Addiction and Responsibility

The American Society of Addiction Medicine has released a new definition of “addiction” which focuses on the disorder’s biological underpinnings in the brain. As I discuss at Stanford Medical School’s SCOPE blog today, distinguishing addiction from “a lot of substance use” is useful for many reasons, not least so that doctors will not undertreat acute pain with opioids out of fear of addicting their patients.

The biggest barrier for the public and the political class to accepting that addiction involves a fundamental, lasting and adverse biological change in the brain is that it can appear at first blush to invalidate the idea of personal responsibility for behavior. Some advocates of the “brain disease model” have exacerbated this resistance by trying to shame people who are afraid of or angry at addicts. Sometimes when the biological aspects of addiction are conveyed, the implicit message, in essence, runs “How can you be so heartless towards these victims of a brain disorder! Would you get angry at someone for having Alzheimer’s disease?”.

This debate is unproductive and unnecessary, a position I can best defend by discussing my bad hip.

I used to exercise on an elliptical machine for about an hour a day every other day. After a year or so of doing this, I began to feel some pain in my left hip. Being an educated, clinically skilled and mature health professional, I reacted by ignoring the problem and hoping it would go away. It didn’t. Indeed it got worse such that my hip began to hurt even when I wasn’t exercising. My doctor X-rayed my hip and found some bone spurs and calcification in the joint which will trouble me for the rest of my days.

I thus now have a lasting, adverse, physically based medical problem. But I got it entirely through voluntary behavior. One could add in further that I got it in part because I foolishly ignored the signs that my behavior was damaging my health. Those observations about my behavior, judgment and responsibility in no way contradict the reality that I now have a permanent biological change in my body.

Next question: Who is responsible for managing my medical condition? I am. If I am diligent about my stretching exercises each morning, my hip will not hurt, but if I slack off as I sometimes do it will get stiff and sore. I have no power to eliminate the damage to my hip through my behavior, but I can manage it if I act responsibly.

To sum up, my bad hip is a biologically-based medical problem that came about in part from my own behavior and from my own poor judgment (I say “in part” because another person with a different hip might have exercised just as I did and had no problems…indeed my right hip is as right as rain). My future behavior can’t eliminate the problem but it can influence how much trouble it causes. I thus have some responsibility for the origin of my medical problem and for its management as well, but no matter how responsible I am, I can’t ever eliminate it because it has an independent biological existence.

As with my hip, so with addiction. It is reasonable to say to someone who is not addicted “Please be more responsible about your substance use — you are choosing to act in a fashion that may eventually get you addicted.” It is equally reasonable to say to someone who is addicted “Are you being responsible in the management of your addiction, are you attending your AA meetings, staying out of bars, etc?.” But it is not logically reasonable to say “Why don’t you stop being addicted?”. They would if they could, but they can’t, and that should I think evoke some sympathy, which is in no way contradictory with expectations that the person will be responsible about how they manage their disorder.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

22 thoughts on “Addiction and Responsibility”

  1. Just to be devil’s advocate for a minute, there’s still a difference. Presumably no one warned you when you went on the elliptical the first time that it might cause you permanent damage, or become habit-forming. I’m just saying. (I stopped using them because it hurt my neck. My guess is they’re not height-adjustable.)

    Btw, are you sure that’s what hurt your hip? I got injured from an airbag in a car accident, but it didn’t start hurting until months afterward.

    I agree with your larger point though. It’s fundamentally unfair that some people get addicted and others don’t. Blaming people for that is at some point not useful to anyone.

  2. Your post sort of skitters at the edge of a big issue – what seems to me a big issue – about which we rarely think. It’s competence, diminished or forming or never-full. We do deal with it piece-meal: drivers license when you are 14, or 16, or 18, and maybe you don’t get to drive at night, or in the company of other teens. We take the license away after you fail an examination when you are 80 – or not, in parts of Switzerland where licenses are for life. We are squeamish when Granny marries her much-younger caregiver and bequeaths the family fortune, unless we managed to get a power of attorney in place. People with dull normal IQs can vote, now that voter exams are outlawed. People who seem normal, but can’t control their vile impulses towards young children, get lifetime supervision – or at least we all get to know if they move next door. And there’s inability to control your urge for Oxycontin, or Jack Daniels, or methamphetamine. Each of these seems to be some sort of diminished competence, but generally society and the law treat people as either fully competent or not competent at all.

