Medical Humanities Blog

On Eugenics and History (II)

I have the privilege of corresponding, from time to time, with historian of eugenics Gie van den Berghe, a professor at the University of Ghent.  I reprint below his comments on my recent post on eugenics and history:

You call Oliver Wendell Holmes' line 'Three generations of imbeciles are enough' "infamous", but that is how we judge it here and now. In fact it was, seen in its time, a courageous and logical standpoint (and of course not only the decision of Holmes but of the almost unanimous Supreme Court). So his/their decision shouldn't, in my opinion, so much be admired ('Holmes was nevertheless ready, willing, and able to utter the infamous line') then understood.

"We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices, often not felt to be such by those concer­ned, in order to prevent our being swamped with incompetence. It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are mani­festly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Jacobson v. Massachusetts, 197 U.S. 11. Three generations of imbeciles are enough".

 Generally one cites only this part of 'The Supreme Court Opinion in Buck v. Bell' (or some extract of it), but the Opinion continues and ends by the following line:

 "But, it is said, however it might be if this reasoning were applied generally, it fails when it is confined to the small number who are in the institutions named and is not applied to the ultitudes outside. It is the usual last resort of constitutional arguments to point out shortcomings of this sort. But the answer is that the law does all that is needed when it does all that it can, indicates a policy, applies it to all within the lines, and seeks to bring within the lines all similarly situated so far and so fast as its means allow. Of course so far as the operations enable those who otherwise must be kept confined to be returned to the world, and thus open the asylum to others, the equality aimed at will be more nearly reached."

This kind of argumentation had been employed in the 1920s by several eminent American and European men, frequently with a reference to the many thousands young, vigorous men who had died or ho were mutilated during the devastating Great War. In 1920, in Weimar Germany, the reknowned jurist Karl Binding and doctor Alfred Hoch pleaded wit this and other arguments for the 'euthanasia' for so-called lifes unworthy of life (Die Freigabe der Vernichtung lebensunwerten Lebens), and Adolf Hitler did the same in 1924 in the first part of his Mein Kampf.

his is not to claim that Nazism was founded on Darwinism. There is no direct link, but indirectly one can trace a kind of reasoning about asocial, marginal 'elements' in one's community, a community that was seen as of much greater importance than the individual. The people (Volk), the nation, the body of the nation (Volkskörper in German) had to be saved of the contaminated, rotten cells/individuals it contained. This kind of thinking generated in Great-Britain, shortly before Darwin wrote his 'On the origin of species' (1859) - think for instance of Herbert Spencer. And after the publication of Darwins masterpiece, more and more thinkers, such as Francis Galton, adopted it. Now that the motor of evolution, natural selection, was discovered, one was afraid that the biological evolution, this progress of the human species, was countered or even stopped by Civilisation. A civilisation who not only kept in live marginals that Nature normally would have eleminated (poor laws, medicine, hospitals, asiles), but even made possible that these unfit breed and multiply themselves at a faster rate then the fittest specimens of the nation.

On Eugenics & History (I)

H-Law published a review by Lynne Curry of two recent books on eugenics, including Paul Lombardo's account of Carrie Buck, and her experiences before, during, and after the notorious case of Buck v. Bell. 

Here is an excerpt from the Review:

Eugenicists, many of whom were associated with the Eugenics Record Office in Cold Springs Harbor, New York, exercised a profound and disturbing influence on law and social policy, including drafting a model compulsory sterilization law and then vigorously campaigning to have it replicated in the states.  While much of this material will not be new to historians, Carrie Buck’s story becomes even more compelling steeped in the rich detail that Lombardo provides.  Buck was an extremely poor, barely educated, seventeen-year-old rape victim, who in 1920s Virginia became a pawn of a blatantly self-serving cast of incredibly shady characters.  Mandatory sterilization laws had met with mixed success in state courts, and therefore in Virginia a small circle of eugenicist lawmakers, doctors, and institutional directors conspired to write and enact a statute and then manufacture a test case to gain a judicial stamp of approval for their own project.  Lombardo vividly presents the patently absurd case concocted purporting to show that Buck was both “feeble-minded” herself and the daughter and mother of feeble-minded females, rendering her a genetic threat to the population and a fit subject for the operation. (Her younger sister was also sterilized.)  Buck’s lawyer, himself a major crusader in Virginia’s sterilization campaign, “violated every norm of legal ethics” in deliberately failing his client at each step in the case, leaving Buck quite literally defenseless (p. 155).

