New Blog Location

Thanks for dropping by - this blog has moved to a new location:

The Doctor Is In

Please update your bookmarks and come visit my new site.

Moving to a New Location

It has been said that fools rush in where angels fear to tread, so April Fools seems an appropriate time to announce the new location of my blog: The Doctor Is In.

Blogger has been a great way to get started - free, instant setup, no host maintenance, virtually no development except a little CSS. But with ease comes limitations, and growing performance problems. My new location is powered by WordPress and hosted by HostingMatters. This combination is very robust and flexible, and has been a lot of fun getting up and running.

My most recent posts are also posted at the new location, although existing comments from this site cannot be moved. Most of my older posts are also linked under the "Best of:" blogroll categories, which makes them a lot easier to access by topic.

This site will remain up, and I will leave comments on for a few days, but all new posts will be at the new site.

So update your bookmarks and join me in my new home!

Thoughts on a Life's End

I have been avoiding any comment on the Terry Schiavo case for a host of reasons: first and foremost, I simply do not have enough information to make a reasoned judgment (nor, as far as I can tell, are the majority of people opining on her case). There is a huge amount of heat, and very little light, surrounding this case, and countless emotional, impassioned, and often irrational arguments have been made in the media and on the blogs. I despair of adding anything meaningful to this noisy melange, and frankly, the media frenzy, and excesses of both the pro-life and pro-death sides has become offensive and ghoulish.

Yesterday, however, Jerri at the always-thoughful Sue Bob's Diary, e-mailed me with the following comment and question:

I notice that you have stayed out of the Terri Schiavo issue. I figure that you have a good reason for that. But, I was wondering if you'd answer a question.

... I have a real problem with the idea of removing someone's feeding tube unless their systems are shutting down and they can no longer absorb nutrients ... I just heard a Medical Director of a nursing home on the radio talking about Alzheimer's patients losing their appetite and having feeding tubes inserted. The MD thinks removing the tube in such circumstances is justified. Perhaps it is if their systems are shutting down and they no longer want to eat...

I saw your post about extraordinary measures and agreed with it. But, as a Christian doctor, do you see acceptable parameters in all this?

Jerri has a habit of prodding me to write about things which I would prefer not to tackle. But not infrequently, such encouragement and the discipline of writing proves helpful in clarifying my own muddled thoughts about a difficult subject. So I'll give it my best shot.

My comments about Terri Schiavo herself will be very limited, based on what limited knowledge I have. As best I can ascertain, she appears to be in a persistent vegetative state, and it seems likely that her chances for any sort of cognitive recovery are virtually nil. On matters regarding her husband's and family's decisions, the courts, governor and congress, I won't comment for lack of sufficient information. Nevertheless, the issue of end-of-life decisions is far broader, and in my mind far more complex, then the current firestorm could ever resolve. My ambivalence on how best to handle such a situation is my strongest reason for refraining from posting on her case so far.

The challenge of end-of-life decisions is a byproduct of our successes and breakthroughs in preserving and sustaining life. They are the unintended consequence of technological advancement. 50 years ago, it is likely that a young woman with cardiac arrest would have died before she received emergency care, or if not, would likely have passed away shortly thereafter from complications, such as sepsis, embolus, or pneumonia. The advancements in acute emergency medical care and resuscitation have saved many lives, but some of these lives end up so severely impaired that the success proves a pyrrhic victory.

The moral and ethical dilemmas which have arisen from our dramatic improvements in emergency care go straight to the heart of what it means to be human, to be alive, to have meaning and quality in life. If one must use a pigeonhole, I would certainly be classified as a pro-life proponent. Life is perhaps the most precious gift given by our Creator, and cannot simply be measured by a superficial standard such as health, mobility, or even lucid mentation. Yet life is a gift, and not a god. As I have written in Dancing with Death, dying itself is also an integral part of life, and irrational and misguided attempts to prolong it can be very destructive, demeaning, and degrading to its dignity.

It seems to me that there is considerable confusion in our contemporary discussion of end-of-life decisions, engendered by such unfortunate and inexact terms as "pulling the plug." And each situation must be judged by its own merits, taking into account the overall prognosis for life, patient and family wishes, and the potential for the patient to return to some measure of meaningful relationship with family and others. Here are the core principles I fall back on when considering these difficult decisions. They are by nature generalizations, and exceptions will arise (especially in the very elderly), but they are useful guideposts nevertheless:

 • Life is more than any of its components.

We are more than our health, more than our bodies or mind. We are a composite of these things, and more: comprised of soul and spirit, defined as much by our relationships as by our physical or mental capabilities. Our lives do not become meaningless because of physical illness or disability, nor because of mental incapacitation -- hereditary or acquired. Our relationships with other humans and with God define us -- and not only our ability to relate to others (lost in persistent vegetative state and severe retardation or dementia), but also the relationship of others to us. This why, even though severely mentally impaired and unable to relate to others, an individual still has great value: they are of great value to God, and to others who love and care for them. When we narrow the meaning of life down to physical health or mental capacity, and deem it unworthy based on such factors alone, we are destroying that which is precious to others.

 • When the individual's outlook from a life-threatening acute or chronic illness is optimistic, or at least reasonably uncertain, we should choose to preserve life.

Consider two scenarios: a previously healthy man arrives at the emergency department with cardiac arrest of undetermined length. He is resuscitated, requiring placement on a ventilator. His cerebral function is impaired, perhaps comatose, but it is early in the illness, and his expectancy of return to a normal life is potentially optimistic. Ventilatory or other artificial life support in this situation, where the prognosis of the underlying condition and the chances for optimistic recovery are good, or uncertain, should be aggressively pursued.

This is an entirely different situation from stopping ventilatory support for patient who requires it to live, and for whom clinical evidence, such as length of time in a coma, or absence of brain activity on EEG, indicate little or no chance for functional recovery. In the first case, the cessation of life support will terminate the patient who may well have a very good outcome and lead a normal or nearly normal life; in the second, the patient's chances of recovering spontaneous breathing and cerebral function are nil, and therefore cessation of ventilatory support allows the underlying disease process to take its natural course. A similar scenario might be found in the patient who is dying of cancer and requiring ventilatory support, where the life support has no hope of changing the outcome -- death -- but only of changing its timing and prolonging its suffering. The outlook spoken of here involves both mental, relational, and physical, although mental and relation have a much higher priority. Few would argue that Christopher Reeves should have had his life support terminated, despite the fact that he required a ventilator to live, as his mental facilities and ability to have relationships was intact.

 • Those who have lost all functioning mental, social, and relational abilities, but whose underlying condition is not a threat to life (e.g., persistent vegetative state), should be sustained with basic care and life support.

The persistent vegetative state is very different from that in which the underlying disease is terminal or life-threatening, and poses a very difficult situation. The patient is physiologically alive, requiring no assisted ventilation or cardiac or vascular support to continue living -- in other words, their underlying disease will not kill them. In the early days and weeks of such as state, it is often very difficult to determine what the long-term recovery capability of the brain and nervous system may be. Healing of central and peripheral nervous system damage is often agonizingly slow, and may take a year or more to determine their final steady state. When it becomes clear that brain or central nervous system function has reached its maximum recovery, and it is at that time evident that no function associated with higher cortical function -- such as speech, comprehension, purposeful movement, or understanding of communication -- is possible, then, although the individual is technically alive, they no longer possess the capabilities of a normal functioning human being in society and relationships.

It is at this point that wisdom faces its greatest challenge. The question of whether to cease the most fundamental of life support measures -- food and water -- is a question which I myself have not completely resolved to my satisfaction, although I lean strongly toward basic life support -- food, water, basic care.

The problem I have with stopping food and water is the great risk of crossing a very dangerous boundary. If we define life only by our mental state, rather than as a union of mental, physical, and the relationships of ourselves to other and of others to us, it seems dangerously easy to move this boundary based on a subjective judgment about which specific mental capabilities constitute a meaningful life. An otherwise healthy patient with severe Alzheimer's disease most certainly has very little mental capabilities from a social interaction standpoint. Shall we deprive food and water from such patients? How about the severely mentally impaired who are younger, or unable to speak or hear? Certainly, none of us would choose a life with such severe quality constraints, given the choice. But forcing death when the underlying condition is not fatal, based on a subjective assessment of mental quality, strikes me as a very dangerous boundary to cross.

However, in a case where severe mental impairment or functional brain death is obvious, I would have no moral or ethical quandary with allowing another disease process which might prove fatal to run its natural course. An example would be a severe pneumonia or a septic condition. My own inclination would be toward a very non-aggressive approach in treating such a condition in a patient who clearly had no potential for recovery of higher mental or social function.

This may seem like splitting hairs, but it is not: in one case it is man who initiates death -- actively or passively; in the other death is determined by the natural course of a disease. I do not trust man to terminate life based on his own perception of quality of life, cost, burden, or ill-informed self-projection about what the patient might want. The power to initiate death (outside of the safeguards of a judicial context, when society deems a crime warrants it) will invariably lead to an ever-broadening array of "quality of life" issues for which death is "merciful."

This is, I understand, something of a compromise, and may be viewed by some as inconsistent with a pro-life position, or perhaps the opposite, of playing God. So be it. I believe the danger of actively terminating life, based on purely on an assessment of one's mental state or quality of life outweighs the obvious burden on society and individuals of preserving life at its most basic function, without functioning mental capacity. Nevertheless, when higher mental function is severely impaired, and the underlying disease process is invariably fatal, or potentially so, allowing that disease process to run its course without aggressive intervention seems to me both ethical and moral. Disease holds the power of death, rather than man.

 • Patient and family input on end of life decisions is vital, but not absolute.

Because the heart of human nature is relational, decisions about end of life must involve those in close relationship with the individual as well as the individual's own preferences. But these wishes are not an absolute. Our individual decisions are not autonomous, but affect others: we do not exist in a vacuum. This is why suicide is both morally wrong and illegal: suicide transfers the emotional pain and personal responsibilities from its victims to their families, and to society. A family's decision to keep a terminal patient alive on artificial support when hope is gone damages the dying person's dignity in death, and places the financial burden on society. Such issues are often very difficult to address, since there are many gray areas in predicting timing of death and recovery prognosis.

You see, it's not just about us, about our vaunted "quality of life." Jay Nordlinger, in his NRO Online column Impromptus, quotes a reader as follows:

I've come to understand that "the point" has little or nothing to do with what the Terri Schiavos, Aunt Winnies, and Aunt Maceys of the world have to offer, or even with their so-called quality of life. Rather, in expecting us to care for and continue to love those who no longer have the capacity to give anything in return, God invites us to pick up the cross. It's not really about them anymore, it's about us and what we are willing to give of ourselves in response to the challenge. I have watched hours of coverage regarding the Schiavo controversy; not once has anyone suggested that Terri's suffering presents an opportunity for her family to give of itself purely...

In far more words, I could not -- and have not -- stated it as eloquently as this.

Three Men on a Friday

Three men on a Friday, condemned to die. Ensnared by Roman justice, convicted, and sentenced to a lingering death of profound cruelty and excruciating agony.

The Romans knew how to do it right: execution designed to utterly humiliate its victims, and maximize their suffering -- a public spectacle and object lesson to others about the foolishness of defying Roman authority. First used by the Persians in the time of Alexander the Great, and adopted by Rome from Carthage, crucifixion was so horrible and debasing a fate that it was not permitted for citizens of Rome. Victims hung for days, their corpses consumed by carrion.

Our knowledge of these three men is incomplete. Two are described in ancient texts as thieves, the other a preacher run afoul of religious leaders, delivered to the Romans under pretense of imperial threat. There should have been nothing unusual about this event: the Romans crucified criminals often, sometimes hundreds at a time. Yet these men, in this spectacle, were different: on these crosses hung all of mankind.

Two thieves and a preacher -- an odd picture indeed. And even more peculiar: the most hated was the preacher. Taunted, insulted, ridiculed, reviled. A miracle worker, he, a man who supposedly healed the sick and raised the dead, yet now hung naked in humiliation and agony, unable to extricate himself from his dire circumstance. Even those convicted with him -- themselves dying in unbearable pain and mortification -- join the fray. Insulting the rabbi, demanding he set himself -- and naturally, themselves as well -- free. They know his reputation, yet selfish to the end, desire only their own deliverance.

But one thief is slowly transformed, in frailty considering his fate and the foolishness of demanding release when his punishment is just. And he marvels at the man hung nearby -- why? Why does this preacher, unjustly executed, not proclaim innocence nor demand justice or vengeance? Why does he -- amazingly -- ask God to forgive those who have so cruelly and unjustly punished him? Why, in the extraordinary agony only crucifixion can bring, does he seem to have peace, acceptance, perhaps even joy?

His revulsion at the baying crowd, at the arrogance of his fellow convict reviling this man of character and grace, bursts forth in rebuke at him who ridicules: "This man has done no wrong!" Turning to the preacher, he makes a simple, yet humble, request: to be remembered. Only that. No deliverance from agony, no sparing of death, no wealth, prosperity, or glory, no miracles -- only to be remembered.

The reply reverberates throughout history: "This day you shall be with me in Paradise." A promise of hope, a promise of relationship, a promise of forgiveness, a promise of comfort, joy, healing, peace.

Three men on a cross. In these three men are all who have lived: two are guilty, one innocent. Two are justly executed, one unjustly. All three have chosen their fate: one thief to revile, ridicule, hate, blaspheme; one criminal to trust, to seek consideration and mercy from one greater; one man to submit to brutal and humiliating torture and death, willingly, for no crime committed -- or for all crimes committed, everywhere and for all time. Yet only one promise given -- to the one who, though guilty, trusted and turned.

Who was this man in the middle, this preacher? A charlatan, perhaps - but an imposter abandons his schemes when such consequences appear. Delusional, deceived zealot, or presumptuous fool? Such grace in agonal death is inconceivable were he any such man. What power did he have to make such a promise? What proof that the promise was delivered?

An empty grave. A promise delivered by a cavern abandoned, a stone rolled away. A gruesome death transformed into a life of hope, meaning and purpose for those who also trust.

An Angel From God

Sometimes in the rush of the high-speed news cycle a story just reaches out and grabs you. Brian Nichols -- on trial for raping his ex-girlfriend at gunpoint for three days -- shot a judge and three others in a courtroom in Atlanta, before escaping as a an armed, hunted and highly dangerous fugitive. At 2 AM in a parking lot, he encountered Ashley Smith, and took her hostage in her own apartment:

[Smith] said Nichols tied her up with masking tape, a curtain and extension cord and told her to sit in the bathroom while he took a shower ... Smith told Nichols about her daughter and bonded with him after he said that he had a son who had been born the night before.

'My husband died four years ago, and I told him if he hurt me my little girl wouldn't have a mommy or daddy,' Smith said.

Smith's attorney, Josh Archer, said her husband died in her arms after being stabbed.

...'You're here in my apartment for some reason,' she told him, saying he might be destined to be caught and to spread the word of God to fellow prisoners. She also read the bible to Nichols ... 'He told me I was his angel, sent from God, and that I was his sister and he was my brother in Christ,' said Smith.

It is easy to be cynical about the religious experience described here; there may in time prove to be ample reason for such cynicism. A cornered and defeated criminal may turn to religious talk or claim conversion in hopes of gaining leniency in sentencing or to sway a jury in a region where religious conviction means a great deal, such as the deep South. Such leniency seems a remote hope when an accused rapist has murdered four people in the criminal justice system and taken a hostage, but desperate men take desperate measures.

But the story of Ashley Smith is a truly remarkable one -- one which should cause everyone to pause and consider what makes a women behave with such extraordinary grace and poise in such a situation.

Consider: Ashley Smith is a widow with a young daughter, her husband a victim of violent crime. She finds herself taken hostage at gunpoint, bound and gagged in her bedroom by a rapist who has just murdered four people. Her response? She engages her kidnapper, discusses her life with him and inquires about his. When finally unbound, she asks if she can read! Consider this remarkable description from the Wichita Eagle report:

Smith asks if he would mind if she reads.

Nichols says OK. She gets the book she'd been reading, "The Purpose Driven Life." It is a book that offers daily guidance. She picks up where she left off -- the first paragraph of the 33rd chapter.

'We serve God by serving others. The world defines greatness in terms of power, possessions, prestige and position. If you can demand service from others you've arrived. In our self-serving culture with its me-first mentality, acting like a servant is not a popular concept.'

He stops her and asks her to read the passage again.

It gets even better: Nichols needs to hide the truck he has stolen, and asks Smith to help. After moving the truck,

She drives him back to her apartment, where she cooks him eggs and pancakes, gives him fruit juice. They have breakfast together.

Smith washes the dishes and gets ready to leave.

Nichols asks her to come visit him in jail. 'You're an angel sent from God to me,' he tells her. "I want to talk to you again. Will you come see me?"

She tells him she will.

Now think about this for a moment - especially those of you who are skeptical, dismissive or even antagonistic about Christianity: what would a sane woman do in these circumstances? Indeed, what would you do? Perhaps you might have smooth-talked your way out of duct tape and hand cords (nice work, as a women alone with a rapist -- how'd you manage that?) Then you start reading the Bible and a devotional book (The Purpose-Driven Life) to him -- and he listens and asks you to repeat it. Then, when he decides to move a stolen truck -- having left his guns in the apartment (another nice trick, that)-- and has you drive alone in a separate car, you drive him back to your apartment (rather than drive away as fast as you can, calling the cops as you run) and you fix him breakfast, dine with him, and calmly clean up the dishes. He sets you free, then gives himself up.

Does anyone find this anything less than astounding? Either Ashley Smith is one of the shrewdest psychologists on planet Earth -- and a mind-reader and master manipulator to boot -- or something out of the realm of reason and normal human experience has happened here, and two lives have been utterly overtaken by its power. The word awe is not inappropriate here.

