Room for Debate: Smaller Footprints on the World's Welcome Mats

Tourism has become one of the world's largest industries as the cost of travel has dropped, political barriers have fallen and the global middle class has grown. The variety of vacation spots has bloomed, with myriad destinations available to millions more people. But along with the pleasures of travel have come problems — cultural disruption and homogenization, overcrowding and pollution.

How can tourism flourish while causing as little harm as possible?

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Room for Debate: Have Human Rights Treaties Failed?

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Human Rights Law Is Too Ambitious and Ambiguous

Eric Posner 7:36 PM

While the vast majority of countries have ratified nearly all the major human rights treaties, rights violations remain common. Political repression exists around the world, and not just in China and Russia. In many developing countries, the criminal justice system works poorly, and the police frequently resort to extrajudicial methods like using torture to extract confessions. Age-old blights like child labor, the subjugation of women, religious persecution and even slavery are amazingly common. Even in the United States, torture has been used against suspected terrorists, police brutality flourishes and convicted criminals often receive extraordinarily harsh punishments.

More focused and pragmatic interventions, including relying heavily on foreign aid for economic development, rather than coercion or shaming, is the better way to go.

Many people argue that the solution to these problems is to strengthen human rights law. They argue that we need more treaties, with stricter obligations and better-funded, more powerful international institutions. But my view is the opposite. Human rights law is too ambitious — even utopian — and too ambiguous: it overwhelms states with obligations they can't possibly keep and provides no method for evaluating whether governments act reasonably or not. The law doesn't do much; we should face that fact and move on. This doesn't mean that we shouldn't care when governments abuse their citizens. But more focused and pragmatic interventions, including relying heavily on foreign aid for economic development, rather than coercion or shaming, is the better way to go.

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Abandoning Human Rights Laws Would Be Wrong

Kenneth Roth 7:36 PM

Abandoning human rights law because human rights violations persist would be like repealing the criminal code because people continue to commit crimes. The result might satisfy the hypocrisy police but would hardly improve public safety.

That governments violate human rights is hardly surprising. People in power are often tempted to discriminate against a disfavored minority, order torture in the name of fighting terrorism or silence a pesky critic if they can get away with it.

Human rights treaties help to explain why these abuses are wrong. They may not always provide definitive answers — any text requires interpretation — but they codify a widely endorsed set of principles from which the conversation can begin.

That governments violate human rights is hardly surprising; human rights treaties help to explain why these abuses are wrong.

Would we really be better off, as Eric implies, if each discussion of governmental behavior started from scratch — if, rather than debating what constituted a violation of, say, the right to a fair trial, we had to begin by discussing whether people should be given fair trials?

Eric is taking on a straw man by claiming that the human rights movement's answer to violations is "more treaties." Yes, over the years new treaties have been adopted to flesh out rights for certain categories of people — be they women or people with disabilities — or to fill in ambiguities in the law, such as explaining that the prohibition of indiscriminate warfare bars antipersonnel landmines and cluster munitions. But the human rights movement spends the vast majority of its energy trying to enforce existing rights rather than seeking to create new ones.

Eric sees treaties as "utopian" statements of overly ambitious goals that cannot possibly be met, but that's not what government officials say. They don't plead, "I signed up for the impossible so don't hold me to it," but rather, "I didn't shoot those protesters," or "I'm not imprisoning her for criticizing me." They typically accept that the right involved is legitimate and contend that they comply. When they don't, human rights investigations contrast their claim with the hard facts on the ground.

Arguing that we should rely instead on foreign aid for economic development must be music to autocrats' ears. Sympathizers of the Chinese government have argued for decades that economic development will inevitably bring respect for rights. Instead, we have unaccountable government and pervasive corruption.

There is no single way to build rights-respecting societies. But if I were condemned to live under an abusive government, I'd prefer one that paid lip service to rights treaties it had signed — and thus could be shamed for falling short — to one that was bound only by its ambitions.

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Human Rights Treaties Are Expensive to Follow

Eric Posner 7:36 PM

I confess I do sympathize with the Chinese government though I do not think China needs development aid. As a result of the economic reforms pursued by the Chinese government since 1981, more than 600 million people have been raised from terrible poverty to a decent middle-income existence. This was one of the greatest humanitarian achievements of all time. The Chinese government also denied political rights to its citizens, and did not hide the reason. It feared political unrest — of the sort that killed and impoverished hundreds of millions of Chinese in civil war and social turmoil through most of the 20th century, and made China vulnerable to exploitation and military invasion from foreign countries.

This is not to say that the China model is right for us or for any other country. But it is too easy for people in the West to argue that China should have reformed the economy and introduced democracy, religious freedom, free speech, fair trials and all the rest. Just how much do we understand political and social conditions in China? While it is possible, even likely, that Chinese government officials suppress political freedoms to protect their power, we in the West just don't know whether the introduction of political freedoms — and if so, which ones, and how much, and over what period of time — would benefit the Chinese or hurt them.

In most developing countries, bureaucracies and courts are corrupt, slow and ineffectual. Cleaning them up comes at a cost that most countries can't afford.

What is true for China is also true for countless other countries, especially the poorest ones, which also can't afford most of the rights in the human rights treaties. Americans seem to think that rights are cheap, just a matter of the government doing the right thing. This is wrong. The right to a fair trial, for example, requires that a complex institutional infrastructure be in place — staffed by honest, well-paid, well-trained lawyers, judges, police officers, administrators and prison guards, who possess a sophisticated understanding of the law, moral norms and social conditions. In most developing countries, bureaucracies and courts are corrupt, slow and ineffectual. Cleaning them up means raising salaries, training people and enforcing anti-corruption laws — all at great cost that most countries can't afford.

The human rights treaties do not recognize that rights are expensive, both financially and politically; that different types of rights are easier to respect in different types of countries; and, therefore, that the right course of action that each government should follow differs radically. While many human rights scholars argue that for this reason we should only demand that governments respect certain "basic" rights that all can afford, it turns out that those basic rights are impossible to identify, which is why the human rights treaties guarantee hundreds of rights rather than just a few.

The release of the Senate committee report on C.I.A. torture should remind us how difficult it is, even for a rich country with strong liberal traditions, to respect rights. Torture violates the law in this country, and yet it happened anyway, at a massive scale. Foreign countries will reasonably ask: If Americans both hate torture and can't stop government officials from using it, how can we?

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No, They Are a Tool for Holding Governments to Account

Kenneth Roth 7:36 PM

Of course the institutions needed to protect rights require resources. But why does that mean we should abandon human rights treaties? Should people in poor countries have no rights? Should they stop pushing for investment in the necessary institutions even as their abusive leaders devote resources to self-preservation and personal enrichment?

And yes, rich countries, too, violate rights, as the C.I.A.'s torture illustrates. But that doesn't mean we should jettison all rights treaties; instead, we should redouble efforts to enforce them.

Eric blames "political rights" for the millions of Chinese who lost their lives to "political unrest" in the 20th century. But in fact millions lost their lives because of a lack of political rights, when the unaccountable Chinese Communist Party, which is still in power today, launched the Great Leap Forward and the Cultural Revolution. As in so many countries, the political unrest and violence came from government power unrestrained by rights.

China has signed many rights treaties and put human rights protections in its constitution, not because it is fond of these limits on its power, but because it needs to pretend to respect rights for legitimacy among its people.

Even now, the lack of government accountability in China means that, despite economic advances, the Chinese people still must endure land seizures, insufferable pollution, massive corruption and arrest if they complain. That's the problem with governments that don't respect rights. Some unaccountable leaders may rule with enlightenment, but many rule to keep power and pad their wallets, with whatever brutality it takes.

Eric portrays human rights mainly as a cudgel for Westerners to second-guess other governments, as if oppressed people have no role. I see rights foremost as a tool for people worldwide to hold their own governments to account. That's how Cao Shunli saw it — the activist who recently died in detention after China arrested her for trying to participate in the U.N. Human Rights Council's review of China's rights record. Or Liu Xiaobo, the Nobel Laureate serving an 11-year term in a Chinese prison for seeking greater democracy.

Even the Chinese government doesn't buy Eric's rejection of rights standards. It has signed many rights treaties and put human rights protections in its constitution — not because it is fond of these limits on its power, but because after the horrors it inflicted, it needs to pretend to respect rights for legitimacy among its people. Eric sees this hypocrisy as reason to rip up rights treaties, but increasing numbers of people in China see it as an opportunity to press their government to move from lip-service to reality.

The Chinese government is not immune to that pressure. In the last couple of years, it has curbed the death penalty, abolished re-education through labor, liberalized the one-child policy and started efforts to limit the use of torture for confessions. China still has a long way to go, but if the Chinese government isn't trying to shed its rights commitments, why should we?

