There are, of course, more important things . . .

. . . than pink bowling balls. Here is a perhaps insufficiently alarmist review of the emerging global food supply crisis. It leaves out some huge problems, including the steady degradation of farm land, the likely catastrophic impacts of climate change, peak phosphate, and the growing competition between food and fuel for agricultural output.

The fact is, the only way we're ever going to feed the population two decades from now is if we do absolutely everything right. That means greatly improving the sustainability of farming techniques the world 'round; recycling phosphorous instead of letting it flow into rivers (and generally keeping agricultural runoff out of the water and recycling it back into the soil); and oh yeah, much less consumption of meat. Base your diet on vegetables, fruits, whole grains and legumes. The planet is depending on you. And I mean it -- things could get mighty ugly.

Not that this has anything to do with politics or policy as it is actually practiced in the United States.

Bob Abeshouse for Al Jazeera runs down the quite likely successful project of the Koch brothers to buy the government of the United States. Which largely explains our predicament.

Update: For some reason, I am unable to post a comment to my own blog -- I get an error message. So, I'm not trying to big foot Mr. Anonymous, but in response to the comment:

Turning grain into meat uses 8 times as much land and other agricultural inputs as eating grain directly. And whatever nutrients animals add to the soil came out of the soil in the first place. True, cattle can graze marginal land unfit for planting, and chickens and pigs can clean up some waste, but that's not how we're using those animals today. A sustainable agricultural system requires far less meat consumption than at present.

Eating whole wheat causes health problems only for people who are allergic to gluten, which is actually uncommon, although there's a quack fad against wheat. Soy is good for you, excellent food.

Is Rick Santorum actually satirical performance art?

Maybe I've failed to understand him all this time:

Washington – At a campaign event at a bowling alley in Wisconsin today, GOP presidential hopeful Rick Santorum told a boy who reached for a pink bowling ball: “You’re not gonna use the pink ball. We're not gonna let you do that. Not on camera.” Santorum went on to say “Friends don’t let friends use pink balls.” The comments were tweeted by Reuters reporter Sam Youngman.

Dream on . . .

The shiny silver lining meme that's going around progressive circles these days is that if the Supreme "Court" tosses the Affordable Care Act, congress will have no choice but to go to single payer national health care. This was actually first proposed by Robert Reich in the Puffington Host, but I don't link to purveyors of quackery and pseudo-scientific gibberish.

In fact the "justices" are going to have a hard time twisting themselves into the contortions necessary to hand the far right a victory in this case. Note that I say "far right" advisedly because the basics of the Affordable Care Act were first proposed by the Heritage Foundation. If they toss the whole thing, it's unclear what happens to the money that's already been spent and the structural reforms that have already happened. For example, the Patient Centered Outcomes Research Institute already has its income stream and has started to spend the money. The Center for Medicare and Medicaid Innovation, the Independent Medicare Payment Advisory Board, high risk pools, limits on medical loss ratios, extending eligibility for inclusion in family policies to age 26 -- all of these would seem to have nothing to do with the individual mandate, and the closely linked provisions of guaranteed issue and community rating. (All of which are contrary to the Bible, of course, as well as the Constitution.)

So they could leave all that alone, and just toss the individual mandate along with guaranteed issue and community rating. But if they do that, they will have to admit that health insurance isn't anything like broccoli after all, and that congress did indeed have a perfectly good reason for including the individual mandate in order to accomplish its clearly legitimate and constitutional goals of regulating interstate commerce; and that there is indeed a limiting principle in that a similar problem does not apply to any other good or service.

But if they just toss the mandate and leave the rest alone, the result will be a disaster, which will cause utter chaos and destroy the market for health insurance. The presumption by Reich and others is that at that point, congress will just have to do something, and the only something that's left which is clearly constitutionally legitimate is single payer.

Hah! The very same powerful interests that made single payer impossible in the first place and left the individual mandate as the only option aren't suddenly going to let that happen after all. They'll get congress to clean up the mess by repealing community rating -- and they'll probably get the medical loss ratio requirement repealed in the process. We'll just pretty much end up where we started, only three years further down the road to ruin.

Sorry to be a downer.

Million Dollar Idea

I'm going to print up some bumper stickers that say "I'm an ignorant idiot -- and I vote!" So many people nowadays are proud of being ignorant idiots, and are fully committed to political representation of their idiocy, that I know I could sell them.

Yesterday I got behind a pickup truck and the guy had a decal in his back window. It consisted of a confederate flag, and the legend "Why the hell should I have to press 1 for English?" That makes perfect sense because the noble cause of the confederacy was not having to coexist with people who speak languages other than English. As a matter of fact the Civil War started because the federal government was trying to force the God fearing people of the South to speak Yoruba and Fulani like their immigrant workers. I expect the guy bought the decal at a truck stop. I could sell my bumper stickers at truck stops and liquor stores.

I have another idea which is even better. I'd even buy this one myself. You know those giant foam hands with the upraised index finger, with "We're Number One!" printed on them, that they sell at the ballpark? I'm gonna have some made with the middle finger extended, print "Yankees Suck!" on them, and sell them at Fenway Park. I'll be richer than Mitt Romney in no time.