I had the opportunity to meet Dr. Lombardo at the AAHM Meeting in April, and it was wonderful to get the chance to chat with him a bit about the history of eugenics.

Dr. Lombardo has compiled a wonderful web site in support of his book and his work, which features a rich digital supplement chock-a-block with downloadable primary sources from the public domain.  I cannot recommend either the book or the website enough.

As notorious as Buck v. Bell is, I think it is actually underemphasized in terms of its importance, mostly because the case aptly demonstrates how powerful was the hold eugenics exercised on American society during the 1920s.  Lombardo's book, which I am currently in the middle of, does an excellent job of separating the scholarly and religious debate over eugenics from the widespread acceptance it enjoyed among wide swaths of the lay public.  This last point is an important methodological aspect of any social history, which both Fairburn and Jenner warn against (presuming that the attitudes, beliefs, and practices of an elite subsume those of various less privileged communities and subgroups).

Having legal training as to Buck v. Bell helps, not so much because the case is difficult to interpret, but more because knowing anything at all about American legal history suggests just how visionary and singular a mind was Oliver Wendell Holmes.  Arguably the most important jurist in that history, and one of the most influential in Anglo-American jurisprudence itself over the last 100 years, Holmes was nevertheless ready, willing, and able to utter the infamous line: Three generations of imbeciles are enough.  This is a critical example of the reach and power of eugenics ideas, and it is absurd, as so many do, to see this history as a curio, an artifact. 

Roughly 90% of pregnant women informed that their fetus has trisomy 21 (Down Syndrome) choose to terminate the pregnancy.  I do not judge this decision, but do want to note that there is no way to interpret this as anything other than an example of the persistence of eugenics tropes.  Disability studies scholars have repeatedly pointed out that prenatal testing itself is founded on eugenics, whether we endorse or reject the practice.

The history of eugenics demonstrates the importance of understanding history dialectically, as events, ideas, and conditions continue to shape the world we inhabit in profound ways.  There are, in my view, fewer short-sighted approaches to the study of history then to perceive it as a linear "that-was-then-this-is-now" phenomenon.  History has much more to offer than that.  Despite the frequency with which people bandy about Santayana's quote, my suspicion is that a much lower percentage of those who quote him approvingly actually understand why it is that history repeats itself.  It does so, in short, because it never really leaves us.

Thoughts?

On Clinical Anthropologists

As most readers of MH Blog know, while I am no social scientist, I am, shall we say, an exceedingly friendly outsider when it comes to (medical) anthropology.  I read widely in the field, attempt to understand the implications of anthropological research for all manner of topics (e.g., pain, stigma, ethics, religion and medicine, etc.), and count it a great fortune that I have ongoing dialogue with several medical anthropologists.

Why so? After all, it is hardly as if, say, health psychology or medical sociology has nothing to offer the medical humanist.  Why am I particularly attracted to anthropology? The short answer is 'who knows;' why is any one person attracted to one field over another? There are many interesting answers to this question, but the majority of these, in my view, will vary widely depending on the context and the persons involved.

The longer, pedantic answer is that if nothing else, I think a medical humanist is or ought to aspire to be a social and cultural scholar as to medicine and medical practice.  If indeed the study of culture is central to the MH, then how, pray tell, can one pretense to get at that inquiry without guidance and insight from the very discipline which arguably centers the study of culture? 

In any case, in my travails at a medical school and an academic medical center, I have often wondered why it is that I have encountered so few "clinical" anthropologists, or medical anthropologists working in clinical settings, at the bedside, so to speak, and on staff at hospitals.  I do not mean to suggest that such practice is unheard of, but it certainly is not de rigeur the way clinical ethicists have become in clinical setting.  I do not have much of an answer to this question, but I have felt for some time that the relative lack of a continuing presence for anthropologists in the clinical setting -- not just doing time-limited field research -- is something of a loss, if not for the anthropologists, then for the rest of us, who could, IMO, benefit greatly from the insights and approaches regarding that most complicated of creatures -- humans, and human culture.

