GREEN PAPER – What is Moral Distress? Experiences and Responses

1. What is Moral Distress?

The term ‘moral distress’ entered nursing literature in 1984 when Andrew Jameton first described the phenomenon. According to Jameton, moral distress occurs ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (Jameton, 1984: p.6). As we shall see, this brief statement has come in for criticism, led to some confusion, and spurred subsequent attempts at refinement. Our aim in this Green Paper is to present a critical review of discussions of moral distress, propose a phenomenologically grounded analysis of the phenomenon, and sketch an array of possible ways of responding to experiences of moral distress as described.

By way of initial orientation toward the phenomenon, we can begin by following Jameton in contrasting moral distress from the experience of moral dilemmas. When an individual faces a moral dilemma she is confronted with two mutually exclusive courses of action, one of which she must choose but neither of which appears to present decisive moral reasons for action. Moral dilemmas thus present a distinctive challenge that requires a distinctive response: the agent has somehow to make up her mind over a moral matter in the apparent absence of clear guidance. In contrast, Jameton’s description of moral distress focuses attention on those cases in which an individual has already determined for herself what she considers to be the morally correct course of action, only to perceive that she is prevented from undertaking that course of action. Moral distress is thus taken to present a distinctive challenge to those who experience it, since it does not involve a difficultly in making up one’s mind but the difficulty in dealing with one’s perceived inability to undertake the action that one has determined to be best.

Moral distress has been a highly influential concept in nursing literature in the US (Oh & Gastmans 2010), is beginning to see application in discussions of healthcare in the UK (Morley 2016), and has even found application in literature concerning the state of academia (Ganske 2010). The literature on moral distress is, however, subject to a great deal of confusion concerning the meaning of the concept and, therefore, which phenomena are supposed to be under examination. To illustrate the confusion of the concept, we can consider a number of putative examples of ‘moral distress’ presented across several studies. One study invited nurses to define ‘moral distress’ and received the following responses:


“Perhaps (…) [moral distress is] the feeling of discomfort (…) not feeling able to do something or (…) that feeling of leaving work and not being able to do what you should have done, either because of (…) an institutional technical matter or your own technical matter, I think this is what makes me more (…) upset.”


“I think it’s the emotional damage caused (…) by your own perspective in relation to the patient”


“Some sort of negative feeling (…) I think that is what weighs heavily regarding working in the ICU”


“Some situations in which we feel powerless (…) to make some decisions, which leaves you so in the middle of a situation when it is difficult for you to choose what you are going to do.” (Fachini et al.)


Plainly, there is significant variation in how these nurses understand moral distress. For one, it is to be identified with emotional damage caused by the agent’s perspective on the patient; for another, it is a particular sort of situation in which agents feel powerless; for another still, there is some sense of its being a negative feeling, but with little clarity on the precise character of that feeling; and finally the last nurse seems to have in mind a phenomenon closer to a moral dilemma, the phenomenon in contrast to which Jameton described moral distress.

These nurses can hardly be blamed for providing apparently inconsistent definitions of a phenomenon that they have been asked to define on the spot, not least because a lack of clarity on the issue is also to be found within the studies themselves. In the work cited, for example, the authors use ‘moral distress’ to refer also to the experience of complicity with an institution that allocates resources in a way that is perceived to be unjust. In another study, one nurse reports moral distress upon having witnessed ‘personal (dating) relationships between a supervisor and their employees impacting the team’ and another describes a situation in which ‘a patients (sic) brother had died in the same car accident. When the patient asked about him they lied for fear the bad news would impede the patients recovery. Family wanted staff to do likewise’ (Mukherjee et al.).

While each of these situations is surely distressing in its own right, it is not clear that each corresponds to Jameton’s definition or presents a case of the same phenomenon. Witnessing an inappropriate relationship is quite different to perceiving oneself to be prevented from undertaking a course of action that you believe to be morally appropriate. I might, after all, find out that there is something I should and can do about the effect of the relationship on the working environment. In a similar vein, to be asked by a family to lie to a patient seems much closer to an experience of a moral dilemma, rather than a clear-cut case of moral distress, since we can imagine someone in this situation feeling torn between two moral options: fulfilling the wishes of the family and being honest with the patient. The cases presented in the literature, then, do not all conform to Jameton’s initial definition and do not consistently refer to the same phenomenon.

In view of the range of examples of moral distress offered in the literature, some authors have opted for an umbrella definition, designed to encompass all the proposed definitions under one master concept. Campbell, et at. (2016), for example, define moral distress as ‘one or more negative self-directed emotions or attitudes that arise in response to one’s perceived involvement in a situation that one perceives to be morally undesirable’ (p.6). To be sure, this definition covers all of the examples described above. But it is also considerably, indeed indefinitely, broader than Jameton’s initial definition. This is problematic, since instead of drawing our attention to a specific phenomenon, Campbell et al. are suggesting that moral distress should be taken to refer to any situation in which one is involved and which leads to negative self-directed emotions. As Lucia Wocial puts it, the definition offered ‘reduces the experience of moral distress to feeling bad because one is caught in a morally undesirable situation’ (Wocial, p.21).

The confusion over the meaning of moral distress is nothing new; conceptual problems with the definition reach as far back as Jameton’s initial presentation of the phenomenon. As we have seen, Jameton defines moral distress as occurring ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. There are four broad problems with this definition:

  • Firstly, the definition entails that moral distress can only occur in those cases in which individuals have correctly identified the appropriate course of action. This sets the threshold for moral distress unacceptably high, since it excludes those cases in which the individual’s sense of what is morally appropriate is either indeterminate or misguided. There are, however, plausibly many such cases: I might have no clear sense of what I should do but nonetheless feel that I am not acting appropriately, whatever the morally appropriate action turns out to be. Moreover, I might be misguided in my sense of right and wrong, but it would seem moralistic to suppose that I must be immune to the possibility of moral distress simply because I am mistaken in my beliefs.
  • Secondly, the definition entails that it is as a matter of fact ‘nearly impossible’ to act upon one’s understanding of the correct course of action. Once again, the bar is set too high and cases to which we should give consideration are ruled out of hand. It might be, for instance, that there is much that the individual could do, but she simply lacks the time to discover these available possibilities. In such situations, the problem is not that morally appropriate action is objectively nearly impossible but rather that the morally appropriate actions that are in fact available are unseen.
  • Thirdly, the definition as stated makes no reference to the subject’s affective condition. Jameton’s brief statement allows for the possibility that an individual may as a matter of fact be, unbeknownst to herself, in a situation in which it is nearly impossible for her to act on her moral knowledge. On Jameton’s definition, such a person would be in moral distress without feeling any distress at all.
  • Finally, Jameton’s definition draws an essential connection between moral distress and institutional constraints. While moral distress may quite plausibly occur under conditions of great institutional pressure, we should be reluctant to suppose that it could only occur as the result of such conditions. Why should we rule out in advance the possibility that one might feel moral distress in situations made demanding by ‘internal’ issues, such as fear or anxiety, rather than the unjust imposition of institutional constraints? It might be, for example, that I know what I should do and can see a way of doing it, but find myself too afraid to act. In sum, then, there are four problems with this definition:
  1. Epistemic Threshold: It requires the individual to have knowledge of the right course of action;
  2. Objectivity Condition: It requires that it must as a matter of fact be ‘nearly impossible’[1] to pursue a morally appropriate course of action;
  3. Absent Affectivity: It is compatible with the absence of any feelings of distress;
  4. Narrow Aetiology: It is too narrowly focused on cases in which the individual is suffering from institutional constraints.

These problems are often repeated in subsequent attempts to refine Jameton’s definition:

  • Webster and Bayliss, for example, describe moral distress as the objective situation in which one ‘fails to do the right thing (or fails to do it to one’s satisfaction)’ (Webster and Bayliss, 2000). The first half of this definition is subject to the problem of Absent Affectivity sketched above: I might actually be in that situation without being aware of it at all, since I might be unaware of having failed to do the right thing or having failed to do it to my satisfaction. On this definition, then, I could count as being in moral distress without experiencing any actual distress. The second half of the definition seems to miss the mark in another way: it is one thing to fail to do something to your satisfaction, but nonetheless think that your efforts will have to do, and quite another to feel that you have fallen profoundly short of your understanding of morally appropriate action, which appears to be closer to the experience of moral distress.
  • Austin, Rankel, Kagan, and Lemermeye take a step in the right direction by defining moral distress as “the state experienced when moral choices and actions are thwarted by constraints” (Austin et al. 2005 p.197). In contrast to Webster and Bayliss, there is some reference to the subject’s experience of her situation. The definition offered, however, is subject to the second criticism raised above (objectivity condition): to be in a situation of moral distress, on this account, your moral choices or actions must in fact be ‘thwarted’ by the circumstances. The definition thus rules out those cases in which the individual fails to see what possibilities are in fact open to her.
  • Epstein and Delgado claim that ‘moral distress occurs when an individual identifies the ethically appropriate action but feels unable to take that action’ (Epstein & Delgado, 2010). While they make space for the possibility that the agent may be unable to see options that are nonetheless open to her (on their definition, the individual need only feel unable to act), they still require the individual to have identified the actual appropriate course of action: in the abstract of the cited paper, the authors claim that moral distress occurs when the individual knows what she should do. The account offered therefore falls foul of the first problem identified above, that of Epistemic Threshold.
  • Finally, according to the American Association of Critical-Care Nurses’ guide to addressing moral distress, moral distress occurs when either a) ‘you know the ethically appropriate action to take, but you are unable to act upon it’ or b) ‘you act in a manner contrary to your personal professional values’.[2] In the first case, the threshold seems to be too high, in that individuals are required to have knowledge of the morally appropriate course of action (Epistemic Threshold); in the second case, there is no reference at all to the individual’s experience, such that moral distress might occur without any feelings of distress (Absent Affectivity).

In Jameton’s definition, as well as the subsequent attempts at refinement we have just reviewed, then, there are serious conceptual problems which seem to set the bar too high in various respects: each of the definitions fails to make room for a range of plausible cases of moral distress. We submit that many of the problems we have identified above have the same root cause: lack of emphasis on the individual’s fallible understanding of the situation she is in. That is to say, many of the problems arise because the account in question does not recognise that moral distress is primarily a function of how the world appears to the individual, which may be different from how world objectively happens to be. To be sure, the world might appear to be a certain way because it actually is that way. But whether or not a person is in a state of moral distress should not depend on the world actually being as she understands it to be.

This diagnosis allows us to stipulate some desiderata that any convincing account of moral distress will have to meet. Firstly, any account of moral distress should allow for the possibility that the agent either has an indeterminate sense of what she should do or is mistaken in her assessment of the morally appropriate action. In other words, we should not restrict moral distress to those possibly very few cases in which the individual in fact knows what is the right thing to do; it may merely appear to the agent that a course of action that is out of reach is morally appropriate, or she may have a more or less indeterminate sense that something needs to be done, even if she does not know what that is. Secondly, any account of moral distress should allow for the possibility that the individual does not see all the possibilities that are in fact open to her, rather than requiring her to be in a situation that objectively excludes (or nearly excludes) the possibility of doing the right thing. In other words, it is possible that agent who experiences moral distress does not see all the options open to her; in such cases, she feels that she cannot act because she fails to see, perhaps for good reason, what possibilities for action are available to her. Thirdly, any account of moral distress should recognise that the painful feelings that arise in light of the individual’s understanding of her place in the situation are an essential part of the phenomenon. One cannot experience moral distress without feeling bad, and any satisfactory account of moral distress should reflect this. Finally, any account should be broad enough to make room for a wide range of causes for moral distress, so as to avoid arbitrarily restricting focus on a subset of the cases of interest. In summary, any account of moral distress should:

  1. Avoid the Epistemic Threshold by allowing for the agent’s sense of what is morally appropriate to be fairly indeterminate (e.g. she feels that there is something she should do but she is not sure what) or mistaken. Consequently, allow for the agent’s fallibility in assessing which of her available options is morally appropriate
  2. Avoid the Objectivity Constraint by allowing for the agent’s fallibility in assessing all options open to her.
  3. Avoid the problem of Absent Affectivity by making essential reference to the agent’s feelings of distress in light of her understanding of the situation and her place in it.
  4. Avoid Narrow Aetiology by refusing to arbitrarily restrict focus on cases with a specific causal profile (e.g. institutional constraints).

In the next section, we shall turn to some testimonials of experiences of moral distress to help us refine an account that can meet these desiderata. Before we do so, however, we can add one further constraint that our account should be able to meet.

As we have seen, some definitions of moral distress are problematically ad hoc. Campbell et al., to recall, define moral distress in a maximally broad sense, driven by the attempt to capture as many of the proposed definitions as possible. Here, the work of definition is not in the first instance guided by how the phenomena present themselves, but rather by the desire to create parsimony in a conflictual discursive field. The result is highly unsatisfactory, precisely because of its generality and abstraction from the concrete cases that motivated the study of moral distress to begin with. If we are to make progress on the question of the nature of moral distress, then, we should do so in a way that we keep our eye trained on the relevant phenomena and allow them to guide us. Are we, then, able to account for moral distress in such a way that meets our four desiderata and is grounded in the phenomena themselves?

Section Summary:

  • The concept of moral distress is often confusingly defined.
  • Any successful account of moral distress will have to meet four desiderata:
    • Allow for the agent’s sense of what is morally appropriate to be fairly indeterminate (e.g. she feels that there is something she should do but she is not sure what) or mistaken.
    • Allow for the agent’s fallibility in assessing all options open to her.
    • Make essential reference to the agent’s feelings of distress in light of her understanding of the situation and her place in it.
    • Refuse to arbitrarily restrict focus on cases with a specific causal profile (e.g. institutional constraints)
  • Further, any successful account of moral distress should be grounded in the phenomena themselves

2. The Phenomenology of Moral Distress

 A: Methodology

What, then, is moral distress? In order to answer this question, we propose to return to examples of moral distress themselves and allow them to guide us in our analysis of the phenomenon. In this respect, our approach shall be phenomenological: our aim is to describe the relevant phenomena as they show themselves and thus allow our theory to be guided by and grounded in the things themselves. This proposal brings with it some methodological complexity, however. We have just said that we lack any precise definition of moral distress. How, then, are we to identify the relevant cases that we will then use to guide our analysis? It would seem that we are faced with a dilemma: either we must presuppose a definition of moral distress that will work implicitly in guiding our selection of relevant phenomena, or we lack any criteria for selection. In the first case, we will simply choose those phenomena that confirm our prejudices and thus make no progress at all; in the second case we will be unable to move in a principled way towards a better understanding.

There is, however, a way out of this dilemma. We can begin with a formal, stipulated, but preliminary description of a phenomenon of interest. We can then look at examples that fit the bill exactly and others that are in the same ballpark, that is, other examples that suggest themselves as similar to those that meet the stipulated definition. We can then ask whether any similarities emerge between the phenomena in the ballpark. We need not presume that there is any one phenomenon here: it might be that we find only a rag-bag of similar cases that overlap in some respects but which cannot be subsumed to any one definition. But we might also discover a structural homogeny that we had not anticipated. If so, then we would have found a principled way of describing a range of phenomena as of a piece that is grounded in the phenomena themselves. To be sure, there is some circularity here, since we begin with stipulating a rough area of interest and then only pay attention to those phenomena that appear within that area of concern. But it is not the problematic circularity with which we were concerned, since our aim is to revise the merely stipulated definition in terms of what is revealed by analysis of those examples that show up within the same ballpark, rather than as simply matching our prejudice.

To this end, we propose to begin with the following preliminary, formal, stipulated definition, in light of the constraints we have described above:

Moral Distress: an agent experiences moral distress if she experiences painful feelings through understanding herself to be unable to realise an action that she perceives to be morally appropriate to the situation as she understands it.

This definition meets our desiderata since it allows for the fallibility of the individual’s understanding of right and wrong; allows for the individual’s fallibility regarding her assessment of which options  are open to her; makes essential reference to the affective dimension of moral distress; and finally makes no reference to institutional constraints as a necessary causal factor. Note that it is preliminary, since our aim is to revise it in light of whatever saliences emerge once we turn to the phenomena it describes and those similar to them. It is also formal in that it leaves a number of important issues open for refinement. In particular, this definition makes no initial description of the character of the distress that is experienced in these cases. Now that we have a preliminary definition, we can turn to a number of case studies before analysing them so as to attempt a revision of our preliminary definition.

 B: Testimony

  Case 1

An elderly woman is in the advanced stages of cancer and is entering the last hours of her life. She and her family have expressed the wish that the medical staff should not attempt to resuscitate the patient. However, the patient codes (enters cardiopulmonary arrest) before the attending staff have completed the formal ‘Do Not Resuscitate Order’. Consequently, the interns and residents that arrive on the scene quickly begin to attempt to resuscitate the patient. An attending nurse, aware of the situation, attempts to intervene and stop the resuscitation but is overruled by the attending physicians and is physically removed from the bedside.

She died, and of course it was awful. They broke every rib in that poor woman’s body and she was left like this, and then they walked out. I went to my manager and to the Director of Nursing and I got no support for what I’d done, to try and intervene in this hopeless situation, and it was a matter of paperwork. Everyone in that unit knew… There was one family member there saying, “No, no, no! We made her a DNR.” That was my final night in a hospital. I never went back to a hospital after that.[3]

  Case 2

An intoxicated man arrives in hospital by ambulance having fallen down some stairs and hit his head. The man loudly and aggressively asks why he has been admitted to hospital and dismisses the nurse’s explanation that, since he may be suffering from concussion, the staff are not permitted to let him leave before he has received a CT scan. He becomes louder and more aggressive, at which point a member of security calls for backup. A number of security guards arrive, ask an attending student nurse to hold a bag of restraints, and try to calm down the man. This does not work. The student nurse is asked to hand over the restraints so that the man can be tied to a stretcher in the hallway.

After the incident, the student nurse feels as though the man had been poorly treated and wishes to raise her concerns with the head of psychiatry in the hospital. Her teacher, however, does not believe that anything was done wrong and blocks the student from raising the concern, insisting that the student is merely naïve and idealistic, ignorant of the realities and daily life of the psychiatric ward. She is told that being a student is ‘mutually incompatible with activism’.

To my lasting regret, while I chafed at her claims of the student vs. activist mismatch, I did end up keeping quiet. She reported my outrage and my questioning to the director of my program. And though my program director privately agreed with my assessment that something was wrong about what I had witnessed, she asked me not to rock the boat. I finished out my rotation without a peep. But in doing so I feel I betrayed the people in my life who have mental illnesses. I betrayed the belief in human rights, which had led me to healthcare in the first place. And I betrayed the patients who come to that hospital seeking help and compassion and are instead treated like criminals. (Hensel, 2013: p100)

  Case 3

A physician involved in organ donation is presented with a difficult case: a woman has suffered brain death while carrying a premature and yet still viable foetus. Although the foetus is too young to be delivered immediately, the physician wonders whether options for preserving the pregnancy had been reasonably considered and explored. She also questions whether the attending doctors have considered the wishes of the parents. The physician has not been alerted in advance to the nature of the case and is not provided with support in thinking through what options are open to her. Due to the nature of organ donation, the time to think through the situation is severely limited. The physician attempts to raise concerns with the ethics team, asking whether a proper assessment of consent had been conducted, but is denied an ethics consultation. She believes that this is the result of having miscommunicated her concerns, due to a lack of experience in filling in the request form for an ethics consultation.

The decision-making in this instance felt rushed and failed to solicit the advice of the broader team. The result was that many clinicians that day felt morally distressed. What was my reaction to that moral distress? It best can be described as isolation, although I was active member of the care team to be involved, I felt I was relegated to being a quiet bystander, a technician expected to provide the skills, but not the critical reflection, which I still feel makes us physicians. I wasn’t the only healthcare worker on the team that day that felt distress, but the circumstances that day made me feel rather alone. A few of us removed ourselves from the care team that day. My decision to do so stemmed from my uncertainty but also from my belief that my actual distress would impact my ability to provide care, my feelings of isolation from the team impede communication in some critical fashion. My actions certainty registered vey publically my distress and some probably felt it was unprofessional, but I believe going forward to provide care under such circumstances would have been truly unprofessional. (Mack, 2013: pp.106-7)

  Case 4

A healthcare professional has been involved for the last decade in the care of a patient with a degenerative musculature disease. His patient has authored a healthcare directive, which has legal weight in directing the care of the patient once competency has been lost. Despite the presence of the directive, the attending physicians are not willing to grant that the directive has legal force, preferring to pursue a direction agreed by all of the patient’s family. The professional who insists on the importance of the directive believes that neither the family nor the healthcare team want to take responsibility for putting the patient’s wishes into practice.

The health care team was no more eager to address the issue than the family. I had produced specific state statutes regarding the health care directive of a previously competent person and even in light of this information, some individuals continued to believe the surrogates decision took precedence over the directive. This growing tension left me feeling angry and ineffective, questioning my role in the organization, while watching A. J. [the patient] linger in a state not chosen. I believed I had failed in my obligations as a professional. (Shuhan, p.121)

  Case 5

A child was previously born prematurely and addicted to opiates. ‘After several months in the Neonatal ICU, he was sent home, ventilator–dependent but with a high likelihood of survival and a low chance of severe, lasting disability.’ His prognosis has now deteriorated, despite frequent trips to the hospital. The ICU team believe that the continuation of aggressive treatments is no longer in the child’s best interests, but the parents are unwilling to remove the child’s life-support, believing that all possible support should be given and that it should be God’s decision alone whether the child dies. An ethics consultant reviews the case and, through the process of compiling a case for the ethics board, comes to the conclusion that the morally appropriate action is to withdraw life support. Despite this conclusion, however, the internal ethics committee overrules the consultant, stating that the decision whether to continue the treatment lies solely with the parents. The consultant is obliged to communicate to the ICU team a directive with which he profoundly disagrees.

On a personal level I agreed with the ICU team: it wasn’t right to continue to treat Jay aggressively. But from a professional perspective, there didn’t seem to be a lot of wiggle room. I hit the books, checked state law, and worked with in–house resources, but everything I learned confirmed what I already knew intellectually: this was the parents’ decision. I told the ICU team, “This isn’t what I would want for my child, but . . .” It was incredibly difficult to try to persuade the medical team—who were becoming angry that I was not telling them what they wanted to hear—of something that I personally didn’t agree with. I was advocating for a route that I found personally repugnant. (Volpe, p.122)

  Case 6

A baby has been born at 35 weeks of gestation. She experienced hypoxia at delivery, required resuscitation and ventilation to keep breathing, and had brain damage whose severity could not be determined. The parents of the child decide to withdraw care. She subsequently starts to breath without the help of the ventilator and her condition becomes more stable. Protocol would normally require that feeding is maintained, but since the parents have decided to withdraw care, doctors and nurses decide to remove the feeding tubes. A Roman Catholic nurse, involved in the baby’s treatment, believes that the child should continue to receive treatment. She comes to the conclusion that she should attempt to foster the child. Her attempts seem to her to fall on deaf ears, or to be rebuffed by those who insist that ‘the parents’ wishes should be respected’. On the day that the baby’s feeding tubes are removed, the nurse is prevented from seeing the baby and told that ‘religious hang ups’ should not interfere with medical procedure.

I was working that day in an office by myself and there was-no one to talk to – no support. One of the nurses I was working on the project with came by – I thought I would feel her out about the no cuddle order and her response was: “it’s too bad that we couldn’t give something to hasten the death.” I couldn’t believe the words that I heard. I felt so alone, I felt fear, deep sadness, anger and helplessness. It is difficult to be a prolife nurse – the distress I have felt this past week is more than I thought it would be.[4]

The baby subsequently dies of starvation. On the day of the baby’s death, the nurse is invited to visit the child.

