By Ann Neumann

But the goat, on which the lot fell to be the scapegoat, shall be presented alive before the Lord, to make an atonement with him, and to let him go for a scapegoat into the wilderness. Leviticus 16:10

The American Dream has always been both a carrot and a stick. A hope, a dream, a mythic goal of attainment with just enough anecdotal evidence to make it perpetually credible. But the American Dream is also a visceral judgment on those who fall short. It presupposes that we can all be self-made if we work hard, save our money, and assimilate in the ways that have made this nation great.

The American Dream is both abstract and concrete: freedom, liberty and happiness; an education, a house and two cars. We succeed because that’s what being American means. And we tend to measure our success quite narrowly: upward social mobility, increasing income, better zip codes, better colleges, better teeth. Fail, however, and you’re no longer one of us because here you fail on your own. We’re a nation who makes sinners of those who can’t make it; and we absolve ourselves of responsibility by casting sinners out into the wilderness. It is this blaming of victims—to deflect our own blame, to protect the explicit meritocracy at the heart of the American Dream, to keep the control of capital and resources in the hands it now rests in—that animates our current political climate.

In much contemporary political discourse, America’s challenges and faults become the result of an unhealthy, immoral national body rife with laziness, poverty, “non-traditional” families, immigration, crime, suicide, addiction. Public policies and programs, designed to reward or punish behaviors that are perceived as crippling to national achievement, have become a battleground. Health care, food stamps, mental health services, substance abuse programs, education, day care, worker protections—in this narrative, entitlements are accessible only to those who can afford them. And those who can’t are a burden, a moral failure, the cause of our decline. If the American Dream is achieved by those individuals who have worked hard, led moral lives and been blessed by god and good health, those who fall short are scapegoated for their plight.

Our political stage has been divided—almost literally over the past months, as each party competes for the presidency—along distinct prognoses for how to keep America healthy, how to keep the dream alive. The health of the nation—its economic success, its influence around the world—has always been inextricably tied to the moral health of its citizens.

Here are five indelible scenes from my week (two fictional, two anecdotal, one scientific) that show an interplay between American Dream and socioeconomic class, race, American faith and public health—even as they’ve drawn and quartered them:

August: Osage County—(Spoiler Alert!) Netflix offered me this 2013 filmic knock-down as a respite between an article’s draft and its edit. Rather than a head-clearing, I got a gut-punching. Meryl Streep plays a 60-something bitter shrew whose mouth is (appropriately, it seems) riddled with cancer from chain-smoking and whose brain is disabled by a chronic pill addiction. She had lifted herself from poverty to respectability by marrying an award-winning (but disloyal…with her sister) poet, whose suicide she may or may not have been able to prevent. She’s made enemies of all three of her daughters by exposing, denigrating and resenting their un-charmed lives. She accuses them of abandonment (for moving away from their family home in rural Oklahoma), and of stupidity and failure (for not holding an adulterous marriage together, for getting old, for pursuing flashy men, for not intuiting family secrets). The crisis scene is a funeral dinner in which the ritual of an opening prayer leads to a usurpation of the family assets and a multi-generational physical fight on the dining room floor. In the end, the matriarch finds herself abandoned, only finding solace in the lap of the Native American maid she has slurred and insulted all along.

Preparation for the Next Life—(Spoiler Alert!) Atticus Lish’s star-crossed love story from last year is, yes, “ a sledgehammer to the American dream” (Kirkus Reviews). A 23 year-old white soldier, Skinner, with three tours in Iraq under his camouflage, finds himself in a basement apartment in an outer borough of New York, unwilling and unable to get enough alcohol down his throat to evade the suicidal, PTSD-fueled dreams and hallucinations that hunt him. He falls in love with an illegal Uighur-Chinese immigrant, Zou Lei, who’s slipped across the US-Mexican border. She works kitchen jobs, hiding away every minuscule dollar she scrapes, with dogged but earnest labor, from greasy restaurant kitchens. She visits an immigration lawyer she can’t afford, a sweatshop factory, where seamstresses are going blind at their machines, and a Uighur mosque where, “Preparation for the Next Life,” is inscribed above the door. Skinner makes war with the upstairs neighbor, a strapping Irish convict without scruples, and ultimately kills him with his army issue handgun. The lovers are disoriented, separated by police, violence, the city streets. Skinner shoots himself in the head in a train tunnel. Zou Lei makes her way by Greyhound to Arizona with funds she’s drained, with his blessing, from his bank card.

