Andrew Sullivan's Blog, page 361

Crawling Out Of A Bottle

Eve Tushnet criticizes both the disease theory of addiction and those who react against it with contempt. She admits that, “When I was drinking my will really was damaged.” But that’s not the whole story:

I am convinced that there were times, within this compulsion and constriction, when I was capable of choice.  Sometimes I chose heaven—often tiny little choices which seemed pointless at the time, like the choice to read a book about addiction even though I was stressed and scared, or sincere prayers which were quickly swamped by rationalization, exhaustion, and fear—and a lot of times I chose the other place. But even in my own past, I doubt I could accurately gauge the depth of my own freedom in any individual moment. How can I hope to gauge it for others?

This is the point that both sides of the disease/choice divide get wrong. Of course your will is constrained. Your background, what you were taught (explicitly or implicitly) growing up, your brain chemistry, your mental health—a whole host of factors out of your control, unchosen and not always even noticed, constrain your choices. But within that landscape of constraint we often do choose. We make huge leaps or crawl tiny, painful inches up or down. You’re not trapped in your brain or your past—at least, not always. But even from the inside, you can’t always see the moments when you’re free.

Relatedly, Keith Humphreys offers an explanation of why programs like needle exchanges help addicts make better choices:

People are more prone to take care of themselves if they think that others care about them. If you are using drugs and sleeping rough, you can go through long periods where no one expresses any feelings toward you other than contempt, disgust or hostility. In contrast, when a stranger stretches an open hand into the cold night and offers to help you, it communicates something markedly different: You have worth. Knowing that you are not worthless after all provides a motivation to try to make changes that will improve your health and well-being.

Recent Dish on addiction here, here, here, and here.

The Laughter Of Puritans

When Tocqueville visited America, he wasn’t impressed with our humor, claiming that “people who spend every day in the week making money, and the Sunday in going to Church, have nothing to invite the muse of Comedy.” Reviewing John Beckman’s American Fun: Four Centuries of Joyous Revolt, Ben Schwarz thinks that’s not the whole story:

The country’s true comic muse, [Beckman] suggests, has always resided in rebellious, unacceptable humor and entertainment. He begins this chronicle with the forgotten hedonist pilgrim Thomas Morton and his lively seventeenth-century settlement, Merry Mount. The name alone was a pornographic joke to the locals. In his satirical poetry, Morton referred to Puritan leader Myles Standish as “Captain Shrimpe,” and at Merry Mount he encouraged forbidden Maypole dancing, refused to recognize bonded service, embraced Native American culture aesthetically, and Native American women literally. Within a year, Standish’s and Morton’s followers negotiated at gunpoint for Morton’s expulsion from the New World, after which Standish had the pilgrim playboy’s Maypole chopped down. From there, Beckman offers a narrative history touching on the revolutionary bonhomie of Samuel Adams’s taverns (a barroom insurgency that led, in turn, to the rowdy, whooping Boston Tea Party), the subversive revelry of plantation slave culture, Western prank journalism, P. T. Barnum, jazzmen, flappers, merry pranksters, and riot grrrls. In American Fun, humor and music catalyze cultural subversion, breaking out spontaneously in response to intolerant majority rule.

(Video: Bill Hicks’ 1993 standup routine that David Letterman refused to air. Update from a reader: “Letterman didn’t refuse to air it. The network did. I know that’s what you meant, but it reads like Letterman wanted to censor another comic.” Previous Dish on Hicks here and here.)

Mammograms, Reconsidered

A long-term study published this week found that mammograms don’t increase women’s odds of surviving breast cancer:

The University of Toronto study split a group of 89,835 women in two. Half of them got mammograms, and half did not. After 25 years, the rate of death from breast cancer was the same in both groups. Some of the women who underwent mammograms ended up with unnecessary treatment.

The research is well done and will influence a global conversation. Dr. Richard Wender, chief of cancer control for the American Cancer Society, said an expert panel will factor this research into new guidelines to be released within the year. Until then, current recommendations stand.