What drove Ashley Smith to respond this way? The answer, I believe, was that she was ruled not by fear, but by faith and by love. Fear is a natural response to a personal threat, and there is no doubt she experienced a great deal of fear in her situation. Yet her behavior arose not from the fear, but rather from trust. She understood that she was in the hands of God -- a God who had paid the ultimate price for her already, having given up His Son to torture and death to restore her to relationship with Him -- the most central tenet of the Christian faith. Such a God, whom she trusted to be in control of every situation in life, had allowed this very crisis for some good purpose, though her fear screamed otherwise. Her job was to trust, to pray, and to serve her God by communicating His love as best she could, no matter what the outcome. She did this through her words made verity by her service.

The concept of love is horribly twisted in our culture. It describes a host of things -- infatuation, attraction to superficial beauty, sexual desire, materialism -- which are peripheral, or even inimical, to its true meaning: the sacrifice of one's self for the good of another. Yes, Ashley Smith demonstrated love to Brian Nichols -- in seeking to build a relationship with him; to encourage his better angel which she trusted was present (though all evidence pointed to no such redeeming virtue in him); to avoid fleeing and calling police, as his demise was far more likely in a solo standoff with law enforcement; to risk her own life and safety to return to the apartment willingly; to grace this evil and fearful man with a meal prepared and shared; to demonstrate poise and inner peace in attending to routine chores in his presence.

Ashley demonstrated that she had learned the lessons of The Purpose-Driven Life in the brutal schoolroom of an evil world: that life has purpose and power in relationship to God, in service to Him in the mundane and the terrible, in happiness and in horror. God made her something she was not when she arrived in the parking lot that night. No doubt He had prepared the soil through the suffering of a husband murdered -- a pointless agony with incomprehensible pain, when you do not know whether to cry out to God or curse Him for allowing it, when life's plans are shattered and there is nothing left but a slender thread of faith to grasp. Yet grasp it she did, and slogged on in trust -- to be rewarded again for her trust as a hostage to a murderous rapist. It all makes no sense: God cannot be fair or just in reason's eye when such evil overwhelms. Yet her life will be forever changed by her experience, profoundly, for the better, as will those of many, many others.

And what of Brian Nichols? A foxhole conversion? Slick, manipulative religious words in hope of leniency? Time alone will tell; perhaps he will sink into the black hole of life imprisonment, never to be heard from again. But maybe, just maybe, his life -- and the life of many he touches -- will be likewise transformed by the extraordinary grace given to a woman in service to God. I for one will be watching for it.

Travelling East

I will be travelling with family to the East Coast tomorrow for the week (Washington D.C., Baltimore, and maybe Philadelphia), so there won't be much -- if any -- blogging until then. I was hoping to get a post up before leaving, but alas, work and trip prep were unrelenting. Looking forward to recharging the batteries with some much-needed time off.

God bless, and God willing, I'll be back soon.

Dancing with Death

The war rages on. It is a battle with ancient roots, deeply embedded in religion, culture, and the tensions between rich and poor. It is a war of contrasts: high technology and primitive cultural weapons; knowledge versus ignorance; speed and urgency against the methodical slowness of an enemy who knows time is on his side.

It is a war in which enormous strides have been made, with countless victories large and small.

The enemy is death. The avenger is medicine. And the war is going very poorly indeed.

In many ways, the gains of modern medicine against death and disease are truly impressive: longer life expectancies; progress and cures against heart disease, cancer, and diabetes; surgical and procedural marvels hard to imagine even 15 or 20 years ago. Yet, it is these very advances which seem to lie at the heart of a growing problem. We are so engaged in the battle, so empowered by our growing capabilities, that we have lost sight of the bigger picture. While pushing back the adversary of death, we are ever so steadily being destroyed by the very battle itself.

Several recent experiences have driven this dichotomy home for me. Last week, I was asked to evaluate a man who had been hospitalized for a over a week. A nursing home resident in his late 80's, his overall health was fair to poor at best, and he suffered from severe dementia. He was unable to communicate in any way, and could recognize no one -- not even his wife of many years, who remained in possession of her full facilities. He was admitted to the hospital with a severe urinary tract infection with a highly resistant bacteria, and septic shock. When he arrived at the ER, the full extent of his dementia was not apparent to the physicians there, and his wife insisted that all measures be engaged to save him. Aggressive medical care was therefore initiated -- intensive care unit, one-on-one nursing care, hemodynamic monitoring, drugs to support blood pressure, intravenous nutrition, and costly antibiotics. After nearly two weeks of such intensive therapy, the patient largely recovered from his life-threatening infection -- returning to his baseline of profound dementia. Yet the underlying risk factors which led to it -- his age, a chronic bladder catheter and bacteria-harboring stones, diabetes, -- remained in place, lying in wait for another, inevitable opportunity, in a matter of weeks or months. The cost of his hospitalization was easily in 6 figures.

In another situation, an elderly women presented to the hospital with signs of a serious, life-threatening infection in her abdomen. A healthy widower, she lived independently with her sister prior to her illness. Emergency surgery was performed, and an abscessed kidney removed. Her medical condition deteriorated after surgery, with coma due to stroke and failure of her remaining kidney brought on by the infection.

The patient's sister and living companion communicated the clear final wishes of the widower: a women of strong faith, she wished no extraordinary measures, such as ventilators or dialysis, to extend her life needlessly. She was comfortable with death, and not afraid. The staff prepared to allow her to die gracefully, comfortably, and in peace.

But such was not to be. There was no living will, and the sister did not have legal authority to make such decisions. But the widower's daughter, a nurse living out-of-state with little recent contact with her mother, arrived in town demanding that aggressive measures be taken to save her. A nephrologist (kidney specialist) was called in. A superb physician, compassionate and dedicated, he had been successfully sued in a similar case after recommending that dialysis be withheld in a patient with a grim prognosis. This was a mistake he would not make twice: the widower was transferred to another hospital, placed on dialysis, and died 3 weeks -- and a quarter of a million dollars -- later, in an ICU. She never woke up.

The issues which these two cases bring up are numerous, complex, and defy easy answers. They touch upon the subjective measure of quality-of-life and what it is worth; the finite limit of economic health care resources; the relative responsibilities of physicians, patients, and their families in end-of-life decisions; the pressures placed on the health care system and its practitioners by after-the-fact second-guessing in an aggressive tort environment; and a host of others greater or lesser in weight and substance, up to and including the meaning of life itself.

All the players bear responsibility in this passion play. Physicians excel at grasping what they can accomplish, but are woefully inadequate for the task of deciding whether such things should be done. In the urgency of acute care, delay to consider the ramifications of a decision to treat may cost an opportunity to save a patient for whom such treatment is desirable; better always to err on the side of salvage. Pressured by family, potential litigation, or instinct, the path of least resistance is to follow your training and use your skills. And physicians themselves are uncomfortable with death, though inundated in its ubiquity.

Family members naturally resist the agonal separation of their loved ones, often harboring unrealistic hopes and expectations of recovery in the face of inevitable death. A curious dance of denial often ensues between physician and family, as each, unwilling to face the unpleasantness of the inevitable, avoids the topic at all costs. The physician hides behind intellect, speaking of blood counts, medications, and ventilators, or at best tiptoeing around the core issue with sterile terms like "prognosis." Family members hesitate to ask questions whose answers they already know. Too rarely are the physician and family willing to place the subject squarely on the table, in all its ugliness and fearfulness. Decisions which need to be made are put off, unspoken and deferred. The clock ticks on, the meter is running, and only the outcome is not in doubt.

The tort system provides a ready outlet for the anguish and anger of death of a loved one. In such a period of intense emotional turmoil, the real or perceived indifference of physicians (often a mechanism of detachment by which doctors deal with the horrors of death and illness); the parade of unfamiliar medical faces as no-name consultants come and go during the final days; the compounding burden of crushing financial load from the extraordinary costs of intensive terminal medicine; the Monday-morning quarterbacking by the tort system of complex, often agonizingly difficult medical decisions in critically-ill patients: all present a toxic and intoxicating brew which impels the health care system forward to leave no avenue untravelled, no dollar unspent in prolonging life beyond its proper and respectful end.

This march of madness is not without resistors. Seizing on the high costs, the futility, and especially the lack of personal control fostered by impersonal, highly technical terminal care, the euthanasia movement is maneuvering into the gap. Cloaked in slogans of personal autonomy and "Death with Dignity", active euthanasia proponents seek to replace the sterile prolongation of a now-meaningless life with the warm embrace of Death herself. Terrified by an out-of-control dying process, an end of a life which embodies all meaning, they seek to control death as their final act of significance. But Death will not be controlled, and those who dance with Death are seduced by her siren. Euthanasia starts with compassionate intent, but ends with termination of the useless. Man does not have the wisdom to control death; The Ringbearer is corrupted by its power.

Our discomfort with death is our confusion about life. Man is the only species cognizant of his coming demise -- who then, in the ultimate paradox, lives his entire life pretending it will not happen. Our Western culture, enriched with a wealth of distractions, allows us to pass our living years without preparing for the inevitable. When the time arrives, we use all the weapons at our disposal -- wealth, technology, information, law -- to resist the dragon. We drive it back for a time -- at enormous cost, personal, financial, physical and emotional. Death always wins -- always.

I am not of course yearning for a return to the past, a passive resignation to the inevitable anabasis of disease and death. The benefits of medicine and the forestalling of death are precious and powerful gifts, which have greatly benefited many. But like all such great powers, they are useful for good or ill. When the defeat of death becomes an end in itself, detached from the meaningfulness of life lived, it has great destructive energy.

We must learn how to die. And to learn how to die, we must learn how to live -- how to seek the transcendent, the power of love, and sacrifice, and giving which makes life rich and enduring. The selfish, the superficial, the transient all gratify for a time, but when this is all we possess, we grasp desperately to their threadbare fabric when beauty and health give way to weakness, fear and death. All great religions understand this: the meaning of life transcends life. In the Judeo-Christian view, life is an opportunity to draw ourselves and others closer to the light and goodness of God, with the promise of an even greater life and deeper relationship after death. Yet even for the agnostic or secular among us, service to others -- personal and social -- has the potential to endure long after us. None of us will be remembered for our desperate clinging to life in its waning days, but rather for the lives we touched, the world we made better when we lived.

Comments on Comments

I have turned off comments on the site for now. After my last post, I received a flurry of comments, the basic premise of which was that I was an arrogant physician who cared nothing for patient autonomy, was a greedy SOB, and that I -- and all doctors with me -- deserve to be sued out of our BMWs. And that was the warm, fuzzy icebreaker -- it went downhill from there.

Now, far worse things have been said about folks on the Internet. But what was evident in the comments was the presumption that physicians are arrogant and greedy, and deserve every lawsuit they get and more. Most of the negative comments were anonymous.

Comments on a blog are a decidedly mixed bag. They are public, and become part of the post. This can be a good thing: well-thought-out comments may challenge the poster's facts or suppositions, or may add significant information on the topic which enriches the overall post. This is true even of negative comments, posted respectfully. Conversely, the anonymity of the Web seems to bring out the worst in some people. The idea that you are going to win someone over to your point of view by starting a conversation with a stranger, impugning their character and integrity, and smearing their entire profession, frankly strikes me as a bit odd, and certainly stupid. There is a great deal to impugn in my character, and no shortage of character defects and shortcomings, -- but that is why I have friends and family. They have earned the right to point out my defects based on a mutually strong and trusting relationship, and I accept such criticism -- though unpleasant -- far more readily. But from an anonymous moron on the Web with an ax to grind? Yeah, right. The public nature of such comment flame wars tends to demand a response, which in me brings out the snarky, sarcastic, condescending side of my nature. This is a character flaw I would rather not practice to perfection. Furthermore, there is barely enough time to post semi-intelligent essays on this blog. Devoting additional time to extinguishing ill-willed flamethrowers is utterly pointless.

And let's get a grip, folks. This is a personal blog. It is a labor of love, a useful tool to help me organize my thoughts, and hopefully provide some value to others. If you enjoy reading, I'm grateful, and appreciate your interest. If you're bored, perhaps some other post may be of more interest, or there's a million other blogs to interest you. If it enrages you to the point of seething anger, perhaps the issue is less me than you, and you most certainly need to find some other more enjoyable and less stressful activity. Of course, if you just want to spew venom at strangers whom you dislike or hate, perhaps it's time to do a little soul-searching of your own. Just do it elsewhere, please.

For now, readers who appreciate these posts and want to express that, or want to contribute other thoughts or corrections, are more than welcome to e-mail me. If you strongly disagree with me, and wish to carry on a conversation in a mutually respectful manner, I am more than open to that, time permitting. I most certainly do not have all the answers, and will treat every such e-mail with respect it earns. If you just want to rant and seeth, do whatever you need to do to vent your rage: kick your dog, punch the wall, sacrifice a goat to Satan, whatever it takes. But please don't waste your time, my time, or my readers time with this drivel.

One point raised by my erudite detractors is worth repeating, since my response in the comments is now hidden. This is the issue of patient autonomy. For me personally, -- and for every physician I know -- patient autonomy is extremely important. The myth of the paternalistic physician snapping orders to the passive and demure patient is utterly out of touch with reality. The common thread of comment criticism was that, as a patient, you pay me your money, and you get therefore to dictate my services. This is an extremely contractual view of the physician-patient relationship. My job is a physician is to use my skills, training, experience, and intellect to determine the nature of the patient's disease or problem, to educate them on the treatment options available, and make recommendations when appropriate. The patient is entirely free to accept or reject my recommendations. I may encourage them not to reject them, and explain the potential adverse consequences of such a decision, but it is their decision entirely. There is one important distinction, however. The patient is not free to demand that I performed a service or treatment which is unethical, or which I know to be harmful to the patient. This is both my responsibility and my autonomy in the relationship. If you find that arrogant, well, tough.

This is the exact point I was trying to emphasize in my prior post: the patient is entirely free to reject a recommendation that his testis be removed, because of the high risk of cancer, knowing that a small percentage of that time there will not be cancer present. He is not free to demand that I perform a biopsy which will pose a significant risk to his life or health, where the risk far outweighs the benefit. Patient autonomy is not unlimited, although it is broad. Physicians are constrained morally and ethically from doing harm to patients deliberately, no matter what the patient demands of them, or the economics involved. A society which penalizes physicians who make such moral and ethical choices, by means of lawsuits or otherwise, is one which will live to regret the destruction of this boundary.

Update: Thanks to the many folks who wrote and encouraged me about comment trolls and asking to restore comments. I'll turn them back on this weekend -- albeit with a short leash on morons. As I've said, I don't mind disagreement (in fact, I encourage other viewpoints -- "as iron sharpens iron", etc.), but ad hominem attacks on me or against other commenters, or otherwise abusive comments, will be deleted and IPs banned. Battling the morlocks is not a productive use of my time. But I am deeply grateful to those who appreciate the blog - come back often, and leave comments!

Sued for Proper Care

A recent brief AP wire story highlights the adversarial and often irrational legal environment in which physicians practice today. The article, Man sues over botched testicular surgery (hat tip: Kevin, M.D.), is very brief, and it is obviously not possible to determine the validity of such a suit based on a such a brief press release or wire story.

One wonders why such a story is newsworthy at all -- but the headline gives us all the clues: there's been a medical screw-up, and it involves a sexual organ. Titillating stuff indeed -- far more interesting to readers than, say, a story about a CNN executive claiming that U.S. troops were assassinating journalists. Problem is, I strongly suspect the physician here is being sued for providing good, appropriate care.

Here's the brief description of the case:

Danny Curtis claims the surgeon at Kern Medical Center did not conduct a biopsy before arranging urgent surgery to remove a testicular tumor in July 2004, according to the lawsuit filed in Kern County Superior Court.

Doctors later discovered that the tumor was not malignant and did not need to be removed, according to court documents.

Testicular cancer is a rare but very aggressive malignancy, typically affecting men between the ages of 18-35 years of age. It usually presents as a painless lump or swelling in the testes itself, and not infrequently is ignored by the patient or misdiagnosed by physicians as a benign infection called epididymitis. The tumor may grow rapidly and spreads by the blood stream or lymph system. Patients may present with huge metastatic tumor masses in the abdomen, chest, liver or brain. This was how Lance Armstrong -- perhaps one of the most famous testes cancer patients -- presented. Although aggressive chemotherapy has made huge advances in successful treatment of such often-lethal cancers in the past decade, testicular cancer remains a killer of otherwise healthy young men.

The diagnosis is suspected in most cases by physicial examination and ultrasound. A solid growth in the testes itself -- as opposed to the structures adjacent to it -- has an extremely high risk of being malignant - about 95-97% in most studies. While biopsy prior to removal would appear to be logical and prudent, it is in fact a very risky proposition.

When the cancer is entirely confined to the testes, it is curable by simply removing the testes and the accompanying spermatic cord surgically. Biopsy violates the natural barrier confining the cancer to the testes, and risks spilling cancer cells into the surrounding tissues or the blood stream. Once this occurs, far more drastic measures are needed to eradicate the cancer, including very toxic chemotherapy treatments, or possibly radiation or additional major abdominal surgery to remove lymph nodes or tumor. The risk of serious complication -- or even death -- rises dramatically.

This is a classic example of the risk-benefit decision-making process in medicine. All medical treatments carry risks; one penicillin tablet can kill you. In the realm of testicular cancer, the calculus is straightforward: if there is a solid growth in the testes, it needs to be removed surgically, with a known 3-5% risk of removing a testes which does not contain cancer. Performing a biopsy first, to spare this small percentage of testes which do not have cancer, exposes the patient to the more serious risk of spreading the cancer, and changing treatment from simple low-risk surgery to high-risk chemotherapy, radiation or major surgery.

The details of this specific case are unknown, but easy to imagine: the patient presents to the doctor with an abnormal testes, which the doctor finds very suspicious for cancer. The physician recommends surgical removal, the patient assents, and the pathology report shows the uncommon benign tumor. The patient is understandably unhappy about losing a testicle unnecessarily (as he understands it).

