Harvard University Press Blog

Religious Freedom, Health Care, and Women in the Church

When then-candidate Rick Santorum declared in February that John F. Kennedy’s 1960 comments on the role of people of faith in the public square made him want to “throw up,” he merely presaged a showdown to come. After this week’s announcement of a lawsuit brought by Catholic groups upset with the Obama administration, HUP Publicity Assistant Bridget Martin turned to a few books for context, and offers the post below.

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This week, 43 Catholic organizations including schools and hospitals filed lawsuits against the Obama administration in response to the federal mandate that birth control coverage be included in health care plans. Though the Obama administration proposed a compromise by which the responsibility for payment could be shifted from employers to the insurance companies, those bringing suit characterize the mandate as an assault on religious liberty. The lawsuits have set off a maelstrom of responses, unveiling the political, ethical, and social complexities embedded in the issue.

In a Wall Street Journal opinion piece entitled “Why the Bishops Are Suing the U.S. Government,” Harvard Law School professor Mary Ann Glendon defends American bishops and their initiative to preserve the separation of Church and State. Glendon, whose HUP books include Abortion and Divorce in Western Law, argues that the health insurance mandate violates the Catholic Church’s constitutional liberty, ultimately demoting religion to a second-class right. She sees the debate not as an argument about contraception, but as a principle for preserving religious liberty, asserting, “The main goal of the mandate is not, as HHS claimed, to protect women’s health. It is rather a move to conscript religious organizations into a political agenda, forcing them to facilitate and fund services that violate their beliefs, within their own institutions.”

But what exactly did the founders intend when they included the separation of church and state clause in the US Constitution? In Religious Freedom and the Constitution, Christopher L. Eisgruber and Lawrence G. Sager caution us against imagining an impenetrable wall between church and state when we consider the ideal. Rather, they argue that while religious institutions and practitioners have the right to be free from governmental discrimination on account of religious beliefs, those religious beliefs do not on their own exempt institutions and practitioners from generally applicable laws. This interpretation sheds a different light on the relationship between church and state, especially as US bishops turn to the court in fear of being marginalized by the federal government.

Government influence is not the only social issue driving the contraception controversy. A day after Glendon’s piece was published, Maureen Dowd’s op-ed in the New York Times took an opposing stance. Dowd frankly rejects the position adopted by Glendon and others: “The church insists it’s an argument about religious freedom, not birth control. But, really it’s about birth control, and women’s lower caste in the church.”

Dowd’s argument is a window into the gender and power implications of this debate. As an institution dependent on male hierarchy, is the Church’s disapproval of contraception a tool to subordinate women? The struggles of women within the male power structure of the Church are chronicled in Jo Ann Kay McNamara’s Sisters in Arms, which traces the history of Catholic nuns in the Western world. McNamara shows that the earliest female converts were attracted to the Church by the proclamation of equality in the Kingdom of Heaven, a notion vastly different from the patriarchal societies of the Early Church. Yet since the establishment of female ministries, women have struggled to be recognized as equals in the church.

Garry Wills emphasized this subordination in an April post on the New York Review blog. Wills explains how the Vatican recently “stripped the Leadership Conference of Women Religious, representing most American nuns, of its powers of self-government, maintaining that its members have made statements that ‘disagree with or challenge the bishops, who are the church’s authentic teachers of faith and morals.’” Outraged by this blatant reduction of power for women in the Church, Wills calls attention to the nuns’ unwavering commitment to the social Gospel, aiding those suffering regardless of political implications involved, as in their response to the AIDS crisis, their facilitation of the spiritual needs of gay people, and their activism in the civil rights movement.

Debates over the politics of religious freedom and gender inequality seem certain to reach a fever pitch in this election year. The Catholic Church is planning a national campaign for their cause, “Fortnight for Freedom,” to run from June 21st through the symbolically chosen July 4th. The initiative, intended to encourage prayer, education, and public action about religious freedom, was created in direct response to the perceived threat posed by the Obama administration. With the Church seemingly demonstrating the primacy of a respect for life in its political motivations, it will be interesting to watch the extent to which American Catholics embrace Mitt Romney, even in light of his Mormonism, which some may still find unsettling.