I prayed for her and her parents. She was very quiet and still and her breathing was shallow but I knew that it was a graced moment. The next day she died – she lived for 27 days. God gave me consolation by providing the opportunity to give her my love.[5]

  Case 7

A patient is brought in to hospital suffering from an overdose. As the hospital is short-staffed, the administrative coordinator enters the trauma room to assist. The patient is a First Nations woman who is very upset and strongly resisting medical care. She is in restraints and is being verbally abusive towards the staff. The emergency physician several times tells the patient to ‘shut up’, before stuffing a flannel in the patient’s mouth in order to silence her. Although many of the staff laughed at this behaviour, the administrative coordinator is distressed. Feeling frightened and isolated, she does not intervene, even though she has a strong sense of what she should do.

My feelings on that night remain with me to this day. I now wish that I had found the courage to walk over to the patient, remove the washcloth and say why I believed the doctor’s act was wrong, but this action did not seem to be open to me at the time. The culture of the emergency room in that hospital was such that I set aside deeply held (and publicly professed) beliefs, values and principles. Here was a very vulnerable person in our care, and we were removing the last vestige of her autonomy and, on top of that, laughing at her! I was not facing moral uncertainty in this situation: I knew there was a moral problem, and I knew what it was. I didn’t have a moral dilemma (in the classical sense): I knew what the right thing to do was. I simply did not have the courage to do it. (Hardingham, p.129)

 C: Analysis

What do these examples tell us about our preliminary definition of moral distress? Recall that this definition is as follows:

Moral Distress: an agent experiences moral distress if she experiences painful feelings through understanding herself to be unable to realise an action that she perceives to be morally appropriate to the situation as she understands it.

To begin with, we should note that several cases appear to correspond to our definition. Cases 1, 4, 5, 6, and 7 each describe experiences of understanding oneself to be prevented from carrying out an action that the agent had identified as morally appropriate to the situation as she comprehends it. We should also note, however, that cases 2 and 3 do not so neatly fit this description. In these examples, the individuals have not identified anything as an appropriate course of action but, rather, experience distress at a perceived lack of institutional support for the kind of thinking that would lead to the identification and implementation of morally appropriate option. Our selection of cases, then, provides a range of examples which extend beyond the preliminary definition. Not every case describes a situation in which an individual understands herself to be prevented from realising what she has already determined to be a morally appropriate course of action. Are there any key commonalities between the cases that suggest a unified account of a phenomenon?

There is some reason to suppose that a unifying account may be out of reach. Consider, for example, the variety of the feelings reported across these cases: individuals report feeling a sense of betrayal, hopelessness, guilt, isolation, uncertainty, anger, impotence, disaffection with their chosen career, fear, sadness, helplessness, cowardice, and even consolation. On first glance, the case studies thus may appear to present too rich a variety of human feeling to be faithfully reduced into an overarching description. A second look, however, may give us pause for thought. For while the various feelings expressed may differ from case to case, the significance of those feelings may be more continuous. To see what we have in mind, consider Varcoe et al.’s definition of moral distress: ‘the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards’ (Varcoe et al., 2012, p.59). To be sure, this definition, as stated, does not capture all the cases we have surveyed: not every individual we have looked at acted in accordance with accepted professional values and standards; some felt distressed and isolated through the failure to conform to such values and standards. Nonetheless, the first half of the definition does seem to point to a recurrent theme: these individuals appear to report moral distress when their feelings amount to a sense of being morally compromised:

Case 1: the nurse felt unable to carry on working within the hospital;

Case 2: the student nurse felt that betrayed people with mental illnesses and the beliefs that led her to healthcare;

Case 3: the physician found it so hard to be within the situation that she removed herself from the context in which the decisions and actions had to be made. She believed that she could not be a professional in the immediate context from which she removed herself;

Case 4: the individual believed that he had failed as a healthcare professional through being unable to put into effect his patient’s wishes;

Case 5: the consultant’s personal beliefs were inconsistent with the demands of his job such that he felt pushed into putting into practice a course of action that he found repugnant;

Case 6: the nurse felt pushed out of the context of care in which she had to accept a decision she strongly disagreed with on moral and religious grounds;

Case 7: the administrative coordinator felt that the situation was such that she failed to express her deeply held beliefs; these were put aside while she allowed the situation to unfold.

In each case, we submit, the individual experiences herself to be compromised by her involvement in the situation as she understands it. In this respect, we endorse the claim made by a number of authors that central to moral distress is the experience of loss of moral integrity (Varcoe et al.; Rushton, 2016; Epstein and Delgado, 2010; Cox, 2008). While we endorse this claim, we note that the concept of ‘moral integrity’ tends to receive very little attention in its own right. While Hylton claims, for example, that moral distress ‘ensues when clinicians […] are unable to translate their moral choices into ethically grounded action that preserves integrity’ (Hylton 2016, p.111) she does not provide a detailed analysis of either ‘ethically grounded action’ or ‘integrity’. Other authors claim that the experience of moral distress involves a sense of a loss of integrity. Epstein and Delgado, for example, claim that ‘moral distress involves a threat to one’s moral integrity’ (Epstein and Delgado, 2010 p.3). But what this really amounts to is not subjected to extended discussion, such that the relationship between the definition of moral distress presented (of which we have made some critical comments above) and the loss of integrity adverted to is left unclear. In what follows, we attempt to address this lacuna by providing an extended analysis of the experience of being compromised in experiences of moral distress, grounded in the testimony we have presented above. We thereby hope to contribute to the literature by pursuing an analysis of a concept that is central to what we take to be a compelling account of moral distress.

To begin with, we can note that while many of these cases might involve a sense of being unable to perform a particular action, the sense of being compromised seems to goes far beyond this. We can see this most clearly in those cases in which the agents explicitly claim to have suffered a crisis in the ability to be a particular sort of person in a specific situation: in case 1, the individual experienced herself to be unable to continue to be a nurse, such that she left the profession; in case 3, the physician literally removed herself from the particular context in which she felt that she was unable to be a professional; case 4 similarly involves the experience of having been unable to be a healthcare professional; in case 6, the nurse found that she struggled to be a ‘prolife’ nurse within the healthcare context. In each of these cases, the experience of moral compromise goes beyond being unable to perform this or that action; the experience is one of being unable to be this or that sort of person.

While this reflection takes us a step further in understanding the experience of being compromised, it is not sufficient. In watching a concert, I might experience myself to be unable to be a virtuoso. This might manifest a sense of awe at the performing musicians, rather than a sense of being compromised. Why does the experience of not being able to be this or that sort of person manifest an experience of compromise in some cases but not others? We can turn back to the case studies to glean an answer. In case 2, the student nurse understands herself as someone who cares deeply about issues in mental health and human rights and attempts to live out this self-understanding through a career in nursing. In her training, however, she finds that her chosen career inhibits her ability to be herself, since it appears to block the expression of the values that she acknowledges as her own. In case 5, the consultant found that he was unable to be himself in his role, since his personal views of right action were diametrically opposed to the requirements of the position. Again, in case 6, the nurse understood herself in terms of her commitments to Roman Catholicism and her commitment to prolife practice, which she struggled to effectively express within the treatment context. She consequently felt isolated from the setting, unable to be herself easily within her working environment. In each of these cases, we submit, the individual experiences herself to be compromised insofar her ability to be herself is severely constrained and placed in a state of crisis, since there appears to be no clear way of living out the roles or values with which she identifies within the context.

While this takes us closer to understanding the distinctive character of experiencing oneself to be morally compromised, it still does not take us far enough. This is because we have so far said nothing about the distinctively moral character of these experiences. There are many different ways in which you might experience yourself to be unable to be yourself. Those who experience debilitating medical conditions, for example, often report experiencing themselves to be unable to fulfil a variety of roles integral to their sense of self as a result of their loss of capacity:

One participant explained that she had not been able to be fully a grandmother because of her fear that she might drop her grandchildren while trying to hold them in her arms when they were babies. […] One male participant felt particularly distressed, as he felt he could be neither a proper spouse nor a proper father, and maybe not even a proper man. (Aujoulat et. al., 2007 p.781)

In these cases the individuals plainly feel unable to be themselves because they feel that they cannot be a particular sort of person: grandmother, father, man. And yet these cases do not look like examples of being morally compromised. To be sure, these experiences are surely distressing for those who undergo them and these individuals do indeed appear to experience themselves to be compromised. But these examples lack a distinctive moral character. Being unable to be yourself, then, is not sufficient for an experience of being morally compromised. How, then, are we to account for the distinctively moral character of the sense of compromise we have found in the cases reviewed above, in such a way that distinguishes these cases from other experiences of being unable to be a particular sort of person?

We suggest that in each case the individual experiences herself to be unable to be herself because she feels that she should have been (but was not) able to do the right thing. On this suggestion, the distinctively moral character of the sense of compromise is explained as follows: the individual experiences herself to be unable to be herself through feeling that she should have been able to do the right thing as herself. We can state the proposal formally: in cases of moral distress, an individual feels morally compromised by a situation S when she takes it that she was unable to be herself in S, because she should have been (but was not) able to do the right thing in S. To help see what we have in mind, we can see how this formal proposal helps us to describe those cases we have discussed above:

  1. The individual experiences herself to be unable to be a nurse because she experiences herself to be unable to act in a morally appropriate way as a nurse.
  2. In the context of the psychiatric ward, the individual experiences herself to be unable to be a friend to those people close to her with mental illnesses because she experiences herself unable to act in a morally appropriate way as someone who is committed in that way.
  3. The physician finds herself unable to be a professional within a particular situation because she feels unable to act in a morally appropriate way.
  4. Similarly, the individual experiences himself to be unable to be a carer through experiencing himself to be unable to act in a morally appropriate way with respect to his client.
  5. The individual experienced himself to be unable to be himself because he experienced himself to be unable to act in a morally appropriate way: he is limited to acting ‘as a professional’.
  6. The Roman Catholic nurse experienced herself to be unable to be a ‘prolife’ Christian because she experienced herself to be unable to act in a morally appropriate way as a Christian.
  7. Finally, the individual experienced herself to be unable to be a good person, since she experienced herself to be unable to act upon what she nonetheless understood to be the correct course of action.

Thus our proposal allows the distinctively moral aspect of the distress experienced by the agent to come to the fore in an intelligible manner. Note, however, that our proposal does not entail that in each situation of moral compromise the individual understands herself to be prevented by external factors from acting in a morally appropriate way. I might be unable to win at chess because I lack the concentration to follow through my plan, rather than because someone is stopping me from acting. Similarly, I might feel that I am unable to do the right thing because I believe myself to lack the requisite foresight or courage for the challenging circumstances. Our proposal, then, is neutral on the question of the cause of the lack of the ability to do the right thing.

This neutrality, however, leads to a central ambiguity to our formulation: in what sense does the agent feel that she ‘should’ have had the ability to pursue a morally appropriate course of action? Are we claiming that she must feel personally responsible for her inability? Or are we claiming that she must feel that she has been disempowered by her circumstances? Is the ‘should have’ in this formulation a recognition of institutional injustice or personal failure? Or both? In the first case, the individual might understand herself as a victim of moral distress. In the second case, her moral distress might be experienced as a symptom of guilt.

We submit that this question is central to feeling morally compromised, and that in most cases it cannot be answered by the individual in a straightforward manner. This, in turn, makes moral distress very ambiguous because the individual is torn in two opposite directions: her feeling of being a victim on the one hand, and her feelings of responsibility and guilt on the other. If you feel as though you should have been able to pursue a morally appropriate course of action, you face the difficult challenge of reckoning with the extent of your own complicity in your perceived inability. Suppose, for example, that an institution requires you to make a difficult decision within challenging time constraints. You find yourself to be incapable of identifying a morally appropriate course of action within that timeframe, and consequently feel compromised by the situation. Even if we grant that the fault lay with the institution for throwing you into an overly demanding situation, and even if you are very much aware of the injustice of the circumstances, the situation into which you were unfairly thrown showed you to be incapable of it and this can be a difficult realisation to bear. This realisation is difficult not least because of its deep ambiguity. While you might recognise that the institution forced the crisis on you, you would still feel that the crisis revealed something about you, namely, that you were incapable of it. Concomitant with that realisation is the nagging sense of the possibility that there is something more you could have done within that situation, and which you simply failed to do. Perhaps if you had had an earlier night you would have been sharper; perhaps if you had paid more attention to your supervisors over the years you would have been better prepared. Questions such as these are likely to emerge with the sense of being morally compromised by the situation. Part of the difficulty of living with moral distress, we propose, is dealing with this ambiguous sense of your own complicity in your inability to do the right thing: no matter how challenging the circumstances, they reveal you to be incapable of them.

This distinctive feature of moral distress presents particular challenges, not least because the experience seems to further inhibit the individual’s ability to pursue the practices to which she remains committed. Under normal conditions, if you have made a mistake in the course discharging a commitment, then maintaining that commitment is likely to involve identifying what you have done wrong, owning up to it, and seeing how you can improve in light of the mistakes you have made. If I have hurt a friend, for example, then it behoves me to find out what I did wrong, take responsibility for that, and try to live better in light of my understanding of how I went awry. Where there is no straightforward way of identifying either whether you have done something wrong or what it is that you have done wrong, however, there is no obvious way of going forward with your commitments in a responsible manner. This seems to be the situation of moral distress: those who remain committed to those practices in light of which they feel moral distress may find no straightforward way to identify what they did wrong or even if they did anything wrong, and so find no immediate way of taking responsibility in the practice in light of what they (may) have done. Moreover, the very experience of oscillation between feeling as if you are a victim and feeling as if you are a perpetrator is likely to provide a distraction, at least, and an obstruction, at most, to a lucid vision of the moral situation in which you are required to further act. If I am painfully confused about my role in events previously, it will be harder for me to press on with the continuing demands I am required to address. In summary, then, the unstable oscillation between seeing oneself as a passive victim, on the one hand, and seeing oneself as a perpetrator, on the other, is likely to generate painful feelings of paralysation of the sort we have just described.

To be clear, our aim here is not to determine in the abstract the moral responsibility of any individual in any concrete case.Our aim is not to apportion blame or cast aspersions. We are not claiming that those who experience moral distress really are to blame for not doing the right thing. Rather, we hold that in order to capture the particular psychological, felt character of moral distress—that is, if we are to articulate what is so distressing about the experience—we have to recognise that the feeling of being morally compromised involves the difficulty of coming to terms with your sense of the ambiguous status of your own complicity in your perceived inability to pursue a morally appropriate course of action. In feeling morally compromised, it is difficult to attain consolation simply by apportioning blame to the institution that brought on the compromising situation. Even if you believe, truly, that the institution is at fault, it remains the case that that you were incapable of the circumstances, which realisation is hard to bear.

We have suggested that, in each of the cases we described above, there is an abiding sense that the individuals felt morally compromised by the situations as they understood them. We have suggested the following analysis of the experience of being morally compromised: to feel morally compromised is to feel incapable of being yourself within a particular situation because you should have been (but were not) able to do the right thing in that situation. This feeling is likely to be accompanied by a felt sense of deep ambiguity regarding the extent of your own complicity in your inability. We have suggested that this description maps on to the seven case studies we presented above. For this reason, we are now in a position to make the following hypothesis: the feeling of being morally compromised, as we have just described it, is the central experience of moral distress. Does this suggestion meet each of the constraints on any account of moral distress that we identified above?

Firstly, our account allows for the possibility that the individual may her erred in her assessment of the moral value of those options that she experiences as being open to her. Our account therefore avoids the problem of Epistemic Threshold. Secondly, our account allows for the possibility that the individual may have failed (for whatever reason) to identify a course of action that was in fact open to her. In this way, an individual need not in fact have no appropriate course of action open to her to experience moral distress; it may merely seem to her that way. Accordingly, our account avoids the Objective Constraint problem. Thirdly, our hypothesis makes essential reference to the painful feelings involved in understanding yourself to be unable to undertake a morally appropriate action; it is the painful feeling of being morally compromised. Thus, our account avoids the issue of Absent Affectivity. Fourthly, our account is neutral on causes of the experience of moral distress: our account is broad enough to accommodate those cases in which the individual feels moral distress because of institutional constraints as well as those cases in which the individual feels moral distress because of ‘internal’ constraints, such as fear or anxiety. Therefore, our account avoids the problem of Narrow Aetiology. Finally, the hypothesis we have developed has been constrained by the testimony of a number of individuals who report moral distress and so, for that reason, is not ad hoc and abstract but principled and grounded. In this way, we have provided a grounded analysis of moral distress as the experience of the loss of moral integrity or, in our preferred terminology, the experience of being morally compromised that supports and complements those accounts of moral distress that emphasise the importance of integrity in understanding moral distress but which do not provide an extended analysis of this key concept.

If our suggestion is to be a viable hypothesis for an account of moral distress, however, it will have to do more; it must be able to accommodate a number of important features of moral distress that we have so far not discussed, in particular ‘moral residue’ and the ‘crescendo effect’. Before we move on to discuss how one might respond to an experience of moral distress, as we have described it, we shall briefly discuss these two features and suggest how our hypothesis can accommodate them.

Section Summary:

  • Many examples of moral distress appear to display this common feature over variations: the experience of being morally compromised.
  • We suggest that the experience of being morally compromised is the feeling of being unable to be yourself in a situation in which you feel that you should (but are not) able to do the right thing.
  • The feeling of being morally compromised, so described, is central to the experience of moral distress.
  • We suggest that this feeling brings with it a sense of ambiguity over your own responsibility for your perceived inability to do the right thing in those circumstances.
  • This is likely to be accompanied by a sense of premonitory guilt, in half-anticipation of a verdict to which one suspects oneself to be subject, but cannot rule out.
  • This suggestion meets all four desiderata and is grounded in an analysis of the phenomena themselves.

 D: Moral Residue and the Crescendo Effect

Jameton’s initial description of moral distress distinguished two aspects: initial distress and reactive distress. According to him, initial distress occurs at the moment of crisis, while reactive distress lingers, after the occasion that gave rise to the distress initially has passed. In light of this distinction, Epstein and Hamric (2009) have described what they call the crescendo effect of moral residue. ‘Moral residue’ is their term for ‘reactive distress’, that is, the lingering effects of moral distress after the initial crisis is over. They argue that repeated exposure to situations that give rise to moral distress leads to a ‘crescendo effect’. This effect has two features: 1) a particular episode of moral distress becomes increasingly distressing the longer it lasts; 2) the resulting moral residue amplifies the distress of subsequent experiences of moral distress. Together, these two aspects combine to describe a crescendo of distress over the course of time. Each new experience of moral distress is more distressing than the last and lays the ground for subsequent experiences to be more distressing still. Can our proposed framework accommodate the crescendo effect of moral residue?

We submit that our proposal provides a natural explanation for these phenomena. Indeed, our account is in line with, but provides a substantial extension of, Epstein and Hamric’s suggestion that the crescendo effect should be understood as ‘a result of repeated threats to moral integrity’ (Epstein and Hamric, 2009, p.340). Let us begin with moral residue. According to the proposal we have sketched here, to experience moral distress is, among other things, to feel unable to be yourself in a situation because you feel that you should be (but are not) able to do the right thing in that situation. This is, quite plausibly, an experience that is likely to stay with you, not least because understanding yourself to have been incapable of a morally demanding situation raises deep questions regarding your character, which are not easy to either dismiss or resolve. The extent of your own complicity in your inability to have acted morally is not an easy question to answer, even if you rightly believe the institution to be at fault. In this way, we suggest, our proposal has a natural place for moral residue. Consider, for example, the sense of being morally compromised through your involvement in a situation in which a patient has died in pain because a ‘do not resuscitate’ form was not filed in time. We have suggested that situations like this are likely to lead you to question what more you could have done and bring with it a sense of guilt. These questions are not easy to answer and hard to avoid. Consequently, the pain of having been morally compromised stays with you. What about the crescendo effect?

Here too it seems that there is a natural place for the crescendo effect within our description of moral distress. To recall, the crescendo effect has two aspects: 1) an increase in distress the longer a morally distressing situation continues; 2) the amplification of subsequent experiences of moral distress by moral residue. The first aspect can be given a relatively brief explanation: if a situation is painful to be in, then the longer it goes on the more the individual will experience pain. If a situation of moral distress involves the painful realisation of being incapable of a morally demanding challenge, as we have suggested, then the longer one is forced to bear that fact at the forefront of one’s mind, the longer it will remain painful. On our account, then, we should expect experiences of moral distress to exhibit the first feature of the crescendo effect. Let us move on to the second aspect: why should moral residue as we have interpreted it lead to an amplification of distress in subsequent experiences of moral distress? We have suggested that moral distress is situation specific: it is the feeling of being unable to be a particular sort of person within a given situation, because you feel morally compromised. We have suggested that the sense of being compromised is likely to linger, since the questions it raises regarding your own character and responsibility with regards to your incapacity are difficult to resolve or dismiss. We can also add that the more experiences of this nature that you have, the more likely it is that your sense of incapacity will spill out of the specific situations that occasion it and transform into a sense of being generally incapable. To take a mundane example, if I lose one or two games of chess, I am unlikely to think myself incapable of chess; I may reasonably feel that those games got the better of me. But if I keep on losing, I may start to feel as though I am not up to the game as such, rather than a few cases. Similarly, if I experience myself to be unable to be a nurse in a specific context, I may nonetheless experience myself to be able to be a nurse in other contexts. But the more times I pass through situations in which I experience myself to be morally compromised, the greater the possibility of experiencing myself to be unable to be a nurse in any context. I may experience myself to fall short of nursing as such, rather than simply not being up to a handful of difficult cases. In this way, we suggest, our account makes room for the second feature of the crescendo effect, since we should expect it to be harder to hold on to the sense of being capable of being a particular sort of person the more times you are exposed to situations in which you feel morally compromised as that sort of person.

We have, then, proposed that moral distress is the feeling of being morally compromised by a specific situation. We suggested that the feeling of being morally compromised is the feeling of being unable to be a particular sort of person in a specific context because of your (perceived) inability to pursue a morally appropriate course of action as that sort of person, which ability you feel you should have had. This suggestion meets each of the desiderata we identified at the end of the previous section and is grounded in testimony. Furthermore, we have suggested that our proposal is able to accommodate moral residue and the crescendo effect. If this hypothesis does accurately describe moral distress, however, what might it mean to live well in light of such experiences? In the final section of this Green Paper, we shall review a number of possible ways of responding to experiences of moral distress.

Section Summary:

  • The crescendo effect of moral distress has two features:
    • The distress of a situation of moral distress increases the longer the situation lasts;
    • The residue of moral distress amplifies the distress of subsequent experiences of moral distress.
  • Our proposal makes room for the possibility of the crescendo effect.
  • On our account, it will be increasingly painful to be confronted with the sense of being incapable of an action.
  • Further, on our account the more times you experience being morally compromised in particular situations, the more likely you are to feel morally compromised as such.

3. Living in Light of Moral Distress

 A. The ‘4 A’s’ Model

Perhaps the most prominent model for addressing moral distress is presented in ‘The 4A’s to Rise Above Moral Distress’[6]. According to this model, those who experience moral distress should respond in four steps:

  1. Ask: the individual should ask whether her symptoms are consistent with those associated with moral distress. The goal of this step is to become aware that moral distress is present, if it is present.
  2. Affirm: Once moral distress has been identified, the individual is recommended to affirm her distress and commit to taking care of herself; validate her feelings and perceptions with others; and affirm her professional obligation to act. The goal of this step is to make a commitment to address moral distress.
  3. Assess: Once the individual has made a commitment to address moral distress, she is recommended to begin to assess the sources of her experience, be they personal or environmental. She is encouraged to ‘contemplate [her] readiness to act’. Here the goal is stated as follows ‘you are ready to make an action plan’.
  4. Act: This step involves preparing to take the action set out in your action plan, to implement ‘strategies to initiate the changes you desire’ and to anticipate possible set-backs. The goal of this step is the preservation of moral integrity and authenticity.

This model is severely problematic. Consider, for example, step one. To be sure, it is important that individuals are encouraged to gain a deeper understanding of their situation. But we submit that treating moral distress as a sort of disease that can be diagnosed third-personally by comparing one’s own ‘symptoms’ to a list of diagnostic criteria, risks distorting the phenomenon in the eyes of those who experience it: it goes against the aims the model espouses, namely the preservation of moral integrity and authenticity, to treat moral distress as a condition from which individuals passively and third-personally suffer, rather than a moral crisis in which they are first-personally implicated, in the ways we have highlighted above. The attempt to come to a better understanding of your own moral distress should not be modelled on the attempt to identify what disease you are suffering from.

