Abstract

“A Liberal Account of Addiction‘ is a major contribution to the discussion of addiction, its treatment, and the social and policy issues which arise from it. Questioning as it does many generally accepted assumptions about addictive behavior, particularly the use of hard drugs, it will provoke even those who do not agree with it to rethink their positions. Many of its suggestions are relevant also, in my opinion, to thinking about other areas of psychiatric interest. Nevertheless, I want to argue that its authors have perhaps not freed themselves sufficiently from some common assumptions, in particular about the nature of mental disorder, and that their argument might benefit from such liberation. The central assumption that I have in mind is that understanding human actions is nothing but understanding the brain activity that accompanies them. If so, then a pattern of behavior can count as a ’mental disorder’ in any clinically or legally relevant sense only if it is the result of a brain disease, causing a breakdown in normal brain functioning. Starting from this assumption, the authors seek to show, by means of evidence from neuroscience, that addiction to drugs does not have a unique ’neural substrate,’ distinct from that of any other kind of pleasure-seeking behavior. When we have a pleasurable experience of any kind, as they point out, dopamine is normally released within the brain. This, they say, activates the ’reward’ pathways, making the person more likely to repeat the behavior that gives rise to the pleasurable experience in questionÑwhether it is eating, sex, or injecting heroin. Addiction, they argue, is therefore just a tendency to repeat an intensely pleasurable experience, whatever the nature of that experience might be. The particular chemistry of the substance involved in this particular form of pleasure is, they argue, irrelevantÑall that matters is that the experience it gives someone is pleasant. Addiction, they