Ezekiel Emanuel is half right . . .

But there's a bit more to the story. He points out that 10% of the population account for almost two thirds of health care costs. As a matter of fact, based on data from the Medical Expenditure Panel Survey, the top 5% account for more than half, while the bottom 50% account for 5%. (Abstract only for the unwashed. This data is 10 years old but it had been stable since 1970. It doesn't change.)

Dr. Zeke wants to make the care of those people more efficient using bundled payment instead of fee for service and care coordination strategies. That's fine, it might save a few percent and make those folks lives a little better. I'll let his argument about that speak for itself if you care to read the article.

But here are some points he doesn't make.

First, you've heard all that yackety yack from conservatives about how if we had to pay for more of our health care out of pocket, people would choose more wisely and we'd save a lot of money. Pish tosh. These people are soaking up tens of thousands of dollars a year in health care expenditures because it's free to them so why not go for it. They are seriously, chronically sick. They have kidney failure, heart failure, complications of diabetes, cancer, or serious congenital diseases. (No, they aren't all elderly, only about half.) People don't get kidney dialysis because they feel like it, they do it as the only available alternative to dying. Making the rest of the people pay fifty bucks to see the doctor isn't going to save diddly, but it is going to make them more likely to end up in the top 5% where they are costing real money.

Second, suppose we could save a few percent on the care of these really sick people. That's better than nothing but it's still only a dent -- and the underlying trend of increasing costs would continue, it would just be set back a couple of years. The problem would not be solved.

Unlike Ron Paul, I am not in favor of abandoning the unfortunate. So what do I propose? A few things that Emanuel doesn't want to talk about because of politics.

First, we need to do cost effectiveness analysis and we need to set limits. This doesn't actually have to hurt people. Do people really benefit if they get three or four weeks of extra life semi-conscious in a hospital bed? I don't think so. That's not where most of this money is going, but it's a chunk. A bigger chunk can come from just knowing what's most effective and setting up enforceable guidelines that prohibit wasting money on useless or harmful treatments, such as angioplasty for people who haven't had heart attacks. People are making money off of this stuff, which is why Republicans won't let us even study the question. Well screw 'em.

Second, we need to invest much more in public health. We'd have a lot fewer people in this situation if we really made the effort to combat obesity, tobacco addiction, and other preventable harms. There's net social benefit from reducing particulate pollution from motor vehicle exhaust, chemical contamination of food (such as BPA from can liners), mercury in fish, food-borne infectious diseases. And a lot more. But that requires spending government money to improve the social and physical environment, and regulating powerful industries. Again, Republicans think that infringes on the freedom of rich people to rob us. See final comment above.

Third, we need to use the buying power of Medicare, Medicaid and public employee health care -- and eventually the buying power of the single payer program that will cover everyone -- to reduce the incomes of overpaid medical specialists and the price of drugs and medical devices. And no, using the promise of obscene profits as the basic mechanism to finance drug development is grossly inefficient. Yes, that costs a lot of money, but it would be cheaper for the government to finance the research directly, which would direct the research in the most socially beneficial, as opposed to the most profitable direction; and then buy the drugs cheaply, instead of having most of the money go to profits, executive salaries, and marketing costs.

In other words, we can't get there by mucking around on the edges. We need fundamental reform.

We need universal, comprehensive, single payer national health care. Nothing else. That's what we need.

Dr. Murray

I don't think I need to provide a link, but in case you haven't heard, Dr. Conrad Murray, physician to the late Michael Jackson, has been sentenced to four years in prison for involuntary manslaughter. I certainly agree that his actions were egregious, and that in principle, bad doctoring can constitute criminal behavior. But, it's always a tough call and it seems like a very slippery slope.

The essence of the problem is that physicians have a license to take actions that are ordinarily crimes. They can slice us open, remove body parts, and feed or inject us with powerful toxins that might just end up killing us. If we aren't conscious or competent, they don't even need our permission. Although you may have heard that it's a principle of medical ethics dating to Hippocrates to "First, do no harm," it is not. Just about anything substantial that doctors do carries a risk of harm -- all medical interventions represent a tradeoff of uncertain benefits, predictable harms, and serious risks. Not only that, but a medical degree does not confer superpowers -- doctors make mistakes, even the best of them, and those mistakes harm people.

I once made the acquaintance of Gilbert "Punky" Mudge, the cardiologist who treated Reggie Lewis, who told him it was okay to play basketball. It wasn't. Lewis had a cardiomyopathy that caused him to die of cardiac arrest when he took to the practice floor. Lewis's widow sued, but ultimately Dr. Mudge was found by a jury not to be responsible for Lewis's death. In a sense, of course, he was -- his advice was wrong. But that's the tough thing about being a physician. If most people make a mistake in their work, it's not a big deal, or it's correctable. But we can't start making physicians criminally responsible for their human frailties or, obviously, nobody will do the job. In Dr. Mudge's case, his judgment may have been affected by some personal history which I won't go into because that wouldn't be fair, but in any case, he wanted very much to save Reggie Lewis's career and give such a promising, talented, and likeable young man a chance to realize his dreams. After Reggie Lewis and his widow, I doubt anyone was more damaged by the matter than Dr. Mudge.