    This comment is sort of scattered, but it does seem to me that we’ve got a general issue with which we don’t deal in any kind of a general way.

  3. Dave Schutz makes an important point — however “smart” a young person may be, they may lack perspective. They probably all think *they* won’t be one of the ones who gets addicted. Or they don’t believe it happens at all. This is but one of the common cognitive errors young people are more prone to, though I think we all make them sometimes regardless.

    We ought to provide more (relatively) safe ways for young people to rebel. I’m not sure how we do that though. I think we need to be a lot more uptight about certain kinds of misbehaviors earlier. Not that we’d beat them into submission or anything — just maybe some kind of gentle version of the feedback that Mark talks about. And we’d have to do this without going too far and becoming like one of those countries where you can’t chew gum, or whathaveyou.

  4. The biggest complication here is that you are your brain; There’s not really any basis for distinguishing concepts like “resolve” and “willpower” from fundamental biochemistry and neurology. They’re the same thing. That makes it kind of difficult to distinguish between a strong bad habit and “a fundamental, lasting and adverse biological change in the brain”.

  5. That’s fundamentally incorrect, Brett. Addiction represents an actual chemical change in your brain. Without that change, you have a bad habit. With it, you have an addiction.

    The same thing is true about many kinds of mental health. I’m running into one of the disease theory absolutists Harold describes in my own therapy at the moment. That she is wrong, and that there is a strong behavioral component does not change the fact that, when I am in the midst of serious depression, there is a chemical difference.

    That our consciousness lives in our brain does not validate that our brain and ourselves are co-terminus.

  6. Addiction represents an actual chemical change in your brain. Without that change, you have a bad habit. With it, you have an addiction.

    Brett is right. As per physicalism, your brain is changing all the time. Your brain underwent some actual chemical change when your eyes focused upon this comment. The brain is a homeodynamic substrate. All mental activity is reified as chemical changes. When the addiction researchers talk about “fundamental, lasting and adverse biological change”, they just mean they can identify some tangible difference at the structural or functional level which they think is important (“fundamental”) as opposed to all the variations which are ignored or assumed as standard deviation, and which they think is not amenable to change (“lasting”) and which they think is not how a brain ought to be (“adverse”). But having identified such changes in itself doesn’t make those changes any more fundamental, lasting or adverse than the changes impressed by other experiences or behaviors. The marriage of the aims of the drug war alongwith the reductionist paradigm of neuroscience has allowed to entrench a certain fatalist attitude in the popular culture but that which is philosophically suspect.

  7. @daksya – The only way your argument makes any sense to me is as a categorical rejection of categories and distinctions. Keith used three clear and distinct adjectives to describe the quality of brain changes in addiction: fundamental, lasting, and adverse you attacked and dismissed all three in turn, but for two of them your dismissals are facile and potentially mendacious.

    For “lasting” you weasel out passively accusing the scientific mainstream of capriciousness with “they think.” Never mind that “they” is the king of weasel words for identifying a group of people, “lastingness” is a readily falsifiable quality of a defined phenomenon. If a phenomenon goes away on its own or with trivial intervention it is not lasting. Since these are scientific findings there are three paths you can take tin dismissing them. You can argue the experimental setup is incomplete or biased, you can argue the data are inaccurately reported, or you can argue the data do not support the conclusion. All other attacks are philosophically suspect.

    For “adverse” you take a variation on the theme of weakly accusing capriciousness. Labeling addiction associated brain changes as adverse, as Keith does, implies the changes are a causal factor in continuing the negative features of addiction. To argue the word is inappropriate you can attack the idea that addiction has negative features, which you wisely avoid, or you can argue against a causal link. You don’t do that either, which is disappointing since arguing one factor is a consequence of another, and not merely associated, is an area where clinical sciences have a rocky track record. Instead you passively attack the notion that scientists have agency to make normative judgements about brain conditions at all.

