THE
MILBANK QUARTERLY A MULTIDISCIPLINARY JOURNAL OF POPULATION HEALTH AND HEALTH POLICY
What We Talk about When We Talk about Risk: Refining Surgery’s Hazards in Medical Thought M A R K D . N E U M A N and C H A R L E S L . B O S K University of Pennsylvania
Context: Current efforts to improve the cost-effectiveness of health care focus on assessing accurately the value of technologically complex, costly medical treatments for individual patients and society. These efforts universally acknowledge that the determination of such value should incorporate information regarding the risks posed by a given treatment for an individual, but they typically overlook the implications for medical decision making that inhere in how notions of risk are understood and used in contemporary medical discourse. To gain perspective on how the hazards of surgery have been defined and redefined in medical thought, we examine changes over time in notions of risk related to operative care. Methods: We reviewed historical writings on risk assessment and patient selection for surgical procedures published between 1957 and 1997 and conducted informal interviews with experts. To examine changes attributable to advances in research on risk assessment, we focused on the period surrounding the 1977 publication of an influential surgical risk-stratification index. Findings: Writings before 1977 demonstrate a summative, global approach to patients as “good” or “poor” risks, without quantifying the likelihood of specific postoperative events. Beginning in the early 1980s, assessments of operative risk increasingly emphasized quantitative estimates of the probability of dysfunction of a specific organ system after surgery. This new approach to establishing surgical risk was consistent with concurrent trends in other domains of medicine. In particular, it emphasized a more “scientific,” standardized approach to medical decision making over an earlier focus on individual physicians’ judgment and professional authority.
Address correspondence to: Mark D. Neuman, University of Pennsylvania, Department of Anesthesiology and Critical Care, 423 Guardian Drive, 1117A Blockley Hall, Philadelphia, PA 19104 (email: [email protected]). The Milbank Quarterly, Vol. 90, No. 1, 2012 (pp. 135–159) c 2012 Milbank Memorial Fund. Published by Wiley Periodicals Inc. 0002
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Conclusions: Recent writings on operative risk reflect a viewpoint that is more specific and, at the same time, more generic and fragmented than earlier approaches. By permitting the separation of multiple component hazards implicit in surgical interventions, such a viewpoint may encourage a distinct, permissive standard for surgical interventions that conflicts with larger policy efforts to promote cost-effective decision making by physicians and patients. Keywords: Surgery, risk assessment, medical decision making, medical sociology.
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he high and rising costs of medical care in the United States (Bodenheimer 2005; Cutler, Rosen, and Vijan 2006), along with persistent regional variations in health services utilization (Fisher et al. 2003a, b; Wennberg 2010) have thrust to the fore the processes of medical decision making—particularly in regard to costly interventions with equivocal or poorly defined benefits—in efforts to restrain potentially wasteful medical spending (Neuman 2010). At the level of the doctor-patient encounter, efforts to increase the transparency of medical decisions and the extent to which treatment choices align with the preferences of individual patients have featured prominently in proposed policy strategies to control growth in medical spending. Such efforts are exemplified by shared decision-making strategies (Guadagnoli and Ward 1998) and tools such as structured decision aids, which seek to supplement discussions between clinicians and patients with information about the risks and benefits of treatment alternatives (Barry 2002; O’Connor, Llewellyn-Thomas, and Flood 2004; O’Connor et al. 2007). Calls for the more widespread use of tools such as patient decision aids imply that the mechanics of everyday medical decision making are flawed. Such calls bespeak a desire for more standardization of the processes by which practitioners and patients communicate “information on options, outcomes, probabilities, and scientific uncertainties,” and “the personal value or importance [that patients] place on benefits versus harms” of specific treatments (O’Connor, Llewellyn-Thomas, and Flood 2004, 64). As a result, they frame current patterns of health care use and spending as symptomatic of failed communication between physicians and patients on a large scale and assume that reforming such communication will yield a better, more sustainable pattern of health care utilization.
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While frequently acknowledging the uncertainties present in all medical choices, such efforts to improve the mechanics of medical decision making view the inputs to treatment choices, such as risks and benefits, as stably defined “outcomes and probabilities” waiting to be communicated (O’Connor, Llewellyn-Thomas, and Flood 2004). Yet in regard to the risks of medical treatments in particular, alternate viewpoints articulated over the last three decades have framed “risk” itself as a contingent, “collectively constructed” category and entity (Douglas and Wildavsky 1982; Slovic, Fischhoff, and Lichtenstein 1980). From this standpoint, the selection and definition of risks at any given moment in time are subject to specific, largely unseen and unappreciated cultural assumptions and biases (Heyman, Henriksen, and Maughan 1998; Slovic 1999). As a result, the way in which “risk” is defined in current medical practice carries its own set of implications for the personal, professional, and policy discourse that determines which patients are thought to be appropriate candidates for costly medical interventions, how this information is communicated between physicians and patients, and how physicians and third-party payers agree on “routine indications” for a given treatment. Past work in the sociology of medicine has shown that research and the evidence it produces are culturally shaped (De Vries and Lemmens 2006; De Vries, Lemmens, and Bosk 2008; Mol 2002). Nonetheless, the notion of risk as a subjective phenomenon challenges assumptions common to current medical thought and practice. For example, an excerpt from a recent textbook of surgery characterizes risk assessment as a straightforward, value-free exercise in measurement: “The aim of preoperative evaluation is . . . to identify and quantify comorbidity that may impact operative outcome” (Neumayer and Vargo 2008, 251–2). This text, like others in surgery, internal medicine, anesthesiology, and other disciplines, offers simple, statistically derived prediction rules to facilitate the process of risk quantification before surgery (Arozullah et al. 2000; Detsky et al. 1986; Goldman et al. 1977; Lee et al. 1999). This conceptualization of operative risk assessment contrasts sharply with the understanding of risk assessment evident in similar textbooks from just over four decades ago: The assessment of operative risk should be approached as a statistical problem. . . . However, the statistical approach demands accurate data pertaining to the effects of many factors such as age, starvation, heart disease, etc. . . . upon the operative risk. These are practically
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nonexistent. . . . Obviously, because of these factors the accurate assessment of the operative risk for an individual case is impossible today. All we can do is guess. (Moyer 1970, 232) Just how operative risk assessment changed from an enterprise perceived by physicians to be a matter of “guesswork” to one seen as a process of “quantification” represents an overlooked chapter in the history of medical thought. Past scholarship has demonstrated the emergence since the 1950s of the “risk factor” as a concept that has come to define the contemporary study, treatment, and experience of illness across a range of conditions by creating a status of being “at-risk” that coexists with states of “sick” and “well” (Aronowitz 1998, 2009; Rothstein 2003). Over this same period, an analogous terminology of risk factors also emerged in the context of decision making for surgical interventions. Drawing on analytic methods and concepts originating in epidemiologic studies of chronic disease, this new terminology came to be applied to, and in turn altered, the task of characterizing, categorizing, and making sense of the hazards of surgery. To gain perspective on how surgery’s hazards have been defined and redefined in medical thought, we examine in detail here changes over time in notions of risk related to operative care. Choices to undertake surgery all involve, to a greater or lesser degree, an acceptance of implicit procedural hazards, making physicians’ assessments of the dangers of treatment to an individual a central element of decision making surrounding surgical procedures (Bosk 1979). Accordingly, we studied writings from the years surrounding the 1977 publication of the first major statistical “risk factor” system focused on predicting a subset of adverse surgical outcomes, the Cardiac Risk Index (Goldman et al. 1977). We traced how the rapid appearance of this index in academic and clinical surgical writings, along with the development of similar statistical models to predict a range of other postoperative outcomes, offered physicians an increasingly standardized and statistically grounded way to assess the risks of surgery in individual patients. Taking the widespread acceptance of probabilistic statements regarding surgery’s specific risks as a development to be explained rather than as a simple step forward for medical science (Berg 1995; Hacking 1990), we follow in this article Douglas and Wildavsky’s admonition that “what needs to be explained is how people agree to ignore most of the potential dangers that surround them and interact so as to concentrate only on
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certain aspects” (Douglas and Wildavsky 1982, 9). We explain how the adoption of a new way of assessing the likelihood of a specific type of negative outcome—postoperative cardiac complications—implied a focus on certain dangers of surgery and the relative neglect of others while simultaneously obscuring the subjective nature of risk assessment itself. Further, we look at how such an approach to risk assessment created distinct challenges to cost-effective decision making by physicians and patients that remains beyond the reach of probabilistic rules, statistical guidelines, and applicable decision-making tools.
Methods We reviewed major textbooks of surgery and anesthesia published between 1956 and 1997, supplemented by selected editorials and original research articles published in the medical literature during the same period. The textbooks we reviewed included the sixth (1956) through fifteenth (1997) editions of The Textbook of Surgery, which was the continuation of the first major multiple-authored American textbook of surgery (Anonymous 1942) and today remains the “gold standard” surgical reference (Organ 2001; Purcell 2003); the third, fourth, and fifth editions of Surgery: Principles and Practice, published in 1965, 1970, and 1977, a highly regarded surgical text (Raffensperger 1966) in print until 1977; the American College of Surgeons’ Manual of Preoperative and Postoperative Care in its 1967, 1971, and 1983 editions; and the first (1957) through ninth (1997) editions of Introduction to Anesthesia: The Principles of Safe Practice, an influential early textbook of anesthesiology (Hedley-White 1979). Both of us closely read excerpts from chapters devoted to the assessment of operative risk, as well as chapters on principles of patient evaluation before surgery more generally. We also examined sections in these surgical textbooks that discussed the role of statistics and computing technologies in the study of patient outcomes. In addition, we reviewed selected editorials and original research articles published in major academic medical journals, including the New England Journal of Medicine, the Journal of the American Medical Association, Annals of Surgery, and Anesthesiology. We identified articles to review by reviewing the chapters’ bibliographies and through online databases, including MEDLINE and the ISI Web of Knowledge, which we chose as comprehensive
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listings of medical journal articles published during this period. Our documentary research was supplemented with informal interviews with experts in preoperative risk assessment. From a methodological standpoint, it was not our aim to write a history of risk assessment practices in surgery during the last half of the twentieth century in the United States. Rather, we sought, in Ian Hacking’s words, to gain insight into “the public life of concepts” (Hacking 1990, 7) related to risk assessment in surgery and, in particular, how one specific notion of operative risk gained authority over time. We recognize that the majority of physicians’ assessments of patients’ operative risks, in both the past and the present, are likely to take place as unrecorded acts. Thus, we consider the historical writings we review here as an opportunity to learn what leading academic clinicians believed to be the best available knowledge at different points in history (Christakis 1997; Rabow et al. 2000). Finally, surgical textbooks are especially valuable for tracking temporal changes in thinking about the basic principles of surgical decision making. Textbooks are updated frequently, and they offer the prevailing guidance to physicians on how to assess risks. Thus, changes from one edition to the next offer an opportunity to understand how prevalent definitions of operative risk change over time.
Results From the 1950s through the first half of the 1970s, “operative risk” figured as a prominent theme in academic and clinical surgical writings. Indeed, “risk” was often the defining characteristic of an individual patient, who was commonly described as a “good” or a “poor” risk, without clearly specifying the hazards or predisposing factors underlying these categories. As the 1967 American College of Surgeons’ Manual of Preoperative and Postoperative Management states, An early assessment of risk as one of three kinds should not be difficult. Good risk patients are those in excellent health admitted to the hospital for surgical correction of a lesion of a local nature which has no obvious systemic effects. There is no disease immediately apparent involving other organ systems. A poor risk patient is one whose local lesion is
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of sufficient severity to produce pronounced systemic effects or who has severe disease of one or another vital organ system. . . . Many other patients fall into a large intermediate risk category in which for reasons of age, mild systemic disease or early systemic effects of the surgical lesion itself, certain corrective procedures should be instituted and more than the routine preoperative investigation should be carried out. (Ballinger 1967, 7) Here the Manual distinguishes between “good” and “poor” risk patients as distinct archetypes, for whom “operative risk” is a defining attribute encapsulating a broad medical biography. This concept of risk does not separate preexisting diseases from the surgical lesion itself. In fact, risk is dissociated from any single outcome in particular. Instead, risk here encompasses the vast range of potential adverse outcomes that may occur in individuals with a “severe disease of one or another vital organ system.” Categories of risk occur as attributes of patients whose assignment requires an act of individual judgment by an authoritative physician-observer (Berg 1995). Thus, the separation of “good risk” patients from “poor risk” patients relies on a physician’s judgment of what constitutes “excellent health,” a “local lesion,” or “pronounced systemic effects.” Such judgments themselves are elevated in status by the fact that a patient’s degree of risk is conceptualized in deterministic, rather than probabilistic, terms. Here, risk occurs as a largely fixed quality of an individual, whereas “corrective procedures” may ameliorate the hazards of surgery for intermediate-risk patients. No consideration is given to how clinical interventions might change surgery’s hazards for individuals at the extremes of risk or how an individual patient might move from one risk category to another. Archetypes of the “good” and “poor risk” patient appear in the surgical literature as early as the 1940s. But the Manual’s easy assurance that the assessment of risk “should not be difficult” belies deeper disagreements over whether meaningful assessments of “operative risk” could be achieved, as well as more fundamental uncertainties as to exactly what constitutes “operative risk.” Ten years before the Manual’s publication, the first edition of Dripps, Eckenhoff, and Vandam’s influential anesthesia text had already characterized the assignment of patients to categories of good or poor risk as an enterprise so uncertain as to be meaningless: “The term [risk] as ordinarily used by surgeon or anesthetist is unsound and should be abandoned.” They go on:
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To evaluate a “risk” completely would necessitate foreknowledge of such variables as reliability of suture material to be used, adequacy of sterilization of instruments, availability of drugs, the responsibility of those in charge of postoperative nursing care, and a host of other aspects which cannot be assessed for each patient. (Dripps, Eckenhoff, and Vandam 1957, 5) For Dripps, Eckenhoff, and Vandam, the large number of unmeasurable factors contributing to an individual’s surgical outcome makes futile any efforts to sort patients into categories of good and poor risk. Yet even for those who saw operative risk assessment as a valuable and necessary task, these efforts represented an inherently imprecise undertaking (Moyer and Key 1956). Carl Moyer, chairman of surgery at Washington University in St. Louis, noted in 1970: The factors ostensibly affecting the operative risk are: the anatomic site, the magnitude of the procedure, the age of the person, the character of the disease, the duration of the illness, the metabolic state of the individual, the technic employed to perform an operation, [and] the quality of ancillary medical care and anesthesia. (Moyer 1970, 232–3) Unlike Dripps, Eckenhoff, and Vandam, Moyer does not see the multiplicity of factors affecting a patient’s operative risk as an argument against the value of risk assessment itself. Nonetheless, for Moyer, as for Dripps, Eckenhoff, and Vandam, risk assessment appears as an enterprise firmly rooted in the individual judgments of clinicians. While disagreeing on the utility of such judgments as a guide to clinical decision making, both sources frame the principal challenges of risk assessment as essentially epistemological ones. As a task demanding the simultaneous consideration of multiple unmeasurable influences on the likelihood of an adverse surgical outcome, operative risk appears as abstract and fundamentally unquantifiable. Beyond debates as to whether operative risk could be meaningfully assessed, writings on surgery and anesthesia before the mid-1970s also disagree on what was meant by “operative risk” in the first place. To Carl Moyer, “operative risk” equaled the likelihood of death: “The appraisal of the operative risk to be assumed by an individual is a sketchy, intuitive evaluation of the probability of dying during an operation and convalescence” (Moyer and Key 1956, 853). For others, it was “an estimate of prognosis from the standpoint of either mortality or morbidity”
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(Dripps, Eckenhoff, and Vandam 1957, 5), a measure of the likelihood of a “normal convalescence” (Simeone 1972, 118), or the chance of a recovery “free from complications” (Varco 1968, 175). Such divergences situate the approach to operative risk assessment common to medical writing through the mid-1970s still more firmly within the realm of physicians’ authority and individual judgment. Indeed, beyond relying on the qualitative assessment of an individual clinician to determine a patient’s status as a good or poor risk, determining the very meaning of such categories appears as each individual physician’s prerogative. Thus, it was a matter of clinical judgment (Bosk 1979) informed by “local knowledge” (Geertz 1983) not only to determine what risk category a given patient occupied but also to decide whether such risk categories should be defined in terms of “the probability of dying” or simply as the odds of a “normal convalescence.” By the late 1970s, however, broader trends in medical thought had begun to question the place of individual judgment and professional authority as a foundation for medical decision making. Harry Marks (Marks 1997), Jeanne Daly (Daly 2005), and others (Berg 1995; Timmermans and Berg 2003; Weisz et al. 2007) have identified the last half of the twentieth century as the time when a newly “scientific” and standardized approach to medical care emerged in the United States, and reasoning grounded in clinical experimentation and statistical analysis began to challenge practices accepted on the basis of physicians’ authority and individual judgment (Chalmers, Enkin, and Keirse 1989). Alvan Feinstein, an internist at Yale University, and other early advocates of such an approach (Fletcher and Fletcher 1979; Sackett 1969; Wulff 1976, 1986) argued for the application of “scientific methodology” to “the basic elements of clinical medicine” (Feinstein 1963a, b, 1964a, b, c, d) as a means of evaluating and standardizing the “exercises in deductive and inductive reasoning” implicit in “every act of diagnosis, prognostic estimation, [and] therapeutic decision” by physicians (Feinstein 1963b, 929). For Feinstein, improving the means by which physicians could categorize and classify disease states represented a key dimension through which an increasingly “scientific” approach to medical practice could yield marked improvements in clinical care (Daly 2005; Feinstein 1963b): Clinicians had often analyzed each disease as though it were a single homogeneous fruit salad, rather than a mixture of heterogeneous
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fruits. Many of our misunderstandings and confusion about the biology of disease had arisen because different clinicians, seeing different mixtures of patients with the same disease, had been neglecting the clinical distinctions of the patients and referring only to the morphologic and other non-clinical characteristics of the disease. By distinguishing and analyzing the clinical components separately, we should be able to clarify many aspects of biologic behavior in human disease; we should be able to prognosticate more accurately and to evaluate therapy more effectively. (Feinstein 1967, 11) Feinstein and his contemporaries anticipated that all these advances in classification, prognostication, and evaluation would be enabled by developments in computer technology (Barnett 1968; Bleich 1971). To Feinstein in particular, computers promised to “expand the human horizon of clinical medicine” (Feinstein 1967, 370) and be able to resolve fundamental problems that had previously complicated a range of clinical assessment tasks, including determinations of operative risk. Computers would enable individual clinicians to “manage . . . data with mathematical and quantitative agility” (Feinstein 1967, 370) and to consider a broader array of clinical variables than previously thought possible. Furthermore, it appeared within the grasp of computing technologies to decrease the number of clinical “aspects which cannot be assessed for each patient” that Dripps, Eckenhoff, and Vandam had previously seen as standing in the way of meaningful risk assessments (Dripps, Eckenhoff, and Vandam 1957, page 5). Specifically, computers promised to “complete gaps in [the clinician’s] own immediate experience,” potentially making evaluations of patients and clinical decision making more accurate, uniform, and reproducible both within and across physicians (Feinstein 1967, 370). During the 1970s, themes articulated by proponents of a more “scientific” clinical practice began to permeate surgical textbooks. The 1977 edition of the Textbook of Surgery cites Feinstein’s 1967 monograph, Clinical Judgment, as a detailed discussion of “the process of assessing operative risk,” and new chapters on computers and statistical techniques in surgery described the potential for new analytic technologies to “permit the division of the total patient population . . . into particular subgroups that may have different prognoses” (Siegel 1972, 218). These writings presaged the publication in October 1977 of a multivariate index to predict cardiac complications of noncardiac surgery by Lee Goldman and his collaborators (Goldman et al. 1977). Goldman,
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TABLE 1
The Cardiac Risk Index Risk Factor 1. Age over 70 years 2. Myocardial infarction in previous 6 months 3. Third heart sound or jugular venous distention 4. Important aortic stenosis 5. Rhythm other than sinus or premature atrial contractions 6. More than 5 premature ventricular contractions per minute 7. Hypoxemia, hypercarbia, hypokalemia, acidosis, renal dysfunction, liver dysfunction, or bedridden status 8. Intraperitoneal, intrathoracic, or aortic operation 9. Emergency operation Total Possible
Points 5 10 11 3 7 7 3 3 4 53
Note: Percentage experiencing cardiac complications: 0 to 5 points, 1%; 6 to 12 points, 7%; 13 to 25 points, 14%; more than 25 points, 78%. Source: Goldman et al. 1977.