Moreover, they can actually be harmful:

The BMJ study calculated that 22 percent — more than 1 in 5 — breast cancers diagnosed by a screening mammogram represented an overdiagnosis. These were breast cancers that did not need treatment, and the women who received these diagnoses needlessly underwent treatments that could damage their hearts, spur endometrial cancer or cause long-lasting pain and swelling. …

These treatments are totally worth it if it means that you avoid dying from the cancer. But if they’re aimed at curing a cancer that was never going to become deadly, then what early diagnosis has actually done is made a healthy person sick. I think it’s safe to say that no one wants that. Treatments and awareness about breast cancer seem to have created most of the improvements in breast cancer outcomes, and we should celebrate those accomplishments.

Still, Kate Pickert says regular mammograms are likely here to stay:

Otis Brawley, chief medical officer for the ACS, has been outspoken about the downside of various types of cancer screening, arguing that benefits are often over-stated. But even he points out that the ACS examined the ongoing Canadian study when the group last updated its breast cancer screening guidelines seven years ago and concluded that annual mammograms for women over 40 were still warranted. (Findings from the study back then were similar to those published this week.) The ACS will take a fresh look at the research on mammography this year and may change its recommendations, but there’s no guarantee.

Cohn gets Ezekiel Emanuel’s take:

“There will never be a truly definitive mammogram study,” says Emanuel, who was longtime head of the National Institutes of Health Bioethics Department and is now a vice provost at the University of Pennsylvania. “You’re in this circle where you will never resolve the issue. You need a long timeline to get the best results, but in that time span the technology always improves—and people will always say, well, this is based on old technology so it’s not so relevant anymore.”

Aaron Carroll adds:

If you’re not going to be swayed at all by a randomized controlled trial of 90,000 women with 25 year follow up, excellent compliance, and damn good methods, it might be time to consider that there’s really no study at all that will make you change your mind.

John Horgan thinks it’s up to patients to stop demanding expensive, ineffective medical tests:

[U]ltimately, the responsibility for ending the testing epidemic comes down to consumers, who too often submit to—and even demand–tests that have negligible value. Our fear of cancer, in particular, seems to make us irrational. When faced with evidence that PSA tests and mammograms save very few lives, especially considering their risks and costs, many people say, in effect, “I don’t care. I don’t want to be that one person in a million who dies of cancer because I didn’t get tested.” Until this attitude changes, the medical-testing epidemic won’t end.

But Leah Libresco sympathizes with patients:

It’s tempting to be skeptical whenever a medical recommendation is reversed. If the last thing they told us was wrong, why should we trust them again? However, health care has changed since the advent of mammography. The old studies on the benefits of mammography weren’t necessarily wrong, just out of date. As awareness of breast cancer has increased, self-screenings have begun to do the work of mammography. As cancer drugs have improved, it’s no longer critical to identify diseases at their earliest stages to be able to survive.

But for a patient, who just hears conflicting recommendations, and not a discussion of research methods or the history of medicine, it’s hard not to come away with a sense of unease.

Face Of The Day

Canada’s Jill Officer throws the stone during the Women’s Curling Round Robin Session 6 match Switzerland vs Canada at the Ice Cube Curling Center during the Sochi Winter Olympics on February 13, 2014. By Damien Meyer/AFP/Getty Images.

The Art Of The Condolence Letter

Saul Austerlitz considers it:

A condolence letter is a strange hybrid of forms. It is for the mourner, but about the deceased. It is formal, but emotional. It gestures simultaneously at the past, the present and the future. It seeks to provide solace while acknowledging that there is no genuine solace to be provided. It follows a rigorous order while retaining an open-ended flexibility. … A good condolence letter requires balance, demanding an “I” capable of turning its attention away from itself, and toward a missing other. It is about what death requires of all of us who are left behind, and often finds us incapable of providing: compassion. A condolence letter is an act of self-erasure. It is also an acknowledgment of failure. We provide comfort, but never enough; we pay tribute, but never fulsomely enough; we remember, but not deeply enough. We fail. We can only offer condolences, because we are unsure if they will be taken. All we can do is make the attempt.

A Poem For Thursday

From “far memory, a poem in seven parts” by Lucille Clifton:

my knees recall the pockets

worn into the stone floor,

my hands, tracing against the wall

their original name, remember

the cold brush of brick, and the smell

of the brick powdery and wet

and the light finding its way in

through the high bars.

and also the sisters singing

at matins, their sweet music

the voice of the universe at peace

and the candles their light the light

at the beginning of creation

and the wonderful simplicity of prayer

smooth along the wooden beads

and certainly attended.