    You continue to attack scientists agency by implying their interest in controlling addiction is among the “aims of the drug war.” It is true the drug war justifies many evils, and may be motivated by Fascist tendencies in both the governing and the governed, it’s proximal aims with regard to addiction are solid. Are you arguing that single minded drug seeking behavior is positive, even when the affected person expresses a desire to limit that behavior? Are poor hygiene, needle sharing, petty crime, and entreated homelessness mere lifestyle choices you would defend as valuable and desired? If not then your “aims of the drug war” statement is just a throwaway insult.

    Wrapping up your assault on science’s legitimacy you accuse them of spurious reductionism, and you do this _after_ appealing to the philosophical Physicalism. It’s really hard to start out at Physicalism and end up denying the legitimacy of reductionist science. If we can’t take the human brain in all it’s complexity and view it as a composition of similar yet varied components interacting according to the laws of logic and physics to produce observable behaviors (that’s reductionism after all!) and we can’t claim an immaterial soul or conscious, then can we talk about the brain at all??

    If I took your post as a serious statement and not manipulative trash then I would say you, sir, are the one suffering from fatalism.

  8. @Dr. Buzzsaw – “lastingness” is a readily falsifiable quality of a defined phenomenon. If a phenomenon goes away on its own or with trivial intervention it is not lasting. Since these are scientific findings there are three paths you can take tin dismissing them

    Endurance is a falsifiable phenomenon, but I’m not aware of studies which scanned human addicts regularly over a period of many years to test for stability of the identified brain changes; do you? But besides that, KH isn’t arguing simply for trivial stability of these changes, but for practical permanence. So, they can be worked around by diligent behavior (i.e. stretching exercises in the hip analogy*) but can’t be removed or altered. So once an addict, always an addict.

    you passively attack the notion that scientists have agency to make normative judgements about brain conditions at all

    Yes, because the ASAM definition positively assigns the dominant weight of the addictive behavior to these brain changes in an implied causality, without making the philosophical case for it, and seemingly relying on the popular take-away conceptions of neuroscience.

    Are you arguing that single minded drug seeking behavior is positive, even when the affected person expresses a desire to limit that behavior? Are poor hygiene, needle sharing, petty crime, and entreated homelessness mere lifestyle choices you would defend as valuable and desired?

    No. But these behaviors aren’t effected in isolation by a deformed human computer enacting bad decisions. They occur in the environment of the drug war in a skewed group of people participating in an anti-establishment culture, subject to restriction and persecutions from the establishment, both formal and social. And that depending on the stimulus, accommodation and environment But the ASAM definition reframes their behavior simply as largely a cause-effect or compulsive outcome of brain changes with environment playing a supporting role. The brain changes shape behavior, IMO, but it’s not philosophically clear that these changes *control* behavior as the definition implies.

    It’s really hard to start out at Physicalism and end up denying the legitimacy of reductionist science.

    All physicalism does is constrain the mind to the brain. Neuroscience, as applied here, goes further. It may associate brain changes with behavior and apparent facility but can’t, as of yet, define and delimit the elasticity and malleability of behavior with respect to brain structure and vice-versa. But the ASAM definition isn’t that tentative.

    Ultimately addiction has to be manifest & diagnosed in behavioral terms. Would someone be an addict if they didn’t exhibit compulsive drug-seeking behavior, irrespective of what their brain scans looked like? By locating the addiction as a feature of the brain, all ASAM does is influence the academic, cultural and policy agenda, but not actually unravel any philosophical knots.

    *KH’s hip analogy fails because the locus for behavior control (the brain) isn’t the locus of impairment (the hip), unlike the case in addiction.