who had designed, conducted, and published the work while still a trainee—first as a senior resident in internal medicine at Massachusetts General Hospital and then as a cardiology fellow at Yale—had not published previously on the topic of operative risk assessment, nor had he completed formal training in advanced statistics (Goldman, personal communication, March 31, 2011). Although he did not meet or work with Feinstein until after his cardiac risk project was completed, Goldman’s 1977 publication resonated with Feinstein’s earlier emphasis on efforts at standardizing the means of “distinguishing and analyzing . . . separately” the “clinical components” of phenomena observed in daily practice (Feinstein 1967, 11). Motivated by his own experiences in risk assessment as a consulting physician, Goldman drew on multivariate modeling techniques similar to those used to define coronary heart disease risk factors in the Framingham Heart Study (Aronowitz 1998; Kannel 1992; Rothstein 2003) to develop a simple bedside prediction method for postoperative cardiovascular events. Goldman’s method, the Cardiac Risk Index, was the first major “risk factor” index designed to predict surgical outcomes, incorporating nine patient characteristics obtainable from history, physical examination, and laboratory studies to estimate the varying probabilities of specific postoperative cardiac complications (see table 1).
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Goldman’s index was quickly absorbed into the medical literature. By 1982, it had been cited by 80 biomedical journal articles, and by 1987 it had been cited 224 times. As early as 1981, surgical textbooks praised Goldman’s work for going beyond “initial efforts to quantitate what appeared to be subjective impressions” to advance a “whole line of inquiry toward precise determination of operative risk” (Polk 1981, 123). Goldman’s focus on the prediction of postoperative cardiovascular events rather than a more broadly defined set of postoperative complications emerged as both a key innovation and a limitation of his work. While contemporary surgical researchers had already employed multivariate statistical methods to examine mortality among patients with a particular operative illness (Irvin and Zeppa 1976), Goldman’s index predicted the occurrence of any one of several potential negative outcomes, all linked to the dysfunction of a single organ system, across a range of surgical procedures. And while cardiac events had been recognized in Goldman’s time to be a principal contributor to surgical morbidity and mortality (Arkins, Smessaert, and Hicks 1964; Tarhan et al. 1972), the “precise determination” promised by Goldman’s approach was limited to the extent that it did not predict a range of other key end points, such as noncardiac complications or all-cause mortality, relevant to operative risk assessment (Goldman 2010). In contrast to the apparent “guesswork” implicit in earlier approaches to risk assessment, Goldman’s index promised a precise, numerical estimate of risk but did so for only a selected set of complications, described in the 1981 edition of the Textbook of Surgery as “fatal and nonfatal, but life-threatening, complications of cardiac origin” (Polk 1981, 123). Goldman’s notion of a discrete “cardiac risk,” distinct from a more general “operative risk,” quickly became a part of didactic writings on risk assessment in surgery and anesthesia, markedly changing discussions of the relationship between preexisting cardiovascular disease and surgical outcomes. In his 1977 chapter on preoperative evaluation, Hiram Polk, chairman of surgery at the University of Louisville, emphasized the potential for symptomatic heart disease to drastically alter a patient’s global operative risk: “The patient with congestive heart failure poses an absolutely prohibitive operative risk and should not undergo operation, except those known to be immediately and unequivocally lifesaving” (Polk 1977, 127). Four years later, Polk’s chapter was extensively revised to incorporate Goldman’s findings. In the later edition, the section
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on cardiovascular evaluation is largely silent on the implications of advanced heart disease for overall operative risk. The focus is instead on factors found to predict postoperative cardiovascular events: [Goldman’s] work is a useful advance on prior methods to the same end and is as important for what it did not find as for its positive observations. . . . Goldman and associates did not confirm the significance of diabetes mellitus, smoking, hypertension, hyperlipidemia, stable angina pectoris, remote myocardial infarcts, ST segment or T wave changes on EKG, bundle branch blocks, mitral valvular disease, or cardiomegaly. These must not be ignored but are apparently less pertinent determinants of cardiac risk than had been previously thought. (Polk 1981, 123) This change, occurring over a period of only four years, suggests an immediate, marked influence of Goldman’s work on discussions of risk assessment in surgery. Here the statistical prediction of “complications of cardiac origin” has emerged as a central task of operative risk assessment, replacing an earlier emphasis on the relevance of cardiovascular disease to physicians seeking to distinguish “good risk” from “poor risk” patients on the basis of professional judgment. Stated differently, the focus shifted away from the determination of “surgical risk in the cardiac patient” (Skinner and Pearce 1964, 57) and toward the assessment of “cardiac risk” in the surgical patient. Over the next two decades, Goldman’s index gained progressively greater influence in textbooks writing about anesthesia and surgery related to cardiac risk assessment before surgery. Moreover, the “risk factor” approach adapted by Goldman to the study of postoperative cardiac events came to be applied to predict a progressively greater range of surgical end points. Hiram Polk’s 1991 chapter on preoperative evaluation listed “basic factors affecting operative risk,” as well as separate tables listing “cardiac risk factors” and “risk factors for pulmonary complications” (Polk 1991, 82). Similarly, the chapter on patient evaluation in the 1997 edition of the Introduction to Anesthesia lists “predictors of perioperative cardiac risk” and “preoperative risk factors . . . associated with postoperative pulmonary complications” (Traber 1997, 16–18). Such a transition to a “risk factor” approach to operative risk assessment is further evidenced by a proliferation of statistical models since Goldman’s time to predict postoperative complications across a range of organ systems (Arozullah et al. 2000; Detsky et al. 1986;
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Kheterpal et al. 2009; Lee et al. 1999; Wijeysundera et al. 2007). Goldman’s index itself, revised and simplified in 1999 (Lee et al. 1999), has remained prominent in clinical research and guidelines for practice, informing the design of observational studies (Lindenauer et al. 2005; Wijeysundera et al. 2010), clinical trials (Devereaux et al. 2008; Poldermans et al. 2006), and consensus-based algorithms to guide cardiac evaluation before surgery (Fleisher et al. 2007).
Discussion Decision researcher Paul Slovic has argued that “defining risk is . . . an exercise in power” and that “whoever controls the definition of risk controls the rational solution to the problem at hand” (Slovic 1999, 689). From this perspective, the changing status of operative risk as a concept in medical thought evades simple characterization as a story of progress, enabled by statistical innovations, from a state of confusion to one of understanding. Rather, it offers an example of the abandonment of an older formulation of operative risk for a newer one, with implications for how problems in decision making related to surgical care are defined and how acceptable solutions to these problems come to be found. Our work spans a period in which the hazards of surgery changed in important ways, characterized by steep declines in associated mortality (Crawford et al. 1981; Hannan et al. 1995; Katz, Stanley, and Zelenock 1994), the migration of a range of surgical procedures from inpatient to outpatient settings (Cullen, Hall, and Golosinskiy 2009), and the development of minimally invasive surgical technologies (Zetka 2003). Yet as the practice of surgery changed, the ways in which physicians thought and wrote about the hazards of surgery also were transformed. Our work traces this conceptual shift related to operative risk as exemplified by the 1977 publication of Lee Goldman’s multivariate predictive index for postoperative cardiovascular complications. Goldman’s work resonated with broader, ongoing intellectual trends that emphasized practices based on evidence from randomized trials and systematic reviews (Berg 1995; Daly 2005; Marks 1997) and applied industrial principles of standardization to clinical decision making (Timmermans and Berg 2003; Weisz et al. 2007). More generally, Goldman’s approach also echoed a growth between the 1960s and 1990s in the concept of “risk” itself as an organizing theme,
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not only in medical thought (Skolbekken 1995), but also in society as a whole as a means of articulating and quantifying threats emerging from modernization itself (Beck 1992). Arising during a period of rapid technological change in surgery, Goldman’s index offered a way in which the prediction of adverse outcomes after surgery, once the domain of expert physician judges, could, for a subset of surgical complications, be standardized and made quantifiable with equal facility by senior surgeons and first-year trainees. This approach allowed operative risk assessment and, by extension, operative decision making to begin to be reframed as a matter of scientifically reproducible measurement that could be carried out by a range of practitioners with various levels of experience or skill. Thus, along with the many risk-prediction indices that followed it, Goldman’s work can be seen as an early step toward situating surgical care in a larger “risk society” (Beck 1992) by meeting the demand for a consistent, uniform language through which physicians, patients, and payers could conceptualize and articulate the distinct hazards of operative care. Goldman’s work appeared at a time in which authorities in surgery and anesthesia voiced dissatisfaction with the available tools for risk assessment yet still saw the ideal, “statistical approach” to operative risk assessment as a technical “impossibility.” As a means to move past guesswork toward quantification in risk assessment, Goldman’s index was embraced rapidly as a key first step to overcoming this “impossibility.” That it appeared almost immediately in prominent surgical texts contrasts markedly with the slow diffusion of medical innovations noted by other observers (Antman et al. 1992; Berwick 2003) and argues for its status as what Joseph Ben-David characterized as a “revolutionary” innovation. Notably, for Ben-David, such innovations derive their impact in part from their emergence from outside an established field of scientific inquiry (Ben-David 1960). By virtue of Goldman’s professional orientation as an internist, rather than a surgeon or anesthesiologist, his academic status, and his lack of prior research on operative outcomes, his work likewise emerged from outside the “invisible college” of researchers (Crane 1972) then focused on the study of surgical outcomes (Goldman, personal communication, March 31, 2011). Goldman’s external perspective drew on his own practical experiences to interrupt and shift prevalent modes of discourse on how one key dimension of operative risk should be defined and measured (Ben-David 1960). As a resident and fellow, he was called on
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often to provide preoperative risk assessments and, like Carl Moyer, was frustrated that all he could do was guess. Goldman’s alternative to risk assessment based on “guesswork” was rapidly embraced in surgical writing as an authoritative approach to assessing cardiovascular risk before surgery and came to serve as a model for subsequent efforts to develop analogous prediction rules for a range of other operative complications. Such observations attest to the utility of Goldman’s approach as an organizing theme in clinical research and practice. At the same time, however, our observation of a shift from an older notion of operative risk to a newer one demands reflection on not only what insights may have been gained in this transition but also what may have been lost. Implicit in the notion of operative risk as a statistical phenomenon, defined in terms of event probabilities for a population of patients, is a separation of surgery’s outcomes from the experience of any individual in particular. Whereas earlier, more general notions of operative risk were tightly connected to patients’ unique disease histories, more recent efforts to define sets of risk factors for specific surgical outcomes offer a generic, de-personalized view of the hazards of surgery. To the extent that risk-factor approaches implicitly or explicitly influence the ways in which physicians interpret surgery’s hazards, they carry with them the potential to prioritize certain outcomes over others. By defining operative risk as those end points for which prediction rules exist, physicians and clinical researchers elevate a set of predictable outcomes over alternative end points such as changes in quality of life that, albeit difficult to predict, may nonetheless be important to individual patients. Thus, an approach to operative risk assessment that lends primacy to the prediction of near-term cardiovascular or pulmonary complications could marginalize the assessment of other important hazards by separating the immediate dangers of surgery from downstream risks such as those associated with rehabilitation or convalescence. This—along with shortened lengths of stay and the emergence and growth of medical specialties devoted to managing surgical recovery, such as physiatry and critical care—may enable a separation and revaluing of the multiple components of medical work, permitting those decisions related to surgery itself to be abstracted from the social costs of the postsurgical recovery period. Still more problematic is the observation that statistical prediction models for discrete complications of surgery, such as cardiac, pulmonary, renal, or infectious events, disarticulate the overall hazards of surgery
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into several smaller component risks. Moreover, these statistical models themselves offer no guidance as to whether or how predictions regarding multiple discrete risks can be reassembled to yield a summative statement of the danger or safety of surgery for an individual patient. Thus, the task of integrating the predictions of diverse statistical models to formulate a coherent notion of operative risk for the individual continues to rely on qualitative judgments regarding the relative importance of surgical hazards that differ in their nature and timing. For example, by disaggregating the experience of operation from that of convalescence, contemporary statistical approaches to risk assessment make it all the more difficult to integrate information on the diverse hazards faced by an individual surgical patient. Such considerations make Carl Moyer’s 1970 dictum—“all we can do is guess”—likely to be as relevant a comment on operative risk assessment today as it was in its own time. Yet where Moyer acknowledged the substantial amount of uncertainty in risk assessment, contemporary discussions appear to overlook the high degree of guesswork implicit in how such assessments are made and used in decision making. Furthermore, by separating complications occurring immediately after surgery from those emerging during rehabilitation and recovery, statistical approaches to risk assessment are likely to contribute to a permissive standard for decisions regarding surgical care by inflating the benefits of a surgical intervention at the same time as they work to deflate its potential costs to individuals, their primary caregivers, and society. Our findings must be interpreted in the context of important limitations. The academic and clinical writings we have examined here can only approximate how individual physicians have comprehended and assessed risks in practice. Further research is required to confirm these findings and explicate how the hazards of surgery are conceptualized by clinicians in practice, communicated to patients, and incorporated into decision making, particularly in the context of changing clinical evidence surrounding interventions intended to mitigate surgical risk (McFalls et al. 2004). Finally, our study did not look at other factors that also likely influenced the utilization of surgical service over this period, such as changing reimbursement practices, the development of minimally invasive technologies, and the development of safer anesthetic and surgical techniques. Nonetheless, the changes we describe here regarding notions of operative risk occurred over a period in which operative decision making and patient selection for surgery changed in dramatic ways. Since
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the 1960s, efforts to determine the “age limit for operations of a certain magnitude” (Wojnar and Moghul 1963) and to define the safety of major surgery among the oldest old (Burnett and McCaffrey 1972; Djokovic and Hedley-Whyte 1979; Kohn et al. 1973; Marshall and Fahey 1964) have given way to concerns that the surgical workforce in the United States will not be sufficient to meet older adults’ growing demands (Etzioni et al. 2003) and that not enough physicians will be available to oversee the advanced medical treatments needed to support their recovery (Kelley et al. 2004). Such shifts over time in the nature of surgical patients bespeak real changes since Carl Moyer’s time in how individuals come to be classified as “good” or “poor” surgical candidates from the standpoint of operative risk. Taken alongside our review of historical medical writings over four decades, they speak to important gaps in our knowledge of how advanced medical and surgical treatments ceased to be exceptional events in a person’s life and came instead to be an everyday part of a process of aging. Our discussion of how a new way of categorizing and measuring surgery’s hazards emerged in medical thought points to the need to understand better what we talk about when we talk about risk in the context of medical decisions. Such an understanding is necessary for grasping the unintended and unacknowledged ways in which our current language of risk informs how decisions regarding medical interventions are made and how this language helps create and sustain the viewpoint from which the utilization and outcomes of surgical care are now measured.