Perhaps the physician did not explain the above scenario to the patient; perhaps he did, but didn't document it, and the patient doesn't remember it. If it's not on paper, it didn't happen, from a legal standpoint. There are, of course, issues of informed consent here: patients have a right to decide on treatment after being presented with the risks, benefits, and alternatives. But very few patients, when presented with the above facts, will refuse treament and take the risk of unnecessarily spreading a curable cancer.

So the informed consent issue (likely the basis for filing this case) becomes a loophole through which the unhappy patient seeks redress for an undesirable outcome. The physician likely made the correct medical decision -- one endorsed as standard of care by every expert in testicular cancer -- and is rewarded with a lawsuit.

Now of course, the physician in this case may have been incompetent, and removed a testes at low risk for cancer, or failed to meet the standard of care for half a dozen other reasons. But far more often than not, this is not the case. The outcome was bad, the loophole was found, and the solution was a lawsuit.

These are the situations which keep doctors up at night, burden the doctor-patient relationship with highly detailed, patient anxiety-provoking, time-consuming and paperwork-generating counseling sessions, and undermine the trust between doctors and their patients. Much emotional and physical energy is diverted from caring for the patient and building the relationship to self-defense measures. This is the true cost of defensive medicine: not merely the ordering of expensive, low-yield tests in anticipation of future depositions and Monday-morning legal quarterbacking, but the undermining of the trust and relationship between doctor and patient.

The case may go nowhere, but there will be significant costs to litigation even then, and inevitable emotional, personal and professional detriment to the physician. The patient may win the suit, but the settlement received will not restore his testicle. Nor will the settlement change the behavior of the physician, who likely acted in accordance with proper professional standards and training. The only effect will be to make him or her more wary of patients, and perhaps slower to remove a malignant testes in the next patient who presents with cancer.

Is this really the best system we can devise for resolving undesireable medical outcomes?

Medical Bankruptcy

Considerable media attention has been paid to a recent study demonstrating a strong link between bankruptcy and medical illness. When I first read of the study in the Wall Street Journal, I must confess I was skeptical. Studies which receive large media attention are sometimes driven by an underlying agenda, and in some instances, have used questionable study populations and statistical analysis to produce a result less scientific than political in nature. One such controversial study was the Institute of Medicine (IOM) Medical Error Report of estimated morbidity and mortality from medical mistakes. The study has been widely criticized for its overly broad definition of a medical error, retrospective analysis of data over 10 years old, study populations which may not be representative, and the statistical sleight-of-hand of multiplying the findings in a small population nationwide produce a staggering estimate of deaths and injuries due to medical mistakes. Nevertheless, the study has fully entered the public consciousness, and is often quoted as a solid fact in health policy discussions.

The bankruptcy article, published in Health Affairs, initially raised some red flags. Its chief author, David Himmelstein, is a health care activist and strong proponent of nationalized healthcare -- a fact not mentioned in the media reports. While this is an entirely legitimate philosophy to promote, it is also true that such a bias might produce a study strongly inclined to reach conclusions supporting the authors preconceived philosophy.

However, after studying the article, I was pleased to find a thorough and detailed methodology which suggests a strong effort to obtain useful data as little influenced by bias as possible. Nevertheless, the big media splash suggests the authors conclusions were in line with their philosophical bent. Yet reading the study, such conclusions seem strained.

The authors reviewed nearly 1800 personal bankruptcy files from five federal courts (geographic locations not specified), and followed up approximately half of these with detailed, in-person interviews. The demographics showed bankruptcy filers to be predominantly middle or working-class, with women slightly outnumbering men. Approximately one quarter of bankruptcy filers cited illness or injury as the specific reason for bankruptcy, and a similar number cited medical expenses as a contributing factor, with uncovered medical bills in excess of $1,000. However, somewhat surprisingly, medical debtors were no less likely than other debtors to have coverage at the time of bankruptcy filing.

The media headlines trumpeted one conclusion of the study: that 55% of bankruptcies were related to medical illness or expenses. The inference in several of the newspaper articles was that lack of health insurance or high medical bills was the cause of over half of all bankruptcies. Reviewing the study, however, such a startling conclusion does not appear warranted. First of all, the 55% figure is a fruit salad of risk factors for bankruptcy. The study groups together medical bills in excess of $1,000 with major medical illness or injury resulting in loss of work time and work-related income. The more accurate conclusion, to my reading, is that illness or injury resulting in loss of job or loss of income is significantly more important, although often added to, unpaid medical bills. This conclusion is reinforced by the fact that many of those filing for bankruptcy were not without health insurance coverage. In many cases, the illness resulted in loss of employment, and subsequent loss of health insurance.

Somewhat surprisingly, few medical debtors studied had elected to go without insurance coverage. Furthermore, debtors out-of-pocket medical expenses were often well below catastrophic levels. In the year prior to bankruptcy, the average out-of-pocket medical expenses was $3,700, and the average out-of-pocket costs since onset of illness was less than $12,000.

A far more significant risk is the loss of work and income due to illness or injury. The intimate connection between employment and health insurance doubles the bet, as prolonged illness means lost income, lost jobs, and lost health insurance.

The medical dollar amounts -- annual medical expenses over $1,000, multi-year expenses over $10,000 -- certainly represent a significant burden to low or middle-income families. Yet to a far greater degree they reflect the extreme financial brittleness of those who end up in bankruptcy. The numbers cited are far less than many families spend on an automobile, or on car repairs, or to fix a leaking roof. How many of these families were living beyond their means, overextended by credit card debt or large mortgage payments, is not clear. How many women were abandoned by husbands with children to raise, and little or no income to support them? Such issues are social in nature, reflecting the breakdown of marriage commitment, the indirect effects on families from an epidemic of drug and alcohol abuse, public policies discouraging savings, individual lack of financial discipline, and a potential host of other social pathologies unrelated to health care costs. Indeed, the authors themselves admit that even universal health care coverage would not have prevented many of the bankruptcies. Medical expenses are certainly one factor, and medical catastrophy can and does result in financial devastation to some, but health care costs alone do not shoulder the responsibility of over half of all bankruptcies.

Health Care Is Not a Widget

This essay begins a series on problems and possible solutions to the current mess we call health care in our country. It takes no small amount of hubris to assume that one has all the answers to the health care quagmire -- I most certainly don't -- especially when far smarter and more knowledgeable folks have been beating their heads against this problem for ages, with little apparent results. But I have observed that basic principles of common sense, human behavior, good business principles, and yes, morals and ethics, are often ignored when crafting solutions to health care. What I hope to accomplish in these posts is to lay out some defining principles based on many years of experience in patient care and managing a medical practice business, seasoned with a life perspective of grace, and hopefully humility, derived from my faltering, but ever enlightening, journey in the Christian faith.

And so we begin with Lesson I: Health Care Is Not a Widget

Ahh, widgets: those ubiquitous fictional entities seemingly discussed everywhere, yet unseen by human eyes. They are defined thusly:

Widget: A fictitious good, commonly used by economic instructors to demonstrate economic principles or undertake hypothetical analyses ... If such a good exists -- and there is no clear evidence that widgets have every existed -- it is a small mechanical device, constructed of interlocking cogs, several knobs, and at least one handle. Widgets are most often used when thingamajigs and dohickies are unavailable.

Widgets are used as instructional tools to demonstrate the effects of economic principles, such as supply and demand. Health care being an industry with broad economic reach, its component services are sometimes thought of in classical economic supply-and-demand terms. Yet health care economists and politicians seem puzzled that medicine is so often unresponsive to the typical economic rules governing most other industries and service sectors.

There is a reason for this: health care is not a widget.

The problem is not that health care services are entirely outside the laws of economics; indeed, many of our health care financial problems stem from distorted or perverse economic incentives. But the nature of the services themselves differ from virtually every other service industry. How so, you wonder? I thought you'd never ask. Here's just a few key distinctions:

• Health care services are not generally subject to choice.

At the heart of free-market economics is the idea of choice -- you are free to buy my product if it is something you want or need, and the price is agreeable. You are also free not to purchase it, or to buy it elsewhere if you find a better price or quality. To a limited extent this is true in health care -- if I want a tummy tuck or facelift, I can shop around for the best balance between surgical expertise and price, and if I fail to find that balance, I can choose to forego the service.

In most cases, however, such detached rational decisions do not apply to health care, since the service is non-optional. If you have crushing substernal chest pain, you are not in a position to evaluate the optimal price or quality of the service you require: you need to get to the hospital before your heart attack kills you. The ER physician who sees you is someone you have never met; you do not know his skill or credentials; you have not negotiated a price for her services. While you may have some choice about which hospital to attend, even here your choice is severely limited by expediency -- you drive (or are taken) to the nearest one, lest you die en route.

Even in health care situations more routine and less urgent than such medical emergencies, many factors preclude free choice and free market decisions in health care. In the marketplace, the buyer typically judges the value of the product, then judges whether the asking price is appropriate to this value. In medicine, the true value of the services provided is extremely difficult to determine. We must often make choices of physician or facility purely on hearsay, or the recommendations of another physician or friends, or other factors unrelated to quality, such as proximity to home or work. The system lacks transparency. So the quality of the product you are purchasing is extremely difficult to assess prior to purchase.

Further restrictions are introduced due to the high market penetration of managed care health insurance. Insurance carriers contract with specific physicians to provide care to patients enrolled in their plans. While often touting the "high quality" of their network providers in marketing materials, contract decisions are based either on the willingness of physicians to accept the insurance carrier's fees, or the desire of the carrier to provide broad physician access for their clients -- a "take all comers" approach. Either way, quality is a virtual non-issue. Insurance quality screens weed out only the most egregious offenders -- and sometimes not even those.

Lastly -- and most importantly -- those seeking health care are almost entirely shielded from the actual cost of the service. While you often pay a percentage of the cost -- through copays and deductibles -- this amount is totally unrelated to the quality of the service. The payment has been predetermined by your insurance carrier, and the premium likely paid by your employer, or the government. So virtually all the normal forces of the free market are constrained or eliminated.

• The satisfaction with the product is not uniquely dependent on its provider.

When you buy a car, you make certain assumptions: the manufacturer has taken pains in design and manufacture to ensure a high-quality product; that quality-assurance programs are in place to monitor its manufacture; should a major problem arise, the vehicle will be recalled and the problem fixed without cost -- save inconvenience -- to the owner. These assumptions are legally spelled out in the vehicle warranty - which also spells out the owner's responsibility to maintain the car at specified intervals.

Medicine is a different animal in many ways. There are a host of variables which affect the quality of the final product. Obviously, the skill and training of the physician providing care is a critical factor. The quality of the complex system which supports the service -- the hospitals, nurses, medical equipment, suppliers, pharmaceutical companies, etc. -- comprise together another key ingredient. Often overlooked is one other, critical factor, however: the quality of the purchaser of the service.

By quality, there is no inference or intent to disparage, but rather to point out a number of patient/purchaser-related factors which greatly influence outcomes and service satisfaction: the overall health of the patient/purchaser; the disease itself under treatment; other disease states which influence the performance and outcome of the service; the cooperation and compliance of the patient/purchaser with the instructions and healing program recommended; and the vast complexity and frequent unpredictability of the human machine, which far outstrips any manufactured item in sheer randomness and near-capriciousness of makeup, performance, and response. A perfectly-performed surgery can have a disastrous outcome; a miracle drug, rare but deadly side effects; an abnormal variant in anatomy can make a routine procedure treacherous or unsuccessful. Furthermore, should such an adverse event or circumstance arise, there may be harm to the patient which cannot be undone -- or if it can, which may require additional cost, procedures, or suffering to resolve. There are no product recalls in medicine; warranties are a fanciful dream when so many aspects of the service product are not under the seller's control.

• The relationship between patient and physician is less contract than covenant.

I will cover this more fully in another post, but the distinction is important. Most economic transactions occur in the context of contract -- the rules defining the terms of the agreement, what goods or services will be offered at what price, and perhaps most importantly, what will occur should the transaction prove unsatisfactory: e.g., the product is defective, the buyer does not pay the agreed price in the time or manner specified. Although medical care is becoming increasingly contractual (to its detriment), it is in its highest form closer to a covenant -- an agreement between two parties to pursue a common goal based on mutual trust. In a contract, the transaction is king; the contract serves to define its terms and boundaries. In a covenant, the relationship rules; trust and the best interests of the other party, toward a common goal, are dominant. In medicine, such a relationship by necessity means that the transaction -- the financial side of the interaction -- must be subservient to the goal. Hence the physician must put the patient's best interest ahead of his or her own financial well-being, and must intercede on the patient's behalf when third parties threaten the goal for financial reasons.

While I am sure I have not exhausted the unique nature of medical services in the economic realm, hopefully you can begin to see more clearly why simplistic economic models fail so often when applied to health care. Yet this framework of understanding can hopefully provide some guideposts out of the dark woods of our health care crisis.

Hugh Hewitt's 'Blog'

In my free time, between practicing medicine, doing a major rewrite of my electronic medical records software, photographing my wife's product line and posting it to her web site, and of course, running a blog, I had the chance to read Hugh Hewitt's latest book, Blog. It was, I must admit, a surprisingly good and easy read.

In my experience, many Internet and media pundits who are superb and engaging in short opinion pieces or commentaries, do poorly when turning their talents to a book. There seems to be a different gift package for writing short concise commentary, versus a much longer work, where a different dynamic is needed to keep the reader engaged. Several recent authors who come to mind, who do not fare well in this transition, are Peggy Noonan and David Frum.

I have long enjoyed Hugh Hewitt's insight and writing style in the Weekly Standard, and his blog is a daily visit. Surprisingly, his book successfully leverages his skill at short, insightful commentary, while maintaining an easy readability. He does this, in part, by writing brief, topical chapters. In essence, his book is much like reading a series of his articles, albeit on the same general topic. If there is a shortcoming to this approach, it is the lack of overarching continuity, development and flow which a truly engaging book manifests.

The book started out a bit slowly for me, as many of the illustrative examples, such as Dan Rather and Kerry's Christmas in Cambodia adventure, were old news, having been an obsessive blog reader throughout the political campaign. The role of blogs in exposing Trent Lott and the Jayson Blair affair were somewhat less familiar to me, but nevertheless fell into the same general mold.

His chapter on the influence of technology with the printing press and the Reformation was far more interesting, and I learned a good deal about that period of time with which I had been previously only passingly familiar. Nevertheless, the analogy between the role of the printing press in the Reformation, and the role of the blogs in the media and information revolution are bit of a stretch, and the two are not entirely analogous.

Gutenberg's printing press was truly revolutionary, and represented a world-changing technology. The blogs, on the other hand, are more of an evolution than a revolution. The technology upon which they are based -- the Internet, web sites and web hosting, and the power of the hyperlink -- is long-standing and has already been revolutionary. The power of the blog resides the way in which it represents a perfect storm of communication technology. It is truly the democratization of journalism, and as such will change the way information is dispersed.

I am not nearly as skeptical as Hugh about the future of the large print and television media, however. While lacking the nimble agility of the Internet, the mainstream media has vast resources to place reporters and video in remote parts of the world on a sustained basis, and very deep pockets, which the blogs cannot reproduce. I suspect the mainstream media will evolve into more of a commentary and opinion vehicle rather than a rapid news source. After all, the Catholic Church survived the Reformation, and is a powerful force for good today. Nevertheless, the large media's stranglehold on information has been broken.

Hugh's emphasis on the role of blog communication in business is a genuine insight, and this thought-provoking even for a small business such as mine.

One aspect of blogging which Hewitt overlooks -- perhaps because he has been in the business of putting his thoughts on paper for so long -- is the personal impact of disciplining oneself to write cogent and thoughtful posts which will be read by others. My blog is oriented toward longer, essay-based writing, rather than the far more common link-quote-comment format. For me, the process of writing for a blog has forced me to organize my thoughts more clearly, and has motivated me to research topics in far greater depth. In more than a few instances, this research has resulted in a change in my own opinion, and almost always results in the deepening of my understanding of a selected topic. The power of research, meditation, focused prayer, mental organization, and disciplined writing can be genuinely transformational.

Blogs also have huge potential as agents of true multiculturalism and tolerance -- unlike the thought-police variety ubiquitous on campus or at the NY Times. In a short period of time I can read opinions on the right and left, from Hollywood or Iraq, from soldiers and academicians, from all races and parts of the U.S, Europe, and the world. I've even found a few attorneys I've grown to like (Hugh is one of them, and the guys over at Powerline) -- so the power to overcome bias and stereotyping through the blogosphere is enormous.

The appendices, where Hewitt reprints prior articles he has published on the subject, detract from the quality of the overall work -- one is left with the feeling of being shortchanged. The author should have rewritten these in the context of the other material, or cited short passages to support other parts of the book. Why buy a book to revisit articles one may have already read?

One last thought: I hate the word "blog". To me, it sounds like a cross between a computer geek's wildest fantasy and a GI condition caused by eating too many Pop Tarts. I hope as this information tool evolves, that a better descriptive term arises. Some have suggested the term cyber sherpa -- an accurate, but far too esoteric substitute. Surely, with the many creative and intelligent minds working on this phenomenon, a better term will evolve.

In short, if you are new or relatively new to the blogging phenomenon, you should read this book to better understand where the information age is heading. If you are an experienced blogger or regular blog reader, you should buy this book to expand your horizons about the potential of blogs. If you are a wild-eyed lefty who believes America is the cause of all the evil in the world, and a Michael Moore groupie, by all means don't buy this book. The religious references will give you heartburn, the political viewpoint will give you a high blood pressure, and most importantly, you may learn something useful to promote your worldview, which will be bad for the mental health of the rest of us. Besides, the book may raise cholesterol levels in susceptible individuals. As your physician, I would strongly advise against it.

