What are the benefits and problems that attend the use of alcoholic beverages? In what ways may drinking cause harm? Is the use of alcohol hazardous for all individuals or only for some? Who is at risk? Should an intoxicated person be held accountable for his or her actions while "under the influence"? How is excessive drinking like or unlike other self-injurious appetitive behaviors such as overeating, smoking, or other substance abuse? Should society limit or control the use of alcohol, and should it warn consumers of potential risks associated with drinking? Is alcoholism a disease, primarily a medical rather than a moral problem? Is alcoholism an illness.
Opinion remains divided on many of these issues, reflecting the diversity of beliefs, practices, and emotions surrounding the use of beverage alcohol in various cultures. Historical and cross-cultural investigations indicate that prevailing cultural beliefs about alcohol and alcohol problems play an important role in determining moral attitudes. Research continues to generate new data about the biomedical and behavioral aspects of drinking. An informed consideration of the use of alcohol must attend simultaneously to the implications of new information and the influence of shifting values.
Alcohol: Blessing or Curse?
A product of natural fermentation, beverage alcohol, or ethanol, is perhaps the oldest known and most universally consumed psychoactive substance. Ancient peoples drank copious amounts of wine, beer, and other naturally fermented alcoholic beverages, praising their ability to lift the spirits, relieve fatigue, and enhance health. In many societies, alcohol was regarded as a divine gift and was incorporated into religious rituals. Early historical records indicate, however, that alcohol also brought problems. The Hebrew Bible, for example, tells how Noah embarrassed his sons by getting drunk (Gen. 9:20–24) and warns of calamity for "those who tarry long over wine" (Prov. 23:29–35).
Ambivalence toward alcohol use has persisted into modern times and is expressed cross-culturally in a wide diversity of attitudes, beliefs, and practices. The French, for example, regard wine as essential to their diet and lifestyle, and tend to view abstainers as deviant. Millions of Muslims, by contrast, forswear all alcohol as evil. Even within a particular society, attitudes may be heterogeneous and historically variable. Seventeenth-century colonial settlers in North America, for example, viewed drink as the Good Creature of God, three centuries later, the United States banned Demon Rum (Rorabaugh).
Empirical evidence suggests that the use of alcohol offers both modest benefits and significant hazards. In moderate amounts, alcohol is a mild relaxant that stimulates appetite and facilitates social interaction. Sociocultural norms play an important role in determining specific contexts in which drinking may normally occur and influence the experience and behavior of the drinker as well. Aside from alcohol's subjective benefits, there is evidence that moderate drinking may reduce the risk of coronary artery disease in some individuals (Klatsky).
Hazards of Alcohol Use
The potential social and economic costs of alcohol use to society can be staggering. In the United States alone, it is estimated that abuse of alcohol cost $136.3 billion in 1990 for alcohol-related diseases, accidents, lost productivity, and rehabilitation (Harwood et al.). Three aspects of alcohol use may present problems: drinking itself, acute intoxication, and chronic heavy drinking, commonly referred to as alcoholism.
Ethanol is a simple yet highly toxic molecule that is rapidly absorbed throughout the body and brain. While moderate consumption of alcohol (no more than two drinks per day) does not appear to pose significant health risks for most individuals, there are some populations for whom even moderate drinking may be ill-advised. Specifically, there is evidence that drinking by pregnant women may expose the fetus to serious risk of a number of permanent morphological and cognitive defects collectively known as fetal alcohol syndrome (FAS) (U.S. Department of Health and Human Services). The relatively recent discovery of FAS (and its milder form, fetal alcohol effects [FAE]) has raised vexing ethical questions concerning the moral and legal culpability of women who drink during pregnancy. Acknowledging society's duty to warn consumers about this previously unrecognized hazard, the U.S. government passed legislation in 1988 that requires manufacturers, bottlers, and importers of alcoholic beverages to include a surgeon general's health warning on all containers.