The second step also has considerable problems. As we have seen, this step involves acknowledging that one has an obligation to act. This presupposes that the best way to address moral distress is to make a commitment to act for the best. We have just seen, however, that moral distress involves the feeling of being unable to be yourself because you feel that you should have been (but were not) able to do the right thing. In other words, the experience of moral distress involves a sense of being compromised in one’s ability to act for the best. It is unclear how someone who feels that they are suffering such a compromise could simply commit to act for the best, since their ability to make such commitments is precisely what may be experienced to be undermined through moral distress.

The third and fourth steps inherit this problem from the second: by setting the goal of the third step as the development of an action plan, the model once more presupposes that the individual understands herself to be capable of acting for the best; here we are presented with a strategy for exercising that ability. And yet it is precisely this sense of one’s own capacity for right action which is experienced to be compromised in cases of moral distress. When the model states, then, that the goal of step four is the preservation of integrity and authenticity, and that this is to be met through putting into action one’s sense of what is best, it is presupposed that the individual to whom the model is addressed already has the capacities that the model is supposed to help cultivate.

In summary, then, the ‘4A’s’ model is severely problematic, since it both frames moral distress as a kind of disease with characteristic symptoms (and so distorts its character as a crisis in your first-personal experience of your own moral agency) and moreover presupposes that individuals already unproblematically possess the very capacities that are supposed to be cultivated by the model. This model is not the only prominent suggestion as to how we might respond to moral distress. Recent years have, for example, seen the emergence of the concept of ‘moral resilience’. Does moral resilience provide a more compelling model than the alternative we have just surveyed?

 B: Moral Resilience

‘Moral resilience’ refers to the character profile of individuals who appear best able to resist burnout as a result of continued exposure to situations that give rise to moral distress. Cynda Rushton’s work is prominent in this area and has largely been directed to the attempt to provide a description of this character profile, demonstrate the effectiveness of moral resilience in protecting individuals from burnout, and surveying possible ways to cultivate moral resilience in nurses. According to Rushton, those with moral resilience demonstrate the following characteristics (Rushton 2016, pp.112-116):

  1. Knowledge of who you are and what you stand for in life
  2. A commitment to ongoing exploration, refinement, or in some cases revision of one’s values, ideals, and point of view
  3. The cultivation of capacities such as ‘mindfulness’ that allow the individual to ‘fully experience’ moral distress and ‘release its grip on them more easily’;
  4. Responsivity and flexibility in complex ethical situations
  5. The capability to discern the boundaries of integrity, including the exercise of conscientious objections
  6. The ability to be resolute and courageous in one’s moral action despite resistance or obstacles
  7. The ability to discern when one has exerted sufficient effort to fulfil one’s ethical obligations and to be realistic about one’s limitations and the constraints and pressures of the situation
  8. The attempt to seek meaning in the midst of situations that threaten integrity or cause dissonance with one’s moral sensitivity and reasoning

This list presents an intriguing and richly suggestive description of various character traits that may protect individuals from burnout. There are, however, a number of issues with this description as a presentation of a viable response to moral distress. To begin with, we should note that none of the items on this list has been accompanied by an extended analysis on the basis of which systematic distinctions and relations could be drawn between the other items on the list. This is problematic for a number of reasons. Firstly, it may be that there is substantial overlap between the enumerated items: how are we to distinguish between, for example, the capability to discern the boundaries of integrity (item 5) and the ability to discern when you have exerted sufficient effort (item 7)? What grounds are there to warrant this distinction at all? Secondly, the absence of any systematic analysis of the relations between the features of moral resilience means there is no real explanation as to why these and only these items have been included. Might there be other items we are missing? Might we have captured features that are mere contingent accompaniments to the phenomenon of interest?  Thirdly, through the absence of a systematic analysis we lack any account of the relation between the items on the list and the contribution of each to the constitution of the phenomenon of moral resilience. What is it about the attempt to seek meaning, for example, that is important to resisting burnout? How does the attempt to seek meaning relate to the exercise of courageous action? Can one seek meaning through courageously enacting one’s plans? Is the attempt to seek meaning prerequisite of this action? If progress is to be made in pursuing the cultivation of moral resilience, we should first attempt to be clear about the phenomenon, both in identifying the relevant examples and systematically elaborating their features in a way that explains how the features relate to each other and contribute to the phenomenon of which they are a feature.

Besides the lack of systematic analysis, however, there is a more general issue with focusing on moral resilience as a response to moral distress. As we have seen, Rushton conceives of moral resilience as that character profile that protects individuals from feeling profoundly compromised in distressing situations. It therefore looks to be directed, primarily, at the prevention of the worst cases of moral distress, in which the individual feels that she cannot go on at all. The aim is to cultivate in nurses those virtues which allow them to best resist a loss of integrity in situations of great moral strain. Does moral resilience, however, provide a viable way of addressing those cases in which the individual has already reached a point of crisis? It is not obvious that the virtues that are supposed to protect an individual from being compromised will be appropriate to those cases in which the individual is already compromised. Perhaps, in these cases, we need an altogether different approach; since the aim is not to battle on through difficult circumstances so much as to, so to speak, recover from defeat. To be clear, we are not suggesting that ‘moral resilience’ is not a viable account of how to best respond to moral distress. Rather, we indicate some of the difficulties faced at this early stage of thinking through the concept that will have to be dealt with if the idea is to come to fruition.

Section Summary:

  • The ‘4 A’s’ model of addressing moral distress is highly problematic for two reasons:
    • It encourages individuals to relate to their moral distress as a condition with symptoms that can be third-personally diagnoses, rather than a crisis in your first personal experience of yourself in your situation.
    • It presupposes that individuals already have the very capacities that are experienced to be undermined in cases of moral distress and which are supposed to be cultivated by following the model.
  • The ‘moral resilience’ model of addressing moral distress presents an interesting and rich range of character traits that may be involved in protecting the individual from burn out as a result of moral distress.
  • This model is also problematic, however:
    • It is not systematically developed
    • It is not clear that the virtues that are helpful from protecting against burnout must be the same virtues that you need to cultivate in the response to a crisis.


 C. Alternative Responses to Moral Distress

There are, then, some major issues with some prominent models of responses to moral distress. How, then, should we respond to moral distress? In conclusion, we once more turn back to our case studies. We shall identify a number of ways of addressing moral distress that are exemplified in these examples. Our aim is to identify a range of possible responses to moral distress and present a brief analysis of them in light of our discussion of moral distress. We do not aim to adjudicate the value of any of these responses: we present them here to raise the question of the respective value of each and how these examples might better help us refine our understanding of what it might mean to live well in light of moral distress.

  i. Rebellion

If moral distress is the experience of being morally compromised within a given situation, as we have suggested, then a natural way of resolving the experience would be to remove oneself from the situation in which one feels compromised. We can distinguish between two ways in which one might pursue this strategy, in response to moral distress.

1. Leaving the immediate context

Firstly, you might decide to leave the immediate context which has given rise to the experience of moral distress while nonetheless remaining committed to the overarching context. You might, for example, decide to rescind responsibility for a particular treatment decision while nonetheless remaining committed to professional healthcare. In this way, you would resolve an experience of moral distress by evacuating the compromising situation that gave rise to it. This response appears to be exemplified by case 3 above: the physician felt that she could not continue in a morally appropriate way within the immediate context in which a treatment decision needed to be made, and so vacated that context.

2. Leaving the broader context

A more radical way of pursuing a similar strategy would see the individual not only removing herself from the immediate context, but also the overarching context to which she had been committed and within which the immediate situation of moral distress arose. Rather than simply leaving a particular treatment decision to others, for example, you might decide to quit healthcare altogether. This response appears to be exemplified by case 1 above. To recall, the nurse states that after witnessing the unnecessarily painful death of a patient in a situation within which she could not intervene, she never returned to the hospital.

   ii. Acquiescence

Rather than attempting to remove yourself from the situation that you find compromising, you might undertake an alternative approach. In the situation we have in mind, the agent goes along with the situation irrespective of her moral scruples about doing so. In this way, the situation of moral distress is resolved by not allowing your moral principles to stop your work from proceeding. We can identify two varieties of this approach.

1. Choosing your battles

On this approach, the individual so to speak concedes defeat on a number of fronts in order to maintain her commitment to the overarching context and allow herself to be steadfast in situations in which she may be more insistent. This approach appears to be exemplified by case 5 above. To recall, in this example the ethics consultant reports relays instructions to the treatment team even though he finds repugnant the course of action the instructions recommend. He does so, it appears, in view of his commitment to professionalism.

2. Full surrender

On a more radical form of pursuit of a similar strategy, the individual gives up any attempt to act in accordance with her moral beliefs and, rather, decides simply to go along with whatever is asked of her. In this case, the individual does not decide to strategically concede defeat, as it were, to continue to fight another day; she more generally abandons her moral principles as restraints on her conduct at work. Although none of the cases above seem to exemplify this approach, there may be references to such a response in case 2. In that example, the student nurse makes reference to a number of professionals who seem to her jaded and relaxed with the situation which she perceives to be extremely morally problematic.

  iii. Rediscovery

We have, then, reviewed two broad ways of responding to experiences of moral distress: in the first case, the individual more or less radically rejects the context that gives rise to moral distress, while holding on to her moral principles; in the second case, the individual more or less radically accepts the context that gives rise to moral distress, while letting go of her moral principles. In the final set of cases we shall examine, matters are more complicated, since they seem to involve both accepting and rejecting the apparently morally problematic context in a complicated way.

1. Rediscovery of possibilities of moral self-expression

Consider case 6, in which a Roman Catholic nurse initially finds no way of being able to be a Christian within the immediate context of care. She does not remove herself from that context; she continues to attempt to find a way to care for the child, despite the distressing sense of her inability to do anything. But nor does she simply accept the context; she holds herself in that distressing situation until she is able to find a way of being a ‘prolife’ nurse that she had not previously envisaged: in praying for the child, she found a way of being able to be a ‘prolife’ nurse within the context. We might call this a rediscovery of the possibility of moral self-expression within the context, made possible by accepting the difficulty of the situation as presented it and letting go of her sense that there was only one morally acceptable course of action open to her, which was foreclosed. In other words, the nurse had believed that the only morally appropriate course of action within this situation was to save the life of the child. Only by letting go of belief in that action as the solely morally appropriate was she able to see her way to another possibility of caring for the child.

2. Rediscovery of commitment to practice

Although none of our examples exemplify the approach we have in mind, we can nonetheless imagine a plausible case along the following lines. Imagine a nurse who finds that she can no longer remain at the frontline of care. Accordingly, she decides to remove herself from the hospital permanently. This need not amount to a rejection of her commitment to caring, however, since she may seek to find a new avenue for the expression of the commitment to that practice. She might, for example, decide to work for a healthcare charity. In this respect, the nurse rediscovers her commitment to a practice of care by first letting go of her previous sense of what is involved in following through that commitment but nonetheless accepting being bound by that commitment despite her sense of being unable to continue as she had before. In other words, the nurse had believed that the only way of being committed to care was to remain working within a hospital. Only by freeing herself from this conception was she able to find her way to another way of maintaining that commitment outside of the nursing profession.


We have, then, surveyed a number of different responses to moral distress as we have understood it. Each example represents a different way of living in light of moral distress and several are exemplified in the case studies we have presented. The first set of examples involved more or less radically letting go of the situations in which moral distress arose, so as to hold on to one’s moral principles. The second set of examples involved more or less radically letting go of one’s moral principles, so as to hold on to one’s commitment to the practice. The third set of examples involved a more complicated relationship between holding on and letting go. In the first example of this cluster, the individual remains in the tense situation but lets go of her previous judgement as to what options are open to her so as to find a new way of expressing her moral principles within that context which she had not seen hitherto. In the second example, the individual holds on to her commitment to care but lets go of her sense of how to play out that commitment, so as to find a new way of being committed to care despite her inability to carry on before. We do not claim that this list is exhaustive. 

Section Summary:

  • Our case studies demonstrate a number of different ways of responding to moral distress:
    • Rebellion: individuals may more or less radically remove themselves from the context that gives rise to moral distress;
    • Acquiescence: individuals may more or less radically submit to courses of action to which they disagree.
    • In the first case, individuals hold on to their moral principles and let go of those contexts in which they cannot be expressed.
    • In the second case, individuals hold on to the contexts and let go of the principles which cannot be expressed in those contexts.
    • Rediscovery: individuals may find ways of both holding on and letting go:
      • You might let go of your preconceptions of the correct moral action to hold on to the possibility that another option may emerge;
      • You might let go of your specific practice in order to hold on to the possibility of another way of expressing your commitment to care.


 F. Summary

To conclude, let us briefly sum up and raise some questions that remain outstanding. We began by reviewing the literature on moral distress. We identified four desiderata any successful account of moral distress would have to meet and one methodological constraint: any account of moral distress should avoid the problems of a) Epistemic Threshold; b) Objectivity Constraint; c) Absent Affectivity; and d) Narrow Aetiology, while developing an analysis that is grounded in the phenomena themselves.  We then turned to testimony of experiences of moral distress and developed an analysis of the cases we presented. We argued that each case presented an example of an individual who has experienced him- or herself to have been morally compromised. We offered an analysis of moral compromise: to experience yourself to be morally compromised is to feel that you are unable to be yourself within a given situation because you feel that you should be able to do what is right (but are not) within that situation. On the basis of this analysis, we raised a hypothesis: moral distress is the ambiguous and painful experience of feeling morally compromised, as described. We showed how this hypothesis meets the desiderata and constraints we identified and how it is further able to accommodate the crescendo effect of moral residue. We then explored a range of possibilities of what it might mean to live well in light of moral distress. A number of questions, however, remain unanswered. We submit that the pursuit of these questions would be fruitful in coming to better understand how to address moral distress:

  • How should we assess the appropriateness of each of these responses?
  • How far can we generalise any of these responses?
  • Are there further responses to moral distress, if so, how are we to understand and assess their effectiveness?
  • How are we to understand the ambiguity between feeling like a victim and feeling like a perpetrator?
  • Are there other ways of experiencing this ambiguity in different areas of moral life that are experienced as empowering, rather than paralyzing?
  • Is there a role for resilience in the rediscovery of one’s practice or commitment in light of moral distress?
  • What would it mean to live with moral distress and would this involve resilience in a new role?
  • In previous Green Papers, we found that a pattern of ‘letting go’ and ‘holding on’ may be central to living well in light of experiences of powerlessness. Could such a dynamic be helpful in response to moral distress? If so, what would this look like?



Aujoulat,  I et al. 2007‘The Perspective of Patients on Their Experience of Powerlessness’ in Qualitative Health Research (17)6: 772-785


Austin, W., Rankel, M., Kagan, L., Bergum, V., & Lemermeyer, G. (2005). To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by psychologists. Ethics & Behavior, 15(3)


Campbell, SM, et al. 2016 ‘A Broader Understanding of Moral Distress’ American Journal of Bioethics 16(2) 2-9


Cox, K. 2008 ‘Moral Distress: Strategies for Maintaining Moral Integrity’ Perioperative Nursing Clinics 3 197-203


Epstein, E., Delgado, S. 2010 ‘Understanding Moral Distress’ OJIN The Online Journal of Issues in Nursing 15(3) Manuscript 1


Epstein, E., Hamric, A, 2009 ‘Moral Distress, Moral Residue, and the Crescendo Effect’ Journal of Clinical Ethics 20(4): 330-342


Fachini, J S et al. (2017). Moral distress of workers from a pediatric ICU. Revista Bioética, 25(1), 111-122.

for action. HEC Forum 24: 51–62.


Ganske, K 2010 ‘Moral Distress in Academia’ OJIN: The Online Journal of Issues in Nursing 15(3) Manuscript 6


Hardingham, L. 2004 ‘Integrity and moral residue: nurses as participants in a moral community’ Nursing Philosophy 5 127-34


Hensel, J 2013, ‘To Nurse Better’ Narrative Inquiry in Bioethics 3(2) 98-100


JAMETON, A. 1984. Nursing Practice: The Ethical Issues, Englewood Cliffs, NJ: Prentice Hall.


Mack, C. 2013 ‘When Moral Uncertainty Becomes Moral Distress’ Narrative Inquiry in Bioethics 3(2) 106-9


Morley, G. 2016 ‘Efficacy of the nurse ethicist in reducing moral distress: what can the NHS learn from the USA? Part 2’ British Journal of Nursing 25(3): 156-61


Mukherjee, D, Brashler, R, Savage, T, Kirschner, K. “Moral Distress in Rehabilitation Professionals: Results From a Hospital Ethics Survey”. American Academy of Physical Medicine and Rehabilitation, Vol. 1, 450-458, May 2009. DOI: 10.1016/j.pmrj.2009.03.004


Oh, Y & Gastmans, C 2013 ‘Moral distress experienced by nurses: A Quantitative literature review’ Nursing Ethics 22(1) 15-31


Rushton, C. 2016 ‘Moral Resilience: A Capacity for Navigating Moral Distress in Clinical Care’ AACN Advanced Clinical Care 27(1) 111-119


Shuhan, 2013 ‘These Things I Believe’ Narrative Inquiry in Bioethics 3(2) 119-122


Varcoe, C., B. Pauly, G. Webster, and J. Storch. 2012. Moral distress: Tensions as springboards


Volpe, R. 2013 ‘“Please Help Me”’ Narrative Inquiry in Bioethics 3(2) 121-124


Webster G, Bayliss F. 2000, ‘Moral Residue’  In Margin of Error: The Ethics of Mistakes in the Practice of Medicine eds. Rubin S, Zoloth L, editors. Hagerstown, Md: University Publishing Group


Wocial, L 2016 ‘A Misunderstanding of Moral Distress’ American Journal of Bioethics 16(2) 21-23



[1] A unfortunately ambiguous turn of phrase since by definition a ‘nearly impossible’ event is, in fact, possible (but unlikely).






Virtues of Powerlessness? Faith, Love and Hope in a Secular World – 15 & 16 June 2018


Our 2018 end of year conference, ‘Virtues of Powerlessness? Faith, Love and Hope in a Secular World’ took place at Senate House, London on Friday and Saturday 15th and 16th of June, 2018.

In Christian thought, empowerment and powerlessness are not simply opposed: they are two sides of the same coin. Specifically, empowerment comes through the exercise of the so-called theological virtues: faith, hope and love (caritas). These are thought to afford human beings spiritual empowerment by expressing a proper acknowledgement of our temporal vulnerability and powerlessness, before God. The theological virtues are in this sense ‘virtues of powerlessness’.

In this conference, we asked: is this paradoxical structure essentially religious? Does it require a robust notion of transcendence? Can we make sense of virtues of powerlessness without relying on theological commitments? While leaving open to investigation the question of the extent to which ours is a secular world, we ask: are faith, love and hope, in particular, available to us as virtues of powerlessness in a secular world?


  • Havi Carel (University of Bristol)
  • Taylor Carman (Colombia University)
  • John Cottingham (University of Reading)
  • Ken Gemes (Birkbeck, University of London)
  • Discussant – Adrian Moore (University of Oxford)
  • Geoff Morgan (North Middlesex NHS Trust)
  • Andrew Pinsent (University of Oxford)
  • Mark Wrathall (University of Oxford)


Day 1 – Friday 15 June 2018

09.00:                   Registration

09.20:                   Welcome

09.30 – 11.00:    Andrew Pinsent: The Challenge to Second-Person Relatedness in a Secular World.

11.00 – 11.15:      Break

11.15 – 12.45:      John Cottingham: Strength made perfect in weakness’: Aristotelian versus Christian conceptions of the good life

12.45 – 13.45:     Lunch break (lunch not provided)

13.45 – 15.15:      Geoff Morgan: Faith in powerlessness: explorations in positivity & spiritual care with independent advocates, service users and chaplains.

15.15 – 15.30:      Break

15.30 – 17.00:     Ken Gemes: Powerlessness as the Most Uncanny Expression of the Will to Power


Day 2 – Saturday 16 June 2018

09.15:                    Registration

09.30 – 10.30:   Mark Wrathall: Religion and the Transformation of Existence.

10.30 – 10.40:    Short Break

10.40 – 11.00:     Adrian Moore responds to Mark Wrathall

11.00 – 12.00:     Q & A

12.00 – 13.00:    Lunch Break (lunch not provided)

13.00 – 14.30:    Taylor Carman: Kierkegaard’s Concept of Faith

14.30 – 14.45:     Break

14.45 – 16.15:      Havi Carel: Virtue without excellence; excellence without health.


Havi Carel

Havi Carel is Professor of Philosophy at the University of Bristol, where she also teaches medical students. She is currently a Wellcome Trust Senior Investigator, leading a five year project, the Life of Breath ( Her third monograph was published by Oxford University Press in 2016, entitled Phenomenology of Illness. Havi is the author of Illness (2008, 2013), shortlisted for the Wellcome Trust Book Prize, and of Life and Death in Freud and Heidegger (2006). She previously published on the embodied experience of illness, epistemic injustice, wellbeing within illness and on the experience of respiratory illness.

Taylor Carman

Taylor Carman is professor of philosophy at Barnard College, Columbia University. He is the author of Heidegger’s Analytic (2002) and Merleau-Ponty (2008) and coeditor of The Cambridge Companion to Merleau-Ponty (2005)

John Cottingham

John Cottingham is Professor Emeritus at Reading University, Professor of Philosophy of Religion at Roehampton University London, and an Honorary Fellow of St John’s College Oxford. He is the author of numerous publications on the history of philosophy (especially Descartes), moral philosophy, and philosophy of religion. His recent books include On the Meaning of Life (Routledge), Cartesian Reflections (OUP), The Spiritual Dimension (CUP), Philosophy of Religion: Towards a More Humane Approach (CUP), and How to Believe (Bloomsbury).

Ken Gemes

Ken Gemes is a Professor of Philosophy at Birkbeck College, University of London. He has published on the notion of logical content, confirmation theory, the will to truth, and sublimation, among other topics.

Geoff Morgan

Geoff Morgan is Head of Spiritual Care – Chaplaincy at North Middlesex University Hospital NHS Trust, north London and Team Chaplain at Oxford University Hospitals NHS Foundation Trust. Previously he was employed as an Independent Mental Capacity Advocate (IMCA practitioner) across south London (2007-2011), and a chaplain and service manager at Imperial College Healthcare NHS Trust (2011–2016). Geoff is a licensed Anglican priest in London and Oxford dioceses and has published in the areas of healthcare advocacy and post-colonial studies. A practitioner-researcher, he obtained his doctorate from King’s College London (2014) and the monograph, Independent Advocacy and Spiritual Care, Insights from Service Users, Advocates, Healthcare Professionals and Chaplains (Palgrave MacMillan) was published in January 2017.

Adrian Moore

A.W. Moore is Professor of Philosophy at the University of Oxford, Vice-Principal of St Hugh’s College Oxford, and joint editor of MIND.  His publications include The Infinite; Points of View; Noble in Reason, Infinite in Faculty: Themes and Variations in Kant’s Moral and Religious Philosophy; and The Evolution of Modern Metaphysics: Making Sense of Things.

Andrew Pinsent

Andrew Pinsent is Research Director of the Ian Ramsey Centre for Science and Religion at Oxford University. Formerly a particle physicist on the DELPHI experiment at CERN, he has degrees in philosophy and theology and a second doctorate in philosophy. A major theme of his current research is second-person (I-you) relatedness in science, philosophy, and theology. His publications include work in virtue ethics, neurotheology, science and religion, the philosophy of the person, insight, divine action, and the nature of evil.

