral evidence and phenomenological report strongly suggest both the dissociation between wanting and liking in human addicts that Berridge claims to have found in rats, and the monopolization of attention and cue-driven action in addiction. Certainly the claims about monopolization of attention, cue sensitization, and cue-driven behavior in addiction are uncontroversial and have been established in many psychological studies that do not rely on neuroscience. Addiction neuroscience aims to uncover the neural mechanisms that drive behavior. Perhaps the work we have cited – though it is certainly in the mainstream – does not successfully uncover those mechanisms and explain the observed phenomena. It might explain too little: there could be other relevant pathways that explain addictions not well explained by the dopamine theory. It might on the other hand explain too much. This seems to be the thrust of much of Foddy and Savulescu's discussion of the data. They say the same responses have been observed for a wide range of non-drug substances so either we must say that people may be addicted to all these other substances (a reductio) or the research simply describes normal responses to pleasure and does not serve to support the view that addicts are in any way impaired (qua addicted). Perhaps they are right; more work needs to be done to test this view. But there is at least a respectable body of opinion that people may form addictions to non-drug substances such as sugar and to activities such as gambling, with similar behavioral features and consequences (mutatis mutandis) to drug addictions. Whether this will extend to include such apparently innocent substances such as water and milk as Foddy and Savulescu suggest remains to be seen since the studies they refer to have not, to our knowledge, been replicated.

drugs and pretty much straight away trying to stop all the time. Like I know people talk about that it was nice and exciting and it was a carnival at the beginning but I didn't find it like that (. . .). I hardly even remember starting drugs, I mostly remember trying to stop all the time. (R47)

Others within this group described the use of substances as a way to feel normal, as a painkiller, or self-medication for psychological problems. One young woman described how she always felt she didn't have a right to belong in the world the same way other people do, she would stare in the mirror for hours, trying to figure out who she was.

[U]sing heroin made me feel normal, it took that away, so I didn't feel bad about it at all, I thought I'll do anything I can to get it, I don't mind if I have to work [in prostitution] and I thought that it was the only thing that would help but of course it's taken everything away from me now (. . .). Yeah I didn't use it to have fun I used it to feel normal, then it turned into just an addiction. (R22)

Addiction is seen by many of our subjects as a motivating force that is separate to and distinct from the desires for pleasure or relief or acceptance that originally motivated their drug use and as undermining both their pleasures and their plans. In the light of the costs their drug use imposes on them we think that,for at least a subset of users, pleasure, and reward do not explain continued use.

# **AUTONOMY AND ADDICTION**

In light of the distinctions of the role of pleasure in addiction we think it appropriate to respond more fully to an argument from Foddy and Savulescu regarding addiction and autonomy. We would claim that the evidence of dissatisfaction and repeated failed attempts to quit calls into question the autonomy of the addict.We do not assert that it calls into question a *substantive* conception of autonomy, for we are not here making any normative claims about the irrationality of seeking pleasure through substances over more healthy activities. We agree with Foddy and Savulescu [(1): p. 8] that in testing whether addiction threatens autonomy the correct conception is a procedural account. Then the question of whether autonomy is threatened has nothing to do with the *content* of the desire one acts upon, yet fails to identify with or endorse. Whether autonomy is threatened is a matter of whether the machinery of the will – involving the interplay between the motivational and valuational systems – functions properly. Foddy and Savulescu claim that addiction does not diverge in any significant way from many other phenomena in which agents repeatedly regret past actions. They write (p8)

Human beings make choices they regret, sometimes even repeatedly. There may be an ideal conception of autonomy, according to which making choices in the knowledge that one will regret them later, is non-autonomous. But telling us that addiction is non-autonomous in this sense is telling us very little: It is not distinguishing it from ordinary cases of weakness of will.

But, on the contrary, we think severe cases of addiction are not like the ordinary cases of weakness of will they have in mind. To explain this more fully we invoke a tripartite distinction between wanting, liking, and valuing. In ordinary cases of weakness of will wanting combines with liking in opposing the agent's best judgment. When I eat chocolate though I'm on a diet or snuggle up in bed instead of going for an early morning swim in accordance with my fitness regime I am doing what I both want to do and enjoy doing at that time though I think that all things considered I should be doing something else and even though I know I will regret it later. But I *like* chocolate and warm beds. If I did not, my actions would be puzzling indeed.

That we can describe these cases as weakly giving in to one's desires for chocolate or for comfort makes sense partly because the pleasure or reward competes against the value judgment3 . Are cases of addiction just like this? If they are, then we do indeed have reason to be skeptical about the category of addiction, since in the story just given we have no reason to conclude that I am addicted to chocolates, warm beds, or whatever else.

However, if we take the self-report data from addicts seriously, as we have argued that we should, this is not true of at least a subset of addicts for whom even the immediate outcome of their consumption is dominated by pain and regret. For this group, pleasure (or reward) and the expectation of pleasure (or reward) – that is, what they *like* – has dropped out of the picture4 . An appetite toward pleasure or reward does not explain their actions. Here the competition is between valuing and mere wanting. You may want something you neither like nor value; furthermore you may want it so strongly that you simply cannot stop thinking about or successfully inhibit the automatic action tendencies that arise in response to environmental cues, and any attempt you make at synchronic self-control will eventually fail. Both strength and persistence of wanting and the opposition of wanting to liking or valuing, are important elements of what distinguishes weakness of will – even persistent weakness of will – from compulsion. Autonomy comes in degrees and while there will be borderline cases we claim that at least some hard cases of addiction are clear cases of compulsion rather than weakness of will – even chronic weakness of will – or unthinking habit5 . If the distinctions outlined here are correct they suggest that addiction cannot be as readily assimilated to everyday moral experience as proponents of the Liberal View suppose and places the onus back on them to explain, consistently with their view, what has gone wrong in such cases.

We see a significant problem with the Liberal position of neutrality between synchronic and diachronic perspectives in an

3This is not the full story of weakness of will. See Kennett (20) for a detailed account. 4That is, the expectation of pleasure at a personal level. Perhaps the system "expects" pleasure – in the sense laid out by the neurobiological accounts. If so the explanation of action is sub-personal and as argued elsewhere (3) this would be inconsistent with an important feature of choice accounts – that the addict's action is susceptible to a rationalizing explanation, in terms of their beliefs and expected reward.

5Note: this is *not* to suggest that addicts lack autonomy altogether or that it is impossible for the compelled addict to reduce or quit – since they may be able to avail themselves of techniques of diachronic self-control. Nor is to suggest that *chronically* weak-willed individuals are not also lacking autonomy.We think they are to the extent that they become synchronic, disunified agents – see discussion below and see also Levy (21) for an interpretation along these lines of the failure of autonomy in addiction. There is no space here to provide a complete description and defense of the distinction we have outlined between weakness of will and compulsion: for a book length treatment see Kennett (20), and for particular application to the case of addiction see Kennett (3, 22) and Kennett et al. (23).

account of autonomy. The Liberal position does not want to privilege the satisfaction of our reflective desires over the satisfaction of desires formed in the heat of the moment. We of course agree that the satisfaction of momentary desires for such things as food, sex, or drugs can often contribute value to someone's life, and that we should not automatically assume that a person who prioritizes synchronic pleasures lacks autonomy. A view which prioritizes reflective preferences can accommodate the endorsement of the satisfaction of synchronic desires as autonomous and can also describe when they become non-autonomous. But what, on the neutral Liberal view, could count as impaired autonomy at all? Foddy and Savulescu agree that it is possible some addicts lack autonomy. Which addicts, and what would they have to lack *qua addicts* for Foddy and Savulescu to count them as having impaired autonomy?