Rocket Scientists

Like most states, Medicaid in Washington State has struggled to provide health care for the poor. In Washington, Medicaid has been on life support for least several years. Its shortcomings are legion: very low reimbursements for services to providers; a poorly-written provider contract which put physicians at a severe disadvantage in any disputes; retroactive computer-generated audits of providers demanding repayment for services provided four or five years prior, under different payment rules, based purely on computer algorithms without chart review. As a result, physicians have been fleeing the program in large numbers. Statewide, only 33 percent of Washington physicians accept Medicaid patients, and most of those who do are severely limiting the numbers of such patients they will see. This has created an enormous crisis of access to health care services for the poor, which has resulted in a surge in visits to emergency rooms by patients far sicker than they would be if they had ready access to routine health care. I have personally cared for numerous patients who drove two or three hours to see me, because they could not find a provider in my specialty any closer to home.

The large majority of Washington physicians would prefer to see Medicaid patients, but are quite simply financially unable to do so. For years, both Medicare and Medicaid have operated under an unspoken and hidden tax, paying for less than the cost to provide services while relying on providers to make up the difference from their insured patients. As insurance carriers have progressively ratcheted their reimbursements down in response to spiraling health care costs and insurance premiums, subsidizing patients insured under Federal programs such as Medicare and Medicaid is no longer feasible.

For most medical practices in our area, Medicare currently reimburses at, or slightly below, the cost of providing those services. It is not widely recognized that Medicare does not pay the same for services across the country. Because of historical cost formulas, reimbursements in areas such as the Southeast or large urban areas like New York or Chicago are substantially greater than in areas where care has historically been provided at lower cost. This, however, is not a dynamic formula, and therefore regions which previously provided care at lower cost when Medicare was new, but which have since become high-cost areas, are penalized by very low Medicare reimbursement rates. Washington is such an example, and despite the current high cost of providing care in the Puget Sound area, Washington State ranks 46th out of all states for Medicare reimbursement. Medicaid in Washington State provides significantly lower reimbursements than Medicare; according to recent statistics, Medicaid in Washington State is paying at 62 percent of the Medicare rate for its services.

The State government in Olympia has come up with an ingenious new plan to solve this crisis: it plans to tax physicians to generate additional revenue to pay for higher Medicaid reimbursements. In his final budget, our previous Democratic governor, Gary Locke, proposed a 67% increase in the state business and occupation tax on physicians. Unlike most states, Washington does not have an state income tax, but instead levies a business and occupation tax on gross receipts, as well as a substantial sales tax. The specific tax rate varies by industry and business type. Our new governor, Christine Yanukovich Gregoire, formerly Governor Locke's Attorney General, also supports this idea:

Gregoire said she supports the goal behind Locke's proposal. "I can't imagine that it wouldn't get us more providers," she said. "I hope that means that those who are in need actually have access.

The rocket scientists are hard at work in state government again.

Now, as a physician, it should come as no surprise that I am somewhat resistant to the idea that I have been specially singled out for this honored responsibility. But it really does go beyond my personal reluctance to pay higher taxes -- even narrowly targeted ones such as this proposal. The simple fact is, this legislation, if passed, will not result in "those who are in need actually have[ing] access", but will severely exacerbate the crisis of access to health care for low income individuals in Washington State.

According to Governor Locke's own statistics, Medicaid currently reimburses at 62 percent of Medicare rates. Hence, even without considering the issue of profit, physicians seeing Medicaid patients are already picking up over a third of the tab for provider services in Washington State. The proposed legislation would increase reimbursements to 75 percent of the Medicare rate. So, a substantial new tax will be added for providers, while still paying them less than the cost to provide this care. The income from services to Medicaid patients is not exempt from the tax on gross receipts, and therefore the higher reimbursements will also be taxed at the new rate.

Imagine you are selling computers. You build a computer with a supply cost of $1000 (not including your time and expertise to make it), and must sell it retail for $620. Needless to say, this business model will not win you any Nobel prizes in economics. Now the State comes in, and wants to buy a large number of your computers, and offers to pay you $750 a computer -- but is going to nearly double your tax on that $750. Such a deal! It is not hard to see what you will do: you are going to stop selling computers, or sell them only to someone who will pay you more than $1000 -- or go out of business. The end results of this brain-dead legislation is simple: physicians in large numbers will simply stop seeing Medicaid patients, as they will be increasingly unable to afford to do so, no matter how strong their desire to care for the poor.

I never cease to be amazed at how seemingly intelligent individuals in government so completely and utterly fail to understand the ramifications of these sort of policies. I guess I am setting my expectations far too high.

Nevertheless, there's not much value to another "this policy will never work!" commentary on health care, so in following posts I will explore some principles and reforms which I believe stand a much better chance for success.

UPDATE: My statistic that only 33% of Washington physicians accept Medicaid patients was based on incorrect interpretation of data. The actual percentage appears to be approximately 47%, based on WSMA surveys. I will try to confirm this and post an update when I have more accurate numbers.

The Pioneer Spirit

Some of my readers want me to stop startling the sheep with terrifying tales of wolves at the gate, but rather rest peacefully in pastoral bliss, secure in the knowledge that our appointed shepherds have their security measures and manuals close at hand. Blessed assurance, thy rod and thy staff meetings, they comfort me. Stick to the Marcus Welby script, they tell me. And so I shall (in due time) -- although the long-promised malpractice essay is still a work in progress. Patience, my flock -- like the Gallo vineyards, I shall release no whine before its time. But in the meantime, let me lead you beside restful waters, and revive your souls.

Indeed, I bear good news: the Pioneer Spirit is alive and well in America.

True, the American frontier was conquered long ago. But ancestors of those intrepid explorers are setting out anew to explore the unknown, the uncharted, to brave the savages and convert the heathen. To wit: Blue-staters are hitching up their wagons and heading Red. They may be coming to a town near you.

Two recent articles tipped me off to this modern-day Manifest Destiny movement, one on each coast, from the Washington Post and the Seattle Post-Intelligencer. One can only speculate on the motivation for such intrepid ventures: perhaps the electoral drought and near-dustbowl voter yields have prompted the search for more fertile land (although it is rumored that Seattle has genetically engineered new loss-resistant voter ballots, which may help avert the impending famine). But whatever the reasons, there is a spirit of adventure in the air.

David Von Drehle, writing in the Washington Post Sunday Magazine, begins with a tale of his journey to the Red Sea:

Early in December, with a photographer and his assistant, I drove from Nebraska, near the geographical center of the United States, to the heart of Texas -- more than 700 miles, through empty spaces and sprawling cities and all or part of four states. We headed pretty much due south, no dodging or weaving. And never did we pass within 100 miles of a county that voted for Democrat John F. Kerry in the recent election.

We were voyaging on the Red Sea.

Drehle actually paints a surprisingly balanced view of what he found on his journey - albeit in language whose flourish contrasts sharply with the simplicity of middle America. ("The sun was low in the south; its rays arrived languidly and aslant through the gray, tufted stubble of a cornfield.") He seems encouraged to find people who voted for Bush, even though they disliked him (as if this were an unusual phenomenom in national elections), but periodically reveals his confusion about Red America as viewed through his dark blue sunglasses:

Kern returned several times to his belief that cities have become dangerous, expensive, disorderly places, in contrast with the safe and dependable countryside. And he seemed convinced that there is some causal link between the unpleasantness of that other America -- the one beyond the Red Sea -- and the variety of people who live there. The idea of diversity appeared to be meshed in his mind with the specter of change, and change is clearly something he prefers to avoid. Monochrome Nebraska, as he put it, is "the last frontier. Where else do you have a place where you don't have to worry about crime, about juvenile delinquency, where you can leave your doors unlocked?"

Drehle seems unable to grasp that cities generally are dangerous, expensive, disorderly places (although obviously not without offsetting benefits for many), and that most Red state residents don't frame their view of the world through the lens of "diversity" (much less think of Nebraska as "monochrome"). And change -- that bogeyman that Mr. Kern is thought to dread -- is not an inherently good thing when it brings about crime, personal risk, and social disorder.

Far from home and feelin' Blue, Drehle is mystified and intrigued by these strange Red ciphers he has unearthed. He finds his Rosetta stone in a small Midwest bookstore:

I heard a lot about a book that claimed to explain how people ... have been tricked by the moneyed class into voting against their own best interests. I found a copy of What's the Matter With Kansas? at a bookstore in Ada and began reading it as we resumed our southward journey.

The author, Thomas Frank, grew up in a wealthy suburb of Kansas City and received a PhD in cultural criticism from the University of Chicago. ... In Frank's view, if Red Sea residents knew what was good for them, they would vote for capitalist-scourging Populists today. But they don't know what's good for them, Frank explains, because of 'a species of derangement.' The deranged people of the Midwest are no longer able to make 'certain mental connections about the world,' because those once-'reliable leftists' have been deluded into caring about moral issues ... Frank kept me reading until it was too dark to read anymore.

It doesn't get much deeper blue than a Ph.D in cultural criticism at Chicago University, now does it? Drehle has found comfort, like a kid reading a letter from home at camp, in his bunk, flashlight under the blanket.

He seems perplexed when encountering an Oklahoma woman who opposed Kerry for his position on abortion and gay marriage:

She was too polite to say, in so many words, that she felt John Kerry was a man of bad morals. Instead, she put it this way: 'When Kerry said he was for abortion and one-sex marriages, I just couldn't see our country being led by someone like that.'

Later, I double-checked what Kerry had said on those subjects. During his campaign, he opposed same-sex marriage and said that abortion was a private matter. But Joyce Smith heard it the way she heard it, and voted the way she voted.

Doesn't the poor woman understand that a Democrat man's word is his bond? Except when its not, of course. Sometimes eyes and ears comprehend things which Google searches don't disclose.

On the Left coast, another journalist in Seattle hitches his Conestoga to the Google search engine in search of the abominable snowman of electoral politics: the Christian voter ("I've seen their footprints in the snow, Myrtle, but have yet to spot the beast!"). Tony Robinson, in Who Are Those Christians?, rapidly dismisses the vile misconception that Christians are all narrow-minded, hate-filled moronic drones:

For some today, all Christians are closed-minded religious bigots whose politics are somewhere to the right of the Terminator. For others, Christians can be explained in terms of two-party theory: There are liberal and progressive Christians on one side and the conservative and evangelical Christians on the other.

Both explanatory frameworks are inadequate to the diverse and complex reality of Christianity in America today. Like much else in post-modern America, the situation is wonderfully messy. It doesn't lend itself to neat explanations or to a simple duality of liberal and conservative. Post-modernity is transgressive, that is, given to crossing boundaries. So today you have progressive evangelicals, theological post-liberals, the new orthodox, as well as ancient-modern Christians. Such stereotype shattering and boundary crossing strikes me as promising.

It is reassuring to know that Christians are not merely closed-minded religious bigots with bulging muscles and German accents, but rather boundry-crossing, stereotype-smashing, post-modern transgressives. Robinson finds this promising -- as do I. I think. And as any good teacher, he does not simply leave us wondering what such wonderfully messy transgressiveness implies, but expands the outline in exquisite detail. He has discovered that Christians fall into different categories: mainline, evangelical, fundamentalist, charismatic and, yes -- Catholic!

One can almost hear the audible gasp from Belltown readers, sipping their not-too-hot Chai lattes as they gaze over Elliott Bay: "There are different types of Christians -- who knew? Say, what time is that Mapplethorpe exhibit at the Seattle Center?"

Robinson's depiction reads like an African safari adventure written by a National Geographic reader: one gets the sense -- unlike Drehle -- that he's never actually met the people he's describing.

From a sociological point of view, his overview of Christianity in America is reasonably accurate. But as an overview, it approaches being entirely meaningless -- or at least irrelevant. He divides two broad stereotypes into five broad stereotypes -- then tells us that these stereotypes are, well, not stereotypical. For example, when contrasting the mainline churches with the fundamentalists, he says:

One broad-brush way to differentiate the dominate Christian groups is how they relate to modernity or what some call 'The Enlightenment Project,' with its hallmark values of reason, progress, optimism, individualism and tolerance. Mainline Christians have been open and receptive to modernity, working to accommodate Christianity and modernity. By contrast, fundamentalists circled the wagons against modernity, which they perceived as a threat.

Aahh, modernity -- who does not desire to be thoroughly modern, Millie? The red flag here is the "Enlightenment Project" -- a key element of postmodernism, which emphasizes, in essence, opposition to all forms of darkness and superstition, as exemplified by religion:

Enlightenment was defined as the project of dispelling darkness, fear and superstition. It was the project of removing all the shackles of free enquiry and debate. It opposed the traditional powers and beliefs of the church (branded as 'superstition') and raised questions of political legitimacy.

Without plunging the depths of the contrasts and conflicts between the relativism of postmodernism and the centrality in religion (especially in Judeo-Christianity) of an absolute Truth over and above imperfect human reason, it suddenly becomes clear why this sort of generalization about Christianity is so vacuous: the labels are meaningless. If the mainline churches espouse postmodern skepticism, rejecting ideas of absolute truth of divine origin (a characterization not far off, in many cases), then they are no longer Christian in any meaningful sense, other than by name.

Herein lies the source of enormous confusion for our intrepid explorers: you cannot rely on descriptions, like "Christian", or "fundamentalist", or "evangelical", because their meaning has become so amorphous, and they are overlaid with ambiguity and inferences which cripple their utility as vehicles of fact. For example, "fundamentalist" originally referred to Christianity's emphasis on absolute, transcendent Truth as opposed to relativism. While the specifics of exactly what that Truth entails remains controversial to a degree, even to this day, within Christianity, the fact that there is an absolute truth of divine origin is undisputed in the faith. Yet "fundamentalism" has become a societal codeword for rigid intolerance, ignorance, anti-intellectualism, and even violent repression. It has been linked by common usage to Islamic terrorism, adding additional baggage, though the two religions could not be more different. While many devout Christians acknowledge the fundamentals of belief in absolute truth and Christian doctrine, few today will publicly admit to being a "fundamentalist". The connotations of the word are too profoundly negative in our modern society.

To understand Christians, or those mysterious Red state middle Americans, you have to get down to individuals, without preconceived notions carried forward from the lofty towers of intellectualism and social theory. The fruits of postmodern relativism and social concepts, detached from the real-life problems and solutions of everyday living -- which many understand to require transcendent Truth and reliance on divine strength and guidance -- are increasingly seen as empty and destructive by a growing plurality of Americans. It is this, perhaps more than anything else, which divides Red and Blue in America today.

An Attack Averted

I had a most interesting and troubling conversation with a patient of mine yesterday. The patient, a Federal Air Marshall, related an incident in which he was involved this past year.

He and his partner were assigned to a flight (the airline, airport, and destination were not disclosed) in their customary undercover security role. They boarded the airplane early in order to meet the flight attendants, at which time the cleaning crew was still on the airplane -- somewhat longer than expected. My patient and his partner sat together in seats near the middle of coach class.

The passengers began to board, and he and his partner noticed a single Middle Eastern man sitting near the front of first class. After a number of passengers had boarded, two Middle Eastern men walked by this man and made eye contact, but said nothing. They sat down together in the front of coach class. Shortly thereafter, two other Middle Eastern men also walked by the man in first class and made eye contact without speaking. They sat near the back of coach class.

Shortly after the flight attendants completed their post-boarding check of the overhead bins, an announcement came from the cockpit: the pilot stated that there had been a security breach, and everyone needed to deboard the plane for a second, more thorough, security screening. The Air Marshall and his partner were confused, as they had not triggered the security alert nor been notified of it prior to the announcement.

After all the passengers had deplaned, the Federal Air Marshalls checked with the flight attendants for more information. During a final check of the overhead bins, a flight attendant had noticed that one of the blankets was slightly unfolded, and he repositioned it in the bin. At this time, a razor blade fell out of the blanket. Concerned, but still believing this might be a straightforward mistake, the flight attendant began to check other overhead bins. Several additional incompletely folded blankets were noted, and hidden in each one was a box cutter: a total of five. It appeared that these had been placed there by the cleaning crew prior to the boarding of the airplane.

After the repeat security screening, the passengers reboarded -- all except the five Middle Eastern men, who were nowhere to be found. The flight proceeded to its destination uneventfully.

The man who relayed this story to me is a reliable and sober individual, and I have no reason to question his integrity or its veracity.

Anyone who believes the War on Terror is a fabrication trumped up for political gain needs to take a strong dose of reality medication and lie down until this hallucination passes.

Kidney Stone Blogging

I have been working on a posting -- or series of postings -- on medical malpractice, a project which has taken longer than I anticipated. So, in the meantime, I thought I would treat you to some kidney stone blogging.

Say again? Kidney stone blogging.

Management of kidney stones has changed dramatically over the past 20 years. In the past, patients who formed kidney stones often required open surgery, with some active stone formers undergoing multiple open surgical operations. Things began to change in the early 1980s, first with the advent of percutaneous renal surgery -- a precursor of today's laparoscopic procedures. After placing a tube in the kidney using x-ray guidance, fiber-optic scopes were placed into the kidney, and kidney stones could be directly retrieved or fragmented.

The next, and perhaps most important, evolution in surgical technique was ESWL (extracorporeal shockwave lithotripsy). This technique was developed in Germany, after aerospace engineers noticed that a peculiar pitting was occurring on military jet aircraft which broke the sound barrier. Research determined that the sonic wave thus created was focused by condensation on the surface of the jet, creating a pit at the apex of the droplet. As perhaps only the Germans could deduce, this logically led to the use of focused sound waves for kidney stone fragmentation. The concept is not dissimilar to a magnifying glass in the sun. Solar energy, a quite comfortable temperature at the magnifying glass level, is intense enough to start a fire at its focal point. Similarly, soundwave energy at its source is weak, and can pass through water (and therefore human tissue) with virtually no damage, but at the focal point, creates a tremendous pressure wave. Using dual-plane x-ray control (for 3D imaging), the focal point could be directed at an internal kidney stone, and a series of shocks could break it into tiny fragments. This, somewhat amazingly, causes little or no injury to the surrounding kidney tissue.

