Steve Matthews

Pleasure and Addiction

What is the role and value of pleasure in addiction? Foddy and Savulescu (1) have claimed that substance use is just pleasure-oriented behavior. They describe addiction as “strong appetites toward pleasure” and argue that addicts suffer in significant part because of strong social and moral disapproval of lives dominated by pleasure seeking. But such lives, they claim, can be autonomous and rational. The view they offer is largely in line with the choice model and opposed to a disease model of addiction. Foddy and Savulescu are sceptical of self-reports that emphasize the ill effects of addiction such as loss of family and possessions, or that claim an absence of pleasure after tolerance sets in. Such reports they think are shaped by social stigma which makes available a limited set of socially approved addiction narratives. We will not question the claim that a life devoted to pleasure can be autonomously chosen. Nor do we question the claim that the social stigma attached to the use of certain drugs increases the harm suffered by the user. However our interviews with addicts (as philosophers rather than health professionals or peers) reveal a genuinely ambivalent and complex relationship between addiction, value, and pleasure. Our subjects did not shy away from discussing pleasure and its role in use. But though they usually valued the pleasurable properties of substances, and this played that did not mean that they valued an addictive life. Our interviews distinguished changing attitudes towards drug related pleasures across the course of substance use, including diminishing pleasure from use over time and increasing resentment at the effects of substance use on other valued activities. In this paper we consider the implications of what drug users say about pleasure and value over the course of addiction for models of addiction.

Dementia and the power of music therapy

Dementia is now a leading cause of both mortality and morbidity, particularly in western nations, and current projections for rates of dementia suggest this will worsen. More than ever, cost effective and creative non-pharmacological therapies are needed to ensure we have an adequate system of care and supervision. Music therapy is one such measure, yet to date statements of what music therapy is supposed to bring about in ethical terms have been limited to fairly vague and under-developed claims about an improvement in well-being. This article identifies the relevant sense of wellbeing at stake in the question of dementia therapies of this type. In broad terms the idea is that this kind of therapy has a restorative effect on social agency. To the extent that music arouses a person through its rhythms and memory-inducing effects, particularly in communal settings, it may give rise to the recovery of ones narrative agency, and in turn allow for both carer and patient to participate in a more meaningful and mutually engaging social connection.

Stigma and self-stigma in addiction

Addictions are commonly accompanied by a sense of shame or self-stigmatization. Self-stigmatization results from public stigmatization in a process leading to the internalization of the social opprobrium attaching to the negative stereotypes associated with addiction. We offer an account of how this process works in terms of a range of looping effects, and this leads to our main claim that for a significant range of cases public stigma figures in the social construction of addiction. This rests on a social constructivist account in which those affected by public stigmatization internalize its norms. Stigma figures as part-constituent of the dynamic process in which addiction is formed. Our thesis is partly theoretical, partly empirical, as we source our claims about the process of internalization from interviews with people in treatment for substance use problems.

Introduction: Testing and Refining Marc Lewis’s Critique of the Brain Disease Model of Addiction

In this introduction we set out some salient themes that will help structure understanding of a complex set of intersecting issues discussed in this special issue on the work of Marc Lewis: (1) conceptual foundations of the disease model, (2) tolerating the disease model given socio-political environments, and (3) A third wave: refining conceptualization of addiction in the light of Lewis’s model.

SURVIVAL AND SEPARATION

Almost all recent theorists in the philosophy of personal identity over time make causation an essential condition of one’s survival: unless a person-stage is causally connected to one existing at an earlier time, it simply cannot count as a survivor of the earlier one. 1 This is supposed to be the case even if the later person-stage has all of what is required for survival in terms of its mental and physical similarities to the earlier one. Quite some time ago a challenge was put forward to those who give either explicit or tacit support to the causal condition. Kolak and Martin (1987, p. 339) wrote: A curious fact about this near-consensus, a fact which ought to make us deeply suspicious, is that there is in the literature, so far as we know, not a single argument for the causal condition. To my knowledge, no one has yet responded to Kolak and Martin’s challenge; hence the motivation, partly at any rate, for the present paper. The causal condition, I want to claim, is essential to an account of personal identity because inter alia it is essential to a thesis about the individuation of persons, that is, to the separation of different persons. Accounts of personal identity that dispense with causation altogether will lack the resources for individuating persons, and that is a theoretical cost which cannot be tolerated. In testing whether we need a causal condition in personal identity it is possible also to test the limits of what counts as a philosophically defensible view of personal identity. I do so by tampering with the way the causal condition may be built in to one’s favoured continuity account. In particular, I ask to what extent we can minimise use of the causal component in the survival relation before we arrive