Let us briefly sketch a reason for thinking that the procedural account we favor is to be preferred over neutrality. Who or what can be autonomous? It seems to us that a condition of autonomy is diachronic agency. Purely synchronic agents, e.g., very young children or deeply amnesic patients, cannot be autonomous. You need to be capable of remembering the past and projecting yourself into the future – you need the capacity for mental time travel – in order to be autonomous. But of course mere access to your past and the capacity to predict the likely future is not enough for autonomous agency. As two of us have argued at length elsewhere both planning and diachronic self-control are fundamental to the construction of the kind of unified agent who can properly be held responsible for their actions (16–19). The importance of diachronic capacities and perspectives in the construction of an agent who is even so much as capable of autonomy or failures of autonomy does at least suggest a reason for privileging the reflective perspective in identifying when autonomy is impaired and to what degree. In severe cases of addiction the radical impairments to diachronic agency can be understand only when we see the individual as failing to unify their agency in accord with their reflective selves.

# **CONCLUSION**

Pleasure seems to play a significant role in addiction though this diminishes across time and users become increasingly resentful of, or despairing of, the effects of their substance use on their capacity to realize other values. The Lay and Liberal Views are of course right that a desire for pleasure can play an important role in explaining consumption in first-stage substance use, though this excludes the category of users who self-medicate. But in the long run the influence of substance use on health and on social relationships seems, to many users, not to be worth the trouble, especially when the early pleasurable effects fade. Yet, for a significant number of users in this group, *the loss of pleasure does not result in a cessation of addictive use*. Even for the people who seemed to want to pursue a life of hedonism, substance use has only a temporary role in this. Although our respondents did not deny the pleasurable effects of substances during the early stages of their use, they were mostly quite skeptical about the pleasurable effects in the long run. This seems to us to present a problem for accounts that depend on an assumption that the desires for pleasurable

rewards continue, more or less in the same form, throughout different phases of addiction. The Lay View seems particularly taken with this assumption. It also presents a problem for the idea that we should err on the side of assuming that those who are called addicts are rational choosers who value drugs for the pleasure they produce more than they value anything else.

Our interviews combined with other data call into question each of Foddy and Savulescu's three assumptions: First, while we do not know for certain whether any addict values anything more than the satisfaction of his addictive desires, the clear unhappiness of many of them with their drug-taking lifestyle and their repeated attempts to quit suggest that they do.

Second, the same evidence of unhappiness and failed attempts to quit also calls into question the autonomy of the addict. Many are no longer motivated by what they like about drugs and so cannot be characterized correctly as acting weakly in the way we might characterize someone who regrets eating too much chocolate (for pleasure) on some occasion. The addicted person is not weak of will in that sense. The stubborn resistance of their goals to their reflective judgments is not properly explained by assimilation to ordinary cases of temptation where for the most part we do manage to act in accordance with our judgments.

Third, addictive desires appear to shift from being,"just strong, regular appetitive desires" to desires which have lost the ordinary connection with reward. With or without any normative bias that may play a role in shaping an addicted person's preference structure, it is misleading to portray people struggling with addiction simply as motivated by strong appetites for pleasure. For the last group we identified it looks false. Those people never experienced the claimed rewards. Others struggle to quit despite extraordinarily heavy and increasing costs. Many of our respondents continued using in the face of costs which were not comfortably relegated to a distant and discounted future but were rather experienced by them daily, including at the point of use – such as pain, serious, and disabling health problems, and very credible risk of death. In our view it does not appear that such users are acting autonomously on the basis of a strong appetite for pleasure, or that their motivation conforms to the supposed universal principles underlying the choice model. If the choice view or the minimal Liberal view licenses agnosticism on the issue of whether such individuals suffer impaired autonomy or not it leaves us wondering what,if anything, a clear case of impaired autonomy could be.

As one of us has argued elsewhere, to insist either that such users *are* motivated by pleasure or reward or to make this the default assumption makes the Choice model stipulative rather than genuinely explanatory of a range of cases (3, 4). This is a pity since both the choice model and the Liberal view to which it gives rise have insightful things to say about addiction and the role of pleasure in establishing and maintaining it.

# **ACKNOWLEDGMENTS**

We thank the editors and the referees, Owen Flanagan and Bennett Foddy for their very helpful comments on this piece.We also gratefully acknowledge the support of the Australian Research Council (DP1094144) for our research project on addiction and moral identity.

# **REFERENCES**

**Conflict of Interest Statement:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

*Received: 27 May 2013; accepted: 11 September 2013; published online: 25 September 2013.*

*Citation: Kennett J, Matthews S and Snoek A (2013) Pleasure and addiction. Front. Psychiatry 4:117. doi: 10.3389/fpsyt.2013.00117*

*This article was submitted to Addictive Disorders and Behavioral Dyscontrol, a section of the journal Frontiers in Psychiatry.*

*Copyright © 2013 Kennett, Matthews and Snoek. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.*

# The shame of addiction

# **Owen Flanagan\***

Department of Philosophy, Duke University, Durham, NC, USA

### **Edited by:**

Hanna Pickard, University of Oxford, UK

### **Reviewed by:**

Serge H. Ahmed, CNRS, France Neil Levy, Florey Institute of Neuroscience and Mental Health, Australia

**\*Correspondence:**

Owen Flanagan, Department of Philosophy, Duke University, 201 West Duke Building, Durham, NC 27708, USA e-mail<EMAIL_ADDRESS>
Addiction is a person-level phenomenon that involves twin normative failures. A failure of normal rational effective agency or self-control with respect to the substance; and shame at both this failure, and the failure to live up to the standards for a good life that the addict himself acknowledges and aspires to. Feeling shame for addiction is not a mistake. It is part of the shape of addiction, part of the normal phenomenology of addiction, and often a source of motivation for the addict to heal. Like other recent attempts in the addiction literature to return normative concepts such as "choice" and "responsibility" to their rightful place in understanding and treating addiction, the twin normative failure model is fully compatible with investigation of genetic and neuroscientific causes of addiction. Furthermore, the model does not re-moralize addiction. There can be shame without blame.

 Among men who feel shame, more are saved than die." Ajax to his troops in Homer's *Illiad*

**THE TWIN NORMATIVE FAILURE MODEL OF ADDICTION**

I propose a twin normative failure model of addiction in which the self-regarding reactive attitudes of bewilderment, disappointment, and shame play a constitutive role1 . The addict cannot pass her own survey because she self-interprets, and self-interprets correctly, that she fails to execute normal powers of effective rational agency, she decides not to use and uses; she also fails to live up to the hopes, expectations, standards, and ideals she has for a good life for herself because of her addiction. It is possible and desirable to understand addiction as a normative failing in both these respects, one of rational effective agency, the second of moral quality broadly construed, without also moralizing addiction. Recognition of these twin normative failures is a powerful source of desperation and motivation to heal on the part of the addict and an immensely valuable tool for the therapeutic community to keep in view and use non-moralistically, as it tries help the addict to heal. In earlier times, it may have been that most addicts died for reasons related to addiction. Now, perhaps, with much deeper knowledge of the causes, components, effects, and nature of addiction we can make Ajax's maxim true for addicts: "Among men who feel shame, more are saved than die."

I intend the twin moral failure analysis to be true to the perspective of the addict, his close relations, as well as from the perspective of the professional and non-professional therapeutic communities that work and live with addicts. I also intend the analysis to describe normal and reliable features of addiction. The exceptions, the cases where there is no shame on the part of the addict descriptively, and where shame would be unwarranted normatively involve abnormal psychiatric conditions, e.g., schizoid personality disorder, or unusual social conditions where there are no choice-worthy options for a good human life, or where the addict has a certain social status, social permission (opiate addicts in hospice), and/or financial resources to be an addict with impunity.