Making Chefs and Surgeons

The latest dose of Lucky Peach, the newish quarterly journal of food and writing, is the Cooks and Chefs issue. With their characteristic blend of smart, irreverent writing and terrific illustration and design, the Lucky Peach team spends the issue riffing on celebrity chefs, cooking shows, old masters, lunch ladies, and the changing world of the culinary arts. A common thread running through the issue is a collective sense of loss over the ways in which the forty hour work week has changed both the education of cooks and the workings of restaurants.

In a piece titled “I See a Darkness,” Lucky Peach co-creator and chef/owner of Momofuku David Chang issues his own lament in pink type on black pages beneath a stark opening line: “I am convinced that cooking is dying.” From his piece:

(I)n the past, at almost all high-end restaurants, you just worked. One of the fundamental changes to the profession is the elimination of “shiftpay”—i.e. you make $80 for the period of time known as “Monday” regardless of how many hours you’re there. That’s been replaced by the forty-hour work week. You just can’t learn to cook in forty hours a week.

“There is a whole style of restaurant that has evolved from that restriction,” (Andrew) Carmellini explained. “You basically come in at four in the afternoon and just go shopping, because everything is ready for you. Get your fish, chives, shallots, or whatever, and then you’re just waiting for the cream and whatever to come down the conveyor belt. Unfortunately, it does affect the process. No one was paid to teach me how to make pasta, but the Italian guy downstairs would put in the extra hours to do that, and I’d put in the time to learn. It’s hard to do that now. Even if cooks wanted to stay late or work from start to finish, they are legally not allowed to.”

The response of the restaurant world—and I’m as guilty as anyone—has been to systematize and streamline the way food is prepared. You either have to do that or break the law. The best restaurants used to have minimal staff; they’d have a couple of prep cooks, but everyone was responsible for their own station and partner. Time was relative to the work that needed to be done. Now many restaurants operate with multiple crews—one team preps, and then, as Carmelini put it, the next shift “shops” for their mise en place.

Now, despite there being foodies among us, we’ve published too many books on labor history to sit here and worry much about what worker protections have done to the state of pasta-making. That said, the general concern for the ways that new restrictions can impede the training of current and future generations has put us in mind of a book on a different sort of knife skills, Dr. Nicolas Tilney’s Invasion of the Body: Revolutions in Surgery. Forgive the implications of the comparison, but, hey, chefs and surgeons DO both wear white coats, get their hands bloody, and surround themselves with stainless steel. And Tilney’s explanation of what’s lost when budding surgeons have their work weeks restricted has a number of parallels with Chang on cooks.

The Rise and Fall of American Madness

Richard Noll’s American Madness describes the electric rise and fall of the psychiatric diagnosis of the mysterious disorder known as “dementia praecox.” As the first specified disease of psychiatry, dementia praecox’s curious history has a great deal to teach us about the nature of the field. As the American Psychiatric Association engages in the vexed process of revising its Diagnostic and Statistical Manual of Mental Disorders, American Madness is a more timely study than many in the discipline would probably like to admit. We invited Noll to answer a few questions about what we can learn from the story.

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Q: Prior to your work, the last time “dementia praecox” appeared in the title of a book published in English was 1950. Clearly it has slipped into our cultural unconscious. Briefly, what is the narrative of the rise and fall of dementia praecox?

Ah, yes . . . dementia praecox is indeed a vanished kingdom of suffering and despair. Hundreds of thousands of Americans who received this diagnosis between 1896 and 1952 were stigmatized by both physicians and everyday people as incurably insane. One only has to remember how frequently it was invoked in the culture of that era (such as in the Tennessee Williams play Suddenly, Last Summer) to get a sense of how terrifying those two words once were.