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Change Has Come About Without Human Rights Treaties

Eric Posner 7:36 PM

Let's take a look at some actual treaties. The Convention against Torture bans torture and requires countries to prosecute torturers. The United States is hardly alone in violating these requirements. Governments in some 150 countries (out of about 193 U.N. members) use torture, not much different from when the treaty went into force in 1987.

The International Covenant on Civil and Political Rights guarantees the rights to political participation and right to be free from arbitrary law enforcement practices, among others. The treaty has been in effect since 1976, and 168 countries are parties. Yet, according to Freedom House, only 88 countries are "free," after eight straight years of decline. Russia, Turkey and Indonesia have become less free in recent years. Nine of the ten most authoritarian countries, including North Korea and Uzbekistan, have ratified the treaty.

The Convention on the Elimination of All Forms of Discrimination Against Women has been ratified by 188 countries (though not by the United States). Yet in virtually all countries of the world outside the West, laws and customs subordinate women. Notable parties of the treaty include Saudi Arabia (where women are prohibited from driving) and Egypt (where 97% of married women were found to have undergone genital cutting in 2000).

The International Covenant on Economic, Social and Cultural Rights -- which guarantees rights to work with fair pay, education, welfare and health care -- has been ratified by 162 countries. Nobody really knows what it means to guarantee these rights. Spain's unemployment rate is 24 percent, in part, because laws that ensure employees are well-paid and receive job security also deter employers from hiring them. Is Spain violating people's right to work or protecting it?

People don't need, and never have needed, the human rights treaties to criticize official abuse and incompetence.

I don't want to paint an excessively bleak picture. Many more countries are democracies than 40 years ago, thanks to the collapse of communism. Women have made enormous gains, and global poverty has declined significantly. But there is no evidence that the treaties have played a causal role in these developments.

The treaties themselves, understood in an impartial sense, are too vague to provide guidance to countries because they demand more than most countries can deliver. Consider, for example, the guest worker programs in the Gulf countries like Qatar and the United Arab Emirates. Human Rights Watch, Ken's organization, has heatedly criticized these programs because they deny guest workers some basic rights and many workers live in deplorable conditions. But the guest worker programs are incredibly beneficial because they enable desperately poor people from other countries to earn five or more times what they could make back home, much of which they send back to their families as remittances. The Gulf countries probably do more than any other country (on a per capita basis) to reduce global inequality.

The Gulf countries operate these guest worker systems only because they want cheap labor. Human Rights Watch's proposed reforms would raise the cost of labor, and so reduce the number of workers who benefit from the system. Would people really be better off as a result?

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Human Rights Treaties Have Made a Difference

Kenneth Roth 7:36 PM

The F.B.I. reported about 14,000 homicides and almost 80,000 rapes in the United States in 2013, yet no one suggests repealing the criminal prohibition of murder and rape. But because human rights violations persist in many countries, Eric would repeal human rights treaties. I still don't see his logic.

He claims that treaties are too vague and demanding to change governments' behavior, but I regularly find the opposite. The use of antipersonnel landmines and cluster munitions plummeted after treaties were adopted banning these indiscriminate weapons. Chile and Argentina cited human rights treaties to strike down military self-amnesties for mass atrocities and then convicted hundreds of people. Brazil followed treaty requirements to enhance punishment for domestic violence and permit regular prison visits against torture.

Kenya cited the women's rights treaty to grant women equal access to inheritances. Europe's human rights treaty led Britain to end corporal punishment in schools, Ireland to decriminalize homosexual acts, and France to grant detained people access to lawyers. A new labor treaty spurred an increased minimum wage, social security protections, and days off for domestic workers in parts of Asia and Africa. The South African Constitutional Court ruled that the right to health requires that people with HIV be granted access to anti-retroviral drugs, saving hundreds of thousands of lives. I could go on and on.

Treaties are effective even when courts are too weak to enforce them because they codify a public's views about how its government should behave.

Treaties are effective even when courts are too weak to enforce them because they codify a public's views about how its government should behave. Local rights groups, working with their international partners like Human Rights Watch, are able to generate pressure to respect these treaties by contrasting a government's treaty commitments with any practices that fall short. The shame generated can be a powerful inducement to change.

Eric cites the C.I.A.'s use of torture to suggest that the treaty banning it is worthless. But the C.I.A. claims (falsely) that it didn't torture, not that torturing people is O.K. Moreover, if not for the treaty, President Obama would be able to say he had done his duty by stopping the Bush administration's torture. Instead, he must fight pressure to abide by the treaty's requirement to prosecute the torturers. Senegal recently felt compelled to comply with that duty by initiating prosecution of Hissène Habré, the former Chadian dictator, whom it had long harbored in exile.

And the United States does change its conduct to respect treaty obligations. For example, the Pentagon stopped deploying 17-year-olds because of the treaty banning child soldiers. The Supreme Court cited the relevant treaty when it stopped the death penalty for youth offenders.

Eric argues that economic rights can be counterproductive if workers lose their jobs because enforcing labor rights might increase costs. That's hardly a risk in the Persian Gulf countries he mentions, which depend on migrant labor to run their economies and use regressive laws mainly to control their migrant workers. By his logic, we should accept the cheaper cost of slaves or bonded laborers to maximize employment, or the deaths of workers forced to labor in dangerous conditions because safe conditions would be too costly. Rather than acquiesce in such a race to the bottom, human rights groups in these countries prefer broad enforcement of the basic labor rights that treaties uphold.

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Room for Debate: Adulthood, Delayed or Forgone?

If you've been cooped up with relatives of a certain age this holiday season, you may have noticed that millennials are taking longer to finish school, achieve financial independence, marry and have children, compared with their parents' generation.

Are they being smart by delaying the rituals of adult life until they're more stable, or are they being irresponsible?

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Room for Debate: Keeping Only the Best Behaved

What Success Means

Richard D. Kahlenberg and Halley Potter, The Century Foundation

We must consider charter schools' suspension and expulsion rates when we evaluate their successes, especially when it comes to standardized testing.

Doing What's Best for Students Who Care

Michael J. Petrilli, Thomas B. Fordham Institute

Schools of choice, including charters, need not make compromises on discipline that lets learning flourish. That's a feature, not a bug.

Getting Results by Inspiring Students

Tim King, Urban Prep Academies

Our students succeed because they buy into a school culture based on respect and responsibility — not retribution.

High-Suspension Rates Don't Help Students

Luis Huerta, Teachers College

Policy makers should resist being seduced by achievement scores and, instead, hold charter schools accountable and aligned with the long-standing purpose of public schools.

Arbitrary Rules, Dire Consequences

Marilyn Rhames, charter school teacher

I have been appalled by the discipline policies of certain charter schools, which accept all students by lottery but then make it oh-so easy for troublesome kids to leave or get pushed out.

Cherry-Picking From Admission to Expulsion

Carol Burris, School principal

When students are pushed out or leave their charter school, they enter the public schools discouraged and further behind.

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Room for Debate: If Israel Turns Right, Where Will It End Up?

Prime Minister Benjamin Netanyahu has ousted the two most prominent centrist ministers from his government. With new elections slated for March, he appears ready to form a government of rightist allies and religious parties. Does the prospect of a purely rightist government show how much Israel has changed? Could the coming elections transform Israel's future, it's place in the world and chances for peace?

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Room for Debate: The Possibility of Post-Election Bipartisan Deals

After a sweeping Republican victory on Tuesday that gave control of the House and Senate to Republicans, President Obama and Mitch McConnell, the presumptive majority leader of the next Senate, both spoke of working together, even as Congressional Republicans vowed to push a vigorous agenda.

Given the contentious relationship for the past six years, are their any legislative deals that President Obama and the new Congress can make?

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Room for Debate: Should Voting Be a Constitutional Right?

The midterm elections on Tuesday are the first since the Supreme Court, in Shelby County v. Holder, ended federal oversight of electoral changes in areas with a history of racial discrimination, and permitted laws in several states increasing requirements for voter identification, supposedly to limit fraud. Critics have said these measures disenfranchise legitimate voters and disproportionately burden poor, minority voters.

Some say a constitutional amendment is needed to clearly establish a right to vote, and fend off efforts that inhibit and restrict voting. Is that necessary? Would it be effective?

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Room for Debate: Trick-or-Treating for a Purpose

The Beauty of Going Local

Andy Hinds, blogger

When families do Commuter Halloween, they miss a great opportunity for community bonding.

Come Trick-or-Treat at My Big House

Sarah Werthan Buttenwieser, blogger

On Halloween, big houses should give plenty of candy to all trick-or-treat goers, no matter how old they are or where they live.

A Give-and-Take Tradition

Nick Rogers, historian

The original threshold encounter on the eve of All Saints was for poor people to come to the door to pray for the recently departed in return for victuals and ale.

Halloween Can Build a Bridge Across Communities

Imani Perry, Princeton University

Children, if no one else, ought to have an opportunity to cross the tracks.