To many, the view will seem too strong in two respects. First, some addicts are willing and not ashamed, so the view is descriptively false. Second, the view is reactionary: despite my claim that the twin normative failure model does not moralize addiction because it acknowledges shame without endorsing blame, it nonetheless returns us to the view that addiction is a moral failing. After spelling out the view more fully, I reply to these and several other objections.

# **ADDICTION IS A NORMATIVE DISORDER**

In a seminal paper in philosophy and cognitive science, "Intentional Systems," Dennett (1) distinguished between three stances we commonly take toward ourselves and other human beings, the "intentional stance," the "design stance," and the "physical stance." From the perspective of the intentional stance we deploy psychological or mental vocabulary to describe, explain, and predict our own mental states and actions and those of others. We think of ourselves and our fellows as "intentional systems," as human individuals chock full of beliefs, desires, emotions, and goals. And we think of a particular integrated suite of embodied intentional states and dispositions as what makes an individual tick, what makes them who they are, what's behind the personality and character they display. The design stance goes below the intentional or person level and uses concepts related to normal or proper function: drinking a cup of coffee involves a perceptual system that registers that there is a cup of coffee, a system that computes desire and eventuates in a decision to drink it, which sends a signal to the motor system to move the hand in the right way, lift-to-lips, and drink. The physical stance goes lower still to the level of actual physical realization. The physical stance is especially useful when there is breakdown of proper function: Ann drinks coffee through a straw because in the bike accident she badly sprained both wrists.

1 I mean the view to apply in the first instance to alcohol, cocaine, and opiate addiction.

Higher levels depend upon and are implemented by the lower levels. One could take the physical stance description lower: sprains are implemented on wrists, specifically on ligaments, which are made of flesh, which is eventually, like everything else, implemented on bosons and fermions2 . But higher levels also have emergent properties in one perfectly natural sense. Wiffle balls are round, but the molecules that compose them are not. A hard hit wiffle ball can cause a bruise, but a hard hit polymer atom in a wiffle ball cannot cause a bruise. Wholes have properties that their parts don't.  Addiction is a person-level phenomenon. Neither brains nor genes are the sole cause of addiction; nor do brains or genes become addicted. That said genetic and neural malfunctions are clearly an important part of the explanation of how and why some people, some intentional systems, become addicts and suffer addiction.

At the intentional stance level, but not at lower levels, persons, whole persons, are normative creatures in two senses, one constituted by our power to assess or evaluate ourselves as rational or reason-responsive agents in a broad sense and to do what we decide is best to do all things considered; the other constituted by our power to assess or evaluate ourselves morally or from a moral point of view. Normative governance consists of two complex and highly interactive capacities, rational governance and moral governance. Rational governance refers to the capacity of persons to determine what we have reason to do,what makes sense to do given our aims, interests, and the way(s) the world is. Moral governance is the capacity to judge some of the things we do (or intend to do) as good or bad, right or wrong.

Our power to assess or evaluate ourselves as rational or reasonresponsive agents is both episodic and diachronic. Episodically, at any one time or period in a life, there is always a set of possibly true answers to two sorts of questions. One set concerns what a person is doing here and now (at this time or within this period of time); the other set concerns why the person is doing it. As to the question of what I myself am doing, suppose what I am doing here and now is driving my car through the Holland Tunnel from Manhattan to New Jersey. As to why, the reason is that I believe that for someone in my physical position, in lower Manhattan, with a car, and wanting to get to Jersey, the best or most convenient way to get to Jersey is to take the Holland Tunnel. My physical position and my desire to get to Jersey give me good reason to drive through the Tunnel. I am responding to that reason in driving through the Tunnel. Normally, when a person has reason to Φ, she Φ's. Addicts are puzzling including to themselves. When it comes to their drug of

choice (DOC), what David FosterWallace types as"the Substance," they are performatively inconsistent (2). They resolve not to use and use. Many addicts report that the resolve and the action that undermines it occur at the same time, virtually in the same instant.

Our lives are also lived and led in diachronic psychological space and not just in the moment or in brief episodes. We experience ourselves as someone who was there in the past and we conceive ourselves as someone who will be there in the further future, short-term and long-term. We experience ourselves as not just being alive, but as having a life to lead, self-direct, or control, where a life is conceived as "the sum of one's aspirations, decisions, activities, projects, and human relationships" [(3), p. 5]. Most of us probably do not have a blueprint for our whole life, what Rawls (4) called a "life plan," but we do have for ourselves multifarious projects and plans nested together in various, possibly ever-adjusting, relations of priority and expansiveness. For many, most, perhaps all of us persons, we develop a narrative self-interpretation of ourselves as persons and perpetually evaluate how well we are doing in becoming who we aim to be and in accomplishing what we aim to accomplish. A basic way in which to understand the inter-relationships between our past, present, and future is to conceive of the lives we lead "as an unfolding story" (5, 6) 3 . There comes a time in every addict's life when he comes to see that his "self-represented identity" and his "actual full identity" are on divergent paths, likely far apart, possibly inconsistent (7) 4 .

Finally, our lives are lived in social space as gregarious social animals. Most humans have natural desires for companionship and most of us recognize, even if only inchoately, that we cannot survive, develop ourselves as persons, or live good lives, that is, lives which are happy as well as meaningful and fulfilling, without situating ourselves in complex socio-moral relationships with other persons. And despite wide cultural variation in the exact norms governing social practices we all typically engage in normatively governed practices of "lending and borrowing, promising and consenting, buying and selling, making friends, entering into marriage, establishing a family, offering and accepting aid, and so forth" [(8), 20]. Reliably gaining the goods associated with these practices – security, self-esteem, self-respect, social trust, friendship – involve broadly moral evaluation diachronically by oneself and others5 .

2According to Dennett's pragmatic taxonomy, the "intentional stance" is personlevel psychology; the "design stance" is computational cognitive psychology, and the "physical stance" is neuroscience. One could, for pragmatic reasons and perfectly in the spirit of his taxonomy go higher than the intentional stance – to sociology and then anthropology – and lower that his physical stance, to biochemistry and eventually to basic physics. One my view, but possibly not on Dennett's (he is wellknown for his instrumentalist or eliminativist tendencies), the higher-level entities truly have properties that the lower levels don't have. There really are such things as beliefs and desires. People have beliefs and desires; people contain brains and brains contain neurons; but neurons don't have brains and brains aren't people, and probably brains do not have beliefs and desire, although people with brains do, and so on.

3 I don't mean to overstate the degree to which people do or ought to examine and evaluate their lives from an articulate reflective pose (see Flanagan (33), for a critique of Charles Taylor for this intellectualist mistake). The point is that people have ideals, ends, goals, and purposes – many of which are socially scripted – and we are consciously or semi-consciously aware of how we are doing in relation to these ideals, ends, goals, and purposes. There are rational evaluations and adjustments of both ends and means along the way, as well as all the familiar kinds of rationalization and defensive denial that one really wanted to do such and so, or be such and so in the first place.

4 "Self-represented identity" is the story from the first-person point of view; "actual full identity" is the true story of who one is, what one is like, the story that would be told by an ideal observer with the right theory of the human mind and action and knowledge of all the facts.