As the influential psychiatrist Adolf Meyer once said, the history of dementia praecox is the history of psychiatry. American Madness is, at one level, the biography of a disease, but most importantly I regard it as the story of how, in the late 1890s, American alienists (as they called themselves) strove to rejoin an American medical profession that was moving toward a science-based, laboratory-driven moral economy founded on a new (circa 1860) European concept of diseases as separate, biologically-specifiable entities with specific biological mechanisms and typical courses and outcomes. For American psychiatry to survive as an accepted branch of medicine, and not remain as a queer survival of a nineteenth-century therapeutic sect, its legitimacy and authority depended upon adopting this doctrine. In an era where one was either sane, nervous, or insane, most alienists and neurologists assumed insanity was a hydra, a single monster with many faces, not separate creatures.

In 1896 German psychiatrist Emil Kraepelin proposed a classification of mental diseases based on this new fundamental medical principle, and described dementia praecox as a psychotic process that began in the decade after puberty with a distinctive course and outcome. Mental deterioration, weakness and defect worsened and became permanent. It was a hopeless diagnosis. But Kraepelin argued that dementia praecox, as well as other major mental diseases that he created, would one day be found to be rooted in natural, biological disease processes. This claim, in part, made Kraepelinian classification attractive to American alienists who desired to retain their status as physicians. There is a co-dependency of the psychiatric profession and a biological disease concept that persists today.

Beginning in 1896, as one American asylum after another slowly introduced dementia praecox as a diagnostic box, it became the most frequently diagnosed condition, labeling a quarter to a half of all patients in each institution. How American psychiatrists were making this diagnosis is anyone’s guess—they were probably just snap decisions based on whether someone was suffering from a “good prognosis madness” (such as manic depression) or a “bad prognosis madness” (dementia praecox). What we do know is that being young and male made it more likely someone would receive this diagnosis.

As dementia praecox and its successor (a uniquely American re-interpretation of the Swiss psychiatrist Eugen Bleuler’s concept of schizophrenia) became the natural focus of biological research for much of the twentieth century, American Madness also provides the heretofore untold story of the rise of biological psychiatry and laboratory research in the United States. By 1927 schizophrenia became the preferred term for inexplicable madness, but the Americans reframed Bleuler’s disease concept as a primarily functional or psychogenic condition that was caused by mothers or maladjustments to social reality. When Bleuler visited the United States in 1929 he was horrified to see what the Americans were calling schizophrenia. He insisted it was a physical disease with a chronic course characterized by exacerbations and remissions of hallucinations, delusions and bizarre behaviors.

Q: Is it possible to speak of a “typical” case of dementia praecox?

No. The label was so frequently used in an inchoate medical environment absent of consensual agreement on classification and nomenclature that we have little historical evidence as to how, on a daily basis, an individual physician applied these social constructions in his or her practice. Historian Gerald Grob termed this problem for historians of psychiatry as that of the “Invisible Patient.” Knowing the diagnosis of a person of the past tells us next to nothing about their history, signs or symptoms. Alienists and neurologists operated on a gut-feeling level. Diagnosis was not based on an explicit cognitive exercise, like running down a checklist of signs and symptoms, but was more like the experience of recognizing a melody or a scent. A “precox” patient evoked an uncanny feeling of remoteness or of the “bizarre” in a physician, and that was the most important basis of a diagnosis.

Q: How should American Madness help us to understand the sort of epistemic crisis currently confronting American psychiatry?

As everyone knows, the American Psychiatric Association is involved in a highly controversial effort to revise its diagnostic manual. DSM-5 (as it will be called when it appears in 2013) reflects the fact that scientific medicine has not yet solved the problem identified by American alienists a century ago: the linkage of clusters of signs, symptoms, and clinical history to biologically specified disease concepts. The proposed diagnostic criteria in DSM-5 requires a “bottom-up” differentiation of patients, which can be achieved only through an objective biological test (or tests). Until such a tool is developed for schizophrenia, a heuristic associated with an unimaginable assortment of confusing biological findings, we can neither validate nor invalidate our era’s schizophrenia concept. Genetic tests will almost certainly not be the answer, nor will the exclusive emphasis on the brain. As Sabine Bahn and her associates at the University of Cambridge are demonstrating with their new biomarker-based blood test for schizophrenia, severe psychotic disorders might be due to a life-long smoldering systemic or “whole body” disease process that involves glucose metabolism and immune system dysfunction. This is what Kraepelin proposed for dementia praecox, and it might be true for our era’s schizophrenia as well.