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MILBANK QUARTERLY A MULTIDISCIPLINARY JOURNAL OF POPULATION HEALTH AND HEALTH POLICY
What We Talk about When We Talk about Risk: Refining Surgery’s Hazards in Medical Thought M A R K D . N E U M A N and C H A R L E S L . B O S K University of Pennsylvania
Context: Current efforts to improve the cost-effectiveness of health care focus on assessing accurately the value of technologically complex, costly medical treatments for individual patients and society. These efforts universally acknowledge that the determination of such value should incorporate information regarding the risks posed by a given treatment for an individual, but they typically overlook the implications for medical decision making that inhere in how notions of risk are understood and used in contemporary medical discourse. To gain perspective on how the hazards of surgery have been defined and redefined in medical thought, we examine changes over time in notions of risk related to operative care. Methods: We reviewed historical writings on risk assessment and patient selection for surgical procedures published between 1957 and 1997 and conducted informal interviews with experts. To examine changes attributable to advances in research on risk assessment, we focused on the period surrounding the 1977 publication of an influential surgical risk-stratification index. Findings: Writings before 1977 demonstrate a summative, global approach to patients as “good” or “poor” risks, without quantifying the likelihood of specific postoperative events. Beginning in the early 1980s, assessments of operative risk increasingly emphasized quantitative estimates of the probability of dysfunction of a specific organ system after surgery. This new approach to establishing surgical risk was consistent with concurrent trends in other domains of medicine. In particular, it emphasized a more “scientific,” standardized approach to medical decision making over an earlier focus on individual physicians’ judgment and professional authority.
Address correspondence to: Mark D. Neuman, University of Pennsylvania, Department of Anesthesiology and Critical Care, 423 Guardian Drive, 1117A Blockley Hall, Philadelphia, PA 19104 (email: [email protected]). The Milbank Quarterly, Vol. 90, No. 1, 2012 (pp. 135–159) c 2012 Milbank Memorial Fund. Published by Wiley Periodicals Inc. 0002
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Conclusions: Recent writings on operative risk reflect a viewpoint that is more specific and, at the same time, more generic and fragmented than earlier approaches. By permitting the separation of multiple component hazards implicit in surgical interventions, such a viewpoint may encourage a distinct, permissive standard for surgical interventions that conflicts with larger policy efforts to promote cost-effective decision making by physicians and patients. Keywords: Surgery, risk assessment, medical decision making, medical sociology.
T
he high and rising costs of medical care in the United States (Bodenheimer 2005; Cutler, Rosen, and Vijan 2006), along with persistent regional variations in health services utilization (Fisher et al. 2003a, b; Wennberg 2010) have thrust to the fore the processes of medical decision making—particularly in regard to costly interventions with equivocal or poorly defined benefits—in efforts to restrain potentially wasteful medical spending (Neuman 2010). At the level of the doctor-patient encounter, efforts to increase the transparency of medical decisions and the extent to which treatment choices align with the preferences of individual patients have featured prominently in proposed policy strategies to control growth in medical spending. Such efforts are exemplified by shared decision-making strategies (Guadagnoli and Ward 1998) and tools such as structured decision aids, which seek to supplement discussions between clinicians and patients with information about the risks and benefits of treatment alternatives (Barry 2002; O’Connor, Llewellyn-Thomas, and Flood 2004; O’Connor et al. 2007). Calls for the more widespread use of tools such as patient decision aids imply that the mechanics of everyday medical decision making are flawed. Such calls bespeak a desire for more standardization of the processes by which practitioners and patients communicate “information on options, outcomes, probabilities, and scientific uncertainties,” and “the personal value or importance [that patients] place on benefits versus harms” of specific treatments (O’Connor, Llewellyn-Thomas, and Flood 2004, 64). As a result, they frame current patterns of health care use and spending as symptomatic of failed communication between physicians and patients on a large scale and assume that reforming such communication will yield a better, more sustainable pattern of health care utilization.
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While frequently acknowledging the uncertainties present in all medical choices, such efforts to improve the mechanics of medical decision making view the inputs to treatment choices, such as risks and benefits, as stably defined “outcomes and probabilities” waiting to be communicated (O’Connor, Llewellyn-Thomas, and Flood 2004). Yet in regard to the risks of medical treatments in particular, alternate viewpoints articulated over the last three decades have framed “risk” itself as a contingent, “collectively constructed” category and entity (Douglas and Wildavsky 1982; Slovic, Fischhoff, and Lichtenstein 1980). From this standpoint, the selection and definition of risks at any given moment in time are subject to specific, largely unseen and unappreciated cultural assumptions and biases (Heyman, Henriksen, and Maughan 1998; Slovic 1999). As a result, the way in which “risk” is defined in current medical practice carries its own set of implications for the personal, professional, and policy discourse that determines which patients are thought to be appropriate candidates for costly medical interventions, how this information is communicated between physicians and patients, and how physicians and third-party payers agree on “routine indications” for a given treatment. Past work in the sociology of medicine has shown that research and the evidence it produces are culturally shaped (De Vries and Lemmens 2006; De Vries, Lemmens, and Bosk 2008; Mol 2002). Nonetheless, the notion of risk as a subjective phenomenon challenges assumptions common to current medical thought and practice. For example, an excerpt from a recent textbook of surgery characterizes risk assessment as a straightforward, value-free exercise in measurement: “The aim of preoperative evaluation is . . . to identify and quantify comorbidity that may impact operative outcome” (Neumayer and Vargo 2008, 251–2). This text, like others in surgery, internal medicine, anesthesiology, and other disciplines, offers simple, statistically derived prediction rules to facilitate the process of risk quantification before surgery (Arozullah et al. 2000; Detsky et al. 1986; Goldman et al. 1977; Lee et al. 1999). This conceptualization of operative risk assessment contrasts sharply with the understanding of risk assessment evident in similar textbooks from just over four decades ago: The assessment of operative risk should be approached as a statistical problem. . . . However, the statistical approach demands accurate data pertaining to the effects of many factors such as age, starvation, heart disease, etc. . . . upon the operative risk. These are practically
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nonexistent. . . . Obviously, because of these factors the accurate assessment of the operative risk for an individual case is impossible today. All we can do is guess. (Moyer 1970, 232) Just how operative risk assessment changed from an enterprise perceived by physicians to be a matter of “guesswork” to one seen as a process of “quantification” represents an overlooked chapter in the history of medical thought. Past scholarship has demonstrated the emergence since the 1950s of the “risk factor” as a concept that has come to define the contemporary study, treatment, and experience of illness across a range of conditions by creating a status of being “at-risk” that coexists with states of “sick” and “well” (Aronowitz 1998, 2009; Rothstein 2003). Over this same period, an analogous terminology of risk factors also emerged in the context of decision making for surgical interventions. Drawing on analytic methods and concepts originating in epidemiologic studies of chronic disease, this new terminology came to be applied to, and in turn altered, the task of characterizing, categorizing, and making sense of the hazards of surgery. To gain perspective on how surgery’s hazards have been defined and redefined in medical thought, we examine in detail here changes over time in notions of risk related to operative care. Choices to undertake surgery all involve, to a greater or lesser degree, an acceptance of implicit procedural hazards, making physicians’ assessments of the dangers of treatment to an individual a central element of decision making surrounding surgical procedures (Bosk 1979). Accordingly, we studied writings from the years surrounding the 1977 publication of the first major statistical “risk factor” system focused on predicting a subset of adverse surgical outcomes, the Cardiac Risk Index (Goldman et al. 1977). We traced how the rapid appearance of this index in academic and clinical surgical writings, along with the development of similar statistical models to predict a range of other postoperative outcomes, offered physicians an increasingly standardized and statistically grounded way to assess the risks of surgery in individual patients. Taking the widespread acceptance of probabilistic statements regarding surgery’s specific risks as a development to be explained rather than as a simple step forward for medical science (Berg 1995; Hacking 1990), we follow in this article Douglas and Wildavsky’s admonition that “what needs to be explained is how people agree to ignore most of the potential dangers that surround them and interact so as to concentrate only on
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certain aspects” (Douglas and Wildavsky 1982, 9). We explain how the adoption of a new way of assessing the likelihood of a specific type of negative outcome—postoperative cardiac complications—implied a focus on certain dangers of surgery and the relative neglect of others while simultaneously obscuring the subjective nature of risk assessment itself. Further, we look at how such an approach to risk assessment created distinct challenges to cost-effective decision making by physicians and patients that remains beyond the reach of probabilistic rules, statistical guidelines, and applicable decision-making tools.
Methods We reviewed major textbooks of surgery and anesthesia published between 1956 and 1997, supplemented by selected editorials and original research articles published in the medical literature during the same period. The textbooks we reviewed included the sixth (1956) through fifteenth (1997) editions of The Textbook of Surgery, which was the continuation of the first major multiple-authored American textbook of surgery (Anonymous 1942) and today remains the “gold standard” surgical reference (Organ 2001; Purcell 2003); the third, fourth, and fifth editions of Surgery: Principles and Practice, published in 1965, 1970, and 1977, a highly regarded surgical text (Raffensperger 1966) in print until 1977; the American College of Surgeons’ Manual of Preoperative and Postoperative Care in its 1967, 1971, and 1983 editions; and the first (1957) through ninth (1997) editions of Introduction to Anesthesia: The Principles of Safe Practice, an influential early textbook of anesthesiology (Hedley-White 1979). Both of us closely read excerpts from chapters devoted to the assessment of operative risk, as well as chapters on principles of patient evaluation before surgery more generally. We also examined sections in these surgical textbooks that discussed the role of statistics and computing technologies in the study of patient outcomes. In addition, we reviewed selected editorials and original research articles published in major academic medical journals, including the New England Journal of Medicine, the Journal of the American Medical Association, Annals of Surgery, and Anesthesiology. We identified articles to review by reviewing the chapters’ bibliographies and through online databases, including MEDLINE and the ISI Web of Knowledge, which we chose as comprehensive
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listings of medical journal articles published during this period. Our documentary research was supplemented with informal interviews with experts in preoperative risk assessment. From a methodological standpoint, it was not our aim to write a history of risk assessment practices in surgery during the last half of the twentieth century in the United States. Rather, we sought, in Ian Hacking’s words, to gain insight into “the public life of concepts” (Hacking 1990, 7) related to risk assessment in surgery and, in particular, how one specific notion of operative risk gained authority over time. We recognize that the majority of physicians’ assessments of patients’ operative risks, in both the past and the present, are likely to take place as unrecorded acts. Thus, we consider the historical writings we review here as an opportunity to learn what leading academic clinicians believed to be the best available knowledge at different points in history (Christakis 1997; Rabow et al. 2000). Finally, surgical textbooks are especially valuable for tracking temporal changes in thinking about the basic principles of surgical decision making. Textbooks are updated frequently, and they offer the prevailing guidance to physicians on how to assess risks. Thus, changes from one edition to the next offer an opportunity to understand how prevalent definitions of operative risk change over time.
