Presidential Address: New Challenges for Proven Values

What a wonderful meeting we anticipate here in glorious Toronto! The engines of science, humanism, and collegiality will drive this uplifting event beyond what we have experienced in annual meetings over the past decade.

I have been proud and even exhilarated to have been your 126th President in the most exciting days in our history. This peak experience in my personal and professional life could not have been achieved without the enthusiastic contributions of my successor, President-Elect Rod Muñoz. His deep organizational experience and readiness to challenge the perceived wisdom of the past synergized our working relationship.

I cannot move ahead in my message to you without recognizing the generous advice and counsel of leaders such as Gerry Flamm, Allan Tasman, Jerry Lazarus, Hugo Taussig, Dan Borenstein, and Drew Clemens. I am truly grateful to my friends and fellow Board members and the many colleagues on the more than 20 components on which I served. Their judgments and insights have confirmed our proven values.

Helen, my caring wife, is my advisor and my critic who has kept me on course during the past 2 years. This consummate professional, who directed a psychiatric clinic for the assessment of serious offenders in the New Haven Juvenile Court, has quietly supported my 20 years of activities in the national APA. We wed many years ago, when I was a first-year medical student at Cornell. From the two of us, we are now 15 (not counting five dogs). Three of my four children are married; two are lawyers—Kate is general counsel and senior vice president of a major hospital, and Russell worked with the Navajo Nation, living on the reservation. Two sons, Eric and Doug, are in the financial industry in New York City. That band of thinkers, creative folks, and merrymakers with social commitments made me the proud grandfather of six grandchildren. My family’s support of my efforts at APA, accepting my absences at important events and celebrations, telling me of the wondrous seasonal changes surrounding our beloved old farm in Vermont—a home I have not visited in many months, has kept my spirits alive. I cannot believe that theater, chamber music, museums, and opera have flourished in my absence. Haley, a 6-year-old granddaughter at the Dalton School in New York City, presented her grandfather’s work to her class: “He’s President of the doctors of the world. But I never see him anymore.” Traveling 60% of my time has kept me from Haley but has introduced me to incisive and courageous colleagues committed to high-quality patient care. You are a pluralistic company of dedicated men and women looking to the future with optimism, encouraging fresh ideas.

Our brilliant Medical Director, Steve Mirin, possesses extraordinary administrative and quantitative skills, steering our ship through the wave action expected in organizational transition. All of his work has been touched by equanimity and humor. I treasure our close working relationship, which has catalyzed APA’s advances in the past year. During this year, the Board has once more shown its wisdom in selecting Jim Krajeski as the new Editor in Chief of Psychiatric News, replacing the eminence grise Bob Campbell, who has served us with great distinction.

CIVILITY, CONSENSUS, AND DEBATE

Increasing numbers of members who attend Assembly meetings and Board proceedings, are impressed by our civility as we seek solutions to emergent problems. In his new book Civility(1), Stephen Carter, a Professor at Yale Law School, offers a concise definition of his subject. “Civility,” he writes, “is the sum of the many sacrifices we are called upon to make for the sake of living together.” If we are to make grand ideas work, he argues, we ought to attend to such everyday matters as politeness, respect, promise keeping, and ritual.

In the service of civility, leaders applaud consensus. Except for me. Consensus is the most detrimental alternative to informed debate, debate that can generate creativity. Lewis Lapham, a Harper’sWeekly Editor, warns us that “in place of honest argument among consenting adults, politicians substitute a lullaby for frightened children: The pretense that conflict doesn’t really exist and that we have reached a consecrated state in which we no longer need politics.” (Harper’s Weekly, November 1990). Consensus thinking seems to be the process of abandoning belief, values, and many principles.

This past year has been blessed by enlightened controversy on the Board. William Blake reminds us that “without contraries there is not progression.” This does not mean that all ideas are equally true but that controversy nourishes creativity. Intellectual exploration and challenge thrive in APA thanks to dissenters who enjoy a lively argument better than genial consensus.

FAIRNESS, DECENCY, DIGNITY, AND ETHICS

Fairness for our patients, decency, and respect for human dignity have been sullied by corporate organizations driven by profit maximization, aided by weak government regulation. These groups are disconnected from compassion, human suffering, and science. When insurance companies dictate medical practice standards, a weakening of professional ethical values is inevitable.

We have fought back in state legislatures, where 30 comprehensive bills have been passed since 1995, and another thousand await consideration. The President’s Quality Care Commission has issued a series of recommendations, some of which have been incorporated in planned future congressional actions. We have supported litigation across America and have been a plaintiff in a major class action suit.