Three Operations

On January 22nd, 1913, a Mary Agnes Turner was the first patient admitted to the newly completed Peter Bent Brigham Hospital in Boston. After the birth of her first child the veins in her legs had begun to swell, and long hours on her feet as a maid only made things worse. By 1913, at age 45, her varicose veins had become so bothersome that she sought help. Her doctors at the Brigham planned an operation to strip her varicose veins, still a new procedure at the time. Medical personnel attending to the operation were clad in the newly conceived cotton face mask. In a brand new wooden operating room Turner was rendered unconscious through the use of ether, dripped onto gauze across her face. Using the newly introduced razor-blade scalpel and techniques developed just a few years earlier, doctors stripped segments of the veins by running a cable down their lengths and removing them forcefully. Turner was stitched up with catgut and silk, and discharged after ten days of postoperative care.

By 1965 the Brigham had grown to 300 beds. A stocky, muscular, 68-year-old Joseph Costello was admitted to treat a dangerously widened aorta. Relatively few procedures had been performed in the new field of vascular reconstruction, but the risks of operating on Costello were considered overshadowed by the consequences of inaction. Radio-opaque dye was injected into his aorta and an X-ray taken at the exact right moment to produce an image of the arterial tree. Costello’s aorta was seen to contain an aneurysm the width of a fist. Costello was sedated and wheeled to the very room where Turner’s operation had occurred, now with tiled walls and linoleum floor. A catheter was run to his bladder, a tube to his nose, and various intravenous lines were set. An electric knife opened Costello’s abdomen, and the aneurysm was isolated, clamped, removed, and replaced by a synthetic woven tube graft. His abdominal wall was closed in layers, the five-hour procedure ended successfully, and Costello was discharged ten days later.

At the same hospital in 2007, Shirley Laverne sought treatment for morbid obesity, an emerging and rather unexpected health problem. At 37 Laverne weighed nearly 350 pounds. An obvious candidate for gastric bypass surgery, in which the size of the stomach is drastically reduced, she went through an extensive series of information sessions and consultations before the course was set. She then was evaluated by a psychiatrist, dietitian, cardiologist, and radiologist, along with her physician and surgeon. On operating day, in a pristine room on a stainless steel table custom-built for morbidly obese patients, Laverne was fitted with pneumatic boots that could be pulsed to prevent blood clotting. She was rendered unconscious nearly instantly, catheterized, tubed, intravenously lined, and connected to an automatic respiratory unit. The procedure was conducted via laparoscopy, the training-intensive, minimally invasive technique of inserting instruments through relatively small incisions rather than opening the entire operating field. Five incisions were made for implements and a camera, and the surgeon watched a feed from the camera on a television monitor. He used stapling devices to isolate a small gastric pouch, restored intestinal continuity, and closed the incisions. Blood loss was minimal, the postoperative course was smooth, and three years later Laverne weighed 140 pounds.

Housing and Mental Illness

The post below comes from Russell K. Schutt, co-author with Stephen M. Goldfinger of the recently published Homelessness, Housing, and Mental Illness.

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A recent New York Times article examined the tragic and brutal murder of the group home counselor Stephanie Moulton by Deshawn James Chappell, a group home resident diagnosed with schizophrenia. The circumstances of the murder force our attention to two questions: What is schizophrenia? And what are the prospects for community integration of persons with schizophrenia? We need look no further than the comments elicited by the NYT article to realize the extent of controversy about these questions. But what does scientific research actually show about these issues?

Schizophrenia is a serious mental illness, the causes of which are not yet well understood. It afflicts about 1% of the population, typically emerging in late adolescence or early adulthood. Neuroimaging and functional testing identify diminished brain volume in key areas and declining cognitive and social functioning at the time that symptoms of the disease emerge. After onset, the symptoms persist, although their intensity fluctuates and some long-term research has identified patients in whom symptoms have dissipated many years after onset. Psychotropic drugs relieve symptoms such as hallucinations and paranoid delusions for some patients, but they have no effect on cognitive or social functioning.

