Ethical and Moral Consistency: 2.0

One wonders the extent of the reaction from the Christian fundamentalist community if a person was to drive around town in a panel truck festooned with huge reproductions of Mapplethorpe's Piss Christ. No doubt there would be fiery attacks on anyone who so dared. After all how could someone be so vile as to drive around town where any child might see the image. How would a parent feel safe taking their kids out for a drive when at any moment such 'pornography' might pull along side. And what right would such an art installation have to prevent other decent parents from deciding what imagery and ideas to which their child is exposed and when.

Yet many of the same people who would object to the above seem to have no trouble doing a couple of things which I find just as objectionable and which tread upon my abilities to protect my kids from imagery which is inappropriate for their age. Oregon has about the most open-ended First Amendment rights of any state in the union. Essentially everything is considered protected free speech. And in this town there is a group of fundamentalists who drive around in a panel truck covered with images of aborted fetuses. Others love to set up shop in front of one of the planned parenthood offices with similar signs that they wave to passing cars. They cloak themselves in the protective aegis of scripture and sanctimony and smile dismissively at anyone who is offended by their actions. [The only weapon that I have seen which fractures their carefully manicured exterior tranquility is that each time I encounter them, I stop my car, write out a new donation check to Planned Parenthood, deposit it in the office and thank then for reminding me to support this important organization.] As a parent I want to decide if and when my kids are exposed to disturbing imagery the nature of which would get a movie an R rating.

In Texas the school board narrowly defeated another one of those creationist attempts to insert disinformation into science texts in order to discuss the so-called problems with evolution. Sorry but the rest of us know what the problem is with evolution - if your kids learn about it they might just start questioning all the other ideas that you've carefully brainwashed into them. But the fundamentalists want to have a say in controlling what their kids see and hear.

Which brings me back to that notion of ethical and moral consistency that I mentioned a while back. It is hypocrisy to rail about images of breasts in the media, evolutionary texts, and avant garde artwork's influence on your kid's impressionable mind when you turn around and do the Lord's work by pushing objectionable imagery on my kids. Hypocrisy robs you of any claim to the high ground. Hypocrisy in the service of religion can easily turn to evil. If you want to debate the merits of these issues as adults, fine by me. Just leave the kids out of it. When you threaten to expose my kids to things that are age inappropriate I'm not going to hear what you have to say. You're not a crusader - you're just a pornographer.

Dammit Sam!

Ok, we can debate for years why people have a far easier time getting their bile up over politician's sexual exploits rather than far more substantive reasons such as lying about WMD's. Part of it is that we all have experience with it to some degree and have a sense for what is right and what is wrong when it comes to love and sex. Part of it is probably Dr Goebbels's big lie vs the small ones. The big ones are harder to fathom. The little ones not so much.

Which brings us to the sad case of Sam Adams. Sam is the first openly gay man elected mayor of a large American city - Portland Oregon. Now Oregon in general and Portland in particular are well known as libertarian bastions. I am a stereotypical Oregonian. What ever you choose to do is of absolutely no consequence to me as long as I am not directly involved or the innocent are threatened. Like Tommy Lee Jones in the Fugitive - "I don't care!". My friends who happen to be gay know that I don't want to hear about their sex lives. That's simply because I don't want to hear about anyone's sex life other than my own. It's none of my business as long as it's legal. In November I joined a whole lot of other people in electing Sam mayor for the simple reason that he seemed qualified for the job.

Now Sam got caught lying just a few short weeks after the election. A while back rumors circulated that he had an affair with an intern in his department who started working at age 17 (hence the part about legal). The young man turned 18 and the rumors got a little more explicit. When confronted by these questions Adams repeatedly denied the allegations that he had ever had sex with this young man. Furthermore he took a sanctimonious approach to the denials calling it the worst kind of stereotypical smear campaign against a gay man. Now it turns out that he lied repeatedly.