Just for example, I have often wondered how different my local world would be if it were anthropologists in charge of designing, implementing, and teaching cultural humility, instead of the relatively thin but conventionally dominant and poorly named "cultural competence."  How much richer would the learning opportunities be?

On the H-MED-ANTHRO listserv, a participant queried whether any of the members had any experience in clinical settings, and one of the answers struck me as so important, I requested and received permission to repost it here.  The question was posed by Nick Jefferson-Lenskyj from the University of Queensland (which serves large numbers of indigenous Australians), and the reposted answer is authored by Lissie Wahl:

On Swine Flu

It is fascinating to observe the current American discourse on swine flu.  Keller reminds that scientific discourse is a praxis, which indicates that the phenomena of the reaction to swine flu plays out in a space between public, lay, media, and professional stakeholders.  Public reactions, impressions, and language shape scientific, epidemiological, and political responses and actions, and vice-versa, in a constant feedback loop.

One of the most prevalent themes in the social construction of disease in general, but especially as to infectious disease, is the tight connection between illness and culpability.  This is a topic I am currently working on, though it has consistently enjoyed ample attention in the medical humanities literature.  But no sooner does news break of a potential influenza pandemic then the finger-pointing and responsibility-assessing begin.  As countless historians of medicine & public health, and other medical humanities scholars have painstakingly demonstrated, these assessments frequently stratify along social fault lines, typically coming to rest at the feet of already marginalized and disadvantaged social groups.  Thus, it should be entirely unsurprising that the "patient zero" trope identifies impoverished, rural Mexican pig farmers, and, predictably, the nascent anti-immigrant predilections in the U.S. have also been activated.

Perhaps, then, this is a good time to revisit Wendy Parmet's recent article on the ethical inadvisability of the "dangerous patient perspective," which traces causal roots of infectious disease outbreaks to individual actors.  This makes absolutely no sense epidemiologically, of course, because epidemic disease are primarily the result of social, economic, and political conditions.  Mary Mallon did not cause any epidemics of typhoid fever (<50 people were infected as a result of contact with her -- this is not trivial, but is nevertheless a tiny fraction of the numbers of persons infected with typhoid fever at the time); as Leavitt demonstrates, and Parmet notes, thousands of persons became infected with typhoid fever in NYC at the fin-de-siecle, persons who had no contact with Mallon.  Once again, I suggest, thinking deeply about our attributions of disease causality is a powerful window into the social and cultural meanings of illness.

Thoughts?

UPDATE: Erin Koch, over at Somatosphere, has a fine post where she explains in a bit more detail some of the social and economic factors that are prime determinants of the spread of this particular influenza outbreak:

  . . . industrial livestock production is the main culprit here . . .

[I]ndustrial livestock production is a powerful driver of viral (and bacterial) evolution. Davis emphasizes that the transition "from old-fashioned pig pens to vast excremental hell, unprecedented in nature, containing tens, even hundreds of thousands of animals with weakened immune systems, suffocating in heat and manure, while exchanging pathogens at blinding velocity with their fellow inmates and pathetic progenies" creates a perfect storm for evolving pathogens likely to establish resistance to antivirals and antibiotics. This is not just the case in China (everyone's favorite target for allocating bird flu blame) or Mexico (everyone's new favorite target for allocating swine flu blame). 

Quite.

UPDATE II (5.3.09): Friend of MH Blog Dan Bustillos points me to an article discussing the predictable linking of swine flu with concerns over immigration.  From the article:

The North Carolina-based Americans for Legal Immigration called for the border to be shut down and asked for the resignation of Homeland Security chief Janet Napolitano because she did not order agents on the border to wear masks . . .

Swine flu is a mix of pig, bird and human genes, and some radio hosts are calling it the Fajita flu – including Neal Boortz, an Atlanta-based radio talk show host.

