John

Giving, 2024 Q4

January 5, 2025 0 John Uncategorized

I currently give away appx. 10% of my net income (that is, income received after tax withholding etc.). For the last quarter (10/1 to 12/31 of 2024), my donations were as follows:

• 72% to New Incentives cash transfers for childhood vaccination (via GiveWell)

• 28% to the Wild Animal Initiative

Disability Determination for Addiction: A Response

December 20, 2024 0 John Uncategorized

In a 2023 article in the AMA Guides Newsletter, a group of medical experts addresses the question of whether drug addiction is best considered a disability (Hirsch et al., 2023). Their answer is inconclusive:

This article takes no position for or against a determination of disability for those with SUD [substance use disorder]. A consensus on whether drug addiction is a disability, or the advisability of financial support for drug addiction as a disability in the absence of a comorbid disorder could not be reached. (Hirsch et al., 2023, p. 7)

They do however raise several questions that, in their view, are ‘cautionary considerations’ against the positive claim that addiction is a disability:

Disability status is associated with increased mortality and reduced lifespan. Therefore, assigning drug addiction as a disability may have adverse consequences for the individual and society.
Beyond fraud and advocagenic and similar claims, there is no comparable class of disorders in which there must be an active, conscious decision to opt in and maintain a disabled status. If a determination of disability was made regarding a conscious decision to opt in, could there then be other classes of disorders to be similarly managed?
There is a risk of reinforcing drug addiction by providing financial assistance for drug dependence disability.
The financial costs to Social Security and private disability systems may likely be unsustainable. (Hirsch et al., 2023, p. 6)

I have previously argued at length that, on our best understanding of addiction and disability, addiction is indeed a disability (Maier, 2021), (Maier, 2024). By their own account, this group of medical experts neither endorses nor rejects this view. Their ‘cautionary considerations,’ however, may be thought of as articulating concerns about the view that addiction is a disability (or, for short, the ‘disability view’ of addiction). So I want to take some time to explain how an advocate of the disability view should respond to these considerations and, more generally, to explain the disability view and its implications for the medical care of people with addictions.

Let us then take these considerations in turn.

Consideration 1: Morality and Lifespan

Disability status is associated with increased mortality and reduced lifespan. Therefore, assigning drug addiction as a disability may have adverse consequences for the individual and society.

It is true that disability status is associated with increased mortality and reduced lifespan. It is also true that addiction is associated with increased mortality and reduced lifespan. If anything, these correlations tend to weakly support the view that addiction is a disability. Why is this labeled as a concern for the view?

The authors suggest that these correlations suggest that assigning addiction as a disability may have adverse consequences. I am not entirely sure how to read this remark. One thought is that the very identification of something as a disability, whether it is in fact a disability, would itself lead to increased mortality. That is if we take some non-disability condition with a known mortality rate, such as the seasonal flu, the counterfactual act of considering the flu a disability would itself raise the antecedent mortality rate. This is a sort of ‘self-fulfilling prophecy’ view of disability, where the very act of understanding something as a disability leads to worse outcomes.

If this view were true, then it might be a consideration against labeling addiction a disability (though it still would not touch the underlying question of whether addiction is in fact a disability). But I am unaware of any evidence for this view, and the authors do not provide any (to be fair, it is not clear whether they are actually endorsing this view). If anything, the correlations would seem to run in the other direction. Labeling something a disability can lead to resources and supports that lower the rate of poor outcomes. Indeed, there is good reason to think this is true in the case of addiction. If people with addictions were recognized as disabled, they would have greater support and legal protections, and this in turn might significantly reduce the bad outcomes associated with addiction. That is precisely the guiding hope of the disability view of addiction.

Consideration 2: Opting In

Beyond fraud and advocagenic and similar claims, there is no comparable class of disorders in which there must be an active, conscious decision to opt in and maintain a disabled status. If a determination of disability was made regarding a conscious decision to opt in, could there then be other classes of disorders to be similarly managed?

There is a measure of subjectivity in the determination of addiction. This raises a number of moral questions if addiction is a disability. One set of issues is people who feign an addiction in order to obtain the benefits of disability status, as well as pressure on the provider to make a diagnosis of addiction even when it is not warranted, so that the patient may have access to benefits. These are concerns about fraud and advocagenicity, which are addressed elsewhere in the discussion and which the authors here set aside.

The authors here instead raise, as I understand it, a separate consideration about subjectivity. This consideration involves two claims. First, the determination of addiction involves a ‘conscious decision to opt-in,’ and therefore the determination of disability depends on that decision. Second, if we admit some disabilities that depend on such a decision, this may open the door to still others.