So what are the factors that ought to make bad doctoring criminal? Malicious intent is presumably one. For example, doctors who operate opioid prescription mills are intentionally working against their "patients'" interests out of purely venal motives. On the other hand, whether somebody legitimately ought to get a prescription for opioids is a matter of judgment and there have been prosecutions that seem inappropriate. Addicts are often very skilled at deceiving doctors, and not only that, but some of them are also genuinely in pain and maybe it's just as well for them to get the drugs.

Dr. Murray appears to have been trying to serve what he understood to be his patient's best interest. Jackson was a tormented soul who could not sleep, and evidently Murray kept resorting to stronger and stronger measures until he finally started anesthetizing his patient. That seems like very poor judgment already but doctors can legally prescribe off label and again, poor medical judgment is not a crime. He apparently left his patient unattended while he was in a propofol-induced coma. That is the sort of negligence that would support a malpractice suit but is not ordinarily prosecuted. (We had a surgeon in the Boston area who left a patient on the operating table so he could cash a check and buy drugs. He lost his license and got sued, but he was not prosecuted for that specific act.) Finally, Murray apparently did not immediately call for an ambulance when he discovered his patient in respiratory arrest, and that could be what pushes this over the line. I suppose if I were a juror it would be the fact upon which I would focus, although in fact it was probably too late anyway.

So what I'm saying is that I suspect most physicians, not out of self interest since few imagine themselves behaving so inappropriately, but out of a general interest in protecting professional judgment from unseemly second guessing, would prefer to see this situation handled in civil court. Murray would no longer be able to practice, he would be ruined professionally and financially, the world would be safe from his professional poor judgment, and either way, Michael Jackson is already dead. But it's a tough call.

Credit where it's due

Every morning and evening, I am strapped into a chair and forced to listen to NPR against my will. (Well okay, maybe I could listen to something else . . . ) I am not often kind to them here -- lately they've featured a fairly steady diet of long, sycophantic interviews with insane Republican power brokers, apparently in a craven and obviously futile attempt to save their federal funding -- but they finally give us a piece on climate change, occasioned by the hopeless Durban conference, in which they do not feel compelled to "balance" truth with ideological hallucinations.

As Richard Harris reports, "The United States is second only to China in emitting gases that cause global warming." Yep, he said it. Also, he quotes Kevin Kennedy of the World Resources Institute: "'Nowhere else in the world do you see a political debate about whether climate science is real, whether or not the climate is actually changing,' Kennedy says. 'That political climate makes it very difficult to move forward in a comprehensive way. And that is something we need to address in this country.'" And he doesn't make room for a rebuttal from climate science experts such as James Inhofe or Rick Perry.

The Durban conference is hopeless, of course, precisely because the United States will not support any effective action on climate change. And that is because the corporate media, in general -- and that includes the New York Times, by the way -- continues to treat the question of how much it matters, whether it's worth doing anything about, and even whether it is even happening, as a political controversy rather than a question of scientific fact; and because public discourse is largely controlled by wealthy psychopaths who are perfectly happy to destroy civilization in order to keep a few more millions in their pockets.

I don't write about this much because it terrifies me too much and I really don't know what I can add. I will, however, add Climate Progress to my sidebar, and I hope you all will visit and educate yourselves. Then take action -- no politician who won't commit to making this a priority deserves your vote.

Donald Berwick

Just a quick note that, to no-one's surprise, the corporate media has pretty much ignored the Republican filibuster which prevented the appointment of Donald Berwick to head the Centers for Medicare and Medicaid Services (known for historical reasons as CMS) from becoming permanent.

They claim it's because he once praised the British National Health Service, which makes him a commie, but Brian Beutler does an excellent job of explaining what's really going on. Berwick is a proponent of comparative effectiveness research and cost effectiveness analysis -- as well as being darn right radical in his advocacy for patient centered care and the empowerment of patients as the decision makers in their own health. But the Republicans ignore the part of the previous sentence after the dash and focus on the first part, which of course makes him a death panelist.

What they are really afraid of is that he can prove that public insurance, and especially a single payer system like Medicare, can deliver better health care with happier customers for less money than private insurance. If they let him get away with proving that, their corporate owners won't be happy.

Repealing the Enlightenment

I have said it before, but Naomi Klein says it at greater length, and maybe even a bit better. Climate change denialism is an example of thinking backwards. Since we already know that unregulated markets maximize human welfare, it is impossible for carbon dioxide emissions from burning fossil fuels to cause any serious problems. That would imply a need for some sort of intervention by government to reduce those emissions, and that conclusion is logically impossible, right?

Klein goes on to show how anthropogenic climate change implies many other conclusions which are not permitted in conservative ideology, but that's the basic idea. Anyway it's worth reading so go ahead. (I get the dead trees Nation so I got to read it sitting on the sofa and then do the puzzle.)

Tom Levenson at Balloon Juice is generally taken aback, nonplussed and aghast at what appears to be a growing global rejection of science as in any way authoritative. It's antivaxers trying to get their kids infected with chickenpox that sets him off, but then he broadens out. "The tyranny of facts undermines privilege . . ." The Republican War on Science is motivated by greed -- tobacco industry greed, coal and power generation industry greed, oil company greed.