Debates over the prospects for community integration of persons with schizophrenia have framed mental health service policies since the 19th century. The first state psychiatric hospitals were designed to provide a protected, humane environment for persons with serious mental illness. Without much quality evidence, state hospital superintendents in the 19th century issued glowing reports about patient improvement. Even still, the hospitals were soon overwhelmed by a rapidly increasing patient census, inadequate resources, and a shift in professional psychiatrists’ focus to private patients. Exposés in the 20th century suggested that the environment of state hospitals was more likely to exacerbate patients’ symptoms and diminish their prospects for return to the community than to restore their health.

The proponents of deinstitutionalization sought to end the warehousing of persons with serious mental illness and to instead provide community-based care that would normalize treatment services and facilitate community engagement. They were motivated as well by the discovery of psychotropic medications that lessened symptoms; state governments’ desire to shift costs to Medicaid-reimbursable community-based care; and the growing demands of advocacy groups for patients’ right to make their own treatment decisions.

Whatever the precise mixture of commendable and crass motives, the goals of deinstitutionalization were only partially achieved. State hospitals were indeed depopulated, but alternative community-based care was only partially funded and psychotropic medications proved to be only partially effective. In addition, rising housing costs and the widespread destruction of cheap single room occupancy hotels made it impossible for many persons with serious mental illness to maintain any type of community residence. The large number of people with serious mental illnesses who became homeless or were incarcerated indicates the failures of this new service system.

An Interview with Dr. Augustus A. White

Dr. Augustus A. White is Professor of Medical Education and Orthopedic Surgery at Harvard Medical School, and the author, with David Chanoff, of Seeing Patients: Unconscious Bias in Health Care. After growing up in the Jim Crow-era South, Dr. White went on to become the first African American graduate of Stanford University’s medical school, and later the first African American department chief at Harvard’s teaching hospitals. Seeing Patients draws on both original research and Dr. White’s own experiences to examine how care is affected by the unconscious prejudice of providers. You can listen to a podcast interview with Dr. White here. Below, Dr. White responds to a few questions about his book and health care disparities.

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Q: Much has changed in terms of access to health care for different groups of people since you began your career in medicine. What are some things that haven’t?

I think that while there may be diminishment of conscious bias on the part of caregivers and the healthcare system, unconscious bias may still persist. But when I started my career, healthcare was largely segregated in the United States, and, especially in the South, patients would go to their private physicians (that is, Caucasian physicians) either on a special day, or through the back door, and sit in separate waiting areas. That is, segregation accompanying the discrimination. That separation is essentially nonexistent at this point, and I would presume that some of the unconscious bias may have diminished as well, but clearly there remains unfortunately substantial conscious and unconscious bias, experienced not just by people of different races, but many other differences are operative. That is, essentially 13 groups of people currently still receive disparate treatment -- African Americans; Native Americans; Asian Americans; Latinos; prisoners; the Appalachian poor; disabled individuals; immigrants; certain religious groups; gay, lesbian, bisexual, transgendered people; obese people; elderly people; and women.

Q: Can you give some common examples of the manifestations of the “unconscious biases in health care” that you describe in Seeing Patients?

I can give any number of examples, though I cannot always know which are unconscious and which are conscious, because clearly both mechanisms are operative. African Americans receive lower rates of cardiac surgeries, fewer hip and knee replacement surgeries, fewer kidney and liver transplants. African Americans receive more open surgeries, rather than less dangerous laparoscopic procedures. Diabetic Blacks are more often amputated than diabetic Whites. Women (not just minority women) with osteoarthritis of the knee are less likely to receive total joint replacements than men. Women with heart disease receive less angioplasty than men. Women with heart attacks are almost twice as likely to die as men. It even takes more time for emergency services to transport women with heart attacks to hospitals. Hispanics receive less pain medication during cancer treatment and during childbirth. Elderly people are not being treated with the degree of attention, consideration, and dignity that younger patients are given. Gays, lesbians, bisexuals, and transgendered people are prone to high rates of suicide, alcoholism, and tobacco use. Homosexual women have less health issues related to their sexuality. However, in contrast, male homosexuals and bisexuals are at a special risk for a variety of serious and sometimes fatal ailments that often go unnoticed in primary care examinations.