Results From the 1950s through the first half of the 1970s, “operative risk” figured as a prominent theme in academic and clinical surgical writings. Indeed, “risk” was often the defining characteristic of an individual patient, who was commonly described as a “good” or a “poor” risk, without clearly specifying the hazards or predisposing factors underlying these categories. As the 1967 American College of Surgeons’ Manual of Preoperative and Postoperative Management states, An early assessment of risk as one of three kinds should not be difficult. Good risk patients are those in excellent health admitted to the hospital for surgical correction of a lesion of a local nature which has no obvious systemic effects. There is no disease immediately apparent involving other organ systems. A poor risk patient is one whose local lesion is
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of sufficient severity to produce pronounced systemic effects or who has severe disease of one or another vital organ system. . . . Many other patients fall into a large intermediate risk category in which for reasons of age, mild systemic disease or early systemic effects of the surgical lesion itself, certain corrective procedures should be instituted and more than the routine preoperative investigation should be carried out. (Ballinger 1967, 7) Here the Manual distinguishes between “good” and “poor” risk patients as distinct archetypes, for whom “operative risk” is a defining attribute encapsulating a broad medical biography. This concept of risk does not separate preexisting diseases from the surgical lesion itself. In fact, risk is dissociated from any single outcome in particular. Instead, risk here encompasses the vast range of potential adverse outcomes that may occur in individuals with a “severe disease of one or another vital organ system.” Categories of risk occur as attributes of patients whose assignment requires an act of individual judgment by an authoritative physician-observer (Berg 1995). Thus, the separation of “good risk” patients from “poor risk” patients relies on a physician’s judgment of what constitutes “excellent health,” a “local lesion,” or “pronounced systemic effects.” Such judgments themselves are elevated in status by the fact that a patient’s degree of risk is conceptualized in deterministic, rather than probabilistic, terms. Here, risk occurs as a largely fixed quality of an individual, whereas “corrective procedures” may ameliorate the hazards of surgery for intermediate-risk patients. No consideration is given to how clinical interventions might change surgery’s hazards for individuals at the extremes of risk or how an individual patient might move from one risk category to another. Archetypes of the “good” and “poor risk” patient appear in the surgical literature as early as the 1940s. But the Manual’s easy assurance that the assessment of risk “should not be difficult” belies deeper disagreements over whether meaningful assessments of “operative risk” could be achieved, as well as more fundamental uncertainties as to exactly what constitutes “operative risk.” Ten years before the Manual’s publication, the first edition of Dripps, Eckenhoff, and Vandam’s influential anesthesia text had already characterized the assignment of patients to categories of good or poor risk as an enterprise so uncertain as to be meaningless: “The term [risk] as ordinarily used by surgeon or anesthetist is unsound and should be abandoned.” They go on:
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To evaluate a “risk” completely would necessitate foreknowledge of such variables as reliability of suture material to be used, adequacy of sterilization of instruments, availability of drugs, the responsibility of those in charge of postoperative nursing care, and a host of other aspects which cannot be assessed for each patient. (Dripps, Eckenhoff, and Vandam 1957, 5) For Dripps, Eckenhoff, and Vandam, the large number of unmeasurable factors contributing to an individual’s surgical outcome makes futile any efforts to sort patients into categories of good and poor risk. Yet even for those who saw operative risk assessment as a valuable and necessary task, these efforts represented an inherently imprecise undertaking (Moyer and Key 1956). Carl Moyer, chairman of surgery at Washington University in St. Louis, noted in 1970: The factors ostensibly affecting the operative risk are: the anatomic site, the magnitude of the procedure, the age of the person, the character of the disease, the duration of the illness, the metabolic state of the individual, the technic employed to perform an operation, [and] the quality of ancillary medical care and anesthesia. (Moyer 1970, 232–3) Unlike Dripps, Eckenhoff, and Vandam, Moyer does not see the multiplicity of factors affecting a patient’s operative risk as an argument against the value of risk assessment itself. Nonetheless, for Moyer, as for Dripps, Eckenhoff, and Vandam, risk assessment appears as an enterprise firmly rooted in the individual judgments of clinicians. While disagreeing on the utility of such judgments as a guide to clinical decision making, both sources frame the principal challenges of risk assessment as essentially epistemological ones. As a task demanding the simultaneous consideration of multiple unmeasurable influences on the likelihood of an adverse surgical outcome, operative risk appears as abstract and fundamentally unquantifiable. Beyond debates as to whether operative risk could be meaningfully assessed, writings on surgery and anesthesia before the mid-1970s also disagree on what was meant by “operative risk” in the first place. To Carl Moyer, “operative risk” equaled the likelihood of death: “The appraisal of the operative risk to be assumed by an individual is a sketchy, intuitive evaluation of the probability of dying during an operation and convalescence” (Moyer and Key 1956, 853). For others, it was “an estimate of prognosis from the standpoint of either mortality or morbidity”
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(Dripps, Eckenhoff, and Vandam 1957, 5), a measure of the likelihood of a “normal convalescence” (Simeone 1972, 118), or the chance of a recovery “free from complications” (Varco 1968, 175). Such divergences situate the approach to operative risk assessment common to medical writing through the mid-1970s still more firmly within the realm of physicians’ authority and individual judgment. Indeed, beyond relying on the qualitative assessment of an individual clinician to determine a patient’s status as a good or poor risk, determining the very meaning of such categories appears as each individual physician’s prerogative. Thus, it was a matter of clinical judgment (Bosk 1979) informed by “local knowledge” (Geertz 1983) not only to determine what risk category a given patient occupied but also to decide whether such risk categories should be defined in terms of “the probability of dying” or simply as the odds of a “normal convalescence.” By the late 1970s, however, broader trends in medical thought had begun to question the place of individual judgment and professional authority as a foundation for medical decision making. Harry Marks (Marks 1997), Jeanne Daly (Daly 2005), and others (Berg 1995; Timmermans and Berg 2003; Weisz et al. 2007) have identified the last half of the twentieth century as the time when a newly “scientific” and standardized approach to medical care emerged in the United States, and reasoning grounded in clinical experimentation and statistical analysis began to challenge practices accepted on the basis of physicians’ authority and individual judgment (Chalmers, Enkin, and Keirse 1989). Alvan Feinstein, an internist at Yale University, and other early advocates of such an approach (Fletcher and Fletcher 1979; Sackett 1969; Wulff 1976, 1986) argued for the application of “scientific methodology” to “the basic elements of clinical medicine” (Feinstein 1963a, b, 1964a, b, c, d) as a means of evaluating and standardizing the “exercises in deductive and inductive reasoning” implicit in “every act of diagnosis, prognostic estimation, [and] therapeutic decision” by physicians (Feinstein 1963b, 929). For Feinstein, improving the means by which physicians could categorize and classify disease states represented a key dimension through which an increasingly “scientific” approach to medical practice could yield marked improvements in clinical care (Daly 2005; Feinstein 1963b): Clinicians had often analyzed each disease as though it were a single homogeneous fruit salad, rather than a mixture of heterogeneous
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fruits. Many of our misunderstandings and confusion about the biology of disease had arisen because different clinicians, seeing different mixtures of patients with the same disease, had been neglecting the clinical distinctions of the patients and referring only to the morphologic and other non-clinical characteristics of the disease. By distinguishing and analyzing the clinical components separately, we should be able to clarify many aspects of biologic behavior in human disease; we should be able to prognosticate more accurately and to evaluate therapy more effectively. (Feinstein 1967, 11) Feinstein and his contemporaries anticipated that all these advances in classification, prognostication, and evaluation would be enabled by developments in computer technology (Barnett 1968; Bleich 1971). To Feinstein in particular, computers promised to “expand the human horizon of clinical medicine” (Feinstein 1967, 370) and be able to resolve fundamental problems that had previously complicated a range of clinical assessment tasks, including determinations of operative risk. Computers would enable individual clinicians to “manage . . . data with mathematical and quantitative agility” (Feinstein 1967, 370) and to consider a broader array of clinical variables than previously thought possible. Furthermore, it appeared within the grasp of computing technologies to decrease the number of clinical “aspects which cannot be assessed for each patient” that Dripps, Eckenhoff, and Vandam had previously seen as standing in the way of meaningful risk assessments (Dripps, Eckenhoff, and Vandam 1957, page 5). Specifically, computers promised to “complete gaps in [the clinician’s] own immediate experience,” potentially making evaluations of patients and clinical decision making more accurate, uniform, and reproducible both within and across physicians (Feinstein 1967, 370). During the 1970s, themes articulated by proponents of a more “scientific” clinical practice began to permeate surgical textbooks. The 1977 edition of the Textbook of Surgery cites Feinstein’s 1967 monograph, Clinical Judgment, as a detailed discussion of “the process of assessing operative risk,” and new chapters on computers and statistical techniques in surgery described the potential for new analytic technologies to “permit the division of the total patient population . . . into particular subgroups that may have different prognoses” (Siegel 1972, 218). These writings presaged the publication in October 1977 of a multivariate index to predict cardiac complications of noncardiac surgery by Lee Goldman and his collaborators (Goldman et al. 1977). Goldman,
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TABLE 1
The Cardiac Risk Index Risk Factor 1. Age over 70 years 2. Myocardial infarction in previous 6 months 3. Third heart sound or jugular venous distention 4. Important aortic stenosis 5. Rhythm other than sinus or premature atrial contractions 6. More than 5 premature ventricular contractions per minute 7. Hypoxemia, hypercarbia, hypokalemia, acidosis, renal dysfunction, liver dysfunction, or bedridden status 8. Intraperitoneal, intrathoracic, or aortic operation 9. Emergency operation Total Possible
Points 5 10 11 3 7 7 3 3 4 53
Note: Percentage experiencing cardiac complications: 0 to 5 points, 1%; 6 to 12 points, 7%; 13 to 25 points, 14%; more than 25 points, 78%. Source: Goldman et al. 1977.
who had designed, conducted, and published the work while still a trainee—first as a senior resident in internal medicine at Massachusetts General Hospital and then as a cardiology fellow at Yale—had not published previously on the topic of operative risk assessment, nor had he completed formal training in advanced statistics (Goldman, personal communication, March 31, 2011). Although he did not meet or work with Feinstein until after his cardiac risk project was completed, Goldman’s 1977 publication resonated with Feinstein’s earlier emphasis on efforts at standardizing the means of “distinguishing and analyzing . . . separately” the “clinical components” of phenomena observed in daily practice (Feinstein 1967, 11). Motivated by his own experiences in risk assessment as a consulting physician, Goldman drew on multivariate modeling techniques similar to those used to define coronary heart disease risk factors in the Framingham Heart Study (Aronowitz 1998; Kannel 1992; Rothstein 2003) to develop a simple bedside prediction method for postoperative cardiovascular events. Goldman’s method, the Cardiac Risk Index, was the first major “risk factor” index designed to predict surgical outcomes, incorporating nine patient characteristics obtainable from history, physical examination, and laboratory studies to estimate the varying probabilities of specific postoperative cardiac complications (see table 1).
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Goldman’s index was quickly absorbed into the medical literature. By 1982, it had been cited by 80 biomedical journal articles, and by 1987 it had been cited 224 times. As early as 1981, surgical textbooks praised Goldman’s work for going beyond “initial efforts to quantitate what appeared to be subjective impressions” to advance a “whole line of inquiry toward precise determination of operative risk” (Polk 1981, 123). Goldman’s focus on the prediction of postoperative cardiovascular events rather than a more broadly defined set of postoperative complications emerged as both a key innovation and a limitation of his work. While contemporary surgical researchers had already employed multivariate statistical methods to examine mortality among patients with a particular operative illness (Irvin and Zeppa 1976), Goldman’s index predicted the occurrence of any one of several potential negative outcomes, all linked to the dysfunction of a single organ system, across a range of surgical procedures. And while cardiac events had been recognized in Goldman’s time to be a principal contributor to surgical morbidity and mortality (Arkins, Smessaert, and Hicks 1964; Tarhan et al. 1972), the “precise determination” promised by Goldman’s approach was limited to the extent that it did not predict a range of other key end points, such as noncardiac complications or all-cause mortality, relevant to operative risk assessment (Goldman 2010). In contrast to the apparent “guesswork” implicit in earlier approaches to risk assessment, Goldman’s index promised a precise, numerical estimate of risk but did so for only a selected set of complications, described in the 1981 edition of the Textbook of Surgery as “fatal and nonfatal, but life-threatening, complications of cardiac origin” (Polk 1981, 123). Goldman’s notion of a discrete “cardiac risk,” distinct from a more general “operative risk,” quickly became a part of didactic writings on risk assessment in surgery and anesthesia, markedly changing discussions of the relationship between preexisting cardiovascular disease and surgical outcomes. In his 1977 chapter on preoperative evaluation, Hiram Polk, chairman of surgery at the University of Louisville, emphasized the potential for symptomatic heart disease to drastically alter a patient’s global operative risk: “The patient with congestive heart failure poses an absolutely prohibitive operative risk and should not undergo operation, except those known to be immediately and unequivocally lifesaving” (Polk 1977, 127). Four years later, Polk’s chapter was extensively revised to incorporate Goldman’s findings. In the later edition, the section
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on cardiovascular evaluation is largely silent on the implications of advanced heart disease for overall operative risk. The focus is instead on factors found to predict postoperative cardiovascular events: [Goldman’s] work is a useful advance on prior methods to the same end and is as important for what it did not find as for its positive observations. . . . Goldman and associates did not confirm the significance of diabetes mellitus, smoking, hypertension, hyperlipidemia, stable angina pectoris, remote myocardial infarcts, ST segment or T wave changes on EKG, bundle branch blocks, mitral valvular disease, or cardiomegaly. These must not be ignored but are apparently less pertinent determinants of cardiac risk than had been previously thought. (Polk 1981, 123) This change, occurring over a period of only four years, suggests an immediate, marked influence of Goldman’s work on discussions of risk assessment in surgery. Here the statistical prediction of “complications of cardiac origin” has emerged as a central task of operative risk assessment, replacing an earlier emphasis on the relevance of cardiovascular disease to physicians seeking to distinguish “good risk” from “poor risk” patients on the basis of professional judgment. Stated differently, the focus shifted away from the determination of “surgical risk in the cardiac patient” (Skinner and Pearce 1964, 57) and toward the assessment of “cardiac risk” in the surgical patient. Over the next two decades, Goldman’s index gained progressively greater influence in textbooks writing about anesthesia and surgery related to cardiac risk assessment before surgery. Moreover, the “risk factor” approach adapted by Goldman to the study of postoperative cardiac events came to be applied to predict a progressively greater range of surgical end points. Hiram Polk’s 1991 chapter on preoperative evaluation listed “basic factors affecting operative risk,” as well as separate tables listing “cardiac risk factors” and “risk factors for pulmonary complications” (Polk 1991, 82). Similarly, the chapter on patient evaluation in the 1997 edition of the Introduction to Anesthesia lists “predictors of perioperative cardiac risk” and “preoperative risk factors . . . associated with postoperative pulmonary complications” (Traber 1997, 16–18). Such a transition to a “risk factor” approach to operative risk assessment is further evidenced by a proliferation of statistical models since Goldman’s time to predict postoperative complications across a range of organ systems (Arozullah et al. 2000; Detsky et al. 1986;
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Kheterpal et al. 2009; Lee et al. 1999; Wijeysundera et al. 2007). Goldman’s index itself, revised and simplified in 1999 (Lee et al. 1999), has remained prominent in clinical research and guidelines for practice, informing the design of observational studies (Lindenauer et al. 2005; Wijeysundera et al. 2010), clinical trials (Devereaux et al. 2008; Poldermans et al. 2006), and consensus-based algorithms to guide cardiac evaluation before surgery (Fleisher et al. 2007).
