Drug Addiction. Is it a disease or is it based on choice?

A review of Gene Heyman's

Addiction: A disorder of choice.

In Addiction: A disorder of choice Gene Heyman makes a case for drug addiction to be a result
of natural processes involving voluntary (i.e., operant) behavior, specifically choice. This
approach stands in stark contrast to the current received view, at least as promulgated by the
National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and
Alcoholism (NIAAA), that drug abuse is a disease, specifically, “Addiction is a chronic, often
relapsing brain disease…[s]imilar to other chronic, relapsing diseases, such as diabetes, asthma,
or heart disease….” (NIDA, 2008). Over the course of seven chapters Heyman makes his case by
describing the history of drug abuse and addiction, societal responses to it, case histories from
addicts, the epidemiology of drug addiction, “rational” and “irrational” choice, brain–behavior
relationships, and approaches to treatment of drug addiction. These descriptions provide the
bases for the focal points made, which are that normal, apparently rational choice processes can
lead to poor long-term outcomes (e.g., addiction), and that an understanding of such processes
offers a viable approach to the prevention and treatment of drug addiction. Of particular interest
to readers of this journal is that the behavioral processes involved have been studied and
characterized to a considerable degree by those who investigate operant choice. In addition,
scattered throughout the exposition is a litany of evidence making the view that drug addiction is
a disease, at least in the normal sense of that word, difficult to defend. In this review I endeavor
to describe briefly and evaluate some of the key points made by Heyman about how normal
choice processes play a role in drug addiction and to highlight his arguments countering the
“addiction is a brain disease” view.

The first of the seven chapters provides an overview of the history of drug use and abuse, as well
as information about its current prevalence. Although alcohol abuse has been documented from
time to time for centuries, abuse of other drugs is a relatively recent phenomenon. Heyman notes
that the first “epidemic” in the United States occurred in the late 19th century, before legal
prohibitions were established. In addition to the perennial problems with alcohol abuse, the
period was noted for abuse of opiates. Some of that abuse was centered in the wealthy “opium
eaters” who abused laudanum. Interestingly, incidence rates from that period, before legal
sanctions, were similar to current ones. However, abuse also extended to those of lower
socioeconomic status, largely in the form of opium smoking in “opium dens.” Heyman makes
the case that public concern raised by drug abuse among the lower classes set the wheels in
motion for governmental responses. The passage of the Harrison Act in 1914 marks a pivotal
point in the public response to drug use and abuse. That act applies to the tax code, and since that
time the Federal response to drug abuse has been the purview of the Treasury Department, rather
than the Department of Justice. The Drug Enforcement Administration (DEA), the successor to
the Bureau of Narcotics and Dangerous Drugs (BNDD), is an arm of the Treasury Department.
The activities of that organization and the criminal-justice system help to establish the current
situation in which societally imposed penalties are applied to those said to be suffering from a
disease.

Reaction:

Drug addiction has become a worldwide problem, especially in teenagers. Many young people
become dependent on different types substances and stimulating medicines that comes hand-in-
hand with narcotic effect. The life of addicts becomes spoiled in all aspects, as they lose contact
with their family and live in a different world. They spend lots of money on drugs, and then look
for ways to earn money illegally. If we compare the health problems, there are many dangerous
effects of drugs.

The most disturbing thing about drug addiction is that people in different countries of the world
are becoming addicted to all kinds of drugs. There are different types of street drugs such as –
cocaine, meth, marijuana, crack, heroin etc. Heroin is one of the dangerous drugs that suppress
your heart’s work and is appropriate to achieve narcotic effect.

The alarming rate of drug consumption has always been a problem and has detrimental effects on
the society. Personal and family problems also lead to drug abuse among youngsters who fail to
deal with personal problems. The physiological effects of drug addiction can be difficult to
endure and this is why the addict must be treated for their condition. The worst thing is that
drugs are that they affect youth in every country of the world.

The term drug not only means medicine, but fatal narcotics with different specifications. These
drugs have their evil effects on mind and body cells of the addicts. The addict becomes
dependent on the drug to a great extent that he/she cannot stop using it. Despite of having full
knowledge of its effects on health, addicts use it on a regular basis.

