The question it raises, however, is what kind of backlash this will trigger. One likely possibility is an attempt to push through a Constitutional amendment imposing discrimination nationwide. Although that possibility concerned me greatly, I am – with fingers crossed – hopeful that such a movement would be unavailing. By the time any such plan could gain traction, there will have been several years’ worth of experience with gay marriage, and increasing experience of life under a national-level Supreme Court decision for equality, tending to reduce the panic over the supposed consequences of gay marriages. The political winds have shifted, also; it’s true that the GOP is somewhat resurgent, but the grounds for debate are now dominated by economic issues, and the religious-right/teabag movement is proving more and more of a liability for the GOP. I suspect the homophobic firestorm the GOP deliberately stoked in 1996, which created gay marriage as a political issue for their base, will not be possible in 2012. And, too, Constitutional amendments over controversial issues are hard to pass, and this one is unlikely to have enough momentum to overcome the inevitable decline of the homophobic movement as the reality of gay marriage proves their crazy ranting is just pointless. So I suspect there will be an attempt to pass the first-ever Constitutional amendment creating a new form of discrimination, but it will fizzle out.

However, I just read speculation elsewhere that gay marriage will become “another Roe v. Wade” – that is, a cultural flashpoint issue that will polarize society and give the right wing something to agitate about forever. That is no reason to oppose equality, of course, but it is a daunting prospect nonetheless. And that commenter was surely right that the (presumptive) institution of equality by the Supreme Court, and the failure of legislative or Constitutional processes to maintain discrimination, will energize the right wing and serve as a focus of grievance for them for the forseeable future. And yet, as I think about it, it occurs to me that this outcome may not be as destructive as it would seem, and could even have an upside. I suspect that the wingnuts will indeed agitate interminably over gay equality, and this will have two consequences: (1) it will further marginalize the religious right, and (2) it could conceivably bolster support for abortion rights as well.

The argument for the first possibility above is obvious. As gay marriages become more and more commonplace, and as disinformation about priests being forced to perform gay marriages, or children being “indoctrinated” in schools, are disproven by everyday experience, the disingenuous fearmongering that drives the hate movement will be undermined. The haters will simply serve to highlight the unhinged and bigoted streak that infects the Republican party and, as Sarah Palin is quickly becoming, and Sharron Angle already has become, will be an albatross around the neck that the GOP will eventually be glad to be rid of.

The argument toward a pro-autonomy rebound is less intuitive, but not implausible, I think. The idea that gay marriage will galvanize conservatives like abortion did is likely true. The parallels between the issues are strong: each is a cause celebre’ for the religious right, grounded on religious visions of morality, driven by a deep-seated revulsion to sex, and centering on a despised group whose claims to equality and autonomy the religious right hates and resents.  And the campaigns waged by the right against autonomy and self-determination in both cases are again similar: bizarre predictions of the consequences of allowing people to make their own decisions, Biblical injunctions against equality and non-patriarchal sex, deliberate lies and disinformation about the implications of freedom in each case, hateful moralistic judgmentalism, simply deluded scientific disinformation, and a manipulative pretended concern “for the children”, all of it as grossly distorted and dishonest as it is possible to be. As wingnut hot-button issues, they do have much in common.

It is that close parallel that, I think, spells (indirect, and uncertain) good news for the pro-choice position. The campaign against equality for gays is very similar to the campaign against self-determination for women. The basic idea at the bottom of both campaigns – that one particularly backward and restrictive religious view of how people should live their lives should be made mandatory for everyone, by law – is the same, and the attempt to regulate sexual behavior that they disapprove of is likewise a common central element in both campaigns. The gay-marriage controversy brings this to the fore because that issue is clearly solely driven by sex-based animus, but the same elements are at work in the abortion issue. And so, as the gay marriage controversy is exposed as the panicky, lunatic hatefest that it is, all other attempts to restrict the rights of autonomous adults to make their own decisions in areas reflecting on their sex lives will be simultaneously undercut. To the extent it becomes obvious that “gay marriage” is a wholly invented controversy based on ludicrous and bizarre apprehensions about other people’s sex lives, and the characterizations of its proponents and participants were absurdly false and fantastical, and its presence in the community is not a threat or a curse, and the claims and predictions made about it were false and invented, it will become that much easier to see how those same distortions have driven the anti-choice campaign in the same ways. And, most of all, the more it becomes obvious that the anti-gay-marriage people are simply hateful and barely sane, and that their movement is a product of their religiously-inspired reactionism, and that they are the same people who are driving the anti-choice campaign, the true nature of that project will become more obvious as well.

The bottom line is, letting the wingnuts discredit themselves over gay marriage can only work to the advantage of the pro-choice community (and related progressive movements). It will be an ugly and hateful process, but a necessary cleansing, and possibly a road to a better day in the future.