Discussion Decision researcher Paul Slovic has argued that “defining risk is . . . an exercise in power” and that “whoever controls the definition of risk controls the rational solution to the problem at hand” (Slovic 1999, 689). From this perspective, the changing status of operative risk as a concept in medical thought evades simple characterization as a story of progress, enabled by statistical innovations, from a state of confusion to one of understanding. Rather, it offers an example of the abandonment of an older formulation of operative risk for a newer one, with implications for how problems in decision making related to surgical care are defined and how acceptable solutions to these problems come to be found. Our work spans a period in which the hazards of surgery changed in important ways, characterized by steep declines in associated mortality (Crawford et al. 1981; Hannan et al. 1995; Katz, Stanley, and Zelenock 1994), the migration of a range of surgical procedures from inpatient to outpatient settings (Cullen, Hall, and Golosinskiy 2009), and the development of minimally invasive surgical technologies (Zetka 2003). Yet as the practice of surgery changed, the ways in which physicians thought and wrote about the hazards of surgery also were transformed. Our work traces this conceptual shift related to operative risk as exemplified by the 1977 publication of Lee Goldman’s multivariate predictive index for postoperative cardiovascular complications. Goldman’s work resonated with broader, ongoing intellectual trends that emphasized practices based on evidence from randomized trials and systematic reviews (Berg 1995; Daly 2005; Marks 1997) and applied industrial principles of standardization to clinical decision making (Timmermans and Berg 2003; Weisz et al. 2007). More generally, Goldman’s approach also echoed a growth between the 1960s and 1990s in the concept of “risk” itself as an organizing theme,
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not only in medical thought (Skolbekken 1995), but also in society as a whole as a means of articulating and quantifying threats emerging from modernization itself (Beck 1992). Arising during a period of rapid technological change in surgery, Goldman’s index offered a way in which the prediction of adverse outcomes after surgery, once the domain of expert physician judges, could, for a subset of surgical complications, be standardized and made quantifiable with equal facility by senior surgeons and first-year trainees. This approach allowed operative risk assessment and, by extension, operative decision making to begin to be reframed as a matter of scientifically reproducible measurement that could be carried out by a range of practitioners with various levels of experience or skill. Thus, along with the many risk-prediction indices that followed it, Goldman’s work can be seen as an early step toward situating surgical care in a larger “risk society” (Beck 1992) by meeting the demand for a consistent, uniform language through which physicians, patients, and payers could conceptualize and articulate the distinct hazards of operative care. Goldman’s work appeared at a time in which authorities in surgery and anesthesia voiced dissatisfaction with the available tools for risk assessment yet still saw the ideal, “statistical approach” to operative risk assessment as a technical “impossibility.” As a means to move past guesswork toward quantification in risk assessment, Goldman’s index was embraced rapidly as a key first step to overcoming this “impossibility.” That it appeared almost immediately in prominent surgical texts contrasts markedly with the slow diffusion of medical innovations noted by other observers (Antman et al. 1992; Berwick 2003) and argues for its status as what Joseph Ben-David characterized as a “revolutionary” innovation. Notably, for Ben-David, such innovations derive their impact in part from their emergence from outside an established field of scientific inquiry (Ben-David 1960). By virtue of Goldman’s professional orientation as an internist, rather than a surgeon or anesthesiologist, his academic status, and his lack of prior research on operative outcomes, his work likewise emerged from outside the “invisible college” of researchers (Crane 1972) then focused on the study of surgical outcomes (Goldman, personal communication, March 31, 2011). Goldman’s external perspective drew on his own practical experiences to interrupt and shift prevalent modes of discourse on how one key dimension of operative risk should be defined and measured (Ben-David 1960). As a resident and fellow, he was called on
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often to provide preoperative risk assessments and, like Carl Moyer, was frustrated that all he could do was guess. Goldman’s alternative to risk assessment based on “guesswork” was rapidly embraced in surgical writing as an authoritative approach to assessing cardiovascular risk before surgery and came to serve as a model for subsequent efforts to develop analogous prediction rules for a range of other operative complications. Such observations attest to the utility of Goldman’s approach as an organizing theme in clinical research and practice. At the same time, however, our observation of a shift from an older notion of operative risk to a newer one demands reflection on not only what insights may have been gained in this transition but also what may have been lost. Implicit in the notion of operative risk as a statistical phenomenon, defined in terms of event probabilities for a population of patients, is a separation of surgery’s outcomes from the experience of any individual in particular. Whereas earlier, more general notions of operative risk were tightly connected to patients’ unique disease histories, more recent efforts to define sets of risk factors for specific surgical outcomes offer a generic, de-personalized view of the hazards of surgery. To the extent that risk-factor approaches implicitly or explicitly influence the ways in which physicians interpret surgery’s hazards, they carry with them the potential to prioritize certain outcomes over others. By defining operative risk as those end points for which prediction rules exist, physicians and clinical researchers elevate a set of predictable outcomes over alternative end points such as changes in quality of life that, albeit difficult to predict, may nonetheless be important to individual patients. Thus, an approach to operative risk assessment that lends primacy to the prediction of near-term cardiovascular or pulmonary complications could marginalize the assessment of other important hazards by separating the immediate dangers of surgery from downstream risks such as those associated with rehabilitation or convalescence. This—along with shortened lengths of stay and the emergence and growth of medical specialties devoted to managing surgical recovery, such as physiatry and critical care—may enable a separation and revaluing of the multiple components of medical work, permitting those decisions related to surgery itself to be abstracted from the social costs of the postsurgical recovery period. Still more problematic is the observation that statistical prediction models for discrete complications of surgery, such as cardiac, pulmonary, renal, or infectious events, disarticulate the overall hazards of surgery
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into several smaller component risks. Moreover, these statistical models themselves offer no guidance as to whether or how predictions regarding multiple discrete risks can be reassembled to yield a summative statement of the danger or safety of surgery for an individual patient. Thus, the task of integrating the predictions of diverse statistical models to formulate a coherent notion of operative risk for the individual continues to rely on qualitative judgments regarding the relative importance of surgical hazards that differ in their nature and timing. For example, by disaggregating the experience of operation from that of convalescence, contemporary statistical approaches to risk assessment make it all the more difficult to integrate information on the diverse hazards faced by an individual surgical patient. Such considerations make Carl Moyer’s 1970 dictum—“all we can do is guess”—likely to be as relevant a comment on operative risk assessment today as it was in its own time. Yet where Moyer acknowledged the substantial amount of uncertainty in risk assessment, contemporary discussions appear to overlook the high degree of guesswork implicit in how such assessments are made and used in decision making. Furthermore, by separating complications occurring immediately after surgery from those emerging during rehabilitation and recovery, statistical approaches to risk assessment are likely to contribute to a permissive standard for decisions regarding surgical care by inflating the benefits of a surgical intervention at the same time as they work to deflate its potential costs to individuals, their primary caregivers, and society. Our findings must be interpreted in the context of important limitations. The academic and clinical writings we have examined here can only approximate how individual physicians have comprehended and assessed risks in practice. Further research is required to confirm these findings and explicate how the hazards of surgery are conceptualized by clinicians in practice, communicated to patients, and incorporated into decision making, particularly in the context of changing clinical evidence surrounding interventions intended to mitigate surgical risk (McFalls et al. 2004). Finally, our study did not look at other factors that also likely influenced the utilization of surgical service over this period, such as changing reimbursement practices, the development of minimally invasive technologies, and the development of safer anesthetic and surgical techniques. Nonetheless, the changes we describe here regarding notions of operative risk occurred over a period in which operative decision making and patient selection for surgery changed in dramatic ways. Since
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the 1960s, efforts to determine the “age limit for operations of a certain magnitude” (Wojnar and Moghul 1963) and to define the safety of major surgery among the oldest old (Burnett and McCaffrey 1972; Djokovic and Hedley-Whyte 1979; Kohn et al. 1973; Marshall and Fahey 1964) have given way to concerns that the surgical workforce in the United States will not be sufficient to meet older adults’ growing demands (Etzioni et al. 2003) and that not enough physicians will be available to oversee the advanced medical treatments needed to support their recovery (Kelley et al. 2004). Such shifts over time in the nature of surgical patients bespeak real changes since Carl Moyer’s time in how individuals come to be classified as “good” or “poor” surgical candidates from the standpoint of operative risk. Taken alongside our review of historical medical writings over four decades, they speak to important gaps in our knowledge of how advanced medical and surgical treatments ceased to be exceptional events in a person’s life and came instead to be an everyday part of a process of aging. Our discussion of how a new way of categorizing and measuring surgery’s hazards emerged in medical thought points to the need to understand better what we talk about when we talk about risk in the context of medical decisions. Such an understanding is necessary for grasping the unintended and unacknowledged ways in which our current language of risk informs how decisions regarding medical interventions are made and how this language helps create and sustain the viewpoint from which the utilization and outcomes of surgical care are now measured.
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(Redirected from The Invisible Hand)
The invisible hand describes the unintended social benefits of an individual's self-interested actions, a concept that was first introduced by Adam Smith in The Theory of Moral Sentiments, written in 1759, invoking it in reference to income distribution. In this work, however, the idea of the market is not discussed, and the word 'capitalism' is never used.[1]
By the time he wrote The Wealth of Nations in 1776, Smith had studied the economic models of the French Physiocrats for many years, and in this work the invisible hand is more directly linked to production, to the employment of capital in support of domestic industry. The only use of 'invisible hand' found in The Wealth of Nations is in Book IV, Chapter II, 'Of Restraints upon the Importation from foreign Countries of such Goods as can be produced at Home.' The exact phrase is used just three times in Smith's writings.
Beyond The Reach Of The Invisible Hand D.a. Yao Pdf Download
Smith may have come up with the two meanings of the phrase from Richard Cantillon who developed both economic applications in his model of the isolated estate.[2]
The idea of trade and market exchange automatically channeling self-interest toward socially desirable ends is a central justification for the laissez-faire economic philosophy, which lies behind neoclassical economics.[3] In this sense, the central disagreement between economic ideologies can be viewed as a disagreement about how powerful the 'invisible hand' is. In alternative models, forces which were nascent during Smith's lifetime, such as large-scale industry, finance, and advertising, reduce its effectiveness.[4]
Interpretations of the term have been generalized beyond the usage by Smith.
- 1Adam Smith
- 3Understood as a metaphor
- 4Criticisms
Adam Smith[edit]
The Theory of Moral Sentiments[edit]
The first appearance of the invisible hand in Smith occurs in The Theory of Moral Sentiments (1759) in Part IV, Chapter 1, where he describes a selfish landlord as being led by an invisible hand to distribute his harvest to those who work for him:
The proud and unfeeling landlord views his extensive fields, and without a thought for the wants of his brethren, in imagination consumes himself the whole harvest .. [Yet] the capacity of his stomach bears no proportion to the immensity of his desires .. the rest he will be obliged to distribute among those, who prepare, in the nicest manner, that little which he himself makes use of, among those who fit up the palace in which this little is to be consumed, among those who provide and keep in order all the different baubles and trinkets which are employed in the economy of greatness; all of whom thus derive from his luxury and caprice, that share of the necessaries of life, which they would in vain have expected from his humanity or his justice..The rich..are led by an invisible hand to make nearly the same distribution of the necessaries of life, which would have been made, had the earth been divided into equal portions among all its inhabitants, and thus without intending it, without knowing it, advance the interest of the society, and afford means to the multiplication of the species. When Providence divided the earth among a few lordly masters, it neither forgot nor abandoned those who seemed to have been left out in the partition.
Elsewhere in The Theory of Moral Sentiments, Smith has described the desire of men to be respected by the members of the community in which they live, and the desire of men to feel that they are honorable beings.
The Wealth of Nations[edit]
Adam Smith uses the metaphor in Book IV, Chapter II, paragraph IX of The Wealth of Nations.
But the annual revenue of every society is always precisely equal to the exchangeable value of the whole annual produce of its industry, or rather is precisely the same thing with that exchangeable value. As every individual, therefore, endeavours as much as he can both to employ his capital in the support of domestic industry, and so to direct that industry that its produce may be of the greatest value, every individual necessarily labours to render the annual revenue of the society as great as he can. He generally, indeed, neither intends to promote the public interest, nor knows how much he is promoting it. By preferring the support of domestic to that of foreign industry, he intends only his own security; and by directing that industry in such a manner as its produce may be of the greatest value, he intends only his own gain, and he is in this, as in many other cases, led by an invisible hand to promote an end which was no part of his intention. Nor is it always the worse for the society that it was not part of it. By pursuing his own interest he frequently promotes that of the society more effectually than when he really intends to promote it. I have never known much good done by those who affected to trade for the public good. It is an affectation, indeed, not very common among merchants, and very few words need be employed in dissuading them from it.
Other uses of the phrase by Smith[edit]
Only in The History of Astronomy (written before 1758) Smith speaks of the invisible hand, to which ignorants refer to explain natural phenomena otherwise unexplainable:
Fire burns, and water refreshes; heavy bodies descend, and lighter substances fly upwards, by the necessity of their own nature; nor was the invisible hand of Jupiter ever apprehended to be employed in those matters.[5]
In The Theory of Moral Sentiments (1759) and in The Wealth of Nations (1776) Adam Smith speaks of an invisible hand, never of the invisible hand. In The Theory of Moral Sentiments Smith uses the concept to sustain a 'trickling down' theory, a concept also used in neoclassical development theory: The gluttony of the rich serves to feed the poor.
The rich … consume little more than the poor, and in spite of their natural selfishness and rapacity, though they mean only their own conveniency, though the sole end which they propose from the labours of all the thousands whom they employ, be the gratification of their own vain and insatiable desires, they divide with the poor the produce of all their improvements. They are led by an invisible hand [emphasis added] to make nearly the same distribution of the necessaries of life, which would have been made, had the earth been divided into equal portions among all its inhabitants, and thus without intending it, without knowing it, advance the interest of the society, and afford means to the multiplication of the species. When Providence divided the earth among a few lordly masters, it neither forgot nor abandoned those who seemed to have been left out in the partition. These last too enjoy their share of all that it produces. In what constitutes the real happiness of human life, they are in no respect inferior to those who would seem so much above them. In ease of body and peace of mind, all the different ranks of life are nearly upon a level, and the beggar, who suns himself by the side of the highway, possesses that security which kings are fighting for.[6]
Smith's visit to France and his acquaintance to the French Économistes (known as Physiocrats) changed his views from micro-economic optimisation to macro-economic growth as the end of Political Economy. So the landlord's gluttony in The Theory of Moral Sentiments is denounced in the Wealth of Nations as unproductive labour. Walker, the first president (1885 to 92) of the American Economic Association, concurred:
The domestic servant … is not employed as a means to his master's profit. His master's income is not due in any part to his employment; on the contrary, that income is first acquired … and in the amount of the income is determined whether the servant shall be employed or not, while to the full extent of that employment the income is diminished. As Adam Smith expresses it 'a man grows rich by employing a multitude of manufacturers; he grows poor by maintaining a multitude of menial servants.'[7]
Smith's theoretical U-turn from a micro-economical to a macro-economical view is not reflected in The Wealth of Nations. Large parts of this book are retaken from Smith's lectures before his visit to France. So one must distinguish in The Wealth of Nations a micro-economical and a macro-economical Adam Smith. Whether Smith's quotation of an invisible hand in the middle of his work is a micro-economical statement or a macro-economical statement condemning monopolies and government interferences as in the case of tariffs and patents is debatable.
Economists' interpretation[edit]
The concept of the 'invisible hand' is nearly always generalized beyond Smith's original uses. The phrase was not popular among economists before the twentieth century; Alfred Marshall never used it in his Principles of Economics[8] textbook and neither does William Stanley Jevons in his Theory of Political Economy.[9]Paul Samuelson cites it in his Economics textbook in 1948:
Even Adam Smith, the canny Scot whose monumental book, 'The Wealth of Nations' (1776) , represents the beginning of modern economics or political economy-even he was so thrilled by the recognition of an order in the economic system that he proclaimed the mystical principle of the 'invisible hand': that each individual in pursuing his own selfish good was led, as if by an invisible hand, to achieve the best good of all, so that any interference with free competition by government was almost certain to be injurious. This unguarded conclusion has done almost as much harm as good in the past century and a half, especially since too often it is all that some of our leading citizens remember, 30 years later, of their college course in economics.[10]
In this interpretation, the theory is that the Invisible Hand states that if each consumer is allowed to choose freely what to buy and each producer is allowed to choose freely what to sell and how to produce it, the market will settle on a product distribution and prices that are beneficial to all the individual members of a community, and hence to the community as a whole. The reason for this is that self-interest drives actors to beneficial behavior in a case of serendipity. Efficient methods of production are adopted to maximize profits. Low prices are charged to maximize revenue through gain in market share by undercutting competitors.[citation needed] Investors invest in those industries most urgently needed to maximize returns, and withdraw capital from those less efficient in creating value. All these effects take place dynamically and automatically.[citation needed]
Since Smith's time, this concept has been further incorporated into economic theory. Léon Walras developed a four-equation general equilibrium model that concludes that individual self-interest operating in a competitive market place produces the unique conditions under which a society's total utility is maximized. Vilfredo Pareto used an edgeworth box contact line to illustrate a similar social optimality.