The Problem with Candy Mania

Samira Kawash, author, "Candy: A Century of Panic and Pleasure"

Kids need to have more freedom to explore and make mistakes, more room to roam unsupervised and maybe even get in trouble.

Let Halloween Be the Weird Holiday That It Is

Karen Karbo, novelist and memoirist

Trick-or-treat is basically a celebration of extortion and I see no reason to rehabilitate it into a noble community event.

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Opinionator | The Stone: Dreamboat Vampires and Zombie Capitalists

Photo Alexander Skarsgard, who played the vampire Eric Northman in "True Blood," left, and a zombie from "The Walking Dead."Credit Left, Lacey Terrell/HBO; Greg Nicotero/AMC

If popularity on television and movie screens is any indication, a good number of the costumed ghouls knocking on our doors this October 31 will be the modern West's two preferred trespassers from the afterlife — vampires and zombies. At first blush, these nightmarish cousins couldn't be further apart. Vampires — which have been with us in their current form at least since the Industrial Revolution — are fast, sexy, cunning and imperishable. They are sleek nocturnal hunters, and even in the violence of the kill they can be depicted as elegant, like great cats. Zombies — not the Afro-Caribbean variety, controlled by a shaman, but the mindless, flesh-eating dead injected into American popular culture by the filmmaker George Romero with his 1968 film, "Night of the Living Dead" — are most often the opposite: slow, mindless, shambling, putrid excrescences in a state of perpetual decay. Vampires represent a kind of higher place on the food chain — one could at least imagine wanting to become a vampire; the current vogue of carnival-like zombie walks notwithstanding, we can safely assume that no one would want to become a zombie.

The Stone is a forum for contemporary philosophers and other thinkers on issues both timely and timeless.

Nevertheless, beyond their obvious differences lies a common core, one that stems from a universal ambivalence that humans, condemned to know they will die, share toward what Shakespeare called "the dark backward and abysm of time." On the one hand, the dead, while dear to us, lose their human aspect and in their physical existence take on the repulsive quality of decay; on the other, we yearn for and project something eternal, unchanging, an animate presence that we refuse to surrender to the degeneration of time.

That humans live simultaneously real, physical lives and symbolic, meaningful existences means that they must die not once, but twice. As the French psychoanalyst Jacques Lacan wrote, it is possible in the human imagination for these two deaths, one symbolic and one real, to not entirely coincide. In such cases we enter a peculiar state, one he called "entre deux morts" — or between two deaths.

Those whose symbolic selves die while their bodies still live attain a kind of extra-worldly beauty. Lacan identified Sophocles' great character Antigone with this state — condemned to death by Creon for having defied the state's law by burying her treasonous brother, she burns with a righteous splendor that puts to shame Creon's pathetic attachment to the state's laws.

Those whose bodies die while their symbolic selves linger constitute an entirely different breed. Chained by a law or obligation to an animate state their bodies can no longer support, such beings become monstrous specters, condemned to walk the earth as embodiments of some insatiable hunger.

It is not too difficult to see in these two archetypes our modern vampires and zombies, the former "radiating a sublime beauty," in Lacan's words, the latter monstrous excrescences driven on by a fundamental imbalance in the world of men.

The image of the uncannily beautiful vampire has become familiar enough to cross over into teenage fantasies, starting with the popular TV show "Buffy the Vampire Slayer," and continuing with the hit series "The Vampire Diaries" and the "Twilight" book and movie phenomenon. In these, as well as in adult-oriented novels, movies and TV series — such as Anne Rice's "The Vampire Chronicles" and their film adaptations, and the series "True Blood" and "Dracula" — vampires and humans are sometimes difficult to distinguish from one another. Vampires are often "humanized" in these pop culture blockbusters. In the case of "True Blood," it's more the case that humanity is "vampirized"; that is, humans are represented as vampire-like monsters just as likely to prey on the vampires as the vampires are to prey on them.

"True Blood" goes furthest in projecting a fantasy world in which vampires and humans may coexist, thanks in part to the mass-production of a synthetic blood substitute for vampire consumption. The availability of this nutritional product allows some vampires to "come out of the casket." Indeed, the show makes no attempt to hide that it is in part an allegory of conservative entrenchment in the face of the liberalization of sexual morality and the mainstreaming of gay life. As the billboard featured prominently in the credit sequence screams, "God hates fangs."

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More From The Stone

Read previous contributions to this series.

It is hardly surprising that vampires continue to evolve in ways that mirror psychosexual anxieties. As children of the romantic age of horror, they are bound to the compulsive cycle of sin and punishment that is characteristic of the tradition of gothic horror. Yet there is another dimension of the repressed that has marked the figure of the modern vampire since its Victorian incarnation in Bram Stoker's "Dracula": namely the economic repressed that Karl Marx remarked upon when he spoke of the monstrous face of capitalism as a vampire-like machine, "a circulating thing which gains its energy only by preying upon 'living labor.'"

In fact, the Marxist identification of the vampire with the predatory practices of capital has proved to be as enduring as the undead monster himself. Among recent literary offerings, Seth Grahame-Smith takes the association of the vampire with blood-draining sociopolitical practices in the direction of traditional slavery in "Abraham Lincoln, Vampire Hunter" (2010), while Guillermo del Toro and Chuck Hogan refocus the lens to reveal the vampire monster in the figure of the cunning capitalist in the "Strain" trilogy and its TV spinoff. Remarkably, "The Strain" features "blood factories" dedicated to the "efficient extraction and packaging of human blood."

While the vampire continues to haunt our modern imagination, it may fall to its less attractive brethren to claim the title of the perfect monster for the age of globalization, sometimes called the age of the post-human. In effect, the anonymous zombie crowds pack into one moving bundle everything monstrous and terrifying about a global economic machine that leaves nothing but lifeless bodies and undead remnants in its wake. In late capitalism, the German philosopher Niklas Luhmann once wrote, the scandal is not class exploitation but the uncountable masses of people who are born not even to be exploited, but just to die:

If we look at the huge masses of starving people, deprived of all necessities for a decent human life, without access to any of the function systems, or if we consider all the human bodies, struggling to survive the next day, neither "exploitation" nor "suppression" — terms that refer… to stratification — are adequate descriptions. It is only by habit and by ideological distortion that we use these terms. But there is nothing to exploit in the favelas.

"Human debris," Rush Limbaugh sneered at the Occupy Wall Street protesters, by which he meant to imply that they were simply unemployed; like zombies, they were bodies without a purpose.

If the modern vampire may have functioned as an apt metaphor for the predatory practices of capital in colonial and post-colonial societies, today's zombie hordes may best express our anxieties about capitalism's apparently inevitable byproducts: the legions of mindless, soulless consumers who sustain its endless production, and the masses of "human debris" who are left to survive the ravages of its poisoned waste.

Perhaps our fixation with images of the zombie apocalypse is ultimately tied to the conviction that there is no possible alternative to capitalism as a worldwide economic system, paired with the realization that the logical evolution of global capitalism leads to nothing but destruction. As the philosopher Slavoj Zizek has said of our love of films depicting cataclysms of Earth-threatening proportions, we have come to a time when "it's much easier to imagine the end of all life on Earth than a much more modest radical change in capitalism."

So as the vampires and zombies creep out of our screens and up to our doorsteps on Halloween night, we should recall what one survivor says to the others in Romero's "Dawn of the Dead," as they stare out in terror at the advancing zombie hordes approaching the shopping mall where they have taken refuge: "They are us!"

David Castillo is a professor and chairman of romance languages and literatures at the State University of New York at Buffalo. William Egginton is the Andrew W. Mellon Professor in the Humanities at the Johns Hopkins University. They are currently writing a book on the media and the crisis of reality.

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Room for Debate: Keeping Up Appearances

Many thought Renee Zellweger was unrecognizable when she appeared at an event on Monday night. She's attributed her transformation to "living a different, happy, more fulfilling life." But others saw evidence of plastic surgery — the kind Joan Rivers frequently joked about — and questioned the drive for eternal youth.

Has the use of plastic surgery gone too far? What does it mean (or take) to age gracefully, especially in the public eye?

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Opinionator | The Conversation: What Would Edmund Burke Say?

In The Conversation, David Brooks and Gail Collins talk between columns every Wednesday.

David Brooks: Gail, as you know I have a policy of teaching at colleges I couldn't have gotten into, and as a result I find myself teaching at Yale.

Gail Collins: I didn't go to Yale either. But I spent the '70s living in New Haven. Does that count for anything?

David: I just got out of a class in which we discussed Edmund Burke's "Reflections on the Revolution in France." As you may know, this book changed my life. I began reading it as a big lefty and I loathed Burke. But over the years, I came to see wisdom in it. Have there been big books like that for you, which had a pivotal effect on your thinking?

Gail: When I was in high school, I decided I needed to read the work of a great mind on the subject of politics. I picked Dwight D. Eisenhower's "Mandate for Change" because at the time I believed that all presidents were deep thinkers.