After nine years of war, the Army attracts recruits ready for combat but inclined toward risky personal behavior — a volatile mix that led to more deaths from suicide, drug overdoses and drinking and driving than from warfare, an Army review concludes. “Simply stated, we are often more dangerous to ourselves than the enemy,” says the 15-month study, released Thursday.

 Commanders have failed to identify and monitor soldiers prone to risk-taking behavior, the report says. As a result, suicides among soldiers have soared. . . .

Many recruits join the Army knowing they will be sent to combat, so they may “even be more comfortable accepting high levels of risk and uncertainty in their lives,” the report says. . . .

Chiarelli commissioned the review 15 months ago as the Army suicide rate exceeded that for civilians. The study says poor command decisions helped contribute to a record 160 suicides by active-duty soldiers last year and an additional 146 deaths resulted from risky behavior such as drug or prescription medication abuse. Seventy-four of those deaths were overdoses.

Randall McElroy III, at The Distributed Republic, has a useful comment:

Internal investigations by government agencies always seem to turn out this way. It’s not the multiple deployments, the stress of fighting in a conflict where you can’t tell who wants to kill you until they’re doing it, the moral burden of shooting at innocent people, the vagueness of the goals of the conflict, or any of that. In other words, it’s not the essential part of what soldiers do these days.

It’s that, for some reason, without any causes, soldiers are engaging in risky behavior, and their commanders are just too darn earnest about prosecuting the war to notice.

However, I wanted to note the way drug- and alcohol-related deaths are handled in this story.

Half of all such deaths in this study, and a quarter of all “risky behavior” deaths for last year, were caused by drug overdoses. Soldiers are taking illegal drugs and dying from them, at higher rates than among civilians. Had these been civilian deaths, the narrative would have been simple: junkies OD and die. Surely far more than 74 civilians fatally ODed last year (though the per-capita rate is still lower); you don’t see many stories about this growing menace. What you certainly don’t see are civilian drug users characterized as “risk takers” or “comfortable accepting high levels of risk and uncertainty in their lives”. Convulsing to death with a crack pipe in your hand, if you’re a soldier, however, is apparently something like fastroping into a hot LZ or charging a machine-gun with a bayonet – the sort of thing those gung-ho heroes do because, you know, they just can’t help being so macho.

I wouldn’t mind this so much, if it were in any way honest. Identifying psychological factors that contribute to drug-taking, in fact, is a welcome step forward (even if slightly implausible in this case; chalking drug use up to simply being “prone to risk-taking behavior” is not only vague and one-dimensional, but even in some way circular). If the government were to take its own treatment of this issue seriously, and begin to sincerely probe the psychological and circumstantial factors that lead some people to drugs, we might be able to approach the issue of drug use in a more rational and realistic way. But of course that’s not what is being done here.

Characterizing drug-using soldiers as “risk-takers” is simply assigning a convenient euphemism to behavior, and its tragic consequences, that are relentlessly condemned in other circumstances. This is convenient in several ways: as McElroy notes, it lets the military off the hook for putting these soldiers under the stresses that, indirectly, killed them; it also preserves the unchallengeably heroic facade that the military is allowed to hide behind in all circumstances; and it gives these soldiers a pass on the judgmentalism that otherwise greets mental illness or drug use. Even outright suicide is treated as “risk-taking” – an absurd circumlocution that neatly obviates the inquiries into soldiers’ mental states, and the effect that military service has on them, that would otherwise be inevitable. In this way, behavior that would certainly be categorized as pathological, illegal, and disreputable in anyone else is folded into the military’s self-assumed and deliberately promoted ethos of heroism and rugged virtue.

Nobody is going to go on from here and say “Hey, you know, civilians also experience stress, self-medicate to deal with it, and exhibit a range of coping mechanisms influenced by their own psychology and their propensity for risk-taking. Maybe we should lighten up on the moralistic rhetoric about drugs and start recognizing the real-world factors that influence behavior, so we can respond more sympathetically and effectively. Maybe some proactive interventions with people at risk would help them out. Maybe our leaders have a responsibility to create better living conditions and offer better interventions to people at risk to help prevent self-destructive behaviors ahead of time, rather than sending millions of people to jail for being heroic, macho, rugged risk-takers.” Because the people who are painting military junkies and suicide cases as heroic, combat-ready risk-takers don’t really believe that and don’t really give a shit about people’s problems, in or especially out of the military. They certainly have no investment in being accurate, honest, realistic, or sympathetic about stress, pathology, and self-destructive behavior. Sugar-coating America’s Heroes to sweep a military-related drug problem under the rug avoids dealing with drugs realistically in any venue – which is the one thing any of our drug programs can never do.

You’re like the mean proctologist with a fetish.

My work is done.

