Medicalization and the Philosophy of Addiction

The term "medicalization" was popularized by the Catholic philosopher and social critic Ivan Illich. Illich was troubled by the way in which what was formerly regarded as deviant behavior had come to be the province of medicine, as well as with the prevalence of those harms he deemed "iatrogenic"—that is, caused by medical treatment itself—in another term popularized by Illich.

Illich's major work on this topic, Medical Nemesis, was published in 1975, and is not nearly as widely discussed as it once was. (He used to be discussed regularly in American mass media, such as Time magazine, but I find that many philosophers and social workers today don't know his name). As it happens, this was around the same moment that the field of "addiction medicine" as we now know it was born. The National Institute of Drug Abuse was founded in 1974, and the American Academy of Addictionology (a precursor to the American Society of Addiction Medicine) was founded by physician G. Douglas Talbott shortly afterward.

Now, roughly 50 years later, addiction medicine has expanded vastly while Illich's work has become, as I have said, obscure. Nonetheless, it is worth reconsidering the achievements of addiction medicine from the point of view of Illich's work, or from the point of view of what Illich might have called the "medicalization of addiction."

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The achievements of addiction medicine are many and probably not celebrated frequently enough: the management of alcohol withdrawal (which can be fatal when untreated), the development and deployment of nicotine replacement therapy for tobacco addiction, and, perhaps most prominent in recent discussions, the deployment of medicines (such as Suboxone) for the management of opioid use disorder, as well as of medicines (Naloxone) that reverse opiate overdoses. These medical interventions have simply been life-saving for many people.

Yet the specter of "medicalization" still looms. It is perhaps most clear when we consider addictions whose relationship to substances, and so to the traditional provinces of medicine, are more remote.

In a 2011 article, the British physician Andrew Moscrop argued that "problem gambling" has increasingly come to be seen as a medical issue, with primary care physicians expected to serve as the first line for intervention with gamblers. Moscrop's hypothesis is that our traditional tendencies to scorn those who are profligate or wasteful has been transmuted, in an era of medicalization, to see "problem gambling" as a medical issue, and to see "problem gamblers" as individuals in need of treatment. Among other things, this framing has the advantage of allowing us to understand gambling challenges in individual-level terms, rather than as understanding them as consequences of larger social and economic inequities.

Moscrop therefore proposes that, for at least some addictions, we should exercise some caution in understanding them in medical terms. This does not require us to be Illichian skeptics about much of medicine, but it does call for a certain degree of humility about the medical enterprise. He writes: "Our patients present problems that are frequently neither physical nor psychological, but social or even spiritual. For their sake and ours it is imperative that we possess a secure sense of what problems we might address usefully and which ones we risk medicalising with admirably-intentioned, but ultimately unhelpful, interventions."

Despite the reservations voiced by Moscrop and some other physicians, many people continue to take a medicalized view of addiction – even in addictions, such as gambling, that tend to take place outside the purview of the traditional provinces of medicine. This is true not only of physicians themselves, who may in fact be more sensitive than most to the limits of medical interventions, but of the broader culture. Why is this?

One reason, I believe, is a limited sense of the available alternatives. Medical approaches to addiction have displaced more legal and indeed criminal approaches to the treatment of addiction, though this process is still incomplete in many places. And if our only alternative to a medical approach to addiction is a criminal one, then we should take it. Even if a hospital or a primary care office is not the ideal setting for the treatment of a gambling addiction, it is certainly much better than a jail.

But these are not our only alternatives. I argue that addiction is a disability, and – like disabilities generally – it should not be presumed to be a defect that needs to be treated or managed by physicians, though disabilities have often been seen that way in the past, and in many places still are. Rather, people with disabilities are different, and may want to avail themselves of medical interventions, but may also rationally choose to decline them. So too, I want to say, for addiction.

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This does not mean addiction should be treated criminally, any more that we think disabilities call for criminal sanction (which, of course, they do not). Rather, it calls us to articulate a third alternative, on which addiction is to be approached neither through the criminal law, nor primarily through medicine, but through politics. People with addictions are a class of people, with certain interests, and what is needed, I think, is that their interests be fairly represented in the political process. Physicians will have a role in this process, but not an authoritative one. Rather, it is addicted people themselves who must have the final say.