5 I need to emphasize the idea that evaluation occurs "in broadly moral terms." Later, following Williams (34), I distinguish between "morality, the peculiar institution," which is roughly the kind picked out as "moral" inside the Abrahamic traditions and "the ethical," which is much broader and includes the aspirations to live well

This picture of levels of explanation and of persons as normative beings in the twin – rational self-interpretation and self-control sense, what I call, the "rational effective agency sense", and "the moral sense" – has implications for thinking realistically and humanely about addiction. Addiction is a person-level disorder – actually a person-in-a-particular-social-world disorder – in which there is failure of normative governance by rational norms of narrative or biographical integration and moral norms. The result is first bewilderment on the part of the agent that she has lost some of her normal capacities to direct her behavior by what she judges as her considered desires and reasons (for example, to drink like a normal person; not to drink to blackout), and eventually deep shame, as well as a host of other reactive attitudes, at the fact that she is not doing well by her own and often widely shared standards6 . The model of addiction, the "twin normative failure model," and of the addict, I propose rejects reductive models of addiction that claim that addiction is a design or physical level disorder. Addiction occurs in creatures with brains and genes (and bosons and fermions) but it is not a disorder of brains and genes (or bosons and fermions). It might involve disorders of either or both (9–11) 7 . Persons are addicts. Addiction is a person-level disorder, a diachronic intrapersonal and inter-personal disorder; it is a disorder of persons that involves normally and reliably shame in one's own eyes, and thus losses of self-respect and self-esteem, as well as social shame, a sense that even if one is not actually seen for who and how one is by others, one would be judged weak, weird, undisciplined, untrustworthy, and scary if one were seen for how one is as a person-in-the-grip of an addictive behavior pattern. Addiction fully engages the reactive attitudes of the addict, even if neither he, nor his community, judges him harshly or moralistically8 .

One consequence of my view of addiction and its relationship to the experience of being an addict is that it accepts rather than resists the idea that addiction really is, in the eyes of the addict, and those with whom she is in community, a normative problem. The addict has trouble with respect to her addiction putting her reasons, her best thinking, in reliable control of her actions, and she has trouble (perhaps for this reason) abiding by the moral norms upon which her sense of her own integrity and self-worth turns. It is disrespectful to the phenomenon of addiction, to addicts who experience their addiction as involving these twin normative failings, and to the wider community, which judges addiction as bewildering, sad, and shameful to deny that it is a straightforward normative disorder. It is equally extremely shortsighted and inhumane to think that the problem that an addict has is a straightforward problem that can be solved by a psychopharmacological intervention to stop the desire to use or the effects of using. What most don't see because of the meager dialectical offerings – addiction is either a moral or a brain/gene disorder – is the prospect that one can see addiction as involving biographically interpretative assessment of one's own reason responsiveness failings as well as moral failings without either the addict herself or her community moralizing and blaming her. The theory is that at the level of persons, social persons, addiction is a failure in two highly interactive normative systems at once. One can think this, just as one can think that addiction involves some choice and some responsibility without blaming the addict and moralizing addiction. Let me explain.

# **DSM 5 ON SUBSTANCE ABUSE AND ADDICTIVE DISORDERS**

Technically DSM 5, (12) like its predecessors, is only a diagnostic manual. It offers a classificatory scheme. DSM 5 taxonomizes and conceptually disciplines disorder. It doesn't claim to explain (indeed it positively refuses to provide etiologies), or to offer treatment or therapeutic regimens. What DSM 5 is not agnostic about is that the symptom cluster it uses to diagnose substance-related disorders will yield to neuro-specification9 . The manual is full of strong hints that it expects its symptom clusters to be filled in by neuro-specifics. We learn that all drugs of abuse have in common "direct activation of the brain reward system;" that people with "impairments of brain inhibitory mechanisms may be particularly predisposed to develop substance use disorders." The section on substance abuse disorders, like the rest of DSM 5, is filled with "maybes" about connections to genes and the brain. The facts are that there must be such connections; humans are genetically endowed animals and our nervous systems are involved in everything we do. But it is a mistake to think that all properties of persons reduce to properties of parts, even especially important parts. I could argue that all the winks and nods to neuroscience

by achieving maximal intersection of the goods that comprise what is true, beautiful, and good. I intend what I am calling "moral" and what constitutes "the moral failing" of the addict to align with "the ethical" and not with "morality, the peculiar institution."

6The *Big Book of AA* describes the relevant first-person phenomenology as "incomprehensible demoralization (p. 30)."

7 I am collaborating on a project with geneticists (31) who find that in mice, cocaine and opioid use activates genes associated with the salt and water instincts. The instincts to maximize salt and water intake when these are present and the organism needs them, are clearly adaptations, perhaps in exactly the form that leads some, but by no means all mice (29, 30) to become addicted mice. The addiction that piggybacks on these instincts is not an adaptation; it was not selected for in the original evolutionary environment or in recent ones to serve a fitness-enhancing effect. Liedtke thinks that this gene-level activity may be what at the genetic level subserves what some neuroscientists call the "midbrain mutiny" that involves the "hijacking" of normal reasons-responsiveness and control capacities by unusual schedules of reinforcement (35), or by an unwelcomed disassociation of the normally coordinated brain based "liking-wanting" systems (36), or by exhaustion of the brain's mental muscle, aka, "willpower" (37), or by stress hypersensitivity (38). This gene-level explanation of higher order brain level processes that subserve addiction, which itself rests on an evolutionary explanation of selection of genes that code for salt and water instinct, and (45) one of these higher order brain explanations can both be true as far as what happens at the gene level and the brain level without even the combined resources of both levels remotely describing or explaining addiction at the person level.

8 "The reactive attitudes" according to Strawson (18) are the set of familiar sentiments, emotions, or attitudes such as anger, guilt, shame, forgiveness, resentment, happiness, and gratitude that regulate human interaction.

9 Insell (39) the head of NIMH is impatient about filling in the details, and wants to push on to the neuro-specifications of all bona fide mental disorders quickly. And he is willing to put the money he controls as head of NIMH where his mouth is Meanwhile, Frances (40) former head of the DSM IV taskforce laments the rush to neuroscientific reduction because neuroscience is immature, and because, like me, he is skeptical that all mental disorders are brain disorders, and third because he worries about the dominance of money in seeking neuro-pharmacological "cures" for problems that either are not in the brain at all or, even if they have a brain dysfunction component, are mostly psychosocial problems.

(and to a lesser extent, to genetics) is part of the mindless cultural spread of neuro-enthusiasm (and what Rob Wilson calls "smallism"), which although true, would distract from my aim to describe what addiction is in a way that is true to the phenomenon and that is also therapeutically useful, recognizing the many roles that shame and related reactive attitudes can and do play in healing from addiction.

It is also a mistake – a related one – to think that all the essential features of addiction are features that can be revealed in non-human animal models of addiction. The brain reward system of non-human animals has interesting similarities to the human reward system, but the social ecologies of mice and humans are entirely different, as are the capacities served by culture and an enormous prefrontal cortex. A rodent cannot consciously resolve, possibly in consultation with fellow mice, to refrain from consuming a drug because its life is not going well, because it is causing communal harm. A rodent cannot relapse, and then regret and feel ashamed or guilty for its failure to maintain abstinence. Animal models may teach us about how dangerous and imprudent it can be to suddenly reverse preferences over time, but the full character of human addiction is no mere preference reversal or oscillation. It normally involves an interpretation and evaluation of oneself as having let oneself down; of having broken promises to one's own self (and others). Non-human animals, at least the ones studied in addiction labs, are not self-interpretatively normed. They don't see themselves as leading a life. Nor are they moved by thoughts of what counts as a good person/rodent, nor puzzled or disturbed by feelings of guilt, shame, and embarrassment. The moral virtue or value of self-control and of responsibility for self is irrelevant to animal addiction.

