Flies in the Ointment

A. In this week's New York Times Peter Singer (a philosopher who, like gadfly Socrates I suppose, makes it his practice to publicly point out inconvenient truths, like the contingency of world poverty and the role of animals in our food supply), makes the incontrovertible case for rationing health care. The sad thing (for our cherished vision of ourselves as rational creatures) is that this is still a case that has to be made.

Health care is an expensive commodity, particularly with respect to end-of-life care and the cutting-edge or experimental treatment of severe conditions. I'm no economist, but I think most would agree that resources, ultimately, are finite. How could we think that health care could not be rationed? The question is merely how it can be most justly rationed. Isn't every other commodity rationed? Is everyone guaranteed an Ivy League education, or a private jet? The point is not that life is not precious, but that given limited resources it cannot possibly be infinitely precious (in dollar terms). If it were, we would be spending 100% of GDP on health care.

(Addendum: Jacob Weisberg has a pertinent article in Slate that looks at the health care system, and prospects for reform, as reflections of American culture and values).

B. Somebody in psychiatry (besides me) has some sense. Allen Frances, M.D. the chair of the Task Force that developed the DSM-IV, published in 1994, has written this scathing criticism of the process under way to produce the DSM-V by 2012. He points out the generally haphazard, secretive, and underfunded nature of the endeavor, but his two bigger points are these:

1. Practical knowledge in psychiatry has not increased sufficiently in the past 15 years to justify radical revisions of diagnostic criteria. Research in neuroscience has generated oceans of theoretical information, but none of this yet alters what a psychiatrist can practically do for a patient in the office. So wholesale diagnostic changes amount to what Frances aptly likens to merely rearranging the furniture.

2. The addition of milder, "subthreshold" conditions threatens to greatly expand the prevalence of "mental disorders," which will in turn generate numerous "false positives" and play into the hands of both pharmaceutical companies eager for new "patients" as well as those eager to criticize psychiatry's imperialistic tendencies. There is already plenty of controversy over exploding diagnoses such as bipolar disorder and ADHD; to codify a wider purview for these in DSM-IV would merely fan the flames.

Psychiatry may be well-intentioned, but it is forever trying to advance farther than its secure knowledge base justifies, and at times it seems like one colossal hammer that is hallucinating nails wherever it looks.

As full disclosure and on a personal note, I would add that soon after I was accepted for my psychiatry residency at Duke in 1995, I received in the mail a warm-off-the-press edition of the DSM-IV signed by none other than Allen Frances, who was chairman at that time. He would agree (and has often volunteered) that the DSM-IV is a flawed instrument, as it would have to be; we just haven't advanced enough yet to radically improve upon it.