The Medical Case Presentation: The United States  Political System 2020


Presented by: The Madison Project

“what is government itself but the greatest of all reflections on human nature?”

Publius, The Federalist No. 51

Using the Medical Case Presentation for deliberative dialogue to address the challenges facing the United States body politic (Practical example).

Presenting complaint:

Americans are politically divided. We are challenged by regionalism and partisanship like no other time in recent American history. The 2016 election highlighted the many divisions that separate Americans, while ignoring the remarkable achievement of our democratic government.

We are continuing to experience a political environment where passions have become the main driver of political discourse. Politicians and interest groups with access to sophisticated digital tools leverage a deeper understanding of psychological drivers for political action by addressing and personalizing messages that promote emotional response and action.


About the Case of the United States 2020

Building on Madison’s use of the disease metaphor to describe the pathology of the governments of his time, and the constitutional architecture that was informed by his analysis, the medical case presentation will be introduced as a framework to better understand and potentially intervene in our current complex political ecosystem.


We leverage a Madisonian informed framework to better understand our current “ national vices” and explore strategies to reclaim the role of the citizen. In particular, I focus on the impact of passions and factions that energize them on the body politic. The medical case presentation that uses a Madisonian metaphor for the disease, will be introduced to examine the complexity of the body politic. The case will focus on the values (vision), symptoms, history of the present condition, review of the systems, data and information, diagnosis, treatment plan and progress notes for the challenges of the “body politic.”

The Case Presentation of the United States 2019   builds on the understanding of the biologic process and current treatment approaches to medical conditions as a framework to address the political disease that had led to the 1787 Constitutional Convention. It is our goal to a more deliberative, respectable solutions-oriented process inspired by hope and built on a compromise that serves the public.


Our treatment plan focuses on citizens as crucial contributors to the healing process. The series includes resources such as an examination of the similarities of the biology of cancer and the current US political system.  Offering “clinical examples” from our politics (including the challenges that led to the establishment of the United States), this series describes the symptoms of the American political system and the solution offered through the constitution. We highlight the similarities in the pathology of our current political situation and various diseases.

The medical case presentation includes multiple features to engage citizens. Like the diagnostic and treatment tools in the hands of medical clinicians, these features can be thought of as the toolbox for citizenship.



America faces many daunting problems—stagnant wages, high healthcare costs, neglected schools, deteriorating public services. Yet, our government often seems to ignore the needs of its citizens. Policymakers pay more attention to organized interests than to ordinary Americans, our political parties are dominated by ideological activists, and our government gets bogged down in partisan gridlock and inaction. The solution to these problems is more democracy: more equal opportunity for citizens to shape what their government does. To strengthen our democracy we must change the way we choose candidates and conduct our elections, reform the internal rules of our governing institutions, and curb the power of private money in our politics. By forcing political parties and officeholders to respond to the preferences of ordinary Americans, we can reduce polarization and gridlock, address pressing challenges, and enact policies that better reflect the interests of average Americans.

Americans are politically divided. We are challenged by regionalism and partisanship like no other time in recent American history. The 2016 election highlighted the many divisions that separate Americans while ignoring the remarkable achievement of our democratic government.

History of Present Condition:

In 2020, we are experiencing a political environment where passions have become the main driver of political discourse. Politicians and interest groups with access to sophisticated digital tools leverage a deep understanding of psychological drives to channel political action by addressing and personalizing messages that promote emotional response and individual action. Information and facts are replaced by opinions and self-serving statistics. The media are fragmented and driven by the need to appeal to factions and interest groups rather than a desire to provide the accountability and meaningfully engage citizens as envisioned by our founding fathers. Rapidly evolving developments in the areas of artificial intelligence and machine learning weaponize digital technology and make seeking a different approach essential.

History of Issue:


In the past decade, we have witnessed an increasing inability of our political system to address the challenges facing our nation. The political dysfunction has led to increasing public distrust, with Tea Party and OWS activism. The political debate in Washington has become partisan, hyper-charged, fueled by lots of money, media obsession with adversarial dialogue, and sport like coverage. Opinion and half-truths and projections based on questionable assumptions. As the U.S. Congress and the President continue their battle over the budget, deficit, debt ceiling, sequestration, the ideological, special interests and hardened personal positions reign rather than a rational approach to addressing our challenges that threaten our future.


The “DNA” (the intelligently designed governmental structure) building on the division of federal and state authority, checks and balances, the centrality of the citizen in the political process provided for constant advancement of individual well-being, seen peaceful national elections and succession of political power. In the 230 years since it took its place among the nations of the world, the United States has become a global superpower and the standard of living of our citizens has been unprecedented.

Review Of Systems: 

An informed review of systems provides an organized approach to provide further information that can inform the diagnosis and the treatment of the medical problem.


