Schaler, J.A. (1988, October 25). Alcoholism is not a disease.
The Washington Post, Letters to the Editor, p. A26.
It is unfortunate that the House of Representatives recently voted to overrule a Veterans Administration policy calling alcoholism ''willful misconduct'' [''House Votes to Restore Benefits to Alcoholic Veterans,'' Oct. 18]. Contrary to the claim that this is an important victory for all recovering alcoholics, it is first and foremost a victory for the alcoholism treatment industry and a defeat for scientific medicine.
Ironically, on April 20, 1988, the U.S. Supreme Court agreed with the bible of Alcoholics Anonymous (AA). AA is one of the strongest proponents of the disease model of alcoholism. The court upheld the authority of the VA to define alcoholism as the result of ''willful misconduct.'' And as The Big Book says: ... the main problem of the alcoholic centers in his mind rather than in his body."
Although Justice Byron R. White, writing for the majority, said that the court was not deciding ''whether alcoholism is a disease whose course its victims cannot control,'' he also noted that there was ''a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility.''
A person does not will the onset of diabetes, hypertension, the presence of a malignant tumor. Here it would be wrong to assign responsibility for the disease. This is not the case with an alcoholic or drug addict. A person both enters and exits usage through an act of will.
Since the word addiction is defined as a volitional act and the relationship between the mind and the body is unknown, it is inaccurate to state with certainty that alcoholism is a disease. The mind can't be sick.
Many disease model spokespersons are recovered alcoholics and have an emotional investment in viewing themselves as helpless to their own behaviors. A majority of these people are seriously lacking in scientific backgrounds. They say scientific validity ''interferes with the process'' of helping people who need help and claim special qualification to help others.They perceive any challenge to the disease concept as ''a challenge to the validity of their own emotional ordeal and conversion to sobriety.''
The treatment industry also has a substantial economic investment in maintaining the disease concept. As long as alcoholism is considered a disease, medical insurance pays for treating it.
Is the disease model of alcoholism scientific? No. Simply calling behavior a disease process does not make it one, even if doing so assists in creating sobriety. Is the treatment policy based on bad science? Yes. Is there any chance that this attitude will change in the near future? Bloody unlikely.
JEFFREY A. SCHALER
The writer was chairman of the Montgomery County Drug Abuse Advisory Council.
Responses to the above letter by Schaler as published in The Washington Post: November 5, 1988, Saturday, Final Edition
SECTION: EDITORIAL; PAGE A21; FREE FOR ALL HEADLINE: Alcoholism Most Certainly Is a Disease
Jeffrey A. Schaler's letter ["Alcoholism Is Not a Disease," Oct. 25] raises important questions about the convergence of illness, behavior and personal choice in alcoholism, but his biases distort his conclusions.
For some 90 percent of adults who drink, the behavior is voluntary. They often find it hard to understand that for one in 10 persons, alcohol can be fatally attractive.
We are only beginning to unravel the reasons why, for a small minority even a single, first exposure to alcohol shifts the odds in favor of severe behavioral and medical outcomes. Yet our limited understanding of the causes does not negate the fact that alcoholism meets the accepted criteria of medical disease -- an identifiable cluster of symptoms that predict a particular course and outcome.
In making his case against alcoholism as a disease, Schaler asserts that "the mind cannot be sick." In doing so, he goes against 20 years of brain research. His position reflects outdated notions that mental and addictive disorders stem from human failings. Yet the evidence now is that these disorders involve brain mechanisms gone awry.
In manic-depressive illness, for example, lithium virtually eliminates the behavioral and psychological disturbances associated with a chemical abnormality in the brain. Moreover, a specific gene has been identified that leads to manic-depressive illness. Scientific evidence also attests to the presence of specific brain disturbances in schizophrenia, the mental illness that accounts for more than one-third of the nation's homeless.
