Reason Doesn't Have a Chance

In the eternal struggle between reason and emotion, reason doesn’t have a chance. 

Not wishing to give up, however, let me try again to inject facts and reason into discussions of health reform. Here are some observations I hope you will consider objectively.

One: The health reform laws (collectively the ACA or “Obamacare”) do not so much change the healthcare system as they reform the insurance industry. Those who claim the ACA is a “takeover” or “power grab” by the federal government are either woefully uninformed or being disingenuous. Helping people choose insurance from private insurance companies is not a takeover.

Two: These insurance reforms—

• Guarantee you can get coverage even if you have pre-existing conditions
• Prevent your being charged higher a premium based on health status
• Cover prevention services including vaccines and screenings
• Eliminate lifetime and annual limits
• Allow young adults to continue on their parents’ plans to age 26
• Make it easier to shop for private insurance through the health insurance marketplaces (“exchanges”) with refundable tax credits if needed
• Provide standardized information and greater transparency about prices for purposes of comparison shopping
• Shrink and eventually close the Medicare “donut hole” for prescription drugs
• Expand Medicaid for states that voluntarily decide to extend coverage

When asked about these changes one by one, without being told that they are part of the ACA, people overwhelmingly approve of them. Only when the epithet “Obamacare” is used does support for them go down. 

Three: Yes, there is an “individual mandate” – a requirement that everyone have insurance beginning next year or pay a penalty. With more than 40 million uninsured people in this country, the policy issue is: is it better that a few be inconvenienced than millions of others have no coverage? This is, fundamentally, a moral issue as well as an economic one. But laying aside issues of morality, the purpose of insurance is to spread risk. The only way to do that is to have everyone in the insurance pool. And, by the way, an individual mandate is part of “Romenycare,” the Massachusetts health insurance plan on which much of “Obamacare” was patterned.

Four: Yes, the insurance marketplaces have had a rocky start, especially the federal Website healthcare.gov. But what new computer system doesn’t have bugs in the early going? Just think of upgrades to the Windows operating system or your iPhone. Those are never perfect on day one and always require “fixes.” (And, by the way, the federal site worked fine for me. That may be because I’m in California, one of the states that embraced reform.) 

Five: It is unfortunate that the President said “if you like your health plan you can keep it.” That was not totally accurate and he’s had to backtrack, thus giving his opponents political ammunition. But more fundamentally, it means that some substandard policies will continue in force, to the detriment of those individuals’ coverage and causing a delay in getting to the goal of spreading risk.

Finally: Obama is the eighth president to champion health reform: TR, FDR, HST, JFK, LBJ, RMN, WJC, and now Obama. If Watergate hadn’t intervened we probably would have adopted universal health insurance 40 years ago because that was Nixon's plan. I wonder what Tea Partiers and Republicans would have said about that. 

Churchill once said: "Americans always do the right thing ... after they've tried everything else first." I say: a century of trying other things is enough.

I don’t care whether you agree with me or not, but please base your opinion on facts and reason, not emotion and the “spin” you get from Fox News, politicians, etc. The highest form of ignorance is when you reject something you don’t know anything about.

Death as a Fact of Life

A recent story out of Bakersfield got a fair amount of press here in So. Cal. and elsewhere. A “nursing home” staff member saw an 87-year-old resident in apparent cardiac arrest and called 911. Despite the desperate pleas of the call center operator—"This woman's not breathing enough. She's gonna die if we don't get this started. ... Is there anybody there that's willing to help this lady and not let her die?"—per corporate policy the staff member (a nurse) refused to do CPR and the resident did in fact die.

Outrage followed, of course. Juicy story for the media. Sells air time. Some called it a “tragic death” and pointed fingers at the staff member and the facility. The problem is: the incident didn’t happen in a nursing home. It happened in the dining hall of Glenwood Gardens, the place where Lorraine Bayless rented an apartment. This retirement community does have a separate skilled nursing wing, but Ms. Bayless wasn’t a recipient of nursing home services.

′Nother problem is: she didn’t have a heart attack. She had a stroke, as confirmed by the autopsy report, so CPR very likely would not have saved her.

Third problem: contrary to what is portrayed on TV, CPR is an ugly, traumatic procedure that in many cases will not prove beneficial. Deciding not to perform it on a frail, elderly person is often the kindest and most appropriate response. And according to the resident's family Ms. Bayless would not have wanted medical intervention. She had expressed a desire to die naturally, without aggressive measures taken. The family are comfortable with the decision not to start CPR.