ESWL, while ideal for stones that are still in the kidney, does not work well for stones that have moved into the ureter -- the thin drainage tube connecting the kidney to the bladder. For such stones, the development of small-caliber, high-quality optical scopes has proved an ideal solution. The scopes are introduced into the ureter by passing them through the lower urinary tract, the urethra and bladder. (This is done under anesthesia, of course, for the squeamish among you -- uncross those legs, now). Stones which are trapped in the ureter, even high above the bladder near the kidney, can be reached with such instruments, in most cases with little difficulty. The challenge then becomes: what do you do with the stone when you finally see it?

If it is tiny, you may be able to grasp it with a wire cage -- called a stone basket -- and extract it. In many cases, however, stones trapped in the ureter are larger, and cannot be removed this way. They must be fragmented.

The answer has been provided through laser technology. Using a tiny fiberoptic fibers -- 350 microns in diameter or less -- passed through the ureteroscope (as these delicate scopes are called), laser energy is used to fragment the stone. Darth Vader, meet Marcus Welby.

There are many different types of lasers used in medicine. Different laser types and wavelengths have markedly different effects on living tissue. Some, like the CO2 laser, work best in air, and are used to vaporize skin lesions, such as warts, with very little deep tissue penetration and virtually no subsequent scarring. Others provide deep thermal energy to destroy tumors or other tissues with minimal effect on the surface. For kidney stone work, a holmium laser in direct contact with the stone is commonly used.

The laser is fired at a very rapid repeating frequency. At the tip of the fiber, which is placed in contact with the stone, the intense light energy vaporizes the water used for irrigation, creating a rapidly-expanding plasma. An intense yet short-radius shockwave results. This has the effect of drilling into the stone, which creates areas of relative weakness and fracture. As a result, the stone breaks into increasingly smaller pieces, which can be extracted or flushed out. Because of the short energy radius, the surrounding tissues are unaffected.

A patient I treated recently shows how extraordinary an advance this is. He was morbidly obese, weighing nearly 400 pounds, a situation which precludes ESWL, as the focal length of the machine is not long enough to reach the stone. He presented with a very large stone just below the kidney, measuring about one-half inch in diameter. The patient also had very poor lung function and was at high risk for general anesthesia, and particularly at high risk for open surgery on the upper abdomen, which can greatly impair lung function. Using the ureteroscope and the laser, I was able to successfully treat his stone without the need for high-risk open surgery. Let's take a virtual walk-through of the procedure (the pictures are a bit grainy because of the low video resolution of the surgical camera).

This image shows the ureteral orifice (the opening in the bladder where the ureter enters, draining one of the kidneys) after the scope has been introduced into the bladder, before entering the ureter:





This image shows the ureter below the stone as seen through the scope. The diameter of the ureter is about 3-4 millimeters:





This image shows the laser fiber in contact with the stone. The fiber is the dark blue linear object on the right, and green spot is the actual laser beam:





This image shows a large fissure created in the stone as it begins to break up:





This image demonstrates how the laser fiber can literally drill a hole through the stone. The central dark spot is actually a narrow cavity created from laser contact:




The patient had an uncomplicated surgery and anesthesia, and was discharged from the hospital several hours after it was completed. Contrast this with an open surgical procedure, which at the very best would have left him hospitalized for nearly a week, with a significant risk of requiring a respirator to support his breathing because of his weight and risk of lung complications secondary to the surgery. He also avoided the need for a long and uncomfortable recovery from a large surgical incision.

Life is good.

Life with Wrigley

The holidays have passed, so it's time to get back into the daily routines which provide predictability and productivity to life. As for many, the holidays provided both ample enjoyment and stress, as the compounding time requirements of work, family, and entertainment formed a potent - if exhausting - brew. The joy of Christmas was tempered by the need to be on call, which foreshortened time with my family. But there were many blessings in the gift of giving, gratitude, great food, and the time spent with my wife and children, now grown and increasingly independent of their parents through the centrifugal forces of adulthood, marriage, and career training.

There were other, more unexpected, blessings. One of our cats, a 13-year-old gray Persian, began to deteriorate rapidly in early December, developing progressive weakness in his hind legs, at first having trouble jumping, then ultimately deteriorating to the point where he was dragging his legs behind him. Several veterinarians - including a cat specialist - were mystified by the disease, and he was ultimately referred to a small-animal neurologist (yes, such specialties exist in veterinary medicine), who ordered an MRI(!). The initial report was bleak - the scan was interpreted as showing a spinal cord tumor. The prospect of euthanizing a member of our family (no, I'm not anthropromorphizing our animals, but anyone who has a special pet knows how deep your attachment to them becomes over the years) - at Christmas time, no less - was depressing, to say the least.

As a matter of course, all MRI scans from the clinic are sent digitally to Washington State University School of Veterinary Medicine, to be reviewed by a radiology specialist. After several tense days, the answer returned: It was not a tumor, but rather a rare parasitic infection called toxoplasmosis.

Toxoplasmosis is extremely common in cats, and rarely causes clinical disease. Spinal cord involvement with parasitic cysts is extremely rare, however - but treatable. After a week of antibiotics, our old friend is nearly back to normal - jumping up on the counters, getting into the butter, stealing the broccoli (he loves vegetables!) and causing his usual mischief. But somehow it's hard to get too angry with him. His recovery is one of our best gifts of the season.

And then there's Wrigley...

During the course of several vet visits for our cat, my wife met a neighbor with a 4-month-old puppy called Wrigley (pictured above). Wrigley is a Golden Doodle - a cross between a Golden Retriever and a miniature poodle - and one of the cutest darn dogs you'll ever lay eyes on. Our neighbor was looking to board him while they were out of town for the holidays, and my wife - in her passion for "cute" dogs - offered to watch him. It was love at first sight - Wrigley was playful, energetic, friendly, and good-natured. And she was easy on the senses, with button-black eyes, a soft coat, minimal odor, and gorgeous, subtle coloration. But love is fickle - and easily extinguished. The honeymoon lasted about one day.

Dogs have many fine attributes which make them wonderful companions. Pack animals by nature, they love the companionship of people. Easily trained, they can be taught to perform many remarkable tasks - service dogs, search and rescue, police work, personal protection, illegal drug detection, - even cancer detection. But above all, the most treasured characteristic in dogs is their loyalty. A dog will love you, and be loyal to you, even though you scold it, neglect it, punish it for misdeeds, leave it - even abuse it, God forbid. You can be a miserable sonofabitch and your dog will worship the ground you walk on. Their friendship and devotion is nearly unlimited. Wrigley was terminally cute and playful - but she was not loyal.

Wrigley was ecstatic to be with us - her true owner forgotten in a nanosecond once the door slammed shut. And ecstatic to be with anyone she met - man or beast.

Wrigley was classic ADD - when you called her, you were the most exciting thing on earth - for exactly two seconds. Then she was off, to the next most exciting thing she'd ever seen. Mixing two breeds can enhance their best traits, but such is not inevitable. With Wrigley, the rambunctious and independent playfulness of the poodle combined with the Golden's unconditional love for all mankind produced a gorgeous and engaging animal. She was all looks and personality - and no loyalty.

The bloom was off the rose rapidly with the liabilities of canine youth - the endless chewing, the hyper-frenetic activity, unceasing barking, the apparent inability to differentiate "indoors" from "outdoors" when tending to bodily functions. When her owner returned, we expressed our sheer joy at her visit through grateful, carefully engineered smiles, as Wrigley ran off, ecstatic to meet her newfound - if dimly-remembered - owner.

Yet she, too, gave us a gift at Christmas - the appreciation of the value of loyalty. How often are we drawn to the beautiful, the engaging, the gregarious - only to miss those quiet, invaluable treasures of devotion, commitment, endurance in trials, true friendship: loyalty, in a word. To have both - as I have been blessed with in my family - is to have all the treasure a man could desire.

Merry Christmas & God Bless

With Christmas week coming up, family in town, shopping yet to do, and the responsibility to be on call on Christmas weekend, there will be little or no time in the next few weeks for blogging. Time to recharge the batteries and treasure life close to home.

Here's wishing each and every one of you a blessed and joyful Christmas. May you find the peace of Christ and the joy of life in Him this season, and every season.

I'm thinking through a series on health care coverage and solving our evolving crisis in health care delivery, which I hope to begin after the holidays.

Take care, be safe, and God bless.

The Children Whom Reason Scorns

In the years following the Great War, a sense of doom and panic settled over Germany. Long concerned about a declining birth rate, the country faced the loss of 2 million of its fine young men in the war, the crushing burden of an economy devastated by war and the Great Depression, further compounded by the economic body blow of reparations and the loss of the German colonies imposed by the Treaty of Versailles. Many worried that the Nordic race itself was threatened with extinction.

The burgeoning new sciences of psychology, genetics, and medicine provided a glimmer of hope in this darkness. An intense fascination developed with strengthening and improving the nation through Volksgesundheit - public health. Many physicians and scientists promoted "racial hygiene" - better known today as eugenics. The Germans were hardly alone in this interest - 26 states in the U.S. had forced sterilization laws for criminals and the mentally ill during this period; Ohio debated legalized euthanasia in the 20's; and even Oliver Wendall Holmes, in Buck v. Bell, famously upheld forced sterilization with the quote: "Three generations of imbeciles are enough!" But Germany's dire circumstances and its robust scientific and university resources proved a most fertile ground for this philosophy.

These novel ideas percolated rapidly through the social and educational systems steeped in Hegelian deterministic philosophy and social Darwinism. Long lines formed to view exhibits on heredity and genetics, and scientific research, conferences, and publication on topics of race and eugenics were legion. The emphasis was often on the great burden which the chronically ill and mentally and physically deformed placed on a struggling society striving to achieve its historical destiny. In a high school biology textbook - pictured above - a muscular German youth bears two such societal misfits on a barbell, with the exhortation, "You Are Sharing the Load! - a hereditarily-ill person costs 50,000 Reichsmarks by the time they reach 60." Math textbooks tested students on how many new housing units could be built with the money saved by elimination of long-term care needs. Parents often chose euthanasia for their disabled offspring, rather than face the societal scorn and ostracization of raising a mentally or physically impaired child. This widespread public endorsement and pseudo-scientific support for eugenics set the stage for its wholesale adoption - with horrific consequences - when the Nazi party took power.

The Nazis co-opted medicine fully in their pursuit of racial hygiene, even coercing physicians in occupied countries to provide health and racial information on their patients to occupation authorities, and to participate in forced euthanasia. In a remarkably heroic professional stance, the physicians of the Netherlands steadfastly refused to provide this information, forfeiting their medical licenses as a result, and no small number of physicians were deported to concentration camps for their principled stand. As a testimony to their courage and integrity, not a single episode of involuntary euthanasia was performed by Dutch physicians during the Nazi occupation.

Would that it were still so.

The Netherlands is today the only country in the world in which euthanasia and assisted suicide are legally performed, having fully legalized the practice three years ago after several decades of widespread illegal - but universally unpunished - practice. The Dutch have come into the public consciousness periodically over the past 15 years, initially with the consideration of assisted suicide laws in Oregon, Washington, Michigan and elsewhere in the early 90's, and again with their formal legalization of physician-assisted suicide and euthanasia in 2001. Once again they are on the ethical radar, with the disclosure last week of the Groningen Protocol for involuntary euthanasia of infants and children.

The Groningen Protocol is not a government regulation or legislation, but rather a set of hospital guidelines for involuntary euthanasia of children up to age 12:

The Groningen Protocol, as the hospital's guidelines have come to be known, would create a legal framework for permitting doctors to actively end the life of newborns deemed to be in similar pain from incurable disease or extreme deformities.

The guideline says euthanasia is acceptable when the child's medical team and independent doctors agree the pain cannot be eased and there is no prospect for improvement, and when parents think it's best.

Examples include extremely premature births, where children suffer brain damage from bleeding and convulsions; and diseases where a child could only survive on life support for the rest of its life, such as severe cases of spina bifida and epidermosis bullosa, a rare blistering illness.

The hospital revealed last month it carried out four such mercy killings in 2003, and reported all cases to government prosecutors. There have been no legal proceedings against the hospital or the doctors.

While some are shocked and outraged at this policy of medical termination of sick or deformed children (the story has been widely ignored by the mainstream media, and has gotten only limited attention on the internet), it is merely a logical extension of a philosophy of medicine widely practiced and condoned in the Netherlands for many years, much as it was in Germany between world wars. It is a philosophy where the Useful is the Good, whose victims are the children whom Reason scorned.

Euthanasia is the quick fix to man's ageless struggle with suffering and disease. The Hippocratic Oath - taken in widely varying forms by most physicians at graduation - was originally administered to a minority of physicians in ancient Greece, who swore to prescribe neither euthanasia nor abortion - both common recommendations by healers of the age. The rapid and widespread acceptance of euthanasia in pre-Nazi Germany occurred because it was eminently reasonable and rational. Beaten down by war, economic hardship, and limited resources, logic dictated that those who could not contribute to the betterment of society cease being a drain on its lifeblood. Long before its application to ethnic groups and enemies of the State, it was administered to those who made us most uncomfortable: the mentally ill, the deformed, the retarded, the social misfit. While invariably promoted as a merciful means of terminating suffering, the suffering relieved is far more that of the enabling society than of its victims. "Death with dignity" is the gleaming white shroud on the rotting corpse of societal fear, self-interest and ruthless self-preservation.

It is sobering and puzzling to ponder how the profession of medicine - whose core article of faith is healing and comfort of the sick - could be so effortlessly transformed into a calculating instrument of judgment and death. It is chilling to read the cold scientific language of Nazi medical experiments or Dutch studies on optimal techniques to minimize complications in euthanasia. Yet this devolution of medicine, with some contemplation, is not hard to discern. It is the natural gravity of man detached from higher principles, operating out of the best his reason alone has to offer, with its inevitable disastrous consequences. Contributing to this march toward depravity:

The power of detachment and intellectualization: Physicians by training and disposition are intellectualizers. Non-medical people observing surgery are invariably squeamish, personalizing the experience and often repulsed by the apparent trauma to the patient. Physicians overcome this natural response by detaching themselves from the personal, and transforming the experience into a study in technique, stepwise logical processes, and fascination with disease and anatomy. Indeed, it takes some effort to overcome this training to develop empathy and compassion. It is therefore a relatively small step with such training to turn even killing into another process to be mastered.

The dilution of personal responsibility: In Germany, the euthanasia of children was performed with an injection of Luminal, a barbituate also used for seizures and sedation of the agitated. As a result, it was difficult to determine who was personally responsible for the deed: was it the nurse, who gave too much? The doctor, who ordered too large a dose? Was the patient overly sensitive to the drug? Was the child merely sedated, or in a terminal coma? Of course, all the participants knew what was going on, but responsibility was diluted, giving rationalization and justification full reign. The societal endorsement and widespread practice of euthanasia provided additional cover. When all are culpable, no one is culpable.

Compartmentalization: an individual involved in the de-Baathification of Iraq said the following:

There is a duality in Baathists. You can find a Baathist who is a killer, but at home he's completely normal. It's like they split their day into two twelve-hour blocks. When people say about someone I know to be a Baathist criminal, 'No, he's a good neighbor!', I believe him.

Humans have the remarkable ability to utterly separate disparate parts of their lives, to accommodate cognitive dissonance. Indeed, there is probably no other way to maintain sanity in the face of enormous personal evil.

The banality of evil: Great evil springs in countless small steps from lesser evil. Jesus Christ was doubtless not the first innocent man Pilate condemned to death; soft porn came before child porn, snuff films, and rape videos; in the childhood of the serial killer lies cruelty to animals. Small evils harden the heart, making greater evil easier, more routine, less chilling. We marvel at the hideousness of the final act, but the descent to depravity is a gentle slope downwards.

The false optimism of expediency: Solve the problem today, deny any future consequences. We are nearsighted creatures in the extreme, seeing only the benefits of our current actions while dismissing the potential for unknown, disastrous ramifications. When Baby Knauer, an infant with blindness, mental retardation and physical deformities, became the first child euthanized in Germany, who could foresee the horrors of Auschwitz and Dachau? We are blind to the horrendous consequences of our wrong decisions, but see infinite visions of hope for their benefits. As a child I watched television shows touting peaceful nuclear energy as the solution to all the world's problems, little imagining the fears of the Cuban missile crisis, Chernobyl and Three Mile Island, the minutes before midnight of the Cold War, and the current ogre of nuclear terrorism.

Reason of itself is morally neutral; it can kill children or discover cures for their suffering and disease. Reason tempered by humility, faith, and guidance by higher moral principles has enormous potential for good - and without such restraints, enormous potential for evil.

The desire to end human suffering is morally good. Despite popular misconception, the Judeo-Christian tradition does not view suffering as something good, but rather something evil which exists, but which may be transformed and redeemed by God and grace, to ultimately produce a greater good. This is a difficult sell to a materialistic, secular world, which does not accept the transformational power of God or the existence of spiritual consequences, or principles higher than human reason.

Yet the benefits of suffering, subtle though they may be, can be discerned in many instances even by the unskilled eye. What are the chances that Dutch doctors will find a cure for the late stage cancer or early childhood disease, when they now so quickly and "compassionately" dispense of their sufferers with a lethal injection? Who will teach us patience, compassion, unselfish love, endurance, tenderness, and tolerance, if not those who provide us with the opportunity through their suffering, or mental or physical disability? These are character traits not easily learned, though enormously beneficial to society as well as individuals. How will we learn them if we liquidate our teachers?

Higher moral principles position roadblocks to our behavior, warning us that grave danger lies beyond. When in our hubris and unenlightened reason we crash through them, we do so at great peril, for we do not know what evil lies beyond. The Netherlands will not be another Nazi Germany, as frightening as the parallels may be. It will be different, but it will be evil in some unpredictable way, impossible to foresee when rationalism took the first step across that boundary to kill a patient in mercy.

Libertarianism and Morality

On April 25th 1990, the long awaited Hubble space telescope was launched. In the planning stages since 1967, delayed in deployment for 4 years by the Space Shuttle Challenger disaster, scientists were ecstatic at its potential to view deep space as never before from above the atmosphere's distorting optical envelope. Within days their excitement turned to dismay, as pictures from Hubble returned out of focus.