Acute intoxication and chronic heavy use of alcohol pose the greatest hazards and raise the most pressing ethical concerns. Acute intoxication directly impairs a range of perceptual and motor functions, thereby increasing the risk of accidental injury and death by motor vehicle accidents, falls, slips, drownings, and other mishaps. The risk of serious accidental injury is greatly increased in modern technological societies, where alertness is required to safely operate heavy machinery and high-powered vehicles. In recent years, there has been a growing movement in many countries to reduce alcohol-related automobile injuries and fatalities through tougher laws and preventive education aimed at deterring drunk driving. The late twentieth-century legal consensus appears to be that while intoxication undoubtedly affects judgment and competence, the drunk driver should be held accountable for the decision to drive while impaired. Doubts about the ability of some individuals to make this choice when drinking is reflected in the enactment of new laws that hold bartenders, party hosts, and other servers of alcoholic beverages responsible for monitoring consumption and refusing drinks to inebriated individuals.
Intoxication may also lead to harm through its apparent ability to break down inhibitions on sexual and aggressive impulses in some individuals. In the United States, for example, alcohol intoxication has been strongly associated with assault, murder, rape, spousal violence, and other types of violence. It has not been established that intoxication itself is the direct cause of these outcomes, since in some societies drinking and intoxication are not commonly associated with such violence. Personality variables and culturally influenced expectations regarding intoxication may be important in mediating the relationship between alcohol and violence (Anglin).
In addition to the problems directly related to episodes of acute alcohol intoxication, there is widespread recognition of the harm caused by chronic excessive drinking, commonly referred to as alcoholism. At sufficient doses, the daily or frequent drinker may experience increased tolerance and, eventually, physiological dependence and withdrawal symptoms. Prolonged heavy drinking is implicated in a number of serious and potentially fatal health problems, including cirrhosis, pancreatitis, peptic ulcer, hypertension and cardiovascular disease, and various cancers. Moreover, both the central and the peripheral nervous systems are damaged by chronic alcohol abuse. In addition to well-known complications such as peripheral neuropathy, ataxia, and alcohol-related dementias, researchers have discovered more subtle cognitive deficits resulting from chronic alcoholism (Tarter et al.).
Epidemiological studies indicate that about one person in ten in the United States is a problem drinker. The persistence of excessive drinking in the face of adverse consequences is the primary criterion in the diagnosis of alcohol abuse, alcohol dependence is diagnosed if tolerance and withdrawal symptoms have developed. Sex, age, and ethnicity are significant variables in the distribution of problem drinking. Men are at least four times as likely to be diagnosed with alcohol dependence as women. D.W.I.related accidents and fatalities are most frequent among the young. In some ethnic groups, such as Chinese Americans and Orthodox Jews, alcohol problems are rare, while in certain Native American tribes alcoholism is a leading cause of death.
Alcoholism is associated with an increased prevalence of psychiatric disorders, although symptoms of anxiety and depression may often abate following detoxification and a period of abstinence. Whether alcoholism is a cause or a consequence of other mental disorders continues to be debated. An important longitudinal study challenges the view that alcoholism is but a symptom of preexisting emotional problems with the finding that the mental health of nonalcoholics and future alcoholics does not differ significantly in childhood (Vaillant).
Is Alcoholism a Disease?
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.
Is alcoholism really an illness
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.
The Role of Alcoholics Anonymous
Despite the widespread acceptance of the disease concept, the leading approach to overcoming alcoholism in the United States is, ironically, not a medical treatment but a self-help program based on principles of moral and spiritual renewal. Founded in 1935 by Bill Wilson, an alcoholic stockbroker, Alcoholics Anonymous (AA) borrowed many of its ideas from an evangelical Christian movement known as the Oxford Group. Though it embraces the disease concept as part of its holistic view of alcoholism as a threefold illness (physical, mental, and spiritual), AA's primary emphasis is on achieving sobriety through a process of moral-spiritual renewal as set forth in the Twelve Steps. Central to AA's approach is the alcoholic's decision to abstain from alcohol "one day at a time." Believing alcoholism to be a disease that may be arrested but never cured, AA views "recovery" as a lifelong process requiring constant vigilance and regular attendance at meetings where members "share their experience, strength, and hope." The Twelve Steps encourage AA's members to admit their faults, make amends to those they have hurt, and help other alcoholics achieve sobriety. Members are also encouraged to select sponsors, experienced AA members who are available for advice and support.
