Glucose metabolism in orbitofrontal cortex (OFC) in healthy (left) and cocaine-addicted (right) subject.The recent death of Phillip Seymour Hoffman as a result of drug addiction has provoked many thoughtful, sympathetic responses in the media, from people in recovery who understand how hard it is to wrestle with addiction, as well as from scientifically informed journalists who understand that addiction is a disease. But it has also prompted others to express the age-old notion than drug use is a choice, and that those who die as a consequence of their drug use are just reaping the consequences of their freely chosen actions. It is unfortunate that that view persists in our society, despite the decades of scientific research soundly disproving it.
Choices do not happen without a brain—it is the mechanism of choice. The quality of a person’s choices depends on the health of that mechanism. However much we may wish that a person’s choices were free in all instances, it is simply a fact that an addicted person’s failures in the realm of choice are the product of a brain that has become greatly compromised—it is readily apparent when we scan their brains. Even if taking a drug for the first time is a “free” choice, the progression of brain changes that occurs after that involves the weakening of circuits in the prefrontal cortex and elsewhere that are necessary for exerting self-control and resisting the temptations of drug use. Once addiction takes hold, there is greatly diminished capacity, on one’s own, to stop using. This is why psychiatry recognizes addiction as a disease of the brain, and why professional intervention is needed to treat it in most instances.
Moreover, even the “freely willed” first choice to take a drug cannot be the basis for judgment and stigma against people suffering from addictions. Matters of choice and lifestyle—what you eat, how active you are, where you live—may contribute to the risk for, or even directly cause, a wide range of medical conditions, including chronic diseases like heart disease, type 2 diabetes, and several cancers. We do not withhold or impede treatment of people suffering from those conditions, even if their health may have turned out differently had they made different choices at various points in their lives.
There is no way of precisely predicting which freely chosen adolescent drink, or cigarette, or experimentation with an illegal substance, opened the door to a later loss of free-choice capacity in a person who has become addicted. But once addiction is established, the sufferer from this disease cannot will themselves to be healthy and avoid drugs any more than a person with heart disease can will their heart back to perfect functioning, or a person with diabetes can will their body’s insulin response to return to normal.
Thus, those who say “it was their own choice” after a person dies of an overdose fail to grasp that an addicted person’s brain has a disrupted choice mechanism. And as revealed by Hoffman’s tragic, ultimately fatal relapse into drug taking, the neuronal disruptions in the brain of an addicted person can persist even after decades of sobriety. Speaking of “free choice” is simply not useful when trying to understand an individual’s addiction or its consequences, as addiction is precisely a disease that disrupts the neuronal circuits that enable us to exert free choice.