addiction and personal autonomy

April 2001

Addiction and Personal Autonomy

Diana V. GardnerNuffield College

University of Oxford

... at the time I began to take opium daily, I could not have done otherwise. Whether indeed, afterwards I might not have succeeded in breaking off the habit, even when it seemed to me that all efforts would be unavailing, and whether many of the innumerable efforts which I did make might not have been carried much further, and my gradual re-conquests of ground lost might not have been followed up much more energetically – these are questions which I must decline.

- Thomas De Quincey18211

A common charge levelled at the chronic user of drugs is that her addiction has robbed her

of free will: she cannot help but take a particular drug when that drug is available to her.

Indeed, a bewildering feature of addicts is that they often and convincingly profess a desire

to refrain from using drugs and yet continue to use them anyway, sometimes showing

remarkable resourcefulness in acquiring the very substances that they ostensibly repudiate.

Are such individuals just particularly convincing liars, are they egregiously fickle, or are they

really in the grip of something that obliterates any ability they might once have had to

refrain from ingesting certain substances? Much of the literature on personal autonomy

tends to assume the latter. Robert Goodin, for example, compares the addict with the

person who has been ‘physically restrained, in a way that rendered him simply unable to do

what he said he wanted to do.’2 I will argue that it is a mistake to conceptualise addiction

as binding a person in this way. For one thing, it denies the fact that many former addicts

have managed to overcome their addictions. Still, if someone makes herself vulnerable to

temptation, she is less free to exercise her will to the extent that she now has other 1 Confessions of an English Opium-Eater, London, Penguin Books, 1997, p.198.2 Robert E. Goodin, No Smoking: The Ethical Issues, Chicago, The University of Chicago Press, 1989, p.98. He also writes, ‘If it is autonomy that we are trying to protect in opposing paternalistic legislation in general, then the same values that lead us to oppose such legislation in general will lead us to welcome it in those particular cases where what we are being protected from is something that would deprive us of the capacity for autonomous choice.’ Ibid., p.27.

of 18 Diana V. Gardnerfor High Time for Reform

April 2001

distractions clamouring for her attention, and these competing stimuli present obstacles that

she would not have to overcome had she not become addicted in the first place. The

question, then, is not whether addiction compromises personal autonomy (it does), but to

what extent. After providing a brief overview of the nature of autonomy, I will consider the

ways in which chronic drug-use creates hurdles for the addict who later decides to abstain,

suggesting that none of these hurdles is insurmountable (although they are impediments to

the free exercise of one’s will and certainly should not be dismissed). I will further suggest

that there may be cases where the agent’s behaviour is assumed to be non-autonomous

perhaps less because of any inability on her part to exercise her will and more because

others disapprove of the content of her choices.

AUTONOMY

A crucial issue when considering the nature of autonomy (or free will3) is the relationship

between a person’s higher- and lower-order desires. Put simply, higher-order desires

consist in the deliberative attitude a person adopts toward her lower-order desires.4 For

example, I might have a lower-order desire to comfort an injured dog I find on the side of

the road. After some critical reflection, I find that I endorse this desire because I believe

that people should show compassion to other sentient beings (or simply because I want to

be the sort of person who is moved by compassion5). Here, my higher-order desire (to

treat animals with compassion) is congruent with my lower-order desire (to tend to this

particular dog). So, my lower-order desire moves me to act in a way that is consistent with

the kind of person I have a higher-order desire to be.

Higher- and lower-order desires won’t always mesh so easily, however. While my own

higher-order reflection might provide me with the conclusion that it is wrong to kill animals

for food, I may still have a lower-order desire to eat roast lamb and hamburgers (or I might

yield to the temptation of a cigarette even though I have a higher-order preference to be fit

and healthy). Now, my lower- and higher-order desires are in direct conflict with each

3 I shall use the terms interchangeably here.4 For a fuller discussion, see Harry G. Frankfurt’s seminal article, ‘Freedom of the Will and the Concept of a Person’, The Journal of Philosophy, v.68, n.1, January 1971.5 Higher-order volitions do not have to be universalizable laws. An agent might, for example, have a higher-order preference to stop smoking marijuana because her employer performs random drug tests and she wants to keep her job. It is perfectly consistent to want to give up cannabis oneself while not thinking that everyone else ought to give it up.