These considerations seem to me somewhat obscure. It is true that addiction involves a measure of subjectivity, and involves deference to the patient’s own experience and to some degree to her self-identification. It is not clear that this implies any ‘conscious decision to opt in’ to addiction status, either on the part of the patient or her physician. Consider someone, for example, with an opiate use disorder. Such a person may not identify as having an addiction, and indeed will frequently reject that claim. She does not ‘opt in.’ Indeed, if her physician is unaware of her use, her physician may not diagnose her with an opiate use disorder. Nonetheless, she has an addiction and so, on the disability view, a disability. It is no part of the disability view of addiction, or indeed any view of addiction that I am aware of, that one must make a ‘conscious decision to opt-in’ in order to count as having an addiction.

Let us waive this concern for a moment, and imagine that there is indeed some opting in involved. What then? The authors are concerned that this may ramify to other disorders. Again, the concern here is somewhat obscure. What does seem true is that addiction involves, as I have said, a measure of subjectivity, and this complicates its epistemic status as a disability. We can observe that many other disorders, indeed most of those that fall under the remit of psychiatry, involve some degree of subjectivity as well. The diagnosis of Major Depressive Disorder (MDD), for example, involves a measure of deference to the patient’s own experience.

Accordingly, the identification of MDD as a disability raises a number of difficult questions, as does the identification of addiction as a disability. Perhaps it is these kinds of concerns that the authors have in mind. But note that, even on this reconstruction of the authors’ argument, there is not actually any consideration against the disability view of addiction, nor a concern that the identification of addiction as a disability will somehow open the gates to a host of new disabilities. Rather, this concern is a reasonable exhortation to thoughtfulness in the identification of addiction, and other disorders (for example, many psychiatric disorders) whose diagnosis and treatment involve a degree of subjectivity.

Consideration 3: Reinforcement

There is a risk of reinforcing drug addiction by providing financial assistance for drug dependence disability.

People with disabilities receive financial assistance, such as that provided by SSI (Supplemental Security Income) and other governmental programs. If people with addictions are counted as disabled, this will potentially qualify them for such programs. At the same time, an increase in income can be expected to increase substance use among at least people with addictions. This is one way in which the designation of addiction as a disability might exacerbate or in the authors’ phrase ‘reinforce’ the scope of addiction.

The concern raised by the authors here is an entirely reasonable and straightforward one. As it happens, it is currently largely moot, at least for the main forms of assistance in the United States. As of 1996, federal law prohibits people from receiving SSI and similar benefits based on a drug or alcohol addiction. So the concern raised by the authors – of people receiving financial assistance just on the basis of a physician’s determination of addiction – is not in fact a realistic concern in the United States, under current law.

The authors’ concern does however raise a broader concern about addiction and the nature of support for it. I think the best response to this concern is not to deny that addiction is a disability but to think more broadly about the forms that disability assistance may take. In the case of physical disability, cash and other liquid assets are often the most effective and easily used form of assistance. But government assistance need not take this form. Well-known programs such as SNAP (Supplemental Nutrition Assistance Program) benefits and various kinds of housing assistance involve non-cash forms of assistance and support.

There are independent reasons for thinking that this is the right way to think about assistance for addictions. Recent research has emphasized the significance of recovery capital in supporting people with addictions. Recovery capital can include cash, but it is much broader than that, encompassing all the resources that can support recovery: housing, education, health insurance, social connections, spiritual support, and much else. It is recovery capital, so understood, that is most helpful for people with addictions.

If this is correct, then the proper response to the authors’ broader worry is to reorient our thinking about assistance for disabilities from cash alone (which may be appropriate for many disabilities) to the broader notion of recovery capital. People with addictions are not best assisted by cash: as the authors point out, this may ‘reinforce’ addiction, and in any case, this form of assistance is prohibited under federal law. But reflecting on the limitations of purely financial assistance has the benefit of encouraging us to think more broadly about assistance and the role of recovery capital. In neither case do any of these considerations tell against the identification of addiction as a disability.

Consideration 4: Costs

The financial costs to Social Security and private disability systems may likely be unsustainable.

The issue here is much the same as that raised by the previous consideration, but the focus is different. While the third consideration focused on the ways in which benefit spending might reinforce addiction, this last consideration focuses on the purely financial dimension of this spending, which, the authors caution, may be considerable.

It bears again tempering this concern with a certain realism about current law. As noted above, in the United States, addiction itself is not a ground for federal disability benefits, and has not been since 1996. There are other kinds of benefits, but if other disability systems were to confront the financial risks posed by the authors, they could well implement similar restrictions. This austere approach to disability benefits for people with addictions is not necessarily the best approach, but it does indicate that the authors’ concerns about sustainability can be – and, under US federal law, have been – given a blunt and effective answer.

