By Adrian Carter, Wayne Hall, Judy Illes (Editors) Academic Press, 2011 Review by Christian Perring on Jan 21st 2014
Addiction Neuroethics is a substantial book at over 300 pages of main text, comprising of 16 chapters and an introduction by some of the main thinkers about the connections between brain research, addiction, and philosophy. The book is divided into five sections of different but overlapping themes: the science of addiction, treatments focused on the brain, philosophical issues, the history and media representation of the relation between neuroscience and addiction, and finally, public policy and legal issues.
In their introduction, the editors make a distinction between a moral model of addiction, which holds that addicts should be held morally responsible for their behavior, with a brain disease model of addiction, which holds that addiction "hijacks the brain" and gets people to act against their own wishes. The editors seem to endorse these as the main alternatives, and as mutually exclusive options. This is a concern, since they are not mutually exclusive: it is possible that a person can have a brain disease and at the same time be morally responsible (to some degree) for their actions. However, the editors are right that these two models have been influential and they are useful as ways of classifying how different authors understand addiction.
In the first chapter on brain imaging, the authors David Nutt, Anne Lingford-Hughes, and Liam Nestor contrast different approaches to understanding how addiction affects people. They start off by contrasting what appear to be two competing theories of addiction. First, there is one associated with Volkow and colleagues, which posits four independent "circuits" in the brain; these consist of reward, motivation, memory and learning, and finally cognitive control. Second, there is a theory of Bechara, that the impulsive amygdala system together with a reflective prefontal cortical system, together interact and form the basis for the development of addiction. These systems respectively signal immediate and then future pleasures and pains. Normally the prospect of future pleasure or pain dominates and controls behavior, but it can happen that the former system becomes hyperactive and thus dominates the longer term planning.
The authors then look at the kinds of evidence that are collected through various kinds of brain imaging. It seems that rather than competing, both the theories of addiction apply in different cases, and the 4 circuits highlighted by Volkow are all involved in addiction in different ways. So there is no definite answer to the question that the paper started with, and it ends on a note of caution, saying that there is still plenty of overlap between addicts and control groups, and brain scanning cannot be used for diagnosis.
"Molecular Neuroscience and Genetics" by Jhodie R. Duncan, Andrew J. Lawrence discusses mainly the effects of drugs on the brain, and most notably the genetic effects. While relevant to ethical issues, it does not any explicitly. The list of references at the end of the article occupies 6 pages, and alerts readers to the scholarly nature of the work, but raises question as to whether all the references are necessary.
The section on treatment has 4 papers. They address explicitly ethical issues in treatment, although their approaches use little theory. The third chapter explores the use of opioids in opioid treatment, such as methadone maintenance. The authors show that it is hard to justify such treatments, because they are not very successful, they have bad effects, and it is very difficult to get truly informed consent from an addict when asking them if they want an opioid. Chapter 4 on approaches to tobacco harm reduction is a bit bland, but it contains some useful information. The fifth chapter explores neurobiological treatments such as anti-craving drugs, vaccines, sustained-release drugs, psychopharmacology, neurosurgery and other interventions in the brain. They point out that these approaches do not provide straightforward cures and carry their own dangers. They spell out these dangers clearly. The final chapter in the section shows that the use of genetic information to predict who is liable to suffer from addiction, and that using genetic information does not necessarily help people to end their addiction. Furthermore, the use of genetic information by others can be morally problematic, since it can lead to discrimination. In order to use the information well, the public will need to be better educated as to what it means. Overall, this section takes sensible positions that urge caution in using new technology in treating people and in public policy.
The section on philosophy is probably the most interesting in the book. It has three papers. Neil Levy contributes the eminently sensible idea that an addiction does not need to completely rob a person of choice in order to count as a mental disorder, and that autonomy is complex and variable. He shows that experimental work shows that most people diagnosed with substance abuse problems remain able to control their actions to at least some degree. People with addictions can still have some moral responsibility for their behavior. The medical and moral approaches are not mutually exclusive. In Chapter 8, Wild et al spell out reasons to be suspicious of coercive treatment of addicts, in a paper that overlaps a good deal with several chapters in the Treatment section, and especially Chapter 3. The authors show that it is ethically problematic and there is little to justify such coercive treatment, since it has bad effects and limited success, with recovery rates comparable to those who get no treatment. The most provocative paper in the section is by Fry and Buchman, with the puzzling title of "Toward a Lay Descriptive Account of Identity in Addiction Neuroethics." It is an unusual piece, arguing that the identity of an addict is unhelpful. This sounds a lot like labelling theory, which argued against labelling, and it has connections to "narrative theory" too. It argues for new approaches for identifying addicts that don't leave them stuck and stigmatized. The authors pay attention to how addiction identities are changing with the rise of influence of brain science and genetics, but they note that there has not been much study of this. This shows one of the problems the authors face: while this area Is theoretically rich, it is hard to carry out much definitive research. Furthermore, while we can speculate as to what new identities we might want to create, the history of the disability movement and in particular those fighting the stigma of mental illness shows that creating new identities or language is fraught with possible unexpected consequences that might backfire. So as a political call for change, it is worth investigating, but it is action that needs to be taken carefully.
The fourth section is on "Addiction History and the Media." This is an important part of a full understanding of mental health issues, and it is good to see that media studies are gaining a foothold in neuroethics. There are three papers. The first covers the history of the US Narcotic Farm in Lexington, Kentucky, which was both aimed at treatment of serious addicts and also at neurological research on addiction. This caused ethical problems for the staff, because treating people as research subjects requires different approaches from helping them as patients. Nevertheless research did proceed, and a good deal of important work was done. Some of it was ethically problematic, and this provides good material for ethical investigation. Chapter 11 is about the way that the press reports legal issues in addiction, especially concerning the relevance of neuroscience. It is very quantitative. Chapter 12 is about the way that neuroscience gets transmitted to a wider audience. This is a very programmatic paper, setting out goals for good communication of scientific findings.
The last section has 4 papers in on public policy and legal issues. While the issue of what laws and policies we should have is important, it is less theoretically interesting here. The papers tend to be more summarizing of existing work. The papers here are careful, but less provocative than many others in the collection. The most striking article here is by Miller et al on the vested interests in neuroscience research of addiction. They ask why there is so much investment in addiction neuroscience, and whose interests are served by this investment. They give the example of the tobacco industry funding genetic research into cancer, where the concern is that their motivation is to show that the causes of cancer are less to do with tobacco and more to do with an individual's DNA. Similar concerns apply to the funding of research by the alcohol industry, and the gambling industry. The authors point out what has long been explained and crystal clear for decades, that focusing on neurobiological treatments is generally done at the expense of focus on social and public health initiatives. They also point out that neuroscience has failed to deliver on its initial promise. So the authors call for greater caution when deciding research priorities, and they direct their comments not to policy makers, but to neuroscientists.
This is an important collection that explores the ethical dimensions of neuroscientific approaches to addition. Given the way that brain science is changing so many people's ways of talking about addiction, the topic is in strong need of investigation, even for those who are skeptical about how much brain science will be able to deliver in practical results. It has a good balance of different approaches from various disciplines and the standard of the argumentation is strong.