April 2001

other. That a person’s higher-order volitions dictate that she should act in a particular way

by no means guarantees that she will always refrain from succumbing to contrary lower-

order desires. Armed with my commitment to the preferences I want to guide my life,

including my preference to be a vegetarian non-smoker, I may still find myself defeated in

the arena of free will if I submit to my predilection for meat and cigarettes.

Autonomy is, however, a ‘global’ rather than a ‘local’ concept. That is, to say that someone

is autonomous – that she has the capacity for free will – is usually meant to convey the idea

that she is generally self-directing over the course of her life. It is not to say that every

action she performs satisfies the requirements of the ideal of autonomy.6 In this way, then,

the would-be vegetarian who only occasionally yields to the temptation of roast lamb can

still be thought of as an autonomous agent. Where the would-be vegetarian regularly eats

meat, however, we have cause to doubt either her commitment to her professed higher-

order desire or her competence to direct her life where she wants it to go. If the

commitment is real but her competence lacking, then it is plausible to say that her free will

has been significantly undermined.

It should be noted at this point that it also matters in which direction conformity between

one’s higher- and lower-order desires is secured. If, for example, I believe that it is beyond

my powers of self-control to stop smoking and consequently change my higher-order

volition to one where I want to be moved to act by my lower-order desire to smoke, I have

secured congruency but in the wrong direction.7 It is not a manifestation of freedom to

come to endorse certain lower-order desires just because one believes that one has no

choice but to obey them.

ADDICTION

6 For more on the distinction between general self-directedness and perfect autonomy, see: Gerald Dworkin, The Theory and Practice of Autonomy, Cambridge, Cambridge University Press, 1988, ch.1; Stanley I. Benn, A Theory of Freedom, Cambridge, Cambridge University Press, 1988, ch.8; Robert Young, ‘Autonomy and the “Inner Self”’, in John Christman (ed.), The Inner Citadel: Essays on Individual Autonomy, New York, Oxford University Press, 1989; Lawrence Haworth, ‘Dworkin on Autonomy’, Ethics, v.102, n.1, October 1991.7 For more on this phenomenon, which is known as ‘adaptive preference formation’, see Jon Elster, Sour Grapes, Cambridge, Cambridge University Press, 1983.


April 2001

Addiction has been described as an ‘essentially contested concept’8 and definitions of

addiction are as numerous and various as the agendas of the individuals who proffer them.

While some experts hold that addiction is both physiological and psychological, others insist

that it is predominantly psychological, others that it is psychological only, and still others

hold that physical dependence is the only requirement for something’s being regarded as

an addiction.9 A telling sentiment is expressed by Philip Bean when he writes, ‘Once the

definition [of addiction] is allowed to slip its physiological anchor, it allows greater levels of

moral evaluations to be included, and hence greater opportunities for controlling such

activities as are seen as unworthy or merely disliked.’10 However, this insistence that

‘addiction’ remain rigidly fastened in the physiological seems somewhat arbitrary. It might

draw a clear line, but it tells us little about why that line has been drawn where it has or how

we should regard activities on either side of it. The assumption that physical dependencies

are somehow worse than other dependencies itself involves a moral evaluation that needs

to be argued for. Moreover, the claim suggests an underlying assumption that addiction is

necessarily bad, which also needs to be established. Many coffee drinkers, for example,

are content to be addicted to caffeine, and there are probably few people who would pass

unfavourable moral judgements on a cancer-patient’s being physically addicted to

morphine. And it is, of course, conceptually possible for a person to be addicted to

something that actually promotes her well-being.

Nevertheless, despite disagreement over definitions and the unstated impedimenta that

often accompanies use of the word, descriptions of certain phenomena tend to recur

throughout the literature on addiction. Included among these are withdrawal, relapse,

‘crowding out’, chronic (or long-term) administration, tolerance, craving, compulsive use,

and ambivalence. Rather than adopting a single definition of addiction here, then, I will

consider the evident features of drug dependency and discuss the ways in which these

might show that one’s personal autonomy has been compromised.

8 James B. Bakalar and Lester Grinspoon, Drug Control in a Free Society, Cambridge, Cambridge University Press, 1984, p.36.9 Additionally, some cultures do not even have a concept of addiction. The fact of addiction may exist in those societies (that is, the pattern of drug use accords with what would be called addiction in England, for example) but members of the culture simply do not conceptualise it as such. See Jon Elster, Strong Feelings: Emotion, Addiction, and Human Behavior, Massachusetts, The MIT Press, 1999, pp.114-5.10 Philip Bean, ‘Cocaine and Crack: The Promotion of an Epidemic’, in Cocaine and Crack: Supply and Use, Philip Bean (ed.), Hampshire, The MacMillan Press Ltd, 1993, p.70.


