The Problem with “Pathological” Gambling

by Hans Madueme, M.D.

The chips are down. Americans have taken to gambling in a big way. In 1998, legalized gambling grossed more than the music industry, the motion picture industry, and theme parks combined ($50 billion).¹ Gambling problems have increased rapidly in the wake of these trends. Of greatest social concern is “pathological gambling,” a diagnosis established in 1980 by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Pathological gambling, broadly speaking, is a “persistent and recurrent maladaptive gambling behavior” that disrupts daily activities and relationships, but is not caused by manic episodes.² An interesting study was presented at the 57th annual meeting of the American Academy of Neurology in Miami in April 2005.³ Led by Dr. Maria Roca, the study investigated pathological gamblers’ decision-making and executive function capacities (all associated with the brain’s frontal lobe). “Executive functions encompass a variety of processes and are defined as the ability to abstract, plan, organize, shift set, and adapt current and past knowledge to future behavior,” explains co-author of the study, Dr. Facundo Manes: “Decision-making involves assessment of possible reward and punishment outcomes from the various response options, and the selection of the option that one thinks will be best.”⁴ The research included 11 pathological gamblers with a control group of 10 non-gamblers. All subjects were assessed with decision-making tasks, attention and inhibitory control tasks, and other similar tools.

The significant results: pathological gamblers showed more impairment in inhibitory control and attention tasks, and made more disadvantageous choices in decision-making tasks. Manes concludes: “First, our findings add more evidence to the possible role of the prefrontal cortex in the pathophysiology of this neuropsychiatric disorder. Second, the characterization of executive deficits involved in chronic pathological gambling has clear implications for rational pharmacological and rehabilitative treatment strategies.”⁵ This is interesting. Much could be said, not least on the question of study validity: Is the number of subjects large enough for wider generalization? Were the selection criteria clear? Is this research study compelling? While not avoiding these matters completely, this brief essay focuses instead on one limited question: Is this a complete diagnosis? The traditional Christian view of pathological gambling is that it falls broadly under the category of sin. But this study may suggest to some a diagnosis that comports better with medical disease.⁶ Somaxon Pharmaceuticals thus considers pathological gambling “an Impulse Control Disorder (ICD) which also includes pyromania, kleptomania, and intermittent explosive disorder.”⁷ Further, their recommended treatment is a medication undergoing testing in Phase II/III clinical trials—oral nalmefene. As the diagnosis goes, so goes the therapy.

Addicts feel controlled by their desires, which seem demonically inspired; the temptations are like seductive voices beckoning the addict to the next casino. All attempts at resistance, in the end, prove hopelessly futile. Worse, the addict lives in a culture sprawling with casinos, lotteries, horse racing, video poker, and Internet gambling.⁸ Are pathological gamblers culpable for this behavior—in other words, is pathological gambling a sin?⁹ This way of putting the matter may raise eyebrows. Addiction is bad enough as it is—now you want to add sin into the mix? The concern is a legitimate one, and will be addressed in due course. The news is stale that belief in the reality of sin has fallen on hard times. The rumors of its demise are everywhere, but they are not finally persuasive. Sin just is an incontestable part of the world’s empirical furniture. Nor is the disappearance of sin an exclusively religious concern; even secular voices have lamented the sterility of sin-free public discourse.¹⁰ Christians claim, unfashionably, that sins are blameworthy. All of us will give account one day for our transgressions before God because we are culpable for our sins. Envy, materialism, sexual promiscuity, greed, and conceit are typical symptoms of the deep malaise that afflicts us all.

The notion of sin, however, is a two-edged sword. Those who wield it will be wounded by it. In pointing out the speck of sin in someone else’s eye, be careful about the beam in your own. Accordingly, in the intellectual domain, the category of sin favors democracy, not aristocracy. That is to say, no one is exempt. Quite possibly sin has clouded our own judgments. We ourselves may have gotten things wrong.¹¹ In theological vernacular: the intellectual (noetic) effects of sin imply the need for epistemic humility.¹² We simply are mistaken about many things. Do we then need to reexamine our stance on pathological gambling, a behavior Christians have usually tagged as sin? Might we be mistaken on this traditional assumption?

