Michael S. Victoroff, MD

Defining noxious people as 'sick' distinguishes them socially from sinners, criminals, and scoundrels

Michael S. Victoroff, MD

Psychiatric researchers recently proposed a new category of mental disorders for "social bias." Some people are so prejudiced against others' races, lifestyles, or personal characteristics that they actually become incapacitated. They can't bear contact with the subjects of their aversion, and their lives become constricted and phobic. The researchers say this dysfunctional state qualifies as a "disease." They advocate applying the label "pathological bias" to extreme cases of racism, sexism, homophobia, and so on.

This is a swell idea in principle, but, although I buy the "disease" label, I'm skeptical about its usefulness, either scientifically or socially. As a health plan medical director, I would ask, "What treatment is covered, and does it work?"

The term "disease" is the source of two divergent streams. One carries scientific concepts like pathophysiology, diagnosis, and treatment. The other wends through social and sentimental agendas like coverage, stigma/honor, and forensics. From an insurer's perspective, it is critical to know what is a "disease" and what is not, because underwriting puts great weight on this distinction. This is the origin of that odd political contrivance, "biologically-based mental illness."

As a biological determinist, I trust we will eventually figure out the genetic and physiologic bases for many behaviors, including some we define as criminal or antisocial. But, behavioral science is like 18th century botany — classifying things based on appearances, without a clue about DNA. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders already bristles with social conditions whose definitions are rooted in sentiment, cultural preference, and contemporary manners. I am sure most of these have genetic and chemical roots. Of course, this is intuition talking, not hard data. But it seems right to speak of "bigotry" in the same breath as "social phobia."

The limits of technology (and moral scruples) impede our probing of character, behavior, and inner experience. This leaves us open to ludicrous blunders in assessing human motivations, and it mires our judicial system in pre-scientific — even prehistoric — inherited traditions and superstitions about crime and illness that have feeble supporting evidence.

Indeed, science and medicine are vulnerable to sociopolitical hijackers. So-called "psychiatry" in modern totalitarian states mirrors so-called "theology" in the days of the Inquisition, for the same reasons and with the same effects. However, this does not validate cultists who sometimes claim the entire field of behavioral science is nothing more than politics. The blind shouldn't really try to lead.

All human behavior is biologically based, right? And since we all come from the factory with defects, it is evident that lots of our ugly behaviors are diseases as much as scoliosis and Down Syndrome. Labeling social traits we disvalue as "disease" is satisfying and technically accurate. But pragmatically, what does it get us, to reframe "prejudice" from an ugly habit into a malady? (Besides insurance coverage?)

Medical name-calling

In a practical sense, a disease should either have a cure, or at least a mitigating treatment, or it must represent an objective deviation from normal biophysical process. Like cleft palate. How are these criteria met by "being a flaming bigot?" How does medical name-calling improve on the epithets we traditionally use?

Defining noxious people as sick distinguishes them socially from sinners, criminals, and scoundrels, but it all comes from the same protoplasm. Without a doubt, some crimes are so deviant they have to be comprehended as errors of nature.

Pedophilic murder is so aberrant and compulsive that it must surely be involuntary. Asking why someone "chooses" to be a homicidal pedophile proves the point. This behavior meets any rational criteria for a disease, despite the fact that there seems currently to be no good therapy, and nobody knows its biological basis. Yet, like Lesch-Nyhan Syndrome (genetic auto-cannibalism), I wager that someday we will find a gene.

For now, our attitude to this disorder is purely punitive, like schizophrenia in the 13th century. Rather than treating the perpetrator/victim with understanding (like, say, a rabid pit bull), our ignorance makes us fearful and mean, like monkeys in a storm. Pasteur's vaccine allowed us to sympathize with the poor dog. (We still can't cure rabies, but we understand it's not Old Yeller's fault, even if we don't give him a hug.)


So, how about them bigots? Some protest calling them sick, because they might evade due punishment. Now, punishment, judiciously applied, is a valid remedy for some behaviors, in some circumstances. I think it works best on little kids. But is there evidence of effectiveness for all the problems we apply it to? We treat a handful of mental illnesses (like bipolar disorder) with empiric nostrums analogous to foxglove and arsenicals that were first used 200 years ago. The fact that they work — a bit — elevates these conditions to a plane beyond voluntary behavior. Having a pill is all the difference between medicating psychotics and incarcerating psychopaths.

Punishment of the ill is traditional in our prehistoric penal system, consistent with our instinct to revenge ourselves on those who do harm. We can't help it. Maybe we have a disease.

Medicalizing antisocial behavior implies scrapping those time-honored categories "innocence" and "guilt" in favor of clinical terms. The McNaughton standard of 1843 ("innocent by insanity") and its modern refinements (e.g., 18 U.S.C. § 17, 1984, "incapable of appreciating the wrongness...") still focus on guilt. A true medical model would concern itself with things like risk (danger to self or others) and prognosis (curable vs. chronic).

In a merger/acquisition between the justice and public health systems (in a thousand years), "guilt" and "innocence" would be as archaic and irrelevant for bigots and murderers as for folks with avian flu. ("Your honor, the jury finds the accused innocent of diabetes.") Treatment would be paid for using the funds we use today to quarantine people with behavioral maladies in prisons.


Meanwhile, back on earth, health insurance does not cover the legal defense costs of our diseases, whether alcoholism, explosive personality, or kleptomania. There is a dichotomy. When I'm the suffering subject, call the doctor. When I harm my neighbor as a consequence, call the police. Our concept of accountability draws a sharp line between internal and external injuries.

A measure of how society views disease and crime is how it underwrites them. The medical model is fragile. It might be visionary to pay psychiatrists for counseling Ku Klux Klan or al Qaeda, although the nature of the disease would seem a barrier. The blurry border between health care and law enforcement involves guidelines for those who are sentenced to a criminal "diagnosis," how to finance their treatment, and when they have had enough.

If I were a prison warden struggling to subsist on tax revenue, I would look to the health plans to reimburse the long term care of my clients with social diseases. If I were a health plan CEO, I would take pains to guard my coverage policy from any such mandate. And, if I were a public policymaker, I would ponder the definition of "illness" in my community, and gaze wistfully at the laboratories of neuroscience.

Michael S. Victoroff, MD, is a family practitioner and ethicist in Denver who has also been an HMO medical director. He reports no conflicts of interest in relation to his column in Managed Care.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.