April 2001

Physical Withdrawal and Learned Behaviour

One discernible feature of drug addiction is that addicts often suffer withdrawal symptoms

when they abstain after prolonged drug use. The severity of these symptoms varies

widely, from irritability and mild headaches when one gives up caffeine, anxiety and

(sometimes) tremor when one gives up alcohol, and stomach cramps, diarrhoea and

tremor when one gives up opiate drugs. Other drugs, such as LSD (lysergic acid

diethylamide), appear not to produce withdrawal symptoms at all.11

Withdrawal syndrome may compromise personal autonomy in a number of ways. The

most obvious is that the desire to avoid discomfort and pain may lead an agent to relieve

her withdrawal symptoms by taking a further dose of the drug, even though she has a

higher-order desire to cease using that drug. Psychological research also suggests that

withdrawal may operate in more subtle ways to increase motivation for drug consumption.

For instance, individuals may learn to perform acts that alleviate unpleasant withdrawal

symptoms (further drug-taking being such an act) and so create a psychological

association between ingesting the drug and experiences such as relief and contentment. If

this is the case, then further drug use not only alleviates the physical unpleasantness of

sudden abstention but also works to reinforce the ‘appetite’ for continued drug use.12

Withdrawal, then, may plausibly be said to bolster an addict’s motivation for continuing to

use drugs. What needs to be shown, however, is that this motivation deprives the addict of

personal autonomy.

The mere wish to avoid the physical discomfort of withdrawal symptoms is clearly not

sufficient to show that an addict’s autonomy has been so undermined that she now lacks

any control over whether to ingest further drugs. If the avoidance of pain or discomfort

were sufficient to such a task, I would have no choice but to avoid visits to the dentist and

very few people would ever have elective surgery. Moreover, it does not explain why

addicts often do voluntarily and successfully endure the process of physical withdrawal (on

their own or in detox clinics, for example) only to relapse long after the unpleasant

symptoms have passed.

11 N.I.D.A. (National Institute on Drug Abuse, USA), ‘LSD’, Research Report Series, 014, p.2.12 Jim Orford, Excessive Appetites: A Psychological View of Addictions, Chichester, John Wiley & Sons, 1985, pp.194-5.


April 2001

The learned behaviour arising from the relief of withdrawal symptoms may provide a

stronger reason for supposing that an addict’s personal autonomy has been compromised,

since it is more subtle and the addict may not always be aware of the psychological

association that has formed, but this too seems inadequate to showing that her autonomy

has been undermined to a sufficiently significant extent. The same learned behaviour is

exhibited by laboratory mice who have been subjected to repeated doses of a drug and

have learned to self-administer further doses - the association between the discomfort of

withdrawal and the relief of another dose has created in them an “appetite” for the drug.

Yet mice (and other non-human animals) do not have deliberatively adopted higher-order

preferences over whether they persist with certain behaviours.13 That is, non-human

animals do not have the capacity for autonomy in the first place, and so cannot find

themselves acting in ways that run contrary to their own perceived higher-order interests in

leading a particular kind of life. Human-beings, on the other hand, can express a

preference about the kind of life they wish to live, and then find themselves acting in ways

that conflict with that stated preference. However, because they are able to recognise a

particular behaviour as incompatible with their conception of the kind of person they want to

be, they are able to dis-identify with the behaviour and, further, to take measures to change

it. For instance, a shy person may take an assertiveness-training course or a ‘hot-head’

may take an anger-management course. Similarly, an addict can attend a drug-

rehabilitation course or attend a self-help group such as Narcotics Anonymous or

Alcoholics Anonymous. Learned behaviour is an impediment to changing one’s behaviour

patterns, but not an insurmountable one.

‘Crowding-Out’/Salience

Another phenomenon purportedly arising from addiction relates to the priority given to drug-

using behaviour in a person’s life. For many addicts, drug-use becomes increasingly

salient in their lives; it leads them to shed other interests they may once have had in order

to satisfy their desire to get high. This phenomenon is often referred to as ‘crowding-out’.