Carried that sucker around for six months. Read every page. There wasn't much philosophy, but I did learn that if we lost Vietnam we would forgo an important source of tin.

I believe this had a crippling effect on my ability to appreciate genuine political philosophy when it was thrust upon me in later life. And I want to say how impressed I am that after reading "Reflections on the Revolution in France" and not liking it, your response was to read it again.

David: Burke is famous for his belief in gradual change. He didn't believe in revolutionary change because he thought that society was too complicated to be planned through reason and remade according to that plan. My students were divided on this. Some saw wisdom in this modesty, pointing to failed efforts to remake societies, ranging from the war in Iraq to the Russian revolution. Others pointed out that most systems are constructed by those in power for those in power. If you don't have radical change, you just allow entrenched privilege to stay in power forever.

Did you ever go through a revolutionary phase? Are you still in one?

Gail: When I was in college and graduate school I hung around with a lot of people who believed that revolution was both necessary and inevitable. That was less because I agreed than because I felt they were much nicer than the folks who believed things were just peachy the way they were.

David: Burke is known as the founder of conservatism, but his thought sits oddly these days with the Republican Party and those who call themselves conservative. The party has become much more populist, supporting term limits and political outsiders over those who have been educated by experience. Most call for pretty radical change to the welfare state. It's the Democrats who fight to preserve the current structures of Social Security, Medicare and food stamps. It's the Democrats who have been running ads through this election campaign accusing their opponents of being a bunch of wild-eyed radicals. Are Democrats now the conservators of tradition?

Gail: The difference between the two parties is about empty places versus crowded places. You have heard me say this before – it's my long-standing theory, which takes the place of a political philosophy.

People who perceive the world as a crowded place believe that government has a very important role to play. They see it in action every day – enforcing the law, directing traffic, removing garbage and providing clean water. They're also likely to witness the inequality of the world and they want government to at least make the divisions less painful.

The current crop of Republicans, especially the Tea Party types, see the world as an empty place, where people can take care of themselves and government exists only to levy taxes and get in their way. Given the fact that the country is becoming increasingly crowded, I don't think you can define that as a message of change.

David: I do think Republicans are seen as the party of change this election. My sense is that in state after state, polls are swinging their way. The peculiarities of each candidate matter a bit less and the national tide is mattering a bit more. I'd now guess that the G.O.P. will pick up seven or eight Senate seats. It's just hard to be a Democrat in a red state or a Republican in a blue state. Do you have a different read on the trends?

Gail: I suspect you may be right about the outcome. The Democrats are in trouble in states where a large number of people either live in empty places or tell themselves they do. There's a lot of delusion in this game – we've all seen the guy who lives on Social Security and depends on Medicare for his visits to the doctor, yelling that he wants government off his back.

David: I'm not sure either party has an agenda.

Gail: You don't think announcing that terrorists are infecting themselves with Ebola and crossing the Mexican border is an agenda?

David: As you know I've been depressed by the vacuousness of the campaign.

Gail: Me too. Another one of my theories is that politics is at its worst when the country is almost evenly divided and each party thinks it can win if it just avoids saying anything.

David: But people do believe that things are pretty seriously off track, and so of course they are going to register some protest. Peter Wehner had a piece on the Commentary website that nicely sketched out how much the fundamentals favor the party out of power. It was called "America's Anxious Mood and What It Means for Republicans."

Wehner pointed to the drop in median household income, the fact that income inequality is nearing its highest levels in 100 years, the fact that the poverty rate has stood at 15 percent for three consecutive years (the first time that has happened since the mid-1960s), the fact that a record number of people are now on food stamps and the fact that only a quarter of people think the country is on the right track.

I sort of agree that Republican proposals on what to do about all this are less than, er, fully developed, and have not been fully explained. But isn't it an indictment of the Obama administration that it has made so little progress even on, say, reducing the poverty rate?

Gail: Well, Obama did run on the argument that our biggest problem was too much partisanship in Washington, and that he'd cure that by being less partisan. So I guess you could blame him for the fact that that definitely did not work.

I give Obama credit for the fact that we've gotten out of the recession, which never would have happened if the Republicans had their way. I guess I blame him for not actually being the kind of great communicator we needed to explain that the keys to reducing inequality lie in more government spending and higher taxes on the wealthy.

David: Wehner also points out that two-thirds of Americans think it is harder to reach the American dream, and three-quarters think it will be harder for their children and grandchildren to succeed. Of course they're going to favor the party out of power in such conditions.

Gail: Yes, and we may just keep switching parties without ever resolving anything.

David: All of this may be reason for some sort of radical change — maybe a Rand Paul type change or an Elizabeth Warren type change.

Gail: Ah, Rand Paul. What this country needs is a libertarian who believes the government has no right to control anything except women's reproductive systems.

David: If I was 25 I wonder if I'd be a radical libertarian or even a Marxist on the ground that a country that has been on the wrong track for so long needs a sharp kick in the pants.

Gail: This is possible. I'd say a 25-year-old who reads a lot of political philosophy is capable of anything.

David: But I'm sticking to my Burkean roots. Change should be steady, constant and slow. Society has structural problems, but they have to be reformed by working with existing materials, not sweeping them away in a vain hope for instant transformation. My only fear is that if I keep thinking this way I'll end up voting for Hillary Clinton, who will be the most conservative candidate from the party of the status quo.

Gail: Tee-hee.

David: That can't be right.

Gail: No, but I'm sure Hillary will be happy to accept your vote anyway.

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Room for Debate: Who Needs Football?

The recent scandal in which a New Jersey high school cancelled its football season after seven varsity players were charged with hazing and sexually assaulting younger players, has led to more scrutiny about football and youth sports.

Have competitive teenage athletics gotten out of hand? Should high schools eliminate their sports teams?

Read the Discussion »

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Opinionator | The Stone: The Reign of ‘Terror’

The Stone is a forum for contemporary philosophers and other thinkers on issues both timely and timeless.

When President Barack Obama spoke to the public in September about his decision to use American military force against the Islamic State in Iraq and Syria he used familiar language. ISIS (or ISIL as the White House and others refer to the group), the president said, "is a terrorist organization, pure and simple. And it has no vision other than the slaughter of all who stand in its way." The man picked to manage Obama's strategy, General John R. Allen, wrote in the publication Defense One that "the Islamic State is an entity beyond the pale of humanity and it must be eradicated."

The powerful rhetoric centered on the word "terrorism" makes it difficult to speak intelligently about its real sources.

It is undeniable that many of the tactics being used by ISIS — executions of civilians and well publicized beheadings of hostages — do violate accepted standards of conduct in conflict (detailed in an evolving legal and philosophical code known as just war theory.) And understandably, those moved by language of the sort used by the president and his staff are in no mood to consider softer tactics like negotiation with ISIS, nor to ponder the complex causes contributing to its rise. Obama's stated policy of removing the "cancer" threatening the established political order in the Middle East is already underway, and is facing little resistance.

This is merely the latest example of a powerful rhetoric centered on the word "terrorism" that has shaped — and continues to shape — popular conceptions about contemporary political conflicts, making it difficult to speak intelligently about their real sources.

If individuals and groups are portrayed as irrational, barbaric, and beyond the pale of negotiation and compromise, as this rhetoric would have it, then asking why they resort to terrorism is viewed as pointless, needlessly accommodating, or, at best, mere pathological curiosity. Those normally inclined to ask "Why?" are in danger of being labeled "soft" on terrorism, while the more militant use the "terrorist" label to blur the distinction between critical examination and appeasement.

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Part of the success of this rhetoric traces to the fact that there is no consensus about the meaning of "terrorism." While it is typically understood to mean politically motivated violence directed against civilians, the Federal Bureau of Investigation and the Department of Defense, for example, describe terrorism as the unlawful use of violence to achieve political goals by coercing governments or societies. The State Department cites a legal definition of "terrorism" as "premeditated, politically motivated violence perpetrated against noncombatant targets by sub-national groups or clandestine agents." It adds: "The term 'noncombatant' is interpreted to include, in addition to civilians, military personnel who at the time of the incident are unarmed or not on duty." Thus, by means of linguistic gerrymander, members of uniformed government military forces acting under government authorization are incapable of committing acts of terrorism no matter how many civilians are ground up in the process.

When violent political groups like ISIS are labeled as irrational and barbaric, asking why they resort to terrorism becomes pointless.

Even when a definition is agreed upon, the rhetoric of "terror" is applied both selectively and inconsistently. In the mainstream American media, the "terrorist" label is usually reserved for those opposed to the policies of the U.S. and its allies. By contrast, some acts of violence that constitute terrorism under most definitions are not identified as such — for instance, the massacre of over 2000 Palestinian civilians in the Beirut refugee camps in 1982 or the killings of more than 3000 civilians in Nicaragua by "contra" rebels during the 1980s, or the genocide that took the lives of at least a half million Rwandans in 1994. At the opposite end of the spectrum, some actions that do not qualify as terrorism are labeled as such — that would include attacks by Hamas, Hezbollah or ISIS, for instance, against uniformed soldiers on duty.