The Increasingly Angry, Abusive Undead—When I turn down Sunday afternoon plans, friends ask, “Is she still alive?” Yes, I say, she still is. And it’s become an angry, unpleasant household. Intimate small scale gossip, chronic pain and disintegration, bitter petty wiles and self-victimization have made my hospice visits a weekly chore. But too, a labor of love I don’t know how I’ll get on without. The home health aid, a devout, undocumented Panamanian woman who does the hardest of hard work—vomit, feces, disregard, invisibility, domineering commands, slights, pouts and scapegoating—for peanuts, lest she lose her only source of piddling income. She begs god for the strength to get through the day, her faith tethering her to abuse and emotional and financial insecurity. Too, she is proud. She’s never abandoned a patient, never. But as she labors, the wealthy, well-educated, octogenarians she cares for are thrashing and lashing under pain, isolation, boredom and slow-creeping grief. Pain is both relative and it is not. This too is how we die, more often than is polite to acknowledge.

A Lunch Conversation-cum-Slow Motion Slap Down—I can’t wade into 4chan. I don’t have the faculties required to master the uncanny evolution of its jargon or the (il)logic of its vomits onto caustic pages like Breitbart. But this I know: All kinds of highly-developed hate—for women, for minority groups, for the debilitated and earnest—get eyeballs, kudos and legitimacy from their stewing in like-hating juices. I lunched last week at a Ukrainian place in Manhattan with a friend, white, from Texas, almost two decades younger than I am, and what I thought was a discussion about despair and downward mobility turned into a rift about the parameters of humor. It’s left me with thought-scars. There is so much to learn from a deep-dive into the sources of our cultural anxieties and their expressions; twenty-something white males are feeling cheated, neglected, disrespected. A few some are hating, a fewer some are killing—others and themselves. So my question is: What do we do about the bile these anxieties are coating our social underbelly with? Call it privilege, self-indulgence, prosecutable? Look the other way? Excuse it because it comes from pain? And what do we do about how it threatens the lives of others? I’m a hypocritical excuser, prone to ascribe my own morality to behavior. I’m down on civility—we’re better off when we scrap things out—and up on free speech. But one young white man’s hate speech is another’s…humor? Community? Politics? Public policy? Escape? Reason to add more cops to the college campus beat?

Middle Aged White People, Bereft of Economic Opportunity—and Achievable Dreams—Are Dying—Ross Douthat, usually a bur in the mind, has summed up last month’s study thusly:

Starting around the turn of the millennium, the United States experienced the most alarming change in mortality rates since the AIDS epidemic. This shift was caused, not by some dreadful new disease, but by drugs and alcohol and suicide — and it was concentrated among less-educated, late-middle-aged whites.

We had hints that something like this was happening. We knew suicide was increasing among the middle-aged, that white women without a high school degree were struggling with health issues, that opiate addiction was a plague in working-class communities. But we didn’t know it was all bad enough to send white death rates modestly upward in the richest nation in the world.

Now we know, thanks to a new paper from the Nobel laureate Angus Deaton and his wife, Anne Case. And their findings, inevitably, are the latest ideological Rorschach test in the debate over how to save the American working class.

Douthat goes on to account conservative and liberal readings of the Dean-Case study. But neither, he concludes, is enough to stop the rise in mortality rates. Conservatives blame the way liberalism “undercuts the rootedness, discipline and purpose that marriage and religion once supplied, and the latter eases people into a life of dependence and disability payments that only encourages drug abuse and suicidal thought.” In short, if you hold a population to impossible, unrealistic expectations and they fail, you prove your accusations of immorality are true.