Crowding-out, however, is neither a necessary condition of drug addiction nor exclusive to

drug addiction. For instance, nicotine- and caffeine-addiction constitute obvious counter-

examples to the salience thesis (it is uncommon to hear of a caffeine-addict’s giving up a

13 The motivational structure of the will presupposes a certain level of reason that animals simply do not have.


April 2001

hobby because she is now too busy drinking coffee or of smokers’ giving up work because

they want to stay home and smoke) but that does not give us any reason to suppose that

smokers and coffee-drinkers are any less addicted to nicotine or caffeine.

As well as noting that ‘crowding out’ does not occur across all addictions, it is important to

note that it is not peculiar to drug addiction either. Monomaniacal behaviour can also be

observed in cases of religious devotion and romantic attachments (famous novels, as well

as daily newspapers, frequently recount episodes in which individuals have allowed

religious zeal or romantic fervour to overrun their lives). While it might be said that, with

regard to religion and personal relationships, ‘crowding out’ is the exception rather than the

rule, there is little reason to suppose that this is not also true of drug dependency.

Numerous alcoholics, for example, pursue careers and maintain relationships while

continuing to drink, and in Switzerland, where heroin (rather than methadone) has been

legally dispensed to some addicts since 1994, participants in this program seem to be able

to prevent their addiction from crowding out other activities in their lives. Whereas a

number of participants had previously been homeless and unemployed, stealing to finance

their addiction, they were reported as holding down steady jobs and maintaining stable

homes after they entered the program.14 Many recreational users of drugs (including a

significant number who would experience physical withdrawal upon cessation) do not allow

the drug to inhabit a position of excessive prominence in their lives, just as most dieters do

not develop dangerous conditions such as anorexia nervosa and most churchgoers do not

become fanatics. It is the extreme cases that make headlines, but extreme cases should

not define our view of an activity generally. Moreover, it is not the business of others to

dictate what an individual’s commitments and priorities should be. While the obsessive life

is not the best life to live (for instance, we might think that the so-called ‘workaholic’ misses

out on other valuable experiences in life by devoting all or most of her energies to her

work), we ought not to impose our own conception of the good life on those whose

lifestyles do not conform to our values.

Relapse and Rapid Reinstatement

Another observable feature of addiction is that of relapse or rapid reinstatement of

behaviour that one has periodically managed to abstain from. There are a number of

14 Kevin Williamson, Drugs and the Party Line, Edinburgh, Rebel Inc., 1997, pp.109-110.


April 2001

psychological and neurobiological theories about why drug addicts often relapse even

though they have survived the unpleasant withdrawal process and have managed to

maintain a period of abstinence. One mechanism said to underlie an addict’s continued

drug use is that of shame. Not only can feelings of shame and guilt can work to sustain

alcoholism, gambling problems, compulsive shopping and overeating,15 they may also be

causally implicated in relapse and reinstatement - following minor lapses, the agent may

cope with her feelings of guilt over ‘abstinence violation’ by returning to her old ‘coping’

behaviours (for example, drinking, smoking or over-eating). Moreover, the abstinence-

violation effect can also pose a threat to an agent’s self-image in that one or two minor

lapses may cause the agent to relinquish her decision to abstain because her experience of

failure either threatens her self-perception (she does not want to see herself as a failure)16

or leads her to believe that she is the kind of person who becomes hopelessly addicted (by

conceptualising herself this way, she has an excuse to abandon the struggle).17

Another theory of addiction holds that relapse is caused by cue-conditioned craving.

According to George Loewenstein, ‘Relapse is a constant threat because craving can be

initiated by almost any environmental cue that becomes associated with the drug’.18

Throughout an individual’s drug-using ‘career’, various cues will come to be associated in

her mind with drug use, and this cue-conditioning has implications for the success of any

decision she later makes to abstain. For one thing, abstention will require that the addict

change her environment, either by ridding it of evocative cues or by removing herself from

it. As Loewenstein observes, ‘Successful quitting is thus likely to require a substantial

investment in change of environment and lifestyle’.19 Another strategy might be to defuse

the cues themselves by changing the attitudes and behaviour one associates them with,

15 Jon Elster, Strong Feelings: Emotion, Addiction, and Human Behavior, Massachusetts, The M.I.T. Press, 1999, p.125.16 Jim Orford, Excessive Appetites: A Psychological View of Addictions, Chichester, John Wiley & Sons, 1985, p.290.17 Elster argues, for instance, that ‘A particularly important set of beliefs is the idea that a given substance is addictive. Once a behavioral pattern is conceptualized as an addiction, with the concomitant causal beliefs, it may change dramatically’ and ‘To some extent, it doesn’t matter whether a substance or behavioral pattern is actually addictive, as long as people believe it is.’ See Jon Elster, Strong Feelings: Emotion, Addiction, and Human Behavior, Massachusetts, The M.I.T. Press, 1999, p.129 and p.134. This suggests that it may be harmful (with regard to the person who is already addicted) to depict addiction as something impossible to overcome.18 George Loewenstein, ‘A Visceral Account of Addiction’, in Jon Elster and Ole-Jorgen Skog (eds.), Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999, p.244.19 George Loewenstein, ‘A Visceral Account of Addiction’, in Jon Elster and Ole-Jorgen Skog (eds.), Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999, p.245.


