Human Nature: Science, Technology, and Life.

Doping and Deficits

Would you like to take performance-enhancing drugs to boost your pro sports career? Are the drugs banned as a form of cheating? No problem. Just find a doctor willing to certify that you have a "deficit" of the performance factor in question.

That's what seems to be happening in Major League Baseball.

More here.

The Purple Brain

Are mental disorders as important as physical injuries? Many advocates say that they are and that we should treat them accordingly. Most of the fight is over insurance coverage of mental health. But part of the action is in the U.S. military. There, the question has been whether to award the Purple Heart for post-traumatic stress disorder. This week, the Defense Department announced its decision: No.

Eight months ago, when we first checked in on this debate, I was skeptical for two reasons. One was that PTSD would turn out to be widely overdiagnosed. In general, mental wounds are harder to define and identify than physical wounds are. There are obvious cases, but there are also fuzzy ones. Where do we draw the line? How do we keep the Purple Heart from being cheapened?

The second reason was that the Purple Heart, unlike basic health insurance, isn't a policy instrument. It's an honor. Officially, it denotes "meritorious action." And honor isn't the first step in a cultural transformation, no matter how worthy that transformation may be. It's the last.

I've been reading DoD's explanation of its decision and looking back at what I wrote eight months ago. And I'm beginning to think the decision may be wrong.

The reason has to do with gay marriage. The "honor" argument against the Purple Heart for PTSD is a lot like the argument against same-sex marriage. Marriage isn't a right or benefit, conservatives argue. It's a special commitment, a moral institution. Gays may deserve equal employment opportunity, just as mental-health patients deserve basic health insurance coverage. But marriage, like the Purple Heart, is a higher standard. It's an honor that should be awarded last, or maybe never.

Andrew Sullivan nailed this argument 20 years ago: Conservatives are largely right about what marriage is. They're just wrong that this understanding precludes extending it to homosexuals. In fact, they have it backward: Marriage would anchor gays, like straights, against "the chaos of sex and relationships to which we are all prone. It provides a mechanism for emotional stability, economic security, and the healthy rearing of the next generation." The key is to preserve the definition of marriage as commitment: to let go of the heterosexual requirement while fortifying the distinction between marriage and shacking up. My favorite proposal, to prove the point, is same-sex covenant marriage.

Something like that should be the solution to the Purple Heart debate. Opponents of the Purple Heart for PTSD say mental disorders can't qualify because the warrior doesn't "shed blood." That's foolish fundamentalism: Lots of people are wounded without literally shedding blood. DoD also says the wound must be "intentionally caused by the enemy." But the Purple Heart is already awarded for wounds that weren't precisely intended by the enemy. The enemy just throws his grenade at your platoon. Exactly which of you gets incapacitated and how—shrapnel, shock, whatever—isn't his concern.

On the other hand, DoD rightly points out that there have to be "objective" medical ways to distinguish clear-cut PTSD from fuzzy or fake versions. Otherwise, Purple Heart awards will become cheap or arbitrary. Along these lines, the department articulates three clear, reasonable, and tight criteria. First, the wound must be "the result of enemy action where the intended effect of a specific enemy action is to kill or injure the servicemember." Second, it must be "an injury to any part of the body." Third, it must be "caused by the enemy from an outside force or agent."

Can PTSD satisfy these criteria? In principle, I think so. The first criterion is relatively easy to address: You must face the same physical risks as any other Purple Heart recipient. The second is more difficult: Objective physical measures of PTSD must be established. This could be done, for example, with brain scans. We aren't there yet, so consider this a research project for the PTSD movement. The third criterion is a nexus of the first two: You would have to assemble some kind of case file showing that the signs of PTSD in the brain scans or other physical measures postdate the combat incident.

Will service members and veterans with PTSD actually meet these standards? Some won't, and even the most qualified cases will be hard to prove. But they should be, because the Purple Heart is sacred. It's just that there's nothing inherently more sacred about being wounded in your backside than in your brain.

Purple Hearts and Minds

The decisive battles in American culture wars often take place in the armed forces. That was true of racial integration decades ago, and it's true of homosexuality today. Now it's happening to mental health. If psychiatric disorders end up being culturally accepted as medical conditions, with all the attendant insurance coverage and workplace protections, the decisive player in this revolution will probably be the military.

The transition is taking place in three steps. First, mental illness has to be destigmatized. As Yochi Dreazen reports in the Wall Street Journal, this is already underway: Defense Secretary Robert Gates has changed department rules so troops with PTSD can seek counseling without losing their security clearances.

The next step is to treat mental illness like physical illness as an insurance matter. This is harder, because it's expensive. Dreazen reports that legislation in the Senate would take this step by opening Veterans Administration facilities to active-duty troops with psychiatric problems. The bill's architect argues that the expense is worth it because soldiers' mental wounds, like their physical wounds, can be fatal. Specifically, post-traumatic stress disorder (PTSD) can lead to suicide.

Now there's talk of a third step: awarding the Purple Heart for psychic wounds. Dreazen notes that earlier this month, Gates called it "an interesting idea" and "clearly something that needs to be looked at."

The argument against expanding eligibility for the Purple Heart is that mental wounds, unlike visible physical wounds, can be faked. Or they can be unrelated to combat, even if the affected service member thinks they are. In response, proponents of the change point out that PTSD is an officially certified disorder and that research has linked it to combat incidents.

The debate won't be settled overnight, any more than integration or homosexuality were. That's because the medicalization of mental health is in part a social issue. Yes, it's medical. But it's also defined and complicated by the problem of invisibility. You can't see psychic wounds the same way you can see physical ones.

Fortunately, science has already encountered and worked through this problem in other contexts. We can't see molecules, but we can measure their effects and correlate their existence with physical conditions. The same should be true of mental illness, even if the variables and data are far more complicated. My guess is that as research progresses, it will satisfy neither side. We'll find that PTSD is as real as any visible wound but that, like attention-deficit hyperactivity disorder, it's also widely overdiagnosed.

So let's be careful with the Purple Heart. People who want to award it for psychic wounds argue that this will eliminate stigma and encourage counseling. That's the wrong way to look at it. The Purple Heart isn't a policy instrument. It's an honor. In the words of George Washington's original order, it denotes "meritorious action." And honor isn't the first step in a cultural transformation, no matter how worthy that transformation may be. It's the last.