Ludwig von Mises, in Human Action uses the expression 'the invisible hand of Providence', referring to Marx's period, to mean evolutionary meliorism.[11] He did not mean this as a criticism, since he held that secular reasoning leads to similar conclusions. Milton Friedman, a Nobel Memorial Prize winner in economics, called Smith's Invisible Hand 'the possibility of cooperation without coercion.'[12]Kaushik Basu has called the First Welfare Theorem the Invisible Hand Theorem.[13]
Some economists question the integrity of how the term 'invisible hand' is currently used. Gavin Kennedy, Professor Emeritus at Heriot-Watt University in Edinburgh, Scotland, argues that its current use in modern economic thinking as a symbol of free market capitalism is not reconcilable with the rather modest and indeterminate manner in which it was employed by Smith.[14] In response to Kennedy, Daniel Klein argues that reconciliation is legitimate. Moreover, even if Smith did not intend the term 'invisible hand' to be used in the current manner, its serviceability as such should not be rendered ineffective.[15] In conclusion of their exchange, Kennedy insists that Smith's intentions are of utmost importance to the current debate, which is one of Smith's association with the term 'invisible hand'. If the term is to be used as a symbol of liberty and economic coordination as it has been in the modern era, Kennedy argues that it should exist as a construct completely separate from Adam Smith since there is little evidence that Smith imputed any significance onto the term, much less the meanings given it at present.[16]
The former Drummond Professor of Political Economy at Oxford, D. H. MacGregor, argued that:
The one case in which he referred to the ‘invisible hand’ was that in which private persons preferred the home trade to the foreign trade, and he held that such preference was in the national interest, since it replaced two domestic capitals while the foreign trade replaced only one. The argument of the two capitals was a bad one, since it is the amount of capital that matters, not its subdivision; but the invisible sanction was given to a Protectionist idea, not for defence but for employment. It is not surprising that Smith was often quoted in Parliament in support of Protection. His background, like ours today, was private enterprise; but any dogma of non-intervention by government has to make heavy weather in The Wealth of Nations.[17]
Harvard economist Stephen Marglin argues that while the 'invisible hand' is the 'most enduring phrase in Smith's entire work', it is 'also the most misunderstood.'
Economists have taken this passage to be the first step in the cumulative effort of mainstream economics to prove that a competitive economy provides the largest possible economic pie (the so-called first welfare theorem, which demonstrates the Pareto optimality of a competitive regime). But Smith, it is evident from the context, was making a much narrower argument, namely, that the interests of businessmen in the security of their capital would lead them to invest in the domestic economy even at the sacrifice of somewhat higher returns that might be obtainable from foreign investment. . . .
David Ricardo . . . echoed Smith . . . [but] Smith's argument is at best incomplete, for it leaves out the role of foreigners' investment in the domestic economy. It would have to be shown that the gain to the British capital stock from the preference of British investors for Britain is greater than the loss to Britain from the preference of Dutch investors for the Netherlands and French investors for France.'[18]
According to Emma Rothschild, Smith was actually being ironic in his use of the term.[19]Warren Samuels described it as 'a means of relating modern high theory to Adam Smith and, as such, an interesting example in the development of language.'[20]
Understood as a metaphor[edit]
Smith uses the metaphor in the context of an argument against protectionism and government regulation of markets, but it is based on very broad principles developed by Bernard Mandeville, Bishop Butler, Lord Shaftesbury, and Francis Hutcheson. In general, the term 'invisible hand' can apply to any individual action that has unplanned, unintended consequences, particularly those that arise from actions not orchestrated by a central command, and that have an observable, patterned effect on the community.
Bernard Mandeville argued that private vices are actually public benefits. In The Fable of the Bees (1714), he laments that the 'bees of social virtue are buzzing in Man's bonnet': that civilized man has stigmatized his private appetites and the result is the retardation of the common good.
Bishop Butler argued that pursuing the public good was the best way of advancing one's own good since the two were necessarily identical.
Lord Shaftesbury turned the convergence of public and private good around, claiming that acting in accordance with one's self-interest produces socially beneficial results. An underlying unifying force that Shaftesbury called the 'Will of Nature' maintains equilibrium, congruency, and harmony. This force, to operate freely, requires the individual pursuit of rational self-interest, and the preservation and advancement of the self.
Francis Hutcheson also accepted this convergence between public and private interest, but he attributed the mechanism, not to rational self-interest, but to personal intuition, which he called a 'moral sense.' Smith developed his own version of this general principle in which six psychological motives combine in each individual to produce the common good. In The Theory of Moral Sentiments, vol. II, page 316, he says, 'By acting according to the dictates of our moral faculties, we necessarily pursue the most effective means for promoting the happiness of mankind.'
Contrary to common misconceptions, Smith did not assert that all self-interested labour necessarily benefits society, or that all public goods are produced through self-interested labour. His proposal is merely that in a free market, people usually tend to produce goods desired by their neighbours. The tragedy of the commons is an example where self-interest tends to bring an unwanted result.
The invisible hand is traditionally understood as a concept in economics, but Robert Nozick argues in Anarchy, State and Utopia that substantively the same concept exists in a number of other areas of academic discourse under different names, notably Darwinian natural selection. In turn, Daniel Dennett argues in Darwin's Dangerous Idea that this represents a 'universal acid' that may be applied to a number of seemingly disparate areas of philosophical inquiry (consciousness and free will in particular).
Tawney's interpretation[edit]
Christian socialistR. H. Tawney saw Smith as putting a name on an older idea:
If preachers have not yet overtly identified themselves with the view of the natural man, expressed by an eighteenth-century writer in the words, trade is one thing and religion is another, they imply a not very different conclusion by their silence as to the possibility of collisions between them. The characteristic doctrine was one, in fact, which left little room for religious teaching as to economic morality, because it anticipated the theory, later epitomized by Adam Smith in his famous reference to the invisible hand, which saw in economic self-interest the operation of a providential plan.. The existing order, except insofar as the short-sighted enactments of Governments interfered with it, was the natural order, and the order established by nature was the order established by God. Most educated men, in the middle of the [eighteenth] century, would have found their philosophy expressed in the lines of Pope:
- Thus God and Nature formed the general frame,
- And bade self-love and social be the same.
Naturally, again, such an attitude precluded a critical examination of institutions, and left as the sphere of Christian charity only those parts of life that could be reserved for philanthropy, precisely because they fell outside that larger area of normal human relations, in which the promptings of self-interest provided an all-sufficient motive and rule of conduct. (Religion and the Rise of Capitalism, pp. 191–192.)
Criticisms[edit]
Joseph E. Stiglitz[edit]
The Nobel Prize-winning economist Joseph E. Stiglitz, says: 'the reason that the invisible hand often seems invisible is that it is often not there.'[21][22] Stiglitz explains his position:
Adam Smith, the father of modern economics, is often cited as arguing for the 'invisible hand' and free markets: firms, in the pursuit of profits, are led, as if by an invisible hand, to do what is best for the world. But unlike his followers, Adam Smith was aware of some of the limitations of free markets, and research since then has further clarified why free markets, by themselves, often do not lead to what is best. As I put it in my new book, Making Globalization Work, the reason that the invisible hand often seems invisible is that it is often not there. Whenever there are 'externalities'—where the actions of an individual have impacts on others for which they do not pay, or for which they are not compensated—markets will not work well. Some of the important instances have long understood environmental externalities. Markets, by themselves, produce too much pollution. Markets, by themselves, also produce too little basic research. (The government was responsible for financing most of the important scientific breakthroughs, including the internet and the first telegraph line, and many bio-tech advances.) But recent research has shown that these externalities are pervasive, whenever there is imperfect information or imperfect risk markets—that is always. Government plays an important role in banking and securities regulation, and a host of other areas: some regulation is required to make markets work. Government is needed, almost all would agree, at a minimum to enforce contracts and property rights. The real debate today is about finding the right balance between the market and government (and the third 'sector' – governmental non-profit organizations.) Both are needed. They can each complement each other. This balance differs from time to time and place to place.[22]
The preceding claim is based on Stiglitz's 1986 paper, 'Externalities in Economies with Imperfect Information and Incomplete Markets',[23] which describes a general methodology to deal with externalities and for calculating optimal corrective taxes in a general equilibrium context. In it he considers a model with households, firms and a government.
Households maximize a utility function , where is the consumption vector and are other variables affecting the utility of the household (ex:pollution). The budget constraint is given by , where q is a vector of prices, ahf the fractional holding of household h in firm f, πf the profit of firm f, Ih a lump sum government transfer to the household. The consumption vector can be split as .
Firms maximize a profit , where yf is a production vector and p is vector of producer prices, subject to , Gf a production function and zf are other variables affecting the firm. The production vector can be split as .
The government receives a net income , where t=(q-p) is a tax on the goods sold to households.
It can be shown that in general the resulting equilibrium is not efficient.
Proof |
---|
It is worth keeping in mind that an equilibrium for the model may not necessarily exist. If it exists and there are no taxes (Ih=0, ∀h), then demand equals supply, and the equilibrium is found by: Let's use as a simplifying notation, where is the expenditure function that allows the minimization of household expenditure for a certain level of utility. If there is a set of taxes, subsidies, and lump sum transfers that leaves household utilities unchanged and increase government revenues, then the above equilibrium is not Pareto optimal. On the other hand, if the above non taxed equilibrium is Pareto optimal, then the following maximization problem has a solution for t=0: This is a necessary condition for Pareto optimality. Taking the derivative of the constraint with respect to t yields: Where and is the firm's maximum profit function. But since q=t+p, we have that dq/dt=IN-1+dp/dt. Therefore, substituting dq/dt in the equation above and rearranging terms gives: Summing over all households and keeping in mind that yields: By the envelope theorem we have: Fallout 4 must have mods. ;∀k This allows the constraint to be rewritten as: Since : Differentiating the objective function of the maximization problem gives: Substituting from the former equation in to latter equation results in: Recall that for the maximization problem to have a solution a t=0: In conclusion, for the equilibrium to be Pareto optimal dR/dt must be zero. Except for the special case where ∏ and B are equal, in general the equilibrium will not be Pareto optimal, therefore inefficient. |
Noam Chomsky[edit]
Noam Chomsky suggests that Smith (and more specifically David Ricardo) sometimes used the phrase to refer to a 'home bias' for investing domestically in opposition to offshore outsourcing production and neoliberalism.[24]
Rather interestingly, these issues were foreseen by the great founders of modern economics, Adam Smith for example. He recognized and discussed what would happen to Britain if the masters adhered to the rules of sound economics – what's now called neoliberalism. He warned that if British manufacturers, merchants, and investors turned abroad, they might profit but England would suffer. However, he felt that this wouldn't happen because the masters would be guided by a home bias. So as if by an invisible hand England would be spared the ravages of economic rationality. That passage is pretty hard to miss. It's the only occurrence of the famous phrase 'invisible hand' in Wealth of Nations, namely in a critique of what we call neoliberalism.[25]
Stephen LeRoy[edit]
Stephen LeRoy, professor emeritus at the University of California, Santa Barbara, and a visiting scholar at the Federal Reserve Bank of San Francisco, offered a critique of the Invisible Hand, writing that '[T]he single most important proposition in economic theory, first stated by Adam Smith, is that competitive markets do a good job allocating resources. (..) The financial crisis has spurred a debate about the proper balance between markets and government and prompted some scholars to question whether the conditions assumed by Smith..are accurate for modern economies.[26]
See also[edit]
- Books
- Essays on Philosophical Subjects by Adam Smith
- I, Pencil by Leonard Read
- The National Gain by Anders Chydenius
- The Theory of Moral Sentiments by Adam Smith
- The Visible Hand by Alfred Chandler
- The Wealth of Nations by Adam Smith
- Articles
- 'The Use of Knowledge in Society'
References[edit]
- ^Sen, Amartya. Introduction. The Theory of Moral Sentiments. By Adam Smith. 6th ed. 1790. New York: Penguin, 2009. vii–xxix.
- ^Thornton, Mark. 'Cantillon and the Invisible Hand'. Quarterly Journal of Austrian Economics, Vol. 12, No. 2 (2009) pp. 27–46.
- ^Slater, D. & Tonkiss, F. (2001). Market Society: Markets and Modern Social Theory. Cambridge: Polity Press, pp. 54–5
- ^Olsen, James Stewart. Encyclopedia of the Industrial Revolution. Greenwood Publishing Group, 2002. pp. 153–154
- ^Smith, A., 1980, The Glasgow edition of the Works and Correspondence of Adam Smith, 7 vol., Oxford University Press, vol. III, p. 49
- ^Smith, A., 1976, The Theory of Moral Sentiments, vol. 1, p. 184 in: The Glasgow Edition of the Works and Correspondence of Adam Smith, 7 vol., Oxford University Press
- ^Walker, A., 1875, The Wage Question, N:Y: Henry Holt, p. 215
- ^A. Marshall, Principles of Economics, 1890
- ^S. Jevon, The Theory of Political Economy, 1871
- ^Paul Samuelson, Economics, 1948
- ^Ludwig von Mises (2009), Human Action: Scholar's Edition, Ludwig von Mises Institute
- ^Friedman's Introduction to I, Pencil
- ^Basu 2010, p. 16.
- ^Kennedy, Gavin. 2009. Adam Smith and the Invisible Hand: From Metaphor to Myth. Econ Journal Watch 6(2): 239–263.
- ^Klein, Daniel B. 2009. In 'Adam Smith's Invisible Hands: Comment on Gavin Kennedy'. Econ Journal Watch 6(2): 264–279.
- ^Kennedy, Gavin. 'A Reply to Daniel Klein on Adam Smith and the Invisible Hand'. Econ Journal Watch 6(3): 374–388.
- ^D. H. MacGregor, Economic Thought and Policy (London: Oxford University Press, 1949), pp. 81–82.
- ^Marglin, Stephen (2008). The Dismal Science: How Thinking Like an Economist Undermines Community. Cambridge, MA: Harvard University Press. p. 99 n.1. ISBN978-0-674-02654-4.
- ^Rothschild, Emma (2001). Economic Sentiments: Adam Smith, Condorcet, and the Enlightenment. Cambridge, MA: Harvard University Press. pp. 138–42. ISBN978-0-674-00489-4.
- ^Samuels 2011, p. xviii.
- ^The Roaring Nineties, 2006
- ^ abALTMAN, Daniel. Managing Globalization. In: Q & Answers with Joseph E. Stiglitz, Columbia University and The International Herald Tribune, October 11, 2006 05:03AM.Archived June 26, 2009, at the Wayback Machine
- ^Greenwald, Bruce C.; Stiglitz, Joseph E. (May 1986). 'Externalities in economies with imperfect information and incomplete markets'. Quarterly Journal of Economics. Oxford University Press via JSTOR. 101 (2): 229–64. doi:10.2307/1891114. JSTOR1891114. (PDF; 853 kb)
- ^'American Decline: Causes and Consequences' Noam Chomsky
- ^http://rabble.ca/audio/download/83486/NNI+Noam+Chomsky+.mp3
- ^'Is the 'Invisible Hand' Still Relevant?'.
Bibliography[edit]
- Basu, Kaushik (2010). Beyond the Invisible Hand: Groundwork for a New Economics. Princeton, NJ: Princeton University Press. ISBN978-0-691-13716-2.
- Samuels, Warren J., ed. (2011). Erasing the Invisible Hand: Essays on an Elusive and Misused Concept in Economics. Cambridge: Cambridge University Press. ISBN978-0-521-51725-6.
Further reading[edit]
Wikiquote has quotations related to: Invisible hand |
- The Wealth of Nations (full text)
External links[edit]
- Oslington, Paul (2012). God and the Market: Adam Smith's Invisible Hand // JSTOR
Retrieved from 'https://en.wikipedia.org/w/index.php?title=Invisible_hand&oldid=900162603'
In Americanpolitical discourse, states' rights are political powers held for the state governments rather than the federal government according to the United States Constitution, reflecting especially the enumerated powers of Congress and the Tenth Amendment. The enumerated powers that are listed in the Constitution include exclusive federal powers, as well as concurrent powers that are shared with the states, and all of those powers are contrasted with the reserved powers—also called states' rights—that only the states possess.[1][2]
- 3Controversy to 1865
- 3.3Civil War
- 4Since the Civil War
Background[edit]
The balance of federal powers and those powers held by the states as defined in the Supremacy Clause of the U.S. Constitution was first addressed in the case of McCulloch v. Maryland (1819). The Court's decision by Chief Justice John Marshall asserted that the laws adopted by the federal government, when exercising its constitutional powers, are generally paramount over any conflicting laws adopted by state governments. After McCulloch, the primary legal issues in this area concerned the scope of Congress' constitutional powers, and whether the states possess certain powers to the exclusion of the federal government, even if the Constitution does not explicitly limit them to the states.[3][4]
Text[edit]
The Supremacy Clause of the U.S. Constitution states:
This Constitution, and the Laws of the United States which shall be made in pursuance thereof; and all treaties made, or which shall be made, under the authority of the United States, shall be the supreme law of the land; and the judges in every state shall be bound thereby, anything in the constitution or laws of any state to the contrary notwithstanding. (Emphasis added.)
