Dependent on D.C.: The Rise of Federal Control over the Lives of Ordinary Americans, by Charlotte A. Twight, 422 p., index, $26.95, ISBN 0-312-29415-8, New York, NY, Palgrave, 2002.

Review by Jane M. Orient, M.D.

How did it happen that Americans "traded individual liberty piecemeal for dependence on government, without revolution, without reflection, often without systematic understanding?" How could a nation rooted in liberty accept the unchecked, pervasive federal intrusions into our lives?

Dr. Twight invokes no conspiracy theories. The problem is much more difficult than simply thwarting the monolithic agenda of an elite group. The book describes actions taken by various individuals and groups pursuing their own separate agenda, trying to get their way through strategies that simply work in politics.

Dr. Twight’s key insight is the importance of manipulating political transaction costs: the cost of perceiving and acting upon our assessment of the net costs of a particular government action. Government grows by progressively raising the cost of resistance.

There is the naturally high transaction cost of organizing large groups whose members have small individual stakes in a policy outcome. In addition, there are "contrived" transaction costs, such as those created by deliberately concentrating benefits and diffusing costs.

Covert manipulation makes it possible for government officials to sustain outcomes that contravene the popular will without the overt use of force. It is a crucial technique for creating that "servitude of the regular, quiet, and gentle kind" described by Tocqueville.

The foundations of the welfare state--Social Security and income tax withholding--are explained in depth. Harsh reality has been disguised by such methods as splitting the payroll tax. A pretense of compassion veils the true motive, best expressed by Bismarck in 1881:

"Whoever has a pension for his old age is far more content and far easier to handle than one who has no such prospect." Dr. Twight tells it like it is in her subtitles: "Wealth Destruction Through Social Security: Forced Non-saving."

Contrary to the common perception, there was no public outcry for compulsory old-age insurance in the wake of the Depression. Roosevelt, in fact, urged the deferral of a widely supported bill for needs-based assistance in order to preserve it as a lever for the later enactment of universal insurance.

Getting Americans to relinquish the cherished right to shape the education of their children--essential for achieving consolidation of federal power--is another example of transaction-cost manipulation. Incrementalism is an important feature of the strategy. The appalling results have led to pressure for even more federal intervention. Yet, Dr. Twight points out that in 1812, 40 years before the first compulsory school laws, fewer than four in 1,000 Americans lacked the ability to read and do numbers well. In 2000, 37 percent of children couldn’t read. The method was, again, imported from Prussia:

Froebel’s "kindergarten" with its early removal of the child’s parents and culture from the scene, and its replacement of serious learning with songs, games, pictures and organized group activities was remarkably effective in delivering compliant material to the State.

Of greatest interest to AAPS members is the chapter on "Health Care Controls: Exploiting Human Vulnerability." There is an excellent summary of the political machinations that culminated in the enactment of Medicare -- and of its predictable, not necessarily unintended consequences.

The erosion of privacy is of special concern to Dr. Twight. She refers to government-compelled information collection as "dependency’s forgotten vector," quoting a 1971 admonition by H.B. Acton:

When a large part of the information about economic statistics or administrative arrangements is collected and issued by government, investigators and critics are forced to approach the very officials they may criticize for the information that might give substance to their criticism.

The end result of dependence on government is evisceration of the rule of law. Physicians are not the only citizens affected by the rampant federal criminalization of all manner of ordinary private acts not generally regarded as criminal. However, too many AAPS members have first-hand experience of being charged with "money laundering," aptly defined as the single, basic prohibited act of "doing something and not telling the government about it."

Dr. Twight’s lively and lucid style, her trenchant legal analysis and careful annotation, and her sense of history make this work a book for reading cover-to-cover as well as for keeping on the reference shelf.

Journal of American Association of Physicians & Surgeons Spring 2003