Somewhere in your town there is a row of graves at the cemetery, called smartypants lane, filled with people who were buried at poorly attended funerals, whose headstones say “Well, at least I was right.”

The post is actually a useful discussion of the phenomenon of rationalization of bad thinking – something that is most perniciously prevalent in bioethics, it seems. But it really caught my attention just because I now know what my headstone is going to say.

Quelle horreur!

Coffin’s conclusions are that this is a “distortion of science”, that “language purporting to be the judgment of an independent body of medical experts devoted to the care and treatment of pregnant women and their children was, in the end, nothing more than the political scrawling of a White House appointee”, and that “Miss [sic] Kagan’s decision to override a scientific finding with her own calculated distortion in order to protect access to the most despicable of abortion procedures seriously twisted the judicial process” – naturally she he rolls this up into the ongoing Kagan Supreme Court confirmation hearings as well. The right-wing idiotocracy is all a-Twitter, too, natch: Powerline declares this is a “smoking gun” and “shocking”; Riehl calls it “misrepresenting science” and “dishonest”; the risible Betsy, of Betsy’s Page, reads this and concludes that “there was a doctors’ opinion that said that partial birth abortion was not necessary and she, with no medical background at all, drafted a statement that said the exact opposite”. Yuval Levin, the severely bioethics-challenged former staff manager of Bush’s Presidential Council on Bioethics, declares this to be a “war on science”, “astonishing”, and “easily the most serious and flagrant violation of the boundary between scientific expertise and politics I have ever encountered”.

This sort of nonsense is particularly astounding from Levin, who was a central player in the workings of an “ethics” commission that remains a watchword for right-wing distortion and duplicity, whose major policy statements drew dissenting opinions from its own most scientifically-qualified members, and which then censored, and later fired, those same members. Levin – a political scientist and former Bush White House policy staffmember who has spent his entire career crafting right-wing bioethics policy - also castigates Kagan for her lack of medical expertise and her involvement in healthcare policymaking. You really just can’t make this stuff up.

It’s especially disingenuous for people like Levin and Coffin – political hacks whose entire career consists of trying to influence policy to fit their ideological leanings, from both inside and outside the government – to claim that there’s something untoward in political policy staff conferring with the policy-making boards of professional organizations to shape language on statements issued in clearly political and legal contexts. That sort of thing goes on all the time, and it’s appropriate for such bodies of experts to confer with political authorities to ensure that their statements are effectively written and focused. It would be inappropriate for them to turn themselves over to the political authorities as tools of policy, and to issue statements they did not believe were true, but it’s not inappropriate to get guidance on language and emphasis in order to convey an effective message. (As Coffin herself notes, ACOG already opposed the anti-choice bill. Obviously they would want their policy statement to reflect the reasons why.) To suggest that a policy expert drafting language for a policy statement endorsed by a professional body is somehow scandalous – let alone unusual – is simply stupid. And to suggest, as Coffin and others have recklessly done, that ACOG is somehow compromised or tarnished in doing so, is not merely stupid and dishonest, but libelous.

Aside from the completely manufactured, and fictional, scandal that the right-wing noise machine is busily whipping up over this, there is also the simple fact that the language Kagan suggested does not replace or contradict the language previously present. The statement that there are “no circumstances under which intact D&X would be the only option” is entirely compatible with the claim that it “may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman” (emphases added). It’s simple, really: the fact that something is never the only option in no way means that it is a bad option; the revised language not only implicitly acknowledges this but clarifies for the dim-witted (i.e., conservatives) the even more important point that it is in fact sometimes the best option. (Obviously, Intact D&X is never the only option: you can always perform an unnecessary Cesearean section or force the woman to deliver a fetus that may be dying and may possibly kill her - options that are much prefereable, for conservatives, than allowing a woman to choose the safest option on her own authority. ACOG’s point, which Kagan nudged them towards, is that there are often better  options – and that women should have the right to choose them.)

The fight over Intact D&X was particularly nasty because it encapsulates so much of right-wing misogyny, so clearly: it was not a ban on abortion, and it was not a ban on late-term abortions; in fact, it did not ban any abortions under any circumstances. It was only and entirely a ban on one particular procedure for performing abortions. It banned the procedure that was preferable in specific circumstances – leaving abortions entirely legal under those circumstances but forcing women to submit to a procedure that was less safe and more debilitating for them. It was straightforwardly an attempt to punish women by making them accept higher risks and a lower standard of care, as the price for choosing a procedure the right wing disapproved. And ACOG’s policy statement implicitly recognized this: it notes that there are always alternatives to the ID&X procedure, but that in some circumstances those alternatives are worse, and ID&X is, in those circumstances, the best or most appropriate procedure. Kagan’s contribution – appropriate, useful, and highly pro-woman – was to encourage them to clarify that distinction. (Note, again, that ACOG explicitly reiterated this policy, and the important distinction it makes, three times after Kagan supposedly “overrode” their scientific judgment in the matter by forcing them to include language that does not contradict that judgment.)