The giant mirror, 94 inches in diameter, had a spherical aberration. When the mirror was being polished to its correct shape, the device used to test its curvature — called a null corrector — had been made to the wrong specifications. Thus, when the null corrector indicated that the mirror was perfect, it was in fact slightly aspherical. The extremely faint light of distant celestial objects could not therefore be sharply directed to the focal point, resulting in a halo effect and a fuzzy image. Upon investigation, the problem was found to be due to the interchange of metric and English measurements when engineering the testing device. Subsequent space shuttle repairs rendered the optics perfect again, giving rise to the spectacular photographs which the Hubble telescope has since obtained.

In the case of Hubble's mirror, an inadvertent change of standards, resulting in an aberration 1/50th the diameter of a human hair, nearly doomed a multi-million dollar space project. Consider the likelihood of success if each of the engineers on the project had been allowed to use their own set of standards. Yet in the realm of human behavior and morality, an idea preposterous to a scientist is widely accepted as legitimate, even desirable.

Dale Franks, writing in the excellent libertarian Q and O blog, reviewing a recent Tom Wolfe book in his post on Morality and Society, poses the following question:

God, as Friederich Nietzsche famously said, is dead. But what is rarely appreciated is that Nietzsche wasn’t very happy about it. It wasn’t a statement of triumph over the stultifying hand of religion, but rather a complaint that caused him to question how we would, in the absence of a God-given standard, find our moral way in a world where a transcendent standard of right and wrong had been obliterated.

Of course, he went on from there to muse about the rise of a new superman, and his will to power, and a lot of other spectacularly silly stuff, but the initial question, the subject of his lament about the passing of God as a giver of moral standards, remains.

This question should be one of special concern to Libertarians. Most libertarians have the idea that the government should have no place in regulating morality. The government should confine itself to enforcing laws only against those that physically harm the person or property of another, non-consenting person. Under such a regime, a huge swathe of current law would be swept away. No more drug convictions, no more prostitution stings, you know the drill ... The trouble with the argument that we should all be free to work out our individual morality as best pleases us is that we don’t all live alone on an island. We live in a society. We are social beings who are happiest when we have intercourse with others. And the type of society we build is directly related to the moral sense we create in it.

Our culture is increasingly drawn to the idea that the individual should be the final arbiter of his or her own morality. Behavior formerly judged to be aberrant or wrong is now by default tolerated and even celebrated under the umbrella of "diversity". The only standard is that "no one gets hurt" - although the definition of "hurt", and whom might be so affected, is similarly left up to the individual to determine - generally using the narrowest and most self-serving criteria.

There are two fundamental approaches to defining moral values. Moral behavior may evolve as consensual in a culture, arrived at by experience, whereby the needs of the many overrules the contrary tendencies and demands of the few, enforced over time by social pressure, ostracization, or overt punishment. Conversely, moral standards may proceed from a higher moral source, hopefully one of pure goodness with the best interests of man at heart. Such moral standards are enforced by delegated authority - typically religion or government - much as a parent guides and disciplines a wayward child. At a higher and more sublime level, the moral code will be inculcated and infused from its higher Source into the heart and fiber of the individual, by instruction or spiritual transformation. Such is the ideal framework for a civil society, for moral restraint then lies within the individual, rather than being coerced. Government and the rule of law are thereby not the source of morality, but are delegated to the lesser role of admonition and correction of the remaining moral shortcomings and excursions of man from the transcendent ideal.

Morality derived from consensus of the many alone, without reference to a higher Source, can function reasonably well in a homogeneous society with strong cultural and family ties. Their self-referential standards, while functional at some level, may ultimately prove to be errant, however, in the light of cultural enlightenment or scientific progress. They may in fact bring considerable harm over time to the culture and its members, such as mores permitting cannibalism, polygamy, slavery, or predatory sexual behavior, for example.

In advanced cultures such as the West, the consensus approach is far less workable. Family and ethnic ties break down rapidly in cultures with rapid transportation and information exchange, as people move, travel, and exchange ideas far away from their moral center of gravity. As a result, cultural moral consensus becomes individual moral autonomy, with increasingly chaotic and disruptive effects.

The problem with individual moral autonomy is mankind's inborn self-centric bias. Our formidable intellectual capabilities allow us to use advanced psychological tools such as denial, rationalization, and minimalization, yet are not advanced enough to perceive the wide-ranging personal and social implications - both short- and long-term - of our moral decisions and behavior.

Consider the sexual revolution of the 1960's, for example. Launched by the technological advance of readily-available and reliable birth control, nurtured by the anti-authoritarian environment of an unpopular war and a universal military draft, conventional wisdom evolved to the point where sexual activity between any two "consenting adults" was permissible and desirable - as long as "no one gets hurt". The consequences of millions of individuals defining sexual morality in such constricted and self-referential terms is nothing short of staggering: spiraling rates of divorce and sexually transmitted diseases (including AIDS); exponential growth of children raised in single-parent homes or born to unwed mothers; breakdown of families with deteriorating educational systems and outcomes; increased rates of juvenile crime and drug use; epidemic levels of domestic and child abuse. Whatever benefits may have accrued from this moral earthquake in the areas of sexual repression and prudishness are swamped by the adverse consequences - consequences never even imagined by those making these individual moral choices.

This is one of my main objections to the libertarian idea of individual moral decision-making as the foundation for a free society: it ignores (or minimizes, at best) the profound effect that our individual moral choices have on on other individuals and society as a whole. When your airline pilot or surgeon smokes pot every night in the privacy of their own homes, the resultant long-term impairment of reflexes, judgment, and decision-making ability may have potentially disastrous consequences on lots of other people. When you choose to have a child as a single mother, the high likelihood of poverty and social disadvantage affects your child, his peers, the society he grows up in, and the child's future children, in countless ways you cannot anticipate, and which are very likely negative.

The libertarian opposition to the government imposition of morality through regulation is one for which I have considerable sympathy, but which I believe is misdirected. I'm no cheerleader for excessive government regulation, by any means: as a physician, I am watching my profession crumple under its weight like a Datsun under Godzilla. Yet, as I pointed out in my earlier post on The Law of Rules, excessive government regulation is not the disease, but rather the symptom of a culture where individual moral restraint is deteriorating.

The resistance to the idea of God as the Source for universal moral standards comes from many directions: the projection of human failings on God, perceiving Him as vindictive, capricious, angry and judgmental; the resistance to constraint on our behavior which we justify as moral but know to be morally suspect; the confusion engendered by different religions and theologies. Yet if we posit a higher being who is morally pure and good, all light and no evil, with a love and caring for His highest creation in man, it should not be unreasonable to conclude that such a being would desire that this creation behave in ways which are beneficial rather than destructive, guiding them toward light rather than evil. The challenge for such a God would be to overcome our own limited sight and moral failings while respecting our freedom to reject such guidance - the very prerequisite for the love He desires returned from us.

The Religion of Politics

The year was 1914. The Great War was raging in Europe, with America as yet spared its suffering. For the followers of Charles Taze Russell, the war was but one sign of a far more portentous event: 1914 was the predicted year for the parousia, the visible return of Christ in power.

Russell, a clothing merchant and self-proclaimed "Bible student", had become interested in the teachings of William Miller - founder of the Adventists. Picking up the pieces of Miller's failed chronology, which had predicted Christ's triumphant return in 1844, Russell's "new light" blended Miller's chronological formulas from the Bible with measurements from the Great Pyramid at Gaza and other numerology sources to conclude that Christ would return visibly in 1874. When this prediction likewise failed, he quickly revised his revelations to conclude that Christ had come invisibly in 1874, and would surely come visibly in power in 1914.

Anticipation among his followers was intense as 1914 drew to a close. When the New Year dawned with no Jesus in sight, disappointment and anger were widespread among Russell's followers. Many fell away, recognizing the emptiness of their trust in their charismatic-but-disgraced leader. One of Russell's most loyal and dedicated followers, Judge Joseph Rutherford, was unwilling to reject the teachings of the man he regarded as a prophet, and saw an opportunity to change the subject and re-energize their discouraged followers. He launched a vitriolic attack on the churches and clergy of Christendom, whose opposition to and exposure of the false prophecies of Russell led so many to abandon the Truth. Those who had left were branded apostates, and shunned. Rutherford succeeded in salvaging and reinvigorating the religion, and became the father of today's Jehovah's Witnesses.

So what does any of this have to do with politics? Bear with me a moment.

Religious cults like Russellism and its offspring, the Jehovah's Witnesses, centralize all their faith and hopes in one person or group, who acts as the sole spokesman for God. When prophetic predictions by leadership fail to materialize, followers are faced with a difficult choice: to admit that the authority in which they have placed so much trust and invested so much energy is a sham, and therefore conclude that they themselves are fools, or risk the wrath and rejection of a group they believe to be their only salvation. Such conflict produces severe cognitive dissonance, and often results in thought patterns, rationalization, and behavior which the outside world will view as bizarre or irrational.

Now, politics is not religion, much less a cult. But there are many in the political arena, both right and left, for whom politics and political power represent the only hope and salvation for mankind's problems. They invest in their political vision, and in the power necessary to impose it (governmental and judicial), enormous energy and commitment. Among some Christian conservatives, this manifests itself through the political imposition of morality. Although authority is nominally attributed to God, in practice righteousness must be imposed on society by the election of morally upright representatives, the opposition to morally abhorrent legislation and societal practices, and the rapid attribution of adverse social or political events to the judgment of God on the wicked. The progress of spiritual transformation on an individual level, one person at a time having their lives changed by God, is far too imperceptible and untrustworthy for such folks, like waiting for continental drift to change your zip code. There is little perspective on how disastrous the imposition of morality through politics has been throughout history. Fortunately, most people of faith eschew purely political solutions to society's problems, having experienced far more personal success with individual redemption and spiritual change.

On the secular side, where God does not exist or is an ineffectual (though sometimes useful) concept, change can only come through raw power, as there exists no authority wiser nor of sufficient potency to bring about the changes seen necessary to better ourselves and our society. One's political and social philosophy therefore becomes both the ultimate authority and judge of a societal direction and morality. Opposition to such well-intentioned and enlightened purposes represents not merely a difference of opinion, but instead a force of ignorance and hate to be opposed at all costs. The opponents of your politics are the personification of evil, the enemies of men's souls.

This worldview is rarely as clearly demonstrated as it has been in the reaction of the secular Left to the recent election. Convinced of the rightness of their cause, the stupidity, corruption and mendacity of the President and his administration, they were certain that the time for deliverance from the Neanderthals and their hordes was at hand. How could the enlightened people of America not heed the call to such a shining city on the hill? Reinforced by the echo chamber of the mainstream print and television media, the parousia of political deliverance surely seemed close at hand.

When the harsh reality of November 3 struck, the idea that America had rejected their political vision proved a devastating blow. The possibility that they themselves might be at fault - that their enlightened vision of America was flawed and unacceptable to the electorate - was too much to bear. There had to be another explanation, since the vision itself could not be questioned. Cognitive dissonance had arrived in spades.

Of course, there was the obligate back-biting about the ineffectiveness of their candidate, and conspiracy theories abounded: the evil genius of Karl Rove, the veracity of the pro-Kerry exit polls overwhelmed by massive voter fraud and intimidation of voters, and even theories about Republican origins of Osama bin Laden's tape. But the wide vote margin refused traction to the idiocy so manifest in Florida in 2000. The answer, however, came quickly and intuitively. Like Nero, having torched their own city, who better to blame for this disaster than the Christians?

Lest you think I am overstating my case, consider the following. The delightfully-but-inappropriately-named Jane Smiley, writing a post-election analysis in Slate, says the following:

Here is how ignorance works: First, they put the fear of God into you-if you don't believe in the literal word of the Bible, you will burn in hell. Of course, the literal word of the Bible is tremendously contradictory, and so you must abdicate all critical thinking, and accept a simple but logical system of belief that is dangerous to question. A corollary to this point is that they make sure you understand that Satan resides in the toils and snares of complex thought and so it is best not try it ... The history of the last four years shows that red state types, above all, do not want to be told what to do-they prefer to be ignorant. As a result, they are virtually unteachable... when life grows difficult or fearsome, they ... encourage you to cling to your ignorance with even more fervor. But by this time you don't need much encouragement-you've put all your eggs into the ignorance basket, and really, some kind of miraculous fruition (preferably accompanied by the torment of your enemies, and the ignorant always have plenty of enemies) is your only hope. If you are sufficiently ignorant, you won't even know how dangerous your policies are until they have destroyed you, and then you can always blame others.

Gary Wills, writing in the NY Times, says this:

Can a people that believes more fervently in the Virgin Birth than in evolution still be called an Enlightened nation?
... The secular states of modern Europe do not understand the fundamentalism of the American electorate... In fact, we now resemble those nations less than we do our putative enemies. Where else do we find fundamentalist zeal, a rage at secularity, religious intolerance, fear of and hatred for modernity? Not in France or Britain or Germany or Italy or Spain. We find it in the Muslim world, in Al Qaida, in Saddam Hussein's Sunni loyalists.

Maureen Dowd, in the NY Times:

The president got re-elected by dividing the country along fault lines of fear, intolerance, ignorance and religious rule. He doesn't want to heal rifts; he wants to bring any riffraff who disagree to heel.

Donna Brazille, in Slate:

When one of my sisters-who, coincidentally, is a recovering Republican-was told in church that she would go to hell if she voted for Sen. Kerry, she stood up and denounced the preacher's message ... despite our personal differences on matters of faith and religion, we believe that in order to be good disciples of Jesus, you have to not only know his words but also perform his deeds. That is where we draw the line with those who spend hours and hours in church, only to come out and hate everyone around them.

Imagine for a moment, that Kerry had won the election. Consider the reaction if the Wall Street Journal and National Review had published opinion stating the same things about any other group which supported Democrats - African Americans, Hispanics, Jews, labor unions. Called them ignorant, unteachable, hate-filled, the moral equivalent of Al Qaeda. Can you imagine the sheer outrage, the 'round-the-clock news coverage, the 60 Minutes specials on bigotry and intolerance? Yet for the secular Left, this is not bigotry; it is Truth.

When politics is your religion, rejection at the polls is more than a disappointment; it challenges the very core of your enlightened belief system, your very soul. It is the failed prophecy, the betrayal by the ignorant and unfaithful, the repudiation of your core being, the smashing of your dreams. The Vision is Truth; the enemy who impeded its inevitable and righteous triumph must be identified, hated, repudiated, scorned. Only then can the True Believer be at peace again, in the assurance of their moral superiority and the destiny of their dominance.

The Left Shift

The talking heads of the mainstream media are echoing the refrain that President Bush - having won by a significant margin in the popular and electoral vote, as well as significant gains by his party in Congress - should recognize the bitterly divided nature of the electorate, and promote healing by adopting a conciliatory philosophy of governance. This presumably would include the appointment of liberal federal and Supreme Court justices, avoidance of controversial policy initiatives such as reforming Social Security, increasing taxes, and reaching out to our aggrieved-but-eager-to-help allies such as France and Belgium.

Can we have a reality check here?

First of all, if Kerry had won, would anybody be saying such things? Would we expect a Kerry administration to promote pro-life issues, or submit conservative (or even moderate) judges for appointment, to help salve the divisive wounds of the nation? Why do only conservatives and Republicans have to change to reduce the bitterness? Will there be no turning down the volume of vicious rhetoric by the Michael Moores, the Moveon.orgs, the Hollywood loonies? Will CBS and the NY Times stop their hit pieces and look for common ground for the good of the country? Don't count on it. What the liberal Democrats and their supporters in the mainstream media could not convince the majority of Americans to support in the voting booth, they will attempt to impose on the electorate through guilt, media assault, judicial fiat and coercion.

Secondly, that's just the way it goes in a democracy: the winner gets to set the agenda. In any national election, a whole bunch of folks - slightly less than half the voters - are very unhappy with the outcome. Conservatives were stunned and depressed when Clinton won in 1992 and 1996. Tough cookies - suck it up. Your options in this uncomfortable dilemma are straightforward: try to get more people to agree with your party, policies and candidate the next time around, and in the meantime you get to block or alter the governing party's policy initiatives through the Congress, which directly represents the people. Staggered elections provide another outlet - some House and Senate seats come up for election every 2 years. The opportunities to change the system on a frequent, regular basis are legion. Furthermore, the courts serve as the final check, when one party dominates both branches and moves too far outside the lines.

The problem for the Democratic Party is that they have been drifting farther away from the mainstream of American thought - or, perhaps more accurately, the majority of Americans are moving away from their ideas. Bitch-slapped into reality by watching 3000 Americans die in horror on 9/11 - ironically shown to them in vivid detail by a media which still fails to grasp the implications of this seminal event - many Americans have been reassessing their priorities. The environment, health care, racial inequality, day care and school lunches are important to many, but don't mean squat if bin Laden or some other Islamic fanatic slips a nuke into Boston, or crop-dusts anthrax over Atlanta.

The pundits are correct: there is a sharp divide in America, and like shifting tectonic plates, there's a lot of heat at the interface. But what is striking is where this division occurs: it has shifted sharply to the left.

When I first discovered the blogsphere, I was struck both by its depth and resources, but also by its tendency to be an echo chamber. You could surf to a dozen like-minded blogs, and find the same links and quotes discussed. I began to seek out diversity of opinion, but found that on the left, the same was true - albeit with far more emotion and vituperation, and far less reasoned thought or plausible alternatives for the realities of the post-9/11 world. As I continued to read, however, I noticed that many writers who understood the harsh realities of a global terrorism war would have been my political and philosophical opponents in the 9/10 world; we would disagree on a host of issues, from abortion, to stem cell research, to the role of faith in the public square, to the size and involvement of the federal government in our lives. Yet these individuals, by and large, were supporting Bush and the war on terror - albeit often with spirited differences on its execution and priorities, some with clenched teeth and near revulsion at the thought.