Of the liberal prescription for white death rates, Douthat allows only an economic explanation: redistribution of wealth upwards. Nonetheless, he concedes—as he so often snidely does—that a little bit of both might solve the problem. Teach whites, who have lost their way, how to find it (by returning to America’s moral parameters of “traditional” family, national loyalty and health). Improve the economy a little bit. It’s a position that’s no less paternal than the one he ascribes liberals. I loathe Douthat’s nostalgic and narrow version of morality—women at home raising kids, families attending church (from where charity is doled onto those who have failed), then returning home to a square meal at the dining room table—as much as I abhor his smug jabs at Blacks, purportedly resigned to their place (perhaps he means jail or section 8 housing in lieu of the morgue?). He closes the piece with a semantic punch to Black Lives Matter’s ribs, scapegoating demands for equality, saying that we must make “some of the unhappiest white lives feel like they matter again.”

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A terminal midwestern matriarch with all the money and power but none of the familial love, whose only comfort is a subservient Native American maid. A loyal soldier who comes home to internal and external horror, his Muslim lover making a little life from his discharge payment after he shoots himself in the head. A wealthy dying couple abusively taking out the vagaries of their approaching mortality on an undocumented aide with nowhere to go. A community of disenchanted young white men opting for hatred because it is a more empowering outlet than activism. And a national study that shows the “richest nation in the world” is nonetheless undergirded by self-abuse and self-murder. What does any of this tell us about the American Dream? That it is alive and well because we have banished and blamed those who aren’t. That it exists only for those who have had the system rigged for them—and finding your place in this system means blaming those whom the system fails.

The American Dream that ushered us through the 1980s and ‘90s, that we have dragged through the early 21st century on feeble, useless legs, that yet imbues our political discourse with its rhetoric, is terminal. It’s not within our power alone to reach out and grab it. Community and family, the structures that stabilize us, cannot be bought or dictated by outdated (or imagined) forms of moral behavior, but must be carefully, painstakingly fostered. Disease, disability, age, poverty and addiction are not an immoral choice, but rather the responsibility, without paternal moralizing, of society.

And yet our hobbled American Dream serves a perverse purpose. It’s a rhetorical trope and blind for legislators who find it easier to blame those on the bottom than to address systemic inequality. The American Dream gives corporate management the legal right to suck opportunity and wealth from employees, while claiming to be makers of opportunity. And they’ve made scapegoats of others, immigrants, minority groups, the sick, the ill, the poorly educated, rather than confront the fallacy of willful achievement. Those who have the power and agency of (what we call) success can tout the meritocratic American Dream; it comes from privilege, it is perpetuated by privilege. But this is the saddest part of all: we participate in this American Dream discourse and go on thinking that we are responsible for our plight, that we can beat the systems we are subject to, that we’re somehow responsible for not making the rent, for not getting that degree, for falling behind on the car payment. We’ve become our own scapegoats. In desperate need of a new American Dream.

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Past “The Patient Body” columns:

Using Disability

Memorials and Body Counts

How Ethics Saved the Life of Medicine

Impossible Purity

In the Blood

Pathological Sex

Choosing Childlessness

Old Man in Winter

Oh Canada!

End-of-Life Books, 2014

The Great Organ Shortage

Tending to One Another

Moral Highs and Lows

Old Philosophical Certainties

On Suicide

Reading HuffPo’s “Hospice, Inc.”

The End of Eating

Wakeful Unawareness

Faith, a Chronic Condition

A Special Sustaining Power

Your Ethical and Religious Directives

Hospitals and the Pretense of Charity

A Closely Held Business

What’s a Kidney Worth

An Irresistible Force

Ann Neumann is a contributing editor at The Revealer and Guernica magazine and a visiting scholar at The Center for Religion and Media, NYU. Neumann‘s book, The Good Death, will be published by Beacon Press in February 2016.