  9. Keith: can we have a little more of the underlying neuroscience here, to address Brett’s fundamental point?

    Suppose I witness or endure something horrible. I have a memory of this event, which I can’t erase. The memory is embedded in a set of synaptic connections; these connections are therefore, I suppose, permanent and irreversible. I can up to a point manage the trauma by creating a (true or false) context for the memory, for example disculpating myself from blame. There are also short-term memories, also embedded in synaptic webs, that seem to get wiped if they are aren’t important enough to merit a long-term record. Are you saying that addiction is as irreversible as the traumatic permanent memory, and a bad substance abuse habit like the eminently forgettable short-term memories?

    I can also have semi-permanent learned mental habits – a stammer or phobia – which are also presumably embedded in a resilient synaptic web. However, as I understand it, these respond to cognitive therapy, which, with difficulty, allow me to unlearn them. How is addiction not like this? Some people who give up smoking seem to lose the desire completely; others have to fight the craving forever.

  10. Let me give an example based on my own experience:

    When my first wife suddenly, out of the blue, announced she was leaving me, I crashed. I was literally curled up on the floor, shivering. This was, biochemically, a withdrawal reaction to my brain ceasing to produce significant amounts of a neurotransmitter. Biochemically no different from stopping an opiate cold turkey.

    I spent a year clinically depressed. Bad thoughts? Neurons dying! A depressed person’s brain actually shrinks due to widespread death of certain classes of neurons. How’s that for “a fundamental, lasting and adverse biological change in the brain”? But it wasn’t caused by a drug, it was caused by a few words, and my mental reaction to them.

    Subsequent to developing a case of traumatic arthritis in my ankle, I started taking SAMe. Which, coincidentally, has anti-depressant effects. I started coming out of the depression. Biochemically neurotransmitter production in certain brain cells was boosted, while my brain actually started growing new cells to replace the ones which had earlier died.

    SAMe is a relatively expensive supplement, at times I couldn’t afford it, and the depression would return. Each time, not as bad, because the new cells stuck around, and only the boost in neurotransmitter production was going away.

    Eventually, I remarried, and ceased needing SAMe at all to stave off depression. Thoughts and social interactions were restructuring my brain, on a level which would have been quite measurable if somebody had been doing an MRI study on me.

    These huge changes in my brain, quite comparable in scale to the changes we call “drug addiction”, were a consequence of thoughts. Thoughts can kill brain cells, permanently restructure your brain, even to the point where an autopsy would show it.

    Addiction is nasty. It’s still not categorically different from other mental events people around you are subject to all the time. I’m not sure that getting addicted to a drug, and going through withdrawal, is actually medically worse than getting divorced; Stats do show that guys tend to die off at a remarkably rapid pace in the first few years after a divorce.

    Short form: Addiction makes biochemical and structural changes in your brain? Of course it does, so does thinking. It’s not so different as it’s being portrayed.

  11. Hello James — not all lasting changes to our brain are the same, even two adverse ones (addition and a horrible memory) could have completely different mechanisms and impact on learning, memory and reward. That said, in terms of the sociology and ethics of how we respond to people, the same rule could apply to a traumatic memory and addiction, i.e., if every time you peer out over the edge of a precipice you feel a horrifying memory of looking down out of a copter in Viet Nam, I would be sympathetic with you that you have this problem…but I would still encourage you to engage in behavior that helped you manage it, like not living on the 50th floor of apartment building, getting an aisle seat on airplanes, not rewatching the film Vertigo etc.

    As for the neuroscience, it’s an enormous and complex literature, but ASAM does a good job trying to condense and de-jargonify it. This is from their statement:

    Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.

    The neurobiology of addiction encompasses more than the neurochemistry of reward. The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, altered judgment, and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction–despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors. The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex. Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.

  12. Trying to make sense of this in terms of my concerns, I see references to addiction as lasting rather than permanent. The statement leaves open the possibility that addiction is more like the reversible (with difficulty) phobia rather than the irreversible traumatic memory, or the cognitive losses from a brain lesion like the war wound of Luria’s famous patient “Zasetsky”. The AA requirement for members to recognize themselves as alcoholics for life may be too pessimistic in the long run, though since there’s no cure now it doesn’t make any practical difference yet.