We possess considerable evidence that alcoholism, too, meets the criteria of disease and that biological factors are involved. Animal studies have shown that alcohol-seeking behavior is highly genetic, even while being influenced by the environment. As with all illnesses caused by behavior -- for example, smoking leading to lung cancer -- biology and free will interact in the onset of alcoholism.
When Schaler says, "A person does not will the onset of diabetes, hypertension [or] the presence of a malignant tumor," he ignores the interaction between will and biology. A person with a family history of diabetes in whom testing shows minor abnormalities in sugar metabolism is a strong candidate for adult-onset diabetes. The biological cards have been dealt. Yet by changing exercise and diet, the at-risk person may reduce the chances of full-blown diabetes.
Schaler is wrong that the alcoholic "both enters and exits usage through an act of will." With the evidence that some types of alcoholism are genetically transmitted, researchers now are making headway in determining how the inherited vulnerability is expressed -- perhaps by a deficiency in some brain chemical that is compensated for by alcohol. In any event, Schaler's opinion notwithstanding, research on the physiology of addiction indicates that once the biological factors gain momentum, more than willpower is needed to reverse the addiction.
For most of us, an interest in good health enables us to choose not to abuse alcohol; for others, parental, moral or civil sanctions do the trick. But where biological vulnerability for destructive drinking exists, we must find ways to enhance the ability of the individual to exercise his will through an informed choice. The individual who is highly vulnerable to alcoholic disease requires that the risks be more clearly drawn, the educational messages more precisely focused and the sanctions more potent.
Finally, Schaler's swipe at the alcoholism treatment sector is wrongly taken. In the United States, treatment costs for alcoholism are approximately $ 15 billion annually. Of this amount, 80 percent, or $ 12 billion, pays for the medical complications of unrecognized or untreated alcohol abuse. Less than 20 percent is billed by the professionals in alcoholism treatment settings who are addressing the primary problem -- the abuse of alcohol.
-- Frederick K. Goodwin, MD is head of the Alcohol, Drug and Mental Health Administration.
-- Enoch Gordis, MD is director of the National Institute on Alcohol Abuse and Alcoholism.
Twenty years ago, I commented on the U.S. Supreme Court's refusal in Powell v. Texas to rule that chronic alcoholism was a disease that ought to be treated as such ["Court and Alcohol," June 28, 1968]. This April, the Supreme Court declined to abandon that position, prompting Jeffrey A. Schaler's letter of approval.
Such attitudes can serve only to postpone adoption of overall, sound policies with respect to one of the nation's major health problems. Nevertheless, as progress in dealing with other old and difficult medical problems has shown, eventual change for the better is probably inevitable. We may find some comfort in looking back on other firmly held but wrong attitudes of the past.
The last execution for witchcraft in England was in 1684, and in 1736 prosecutions for witchcraft were forbidden by Parliament. Nevertheless, the great English jurist William Blackstone said almost 50 years later that "to deny the actual existence of witchcraft and sorcery is flatly to contradict the revealed word of God." And in 1862, a lord chancellor said in regard to insanity and crime that "the introduction of medical theories into the subject has proceeded upon the vicious principle of considering insanity as a disease" (quoted from "Drug Addiction: A Medical Problem").
-- Donald L. Hardison
As a psychiatrist and recovered alcoholic who has been active in AA since 1963, I find it tragic that so many Americans still cannot accept alcoholism as a disease. This, of course, is why it is so poorly handled at every level, including being almost ignored in many medical schools. Doctors in AA call it the 4-2-1 disease: in four years of medical school, two hours are spent learning about our No. 1 disease. How tragic.
Benjamin Rush, father of American psychiatry and signer of the Declaration of Independence, said it was a disease. The AMA classified it as an illness in 1956. As long as our prejudice continues, millions will die, not from alcoholism but from apathy. When will we learn?
-- Leo P. Hennigan, MD
© Copyright Jeffrey A. Schaler, 1997-2002 unless otherwise stated. All rights reserved.