Mark Wrathall

Mark Wrathall is Professor of Philosophy at the University of Oxford, and a Tutor and Fellow at Corpus Christi College.  He works in the phenomenological tradition of philosophy, and is interested in issues surrounding selfhood, responsibility, authenticity, temporality, and the phenomenology of religious life. He is the author of Heidegger and Unconcealment: Truth, Language, and History (Cambridge UP) and How to Read Heidegger (W.W. Norton). He has edited a number of volumes, including Religion after Metaphysics (Cambridge UP) and The Cambridge Companion to Heidegger’s Being and Time (Cambridge UP) and The Cambridge Heidegger Lexicon (forthcoming).


Titles and Abstracts

Virtue without excellence; excellence without health

Havi Carel

In this talk I respond to Edward Harcourt’s suggestion that human excellences are structured in a way that allows us to see the multiplicity of life forms that can be instantiated by different groups of excellences. I accept this layered (as he calls it) model, but suggest that Harcourt’s proposal is not pluralistic enough, and offer three critical points. First, true pluralism would need to take a life-cycle view, thus taking into account plurality within, as well as between, lives. Second, Harcourt’s pluralism still posits physical health as a requirement for excellence, whereas I claim that the challenges of illness give more, not less, opportunity for excellence. Third, I make a more general claim that in certain salient cases (illness being one of them) it is precisely the absence of excellence that can facilitate virtue.

Kierkegaard’s Concept of Faith

Taylor Carman

Kierkegaard’s name will forever be associated with the “leap of faith” that figured prominently in Jacobi’s conversations with the dying Lessing. That association puts the emphasis firmly on agency. Jacobi insisted on the necessity of a leap of faith as a matter of ethical and metaphysical principle, but it was Lessing who had the deeper insight into the “awful wide ditch” we actually face in contemplating such a jump. Like Lessing, Kierkegaard does not conceive of faith wholly in terms of spontaneity. Instead, with Luther, he defines it as trust, which can be only partly voluntarily. Faith is indeed a kind of commitment, but one that necessarily involves receptivity: it is, he says, passionate commitment. In this paper I take issue with several recent readings of Kierkegaard that miss this point and so fail to grasp the nature and import of his existential interpretation of faith.

 ‘Strength made perfect in weakness’: Aristotelian versus Christian conceptions of the good life.

John Cottingham

The picture of a good human life found in classical Aristotelian ethics looks very different from the Christian picture, and their respective conceptions of virtue are correspondingly different. Aristotle’s virtues, excellences of character acquired by a good upbringing, are geared to success, pre-eminence and flourishing as a respected member of the community. This schema finds no place for Christian virtues like humility, nor can it readily accommodate the ‘theological’ virtues of faith, hope and love. This paper will explore these contrasts, and will suggest, without begging any questions as to the truth or otherwise of theism, that the Christian conception exposes certain flaws in the Aristotelian conception of virtue. By accommodating and affirming our human weakness and dependency, rather than treating it as something to be ignored or regretted, it may offer a psychologically richer and more insightful conception of what it is to lead good human life, and one that may serve to challenge some of the underlying assumptions of contemporary philosophical ethics.

Powerlessness as the most Uncanny Expression of the Will to Power

Ken Gemes

Nietzsche argues that the modern secular outlook is not in opposition to the Christian outlook but is rather its most sublime manifestation. Secular atheists who value truth and compassion above all else have merely dropped Christian ontology to perfect the moral core of Christianity. On this view, and counter enlightenment propaganda, the decisive historical break in the west is not between the modern world of science, objectivity and truth and the medieval world of religious superstition and faith.  Rather the decisive break is the transition from the pagan world with its ethical code of honour, and its concomitant valorisation of power, to the Judeo-Christian world which takes compassion, love of one’s neighbour, and its concomitant value of humility, to be core moral values.  The Christian valorisation of powerless on this view serves two purposes; first, it allowed the weak to make sense of their otherwise meaningless suffering, and second, it became a tool for the subjugation of the strong.

Faith in powerlessness: explorations in positivity & spiritual care with independent advocates, service users and chaplains

Geoff Morgan

The Mental Capacity Act (2005) and the amendments to the Mental Health Act (1983) in 2007 made it a statutory duty for the NHS and local authorities to refer to advocacy services. These came into effect in 2007 and 2009 respectively in England and Wales and were further expanded under the Health and Social Care Act 2012 which was part of a steady growth in advocacy which coincided arguably with an increase in literature on mental health and spirituality. Independent advocates are specialists who support the powerless and the vulnerable; and spiritual care coordinators (or chaplains) provide expressions of advocacy. For Independent Mental Capacity Advocates (IMCAs), social, cultural and spiritual factors are influential. For these advocates, emergent theological categories of ‘faith, hope and love’ may be able to provide wider secular and ethical valence for their thinking, practice and training. Background research involved a literature review of the history of advocacy, some comparisons with its forms in other European contexts, interviews with 40 advocates, chaplains and service users; this issued in subsequent empirical analysis via case study methodology. The attested ‘rediscovery of the spiritual dimension in health and social care’ highlighted both issues in the professionalisation of advocacy in relation to culture and spirituality; and advantages in conversation between faith and advocacy practitioners. Models of understanding arise, and conclusions are drawn which illustrate a cross-fertilisation between theory and practice in the diverse fields of the occupation as experienced both as a professional and as a service user.

The Challenge to Second-Person Relatedness in a Secular World

Andrew Pinsent

The transition from the classical to the Christian world introduced second-person relatedness, with the embryonic form of caritas, as the form of all virtues, especially the theological virtues. These dispositions in turn shaped the treatment of those powerless to help themselves, especially in healthcare. But one concomitant of a secularising society has been a comparative loss of the second person to a narcissistic first-person or objectifying third-person perspective. In this presentation I consider the implications of this trend and prospects for reversing it or at least ameliorating its undesirable consequences.

Religion and the Transformation of Existence

Mark Wrathall

I will explore the thought, shared by philosophers like Pascal, Kierkegaard, Dostoevsky, Buber, and Heidegger, that religion can only be understood as a specific type of existential transformation rather than as a noetic structure.  If this is right, then the challenge that secularism poses to religion is to be located in the practices and existential forms of secular life.  I conclude by considering specific ways in which the theological virtues, understood as modes of religious existence, conflict with secular practices.


GREEN PAPER – Addiction as Powerlessness? Choice, Compulsion, and 12-Step Programmes


In this Green Paper we shall provide an overview of the difficulties involved not only in responding effectively to addiction but in understanding the nature of the condition. In particular, we shall focus our attention on a major question in the literature: to what extent, if at all, are addicts disempowered by their addiction? We shall first review some prominent responses to this question, which provide paradigmatic cases of some of the diametrically opposed positions occupied by theorists. We shall then turn our attention to the 12-Step programmes. We shall ask whether these programmes offer a different perspective on the debate and, if so, what view of addiction they afford.

The Antinomy of Addiction

In recent years, there has been a striking proliferation in the number of addictions recognised by practitioners and theorists. Nick Heather’s indicative taxonomy of the potentially bewildering array makes reference to supposed addictions to nicotine, cocaine, benzodiazepines, cannabis, inhalants, caffeine, sugar, chocolate, water, carrots, various sexual activities, love, shopping, exercise, work, smartphones, joy-riding, theft, pornography, psychic hotlines, indoor tanning, binge-flying, and Harry Potter books (Heather 2017, pp.4-5). The fact that so many behaviours of no obvious unity have been labelled addictive may invite suspicion: is this list anything more than a motley crew? In light of this, it may appear that we are in need of an account of addiction by which we can adjudicate which among the many proposals are genuine cases of addiction, and which, if any, are spurious.

The attempt to understand the nature of addiction, however, has proved exceedingly difficult. In our view, one of the major reasons for this problem lies in the fact that the relevant phenomena invite theories that characterise addiction in two diametrically opposed ways:

  • On the one hand, the extreme difficulty many addicts have in abstaining from addictive behaviour suggests that addicts are suffering from some loss of power over their behaviour. Consequently, some theories assert that addicts are compelled in their addictive behaviour, and therefore suffer from a total loss of power over their addiction. On this view, it is natural to think of addicts as suffering from a condition that deprives them of responsibility and for which some form of medical treatment is the appropriate response.
  • On the other hand, the fact that many addicts can and do abstain from their addictive behaviour and maintain their abstinence suggests that addicts retain some power over their behaviour, sufficient for quitting. Consequently, other theories assert that the addict suffers no special loss of power. On this view, since addicts maintain responsibility for their actions, an altogether different response is required.

Addiction is puzzling, then, because it invites characterisation in ways that are, prima facie, irreconcilable: either addiction is a condition from which the addict passively suffers, or it is a pattern of behaviour that the individual actively maintains. Either addicts need help, or they are to blame for their addiction. In this paper, we shall refer to this dual characterisation as the antinomy of addiction: each view, considered on its own, has some plausibility; and yet, put together, they seem incompatible. In this section, we shall argue that this antinomy both shapes the history of modern conceptions of addiction and sets the main reference points for many of the major positions currently advanced in the literature on addiction.

Section Summary:

1. The many proposed forms of addiction demands an account to decide among the proposals.

2. Addiction has been difficult to understand because it invites characterisation in two diametrically opposed ways.

3. On the one hand, addicts’ struggles to quit leads some theorists to argue that they are compelled in their behaviour.

4. On the other hand, the fact that many addicts can and do quit leads other theoriests to argue that they suffer from no special loss of power.

5. This is what we are calling the antinomy of addiction: the phenomenon of addiction gives us reason to think that addicts are powerless and reasons to think that addicts retain power. How are we to make sense of this prima facie incompatibility?

A: Modern Ideas of Addiction: A Brief History

It is a commonplace within contemporary psychiatric and medical textbooks to treat addiction as a disease. Gene Heyman, for example, quotes four prominent publications that claim that addiction should be categorised alongside ‘Alzheimer’s, hypertension, Type 2 diabetes, schizophrenia, asthma, arthritis, and even cancer and heart disease’ (Heyman 2009, p.90).  In keeping with the prevalent view, Allen Leshner published an article, while Director of the National Institute on Drug Addiction, entitled ‘Addiction is a brain disease, and it matters’ (Leshner 1997). Not only is addiction commonly regarded as a disease, the disease conception has been promoted by prominent publications and persons within the field of addiction.

The prevalence of the disease conception of addiction may give rise to the impression of timeless obviousness. In a classic paper from 1978, however, Harry Levine argued that the conception of addiction as a disease emerged with changing views on habitual drinking around the beginning of the 19th Century. According to Levine, the ‘idea that alcoholism is a progressive disease—the chief symptom of which is loss of control over drinking behaviour, and whose only remedy is abstinence from all alcoholic beverages—is now about [214] or [239] years old, but no older’ (Levine 1978, p.143, adjusting for time passed since publication). Indeed, Levine claims that before the 19th Century, in which movements encouraging temperance began to gain prominence and support, there was a very different view of habitual drinking, in which there was no language of addiction. As Levine has it:

During the 17th Century, and for most of the 18th, the assumption was that people drank and got drunk because they wanted to, and not because they “had” to. In colonial thought, alcohol did not permanently disable the will; it was not addicting, and habitual drunkenness was not regarded as a disease. With very few exceptions, colonial Americans did not use a vocabulary of compulsion with regard to alcoholic beverages. (op. cit. 144)

Although Levine focuses on the American context, Mairi McCormack has argued for a similar view in her study of the representation of alcoholics in British literature (McCormack 1969).

According to Levine, then, habitual drunkenness used to be understood as an expression of choice over which the individual had control. This view changed around the beginning of the 19th Century, at which point a view of addiction emerged as a disease that deprived the individual of the capacity to control her behaviour. At what point did the paradigm shift, such that we are left with the modern conception, according to which alcoholism is understood to be a disease that drives the individual to act in self-destructive ways? As we shall see, in working out answers to these questions Levine helps us to see that the contemporary debate over the degree of powerlessness in addiction reflects a central tension in the conception of addiction which emerged in the 19th Century, and set the pattern for what we have called the antinomy of addiction.

To begin with, Levine reconstructs what he calls the ‘traditional paradigm’. To understand this ‘traditional’ way of understanding habitual drinking, it is important to first note just how prominent alcohol was in the culture that would later come to regard excessive consumption as symptomatic of a disease. At the funeral of the wife of a minister in Boston, for example, mourners apparently consumed fifty-one and a half gallons of wine, roughly equivalent to 312 bottles of today’s standard size. Similarly, at one ordination, guests drank six and half barrels of cider, twenty-five gallons of wine, two gallons of brandy, and four gallons of rum (op. cit. 145). Levine does not tell us how many guests were at these events nor how strong was the alcohol consumed, but he supposes that the fact that such quantities were consumed under the ministry of the Church is indicative of the public acceptability of prodigious alcohol consumption. This is perhaps less surprising once we take into consideration the dangers associated with drinking water at that time.

By the mid-18th Century, some prominent Americans had begun to take a dim view of levels of public drunkenness, which was seen as a major waste of time that could have been spent on more productive activities. In this regard, Levine quotes Benjamin Franklin claiming that taverns were ‘a pest to Society’ (op. cit. 146). It is sometimes claimed that the later onset of the industrial revolution increased the social demand for a reliable workforce, thus increasing the pressure on the workforce to live more ‘productive’, sober lives (see Nathan et. al. 2015). Indeed, the disapproval of habitual consumption of alcoholism is still sometimes expressed in terms of a lack of productivity. Gene Heyman, for example, claims:

we want to live in an environment that fosters productive lives. Extended periods of heavy drug use are not productive, and they undermine productive activities that could take place during periods of sobriety […] As the emperor of China noted in response to the first recorded drug epidemic, “addiction drains the community of its wealth.” Thus, we are obligated to do what is feasible to reduce the frequency and duration of destructive drug use. (Heyman 2009, pp.167-8)

According to Levine, with a rising tide of disapproval of heavy consumption of alcohol came to public consciousness the concept of a ‘drunkard’, the 18th Century equivalent of the modern ‘alcoholic’. Levine claims, however, that where the modern ‘alcoholic’ is understood to suffer from a form of disease by which the individual is overwhelmed by a compulsion, language such as this was never used to describe the drunkard:

In the traditional view […] the drunkard’s sin was the love of “excess” drink to the point of drunkenness. Thus did Increase Mather distinguish between one who is “merely drunken” and a drunkard: “He that abhors the sin of Drunkenness, yet may be overtaken with it, and so drunken; but that one Act is not enough to denominate him a Drinkard: and he that loveth to drink Wine to Excess, though he should seldom be overcome thereby, is one of those Drunkards” (Levine 1978, p.148)

According to Levine, ‘because in the traditional view there was nothing inherent in either the individual or the substance which prevented someone from drinking moderately, drinking was ultimately regarded as something over which the individual had final control. Drunkenness was a choice, albeit a sinful one, which some individuals made’ (op. cit. p.149).

According to Levine, then, in the ‘traditional view’ drunkenness was seen as an expression of choice over which the individual maintained control, not as a sort of compulsion. As we shall see, it is on the basis of this sketch of the ‘traditional view’ that Levine is able to speak of a transition to a different paradigm. The language of paradigm shifts may lead one to think that the transition described was a leap between one internally coherent way of viewing the world to another. From the evidence that Levine adduces, however, the picture that emerges is rather more complex. For while Levine seems right to claim that there is a striking change of emphasis in the conception of addiction around the beginning of the 19th Century, the ‘traditional view’ contains features supposedly specific to the modern conception, and the modern conception bakes in features inherited from the ‘traditional view’. The result is an emergent conception of addiction that has within it a tension that develops into the vexed debate that characterises contemporary studies on addiction.

To begin with we can note, contrary to Levine, that the ‘traditional view’ has clear connotations of compulsion. As we have seen, Levine points out that while the 18th Century conception of a drunkard was rarely expressed using terms such as ‘overpowering’ or ‘irresistible’, habitual drunkenness was described as a sort of disordered love. Levine takes this to indicate that, on the 18th Century conception, the individual was understood to retain control over his behaviour. This is a doubtful inference, however, on two grounds. Firstly, various sorts of love invite descriptions in terms of compulsion, irresistibility, or even disease. Consider, for example, Shakespeare’s Sonnet 147:


My love is as a fever, longing still

For that which longer nurseth the disease,

Feeding on that which doth preserve the ill,

Th’ uncertain sickly appetite to please.

My reason, the physician to my love,

Angry that his prescriptions are not kept,

Hath left me, and I desperate now approve

Desire is death, which physic did except.

Past cure I am, now reason is past care,

And frantic-mad with evermore unrest;

My thoughts and my discourse as madmen’s are,

At random from the truth vainly expressed:

For I have sworn thee fair, and thought thee bright,

Who art as black as hell, as dark as night. (Shakespeare 2008, p.76)

The very terms that Levine attributes to the ‘traditional view’ have connotations that Levine wishes to reserve for the emerging view. Indeed, Shakespeare is comfortable describing a certain form of love as a disease.

Secondly, the notion of disordered love has a prominent place within Protestant theology, highly influential on the backdrop against which habitual drunkenness was regarded as a form of disordered love. Following Augustine’s lead, Martin Luther insisted that fallen human nature is marked by a corruption that cannot be cured, a corruption that bends the love of humans away from its proper object—namely, God—and towards the self (Batho 2016). The deepest mark of sin, according to Luther, is corrupted love, concupiscence. It is also a tenet of Luther’s view that it is not humanly possible to cure the disorder of love from which humans suffer. Moreover, Luther is wont to describe humans as having no way of stopping themselves from acting poorly: if good works do come from a human being, it is solely down to the grace of God. Disordered love is, therefore, a central component of the theological framework that was prominent during the time of the traditional view, according to which disordered love is a condition that inevitably gives rise to sin and about which individuals can do nothing at all. Once more, the very evidence that Levine cites to support his contention that the traditional view held habitual drunkenness to be something over which the individual retained control, then, pulls at least as strongly in the opposite direction. In viewing addiction as a sort of disordered love, the ‘traditional view’ appears in fact to anticipate the later conception of addiction as beyond the control of the addict.

This is not, however, to deny that there are important differences between the view of addiction that emerged in the 19th century and that which was prominent previously. Levine traces the emergence of what he calls the modern conception of drunkenness as addiction, and addiction as a disease, rather than a moral corruption, to the work of Dr. Benjamin Rush (another signatory of the Declaration of Independence), whose account he reconstructs as follows:

Rush’s contribution to a new model of habitual drunkenness was fourfold: First, he identified the causal agent—spirituous liquors; second, he clearly describes the drunkard’s condition as a loss of control over drinking behavior—as compulsive activity; third, he declared the condition to be a disease; and fourth, he prescribed total abstinence as the only way to cure the drunkard. (Levine 1978, p.152)

In the light of our previous comments, the differences between the view sketched here and that of habitual drunkenness as disordered love appear to be as follows: firstly, where drunkenness as disordered love has connotations of sin, in Rush’s hands it becomes medicalised, so that it is not to be understood in any straightforward sense as an expression of moral corruption. Secondly, Rush holds that the disease of alcoholism can be cured by way of total abstinence. Where Luther held out no hope for a cure for disordered love in this life, Rush suggests that there is a way to heal the corruption that blights alcoholics. To be sure, it is a curious form of cure, closer to the management of remission rather than the application of remedial medication. By describing addiction as a disease, however, Rush, medicalises addiction as a kind of physical corruption that is beyond the power of the agent. As a disease, addiction can be cured. The cure is distinctive: it is no medicine nor surgical intervention; the cure is a commitment to living in a certain way, namely, in abstinence.

Rush’s description of alcoholism as a disease became central to the so-called temperance movement, a popular rise in groups that urged the public to moderate or abstain from drinking, rooted in the American revolution, and which was in ascendance at the beginning of the 19th Century. Robin Room has suggested that the timing of the emergence of this movement, and its readiness to deploy the concept of addiction described by Rush, is significant:

The concept of addiction was thus seen as brought to the foreground in this period by social conditions in the new American republic—by growing population mobility and thus the stretching of extended family ties and the weakening of social support networks for the nuclear family, which objectively made the fortunes of family members more dependent on the self-control of the husband/father. (Room 2003, p.222)

Again, however, although we might accept that there are changes to the conception of drunkenness, and that these are significant in light of the societal changes at the time, we might find further reason to doubt radical discontinuity between the ‘traditional’ and ‘modern’ views of habitual drunkenness, where this is understood as a transition from one internally coherent paradigm to another. This is because the language of the members of the temperance movement is evocative of a theology of sin, understood as corruption, and hence connotative of some of the central features of the ‘traditional’ paradigm supposedly left behind. For example, Levine quotes a prominent member of the movement describing alcoholism as ‘a sin, but I consider it also a disease. It is a physical as well as moral evil’ (Levine 1978. p.156). The complexity of the relation between the disease conception and the traditional view is further evidenced by the fact that the temperance movement at times was willing to describe habitual drunkenness as hereditary and, therefore, a form of corruption and sin that is passed down through the generations.

A National Circular sent out in the 1830s made the argument which was repeated throughout the century: “Unlike the appetite which God gave for water, for bread, and for nourishing food and drinks … [which] will not increase their demands, this cries continually ‘Give, give.’ And no man can form it without being in danger himself of dying a drunkard. Not that every man who forms it dies a drunkard. Some may withstand it; but the appetite which a father may withstand, may kill his children, and the children’s children, to the third and fourth generation” (op. cit. 156)

As Levine has it, the traditional view saw habitual drinking as an exercise of choice, which became morally censured. He also holds that such censure is what the medical model takes away, since on this model the addict is not blameworthy in behaving as he does, since he is compelled. The temperance movement inheritance of the account of alcoholism developed by Rush complicates the picture, however. The movement took Rush’s description of the disease of addiction and understood it as a form of hereditary corruption which is the result of sin, rather as hereditary sin, on the Lutheran model, both compels us to behave poorly and is itself the result of sinful action.

An important consequence of the view that alcoholism is a sin and a disease, is that the drunkard or alcoholic can be viewed as someone deserving of compassion while also serving as a cautionary tale: the alcoholic can both be pitied, as sufferer, and held up as a warning for others, as sinner. In this way, the conception of alcoholism that emerges with the temperance movement builds in a complicated mixture of impressions of personal responsibility: the addict is responsible for having entered into the state of addiction, but has become overrun by the condition of which their voluntary actions were the cause. The addict is both victim and perpetrator, where the consequence of the sin is disease:

Through thousands of temperance pamphlets and novels and innumerable presentations by “experience lecturers” dramatizing the degradations of the drinking life and the rewards of the sober one, the early temperance movement sought to build a sober society by education and example. Once the drinker could be taught the error of his ways, he would give up what he must now recognize as harmful behavior. (Room 2003, p.224)

It is on the basis of viewing alcoholism or habitual drunkenness as a disease, then, that moral disapproval of the consumption of alcohol, understood hitherto in terms of the damage to productivity and society in the 18th Century, that the Temperance Movement could motivate concern for the individual who suffered from the disease, who could be helped through a program of education, while maintaining a moralising tendency, according to which the addict is a victim of his own poor choices. To be sure, this is once more a curious medication, suggestive of a tension in the conception of addiction that is not made explicit by the members of the movement. For if addiction is really a disease, understood on the medical model, why should we think that education is an appropriate response? What sort of sickness can be taught out of someone?

In summary, then, while it appears that the conception of addiction as a disease, which is to be understood in medical rather than theological terms, began to emerge around the beginning of the 19th Century, it is not clear that this change should be understood as a kind of paradigm shift from one internally consistent view to another. Rather than a radical break with the past, the disease conception arose in a context in which habitual drunkenness was understood as a form of disordered love, and in which disordered love was understood as the mark of sin, and was adopted and developed by a proselytising movement of moral improvement that was comfortable drawing on both theological and medical language in its attempts to construct an edifying discourse around the condition. Consequently, the conception of addiction that emerged has built into it a certain tension between the idea that the addict has become diseased through choice, and the idea that the addict has lost the power to choose through becoming diseased, although subject to cure through moral education. This tension drives what we called earlier the ‘antinomy of addiction’ and is explicitly played out in contemporary debates between those who want to argue one side of the antinomy as opposed to the other.

Section Summary:

1.   The modern disease model of addiction appears to have emerged in the early 19th Century.

2.   While Levine claims that the emergence of this model marked a paradigm shift in the understanding of drunkenness, there are reasons to think that the picture is more complicated.