What is really interesting is that the DSM 5 criteria for substance-related and addictive disorders are very plausible and never mention, not once, the brain or genes. What they do mention, and rightly so, are normative impairments. Here is the list of diagnostic criteria for alcohol-related disorders [(12), pp. 490– 491], which are representative of the substance abuses overall:

	- a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
	- b. A markedly diminished effect with continued use of the same amount of alcohol.
	- a. The characteristic withdrawal symptoms for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499–500).
	- b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

# **THE PHENOMENOLOGY OF ADDICTION**

DSM is wisely explicit, despite the thick vein of neuro-enthusiasm that courses through it, that substance abuse involves "*impaired control*" and "*social impairment*." The language it uses to depict addiction is the language of the intentional stance. The addict has trouble carrying out his "intentions" (1); he "desires" to control using and makes "persistent efforts" to do so (2); he spends "a great deal of time in activities necessary to obtain alcohol" (3); he has "persistent and recurrent social and inter-personal problems" (4– 7). Understood in this way, it looks as if DSM 5 embeds something in the vicinity of the twin normative failure model in its description of the typical cluster of features that define, characterize, or constitute addiction.

But, truth be told, DSM 5 is unclear about whether it considers these features merely symptomatic (often that seems the implication) the way fever is with a flu, or whether it understands these features as constitutive, as necessary, or as part of the typical psychological profile of addicts. For any mental disorder we can distinguish among its causes, its components or constituents, and its consequences. Because humans are self-interpreting animals, classifications, components, and consequences are absorbed, recorded, reflectively assessed, and they change the person being classified, who as a consequence of his disorder and his comprehension of it causes myriad further effects on himself and others. If one examines the vast literature comprised of memoirs of addiction (13) as well as writings by therapists who work with addicts, most every entry on the DSM 5 list will be familiar as constitutive of addiction. When the addict feels shame before his own eyes, when he observes his control failures, when he understands that he is an addict not living up to his own standards or best interests,

10Ahmed (29, 30) has done very important work inside the animal modeling tradition emphasizing that most rats offered cocaine do not get addicted and, more importantly for treating addiction, that compulsive cocaine use is lower in environments where there are multiple pleasure-producing and choice-worthy options besides the cocaine. My concern with animal models is not based on denial, not even skepticism, that there are genetic and/or neurobiological components of addiction, or on doubt that the brain might be the best place for interventionist strategies to short circuit the desire to use, the compulsion to use, the effects of use, and so on. It might be. The point is that even if the brain is an effective, even the most effective, site of intervention, this is not evidence that addiction is a brain disorder or that it is sensible or good to model it as such. Removing the battery of a car is an excellent way to immobilize it, but a running car is not a battery phenomenon and is not well modeled by the battery, what the battery is, does, and the ways it can malfunction. See below on Woodward's (32) model of causation for why this is so.

he changes, for better or worse. The story of who he is, what he is like, how well he is doing in the task of accomplishing what he intends, of living well, absorbs ever new material. There is narrative self-interpretative adjustment. Since narrative is partly constitutive of the self, he changes (7, 14). For the addict, along the descent depicted by DSM 5 steps 1–11, he is bewildering to himself, possibly terrifying – he can't get a grip – he's a disaster, a train wreck harming himself and those he loves. This first personal normative assessment does really capture the shape, the texture, and the phenomenology of addiction. Is there a mistake? No. Indeed, it is only by understanding these normative failings that the addict shows himself the self-respect he deserves as a person and leverages, normally with communal assistance, his remaining powers of agency to get back on track and repair himself as well as the situations and relations that have been damaged along the way.

Despite the fact that the DSM 5 list of symptoms includes failures in self-control and in reliability – in behavioral failures with respect to norms – it is missing any reference to normative feeling states, to reactive attitudes associated with these behavioral failures. The addict has "cravings," and greater "tolerance" involves changes in the "effects" of the DOC. He continues to use despite"knowledge" that using causes him problems, etc. But there is nothing in 1–11 about the way the addict experiences his failures to rationally effectively and morally guide his life through and past the allure of alcohol, which consistently undermines, possibly defeats his attempts to live well and to be well11. Interpreting the DSM 5 criteria to include these reactive attitudes or extending its

criteria to include the feelings associated with the twin normative failures it almost always involves, would capture better the psychology of addiction than any purely behavioral, neuroscientific, or genetic model.

# **THE INTERPRETATIVE, REASONS-RESPONSIVENESS, EFFECTIVE AGENCY FAILURE**

The twins that fail in addiction are fraternal, not identical. What I call the interpretive, reasons-responsiveness, effective agency failure is really a set of failures that include cognitive mistakes such as minimization (I don't drink too much; I just need to stop at *n*, where *n*> what a normal person would think is wise), and rationalization (you'd drink a lot too if you had my \_\_\_\_\_). One failure that is most familiar to both addicts and those in relation to them is a failure to execute rational control, to be able to execute rational plans, the failure to be in charge. The simplest way to put this point is in terms of the performative inconsistency mentioned earlier, which every addict understands as constitutive of his situation: I will/decide/pledge/promise to myself (possibly to others as well) that I will moderate or stop using; and then I use. P and not P. The failure is one of effective agency, of leading one's life and not just tagging along for the addicted ride. The addict like everyone else sees himself as a being with hopes, projects and plans, responsibilities and obligations, friendships, and loves, as an historical, enduring being, possessed of long-range interests. But his own defective agency gums up the works, the work of being and becoming the person he aims to be. He fails at reliably enacting in-charge selfhood. If his DOC, the Substance, is available he loses normal self-control against getting lost in a preference oscillating and the preference-reversing moment or episode. He is bewildered and ashamed.

According to DSM 5, this sort of complex failure begins in mild addiction at step 1, where the substance abuser uses more that he at first intends. And it gets worse as the problem becomes more severe. It is sometimes hard to tell from behavior where exactly a drinker is in terms of loss of the ability to stop in a normal reasons-responsive way, i.e., by making an all things/future me considered judgment that they should moderate or stop, and then doing so. The *Big Book of AA* written in 1939, not a scientific work, recognizes correctly a certain kind of "heavy drinker," who if he has reason to stop (the liver, the job, the spouse) stops. And much recent work confirms that many people who drink heavily, possibly in binges, possibly regularly, at some point, in their lives stop (15, 16, 43). But there is a type of drinker who seems not to be like this. They try to stop but can't. Caroline Knapp's, *Drinking: A*

11Contrast DSM 5 (12) with Graham's (9) – what I call "the ignoble eightfold path of addiction," especially, (iii), (iv), and (vii) which emphasize the self-directed reactive attitudes in addiction. DSM 5's 1–11 speak about ways the addict fails to exert various kinds of control despite his best efforts and it speaks about feelings toward alcohol (craving, tolerance). I am emphasizing the addict's feelings toward his SELF, possibly as a result of these failures and the harm he does to himself and others. And these reactive attitudes I claim, are part of what addiction is, and what needs treatment. TWO CAVEATS: first, in (vi–viii) Graham places I think too much stock in the belief that relapse is more or less inevitable. Second, I read (vi) as descriptive not prescriptive. It is true that relapse powerfully engages recognition of the twin normative failures including shame and its suite. Increased knowledge about addiction, of course, teaches that despite the shame, the addict may not in any robust sense be to blame or deserve blame.

behavior after a period of temporary stoppage. The behavior returns together with its negative consequences or risks.

(vii) Relapse is interpreted by the agent as a form of personal disappointment or failure, not just as something destructive or risky, but as a source of shame, regret, self-blame, and embarrassment or as grounds for diminished self-confidence or self-esteem.

(viii) The steps or phases of harmful behavior, temporary abstention, and relapse cycle repeatedly. The recycling, in some cases, may cease permanently, perhaps without harmful long-term residue. And the person just plain quits. (Thousands of addicts just plain quit for good at some point. They "age out" of their addiction.) Or the addictive pattern may lead to an addict.s enduring exposure to harm or personal demise.

*Love Story*, Pete Hamill's, *A Drinking Life*, and Charles Jackson's, *The Lost Weekend* are powerful depiction of such lives.