(Reprinted from Angles of Ascent, A Norton Anthology of Contemporary African American Poetry, edited by Charles Henry Rowell © 2013 by Charles Henry Rowell. Used by kind permission of BOA Editions, Ltd. Video of the poet Sharon Olds reading from the work of Clifton last November, during a Poetry Society of American event honoring iconic black poets)

Can The Embargo Be Broken?

Keating ponders a new poll on the Cuba embargo:

A majority of Americans, and even a majority of Cuban-Americans in Florida (who also supported Barack Obama over Mitt Romney in the last election), may now oppose the embargo, but older voters with visceral personal experience of Castro’s Cuba feel more strongly about it.

The number of people whose votes and donations are determined by their support for the embargo may be dwindling, but it’s probably still greater than the number whose vote and donations are determined by opposition to it. Still, the numbers indicate the downside isn’t as bad as it once was. The reactions to Obama’s handshake with Raúl Castro turned out to be fairly mild. Could something more dramatic be coming?

Greg Weeks doubts it. He argues that it “simply does not matter what a majority of Americans support if they do not really care about it”:

The tiny minority of Americans of oppose normalization care about it very deeply. On a list of priorities it would be high; for some, number one. Therefore they will fight very hard, expend considerable political capital, and spend a lot of money to make sure the embargo and other similar policies remain firmly in place.

Larison chimes in:

The good news is that support for the utterly useless embargo of Cuba has been getting steadily weaker over time, and there is good reason to assume that it will continue to wane until the embargo is finally lifted. Even though this will happen many decades later than it should have, it is encouraging to know that there is some limit to how long such senseless policies can endure. The embargo is a good example of the kind of needlessly harmful policies the U.S. can pursue when it allows its dealings with another country to be shaped almost entirely by ideological and emotional factors. It is also a monument to our government’s remarkable inability to abandon some failed policies decades after their futility has become obvious.

The Felon’s Franchise

Attorney General Eric Holder is urging states to overturn laws that bar people convicted of felonies from voting. How many Americans do these laws affect? Quite a few:

Nearly 6 million Americans are barred from voting due to felony disenfranchisement laws. Moreover, the bulk of disenfranchised felons—75 percent—are no longer in prison. Approximately 2.6 million of those remain disenfranchised despite having completed all parts of their sentence (prison time, parole, probation) because they live in states that bar felons from the polls for life. …

Felony disenfranchisement disproportionately affects people of color. Black men are incarcerated at a much higher rate than the rest of the population. According to the Urban Institute, 11.4 percent of African American men aged 20 to 34 were in prison in 2008, compared with just 1.8 percent of white men. One out of every 13 black Americans of voting age can’t vote due to criminal disenfranchisement laws, a number much higher than for any other demographic. This ratio is more stark in Florida, Kentucky, and Virginia, where more than 1 in 5 black adults is barred from the polls. Overall, 2.2 million black Americans have lost the right to vote because of felony disenfranchisement laws.

Roger Clegg brings up the usual objections:

[Holder] conveniently ignores the reason for felon disenfranchisement, namely that if you aren’t willing to follow the law, then you can hardly claim a role in making the law for everyone else, which is what you do when you vote. We have certain minimum, objective standards of responsibility, trustworthiness, and commitment to our laws that we require of people before they are entrusted with a role in the solemn enterprise of self-government. And so we don’t allow everyone to vote: not children, not noncitizens, not the mentally incompetent, and not people who have been convicted of committing serious crimes against their fellow citizens.

But Kevin Drum thinks restoring their rights is pretty fundamental to democracy:

I believe the right to vote is on the same level as free speech and fair trials. And no one suggests that released felons should be denied either of those. In fact, they can’t be, because those rights are enshrined in the Constitution. Voting would be on that list too if it weren’t for an accident of history: namely that we adopted democracy a long time ago, when the mere fact of voting at all was a revolutionary idea, let alone the idea of letting everyone vote. But that accident doesn’t make the right to vote any less important.