Historically, the rhetoric of terror has been used by those in power not only to sway public opinion, but to direct attention away their own acts of terror. Yet, to the fair-minded, the attempt by governments to justify bombardment of residential districts, schools and hospitals in the name of fighting terrorism is outright hypocrisy. Government forces have long provided outstanding examples of politically-motivated violence against civilians, the very thing they allegedly oppose. Claims about not "targeting" civilians ring hollow when it is quite obvious that high-tech explosives are aimed at buildings known to contain civilians.

If what is insidious about terrorism is its callous disregard for civilian lives in pursuit of political goals, why is there not an uproar about state terrorism? Why do so many reserve their venom for people whose destructive capacity pales in comparison with those who command tanks, artillery and warplanes?

It is easy to lose sight of inconsistencies in wartime hostilities. Instead, the emotional impact of language tends to triumph at the expense of accuracy and fairness. By effectively placing designated individuals or groups outside the norms of acceptable social and political behavior, the rhetoric of "terror" has had these effects:

1) It erases any incentive the public might have to understand the nature and origins of their grievances so that the possible legitimacy of their demands will not be raised.

2) It deflects attention away from one's own policies that might have contributed to their grievances.

3) It repudiates any calls for negotiation.

4) It obliterates the distinction between national liberation movements and fringe fanatics (for example, during the 1990s, the "terrorist" label was applied to Nelson Mandela and Timothy McVeigh alike);

5) It paves the way for the use of force by making it easier for a government to exploit the fears of its citizens and ignore objections to the manner in which it responds to terrorist violence.

This is not just a strategy of the United States government. For decades, Israeli leaders have used such language in their attempt to discredit Palestinian nationalism and deflect attention away from their own policies in the occupied territories. In the 1986 book "Terrorism: How the West Can Win," Benjamin Netanyahu, the book's editor, who is now Israel's prime minister, encouraged pre-emptive strikes "to weaken and destroy the terrorist's ability to consistently launch attacks," even at the "risk of civilian casualties." Addressing the origins of terrorism, he surmised that "the root cause of terrorism lies not in grievances but in a disposition toward unbridled violence" traceable to "a worldview that asserts that certain ideological and religious goals justify, indeed demand, the shedding of all moral inhibitions." Other contributors to the volume voiced similar sentiments in portraying the terrorist as a carrier of "oppression and enslavement," having "no moral sense," "a perfect nihilist," and whose elimination is the only rational means for the West to "win."

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More From The Stone

Read previous contributions to this series.

More careful assessments were made by scholars like Robert Pape of the University of Chicago, who has stressed that foreign military interventions and nationalism are the primary causes of terrorist violence. In his book "Dying to Win: The Strategic Logic of Suicide Terrorism," Pape argued that desires for national self-determination and an end to military occupation were at the root of nearly every instance of suicide terrorism from 1980 to 2003, and that while religion was used a tool for recruiting and procuring aid from abroad, it was rarely the cause. While some took issue with Pape's analysis, he at least employed a more dispassionate, analytical approach in attempting to understand this form of violence.

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Obviously, to point out the causes and objectives of particular terrorist actions is to imply nothing about their legitimacy — that is an independent matter — nor is it any endorsement of a particular method for dealing with the problem of terrorist violence. Yet, to ignore these causes and objectives is to undermine attempts to deal intelligently with terrorism, since it leaves untouched its motivating factors, and paves the way for blind reactions of the sort that are likely to exacerbate rather than resolve the problem.

To put it bluntly, by stifling inquiry into causes, the rhetoric of "terror" actually increases the likelihood of terrorism. First, it magnifies the effect of terrorist actions by heightening the fear among the target population. If we demonize the terrorists, if we portray them as evil, irrational beings devoid of a moral sense, we amplify the fear and alarm generated by terrorist incidents, even when this is one of the political objectives of the perpetrators. In addition, stricter security measures often appear on the home front, including enhanced surveillance and an increasing militarization of local police.

Second, those who succumb to the rhetoric contribute to the cycle of revenge and retaliation by endorsing military actions that grievously harm the populations among whom terrorists live. The consequence is that civilians, those least protected, become the principle victims of "retaliation" or "counterterrorism."

Having been desensitized by language, the willingness to risk civilian casualties becomes increasingly widespread. For example, according to a CBS/New York Times poll of 1216 Americans published on September 16, 2001, nearly 60 percent of those polled supported the use of military force against terrorists even if "many thousands of innocent civilians may be killed," an echo of the view taken by Netanyahu in his book.

Third, a violent response is likely to stiffen the resolve of those from whose ranks terrorists have emerged, leading them to regard their foes as people who cannot be reasoned with, as people who, because they avail themselves so readily of the rhetoric of "terror," know only the language of force. As long as groups perceive themselves to be victims of intolerable injustices and view their oppressors as unwilling to arrive at an acceptable compromise, they are likely to answer violence with more violence. Their reaction might be strategic, if directed against civilians to achieve a particular political objective, but, with the oppression unabated, it increasingly becomes the retaliatory violence of despair and revenge.

In "1984," George Orwell described doublethink as "the power of holding two contradictory beliefs in one's mind simultaneously, and accepting both of them," and portrayed it as a device for destroying the capacity for critical thinking, for controlling populations, and for perpetuating the political status quo. Something like doublethink is occurring as the rhetoric of terror continues to immerse us in a nightmare of skewed reason and perpetual warfare. In condemning terrorism, we think of it as something to be eliminated at all costs. Yet, in sanctioning the use of modern weaponry to achieve this end, regardless of its impact upon civilian populations, we are effectively advocating the very thing we condemn, and this is closer to doublethink than we should ever wish to be.

Tomis Kapitan is a professor emeritus at Northern Illinois University. He is the author of papers in metaphysics, the philosophy of language and international ethics, and the co-author of "The Israeli-Palestinian Conflict: Philosophical Essays on Self-Determination, Terrorism, and the One-State Solution."

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Opinionator | Draft: What Union Soldiers Thought About the Civil War

Disunion follows the Civil War as it unfolded.

Several years ago, a thick sheaf of Civil War letters was discovered in an old barn in upstate New York. Most were sent by a Union soldier, Charles Freeman Biddlecom, to his wife, the former Esther Lapham. Now edited and published by Katherine M. Aldridge, who owns the barn, they provide a remarkably candid window into the outlook of an ordinary infantryman. They also caution us against exaggerating the affinity of common soldiers for the great causes — the Union and emancipation — that we now hold in such high regard.

Today we often remember Union soldiers as principled, articulate and ready to sacrifice their lives for something larger. The historians James McPherson and Chandra Manning each have written influential recent volumes articulating soldiers' views: McPherson's Union soldiers were "intensely aware of the issues at stake and passionately concerned about them"; they knew that they were playing roles in a transcendently important struggle, on which the future of the American nation would pivot. Likewise, the "commitment to emancipation" among Manning's Union soldiers deepened and intensified as the war progressed. For them, "ideals like liberty, equality, and self-government" were not empty abstractions but core principles worth fighting to uphold.

The filmmaker Ken Burns spearheaded this heroic reassessment with his widely watched public television series on the Civil War in the early 1990s. Most memorably, Burns used the emotionally charged letter to "My very dear Sarah" from a Rhode Island infantryman, Sullivan Ballou, written in July 1861 just before the battle of Bull Run. Much as Ballou wanted to return to his loved ones unharmed and to see his sons grow to "honorable manhood," he gave ultimate priority to his country. He and his generation owed a great debt to "those who went before us through the blood and sufferings of the Revolution." He was "willing — perfectly willing — to lay down all my joys in this life, to help maintain this Government, and to pay that debt." Untold millions of television viewers, alerted that Ballou's iconic letter was his last, have listened intently to its dramatic rereading, complete with stringed instruments in the background, tugging at our heartstrings.

Ballou's noble and stoic valedictory makes for splendid theater, but the messy realities of war swept into the Army countless men whose commitment to big causes was far more muddled and erratic – men like Charles Biddlecom, who lived as a farmer in Macedon, N.Y., just east of Rochester.

On the face of it, Biddlecom might have been a promising candidate for Burns's honor roll. He was educated, he wrote vivid prose, he was older than the average (born in 1832) and he came from a region where slavery was deplored and enthusiasm for reform was widespread. So one might expect Biddlecom to have embraced the Union cause for all the right reasons. But in his letters, we find that he saw no purpose in the war and considered himself a helpless pawn in an enormous kill-or-be-killed chess match.