I'm not a constitutional law expert

But I do know something about health care policy. Having consumed a substantial proportion of the universe's supply of bits blogging about the Affordable Care Act and the underlying economic structure and ethical considerations of health care and health insurance markets, I will now state only a couple of points:

Health care and health insurance clearly and entail interstate commerce;
Congress compelled guaranteed issue and community rating in order to regulate the interstate market for health insurance in the public interest;
In order to do the above, the individual mandate to purchase health insurance is necessary. If you don't already understand why, Lawrence Gostin explains it to you, no worse than I already have.

It is my understanding that the great majority of people who are actual constitutional law experts think the act is constitutional. Indeed, in order to rule it unconstitutional the Court would have to find that everything from the EPA to restrictions on what can be sent through the mail is unconstitutional. Not only that, but the ACA is a conservative idea that was originally proposed by the Heritage Foundation and was the Republican's answer to single payer proposal (which, BTW, would be absolutely, no doubt about it, slam dunk constitutionally valid).

The problem, however, is that conservative jurisprudence means "coming to conclusions that conservatives like." As Andrew Koppleman explains here, the conservative majority on the Supreme Court cannot possibly find a principled way to hold the act unconstitutional without blowing up the modern state. But in the light of Bush v. Gore, you know they really, really want to. As Koppleman writes:

Its other option is to avoid those implications by surrounding its holding with the kind of obfuscation that [lawyer for the plaintiffs] Clement offers, so that no one will be able to figure out whether the case’s holding applies to anything beyond its specific facts. This second option, which is the only realistic one, is remarkably result-oriented: like Bush v. Gore, it adopts principles that it has no intention of adopting in any other case, just to reach a result it likes. Because no broader principles are being adopted, there’s nothing at stake beyond the chance to stick a pin in Obama – in a way that is likely to have a devastating effect on the very large number of people with preexisting conditions who were going to get affordable medical insurance as a consequence of the legislation, and who now won’t.

I don't expect honesty or integrity from this gang. Do you?

Christian faith

I believe I have mentioned before that I OD on NPR thanks to my long commute. This morning it got truly weird. It seems crowds have gathered in front of the Supreme Court to demonstrate for or against the Patient Protection and Affordable Care Act. Of course very few of them know anything about the legal issues at stake, they just want the court to vote their way.

The reporter decided to interview a single protester, and naturally she chose a guy who was against the act. Specifically, he was against it because he is a Christian. He and his friends had come to pray "that God will be enthroned in our hearts, and that he will intervene with the Justices" to make the right decision and rule the Act unconstitutional.

I certainly hope that the gentleman will choose prayer as the means to achieve all of his objectives. Pray on, my friend! Pray 24 hours a day! True, one might ask why, if God is all powerful and God hates the Affordable Care Act, he allowed it to become law in the first place. Given that he has the power to intervene in the decision processes of judges he presumably could have done the same with legislators. But I guess he was waiting for enough prayers.

That aside, the more interesting question is where exactly in Christian doctrine and morality one finds condemnation of open enrollment, community rating, and mandatory purchase of health care insurance with subsidies for affordability. I've been combing through the Gospels and the Epistles and I'm afraid I'm not finding it. Perhaps one of those sophisticated theologians can explain it to me.

Rick Santorum will never read this . . .

. . . but he should. Yeah, it's a little highfalutin', but it's what I'm reading right now so I thought I'd share a little. From Jurgen Habermas, The Theory of Communicative Action:

Actors who raise validity claims have to avoid materially prejudicing the relation between language and reality, between the medium of communication and that about which something is being communicated. . . . [M]ythical world views prevent us from categorially uncoupling nature and culture, not only through conceptually mixing the objective and social worlds but also through reifying the linguistic worldview. As a result the concept of the world is dogmatically invested with a specific content that is withdrawn from rational discussion and thus from criticism. . . .

Only against the background of an objective world, and measured against criticizable claims to truth and efficacy, can beliefs appear as systematically false, action intentions as systematically hopeless, and thoughts as fantasies, as mere imaginings. . .. To the degree that mythical worldviews hold sway over cognition and orientations for action, a clear demarcation of a domain of subjectivity is apparently not possible . . . In this connection it has been observed that members of archaic societies tie their own identities in large measure to the details of the collective knowledge set down in myths and to the formal specification of ritual prescriptions.

Alas, it appears that the United States, today, is in large part an archaic society. As I have said many times, the Republicans are not trying to lead us back into the 19th Century. They are trying to undo The Enlightenment, to restore the 14th Century.

Our socialist president

Not so socialist. Dr. Stephen Meltzer of Johns Hopkins informs us of the following:

I was on a recent conference call with Administration officials, during which research funding was discussed. It seemed to me that these officials did not fully understand the central importance of NIH funding to our national research enterprise, to our local economies, to the retention and careers of our most talented and well-educated people, to the survival of our medical educational system, to our rapidly fading worldwide dominance in biomedical research, to job creation and preservation, to national economic viability, and to our national academic infrastructure. In response to a question from a participant, they staunchly defended the proposed flat $30.7 billion FY 2013 NIH budget as being perfectly adequate, remarking that “The NIH receives more funding than any other research entity; it will continue to be strong; it will do just fine.”