3.   The ‘traditional’ view of drunkenness had strong connotations of deep corruption and compulsion; the ‘modern’ view of addiction, as developed by the temperance movement, inherits some of the theological background supposedly unique to the ‘traditional’ view.

4.   The understanding of addiction that emerges in the 19th Century, then, contains a tension that may give rise to the antinomy of addiction: according to the view passed on by the temperance movement, addiction is both a sin and a disease.

B: Addiction as a Compulsive Brain Disease

During his tenure as the Director of the National Institute on Drug Abuse, Alan Leshner authored a number of papers that present a modern form of the disease model of addiction. According to Leshner’s portrayal, the ‘essence’ of addiction is ‘uncontrollable, compulsive drug craving, seeking, and use, even in the face of negative health and social consequences’ (Leshner 2001, p.76). Those who deny that this is the case, Leshner claims, tend to focus solely on the fact that addictions develop through the voluntary choices of those who later become addicted. Those who consider addicts simply to lack willpower, Leshner claims, fail to notice that, through their initially voluntary choices, the brain changes in substantial ways, such that it ‘is as if drugs have hijacked the brain’s natural motivational control circuits, resulting in drug use becoming the sole, or at least the top, motivational priority’ (op. cit. p.75). On this view, addiction is like the Trojan Horse, welcomed in under false pretences only to usurp the power that first received it. Thus, according to Leshner, addiction is first a choice and then a disease, in a structurally similar way to the disease conception endorsed by the temperance movement, according to which addiction is first a sin and second a disease. In a way that further echoes the theological background behind the temperance movement model, in which Adam’s free choice leads to a radical corruption in human nature, Leshner further remarks that ‘once addicted, the individual has moved into a different state of being’ (op. cit. p.76).

Despite these inheritances from the earlier paradigm, however, Leshner presents addiction in a distinctively modern light, holding that addiction can only be treated as a disease, that is, through methods that view it as a medical condition with an identified neurological basis that must be resolved medically, rather than through the moral education of the addict. Against the temperance movement conception of addiction, according to which there is something the agent can do to improve his character and regain control, Leshner holds that the addict is beyond his own help and requires specialised treatment. Leshner therefore represents a continuation of the disease conception of addiction into the modern age, with the added support of neuroscience, while emphasising the medical conception of addiction at the cost of the moralising tone of the temperance movement. He therefore plays up one side of the tension in the temperance movement model, and which is given expression in the modern antinomy: the side that highlights the compulsive, diseased character of addiction. But what is the neuroscience to which Leshner adverts and does it support his conclusion that addiction is a disease marked by uncontrollable addictive behaviour?

Leshner refers to a number of articles, one of which provides a helpful overview of the studies he endorses. According to this article, a number of studies have shown that addictive substances are linked to activity in the areas of the brain associated with ‘the control of motivated and learned behaviors’ (McLellan et. al. 2000, p.1691). More specifically, addictive substances have been repeatedly connected with the dopamine system:

Cocaine increases synaptic dopamine by blocking reuptake into presynaptic neurons; amphetamine produces increased presynaptic release of dopamine, whereas opiates and alcohol disinhibit dopamine neurons, producing increasing firing rates. Opiates and alcohol also have direct effects on the endogenous opioid and possibly the g-aminobutyric acid systems. (ibid.)

By stimulating the dopamine system, addictive substances are able to produce pleasant feelings, such that these substances are experienced as a reward. Animals whose dopamine systems are artificially stimulated when they press a lever, hyperactively and repeatedly press the lever while ignoring food, water, and rest. According to these studies, once an addictive substance has been taken it produces a rise in dopamine which primes the individual to seek a reward from the drug, motivating the user to repeatedly dose. On this view, addictive binges can be explained by the neurochemistry induced by the initial use, since the initial use releases dopamine that leads the user to seek further rewards.

Besides the neurological explanation of binges, however, McLellan et. al. point to evidence that may explain the staying power of addiction, that is, the continued association of the substance with reward despite significant time passing between the effect on the dopamine system by the last binge. McLellan et. al. present two ways of explaining this fact. Firstly, they refer to studies that suggest that repeated usage leads to permanent or lasting changes in the dopamine system which outlive the immediate effects of the substance. Secondly, they point to studies that argue for the interconnectedness of reward circuitry with the motivational, emotional, and memory centres of the brain:

These interconnected regions allow the organism not only to experience the pleasure of rewards but also to learn the signals for them and to respond in an anticipatory manner. Repeated pairing of a person (drug-using friend), place (corner bar), thing (paycheck), or even an emotional state (anger, depression) with drug use can lead to rapid and entrenched learning or conditioning. Thus, previously drug-dependent individuals who have been abstinent for long periods may encounter a person, place, or thing, that previously was associated with their drug use, producing significant, conditioned, physiological reactions, such as withdrawal-like symptoms and profound subjective desire or craving for the drug. These responses can combine to fuel the “loss of control” that is considered a hallmark of drug dependence. (ibid).

Thus, the motivation towards repeated usage is explained by the conditioning of associations with the drug that condition physiological responses, triggering cravings that motivate addicts to re-use.

We shall review further neuroscientific theories regarding the structure of the physical disease attributed to addicts below, which add some further nuance to the picture just sketched. On the brief sketch of the evidence we have just presented, however, we can see that the neuroscience that Leshner endorses provides an explanation for why one dose often leads to another and also an explanation for why binges lead to a pattern of behaviour becoming engrained: repeated stimulation of the dopamine system leads to a conditioning of the individual in which they respond to the addictive substance as a reward and are motivated to seek that reward long after the initial dose through cues presented by associations with the substance within their environment. Does this model, so stated, provide support for Leshner’s claim that addiction produces uncontrollable addictive behaviour?

Although McLellan et. al. indicate that drug addiction is characterised by ‘uncontrolled, involuntary dependence’ (op. cit. p.1693), the evidence they cite does not directly imply that this is the case. Granted that substance dependence is marked by substantial changes in brain chemistry, this does not by itself entail that the individual has lost control of her behaviour. On the plausible assumption that controlled, voluntary activity also has a characteristic brain chemistry associated with it, the fact that there is a change in brain chemistry due to addiction is not sufficient to show that the change has completely undermined the individual’s ability to voluntarily control his behaviour. Further, on the supposition that rats do not have the same sort of agential control over their behaviour as human beings, the fact that the former can be driven in a particular direction by a particular stimulus does not tell us how, if at all, the control of human beings would be affected by a similar stimulation. In order to understand this, we would need much more information regarding the connection in human subjects between, at the very least, an increased craving for a substance and the capacity to voluntary act in response to that craving.

This is not to say that it is impossible for addicts to ever lose voluntary control over their addictive behaviour through repeated substance use; our claim is rather that on the evidence Leshner cites, no compelling reasons have been provided to think that such loss of control must necessarily occur. Our point is methodological: the conclusions that McLellen et. al. and Leshner draw from the evidence adduced go beyond what is implied by the studies cited.

Section Summary:

1. Leshner inherits the temperance model of addiction, but emphasises the ‘disease’ pole at the expense of the ‘sin’ pole: for Leshner, addiction is purely a disease that compels the addict and must be responded to by medical treatment alone.

2. The neuroscientific evidence adduced by Leshner, however, underdetermines his conclusion: even granted that there is a distinctive brain chemistry associated with addiction, much more needs to be shown to demonstrate that this chemistry completely undermines the addict’s ability to control their behaviour.

C: Addiction as Poor Choice

So far we have seen a prominent example of one side of the antinomy of addiction: the view that addiction is a brain disease which involves the loss of voluntary control over addictive behaviour. We shall now turn to the other side of the antinomy, namely to a contemporary account of addiction according to which addiction is not a brain disease, precisely because it does not involve a loss of voluntary control over addictive behaviour.

Gene Heyman (2009) argues that we can understand addiction as a disorder of choice without recourse to the concept of disease. To begin with, Heyman argues that the disease conception of addiction is based on the presumption that self-destructive behaviour cannot be voluntary. It is only on the basis of this presumption, Heyman argues, that the observed self-destructive tendencies of addicts would entail that addicts are involuntarily compelled to act as they do, which involuntariness Heyman sees as central to the disease conception of addiction. Heyman argues that we need to separate voluntariness from rationality. Once we make this separation, we can see that irrational behaviour can be voluntary and, therefore, that self-destructive behaviour need not be compulsive, such that a central plank that supports the disease conception of addiction is removed.

In order to separate out voluntariness from rationality, Heyman appeals to the following distinction:

Research reveals two categories of behavior: activities that are elicited by antecedent states and activities that are governed by consequences that were experienced in the past and are anticipated. (op. cit. 112)

The first category of ‘activity’ is ‘involuntary’; the second category is ‘voluntary’. If it turns out that drug use is voluntary in this sense, namely that it is governed by consequences that were experienced in the past and are anticipated by the individual, then it is voluntary. In that case, we should not think of addiction as a disease that compels addicts to act as they do but, rather, a way in which voluntary choice goes wrong without, for all that, becoming any less voluntary. If, for example, we were to find that addictive behaviour follows a pattern that is predicted by a model of behaviour caused by antecedent states, then we would have reason to think that addiction is involuntary. If, on the contrary, we were to find that the patterns of observed addictive behaviour better fits a model of activity as driven by the anticipation of future reward, then we would have reason to suppose that addiction is involuntary.

To argue that addictive behaviour is a form of activity that is governed by the consequences, Heyman presents a model of voluntary behaviour derived from behavioural economics that predicts that, under certain constraints, individuals will voluntarily act in ways that are consistent with the patterns of behaviour shown by addicts. To be sure, the argument can only establish so much: at best the strong predictive power of a behavioural model. Nonetheless, Heyman argues that the predictive strength of the model gives us a way of making sense of a behavioural profile while preserving the voluntariness of the addict’s actions.

The model of behaviour that Heyman presents is based on three principles that he declares to be self-evident. (However, we shall raise some critical comments on these principles below.) The first principle is that the perceived value of outcomes is dynamic, in that it is affected by the choices that are made. To take a simple example, if I highly value Chinese food right now, then I will value it less the more days in a week that I consume it. Correlatively, I will value other food choices more the longer I neglect them. Thus, the perceived value of outcomes varies as a result of choice. The second principle states that there are different ways of framing decisions. I might view my choice as a discrete item, considered independently of its effects on future perceived values. Call this ‘local’ framing. Alternatively, I might view my choice as part of a sequence of choices, in view of the effects on future perceived values. Call this ‘global’ framing. So, for example, if I approach the choice over whether to have Chinese food through local framing, I will only consider which item I value most now. Alternatively, if I approach the choice through global framing, I will consider whether to have Chinese food in light of how that decision will affect the perceived value of future items. A person who approaches her decision in a local frame will ask simply ‘what do I feel like having tonight?’, whereas a person who approaches her decision in a global frame will ask ‘how will I feel about Chinese food if I have it every night? Might I enjoy Chinese food more if I only eat it at weekends?’ Note that both of these frames are ways of framing voluntary choices, on the conception of voluntariness that Heyman defends: they are both ways of making decisions in light of their consequences, on the basis of remembered experiences. The third principle holds that individuals always choose the better option, where ‘better option’ is differently defined relative to the frame of decision. The better option within the local frame is the item with the highest perceived value. The better option within the global frame is the item consistent with the sequence of choices with a higher combined perceived value.

Heyman then makes a number of assumptions about addiction derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM). The first is that the perceived value of non-drug-use activities will decrease with extended drug use. This is because the pain of withdrawal symptoms and the risk of facing disastrous circumstances increase as time goes by. The second assumption is that the perceived value of drug-use activities will decrease with extended drug use as tolerance develops. The third assumption is that on a day-to-day basis the addict will prefer to take drugs than not. Once these principles and assumptions are in place, the model predicts that over a thirty day period the individual who frames her choices locally will always choose to take the drug, whereas the individual who frames her choices globally will never choose to take the drug. This is because on a day-to-day basis drug-taking is always perceived to be more valuable, and so always the preferable course of action for the person who frames her choices locally. Abstinence, however, is the sequence of choices that yields the highest perceived value over the thirty-day period, and so is the combination of actions that will be preferable to the person who frames her choices globally.

On the strength of the apparently strong consistency between the biographies of addicts and the longitudinal studies of addictive behaviour, Heyman argues that we should consider addiction to be a disorder of choice, in which addicts are understood as those who prefer drug-use over non-drug-use and who frame their choices locally. According to Heyman, then, we need not suppose that addicts are suffering from a disease because we need not suppose that they lack the capacity to act voluntarily. Addicts voluntarily undertake their addictive behaviour since their behaviour is governed by consideration of the consequences. The difference between addicts and non-addicts is to be explained by the manner in which the choices are framed, given a starting preference for an addictive substance/behaviour, and not in terms of a loss of a capacity to choose. Consequently, the response to addiction that Heyman recommends is reminiscent of the edifying intent of the temperance movement: alongside recommending pharmacological interventions that supposedly decrease the perceived value of an addictive substance, Heyman recommends marriage and a broad training in economics that encourages individuals to frame their choices globally:

[V]oluntary behavior is an engine for change. Given the natural bias for local-choice bookkeeping, the global equilibrium establishes incentives for practices that encourage a shift to the global equilibrium. These practices include a more reflective approach to decision making, self-control, and the emergence of social traditions that encourage healthy levels of temperance. As we are almost always engaged in voluntary behavior, the pressure for positive change is continuous. This may be one of the reasons that self-destructive drug use so often ends without formal clinical interventions. (op. cit. p.172)

Despite the sophistication of Heyman’s approach, there are problems with his position. To begin with, we can note that while there may be a close correlation between the actual behaviour of addicts and the behaviour predicted by the model, he has not shown that there is no alternative way of understanding the behaviour. This is a problem, if the lesson we are supposed to take from Heyman’s account is that addiction is in reality a disorder of choice, rather than the less exciting lesson that addiction can be modelled as a disorder of choice, granted some principles regarding voluntary choice.

This leads us into a more serious difficulty, namely, that Heyman’s account seems to beg the question in favour of his conclusion. As we have seen, Heyman’s model has predictive power on the basis of certain ‘self-evident’ principles regarding voluntary choice. Let us grant for the sake of argument that these principles are self-evident when it comes to normal, non-addictive behaviour. It does not follow that the principles will also be exhibited by those who demonstrate addictive behaviour, except on the assumption that we can carry over principles of voluntary action to describe the mechanisms behind addictive behaviour. But this is the very question at issue, namely, whether addicts make choices in ways consistent with principles of voluntary choice. Let us take the first of the three principles as a case in point.

According to this principle, the perceived value of an item will vary according to the choices made by the individual. So, for instance, if I have Chinese food on Monday, Tuesday, and Wednesday, then I will perceive it as having less value on Thursday than I did on Monday. But does this principle obviously apply to the experience of addicts? One reason to think not is the persistence of cravings (and perhaps the increase in desire for the substance) despite repeated use. All that matters for our argument here is the plausibility of the hypothesis that the perceived value of taking an addictive substance, for instance, will not decrease and may even increase through repeated usage. For if that hypothesis is plausible, then we cannot simply take it for granted that addicts’ perceptions of the value of addictive behaviours will decrease through usage. (Heyman draws on the DSM to support the claim that the perceived value of drug use decreases over time, by appealing to the phenomenon of increased tolerance. But this appeal is not made to support the claim that addicts make choices according to his self-evident principles, but rather to plot data points on a graph that presupposes these principles.) In this way, it appears that Heyman’s account makes the questionable presupposition that addicts make decisions according to principles common across populations of addicts and non-addicts alike.

Finally, even granted that Heyman has shown that addictive behaviour is to be explained as a disorder of voluntary choice, it is possible that this conclusion leaves the important questions unanswered, since the minimal account of voluntary choice he offers is compatible with an account of addiction in which the addict still feels driven by her addiction. Consider, for example, Gabriel Segal’s discussion of the addict’s capacity for choice:

[Addiction] consists in a specific type of impairment in the subjects’ choice-making systems […] In active addiction, addicts have, in a certain specific sense, “lost the power of choice” […] This does not mean that when an addict or alcoholic takes drugs or drinks their behaviour is unintentional, or beyond their control in the manner of a reflex knee-jerk […] Nor does it mean that they could not do otherwise if they chose to do otherwise, and stuck to that choice […] To that extent at least, their drinking is intentional action, under their control, and the result of a choice to drink rather than to refrain. In that sense, and that sense only, they have power of choice over their using. (Segal 2017, p.366)

Segal thus concedes the point that Heyman insists on, namely, that the addict in some sense retains the power of choice over using: addictive behaviour is voluntary action. But Segal argues that there is a further sense in which the addict has lost the power of choice. According to him, even though addicts retain the power to refrain, if they were to choose to do so, they have lost the power to choose to refrain. Moreover, addicts often find their choices overturned (ibid.). We need not accept Segal’s conclusion to see the point: establishing that addicts exercise voluntary choice leaves a great deal of room for accounts that point to other ways in which the individual is unfree to choose. To sharpen the point, we can imagine a case in which an addict recognises that she is voluntarily acting, while nonetheless feeling powerless in her behaviour. Suppose that the addict recognises both that she is framing her choices locally and that she always values her addictive behaviour above the open alternatives. She might still feel powerless either with respect to the way in which she frames her decisions or with respect to how she perceives the value of her addictive behaviour, all the more so given the third ‘self-evident’ principle that Heyman assumes, namely, that individuals always choose the ‘better option’ within the given frame and granted the given valuations of the available behaviours. According to this model, the individual will always act out of her addictive preferences, given the frame and valuations that determine her choice.

Section Summary:

1.   Heyman argues that addiction can be modelled as a kind of irrational voluntary choice, according to which the addict systematically frames their choices locally, rather than globally.

2.   Heyman’s model may have predictive power, but it is insufficient to show that it captures the reality of addiction.

3.   Moreover, Heyman’s model begs the question by assuming that the principles that characterise voluntary choice in the standard case also apply in cases of addiction.

4.   Finally, even if Heyman is right that addiction involves no loss of voluntary action, this may miss the point, since there are other ways in which addicts may be powerless while retaining the capacity to act voluntarily.

 D: Attempt at a ‘Third Way’: Holton and Berridge

So far we have examined both sides of the antinomy of addiction in isolation. We have presented an example of the view that addiction is a brain disease that undermines the individual’s ability to voluntarily control her addictive behaviour. We have also presented an example of the view that addiction involves no loss of the ability to voluntarily control addictive behaviour. In both cases, we have found problems. Firstly, the neuroscientific evidence cited by Leshner underdetermines the conclusion that addicts suffer from a loss of voluntary control. Secondly, the predictive power of Heyman’s behavioural economic model of addictive behaviour, such as it is, does not entail that addicts maintain voluntary control over their actions; it may beg the question by presupposing that principles characteristic of voluntary choice are equally applicable in cases of addiction; and it may leave important questions concerning the addict’s freedom unanswered.

Richard Holton and Kent Berridge (2013) have recently developed an account of addiction that is explicitly billed as offering a ‘third way’ between those accounts that see addicts as simply compelled to act as they do and those who argue that the individual retains the capacity for choice. Intriguingly, however, Holton and Berridge argue that addiction is a disease, albeit a disease of desire. In this way, they offer an account that serves to reject a key presumption of Heyman’s account, namely, that the disease conception of addiction has to involve the claim that the addict is simply compelled to act as she does. But they also reject the conclusion that Leshner draws from neuroscience, namely, that the addict is simply compelled to act as she does. Their account is of particular interest because rather than playing one side against the other, they seek to resolve the antinomy of addiction.

Holton and Berridge build on work conducted by Berridge and others that suggests that ‘wanting’ is distinct from ‘liking’. Where ‘wanting’ concerns the identification of some behaviour as providing a reward, ‘liking’ concerns the enjoyment of the behaviour. In a number of experiments conducted on rats, it is reportedly shown that increased levels of dopamine lead to increased ‘wanting’—that is, increased activity in seeking a perceived reward—without a similar increase in ‘liking’. The suggestion is that there are distinct neural mechanisms that explain the enjoyment of a reward, on the one hand, and the desire for something, on the other, and that dopamine is connected to desire for reward, rather than enjoyment of that which is attained.

If rats’ dopamine levels are suppressed, they are no longer prepared to work to gain food rewards that they would previously have worked for. At the extreme, they will not eat pleasant foods that are freely available, even though they still display strong liking for them once the foods are placed in their mouths. Indeed, rats who had 98% of the dopamine neurons in their nucleus accumbens and neostriatum chemically destroyed would have starved to death had they not been intragastrically fed, yet their normal liking reactions indicated that pleasure in the food was unchanged. So liking is not sufficient for wanting. Conversely, by boosting rats’ dopamine levels we find that their wanting can be increased without their liking being increased—we will discuss an example of this shortly. So increased liking is not necessary for increased wanting. Indeed wanting can be artificially engendered in rats without any signs of liking. (Holton and Berridge 2013, p.249)

With the distinction between wanting and liking in place, and the connection made between dopamine and wanting, the pieces are in place to develop a model of the relation between all of these.

According to Holton and Berridge, the distinction between wanting and liking is realised in two conceptually distinct systems. The first system is responsible for identifying what sort of category a foodstuff belongs to, how much goodness is to be taken from ingesting that foodstuff, and sending a signal to a second system responsible for regulating consumption. The second system is responsible for regulating the consumption of the foodstuff in on the basis of the parameters established by the first system. As they describe them, the two systems work in tandem as follows. Upon discovering something to be good, the first system forms a dispositional or intrinsic desire for that substance, shaped by how good the substance is discovered to be. Dispositional desires are distinguished from occurent desires. While I may have no occurent desire for water right now, I have a dispositional desire for water in the sense that I am disposed to desire water (as opposed to some other substance) when I become thirsty. So suppose a creature discovered that a certain berry was good. The first system, as Holton and Berridge describe it, would form a dispositional desire for that berry. If the creature came across the berry again, the first system would send a signal—they call this the ‘A-Signal’—to the consumption regulation system, setting up the parameters for consumption. The consumption regulation system then sends a second signal—the ‘B-Signal’—which triggers an occurent desire to consume the substance when it identifies an item as a berry.

Importantly, Holton and Berridge claim that the identification of an item as belonging to a certain foodstuff is not carried out at the level of the A-Signal. In other words, although the initial consumption of a foodstuff recognised as good will set up an occurent desire for foodstuffs of that type, the identification of something as belonging to that type happens through associative mechanisms. That means that there can be a scenario in which the A-Signal sets the parameters for consumption that are appropriate for a given foodstuff, even though the substance sampled is not the same sort of thing as that which established the dispositional desire. So, for example, a creature could encounter something that is not a berry with the parameters for consumption set as though it was encountering that berry, since the substance has been misidentified through an associative mechanism and has mistakenly set up the parameters for the regulation of consumption. These two systems together describe a process by which creatures act on wantings, irrespective of how much the substance is liked upon consumption, and according to which aberrant desires for the consumption of substances can be explained:

Let us summarize then: the consumption system will set its dispositions—its dispositional desires—on the basis of two inputs, the strength of the A-signal and its own identification of what is being consumed at the time it gets the A-signal. On the basis of these dispositions it will send out an appropriate B-signal whenever it recognizes a food as belonging to a certain group. That B-signal will in turn determine the pattern of consumption. (op. cit. p.255)

One further piece of the picture needs laying in place. For as well as laying down dispositional desires and setting up the parameters for the regulation of consumption, Holton and Berridge claim that the A-Signal has a further accelerative effect, amplifying the effectiveness of the B-Signal. Thus, the A-Signal is responsible for disposing the creature to have certain occurent desires upon the associative identification of something as belonging to a category already identified as good, and to accelerating the signal sent by consumption system, thereby increasing the effectiveness of the subsequent occurent desire for the identified substance.