And it's not just environmental catastrophe and selling people addictive poison. Have you been wondering why the heck Newt Gingrich has suddenly called the Congressional Budget Office a "reactionary socialist institution? It's because the CBO won't agree that gigantic tax cuts for wealthy people increase government revenue. (What the heck is a reactionary socialist, anyway?) Economics isn't really a science, but if we're living in this universe we can agree that the Obama stimulus did save millions of jobs and that the reason we have these big federal deficits stretching over the horizon is because of the Bush tax cuts and wars. If we're Republicans, however, we can't agree with those propositions, because they conflict with our axioms. Adam and Eve must be real historical characters because without original sin, Christ's sacrifice couldn't redeem us. (Not that the whole thing makes any sense in the first place.)

Thinking forward means observing what is out there in the real world and then trying to explain it. Thinking backwards means deciding what we already believe and then trying to force reality to look that way, which means ignoring evidence and making stuff up. Thinking backwards is what conservatives do. We need to laugh them off the stage, but if we don't, what happens won't be funny.

The NYT gets maybe half way there

The Editors, glorying in their anonymous collectivity, take on Medicare spending. They frame the issue correctly -- we need to rein in the growth in the cost of Medicare because we need to keep it universal and comprehensive. If the cost of Medicare continues to grow faster than the economy, it will grow harder and harder to convince the public to continue to pay for it. (Of course, this is a matter of degree. The Editors point with alarm to the projection that Medicare will account for 16% of federal spending by 2021, which Is Just Unpossible! Well no, it isn't, we could do that. But maybe we won't.)

So, The Editors think we should carefully examine proposals to raise the eligibility age, make higher income seniors pay higher premiums, and introduce more "cost-sharing by beneficiaries to deter unnecessary use of medical care." They think all that might be good but they are cautious. Wrong, wrong, and wrong.

Raising the eligibility age would not save any money at all. It would mean that people age, say, 65-67 would still be paying for their health care some other way, or not at all. Since a lot of people are out of the labor force by then, not at all would be a very popular option. But what happens when people that age don't get any medical care is that as soon as they hit Medicare eligibility, they come right in and now Medicare has to pay for all the bad stuff that wouldn't have happened if their health care hadn't been on hold for a few years -- heart disease and kidney disease due to uncontrolled hypertension and diabetes, for example. Baad idea.

Making higher income people pay for their Medicare sounds reasonable, but it would be politically suicidal. The appeal of Medicare is that it's universal. If it becomes a program for low and moderate income seniors only, wealthy people will turn against it -- it will just be "welfare," and we know that's evil.

Cost sharing is an even worse idea because your average senior citizen obviously does not know which medical interventions are worth it and which are not. They'll consume less medical care and medications, but at least half the time, they'll make the wrong choices. Which could end up costing more in the long run.

Then The Editors say that "So-called premium-support or voucher plans come in many flavors — some good, some bad — and would need to be carefully vetted." What all of these plans mean is abolishing Medicare and giving people money to buy private health insurance. Exactly none of the flavors of this disgusting idea are good. Medicare -- a single payer system -- is much more efficient than private health insurance and costs far less to deliver the same benefits. It always will, because it doesn't make a profit for shareholders or multi-millions for its executives, doesn't have to market itself to compete with other payers, and has the market power (should it ever care to use it) to make the medical system behave more efficiently and deliver the goods for even less.

Having tepidly endorsed or at least tolerated all of the really awful proposals that are out there, they are all for payment reform to the extent of moving away from fee-for-service to some form of capitated payment. That's okay although we have a long way to go to prove that it can work well. But, here's what they don't say.

We need to support cost effectiveness analysis and we need to direct resources away from doing stuff that just isn't worth it. Nobody wants to touch that because a former half-term governor of a state with a smaller population than metropolitan Boston will scream about death panels. That's a really stupid reason not to tell the people the truth.

Communicative action

For those not familiar with the philosophy of Jurgen Habermas (Stanford Encylopedia of Philosophy article is here), one of his central interests is in how we go about constructing knowledge together, through discourse.

To crudely summarize (and these conventional English translations of the terms may not be the best) we can engage in either communicative action, or strategic action. The latter is basically when I'm trying to get over on you -- I have a desired outcome, I want you to do something or believe something that's going to get you to do what I want, and I engage in speech or other forms of communication to bring about that end. Communicative action is when we talk with each other, openly and transparently, to discover how we might come to agree. Any one of us may engage in strategic action at one time or another, but it is pretty much impossible for the institutional interests labeled by Habermas as "the system" to do anything else. Corporations try to sell you stuff, political action committees try to get you to vote for the interests of their donors -- you're never going to have a dialogue with them.

I expect Habermas must love the Occupy movement -- they are totally committed to communicative action, at least internally. It does have the downside that they can't state exactly what they want to happen, but then again, maybe we'll all get there together some day.

But, if I may abruptly change the subject, what about doctors and patients? You might think, since the whole point is that the doctor is looking out for your well being, that you and your doctor would be having a lot of conversations about what, exactly, you think that is, and sharing thoughts about how to get there. Well, you may not have thought about this much, but you probably aren't really doing that. I could go on about this at great length, but here's a quick story.

I met the other day with some people who are living with HIV. I was interested in how they would explain what a virus is, and basically, none of them could say much about it. A virus is something that causes disease, that's about all they knew. Now, all of these people thought their doctors were the greatest thing since oxygen, and had been living with HIV and getting treatment for it for years. But the doctor had never bothered to say how she understood the nature of a virus and the way the drugs work to control it.