On the eve of the inaugural a notorious independent rag called the Willamette Week was about to break the story. People rail against this paper all the time but everybody reads it - for the simple reason that even a blind hog can find an acorn once in a great while. And the WW sometimes comes through when the rest of the media falls flat. So Adams came clean on the eve of publication. He admitted to lying. He admitted to getting the young man to lie as well. He covered up the truth. And he admitted that he lied because he didn't think he'd get elected if he had been truthful. Maybe so, maybe not, this was Portland after all. Then he poured gasoline on the fire by not showing up to work yesterday. Sam you are the mayor of a big city - deal with your personal crises on your own time. (A bit of irony - He had to cancel a talk at the local university last night - the topic was on ethics in public life.... The Q+A session would have no doubt been very interesting.)

It's hard to know but there is little doubt that his actions have in fact fed into the stereotypical prejudices against gay men that he piously decried as unfair in the minds of some. But Sam that's not why people like me are pissed. We're mad because you lied about it. Hey, we're adults - we know that affairs of the heart can be tricky and personal decisions don't necessarily impact one's ability to govern, but bold faced lying does. His actions at the very least showed questionable judgment (yes, like Clinton's as well). A person in power is treading on dangerous ground when they engage in any relationship with someone who works for them particularly when there is such an age difference. Then, there is the issue at what age did this relationship become physical. Sorry Sam but your denials ring a bit false based upon your level of credibility with the voters. And like it or not 17 and 18 mark a black and white line with respect to the law and one side or the other is the difference between piss poor judgment and a label of sexual offender. Even Portland ain't that progressive.

Now delving into all that wouldn't have been comfortable and dealing with his age might have been tough. You might respond that your private life is none of our business but here's a fact that many politicians seem incapable of understanding - the voters get to decide what is their business and what isn't if you want our vote. We'll never know if we'd have gotten past it or not since you didn't trust us to decide. Yes it might have cost you the election, but I suspect that would have been better than what's happening now. You'll either resign or likely be recalled for lying. Oregon has a long tradition of recalling politicians who fall from grace. Sex and sexual politics is the one thing that everybody understands. You've created questions in the minds of all those women out there who's bosses come on to them because they can. In all those troglodytes who imagine gay men hiding in the shadows waiting to pounce on young boys. And all those people who know that the city faces a myriad of problems that need honest government to address. You've touched off battles between those who would defend you for your orientation and those who do not. None of that is really relevant - it's just about one guy who screwed up and then lied about it.

But Dammit Sam, you didn't have the luxury of human foibles. Like it or not, your actions reflect on a greater population of people than yourself. And you've just made it harder for them. I'm not talking about sexual orientation here. All the people of this city deserved better.

Ethics Quiz Answer

Those who responded did so with ruthless creativity but according to experts in the field, there really is only one truly definitive answer to the lifeboat dilemma as described.

America's One Enduring Tradition

Old Glory came out of the closet today. It'd been rolled up in there for some time but today I felt like giving the old girl some crisp mountain air. It's not because I have any unrealistic expectations about what our new President can accomplish over night but because I was witness to another example of America's one enduring tradition.

We are still a young nation, but unlike almost any other country we have a seemingly bottomless capacity to re-invent ourselves when crisis looms. Today we did it again. What will this new America look like when the dust finally settles? Who knows. But if the history of our people is any guide, it will be a greater land than the one before it.

An Ethical Dilemma

Quick aside: You've got a lifeboat with D'Souza, Coulter, Hannity, Limbaugh, O'Reilly, Savage, Malkin, Rove, Krauthammer and Lowery in it. There's only food and provisions for 9 people to have any choice of survival. What do you do? Who goes over the side? You must decide.

The ethically correct answer will be posted in 2 days. Good luck.

Other Prominent Appearances in Comics...

Last week Marvel Comics sold out an edition of Spiderman which featured Barrack Obama. I thought you might be interested in seeing some lesser known editions featuring other prominent figures....