    A small quibble: I don’t see how looking out of a helicopter in Vietnam could by itself make a truly traumatic memory. I’m thinking more of the helicopter crashing and your buddies dying in it, or seeing a child aflame with napalm. I’m going by Crews here, who denies flatly the existence of repressed memories of traumatic events. The knockout evidence he cites is from Holocaust survivors, none of whom can apparently forget what they endured and witnessed, with the exception of those who were very young children before the age of permanent memory. If there were a protective mechanism for forgetting trauma, it would surely apply to these survivors. So there isn’t one.

  13. James: I don’t see how looking out of a helicopter in Vietnam could by itself make a truly traumatic memory.

    It’s a real example from a Viet Nam veteran friend, soldiers often sat with the copter doors open (it was hot as hell) and their legs dangling down as the copter zoomed and weaved over the jungle as they looked down for enemy soldiers who might take a shot at them. Lots of brave men tell me it was terrifying; I believe them.

  14. “I don’t see how looking out of a helicopter in Vietnam could by itself make a truly traumatic memory.”

    It’s worth keeping in mind that, with the exception of memories of physical pain, the trauma from a memory is entirely derived from you subjective reaction to it. It’s got nothing to do with the objective character of the event being remembered.

  15. I think that the basic point, that there’s a lot of confusion around questions of responsibility and illness, is completely right. Of course you can be responsible for getting an illness or an injury, even if, once you’ve gotten it, you can’t just wish it away. (I would be responsible for my injuries if I freely decided to jump out of a fourth storey window, for instance.) You can be responsible for an inability to control your conduct that arises from your own free choices: thus, I am responsible for killing someone while driving drunk even if, at the time that person stepped out in front of me, I was literally unable to stop in time because I was too drunk. If I voluntarily got behind the wheel of the car while drunk, I’m responsible for the consequences.

    Moreover, a lot of writing on this topic seems to assume that if addiction involves changes to the brain, those changes must be somehow cause me to do things that I cannot resist. But this is wrong: for instance, PMS, which I assume is a matter of hormonal changes that affect my judgment, makes me more likely to be irritable, and thus more likely to be tempted to snap at unsuspecting receptionists etc., but it does not prevent me from exercising self-control. It should be obvious that different people are subject to different temptations to different degrees: some people have bad tempers while others do not; some people find it hard not to procrastinate while others can’t see what the problem is, etc. A physicalist ought to think: these differing temperaments have some physical cause. But nothing about accepting *that* claim commits you to thinking either that things like bad tempers and tendencies to procrastination *cannot be controlled* — of course they can — or that you cannot, over time, modify these initial dispositions. (Sometimes you can, sometimes you can’t.)

  16. I’m not sure I agree with the idea that “thoughts” control or create our emotions. I think it’s possible this is true, or even partly true, but I don’t think it’s the whole story. And I say this knowing from experience that CBT can work very well, and is worth trying for practically any problem. It’s relatively cheap and won’t hurt you. I’m just not so sure that we are going to be able to figure out our brains this definitively, even with all the gizmos in the world. Not that that would be a reason not to try, of course.

  17. Hilzoy writes: a lot of writing on this topic seems to assume that if addiction involves changes to the brain, those changes must be somehow cause me to do things that I cannot resist.

    This is directly on point, and is a common enough assumption that many people refuse to believe the neuroscientific evidence because they think to accept it means to accept that addicts have zero control over and therefore no responsibility for their behavior. But as you note, these are logically separable things. The brain changes make avoiding substances harder than it is for non-addicts, but clearly not impossible — else no one would ever have recovered from addiction.

  18. Very interesting discussion. Our difficulty getting our heads around (no pun intended) consciousness, action and responsibility once again makes it all so difficult.

    For this reason, I’ve found it important to work out as best I can whether or not I have free will. There is just so much in life that is riding on whether I answer a yes or no to that question.

