On the Grounds for Calling Addiction a Disease

DOI 10.36446/af.e1048 ON THE GROUNDS FOR CALLING ADDICTION A DISEASE* Acerca de las razones para ver la adicción como una enfermedad Federico Burdman a https://orcid.org/0000-0002-8506-9271 a Departamento de Filosofía, Universidad Alberto Hurtado, Santiago, Chile. Abstract In this paper, I look into the debate about the status of addiction as a disease. Although addiction is widely regarded as a disease, several authors have put forward reasons for agnosticism or skepticism about the appropriateness of the disease label. Any attempt to address this issue directly is complicated by its relationship to several other contentious issues, both on the side of theories of addiction and on the side of theories of disease. My primary aim in this paper is to identify the major points of contention. My secondary aim is to offer a limited defense of the disease view. The crux of the debate is whether addiction is aptly pictured as the result of psychological dysfunction. The main hurdle for the psychological dysfunction claim is that we currently lack a relatively unified account of the behavioral trait that most strongly suggests dysfunctional processes: the loss of expectable ability to control behavior. I argue that there is a sense in which the dysfunction claim may be warranted even in the absence of a unified causal account. However, this requires assumptions that are to some extent controversial, most notably, the impaired control view of addiction and the acceptability of dysfunction-talk based on personal- level behavioral traits. Key words: Addiction; Disease; Impaired Behavioral Control; Dysfunction; Harm. Resumen En este artículo, echo una mirada al debate acerca del estatus de la adicción como enfermedad. Aunque la adicción es comúnmente vista como una enfermedad, varios autores han esgrimido razones para el agnosticismo o el escepticismo acerca de la corrección de esta etiqueta. Cualquier intento de abordar esta discusión directamente se complica por su relación con varios otros debates abiertos, tanto del lado de las teorías de la adicción como del lado de las teorías de la enfermedad. Mi objetivo principal en este artículo es identificar cuáles son los principales puntos de controversia. Mi objetivo secundario es ofrecer una defensa limitada de la tesis de la adicción como enfermedad. El punto neurál- * This article is the result of research funded by research projects PICT-2019-02605 (Agencia Nacional de Promoción Científica y Tecnológica, Argentina) and FONDECYT Iniciación 11250503 (Agencia Nacional de Investigación y Desarrollo, Chile). ANÁLISIS FILOSÓFICO 45(1) - pISSN 0326-1301 - eISSN 1851-9636 - CC: BY-NC - (mayo 2025) 203-231 204 FEDERICO BURDMAN gico del debate es si la adicción es el resultado de una disfunción psicológica, y el principal obstáculo para afirmar que hay tal disfunción psicológica es que actualmente carecemos de una explicación relativamente unificada del rasgo conductual que más fuertemente sugiere la ocurrencia de algo disfuncional: la merma de la capacidad esperable para controlar la propia conducta. Según sostengo, hay un sentido en el que la afirmación de disfunción puede estar justificada incluso en ausencia de una explicación causal unificada. Esto requiere, sin embargo, suposiciones que son hasta cierto punto controversiales, incluyendo la visión de la adicción en términos de deterioro del control conductual y la aceptabilidad de predicar disfunción a partir de rasgos conductuales a nivel personal. Palabras clave: Adicción; Enfermedad; Control conductual deteriorado; Disfunción; Daño. 1. Introduction Addiction is widely considered to be a disease1. It has been consistently listed in every edition of the DSM, including the latest one (American Psychiatric Association, 2022), it is listed in the World Health Organization’s classification of diseases, the ICD-11 (World Health Organization, 2019), and it is commonly referred to as a disease by numerous other influential medical and research institutions around the globe. In psychiatric literature, support for the view is almost universal, and it is also widely accepted among treatment providers (Barnett et al., 2022). While popular conceptions of addiction have traditionally considered it to be a moral failing, the view of addiction as a disease has of late gained greater acceptance among the general public (Connelly et al., 2018; Pescosolido et al., 2010; Rise & Halkjelsvik, 2019). In addition, many people with addiction think of their condition as a disease (Snoek, 2017b, p. 189). Even non-medical institutions and support groups such as AA and NA refer to addiction as a disease (Flanagan, 2013). Contrary to the prevailing opinion, some have remained agnostic or outright skeptical about the appropriateness of the disease label. Many have criticized the view of addiction as a disease of the brain (Field et al., 2019; Heather et al., 2022; Levy, 2013; Pickard, 2022a, 2022b), while others 1 A brief note on terminology: I will follow the prevailing trend in the technical literature by focusing on cases of drug addiction, although what I say is intended to be relevant to other types of addiction as well. As for the term ‘drugs,’ I will use it liberally to refer to all substances that can be the object of addictive behavior, including alcohol, nicotine, and other substances not commonly referred to as ‘drugs’ outside the technical literature. People with addiction are often the target of stigmatizing attitudes that are both inhumane and detrimental to their chances of recovery. I intend my use of the term ‘addiction’ to carry no negative connotations about the people who suffer from it. ANÁLISIS FILOSÓFICO 45(1) - (mayo 2025) ON THE GROUNDS FOR CALLING ADDICTION A DISEASE 205 have questioned whether it is aptly seen as a disease at all (Heather, 2013, 2017; Heyman, 2009; Lewis, 2015, 2017; Ross, 2020; for an early defense of the view, see Fingarette, 1988). Skeptics have challenged the arguments advanced in defense for the disease view, pointing to disanalogies with paradigmatic medical conditions and claiming that addiction does not meet plausible criteria for inclusion. In addition, they have sometimes suggested that labeling addiction as a disease may not be in the best interest of those who suffer from it. So, is addiction a disease? Any attempt to answer this question directly is complicated by its relationship to several other contentious issues, both on the side of theories of addiction and on the side of theories of disease. My primary aim in this paper is to lay out what the major points of contention are. My secondary aim is to offer a limited defense of the disease view. The crux of the debate is whether addiction is aptly pictured as the result of psychological dysfunction, and the main hurdle for the psychological dysfunction claim is that we currently lack a relatively unified account of the behavioral trait that most strongly suggests dysfunctional processes: (...truncated)