Raising this issue is simply another example of the right-wing’s reflexive insanity over sex and abortion, coupled with their inherent inability to read and comprehend basic logical statements. (Note “Betsy”‘s analysis: “there was a doctors’ opinion that said that partial birth abortion was not necessary [no, there simply wasn't] and . . . [Kagan] drafted a statement that said the exact opposite” [no, she didn't].) Honestly, the relationship between “not the only” and “sometimes the best” is really not that tricky. It’s too tricky, of course, for the average right-winger, and for people like Coffin and Levin, whose deficiencies were all too apparent back when they were writing policy for Bush, but to people of normal intelligence and reading comprehension, this entire farce is an obviously groundless, and all-too-familiar, political hackery.

The right wing is also up in arms over this because, as Scott Lemieux at Lawyers, Guns, & Money notes:

the only point of this feeble “smoking gun” is to allow Senate Republicans to mention the phrase “partial birth abortion” a lot [and] I should note once again that for reasons Judge Posner and Justice Stevens have explained the entire issue is a farce. The distinction between D&X abortions and other abortion procedures is wholly arbitrary, and for people who have supported irrational laws making such a distinction to pretend to care about rigorous medical science is nothing but comedy of the lowest form.

Mahablog was fast out of the blocks on this, in a post I wish I’d written:

if you actually understand the issue in question — which leaves out righties, naturally — you’d know there is no “there” there. . . . Somehow, in the fevered imagination of righties, a professional organization representing 90 percent of U.S. board-certified obstetrician-gynecologists was duped by Kagan into telling a lie, or something, and because this wording came from Kagan it must not actually reflect the views of ACOG. . . . no scientific finding was “overridden,” just clarified, and ACOG must have agreed with the statement or they wouldn’t have continued to repeat it in their position papers ever after.

Lemieux gets the content issue exactly right:

There’s no contradiction between the two drafts, because D&X abortions are, in fact, not medically necessary in a majority of cases. But this fact doesn’t mean that they are never medically necessary, and indeed the original statement implies that there are cases where D&X abortions are necessary or preferable for a protecting a woman’s health. Adding a statement to clarify what was implicit in the first draft doesn’t “distort” anything, and of course if ACOG didn’t think the statement was accurate Kagan had no power to get them to change it. There’s nothing here.

UPDATE: Corrected pronouns referring to Coffin; he’s a “he”, not a “she”. My apologies to Coffin for the mistake.

UPDATE: Another right-wing website breathlessly announces that Kagan “pressured a second group” on its wording of its pro-choice policy. That group was the AMA. Their claim: “Kagan discussed with other Clinton administration officials whether the AMA could reverse its policy saying there is not an identified situation in which partial-birth abortion is the only appropriate method of abortion. The AMA also noted ethical concerns with partial-birth abortions and said that it should not be used unless it is absolutely necessary.” Note that this repeats exactly the same mistake all the other commentators made about the first memo: the two positions described are not contradictory, and there is no “reversal” in evidence! And Kagan’s particular crime: she wrote an e-mail saying “We agreed to do a bit of thinking about whether we (in truth, HHS) could contribute to that effort . . . . Chuck and I are meeting with the AG on Tuesday; Donna offered to send over some doctors this week”. They don’t even identify who the e-mail was sent to (obviously it was internal), or whether any such meeting ever took place, let alone had any effect. (Apparently the AMA does the bidding of any government staff lawyer who offers to “contribute” to their policy development.) Truly, the stupid knows no bounds with these people.

This book review is excerpted from a detailed forthcoming review in the American Philosophical Association Newsletter on Medicine and Philosophy, v. 10, n. 1, Fall 2010.

Jonathan D. Moreno and Sam Berger (eds.)
MIT Press, Cambridge, 2010
286 pp., with Index
Foreword by Harold Shapiro
Introduction and Afterword by Jonathan D. Moreno and Sam Berger
ISBN: 9780262134880

Bioethics addresses issues shaped by abstruse empirical fact and the technical parameters of the technologized controversies of contemporary culture. It is tempting to imagine that our philosophy must be as technologically-informed as our understanding of our lives has now become – that human flourishing must be in some ways dependent upon technological problem-solving, that the range of values and possibilities accommodated within the morally good life is wider than previously imagined, and that these observations define a particular stance, critical but welcoming, toward the prospect of aggressive engagement with the future through the tools and products of science.

Something like that is the position ascribed to “progressive bioethics” by the authors of the just-issued essay collection, Progress in Bioethics: Science, Policy, and Politics. The volume collects almost 20 essays on questions of the nature of bioethics as a field, its relationship to progressive ideology, and the ways that relationship plays out in particular issues and controversies characteristic of the field now and in the past. The authors are a roll-call of respected and influential figures in contemporary bioethics, not all of them academics, subscribing to a wide range of perspectives on progressivism and the task of progressive bioethics. The impression they give is of a fluid and open-minded community, engaged in a searching and sometimes indeterminate discourse with itself and the wider world.