In Texas, especially, the humorous ignorance of this appellation is perfectly clear.  (Pork is never, ever served with fajitas).

On Translation

Over at the blog for the journal Medical Humanities, Deborah Kirklin (EIC) asks an important question:

So here’s the thing. No matter how interesting (or otherwise) medical school deans and research grant making bodies  find the work done by medical humanities scholars and educators, the bottom line is (almost) always, what’s in it for patients? How will teaching students using art and literature make them better doctors; how will the insights offered by historians, anthropologists, philosophers etc help ensure that patients get better, more affordable, more appropriate care? Why, in other words, given all the other calls on my time and resources, should I support you and your work rather than focussing on biomedical research?

Rebecca Garden posted this query on the Lit&Med-ASBH Affinity Group Listserv, and I offered this comment, which I reprint here:

"One of the ideas I am working on is that, to understand the value of the medical humanities for illness sufferers, it helps to historicize the humanities themselves.  Our notion of the humanities derives of course from antiquity, but was mediated in crucial ways by the medieval and Renaissance humanists.  The studia humanitatis was the name of an educational program, with the overall ethos being a focus on practical engagement.

The humanists found lacking the disputations of the Scholastics precisely because their dialectic was not meaningful outside of the cloister (literally) and the rarefied air of the medieval universities.  They sought a way of learning and of acting that would encourage everyday persons to cultivate virtue in their daily lives, and they (correctly, in my mind), perceived the centrality of rhetoric to this task.

In other words, there is a serious case to be made that the humanists themselves were early translational researchers.  They sought to apply erudition in the service of virtue, and not simply virtue writ small, for scholars, but virtue in practice, in the shaping of moral communities and societies.

I think Deborah's question is absolutely the right one to be asking, but I also maintain that the medical humanities themselves, properly historicized, contain crucial keys to unlocking some promising answers to this question."

(edited slightly for grammar and content)

Thoughts?

On Conflicts of Interest & Atypical Antipsychotics

In few areas of modern medicine are the forces at work relating to COIs more stark than in psychiatry.  There are some particularly good sources for discourse on these matters in the blogosphere, and among the very best is the anonymous blogger at Clin Psyc Blog.  Not content, like most of us, with simply noting and commenting, CP makes a habit of what em terms "research blogging."  The Professor himself, as well as Kalman Applbaum, are other good examples for those of us hoping to do more in the blogosphere than note and comment, but CP's latest research blogging addresses a recent article discussing the use of aripiprazole (branded as Abilify) for unipolar depression.

Here is a taste:

One of psychiatry's big-name academics, Michael Thase, signed on as lead author. I'm hoping that he didn't actually write the paper. Actually, there are eleven authors of the paper, which seems a little ridiculous given that the paper is an analysis of data which had already been collected for two previously published clinical trials. Seven of the authors are employees of Bristol-Myers Squibb (BMS) or Otsuka, which both market Abilify. Wait... If you look closely, you can see my favorite disclosure... In the fine print on the first page...

In case you can't read the fine print: In defense of Thase and the other academic authors, they may have not actually written any of the paper. Much or all of the writing appears to be creditable to Ogilvy Healthworld Medical Education.

Ghost-writing, of course, is an enormous problem in the biomedical literature, and is intimately related to COIs.  It also seems a basic violation of publication ethics, though admittedly such violations are, both in my view and according to the best evidence, rampant.

My favorite portion of CP's post is when he discusses the article's "analysis" of safety:

The authors note that "adjunctive aripiprazole is relatively well-tolerated in patients with MDD." Relatively? Relative to what -- being hit with a baseball bat repeatedly? They note that akathisia occurred in 25% of patients on Abilify compared to 4% of patients on placebo. Restlessness: 12% vs. 2%; insomnia: 8% vs. 3%; fatigue: 8% vs. 4%; blurred vision: 6% vs 1%. The authors report that akathisia resolved in 52% of patients by the end of the study, which would also mean that for 48% of patients with akathisia, they were stuck with it at the end of the study. But don't worry, it's "relatively well-tolerated."

Mmm, yes.  Quite.

Go read the whole thing.