The center has shifted, and the division between opposing views of America lies farther to the left than ever before. The majority of Americans - Right, Center, and Center-Left - understand that the paradigm has changed. Despite misgivings and fears of the journey into preemptive war, the murkiness of non-national enemies, concerns about balancing civil rights while unmasking lethal enemies who hide behind them, despite our enmeshment in the hornets' nest of the Middle East, a growing majority now understands what is of prime importance. Increasingly marginalized are those on the Left who could be tolerated when it mattered little, but who today often undermine our national integrity and align themselves with those committed to destroying us. They are a diminishing minority, yet they have become the financial and philosophical heartbeat of the Democratic Party. It is only through the amplification of the media megaphone, screeching at rock-concert decibels, that the increasingly marginal supporters of the current Democratic Party can pretend to represent anything like a significant portion of voting America.

How long this realignment lasts, and whether the Democrats have the wherewithal to divorce their fringe and return to the mainstream, remains to be seen. Republicans and conservatives have an opportunity in the meantime to tackle a whole host of recalcitrant national problems: the entitlements, the tax code, a failing public education system. To tackle these third-rail issues will be noisy, and heated, and stormy, and will require a courage heretofore lacking in the Republican Party. The outcome may or may not be satisfactory, but it will surely require input from widely varying perspectives. And if it does not turn out well, the American people can choose an alternative philosophy of governance. I for one welcome a strong, engaged Democratic Party, willing to persuade rather than demean, to construct rather than condemn. Perhaps from our common roots in opposing and destroying the merchants of terror can such a Phoenix be resurrected.

Bridge Blogging

There's less than a week to the election, and I'm burned out from checking the polls at Real Clear Politics every 15 minutes. So, to relieve the stress, relax the body and clarify the mind, it's time for some bridge blogging.

Say what?

Bridge blogging. It just so happens that I live near an engineering marvel in progress: the new Tacoma Narrows bridge. Most folks have heard of the Tacoma Narrows bridge - or at least the first one, "Galloping Gertie", which catastrophically failed during a windstorm in November 1940.



Built at the cost of $6.6 million dollars, designed by world-famous bridge architect Leon S. Moisseiff (who also designed the Golden Gate bridge), it embraced the light, elegant design principles in vogue at the time - and was designed with complete ignorance of the aerodynamic effects of high winds on bridges. Moisseiff had inadvertently created a mile-wide airplane wing, with its light-weight narrow deck and plate-girder sides. It survived only 4 months after completion. In a strong-but-typical November windstorm, the wave-like undulations were severe enough to unseat a cable from its saddle on the West tower, creating a corkscrew torsional motion which ripped the bridge to shreds. The only casualty, surprisingly, was Tubby the three-legged dog. May he rest in peace.



The fallen span of the bridge remains at the bottom of the Tacoma Narrows, and has been designated a National Register of Historic Places to prevent salvage. It is one of the world's largest artificial reefs, and home to a plethora of marine life, as well as the world's largest octopuses. The remainder was disassembled and sold for scrap during WWII. The caissons and anchors (for the cables, on either bank) were used, largely unmodified, to support the towers and cables of the second Narrows Bridge.



The second - and current - Narrows bridge was begun in 1948, and completed October 14, 1950, 29 months after construction began, at a cost of $14 million. It was one of the most highly researched bridge engineering projects in history, and greatly advanced the understanding of aerodynamics in suspension bridge construction. A 1/72 replica of both the original and the new bridge were built in a wind tunnel and thoroughly tested for several years prior to design completion.



Designed to carry 60,000 cars per day, the current bridge ferries over 90,000, and has become a major chokepoint for traffic in the rapidly growing South Puget Sound area. These transportation pressures have given rise to the new Tacoma Narrows Bridge project.

The Tacoma Narrows is a formidable natural barrier. Carved out by ancient glaciers, over a mile wide and 260 feet deep, with steep, unstable banks on either side, it is a hostile environment for a suspension bridge. Wild tidal currents rip through the Narrows twice daily, through the sole portal between the Pacific Ocean and the entire South Puget Sound. High winds and fog are common. The Puget Sound area is also prone to major earthquakes.

The new Narrows Bridge project is the largest engineering endeavor in the U.S. in the last 30 years. Construction began in late 2002, after approval of an $800 million public-private financing package. The new caissons underwent initial construction in the Port of Tacoma, and were towed to their location in the Narrows, where they were secured in place on the surface with a series of anchor cables radiating circumferentially. These cables, and flotation tanks in the caissons, where used to control the descent of these floating concrete islands, as layers of concrete were added to the top.



The task was akin to building a 25-story building from the roof down, all the while holding its precise position in the alternating rip tides of the Narrows. The bottom of the caissons is configured to be a mammoth cookie cutter, with a sharp steel knife edge to cut through sediments to reach bedrock 50 feet beneath the bottom.

On the east and west banks are the anchors - enormous concrete fortresses designed to secure the cables with their huge tractive forces to the sandy glacial till on either side of the Narrows.









Over the past several months, the towers have begun to rise from the caissons, and now are nearly at the deck level of the current bridge.



The new bridge is scheduled to be completed in 2006, and renovations to the existing bridge made after this. The final project is scheduled for completion in 2007. You, my faithful readers, will see history unfold on this very blog, with regular updates until then.

Faith and Reality

Ron Suskind's article in the NY Times Magazine, Without a Doubt, addressing the issue of the faith of George W. Bush, begins as follows:

Bruce Bartlett, a domestic policy adviser to Ronald Reagan and a treasury official for the first President Bush, told me recently that ''if Bush wins, there will be a civil war in the Republican Party starting on Nov. 3.'' The nature of that conflict, as Bartlett sees it? Essentially, the same as the one raging across much of the world: a battle between modernists and fundamentalists, pragmatists and true believers, reason and religion.

''Just in the past few months,'' Bartlett said, ''I think a light has gone off for people who've spent time up close to Bush: that this instinct he's always talking about is this sort of weird, Messianic idea of what he thinks God has told him to do.'' Bartlett, a 53-year-old columnist and self-described libertarian Republican who has lately been a champion for traditional Republicans concerned about Bush's governance, went on to say: ''This is why George W. Bush is so clear-eyed about Al Qaeda and the Islamic fundamentalist enemy. He believes you have to kill them all. They can't be persuaded, that they're extremists, driven by a dark vision. He understands them, because he's just like them. . . .

''This is why he dispenses with people who confront him with inconvenient facts,'' Bartlett went on to say. ''He truly believes he's on a mission from God. Absolute faith like that overwhelms a need for analysis. The whole thing about faith is to believe things for which there is no empirical evidence.'' Bartlett paused, then said, ''But you can't run the world on faith.''

There is much to address and analyze in this lengthy article, and no doubt others better versed on the credibility of its sources, the speciousness of its evidence, and its use of unconfirmed hearsay and biased sources will rise to the debate. But I was particularly struck by one line which I believe embodies the heart of the article's core thesis:

He truly believes he's on a mission from God. Absolute faith like that overwhelms a need for analysis. The whole thing about faith is to believe things for which there is no empirical evidence.

Listening to the secular fundamentalists at the NY Times expound on the mind and heart of a man of the Christian faith is akin to a man blind from birth describing a rose: you are far more likely to hear about the thorns than the subtle coloration and beauty of its petals.

"The whole thing about faith is to believe things for which there is no empirical evidence."

Really??

The tension between faith and reason (or "reality", as Suskind calls it) is hardly a new issue, reaching back centuries to such philosophers and theologians as Augustine, Thomas Aquinas, and even Plato and Aristotle. Aquinas has the most fully developed exposition on the seeming dichotomy between that which is discernible to the senses or by logical deduction, and that which is revelation and mystery. Far greater minds than ours have taken - and mastered - this challenge.

There is a name for someone who believes things for which there is no discernible evidence: a fool. And I suspect most journalists for the NY Times would find this an apt assessment of President Bush - and by inference, his religious supporters, lumped together under the tattered banner of the "religious right". As a believing Christian, therefore, I am a proxy target for this accusation. And as a blogger, it is my sworn duty to reply.

So, is this thing I call faith really a fantasy, a trust and hope in some unseen, unprovable philosophy or myth? Most definitely not. There are, from my perspective, quite a few objective reality-based foundations for that which I believe. Among these are:

Historical: The Christian faith is a historical faith. It is based on an individual, Jesus Christ, who lived in history, verified as real not only by His followers (and enemies) but by detached historians with no agenda to promote. The core convictions of this faith are easily demonstrable, not only in its sacred texts, the Scripture, but in writings and teachings of men from many cultures and times, from the earliest years following the death of Christ continuously to the present. The accuracy of its ancient sacred texts is nothing short of stunning, supported by an exponentially greater volume of manuscripts and archeological evidence than any other ancient writings. If the Old and New Testament were not religious texts, there would be no academic dispute about their veracity and reliability. They are challenged because they shine a light on the darkness of the human heart, and make uncomfortable demands on human behavior and belief. If you can prove the judge is a corrupt impersonator, you dodge the sentence for your crimes; if he is unimpeachable, you're busted.

Relational: There are several aspects to the relational nature of Christianity which serve as evidence for its reality. People do not arrive at Christian conviction by lightning bolt or holy vision, but rather by their relationship with others who hold the faith. We witness the effects of Christianity on the lives of others, and are led to consider it not only because of what they say, but far more by what we observe. Few of us would buy a car without talking to other car owners, reading reviews, and taking it for a drive. While not a guarantee of a good car, we consider such information valuable evidence in making our decision. While such evidence can be misleading - people are often seduced into cults by an appealing but deceptive attractiveness, for example - it is nevertheless evidence of the veracity of faith when carefully considered and weighed against other facts and observations.

The evidence of Christianity is also revealed in its ability to transform relationships. Many Christians can testify to the healing and restoration of relationships with spouses, children, employers, between races, class and ethnic groups. Are all Christians so transformed? Not by any means, unfortunately. But the evidence of those who have been - often resolving seemingly hopeless situations and personal divisions - should not be dismissed outright because of the incompleteness of its scope. Do we do abandon chemotherapy because not all survive?

Experiential: Christianity is both doctrinal and experiential: it is comprised of a series of assertions to truth, but is not simply a belief system; it affects - often profoundly - the lives, convictions and experiences of those who follow it. While this is easy to challenge with claims of a purely emotional or psychological basis for such experience, in reality it is not so lightly dismissed. While short-term behavioral change can occur as a result of emotional experiences, and delusional thinking in mental illness can result in bizarre behavior, the vast majority of practicing Christians do not fit this mold. When people from all walks of life - responsible, sane citizens whose behavior is ordinary in every other way - profess their ability to overcome profound personal shortcomings, relationship disasters, personal tragedy or devastating misfortune with a peace and inner strength not available to them apart from their faith, is it not reasonable to conclude that something profound has happened, not attributable to the impotency of pop psychology? Might there not be a plausible explanation involving a Being greater, wiser, and more gracious and loving than ourselves from which such resources come? Scientific proof, no, but certainly evidence not to be dismissed out of hand.

John Edwards is right: there are two Americas - just not the two he imagines. The divide places secular and liberal religious (often no more than thinly-guised socialism, with little connection to historical Judeo-Christian belief) on one side, and people of faith on the other, with lives quietly transformed by God and a vision expanded beyond the tight constraints of materialistic or political thinking. For the secular, religion is like borrowing a sports coat at a fancy restaurant when you've forgotten yours: you use it to get your meal and drink wine with your friends, then shed the ill-fitting garment at the earliest possible time. There is a deep discomfort with and mistrust among the secular of anyone who claims such superficial window dressing could actually guide, direct or empower the lives of others.

I cannot presume to speak for the mind or spirit of President Bush. But many of us who have experienced the inner transformation which faith alone brings, sense in the man a like mind and heart, which despite sometimes strong differences in policy or politics gives us confidence in his inner compass and core principles. Such conviction in our experience leads to discernment, rejecting well-intentioned but misguided advice, and pursuing goals judged to be noble and right despite the high costs of doing so. Faith does not overwhelm analysis; it sharpens and directs it. This is something that political speeches in churches or talk of boyhood alter boy service can imitate, but cannot replicate. The jacket just doesn't fit the man.

The Dangers of High Testosterone

Life can be stranger than fiction.

Much has been written - and considerable media attention given - to the benefits and risks of estrogen replacement therapy, but considerably less attention has been directed at testosterone replacement. Yet androgen replacement therapy is becoming increasingly common, as improved delivery systems have been developed.

Low testosterone is common in aging men, although there is not a uniform sharp decline as seen in women at menopause. The symptoms are variable, but include fatigue, decreased libido, difficulty with erections, weight gain and loss of muscle mass.

Testosterone replacement has been available for many years, but was limited by less-than-ideal delivery systems. Oral replacement is easy and convenient, but most of the testosterone is metabolized by the liver on its way out of the intestine, resulting in low blood levels and higher risk of liver function abnormalities. Injectable testosterone bypasses the liver and achieves good blood levels, but requires frequent injections, typically every 1-3 weeks. Skin patches were developed in the early nineties, but have been plagued by a high incidence of skin irritation and the need (with some systems) to apply the patch to the scrotal area - not a crowd-pleaser, to be sure. The recent development of topical gels - Androgel and Testim - have revolutionized androgen replacement, providing excellent blood levels with very low risk of skin irritation or other side effects.

Testosterone replacement in men with low serum levels provides many benefits, including improved energy, strength, and libido. Preservation of bone mass and muscle mass are also seen. The downside risks appear to be modest, and include weight gain, sleep apnea, and an increased red blood cell count. There is also much concern about long-term effects on the prostate, including an acceleration of benign enlargement or an increased risk of prostate cancer. To date, however, studies indicate that prostate-related risks do not appear to be of great concern, although long-term monitoring will continue.

One other risk is of great concern to researchers, however: the risk that high testosterone levels may cause recipients to become high-strung. Consider the following report from Alaska:

In one of those only-in-Alaska stories that will shock even the sourest of sourdoughs, a trophy-sized bull moose was accidentally strung up in a power line under construction to the Teck Pogo gold mine southeast of Fairbanks. The moose apparently got its antlers tangled in electrical wire before workers farther down the line pulled the line tight about two weeks ago.

The moose was suspended 50 feet in the air when workers, recognizing something was wrong, backtracked and found it...

The prevailing theory is that the moose came across the sagging and swaying wires and, in a testosterone-filled moment, decided to challenge the power line to a fight, as bull moose are known to do during the rut, or mating season.

"My guess is he was in full rut and probably seen that line moving out there," and decided to fight, said Marvin Pickens, line construction manager for City Electric in Anchorage.

I am now counseling my patients to avoid high tension electrical wires at the initiatiation of testosterone replacement therapy. I know I will be sleeping better since informing patients of this risk.

The Chips Are Down

The FDA this week approved the use of the Applied Digital 4Verisign implantable chip in humans. The chip has been in use for some time in animals, to identify pets and livestock. The technology is straightforward: the chip is implanted under the skin, in the subcutaneous tissue, ideally in the right upper arm near the triceps, and contains RFID transmitter which is activated by a hand-held scanner. Contrary to some media reports, the chip stores no medical data, but only a a unique 16 digit identifying number. This number is used to securely access an online database and retrieve information specific to the patient.

The dream of centralized patient information is hardly new. Current medical record technology is little removed from the 19th century - often handwritten and illegible, decentralized, and paper-based. EMR's are gaining acceptance, but are costly, and standards for data structure, communication protocols, and interchange between different vendors and applications are incomplete and not uniformly implemented. My EMR cannot get or send patient information to yours, nor can it easily obtain from, or relay information to, hospitals, pharmacies, insurance companies, or emergency rooms. Even laboratory data - the most widely implemented medical electronic data exchange - varies from one laboratory to the next, and is only partially standardized.

The long-term solution to such standards and interface barriers would appear to be secure database access over the internet, as is currently done in banking and e-commerce. The Verisign chip is being touted as a first step toward just such a system. But color me very, very skeptical about the likelihood of ever seeing a system of this nature in practice. The obstacles seem insurmountable.

A myriad of problems present themselves when addressing online patient medical databases. Some of these include:

Security and Privacy Issues: From start to finish, many of the hurdles to such a system lie in the securty and privacy realm. Who enters a patient in the system? How do we know you are who you say you are? A quick look at the driver license, SSN, and voter registration systems should give one considerable pause. Fraudulant and duplicate entries would be common, and could pose enormous problems and risks. Imagine you get added to the database under someone else's name, to fraudulently obtain health insurance coverage, or are a duplicate name and date of birth with another person. You are severely allergic to penicillin, and your alias or name clone is not, and you end up dead from an anaphylactic reaction, after receiving it while unconcious in an emergency room. Who's responsible? And could hackers or terrorists wreak health havoc by gaining entry to the system? If the Pentagon and banking system can be hacked, the health care databases will be no less vulnerable to cyberterrorism.

And who gets to access your personal health information - a treating doctor, presumably, but let's say you just fired him or her and don't want him accessing your information any longer - can you block access to specific providers? Insurance companies? Hospitals? Lawyers? Government agencies, such as Medicare, Medicaid, workman's compensation?

Then consider the problem of partial information access - for example, information about substance abuse or mental health issues. Such information is generally held to a higher standard of privacy than general medical information in many states. Can you allow the doctor at your company to know about your diabetes, while not revealing your history of bipolar disorder, or substance abuse? The complexities of who gets access to which information are daunting, so say the least.

Database Updates and Accuracy: Who gets to add, edit and delete information from your medical history database? Can your naturopath make an entry about weak adrenals or body toxins? How about your dentist, or pharmacist, or massage therapist? Anyone who has taken a medical history knows that a patient history can be devilishly difficult to obtain with accuracy: prior surgeries and their dates, medications and dosages, allergies, family history - can vary wildly from one provider to another, or from alternative sources such as family or old medical records. What about medical differences of opinion? Dr Jones thinks you have chronic fatigue syndrome, while Dr. Smith is convinced you're a neurotic hypochondriac. And Dr. Johnson understood you to say you had a history of uterine cancer, when you actually had fibroids. But the cancer diagnosis is now in you database. Who is authorized to change that information?