The brain basis of addiction, according to animal studies, lies, in significant part, in the mesolimbic dopamine and brain reward system. It is possible that this area is compromised in humans, not only in opiate addiction, but in alcoholism as well. Suppose it is, and that therefore a compromised mesolimbic reward system is a necessary condition of human addiction. It does not follow that it is sufficient or that it is the only necessary condition (42, 44). In humans, addiction is constituted not only by craving, compulsive use, and "jonesing" for the Substance, which may be subserved primarily by the compromised mesolimbic reward system, it is also experienced and treated just in case the person experiences herself as unable to stop given that she has reason to (the personal and social costs mentioned in DSM 5); and that she is ashamed that she is not able to live as she judges to be good. This sort of self-regarding reactive attitude is I claim is a normal part of the phenomenology of addiction but not mentioned in DSM 5. It is implausible that human beings control against consumption impulsivity and imprudent preference reversal only by virtue of some sort of inhibitory mechanism in the brain reward system. If they did, then it might be plausible to say that addiction represents a disorder of that mechanism, and of nothing else. But human sources of inhibition and self-control are known to be many and various. Human powers of deliberation, self-assessment, and reason responsiveness are subserved by neural systems, especially in prefrontal cortex, that differ in organizational complexity from those of rodents. Furthermore, human linguistic capacities put us in unusual touch with communal norms and with communal reasons for abiding by those norms. To be sure, the addict has trouble making her reasons effective and this may have to do with damage to the circuitry in the mesolimbic areas or in the areas that connect prefrontal cortex to lower regions. But the facts are that addict has her reasons to stop, wishes to stop, but can't. And it is this experience of the failure to execute effective agency, according to my argument, that is also constitutive of human addiction, although almost certainly not of rodent addiction12. A human addict cannot in a situation in which he is considering if he can and should refrain from drug consumption, regard himself "as waiting to discover or to observe in which direction he will be moved" [(17), p. 51]. To be counted by him as a decision of whether or not to refrain, the state of deciding must be thought to conform to some standard of possessing a good reason. The question "Will I abstain?" is unavoidably indistinguishable from "should I abstain here and now?" The total situation I am in as an addict confronts me, and sets the problem. I may try to take account of things about myself that I believe are not in my power to change (because I lack the means or skill to change) and those things I believe I can change. The anxiety, felt need, impulse, the craving, the sudden passion to consume, when they occur, may feel like something that descends upon me. I may try to double back upon myself and think of myself as something more, or less, than I really am. "Can I, or can I not, free myself of this behavior?""Perhaps I can." But the fact is: there

are normative elements in states of mind and types of conduct relevant to being an addict, and these normative elements cannot be reframed in the descriptions of neural inhibitory mechanisms operating in independence of a person's own self-assessment and biographically reflective reason responsiveness. The key for the addict is to find some way – often with professional help or nonprofessional communal help – to leverage his remaining powers of agency, first and foremost in relation to his DOC, to stop using the Substance. Sometimes the first choice is to be tied like Ulysses to the mast for a time. But it is an important but underestimated fact that every addict who does not use any longer has done exactly that, moderated or stopped using (15, 16, 43). Such former addicts have rediscovered, reclaimed effective agency. And they are abundant.

### **THE MORAL FAILURE**

Persons enter the world valuing certain things and not others and they exit the same way. We are creatures with ends. Some of these have to do with resource needs and acquisitive desires related to these needs – for food, clothing, and shelter; others have to do with social needs, with needs for company and affection. We are gregarious animals. No person, no matter what her conception of flourishing or well-being would choose a life without friends, says Aristotle13. When Strawson (18) calls attention to the reactive attitudes, the suite of emotions and sentiments that guide interpersonal commerce and that involve reactions to the good will, ill will, and indifference of others, he is careful to include affection, love, gratitude, and forgiveness, along with anger, resentment, and shame. According to Strawson, these emotional dispositions come with the equipment. He compares the reactive attitudes to induction. We cannot ask whether induction is rational. It is arational, part of our animal nature, not something we can give up. What we can do, however, in both the case of induction and the case of the suite of reactive attitudes is to adjust, moderate, modify, tune up and/or tune down as necessary both natural innate attitudes. We modify our original disposition to apply the straight rule of induction via feedback from its application. For example, when we apply the straight rule to small or unrepresentative samples we get poor predictions and we adjust the rule14. Eventually over world historical time, the methods of inductive logic, statistics, and probability theory develop. With respect to the reactive emotional attitudes, different social ecologies develop different norms for apt emotions (19).

A key idea in Strawson is that the reactive attitudes are not only essential to inter-personal relations, they are also essential to how we see, judge, and regulate our own mind and behavior; they are also intra-personal. I can experience, indeed I do experience, the reactive attitudes to my own mental states and actions. Anger at myself for what I did, as well as disappointment, pride, embarrassment, shame, and guilt are familiar components of a human life. Self-esteem is a general feeling that one is decent, worthy, doing well; self-respect involves knowing with some degree of confidence and proper humility that this feeling is warranted.

12One can, of course, make a rodent a psychological mess, extremely anxious, fearful, and so on, by mixing reinforcement schedules that both encourage and inhibit addiction.

13Psychopaths or people with schizoid personality disorder might be exceptions to Aristotle's surmise.

14The straight rule is crude and says this: if I observe that A's are B's to m/n, then I do/should infer that unobserved A's are B's to m/n.

It is commonplace for modern people to think that ancient and superficial peoples ran on shame whereas we run on guilt.Williams (20) has turned this idea on its head. The idea that, for example, the Greeks were a shame culture not a guilt culture is true but not a weakness or superficial characteristic. Shame is not simply a feeling caused by being seen, naked as it were, by others. It also involves not passing one's own survey. "Shame looks to what I am" [(20), p. 92]. Guilt, the modern emotion, is the narrow reactive attitude. It is largely internalized anger at certain actions and its roots are in what Williams calls "morality, the peculiar institution." Morality, the peculiar institution, is the narrow normative domain that encompasses all and only the domains that the God of Abraham is interested in assessing each person on come Judgment Day (its secular version comes in Kant). Ethics, in the broad sense, prized by the Greeks, by Nietzsche, and by Williams, is concerned with living a good human life more generally. It involves aspirations to flourish, which involves living at the intersections of what is good, true, and beautiful, whereas modern moral philosophy focuses primarily on the good, and even there it is narrowly conceived.

Here is how this relates to addiction. Almost all addicts experience failures of basic agent capacities, for example, in the first criteria of DSM 5 there is a failure to do what one reflectively intends. The non-addict will get that the addict might fail if a drink or drug is right in front of her (we relate from chocolate candy type experiences). But the addict will decide, indeed she will resolve not to purchase alcohol or cocaine and then find herself driving to the liquor store or crack house. This is shameful and is experienced as such both on the way to score, although in something of a blur, and afterward. I am ashamed of who I am, not simply for what I did. And it builds. An addict is someone, who like everyone else, has educational, career, and inter-personal aspirations, and he reliably fails to achieve them; or he achieves them to some degree, and then his addiction undermines these accomplishments. Every alcoholic and every addict in rooms of AA and NA and most every memoir of addiction (even if the author is not inculcated into 12-step ways of speaking) will speak of extreme feelings of shame for who one is, who one has become in one's own eyes, even if one has not yet been fully seen by others and even if objective failures are still in the "not-yet" category (2, 13, 21) 15 .

The main point is that the ongoing epistemic-interpretative failure that involves: (1) the inability to draw normal inferences about the harms one is doing to oneself or others (caused by various classical defense mechanisms); and (2) the inability to get one's mind, body, and behavior to respond to decisions and resolutions in the normal ways; PLUS (3) the persistent failure to live as one expects oneself to live as a worthy human being undermine the basic goods of self-esteem and self-respect. One is ashamed of who one is. The alcoholic needs to put the "plug in the jug" (the crack addict needs to stop scoring eight balls; the smack addict to put down the needle). But the disease of addiction doesn't end there and then. And the reason is simple. Addiction is not a synchronic disorder that ends with the end of taking one's

15The 12-step community speaks of addiction as a medical, psychological, and spiritual disease. Amazingly, the medical aspect was once thought to be or to involve an allergy to alcohol. The psychological and spiritual aspects refer to a host of problems in the self-esteem, self-respect, shame, and self-degradation arena.