Biddlecom first enlisted in May 1861, as a volunteer in the 28th New York Infantry. Suspecting that the "fuss" soon would be over, he wanted to rout the "southern whelps." But his health deteriorated, and he was discharged before he saw combat.

Two years later, however, in the summer of 1863, Biddlecom was called back. The war had grown to proportions unimaginable in 1861. He and many other "poor forsaken conscripts" were assigned to rebuild the depleted ranks of the 147th New York, which had been decimated on the first day at Gettysburg. The re-formed regiment was stationed in a dismal part of Northern Virginia, already scarred by three years of warfare.

As the army went into winter quarters, Biddlecom was sickened by dysentery, afflicted by lice and miserably lonesome and homesick. He and three other men lived in a "little dog kennel," about four feet high. In his darker moments he predicted cynically that the war would grind on inconclusively for 20 years, because "Lincoln and his miserable crew" could never bring it to a successful finish. Biddlecom also second-guessed the decision to go to war in the first place. Much as he hated slaveholders, he mused that it might have been "better in the end to have let the South go out peaceably and tried her hand at making a nation."

Biddlecom longed to go home to rejoin his family. Some men, he observed, had been discharged who were "not a bit more disabled than I am," and he vowed to follow their example. By spring, as the prospect of renewed fighting came closer, the trickle of deserters fleeing into the nearby mountains from the 147th increased. Most nights two or three men quietly absconded to join the euphemistic "Blue Ridge Corps," and Biddlecom predicted that the regiment stood to lose 150 men. In some ways he sympathized with the deserters — he agreed that no conscript should have to serve longer than nine months — but he could not see himself "sneaking off."

In early May 1864, Biddlecom and his regiment were thrown across the Rapidan River into the terrifying caldron of Ulysses S. Grant's Overland Campaign. Ten days of fighting in the Wilderness and at Spotsylvania left his division "terribly cut up," with half his own company killed or wounded, and others missing. By early June, barely 100 of the 550 men in his regiment who had started the campaign remained fit for duty.

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Disunion Highlights

Explore multimedia from the series and navigate through past posts, as well as photos and articles from the Times archive.

Biddlecom initially hoped that Grant could bring the war to a prompt end, but six weeks of inconclusive bloodletting rekindled his cynicism. He dismissed as "bosh" all talk about "great Union victories." Reports about the "pluck and courage" of the Union Army were "the worst kind of exaggeration." The Army was "worn out, discouraged, [and] demoralized." He admonished his wife, Esther, to reject "newspaper hokum" that depicted ordinary soldiers as patriotic. Men would fight to preserve their reputations, but "as for men fighting from pure love of country, I think them as few as white blackbirds."

What motivated Biddlecom to continue fighting? Certainly not the high ideals depicted McPherson or Manning. It was in part personal. Convinced that he was the "black sheep" of his family and that most of his kinfolk "never gave me credit for being much of a man," he carried a chip on his shoulder. He wanted to make it clear that he was "not an absolute failure in all things." He was determined not to disgrace his parents or stigmatize his sons by "showing cowardice." But, he insisted, he was neither a "Union Saver" nor a "freedom shrieker." He rejected all high-flown rationalizations for the war effort — "to hell with the devilish twaddle about freedom."

As late as August 1864, Biddlecom believed that the men in the Army would vote "four to one" against Lincoln. He resolved to support the president's opponent, George B. McClellan, on grounds that wasting "more blood and treasure in this war will be productive of more evil to the white race than it will be of good to the black race." He was content to allow slavery to "die a peaceful death," even if it required 50 or 100 years.

As Union prospects brightened and the election approached, however, Biddlecom reversed himself and spurned the "copperhead ticket." Suddenly, the soldier who was no "freedom shrieker" embraced the war "for freedom, [and] for equal rights." On Election Day in November he sounded entirely unlike his old self, as he pontificated that the contest would decide "the future of American civilization." It pitted "Lincoln and the universal rights of man" against "McClellan and another compromise with the Devil." He heralded the outcome for affirming that "freedom shall extend over the whole nation." The "greatest nation of Earth" would not bow down to "traitors in arms."

So Biddlecom's pithy letters convey a mixed message. Until the autumn of 1864, he disdained all ideological rationalizations for the Union war effort. But he also was a team player, and his team appears to have broken strongly toward Lincoln. The army, he decided, was "a very good school for hot heads such as I was." Home influences may also have played a role — after all, the men in his regiment came from one of the most intensely Republican regions in the country.

The patriotic prose that Charles Biddlecom penned in November 1864 would have delighted Ken Burns. But we dare not forget the long and circuitous journey that finally landed him among the charmed circle of those Union soldiers whose ideas square with modern sensibilities.

Follow Disunion at twitter.com/NYTcivilwar or join us on Facebook.

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Sources: Katherine M. Aldridge, ed., "No Freedom Shrieker: The Civil War Letters of Union Soldier Charles Biddlecom"; James McPherson, "For Cause and Comrades: Why Men Fought in the Civil War"; Chandra Manning, "When This Cruel War Was Over: Soldiers, Slavery, and the Civil War."

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Daniel W. Crofts, a professor emeritus of history at The College of New Jersey, is completing a new book, entitled "Lincoln's Other Thirteenth Amendment: Rewriting the Constitution to Conciliate the Slave South."

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Opinionator | Couch: Why Doctors Need Stories

Couch is a series about psychotherapy.

A FEW weeks ago, I received an email from the Danish psychiatrist Per Bech that had an unexpected attachment: a story about a patient. I have been writing a book about antidepressants — how well they work and how we know. Dr. Bech is an innovator in clinical psychometrics, the science of measuring change in conditions like depression. Generally, he forwards material about statistics.

Now he had shared a recently published case vignette. It concerned a man hospitalized at age 30 in 1954 for what today we call severe panic attacks. The treatment, which included "narcoanalysis" (interviewing aided by a "truth serum"), afforded no relief. On discharge, the man turned to alcohol. Later, when sober again, he endured increasing phobias, depression and social isolation.

Four decades later, in 1995, suicidal thoughts brought this anxious man back into the psychiatric system, at age 70. For the first time, he was put on an antidepressant, Zoloft. Six weeks out, both the panic attacks and the depression were gone. He resumed work, entered into a social life and remained well for the next 19 years — until his death.

If the narrative was striking, so was its inclusion in a medical journal. In the past 20 years, clinical vignettes have lost their standing. For a variety of reasons, including a heightened awareness of medical error and a focus on cost cutting, we have entered an era in which a narrow, demanding version of evidence-based medicine prevails. As a writer who likes to tell stories, I've been made painfully aware of the shift. The inclusion of a single anecdote in a research overview can lead to a reprimand, for reliance on storytelling.

My own view is that we need storytelling in medicine, need it for any number of reasons.

Repeatedly, I have been surprised by the impact that even lightly sketched case histories can have on readers. In my book "Listening to Prozac," I wrote about personality and how it might change on medication. "Should You Leave?" concerned theories of intimacy. Readers, however, often used the books for a different purpose: identifying depression. Regularly, I received — and still receive — phone calls: "My husband is just like — " one or another figure from a clinical example. For a decade and more, public health campaigns had circulated symptom lists meant to get people to recognize mood disorders, and still there remained a role for narrative to complete the job.

Other readers wrote to say that they'd recognized themselves. Seeing that they were not alone gave them hope. Encouragement is another benefit of case description, familiar to us in this age of memoir.

But vignettes can do more than illustrate and reassure. They convey what doctors see and hear, and those reports can set a research agenda.

Consider my experience prescribing Prozac. When it was introduced, certain of my patients, as they recovered from their depression or obsessionality, made note of personality effects. These patients said that, in responding to treatment, they had become "myself at last" or "better than baseline" — often, less socially withdrawn. I presented these examples first in essays for psychiatrists and then in my book, where I surrounded the narrative material with accounts of research. (Findings in cell biology, animal ethology and personality theory suggested that such antidepressants, which altered the way the brain handled serotonin, might increase assertiveness.)

My loosely buttressed descriptions — and colleagues' similar observations — led in time to controlled trials that confirmed the "better than well" phenomenon. (One study of depressed patients found that Paxil drastically decreased their "neuroticism," or emotional instability. Patients who became "better than well" appeared to gain extra protection from further bouts of mood disorder.) But doctors had not waited for controlled trials. In advance, the better-than-well hypothesis had served as a tentative fact. Treating depression, colleagues looked out for personality change, even aimed for it. Because clinical observations often do pan out, they serve as low-level evidence — especially if they jibe with what basic science suggests is likely.

To be sure, this approach, giving weight to the combination of doctors' experience and biological plausibility, stands somewhat in conflict with the principles of evidence-based medicine. The movement's manifesto, published in the Journal of the American Medical Association in 1992, proclaimed a new era that would see near-exclusive reliance on systematic clinical research — the direct assessment of treatments in patients. But even the manifesto conceded that less formal expertise would remain important in areas of practice that had not been subject to high-level testing.