The Man of Steel delivers a long overdue smack down...
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This edition of Spiderman featured sometimes ally Doc MurdOct inadvertently setting loose the evil Hannity Head...



















Captain America comes out of retirement on behalf of the US Constitution...
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Aquaman helps Rush test his theory that waterboarding is just a little dunk...


















In episode 437, Superman decides to relocate the Fortress of Solitude to the South Pole...

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And no cartoon tribute would be complete without a Scooby Doo moment where the villain is unmasked.



Tell me this last one doesn't explain a whole lot of things...






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BeeBaDeee BaDeee That's all Folks! In his case let's hope so....

The Historical Setting of a National Health System: Avoiding the Mistakes of the Past

First let me restate that I whole-heartedly believe that we need a national health system in this country. What we don't need is some half-baked scheme that ends up being worse than what we have now. That's my fear and I've been at this long enough to know that such an outcome is entirely possible at this point. There is great pressure to 'act' but as in most things prudence has to be our guide. And we need to get over the knee jerk reaction to shudder every time some idiot pundit shouts the phrase 'socialized medicine' whatever that really means.

When politicians talk about healthcare reform they almost always mean payment reforms and controls. There are a lot of reasons why this is the case and we'll get into that in later episodes. A big one is that they have no idea that there may be alternatives and admittedly these alternatives won't be easy or come cheap. Often they gravitate to the notion of a single payer - a super sized Medicare program that pays for all health related services using a single standard. Some proposals would have the actual payments being made by regional parties such as either Medicaid or the existing payers (like the Blues for example) operating under contract to administer the programs for the government. A lot of healthcare dollars are already managed that way. Understanding why this has almost nothing to do with the actual practice of medicine and may not significantly improve care is important. This difference is key to making an intelligent choice about what a national system should look like. It's an important topic and will require more than one posting to cover. It's going to take some preliminary review.

Short historical review: We need some background here and please understand that entire libraries have been written discussing what we're forced to handle in a few paragraphs. There will be some simplifications required in the interests of accessibility.

Government payment for healthcare is a relatively recent phenomenon in this country. Come to think of it health insurance is pretty new. Prior to WWII very few people had any kind of medical coverage. In the aftermath of the war, employers sought new ways to compensate their returning and expanding workforce other than by direct, and taxable, salary. Employee benefits such as healthcare really took off at that time. Prior to the late 1940's very few people talked about any rights to healthcare services and there was very definitely a multi-tiered system of care. Most people negotiated for healthcare just like any other commodity and if unable to pay for one of the prestigious hospitals then they went to one of the charity hospitals run by the churches or some municipalities or bartered with physicians. Still, many people were left out in the cold. After WWII, a lot more people could avail themselves of the higher tier of care through their employee benefits.

Ironically this period, and the golden age of fee for service medicine that followed until the 1980's, was a very 'socialized' time in healthcare. How so? Well, what came to be known as balanced billing was pretty rampant. What that means exactly is something to which I will return shortly. Most hospitals and physicians took care of all sorts of patients regardless of their finances. MD's covering emergency rooms didn't perform wallet biopsies all that often and although a lot of the care for the indigent was done by resident physicians in training people got the care they needed for the most part - at least on the acute care side. Wellness, early diagnosis and prevention remained (and remain) huge problems for the underserved. Once they were sick, the acute care system would generally handle their needs if it wasn't too late. This continued imbalance is a prime driver in the need for a true national system.

Doctors and hospitals basically taxed the haves in order to care for the have nots. Part of the fees submitted to insurance companies essentially included a surtax to cover some of the costs for providing services to all the patients without money or coverage. That worked pretty well until medical advances lead to spirally costs and the Government stepped in with the heavy hand of Medicare. (The rise of Medicare and its effects is the topic of the next post.)