April 2001

which would also require considerable effort.20 Nevertheless, having made this investment

in changing her environment (or her visceral responses to it), there is no guarantee that the

individual will be preserved against cue-conditioned craving. For instance, she may not be

aware of all of the cues that are now associated in her mind with her former drug use, and

so will not be able to avoid or eradicate everything that might induce craving. Furthermore,

suggestive cues may appear unexpectedly, so the abstinent addict has little opportunity to

brace herself for the craving that she is about to experience (in this way, cue-conditioned

craving is different from the craving experienced during the withdrawal process, since the

addict is generally able to steel herself psychologically for withdrawal). So, these hidden

cues may suddenly divert the recovering addict’s attention from her commitment to

abstinence.

Neurochemical theories of addiction assert that chronic drug use permanently affects the

release and reuptake of the neurone dopamine21 in the reward pathways of the brain,

rendering the addict continually vulnerable to relapse. While various drugs affect

dopaminergic functioning differently (for example, cocaine eliminates the uptake of

dopamine by neurons and so causes it to become concentrated in the synapses;22 opiates,

on the other hand, work by causing more dopamine to be released into the reward

pathways rather than by retarding reuptake23), most drugs appear to work either by

stopping dopamine from being reabsorbed from the synaptic clefts in the part of the brain

concerned with reward or by causing it to be released into those synaptic clefts.

20 According to Jon Elster, ‘it has been claimed both that Alcoholics Anonymous adopts the strategy of cue extinction and that it uses the strategy of cue avoidance. As these strategies are mutually exclusive, both claims cannot be right.’ Jon Elster, Strong Feelings: Emotion, Addiction, and Human Behavior, Massachusetts, The M.I.T. Press, 1999, p.190. I see no reason, however, why the two strategies cannot be used in tandem. There may be some situations or activities that a pleasant life should not be without but which were previously associated with drinking or other drug-using behaviour (socializing, for example); for these, the association can be changed. At the same time, there may be other situations or activities that were primarily or solely associated with the drug-using behaviour and which can be avoided without significantly diminishing the value of one’s lifestyle (such as frequenting the pub one used to drink at or hanging out in crack houses); for these, avoidance may be the preferred strategy.21 Dopamine neurones belong to the same family as adrenaline, noradrenaline and seratonin, all of which use biogenic amines as neurotransmitters. See O.T. Phillipson, ‘Dopamine’ in Richard L. Gregory (ed.), The Oxford Companion to the Mind, Oxford, Oxford University Press, 1987, p.199.22 Karen Young Kreeger, ‘Drug Institute Tackles Neurology of Addiction’, The Scientist, v.9, n.16, 21 August 1995, p.13.23 Avram Goldstein and Harold Kalant, ‘Drug Policy: Striking the Right Balance’, in Ronald Bayer and Gerald M. Oppenheimer (eds.), Confronting Drug Policy: Illicit Drugs in a Free Society, Cambridge, Cambridge University Press, 1993, p.85, f.8.


April 2001

According to Eliot L. Gardner and James David,24 relapse can be caused by small ‘priming’

doses of drugs that act on particular neurobiological substrates within the brain’s reward

circuitry (that is, drugs that increase dopaminergic functioning in the brain’s reward

centres). The ‘priming’ dose does not have to be of the same drug that the agent was

formerly addicted to, as laboratory research suggests that cross-priming occurs. For

instance, ‘priming doses of morphine reinstate cocaine self-administration and priming

doses of amphetamine or of the dopaminergic agonist bromocriptine reinstate heroin-

trained responding.’25 Gardner and David suggest that chronic drug use has three effects:

it permanently alters the pleasure/reward circuitry in the drug-user’s brain so that

she has an enhanced vulnerability to addictive drugs,

it creates cross vulnerability to other drugs that also increase dopaminergic

functioning in the brain’s reward system (even drugs that one has no previous

experience of), and

it makes the addict vulnerable to internal and external cues associated with her

former drug-taking as well as to priming doses of other drugs.26

They describe these effects as ‘a series of virtually insurmountable neurobiological

hurdles ... erected in the path of drug addicts wishing to stay abstinent.’27 If this is true, then

it has implications for the issue of individual autonomy – the agent now has to contend with

a number of neurobiological distractions which compete with her higher-order preference

for abstinence. Nevertheless, whether they constitute an insurmountable obstacle to her

capacity to exercise volitional autonomy is another matter.