THAT concession covers much of the territory. Making decisions about prescribing, often I exhaust the guidance that trials can give — and then I consult experts who tell me about this case and that outcome. Practicing psychotherapy, I employ methods that will never be subject to formal assessment. Among my teachers I number colleagues I know only through their descriptions of patient encounters. One psychoanalyst, Hellmuth Kaiser, imparted his wisdom through a fictional case portrayed in a stage play. I follow his precepts daily, hourly.

I have long felt isolated in this position, embracing stories, which is why I warm to the possibility that the vignette is making a comeback. This summer, Oxford University Press began publishing a journal devoted to case reports. And this month, in an unusual move, the New England Journal of Medicine, the field's bellwether, opened an issue with a case history involving a troubled mother, daughter and grandson. The contributors write: "Data are important, of course, but numbers sometimes imply an order to what is happening that can be misleading. Stories are better at capturing a different type of 'big picture.' "

Stories capture small pictures, too. I'm thinking of the anxious older man given Zoloft. That narrative has power. As Dr. Bech and his co-author, Lone Lindberg, point out, spontaneous recovery from panic and depression late in life is rare. (Even those who put great stock in placebo pills don't imagine that they do much for conditions that are severe and chronic.) The degree of transformation in the Danish patient is impressive. So is the length of observation. No formal research can offer a 40-year lead-in or a 19-year follow-up. Few studies report on both symptoms and social progress. Research reduces information about many people; vignette retains the texture of life in one of its forms.

How far should stories inform practice? Faced with an elderly patient who was anxious, withdrawn and never medicated, a well-read doctor might weigh many potential sources of guidance, this vignette among them. Often the knowledge that informs clinical decisions emerges, like a pointillist image, from the coalescence of scattered information.

HERE is where I want to venture a radical statement about the worth of anecdote. Beyond its roles as illustration, affirmation, hypothesis-builder and low-level guidance for practice, storytelling can act as a modest counterbalance to a straitened understanding of evidence.

Take psychotherapy. Most of the research into its efficacy concerns cognitive behavioral therapy, or C.B.T., the treatment that teaches patients to moderate their habitual maladaptive thoughts. The reasons for this concentration are historical and temperamental. C.B.T. is rooted in a branch of psychology devoted to research, and the school of therapy attracts students who favor the practical and systematic over the spontaneous and poetic. There are no trials of existential psychotherapy.

But where the comparison has been made — primarily in the treatment of depression — C.B.T. does not outperform alternative approaches. (The alternatives tested are mostly distant derivatives of psychoanalysis.) And detailed research suggests that where C.B.T. works, specific techniques are not the reason. Studies of the components of therapy find that it is factors common to all schools, like the practitioner's commitment and the alliance with the patient, that do the job.

If we weigh "evidence" by the pound or the page, we risk moving toward a monoculture of C.B.T., a result I would consider unfortunate, since there are many ways to influence people for the better. Here's where case description shines. We hear the existential psychoanalyst Leston Havens describe his use of imitative statements, exclamations by the therapist that seem to come from within the patient: "What is one supposed to do?" For me, Dr. Havens's approach — sitting beside the patient metaphorically and looking outward, hand-crafting interventions on the spot — carries what I call psychological plausibility. The vignette corresponds to a convincing account of how people change.

It has been my hope that, while we wait for conclusive science, stories will preserve diversity in our theories of mind. For 17 years, starting in the 1980s, I ran a psychotherapy seminar for psychiatry residents. As readings, I assigned only case vignettes, trusting that one or another would speak to each trainee.

My recent reading of outcome trials of antidepressants has strengthened my suspicion that the line between research and storytelling can be fuzzy. In psychiatry — and the same is true throughout medicine — randomized trials are rarely large enough to provide guidance on their own. Statisticians amalgamate many studies through a technique called meta-analysis. The first step of the process, deciding which data to include, colors the findings. On occasion, the design of a meta-analysis stacks the deck for or against a treatment. The resulting charts are polemical. Effectively, the numbers are narrative.

Because so little evidence stands on its own, incorporating research results into clinical practice requires discernment. Thoughtful doctors consider data, accompanying narrative, plausibility and, yes, clinical anecdote in their decision making. To put the same matter differently, evidence-based medicine, properly enacted, is judgment-based medicine in which randomized trials, carefully assessed, are given their due.

I don't think that psychiatry — or, again, medicine in general — need be apologetic about this state of affairs. Our substantial formal findings require integration. The danger is in pretending otherwise. It would be unfortunate if psychiatry moved fully — prematurely — to squeeze the art out of its science. And it would be unfortunate if we marginalized the case vignette. We need storytelling, to set us in the clinical moment, remind us of the variety of human experience and enrich our judgment.

Peter D. Kramer, a clinical professor of psychiatry at Brown University, is the author of several books, including "Against Depression" and "Listening to Prozac."

A version of this article appears in print on 10/19/2014, on page SR1 of the National edition with the headline: Why Doctors Need Stories.

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Opinionator | Fixes: Treating Depression Before It Becomes Postpartum

Fixes looks at solutions to social problems and why they work.

Shortly after the birth of her daughter, Andrea became severely depressed. She was 17 at the time and she didn't fully understand what she was going through; she just felt like a failure. "I felt like I didn't want to be alive," she recalls. "I felt like I didn't deserve to be alive. I felt like a bad person and a bad mother, and I was never going to get any better."

Postpartum depressions are often assumed to be associated with hormonal changes in women. In fact, only a small fraction of them are hormonally based.

When her baby persisted in crying, she felt her frustration mount quickly. "I was hitting a boiling point," she says. "I was at a point where I didn't want to deal with anything. Sometimes I would just let her cry — but then I would feel very bad afterwards."

Depression is the most common health problem women face. In the United States, outside of obstetrics, it is the leading cause of hospitalizations among women ages 15 to 44. It's estimated that 20 percent to 25 percent of women will experience depression during their lifetimes, and about one in seven will experience postpartum depression. For low-income women, the rates are about twice as high. As my colleague Tina Rosenberg has reported, the World Health Organization ranks depression as the most burdensome of all health conditions affecting women (as measured by lost years of productive life).

Postpartum depressions are often assumed to be associated with hormonal changes in women. In fact, only a small fraction of them are hormonally based, said Cindy-Lee Dennis, a professor at the University of Toronto and a senior scientist at Women's College Research Institute, who holds a Canada Research Chair in Perinatal Community Health.

The misconception is itself a major obstacle, she adds. Postpartum depression is often not an isolated form of depression; nor is it typical. "We now consider depression to be a chronic condition," Dennis says. "It reoccurs in approximately 30 to 50 percent of individuals. And a significant proportion of postpartum depression starts during the pregnancy but is not detected or treated to remission. We need to identify symptoms as early as possible, ideally long before birth."

The major predictors include previous incidents of depression, as well as a woman's past and current life stresses, like childhood trauma or abuse, conflicts with a partner or family members, lack of social support or coping skills, and poverty.

Only about 20 percent to 30 percent of women who experience postpartum depression in the United States get proper treatment, and for low-income mothers, the rate is considerably lower, says Robert T. Ammerman, a professor of pediatrics at Cincinnati Children's Hospital Medical Center who is the scientific director of Every Child Succeeds, a home visiting program for vulnerable first-time mothers.

The consequences for both mother and child can be devastating. If left untreated, postpartum depression can develop into severe clinical depression. In addition to feeling listless, anxious, guilty, lonely and frequently suicidal, mothers who are clinically depressed in pregnancy are three to four times more likely to have a premature delivery or deliver a low-birth-weight baby (both predictors of serious developmental and medical problems for the child) and, just as urgent, less likely to form healthy attachments with their children. Their children are more likely to have attention deficits, difficulties controlling their emotions and behavior, language delays and lower I.Q.s — and they are themselves at increased risk of becoming depressed later in life (PDF).

"We have this idea that during motherhood struggling with emotional issues is normal," Ammerman says. "The message that a lot of moms hear from families and friends and even professionals who may not know much about perinatal depression is 'be tough and fight your way through it' — and they don't seek help."

Ammerman says that while it's true that many mothers have or develop depression, it's not a normal or typical response to the challenges of parenting. There are effective treatments. They include medication as well as a range of therapies – like cognitive behavioral therapy (C.B.T.), which helps people learn how to counter negative thoughts and their associated emotions, and interpersonal psychotherapy (I.P.T.), which focuses on improving the quality of personal relationships and the satisfaction that is gained from them. About a third of women who get treated for chronic or recurrent depression achieve remission, and more than half see an improvement in their symptoms.