The Foreword, Introduction, and essays of both Section I: “Bioethics as Politics” and Section II: “The Sociology of Political Bioethics” investigate the nature of progressivism, the issues that are or should be of interest to progressive bioethics, and the practicalities of politics and policy that bioethics is often involved in. Section III: “The Sociology of Political Bioethics”, addresses questions of the professional identity of bioethics, and how progressive ideology meshes with other personal and professional values. Section IV: “Conflicting Views of Biotechnology” contains one unabashedly pro-technology piece, and another warning against an uncritical stance on science. The concluding Section V: “Progress Beyond Politics”, offers higher-level reflections on the field of bioethics in general. In the “Afterword”, the editors remark upon the prospects for progressivism and healthcare reform in the advent of the Obama administration – a question that could not be more timely.

Necessarily, there are gaps: the definition of progressivism needs further exploration, and it remains unclear why progressivism should have any of the content suggested for it; at times the content or scope of bioethics also seem taken for granted. Even the role of science in progressive bioethics awaits further examination. These are not faults in a collection of diverse viewpoints; however, much remains to be discussed. This volume opens that discussion insightfully, searchingly, and provocatively.

Progress in Bioethics is must-reading for political progressives interested in biomedical issues, bioethicists who identify as political progressives, bioethicists in general who are interested in the conceptual landscape of contemporary biomedical policy and cultural controversy, and for those who seek to develop a humanitarian pro-science viewpoint, whether on biotechnology or other complexities of our technologized modernity.

Dr. Pardi had gone into the field because she thought her experience as a patient would make her a better doctor. Now she came face to face with all the ambiguities of death, and of her profession.

She remembered patients who complained to her that she did not know them well enough to recognize that they were stronger than she had thought. Now she discovered that she felt the same way about her own doctors. “I think they underestimated me,” she said in an interview last summer.

She came to question the advice she had been giving. She thought about quitting. “I just decided I have to believe in what I’m saying,” she said.

It’s tempting to see her treatment choices – demanding extensive low-probability and experimental treatments – as being in some way hypocrtical for someone who had made a point of encouraging others not to continue with therapeutic treatments near death. At times she was quoted expressing anger at doctors who recommended palliative care or hospice, and at times she is described by others as being “in denial” about her own condition – much in keeping with her own attitudes toward palliative care and patients’ beliefs, as seen from her professional perspective. The article at times seem to imply that there is in fact a contradiction there.

But I think, and I think most people in the field would agree, that there is no tension between active therapy and palliative care – that both are available options that different people will choose for different reasons, or even that a given patient will choose under differing circumstances. The idea that some patients would reject palliative care is hardly new; the fact that one such patient would turn out to be a palliative care specialist is merely a coincidence, ironic at most, and hardly that. (Nobody claims that palliative care is right for everybody.)

From that perspective, I was a bit annoyed with this article, because it seems to imply that there really is something wrong in the way Dr. Pardi practiced as a physician, or worse, that there is something wrong with palliative care – that it “underestimates” patients, that it is something that palliative care workers try to impose on others but reject for themselves, or even that it is the sort of “death panel” that the insane right wing keeps conjuring up. Also annoying is the tone attributed to Dr. Pardi herself (she was dead when the article was written): that palliative care was in fact something to be avoided; that she herself questioned whether it was right for her to offer it to her own patients. It’s not clear how authentic this is, but I hope Dr. Pardi was not as much “in denial” about her own profession – let alone her health status – as the article seems to imply; if not, the problem then is not that there is something wrong with palliative care, but that a doctor in that field had not thought deeply enough about what is right with it before it became an issue for her personally.

The meaning of the piece for me was that people’s personal choices are unique and not always predictable, and that this is the reason patients must be allowed to choose the terms of their own treatment. (Dr. Pardi – an MD/PhD with extensive experience – chose to allow her husband to be the point of contact with her own caregivers, and never knew the extent of her own disease, though she was adamant in her choices about how aggressively to treat it.) There is a reminder here of the degree to which aggressive treatment might serve some patients’ needs (Dr. Pardi’s final course took barely a year and a half from her last remission to her death, but it is likely that she extended that period somewhat by refusing palliative-only care and insisting on a high-calorie diet) – though that hardly renders palliative care unnecessary, or argues for returning to the days when painful aggressive treatment was the only option available.

If you voted for Obama . . .
seek Urologic care
elswhere

Changes to your healthcare
begin right now
not in four years

He apparently also fills his waiting room with anti-Obama literature, signs about what “the morons in Washington have done to your healthcare” (NB: nothing has changed about any of his patients’ healthcare; he is the only one who has done anything so far), and explicit instructions on who they should vote for.