There has been public anger over the state of managed care, which has burst into this year’s election campaign as a major issue. In speeches and television advertising, Democrats and some Republicans are seizing on consumer complaints and are calling for a sweeping patients’ bill of rights. The New York Times recently focused on this issue in its lead article (May 17, 1998, p. A1), pointing out that in at least a score of states including New York, California, Texas, Florida, and North Carolina, candidates in primary and general elections for governor and Congress typically are promoting access to more doctors and a right to appeal to impartial tribunals managed care organizations’ decisions on restricting care. There has been a striking shift in public sentiment since Mr. Clinton offered his health plan 5 years ago.

Enrollment in managed care has climbed from half the workforce 4 years ago to 85%, pushed largely by employers trying to contain health care costs. Millions of Americans are complaining of choices they do not like, and millions have no choices at all. Helen Hunt, playing Carol in the movie As Good As It Gets, slams health maintenance organizations with a string of epithets. There is no audience in the nation that has not clapped and cheered in response to Carol’s rage.

A rising number of Americans have no health insurance coverage at all. Since the demise of Clinton’s plan, that number has climbed to more than 41 million, from 38 million, mostly the working poor.

Strangely enough, American medicine has accepted passively the language of macroeconomics. The market­place has cleverly translated the richly traditional words “doctor” and “patient” into the dehumanized semantics of the dismal science-economics. Look at these terms: “client,” “consumer,” “customer,” “provider.”

The word “client” emerged in the fourteenth century, from the Latin cliens. The Oxford English Dictionary(2) tells us that a client is an individual who is under the patronage or protection of another, a dependent, a slave, a vassal, a retainer, as in the Middle Ages. A client is a person who employs the services of professional or businesspersons who act in his or her professional capacity. Thus, I am a client of my lawyer and my accountant.

A consumer is one who uses up an article produced that exhausts its exchangeable value. The magazine Consumer Reports tells us which goods are best values. A customer is one who frequents a place of sale for the sake of purchasing something or services from particular tradesmen (e.g., True Value Hardware, my shoemaker).

Chaucer, in 1374 in Troilus and Cressida, first used the word “patient,” defined as a sick or wounded individual whom a medical person attends; an inmate of an infirmary or hospital. In 1574, Andrew Boorde published The Breviary of Health, in which he wrote, “Surgeons ought not to be boisterous about their patients, but lovingly to comfort them.” Comforting the sick is a core value of our calling. That value is part of our covenant with patients that must not be damaged in the marketplace by economic forces that have stricken “caring” from their lexicon but not from their logos. Caring is part of a larger concept explicit in the healing arts, guided by the Cabalistic idea of tikkun olam, the Hebrew words for repairing the world. We are doctors without borders, epidemiologists without frontiers, who seek to make life better on this planet through service and research. Here in America our mission to repair the world will not be deterred by the dictates of those who profit from human suffering.

Doctors are not fungible, certainly not interchangeable widgets in a system that sees health care as a commodity. But the system is now feeling sick; plummeting profits of the last quarter have led to the jacking up of health premiums from 7% to 9%, and in the case of Kaiser Permanente, to 14%.

We have members who spend their energies as foot soldiers in managed care organizations. Many of them see themselves as economically indentured, unable to make an uncertain move to shortage sectors, such as rural communities, and to workplaces where there are demonstrated needs—family service agencies, community clinics, schools and juvenile courts. There are managed care organization leaders, psychiatrist-directors, who have become ideologues of commerce dis­identified from patient care imperatives that were overriding at another moment in their professional lives. You and I have an obligation to rekindle in them the candle of compassion and sensitivity to human duress.

CHILDREN

An op-ed writer for a major eastern newspaper, once a practicing psychiatrist, has come up with the neologism “kiddiecentrism.” “Kiddiecentrism,” the op-ed doctor explains, is a technique of making public policy through avoidance of substantive political debate and then insisting that the issues addressed are protective of children and their families. The “kiddiecentric” paradigms he uses are airbags, global warming, gun control, welfare reform, and anti-tobacco campaigns. Does the writer-physician really believe that there has been no informed national debate on these matters? Indeed, everyday, the media has given broad coverage to these matters deeply affecting the most powerless group in our society, the one-third of our population under the age of 18 that has been given short shrift by the body politic.

So what can children and adolescents expect from our political system?

A nation is measured by how it treats its children, and we, the world’s richest society, have failed the test.

The APA Division of Government Relations has set up computers at its APA Resource Center booth in the convention center exhibit area in order for each of us to send letters to the Congress opposing Senate Bill 10. All you need to remember is your name and zip code! There are four more letters calling for parity, patient protections, Veterans Administration formulary constraints, and confidentiality. Please, please, help our patients, help yourselves, and help the field by taking political action in these five vital sectors.

