Beliefs about the cause or causes of alcoholism and the nature of drinking problems exert an important influence on public perceptions, institutional responses, and treatment and prevention, and shape the framework that guides ethical inquiry and response.
The disease concept of alcoholism, first articulated by Elvin M. Jellinek in the 1940s, was actively promoted by a loose coalition of reformers, service providers, and recovering alcoholics. Since then, it has become the official view of the American medical profession and the World Health Organization (WHO), and has gained wide acceptance among the public at large in the United States and many other Western countries. Proponents of the disease concept argue that alcoholism, like diabetes, essential hypertension, and coronary artery disease, is a biologically based disease precipitated by environmental factors and manifested in an irreversible pattern of compulsive, pathological drinking behavior in individuals who are constitutionally vulnerable. Central to the disease model is the belief that the alcoholic effectively loses control over his or her consumption of alcohol and can never safely drink again. The disease model also holds that alcoholism is a progressive disease that may be arrested by abstinence but never cured.
Although subsequent research has provided evidence of a genetic predisposition for some types of alcoholism (Goodwin), attempts to demonstrate empirically a biological basis for alcoholism have yielded inconclusive results. Whatever influence genetics and biology have in the pathogenesis of alcoholism, many authorities agree that psychosocial variables are of equal importance to the onset and course of drinking problems. The current consensus among researchers and scholars is that alcoholism is a complex biopsychosocial disorder in which multiple factors play a role.
Critics of the disease concept argue that empirical research has failed to support its basic tenets. Herbert Fingarette refers to the disease concept as a myth, asserting that "almost everything that the American public believes to be the scientific truth about alcoholism is false" (p. 1). Reviewing research, Fingarette challenges the following tenets of the disease concept of alcoholism: (1) irresistible craving and loss of control after the first drink; (2) inevitable progression; and (3) the impossibility of a return to controlled drinking. More specifically, he cites studies that show alcoholics do not always experience craving and retain a considerable degree of volition in their actual drinking behavior (Mello and Mendelson); epidemiological studies that suggest patterns of alcohol abuse are highly variable and may spontaneously remit without intervention (Cahalan and Room); and, finally, evidence that at least some alcoholics have successfully returned to more moderate drinking (Davies; Polich et al.).
Arguing that the disease concept is pseudoscientific, Fingarette and other critics (Peele, 1989) imply that by lending the legitimizing mantle of medical science to the disease concept—at least as it is currently formulated— proponents deprive the public of accurate information that forms the necessary basis for informed consent regarding treatment. Others (Vaillant), while conceding that alcoholism is not a disease in the strict medical sense, continue to defend the disease model; they argue that its value in destigmatizing alcoholism and legitimizing treatment outweighs issues of epistemological rigor.
The modern disease concept emerged and gained acceptance primarily in response to humanitarian concerns rather than on the basis of scientific evidence. Eager to undo the religious underpinnings and moralistic legacy of the
American temperance movement and prohibition, advocates of the disease concept correctly perceived its ability to recast the alcoholic as sick rather than as morally deviant. If the alcoholic is unable to control self-destructive drinking because of an incurable illness, then he or she deserves compassion and treatment rather than blame. Paradoxically, the attempt to reconceive alcoholism in medical rather than moral terms can be seen as fulfilling a moral agenda, that is, a desire to help rather than condemn the problem drinker. This ethical stance can be seen, in turn, as part of a broader movement in modern society to destigmatize deviant behavior of all types by promoting understanding and compassionate intervention. Thus, much of the controversy surrounding the disease model arises out of a tacit conflict between scientific and moral agendas, a confounding of facts and values in society's response to alcohol.
Anthropology offers a possible semantic solution to the disease controversy by distinguishing between illness and disease (Chrisman). Whereas diseases are defined by objective scientific criteria, social anthropologists view illnesses as cultural constructions defined by subjective distress, loss of normal social functioning, and adoption of the sick role. Within these terms, alcoholism can be seen as a culturally defined illness or folk disease for which society has sanctioned the sick role and compassionate intervention.
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