Sunday, March 28, 2010

Ethics, Politics, and Health Care Reform (2)

So how can we understand the virulent backlash against the health reform legislation?

I see two distinctive but inseparable sources for the remarkable eruption of hooliganism and foaming at the mouth that we're seeing.

First, the health reform process has tapped into what Richard Hofstadter called "The Paranoid Style in American Politics" in his 1964 essay. 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 many commentators have pointed out, the Tea Party eruptions are best understood as the pre-death rattle of a demographic group that sees itself fading into the minority.

The paranoid stance is not amenable to rational discourse or political compromise. Here's how Hofstadter described the paranoid approach to politics:

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.
When we add to the paranoid's hypervigilance about external evil the second element - ambitious politicians like John Boehner and Sarah Palin, and ratings-hungry media entrepreneurs like Glenn Beck and Rush Limbaugh - we create an explosive mixture. It's unclear to me how much these fomenters of misinformation believe their ravings and how much they are manipulating the vulnerable Republican base for political power and personal profit.

But there's no doubt about their impact on perhaps ten to twenty percent of the population. Telling a group predisposed to seeing government as the Great Satan that our first African American President is leading a socialist conspiracy to rob us of our freedom tosses a torch of demagoguery onto the petrol of paranoia.

Hofstadter is careful to describe the paranoid style in politics as part of the "normal" spectrum, not as psychopathology. But clinical experience dealing with paranoid illness gives some pointers on how best to respond to over-the-top reaction to the middle-of-the-road health bill:

  1. Arguing with the vehement Tea Party folks won't work. Efforts to persuade zealots that they're wrong will only heighten the fears that drive the paranoid eruption.
  2. Those who see the country as endangered are correct about the risk, but wrong about where the danger is coming from. It's not "big government" that threatens us in health care. The two threats are the risk of untreated illness and avoidable death for the uninsured and the cancer of runaway costs for all of us. The administration should agree about the reality of danger but redefine where the danger is coming from.
  3. The Boehner/Palin/Beck/Limbaugh fomenters, who exploit public vulnerability to paranoia, can only be dealt with by force. They're exploiters, not thinkers. A strong, well-financed opponent to Boehner, or a boycott of the sponsors of Beck and Limbaugh, or persistent exposure of Palin's recurrent lies, is the only way to go.
Ethical reasoning presupposes openness to debate. But the virulent backlash against the health reform bill isn't debate - it's a devil's brew of political paranoia and manipulative exploitation. Sadly, once the Republicans chose to assume a "just say no" posture, the reform process lost all potential for real debate. Ethical reflection had to yield to bare knuckle politics.
Congratulations for the Democrats for taking an initial step forward!


Mary K said...

I believe you reversed some of your words. Wouldn't it be more appropriate to say, "...the runaway costs of cancer"? There are no true evidence-based practices for the treatment of cancer and those illnesses are often what drive families into bankruptcy.

Jim Sabin said...

Hi Mary K -

I'm totally capable of reversing my words, and I understand and appreciate your question, but I really meant to say "The two threats [to our health system] are the risk of untreated illness and avoidable death for the uninsured and the cancer of runaway costs for all of us." The Republicans have been masterful at developing sound bites. I've wanted to see the Democrats refer to runaway costs as a cancer, rather than letting the right wing control public rhetoric with "death panel" duplicity!

The cost of cancer care is a serious issue. Sadly, you're right that cancer treatment often drives families - even those with insurance - into bankruptcy. There are evidence-based practices for cancer care, but all-too-often my fellow physicians recommend care that costs too many dollars but doesn't make sense.