So, in about two minutes, I explained it, like this. As you know, your body is made up of billions of cells, and in the center of each cell -- the nucleus -- there's a molecule called DNA. That consists of very long strings of smaller molecules which spell out the instructions for making the proteins that carry out the functions of the cell and make up the tissues of your body. The instructions are carried from the DNA into the cell by a molecule called RNA, which directly controls the assembly of the proteins.

Well, most viruses are just little pieces of DNA that contain the instructions to make more of the virus. One way or another, the viral DNA gets into a cell and its instructions take over, turning the cell into a factory that just makes more and more of the virus. HIV is a little bit different because it consists of RNA instead of DNA. Same instructions, just in a different form. You have cells circulating in your blood called T-cells, that are part of the immune system that combats viruses. Some of these T-cells have a so-called receptor -- a channel for getting stuff in and out of the cell -- called a CD4 receptor, and when HIV bumps into one of those, it injects its RNA into the cell. The RNA immediately causes a protein to be made which causes the cell to write the instructions for making HIV into the cell's DNA. At some point, that DNA will be activated and the cell will turn into an HIV factory. Over time, as more and more of these CD4+ cells are destroyed, your immune system becomes less and less effective and you start getting weird infections.

That was it. They got it. They were all astonished. It's really that simple, they understood it, and we went on to understand drug resistance and how the various drugs work, among other things. Oh yeah, exactly what those T-cells do when they're working correctly. Other stuff. In about 5 minutes. So why, in maybe 10 years, had their doctors never told them this?

Some disorganized chatter

Yesterday I was in Boston all day for meetings, slept in my old house for what I hope will be the last time -- it's under agreement, just waiting to close -- then drove back to CT, didn't have a chance to blog. So . . .

The main point of my last post is really that we don't know what the consequences will be of technological developments. They often have huge effects that no-one foresees. The automobile wasn't just a faster horse that didn't need farmland to feed it -- it created the suburbs and a whole lot else, including becoming one of the leading causes of death, particularly for young people, and making the world warmer and stormier. We can try to imagine a world with on-the-spot manufacturing and driverless cars, but we'll probably get it wrong. Whatever happens, almost nobody will spend any time worrying about possible bad effects, however. If it's possible, we'll do it, pretty much mindlessly, because it is by definition progress.

Another completely unrelated issue that is on my mind is the prevalence of insane lawyers. To be sure, I'm not one, and I don't know what I would do if I were handed the assignment of defending somebody who doesn't have a chance in hell and probably doesn't deserve one. However, when I was a kid I read Clarence Darrow's "Attorney for the Damned," and he managed to find a way.

I have commented before -- not here I think -- about the lawyer for Joshua Komisarjevsky, whose particular acts of depravity we don't need to mention again. The guy's pretrial strategy was to relentless attack the sole surviving victim, whose family his client murdered; and along the way to hold a press conference on the courthouse steps in which he recited specific details of how his client had raped an 11 year old girl, which he apparently considered somehow exculpatory. Komisarjevsky has now been convicted of 6 capital offenses and his trial is in the penalty phase. The lawyer is trying to convince the judge to allow him to call his client's daughter, who is about the same age as the girl his client raped and murdered. I'm sure that will engage the jury's sympathy. Sheesh.

Now we have the almost equally popular Jerry Sandusky, whose lawyer let's him give a prime time interview to the sportscaster Bob Costas. Mr. Costas is not to be underestimated just because he covers fun and games. He's a smart guy, which Sandusky and his lawyer clearly are not. In the process of denying the allegations against him, Sandusky proved beyond a reasonable doubt that he is El Creepo, and should never be allowed within sight or sound of any boys. All prospective jurors will have a pretty good idea of the most effective way to achieve that.

There is a substantive point to take from this. If our culture did not view the criminal justice system principally as an instrument of retribution, we wouldn't be subjecting the public to these repulsive sideshows. Komisarjevsky was not allowed to plead guilty to a capital offense, so we had to endure a trial, and now this. If the deal had been life in prison to begin with, his lawyer would have haggled over the terms of his confinement and that would have been all there was to it. As for Sandusky, he probably would have been dealt with more appropriately a long time ago, but he wouldn't be resorting to such preposterous and desperate tactics if he wasn't looking at spending the rest of his life in so-called administrative segregation, which is the only place he's headed with a guilty verdict. He wouldn't last ten minutes in a prison population, obviously.

Most people probably think that's just fine, and I know I'm not going to talk anybody out of it. But in both of these cases, subjecting the public, the victims, and the jurors to trials is a major evil. By the way, the TV news stations in Connecticut and the Hartford Courant posted Komisarjevsky's confession on their web sites, accompanied by disclaimers to the effect that you really don't want to hear this. No, you don't.

Tea, Earl Grey, Hot

Prediction is very hard, particularly about the future. But I've been hearing a lot of low-key buzz lately about astonishingly transformative technologies that are not far off. 3-D printers are already not so uncommon. In fact the elementary school where my sister teaches has one. They can make any object you like out of metal, plastic or ceramics, and no doubt we'll soon have more sophisticated models that can use combinations of even more materials, such as made-to-order clothing on the spot. (Books can already be made and sold this way.) Cars that drive themselves are also on the horizon. As a matter of fact, they exist today. When it will be legal to let the car drive you to Grandma's house on the public roads I don't know, but it may well be the case very soon that robocars are safer than human drivers.