Synthesis:

In Addiction: A disorder of choice, Gene Heyman surveys a broad array of evidence—historical,

anthropological, survey, clinical, and laboratory-based to build an argument about the role of
basic choice processes in the phenomena that comprise drug addiction. He makes a compelling,
multifaceted argument that conceptualizing drug addiction as a chronic disease (like
schizophrenia or diabetes) is both misleading and erroneous. In developing his argument, he
points out that the best survey data available indicate that most drug addicts quit their addiction,
a fact inconsistent with a chronic-disease model. He illustrates how basic, normal choice
processes can lead to addiction, arguing that people do not choose to be addicts, but that normal
choice dynamics can lead them to that condition. He points to a variety of factors that keep most
from becoming addicted, with a focus on the role of choice governed by choice-by-choice
contingencies versus choice governed by the outcome of sequences of choices, a difference in an
under-described activity called framing. His view is consistent with the most effective treatments
currently available, and provides a basis for continued basic research on choice as well as
research on treatment and prevention.

Nursing Responsibilities:

 Assessment data include minimization of drug use or dependence, blaming others for
problems, reluctance to discuss self or problems, poor insight, failure to accept
responsibility for behavior, viewing self as different from others, and rationalization of
problems (intellectualization).
 Avoid the PDD’s attempts to focus on only external problems (such as marital or
employment problems) without relating them to the problem of substance use. The
problem of substance use must be dealt with first because it affects all other areas.
 Encourage the PDD to identify behaviors that have caused problems in his or her life.
The PDD may deny or lack insight into the relationship between his or her problems and
behaviors.
 Do not allow the PDD to rationalize difficulties or to blame others or circumstances
beyond the PDD’s control. Rationalizing and blaming others give the PDD an excuse to
continue his or her behavior.
 Consistently redirect the PDD’s focus to his or her own problems and to what he or she
can do about them. You can facilitate the PDD’s acceptance of responsibility for his or
her own behavior.
 Encourage other PDD in the program to provide feedback for each other. Peer feedback
usually is valued by the PDD, because it is coming from others with similar problems.
 Positively reinforce the PDD when he or she identifies and expresses feelings or shows
any insight into his or her behaviors and consequences. You convey acceptance of the
PDD’s attempts to express feelings and to accept responsibility for his or her own
behavior.
 Leadership and Management Are One and the Same

In 1977, Abraham Zaleznik1 authored an opinion piece that became the first publication to
describe leadership and management as two separate functions. Since then, there has been much
effort dedicated to studying the differences between managing and leading, with more than 4000
documented definitions of leadership existing alone. Based upon the existing literature,
leadership skills are generally glorified as being “visionary” and “doing the right thing,” while
managerial skills are dismissed as being “task-oriented” and “doing things right.” However, no
scientific evidence exists to support the described differences between leadership and
management; what remains is an abstraction of two concepts with no consensus and little
application. The authors of this paper are of the opinion that the terms leadership and
management are arbitrarily and yet similarly defined. One of the classic leadership definitions
often recited, “Leadership is the quality that sets great managers apart from good ones,” further
validates this idea as it is simply an illustration of the lexical concept of polysemy.2 That is, the
practice of using words in one lexical context, in a different form, to describe a related concept,
such that the word “leadership,” derived from the verb “leading,” acquires the meanings of those
engaged in the activity “managing,” or as in the case above, as the result of performing the
activity as a “manager” satisfactorily. Thus, leading and managing are not merely
complementary, they are essentially the same concept used to describe different levels of a
taxonomy related to performance or organizational effectiveness.

Together, the two terms “leading” and “managing” form the framework for skills and abilities
that are necessary for an individual to drive team success. In fact, the concepts of leadership and
management are transposable, especially in describing performance effectiveness within
organizations. The functions of leadership and management flow in a continuum that are not
separable. Many of these functions are used in describing the roles of both “leaders” and
“managers,” causing the definitions and functions to blur as a continuum of one role. Over time,
Zaleznik’s separation of these functions has been perpetuated as a false dichotomy through the
continued ambiguous use of these words. For example, according to a 2012 Forbes article,7
“leading” is described as who you are as a person, while “managing” is described as more of a
craft, primarily skill-based, that may be learned, suggesting the former as an identity to be
cultivated within the individual and the latter as a set of behaviors demonstrating a form of
competency. Portraying leadership development as an internal process of self-reflection, in
contrast to becoming a better manager through honing of a craft, provides a misleading
understanding of purportedly different concepts and grossly oversimplifies human and
organizational development.
Reaction:

Leadership inevitably requires using power to influence the thoughts and actions of other people.
Power in the hands of an individual entails human risks: first, the risk of equating power with the
ability to get immediate results; second, the risk of ignoring the many different ways people can
legitimately accumulate power; and third, the risk of losing self-control in the desire for power.
Managers tend to view work as an enabling process involving some combination of people and
ideas interacting to establish strategies and make decisions. They help the process along by
calculating the interests in opposition, planning when controversial issues should surface, and
reducing tensions. In this enabling process, managers’ tactics appear flexible: on one hand, they
negotiate and bargain; on the other, they use rewards, punishments, and other forms of coercion.