In The Federalist Papers, ratification proponent Alexander Hamilton explained the limitations this clause placed on the proposed federal government, describing that acts of the federal government were binding on the states and the people therein only if the act was in pursuance of constitutionally granted powers, and juxtaposing acts which exceeded those bounds as 'void and of no force':
But it will not follow from this doctrine that acts of the large society which are not pursuant to its constitutional powers, but which are invasions of the residuary authorities of the smaller societies, will become the supreme law of the land. These will be merely acts of usurpation, and will deserve to be treated as such.
Controversy to 1865[edit]
In the period between the American Revolution and the ratification of the United States Constitution, the states had united under a much weaker federal government and a much stronger state and local government, pursuant to the Articles of Confederation. The Articles gave the central government very little, if any, authority to overrule individual state actions. The Constitution subsequently strengthened the central government, authorizing it to exercise powers deemed necessary to exercise its authority, with an ambiguous boundary between the two co-existing levels of government. In the event of any conflict between state and federal law, the Constitution resolved the conflict[3] via the Supremacy Clause of Article VI in favor of the federal government, which declares federal law the 'supreme Law of the Land' and provides that 'the Judges in every State shall be bound thereby, any Thing in the Constitution or Laws of any State to the Contrary notwithstanding.' However, the Supremacy Clause only applies if the federal government is acting in pursuit of its constitutionally authorized powers, as noted by the phrase 'in pursuance thereof' in the actual text of the Supremacy Clause itself (see above).
Alien and Sedition Acts[edit]
When the Federalists passed the Alien and Sedition Acts in 1798, Thomas Jefferson and James Madison secretly wrote the Kentucky and Virginia Resolutions, which provide a classic statement in support of states' rights and called on state legislatures to nullify unconstitutional federal laws. (The other states, however, did not follow suit and several rejected the notion that states could nullify federal law.) According to this theory, the federal union is a voluntary association of states, and if the central government goes too far each state has the right to nullify that law. As Jefferson said in the Kentucky Resolutions:
Resolved, that the several States composing the United States of America, are not united on the principle of unlimited submission to their general government; but that by compact under the style and title of a Constitution for the United States and of amendments thereto, they constituted a general government for special purposes, delegated to that government certain definite powers, reserving each State to itself, the residuary mass of right to their own self-government; and that whensoever the general government assumes undelegated powers, its acts are unauthoritative, void, and of no force: That to this compact each State acceded as a State, and is an integral party, its co-States forming, as to itself, the other party..each party has an equal right to judge for itself, as well of infractions as of the mode and measure of redress.
The Kentucky and Virginia Resolutions, which became part of the Principles of '98, along with the supporting Report of 1800 by Madison, became final documents of Jefferson's Democratic-Republican Party.[5] Gutzman argued that Governor Edmund Randolph designed the protest in the name of moderation.[6] Gutzman argues that in 1798, Madison espoused states' rights to defeat national legislation that he maintained was a threat to republicanism. During 1831–33, the South Carolina Nullifiers quoted Madison in their defense of states' rights. But Madison feared that the growing support for this doctrine would undermine the union and argued that by ratifying the Constitution states had transferred their sovereignty to the federal government.[7]
The most vociferous supporters of states' rights, such as John Randolph of Roanoke, were called 'Old Republicans' into the 1820s and 1830s.[8]
Tate (2011) undertook a literary criticism of a major book by John Taylor of Caroline, New Views of the Constitution of the United States. Tate argues it is structured as a forensic historiography modeled on the techniques of 18th-century Whig lawyers. Taylor believed that evidence from American history gave proof of state sovereignty within the union, against the arguments of nationalists such as U.S. Chief Justice John Marshall.[9]
Another states' rights dispute occurred over the War of 1812. At the Hartford Convention of 1814–15, New England Federalists voiced opposition to President Madison's war, and discussed secession from the Union. In the end they stopped short of calls for secession, but when their report appeared at the same time as news of the great American victory at the Battle of New Orleans, the Federalists were politically ruined.[10]
Nullification Crisis of 1832[edit]
One major and continuous strain on the union, from roughly 1820 through the Civil War, was the issue of trade and tariffs. Heavily dependent upon international trade, the almost entirely agricultural and export-oriented South imported most of its manufactured goods from Europe or obtained them from the North. The North, by contrast, had a growing domestic industrial economy that viewed foreign trade as competition. Trade barriers, especially protective tariffs, were viewed as harmful to the Southern economy, which depended on exports.
In 1828, the Congress passed protective tariffs to benefit trade in the northern states, but that were detrimental to the South. Southerners vocally expressed their tariff opposition in documents such as the South Carolina Exposition and Protest in 1828, written in response to the 'Tariff of Abominations'. Exposition and Protest was the work of South Carolinasenator and former vice presidentJohn C. Calhoun, formerly an advocate of protective tariffs and internal improvements at federal expense.
South Carolina's Nullification Ordinance declared that both the tariff of 1828 and the tariff of 1832 were null and void within the state borders of South Carolina. This action initiated the Nullification Crisis. Passed by a state convention on November 24, 1832, it led, on December 10, to President Andrew Jackson's proclamation against South Carolina, which sent a naval flotilla and a threat of sending federal troops to enforce the tariffs; Jackson authorized this under color of national authority, claiming in his 1832 Proclamation Regarding Nullification that 'our social compact in express terms declares, that the laws of the United States, its Constitution, and treaties made under it, are the supreme law of the land' and for greater caution adds, 'that the judges in every State shall be bound thereby, anything in the Constitution or laws of any State to the contrary notwithstanding.'
Civil War[edit]
Over the following decades, another central dispute over states' rights moved to the forefront. The issue of slavery polarized the union, with the Jeffersonian principles often being used by both sides—anti-slavery Northerners, and Southern slaveholders and secessionists—in debates that ultimately led to the American Civil War. Supporters of slavery often argued that one of the rights of the states was the protection of slave property wherever it went, a position endorsed by the U.S. Supreme Court in the 1857 Dred Scott decision. In contrast, opponents of slavery argued that the non-slave-states' rights were violated both by that decision and by the Fugitive Slave Law of 1850. Exactly which—and whose—states' rights were the casus belli in the Civil War remain in controversy.[citation needed]
Southern arguments[edit]
A major Southern argument in the 1850s was that federal laws to ban slavery discriminated against states that allowed slavery, making them second-class states. In 1857 the Supreme Court sided with these states' rights supporters, declaring in Dred Scott v. Sandford that Congress had no authority to regulate slavery in the territories.[11]
Jefferson Davis used the following argument in favor of the equal rights of states:
Resolved, That the union of these States rests on the equality of rights and privileges among its members, and that it is especially the duty of the Senate, which represents the States in their sovereign capacity, to resist all attempts to discriminate either in relation to person or property, so as, in the Territories—which are the common possession of the United States—to give advantages to the citizens of one State which are not equally secured to those of every other State.[12]
Southern states sometimes argued against 'states rights'. For example, Texas challenged some northern states having the right to protect fugitive slaves.[13]
Economists such as Thomas DiLorenzo and Charles Adams argue that the Southern secession and the ensuing conflict was much more of a fiscal quarrel than a war over slavery. Northern-inspired tariffs benefited Northern interests but were detrimental to Southern interests and were destroying the economy in the South.[14] These tariffs would be less subject to states rights' arguments.
Northern arguments[edit]
The historian James McPherson[15] noted that Southerners were inconsistent on the states' rights issue, and that Northern states tried to protect the rights of their states against the South during the Gag Rule and fugitive slave law controversies.
The historian William H. Freehling[16] noted that the South's argument for a state's right to secede was different from Thomas Jefferson's, in that Jefferson based such a right on the unalienable equal rights of man. The South's version of such a right was modified to be consistent with slavery, and with the South's blend of democracy and authoritarianism.[16]Historian Henry Brooks Adams explains that the anti-slavery North took a consistent and principled stand on states' rights against federal encroachment throughout its history, while the Southern states, whenever they saw an opportunity to expand slavery and the reach of the slave power, often conveniently forgot the principle of states' rights—and fought in favor of federal centralization:
Between the slave power and states' rights there was no necessary connection. The slave power, when in control, was a centralizing influence, and all the most considerable encroachments on states' rights were its acts. The acquisition and admission of Louisiana; the Embargo; the War of 1812; the annexation of Texas 'by joint resolution' [rather than treaty]; the war with Mexico, declared by the mere announcement of President Polk; the Fugitive Slave Law; the Dred Scott decision—all triumphs of the slave power—did far more than either tariffs or internal improvements, which in their origin were also southern measures, to destroy the very memory of states' rights as they existed in 1789. Whenever a question arose of extending or protecting slavery, the slaveholders became friends of centralized power, and used that dangerous weapon with a kind of frenzy. Slavery in fact required centralization in order to maintain and protect itself, but it required to control the centralized machine; it needed despotic principles of government, but it needed them exclusively for its own use. Thus, in truth, states' rights were the protection of the free states, and as a matter of fact, during the domination of the slave power, Massachusetts appealed to this protecting principle as often and almost as loudly as South Carolina.[17]
Sinha[18] and Richards[19] both argue that the south only used states' rights when they disagreed with a policy. Examples given are a states' right to engage in slavery or to suppress freedom of speech. They argue that it was instead the result of the increasing cognitive dissonance in the minds of Northerners and (some) Southern non-slaveowners between the ideals that the United States was founded upon and identified itself as standing for, as expressed in the Declaration of Independence, the Constitution of the United States, and the Bill of Rights, and the reality that the slave-power represented, as what they describe as an anti-democratic, counter-republican, oligarchic, despotic, authoritarian, if not totalitarian, movement for ownership of human beings as the personal chattels of the slaver. As this cognitive dissonance increased, the people of the Northern states, and the Northern states themselves, became increasingly inclined to resist the encroachments of the slave power upon their states' rights and encroachments of the slave power by and upon the federal government of the United States. The slave power, having failed to maintain its dominance of the federal government through democratic means, sought other means of maintaining its dominance of the federal government, by means of military aggression, by right of force and coercion, and thus, the Civil War occurred.
Texas v. White[edit]
In Texas v. White, 74U.S.700 (1869) the Supreme Court ruled that Texas had remained a state ever since it first joined the Union, despite claims to have joined the Confederate States of America; the court further held that the Constitution did not permit states to unilaterally secede from the United States, and that the ordinances of secession, and all the acts of the legislatures within seceding states intended to give effect to such ordinances, were 'absolutely null' under the constitution.[20]
Since the Civil War[edit]
A series of Supreme Court decisions developed the state action constraint on the Equal Protection Clause. The state action theory weakened the effect of the Equal Protection Clause against state governments, in that the clause was held not to apply to unequal protection of the laws caused in part by complete lack of state action in specific cases, even if state actions in other instances form an overall pattern of segregation and other discrimination. The separate but equal theory further weakened the effect of the Equal Protection Clause against state governments.
In case law[edit]
With United States v. Cruikshank (1876), a case which arose out of the Colfax Massacre of blacks contesting the results of a Reconstruction era election, the Supreme Court held that the Fourteenth Amendment did not apply to the First Amendment or Second Amendment to state governments in respect to their own citizens, only to acts of the federal government. In McDonald v. City of Chicago (2010), the Supreme Court held that the Second Amendment right of an individual to 'keep and bear arms' is incorporated by the Due Process Clause of the Fourteenth Amendment, and therefore fully applicable to states and local governments.[citation needed]
Furthermore, United States v. Harris (1883) held that the Equal Protection Clause did not apply to an 1883 prison lynching on the basis that the Fourteenth Amendment applied only to state acts, not to individual criminal actions.
In the Civil Rights Cases (1883), the Supreme Court allowed segregation by striking down the Civil Rights Act of 1875, a statute that prohibited racial discrimination in public accommodation. It again held that the Equal Protection Clause applied only to acts done by states, not to those done by private individuals, and as the Civil Rights Act of 1875 applied to private establishments, the Court said, it exceeded congressional enforcement power under Section 5 of the Fourteenth Amendment.
Later progressive era and World War II[edit]
By the beginning of the 20th century, greater cooperation began to develop between the state and federal governments and the federal government began to accumulate more power. Early in this period, a federal income tax was imposed, first during the Civil War as a war measure and then permanently with the Sixteenth Amendment in 1913. Before this, the states played a larger role in government.
States' rights were affected by the fundamental alteration of the federal government resulting from the Seventeenth Amendment, depriving state governments of an avenue of control over the federal government via the representation of each state's legislature in the U.S. Senate. This change has been described by legal critics as the loss of a check and balance on the federal government by the states.[21]
Following the Great Depression, the New Deal and then World War II saw further growth in the authority and responsibilities of the federal government. The case of Wickard v. Filburn allowed the federal government to enforce the Agricultural Adjustment Act, providing subsidies to farmers for limiting their crop yields, arguing agriculture affected interstate commerce and came under the jurisdiction of the Commerce Clause even when a farmer grew his crops not to be sold, but for his own private use.
After World War II, President Harry Truman supported a civil rights bill and desegregated the military. The reaction was a split in the Democratic Party that led to the formation of the 'States' Rights Democratic Party'—better known as the Dixiecrats—led by Strom Thurmond. Thurmond ran as the States' Rights candidate for President in the 1948 election, losing to Truman.
Civil rights movement[edit]
During the 1950s and 1960s, the Civil Rights Movement was confronted by the proponents in the Southern states of racial segregation and Jim Crow laws who denounced federal interference in these state-level laws as an assault on states' rights.
Though Brown v. Board of Education (1954) overruled the Plessy v. Ferguson (1896) decision, the Fourteenth and Fifteenth amendments were largely inactive in the South until the Civil Rights Act of 1964 (42 U.S.C.§ 21)[22] and the Voting Rights Act of 1965. Several states passed Interposition Resolutions to declare that the Supreme Court's ruling in Brown usurped states' rights.
There was also opposition by states' rights advocates to voting rights at Edmund Pettus Bridge, which was part of the Selma to Montgomery marches, that resulted in the Voting Rights Act of 1965.
Contemporary debates[edit]
In 1964, the issue of fair housing in California involved the boundary between state laws and federalism. California Proposition 14 overturned the Rumsford Fair Housing Act in California and allowed discrimination in any type of housing sale or rental.[23]Martin Luther King, Jr. and others saw this as a backlash against civil rights. Actor Ronald Reagan gained popularity by supporting Proposition 14, and was later elected governor of California.[24] The U.S. Supreme Court's Reitman v. Mulkey decision overturned Proposition 14 in 1967 in favor of the Equal Protection Clause of the Fourteenth Amendment.
Conservative historians Thomas E. Woods, Jr. and Kevin R. C. Gutzman argue that when politicians come to power they exercise all the power they can get, in the process trampling states' rights.[25] Gutzman argues that the Kentucky and Virginia resolutions of 1798 by Jefferson and Madison were not only responses to immediate threats but were legitimate responses based on the long-standing principles of states' rights and strict adherence to the Constitution.[26]
Another concern is the fact that on more than one occasion, the federal government has threatened to withhold highway funds from states which did not pass certain articles of legislation. Any state which lost highway funding for any extended period would face financial impoverishment, infrastructure collapse or both. Although the first such action (the enactment of a national speed limit) was directly related to highways and done in the face of a fuel shortage, most subsequent actions have had little or nothing to do with highways and have not been done in the face of any compelling national crisis. An example of this would be the federally mandated drinking age of 21, upheld in South Dakota v. Dole. Critics of such actions feel that when the federal government does this they upset the traditional balance between the states and the federal government.