Now keep in mind a really important feature of being a doctor - you are just as legally liable for what happens to a person who doesn't pay you one red cent as you are to those that do. And we have to add the fact that said doctor has an office and staff to support. Many of those on that staff have nothing to do with actually delivering healthcare - they are there to manage the billing, regulation and administration of services already provided. The overhead for a practicing physician depending upon specialty and efficiency can range from 20% to 60%+ of gross revenues. Like any other business these are fixed costs. Before WWII and the rise of employee health plans most doctors offices didn't need much in the way of administrative staff. Billing was something that happened directly between the patient and the office and wasn't all that complicated of a process.

Employee benefits lead to the golden age of fee for service that I mentioned earlier. Doctors and hospitals were only too happy to deal with these insurance plans rather than directly with the patient. The promise was of more consistent revenues and standardized transactions that would lead to higher reimbursement for services. It turned out to be a somewhat Faustian bargain but only time would reveal that. Now it became necessary and not completely onerous to hire administrative staff to manage the relationship of payer to the clinic and hospital.

Three critical problems would result from this over time. The first was that the patient became distanced from the true cost of the care they received. As far as the average patient was concerned it may as well have been free. That in large part accounts for the change in expectations that patients have experienced over the last few decades. There was no personal incentive to budget or ration one's use of services and no sense of the true cost of care. Couple this to the rapid advances in healthcare itself and fewer and fewer people were interested in preventive maintenance as it were. After all, if they got sick, somebody would fix it and the relative impact financially to the individual was pretty minimal. Healthcare, subtly at first, became perceived to be a right. Even more telling was the fact that it was perceived to be a right without tiers. People who would have looked at you funny if you said that everyone was entitled to a Mercedes even if you could only afford a chevy had no problem with the notion that all the medical bells and whistles should be at the beck and call of all. Single tiered care is extremely expensive. (One of the issue this nation will have to face soon is whether it can be afforded.)

Second, The payers were (and remain) in the business of turning a profit. They are very happy to take all that employer money to cover benefits but not so keen on spending any of it on actual care. Thus was created an enormous and bloated bureaucracy to dispense the funds but also to make it harder and harder for the clinicians and hospitals to get it. This triggered what is essentially an ongoing arms race between clinicians and payers to see who can gain the advantage. More and more layers have been added with time, ostensibly to monitor these transactions and ensure that the money is going to where it should. Over time, two parallel systems evolved in healthcare: one to provide the actual care, and another to manage the business transactions that indirectly were the result of it. And the separation between these two systems has continued to widen with time. This duplication is a major contributor to healthcare costs in this country. More on this in later posts as it has profound implications to Mr Obama's plans for electronic health records.

Third, the fee for service boom times were of greatest benefit to those who performed technical tasks, treatments, and developed acute care technologies. Prevention and wellness were little regarded and financially ignored. People wanted active services, drugs and surgeries and the payers responded. That predilection to pay for procedures rather than other services continues today. 'Show me the money' has provided huge incentives to develop and invest in acute care services and technologies. The cost and complexity of these technologies also tipped the balance of power between physicians and hospitals since among other things the hospitals were better equipped to afford them in the first place. It also didn't help the development of wellness and prevention programs or indigent services - there was no money in it in a largely capitalistic medical R+D world. Again, short of some kind of government services it's hard to imagine that changing significantly.

These and other factors converted the long-standing doctor patient partnering into a triangulated relationship between patient and doctor, doctor and payer, and payer and patient. The interests of these three relationships are often in conflict. The friction thus created breeds inefficiencies that have added to the costs of medicine in a big way. They've also eroded the vital relationship between clinician and patient so necessary to good care.

This became more and more complicated - and that was ignoring the growing dominance of Medicare....

Next time: Medicare, Medicaid, the VA system and the rise to dominance of government healthcare programs.

