Alcoholism as a disease: a bad call?
Santa Barbara, Calif.
HIGH in the hills here overlooking one of the nation's jeweled cities lives a mild-mannered academic with some explosive ideas. Herbert Fingarette is at the forefront of a social counterrevolution that could redefine how the United States views alcoholics and alcoholism.
Dr. Fingarette, a University of California philosopher, has served as a consultant on this subject to the World Health Organization and has written scores of articles and several books challenging popular premises about alcohol consumption.
His latest work, ``Heavy Drinking: The Myth of Alcoholism as a Disease,'' (University of California Press) is provoking widespread debate, including negative reaction among mental health experts. The American Medical Association, among others, has long held that an alcoholic has no primary control over his actions and should not be held personally responsible for his drinking.
Fingarette takes an opposite view. He says there is no solid scientific basis or hard medical evidence that alcoholism is totally involuntary. ``And the disease idea is counterproductive,'' he insists. ``It says that you are helpless - you can't control yourself. You are never cured.''
Fingarette criticizes both health care interests and the liquor industry for capitalizing on the disease concept.
He says the former lean toward a ``medicalization of all our problems.''
``There is a persistent trend to translate what is a social problem into a medical problem - whether it be alcoholism, drugs, crime, or overeating'' he insists. ``People are receptive to scientific [medical] fixes.''
Fingarette also points out that alcohol rehabilitation programs command billions of dollars in public monies and that the ``disease theory'' works to the advantage of medical and health care professionals who ``want to expand their authority and expertise'' in this area.
``It is money,'' he explains. ``But it is also commitment of people in the profession to their own fields.''
``Surgeons want to operate. So they tend to operate,'' Fingarette says by way of example. ``Once medical people get established, and personally involved, in an area such as alcoholism, they look for ways to make it [their agenda] work,'' he says.
Fingarette adds that ``powerful lobbies'' like the American Medical Association propose programs on the theory that they are ``good for the public.''
``But, in fact, they may mislead the public,'' he says - referring directly to the idea that alcoholism is a disease.
``Disease is a key word in getting grants. If a proposal is `health-related,' you get money.''
The philosophy professor says he is heartened by a recent US Supreme Court decision (Traynor v. Turnage) in which the justices upheld a Veterans Administration policy classifying alcoholism as ``willful misconduct.'' This ruling denies certain veterans - with drinking problems - education benefits and disability payments.
The high court, however, circumvented resolving the core controversy in this case: whether alcoholism is a disease with physical and possibly genetic origins.
Medical and health care groups had testified on behalf of benefits for veterans ``disabled'' by alcoholism, arguing that for nearly 30 years ``there has been a consensus in the medical profession ... that such pathological use of alcohol is a disease.''
However, Associate Justice Byron White, writing for a 4-to-3 majority of the court, said: ``Even among those who consider alcoholism as a `disease' to which its victims are genetically predisposed, the consumption of alcohol is not regarded as wholly involuntary.''
Fingarette points out that the justices based much of their reasoning on ``seven pages'' of a Harvard Law Review article that he originally published in l970 indicating that alcoholics have some control over their drinking.
The professor stresses that he has no desire to ``bash'' health care and medical professions over their approaches to alcoholism. He also sees little purpose in taking a hard-line stance with heavy drinkers.
``We can be compassionate and helpful ... but not by saying `You have no responsibility for your addiction,''' he adds.
Fingarette insists that there is strong evidence that heavy drinkers can be successful in controlling their alcohol consumption - or stopping it completely.
``All the newer approaches emphasize that the drinker must accept responsibility and play an active role in bringing about the desired change,'' he writes.
``No longer is the heavy drinker viewed as a victim of disease, a passive patient who will be treated by an expert.''
``In contrast with the disease model and its emphasis on the uncontrollable ... self-control theorists have emphasized that the individual is capable of exercising control and assuming responsibility.''
Fingarette further stresses that a perspective on drinking as a way of life that can be altered - rather than a faceless disease - opens up new avenues for educational, legal, economic, and political action that could discourage harmful alcohol abuse.
He suggests that a combination of state and federal measures increasing liquor taxes, reducing outlets for selling alcohol, and mandating earlier closing times for taverns could have a significant effect on consumption.
Fingarette notes the potential value of broad educational advertising and public information campaigns to ``change society's drinking customs and attitudes.''
He would also encourage strengthening laws that hold bartenders and hosts at private parties legally liable for accidents resulting from overconsumption of alcohol.
In the end, however, he stresses that it comes down to individual responsibility and the willingness of heavy drinkers to view themselves not as helpless victims of a disease but as individuals capable of taking charge of their own lives.