Paranoid Style in the ACA Dissent

My wife and I are in Vermont with two of our grandchildren visiting, so I've only just now finished reading the 193 page Supreme Court decision about the ACA.

Throughout the health reform process I've tried to understand the virulent opposition to the ACA in terms other than "stupidity" and "demagoguery." Stupidity is real, as when Senator Breaux's constituent pleaded "don't you let the government get hold of my Medicare." And demaguguery is all too real, as in Sarah Palin's death panel lies and Mitt Romney's sucking up to the Tea Party and running away from his constructive role in Massachusetts health reform. But the dissent written by Justices Scalia, Kennedy, Thomas, and Alito (that's the sequence of their names on the dissent) offers a uniquely clear insight into hatred of the ACA.

I'm not a scholar of constitutional law, but I found Justice Ginsburg's argument that the individual mandate was constitutionally justified under the Commerce Clause persuasive. But I also found Justices Scalia, Kennedy, Thomas, and Alito's argument that the Commerce Clause does not justify the mandate strong in logic.

It may be the psychiatrist in me, but I believe the conclusion the four dissenters reached (and the virulent hatred of the ACA that some of its opponents express) reflect the dissenter's fear of a slippery slope more than the nuances of interpretation of precedents. The dissent has a framework of logic, but the driving force is emotion. I've highlighted the emotional content of three representative excerpts from the dissent:

...to say the failure to grow wheat (which is not an economic activity, or any activity at all) nonetheless affects commerce and therefore can be federally regulated, is to make mere breathing in and out the basis for federal prescription and to extend federal power to virtually all human activity. (p 129)

...If congress can reach out and command even those furthest removed from an interstate market to participate in the market, then the Commerce Clause becomes a font of unlimited power, or in Hamilton's words, "the hideous monster whose devouring jaws spare neither sex nor age, nor high nor low, nor sacred nor profane." (p 134)

But if every person comes within the Commerce Clause power of Congress to regulate by the simple reason that he will one day engage in commerce, the idea of a limited Government power is at an end. (p 138)

The dissenters see the ACA as unleashing a hideous devouring monster. Their outlook reflects what historian Richard Hofstadter called the paranoid style in American politics. Here's the essence of Hofstadter's analysis:

I believe there is a style of mind that is far from new and that is not necessarily right wing. I call it the paranoid style simply because no other word adequately evokes the sense of heated exaggeration, suspiciousness, and conspiratorial fantasy I have in mind. I am not speaking in a clinical sense...It is the use of paranoid modes of expression by more or less normal people that makes the phenomenon significant.

...As a member of the avant-garde who is capable of perceiving the conspiracy before it is fully obvious to an as yet unaroused public, the paranoid is a militant leader. He does not see social conflict as something to be mediated and compromised, in the manner of the working politician. Since what is at stake is always a conflict between absolute good and absolute evil, what is necessary is not compromise but the will to fight things out to a finish. Since the enemy is thought of as being totally evil and totally unappeasable, he must be totally eliminated—if not from the world, at least from the theatre of operations to which the paranoid directs his attention.

The dissenters see the ACA through the lens of the paranoid style. This is what leads them to the crucial slippery slope argument - that if we allow the individual mandate we allow the government unlimited power to coerce us. The end result is the image of the body politic as an infant, being forced to eat broccoli by a controlling mother:

All of us consume food...But the mere fact that we all consume food and are thus, sooner or later, participants in the "market" for food, does not empower the Government to say when and what we will buy. That is essentially what this Act seeks to do with respect to the purchase of health care. (p 139)

The slippery slope argument - from the health insurance mandate to total government control and forced feeding with broccoli - depends on the emotion, not logic. Justice Ginsburg makes a powerful argument that health care, representing more than one sixth of our national economy, is a distinctive case, not just one stop on a slope leading to broccoli. But from the perspective of the paranoid style, giving an inch is giving a mile.

Hofstadter is clear that the paranoid style doesn't mean that the views being asserted are wrong. In my view the dissenters make cogent arguments about Commerce Clause precedents but, again in my view, the arguments don't trump those advanced by Justice Ginsburg. But for those who see the world through the paranoid style lens, the associated emotions add the necessary weight to arguments that in themselves are not decisive. 

The paranoid style isn't a logical conclusion - it's an emotional predisposition. As a result, logic won't alter it. Between now and November we'll see how the Republicans will seek to fan paranoid style flames and how the Democrats will seek to counter it. Stay tuned!

(The full Supreme Court decision is available here. And for a strong argument as to why the health sector is distinctive and the slippery slope argument fails, see health law professors the amicus brief from 104 health lawyers here.)

Praying for health

When I learned last week that a friend, who is also a colleague I admire, is having major surgery today, I included this sentence in the note I sent him: "Although I don't literally "pray," the phrase "you will be in my prayers feels true - and you will be next Tuesday."

He wrote back: "Technically, I do not "pray" either. However, I find that I have a strong faith in universal purpose, the importance of helping others, and that one's contributions profoundly matter in some way."

By chance on the same day I sent my email, another colleague wrote to me this way about our shared interest and pleasure in Vermont, where I am now: "We are so blessed living in New England!"

What's going on with non-praying prayers, universal purpose, and blessedness?

My love of religious language is not rooted in a theology. When I'm forced to explicate my religious position I define myself as "a religiously minded Jewish atheist." As an atheist, I don't participate in a congregation or community that calls itself religious. But here I was, on the same day, telling my friend that he would be in my prayers, hearing back from him about universal purpose, and hearing from another friend and colleague that we were blessed.