Unfortunately, this is not the case. The proposed flat NIH budget will severely exacerbate a catastrophic crisis that has been ongoing since 2003, when growth in NIH funding fell (and has continued to fall every subsequent year) behind the rate of inflation. As a consequence of this deeply flawed public policy, promising careers have been cut short, amazing research projects have been aborted, hundreds of laboratories nationwide have shrunk or been shut down, established and accomplished senior researchers have been forced to abandon their programs, young scientists have departed from research of even left the country (even after many years of productive training), thousands of ancillary jobs have been lost, our worldwide medical research dominance has been eroded (ceded to China, India, and other nations), and a large support network of laboratory supply and biotechnology companies has been drastically attenuated.

I have discussed these problems here previously, but hearing about the administration's position is appalling. I still think Obama is a spy.

Oh yeah: You can sign Dr. Meltzer's petition here.

Plugola

No, they didn't actually pay me for these. First, from the HIV Prevention Justice Alliance:

Novartis, the Swiss-based pharmaceutical giant, continues its assault on India's generic pharmaceutical industry - legally challenging India's patent law that allows the nation to supply nearly 80% of the developing world's access to high-quality, affordable, life-saving medications.

India's patent law effectively stops evergreening, a tactic used by pharmaceutical companies to make minor tweaks on medications to extend their stranglehold on a patent that is about to expire.

Should Novartis succeed on March 28th, a dangerous precedent will be set...

With a chain-reaction of serious consequences.

The costs?

Crippling the generic pharmaceutical industry

Making essential medications even more cost-prohibitive

Cutting off the supply of medications used by NGO's worldwide

Millions of lives that are dependent on these drugs to fight diseases like HIV/AIDS.

Say NO to Novartis

Send the message to Novartis that no loss of human life can ever be tolerated for profits, by signing a petition here.

Learn more on how to Occupy Pharma by joining our working group.

Rather shrill, aren't they? I also got this:

FOR IMMEDIATE RELEASE CONTACT: David Merchant

19 March 2012 202.408.5565 dmerchant@citizensforethics.org

CREW WITH ADVOCACY GROUPS ASK FTC TO INVESTIGATE ANTI-COMPETITIVE PRACTICES OF VACCINE MAKERS

Washington, D.C. – Today, Citizens for Responsibility and Ethics in Washington (CREW), the National Legislative Association on Prescription Drug Prices (NLARx), the Campaign for America's Future (CAF), and the U.S. Public Interest Research Group (U.S. PIRG) called on the Federal Trade Commission (FTC) to immediately investigate the vaccine bundling practices of Sanofi Pasteur and Merck, which make it harder for pediatricians to use the best vaccines for children. Sanofi and Merck force pediatricians to buy vaccines in a bundle at a discount, or pay exorbitantly high prices to purchase vaccines individually. As a result, some children may not receive the vaccines most suitable for them.

CREW Executive Director Melanie Sloan stated, “When parents take their kids to the doctor, they expect the best medical care available, not the care dictated by drug companies seeking to maximize their profits. Basically, doctors are asked to make a choice they can’t refuse.”

CREW first wrote to the FTC about this issue in 2010, but a whistleblower has now provided new details about the practice. Vaccine discounts are conditioned on an express agreement that healthcare groups will purchase only a particular company’s vaccines. If any member of the practice fails to comply with this exclusivity requirement, the entire practice loses the discounts. These exclusivity contracts deprive consumers of the best healthcare, suppress competition, and prevent new and potentially more effective vaccines from entering the market.

This has real world consequences. For example, pediatricians who agree to purchase vaccines from Merck cannot offer their patients Cervarix, which is produced by GlaxoSmithKline, and is more effective than the better known Gardasil, produced by Merck, at protecting against the human papillomavirus. A meningitis vaccine studies indicate is more effective for certain patients similarly is unavailable.

Sloan continued, “Parents assume doctors are making drug decisions based on the patient, but in fact, they are making decisions based on the price. That will be cold comfort to a young woman who discovers she might have avoided cervical cancer if only she’d received the right vaccine as a girl.”

Click here to read this release on CREW’s website.

Click here to read the letter to the FTC.

Also shrill. The pharmaceutical industry giveth -- no antiretroviral medications and vaccines without them -- but it wants to taketh away far too much in exchange.

With little comment . . .

Except to say that there seem to be no limits to human credulity, this landed in my in-box:

Good afternoon, Michael-

As you may have seen or experienced, we’re in the midst of the worst allergy season in years due to the mild winter. On behalf of Dr. Steven Lamm, “the house” physician for The View, we’d like to gauge your interest in attending a fun, intimate online media gathering to learn about the natural health benefits of Dead Sea salt, particularly for allergy and sinus treatments!

DATE: April 25, 2012

TIME: 4:00pm

LOCATION: Midtown, NYC



The details of the event are still being finalized, but please reply back to this email as soon as possible if you’d like to enjoy amazing cocktails, hors devours and spa-like goodies inspired by the Dead Sea!



