Religious buffs may recall that anger is considered sinful unless it is “righteous anger”. (Gospel of Matthew 21).
We welcome Dr. Terri Lewis to teach us about Moral Entrepreneurs, Moral Indignation, and rapidly unfolding righteous anger among pain colleagues nationwide.
Here’s what Dr. Lewis has to say…
…what a society fears is essential to understanding its core values, and its highest aspirations. Philip Jenkins, Pennsylvania State University
Despite our history and the unprecedented contributions from science to healthcare the U.S. has begun to slip from its foundations of applied scientific practice that generates evidence for policy. Many agree we are living in a moment of anti-science accompanied by profound distrust of scientific institutions as evidenced by the actions of public leadership. This is engendering a system-wide moral anxiety derived from the utilization of techniques and tools associated with a social phenomenon that Goode and Ben-Yehudin (2009) have described as moral panic. A moral panic is a feeling of fear spread among a large number of people that some evil threatens the well-being of society. It develops when a condition or episode emerges to become defined as a threat to societal values and interests. A Dictionary of Sociology (2014) defines a moral panic as “the process of arousing social concern over an issue – usually the work of moral entrepreneurs and the mass media (p.492).” Within the field of public health, examples of moral panic include the belief that vaccines cause autism, access to abortion and birth control must be restricted, disease is spread through immigration, and that a war must be waged on the spread of drugs.
Moral panics have distinct and five identifiable features. First, there must be a concern or belief that the behavior of the group or activity deemed deviant is likely to have a negative effect on society. Second, the belief is associated with increasing hostility toward the group in question – they become “folk devils” with a clear division that forms between “them” and “us.” Third, there must be widespread acceptance that the group in question poses a very real threat to society. At this stage, the “moral entrepreneurs” are vocal and the “folk devils” appear to be weak and disorganized in part because of their characteristics. Fourth, the action that must be undertaken by society is entirely disproportionate to the actual threat posed by the accused group. Fifth, moral panics are highly volatile and tend to disappear as quickly as they appear, but they may wax and wane depending on the public interest or the agenda of those whose interests are served by maintaining the moral panic.
Those who initiate a panic when they fear a threat to prevailing social or cultural values are known by social researchers as moral entrepreneurs. Individuals, organizations, or institutions serving in this role –
- Sound an alarm about an event they perceive to be morally threatening to society
- Assert an agenda that selects social problems that they deem to be newsworthy applying finer filters to select candidates for moral panic and representative events.
- Provide examples through assertions and rhetorical claims designed to create panics and proxies or scapegoats as representations for the moral panic; and,
- Continuously makes and perpetuates the agenda, claims, images, and scapegoats
People who supposedly threaten the social order have been described as ‘folk devils‘ who –
- Are associated with an event that has been identified by a moral entrepreneur as threatening to society
- Act on an agenda that has been determined to be newsworthy or of concern to maintenance of the social order
- Whose activities generate examples that support assertions and rhetorical claims
- Who become proxies for the agenda of moral entrepreneurism, through claims, images and scapegoating.
Scapegoating is a method designed to create a proxy for moral contagion. Scapegoats are necessary to deflect attention and scrutiny from other forms of social intervention and action. A “moral panic” is the best way to do that because scapegoating of a person or group of persons creates concerns and consensus about the characteristics associated with deviance, hostility that divides them from us, acceptance that the perceived threat associated with the scapegoat is real, and requires a disproportional response that consumes attention and resources. Scapegoats are contained within the cloak of stigma and practices designed to marginalize them, reducing their access to public resources and supports. Persons with substance use disorders and persons with complex illnesses occupy the position of scapegoat in the public conversation about the harms or benefits of opiates.
Moral indignation arises from the dissemination of moral panic and the spread of moral contagion. Moral indignation gains power by simply reporting and repeating anti-scientific and alternative ‘facts’ designed to generate concern, anxiety, or panic. Parties to the dissemination of indignation include the media, politicians, and other stakeholders or institutions with a personal interest that will gain (attention, benefits, power) from the outcomes of crusading and muckraking. Moral indignation supports moral panic when the public, political systems or other institutions align together to create a dramatic atmosphere that –
- Breaks the silence and embraces the voices of moral entrepreneurs
- Sets the agenda by selecting deviant or socially problematic events deemed as newsworthy, applying finer filters to selected targets upon which to exercise moral panic and representative events
- Transmits the images – transmitting assertions and claims by using the rhetoric of moral panics and reinforcing the selected scapegoats for the moral panic; and,
- Continuously makes and perpetuates the agenda, claims, images, and scapegoats
It is within this atmosphere of anti-science that the war on drugs has morphed, creating a moral panic manipulated by moral entrepreneurs to distract the public imagination and scapegoat the very persons that would otherwise be protected – those with addiction and those who are sick, injured and require palliation. This particular form of moral panic is doing more damage than good because it has set in motion the structuralization of an unscientific, socially constructed belief system that denies science, has assets and resources allocated to it, and occupies space in the physical world, digital spaces, and legal code books. Examples of this are the appointment of the White House President’s Commission on Combating Drug Addiction and the Opioid Crisis, the passage of state legislation designed to control and track the dispensing of schedule II narcotics, and the implementation of a nationwide PDMP system designed to track sales while using the same data to infer potentially wrongful utilization by the very nature of sales made.