DOC. It is a diachronic molar person-level disorder and as such requires psychological, epistemic,moral, and narrative healing and reconstruction.

### **SOCIAL CAPITAL**

A consistent finding in the literature on human well-being is that the best predictor of well-being – better that income, better than health even – is social capital (22). Almost all the variance between Northern Europeans and North Americans on the one hand, and citizens of sub-Sahara Africa on the other hand, in well-being measures has to do with the fact that almost half of informants in sub-Sahara Africa say that if they fell off a bar stool (here used only metaphorically), there would be no one they could count on to help, not a friend, not their mother, father, brother, or sister.

In his important book, *Bowling Alone*, Putnam (23) plots some of the causes and consequences of breakdowns in community and loss of social capital in America. There are insights for those concerned with addiction in these sorts of studies. First, addictions increase when there is socio-economic displacement, breakdown in community, and the availability of drugs and alcohol. Second, healing individuals typically involves reintegration into community, often a community whose other members have also experienced the bewildering twin normative failures and the selfdegradation that results, and who get, at a minimum, that this sort of thing can happen to otherwise decent, worthy people, and who have experience, strength, and hope to share about how to regain control of one's self, one's life. Eventually, actually at the same time, there is reintegration into the wider social community, doing school or one's job as one is supposed to, being therefor one's friends and family in the way a good person is, an end to actual or psychological isolation and concealment that is a common accompaniment of addiction (2, 13, 16, 21, 24, 25). Self-esteem and self-respect return and shame dissipates, possibly pride grows.

### **RESPONSIBILITY "WITHOUT THE STING"**

Strawson (18) writes about the possibility of taking "the objective attitude" toward certain persons. The objective attitude is one that involves a surmise, possibly a conviction that the normal reactive attitudes are not deserved in certain cases and should be suspended. Children have temper tantrums and anger is not warranted. So we suspend, or try not to act on anger, even if we can't help to feel it to some degree. We also can and do suspend or try to suspend our normal reactions to the insane, to those who suffer from compulsions,who have no rational control over their actions.

Can and should we take an objective attitude toward the addicts in our midst? Probably. Can or should addicts take an objective attitude toward themselves? Probably. But there are psychological limits to our abilities to overcome natural dispositions. Furthermore, the addict feeling shame and the wider community thinking it is a shame that his life is going so badly is a humane reaction. It need not be taken to warrant blame. It signals that both the addict and we recognize that he could do better and be better. Understanding that he is an addict is a humane way of saying that we get that he is in a terrible fix and that we sympathize (46–48).

The more we learn about the complex socio-psycho-biological nature of addiction, about the ways various cultures encourage heavy drinking, about the effects of SES and drug availability, about genetic propensities, about the effects of weird reinforcement regimens, and of brain glitches, we have reason to adjust full normal subjective engagement to the addict. Williams makes this interesting point: "What arouses guilt in an agent is an act or omission of the sort that typically elicits from other people anger, resentment, or indignation. What the agent may offer in order to turn this away is reparation; he may also fear punishment or may inflict it on himself. What arouses shame, on the other hand, is something that typically elicits from others contempt or derision or avoidance" [(20), pp. 89–90]. This seems right; the life of the addict is a source of both guilt and shame. And thus he receives an odd admixture of reactions from others; in part, there are the normal reactive attitudes that full blown autonomous agents receive, anger and indignation; but there is also something else, a set of reactions that indicate that you have put me – us – off. You are puzzling, weird, to be avoided16 .

Williams goes on: "His (the person who is ashamed) reaction is a wish to hide or disappear, and this is one thing that links shame as, minimally, embarrassment with shame as social or personal reduction. More positively, shame may be expressed in attempts to reconstruct or improve oneself" [(20), p. 90].

# **CONCLUSION**

All this seems about right. And in particular: shame is partly constitutive of addiction. The addict cannot pass his own survey. He is appalled by the twin normative failures from which he suffers, and shame is the appropriate, respectful, humane, first-person response to these failures. Shame begets using and more using begets more shame, and the vicious cycle is produced and maintains itself. Overcoming shame is part of overcoming addiction. Shame is also normally a crucial factor motivating the addict's attempt to reclaim, reconstruct, and improve himself. It motivates the addict to want to get a grip. That said, there are many reasons for the addict to forgive himself and engage in the difficult project of reconstruction and improvement with the knowledge that his agentic capacities in relation to the Substance are compromised, deficient; and, at the same time and for the same reasons, there are reasons for others to keep the addict in the realm of the very usual, the puzzling, the not-so-nice-to-be-around, but to also engage him with sympathy and compassion, maybe with forgiveness. The more we know about addiction the more this becomes both possible and sensible. At the same time, both the addict and the community that is asked to understand and treat him with compassion need to acknowledge that the addict is a person who suffers twin normative failure. He will need to heal to once again be treated as a full-fledged normal agent. He must regain his full normative agency and regain traction in his quest to live well.

### **FOUR OBJECTIONS AND REPLIES**

### **THE WILLING ADDICT OBJECTION**

The process or condition that you are calling addiction really includes matters characteristic of a certain kind of addict, a socalled unwilling addict. Some addicts, however, are willing, and

do not feel shame or guilt over their addictive behavior patterns (26). Willing addicts don't double back on themselves and wish that their behavior was otherwise or that they should control their impulses to consume. Pickard (25) offers a powerful version of this objection in correspondence. Based on her clinical experience and standard DSM understanding, she writes that among addicts "are some people who are severely personality disordered, really genuinely don't want people or friends in their lives (this is part of having schizoid PD, diagnostically) and have a 'relationship' with drugs instead; some are so narcissistic and grandiose that the claim that they feel shame or look on their lives critically or think they could do wrong would require very deep, very inaccessible levels of the unconscious to make it true."

The objection is that there are certain individuals with schizoid personality disorder, perhaps there are others in the manic phase of bipolar disorder, who are addicts in the sense that they have lost rational effective control over using, but do not feel shame, and thus do not suffer the twin failures and who thus are not, according to me, addicts. But they really are addicts. So the twin normative criterion is descriptively false.

Before I respond to the objection, I can strengthen it as an objection, by pointing to two recent memoirs where the protagonists might be addicts in the sense of satisfying condition no. 1 of the twin normative failure model – he can't stop if or insofar as he tries – but he doesn't feel shame. *Narcopolis* by Thayil (27) and *The Wet and the Dry* by Osborne (28) brilliantly present two different types of character who don't seem to satisfy the shame condition. In Thayil's semi-fictional memoir, the 1970s opium dens of Mumbai, then known as Bombay, are a romantic haven for souls who have almost no other options, plus opium is really cheap.  Even if Thayil is not proud to be an addict, he is not ashamed either. Osborne's story meanwhile is a hilarious romp through the Middle East by a man who is a "drinker" and who is hoping that laws and social mores of Muslim countries that disapprove of drinking will help him at least temporarily to moderate. They don't and he doesn't.

So now the strengthened objection is this: there are at least four types of addicts that do not satisfy the shame condition: (1) people with personality disorders such as schizoid PD; (2) people in full blown mania; (3) people that have easy access to the Substance, to their DOC, and no other choice-worthy options are available [see Ref. (29, 30)]; (4) "Drinkers," like Osborne – also think of Richard Burton, Richard Harris, Peter O'Toole, and Christopher Hitchens or a heroin user with resources to get reliably pure doses, a Keith Richards type. This latter may be an approved of life style among a certain mostly white elite in the UK, but probably not in the US.