In response to concerns that he might be politicizing his care just a tad, he argues “I’m not turning anybody away — that would be unethical. But if they read the sign and turn the other way, so be it.” So of course he’s not actually doing anything to make patients feel uncomfortable by explicitly telling them to leave his practice because he disapproves of their politics; they just happen to choose to seek another doctor for reasons unrelated to his behavior or his treatment of them.

There’s been commentary over whether this infringes any laws or principles of medical ethics. His supporters claim he is justified in behaving this way because doctors, like everyone, have a right of free speech. There’s a lot to be said about that – most notably that the whole point to medical ethics is that professional practice and the professional relationship impose standards more stringent than those  incumbent on ordinary citizens. Simply having a right of free speech does not justify acting like a jerk toward your patients; the treatment relationship is one-sided, predicated upon the doctor’s commitment to service of the patients’ needs, not their approval of the patients’ politics; admission as a professional is predicated upon acceptance of those standards, and a willingness to put one’s personal inclinations aside in the professional arena.

But aside from that, what strikes me about this situation is the general attitude it reveals. Not only does this doctor fail in the face of any of the above standards, but it seems obvious he simply conceives of medical practice as something that does not in fact entail the authority of such standards or commitments. Doctoring is apparently a job, to him – something he can do if and as he chooses, and which does not impose on him any obligations he does not happen to want to meet. He is – to all appearances – essentially the doctor in Ayn Rand’s Atlas Shrugged, who joins with the amoral capitalist runaways to form a free-market society founded on hard money and ethical egoism. Being a doctor does not require him to do anything for anyone if he doesn’t feel like it, and it doesn’t require him to accept as a patient – or even keep as a patient anyone he has already accepted – who does not personally agree with him on any matter of his choosing.

What I fear, but perceive, is that this attitude is becoming more widespread. Doctoring is just a job, it seems, in the minds of more and more doctors, and in the minds of the right-wingers who are so afraid that Obama is going to destroy healthcare by making it less capitalist. (As usual, facts are of no moment to the right-wing panic apparatus: it is this doctor himself who is “changing” healthcare for his patients – his own sign says so  – but he still manages to blame it on Obama. And it is this doctor who has made healthcare hostile and unwelcoming for his own patients – he is, not a death panel exactly, but a one-man jerk panel to his personal caseload – but they deserve it, he seems to think, because they voted wrong.) Whatever the consequences of Obamacare, I fear that it will be simply impossible to destroy medicine in the US because there will be no medical profession left to destroy – just a bunch of entitled, self-absorbed jobsworths whining about how much less they like their jobs now that the glamor and remuneration has started to fade and they’re left with nothing more than providing better care to more people, which is such an imposition.

Democratic Congressmember Alan Grayson, who represents that district, was notorious for (accurately) characterizing the Republicans’ healthcare policy as “Die quickly”. He notes about Dr. Cassell: “Maybe he thinks the Hippocratic Oath says, ‘Do no good.’” That’s about the size of it.

Health Expenditures vs. Life Expectancy

(See link for larger version.)

The graph is a ranking of industrialized countries by per-capita healthcare expenditures. The average figure is $2,986/year; Finland and Spain come in a little below that, and Australia and Sweden are a little above. Canada spends about $1,000 more per person per year than the major-nations average; free-wheeling Switzerland is about $1,400 above average.

See that lone, single red figure wa-a-a-a-a-y up in the left-hand corner? That’s the US. Our per-capita healthcare expenditures, at $7,290/year (!), are more than 240% of the average of all those nations together (actually, more than 260% of the average of all those nations other than the US, which comes to only $2,771/year if you leave the US out of it). And note that those expenditures, in the US, are for only 85% or less of the population; for every other country on the graph except Mexico, that figure covers every permanent resident of the country without exception.

Now look on the right-hand column: the same nations are ranked by average life expectancy. This is a crude, but still useful, indicator of what we’re getting for our healthcare costs. (Crude, because simple measures like sanitation and nutrition can contribute a great deal more to life expectancy than high-tech medical care. But the whole point is that better medical care produces longer and better lives, at the margin at least, and there is good evidence that this is true. So this is not a bad way to scale things out for quick and easy comprehension.) Implicitly, this graph establishes a relationship: assuming all things are equal, average healthcare expenditures should produce average life expectancies (which you could quantify as a numerical ratio, though that would be taking the thing rather too literally). In fact, that is almost exactly what the UK achieves ($2,992/year for about 79.1 years lifespan). About two-thirds of the countries on the list do better than that: their life expectancies, relative to average, are greater than would be expected given their healthcare costs relative to average. (This is indicated by the lines sloping up to the right on the graph. The slopes are not precisely indicative, because the right-side scale range does not match the left-side scale – the ranges should have been correllated better. But a positive or negative slope indicates an above- or below-average ratio, respectively.) A relatively small number of countries do worse.