Thank you!

Kelsey

Dead Sea salt is otherwise known as salt.

Remember reality?

You know, the actual true world in which we live? That old place? Via Climate Progress, I came across this very sad essay by Jeff Turrentine. You may have noted the recent passing of F. Sherwood Roland, who discovered that chlorofluorocarbons used as coolants in air conditioners and other heat pumps were eroding the stratospheric ozone that protects us tender organisms from the earth's ultraviolet radiation.

Back then, when Ronald Reagan was president, we argued a lot over public policy but we largely inhabited the same reality. Although there was the usual denialist reaction by industry, the countries of the earth came together to write the Montreal Protocol that banned chlorofluorocarbons and Ronald Reagan -- yep, the conservative hero that all Republicans today want to compare themselves to -- signed it. Why? Because back then, the future of human civilization and of all life on earth was considered more important than somebody's short term profits, even by conservatives.

I have to say, global climate change denialism is the greatest evil ever perpetrated. Yeah yeah, Godwin's law, but Nazis only committed mass murder and genocide. How does that stack up compared to civilizationocide and biocide? And how is it possible that our culture is so tolerant of the unimaginable horrors that lie ahead -- that are already starting to happen, in fact -- and the psychopaths who are demanding that we allow them to occur? I mean you, James Inhofe, David Koch, Charles Koch, Rick Santorum, Mitt Romney -- yes you. There is no circle of hell deep enough for you.

What, Me Robot?

It seems a hot subject in moral philosophy these days is robot ethics, which partly means the ethics of humans employing robots, but also means the ethnics which which autonomous artificial intelligences should be equipped.

When it comes to robots, the future isn't what it used to be -- or rather, the present isn't what the future used to be. The Jetsons had a humanoid robot maid complete with frilly apron and cap. Commander Data, apart from his sickly pallor and weird eyeballs, was indistinguishable from Brent Spiner. Isaac Asimov's universe was filled with humanoid robots employed in every sort of job, their autonomy constrained only by the famous Three Laws of Robotics.

As it turns out, robots, so far, don't look anything like people. In fact most of them don't look like anything at all, their existence is purely virtual. Siri's only physical manifestation is a voice. Watson is a voice plus a lever that presses a button. The Google driverless car doesn't have a humanoid machine sitting in the driver's seat. The roomba doesn't consist of the Jetson's maid pushing around a vacuum cleaner, it's just a vacuum cleaner that runs around the room on its own. Assembly line robots don't look like UAW members, they consist of specialized implements mounted on retractable turrets.

Most of these devices don't pose much of an ethical problem. Watson has already violated Asimov's First Law by beating humans at Jeopardy! and thereby depriving them of cash winnings. The Google car presumably must obey the traffic laws, but I don't know exactly what it will do at a four-way stop sign or in a dispute over a parking space. Anyway these are not profound problems.

I tried to think of an application for which a humanoid robot would actually make sense, and that seems feasible in the near future given current technology. The only thing I could come up with is playing golf. The rules of golf require that professionals under age 50 walk the course, so it does indeed need to be bipedal. You have to use approved clubs, so it has to swing from shoulder height. You might as well use two arms for esthetic reasons, and maybe two hands do give some mechanical advantage. It makes sense to put the visual and communicative apparatus on top, so it might as well have a head. So, a basically humanoid body plan.

The rules of golf give a huge advantage to the AI department because it's perfectly legal, indeed customary, to have a caddy who can provide information and advice. This greatly eases the demands on the machine as a human can help it find its way around the course and correct any mistakes in judgment. The bot would need learning capability. It would have the basic swing motions for the various kinds of shots programmed initially, and then it would work out on the range, trying modifications until it gained accuracy. It would need an understanding of the basic components of the game: the drive, where the object is generally to hit the ball as far as possible while ending up in the fairway; the approach shot using an iron, trying to end up as close to the flag as possible; and putting; plus the assortment of pitches and chips from various lies and sand, although I expect it would play so consistently it would never need those, except perhaps in high wind.

It would need pattern recognition ability so it could distinguish the fairway, green, and flag; perceive the ball and the lie; and read the greens. All that, if you can already make a driverless car, seems quite doable. But the big challenge would be social skills. It would need to distinguish among various categories of human and interact with them appropriately, and in context, i.e. during a golf game, during a practice round or on the range, and while not playing golf.

The caddy is a unique individual who the bot would have to recognize, and accept input including instructions. The caddy's evaluation of shots and behavior would be essential input for machine learning as well. It would have to recognize competing golfer and their caddies, and behave toward them appropriately, knowing whose turn it is to play, not creating distractions while the competitor is playing, not stepping in the line of the competitor's putt, etc. It should be programmed to congratulate good shots, but it needs criteria for judging them so it doesn't appear to be mocking. Then there are marshals and rules officials, and fans with whom it can slap hands or sign autographs while waiting for the fairway to clear.

Asimov's three laws clearly don't work. Its very purpose could harm other humans, at least psychologically, by beating them at golf, although I don't suppose it would be eligible for prize money. It has to obey its caddy, but nobody else. Unfortunately, I think the world would quickly lose interest because it would consistently shoot in the low 50s, hitting every fairway, knocking every iron stiff, and making every putt.