### **Reply**

No doubt cases of addiction are heterogeneous in many respects, and dimensional in depth, severity, and so on. Are there willing addicts?17 Surely, there are people who minimize and rationalize,

16Pickard (25) argues that for individuals with both addictions and personality disorders, we can and should decouple (1) Holding a person responsible for what she did; (2) Holding her responsible for her future actions; (3) Blaming a person for failures on 1 or 2.

17Kennett (41) helpfully distinguishes four possible kinds of addicts: willing; unwilling; wanton; and resigned. She is skeptical about willing addicts. Wanton addicts, if there are any, are not reflective in ways that would allow noticing the twin normative failures or perhaps if they did, caring about them. Mice addicts are wanton addicts. I doubt that there are any person addicts who fit the bill since even wantons will need

and people who think they could stop if they decided to do so. Some of these probably do fall into the class of willing users, even willing abusers. They choose to use, but believe they could stop if they had sufficient reason to do so. They like using excessively, asocially, possibly even antisocially. Some of these people might be wrong that they could stop if they tried (in the normal reasonresponsive way), in which case they would be wrong that they are not addicts because they do not satisfy the first normative condition, the effective agency condition. They do; they just don't know that they do. The *Big Book of AA* says if you think you are not an alcoholic, you may be right. There is a test: try some controlled drinking and if you can do so reliably and without always feeling overwhelming desire to use, then you were right – you were just a heavy drinker not an alcoholic. On my view, if a person could stop if they decide to do so, they do not suffer the first normative failure of effective agency (nor would they be self-deceived, etc.).And such an individual would not be an addict according to the view on offer.

But what about the memoir cases and Pickard's psychiatric case(s)? One thing to say about the two memoir cases is that in both cases some shame is experienced; Osborne, at least, is often embarrassed about the blackouts and some of the predicaments his drinking gets him in. The shame condition in the twin normative failure model does not specify how much shame needs to be experienced. This could also be said of people with bipolar disorder when they are not in the grandiose bullet-proof phase, during which down-times they do backtrack, second-guess, and so on.

But this doesn't solve the problems with the Pickard case of schizoid personality disorder where no shame is experienced diachronically; where possibly there is pride instead. A response specifically to these cases might distinguish addicts who satisfy the first condition (call them addicts type-1) and those who satisfy both (addicts type-2). Another is to claim that even the people who don't feel shame ought to, which concedes that the criterion is normative not descriptive. The option I am inclined to take is to restrict the twin normative failure model to people who do not have severe personality disorders (e.g., schizoid PD) and people who are not in the grandiose phases of bipolar disorder. This would still leave the model open to this objection: there are social environments that are so degraded that there is no shame in addiction descriptively – perhaps the addicts are literally and rightly hopeless – and in which shame, guilt, blame are normatively unwarranted. Shamelessly addicted is simply the way some people live. I accept this. In such environments the concept of addiction in my sense has at best only a weak grip, only the first condition of addiction would be met, and even that only in a weak sense: if the resigned or hopeless addicts in such worlds wanted to stop (they don't), they couldn't18. The twin normative failure model is a useful model in environments where there are multiple choice-worthy options, not otherwise.

### **THE ESSENCE AND THE PERIPHERY OBJECTION**

The twin normative failure model of addiction is swollen and inflated. There is too much that you are including as proper parts of addiction or of an addictive behavior pattern. The essence of addiction is at the brain level. The presence or absence of shame and negative self-evaluative attitudes, of various moral attitudes and emotions, the failures of reason responsiveness are sequelae of addiction, not part of addiction.

### **Reply**

First, if an essence involves characterizing the set of properties that are invariant or at least highly reliable accompaniments of a kind, then the two normative failure model has at least as much credibility as any other model. I claim that you will find evidence of both normative failures in most every addict's first personal testimony and in the third personal testimony of professionals who work with addicts. The shame of addiction is shame that is directed to the content that [I cannot control my behavior in relation to the Substance] and that [because of my using the Substance I fail to live up to my ends, values, goals, and standards]. Those who favor only brain or genetic bases for the disease have yet to agree about what that single basis is, if there is one, or whether it is polyneural or polygenic, if there are several, and how exactly (and when) confirmation/disconfirmation might come for the various contender hypotheses. I claim that there is confirmation for the twin normative failure model right now. Second, although a less inclusive or thinner concept of addiction (a least common denominator conception, as it were) may work as an operational stipulation in the case of models of certain non-human animal behavior, it is without merit in the richer conceptual and normative world of human beings, at the person level. Third, and relatedly, the objection favors an unrealistic simplifying assumption requiring that we define the dysfunction of addiction synchronically rather than diachronically, and over some aspect that is hypothesized, but not yet shown to obtain over all creatures that can suffer addiction. But claiming that the hypothesized shared basis is the essence, and that all other features, especially ones that reliably appear in *Homo sapiens* are not, is to change the question. Fourth, the method of gaining insight into essences is unstable. We have already seen how some geneticists think they can reduce the neuroscientific base of addiction to a genetic one in DNA, and even RNA, that serve the salt or water instincts (31) 19. For familiar reasons, this

to schedule desires and trying to do so will result in recognition of their inability to successfully schedule substance-related desires (unless supply is unlimited), and thus in recognition and bewilderment over their control capacities. This much will lead, even the amoralist, to frustration and anger at his failure to live as he wishes, to coordinate demand/need to supply, and to gain the satisfactions he seeks. There probably are resigned or hopeless addicts, but even they will normally experience themselves, and will be seen by others as suffering the twin normative failures of loss of effective agency and life standard failure, although the space of live options for such resigned individuals will have pretty much closed off. Resignation is normally a sad emotion constituted in part by the sense that things could have gone better. When an environment is really objectively hopeless, offering no decent options for a good human life, then there just may be no norms against which the addicts life is better or worse than any other. I accept that in such environments, the twin normative failure model starts to lose its grip; perhaps, it is irrelevant.

18These sad cases are "resigned addicts" (41). It needn't be that a whole social world has no choice-worthy options; it can be that certain social groups are trapped by racism or sexism or terrible poverty to have no or very limited choice-worthy options in a world where there are abundant options for others.

19To be fair, since full blown reduction never occurs, the geneticist should not claim reduction, but something like the further specification of mechanisms at the lower level (genes) that explain partly why the brain is doing what it is doing. Similar humility on the part of those who work on the neuroscience of addiction would claim to provide insight into some of the mechanisms involved in addiction.

move opens the geneticists' account to a further reduction into the language of bosons and fermions or whatever is the language of fundamental physics. With each reduction we move further and further from the phenomenon we started and are providing a less ecologically valid account of that phenomenon. If we are speaking of addiction among humans and addiction constitutes any sort of well-behaved or unified kind, every bit of evidence indicates that it is a psychological or behavioral kind that is also a doublenormed social kind. This is perfectly compatible with this kind also having certain common features at the level of the brain and genes since kinds defined at the higher level have all the properties that the lower levels have but the reserve is not true, and this matters.

# **THE INTERVENTION OBJECTION**

The key to curing addiction is to arrest it, to stop the addict from using.  But you also acknowledge that knowing or experiencing this and also desiring to stop is normally not enough to stop. For this we are working toward pharmacological interventions that help addicts stop using, which is a necessary condition for any and all further healing. There are drugs that make the alcoholic sick if she uses, and others that mitigate the effects of cocaine and opiates. Eventually, work in genetics will yield simple interventions that adjust genes for those predisposed, and so on. If you think these interventions are already working, or might work, to arrest addiction, then you acknowledge that brain or genes cause of addiction.

### **Reply**