While we are oohing and ahhing over cool stuff, we often don't stop to think that technology drives major social transformations. When I was a youngster, my grandfather was a college professor and my grandmother was the secretary to a college professor. My grandfather's job still exists but my grandmother's doesn't. My secretary is Microsoft Office. Even low-level corporate managers who didn't rate their own secretaries would write their letters with a pen on yellow legal sheets or dictate into a tape recorder and send them to the typing pool, then they'd proofread the result and send it back for a final product. No more.

And in case you're agonizing over the decline of U.S. manufacturing, don't. The U.S. still has a robust manufacturing sector, but what we don't have is a robust manufacturing jobs sector, because the way to stay competitive in manufacturing in the U.S. is to replace labor with machinery as fast as possible. Of course people have to make the machinery and write the software, but that requires far fewer jobs than the products displace.

So imagine a world in which, instead of walking into a store and selecting from among the available coffee mugs or dinner plates, you look at samples on a touch screen, pick the one you want, and a machine makes a set for you while you wait. And no, you didn't get in your jalopy and drive to the store. You entered your destination into your smartphone, and the computer (which already knows where you are, obviously) dispatched the nearest car to pick you up and take you there.

Living that way is much cheaper than owning your own car. Cars are constantly in service so the world needs many fewer of them. They just about never crash, and they always know when they need maintenance and get it on time. Everyday manufactured goods are also much cheaper because they don't have to be shipped -- the materials to make them are shipped in bulk instead, which is a lot less expensive. Also you don't have to pay a truck driver. And there are no unsold surpluses -- every object that is made is sold, immediately.

Sounds great, huh? Could even have environmental benefits -- saves energy and waste. Or so it seems. Can anyone think of a downside?

Follow up on psychology research

We had a guest who is planning to get a graduate degree in psychology inquiring about my drive-by comment that some people consider the whole field of social psychology to be "dodgy." This isn't my specialty and I don't know a whole lot about it, but here's Benedict Carey in the NYT reviewing the issue:

In recent years, psychologists have reported a raft of findings on race biases, brain imaging and even extrasensory perception that have not stood up to scrutiny. Outright fraud may be rare, these experts say, but they contend that Dr. Stapel took advantage of a system that allows researchers to operate in near secrecy and massage data to find what they want to find, without much fear of being challenged.

“The big problem is that the culture is such that researchers spin their work in a way that tells a prettier story than what they really found,” said Jonathan Schooler, a psychologist at the University of California, Santa Barbara. “It’s almost like everyone is on steroids, and to compete you have to take steroids as well.”

I'm afraid I'm not getting the distinction between "outright fraud" and telling a "prettier story than what they really found." When you publish research findings, the only story you are permitted to tell is what you really found. It is true that research reports normally end with a "Discussion" section in which the authors often speculate, going beyond the findings to adduce possible implications or further hypotheses. These can be tendentious, to be sure, but at least an alert reader will be able to spot that, if the "Results" section is accurate and presents the information needed to correctly interpret the observations. Abstracts are often misleading, as are titles, and that's a problem because many readers never look beyond them.

But Schooler obviously understands that using steroids is against the rules in athletics, and telling a prettier story than what you really found is against the rules in science. The analogy is imperfect, not least because the consequence of using performance enhancing drugs is that somebody wins a game, which doesn't actually matter; whereas the consequence of falsely reporting on research is that the world is misled, careers and money are spent chasing down the wrong path, and quite often, people -- likely in their role as patients -- are directly harmed. I don't know whether this is available to the public -- I don't think so, but unfortunately I'm using a computer that has privileges to read BMJ whether I log in or not -- but they have much more this week on the Andrew Wakefield fraud. It turns out that a) not only did the kids not have autism, they didn't have inflammatory bowel disease either; b) the pathologist whose name was on the paper as a co-author had in fact found them not to have bowel disease but signed onto the paper anyway; and c) the institution - University College London -- has refused to do any investigation of the whole matter.

Although I have never seen anything but integrity among my own colleagues, recent publicly reported scandals are making me wonder how widespread the corruption of science may be. It's disconcerting, to say the least.

These kids today . . .

Oh my God, am I becoming a curmudgeon? No, I really don't think so. The NYT sent a reporter to State College, who had a front row seat as students set fires, trashed a TV van, attacked police, and otherwise vandalized their campus in their outrage over the firing of the football coach. I don't know if reporter Nate Schweber went out of his way to find morons, but he evidently didn't have much trouble.

“I think the point people are trying to make is the media is responsible for JoePa going down,” said a freshman, Mike Clark, 18

Demonstrators tore down two lamp posts, one falling into a crowd. They also threw rocks and fireworks at the police, who responded with pepper spray. The crowd undulated like an accordion, with the students crowding the police and the officers pushing them back. “We got rowdy, and we got maced,” Jeff Heim, 19, said rubbing his red, teary eyes. “But make no mistake, the board started this riot by firing our coach. They tarnished a legend.”

Justin Muir, 20, a junior studying hotel and restaurant management, threw rolls of toilet paper into the trees. “It’s not fair,” Mr. Muir said hurling a white ribbon. “The board is an embarrassment to our school and a disservice to the student population.”

Paul Howard, 24, an aerospace engineering student, jeered the police. “Of course we’re going to riot,” he said. “What do they expect when they tell us at 10 o’clock that they fired our football coach?”