These are some examples. Some of them are occurring at a subconscious level while others to varying degrees are occurring at a conscious level.

Q: What kinds of research did you conduct for the book?

I relied on my own experience of about 40 years in the field of medicine, and on the literature, largely the Institute of Medicine Report. I conducted interviews with other caregivers, exploring and inviting their perspective and their experience, some of them being minority caregivers, some being women, one is an openly gay individual, surgeons and non-surgeons, as well as medical educators. I also reviewed books and individual publications by psychologists and psychiatrists and others who are involved in medical education.

Q: How do you think the health care profession could best address these biases and their effects?

White House joins blog fray

Via Braniac, we learn that White House Office of Management and Budget Director Peter R. Orszag has got a blog, and he's using it to engage commentators and critics, including our own Richard Posner (link | link | link), on the question of how, in these trying economic times, we are going to pay for health care reform.

||| "Debating Health Care" at the OMB Blog

The placebo effect -- it works, go with it

The term has a negative connotation, as if relief delivered by one's own body is somehow illegitimate, but the effect is real, and more and more studies are being published to show that one has a degree of power over the body's healing from a variety of illnesses. That's one of the insights delivered by Esther Sternberg in following video on HUP's brand new YouTube channel:

The idea that environmental stimuli, as transmitted through one's senses, can play a role in the healing process is both quite old, in the sense that we can find similar sentiments expressed in the writings of the ancients, and quite new, at least in terms of its elaboration within the framework of Western empirical science. Sternberg's book Healing Spaces: The Science of Place and Well-Being articulates the growing scientific interest in these connections for the layperson. Sternberg is well-placed to fulfill this role; after receiving an MD from McGill University and specializing in rheumatology, she went on to teach at Washington University in St. Louis and now serves as Chief of the Section on Neuroendocrine Immunology and Behavior at the National Institute of Mental Health, as well as heading up the Integrative Neural Immune Program, a joint venture between NIMN and NIH.

Hysterical men

No, not Richard Pryor "hysterical." Mark S. Micale's new book takes on the other kind of hysteria, the kind that's been attributed mainly to women ever since crusty old Hippocrates described the malady as the unfortunate result of a "wandering uterus" (thanks for the oath, Hippocrates, perhaps we'll pass on the "wandering uterus" theory). In Hysterical Men: The Hidden History of Male Nervous Illness, Micale locates the cracks in Western medicine's vision of the "stable and secure male"--a vision whose coherence rests, of course, on a converse notion of women as just the opposite, i.e. "hysterical"--and drives a big fat scholarly chisel into them. For hundreds of years, Micale shows, Western physicians have been covering up and explaining away signs of male weakness (how can men be hysterical, anyway, when THEY DON'T EVEN HAVE A UTERUS??) while simultaneously indulging in extravagant theorizing regarding the origins of perceived female weakness, over-emotionality, and madness. Some might even call their efforts, well, "hysterical."

Hysterical Men has found some review space in what we like to consider our natural home within the media landspace--the New York Times Sunday Styles Section. Therein, Holly Brubach sees in Micale's work an attestation that "researchers discover and doctors diagnose only those conditions that their culture allows them to find." Yup!

Image: Hans von Gersdorff, Fieldbook of medicine (1517). Treatment of a skull injury. Wood cut work attributed to Hans Wechtlin. Click to enlarge.

Bilgrami to speak at New York Academy of Medicine

From the excellent 3quarksdaily we learn that Akeel Bilgrami will be delivering the Abram Kardiner Lecture at the New York Academy of Medicine a week from today on October 2. The topic is "Unconscious mental conflict and our democratic culture." Dr. Bilgrami is the author of Self-Knowledge and Resentment (HUP, 2006).