But what is the role of dopamine in all this? Holton and Berridge claim that dopamine is the A-Signal. That is to say, dopamine is responsible for establishing dispositional desires, for setting up the parameters of the consumption system, and for accelerating the B-signal that drives the creature to consume the identified substance. Dopamine is thus responsible for the subsequent wanting for a substance, both in the sense that it is responsible for setting up long-standing dispositional desires for the substance and for accelerating the effectiveness of the occurent desire for that substance upon identification. Wantings can persist independently of likings.

Now that we have seen how Holton and Berridge understand the relation between wanting and liking and the role of dopamine in the establishment of dispositional desires and their relation to the regulation of consumption, we are in a position to understand their account of addiction. With all the pieces in place, their summary of their account is brief:

Since the addictive drugs artificially stimulate the dopamine system so powerfully, they give rise to long-lasting dispositional desires. The dispositional desires are triggered by cues surrounding the consumption of the drugs: the drugs themselves, but also, given the associative nature of the process, the places in which they are consumed, the paraphernalia surrounding their consumption, and so on. Since these are intrinsic and not instrumental desires, they are not undermined by the belief that consumption of the drugs will not be pleasurable, or that it will be harmful in some other way. These dispositional desires may persist long after the subject has stopped taking the drugs and has gone through any associated withdrawal. A cue provided by seeing the drug, or the environment in which it was once taken, or even by imagining it, may provoke a powerful occurrent desire for it; and if this results in further consumption, the whole pattern will be repeated (op. cit. p.260)

In summary, then, Holton and Berridge present addiction as a condition in which the addict is subject to strong cravings that are a result of the artificial stimulation of the dopamine system. This provides a boost to occurent and dispositional desire for the substance without leading to increased enjoyment of the substance. Holton and Berridge’s account thus provides the following answer to the question of the addict’s relative freedom. The agent has an unchecked freedom to resist her cravings. If she does not resist her cravings, she will act out her addictive behaviour. It takes a lot of effort to resist cravings, however, because of the established neurology of the condition. Accordingly, while the individual has freedom to refrain from addictive behaviour, it is hard to exercise this freedom. The addict is compelled, then, to the extent that she has strong cravings, but she remains in control to the degree that she can resist these cravings. In this way, Holton and Berridge believe that they have charted a middle course between compulsion, on the one side, and control, on the other.

There are, however, some problems with this account. Holton and Berridge argue that some addicts do act contrary to their cravings, such that cravings as such must be resistible. There is a sense in which this claim is true: in principle, the presence of cravings does not in all cases determine whether the agent acts on them. Yet the mere fact that cravings are the sort of thing that, in principle, are not necessarily determinative does not tell us whether, in any particular case, the individual has the power to resist her cravings. The individual may lack the ability to realise what is in principle possible, since the conditions necessary for realising the possibility may not be in place for her. Moreover, it may be the case that addicts whose addictions have severely damaged their brains may be so damaged as to lack the capacity for free choice. Once we see this, then we realise that although Holton and Berridge’s account leaves unanswered the question of any particular individual’s freedom with respect to her addiction. Since they have no account of how or how often the individual has the ability to resist her cravings, they have no answer to the question of the circumstances under which some particular individual may ever be in a position to do so. For this reason, they offer no solution to the question of whether addicts are compelled or whether retain control, despite presenting their account as a third way between these extremes, and thus leave the apparent antinomy of addiction in general standing unresolved.

In the following section we shall turn our focus to a different sort of resource for theoretical reflection on addiction: the 12-Step Programmes. Our aim shall be to identify whether, implicit within these programmes, there are to be found resources for an alternative solution to the antinomy between compulsion and choice.

Section Summary:

1.   Holton and Berridge provide a sophisticated and nuanced account of the brain processes that underlie addiction.

2.   According to this account, addictive substances artificially stimulate the dopamine system, which 1) creates dispositional desires for the substance; 2) triggers occurent desires for the substance; and 3) accelerates the occurent desires.

3.   According to this account, addiction creates strong cravings in the addict that are very difficult, but not impossible, to resist.

4.   Since Holton and Berridge give no account of the particular conditions under which addicts may be able to resist their cravings, however, they provide no ‘third way’ between the antinomy of compulsion and choice we have been discussing above.

12-Step Programmes

A: Introducing 12-Step Programmes

The first 12-step program was developed by Bill Wilson, one of the two founding members of Alcoholics Anonymous (AA) and author of the fellowship’s basic textbook, Alcoholics Anonymous. Since the publication of Alcoholics Anonymous in 1939, not only has the organisation been hugely successful in establishing itself worldwide (AA counts two million members among its ranks), it has also been hugely influential in the establishment of other organisations, geared to the recovery of other forms of addiction. These further 12-Step programmes include Narcotics Anonymous (est. 1953), which provides support for those who have problems with drugs, and Gamblers Anonymous (est. 1957), which focuses on gambling addiction. A great many other support groups have taken up the AA model, ranging from groups that address problems with debt (Debtors Anonymous, est. 1971), to organisations set up in response to reported addictions to sex (Sex Addicts Anonymous, est. 1977) and cluttering (Clutterers Anonymous, est. 1989).

The 12-steps, as formulated by AA, reads as follows. The steps are presented as both a record of a reportedly successful program of treatment as well as offering a guide for the reader’s own recovery:

  1. Admitted we were powerless over alcohol – that our lives had become unmanageable.
  2. Came to believe that a Power greater than ourselves could restore us to sanity.
  3. Made a decision to turn our will and our lives over to the care and direction of God as we understood Him.
  4. Made a searching and fearless moral inventory of ourselves.
  5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
  6. Were entirely willing that God remove all these defects of character.
  7. Humbly, on our knees, asked Him to remove our shortcomings – holding nothing back.
  8. Made a list of all persons we had harmed, and became willing to make complete amends to them all.
  9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
  10. Continued to take personal inventory and when we were wrong promptly admitted it.
  11. Sought through prayer and meditation to improve our contact with God, praying only for knowledge of His will for us and the power to carry that out.
  12. Having had a spiritual experience as the result of this course of action, we tried to carry this message to others, especially alcoholics, and to practice these principles in all our affairs. (Alcoholics Anonymous 2001, pp.59-60)

Since the large number of existing 12-Step programmes would make a comprehensive survey of the field unmanageable within this Green Paper, and since many programmes base their practice on or are affiliated with Alcoholics Anonymous, in what follows we shall focus our attention on the 12-Step programme that is run by AA. To understand the 12-Steps further, it will be helpful to survey the context from which they emerged. This will also help us to understand some of the criticisms that have been raised against the programmes, which we shall discuss below, before moving on to discuss how 12-Step programmes might provide us with the resources to provide a novel response to the antinomy of addiction.

B: A Brief Prehistory of 12-Step Programs

Steven Finlay (2000) traces the development of the ideas that led to the formation of Alcoholics Anonymous to an encounter in Zurich between an American stockbroker, Rowland Hazard, and the renowned psychoanalyst Carl Jung. After a period of treatment for alcoholism in Zurich in the care of Jung, Hazard returned to the US believing himself to be cured. He soon reverted to addictive behaviour, however, and returned to Zurich for another spell of treatment. When he arrived, however, Jung told Hazard that there was nothing more that he could do for him, and indicated that his only hope lay in the possibility of transformative religious experience. Jung claimed to have seen a number of alcoholics recover after such a conversion.

Upon returning to America, Hazard became a member of the Oxford Group, an anti-establishment religious association focused on reviving early Christian practices. Among the practices undertaken by members of the group, members of the organisation were encouraged to:

(a) practice public and private confession of sin; (b) surrender completely to the will of God; (c) listen in quiet times for divine guidance; (d) make restitution to those they had harmed; (e) practice the “four absolutes” of purity, honesty, love, and unselfishness; and (f) carry the message to those still defeated. (op. cit. p.4)

In the hands of Bill Wilson, these principles were transformed into the 12-steps of recovery, which, as we have seen, require participants to confess wrongdoings to at least one other person, surrender to God (‘as we understood him’), improve contact with God through prayer and meditation, offer acts of reparation where this would not harm others, and to carry the message to others. Jung’s admission of his inability to cure Hazard’s addiction, then, along with his belief that recovery was possible through a transformative spiritual episode, both inclined Hazard towards the Oxford Group, from the doctrine of which the 12 steps of Alcoholics Anonymous were eventually derived, and set up the basic goal of the recovery program that was to later develop, namely, spiritual transformation.

Through his membership of the Oxford Group, Hazard became aware of another alcoholic, Edwin Thatcher, who was facing incarceration for behaviour connected to his addiction. Hazard and other members of the Oxford Group managed to convince the presiding judge to release Thatcher into their care, whereupon Thatcher learned of the techniques of the Group and experienced an extended period of sobriety. Thatcher, enthused by the apparent success of his practice and presumably accepting of the Oxford Group’s message to spread word of its message, approached an old school friend, Bill Wilson, whose alcoholism had developed during the years of the Great Depression. Through Thatcher, Wilson learned of the methods of the Oxford Group and the possibility of recovery through conversion. While convalescing in hospital after an extended and disastrous period of drinking, and while under heavy medication known for its hallucinogenic effects, Wilson had what he later came to understand as a religious experience. He describes it as follows:

All at once I found myself crying out, “if there is a God, let Him show Himself! I am ready to do anything, anything!” Suddenly the room lit up with a great white light. I was caught up into an ecstasy which there are no words to describe. It seemed to me, in the mind’s eye, that I was on a mountain and that a wind not of air but of spirit was blowing. And then it burst upon me that I was a free man. Slowly the ecstasy subsided. I lay on the bed, but now for a time I was in a new world, a new world of consciousness. All about me and through me there was a wonderful feeling of Presence and I thought to myself, “So this is the God of the preachers!” A great peace stole over me and I thought, “No matter how wrong things seem to be, they are still all right. Things are all right with God and His world.” (Wilson 1957, p. 63)

At this point, Finlay introduces another intriguing influence upon the development of Alcoholics Anonymous: William James. In the days following this experience, Wilson found himself introduced to James’ The Varieties of Religious Experience. Wilson was interested in James’ discussion of religious conversion, in particular the need for what Wilson later described as ‘deflation at depth’. The thought here seems to be that it is only by cultivating a condition of openness for a transformative religious experience that individuals will be prepared for, and thus capable of experiencing, a radical transformation to which they may otherwise have been closed.

As Finlay has it, the program of AA as manifest in the 12-Steps represents Wilson’s attempt to refine the message of the Oxford Group so as to help a wide audience. Having repeatedly failed to help other alcoholics by directly presenting the message of the Oxford Group its explicitly religious form, Wilson found that his program was more effective if the audience was appropriately primed. In this, Wilson was apparently following the advice of his friend Dr. Silkworth, who counselled him as follows:

You’ve got to deflate these people first. So give them the medical business and give it to them hard. … [Tell them] about the obsession that condemns them to drink … [that they will] go mad or die if they keep on drinking. Coming from another alcoholic, one alcoholic talking to another, maybe that will crack though tough egos deep down. Only then can you begin to try out your other medicine, the ethical principles you have picked up from the Oxford Group. (op. cit. p.68)

From its inception, then, Alcoholics Anonymous appealed to medical language as a means of cultivating openness to the further principles of recovery that it espoused. This provides an interesting view on the history of AA’s adherence to the disease model of addiction. Rather than arising from any metaphysical commitments about the nature of addiction, the ‘medical business’ was primarily appealed to as a way of presenting the problem of alcoholism to alcoholics in a manner that they would be likely to accept, and which would lead them towards the specific program of recovery that was derived from the principles of the Oxford Group, the aim of which was to cultivate the possibility of the sort of spiritual recovery attested to by Carl Jung.

According to the brief sketch of the prehistory of AA we have just developed, then, the content of the twelve steps that were later to be taken up and developed by many different organisations is derived from an explicitly religious association concerned to revive early Christian practices, and designed to appeal to a secular audience by drawing upon a medicalised language of disease.

Section Summary:

1.   Holton and Berridge provide a sophisticated and nuanced account of the brain processes that underlie addiction.

2.   According to this account, addictive substances artificially stimulate the dopamine system, which 1) creates dispositional desires for the substance; 2) triggers occurent desires for the substance; and 3) accelerates the occurent desires.

3.   According to this account, addiction creates strong cravings in the addict that are very difficult, but not impossible, to resist.

4.   Since Holton and Berridge give no account of the particular conditions under which addicts may be able to resist their cravings, however, they provide no ‘third way’ between the antinomy of compulsion and choice we have been discussing above.

C: Following the 12 Steps

In this section, we shall briefly summarise the process of following the 12 steps, as described in Bill Wilson’s (1981) guide The Twelve Steps and Twelve Traditions. As we shall see, one of the recurring difficulties with understanding how the twelve steps work concerns the relationship between the individual’s activity and passivity in following the programme. For while some of Wilson’s formulations place the onus on the side of the agent’s activity, presenting a prescriptive course of treatment that the addict may follow, other statements of his describe a process by which the individual finds herself passively subject to changes.

To anticipate, we shall suggest that although it is not the explicit focus of Wilson’s (or the AA’s) approach, this mixture of activity and passivity within the description of the twelve-steps may provide the resources for a resolution of the antinomy of addiction. For where every other theory we have surveyed has taken for granted the mutual exclusivity of activity and passivity, and consequently favours one side or the other of this divide, Wilson’s willingness to describe a process of recovery in which these categories are not neatly separated provides a novel possibility: if we can find a way to make sense of a form of agency that is neither simply active nor entirely passive, we may be able to make sense of the agent’s involvement in her own recovery in a way that does not presuppose that she must either be purely active, nor simply passive with respect to the delivery of a treatment plan. For this reason, we see Wilson’s formulations of the 12 Steps as affording us with clues towards an intriguing solution to the antinomy, according to which the distinction between activity and passivity that underpins it would be dissolved. In what follows, we present our interpretation of the twelve steps accordingly, by focusing on and drawing out the complex relations between activity and passivity in Wilson’s account.

Step 1:

Admitted we were powerless over alcohol – that our lives had become unmanageable.’

The paradoxical mix of activity and passivity that marks Wilson’s descriptions of the steps is perceptible from the first. While it may appear that there is nothing particularly problematic with admitting that you are powerless over alcohol, Wilson’s description of this stage makes it appear less of a step and more of a forceful shove. This is because in order to take this first step, individuals must have ‘hit bottom’. Here is Wilson:

We perceive that only through utter defeat are we able to take our first steps towards liberation and strength. […] [Little] good can come to any alcoholic who joins A.A. unless he has first accepted his devastations weakness and all its consequences. (Wilson 1981, p.21)

Why all this insistence that every A.A. must hit bottom first? […] the average alcoholic, self-centred in the extreme, doesn’t care for this prospect [of being honest and tolerant, of confessing faults and making restitution, of submitting to a higher power, of sacrificing time to deliver the message of A.A. to others]—unless he has to do these things in order to stay alive himself (op. cit. 24)

Here we see quite clearly the way in which, in this conception of the first of the 12 steps, active and passive aspects are thoroughly intertwined. On the side of passivity, the alcoholic must be defeated by their addiction before she can make moves to improve her lot. On the side of activity, the alcoholic must accept her defeat. But even this is a strange sort of activity: where we might think of agency as the ability to bring about a change in the world, here we have a form of action that consists in the agent’s acknowledgement of her inability to do just that.

In the early formulations of AA, Wilson claims, the organisation focused its efforts on those who hit rock bottom by ruining their relationships and commitments. This was problematic, however, as many alcoholics who joined AA had yet to hit this point. How might AA help these alcoholics to avoid the ‘literal hell’ of the rock bottom that other alcoholics had experienced? According to Wilson, the solution to this problem involved allowing alcoholics to identify with tales of devastation without having to live through a similar experience. This was achieved through presenting rock bottom as the inevitable end of a pattern of decline, and drawing others to see themselves as exhibiting this pattern. The identification came about through taking part in a simple test:

To the doubters we could say, “Perhaps you’re not an alcoholic after all. Why don’t you try some more controlled drinking, bearing in mind meanwhile what we have told you about alcoholism?” This attitude brought immediate and practical results. It was then discovered that when one alcoholic had planted in the mind of another the true nature of his malady, that person could never be the same again. Following every spree, he would say to himself, “Maybe those A.A.’s were right…” After a few such experiences, often years before the onset of extreme difficulties, he would return to us convinced. He had hit bottom as truly as any of us. (op. cit. pp.23-4)

Thus, the first step involves hitting rock bottom, either through suffering significant damage to one’s well-being or through identifying oneself as being on a course that would lead to such damage absent intervention. There is, however, another point at which the paradoxical relation between activity and passivity is evident. For why should any particular alcoholic identify himself with those who have actually reached a point of personal devastation? To be sure, there may be commonalities between the behaviour of one alcoholic and another, but that is not enough to force someone to identify as an alcoholic on the path to ruin, since there is surely enough scope for the alcoholic to reject the identification by pointing to salient differences. Here Wilson points out that the alcoholic may be helped to make the identification by being encouraged to consider the possibility that he is self-deceived. But again, coming to see oneself as self-deceived cannot be understood simply as an act of will, since someone who truly is self-deceived is surely in no position to accept that they are self-deceived: part of the deception is the denial of deception.

In this way, then, the first step is described in a way that presents a paradoxical mix of activity and passivity: the addict has to come to realise that he is already at rock bottom, either as a certain present or an inevitable future, which realisation can be realised through having come to ruin or otherwise by recognising ruin as the inevitable end of one’s current condition. Though hitting rock bottom seems to be something that comes to the addict, accepting defeat seems to be something that the addict does, even though this is a highly distinctive form of activity, marked by the realisation of one’s inability to bring about a change in the world.

Step 2

‘Came to believe that a Power greater than ourselves could restore us to sanity.’

The second step also involves a similar difficulty with regards to the relation between activity and passivity. Supposing that this is really a step, and therefore a movement that the individual is able to undertake, what sort of action is involved in ‘coming to believe’ that a higher power could restore one to sanity? Are we to suppose that belief is under the direct control of the will? This latter question is a substantial philosophical issue and has attracted a great deal of attention. On the one hand, we appear to respond to people as though they were causally responsible for the beliefs they hold: we can speak of beliefs as appalling and castigate those who hold them. On the other hand, it appears that we cannot simply decide to believe something at the drop of a hat. Try as I might, I cannot decide to believe that I am a turnip. (It is perhaps not irrelevant that one of the major figures in the debate over the voluntariness of belief is William James, whose essay ‘The Will to Believe’ emerged around ten years before the publication of The Varieties of Religious Experience, which book, as we have seen, was influential on Bill Wilson.[1])

As Wilson elaborates the step, however, there is no requirement to voluntarily believe that there is a power greater than oneself that can restore one to sanity. Rather, the second step consists in being open to the possibility that a power greater than oneself could restore one to sanity. Wilson imagines a dialogue between a sceptic and his sponsor, in which the sponsor claims that there is really nothing to accept at this stage: the addict must only renounce a defiant stance towards the possibility of a higher power with the ability to restore him to sanity, after which his eyes will be opened to the success of the programme and its relevance to him (Wilson 1981, p.27). Step 2, then, is the adoption of an open mind to a possibility that one might have renounced on the basis of a recognition of one’s own inability to perform the restoration one is willing to believe may be brought about by a higher power, which allows for the perception of the success of the programme, to which the addict had apparently been wilfully blind.

Nonetheless, despite this qualification there is still some ambiguity as to what sort of actions are involved in taking this step. On the basis of the first step alone, you have reached a position from which you accept that you are unable to do anything by yourself to overcome your addiction. This acknowledgement does not entail the further acknowledgement that something else may be able to help you: it is compatible with the first step that there is no possibility of recovery. On what grounds is the addict to accept that there remains a possibility for help? Again the answer comes through identification: having identified as an addict whose life would inevitably lead to ruin without intervention, one has also identified with those who claim to have been helped by the program. The identification with other members of the group, then, allows for the sense that a possibility for recovery lies open for you. Since you acknowledge that the possibility cannot be brought about through your own efforts, it would follow that only something other than you could fulfil this role. This step is not, however, free from the difficulties of coming to identify with the group that we have discussed above.

Step 3

Made a decision to turn our will and our lives over to the care and direction of God as we understood Him.

Once more, this step involves a paradoxical mix of activity and passivity. Here is one of Wilson’s formulations:

No matter how much one wishes to try, exactly how can he [the alcoholic] turn his own will and his own life over to the care of whatever God he thinks there is? Fortunately, we who have tried it, and with equal misgivings, can testify that anyone, anyone at all, can begin to do it. We can further add that a beginning, even the smallest is all that is needed. Once we have placed the key of willingness in the lock and have the door ever so slightly open, we find that we can always open it some more. Though self-will may slam it shut again, as it frequently does, it will always respond the moment we again pick up the key of willingness.[2] (op. cit. p.35)

The difficulty with this passage is that it seems to provide two conflicting roles for wilfulness: wilfulness is to be avoided, since the aim is to surrender one’s will to God, as He is understood, and yet wilfulness is also the means of evasion, the method by which the door is opened and wilfulness held at bay. How can wilfulness be overcome by an act of will?

In reply, one might claim that while it is one thing to aim to empower yourself through your own power, it is quite another to disempower yourself by the same means. While it is not clear by what right Napoleon could have crowned himself, once crowed he was well within his rights to effect an abdication. Moreover, the objection rests on a lack of sensitivity to the letter of Wilson’s description. For Wilson does not say that wilfulness can be overcome by wilfulness: his claim is that wilfulness can be overcome by willingness. What, then, is the willingness that Wilson describes? Where wilfulness brings with it connotations of defiant arbitrariness, by which an agent is driven to act simply to assert herself, willingness suggests yielding to something else, external to the agent. I might, for example, exhibit wilfulness is pushing a plan through regardless of everyone’s reasoned objections, whereas I might show willingness by being ready to undergo a medical procedure the effectiveness of which I must accept on trust. Again, we find the mix of activity and passivity. On the side of activity, the agent makes a decision to let God (as He is understood) take control. But, on the side of passivity, since this is not wilfulness, it more a surrendering of one’s own authority than the affirmation of another.

Steps 4 & 5

‘Made a searching and fearless moral inventory of ourselves.’

‘Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.’

We shall treat steps four and five together, since they are really two sides of the same coin. Step four involves identifying character flaws and step five involves making this identification into a public disclosure. Once again, this process is marked a similar mixture of activity and passivity we have been tracking in the previous steps. The process is described as one in which the agent seeks to discover her faults, and so cultivates a receptivity to those negative aspects of her character. But unlike a search, in which the object of the search lies somehow outside of oneself and perhaps far away, in compiling a searching moral inventory, the object of the search is, so to speak, already right before one’s eyes: in a sense, nothing could be closer. The character of the search is, then, correspondingly peculiar to the specificity of the alcoholic’s relation to her object of study. The alcoholic is attempting to see what is already in view. The problem is compounded by the fact that the alcoholic is supposed to be ready to see what she does not want to see: the composition of the inventory is supposed not to be guided by the wilfulness of the alcoholic but allowed to emerge by his willingness to see himself as he is. Wilson is on to this point when he describes the kind of confessional practice as involving navigating between two pitfalls: on the one hand, the alcoholic has to avoid the kind of self-congratulating self-affirmation that one finds in autobiographical works such as Richard Strauss’ Ein Heldenlieben (‘The Hero’s Life’), a result of the fact that Strauss reportedly found himself ‘no less interesting than Napoleon’. On the other hand, the alcoholic has to avoid the overly self-lacerating, but equally prideful, ‘painful pleasure’ of ‘guilt and self-loathing’. In both cases, the alcoholic distortedly presents herself to herself under some guiding preconception of who she is. Somehow, the alcoholic has to be able to cultivate a relation to herself so she can try to see herself as she is, rather than as she wishes to be.

There is yet one more aspect to the mixture of activity and passivity in this step. For not only does the alcoholic need to cultivate a kind of receiving/perceiving relationship to himself, Wilson claims that he needs to do so because ‘in A.A. we slowly learned that something had to be done about our vengeful resentments, self-pity, and unwarranted pride. […] We learned that if we were seriously disturbed, our first need was to quiet that disturbance, regardless of who or what we thought caused it’(Wilson 1981, p.47). In this step, then, Wilson points out that members who have succeeded in the program had come to realise that ‘we needed to change ourselves’. But the extent to which the individual is able to change themselves, and so is active in their own process of recovery, is immediately complicated by steps six and seven:

Steps 6 & 7

‘Were entirely willing that God remove all these defects of character.’