Okay, we've developed this great toy. Watson now goes on to provide expert advice to doctors, but what does out golfbot do? Sure, you could adapt it to work in the carwash or tend bar or hang seamless gutters, but I suspect it's cheaper in the long run to hire humans for those jobs. I can imagine that it's really only good for two things: being a soldier and killing people, or being a sex partner. And as you can see if you read the link at the top of this post, those are the main problems that seem to concern robot ethicists nowadays. For the first function, Asimov's laws won't work at all.

Health care reform for dummies

One of my great and enduring frustrations is that the problem of health care organization and financing, and the reasons why 90% of what politicians say about it is baloney, are just too complicated for a sound bite or a bumper sticker. I wrote a long series on this subject a while back. You can start here and then keep clicking the "newer post" button to continue. There are also two essays in the new NEJM, which they have kindly made available to the Great Unwashed. Victor Fuchs discusses the history of the U.S. health economy since 1950, and Harvey Fineberg discusses why our health care non-system is messed up and what he would like to do about it. Both of these assume that you already know and understand what most politicians don't want you to know and understand (assuming they understand anything themselves), so let me lay out what I would say if I were running for office.

Health care isn't like most goods and services. Everybody needs approximately the same amount of food, clothing and shelter, and other basic goods. Beyond that, if you're lucky enough to be able to afford it, you might by more and better stuff and exactly what you buy will be according to your own taste and desires.

Your need for health care, on the other hand, goes up and down throughout your life and is much different from other people's need. That might have something to do with choices you have made (i.e. tobacco or chicken fat) but it also has a whole lot to do with circumstances completely beyond your control, such as your genetic endowment, the family you were born into, where you live, being hit by a bus, and just plain luck, not to mention how old you are. So you may just end up with a need you can't afford to pay for, and that can happen to just about anybody except really, really rich people.

Second, the reason you go to a doctor is because the doctor is an expert about medical care and you are not. You don't know what you need, the doctor has to tell you. If you are lucky you may meet a doctor who explains what's going on in a manner that you can understand, and makes clear the alternatives, and empowers you to make an informed choice in your own best interest. As I say, if you are lucky. But a) that probably won't happen, at least not in 2012, although we're working on it; and b) even so, you still might need something you can't afford.

That's why the whole idea of a hypothetical "free market" putting you in the driver's seat is utter nonsense. The only way to make the world more just is for everybody to have health insurance that makes it affordable for them to get the care they need, should they happen to need it. And making people pay out of pocket till it hurts won't cause them to make the right decisions about their health care because they don't know how. On the other hand, not having to pay isn't going to cause you to get health care you don't need, because medical procedures are generally unpleasant at best. I'm not going to check in for a triple bypass just because my insurance will pay for it. What will make you get health care you don't need, however, is your doctor telling you that you do need it.

Unfortunately, doctors do that a lot, because they get paid to do stuff. It's usually an unconscious bias, but it has been proven again and again that it exists. So we have two problems: people who don't get care they really do need, because they can't afford it; and people who get care they don't need, because there's an economic incentive. There are many other sources of waste and inefficiency in the system, as Fineberg details, but those are the core problems.

Republicans want to control health care costs by just not paying for health care that low and moderate income people can't afford. They're the real death panel. Democrats are all confused and conflicted, in part because hospitals and doctors and drug companies all give them money to keep the gravy train flowing.

What we really need to do is:

1) Make sure everybody has adequate, affordable health insurance. That requires:
a) Regulation of the insurance market so that insurers compete by offering better benefits and friendlier service, instead of by only enrolling the healthiest people. (Single payer national health care would be much better but I'm not dreaming right now.)
b) Providing subsidies for low income people who cannot otherwise afford the above. And by the way, however smug you are about being successful and well-to-do, and however much you think that poor people are moochers and should drift off on an ice floe, if you should happen to get seriously ill you might just find yourself among them. Yes you can.

The affordable care act does that. It can't do it without the individual mandate because otherwise, (a) could not happen.

2) Change the way doctors and hospitals get paid so that they make money by keeping people healthier at lower cost. Yes, both are possible.

The affordable care act makes a modest start in that direction, but doesn't go far enough because of the Death Panel horseshit. If Democratic politicians (and that includes the president who for some reason has no interest in defending his signature achievement in public) would start making an effort to explain this, the world would be better.

Mad or Bad?

The horrific events in Kandahar province on Sunday remind us of a couple of perplexing moral problems. Leon Panetta says of the massacre of 17 Afghan villages, purportedly* by a single "rogue" American soldier, "War is hell," and as reported by CBS, "He said this "wasn't the first and won't be the last" of this kind of horrible event, adding "I do not believe there is any reason to change our strategy at this time." Well yes. In wars people kill each other. Under specific circumstances it's considered not just okay, but heroic. And it's perfectly alright to kill non-combatants as well, so long as you didn't really mean to, even if you knew it was going to happen but it wasn't your actual purpose. Since war, according to the U.S. Secretary of Defense, expectedly and inevitably means that event such as this will happen, maybe they aren't such a good idea after all?