Synthesis:

Defining the attributes of change catalysts within high functioning organizations, including the
academic enterprise, is desirable. An understanding of these attributes within our academy may
foster faculty interest and engagement in seeking administrative roles and serve to bolster
succession planning within our schools. On one hand, there have been numerous publications
teasing out the purported differences between leadership and management. On the other hand,
does segregating these important characteristics based upon arbitrary distinctions do more harm
than good? This commentary represents the work of a group of academic leaders participating in
the 2015-2016 AACP Academic Leadership Fellowship Program. This work was presented as a
debate at the 2016 AACP Interim Meeting in Tampa, Florida, in February 2016.
 Principles for ethical research involving humans: ethical professional practice in impact
assessment Part I

Introduction: The need for competency in ethics

Ethical issues and dilemmas arise in all forms of professional practice. Academic research in
various disciplines, especially in the social sciences, also encounters ethical issues. While there
has been an increasing codification of research ethics and professional practice ethics with the
establishment of institutional ethics committees, views about the ethical implications of various
research methods and practices vary across disciplines and in different cultural settings
(Castellano 2004; Hoeyer et al. 2005). For example, much concern has been expressed by social
scientists about the dominance of biomedical thinking in research ethics discussions (Israel &
Hay 2006; Shore 2007; Dyer & Demeritt 2009; Amon et al. 2012). Therefore, with evolving
practice in impact assessment practice generally and social impact assessment (SIA) practice
especially (Vanclay 2002, 2003a, 2004, 2006, 2012; Esteves & Vanclay 2009; João et al. 2011;
Vanclay & Esteves 2011; Esteves et al. 2012; Franks & Vanclay 2013), it is appropriate that
ongoing reconsideration be given to the topic of ethical practice and to the kinds of ethical issues
that can arise (Howitt 2005; Baines & Taylor 2011; Fuggle 2012). This is especially the case
because ethical issues in professional practice rarely have simple right and wrong answers
(Guillemin & Gillam 2004). An active awareness of the ethical issues likely to be encountered is
important for reflexive and professional practice (Fisher 2008).
A hallmark of professionalism is an ongoing discussion of ethical issues within the professional
group (Jowell 1986; Savan 1989; Wolpe 2006; Zandvoort 2008). Jennings (2003) considers that
there are five general goals of ethics education for practising professionals:
Stimulating and broadening the moral imagination – practitioners need to learn about ethics, to
understand ethical issues, to gain an empathy for people, and to interpret contexts in moral terms.
Recognizing ethical issues – practitioners need to be aware of when and how ethical issues
occur.
Developing analytical skills – practitioners need to learn the vocabulary of ethics and moral
argument, and to develop skills in analysing and addressing ethical situations.
Eliciting a sense of moral obligation and responsibility – practitioners need to develop an
understanding of their personal obligations and responsibilities.
Coping with moral ambiguity – practitioners need to be aware of and able to cope with situations
in which moral principles are in conflict with each other and/or where there is no obvious moral
choice. Decisions in these cases should be based not on personal preference or vested interest,
but on reasoned moral argument. The potential for moral ambiguity also means that individual
practitioners need to be able to negotiate ethical judgements with others and be able to defend
their decisions and actions on moral grounds.
This paper and its companion paper (Baines et al. 2013) seek to contribute to advancing these
goals in the impact assessment field. While the companion paper discusses a range of ethical
issues from the basis of the authors’ experiences of professional SIA practice, this first paper is
relevant to all fields of impact assessment given that the principles of ethical human research are
considered to apply to any research (i.e. data collection) process that involves human beings,
whether humans are the subject of the research or only the providers of data. Thus, data
collection for an (environmental) impact assessment that relies on asking people for opinions or
information about biophysical issues would still normally be expected to comply with ethical
research principles and procedures. The Australian national ethical research statement, for
example, requires that its ethical principles be used in conjunction with any human research
funded by any of the Australian government research funding agencies. Furthermore, it states
that: ‘in addition, the National Statement sets national standards for use by any individual,
institution or organisation conducting human research. This includes human research undertaken
by governments, industry, private individuals, organisations, or networks of organisations’
(Australian Government 2007, p. 7). Social research ethics therefore potentially extend beyond
SIA to all forms of impact assessment, and extend from academic to all organizational settings.

