Mental health law expert Richard J. Bonnie, L.L.B., would largely agree with the National Institute on Drug Abuse’s (NIDA) recent campaign to characterize addiction as a "brain disease like any other chronic medical disorder, with intermittent periods of remission and relapse." Bonnie has significant concerns, however, about the implications underlying the statement.

"The emphasis on involuntariness of addiction simply bristles with implications for legal responsibility," Bonnie told attendees at APA’s 52nd Institute on Psychiatric Services in Philadelphia in October.

Bonnie, the John S. Battle Professor of Law at the University of Virginia School of Law and an advisor to APA’s Council on Psychiatry and Law since 1979, offered his assessment of the issue during his institute lecture, "Addiction and Responsibility."

Bonnie challenged the notion that "addiction is a brain disease," stating that it is more a political statement or rhetorical tool in a debate on public policy on addiction treatment than it is a scientifically sound model. "Scientifically," Bonnie said, "the claim is both incomplete and premature."

It is incomplete, he argued, because it fails to communicate the entire story of behavioral and contextual or environmental components that influence addiction. It is premature, he added, because research has not yet "connected the dots" between the observed changes in the brain and the behavior associated with addiction.

The "medicalization of addiction," Bonnie said, was meant to negate the common belief that addiction derives from some sort of moral weakness or character flaw, a notion that had led to widespread stigmatization and punishment of those who were addicted.

Presumably, said Bonnie, people should not be held morally or legally accountable for behavior that is involuntarily associated with addiction. However, the addict has the experience of making choices, Bonnie said. "Such cases involve hard choices, but not no choice. People who are aware of their increased vulnerability [to drugs of abuse] might choose to behave in a way to reduce the risk of addiction or, conversely, knowingly take that risk."

According to Bonnie, addiction is just like any other medical disorder in which a patient has choices to make regarding the outcome of his or her disease process. Think about a similar circumstance, Bonnie told his audience: A diabetic who chooses not to follow the prescribed medication regimen, for example, and ends up going into a diabetic stupor while driving. The resulting car accident that the patient causes kills three people. Would the law excuse the behavior of the person because of the diabetic process, Bonnie asked?

No, he answered, and the same should be true in dealing with addiction. "Specialists in addiction should not assume that the concepts of disease and choice are incompatible." Clinically, addiction specialists address impairment of volition, not involuntary behavior. "This important conceptual point is needed to connect the scientific and clinical ideas about addiction to the legal principles of responsibility," said Bonnie.

He challenged addiction specialists to think about "involuntariness" in three different ways with their patients. First, in what sense is their drug use involuntary? Second, in what sense is the occurrence of a relapse involuntary for an addicted individual who has been sober for some time? And third, in what sense is the process of becoming an addict involuntary? All three of these, said Bonnie, are very difficult questions to answer, but the answers are critical to assessing the element of legal responsibility.

Bonnie does not think that the "addiction is a brain disease" model is all bad. "It is useful in many ways," he said. "It promotes continued investment in biomedical addiction research, which can reasonably be expected to yield pharmaceutical advances. It lends legitimacy to the struggle of addicts with their disease process. And it lends itself to the development of standardized, best-practice treatment guidelines."

What must not happen, argued Bonnie, is for addicts to be legally absolved of responsibility for their own behavior, such as through an "insanity" defense. That, said Bonnie, would be a legal as well as a clinical abuse of the model.