That said, we have a muddled and inexplicable view of moral culpability when people commit such unimaginably atrocious acts. Charles Whitman, who climbed a tower at the University of Texas in 1966 and shot 16 people to death, was found on autopsy to have a brain tumor. No-one can say for sure, of course, but it is entirely possible that tumor was a necessary cause of his actions. (Behaviors are complexly caused, of course. What I mean to say is that given the counterfactual that he did not have the tumor, he would not have committed the crime. We cannot do the experiment, but I would still say the statement is meaningful.) If that is so, was he responsible? Was he culpable?

Then consider Jared Loughner, who attempted to kill Representative Giffords and did kill 6 people. He has been diagnosed as paranoid schizophrenic by court-appointed psychiatrists. Based on published reports of his behavior before, during and after the crime, he is what we technically call completely nucking futz. He is as profoundly psychotic as anyone can be, and was clearly fully inhabiting an alternate reality. Does it make any sense for him to have a criminal trial and sentence, presumably death? Or is he also not responsible and not culpable?

Some people will say it doesn't matter, that we are what we do, but most people do not. The law obviously recognizes brain disease as at least mitigating, and sometimes entirely exculpatory, based on a conclusion that the person was unable to comprehend the wrongfulness of his or her actions, or unable to conform to the law.

But what does it mean for someone to be "able" to behave in a way other than the way the person actually does behave? Consider Sergeant X. We are told that he was on his fourth combat deployment, had suffered a brain injury, and was having marital problems. There seems little doubt that he merits some sort of psychiatric diagnosis. Suppose those things had not happened to him. Presumably he would not have committed atrocity. Okay, how is that different from Whitman's brain tumor and Loughner's schizophrenia?

Now let's consider Timothy McVeigh, who blew up the Murrah Federal Building in Oklahoma City. Perhaps he got labeled with a personality disorder, but he was certainly not psychotic. He explained his own motives in affirmatively moral terms: he believed what he did was not only right, but admirable. The vast majority of us see that as preposterous. Even if you are deeply offended by government actions at the Branch Dividian Compound, the workers in the Murrah Building had nothing to do with it. Deciding that they were guilty because they work for the federal government makes about as much sense as going around killing everybody you could find with the last name of Reno, or the first name of Janet; these categories are just irrelevant.

But it made sense to McVeigh, not because he created himself as somebody who believed such a thing, but because the sum of his experiences as they interacted with his neural network created that belief in him. The point is, none of us creates ourselves or could, in a meaningful sense, have done anything than what we have done. The history of the universe leads to each point in time and makes it what it is.

The useful way to think is not to assign blame and seek retribution, but to look for ways of preventing such terrible events. Not going to war seems like a very good place to start.

* I say "purportedly" because there is a great deal about this story which is more than little bit fishy. For one thing, it's more than a little bit odd that a lone soldier could simply walk off the base, carrying a weapon in the middle of the night. The official story that has trickled out seems to imply that the only sentries on duty were Afghans, who apparently didn't feel they could stop him. When they reported it (To whom? The American Sergeant of the Guard? What the hell was he doing?) the response was a head count and a bed check. Really? Nobody saw him leave the barracks? And how did he set fire to the children's bodies? Was he lugging a can of gasoline along with his rifle as he supposedly hiked to the villages on foot? And is it really possible that nobody in this highly confined and intimate space noticed that there was something wrong with the guy? We may never know the real truth, but whatever it is, lots of people are never going to believe the official story. The commanding officer and the OD, at the very least, should be court martialed for dereliction of duty and dishonorably discharged. Want to be that will happen?

Call off the apocalypse?

What if Medicare costs aren't going to grow unsustainably after all? That's what Chapin White and Paul Ginsberg ask. I have mentioned here that the Affordable Care Act contains several provisions that promise to contain Medicare spending (while simultaneously improving outcomes, by the way) including the Patient-Centered Outcomes Research Institute, the Center for Medicare and Medicaid Innovation, and pilot projects to reconfigure the payment structure and reorganize health care. There was also some earlier legislative action that constrains costs.

Well, it turns out that for the past couple of years, Medicare spending per beneficiary has pretty much tracked inflation. That's partly because of the bad economy -- even Medicare beneficiaries have to pay something out of pocket -- and partly because of the retiring baby boomers who, for a period, will mean there is a higher percentage of "young old" in the mix. But White and Ginsberg think there's more to it, that we really are starting to get a handle on costs.

I think they're calling the game too early, but I also do think there is promise in the reforms that have been made so far and that if we can stuff a sock in the Death Panel wingnuttery and equally deranged "free market" fundamentalists, we can do this thing. But we need a much, much better press corps and a Democratic party that's willing to stand up and fight.

Bring on the giant meteorite

Public Policy Polling has surveyed Republican primary voters in Alabama and Mississippi. You can skip the horserace questions in the beginning and go straight to pages 3 and 4 where you will find:

45% say Barack Obama is a Muslim, 12% say he is Christian, and 41% are not sure.

21% say that interracial marriage should be illegal, and 12% are not sure.