Aside from making the individual vulnerable to cue-conditioned craving, chronic drug-use

further entails that the addict who wishes to remain abstinent must refrain from ingesting

certain drugs other than the drug she was formerly dependent upon.28 This does limit the

24 Eliot L. Gardner and James David, ‘The Neurobiology of Chemical Addiction’, in Jon Elster and Ole-Jorgen Skog (eds.), Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999.25 Eliot L. Gardner and James David, ‘The Neurobiology of Chemical Addiction’, in Jon Elster and Ole-Jorgen Skog (eds.), Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999, p.119.26 Gardner and David assert that the cues are neurobiologically encoded in the brain.27 Eliot L. Gardner and James David, ‘The Neurobiology of Chemical Addiction’, in Jon Elster and Ole-Jorgen Skog, Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999, p.120.28 Interestingly, in Narcotics Anonymous it is suggested that recovering addicts also refrain from alcohol and mind-altering substances other than the ones they were addicted to.


April 2001

abstinent addict’s options since, for example, a heroin addict no longer has the option of

taking amphetamines if she wants to avoid craving and (possibly) relapse.29 Had she not

become addicted in the first place, amphetamines would not trigger a ‘heroin-trained’

response in her. Still, this increased susceptibility, while compromising individual autonomy

to the extent that the addict must guard against ingesting other drugs (or, if she does take

them, against the craving that these drugs may subsequently induce), is hardly

insurmountable. It simply means that the former addict must exercise a level of caution

with regard to drugs that the non-addict does not have to exercise.

Furthermore, the neurobiological features of addiction do not appear to be peculiar to drug

addiction, as they also occur in the ‘behavioural addictions’. Gardner and David observe,

for example, that ‘The behavioral addictions ... are strongly suggestive of the

neurobiological underpinnings seen so clearly in the chemical addictions’.30 It may be the

case, then, that all excessive appetites (including such behaviours as compulsive over-

eating and gambling) hijack the same pleasure/reward circuits of the brain and produce an

identical or similar neurobiological effect. (If this is so, the distinction between behavioural

and physiological dependencies is not as clear as earlier thought.) As Gardner and David

also observe, humans differ from laboratory animals in at least two important respects.

First, knowing that drug use may be hazardous and addictive, humans are capable of

refusing to use the drug in the first place. Secondly, after addiction and withdrawal have

occurred, the human agent can employ a number of strategies to help her to avoid relapse

and a return to the lifestyle she now rejects. Where conditioned cues cannot be avoided or

tempered and craving ensues, the addict must decide how to respond – exercising her

capacity for personal autonomy means successfully resisting the temptation to take the

drug. This is when the competing stimuli created by the agent’s previous drug-use is at its

most vociferous and she needs to adopt tools to enable her to endure the craving

episode.31

29 If cross-priming does occur, this has implications for former addicts who require pain relief, for example, following an accident or surgery or during serious illness. Where drug use cannot reasonably be avoided, the former addict should (if possible) take precautions against subsequent craving responses.30 Eliot L. Gardner and James David, ‘The Neurobiology of Chemical Addiction’, in Jon Elster and Ole-Jorgen Skog, Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999, p.127. They also note, ‘Intriguingly, the same mesotelencephalic dopamine circuits that appear to subserve the reward induced by addictive drugs are also biochemically activated by natural rewards, in a manner seemingly identical to the dopaminergic activation produced by addicting drugs.’