Down the Rabbit Hole: A New Model of a National Health System, Part 1

Healthcare is a hot agenda item with the new Obama administration. That's how it should be. With the costs associated with care and the millions of Americans either un or under insured it needs to be fixed. Recently Mr Obama announced a plan to ensure the the universal application of electronic health records in this country as part of his package of reforms. And with that bit of sagely advise that he got from the Harvard folks I have begun to get serious gastrointestinal upset. I'm seeing early warning signs that the Obama proposals are going to be a rehash of what's come before. And trying to prevent this is that to which I have dedicated the last 20 years of my career. The science of healthcare delivery systems is what I study and how I make my living such as it is. It is my passion and my mission.

Many of the people with whom I work would have a cow if they knew I was about to launch into a conversation on this particular topic. My academic and industry work in the area is required to be more accommodating and diplomatic. There are always lots of feathers to sooth and endless meetings with 'stakeholders' and opportunities to create 'buy in' and a thousand other administrative platitudes that result in the appearance of progress in meeting minutes. Then there are the business interests that have a lot to gain or lose depending upon how the political wind sock is pointing. Lastly clinicians, patient advocacy groups payers, governmental agents, academicians, you name it point fingers to all the others as the source of the healthcare meltdown. Few are willing to admit that all have a hand in the problem and all will have to sacrifice something to fix it.

But here it's different. This nom de plume and blog site offers an opportunity to express the more controversial aspects of what this research suggests we should and can build. I'm a medical systems heretic and I love what I'm doing.

My previous post have largely been personal opinions experiences and thought experiments but on this particular topic I'm actually somewhat of an expert. Over the next few weeks and months I'm going to discuss key aspects of a sustainable and logical plan to create a National Health System. A System that could be the envy of the world. And we'll talk about why this electronic health record proposal could kill it before it's born. You see, I believe with all my heart that it's time for a National Healthcare System for the US. But not one like most people imagine... Anyone interested in seeing what's down this particular rabbit hole? I'll give you the first clue - it's not a single payer system. In part 2, I'll share with you what's wrong with that old single payer model.

Answer Me, These Questions Three...

Romesco del Pliny

And now for something completely different... Atheist, deist, scientist, layman, agmystic, whatever - we all gotta eat sometime. Some people pass the olive branch- me I reach for the olive oil... I love to cook and my wife and I both take turns and experiment together trying out new recipes or refining the old staples. This is one is a very reliable fall back for when you just get home from work and don't feel like cooking. No store bought sauce for us! Working together we can churn it out in about 7 minutes. It's extremely simple but very flavorful. Hope you enjoy it.

Romesco del Pliny

10-20 minutes prep time total. A great last minute meal that is always a big hit around our house. Excellent when you are tired and don't want to cook. Much better than standard red sauces. Fairly zippy and can easily be dialed up in heat with more pepper flakes without losing its complex flavor. Serves 3-4 generously and it's pretty healthy as well.

Ingredients
Peppers and tomatoes

• 1.5 or 2 roasted red peppers, drained
• Fire roasted diced tomatoes, can
• Sun dried roma tomatoes (tablespoon or 2)
• Tomato paste 1-1.5 tbls ( a bit more if you want it really 'tomatoee')

The rest

• 1 slice firm white sandwich bread, toasted
• 1/4 cup roasted salted almonds (not smoked)
• 1 large garlic clove
• 1/2 cup reduced-sodium chicken broth
• 1/4 cup extra-virgin olive oil
• 1 teaspoon Sherry vinegar, or more to taste
• 3/4 teaspoon salt, or to taste (don't skimp)
• 1/4 teaspoon dried hot red-pepper flakes, or more to taste
• 1/4 cup finely grated Parmigiano-Reggiano plus additional for serving
• 1 lb corkscrew pasta such as rotini

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Preparation

Begin to cook pasta in a 6- to 8-quart pot of boiling salted water .

Blend the vinegar, almonds, broth and oil for about a minute (I like the almond texture to be a little less apparent in the final mixture but if you prefer the sause to have even more texture, then do all the ingredients together at one time) then add the torn toast and blend with peppers, tomatoes, salt, and red-pepper flakes in a blender until smooth (1-2 minutes), but not too smooth (the texture is part of the appeal). Transfer to a 12-inch heavy skillet and bring to a simmer.