Today, several states, including Illinois, New Jersey, West Virginia and Washington, have initiated mandatory screening for perinatal depression (something that is done nationally in Australia). But inadequate screening is only part of the problem. Cost and access barriers and stigmatization – and an overall lack of awareness among health professionals – are what prevent most mothers who need help from getting it. Many primary care doctors fail to recognize when their patients are depressed. And when they do, they often don't know how to provide the most effective treatments. They also can't ensure that patients will follow up with mental health professionals (many of whom do not accept Medicaid). And communication between doctors is notoriously problematic.

"When people are referred to mental health professionals from primary care settings, the vast majority of the referral slips go into the garbage," says Katherine L. Wisner, director of the Asher Center for the Study and Treatment of Depressive Disorders at Northwestern University.

Given the scope of the problem, new outreach and treatment models are urgently needed. The three that I'm highlighting today are in early stages of development, but they are noteworthy because they demonstrate promise and illustrate pathways for potentially broader system changes.

The first is a collaborative care model called DAWN being pioneered at two urban obstetrics and gynecology (ob-gyn) clinics that are part of the University of Washington system. The innovation here is that mental health care is being integrated directly into ob-gyn care. Why is this such an important idea? About a third of women in the country see their ob-gyn physicians for their primary care, explains Wayne Katon, vice chair of the department of psychiatry and behavioral sciences at the University of Washington School of Medicine. When depression screening and treatment are handled in the same place as primary care, it's more likely that women will get effective help.

Through the DAWN program, when a woman comes in for care, she is screened for depression using a standard questionnaire known as PHQ-9. If her score indicates a likelihood of major depression, she is assigned a care manager who is trained to educate her about depression, explore real or perceived barriers in her life and motivate her to pursue treatment.

It's important that treatments are designed to fit with a patient's preferences. "They're given the choice to start with a form of therapy or an antidepressant," Katon says. "Some say, 'I'm pregnant, I'd rather not be on medication.' Some want to take medication." They can also choose in-person visits or telephone consultations. Physician-supervised care managers follow up regularly for a year, tracking patients' progress. If their symptoms persist, they adjust or increase the intensity of treatment.

In two studies published this year, women experienced significant improvements in depressive symptoms. The gains were particularly notable among women who were uninsured or received public insurance, such as Medicaid. "The women were more satisfied with the care they got and the ob-gyn doctors were more satisfied because their patients got better," Katon adds.

The second model was developed by Every Child Succeeds, a home visiting program for vulnerable first-time mothers based out of the Cincinnati Children's Hospital Medical Center. In recent years, as I have reported in this column, home visiting programs have spread across the country as a result of a $1.5 billion appropriation in the Affordable Care Act. This summer, a study of families served by the Nurse-Family Partnership found, remarkably, that the mothers and children assisted by the program had significantly lower death rates over a 20-year period.

But home visiting programs have one notable limitation. As recent research indicates, when mothers are clinically depressed, they don't benefit as much from the visits. "A mother who is depressed has very little to give her child," said Judith B. Van Ginkel, the founder of Every Child Succeeds, which has worked with 22,000 families. "We found that half of the mothers we were working with were depressed, and three-quarters had witnessed or been victims of violence."

With the leadership of Robert Ammerman and others, Every Child Succeeds has developed a program called Moving Beyond Depression, to train therapists to deliver C.B.T. in conjunction with home visitation.

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Read previous contributions to this series.

This is how Andrea was able to receive treatment. Shortly after her home visits started, Andrea, who lives just north of Cincinnati and works in a call center, was asked to fill out a questionnaire. (I have changed her name.) She learned that she was depressed. "I had been in denial," she said. For months, conflicts with her mother had been getting worse. Her mother suffered from mental illness and depression, had used drugs, and had long counted on, and expected, Andrea to take care of her.

But now Andrea needed every ounce of her strength to care for her baby, and her mother reacted angrily. Over 15 sessions, the therapist helped Andrea develop strategies to manage her feelings and interact with her mother — rather than being thrown repeatedly to anger, negative thoughts and guilt.

Last year, results from a clinical trial funded by the National Institute of Mental Health showed that mothers receiving Moving Beyond Depression's in-home C.B.T. model experienced subtantial improvements in depressive symptoms and decreased diagnosis of major depressive disorder following treatment relative to a control group. The model has spread to several states, including Connecticut, Massachusetts, Kentucky and Kansas, and has been used to assist 600 mothers.

The third model grows out of Cindy-Lee Dennis's research in Canada, and is important because it illustrates the potential of treating women through interventions over the phone. It thus reduces one of the biggest barriers low-income or rural women face in accessing treatment: transportation to and from treatment and scheduling appointments.

In one clinical trial, 700 women in the first two weeks after giving birth, who had been identified as being at a high risk of postpartum depression, were given telephone-based peer support from other mothers — volunteers from the community who had previously experienced and recovered from self-reported postpartum depression (and received four hours of training).

"We created a support network for the mothers early in the postpartum period," Dennis explains. "It cut the risk of depression by 50 percent." On average, each mother received just eight contacts — calls or messages, and the calls averaged 14 minutes. Over 80 percent of the mothers said they would recommend this support to a friend.

In another clinical trial conducted by Dennis, trained nurses provided interpersonal psychotherapy (I.P.T.) over the phone to 240 clinically depressed mothers across Canada. The calls were scheduled at the mothers' convenience. The results have not been published yet, but Dennis says the treatment was highly effective. Treatment compliance rates were greater than 85 percent. Dennis is currently working with health officials to pilot test the model in New York City.

"We underestimate very simple interventions," she says. "We have this huge bias that face to face is the most effective way to provide care. But we have to be innovative about how we offer help to women."

Andrea, who is now 19, remains grateful for the help she received. "I can actually focus on my daughter and be with her the way I want to be with her, and teach her things," she says. "I feel like now that I've been through the program — and distanced myself from people I needed to — I can focus on what I need to focus on rather than everybody else's problems. There's more out there than just being depressed."

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David Bornstein is the author of "How to Change the World," which has been published in 20 languages, and "The Price of a Dream: The Story of the Grameen Bank," and is co-author of "Social Entrepreneurship: What Everyone Needs to Know." He is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.

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Room for Debate: Freezing Plans for Motherhood and Staying on the Job

Facebook and Apple have announced that they will cover up to $20,000 of the cost of egg freezing for female employees who want to delay motherhood. Some welcome the move, others see it as a way to get women to put off having children.

Should doctors encourage young women to use the procedure more routinely? Do companies send the wrong message by offering this coverage?

Read the Discussion »

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Taking Note: In North Carolina, ISIS Is the New Wedge Issue

CHARLOTTE, N.C. — When political ads are reduced to criticizing a lawmaker's absence from a few congressional committee meetings, it's usually a pretty good sign that they're running out of material. In the case of Thom Tillis, the Republican who is running for the Senate from North Carolina, it's actually something more ludicrous.

Mr. Tillis, who has struggled for an advantage against the Democratic incumbent, Senator Kay Hagan, has decided to use the cudgel of the Islamic State to make Ms. Hagan look weak. He is now running television ads here accusing her of missing several Armed Services Committee hearings, including one in February where global threats were discussed. (Though virtually no one, including most Republicans, were particularly concerned about the Islamic State back then.)

In September, the ad says, she missed a hearing to attend a cocktail fundraiser. "While ISIS grew, Obama did nothing," the narrator says. "Senator Hagan did cocktails. To change policy, change your senator."

Set aside for a moment the basic hypocrisy of the ad, since all candidates, including Mr. Tillis, miss legislative business in order to raise money. (Mr. Tillis, the speaker of the state House, has frequently been absent for crucial votes while campaigning, according to the Associated Press.)

What's truly misleading about the ad is the notion that attendance at committee meetings actually has some effect on national security, or that any individual senator can be considered responsible for missing the rise of the Islamic State. Obviously senators should show up for work, but the real problem is that few of them really want to work when they're there. Leaders of both parties in the Senate and the House have been pressured by their members not to allow a vote on President Obama's bombing of the militant group, afraid of sticking their heads up on a controversial issue before the November election.

What's really going on here is an attempt by Mr. Tillis to change the subject from Ms. Hagan's effective attacks on him for the cuts he has made to education and women's health services, and his leadership in trying to suppress the votes of minorities and other Democratic-leaning voters through a very strict voter ID measure.

Capitalizing on fears of a looming national security threat is an old and often successful Republican tactic. For George W. Bush and Dick Cheney, it was al Qaeda; for their successors, it is the Islamic State, which is being waved like a red blanket in several other races as well.

Its usefulness is one of the reasons why the National Republican Senatorial Committee announced yesterday that it would spend another $6 million on ads for Mr. Tillis in the last three weeks of the campaign, more than doubling its current spending. This race is already the most expensive in the nation — $59 million has been spent so far by the two campaigns and outside groups — but Mr. Tillis has not been able to establish a lead. The most favorable poll for him shows the race tied, though others have Ms. Hagan a few points ahead.

But if several million dollars more can make Ms. Hagan appear to be responsible for the rise of the Islamic State, those numbers may start to change.

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