Whether above or below average, the deviations tend to fall into a small range – note that most of the lines up, and down, are roughly parallel. All except one, of course: the US, as usual, is completely alone in its breathtakingly negative ratio of cost to life-expectancy benefit. That screaming red line plunging down the graph from off-the-charts high expenses to below-average benefits has no peer among any industrialized country: nowhere in the world does any country get such an incredibly below-average relative return for its healthcare expenses (and in fact below average in absolute terms compared to all other countries). The US, with per-capita healthcare expenses 260% highher than its peers, actually averages a total life expectancy almost 1.5% lower. (Only one other country, Denmark, manages to achieve above-average expenditures and below-average life expectancy; their expenditures are still less than half ours and their life expectancy is higher).

Note finally the width of the lines, which indicates average number of doctors’ visits provided per year by each country: the fat lines are 12 or more; the medium lines are 4 to 8; the US comes in at an average number of visits per year per person that rounds off most closely to . . . zero. (Note also that of the 4 countries that average effectively 0 visits per year, two of them are the only two on the graph that do not provide universal coverage.) Not only does every other country on this list except Mexico manage to provide universal healthcare coverage at vastly lower expense than the US, not only do 2/3 of them achieve greater life expectancies than the US, not only do 2/3 of them achieve an above-average ratio between relative expenditure and relative life expectancy, but over 80% of them provide an average of at least 4, and in some cases 12 or more, covered visits per person per year for their entire populations.

Note in passing, too, that the only other nation that can’t afford to provide universal health coverage is Mexico, which spends less than 30% of the average among these nations on healthcare and is still getting a vastly greater bang for its its bucks than is the US.

The utter, abject failure of the US’s profit-sucking healthcare morass is made as stark here as it has ever been. Basically, we’re spending over $4,300 per year for every covered person for nothing whatsoever, and giving up over a year of average life expectancy as our reward – while leaving tens of millions of people with no coverage whatsoever for most or all of their needs! It would be almost impossible to have a healthcare system worse than this, other than one with even less protections for patients than the US already has.

As Ezra Klein notes:

consider this: If we spent what Canada spends per person, our deficit problem would go away entirely. And Canada’s per-person average is in a country where everybody is fully covered and so has full access to care. America’s is in a country with 47 million uninsured, and so many people skimp on needed care. So the comparison is actually unfair to Canada. . . .

This is serious pitchforks-and-torches stuff, if only people really understood it. I continue to believe, however, that the improbable size of the disparity is a barrier to understanding. People just don’t believe these numbers. America may not be the best, but we’re not supposed to be the worst by such a large margin.

Oh, yes, we are. The system is designed to suck money out and deny care. It’s working perfectly. But why do we have a system designed to do that?

UPDATE:

There are some problems with the above graph, which I somewhat glossed over in the original post. DanM alludes to them in his comment below. It’s just as well to clarify some of these points.

First, the graph is somewhat misleading because it seems to position life expectancy as a direct function of healthcare spending: a certain amount of money buys you a certain number of years of life, and the slope of the line from one axis to the other describes the mathematical relationship between them. That is the inevitable broad-brush interpretation of the data, that is true (the whole point is that there is a link between the two factors, otherwise there’d be no point graphing them – and indeed the relation is clearly non-random as even a casual inspection of the graph shows) – but the line-graph format makes it much too literal.

Second, the scales of the axes are distorted. There is most obviously the fact that neither the expenditures axis, on the left, nor the lifespan axis, on the right, start at zero. The actual spread between high and low values on both axes is thus exaggerated, especially for lifespan. Also, the data ranges shown for each bear a very different relationship to the total range for data of each type: the top and bottom entries for healthcare expenditures span about 90% of the value of the top end of the scale, or about 80% if you exclude the US; the top and bottom entries for life expectancy span only about 12% of that range. If the two axes were scaled similarly, the right-hand values would all cluster into a tight knot and the blue lines would converge from high and low on the left into that small range, diminishing the impression of a clear correlation between the two values which is created by spreading the lifespan values out so much.

In addition, setting the average values of the two scales at the same vertical level is an arbitrary decision that reinforces the implicit message that the two are correlated. (A ratio between healthcare spending and lifespan that matches the dollars/years ratio of those average values will be a horizontal line at any level on the graph – thus those countries doing better on a dollars/years basis will have lines that slope up, and others will have lines that slope down.) Again, this is not unreasonable as a way of displaying this data, but it requires as an organizing assumption that the implicit correlation illustrated by the graph is in fact true – which puts the cart before the horse.