The myth that prescription opiates are bad is built on the notion of fear, panic, contagion, and spread. We are continuously subjected to a barrage of messaging which uses terms like ‘heroin pills’ or ‘I was hooked after 1 pill.’ As an ideology, it perpetuates the notion that physicians are naïve or predatory, that society must be protected from those who have substance use disorders, that patients are avaricious and dishonest because of their need for medications to palliate their symptoms of pain. This culture of implied harms and fear is continuously used to disempower, exclude, and depoliticize those who are the most affected – consumers, their families, and the physicians who treat them. Authoritative figures who operate as moral entrepreneurs believe that protecting the public from this moral panic of opiate contagion is beneficial to protecting them from imagined catastrophe, along with their innocence and naivete. Moral entrepreneurs continually abuse their accrued power by perpetuating the message that they (individuals, organizations, institutions) know what is best for the public good whether or not the evidence exists to support their messaging. In actuality, patients and physicians are losing access to their self-agency and scientific voice because of it.
Within this climate, the Drug Enforcement Administration (DEA), acting like a moral entrepreneur, has adopted a public stance that renews and heightens moral panic through public pronouncements that lump all opiates into an illicit bucket of social harms that only they have the moral authority to address. Without the support of scientific principles or considerations of effective practice within the scope of either addiction or pain medicine, the DOJ has accelerated a moral panic that conflates the use of opiates by persons who are dependent or addicted or who are sick and injured, with anti-social behavior associated with illicit utilization that simply must be stopped for the social good. Overdoses have been adopted as a representation for contagion and spread, even as prescriptions have become a proxy for causing the deaths and poisonings associated with illicit drugs that flow to America’s streets despite the best efforts of the DEA and other policing systems. The sale of medications serves as a proxy for spread of contagion. Legitimate physicians are scapegoats for the distribution of illicit drugs. While there is evidence that this conflation is accelerating and increasing harms to the public good, the media has become a willing partner to perpetuating the anti-scientific notion that physicians who treat their patients with opiates are engaged in behavior which lies outside the realm of the social good. The continued failure of moral entrepreneurs to fail to distinguish legitimate process from illegitimate process serves an agenda that feeds both moral panic and public anxiety and should cause us to question the gains they derive from doing so.
It is within this climate of moral panic, that Dr. Forest Tennant, MD, DPH, addictionologist, public health expert, and an expert on intractable pain, was targeted last week by a raid on his clinic and his home. Two independent pharmacy organizations that provide his patients with pharmacologic supports were also raided. He is not the first, nor is he likely to be the last physician so targeted. But unlike others, this servant-physician is among the most impactful on professional pain care because he serves the most complex and disenfranchised of patients who require knowledge and skills accrued through a lifetime of practice that are rarely found in communities. Asserting that a physician who had dedicated his career to the study of addiction and pain is responsible for the epidemic of overdoses along with “Big Pharma” is absurd on its face.
Dr. Tennant has a community of careers that relies on and supports his lifetime body of work for persons with intractable pain and or addiction. Much of what we have learned to distinguish the various models of care for all types of pain is derived from his 50 years of experience. We collaborate with this physician through our professional research and educational activities to serve our most complex patients, and have gained confidence in his advising because we see the reduction of harms and increase in benefits to the consumers we serve together. We are better clinicians because of his contributions to the field.
We find the actions of the DEA to be harmful to the care of our sickest community-located citizens and harmful to the physicians who serve this population across the nation. We decry the labeling of persons with intractable pain as potential redistributors (folk devils) of the medications that keep them functioning within their families. By these actions, the structural barriers that must be removed to serve persons with substance abuse disorders, complex illnesses, and pain in all of its forms are once again reinforced as proxies for maintaining contagion and moral panic even as harm the capacity of our health care system as a whole.
Please feel free to comment!
Dr. Terri Lewis has extensive experience in the development and administration of community programs and systems of care for persons with disabilities and chronic health impairments. She has broad community rehabilitation industry experience, having collaborated extensively with local, state, and federal agencies to create community mental health and rehabilitation services for unserved and underserved persons with a wide variety of needs. At this time, she serves on the academic faculty for two universities. She collaborates with vocational programs in the USA and southeast Asia on the design of community based rehabilitation with special emphasis on Allied Health care coordination and personnel training.
Department of Justice (November 13, 2017) Application for Search Warrant Central District of California
Goode, E. and Ben-Yehuda, N. (2009) Deviance, Morality, and Criminal Law, in Moral Panics: The Social Construction of Deviance, Second Edition, Wiley-Blackwell, Oxford, UK. doi: 10.1002/9781444307924.ch6
Otto, S.L. (2012, Nov. 12). Antiscience beliefs jeopardize U.S. Democracy Scientific American, https://www.scientificamerican.com/article/antiscience-beliefs-jeopardize-us-democracy/