26% say they believe in evolution, 60% say they do not, and 13% are not sure.

I must admit this forces me to struggle with the problem of representational government. There is no political communication or educational or organizing strategy that can result in these people understanding and voting in their own best interest. They are a lost cause. What is to be done?

Note: I posted this before Jed Lewison did at Kos, so there.

The Dreams of Reason

For reasons only tangentially related to the following discussion, I am reading The Theory of Communicative Action, by Jurgen Habermas. (I'm afraid I don't know how to make the two little dots over the "u".) Habermas's magnum opus was written over several years but published in 1981.

He begins by announcing (not in so many words but this is how I read it) that the triumph of empirical science has killed metaphysics, and that philosophy has essentially collapsed to epistemology. What this means in standard English is that, since we now expect truth claims to be verifiable, it's no use sitting in your study and making up fancy sounding jive about the ultimate nature of reality or the nature of existence. Whatever we may ultimately conclude about that will be figured out by physicists, or remain a mystery. Philosophy still has a role, however, in working through the puzzles of how we decide what is true, and that's called epistemology. We have decided, however, that argument by assertion is not valid, so forget about the Bible or Hegelian mysticism and so on.

Habermas's project is to understand how society produces and maintains itself in the Age of Reason, now that the authority of church and tradition has decayed. He is not a cheerleader for the Enlightenment - it's here, he's part of it, get used to it, but there has been a price. Humanity has lost something in the bureaucratization and commodification of life, and from that observation grows his famous dichotomy of lifeworld and system. Reason does not necessarily produce justice or humaneness or happiness, because it can be used for antithetical purposes, or have unintended consequences. I would say, however, that it's the only weapon we just, humane, and happiness-pursuing people have that's going to get us anywhere.

That said, I expect Habermas is quite surprised by the powerful reaction against reason now occurring, particularly in the United States. Back in 1980, it seemed to most people, me included, that reason was going to march on and conquer, for better or for worse. This may be a temporary setback. It's partly happening because many people are feeling those negative consequences. The economic system is grinding them down and their lifeworlds are impoverished. But, and this is extremely important, the crusade against reason is also being financed and waged by people who perceive that when the masses possess truth and the tools of critical thinking, their own privileges are threatened. They want to keep it all to themselves.

Am I Weird?

This whole 1950s retro debate about contraception is universally framed as an issue of women's health vs. religious freedom or something like that. It seems to me that there is a certain percentage of the male population -- vanishingly small, it seems, and not worth mentioning -- who like having sex with women who they like and care about, and only want to make babies by mutual agreement. Do we not vote? If you prick us, do we not bleed?

The silent epidemic

Methamphetamine is in the news a lot, what with meth labs exploding left and right -- recently in a nursing home, for crying out loud, and multiple ton busts in Mexico (most of which I'm sure was back on the market after payment of suitable bribes). We're spending a billion dollars a year to incarcerate tens of thousands of people for marijuana offenses, and we've so far spent half a trillion dollars in Afghanistan accomplishing exactly nothing to reduce heroin production. (Basically 100% of heroin comes from Afghan opium.)

However foolishly we are dealing with those issues, they are not any of them our biggest drug problem. (It's unclear that marijuana is much of a problem at all, except to the extent we make it one by prohibiting it. But that's for another day.) Anyway, the truth is that overdose deaths from prescription opioids are more common than deaths from heroin and cocaine combined. And for every OD, there are 461 abusers and 161 addicts, according to a SAMHSA survey -- and that's people who tell a survey taker they are addicts, presumably an underestimate.

As the CDC report linked above tell us, this represents an astonishingly explosive problem. Physicians in the U.S. are now prescribing the equivalent of 700 mg of morphine per capita in the U.S., which is enough to give every single living person a standard dose of hydrocodone every 4 hours for 3 weeks. A lot of these are diverted -- sold to people to whom they are not prescribed. Some of the problem is from prescription mills -- unscrupulous physicians who hand out prescriptions indiscriminately. Much of it is from physicians who are legitimately trying to meet the needs of people in pain but are either scammed by patients or don't have adequate training in pain management.

It used to be, in my view, that doctors were too reluctant to prescribe opioid analgesics, and many people with disabling pain were not adequately treated. A lot of people shared that view and medical culture changed to be more accommodating of opioid prescription but we've gone too far, it seems. These drugs are a great boon to humanity when used properly but they are obviously very dangerous as well. It's a wicked hard problem, as they say in my former hometown of Boston. There should be a very high threshold for prosecuting physicians -- there are clear cut cases where they aren't evaluating patients and are simply in business to hand out scrips all day. But there have also been cases of egregious prosecutorial overreach where DAs just had a different view of what constituted appropriate prescribing. And addicts can be very resourceful about conning people, including doctors.

Who will rid us of this disgusting political party?

As physician Mary Tinetti reminds us in the new JAMA, the whole "death panels" lie campaign is one of the worst acts of political malpractice since the Iraq war. (I believe you will just be able to read the first 100 words, because you aren't a member of our secret society.) As you may recall, the idea that Medicare would pay for you and your doctor to discuss your wishes for end of life care, called Advanced Care Planning, was popular on both sides of the aisle in the Capitol until Sarah Palin started blathering about "death panels."