Database Currency: How up-to-date is the information in the centralized database? To maintain patient medical data currency, the system would have to be universally accessible and ubiquitous in utilization. Ol' Doc Watson, who still writes his chart notes in longhand and doesn't own a computer, isn't likely to enter your severe reaction to his prescribed medication, or log the highly-contagious disease you've acquired, onto the database servers at the Health Information Agency. And, by the way, who will manage this database - government? private companies? insurance carriers? Microsoft? Will it be as reliable as, say, Windows?

The downsides of such centralization of medical information vastly outweight the benefits, in my opinion. And is universal access to medical information really needed? The vast majority of health information is communicated at the local level, within the community where the patient lives, or occasionally to nearby regional medical centers. Rather than compromise privacy and information integrity with a massive centralized medical database and implanted patient RFID chips, it would be far more useful to focus efforts on standardization of information management at the local levels, with policies to encourage the use of standard terminology, communication technologies and protocols (such as XML web services and SOAP), while maintaining the flexibility, security, and privacy of the current decentralized medical information system.

Debating Federal Tort Reform

In the second presidential debate between John Kerry and George Bush, the topic of medical malpractice reform was raised. Here's the exchange:

LAURENT: Senator Kerry, you've stated your concern for the rising cost of health care, yet you chose a vice presidential candidate who has made millions of dollars successfully suing medical professionals. How do you reconcile this with the voters?

KERRY: Very easily. John Edwards is the author of the Patients' Bill of Rights. He wanted to give people rights. John Edwards and I support tort reform. We both believe that, as lawyers — I'm a lawyer, too. And I believe that we will be able to get a fix that has alluded everybody else because we know how to do it...

Now, ladies and gentlemen, important to understand, the president and his friends try to make a big deal out of it. Is it a problem? Yes, it's a problem. Do we need to fix it, particularly for OGBYNs (sic) and for brain surgeons and others? Yes.

But it's less than 1 percent of the total cost of health care.

First of all, the mention of John Edwards' sponsorship (with Ted Kennedy and John McCain) of the Patients' Bill of Rights is a non-sequitur to the issue of the growing malpractice crisis: the Patients Bill of Rights addressed a patient's right to sue their HMO for denial of care, and also allows wronged patients to receive unlimited punitive damages in state court and awards in federal court of up to $5 million. As such, this bill is highly favorable to trial attorneys, and worsens the overall liability crisis. And it has nothing to do with medical malpractice. When the trial attorneys start talking "patients' rights", it's time to hold on to your wallet if you're in the health care industry. "And I believe that we will be able to get a fix that has alluded everybody else because we know how to do it". Hmmm, the fox knows how to solve the chicken-killing spree, because he knows how foxes get into the hen house. Somehow I'm not feeling reassured about this.

It would be interesting to see the origin of Kerry's "1 percent of the total cost of health care" figure. The John Kerry website white paper on malpractice reform does not mention this statistic, or give any references in support of it. I suspect this figure is inaccurate, and very low. And I'm not sure it's relevant anyway - as I'll detail below.

In the MedPAC report on medical liability costs, released in March 2002, physicians' medical malpractice premium costs were estimated to be 3.2% of revenue in 2001. The past 3 years have seen double-digit percentage increases in malpractice premiums for all physicians, along with reductions in revenue, making even the 3.2% figure woefully outdated.

In my practice - a relatively low-premium surgical subspecialty - malpractice premiums represent 10% of my expenses - exceeded only by rent and salaries - and about 6% of revenue. So in my practice, and that of many physicians, malpractice premiums are not yet devastating, although their inexorable and exponential rise adds substantially to the financial vise grip of growing expenses and dropping reimbursements. But rising expenses and declining income for physicians is not really the main problem, at least in the short term; the real problem is patient access.

The reason for this is twofold. First of all, malpractice premiums are not evenly distributed, but disproportionately affect some specialties far more than others. So talk of "average malpractice costs" is meaningless. Most affected are OB-GYN (not "OG-BYN", as Kerry said) and neurosurgery, and certain other high risk specialties. They are the canaries in the medical malpractice mineshaft. They are most affected not because they have the most negligent physicians - indeed, they often are the most skilled and highly trained of physicians. They are adversely affected because adverse outcomes in such specialties may have devastating long-term consequences, or perhaps more important, are most easily sold to juries as due to negligence. It is much easier to convince a jury that a bad baby is due to obstetrician error than it is to convince them that a cardiac event after coronary bypass surgery is surgeon incompetence. The average non-medical lay person expects delivery of a healthy baby to be the norm - don't women deliver at home with a midwife? - but an uneventful recovery from open heart surgery is considered to be something of a miracle. So the crisis strikes first at the high-liability-risk specialists, forcing them to curtail services, relocate to more favorable states, or leave practice altogether. This is already taking place in many areas, is well-known, and is highly detrimental to health care in such areas as critical services go lacking.

The less widely appreciated problem with malpractice costs and access affects far more physicians and patients. For many years, the federal programs of Medicare and Medicaid have contained a hidden tax: they have not paid their way, reimbursing at or below the cost of providing care. For years, health care providers - and patients - have paid this tax by offsetting these losses with reimbursements from private payers. This option is no longer viable, as rising health insurance premiums and dropping third party reimbursements eliminate this income redistribution. As a result, physician practices, with their viability as businesses threatened, are reevaluating their willingness or ability to see such patients - not out of greed, but out of necessity.

A recent WSMA physician survey showed that 57 percent of doctors polled said they were limiting their Medicare patients or no longer seeing any at all. In Bellingham WA, Family Care Network, which has 11 locations and provides about half the primary care for its area, is typical of the dilemma many practices face:

"In every case, when we got above a certain percentage (about 25 percent) of Medicare and Medicaid patients, it was impossible to operate the office in a way that it would pay for itself," said Dr. David Lynch, who directs clinic operations for the 45-doctor group. "And that's before we paid our doctors anything. We realized we would go out of business if we didn't do something." In 2000, Family Care Network lost an average of $4 every time one of its physicians saw a Medicare patient.

The overhead expenses increased by spiraling malpractice premiums make the break point at which medical practices can afford to see low-reimbursement federal health care patients lower each year. Finding a primary care or GYN physician in my area who will accept a new Medicare patient in referral is extraordinarily difficult. Of the 10 practices in my specialty in my area, only 1 will accept new Medicaid patients - and that number is capped. My former group practice, which accepted Medicaid, saw Medicaid patients who would drive 2-3 hours to see us, who could not find a specialist who would take them any closer to home. Coordinating care in such situations - scheduling x-rays or diagnostic studies, or meeting with families - was almost overwhelmingly difficult.

Our malpractice lottery is causing severe disruptions in access to care, as well as eliminating access to certain specialties altogether. This is not merely about preserving physician incomes. The solution requires a radical rethinking of the approach to adverse events in medicine - one which, unfortunately, neither presidential candidate is likely to endorse - especially those who have profited greatly from the current system.

Drugs from Canada

In the Vice Presidential debate last night, John Edwards detailed the Kerry-Edwards health care plan, stressing, among other points, their intention to allow drug importation from Canada:

They've blocked allowing prescription drugs into this country from Canada. We're going to allow it.

Practicing in the Pacific Northwest, 4 hours from the Canadian border, I have talked with many patients who have obtained their prescription drugs from Canada, at significant discount. I also have a few patients who have purchased drugs cheaply in Mexico. The appeal is obvious, and the logic can be hard to refute. Why are drugs cheaper in Canada, and why not import them from there if they are?

The reasons for less expensive Canadian drugs are severalfold. Prescription drugs still on patent are price-controlled in Canada at the wholesale level by the Patented Medicine Prices Review Board (PMPRB), which sets the price of all new patented medications. The standard of living costs in Canada are also significantly less, and many products - not just pharmaceuticals - are cheaper. Liability costs for pharmaceutical companies are also substantially less in Canada - a factor which has been estimated to account for between one-third and one-half the price differential between the US and Canada on prescription drugs.

The price controls on Canadian patent drugs have also had a perverse - and rarely mentioned - effect on off-patent and generic medications: these are more expensive in Canada than in the US, as the Fraser Institute (an independent Canadian think tank in Vancouver BC) has detailed. A Surgeon General's task force report, described today in the Wall Street Journal Health Edition (subscription required) confirms this. Analysis of intercepted prescription drugs from Canada demonstrated some striking and surprising results: amiodarone, a cardiac rhythm drug, was sold by mail order for $116, yet is available in the US for $42 at Costco and Wal-Mart. Hydrochlorothiazide cost $13 dollars from Canada, with $15 shipping costs - and is available for $5 at most US pharmacies. Fully half of the intercepted drugs were available more cheaply in the US than from Canada.

Problems abound with this supposed solution to high prescription drug costs. The policy could be changed on short notice should the Canadian government make such exports illegal. Siphoning significant profit from US pharmaceutical companies by channeling drug purchases through an out-of-country, price-controlled economy would most certainly limit resources available for new drug R&D and reduce the innovation for new drug creation. And then there is the problem of quality control and potential fraud.

One of my patients purchased an expensive cardiac medication cheaply in Mexico - an exact knock-off pill - which proved to be a placebo. Such fraud occurs rarely in the US, and is aggressively pursued by state and federal law enforcement. Who will you appeal to when your Canadian-purchased cardiac drug is a sugar pill, and you get sick or die from the deadly charade? Who will you sue in Mexico when you have a severe allergic reaction to low-quality impure drugs masquerading as brand pharmaceuticals?

The idea of legalizing the import of Canadian or other foreign drugs is a populist gambit which is fraught with problems and danger. It is a prescription for our health care best avoided.

The AMA Conspiracy

Milton Friedman, in his influential work Free to Choose, puts forth the premise that restrictions on medical licensure and the numbers of physicians in training by the AMA is one of the principal reasons for spiraling health care costs and diminshing quality. In a truly free health care market, the consumer would be free to choose from a large number of health care providers - physicians, non-physician health care providers such as nurse practitioners, midwives, chiropracters, and alternative medicine providers. Competition would drive down prices, and those providers with the highest quality and best service would succeed.

While I respect Milton Friedman, and believe in the power the free market, the law of supply and demand only works in a truly unrestricted free market.

American medicine is far more regulated than Soviet state industry ever was. The idea that physicians fees and resulting healthcare costs will magically drop if somehow the AMA loosens up the supply of physicians (which I am not all convinced is done for purely economic reasons, although no fan of the AMA in general - and not a member) is a fantasy. The vast majority of physicians fees are fixed either by federal regulation or contractual agreement with insurance companies. At the same time, physicians are businesses like any other, with rapidly escalating overhead costs which are beginning to bump against their virtually fixed - or falling - receipts. The reasons for this have been well described, and include spiraling malpractice premiums, unfunded federal mandates such as federal compliance and HIPAA, increasing health insurance costs for employee benefits, as well as a relatively scarce pool of highly qualified employees such as nursing and billing specialists. Opening the floodgates of physician supply will not drop prices, since prices are not determined by the usual supply and demand principles, but rather by federal law and an increasingly monolithic health insurance industry.

In my state, Washington, there were over 80 insurance carriers providing health insurance in the late 1980s. There now are three or four. Single insurers now cover huge swaths of the patient market, and therefore physicians have no flexibility to negotiate contracts. Imagine walking away from a bad insurance carrier contract, when 40-50% of your patients are covered under that plan (and will switch doctors if you're no longer on their plan), and you begin to get the idea. Keep in mind that doctors are currently prohibited from collectively bargaining with insurance carriers under antitrust laws, and you can see how unbalanced the marketplace truly is.

Increasing the supply of physicians would in fact likely result in a rise in healthcare costs, as desperate physicians increase volume in an attempt to compensate for worsening financial viability.

Another myth related to the economic arguments for licensure liberalization is that of alleviating the problem of physician shortages in underserved markets, such as rural America. No offense to folks who live in small towns, but I doubt that physicians will flock to tiny rural villages simply because the AMA lets more doctors be trained. Cities have large populations precisely because they offer greater benefits to those who live there - financial, cultural, convenience, lifestyle. While the urban lifestyle is not for everyone, economics and personal lifestyle preference dictate physician distribution far more than absolute numbers.

Licensure restrictions - while certainly having the potential for conflict of interest and market domination - do in fact serve to standardize quality and predictability of physician care, albeit imperfectly. Anyone who has struggled to figure out who a good physician might be for their particular medical problem can imaging the situation when all bets are off - is the physician you selected adequately trained to bypass your coronary arteries, or remove your brain tumor, or simply a charming, good-looking con man? A low-cost brain surgeon somehow doesn't sound like such a great bargain. Airline fares would drop, too, if you loosened the licendure requirements for pilots and flooded the market. No more overpaid pilots. All aboard, anyone?

Further undermining this argument is the fact that a vibrant market in alternative health care already exists. Billions of dollars are spent on remedies, herbs, manipulations, and treatments which are rarely beneficial, often worthless at best or harmful at worst, promoted using misleading advertising or by playing on false hopes or patient desperation (how many weight-loss products are there? How many work?) This is the free market at work, at its best - unregulated, unlicensed, unrestricted, unaccountable. Let the buyer beware.

There is no free lunch. Quality health care is expensive, and requires reasonable regulation - and therefore restriction - of providers to minimize the risks associated with highly complex advanced health care. Conspiracies about the AMA are superficially attractive, but it's time to look elsewhere for answers to our growing health care crisis.

Hospital Charges for the Uninsured

Lucette Lagnado's article today in the Online WSJ (subscription required),
Anatomy of a Hospital Bill, details a couple financially devastated by an uninsured health care crisis, with the couple owing nearly $40,000 for a less-than-24-hour stay for a cardiac stent for myocardial infarction.

Like many of the 45 million Americans who don't have health insurance, the Shipmans gambled -- unwisely, it turns out -- that they could make do without it. Among the many factors they didn't take into account was the high markups hospitals tag onto care for uninsured patients, charging them far more than what they charge big private or government plans for the same care.

Ms. Lagnado then details a number of line items from the Shipmans' hospital bill, comparing the estimated cost of supplies and services with the line item charge, and Medicare and Medicaid reimbursements. From these comparisons come several unstated conclusions: a) hospital charges are exhorbitant with an excessively large profit margin; and b) Medicare and Medicaid reimbursements are a fair estimate of what should have been charged. The first conclusion may or may not be true; the second is most definitely untrue.

Information on what hospital costs are for mandated coverage for the uninsured, or underinsured (Medicaid/Medicare) patients are the missing ingredient in seeing how fair or unfair such charges are. Physicians deal with this problem on a lesser scale. Medicaid in Washington State where I practice reimburses approximately 40-45% of practice expenses for outpatient care. Medicare reimbursement is at or slightly below expenses, depending on your location in the state (Seattle area receives about 30% greater reimbursement than elsewhere in the state). Hence these patients represent a financial loss to a practice, at the same time driving up overall practice costs with a heavy burden of increased administrative and billing costs, unfunded federal compliance and HIPAA mandates, and significant payment delays (Medicaid typically takes 45-60 days to pay uncontested clean claims). Physicians still have the legal freedom (if not always the ethical freedom) to turn away patients unable to pay, or decline to see patients in Federal programs (45% of physicians in Washington state are no longer seeing Medicaid patients). Hospitals, on the other hand, are required by law to see such patients, under anti-dumping and other regulations. This is high-cost care, typically delivered in Emergency Rooms to sicker patients. Liability risks are also substantially higher in this environment and population.

The hospitals maintain that this is the reason for high-charge line items and large markups. This may well be true, but what I have not seen is any detailed accounting from hospitals or hospital associations on what these unreimbursed expenses actually are. This is the missing piece of the puzzle. Since their insured reimbursement rates are fixed by contract or Federal or state law, they can only recover some unreimbursed costs from collecting from the uninsured. Bad PR and bad policy, to be sure - but the alternative is to sustain large losses which may put the entire health care enterprise at financial risk.

There's another aspect of this story that I find troubling:

Indeed, at the time of Mr. Shipman's illness, the Shipmans weren't poor. Mr. Shipman was earning $80,000 a year in salary and commissions selling furniture. They were living in an attractive rented townhouse in suburban Virginia and driving a leased BMW. In March 2002, the Shipmans say, Ms. Shipman left a job with benefits in order to return to college, and the couple decided to go without health insurance. They figured they were healthy and relatively young; health coverage would have cost them several hundred dollars a month, money they figured would be better spent on tuition.

It would seem that there is a problem with priorities here: a couple making $80,000 a year and living well, as they were, can afford health insurance. They are, of course, free to roll the dice and forego insurance, but should they be allowed this freedom?

Now, I'm not a big fan of government regulation, since I daily struggle with the burdens of the vastly over-regulated health care profession. But there is a balance in society between personal liberty and responsibility to others. I cannot get a home mortgage unless I have homeowners insurance, even though I might have lots of other better things to do with the premiums. Nor can I drive a car legally in Washington without car insurance. The reason is simple: my freedom to forgoe such insurance is trumped by the potential consequences to others should my gamble prove wrong. If my house burns down, or I run my car into yours, another person or institution is forced to pay for my mistake or misfortune. Why should it be any different in health care?

One public policy which I believe should be implemented is mandatory catastrophic health care coverage - large deductible plans designed to cover the worst-case scenarios which can bankrupt a family. Making such coverage universal would provide a broad-based risk pool which would keep premiums lower, and designing the plans for expensive medically necessary care (no tummy-tucks, infertility, or liver transplants for end-stage alcoholics) would further make them more affordable. There would need to be some federal or state support - means-tested, of course - for low-income individuals, which could be funded by reducing or eliminating the tax deduction for employer-provided health insurance. This would serve the additional benefit of beginning to break the pathological codependency between employment and health insurance coverage.

Clearly something has to change, and soon. Class action suits against hospitals for price gouging and heartrending stories of families bankrupted by health care costs will not solve the problems of cost-shifting our health care expenses and responsibilites onto others. We're doing that now, and the system is breaking under the strain.