April 2001

It also matters how the individual responds to a moment of weakness in which she yields to

a lower-order desire to use in spite of her higher-preference to be drug-free. Research

suggests that the psychological reaction a recovering addict has to a lapse is vital to her

long-term abstention. For example, a lapse ‘may be viewed in two ways: as catastrophic

and therefore leading to more drug use, or as a learning experience, concentrating on the

potential pitfalls of daily life and the need to acquire new coping skills’32 and ‘Cocaine users

who view themselves as having lost control are more likely to recommence regular use,

compared to the person who sees such an episode of use as a lapse requiring further

concerted effort to learn and enhance relapse-prevention coping skills.’33 The response to

a lapse is also relevant to the issue of whether the recovering addict can plausibly be said

to be an autonomous agent. Solitary or occasional lapses do not, according to the global

conception of autonomy, reveal a person to be nonautonomous. What counts on this

conception is the degree to which a person is self-directing over the course of her life. The

recovering addict who is generally abstinent but occasionally fails to resist temptation does

not fall below the relevant threshold; she is generally self-directing (autonomous in the

global sense). Where a person genuinely has a higher-order preference to be drug-free

but persistently fails to resist temptation, however, her autonomy has been seriously

compromised – she is not exercising control over her life’s direction. The key issue in such

cases, however, is whether the agent truly does have a higher-order volition that she is

unable to act in accordance with.

AMBIVALENCE

Not all motivational conflict is between an agent’s higher- and lower-order desires. The

very notion that someone does not unreservedly endorse a higher-order preference over

some volitional issue such as whether to give up alcohol or other drugs (that is, the

31 See, for example, Living Sober: Some methods A.A. members have used for not drinking, York, A.A. General Service Office, 1975. Referring to another twelve-step program based on AA, Gardner and David describe a compulsive gambler playing the slot-machines in a manner visually and motivationally reminiscent of laboratory rats repeatedly self-administering drugs by pulling on a lever. They write, ‘But this same gambler, the following year, choosing to attend a Gamblers Anonymous meeting rather than buy an airplane ticket to Las Vegas, looks a good deal less like our laboratory animals.’ See ‘The Neurobiology of Chemical Addiction’ in Jon Elster and Ole-Jorgen Skog (eds.), Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999, p.127.32 John Strang, Michael Farrell and Sujata Unnithan, ‘Treatment of Cocaine Abuse: Exploring the Condition and Selecting the Response’, in Philip Bean (ed.), Cocaine and Crack: Supply and Use, Hampshire, The MacMillan Press Ltd, 1993, pp.158-9.33 Ibid., p.159.


April 2001

existence of ambivalence) may tell of conflict between higher-order desires themselves.34 It

is important that ambivalence at this level not be confused with impaired autonomy. If an

agent has a higher-order desire to continue using drugs (even if she also has a competing

higher-order desire, say, to be free of some of the aspects or consequences of her current

drug-using lifestyle), there is no conflict between this higher-order preference and her

acting on a lower-order desire to take drugs. The condition she is in here is one of not yet

having made up her mind which of her higher-order preferences she will identify with, rather

than that she has decided on one or the other and yet finds herself unable to act in

accordance with it. Three points arise from this distinction.

First, it is not freedom of the will that is most obviously at issue here; it is the individual’s

conception of the way she wants her life to go. That is, the ambivalent agent wants a life

that provides both the benefits of drug use and the benefits of being drug-free. Continued

drug use may be harmful to her in certain respects (for instance, it may detract from her

ability to achieve other worthwhile goals in life) and, perhaps for this reason, others think

that she should opt decisively for a conception of the good life that excludes it,35 but it is

really her higher-order volition that they want to shape and not, in this case, her ability to act

in accordance with it. That is, it is not her ability to exercise her capacity for autonomy that

they are really criticizing.

Secondly, committing ourselves to one preference rather than to another (deciding which

desire we will identify with) is something that we do to ourselves. Others may attempt to

influence the decision (using a variety of tactics, from bullying and threats of legal sanctions

to gentle persuasion) but the commitment must come from the agent herself.36 The conflict

that needs to be resolved is an internal one, and it makes little sense to demand that a

person’s actions conform to a higher-order volition that she does not yet have

(notwithstanding that others think she should have it) in order to be considered

autonomous.

34 See Harry G. Frankfurt, ‘Identification and Wholeheartedness’, The Importance of What We Care About: Philosophical Essays, Cambridge, Cambridge University Press, 1988.35 It may be the expectation of disapproval from others that leads some drug addicts to admit only to their desire to be drug-free and not to the co-existing desire to continue with their current way of life.36 Jim Orford suggests that addiction cannot be overcome without such higher-order decision-making on the part of the addict. Excessive Appetites: A Psychological View of Addictions, Chichester, John Wiley & Sons, 1985, ch.13 (esp. pp.271-284).