Dr. Tinetti tells us that she has had 2 patients' families accuse her of being part of a government conspiracy to murder their parents because she asked them if they wanted to talk about their goals for care and how she could make decisions in accordance with those goals. That's what you get for listening to the Alaskan airhead and vulgar pigboy. Since 2 1/2 million people die in the U.S. every year pretty common and something we probably ought to plan for, but people have been lied and terrorized into not doing it.

Dr. Tinetti criticizes the president for giving in to this evil, and not speaking out to correct the lies and fear mongering. Granted, he has a lot of lies to deal with all at once, but I have a feeling he could actually win with the public.

The weird ways of our political culture

Sure, it's a lot of fun to see the vulgar pigboy finally suffering some consequences for his endless spewing of filth but I have to ask, why now? It's not as though his latest outrage is anything special. Racist abuse of the president and other public figures, gross and repulsive sexism, blatant lies, mocking people with disabilities, mocking the poor, despising the unfortunate, hatred and threats of violence -- these are his standard, everyday stock in trade. That hasn't bothered his advertisers or any of the stations that willingly turn themselves into sewers to carry the swill into the nation's automobiles and living rooms.

So what's different all of a sudden? Just that the latest victim is not a public figure, I suppose. That's basically what got Don Imus into trouble. The Rutgers women's basketball team were not wealthy or individually famous or looking ahead to a life as wealthy big time athletes. So you aren't supposed to go there. Pigboy can do whatever he wants to the president or Michael J. Fox, and oh by the way turn politics into a war against the truth, and lie the country into wars and ecological catastrophe. Not a problem. But his latest victim is just a humble law student so apparently that's a step over the line.

No, it doesn't really make any sense.

Mad Magazine has a blog!

Who knew?

Why must I point out the obvious?

If a woman is having sex and using contraception, then a man is also doing so. Only one of them, it seems, is a slut.

This and that

We have entered a chronosynclastic infundibulum, Kurt Vonnegut's imagined cosmic phenomenon consisting of a region where all possible opinions are true. At least that's the corporate media view of the world, and as we know all too well it has allowed sociopathic billionaires to convince much of the public that science is a conspiracy against human freedom, by which they mean their own wealth. The Union of Concerned Scientists has taken a look at the current state of the deceivers' art in Heads They Win, Tails We Lose: How corporations corrupt science at the public's expense. From the publicity material:

Unfortunately, censorship of scientists and the manipulation, distortion, and suppression of scientific information have threatened federal science in recent years.

This problem has sparked much debate, but few have identified the key driver of political interference in federal science: the inappropriate influence of companies with a financial stake in the outcome.

I'm not sure it's true that few have identified the key driver, but whatever.

And along the same lines, Nader's Raiders have something to say about medical device regulation:

Regulation of medical devices—a $350 billion industry that includes such products as heart and brain stents, artificial hips and implantable defibrillators—is at a crossroads. With a major reauthorization bill up for debate, members of Congress already have introduced 14 bills1 that aim to accelerate devices’ path to the market, often by weakening measures intended to ensure patient safety.

The bills reflect industry’s concerted lobbying campaign. In 2011, the medical device industry spent $33.3 million on lobbying, raising its total to $158.7 million since 2007. In just the third and fourth quarters of 2011, at least 225 industry lobbyists—including 107 who previously worked for the federal government—lobbied members of Congress or executive branch officials on issues relating to medical device regulation.

Damn I miss George Carlin.

Drive-by anti-quackery

I don't spend a lot of time here debunking quackery -- I leave that to the crew at Science Based Medicine, which I recommend you visit, and bookmark if you're into it. One of the contributors has his own blog here, which tends toward the ultra-long-winded (where he finds time to do research and patient care I know not), but offers many a righteous rant.

A major frosting of the pumpkin for all these folks, and YT, is the invasion of so-called "Integrative Medicine," which is a propaganda name for irrational BS, into academia. Plenty of medical schools now have centers for "Integrative Medicine" and make room for all sorts of preposterous frauds, which the SBM folks call "quackademic medicine." No, there is no "vital energy," no qi, no meridians, and homeopathy is water. Diet and exercise are not "alternative," they are part of scientific medicine and yes, doctors do talk to their patients about them.

Anyhow . . . I think you can only read the first 150 words of this but I'll give you the 4-1-1. Paul Offit, a Philadelphia pediatrician and a well-known advocate for truth and reason (yeah, it's out of fashion) has tells conference-goers to the American Society for Microbiology that his own hospital has had no luck getting all of its workers to agree to an annual flu vaccine. It's required now - they lose their jobs if they refuse. We can argue about whether that's right or wrong, but 15% of them, it seems, make that choice. Says Offit, on the back of the form they could state why they declined to do so and "it was always things that were not biologically supportable." Meaning, I suppose, that vaccines cause autism or mad cow disease.

The reason the hospital has the policy is because they have many frail and immunocompromised patients whose lives they want to protect. In 2002, says Offit, two little girls got the flu while they were hospitalized, and they died. So Jenny McCarthy kills children. Got that?