In a thoughtful commentary, ethicist Christopher Meyers of the Kegley Institute of Ethics at CSU Bakersfield asked, “Is all of this moral outrage warranted?” My answer, and his, is a firm NO! 

When I read Meyers’ article, related stories by various journalists, and the description of CPR by Jennifer Black, MD (“What you think you know about CPR is probably wrong)" I came away with these thoughts:

1. This was not a “tragic death.” Tragedy involves a disastrous event, especially one involving distressing loss or injury to life. The Titanic was a tragedy. The Hindenberg was a tragedy. The attack on 9/11 was a tragedy. This was the sudden but natural death of an 87-year old woman who suffered a stroke and who had expressed a wish not to have life-prolonging interventions. The tragedy, if any there be, is the emotional trauma caused to all parties by the execrable media attention the case received.

2. As Dr. Black wrote, the controversy over the incident “has generated more heat than light, and … it is extremely unlikely that [Ms. Bayless] would have survived earlier CPR, and if she had, even less likely she would ever have left the ICU alive.”

3. Most importantly, the incident and the media fury surrounding it (here in Southern California, at least) point out the need for all of us to (a) have advance directives and durable powers of attorney for healthcare, (b) discuss these matters with our family, friends, and physicians, and (c) when appropriate ask our physician to put our wishes into effect through a written order (known in some states as a “POLST” or “MOLST” form).

Taking my own advice, I recently sent to my three offspring a durable power of attorney for healthcare, a separate one for financial matters, and a letter explaining that—like Ms. Bayless and many others—I do not want heroic measures in the event that an end-of-life decision needs to be taken in my case. In part of that letter I wrote the following:

If all the world’s a stage and each of us merely players, our scene must come to an end at some point. When it’s time for the curtain to fall, I don’t want to hang around. Let me get off stage quickly, with as little fanfare as possible. All of which is to say that I want no “extraordinary measures” taken to prolong the dying process. If it comes to the point that a proposed treatment, including even the artificial provision of nutrition and hydration, would not be therapeutic and/or the burdens would outweigh the benefit to me, I do not want such treatment used. In fact, were it legal and were I competent to decide, I would opt for euthanasia under those conditions.

You can read in the Glenwood Gardens story, in the “consent” chapter of my textbook, and occasionally in the general media the horror stories of families faced with end-of-life issues. They often drag on for ages and can cause unnecessary grief for all concerned. I do not want you to have to endure anything like what the families of Nancy Cruzan, Karen Quinlan, Terry Schiavo, and numerous others have had to suffer.

Frankly, my attitude is: I didn’t audition for this role; it was just given me. And when the last scene of all ends my strange, eventful history I won’t regret shuffling off this mortal coil. Mind you, I don’t want to do so any time soon, but at some point I hope you will say, as did the Earl of Kent over Lear’s body: 

Vex not his ghost. O, let him pass; he hates him

That would upon the rack of this tough world

Stretch him out longer.

I post this not to be morbid but in the hope that you will do something similar for your loved ones. Write it out. Have a conversation with them. You owe it to them, and to yourself.

Death is just a fact of life. It’s what makes life special.  

# # #

Happy Birthday, Charles John Huffam Dickens!

"It was the best of times, it was the worst of times."

Those words may cause a frisson of dread, painful memories of being forced to read the 135,000 words of A Tale of Two Cities. Similar recollections might accompany “I called myself Pip” from Great Expectations (185,000 words), or “London, Michaelmas term lately over” from Bleak House (213,000).  

When given by my high school English teachers (Sidney Silverman and Waldola Wasson—yes, those are real names), assignments to read these great works caused groans throughout the classroom. But I am glad now to have made Mr. Dickens’ acquaintance and to remember him today, February 7, the 201st anniversary of his birth.

