Thanks to walker for suggesting this reflection by the curmudgeonly Dr. Dalrymple on ‘a moral confusion typical of our age’. A recent Lancet editorial considered the controversy over whether alcoholic liver failure ought to disqualify one for a liver transplant, given the predominant opinion that the condition is self-inflicted. The Lancet authors cite evidence that alcoholism is not the patient’s fault, since “clear genetic and environmental influences exist.” Yet Dalrymple points out that the data the Lancet reviews shows that, after liver transplantation, former alcoholics have vastly increased rates of abstinence compared to those who have undergone ‘conventional treatment’ for their alcohol abuse. His conclusion is that alcoholics with sufficient motivation can control their drinking, that despite influences one has the freedom to resist; Dalrymple considers these equivalent to confirmation of the ‘self-inflicted’ terminology.
If the evidence is clear that motivation can affect abstinence, Dalrymple wonders why the medical profession has gone to such lengths to ‘acquit those suffering from alcoholic cirrhosis of the self-infliction charge.’ He finds the answer in the ‘crude sentimentality of our modern moral sensibility’, in which only victims are worthy of sympathy. Since there are so many alcoholics, it would be cruel to be so unsympathetic, so we perforce pretend that they are all victims of circumstances beyond their control. Dalrymple would rather we take a more spiritual (he does not use the term, but what he really means is more Christian) viewpoint in which one forgives and does not withhold sympathy from someone even who has harmed themself.
Without saying so, Dalrymple has taken on one of the core issues I see in modern medicine — what threshold must a maladaptive lifestyle choice cross to be worthy of being called a disease? However, his moral triumphalism relies on setting up and then overthrowing a straw man. Very few physicians take the black and white view he accuses them of having — that alcoholism must be a matter of either free will or determinism. The more nuanced understanding, that genetic and environmental influences create a likelihood and a vulnerability that makes abstinence more difficult than it would be for the next person, but not impossible, is actually the most common. Dalrymple is back in the ’50’s or ’60’s, when debates about nature vs. nurture raged, at least in psychiatry. These have long since been resolved in the minds of all but the most naive thinkers in the field. And Dalrymple forgets that the helpful emotion for a physician is not sympathy — either for the ‘fallen man’ (and, Dr. Dalrymple, what about alcoholic women?) or the ‘victim’ — but empathy for the complexities of the struggle. True, where free will plays a part, we are in a different realm of medicine than that which treats, for example, juvenile onset diabetes or rheumatoid arthritis, which no one in their right mind would accuse the patient of having caused. (Notice, I did not use the more paradigmatic examples of cancer and heart disease, about which legitimate controversies over lifestyle contributions and ‘self-infliction’ exist.) But embracing the more difficult empathic stance places the physician right with the patient in the midst of the struggle over their motivation and ‘willpower’, rather than at Dalrymple’s morally superior distance. While he may be willing to be sympathetic, to bestow forgiveness, to facilitate salvation, on sufferers, his attitude just as easily leaves itself open to heaping moral opprobrium on them. Although it sounds sophisticated, it is really not very different from that which I hear from the families of my psychiatric patients who in their lack of understanding inject an element of moral failing into their loved ones’ mental illnesses all the time — that the sufferer is ‘just not trying hard enough’, needs ‘nothing more than a swift kick in the pants to get going’, is deliberately prolonging their invalidism, is ‘indulging themself’, ‘everybody gets a little down once in awhile but most of us don’t let it get to us like you do’. It is true that, as a physician educating and counseling such a family, I want to say something like, “(S)he can’t help it, it’s a disease, (s)he needs your sympathy,” but we don’t say it because we believe that only guiltless victims of impersonal forces deserve sympathy; it is in large measure public stigmatization the physician is attempting to counter here. Dr. Dalrymple, I fear, misunderstands, despite the fact that moralists always want to paint themselves as more understanding and sympathetic, and their opponents’ ability for sympathy impaired by their faulty understanding.
Of course, I am talking from the perspective of a psychiatrist, one of whose core skills is examining and clarifying countertransference feelings, one’s own hidden assumptions about and attitudes toward our patients, so these are not the powerful behind-the-scene players they otherwise would be. Most physicians and other healthcare workers outside the mental health end of the field have probably never heard of countertransference, not to mention explored their own.Still, I think, most physicians have a more complicated view of their patients’ moral agency than Dalrymple assumes. What, I wonder, would Dalrymple make of the views of humanity of such physician-writers as Sherwin Nuland, Jerome Groopman, Oliver Sacks or indeed William Carlos Williams?
The unsophistication of Dalrymple’s viewpoint becomes clearer if one examines the most successful technique for helping alcoholics become and remain abstinent, the AA model. What is AA’s position on the role of ‘willpower’ in sobriety? On the surface of it, it seems that AA is dead set against it. The first, dogmatic, step in the AA program is acknowledging that one is helpless against alcoholism and cannot help oneself. Of course, AA doesn’t work for everyone, because of the difficulties some have with its remedy for such powerlessness — to ask for help from the group, and from a ‘Higher Power’. But, for those whose interpersonal capacities and spiritual inclinations allow, those steps are the foundations of success. And it seems to me that they are an embrace of paradox the significance of which is lost on Dalrymple. By acknowledging powerlessness, the alcoholic bolsters their willpower and motivation to exert control for recovery. By invalidating the effectiveness of willpower, one gains power. The embrace of such paradox is clear in the AA credo per the ‘serenity prayer’, in which one yearns for both “the serenity to accept the things I cannot change (and the) courage to change the things I can” (as well as “the wisdom to know the difference”). Perhaps the theory of alcoholism and recovery that elucidates it best is psychiatrist Gregory Bateson’s ‘cybernetic’ model (in Steps to an Ecology of Mind), describing the ways in which willpower and powerlessness are not dichotomous, in conflict in one mind, but that they are rather coexistent and interdependent, at different levels of abstraction of the self.