On Pharmaceutical Marketing, Capitalism, and Medicine (A Series)

I previously mentioned Kalman Applbaum's excellent post on conflicts of interest, and he has since produced a wonderful series of posts on pharmaceutical marketing, capitalism, and medicine.

Excerpting them will not be helpful, IMO, as they should be read in their entirety.

The series consists of three posts: here, here, and here.

As someone with a pronounced interest in matters related to conflicts of interest, I have found over the past few years social science approaches to be especially useful in framing some of the inquiries and illuminating key pieces of data.  For example, the primary evidence suggesting that even small gifts are troubling from an ethical perspective stems from the extensive social science literature on the effect of gifts in producing social cohesion.  Gifting accomplishes this by promoting reciprocity among the gifter and the giftee, which is, of course, exactly the point of doing so in the relationships between prescribers and pharmaceutical/medical device companies.

Analyses of this quality usually languish behind a paywall at a publisher, so take advantage, and go read Applbaum.   

On Mind, Brain, and Reductionism

For those interested in the discourse here on neuroreductionism, several articles in the latest Philosophical Investigations are worth checking out.  Here are the titles and abstracts:

Mind and Matter: A Physicist's View

John Polkinghorne 

Queens' College, Cambridge

ABSTRACT

Physics explores a universe of wonderful order, expressed in terms of beautiful mathematical equations. Mathematics itself is understood to be the exploration of a realm of noetic reality. Science describes matter in terms of concepts with mind-like qualities. The psychosomatic nature of human persons is best understood in terms of a dual-aspect monism, in which matter and mind are complementary aspects of a unitary being. The new science of complexity theory, with its dualities of parts/whole and energy/information, offers modest resources for the speculative exploration of this idea. The intrinsic unpredictabilities present in nature afford the metaphysical opportunity to consider dissipative systems as exhibiting top–down causality.

This looks to be a fascinating essay.  I am fascinated by and have done a bit of work in the implications of complexity theory, and actually think it may be quite important in thinking about the inordinately complex relationship between mind and brain.  (I allude to it in the comments here, where I note that some branches of science have even found ways to harness uncertainty and unpredictability without seeking to eliminate it).

Are We Our Brains?

Stephen Burwood

University of Hull

ABSTRACT

My aim in this paper is to destabilise the brain-is-self thesis, something that is now regarded in some quarters as philosophical commonsense. My contention is that it is the epithelial body that enters into the formation of our sense of self and that largely bears the burden of personal identity as well as playing the key role in grounding our psychological ascriptions. Lacking any sensorimotor or social presence of its own, the brain by itself cannot "underlie" selfhood, but only as part of the whole living human being. If the minded individual is embodied, this must mean more than being embrained.

Well.  Readers of this blog can probably guess that I am assuredly inclined to agree with the author, and the essay is obviously timely and relevant to some of the general discourse going on right now across different disciplines regarding the merits of the conceptual bases of much contemporary neuroscience.

Self and Self-Consciousness: Aristotelian Ontology and Cartesian Duality
Andrea Christofidou

Worcester College

ABSTRACT

The relationship between self-consciousness, Aristotelian ontology, and Cartesian duality is far closer than it has been thought to be. There is no valid inference either from considerations of Aristotle's hylomorphism or from the phenomenological distinction between body and living body, to the undermining of Cartesian dualism. Descartes' conception of the self as both a reasoning and willing being informs his conception of personhood; a person for Descartes is an unanalysable, integrated, self-conscious and autonomous human being. The claims that Descartes introspectively encounters the self and that the Cartesian extent of inner space is self-contained are profound errors, distortions through the lenses of modern theories.

Count me among the growing number of thinkers -- across disciplines -- who think that Descartes has generally gotten a raw deal when it comes to responsibility for mind-body dualism.  David Morris insists that strict mind-body dualism is a creature of the Victorian age,, not stemming from Descartes, and Robert Martensen's early modern history of the brain is particularly good for a sensitive and nuanced exploration of this idea.  This essay seems an interesting contribution to this body of work.

Sadly, I do not have full-text access to these articles, so if any kind reader does and wishes to help a poor graduate student out, giddy up.