‘Humbly, on our knees, asked Him to remove our shortcomings – holding nothing back.’

We have just seen that steps 4 and 5 involve the identification and confession of one’s moral character under the realisation of the need for self-improvement. In step 6 and 7, however, the desire for self-improvement is stripped away and replaced with a readiness for improvement by God, as understood by the alcoholic, and a humble request for that improvement. This might appear to be in conflict with the previous steps: the alcoholic has supposedly just come to the realisation that he needs to improve himself, but now he is supposed to acknowledge that this is beyond his power. The appearance of inconsistency, however, presupposes that the alcoholic has to maintain a consistent view of himself and his powers throughout his engagement with the programme. But the point of the programme is precisely to transform just this self-relation. In other words, we find in each of the steps we have surveyed the encouragement to cultivate some kind of mixture of activity and passivity, in the direction of a series of transitions by which the alcoholic becomes recursively less self-involved. It might be that by the beginning of step 4, for example, the alcoholic comes to believe that he is in need of self-improvement. But by undertaking the complex form of confessional practice advocated in steps 4 and 5, however, he comes to realise that the defects identified include an over-developed sense of one’s own capacity, such that by step 6 the addict is willing to recognise that only the higher power is in a position to bring about the transformation.

Granted that point, we find once more the mixture of activity and passivity, even in the readiness to be transformed by the higher power. For on the side of passivity, Wilson likens the removal of personal defects to the removal of the obsession with alcohol. This is the sort of thing that might happen in a flash, brought about by the higher power. On the side of activity, however, Wilson notes that the personal defects listed in the inventory are not typically removed in this way and in fact require patience and humility from the alcoholic over an extended period. To begin with, the addict finds himself begrudgingly placing his defects, to which he still maintains some affection, before God for removal (op. cit. p.73). In this way, the alcoholic still maintains an attitude of self-assertion towards himself, since he wishes to retain the right to decide which features of his character are valuable and which are not. Gradually, however, Wilson claims that the addict relinquishes this position of self-judge and becomes accepting of the will of God, whatever that should be, such that we are ready to surrender any defects at all. This step is crucial, according to Wilson, since it is fundamental to the reordering of the alcoholic’s concern, away from himself and the desire to preserve the character traits in which he takes pride, to an indifference towards himself by which these traits might be willingly relinquished. Once the alcoholic’s self-concern is surrendered, it becomes possible for him to be concerned in others and God:

The Seventh Step is where we make the change in our attitude which permits us, with humility as our Guide, to move out from ourselves toward others and toward God. The whole emphasis of Step Seven is on humility. It is really saying to us that we now ought to be willing to try humility in seeking the removal of our shortcomings just as we did when we admitted that we were powerless over alcohol, and came to believe that a Power greater than ourselves could restore us to sanity. If that degree of humility could enable us to find the grace by which such a deadly obsession could be banished, then there must be hope of the same result respecting any other problem we could possibly have. (op. cit. p.76)

Reading between the lines, it is not just that the alcoholic accepts humility in order to improve herself but, rather, that humility consists in a kind of indifference to oneself, relative to concern for others and for God. This step is thus markedly similar to the kind of moral improvement described by Christian theologians, such as Augustine and Aquinas, through the infusion of the so-called ‘theological virtues’ of faith, hope, and love, which we have described at length in our two previous Green Papers (Batho 2016, 2017)

This suggests a further twist to the idea of compiling a moral inventory. On the previous steps, the idea seemed to be that, out of concern for self-improvement, one identifies the character flaws that one would like to have removed. Now, however, we have identified a higher-order kind of character flaw, namely, the manner in which one undertakes the task of wishing for self-improvement. One has to guard against undue self-concern in the manner in which one is ready for improvement.

Steps 8, 9 & 10

Made a list of all persons we had harmed, and became willing to make complete amends to them all.’

‘Made direct amends to such people wherever possible, except when to do so would injure them or others.’

‘Continued to take personal inventory and when we were wrong promptly admitted it.’

Steps 8 and 9 may appear to be more squarely on the side of activity, but note once again that step 8 involves becoming willing to make amends to the people one has harmed. Where ‘to will’ may suggest a single act, ‘becoming willing’ suggests an extended process. Step 10 thus builds in an important qualification to the confessional approach. For it might appear that once one has made a moral inventory, one has completed the task and can get on with things. Step 10 blocks off this way of thinking of the kind of self-improvement promoted in the 12-Steps. If the individual came into the 12-Steps looking for a quick fix, he finds at step 10 that he is in fact drawn into a life of continual self-examination, a commitment to vigilance with respect to oneself, where this vigilance consists not just in a wariness for the return of specific character flaws (as in the earlier steps) but a wariness for undertaking the concern for identifying character flaws in the wrong way (hesitantly, with the attitude of one who is ready to be reluctant to let go  of any character flaw). In this respect, the 12-Steps echo a perfectionist practice, according to which the aim is not to reach some final state of complete improvement, but to attain a form of continual reflection and development, to achieve a stable form of movement in the right spirit, rather than a settled position.

Step 11

Sought through prayer and meditation to improve our contact with God, praying only for knowledge of His will for us and the power to carry that out.’

The mixture between activity and passivity that we have been drawing out of the previous steps is clearly on show in this step. On the side of activity, the alcoholic is supposed to engage in prayer. But prayer is a distinctive sort of activity, here described in terms markedly similar to listening. If the contact with a higher power in previous steps involved humbly asking for shortcomings to be removed, here there is no constraint imposed by the alcoholic on what she might learn through her improved contact: she simply asks for knowledge of the will of the higher power, which will she is already (through undertaking the previous steps) willing to affirm. One may illustrate what is involved this step by considering the contrast between hearing and listening. Hearing is passive: we can’t help hearing the sounds around us. However, we can unconsciously tune out some of these sounds (such as a background conversation), in which case they do not register on our consciousness anymore. We still hear them, but we do not respond to them. By contrast, listening is the activity whereby we may recover the ability to hear the tuned out sounds, by focusing our attention on them. Similarly, on Wilson’s view (shared by theologians such as Augustine) our ‘contact with God’ is always present (which is why it only needs ‘improving’): it is always within our power to hear God. Yet in many cases this contact with the divine is tuned out by our focus on ourselves and on worldly matters, and so lost to us. Praying, like listening, is a way to recover what is already there by learning to focus our attention in a different manner, so that our connection with God becomes apparent and is strengthened by this coming to awareness (just as we start understanding a background conversation when we listen to it).

Step 12

‘Having had a spiritual experience as the result of this course of action, we tried to carry this message to others, especially alcoholics, and to practice these principles in all our affairs’

It is possible to read this step as requiring a life-long commitment to AA. This might lead to accusations that AA is operating as a cult, building into its promise of help the requirement that members stay within the organisation’s folds. There is, however, another way of reading this commitment, in line with our discussion of steps 8-10. Consider, for example, the following testimony from an early member of AA:

All the other people that had talked to me wanted to help me, and my pride prevented me from listening to them . . . But I felt as if I would be a real stinker if I didn’t listen to a couple of fellows for a short time, if it would cure them. (quoted in Vaillant 2005, p.433)

Where the earlier steps attempt to align the alcoholic to the good those they have wronged, the final step further inscribes the move by turning the alcoholic’s concern towards helping yet others, not just those that have been wronged, but those who are in need of help.

In Wilson’s descriptions of the steps, then, we find a paradoxical mix of activity and passivity, according to which the agent is presented as both subject to changes brought about by an external power and at the same time involved in bringing about those changes. The relation between activity and passivity is, however, left unthematized and unexplained. Below, we shall take Wilson’s discussion as affording us with resources that may be further exploited in the service of a way of framing addiction that provides a novel response to the antinomy we have been discussing above. For now, however, we turn to (some of) the criticisms extended to the Twelve Steps programmes.

Section Summary:

1.   The 12 Steps, as described by Wilson, involve a paradoxical mixture of activity and passivity.

2.   The steps are introduced as both a retrospective description of what happened and a prescriptive course of recovery.

3.   The relationship between activity and passivity is not thematised by Wilson nor given systematic analysis.

4.   While Wilson’s descriptions of the 12 Steps thus give us intriguing indications, they do not provide a detailed elaboration.

D: Criticisms of 12-Step Programmes

Some have claimed that AA programs demonstrate a shockingly low success rate (see Bufe 1998 ch.7). A number of recent publications, however, based on robust studies some of which are longitudinal, have argued precisely the converse:

Compared to individuals who did not enter AA in the first year, individuals who participated in AA for 9 weeks or more had better 16-year alcohol-related and self-efficacy outcomes […] Some of these differences were quite substantial; only 34% of individuals, who did not participate in AA in the first year were abstinent at 16 years, compared to 67% of individuals who participated in 27 weeks or more. (Moos and Moos, p.742)

Project Match revealed that during the first year AA alone  was  as  effective  as  the two most effective professional alternatives: cognitive behavioural and motivational enhancement therapies. Indeed, AA in some respects was superior to cognitive behavioural therapy. Second, the Match follow up also showed that regardless of the original treatment arm (cognitive behavioural, motivational, or Twelve Steps) the more AA meetings attended the better the outcome.

Perhaps the most convincing controlled study of the efficacy of AA came from an 8-year follow up by a behavioural psychologist, William Miller. […] after 8 years most Miller’s good long-term outcomes were abstinent and not controlled drinkers. In contrast to a long-term abstinence rate of 20% among the 81 clients who went to less than 100 meetings, 53% of the 13 clients who had subsequently made more than 100 visits to AA were eventually stably abstinent – a statistically significant difference.

Finally, at Stanford, a collaborative 8-year prospective study [30,31] underscored the value of AA in contrast to professional treatment. In 8 years, the two outcome goals of less drinking and more abstinence were only weakly related to days of professional inpatient treatment, but robustly related to AA attendance. In short, the effect of AA did not just rest on compliance with treatment. (Vaillant 2005, p.433-4)

Even if we grant the emerging orthodoxy that AA appears to be effective in achieving good clinical outcomes, however, there is still scope for criticism if either a) we can identify room for improvement in recovery; b) there is a rival program which may be ignored by the predominance of the AA model.[3] Here we review three criticisms of AA that take up these approaches respectively. Firstly, we shall review criticisms of 12-step programmes from the perspective of advocates of ‘second stage recovery’, according to whom 12-step programmes should be directed towards relieving their participants of their need. Secondly, we shall present the criticism that 12-Step programmes are crypto-theological. Thirdly, we shall review a vociferous criticism of 12-Step programmes from the perspective of ‘Rational Recovery’, which offers a rival model of recovery based on choice.

a) Dependency on Group Recovery

Firstly, it has been argued that AA and other 12-Step programs encourage an attitude of dependency on membership of the group which may inhibit the possibility of genuine recovery. The very formulation of the steps can immediately lead to the worry that programs foster a sense of dependency. As we have seen, the final step reads as follows: ‘Having had a spiritual awakening as a result of these steps, we tried to carry this message to others, and to practice these principles in all our affairs’. This might appear to commit members to a life of proselytising, as though the final step of recovery leads members into a lifelong commitment to expanding the membership of the program. On this way of interpreting the last of the twelve-steps, programs that abide by these steps constitutively exclude the possibility of a life outside of the programme.

This worry does not just concern the wording of the twelve steps but also the manner in which they are implemented. Some members have reported feeling pressured into accepting a view of addiction according to which it is guaranteed that if one does not regularly attend meetings, or otherwise refrain from a proper observance of the steps, then relapse will be inevitable. Indeed, members of the group are often presented with horror stories of those who have left the group, relapsed, and returned to tell the tale.

These pressures are considered to be problematic for a number of reasons. Firstly, it is simply not true that the only way to recover from addiction is to become a member of a 12-Step program. As we have seen, advocates of AA can cite studies which purport to show an impressive success rate. As Heyman’s compelling literature review has argued, however, many alcoholics leave behind their problem drinking in their mid-30s without signing up AA or any similar program (see Heyman ch.4, particularly p.87). This lends support to Charles Winnicks (1962) study, in which it was claimed that most people ‘mature out’ of addiction in their third decade.

Further worries might be raised by other research. Developing the work of Biernacki (1986), McIntosh and McKeganey (2001) argue that the ‘maturation’ out of addiction depends upon the ability of the addict to imagine a future in which they are no longer addicted. Members of twelve-step programs, however, are often taught that life outside of the program is just that of a ‘dry drunk’, that is, an addict who is not using. To the extent that 12-step programs encourage the thought that addiction is a permanent condition that cannot be left behind, to that degree it both may appear to be unsupported by the evidence and may work against one of the purported central mechanisms by which addicts are able to quit their addictive behaviour, namely, the ability to imagine a future in which they are no longer addicted.

These issues may seem to cast an unflattering light on 12-Step programs. Indeed, if we restrict our focus to these problems then it is not hard to see why some might jump upon such reports to describe the practice of twelve-step programs as one of harmful indoctrination, rather than liberating recovery. We should be careful, however, not to write off 12-Step programs on the basis of reports of bad practice, as though bad practice were either the norm or an inevitable consequence of the way that the program is framed. Nor should we be dismissive of the effectiveness of the programmes, for which there is indeed some robust evidence. A recent focus on ‘second stage recovery’ attempts to accept the benefits of twelve-step programs while also indicating their limitations, in light of the dangers of dependency that we have outlined above. Nixon (2005, 2008), for example, argues that it is helpful to view these programs as offering an effective method of dealing with the initial stage of recovery from addiction, but that they are helpfully complemented by a further stage in recovery, by which the addict is helped to build a new identity for herself outside of the process of recovery.

b) Crypto-Theology

Reformers of 12-Step programmes may also focus on another area of concern. For despite the fact that AA insists that it is not a religious organisation, secularists may worry that it smuggles in religious commitments. The problem, such as it is, may also concern members of other religions, for whom the requirement to admit to the Christian God, if that is what AA requires, may be impossible to accept.

Step three is likely to stand out particularly in this regard. If the ‘higher power’ referred to in step two need not be conceived as God, then why does the third step make explicit reference to God? Why not stick with ‘higher power’? To be sure, the reference to God is highly qualified: God as we understood him would seem to be quite different from God as described in the gospels. Sceptics may claim still to detect some disingenuousness in this qualification, however. Firstly, for an atheist, there is no God to understand, and so nothing to understand ‘Him’ as. On this view, the supposed breadth of the qualification still smuggles in a commitment to belief in God; it merely allows for variation of personal understanding of Him. In response to this objection, it might be argued that the qualification is supposed to be broad enough to allow for any higher power. In keeping with the previous step, in which the alcoholic may identify AA as the higher power, ‘God, as we understand Him’ is intended to be synonymous with ‘a higher power, as we understood it’. But this leads us to a related problem. For despite all the overtures of maximal liberality when it comes to choosing your ‘higher power’, it turns out that not just any god will do. If I am seeking the care of a higher power, in whom I may place my trust to restore me to sanity, I should be disinclined to appeal to Itztlacoliuhqui, ‘Everything Has Become Bent by Means of Coldness’, the Aztec god of frost. Whatever the higher power is, it has to be understood as of the sort that can be trusted to restore the individual to sanity. The danger here is that AA’s liberality over the identification of a higher power may amount to nothing more than the claim that you can pick any higher power you like, so long as it is an omnipresent, omniscient, omnipotent and omnibenevolent God of love and mercy.

Defenders of AA might reply, however, that while AA does place some constraints on the ‘understanding of God’ that is fit for purpose, we need not think that this is so constrained as to specify the Christian God uniquely. If we grant that AA can be a higher power, then this seems to fit the bill: AA is recognised as something that has the power to restore one to sanity, should one decide to turn one’s will and life over to the care of the group. While this reply makes sense in response to the worry raised at step 4, however, it is less obviously satisfying further down the list. For at step 11 the underlying tension between the explicit liberality of the 12-steps, with regards to what is a permissible ‘higher power’ comes into further difficulty. For while we might admit that we can acknowledge that AA itself is a higher power, in the sense that it has the power to restore us to sanity, we cannot straightforwardly carry through this identification to the 11th step. For while prayer and meditation may be appropriate ways of attempting to improve contact with God, they are not obviously appropriate means of improving contact with AA. If I want to know the will of the AA, I would be better advised to simply ask my sponsor what was going on.

There are, however, also ways of reading this step that avoid the problem. If we really take the liberality of the formulation of the AA steps to heart, we can focus on the encouragement for meditation and drop the business about establishing contact with a higher power. This is the approach Gabriel Segal (2013) takes, for example, in explaining his preferred formulations of the twelve steps. For Segal, step 11 need only be read as encouraging a form of meditation (Segal 2013, pp.66-69). However, other difficulties remain.

c) Submission to a Higher Power

A criticism closely connected to the first concerns what some have seen as the culture of victimhood and submissiveness that is cultivated by 12-Step programs. Those who advance a complaint of this kind may also appeal to the formulation of the steps, which repeatedly emphasise the individual’s powerlessness to overcome her addiction as well as the recognition of a higher power to which the individual is invited to submit entirely, six of which appear to present recovery as a matter of submitting oneself entirely to God, as one understands him, and therefore accepting that one is entirely incapable of recovering from addiction on one’s own.

A striking example of criticism of 12-Step programs along these lines is to be found in Jack Trimpey’s efforts over the last three decades to establish a movement around the program of what he calls ‘Rational Recovery’(Trimpey 1996). Trimpey does himself few favours in the presentation of his ideas. He explicitly claims to be recovering the authentically American values of self-reliance and individual responsibility in an age in which the inauthentically American values of victimhood and Big Government are operating as the root cause of addiction. Trimpey’s mission is not just to save addicts, but also to save American liberty. Trimpey’s peremptory voice may, then, be off-putting for some readers. We can, however, strip back much of Trimpey’s presentation of his program to reveal an interesting and provocative alternative to 12-Step programs, which may be effective despite jettisoning both the group-orientated focus of recovery and the insistence on the need to submit to any power beyond oneself.[4] We shall now reconstruct Trimpey’s position.

Every addict has within them an ‘addictive voice’ (AV), which Trimpey personifies as ‘the beast’. The AV or beast is shorthand for any thought, inclination, feeling or desire to drink. Trimpey claims that group recovery programs in fact serve to strength the AV, since they cultivate an understanding of addiction as a disease and addicts as victims for whom there is an ever-present possibility of relapse. This model strengthens the AV, according to Trimpey, since it plays right into its hands. In diagnosing addiction as a disease, group recovery programs provide addicts with a future that their AV desires, namely, one marked with repeated ‘relapses’, that is, continued drinking. That is to say, in seeing alcoholism as an untreatable disease of which the symptom is drinking, the alcoholic is encouraged to view her future as one that will inevitably involve drinking, rather as a diabetic might see her future as inevitably involving hypoglycaemia. Since American society, according to Trimpey, by and large supports group recovery programs through a system of threat, inducement, and reward, he charges the government with being implicated in cultivating the frame of mind that addicts are readily able and willing to accept, namely, that alcohol will always play some sort of role in their lives. This, I take it, is the thought behind Trimpey’s typically hyperbolic claim that ‘social service is provided by agencies that spread illusions, misconceptions, and bad advice we may call the collective Addictive Voice, the root cause of mass addiction’ (Trimpey 1996, p.63).

To counter the tendency to think of alcohol as a permanent feature of the individual’s life whether she likes it or not, Trimpey urges addicts to reclaim individual responsibility for their actions, rather than putting them down to their addiction. To this end, Trimpey has developed a method he calls Addictive Voice Recognition Technique (AVRT). AVRT is designed to focus addicts on their desires, to somewhat externalise them, and in doing so to recognise that they have a choice on whether or not to act on their desires.

AVRT is presented so as to make it seem compellingly straightforward to understand; it acknowledges none of the paradoxes and complexities of the 12-Step programmes. To follow the AVRT, the addict must first clear her mind about all she believes about recovery from addiction. In this way, the addict is encouraged to focus on her addiction directly as it is experienced. Once this has been completed, the addict can focus her attention on her addiction. She is encouraged to ask whether she wants to quit. Trimpey supposes that the addict will feel conflicted: she will want to both quit and not to quit. Once she recognises her conflict, the addict is encouraged to dissociate herself from her cravings by interpreting her desire to continue, and all that goes with it, as ‘The Beast’. Once the AV has been identified as The Beast, the addict can set to work using ‘Addiction Diction’. This technique involves refusing to apply first-personal pronouns to the AV. Instead of saying ‘I want a drink’, the addict now says ‘it wants a drink’. Once this step has been taken, the AV is ‘forced’ into addressing the addict using the second-person pronoun:

­­[I]t [the AV] will say something like, “You can handle it. You’ve been good now for six days, and you can have just a little, just this once.” Rejoice! You are in control. You have forced your adversary to come to you, using the pronoun “you,” arguing, begging, and pleading. Sometimes it will even speak for both parties, you and it, by saying “We need something. Let’s go downtown and get some.” Have no mercy. Be at least as cruel to it as it has been to you. Abstain. (op. cit. p.37)

Now that the AV has been put in its place, so to speak, the addict can go about designing her ‘Big Plan’ for abstinence. The Big Plan for abstinence is the (perhaps deceptively) simple assertion, with meaning, that ‘I will never drink/use again’. All the addict has to do to wrest control is mean what she is saying. She can then trust herself to stick to that commitment, thereby freeing herself from The Beast (op. cit. pp.38ff).

We have noted above that Trimpey cites a study in support of his claim that his programme is effective. We should, however, take this with a pinch of salt. Galanter et. al. (1993) presented findings that ‘73% of engaged members had sustained [abstinence] after an average of 8 month’ membership’ (op. cit. p.506). While this might appear impressive, and may indeed indicate the effectiveness of the programme, Galanter et. al. are properly circumspect in the presentation of their results. Firstly, the study is not longitudinal and, therefore, cannot show the long-term effectiveness of Rational Recovery. Secondly, the authors point out that many of the members were not practicing the methods advocated by the group, which may suggest that unmeasured external factors are at play. Moreover, they explicitly point out that 25% of the respondents had been sober for at least 3 months before joining (op. cit. p.505) and that these members ‘had attended, on average, as many as 19.7 (SD = 16.9) AA meetings in a month at one point in the past’ (ibid.). AA may, then, have some role after all in these addicts’ recoveries. In light of the limitations of their study, the authors do not claim to have demonstrated the effectiveness of Rational Recovery so much as to have provided ‘a context for further study’ (op. cit. p.506).

Perhaps most problematic of all, however, is the fact that Trimpey significantly downplays the complexity of agency that must be involved in carrying out his programme. He believes that it amounts simply to self-assertion and freeing oneself by taking control. But if we look closely at some of the steps we have presented, we will see that matters are more complicated. Firstly, AVRT only gets going once the addict has got into a position from which she genuinely desires to abstain. As we have seen in our discussion of the 12-Step programmes, this cannot be straightforwardly understood as an act of will. Indeed, we might even say that AVRT begs the question, in that the most difficult step of all is the one it presupposes is already in place, namely, the honest desire to quit. Secondly, Trimpey supposes that it is entirely straightforward to dissociate from one’s desires. But how is this possible? It is one thing to say that I do not desire something, and quite another to experience my desires as coming from something alien. This problem reaches a head in the statement of the Big Plan. Trimpey supposes that one can mean something at will. This, however, is doubtful. I cannot mean ‘it is raining’ at will, if I do not believe that it is raining. And I cannot believe that it is raining at will. Why should matters be any different when it comes to the statement of a commitment? I might despondently reflect on my history of failed resolutions and hear in my own voice an echo of those past failures. I can say ‘I will never drink again’, but I cannot mean it unless I am ready to do so, and it is not clear that I can make myself ready to do so simply by an act of will. In these ways, then, Trimpey’s programme of Rational Recovery may in fact harbour many of the complexities that he is trying to avoid, by building in steps that are not straightforwardly comprehensible as assertions of will.

