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The ‘brain disease’ idea, drug policy and research ethics

2003; Wiley; Volume: 98; Issue: 7 Linguagem: Inglês

10.1046/j.1360-0443.2003.00454.x

1360-0443

Mark A. R.Kleiman,

Ethics in Clinical Research

The behavior of some people with respect to intoxicants and stimulants of various kinds seems problematic to them. Some but not all of those who complain about their own drug-taking seek professional help or engage in other organized practices in an attempt to get their behavior back under control. Those attempts are notoriously difficult and uncertain of success, at least in part because of the ambivalence of the drug-takers, who despise their habits but love their drugs. Even after apparent success, marked by periods of abstinence from drug-taking, relapse is common, partly due to the persistence of craving, especially cue-conditioned craving. Other people have similar behavior patterns and do not regret them (or do not consciously regret them, or do not admit to regretting them), but complaints come from those around them (families and employers, for example). For lack of a more precise term, call these unwanted patterns of drug-taking 'substance-related disorders', or 'addictions'. Since these problems are behavioral, presumably they are related to states and functions of the brains of those engaging in them. Those states are atypical, more or less persistent, involuntary (in the sense that they cannot be wished out of existence by those affected by them) and unwanted. Since any atypical, persistent, involuntary and unwanted state or function of any tissue or organ can reasonably be called a 'disease', the language is not strained if we call substance-related disorders 'diseases', and since the states in question are states of the brain it is reasonable to call them 'brain diseases'. On the other hand, the language would also accommodate calling them 'bad habits'. Nothing said earlier is specific to bad habits about chemicals, and it is quite possible to be addicted to gambling, for example. But calling a bad habit a brain disease, or even demonstrating the brain states that constitute a bad habit, does not change its moral status or prescribe what to do about it in policy terms. The recognition that some bad habits are so terribly hard to break that they ought to be called 'addictions'does make a moral difference: the less (currently) voluntary a behavior pattern is, the less justifiable it is to punish people for being subject to it. Nevertheless, contingency management can still be, and in fact often is, among the best ways of reducing the frequency of unwanted behavior in the presence of an established habit and its associated cravings, and eventually of reshaping the response pattern itself. Contingency management takes advantage of the fact that even after the craving to use drugs becomes involuntary, actually using on any given occasion remains responsive to the conditions and consequences of doing so. Those moral and practical inferences depend on the relative involuntariness of the condition, not on its embodiment in the brain. Thus, the policy and moral implications of the 'brain disease' idea are much smaller than they first appear. After all, learning is embodied in brain changes; that does not mean that findings from receptor studies or brain imaging research ought to begin to dictate educational practice or policy. As to the problems that the 'brain disease' idea might create for research, they merely reflect deeper problems with the human-subjects protection process. Institutional review boards have begun to play the role of scientific censors. The result is to forbid research to which the subjects themselves have no objection, which a reasonable, well-informed person, acting on behalf of the research subjects, would regard as more likely to help than to harm the subjects, and which might yield useful knowledge. Wayne Hall and colleagues (Hall et al. 2003) have done us all a service by making clear the conceptual and scientific issues involved, and by raising an important warning. But their analysis, no matter how cogent, will probably not suffice to forestall the threat to research they discuss. If the misinterpretation of the 'brain disease' idea is not allowed to block research, some other equally misleading notion will arise to do so instead, unless the scientific community begins to rise up against its new censors, reasserting the values of scientific freedom and of common sense.