Of course, the current times are quite different than in the 1780s. The US was a pre-industrial, farm-oriented society. The United States comprises 50 states and more than 320 million citizens. The challenges are similar, the recognition that psychological factors play a critical role in maintaining the political framework for a diverse group of individual citizens. While there are no individuals of the Madisonian stature, we can learn from his approach to the challenges faced by the body politic of his time. We examine the tools for addressing the challenges confronting the complexity of our society through the exploration of the constitutional framework formulated by Madison and the other founding fathers in Philadelphia.


Information and facts are often replaced by opinions and self-serving statistics by both the government and the media today the media is fragmented and driven by incentives of faction and interest groups more than the role envisioned by our founding fathers. The developments in the areas of artificial intelligence and machine learning weaponizing the impact of digital technology make seeking a different approach essential.


“A popular Government, without popular information, or the means of acquiring it, is but a Prologue to a Farce or a Tragedy; or, perhaps both. Knowledge will forever govern ignorance: And a people who mean to be their own Governors, must arm themselves with the power which knowledge gives,”      said Madison to W.T. Barry in August of 1822.

States:  50

Population:  300,000,000


Federal Budget: 

Federal Debt: 

US Constitution: 


However anxiously we may wish that these complaints had no foundation, the evidence, of known facts will not permit us to deny that they are in some degree true. It will be found, indeed, on a candid review of our situation, that some of the distresses under which we labor have been erroneously charged on the operation of our governments; but it will be found, at the same time, that other causes will not alone account for many of our heaviest misfortunes; and, particularly, for that prevailing and increasing distrust of public engagements, and alarm for private rights, which are echoed from one end of the continent to the other. These must be chiefly, if not wholly, effects of the unsteadiness and injustice with which a factious spirit has tainted our public administrations.


Differential Diagnosis:

Today’s society (US) is characterized by a set of complex problems — such as inequality, climate change, gun violence and affordable access to healthcare to list a few— that are seemingly intractable. People have looked to traditional societal institutions — like government agencies and advocacy groups — to tackle these problems, and they have become frustrated by the inability of these institutions to act effectively and legitimately. Unsurprisingly, trust in existing institutions is at an all-time low. To survive and flourish in the 21st century our nation must embrace the digital revolution that has transformed most aspects of personal and social life. Current technology allows us to rewire the body politic through information technology. These tools allow unprecedented opportunity to get access to information, mobilize, challenge misinformation provide for a more deliberative dialogue.

“The partisan divide has both widened and deepened over the past 40 years (1). Since the 1970s, Americans have become less trusting of each other and of their governmental institutions (2). Rising levels of economic inequality have depressed political interest, engagement, and participation among all but the most affluent citizens (3); this has led to gaps between the rich and the less affluent in effective representation (4). These gaps are exacerbated by the growth in the physical, technological, and social distance between Americans without shared politics, and the result is a polity rent by suspicion and fear. Whereas each of these developments would be problematic in its own right, their confluence is dire.”



In a recent article that appeared in Science,  The need for a translational science of democracy, David Lazar noted the need for a more scientific approach to our body politics. He writes


“ The bitterly factious 2016 U.S. presidential election campaign was the culmination of several trends that, taken together, constitute a syndrome of chronic ailments in the body politic. Ironically, these destructive trends have accelerated just as science has rapidly improved our understanding of them and their underlying causes. But mere understanding is not sufficient to repair our politics. The challenge is to build a translational science of democracy that maintains scientific rigor while actively promoting the health of the body politic.

No man is allowed to be a judge in his own cause because his interest would certainly bias his judgment, and, not improbably, corrupt his integrity. With equal, nay with greater reason, a body of men are unfit to be both judges and parties at the same time; yet what are many of the most important acts of legislation, but so many judicial determinations, not indeed concerning the rights of single persons, but concerning the rights of large bodies of citizens? And what are the different classes of legislators but advocates and parties to the causes which they determine? Is a law proposed concerning private debts? It is a question to which the creditors are parties on one side and the debtors on the other. Justice ought to hold the balance between them. Yet the parties are, and must be, themselves the judges; and the most numerous party, or, in other words, the most powerful faction must be expected to prevail. Shall domestic manufactures be encouraged, and to what degree, by restrictions on foreign manufactures? are questions that would be differently decided by the landed and the manufacturing classes, and probably by neither with a sole regard to justice and the public good. The apportionment of taxes on the various descriptions of property is an act which seems to require the most exact impartiality; yet there is, perhaps, no legislative act in which greater opportunity and temptation are given to a predominant party to trample on the rules of justice. Every shilling with which they overburden the inferior number is a shilling saved to their own pockets.




There are two methods of curing the mischiefs of faction: the one, by removing its causes; the other, by controlling its effects.


There are again two methods of removing the causes of faction: the one, by destroying the liberty which is essential to its existence; the other, by giving to every citizen the same opinions, the same passions, and the same interests.

It could never be more truly said than of the first remedy, that it was worse than the disease. Liberty is to faction what air is to fire, an aliment without which it instantly expires. But it could not be less folly to abolish liberty, which is essential to political life, because it nourishes faction, than it would be to wish the annihilation of air, which is essential to animal life, because it imparts to fire its destructive agency.