Now listen up. Yeah I'm old now but I went to college. We even had a football team, and it almost became famous. Swarthmore was at one point poised to break the all-time NCAA record for consecutive losses. CBS even sent a crew to cover the historic event. The student body was behind them 100%. The stands were packed and the roar deafening. Well, you could hear something, anyway. The Swarthmore College marching band (which featured an amplified cello) performed its famous amoeba formation at half time for the benefit of national television. But our heroes blew it. They scored a touchdown as time expired to win the game. We were all really bummed out, even more so because it was a bad call. The ball never made it over the goal line.

So yeah, we were 100% behind the coach and players. But in spite of our passionate loyalty, if it turned out that one of the assistant coaches had been raping boys in the locker room and the head coach, athletic director, and college president all covered it up and merely told the guy to do his child raping elsewhere, I'm pretty sure we'd have started the rioting before they all got fired and only would have stopped once they were fully and unceremoniously canned.

Does this signal the decline of the West? Or am I overinterpreting?

Too much going on at once

Well, you can't call this a boring week in the news, that's for sure. Let me get the obligatory comments out of the way on a few of the stories that are trying to drive each other off the front page.

I think the religious fanatics actually made a big mistake with the Mississippi "personhood" amendment. I understand they're trying to do this in a few other states and it ain't over (officially) yet but if you can't do it in the country's most benighted state (sorry to our fans from the land that gave us the blues but you know it's true) where can you do it? Their mistake was to confront the public with the logical conclusion of their claim that "human life begins at conception," that an embryo is morally indistinguishable from a baby. It turns out that lots of people who define themselves as "pro-life" can't actually go there when they have to take it literally. It's a reductio ad absurdum of the anti-abortion position, which they deliberately presented. If people are careful and wise, they can build on this moment to fundamentally shift the terms of the debate.

Next, Joe Pa.(It turns out there's a distant and meaningless connection -- he's an alumnus of Brown University.) Lots of people are pointing out that this is similar to the Catholic Church. Not so much, I think. They have in common the moral failing of putting the perceived good of the institution ahead of the child victims, but the context is otherwise quite different. Penn State and its football program weren't involved in the lives of the victims and weren't actually perpetrating the rapes. And it's pretty clear to me that the culture of the Catholic priesthood is deeply imbued with repressed and twisted sexuality. The guys at Penn State didn't actively protect Sandusky or enable his actions, they just couldn't be bothered to stop him. You may not agree, but it seems to me that along one dimension, anyway, that's even worse, because the cost of acting, and the potential damage to the institution, were far less in the Penn State case. It would have been easy to turn Sandusky in, and while people would have been shocked, it would not have reflected poorly on Penn State or Penn State football. So their actions are not only inexcusable, but rather inexplicable, in my view.

Next, I'm sure you're at least as sick as I am of hearing about Herman Cain, but I'll make one last comment. It's just plain weird that Vulgar Pigboy and the rest of wingnuttery are rallying around him and blaming the liberal media. It would cost them next to nothing to dump him, but it's costing them a whole lot to keep loving him. They're just pathologically incapable of admitting error, I guess.

Finally, as coastal Alaska gets wiped out by a snow hurricane, I wonder if it will have any impact on the climate change denialism that rules in a state where the oil industry mails a check to everybody once a year? We'll see. But no, I don't care what a former half-term governor has to say about it, and neither does anyone else.

The Bernie Madoff of Social Psychology

That would of course be Diederik Stapel of Tilburg University in the Netherlands. I compare him to Bernie because he committed an astonishingly bold, massive fraud over many years that included gross betrayal of friends and colleagues. Oh yeah, he should have been caught many times but his prestige and power protected him. If you want the full story from the university investigating committee, it's here.

In case you haven't read about this and don't want to bother, basically the guy would chat up post docs and faculty colleagues to find out what research questions and hypotheses they were thinking about. Sometimes he would then work with them to design a study, write questionnaires, get funding, etc. He claimed to have relationships with high schools and universities that allowed him to recruit their students, or in a couple of cases faculty, as subjects. He'd go off to ostensibly collect the data, come back with it in a couple of months, and whaddya know, the hypothesis would be confirmed. Sometimes he didn't even bother with all that, he just said he had an old data set that was suitable, which he hadn't gotten around to analyzing, here it is. Only, he never collected any data. At all. He made it all up. Oh yeah, he also supervised dissertations based on phony data.

The really strange question is why? Bernie could have invested the money, and Stapel could have actually done the experiments. Madoff wouldn't have made 12% a year come hell or high water, and Stapel wouldn't always have found what he was looking for, but they still could have been perfectly successful. In Stapel's case, in fact, probably equally successful -- there's nothing stopping us from publishing findings we don't expect.

Just as Bernie brought about financial ruin for his customers, Stapel has brought career ruin on his students and collaborators. Even though they were perfectly innocent of the fraud, their programs of research are now destroyed and their publications will have to be retracted. Although the university says his students can keep their degrees, they are forever tainted and will no doubt find it very difficult to advance their careers. Everyone's CV will shrivel up like bacon.

He has also damaged the university, and the entire field of social psychology, which some people already consider to be a bit dodgy. (Think Marc Hauser.) The psychopathology here is really inscrutable. Yeah, the guy is some version of a psychopath but he seems to have been generally empathic and reliable in other contexts. This is just weird.