A probationary period of some kind is probably reasonable. But once you’re released from prison and you’ve finished your parole, you’re assumed to have paid your debt to society. That means you’re innocent until proven guilty, and competent to protect your political interests in the voting booth unless proven otherwise. No free society should assume anything different.

Meanwhile, Rick Hasen notes how resistant conservatives are to early voting, which would also expand the franchise:

[C]onservative critics of early voting runs don’t just mistrust early voters; they mistrust voters in general. As I explained here, there is a fundamental divide between liberals and conservatives about what voting is for: Conservatives see voting as about choosing the “best” candidate or “best” policies (meaning limits on who can vote, when, and how might make the most sense), and liberals see it as about the allocation of power among political equals. Cutting back on early voting fits with the conservative idea of choosing the “best” candidate by restraining voters from making supposed rash decisions, rather than relying on them to make choices consistent with their interests.

Beinart points out the contradiction between the GOP’s desire to attract more black votes and its efforts to restrict voting:

Do the Republicans pushing these restrictions really want to keep blacks from voting? Not exactly. The more likely explanation is that they want to keep Democrats from voting. As the Republican majority leader of the Pennsylvania state legislature said in 2012, the requirement for voter ID “is gonna allow Governor Romney to win the state of Pennsylvania.”

The problem, of course, is that limiting Democratic voting means limiting African-American voting. And in a country that for much of its history denied African Americans the right to vote, pushing laws that make it harder for African Americans to exercise that right touches the rawest of nerves. As long as many African Americans feel the GOP doesn’t want them to vote, it’s unlikely anything the GOP says to African Americans is going to have much positive impact.

Marriage Equality Update

The Dish covered the debate in Indiana over whether to add an initiative for a constitutional banning marriage for gays to the ballot this fall. I was optimistic, given some Republican opposition to the idea; one of our Indiana readers wasn’t. Today, the inability of the state House and Senate to agree on the wording of the measure means it will be shelved for the foreseeable future. Another day, another win.

The Best Of The Dish Today

One of the weird privileges of mass intimacy is that you can be deeply moved by the lives of people you’ve never met. That’s what the Dish has been for me for the near decade and a half I’ve been writing and editing it. I almost feel I know people from their email addresses, from countless little virtual exchanges that, over the years, accumulate into a person. And so you can imagine the stream of emotions that was prompted by this one:

I’m sitting here in the airport, about to get on a plane for the first time in over a decade and I wanted to take this moment (flight delayed) to renew my subscription and send along a note of gratitude. As an undocumented immigrant, my American partner and I have struggled to build a life together over the last 22 years, navigating the myriad legal, social and practical challenges that thousands of other bi-national same sex couples in similar situations have endured.

In recent years, during my more self-pitying moments, when we thought we might never get out of this bind, it was your blog that helped steel my resolve (that and my guy’s preternatural optimism). Your unrelenting, clear-throated accounting of each and every way marriage inequality directly and indirectly impacts gay peoples’ lives has helped me focus, and more clearly see my own circumstances in the greater context. I know, it’s called perspective, but that can be a distant shore when your struggling to stay afloat.

So now, with the fall of DOMA and our subsequent marriage, my husband and I finally come blinking into the light, clutching that small green card, and the first thing I wanted to do was thank you. I owe you a debt of gratitude for helping me get to the airport. Know hope indeed.

Yes, that’s exactly it: you clutch that small green card. And I can remember when I first did.

Today, I absorbed the life-story so far of Michael Sam, and a reader seconded. The case for adopting an abused dog can be found here in some photographs. This bouncy, psychedelic animation feels like your iTunes visualizer just did some crystal meth. I can’t believe they banned the women’s ski jump because of danger to the ovaries … but they did. I surveyed the new social media news landscape, and praised the literary hatchet job (done right).

The most popular posts of the day were both about the struggles of Michael Sam.

See you in the morning.

(Photo: Crape myrtle berries are covered in ice after a rare winter ice storm swept across the South February 12, 2014 in Summerville, South Carolina. More than 400,000 customers have lost power across the Southeast and at least 13 deaths caused by the storm. By Richard Ellis/Getty Images.)