I do feel blessed to be part of a set of overlapping communities committed to health and health care - clinicians, researchers, and folks involved with health care ethics. An anthropologist studying us would say that these communities are like religious communities in (1) sharing values and (2) regularly talking about ("professing") those values while (3) maintaining recurrent, long term contact with each other. For me, and for folks like the two colleagues I exchanged messages with, these moral communities have the same valence that an organized religion can have for someone for whom the religion as a living experience, not a dutiful routine.

Referring to "prayer," "blessedness" and "universal purpose" uses terms that have been developed in the context of religious commitment and theological belief to affirm and reinforce the commitment that my friends/colleagues share. The religious terms carry a distinctive weight. They help to convey that health care can be a "vocation" and "calling," not a job.

I haven't been down on my knees today, but my friend is definitely in my prayers!

Bereavement, Depression and DSM-V

In January I criticized the American Psychiatric Association (APA) for planning to drop the "bereavement exclusion" from the definition of major depressive disorder in the forthcoming new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Under the exclusion, the diagnosis of depression is not made if:

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

In a recent issue of the New England Journal of Medicine, Richard Friedman, a distinguished psychiatrist at Cornell who writes excellent New York Times columns for general readers, adds to the voices criticizing the APA for medicalizing normal grief (see here). Here's the essence of Friedman's argument:

In removing the so-called bereavement exclusion, the DSM-5 would encourage clinicians to diagnose major depression in persons with normal bereavement after only 2 weeks of mild depressive symptoms. Unfortunately, the effect of this proposed change would be to medicalize normal grief and erroneously label healthy people with a psychiatric diagnosis. And it will no doubt be a boon to the pharmaceutical industry, because it will encourage unnecessary treatment with antidepressants and antipsychotics, both of which are increasingly used to treat depression and anxiety...The medical profession should normalize, not medicalize, grief.

Despite criticism the DSM-V working group has not changed its plan to eliminate the bereavement exclusion, but it has added a footnote that at least acknowledges the challenge of distinguishing normal grief from the illness of depression:

The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss.

I don't know if Dr. Friedman would be mollified by this footnote, but I'm not. For those who want to delve more deeply into the research, the working group presents its rationale here.

To my eye, clinical and epidemiological research relevant to distinguishing the illness of depression from the painful but not unhealthy state of grieving doesn't settle the controversy. The DSM-V working group has chosen to drop the bereavement exclusion out of fear that it might lead to misdiagnosis of some depressive episodes as normal grief. I, along with Dr. Friedman and other critics, see the potential for medicalizing normal grief as a significantly greater danger.

Years ago, when I was teaching a group of primary care physicians about use of antidepressant medication, one of the PCPs commented in the form of a two-line poem:

I know what to do when they're dying,
But not what to do when they're crying.

Between the degree to which harried physicians have become less skilled at dealing with existential concerns like grief and the seductive pharmaceutical marketing that will emerge with the death of the bereavement exclusion, before too long we'll be seeing patients experiencing normal grief being flogged with unwarranted diagnoses and unneeded medication.

Grief typically lifts on its own without medical intervention. Some of these patients and their physicians will conclude that they have been "cured" by the unneeded medication and will remain on it, exposing them to pharmacological side effects. In addition, some will experience an altered self image - "I'm a 'weak' person who got sick when X died and needed medicine to get over it" - rather than "I miss X terribly and experienced severe grief after the death."

The DSM-V working group is factually correct in its belief that loss can trigger the illness of depression and that it's important for clinicians not to miss the diagnosis when this happens. But dropping the bereavement exclusion won't eliminate this risk, and eliminating the exclusion will add to a destructive cultural trend of over-medicalization and excessive use of pharmaceuticals.

Industry, Medicine and Medical Ethics

This morning I co-chaired a meeting of the Massachusetts Association of Health Plans (MAHP) Ethics Forum that used the Massachusetts Gift Ban law as an entry point for discussing the relationship between the medical products industry and the medical profession.

Marcia Hams, program director of the Community Catalyst Prescription Access and Quality Program and Tom Stossel, director of translational medicine at the Brigham & Women's Hospital, kicked off the discussion. Many pharmaceutical companies are affiliate members of MAHP, so participants included pharmaceutical folks as well as health plan medical staff.

What struck me most about the excellent discussion is how the absence of an overall budget for health care has tilted public discourse in a polarized black and white direction. Marcia Hams made a strong, thoughtful advocacy argument that pharmaceutical marketing activities contribute to increased costs and negative impacts on quality. Tom Stossel made a strong, thoughtful advocacy argument that pharmaceutical marketing activities contribute to decreased overall costs and quality improvements.

If we had an overall budget for our health system, or real budgets for components of the system, we'd be having a different set of discussions. Instead of arguing about whether industry influence on medical practice and health care costs is good or bad (it's both), we'd be discussing questions like whether a particular intervention created enough value to justify its use, and how its cost-effectiveness measured up against alternatives.

Many in the policy community argue that the U.S. population is unwilling to recognize and accept limits in health care. In my view, the scattered structure of our health system - most notably, the absence of overall budgets - has made it difficult for us to consider relative value, trade offs, and opportunity costs. By now we're habituated to not thinking about these questions, which makes us progressively immature as a body politic and vulnerable to nonsense like "death panels" and fear that the Affordable Care Act will lead to a government mandate that we all eat broccoli!

(This has been the longest time without a post since I started the blog almost five years ago. I've been unusually busy with teaching activities and a number of projects. It's good to be back!)