As I have already suggested, I believe a better approach is not austerity but instead a more broad-based approach to disability benefits, one which does not rely so exclusively on cash or cash equivalents. Instead, assistance for people with addictions should take the form of recovery capital, which involves a pluralistic and often non-fungible range of goods, including health insurance, education, and community and spiritual support. This is a more sensible approach to disability assistance than either a purely financial approach, on the one hand, or the austere approach, on the other.

It will admittedly be more costly than the austere approach. How costly? The authors are concerned that the spending will be ‘unsustainable.’ Whether this is so will depend on how much exactly adequate support will cost, and how much we are willing to pay. The case of federal disability benefits indicates that citizens have been willing to tolerate a substantial amount of spending for people who are disadvantaged, so we should not be immediately pessimistic about the prospects for increased spending. Might this same attitude be extended to the disability that is addiction? The answer to this crucial question remains for now unclear.

It bears noting that the costs of addiction – on health care and public services, in addition to its incalculable social cost – are vast. So there is not only a cost to providing more support for people with addictions, but potentially a benefit as well. Furthermore, were we asked as a society to bear the real cost of addiction, then we might be less inclined to endorse policies – such as ready access to tobacco cigarettes, marijuana, and alcohol – that tend to promote it. So disability support for people with addictions might, in this roundabout way, lead to less social enablement of addiction in the first place. In these ways, the true accounting of proper disability benefits for people with addictions remains largely untried and largely unknown.

Returning to the authors’ concern, are there grounds here for skepticism that addiction is a disability? It does not seem so. At best, if the costs of disability benefits for people with addictions were unsustainable then, as noted above, we could simply cut off such benefits, as is done on the austere approach. But the question of whether these costs would be ‘unsustainable,’ and what it might take to sustain them, remains an open one.

Conclusion

This article marks an important discussion of addiction and disability, which is especially helpful on appreciating the medical dimensions of this relationship. The authors raise four ‘cautionary considerations’ about the identification of addiction as a disability. All these considerations deserve attention, but none of them tells against the disability of view of addiction. This is simply the claim – which has considerable independent support in philosophy and the law – that addiction is in fact a disability.

Works Cited

Hirsch, J. A., Mandel, S., Hegmann, K. T., Stratyner, A. G., Gitlow, S., Talmage, J. B., & Brigham, C. R. (2023). Considerations for Determining Whether Drug Addiction Is a Disability. AMA Guides Newsletter 28(2):1-38.

Maier, J. T. (2021). Addiction is a Disability, and it Matters. Neuroethics, 14(3), 467–477.

Maier, J. T. (2024). The Disabled Will: A Theory of Addiction. Routledge.

Giving, 2024 Q3

October 1, 2024 0 John Uncategorized

I currently give away appx. 10% of my net income (that is, income received after tax withholding etc.). I take a two-tiered approach: occasional giving throughout the quarter, and then “topping off” my donations at the end of the quarter so it equals roughly 10% of my net income.

For the last quarter (7/1 to 9/30 of 2024), my donations were as follows:

•100% to St. Francis House (Boston)

These donations were in an amount totaling 10.47% of my net income from that period.

The Performance Principle

August 2, 2024 0 John Uncategorized

In Options and Agency, I defend what I call the Performance Principle:

(PP) If an agent performs an act of type A, then A is an option for S

In a thoughtful and generous review of that book, Sophie Kikkert and Barbara Vetter observe that this principle encounters some difficulties. Consider an unskilled player who hits the bullseye on a dart board. From (PP) it follows that she had the option of hitting the bullseye on the dart board. This is so even though, prior to her throwing the dart, her hitting the bullseye was an exceedingly unlikely event (indeed we may make the probability of her hitting the bullseye conditional on throwing the dart arbitrarily close to 0). It was not, in some intuitive sense, something that was under her control. It was just something that she happened, luckily, to do.

As the authors observe, the claim that this was an option for her appears to conflict with the constitutive connection between options and deliberation. Our options are what we properly deliberate about. But hitting the bullseye was not something the agent should have deliberated about, before the fact. Our deliberations and intentions tend to be, as I emphasize elsewhere in Options and Agency, more coarse-grained than this. So (PP) appears to say that we should deliberate about acts that, in fact, we ought not deliberate about.

Perhaps one can make the theory work with some special pleading for these particular cases. But even if one can do that, the authors point out that a deeper worry looms. Options are supposed to be, on my account, something that is basic and familiar to us. But something having these strange properties – normally coarse-grained, but then maximally fine-grained in cases where we actually act – cannot be something that is basic and familiar to us, even if we grant it to be formally consistent.

I want to pull back and consider the rationale for (PP). (PP) is not motivated, in the first place, by reflection on cases (though I grant that it must ultimately be tested against these). Rather, it is motivated by a deep claim about agentive possibility, which is that it has the features of what is sometimes called an alethic modality. Claims about epistemic and deontic possibility in a certain sense float free of what actually happens. This is clearest in the deontic case: from the fact that someone performs an act, it does not follow that it was permissible that she perform it. Claims about agentive possibility, on the other hand, do seem in some sense so constrained: from the fact that someone performs an act, something does seem to follow about what she could in fact do.