Beyond these issues, we may justifiably wonder whether Trimpey has properly captured the character of 12-Step programmes. To see why this is the case, we shall now return to directly discuss the antinomy, specifically with regard to how both Trimpey and the 12 Step programmes sit in relation to the two poles of powerlessness and control.

Section Summary:

1. The 12 step programmes have come in for criticism from a number of different sources.

2. Some argue that the 12 Step programmes need to be complemented by a form of ‘second stage’ recovery, through which members of groups are encouraged to build lives for themselves outside of the programmes.

3. Others may find that the 12 Steps surreptitiously bake in theological commitments that are explicitly disavowed.

4. Yet others find the 12 Step programmes emphasis on powerlessness too disempowering and seek to redress this by offering alternative methods of self-empowerment.

Conclusion: The Antinomy Revisited

In our discussion of Wilson’s descriptions of the 12 steps, we pointed out that his account is marked by a paradoxical mixture of activity and passivity. This is neither emphasised by Wilson himself nor thematised in the literature we have been discussing. This lack of thematisation is problematic, since the addict’s role in their own recovery is left unspecified and subsequently open to criticism, especially from those such as Trimpey who rail against the idea that the addict is simply powerless to overcome her addiction. In this section, we shall articulate a framework in terms of which the mixture of activity and passivity in addiction might be better understood. We shall then apply this framework to the antinomy we have been discussing throughout, and examine some theoretical and practical repercussions for our understanding of addiction.

We shall introduce our case by means of an analogy. Imagine a person at her computer. She is in control of the operations of her computer in the sense that she has the power to make effective choices about how the computer operates. She has power within her relationship to the computer. Also imagine, however, that her computer is connected to a network run by an administrator who has the ability to set the parameters within which the operator’s control may be exercised. The administrator may, for example, allow the user to control the word processor but deny access to all other areas. The administrator also has the ability to step in at any moment and take over operation, such that the operator is left watching the document being written for her. Since the range of the operator’s control is restricted by the administrator and may be overruled, we might say that the administrator has overall domination over the computer user even when the latter is exercising local control within her relationship to the computer,. To anticipate, we shall use a similar framework to model addiction. According to this model, the addict is like the operator, whose control over her behaviour is genuine but limited by parameters set by the addiction and which may be overruled by the addiction. Before we sketch the connections between this model and addiction more carefully, however, we can ask whether the computer operator is totally powerless, even when the administrator has taken charge.

Imagine that the administrator has taken control. Is the user entirely powerless? Not necessarily, since even though she has lost power within her relationship to the computer, she may regain power over her relationship to the computer in several ways. First, she might try to undercut the administrator’s domination, either to restore her own control or to remove the possibility of further interference (or both). Second, she might renegotiate her relationship to both the computer and the administrator, perhaps by leaving the office and finding some other occupation. If either of the these two strategies is viable, the computer user would maintain power over her relationship to the computer, insofar as she could either regain control over it or to leave the matter behind.

We can make two general points. Firstly, whatever power the computer user maintains over her relationship to the computer, it cannot be reduced to the ability to control the computer: in the case in which the administrator has taken control, it is precisely because the user acknowledges that she has lost that ability that she can have recourse to other ways of exercising her agency with respect to the machine. Secondly, although in theory she is able to leave the computer and administrator behind, it might in practice be very difficult for the computer user to realise this possibility, especially if she has come to rely on the relationship to the computer for her livelihood, and so depends on the relationship materially, or if she has come to understand herself as a computer operator, and so depends on the relationship psychologically. Even in that case, however, there is still room for the expression of agency, to the extent that there is something the computer user can do to cultivate possibilities for herself outside of the scope of the relationship to the computer. In response to practical dependence, for example, she might spend evenings in an education programme through which she might gain a qualification that would allow her to quit her job. In this way, she might become eligible for another possibility. Alternatively, in response to psychological dependence, she might spend a long time speaking with others whom she recognises as having been in a similar situation but who found ways of living fulfilling lives outside of their previous occupations. In this way, she might be able to recognise a new possibility as open to her. In the first case, the computer user would cultivate her eligibility for a possibility that she already finds open for her; in the second case she would cultivate the intelligibility of a possibility as open for her.

Before returning to the case of the addict, we can summarise our analogue as follows:

  1. an individual might be in local control while being overall dominated by something that sets the parameters within which her control operates and could overthrow her control at any point;
  2. even in such circumstances, the individual can retain agential sway, insofar as she might either:
    1. be able to work to undermine the dominating power;
    2. be able to find a way of no longer being subject to the dominating power, in one of three ways:
      1. the agent may be able to realise an alternative possibility for which she is already eligible;
      2. the agent may able to make herself eligible for a possibility she already understands as open for her;
      3. the agent may be able to discover possibilities as open for her, for which she may or may not need to work to make herself eligible.

Three points are worth noting. Firstly, each of the possibilities contained under 2) presupposes an acknowledgement of powerlessness as domination within one’s relationship to something. Insofar as I am seeking to either undermine the power of the administrator or otherwise leave my job, for example, I am working in light of the acknowledgement that I am dominated by the administrator. The framework thus makes space for a form of agency in light of acknowledged powerlessness.

Secondly, not all of the possibilities contained under 2) involve the same kind of agential work. A political metaphor will help to make the point. It is one thing to call a population to arms so as to overthrow a tyrant, and quite another to draw a population to come to see that there is a possibility of overthrowing a tyrant, to which they may then be called to arms. Similarly, we might think, an agent might recognise that she is dominated, but if she does not have a sense of an alternative way of carrying on, resistance to subjection by the dominating power may not only seem futile but incoherent. The work involved in coming to recognise a possibility as open would thus appear to be rather different to the work involved in realising a possibility that one understands to be open.

Thirdly, it is possible that each of the possibilities contained under 2) can only be realised in partnership with some other power, such as other people or a ‘higher power’: it might be that I am only able to undertake a course in adult education with adequate childcare; it might be that I am only able come to see a possibility as open for me through extended conversations with others or, perhaps, by the grace of God. In this way, the framework does not presuppose that the further opportunities for the exercise of agency belong to the individual alone or exclude a priori any role for a ‘higher power’.

With all of these points on the table, we can now ask whether this framework can help us tease apart the paradoxical mix of activity and passivity within Wilson’s descriptions of following the 12-Step programme.

We can use this example to model addiction in the following way. A person may be addicted to a substance in the sense that her control over the use of that substance is subject to restraint and overrule by her addiction. The addict can be in control of her behaviour, rather as the computer user can be in control of the machine, while nonetheless being dominated by her addiction: her control is limited to an array of activities delimited by the addiction and she is subject to overrule, rather as the computer user’s control may be overridden. On this model, the addict is subject to a loss of local control through overall domination, rather than necessarily incapable of controlling her behaviour. If we frame addiction in this way, then we can see that the addict might still be able to express her agency in several ways, even under the domination of the addiction.

Firstly, the model allows for the possibility that the addict is in control of her behaviour, so long as she is not overridden by the dominating addiction. In this respect, our model accommodates the possibility that the agent may at times retain control, while still being powerless over whether she is in control. To be sure, her experience of this control is likely to be different to the experience of control outside of a relation of domination: where a person free of domination may experience her control as straightforwardly her own, a person inside a relation of domination may experience what she can do as what she is merely allowed to do.

Secondly, this model makes room for the possibility that the addict may be able to undermine the dominating power of the addiction. Importantly, the model does not entail that addicts do have this ability; our framework is compatible with the possibility that the addict will always be dominated by her addiction. In this way, our framework allows for the possibility that the dominating character of the addiction is determined by the neurobiology of addiction, by which the addict’s relationship within her addiction is determined as one of domination. Our model is thus compatible with (but does not entail) that the dominating character of addiction is something the addict has to live with for the rest of her life, as a threat of subjection to be avoided.

Thirdly, if we grant that the dominating character of the addiction is determined by neurobiology, our framework still makes space for the exercise of agency, since it allows for the possibility that the addict may be able to be freed from the subjection of her addiction. This, however, would require her to become aware of the difference between local control and overall lack of control, and to refocus from the former towards the latter. In other words, the addict would need to realise that rather than focusing on her ability to make local choices (such as using now or later, this substance or that other one, etc.) she needs to become aware of the sway of the addiction over her, and to seek to escape it (rather than to have control over it, as if it was a matter of local choice). A political metaphor will again help to make the point. I might be a citizen of a nation ruled by a tyrant by whom I am dominated. If so, there may be nothing I can do about whether I am dominated if I am a subject. But I might be able to leave the country, in which case there is something I can do about whether I am subject to domination. Similarly, according to our model, there may be something the addict can do about whether she is subject to the domination of her addiction, even if there is nothing she can do about whether the addiction is dominating while she is subject to it. Crucially, that something is not about having control over the addiction in the sense of being able to resist using at will, but about changing the framework itself. In particular, our model makes room for three possibilities.

Before we introduce these possibilities, it will be helpful to make a preliminary qualification. We emphasise that these are possibilities: the framework does not entail that they are realised for every addict or that to exercise these possibilities for agency is at all straightforward in any case. Indeed, we have good reason to suppose that matters are more complicated in the case of addiction than they are with the computer operator. For, however dependent the operator may be on her occupation, she is not biologically dependent on that relationship. The possibilities we sketch here, then, should be read with this in mind. Where the computer user may be able to leave her occupation without physical harm, the addict’s ability to quit may be constrained by her physiological dependency on the addictive substance. With this in mind, what are the three possibilities for no longer being subject to the domination for addiction, for which our framework makes space?

Firstly, the addict may be able to move away from addiction. Rather as many addicts within the US military recovered from their addictions by returning from Vietnam to the US (see Robins et. al. 2010), so too other addicts may simply be able to ‘relocate’ away from their relationship with the addictive substance. Evidently, this possibility for agency may be easier to exercise for some addicts than others, depending (among other things) on the pharmacology of the addiction.

Secondly, addicts may seek to make it possible to move away from the domination of addiction, by making it possible for them to ‘relocate’. This is one way in which we might describe ‘second stage recovery’, in which addicts are encouraged to build lives for themselves outside of their lives as addicts and may also be a role fulfilled by pharmacological treatments which seek to address the physical dependency. In this way, they may work to overcome the material dependency on the addiction.

Finally, addicts may seek to cultivate a sense that there is life for them outside of the addictive relationship. Rather as a person who has been a manager for 20 years might need to recover a sense of what else she might do, upon being made redundant, so too an addict may need to recover a sense that it is possible to live outside of the addiction. In this way, they may seek to overcome the psychological dependency on the domination of addiction.

This framework may help us tease out the paradoxical relationship between activity and passivity, as indicated in Wilson’s remarks, in the following way. On the side of passivity, the addict is subject to the domination of her addiction, in the sense that she is subject to a loss of control. It may also be the case that there is nothing the addict can do about the dominating character of the addiction, so long as she is subject to it. In these respects, the addict is passive within her relationship to her addiction. On the side of activity, however, the addict may be able to move away from subjection by the addiction, while admitting that she is incapable of undermining its dominating character. In this respect, the varieties of which we have just outlined, the addict may retain active over her addiction. She might, for example, actively move away from her addictive behaviour or be proactive in preparing the ground for a life away from her addiction.

There is, however, also a further complication. As we have seen, our framework makes space for the possibility of cultivating the intelligibility of a possibility as open for one. Is this a moment of passivity or activity? On reflection, neither of these categories appears sufficient for accommodating the mode of agency involved in finding possibilities to be open for one. As a comparison, consider the kind of effort that is involved in trying to see a new aspect in a puzzle picture. Against passivity, there is plainly something that the individual does. Against activity, however, what the agent does is something other than exercising control. At best, it appears that she is allowing something to emerge for her, which emergence she cannot control. Similarly, the individual who is trying to find it intelligible that she might live otherwise is plainly doing something, in trying to see a future outside of addiction. But this seems to be something other than an exercise of control: she cannot determine whether she will in the end come to see a new way of being. In reference to the Greek middle-voice, we might refer to this mode of agency which cannot be reduced to either activity or passivity as medio-passivity. (For discussions of medio-passivity, see Han-Pile 2011, 2013, 2017)

If this framework is helpful in demonstrating how addiction involves moments of passivity, activity, and medio-passivity, then it may have some consequences, both theoretically, with respect to the antinomy of addiction we have been discussing throughout, and practically, with respect to ways of responding to addiction. Let us begin by discussing the theoretical implications of this framework.

Each side of the antinomy we presented in section II presupposes that the agent’s power is to be identified with her power within the relationship to the addictive substance, that is, her control over her use of that substance. On this presupposition, those who emphasise that agents appear to lose control over their addictive behaviour infer that addicts’ agency is completely undermined; alternatively, those who point out that addicts’ agency is not always completely undermined, since they can gain and maintain abstinence, infer that agents must retain the power for control over their behaviour. Our framework challenges the assumption that underpins both sides of the antinomy. On our proposal, an agent might be in control and dominated, or have lost control and retain agential power. The presence of control is not sufficient for the full exercise of agency, and the absence of control is not sufficient fully to undermine agency. So agency is not equivalent to the capacity to control. This allows us a way to understand the agent’s involvement in her recovery which is not simply the exercise of control over her behaviour. More specifically, we have identified two other forms of agential sway: 1) the addict may cultivate eligibility for a possibility she understands to be open for her; 2) the addict may cultivate the understanding of a possibility as open for her, for which she may need to further cultivate her eligibility. Accordingly, there are ways in which the individual can exercise her agency over her addiction, while remaining powerless (subject to domination) within her addiction. Moreover, we have also pointed out that the mode of agency involved in cultivating a sense of which possibilities are open for one are is not reducible to either activity or passivity, while the literature we have discussed presupposes this dichotomy.

It is worth pointing out that this framework requires further elaboration, if only to provide more clarity to the possibilities that it frames. What, if any, are the differences between the possibilities for agency that we have identified? How might the ability to cultivate the understanding of a possibility as open for one differ from the ability to cultivate one’s eligibility for a possibility? Moreover, do these modes of agency fall under the power the individual alone, or must they involve the support of others? Furthermore, is the sort of agency involved in the capacity to come to understand certain possibilities as open sufficient for responsibility? The answers to these questions will matter a great deal to how we understand the practical implications of this framework. We can, however, briefly sketch some possible ramifications that our proposal may have with regards our response to addiction.

We have emphasised that our framework makes space for various possibilities for the exercise of agency outside of the direct control of behaviour. None of what we have said entails that any of these possibilities are realised in any individual case. If the framework has practical implications, then, they cannot be based on the assumption that each possibility for agency is realised for any given addict. Rather, if the framework has practical ramifications, they may first be diagnostic, in the sense that the framework may help us specify the sorts of agency that may remain or which may be cultivated, namely: 1) the agent may take up an alternative relationship that is not dominating; 2) the agent may make herself eligible for a non-dominating relationship, which she may then take up; 3) the agent may try to come to understand other possibilities as open for her, which she then may or may not need to make herself eligible in order to undertake. Each of these pathways to recovery suggests a different sort of practical response, for which further research may be required.

In these respects, our framework suggests a number of different approaches that parallel a number of the different responses to addiction that we have surveyed above. Our framework is congruent, for example, with the recommendation made by advocates of ‘second stage recovery’ to focus on the possibility of building a new identity outside of practices connected with the addiction, since these practices seem to be ways in which the agent may express her power over her addiction. Moreover, our approach is compatible with a form of the acceptance of powerlessness, as advocated by 12-Step programmes. On our model, it may be helpful for the addict to recognise and accept that she is dominated by her addiction and is powerless to regain control within the relationship, such that she might seek to express her power over her addiction in other ways. In other words, the addict may be helped through turning away from the attempt to exercise local control over her behaviour and instead to see what ways of expressing agency she may have left over. In these ways, our framework provides a way to unified a number of different approaches in a coherent picture of addiction.

Nonetheless, certain important questions remain unanswered. How are we to understand the nature of what we have called medio-passive agency? How might we help addicts come to see possibilities as open for them? What practical support mechanisms might be put in place to support the addict’s ability to become eligible for other possibilities? Here we submit that if our framework is helpful for understanding addiction, our understanding of how to respond to addiction may be helped by pursuing these questions.


Alcoholics Anonymous 2001, Alcoholics Anonymous New York City: Alcoholics Anonymous World Services, Inc.


Babor TF, Miller WR, DiClemente C, Longabaugh R, 1999, ‘Comments on Project MATCH: matching alcohol treatments to client heterogeneity’ Addiction 94 pp.31-69


Batho, David 2016, ‘Faith, Hope, and Love as Virtues in the Theological Tradition’ (accessed 31/10/2017)

–2017, ‘Faith, Hope, and Love in Critical Perspective’ (accessed 31/10/2017)


Biernacki, P 1986 Pathways From Heroin Addiction: Recovery Without Treatment Philadelphia: Temple University Press


Bufe, Chaz 1997, Alcoholics Anonymous: cult or cure? Tucson: Sharp Press


Emrick CD, Tonigan JS, Little L 1993 ‘Alcoholics Anonymous: what is currently known? In Research in Alcoholics Anonymous: Opportunities and Alternatives eds. McCready BS, Miller WR, Picataway: Rutgers Center for Alcohol Studies


Finlay, Steven 2000, ‘Influence of Carl Jung and William James on the Origin of Alcoholics Anonymous’ Review of General Psychology 4:1 pp.3-12


Galanter M, Egelko S, Edwards H 1993, ‘Rational Recovery: Alternative to AA for Addiction?’ American Journal of Drug and Alcohol Abuse 19:4 pp.499-510


Han-Pile, Béatrice 2011, ‘Nietzsche and Amor Fati’ European Journal of Philosophy 19:2 pp.224-261

—2013, ‘Freedom and the Choice to Choose Oneself’ in The Cambridge Companion to Heidegger’s Being and Time ed. Mark Wrathall, Cambridge: Cambridge University Press

—2017, ‘Hope, Powerlessness, and Agency’ Midwest Studies in Philosophy 41:1 pp.175-201


Heather, Nick 2017 ‘On defining addiction’ in Addiction and Choice: Rethinking the Relationship eds. Heather and Segal, Oxford: Oxford University Press


Heyman, Gene 2009, Addiction: A Disorder of Choice, London: Harvard University Press


Holton, Richard and Berridge, Kent 2013 ‘Addiction Between Compulsion and Choice’ in Addiction and Self-Control ed. Neil Levy, Oxford: Oxford University Press


James, Williams 1960, The Will to Believe: and Other Essays in Popular Philosophy, and Human Immortality London: Dover Publications


Leshner, Alan 1997 ‘Addiction Is a Brain Disease, and It Matters’ Science 278:45 pp.45-47

–2001 ‘Addiction Is a Brain Disease’ Issues in Science and Technology 17:3 pp.75-80


Levine, Harry 1978 ‘The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America’ Journal of Studies on Alcohol 39:1 oo.143-174


Longabaugh R, Wirtz PW, Zweben A, Stout RL, 1998 ‘Network support for drinking, Alcoholics Anonymous and long-term matching effects Addiction 93 pp.1313-1333


Luther, Martin 1980 The Theologia Germanica of Martin Luther trans. Bengt Hoffman USA: Paulist Press


McCormack, Mairi 1969 ‘First Representations of the Gamma Alcoholic in the English Novel’ Quarterly Journal of Studies on Alcohol 30 pp.957-80


McIntosh J, McKegany N 2000 ‘Addicts’ narratives of recovery from drug use: constructing a non-addict identity’ Social Science & Medicine 50 pp.1501-1510


McLellan, A. T., Lewis, D. C., O’Brien, C. P., Kleber, H. D 2000,’Drug Dependence, A Chronic Medical Illness’ Journal of the American Medical Association 284 pp.1689-1695


Miller WR, Leckman AL, Delaney HD, Tinkcom M, 1992 ‘Long-term follow-up of behavioural self-control training’ Journal of Studies on Alcohol 53 pp.249-261


Moos, Rudolf and Moos, Bernice 2006, ‘Participation in Treatment and Alcoholics Anonymous: A 16-Year Follow-Up of Initially Untreated Individuals’ Journal of Clinical Psychology 62:6 pp.735-750


Nathan, Peter; Conrad, Mandy; Skinstad, Helene 2015 ‘History of the Concept of Addiction’ Annual Review of Clinical Psychology 12 pp.29-51


Nixon, Gary 2005, ‘Beyond “Dry Drunkenness”: Facilitating Second Stage Recovery Using Wilber’s “Spectrum of Consciousness” Developmental Model’ Journal of Social Work and Practice in the Addictions 5:3 pp.55-71


Nixon, Gary, & Solowoniuk, Jason 2008 ‘Moving Beyond the 12-Steps to a Second Stage Recovery: A Phenomenological Inquiry Journal of Groups in Addiction and Recovery 3(1-2) pp.23-46


Robins L, Helzer J, Hesselbrock M, Wish E 2010, ‘Vietnam Veterans Three Years after Vietnam: How Our Study Changed Our View of Heroin’ The American Journal of Addictions 19 pp.203-211


Room, Robin 2003 ‘The Cultural Framing of Addiction’ Janus Head 6:2 pp.221-234


Segal, Gabriel 2017, ‘How an addict’s power of choice is lost and can be regained’ in Addiction and Choice: Rethinking the Relationship eds. Heather and Segal, Oxford: Oxford University Press

–2013, Twelve Steps to Psychological Good Health and Serenity: A Guide Surrey: Grosvenor House


Shakespeare, William 2008, The Sonnets Cambridge: Cambridge University Press


Timko C, Moos RH, Finney JW, Moos BS, Kapolwitz MS 1999, ‘Long-term treatment careers and outcomes of previously untreated alcoholics’ Journal Study on Alcohol 60 pp.437-447


Trimpey, Jack 2006, Rational Recovery: The New Cure for Substance Addiction London: Pocket Books


Vaillant, George 2005, ‘Alcoholics Anonymous: cult or cure?’ Australian and New Zealand Journal of Psychiatry 39 pp.431-436


Wilson, W. G. 1957, Alcoholics Anonymous comes of age New York: Alcoholics Anonymous World Services, Inc.


Wilson, W. G. 1981 The Twelve Steps and the Twelve Traditions New York: Alcoholics Anonymous World Services, Inc.


Winnicks, Charles 1962 ‘Maturing out of Addiction’ Bulletin of Narcotics,U.N. Department of Social Affairs 14:1


[1] James summarises his view as follows: ‘Our passional nature not only lawfully may, but must, decide an option between propositions, whenever it is a genuine option that cannot by its nature be decided on intellectual grounds.’ (James 1960, p.11) A ‘genuine option’ is, for James, a decision between hypotheses which is living, forced, and momentous. A decision is living if both possibilities have some credence for us. A decision is forced, if there is no logical space to decline judgement one way or the other. And a decision is momentous if it presents a unique opportunity of huge significance that cannot be reversed. A genuine option that cannot by its nature be decided on intellectual grounds is one for which there is no possibility of being resolved by empirical or analytical enquiry. James holds that the decision of whether or not to believe in God is a genuine option in this respect: no empirical evidence or logical proof will settle the question of God’s existence, so the decision is beyond the pale of intellectual enquiry; the decision is forced, since to decline to decide whether to believe is to decide not to believe; the decision is living, just in case the possibility of God’s existence strikes a chord of credence in the person facing the decision; and the decision is momentous since it provides a unique opportunity to profoundly alter the course of one’s life that is not reversible – when it comes to belief or disbelief in God, James argues, it’s in for a penny in for a pound. Is the belief in a higher power, as described by Wilson, a genuine option that cannot be settled on intellectual grounds? If so, it would be a perfect fit for the sort of hypothesis that can only be believed justifiably by means of our ‘passional nature’, on William James’s view.

[2] It is of interest to note that ‘self-will’ is a Lutheran term of art. See Luther 1980 pp.106ff.

[3] Studies that suggest that AA is an effective form of treatment include: Emrick et. al. 1993; Babor et. al. 1999; Longabaugh et. al. 1998; Miller et. al. 1992; and Timko 1999

[4] Galanter et. al. (1993)