Sometimes it is worth proving the obvious . . .

Or at least I'll concede it might be. It's big national news, it seems, that a survey of 7-12 graders finds sexual harassment is pervasive.

Well duhh. Did the majority of adults somehow skip adolescence? We were there, remember? Well, okay, we probably don't, unless somebody gets our attention and makes us think about it. The world of children and adolescents is often cruel, even depraved. Kids can do a pretty good job of keeping their secrets from adults and within their own world, to the extent it manages to evade oversight, they're in the struggle of all against all, nasty and brutish -- also short since it ends, at least for most of us, with adulthood.

But we have a cognitive bias toward seeing the past with a rosy glow, remembering the good parts much more than the bad. That's good, in that it helps us feel better, but it isn't helpful if we want to look out for young people, really appreciate what they go through, and help to shape their worlds for the better. So I'm very glad that we're seeing a real trend now toward paying attention to bullying -- of which this is a subset, obviously, maybe the biggest piece.

I think it's happening in large part because of real changes in cultural norms about gender, sexuality, and the associated dynamics of power and vulnerability. We're talking about boys who are gay or perceived to be gay being targets of relentless abuse; boys who feel entitled to take what they want from girls, whether physically or symbolically; masculinity defined as cruelty and domination.

It does get better, unless you happen to be a libertarian, in which case Lord of the Flies is your paradise.

Never speak ill of the dead

Hi, I'm Randy Ooney.

Here's a random collection of banal objects. This is a box of cereal. Why can't cereal come in a canister? Who made that rule?

This is a roll of toilet paper. Who invented toilet paper, anyway? We know who invented the telephone and the light bulb, but what's more important? Was it Scott? I don't know.

These are double A batteries, and triple A batteries, and D batteries. What ever happened to B and C?

Somebody sent me this eyebrow trimmer. Who ever trims their eyebrows? I certainly don't.

For CBS News, this is Randy Ooney, good night. And why the heck is anybody sitting and watching this inanity? That's what I'd really like to know.

Hermania!

Last night Rachel Maddow posited -- nay, all but concluded -- that the ever more bizarre Herman Cain presidential campaign is in fact a clever work of performance art. She pointed to various sly allusions and other clues that reveal the true intention.

Okay, that seems the most sensible explanation to a sane outside observer. But why would the Koch brothers sponsor a satiric performance that aims at revealing the absurdity and ignorance of the very constituency they manipulate for their nefarious purposes? Conceivably, their hubris is so great they believe they can simply enjoy the joke and get away with it. Maybe this is a message to current and future Republican candidates to respect the depravity of the Republican primary electorate.

Whatever it is, I'm impressed.

Human life ends at birth

Apparently. The Governor of Mississippi has come out in favor of the so-called "personhood" amendment, which will amend the constitution of the nation's most poorly educated and least healthy state to declare that "every human being from the moment of fertilization, cloning or the functional equivalent thereof" is a "person" with full legal rights. So, apparently, has former abortion rights champion Multiple Choice Mitt. (In some of what follows, I plagiarize myself, which I believe is legal.)

Of course, these people despise human life. They couldn't give a stale communion wafer about sick and dying children in poor countries, or right here in the US of A, where their leading domestic priority is to repeal legislation to provide health care to kids whose families can't afford it.

The entities to which they impute "sanctity" are not human beings, but anything that's kind of like a human being, in having human DNA, but is otherwise unlike what most of us think of us being human in having no ability to survive independently, and no consciousness. And where do they get the idea that lives of microscopic balls of cells, fetuses with unformed cerebral cortexes, and former humans whose cortexes have been destroyed, are somehow "sacred"? They obviously don't get it from the Bible. There is not one word about abortion anywhere in the Bible, Old Testament or New, even though abortion, and for that matter infanticide, were widely practiced in the Biblical world.

For that matter, the Bible certainly does not put forth any concept of the "sanctity of life." The Hebrews are commanded at various times to slaughter people, steal their land, rape their women, and enslave their children. God himself massacres innocent children in Egypt and elsewhere. God commands the Hebrews to stone a man to death for gathering sticks on the sabbath.

And of course, the Bible could not possibly assert that "life begins at conception" because people in Biblical times didn't have the slightest idea what conception was or how fetuses developed. In fact, if you believe in God, then you also have to believe that God is the most prolific abortionist in history, by many orders of magnitude, because something like 2/3 of "human lives" -- the zygotes created at the moment of conception -- never successfully develop. Most of the time, the woman is not even aware that she was ever pregnant. If abortion is murder, this is the death of tens of millions of innocent children every year. Should it not be the absolutely highest priority of medical research to save those babies' lives? But you never hear a peep from these people about it, because they know it's completely illogical.

Christian prohibition of abortion is an entirely modern phenomenon, dating at its very earliest to the 19th Century. And what happened at that time to suddenly provoke the concern of the Pope? It wasn't any scientific discovery -- understanding of the nature of conception and the zygote did not come until about until considerably later. No, what got the Christian fathers riled up was the women's movement. The idea that sex could be uncoupled from reproduction, or that women could choose not to become mothers, was appalling to the (putatively) celibate old men who ran the Catholic Church, and later to the Evangelical "Christian" conservatives who share their views on the semi-human status of women, although they otherwise think Catholics are heretics who God intends to torture for all eternity. And vice versa.

