Peg O’Connor:

A little logic is helpful here, since the “choice or disease” question rests on a false dilemma. This fallacy posits that only two options exist. Since there are only two options, they must be mutually exclusive. If we think, however, of addiction as involving both choice and disease, our outlook is likely to become more nuanced. For instance, the progression of many medical diseases is affected by the choices that individuals make. A patient who knows he has chronic obstructive pulmonary disease and refuses to wear a respirator or at least a mask while using noxious chemicals is making a choice that exacerbates his condition. A person who knows he meets the D.S.M.-IV criteria for chemical abuse, and that abuse is often the precursor to dependency, and still continues to use drugs, is making a choice, and thus bears responsibility for it.

Linking choice and responsibility is right in many ways, so long as we acknowledge that choice can be constrained in ways other than by force or overt coercion. There is no doubt that the choices of people progressing to addiction are constrained; compulsion and impulsiveness constrain choices. Many addicts will say that they choose to take that first drink or drug and that once they start they cannot stop. A classic binge drinker is a prime example; his choices are constrained with the first drink. He both has and does not have a choice. (That moment before the first drink or drug is what the philosopher Owen Flanagan describes as a “zone of control.”) But he still bears some degree of responsibility to others and to himself.

The complexity of each person’s experience with addiction should caution us to avoid false quandaries, like the one that requires us to define addiction as either disease or choice, and to adopt more nuanced conceptions. Addicts are neither hijackers nor victims. It is time to retire this analogy.

Maia Szalavitz:

1. “Once an addict, always an addict.” This statement resonates with people in 12-step recovery, where the problem is generally experienced as a chronic, relapsing disorder. However, research that follows heavy drinkers and drug users over time finds that a majority of people who, at some point, met the criteria used to define addiction no longer do so later in life—and that most have recovered without attending meetings or treatment.

Even more contrary to “in the rooms” beliefs, many of these people resolved their problem through moderation rather than abstinence. For example, some former heroin addicts drink alcohol without risk of becoming drunks; others smoke marijuana from time to time.

While this contradiction of the “once an addict…” truism might be answered by saying that people who recover on their own—without treatment or through moderation—weren’t “real addicts” in the first place, unfortunately, the course of any particular person’s addiction and recovery is entirely unpredictable. Some people who seem “farthest gone” turn around completely without help, while others whose problem seems less severe never get better. Although greater severity of addiction is linked with reduced ability to successfully moderate, the correlation is far from absolute.