The “disease model”, the modern concept of disease, developed alongside enlightenment and the science revolution through the 19th century. One of its components is the absolution from moral responsibility. This means, for example, that one is not held morally responsible for developing the affliction of lung cancer, notwithstanding the fact that twenty years of smoking may be an etiological factor. Similarly we do not hold people morally responsible for developing the disease schizophrenia. It is an affliction unwished for, unwanted, and it has nothing to do with the moral character of the sufferer. And once the disease begins, it is not within the power of the sufferer to stop the disease.
The “medical model” is short-hand for a definable relationship between a doctor and a patient. The responsibilities and privileges of each participant in this relationship are both traditional and defined in codes of ethics. One aspect of this relationship is responsibility. The patient’s responsibility is to do his or her best to get well and follow the prescriptions and proscriptions of the doctor. The doctor’s responsibility is to do his or her utmost to treat the patient’s illness and alleviate suffering. This model, this way of understanding the relationship between healer and sufferer, is age old, and predates science.
Can we apply these two models to addictions, the same way we can and should apply them to cancer and schizophrenia?
There is little argument about the second, the medical model. In its assignment of primary responsibility to the physician (as described above), the medical model always fails when it comes to addictions. When the doctor assumes the same level of responsibility for his or her patient’s alcoholism or heroin addiction as he or she does with pneumonia, cancer, and schizophrenia, trouble ensues. Usually, in fact, we physicians find ourselves contributing to a poly substance addiction. In fact, one can safely say that a major component of any addiction is the sufferer’s failure to assume personal responsibility for his own behavior. An understanding of this is built into the tenets of AA, and most addiction treatment programs. It is, ultimately, unlike with schizophrenia and cancer, the sufferer’s responsibility to stop reaching for that bottle or pipe.
Addicts suffer and we need to help and develop programs for them. But a full frontal medical model does no good.
What about the disease model? A cancer or schizophrenia sufferer cannot stop his illness by simply doing something or simply not doing something. An addict or alcoholic can, though to do so he or she may need extraordinary courage and a willingness to tolerate a lengthy period of physical and mental pain. We should help him find this courage and we should ameliorate his suffering and we should always consider reduction of harm (e.g. safe injection sites). But we cannot and should not assume responsibility for the actual act of his drinking, smoking, swallowing, or injecting.
Inebriation, intoxication, alcoholism, and addiction, do not qualify, under our law, our science or our folk wisdom, for “not criminally responsible due to mental illness.”