More recently, the issue of states' rights has come to a head when the Base Realignment and Closure Commission (BRAC) recommended that Congress and the Department of Defense implement sweeping changes to the National Guard by consolidating some Guard installations and closing others. These recommendations in 2005 drew strong criticism from many states, and several states sued the federal government on the basis that Congress and the Pentagon would be violating states' rights should they force the realignment and closure of Guard bases without the prior approval of the governors from the affected states. After Pennsylvania won a federal lawsuit to block the deactivation of the 111th Fighter Wing of the Pennsylvania Air National Guard, defense and Congressional leaders chose to try to settle the remaining BRAC lawsuits out of court, reaching compromises with the plaintiff states.[27]
Current states' rights issues include the death penalty, assisted suicide, same-sex marriage, gun control, and cannabis, the last of which is in direct violation of federal law. In Gonzales v. Raich, the Supreme Court ruled in favor of the federal government, permitting the Drug Enforcement Administration (DEA) to arrest medical marijuana patients and caregivers. In Gonzales v. Oregon, the Supreme Court ruled the practice of physician-assisted suicide in Oregon is legal. In Obergefell v. Hodges, the Supreme Court ruled that states could not withhold recognition to same-sex marriages. In District of Columbia v. Heller (2008), the United States Supreme Court ruled that gun ownership is an individual right under the Second Amendment of the United States Constitution, and the District of Columbia could not completely ban gun ownership by law-abiding private citizens. Two years later, the court ruled that the Heller decision applied to states and territories via the Second and 14th Amendments in McDonald v. Chicago, stating that states, territories and political divisions thereof, could not impose total bans on gun ownership by law-abiding citizens.
These concerns have led to a movement sometimes called the State Sovereignty movement or '10th Amendment Sovereignty Movement'.[28]
Some, such as former representative Ron Paul (R-TX), have proposed repealing the 17th Amendment of the United States Constitution.[29]
10th Amendment Resolutions[edit]
In 2009–2010 thirty-eight states introduced resolutions to reaffirm the principles of sovereignty under the Constitution and the 10th Amendment; 14 states have passed the resolutions. These non-binding resolutions, often called 'state sovereignty resolutions' do not carry the force of law. Instead, they are intended to be a statement to demand that the federal government halt its practices of assuming powers and imposing mandates upon the states for purposes not enumerated by the Constitution.[4]
States' rights and the Rehnquist Court[edit]
The Supreme Court's University of Alabama v. Garrett (2001)[30] and Kimel v. Florida Board of Regents (2000)[31] decisions allowed states to use a rational basis review for discrimination against the aged and disabled, arguing that these types of discrimination were rationally related to a legitimate state interest, and that no 'razorlike precision' was needed.' The Supreme Court's United States v. Morrison (2000)[32] decision limited the ability of rape victims to sue their attackers in federal court. Chief Justice William H. Rehnquist explained that 'States historically have been sovereign' in the area of law enforcement, which in the Court's opinion required narrow interpretations of the Commerce Clause and Fourteenth Amendment.
Kimel, Garrett and Morrison indicated that the Court's previous decisions in favor of enumerated powers and limits on Congressional power over the states, such as United States v. Lopez (1995), Seminole Tribe v. Florida (1996) and City of Boerne v. Flores (1997) were more than one time flukes. In the past, Congress relied on the Commerce Clause and the Equal Protection Clause for passing civil rights bills, including the Civil Rights Act of 1964.[22]
Lopez limited the Commerce Clause to things that directly affect interstate commerce, which excludes issues like gun control laws, hate crimes, and other crimes that affect commerce but are not directly related to commerce. Seminole reinforced the 'sovereign immunity of states' doctrine, which makes it difficult to sue states for many things, especially civil rights violations. The Flores 'congruence and proportionality' requirement prevents Congress from going too far in requiring states to comply with the Equal Protection Clause, which replaced the ratchet theory advanced in Katzenbach v. Morgan (1966). The ratchet theory held that Congress could ratchet up civil rights beyond what the Court had recognized, but that Congress could not ratchet down judicially recognized rights. An important precedent for Morrison was United States v. Harris (1883), which ruled that the Equal Protection Clause did not apply to a prison lynching because the state action doctrine applies Equal Protection only to state action, not private criminal acts. Since the ratchet principle was replaced with the 'congruence and proportionality' principle by Flores, it was easier to revive older precedents for preventing Congress from going beyond what Court interpretations would allow. Critics such as Associate JusticeJohn Paul Stevens accused the Court of judicial activism (i.e., interpreting law to reach a desired conclusion).
The tide against federal power in the Rehnquist court was stopped in the case of Gonzales v. Raich, 545 U.S. 1 (2005), in which the court upheld the federal power to prohibit medicinal use of cannabis even if states have permitted it. Rehnquist himself was a dissenter in the Raich case.
States' rights as code word[edit]
Since the 1940s, the term 'states' rights' has often been considered a loaded term because of its use in opposition to federally mandated racial desegregation and more recently, same-sex marriage.[33][34]
During the heyday of the civil rights movement, defenders of segregation[33][35] used the term 'states' rights' as a code word—in what is now referred to as dog-whistle politics—political messaging that appears to mean one thing to the general population but has an additional, different or more specific resonance for a targeted subgroup.[36][37][38] In 1948 it was the official name of the 'Dixiecrat' party led by white supremacist presidential candidate Strom Thurmond.[39][40] Democratic governor George Wallace of Alabama, who famously declared in his inaugural address in 1963, 'Segregation now! Segregation tomorrow! Segregation forever!'—later remarked that he should have said, 'States' rights now! States' rights tomorrow! States' rights forever!'[41] Wallace, however, claimed that segregation was but one issue symbolic of a larger struggle for states' rights; in that view, which some historians dispute, his replacement of segregation with states' rights would be more of a clarification than a euphemism.[41]
In 2010, Texas governor Rick Perry's use of the expression 'states' rights', to some, was reminiscent of 'an earlier era when it was a rallying cry against civil rights'.[42] During an interview with The Dallas Morning News, Perry made it clear that he supports the end of segregation, including passage of the Civil Rights Act. Texas president of the NAACP Gary Bledsoe stated that he understood that Perry wasn't speaking of 'states' rights' in a racial context; but others still felt offended by the term because of its past misuse.[42]
See also[edit]
- Federalism in the United States
Notes[edit]
- ^Gardbaum, Stephen. 'Congress's Power to Pre-Empt the States', Pepperdine Law Review, Vol. 33, p. 39 (2005).
- ^Bardes, Barbara et al. American Government and Politics Today: The Essentials (Cengage Learning, 2008).
- ^ ab'The United States Constitution - The U.S. Constitution Online - USConstitution.net'.
- ^ abOrbach, Callahan & Lindemmen, 'Arming States' Rights: Federalism, Private Lawmakers, and the Battering Ram Strategy,' Arizona Law Review (2010)
- ^Kevin R. C. Gutzman, James Madison and the Making of America (2012) pp. 274–76
- ^Kevin R. C. Gutzman, 'Edmund Randolph and Virginia Constitutionalism,' Review of Politics, (Summer 2004), Vol. 66 Issue 3, pp. 469–97
- ^Kevin R. Gutzman, 'A troublesome legacy: James Madison and 'The principles of '98',' Journal of the Early Republic (Winter 1995), Vol. 15 Issue 4, pp. 569–89
- ^Norman K Risjord, The Old Republicans: Southern Conservatism in the Age of Jefferson (1965)
- ^Adam Tate, 'A Historiography of States' Rights: John Taylor of Caroline's New Views of the Constitution,' Southern Studies: An Interdisciplinary Journal of the South (2011) Vol. 18 Issue 1, p. 10–28
- ^James M Banner, To the Hartford Convention: the Federalists and the origins of party politics in Massachusetts, 1789–1815 (1970)
- ^John Mack Faragher, Mari Jo Buhle, Daniel Czitrom Out of Many: A History of the American people (2005) p. 376
- ^Jefferson Davis' Resolutions on the Relations of States, Senate Chamber, U.S. Capitol, February 2, 1860, from The Papers of Jefferson Davis, Volume 6, pp. 273–76. Transcribed from the Congressional Globe, 36th Congress, 1st Session, pp. 658–59.
- ^'Confederate States of America – A Declaration of the Causes which Impel the State of Texas to Secede from the Federal Union'. Yale Law School. March 1845. Retrieved 1 July 2015.
- ^Oliver, Charles (April 1, 2012). 'Analysis: Exploring the roots of The Civil War'. Reason. Retrieved April 1, 2012.
- ^James McPherson, This Mighty Scourge, pp. 3–9. Speaking of alternative explanations for secession, McPherson writes (p.7), 'While one or more of these interpretations remain popular among the Sons of Confederate Veterans and other Southern heritage groups, few professional historians now subscribe to them. Of all these interpretations, the state's-rights argument is perhaps the weakest. It fails to ask the question, state's rights for what purpose? State's rights, or sovereignty, was always more a means than an end, an instrument to achieve a certain goal more than a principle.
- ^ abWilliam H. Freehling, The Road to Disunion: Secessionists Triumphant, 1854–1861
- ^Adams, Henry (1882). John Randolph (1st ed.). Boston, MA, USA: Houghton Mifflin and Co. OCLC3942444. Retrieved 2009-07-26.
- ^Sinha, Manisha (2000). The Counter-Revolution of Slavery: Politics and Ideology in Antebellum South Carolina. Chapel Hill, North Carolina, USA: University of North Carolina Press. ISBN978-0-8078-2571-6. OCLC44075847. Retrieved 2009-03-14.
- ^Richards, Leonard L. (2000). The Slave Power: The Free North and Southern Domination. Baton Rouge, Louisiana, USA: LSU Press. ISBN978-0-8071-2600-4. OCLC43641070.
- ^Murray pp. 155–59.
- ^Bybee, Jay S. (1997). 'Ulysses at the Mast: Democracy, Federalism, and the Sirens' Song of the Seventeenth Amendment'. Northwestern University Law Review. Chicago, IL: Northwestern University Law Review. 91: 505.
- ^ ab'Civil Rights Act of 1964 - CRA - Title VII - Equal Employment Opportunities - 42 US Code Chapter 21 - findUSlaw'. finduslaw.com.
- ^Skelton, George (May 7, 2014) 'Thank you, Donald Sterling, for reminding us how far we've come'Los Angeles Times
- ^Pillar of Fire, Taylor Branch, p. 242
- ^Thomas E. Woods, Jr. and Kevin R. C. Gutzman, Who Killed the Constitution?: The Federal Government Vs. American Liberty from World War I to Barack Obama (Random House Digital, 2009) p. 201
- ^K. R. Constantine Gutzman, 'The Virginia and Kentucky Resolutions Reconsidered: 'An Appeal to the Real Laws of Our Country',' Journal of Southern History (Aug 2000), Vol. 66 Issue 3, pp. 473–96
- ^'Judge Rules Favorably in Pennsylvania BRAC Suit (Associated Press, 26 August)'.[permanent dead link]
- ^Johnston, Kirk. 'States' Rights Is Rallying Cry for Lawmakers'The New York Times March 16, 2010
- ^Johnson, Keith (April 2, 2012). 'Analysis: Anti-Washington Ire Kindles an Old Debate'. The Wall Street Journal. Retrieved April 2, 2012.
- ^'Board of Trustees of the University of Alabama et al. v. Garrett et al., U.S. Supreme Court, decided February 21, 2001'.
- ^'Kimel v. Florida Board of Regents, U.S. Supreme court, decided January 11, 2000'.
- ^'United States v. Morrison'. LII / Legal Information Institute.
- ^ abGreenberg, David (November 20, 2007), 'Dog-Whistling Dixie: When Reagan said 'states' rights,' he was talking about race', Slate, retrieved February 5, 2016
- ^Herbert, Bob (October 6, 2005). 'Impossible, Ridiculous, Repugnant'. The New York Times.
- ^White, D. Jonathan (2009). 'States' Rights'. Encyclopedia of Alabama. Retrieved 2010-09-09.
After the Civil War and Reconstruction, Alabama, along with other southern states, used states' rights arguments to restore a system of white supremacy and racial segregation. .. The term still appears on occasion in political speech, in some cases as code language indicating support of discriminatory practices or outright racism; as a result, its use is often met with skepticism or suspicion by the public at large.
- ^Haney López, Ian (2014). Dog Whistle Politics: How Coded Racial Appeals Have Reinvented Racism and Wrecked the Middle Class. New York: Oxford University Press. p. 4. ISBN978-0-19-996427-7.
- ^Full Show: Ian Haney López on the Dog Whistle Politics of Race, Part I. Moyers & Company, February 28, 2014.
- ^Yao, Kevin (November 9, 2015). 'A Coded Political Mantra'. Berkeley Political Review: UC Berkeley's Only Nonpartisan Political Magazine. Retrieved February 5, 2016.
- ^Lichtman, Allan J. (2008). White Protestant Nation: The Rise of the American Conservative Movement. New York: Atlantic Monthly Press. p. 165. ISBN0-87113-984-7.
- ^Bass, Jack; Thompson, Marilyn W. (2006). Strom: The Complicated Personal and Political Life of Strom Thurmond. New York: PublicAffairs. p. 102. ISBN1-58648-392-7.
- ^ abCarter, Dan T. From George Wallace to Newt Gingrich: Race in the Conservative Counterrevolution, 1963–1994. p. 1.
- ^ abSlater, Wayne (November 19, 2010). 'Analysis: Perry's 'states' rights' battle cry evokes history that could damage his message'. The Dallas Morning News. Retrieved November 21, 2010.
References[edit]
- Althouse, Anne (October 2001). 'Why Talking About 'States' Rights' Cannot Avoid the Need for Normative Federalism Analysis: A Response to Professors Baker and Young'. Duke Law Journal. 51 (1): 363. Retrieved 2 December 2011.
- Baker, Lynn A.; Young, Ernest A. (October 2001). 'Federalism and the Double Standard of Judicial Review'. Duke Law Journal. 51 (1): 75. Retrieved 2 December 2011., which argues at 143–49: 'To many, [the notion of states' rights] stands for an anachronistic (and immoral) preference for the race-based denial of essential individual rights..'.
- Farber, Daniel A., 'States' Rights and the Union: Imperium in Imperio, 1776–1876' Constitutional Commentary, Vol. 18, 2001
- Kirk, Russell K., Randolph of Roanoke: A Study in Conservative Thought (1951)
- Gutzman, Kevin R. C. James Madison and the Making of America (2012)
- Gutzman, Kevin R. C. 'A troublesome legacy: James Madison and 'The principles of '98',' Journal of the Early Republic (Winter 1995), Vol. 15 Issue 4, pp. 569–89
- Gutzman, Kevin R. C. 'The Virginia and Kentucky Resolutions Reconsidered: 'An Appeal to the Real Laws of Our Country',' Journal of Southern History (Aug 2000), Vol. 66 Issue 3, pp 473–96
- McDonald, Forrest, States' Rights and the Union: Imperium in Imperio, 1776–1876 (2002)
- Murray, Robert Bruce. Legal Cases of the Civil War (2003) ISBN0-8117-0059-3
- Risjord, Norman K., The Old Republicans: Southern Conservatism in the Age of Jefferson (1965)
- Sinha, Manisha, 'Revolution or Counterrevolution?: The Political Ideology of Secession in Antebellum South Carolina' Civil War History, Vol. 46, 2000 in JSTOR
- Sinha, Manisha (2000). The Counterrevolution of Slavery: Politics and Ideology in Antebellum South Carolina. University of North Carolina Press. p. 362. ISBN0-8078-2571-9.
- Orbach, Barak Y., et al. 'Arming States' Rights: Federalism, Private Lawmakers, and the Battering Ram Strategy,'Arizona Law Review, vol. 52, 2010
Further reading[edit]
- Sotirios A. Barber, The Fallacies of States' Rights. Cambridge, MA: Harvard University Press, 2013.
- Jefferson Davis, 'The Doctrine of State Rights' (1890). The North American Review, Vol. 150, No. 399, pp. 205–219.
- Frederick D. Drake, ed. States' Rights and American Federalism: A Documentary History (1999)
- James J. Kilpatrick. The Sovereign States: Notes of a Citizen of Virginia Chicago: Henry Regnery Company, 1957.
External links[edit]
Wikiquote has quotations related to: States' rights |
- Tenth Amendment Center Federalism and States Rights in the U.S.
- Missouri Sovereignty Project 'Institutionalizing' the 10th Amendment into the populace and political fabrics of Missouri.
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