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Thirdly, once the agent has identified decisively with one or other of her conflicting higher-

order preferences (and assuming that the preference she eventually commits to is the

preference to be drug-free), the resolution of this higher-order conflict will not automatically

eliminate incongruence between her actions and the decision to lead a drug-free life. She

needs both to maintain this commitment and to resist any lower-order desires she might

experience to use drugs again. The act of deciding to commit to a particular higher-order

preference is not like a conjuring act that suddenly expunges all conflicting lower-order

desires. If it were, freedom of the will would never be a problem. But, once the decision to

abstain has been made, there is no reason to suppose that the competing stimuli produced

by physical dependence and previous behaviour patterns is so overwhelming as to deny

the agent control over her life’s direction. Addiction may compromise personal autonomy

by making one vulnerable to temptation by the object of the addictive behaviour, but it is a

mis-description of the phenomenon to claim that it robs the agent of the ability to exercise

her will.

REFERENCES:

Alcoholics Anonymous, Living Sober: Some methods A.A. members have used for not drinking, York, A.A. General Service Office, 1975.

Bakalar, James B., and Lester Grinspoon, Drug Control in a Free Society, Cambridge, Cambridge University Press, 1984.

Bean, Philip, ‘Cocaine and Crack: The Promotion of an Epidemic’, Philip Bean (ed.), Cocaine and Crack: Supply and Use, Hampshire, The MacMillan Press Ltd, 1993.

Benn, Stanley I., A Theory of Freedom, Cambridge, Cambridge University Press, 1988.Dworkin, Gerald, The Theory and Practice of Autonomy, Cambridge, Cambridge University

Press, 1988.Elster, Jon, Sour Grapes, Cambridge, Cambridge University Press, 1983.Elster, Jon, Strong Feelings: Emotion, Addiction, and Human Behavior, Massachusetts,

The MIT Press, 1999.Frankfurt, Harry G., ‘Freedom of the Will and the Concept of a Person’, The Journal of

Philosophy, v.68, n.1, January 1971. (This article can also be found in Harry G. Frankfurt, The Importance of What We Care About: Philosophical Essays, Cambridge, Cambridge University Press, 1988.)

Frankfurt, Harry G., ‘Identification and Wholeheartedness’, The Importance of What We Care About: Philosophical Essays, Cambridge, Cambridge University Press, 1988.

Gardner, Eliot L., and James David, ‘The Neurobiology of Chemical Addiction’, Jon Elster and Ole-Jorgen Skog (eds.), Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999.


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Goldstein, Avram, and Harold Kalant, ‘Drug Policy: Striking the Right Balance’, Ronald Bayer and Gerald M. Oppenheimer (eds.), Confronting Drug Policy: Illicit Drugs in a Free Society, Cambridge, Cambridge University Press, 1993.

Goodin, Robert E., No Smoking: The Ethical Issues, Chicago, The University of Chicago Press, 1989.

Haworth, Lawrence, ‘Dworkin on Autonomy’, Ethics, v.102, n.1, October 1991.Kreeger, Karen Young, ‘Drug Institute Tackles Neurology of Addiction’, The Scientist, v.9,

n.16, 21 August 1995.Loewenstein, George, ‘A Visceral Account of Addiction’, Jon Elster and Ole-Jorgen Skog

(eds.), Getting Hooked: Rationality and Addiction, Cambridge, Cambridge University Press, 1999.

N.I.D.A. (National Institute on Drug Abuse, USA), ‘LSD’, Research Report Series, 014.Orford, Jim, Excessive Appetites: A Psychological View of Addictions, Chichester, John

Wiley & Sons, 1985.Phillipson, O.T., ‘Dopamine’, Richard L. Gregory (ed.), The Oxford Companion to the Mind,

Oxford, Oxford University Press, 1987Quincey, Thomas De, Confessions of an English Opium-Eater, London, Penguin Books,

1997.Strang, John, Michael Farrell, and Sujata Unnithan, ‘Treatment of Cocaine Abuse:

Exploring the Condition and Selecting the Response’, Philip Bean (ed.), Cocaine and Crack: Supply and Use, Hampshire, The MacMillan Press Ltd, 1993.

Williamson, Kevin, Drugs and the Party Line, Edinburgh, Rebel Inc., 1997.Young, Robert, ‘Autonomy and the “Inner Self”’, John Christman (ed.), The Inner Citadel:

Essays on Individual Autonomy, New York, Oxford University Press, 1989.


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