    In my opinion, we don’t have contra-causal free will. What this means is that we will never have been able to do anything other than what we had done. Yet we can choose to do things differently in the future. Here’s why that isn’t paradoxical. Our thoughts always exist in the past, in the sense that even our projections of the future are based on recollections of the past. So everything is filtered through our past; My thoughts as I type this are nothing more than the sum of everything I have ever learned. I can choose to do anything I like, but that choice will only have ever been the sum of what I had previously known.

    I think the thing that tricks us up, and fools us into feeling like we have more control than we really do, is the simple fact that we are only ever conscious of the tiniest portion of what we are, of what is driving us. Even when we try and be as rational as possible, we routinely fail because our very ability to be rational and logical is dependent on what exists in the unconscious.

    What addiction seems to add to this is that we have more limited control over what we choose to do when we have become addicted. This would explain the fact that addiction can be a spectrum, and work in tandem with many other areas of our ability to choose.

    Speaking of that “ability to choose”, whatever the heck it is, I have to bring up Douglas Hofstadter’s conception of it (as I follow it). He describes the way in which a stack of envelopes, to the blind eye, can feel as though it has a large, round lump in the center. This is the area in which a slightly larger mass of paper forms at the tip of the fold. Yet individually, each envelope seems perfectly flat. So too are we limited by our cognitive faculties to only ever seeing or feeling either one thought at a time, or what feels like a solid mass, or consciousness.

    The question of blame then seems quite difficult. It would be like blaming that sensation of there being a large, round mass in a stack of envelopes. We can feel it, we can even measure it and blame it for something that really did occur, but the closer we inspect it, it sort of unravels into nothingness.

    So instead of blaming, I propose, we simply do our best to reflect upon what happened in the past and try to make any adjustments we can so that the same course does not get taken again. In terms of the envelope, since we don’t have access to the entire shape, we can make educated guesses about each separate envelope and try to adjust them so that hopefully when they assemble into that whole it will be the shape we approve of.

  19. Rather, I would say that, (Aside from quantum uncertainty) what we did, and will do, was dictated by physical facts. But this does not remove personal responsibility, because some of those physical facts consist of what sort of person we are. The physical facts about our brains. And how could we be responsible for our acts if what sort of person we are didn’t help dictate what we do?

    There’s no such thing as “free will”, just causality and chance. But there is such a thing as “freedom”.

    I’d also say that we have a heck of a lot more control over our mental states than we generally realize, because we don’t learn to exert that control, and how to do so is not immediately obvious. It’s rather like, with proper bio-feedback training, you can locally alter blood flow or skin conductivity, or even modulate your heart beat. You can also chose to change your emotions, it’s just that the average person, faced with a demand that they do so, is in much the same position that they’d be if you demanded that they stop sweating on the back of their left hand… Right now!

    This, of course, has very politically incorrect implications, when combined with the long term plasticity of the human brain. 😉

  20. I think I agree – we have a freedom, albeit one limited by what we have learned how to do. And we can expand this freedom. Although its expansion is going to be again, based on our learning how to expand it.

    As for personal responsibility, I would say that we are all responsible, in the sense that we have done things, and as you say we “are a sort of person”. But at the same time, that sort of person was based on what we knew how to do, and any possibility of being someone else based on who we knew how to be.

    (It becomes endlessly recursive when we then say that who we knew how to be was based on knowing how to *know how to* be someone. For example, I want to be a good citizen, so I want to be better informed, so I go online to read an article, which makes me better informed and reinforces my original desire to be a good citizen by teaching me how to become better informed and points toward new avenues of thought. This system of loops is probably what we describe as wisdom, in that someone who has knowledge of these loops, whether having been through them or intuitively grasping their significance, is all the wiser. This is the classic thrust of liberal education. We recognize this process and so encourage our youth to formally familiarize themselves with this open-ended cycle through schooling, with the hope that “lifelong learning” ensues.)

    So, right, we are “that person”. Thus attempts to rehabilitate, deter, etc. But I think in the end, “that person” is still fully caused, and ought to be – even while we’re locking them up – considered as such (even if we will only ever have but a glimpse of what any of those causes might have been).

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