The second expedient is as impracticable as the first would be unwise. As long as the reason of man continues fallible, and he is at liberty to exercise it, different opinions will be formed. As long as the connection subsists between his reason and his self-love, his opinions and his passions will have a reciprocal influence on each other; and the former will be objects to which the latter will attach themselves. The diversity in the faculties of men, from which the rights of property originate, is not less an insuperable obstacle to a uniformity of interests. The protection of these faculties is the first object of government. From the protection of different and unequal faculties of acquiring property, the possession of different degrees and kinds of property immediately results; and from the influence of these on the sentiments and views of the respective proprietors, ensues a division of the society into different interests and parties.


Treatment Plan:


The Call for a Grand Convention

On May 15, 1776, the Second Continental Congress, meeting in Independence Hall, Philadelphia, issued “A Resolve” to the thirteen colonies: “Adopt such a government as shall, in the opinion of the representatives of the people, best conduce to the safety and happiness of their constituents in particular and America in general.” Between 1776 and 1780 each of the thirteen colonies adopted a republican form of government. What emerged was the most extensive documentation of the powers of government and the rights of the people that the world had ever witnessed.


These state constitutions displayed a remarkable uniformity. Seven attached a prefatory Declaration of Rights, and all contained the same civil and criminal rights. Four states decided not to “prefix” a Bill of Rights to their constitutions, but, instead, incorporated the very same natural and traditional rights found in the prefatory declarations. New York incorporated the entire Declaration of Independence into its constitution.


The primary purpose of these declarations and bills was to outline the objectives of government: to secure the right to life, liberty, property, and the pursuit of happiness. The government that was chosen to secure these rights was declared universally to be “a republican form of government.” All of the states, except Pennsylvania, embraced a two-chamber legislature, and all, except Massachusetts, installed a weak executive and denied the Governor the power to veto bills of the legislature. All accepted the notion that the legislative branch should be preeminent, but, at the very same time, endorsed the concept that the liberty of the people was in danger from the corruption of the representatives. And this despite the fact that the representatives were installed by the election of the people. Thus, each state constitution embraced the notion of short terms of office for elected representatives along with recall, rotation, and term limits.


A republic, by which I mean a government in which the scheme of representation takes place, opens a different prospect, and promises the cure for which we are seeking. Let us examine the points in which it varies from pure democracy, and we shall comprehend both the nature of the cure and the efficacy which it must derive from the Union.

The two great points of difference between a democracy and a republic are: first, the delegation of the government, in the latter, to a small number of citizens elected by the rest; secondly, the greater number of citizens, and greater sphere of country, over which the latter may be extended.


The effect of the first difference is, on the one hand, to refine and enlarge the public views, by passing them through the medium of a chosen body of citizens, whose wisdom may best discern the true interest of their country, and whose patriotism and love of justice will be least likely to sacrifice it to temporary or partial considerations. Under such a regulation, it may well happen that the public voice, pronounced by the representatives of the people, will be more consonant to the public good than if pronounced by the people themselves, convened for the purpose. On the other hand, the effect may be inverted. Men of factious tempers, of local prejudices, or of sinister designs, may, by intrigue, by corruption, or by other means, first obtain the suffrages, and then betray the interests, of the people. The question resulting is, whether small or extensive republics are more favorable to the election of proper guardians of the public weal; and it is clearly decided in favor of the latter by two obvious considerations:


In the first place, it is to be remarked that, however small the republic may be, the representatives must be raised to a certain number, in order to guard against the cabals of a few; and that, however large it may be, they must be limited to a certain number, in order to guard against the confusion of a multitude. Hence, the number of representatives in the two cases not being in proportion to that of the two constituents, and being proportionally greater in the small republic, it follows that, if the proportion of fit characters be not less in the large than in the small republic, the former will present a greater option, and consequently a greater probability of a fit choice.




* By a faction, I understand a number of citizens, whether amounting to a majority or a minority of the whole, who are united and actuated by some common impulse of passion, or of interest, adversed to the rights of other citizens, or to the permanent and aggregate interests of the community.

Citizen Briefs: Challenges facing 21-century United States presents an overview of the vices of the political system. In the coming years we will address the following symptoms of the “body politic” 


  • Distrust: Distrust and alienation from the federal government and the toxic political process 

  • Inequality: Inequality of opportunity, political status, income, wealth and employment

  • Healthcare: An unjust, dysfunctional and expensive healthcare (medical) system

  • Justice: An out of control legal system, police and prison system 

  • Immigration: A broken system that has been a source of divisiveness. 

  • Environment: Failure to respond to climate change

  • Surveillance: The surveillance state: Privacy and dignity under assault by government and corporations

  • Fiscal Health: The fiscal health of the nation: The budget, debt and deficit

  • Taxation: Unfairness of the tax system that favors the rich and well connected 

  • Infrastructure: A decaying infrastructure of roads, bridges and other public spaces 

  • Education: A declining public educational system out of reach for many Americans 

  • Declaration of War:  Lack of consensus on how the United States should undertake a decision to go to war.