Add pasta to sauce along with cheese (1/4 cup) and toss to combine. Add additional chicken broth to thin the mixture as you are simming it to thin if necessary. Serve immediately.

You carnivores out there - throw in the sausage, meatballs whatever. Works well with all of it.

The Great Depression of 2011

In my neck of the woods every day brings news of new layoffs, plant shut downs, scaled back operations, and going out of business sales. We recently downsized our own offices and were unable to even donate un-needed furnishings to charity because of the volume of material already donated by other businesses either doing the same or closing up shop.

The winter weather gutted holiday retail and we are seeing a lot of mom and pop stores failing. The cascade of bankruptcies after the poor Christmas sales season hasn't reached its full intensity yet. Boeing announced a reduction in 1700 jobs and Intel is looking at similar numbers in light of the economic downturn. A regional producer of plywood panels (making enough per year to supply 21,000 homes) is closing operations. Once these wage earners are out of the equation how long will it be before trickle down economics results in even more losses to stores, restaurants, you name it.

I fear that we aren't anywhere near the bottom of this pit yet. Anyone else as scared as I am?

You Are What You Eat: Researching the impact of animal treatment on the ultimate health of the consumer

You are what you eat, so it is said. In that light I would like to propose a series of studies that might be of interest. For the majority of Americans who eat meat, said meat is usually the product of American agra-business conglomerates who generally treat the food animals with the same disregard that they show the consumer. The animals are often piled into cramped and minimally sanitary conditions and slaughtered with little regard to the suffering of the animals. Now I'm not going to argue the merits, morality or limitations of eating meat. What I am going to propose is that if meat is going to be consumed, that we should study the potential human health affects of inhuman treatment of food animals. If not for purely humane reasons might there not be practical reasons for treating the animals well. Ok Pliny, what they heck are you driving at? Simply this; is it possible that animals that are poorly treated produce meat that contains higher than normal concentrations of stress hormones? If that is true, is the consumption of those hormones a potential health risk?

The background:

Ok, we know that animals produce stress hormones when stressed (duh). Cortisol is one such hormone. Excessive cortisol is harmful to humans. It leads to central obesity, hypertension, poor wound healing and a myriad of other problems with prolonged exposure. We have seen a change in the pattern of obesity in the US. This could be from a number of factors. Could one such factor be exogenous cortisol present in food? (answer: unknown).

One might argue that such hormones would be digested. But keep in mind that oral administration is a common route for steroid therapies. Plus in many cases it is the break down products derived from metabolism of a substance that may be harmful.

The study:

I suspect that this might be studied in stages. Stage one: compare assays of tissue hormone levels from two animal cohorts. One might be a selection of range feed animals vs the typical agra-business processing. If tissue levels were similar, then the experiment might be over. But if not, then additional studies might be indicated. The first might be too study the bioavailability of the hormones when subjected to digestive enzymes say. Later studies might examine matched populations who consume range feed animals vs more factory processed meats.

I'm not saying that this would show any health risks but it seems like it might be time to consider the impact of the food animal's health and treatment to the ultimate health of the consumer.

Why are Female Breasts such a Threat to the Future of Humanity?

FaceBook bans pictures of breast feeding... I tried to watch 'Fargo' on the tube the other day but all the dubbing of 'foolish idiot' in place of more natural language was too distracting. I did notice that they didn't cut any of the images of murder and mayhem including Steve Buscemi's foot sticking out of the wood chipper. CSI shows mock-ups of rotting and burned corpses in close up, but if it's a female victim, the breasts must be covered. I know this country was colonized by a bunch of Puritans but that was centuries ago. Can anyone explain to me why people in this country would rather have their kids see acts of incredible violence rather than a natural part of the human body?