While academic research in many countries is clearly subject to the national generic and
institution-specific requirements of the particular university in which the academic researcher
resides, it is worth considering the extent to which research ethics might also apply outside the
context of formal research institutions, to the professional practice settings in which most impact
assessment professionals work. Although ethical research principles are sometimes used by
institutions to protect the reputations of those institutions and to address risk considerations,
nevertheless there is a legitimate, widely accepted, fundamental philosophical basis to the ethical
principles. To that extent, these principles also apply to all practitioners, irrespective of their
institutional setting. Thus, good professional practice would mean complying with ethical
research as generally understood.

This paper (i.e. part I of a two-part paper) identifies the currently accepted ethical principles that
apply to research involving humans and reflects briefly on the extent to which they apply to
impact assessment. The companion paper (Baines et al. 2013) considers specifically how the
ethical principles apply to SIA practice, drawing on the practice perspective of the authors. This
first paper starts with a discussion of ethics and professional practice, before considering a range
of codes of ethical research and identifying the major ethical principles in those codes. A
concluding section provides some reflections relating to improving ethical conduct in impact
assessment generally.

Morality, ethics and ethical practice

Ethics, or moral philosophy, is a branch of philosophy that seeks to address questions of
morality. Morality refers to beliefs or standards about concepts like good and bad, right and
wrong (Jennings 2003). When used as the basis for guiding individual and collective behaviour,
ethics takes on a normative function, helping individuals consider how they should behave from
a moral perspective, in other words, what they ought to do. Applied or professional ethics deals
with ethical questions in many fields of professional practice, and many journals have been
established, including: Bioethics; Journal of Business Ethics; Journal of Clinical Ethics; Journal
of Law, Medicine & Ethics; Journal of Medical Ethics; Nanoethics; and Science & Engineering
Ethics. In addition, the mainstream journals of the professions frequently discuss ethical issues.
Ethics apply to all aspects of personal and organizational practice and are therefore relevant to
individuals, small firms, large corporations, government and non-government organizations, and
to professions as a whole.

Reaction:
A code of ethics is a set of written principles regarding conduct and behavior created by the
organization to serve as a guide. The purpose of ethical codes is to give its employees,
management, and any interested party a reference point that adheres to company policy,
standards, and ethical beliefs. The code is made visible to the public to ensure professional
integrity, quality, and to prevent misguided conduct. Regardless of the organization or governing
body a code serves as a go-to guide because ethical issues can stem from anywhere at any given
time. The Code of Ethics for Nurses is so dynamic because as technology changes, so does the
code to ensure that updated knowledge is provided to healthcare workers. Autonomy applies to
the profession of nursing because the patient should always be allowed to make decisions
regarding their care while being treated with respect and dignity; however, autonomy can serve
as a limiting agent when the patient decides to refuse care that would be of benefit to them.
Autonomy is a sensitive issue because it allows the patient to choose to die and all health care
can do from that point is allow the patient to do so comfortably. With healthcare always being
one step ahead, it allows a surrogate to serve as a voice piece for that patient when they are
unable to make decisions.

Summary:
Drawing on various national statements on the ethical conduct of research, the codes of ethics of
professional associations and international agencies, and ethical guidelines in social research
methods textbooks, this paper identifies current principles for ethical research involving humans
and discusses their implications for impact assessment practice generally and social impact
assessment specifically. The identified ethical principles include: respect for participants,
informed consent, specific permission required for audio or video recording, voluntary
participation and no coercion, participant right to withdraw, full disclosure of funding sources,
no harm to participants, avoidance of undue intrusion, no use of deception, the presumption and
preservation of anonymity, participant right to check and modify a transcript, confidentiality of
personal matters, data protection, enabling participation, ethical governance, provision of
grievance procedures, appropriateness of research methodology, and full reporting of methods.
Topics such as a conflict of interest, moral hazard and duty of care are also considered. Also
discussed are Indigenous peoples’ rights and their implications for ethical impact assessment
processes