Finally, as Dan notes, there are other factors influencing lifespan, and implying that it is a direct function of healthcare expenditure, as this graph seems to do, is much too crude.

Nate Silver, brilliant statistical interpreter at “538“, recasts the same data in this fashion (click graph for larger version):

Healthcare Expenditure vs. Life Expectancy Scatterplot

This graph is much fairer in certain ways. By removing the horizontal lines, it removes the visual implication of a direct mathematical function linking the two data sets. By graphing the data as a scatterplot on two orthogonal axes, it allows the viewer to draw their own conclusions without dictating a relationship in the design of the graph. Silver also takes the obvious steps of scaling the axes fairly and accurately, starting a zero for each.

However, this graph also supports the basic point made in the original version: there is an obvious trendline through the data set, and the US is an extreme outlier that falls insanely far below that trend. (To see how far, hold a ruler against your screen, paralleling the slope roughly marked out from the origin through the data cluster running up to the right – about where Canada falls out. Continue that line up to the right until it is directly above the red “USA” below. It should run off the graph up to somewhere in the third paragraph above the graph. That’s where the US should be, given what we spend (on only a fraction of our population). If you want it in numerical terms (and again taking the implied correlation rather too literally), US citizens who actually have access to healthcare should live more than 193 years, on average, if we were spending that money as effectively as most other countries do. From the reverse perspective, given the below-average life expectancy we get for our healthcare dollars, we could spend at least $4,000 per person per year less than we do  and still achieve our current quality outcome, if we were merely as efficient in our expenditures as, say, Denmark. That $4,000 – more than the average amount other industrialized nations spend per person in total – is the amount we are throwing away on our for-profit healthcare system, for no benefit whatsoever to ourselves.

It must be acknowledged that that correlation has not been subjected to statistical analysis, but the basic point is that the original graph, though its designers made some questionable choices, was not as bad as all that.

Hat Tip: to Andrew Gelman at Columbia, who did the original re-analysis from which Silver took his own version.

Happy Fetus

Feto Incognito

Adam Lambert Embryo

The purveyor of the site insists that “Feti is just for fun, no political statements being made here.” I’m tempted to believe that in her case, but the thing still strikes me as weird,  and indicative of a mindset that is worth noting.

The vendor suggests these are intended as gifts for expectant parents, as appropriate additions to the “Baby’s First _____” category of remembrances. (Exactly how, I’m not sure: “Baby’s First Disembodied Hanging on a Christmas Tree”?) In that vein, they play off the very common and understandable practice of many expectant parents in personifying their fetus as it develops – talking to it, playing music, naming it before it is born, and so on. They also seem to accept as a cultural commonplace the fetishizing – literally, in this case! – and personifying of the fetus that is a mainstay of anti-choice propaganda. (Anti-choicers often wear gold-plated fetal-footprint jewelry, and they are forever trying to force abortion patients to look at pictures or sonograms of the fetus.)

I don’t know if the anti-choice movement has so far succeeded in turning the fetus into a fetish object that you can now literally market them to the general public as holiday ornaments, or if the common desire to see fetuses as sort of reverse-extensions of babies simply makes this a natural marketing move, like Cabbage Patch dolls or those weird Anne Geddes photographs of babies in flower petals, and the right wing has merely piggybacked off that common emotional trope for their own purposes. The former would scare me a bit, the latter is merely infuriating. Either way, this sort of thing leaves me with a creepy feeling.

I’m happy for people to be happy about their pregnancies, and to embue their future offspring with emotional valence or even a somewhat overgrandiose sense of promise or accomplishment. In the same way that all parents think their kids are smart and talented, and I wouldn’t quarrel with that, expectant parents can and should go ga-ga over the cute little buns in their respective ovens. There is no point, in the case of people’s emotional experience of the events in their lives, to go around insisting to them “you know it has no functional higher nervous system, right?” . . . “that’s not a ‘person’ you’re carrying, in any meaningful sense of the term – just wanted to let you know” . . . “don’t get too close to it – there’s about a 1-in-12 chance you’ll lose the pregnancy”. But when it comes to law and policy-making, clear distinctions do have to be made – and at that point, the conflict between stark reality and parents’ expectations may be uncomfortable.

Regardless of parental beliefs, not all kids are smart or talented, and thus some won’t make it into selective academic or sports or art programs. And regardless of the fervent, desperately dishonest myth-making of the anti-choice right, the early fetus is not a person and does not make moral claims on a woman’s body and life sufficient to override her autonomy. It is unfortunate to have to disappoint people emotionally invested in believing otherwise, but it is far worse to make policy based on wishful thinking in defiance of the truth.

By all means, have yourself a merry little Christmas, and hang a smiling Adam Lambert Jewish punk fetus upon the highest bough. But let’s keep the “personified fetus” myth firmly in its place when we go to making important decisions about real issues in real people’s lives.