How effective is AA? AA's membership, estimated at1.5 million worldwide (General Service Office), provides impressive evidence of its success in reaching problem drinkers. However, the overwhelming majority of alcoholics remain untreated. Of those who are exposed to AA, many drop out, those who remain may constitute a self-selected group receptive to its message and style. Moreover, because of the methodological difficulties of conducting research on a self-help group of anonymous individuals, few controlled studies exist on AA's effectiveness compared with other treatment approaches (Ogborne and Glaser). Nonetheless, AA has come to exercise a pervasive influence over both inpatient and outpatient treatment programs in the United States, where the primary goal is often to motivate the alcoholic to participate in AA.
Advocates of AA's approach to treatment have been accused of intolerance toward alternative approaches, especially behavior modification therapies that pursue the goal of controlled drinking rather than total abstinence. Despite evidence that not all problem drinking follows a progressive, deteriorating course and that some problem drinkers are able to return to more moderate patterns of consumption, controlled drinking advocates have been criticized as irresponsible for even suggesting an alternative to abstinence (Pendery et al.). AA's success presents a curious dilemma for researchers and clinicians: The very elements that may contribute to its effectiveness as a self-help group—simple beliefs, group loyalty and cohesiveness, and an emphasis on personal experience and testimony—leave it resistant to outside influence and to new information that appears to contradict its core assumptions (Galanter). The employment of large numbers of recovering alcoholics as counselors and administrators in alcohol treatment programs has further complicated the situation as personal loyalty to AA's "one disease, one treatment" approach has come into conflict with the more empirically based, eclectic approach of researchers and of clinicians trained in the mental-health professions. The difficulty of reconciling these two orientations finds expression in a growing trend toward dual diagnosis in which alcoholics are assigned an additional psychiatric diagnosis and treated with medication. Wary of all drugs as potentially addictive, many AA-based paraprofessionals have been uneasy with psychiatric diagnosis and medication, in turn, mental-health professionals have viewed alcoholism counselors as insufficiently aware of psychiatric disorders and treatments. Such tensions point to fundamental differences in the assumptive frameworks that each group brings to diagnosis and treatment.
The first of AA's Twelve Steps declares that the alcoholic is powerless over alcohol and must therefore surrender to a "higher power." Believing this to be a self-defeating prescription for helplessness and relapse in the face of a needlessly mystified "disease," Stanton Peele has argued for restoring an explicitly moral model of alcoholism and other addictions that emphasizes the alcoholic's ability rationally to choose sobriety and commit to new values (Peele, 1988). Advocates of AA's approach argue, however, that this is precisely what AA accomplishes: a daily commitment to abstinence and "a new way of life." That alcoholics may regain a sense of control by admitting powerlessness, they say, may simply reflect a spiritual paradox rather than a contradiction.
Medicalization of alcohol problems has yet to resolve the question of what causes alcoholism or to provide satisfactory solutions to the moral problems posed by the use and misuse of alcohol. Motivated by the desire to destigmatize alcoholism in order to promote compassionate treatment, the disease model still has not adequately disposed of the issue of personal responsibility. The drinker makes choices, but these choices are significantly influenced by biological, psychological, and sociocultural forces beyond conscious control. An important element of AA's success may be that it embraces both aspects of this duality: It holds that alcoholics do not choose their condition—they are subject to multiple systemic forces beyond their awareness—yet, with support, they can effectively assume responsibility for their problem and choose to abstain. Meaningful ethical inquiry must embrace both poles of this duality by recognizing the complex interplay of personal choice with the many factors that may influence or limit it.
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