PROMISES

This is not the moment to offer you a grand panorama of our achievements in the past year. Candidates for APA office present daunting agendas and imply promises should they be elected. But earnest hyperbole is to political campaigns what military music is to music. Here is the fate of some promises I made to you.

THE EMOTIONAL BRAIN: NEW DISCOVERIES IN THE NEUROSCIENCES

We have come far from the Decade of the Brain, a celebration of discoveries that some early critics charged was associated with mindlessness. But now there has been a veritable explosion of remarkable new findings that will create a new intellectual framework for psychiatry. A seminal thinker in this new wave of discovery is Columbia’s Eric Kandel, whose superb lead article in the April 1998 issue of TheAmerican Journal of Psychiatry has ignited discussion across the nation. Among researchers in this sector are Antonio Damasio, Joseph LeDoux, Jerry Kagan, and Allan Schore, whose work is leading to an integrated evidence-based dynamic theory of human development that will engender a rapprochement between psychiatry and neural sciences. In Kandel’s words, “the rapprochement would allow the insights of the psychoanalytic perspective to inform the search for a deeper understanding of the biological basis of behavior.” Of the myriad findings, the investigators have shown how development, stress, and social experience can alter gene expression.

Parallel ideas encompassing a broad vision have flourished in the work of the evolutionary psychologist Edward O. Wilson. In his new book Consiliance(3), Wilson outlines a program of unrivaled ambition to unify the major branches of knowledge under the banner of science and, in particular, the biology that will explain our highest cognitive functions in terms of genetic programming.

To return to Kandel and his distinguished company, components of some neurotic illness may result from reversible effects in gene regulation. Kandel and others show how psychotherapy brings about behavioral change by producing alterations in gene expression, which in turn generates new structural changes in the brain. Similar changes are suggested as a consequence of psychopharmacological treatment. Kandel’s rich extrapolations have important implications for psychiatric education and for the recruitment of the best and brightest medical students. His theoretical positions, supported by evidence, will enable psychiatry to develop rigorous and sophisticated scientific standards and carry with it the prospect of a true renaissance in psychodynamic and psychoanalytic therapy. Most important, Kandel’s work will ultimately lay to rest the old tensions and divisions between biology and psychiatry. Lewis Carroll in Alice’s Adventures in Wonderland(4) captured our present situation. “There’s no sort of use in knocking” said the Footman, “and that for two reasons. First, because I’m on the same side of the door you are; secondly, because they’re mak­ing such a noise inside, no one could possible hear you.”

RESEARCH

APA is gratified by the increase in federal funding for research. In the past 14 years, psychiatry enjoyed a startling 470% increase in grants from the National Institutes of Health (from $82.5 to $385.5 million). Once ranked number 10 among medical school departments in receiving awards, psychiatry has soared now to second place, behind internal medicine. While unusual scientific advances in the field flow from these awards, what do they mean to the practicing psychiatrist?

I have asked the new Editor in Chief of Psychiatric News, Jim Krajeski, to run a regular, lively investigation-focused and investigator-focused column on psychiatric research operations in our country in order to keep clinicians abreast of fresh developments and their clinical applications.

In closing, I express my gratitude to you for honoring me with the most important post in world psychiatry. I have committed myself fully and indefatigably in serving you with fidelity and in fulfilling your expectations of leadership. My loving family and friends have made possible any successes and achievements that characterized my presidency. My failures belong to me. The presidential honor has capped a career marked by a deep investment in patient care and in advancing the frontiers of our field.

As we look at my theme, “New Challenges for Proven Values: Defending Access, Fairness, Ethics, and Decency,” we are sustained and heartened by our history. The powerful play “The Cure at Troy” (5), by the Irish Nobelist poet Seamus Heaney, welcomes the twenty-first century when he speaks of justice and hope, belief, and the conviction that we are being heard. Indeed, American psychiatry is being heard!

History says, Don’t Hope

On this side of the grave.

But then, once in a life time.

The longed-for tidal wave Of justice can rise up,

And hope and history rhyme.

So hope for a great-sea change

On the far side of revenge.

Believe that a further shore

Is reachable from here.

Believe in miracles

And cures and healing wells.

Call miracle self-healing:

The utter, self revealing

Double-take of feeling.

If there’s fire on the mountain

Or lightning and storm

And a god speaks from the sky.

That means someone is hearing

The outcry and birth-cry

Of new life at its term.

Presented at the 151st annual meeting of the American Psychiatric Association, Toronto, May 30–June 4, 1998. Dr. Sacks, 126th President of the American Psychiatric Association, is Clinical Professor of Child and Adolescent Psychiatry, Child Study Center, Yale University School of Medicine, New Haven. Address reprint requests to Dr. Sacks, 260 Riverside Ave., Westport, CT 06880-4804.