It's Not the End of the World, So Why Don't We Feel Fine?

Americans engaged with the political process seem particularly prone to cataclysmic thinking.  I am not a political scientist or a historian, so I do not know if this is something that has been characteristic of Americans generally or whether this is a new phenomenon.  Some aspects of contemporary culture are considered to be detrimental to civility in politics and society generally.  These aspects included the 24 hour news cycle and social media (for its combined ubiquity, immediacy, and unfiltered nature).  These same aspects are blamed for a cultural short attention span, which certainly could lead to or increase the sense that every piece of information is somehow crucial or influential.  This, in turn, would seem to predispose persons to cataclysmic thinking, or the notion that every decision, every change, every political fight is of the utmost importance to both present and future.  The problem is that this type of thinking is neither accurate nor healthy.

One current issue about which Americans engaged with the political process are currently thinking and debating is the vacancy on the U.S. Supreme Court.  Justice Scalia died unexpectedly and it is an election year.  This has the right, in particular, in hysterics over the possibility that President Obama will appoint a 'liberal' justice who will influence the Court's decisions in a wholly untoward and dangerous manner, potentially for decades.  The vacancy and the nomination are cast in stark terms, as if the country would somehow fail or cease to function if the makeup of the court were to become more liberal.

It is undoubtedly true that the decisions of the court would skew more liberal if President Obama appointed and the Senate confirmed an appointee before the election.  This of course fails even to consider the possibility that a Republican wins the presidency and is able to appoint a justice when a member of the liberal voting block leaves the court.  While predicting the future can be difficult, one would think that the actuarial tables are suggest we should not be optimistic that she will live through another presidential term, and certainly not two terms.  The point being that the hyperbolic worry about a President Obama appointee being confirmed to the court is not the guarantee of a long-lived liberal majority on the court that it is made out to be.

Still, what if President Obama appoints a justice and the Senate confirms the appointment and it creates a liberal majority on the court that lasts for a couple of decades?  Would this really doom us?  It seems silly to think it would.  The current makeup of the Supreme Court has been reliably conservative for at least 30 years now and it has not plunged us into the abyss.  The Supreme Court was reliably liberal during the 1950s and 1960s and did not plunge us into the abyss.  Certainly segments of the population have not been happy with decisions that either type of court issued, but the Republic did not dissolve into chaos and life has gone on.  For example, conservatives bemoaned the expansion of rights afforded to criminal defendants under the Warren Court.  Noteworthy among the decisions was the finding in Gideon v. Wainwright that criminal defendants have a constitutional right to legal representation in state criminal proceedings.  Despite expanding criminal defendants' rights, the criminal justice system did not grind to a halt and violent criminals did not go unpunished.  As any moderately aware resident of the United States knows, the reverse occurred in the last two decades during which huge numbers of criminal defendants were charged and convicted of crimes, which caused an explosion in the United States' prison population.  It must be noted, that these criminal defendants were guaranteed legal representation and were still convicted.

The same holds true for the left.  Justice Scalia authored the opinion in District of Columbia v. Heller in which the Court explicitly found that the Second Amendment extends an individual right to bear arms unconnected with military service.  Many on the left concluded that the sky would indeed fall, or at least would be filled with an unremitting hail of bullets.  I personally do not find the need to bear arms of any sort and think the idea that one needs a weapon for personal safety in a civil society suggests at the very least that the society is not civil; nevertheless, the worried panegyrics from the left struck me as hopelessly overblown.  The United States already had a huge number of persons who owned guns.  The United States already had a huge number of persons who died from gunshots.  It struck me as inconceivable that a technical change in the law would change either fact substantially, and it did not.  The most reliable predictor of an increase in firearm ownership is not a loosening of the Second Amendment but rather threats to tighten the rules applying to firearm purchase and ownership.  The bottom line is that most of what the Court decides will not have an impact on the daily life of citizens and that the decisions that do impact daily life are often not as profound as we think they will be.

People need to relax a bit about the political issues and choices with which we are faced.  They are not insignificant, but they are often not as earth-shattering or radical as we make them out to be.  Of course there are exceptions.  In keeping with the U.S. Supreme Court, there are decisions that have a profound impact on American life.  Plessy v. Ferguson, Brown v. Board of Education, Roe v. Wade, Lochner v. New York, West Coast Hotel v. Parrish, Bush v. Gore.  Each of these cases had profound and discernible effects on the lives of Americans.  The problem is that we cannot know when these profoundly significant cases will arise and be ripe for decision one way or the other.  Neither can we always know how courts will decide them.  King v. Burwell is such an example.  Perhaps the Affordable Healthcare Act is not as significant as the aforementioned cases.  Still it was a seminal issue of this political generation and the fact that the decision was 6-3 and that Chief Justice Roberts not joined the liberal block (with Justice Kennedy) but also authored the opinion upholding the availability of tax credits to individuals purchasing health insurance on federal exchanges was not a predictable result.  Whether and when the sky is falling is unfortunately not something that is often knowable in advance.  As such, we should stop acting as if it is constant danger of coming down.

Cataclysmic thinking also perplexes me because many of the persons who think in cataclysmic terms about politics do not have it all that bad and are not likely to be significantly impacted by either political party gaining ascendancy.  This is not true of persons at the margins of society, of those who are vulnerable and rely on the state to protect and provide for them when they are unable to do so for themselves.  The strange thing is that the most vociferous voices on most things political, the ones who worry excessively and loudly, who engage in perpetual hyperbole and panegyric, are not the marginalized.  If a person has a college, professional, or advanced degree and is in any number of white collar fields where upper middle class and upper class salaries are the norm, it really doesn't matter much which party is in charge of the government from a class-wide perspective.  Members of this class will enjoy home ownership, safe neighborhoods, comfortable retirements, health care, reliable transportation, good-to-excellent schools, reliable public services, and myriad other benefits, both public and private, regardless of whether a Democrat or a Republican are president.  For this cohort, it is not the end of the world as they know it and they really ought to feel fine.