First, the matter of definition: In his brilliant book on the subject, Cornelius Plantinga proposes: “Let us say that a sin is any [culpable] act—any thought, desire, emotion, word, or deed—or its particular absence, that displeases God and deserves blame. Let us add that the [culpable] disposition to commit sins also displeases God and deserves blame, and let us therefore use the word sin to refer to such instances of both act and disposition.”¹³ The question follows inexorably, “Is an addict a person who has a bad habit of making sinful choices? Or is an addict the victim of biological and social forces she may resist but is ultimately powerless to overcome?”¹⁴

Addiction and sin are like overlapping circles. In the smaller, non-overlapping areas of the circle, we have addictions that involve no sin (e.g. babies affected by intrauterine cocaine addiction) and sins that have no addictive component (e.g. the tacit prejudice of a racist). In most other instances, sin and addiction are coextensive.¹⁵ “Addicts are sinners like everybody else,” Plantinga reminds us, “but they are also tragic figures whose fall is often owed to a combination of factors so numerous, complex, and elusive that only a proud and foolish therapist would propose a neat taxonomy of them.” This calls for wisdom and humility—“we must reject both the typically judgmental and typically permissive accounts of the relation between sin and addiction: we must say neither that all addiction is simple sin nor that it is inculpable disease.”¹⁶ Some readers may balk at so close an identification of sin with addiction, especially if sins are taken as self-conscious and high-handed acts (like premeditated murder, rape, or lying). But sin is much broader, more mainstream and insidious than that; indeed, sin is an enslaving condition.¹⁷ “In sin, we are both hopelessly out of control and shrewdly calculating; victimized yet responsible. All sin is simultaneously pitiable slavery and overt rebelliousness or selfishness. This is a paradox to be sure, but one that is the very essence of all sinful habits.”¹⁸

In light of all this, Dr. Roca’s gambling study invites three comments. First, the scientific study of behavior helps us understand better our world and ourselves. On the descriptive axis especially, empirical science is in its element as it probes, quantifies, and specifies our psychological weal and woe. Yet even here, we must recall that the age of “objective science” abstracted from ethical, moral, and philosophical assumptions is over. That stance betrayed a naïve scientism (the view roughly that the scientific method is the gatekeeper to all true knowledge); but science has limits.¹⁹ This study (and others of its kind) can help us understand the medical and psychiatric dimension of problems like addiction. It can promote a more holistic grasp of all facets of the human predicament. A Christian perspective that takes scientific research seriously, however, still has some questions to ask. To what degree does the modern penchant to medicalize behavior drive this study? And does this skew the study in minor and/or important ways? The researchers come with their own assumptions and worldviews (as do we all); these inescapably shape their study and are, in principle, open to critical examination. For instance, the diagnosis of “pathological” gambling already suggests that the medical model has (unfairly) won the popularity contest.²⁰ Does the “pathological” modifier already privilege (or presuppose) certain methodological stances over others? This is not a trivial question. In any case, it is debatable whether the study demonstrates a primary role of prefrontal cortical dysfunction in gambling addiction. Perhaps there are other non-organic factors, just as important (if not more), that contribute to diminished inhibitory control and decision-making.

Second, let us accept for argument’s sake the role of the prefrontal cortex in gambling addiction. We still need to beware of the chicken-and-egg fallacy. Manes posits a connection between pathological gambling and the prefrontal cortex. But which came first? To claim the latter may simply beg the question in favor of biological reductionism. Manes himself offers this wise caution: “Our study reveals only an association, not cause-and-effect.”²¹ Exactly right. It is possible that compulsive gambling actually causes prefrontal cortical changes, not the other way round. Still: if that is in fact the case, maybe the subsequent cortical changes actually reinforce and sustain the gambling habit. Maybe repeated gambling causes pathophysiological changes, further intensifying the habit. As in alcoholism, however, I doubt that even this progressively involuntary habit removes culpability: “Perhaps he addicted himself. Perhaps he misbehaved at a time when he did have the power to choose and act well. If he is like other human beings, his habit has a prehistory of choices and acts. The habit that binds him is a part of the chain of his own acts.”²² Seen in this light, this research actually provides more compelling reasons why men and women are wise always to avoid sin. So help us God.

Third, even if we assume that pathological gamblers do have prior prefrontal cortical changes, this hardly warrants the defense: “my prefrontal cortex made me do it.” Personal responsibility remains alive and well. It is not held biologically hostage like some intra-cerebral military coup. That way leads to dehumanization; a point worth pondering, since cognitive neuroscience today is one of the main cheerleaders for the radical biologization of human persons. Or consider the fact that non-organic predispositions (weaknesses) ordinarily are not taken as legitimate excuses for sin. A child abuser is not acquitted because of a known predisposition (weakness) to anger. So too, in cases of pathological gambling, alleged prior changes in the prefrontal cortex are best taken as organic weaknesses. They may predispose, but they do not determine. In short, they are no excuse for sin.²³