The Significance of Habit

Analysis of the concept of habit has been relatively neglected in the contemporary analytic literature. This paper is an attempt to rectify this lack. The strategy begins with a description of some paradigm cases of habit which are used to derive five features as the basis for an explicative definition. It is argued that habits are social, acquired through repetition, enduring, environmentally activated, and automatic. The enduring nature of habits is captured by their being dispositions of a certain sort. This is a realist account of habits insofar as the dispositions put forward must fit into some recognizable underlying system – in the case of humans a biological system – to fill the role as set out by the definition. This role is wide-ranging; in addition to the familiar cases of habitual behavior, habitual activities also include thinking, perceiving, feeling, and willing.

Human vulnerability in medical contexts.

Conceptions of the moral relevance of vulnerability in human life have assumed a deserved prominence in contemporary work in both moral philosophy and political analysis. In the mid-1980s, two important books emerged which had, and continue to have, significant influence within moral and political philosophy and beyond. Those books were Martha Nussbaum’s The Fragility of Goodness [1] and Robert Goodin’s Protecting the Vulnerable: a Reanalysis of our Social Responsibilities [2]. More recently, Catriona Mackenzie, Wendy Rogers, and Susan Dodds edited a collection of essays on this topic in Vulnerability: New Essays in Ethics and Feminist Philosophy [3]. The essays in this special issue of Theoretical Medicine and Bioethics are given context by these important contributions, and can be situated in helpful ways by considering the frameworks set up by them. A key idea in Nussbaum is that it is a condition of the moral life itself, and of being good, that human subjects are vulnerable to having their trust in people, and in things in the world, shattered. Like a plant tended by a gardener, our reliance on another leaves us vulnerable, yet it is the willingness to expose ourselves in this way which allows us to enter into morally important relationships. Indeed, according to this way of thinking, a condition of moral goodness is to be in that state of a permanent possibility of loss. Good people are open and trusting, and must bear up

Lying, narrative, and truth shareability

Mary Jean Walker (2012) argues that the narrative form that self-understanding must take is capable of providing a largely truthful picture of who we are, despite neuropsychological evidence suggesting the contrary. Walker describes three approaches to counter the conclusion of falsity in self-narratives: that some truths are fully intelligible only within a narrative structure; that narratives contain nonfactual content with a significance and meaning otherwise unavailable; and third, and importantly for our purposes, she offers a constraint “on what can count as a correct or good self-narrative . . . to point to ways in which the process of self-narration should be connected to the facts” (70). In this commentary we elaborate on and offer further support to Walker’s claim that “continual intersubjective checking” provides a dynamic and corrective social mechanism for ensuring truth in self-narratives. The importance and ubiquity of the norm of truth-telling is brought into sharp relief when we consider cases of living a lie. (We discuss two such cases at length in Kennett and Matthews [2012].) A spectacular instance of this is the case of Jean-Claude Romand. Romand was completing the second year of a medical degree when he failed to attend a test and then lied that he had passed it. This was the start of a cascading series of extraordinary fabrications in which he told others that he had completed the degree and was practicing as a doctor. His family and friends came to believe Romand was a medical researcher at the World Health Organization (WHO), yet all the while Romand lived a double existence: He spent his time wandering, and would visit the WHO building to consult its free services. He made claims that he was visiting Switzerland on business, but instead would spend his time at the airport studying medical journals. Remarkably, he was able to remain undetected for some 20 years, but finally, at a point when he believed he was about to be unmasked, he killed his family and then (apparently) attempted suicide. Romand was convicted in 1996 and remains in prison. Romand’s case is an extreme example of systematic lying and the double life. Of course, all of us are prone to selfdeception and some of us to confabulation; our point is that it is very plausible that truth-telling in important domains is a norm that does constrain our self-narratives. Despite the cognitive biases Walker surveys that may conceal from us the true causes of some of our actions, we are motivated to give, and succeed for the most part in giving, a truthful account of our actions themselves, both retrospectively and prospectively. We went to work on Saturday, rather than playing golf; we ordered risotto instead of steak; we stud-