I worry about cataclysmic thinking because it creates a socio-political environment that is filled with unnecessary stress and strife.  This cannot be good for us as a nation because it causes our thinking to be clouded with fear and other emotions when what would be best is for us to take a longer view.  Cataclysmic thinking is the ultimate short-term perspective because it focuses everything on the battle at hand without giving any thought to our future as a socio-political collective.  Politics in this country has an internal corrective to bad decisions:  regular and free elections.  Ultimately, if any one party gains ascendancy and behaves so irresponsibly as to damage significant and discernible portions of the population, that party will not be able to hold on to power.  And if they somehow manage to maintain power, they will be forced to modify their positions, at least in part.  The current support for criminal justice reform among elements of the political right is a good example of this.

Civic and political engagement is a good thing.  It is an even better thing if it is well-reasoned and fully informed.  And it is best when we realize that politics is a process, not an endgame.  For Americans not at the margins, things are not that bad.  Stop acting like the sky is falling.  It almost certainly isn't, and it if is neither political party will be able to stop it.

Looking for Salvation in Medicine

Several months ago, Atul Gawande wrote an interesting article in the New Yorker on why people seek unnecessary treatment.  He questions why patients will willingly undergo unnecessary treatments that are objectively more dangerous than undergoing no treatment at all.  He discusses why this is the case and posits, among other ideas, that part of the problem is that people generally don't know what statistics in medicine mean.  Having thought about the piece myself, I question whether it is so much that we don’t know as it is that we want to know about certain things in certain ways.  Alan Levinovitz, author of The Gluten Lie:  And Other Myths About What You Eat, remarked about a similar issue involving diets:

And I thought to myself, you know, it’s funny, people are trying to debunk these fad diets with scientific evidence, but what they’re not realizing is that really these beliefs aren’t scientific at all. They’re wrapped in scientific rhetoric, but ultimately they’re quasi-religious beliefs that are based on superstition and myth.

In his piece, Gawande notes that a patient from whom he surgically removed a benign thyroid cancer that was only discovered due to an unnecessary test “thanked me profusely for relieving her anxiety.”  She was not concerned about her actual physical health condition.  If she were, she would have recognized that the procedure to remove the benign tumor carried with it higher risks of death and physical harm than leaving the microcarcinoma alone and monitoring it.  The need for treatment was not medical.  Her understanding of the condition was conditioned on a belief system about cancer (and medicine) that is mythic.  Dr. Gawande was fulfilling a function perhaps closer to shaman than surgeon.  The problem, if it is a problem, is with modes of understanding and typologies of knowledge.

It is too easy to blame greed.  Certainly greed in medicine exists.  So does false hope and unrealistic expectations.  Charlatans take advantage in medicine as they do in the revival tent (or on the revival screen, as the case may be). 

The idea of medicine in America is, or has become, salvic.  Christ on the Cross is no longer intercessor or savior or redeemer.  Now it is the busy doctor dispensing antibiotics for viral upper respiratory infections or the cardiothoracic surgeon putting in a stent or the plastic surgeon cheating time with a Botox injection who intercedes, saves, or redeems.  The Rosary replaced by the Rx b.i.d.  The actual state of health is unimportant compared to the reassurance of an explanation, the ritual that allows us to feel as though everything is okay, that everything is in order, that we are being taken care of.  The soul has become the body.  Our quest for health is, as Levine notes with diet, quasi-religious.

And pain.  Pain is more than nociception.  Pain is a modality for expressing discomfort, physical or otherwise.  Complaints of pain alone seems not to establish physical pathology.  However, we have learned that when something hurts we go to the doctor.  Unhappy marriages hurt.  Financial distress hurts.  Is it any wonder that we somaticize?  Seeking understanding and counsel in medicine is normal behavior for persons acculturated as we are; that is acculturated to believe every problem is medical and every medical problem has a solution.

One of Foucault’s profound insights in The Clinic is that the patient went from being a person in the pre-clinical era of medicine to a specimen when medicine became “scientific” or clinical.  As a specimen, the patient became an object of inquiry rather than a person in the world.  The goal of treatment became a disease-free state rather than well-being.  Thus, questions about the patient’s overall well-being that were not directly related to the disease state were subverted and minimized.  “Treatment” would only be proffered in the presence of objectively verifiable disease, regardless of the patient’s degree of actual suffering.  Consciously or not, patients came to understand that if they wanted relief from pain they would have to characterize it as a disease-state.

Members of all societies suffer, some more than others, but suffering is a constant.  No society is Edenic.  Nevertheless, contemporary American society seems to predispose its members, at least those members not living in abject poverty, to a certain anomie.  For whatever reason, traditional American cultural institutions seem unable to ameliorate this state.  Instead, this cultural disaffection seems often to be medicalized in forms such as low back pain, arthritis pain, or depression.  

Unfortunately, medicine treats the manifestations of anomie as disease states, with predictably poor results.  Despite the predictably poor results, medicine treats manifestations of anomie with the same confidence and professional brio with which it treats broken bones.  Hence, a perversity of expected outcomes is created for both doctors and patients.  Doctors offer something approximating science while patients seek salvation for existential discomfort out of the firmament of superstition and myth.  Unfortunately, never the twain shall meet.