On its classical development, alethic possibility is understood in terms of a schema in modal logic on which the possibility of a proposition is implied by its truth (or, equivalently, on which the truth of a proposition is implied by its necessity). This is the so-called T axiom. Since I, like others, reject the analysis of agentive modality in terms of classical modal logic, I cannot say that agentive possibility obeys the T axiom. So I need a different way of expressing the core truth that agentive modality is in a certain way constrained by what agents actually do. That is where (PP) comes in. It is, as it were, a way of recapturing the T axiom within an act-based (as opposed to proposition-based) framework for understanding agentive possibility.

That said, I grant the force of the objection raised by Kikkert and Vetter. I especially acknowledge their point about fineness of grain. The coarse-grainedness of options is central to many of the arguments of the book, and it is not plausible to make options go suddenly fine-grained in these cases, just to make the (PP) work. So we are left with a challenge: how do we acknowledge the way in which actuality constrains agentive possibility, without admitting the strange claims about options that this statement of (PP) seems to license?

To begin, note that acts in general are not produced fully formed. They tend to occur as the result of a chain of acts, some more fine-grained than others. I do not simply have a cup of coffee. I put the kettle on, pour the water over the grounds, raise the mug to my mouth, and so forth. In the book I attempted to prescind from this aspect of action in order to stay neutral on various views of the metaphysics of action. But this neutrality cannot be maintained. To answer the authors’ challenge to (PP) we need to say at least something about the metaphysics of action.

Let us define an ancestor of an act as follows. If S performs an act of type A, let an ancestor of that act be any act that causes or constitutes the act of type A. For example, if I hit the bullseye, then an ancestor of my act may be an act of the type: throwing the dart thusly. Let us also stipulate that ancestry is reflexive, so that every act is an ancestor of itself.

Note the background ontology here, as in Options and Agency generally, is one on which acts are actual particulars (act-tokens in one standard lexicon) whereas act-types are properties of acts that may or may not be instantiated. Act-types are the objects of deliberation and the relata of options; acts are actual substratum by which the objects of deliberation and options are realized. The performance principle concerns, as it were, the nexus between act-types and acts.

I propose that we then revise (PP) as follows:

(PP*) If an agent S performs an act x of type A, then S performs some act y of type B such that (i) y is an ancestor of x and (ii) B is an option for S

Informally, what (PP*) says is this: if someone does something, then she has the option of doing that thing, or of doing something that causes or constitutes it. (PP*) simply regiments this informal and I think plausible thought into the metaphysics of acts and act-types.

How does this go? Sometimes, we need only appeal one act and one act-type, and the complexities of (PP*) are redundant. I raise my arm. Which is to say I perform an act x of raising my arm. I also perform an act y of raising my arm, and raising my arm is an option for me. That is the case where x=y and A=B.

Other times, the relationship will be more indirect. I perform an act x of hitting the bullseye. But my act was caused by a prior act y of throwing the dart thusly, and throwing the dart thusly was an option for me. Here x and y and A and B are distinct, and we need to appeal to (PP*) rather than (PP) to properly capture the more complex relationship between what is an option for me and what I in fact do.

Thus (PP*) captures the core connection between action and options in virtue of which, as I have said, agentive possibility is alethic. The introduction of ancestry in no way trivializes the demand that is being proposed. Note, for example, that an analogue of (PP*) is clearly false when applied to deontic possibility: if an agent performs an act, it does not follow that it is permissible for her to perform an ancestor of that act. (PP*) is true of agentive possibility, but not of (for example) deontic possibility, precisely because agentive possibility is constrained by an agent’s actions in a way that deontic possibility is not.

What of Kikkert and Vetter’s concern about the alleged obscurity of the notion of an option? This concern, as I described it, was brought against one way of defending (PP). Does it apply also to (PP*)? I think it does not. My revision of (PP) and defense of (PP*) notably did not turn on any tendentious claims about options or on introducing a distinction in options. The notion of an option remained univocal throughout. The issue turned on an orthogonal issue in the metaphysics of action, one on which the framework of options is neutral.

Finally, (PP*) is fit to play the role of (PP) in the subsequent arguments of the book. For example, in my defense of compatibilism in Chapter Seven, I argue that (PP) is compatible with the existence of unexercised options in a deterministic world, since it concerns only the acts that an agent actually performs. The same is true of (PP*), since it too concerns only the acts that an agent actually performs. In general, the appeal to ancestry in (PP*) does not impact the dialectical work that the Performance Principle is subsequently asked to do.