Dickens’ serialized novels—their appearance in installments and the fact that he was paid by the word help explain their great length—are some of the gems of the English language and home to some of the world’s most memorable characters. Consider, for example, the following (from my favorite, Bleak House)—

A band of music comes and plays. Jo listens to it. So does a dog—a drover’s dog, waiting for his master outside a butcher’s shop, and evidently thinking about those sheep he has had upon his mind for some hours and is happily rid of. He seems perplexed respecting three or four, can’t remember where he left them, looks up and down the street as half expecting to see them astray, suddenly pricks up his hears and remembers all about it. A thoroughly vagabond dog, accustomed to low company and public houses; a terrific dog to sheep, ready at a whistle to scamper over their backs and tear out mouthfuls of their wool; but an educated, improved, developed dog who has been taught his duties and knows how to discharge them. He and Jo listen to the music, probably with much the same amount of animal satisfaction; likewise as to awakened association, aspiration, or regret, melancholy or joyful reference to things beyond the senses, they are probably upon a par.

Do you not feel you know that dog? You can see him, right? And Jo: you know something more about him too, just from having him compared to that “vagabond dog, accustomed to low company.” What masterful, evocative prose this is!

Consider too this description, beginning on page one, that presages the author’s withering criticism of the arcane, slow, murky 18th Century English legal system—

Fog everywhere. Fog up the river, where it flows among green aits and meadows; fog down the river, where it rolls defiled among the tiers of shipping and the waterside pollutions of a great (and dirty) city. Fog on the Essex marshes, fog on the Kentish heights. Fog creeping into the cabooses of collier-brigs; fog lying out on the yards and hovering in the rigging of great ships; fog drooping on the gunwales of barges and small boats. Fog in the eyes and throats of ancient Greenwich pensioners, wheezing by the firesides of their wards; fog in the stem and bowl of the afternoon pipe of the wrathful skipper, down in his close cabin; fog cruelly pinching the toes and fingers of his shivering little ‘prentice boy on deck. Chance people on the bridges peeping over the parapets into a nether sky of fog, with fog all round them, as if they were up in a balloon and hanging in the misty clouds.

… And hard by Temple Bar, in Lincolns Inn Hall, at the very heart of the fog, sits the Lord High Chancellor in his High Court of Chancery.

Never can there come fog too thick, never can there come mud and mire too deep, to assort with the groping and floundering condition which this High Court of Chancery, most pestilent of hoary sinners, holds this day in the sight of heaven and earth.

Whew! By page two of Bleak House we know we are in for a ride, chauffeured by the literary colossus of his age ... one of the greatest of all time.

Happy birthday, Mr. Dickens! Would that I could write half as well as thee.

Geography Quiz

My friends and regular readers of this blog know that I am a natural skeptic. I question most everything, trust only fact not rumor, and abhor unfounded opinions. Blind faith -- "the assurance of things hoped for, the conviction of things not seen" -- just doesn’t work in my book. If it’s not admissible in court, I disregard it.

That tendency kicked in on December 31 as I watched Anderson Cooper and Kathy Griffin ring in 2013 in Times Square. A few minutes before mid- night they cut away to Easton, Me., which a reporter claimed is the eastern-most point in the country and thus the first U.S. location to welcome the new year. I thought, “Really? Is that true?” 

I got out my atlas to find out, and then I started thinking about other geographic oddities. As a result, I have this quiz for your cartographic amusement. Feel free to suggest other questions in the comment section. Here is your quiz:

 

    (a) If you go south from Detroit what is the first foreign country you come to?

    (b) How many U.S. state capitals are west of Los Angeles?

    (c) What is the eastern-most piece of U.S. land?

And the answers are --

    (a) If you were trying to imagine some place in South America, you were way off. When you drive south from downtown Detroit you cross the Detroit River into Windsor, Ontario, Canada.

    (b) Folks who haven’t lived on the left coast seldom get this one, and even those who live in California often miss it. The answer is: six. West of LA lie the state capitals of California, Nevada, Oregon, Washington, Alaska, and Hawaii. For extra credit, name those cities.

    (c) Finally, the eastern-most piece of U.S. land is not in Maine, it’s in Alaska. Yes, that’s right. The Aleutians stick out across the International Date Line, and at 179° East Longitude lies Semisopochnoi Island, Alaska. Alaska, therefore, contains both the western-most and eastern-most bits of U.S. territory. But to give CNN its due, nobody lives on those small volcanic islands at the end of the Aleutians, so Easton, Maine is the first inhabited spot in the U.S. to see a new year.  

Here are some shots of Semisopochnoi Island. I guess you can figure out why nobody lives there.

As this map shows, the Aleutians (red dot) straddle the date line, the meridian that goes straight down from the North Pole in this picture. Semisopochnoi is the first green spot to the left of the date line.