The reason I bring all this up, although you already know it, is because nobody in public life seems willing to take this issue on at the fundamental level of morality and logic. The most assertive anyone is willing to be about it, including NARAL, is to say that people differ in their views of the morality of abortion and that the law should not impose one view on everyone. I say it's time to get serious about this and expose the hypocrisy and fundamentally nonsensical basis of "pro-life" activism. Answer these lying bigots who would lead the world back into darkness. Explain to people why their views and public discourse makes no sense. Reveal their true agenda, to oppress women and for that matter all of humankind. To rule the world through terror and deceit.

Not a damn thing Christian about them.

Speaking of denialism

Henry Aaron - not Hammerin' Hank, but the Brookings Institution economist -- makes it so clear even a Republican could understand it. Whatever savings may be available from making Medicare and Medicaid more efficient, or squeezing providers and beneficiaries, aren't going to cut it:

Whichever approach is followed — repeated modest reductions or a single huge one — if all cuts come exclusively from spending, it will be impossible to sustain anything approximating current commitments under Medicare and Medicaid (and under Social Security) as we know them. Resistance to defense cuts, beyond those already included in the legislation to boost the debt ceiling, is already hardening. A concern about undermining the nation's capacity to meet its international obligations may prevent the repeated allocation of half of spending cuts to national defense. Interest spending will inevitably grow sharply as today's recession-induced, near-zero real interest rates return to normal levels. Outlays other than those for defense, interest, Medicare, Medicaid, and Social Security today constitute only one third of the budget and have been cut deeply already. Following the Willie Sutton principle, Congress would have to “go where the money is” and slash the major social insurance programs, including Medicaid and Medicare.

To avoid this outcome, tax increases must account for a sizable fraction — perhaps most — of any deficit-reduction plan.

That's it. If we want to keep the promise made long ago that elderly people will not have to fear dying uncared for in the cold and dark, the Koch brothers will have to pay more taxes. There's no way around it. That's the cold truth.

Priorities

This brief update on the coming era of the cyborg has gotten some blogospheric attention, but I have my own take. Basically, in case you didn't know, developing technology now allows human brains to be connected directly to computers, via implanted electrodes or scanning devices such as magnetic resonance imaging. Much speculation and alarm concerns the possibility of mind reading, which may sound implausible but is actually already in early stages of actually happening.

For the foreseeable future, this will require sticking your head in a big, expensive device for a considerable period, so it won't be invading your privacy as you walk through the shopping mall. However, it could do interesting things to criminal investigations and who knows, maybe even job applications some day.

But I'd like to focus on the other application, which is prosthetics. The major direction of this research is to enable people who are paralyzed or missing limbs to control replacement limbs or even entire bodies directly with their brains. That could certainly benefit people who have a very tough lot in life. Another example of science fiction becoming real is the field of so-called regenerative medicine. Yes, this also happens to be where all the religious nuts are having fits of moral idiocy over the use of embryonic stem cells. Leaving that aside, amputees may not even need to become cyborgs because they'll be able to grow new limbs. We might also be able to grow new organs -- hearts, livers, kidneys, even brain components. (And therein lie some philosophical conundrums, for another day.)

This isn't happening tomorrow but it might be happening soon enough that we need to think about it hard, starting yesterday. Here's what troubles me.

Of the world's 7 billion people, how many do you think will have access to these technologies? If we invest hundreds of billions of dollars to learn to grow new hearts, the only people who will get them are rich people, who will then have shiny new hearts that keep on pumping till they're 120 years old. It will never be cheap until some time after war and injustice are eradicated.

It's astonishing and wondrous and it has great commercial potential -- the latter being the real reason there's funding for it. It seems wrong to speak against finding ways of healing the sick, but we don't yet offer the astonishing and wondrous medicine we already have to the vast majority of the earth's people. It just doesn't seem right.

I've got a baaad feeling about this

I normally leave the economic gloom and doom to the experts, e.g. Atrios, Krugman, and DeLong. And I do so now, but I refer you particularly to Professor K, who explains it all to you.

The semi-comforting story we always hear is that the current extraordinary rise in economic inequality in the U.S. has to do with rising returns to education. The high school grads just can't make a middle class living bolting cars together any more, but with a master's degree you can scoop up coin like beach sand.

Not. The truth is that the money isn't flowing to the college grads, or even the top 20% of income earners. It's flowing entirely, all of it, to not even the top 1%, but the top .1%. And no, they aren't "job creators," and confiscating their wealth isn't going to put anybody out of work. On the contrary, they are parasites who provide no socially useful services whatsoever. Some, such as Bill Gates, got wealthy by making shrewd and/or fortunate investments in productive enterprises early on, but even in that exceptional instance Bill Gates doesn't need to have billions of dollars in personal assets in order for Microsoft to be a successful business. (To his credit, he knows this, and he's working at giving away his money. So far that hasn't destroyed any jobs to my knowledge.)

Most of them, however, got rich by skimming from the financial markets or, as in the case of Mitt Romney, buying up companies, firing much of the workforce, siphoning off as much cash as they could, and then selling them to somebody else. Or, as in the case of the Koch brothers, they inherited the money. But what can we do about this situation? They can buy all the elections they want and pollute the public discourse with a Niagara of lies. How can we possibly get rid of them?

It's great that people have finally taken to the streets but what happens next? I have a hard time foreseeing anything good.