The bottom line is this: so-called pathological gamblers are, like all of us, morally responsible. There is eminent wisdom, however, in multilevel treatments for addictions. This is because addictions often become highly complex and multi-layered. Medical, psychiatric, and psychological approaches all play a significant role in the long road back to human flourishing. But it would be a grave mistake to forget or ignore sin’s fundamental dynamic in this entire addiction process. Moreover, there is great liberty in accepting the tragic monopoly of sin on the ways of men and women. It gives profound hope and dignity to all of us, including gamblers. From the Christian perspective, the local church community, prayer, and counseling (even exorcism) are all legitimate agents of healing.²⁴ Indeed, it is ultimately God himself, the healer par excellence, who—often through secondary means, to be sure—straightens and sanctifies our distorted, endlessly deviant hearts. CBHD

¹ Marc N. Potenza, et al., “Pathological Gambling,” JAMA 286 no.2 (July 2001): p.141.

² For specific diagnostic criteria, see American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (Washington, D.C.: American Psychiatric Association, 1994), pp.615-18.

³ E.J. Mundell, “Problem Gamblers Show Brain Impairment” HealthDay News, April 13, 2005, available at: http://health.myway.com/art/id/525103.html (accessed May 20, 2005). The AAN meeting took place in Miami Beach, Florida, April 9 – 16, 2005.

⁴ American Academy of Neurology, “Problem Gambling Associated with Brain Impairment,” news release, April 13, 2005, available at: http://www.aan.com/press/press/index.cfm?fuseaction=release.view&release=257 (accessed May 20, 2005).

⁵ Ibid.

⁶ For instance, assistant professor of psychiatry at Yale, Dr. Marc Potenza, says: “Gambling has gone from being considered a sin to being a vice to being just bad personal behavior, and only recently has been conceptualized within a psychiatric or medical context.” Yale Bulletin and Calendar, July 27, 2001, available at: http://www.yale.edu/opa/v29.n34/story11.html (accessed June 17, 2005).

⁷ Somaxon Pharmaceuticals, “Somaxon Pharmaceuticals to Present at the UBS Global Pharmaceuticals Conference,” news release, May 23, 2005, available at: http://www.somaxon.com/UBS_PR_5-23.pdf (accessed May 23, 2005).

⁸ Marc N. Potenza, et al., “Pathological Gambling,” p.141.

⁹ The question of whether gambling per se is a problem (or “sin”) is irrelevant to this essay. That concern is not in view here. This essay, however, presupposes that most/all agree that excessive (immoderate) gambling is a problem.

¹⁰ See, for instance, Karl Menninger, Whatever Happened to Sin? (New York: E. P. Dutton, 1973), and Kenneth L. Woodward, “Do We Need Satan?” Newsweek, November 13, 1995, pp. 63-68.

¹¹ On this intellectual dimension of sin, see Stephen K. Moroney, The Noetic Effects of Sin: A Historical and Contemporary Exploration of How Sin Affects our Thinking (Lanham, Maryland: Lexington Books, 2000).

¹²Epistemology has to do with our theory of knowledge; we need to be appropriately humble about the different things we claim to know.

¹³ Cornelius Plantinga, Jr. Not the Way It’s Supposed to Be: A Breviary of Sin (Grand Rapids, MI: Eerdmans, 1995), p.13.

¹⁴ Plantinga, pp.137-8.

¹⁵Ibid., p.144.

¹⁶ Ibid., p.140.

¹⁷ Edward T. Welch, Addictions: A Banquet in the Grave (Phillipsburg, NJ: P&R Publishing, 2001), pp.32-6.

¹⁸ Ibid., p.34.

¹⁹ Despite all its faults, Kuhn’s book is still important; see Thomas Kuhn, The Structure of Scientific Revolutions, 2nd ed. (Chicago: University of Chicago Press, 1970). For critical interaction, see Gary Gutting, ed., Paradigms and Revolutions: Appraisals and Applications of Thomas Kuhn’s Philosophy of Science (Notre Dame, Indiana: University of Notre Dame Press, 1980).

²⁰ Brian Castellani, Pathological Gambling: The Making of a Medical Problem (Albany: State University of New York Press, 2000).

²¹ Mundell, “Problem Gamblers Show Brain Impairment,” HealthDay News, April 13, 2005, available at: http://health.myway.com/art/id/525103.html.

²² Plantinga, p.138, emphasis mine.

²³ Since I hold to minimal dualism, astute readers will discern that I seek to preserve top-down causality. In other words, I remain unconvinced by current models of physicalism. I realize this stance is not au courant; physicalists will likely find my argument here unpersuasive. I agree there are cases like Phineas Gage in which brain impairment seems to mitigate culpability (bottom-up causality). The exception proves the rule, however. But I accept that I may be wrong! The debate is important and very complex, though we cannot pursue it here.

²⁴ Plantinga, pp.132-3.