(cross-posted to Neuroethics & Law Blog)

On "Science and Scientism in Nineteenth-Century Europe"

Andrea Westermann (ETH Zurich, Institute of History) has a nice review up on H-GERMAN (cross-posted to H-SCI-MED-TECH) of Richard Olson's new book, entitled Science and Scientism in Nineteenth-Century Europe.

Here are some excerpts to whet your appetite:

The book under review deals with the "transfer of ideas, practices, attitudes, and methodologies from the context of the study of the natural world into the study of humans and their social institutions"
(p. 1), a process Richard Olson refers to as "scientism."  It does not deal, as one might expect, with the history of the natural sciences and their popular reception . . . Olson traces a history of those European ideas and social theories which, relying on the authority of natural science, earned some measurable political influence at the time: liberalism, socialism, positivism, communism, and social Darwinism.  As with his earlier works, Olson aims at showing that modern Western political culture, religion, and literature are beholden to the body of knowledge the natural sciences accrued over time.  In short, the book argues that, from the late eighteenth century onward, a basis in science was the driving force in the reasoning about and the political development of social organization.

This is interesting, because the conception of scientism that I have discussed on MH Blog is entirely different from Olson's usage here.  Westermann comments on this:

Olson's need to summarize specific advances in the natural sciences in order to explain what exactly had been transposed into the social realm distracts from a straightforward line of argumentation, and so does his defense of the meaning of "scientism" against the views of rather dated epistemologies (such as that found in Friedrich August von Hayek's pejorative perception of "scientistic" approaches).

Hmmm . . . dated? I am dubious, though I certainly would not choose Hayek as a key expositor of the notion of scientism addressed here.  Nevertheless, the whole review is well-worth reading.

A Learning Module on the Social Determinants of Health

Via the Equidad listserv I learned of this cool learning module for the SDOH.  Here is the relevant information:

Global Learning Device on Social Determinants of Health and Public Policy Formulation 

Mark Akerman
Pan American Health Organization PAHO/WHO - February 2009

English and Spanish at:  http://dds-dispositivoglobal.ops.org.ar/curso/

The purpose of the Introductory Module is to raise awareness of and provide insight into the Social Determinants of Health (SDH) in order to reduce health inequities, encourage changes in the political agenda and contribute to a better administration of social justice and enforcement of human rights. Based on this attitude, we wish to inspire a critical vision of SDH by facilitating both the dissemination of the approach and the understanding of the intervention criteria, drawing on validated scientific papers on SDH, public policies based on the SDH approach, and documents produced by the Commission on the Social Determinants of Health, established by WHO.

This Introductory Module intends to stress the need for and importance of encouraging global learning processes as collective contexts for reflecting upon public policy-making and implementation, so that the Social Determinants of Health SDH approach is not only a well-structured set of scientific evidence and country-based “case studies,” but also a political and educational instrument to encourage reflection on and changes in usual public policy practices.

General objectives of the online Introductory Module

 Understand Health Equity as a value that reflects social justice theory and constitutes a basic factor for the right to health.
 Recognize the potential of identifying health inequities as a strategic element in designing more equitable public policies.
 Recognize intersectoral policies and concerted action strategies from the SDH perspective.
 Analyze the recommendations drawn from the reports drafted by the Commission on Social Determinants of Health and its nine Knowledge Networks,
   as well as foster their discussion and adoption, taking into account both the conditions and priorities in each country.

The Introductory Module is basically targeted at WHO/PAHO staff members as well as Health Ministries’ officials in all countries who are engaged in designing action programs, policies and plans for SDH.

Furthermore, in joining other country initiatives and academic center networks that have organized educational processes with their own public agents and university lecturers, we aim at reaching a broad audience (not only academic and scholars) to lay down the foundations of our process in an attempt to generate, disseminate and increase knowledge as well as facilitate the development of professional qualifications for applying SDH approach to public policies and other strategies via personal and institutional capacity-building processes.

I have not looked through the entire module, but a preliminary look indicates to me it is a valuable set of tools for introducing some of the evidence and implicatons of work on the SDOH.

Recommended!