Deafening Silence

The Perfect Storm?

Just some brief, but disturbing thoughts on a Friday afternoon:

Yesterday, Nidal Hasan was formally charged with 13 counts of murder for gunning down soldiers preparing to deploy to Iraq and Afghanistan.

That same afternoon, reports surface that President Obama is looking for "off ramps" to get the U.S. out of Afghanistan.

This is the P.R. equivalent of screaming "Uncle!  You win!  You win!" at Jihadists everywhere.

It simply does not matter that most rational people realize the two events are unconnected.  The two events occured together, and will make excellent propaganda for  violent radical groups : See!  All we have to do is kill a few soldiers on U.S. soil, and they can't run away fast enough!

And now we have today's announcement that Khalid Sheikh Mohammed will be tried in a New York court.  If this arrangement provides KSM with a platform to effectively place America on trial- and I suspect it will- Jihadists will be swimming in a warm bath of propaganda encouraging them to attempt yet more murders on U.S. soil.

Because such murders appear to be very effective. 

A delay of even 6 weeks between the announcement of Hasan's murder charges and news that the Obama administration wants to exit Afghanistan might have avoided this.  Now extremists can claim that the murders caused the calls for withdrawal, and then sit back while the faithful bask in the anti-American statements burbled by KSM at his show trial.

This will not end well.

The Fort Hood Shooting and Nidal Hasan: Links and Resources

As more information surfaces about the Fort Hood shooting and it's sole suspect, Nidal Hassan, 3 distinct viewpoints on the situation are emerging:

1. Hasan was a mentally ill man whose actions had nothing to do with Jihad.

2. Hasan was a mentally ill man whose delusions and violent impulses were channelled into Jihad.

3. Hasan was a terrorist, and any mental illness is a secondary issue.

I thought I would collect some informational links to help Deafening Silence readers form their own conclusions.

NPR has done surprisingly thorough coverage of the shooting. (As Instapundit recently observed, "NPR’s Daniel Zwerdling has owned this story from the beginning.")

Here are some NPR links worth reading or listening to:

Walter Reed Officials Asked: Was Hasan Psychotic? D. Zwerdling

When a group of key officials gathered in the spring of 2008 for their monthly meeting in a Bethesda, Md., office, one of the leading — and most perplexing — items on their agenda was: What should we do about Hasan?

Hasan had been a trouble spot on officials' radar since he started training at Walter Reed, six years earlier. Several officials confirm that supervisors had repeatedly given him poor evaluations and warned him that he was doing substandard work.

Both fellow students and faculty were deeply troubled by Hasan's behavior — which they variously called disconnected, aloof, paranoid, belligerent, and schizoid. The officials say he antagonized some students and faculty by espousing what they perceived to be extremist Islamic views. His supervisors at Walter Reed had even reprimanded him for telling at least one patient that "Islam can save your soul."

Portrait Emerges of Hasan as a Troubled Man J. Brady

But with the few details that are emerging about Hasan, it's possible to start painting a picture of him.

"The person who carries out a mass shooting wants to create a spectacle and seeks immortality," says Dr. Michael Welner, chairman of The Forensic Panel in New York. Welner testifies as an expert in trials involving mass shootings. He has interviewed four mass shooters over the years.

He says it's clear that the attack at Fort Hood was planned well in advance. For example, Welner says, Hasan allegedly bought the gun used in the attack shortly after moving to Fort Hood.

This informative and interesting discussion between Mr. Zwerdling and Melissa Block gives a clear timeline of Hasan's career, describes his behavior and- in the final two minutes- torpedoes the notion that Hasan was driven to desperation by anti-Muslim bullying.

Hasan's Story Won't Be Easy to Sort Out T. Gjelten- This piece is dated November 6 and I'm including it just to show how recent information has completely changed the debate.  Compare this excerpt to those above:

The vital facts of Hasan's life do not suggest a man determined to kill dozens of his fellows as they sat unarmed in a crowded waiting room. He was born in Arlington, Va. His parents were immigrants, but so are millions of other Americans. His heritage was Palestinian, but he didn't even speak Arabic. He went to Virginia Tech and in 1997 joined the Army. It was through the Army that he got his medical training. He was due to be deployed to Afghanistan.

In this interview, author/researcher Jarret Brachman calls Hasan's association with a certain imam a "huge red flag."

Mr. BRACHMAN: Yeah, I mean, the fact is theres no reason an active-duty officer should be in any sort of conversation with Anwar al-Awlaki. You know, one email maybe for academic research purposes is understandable, but prolonged contact and interaction is just totally, you know, beyond the pale. And this should have sent flags throughout the chain. If you understand that the kind of message that Anwar al-Awlaki is promoting, this is a massive oversight.

Former Colleagues Say Hasan was Detached D. Zwerdling- This interview details how supervisors and colleagues struggled against bureaucracy to get rid of Hasan:

You have to show that you've tried to remediate his behavior. Two committees have to vote on it. Then the resident can hire a lawyer and appeal, there are hearings. So psychiatrists at Walter Reed tell me that residents are hardly ever kicked out of the program, even when they've done something really egregious.

Plus, one of the key officials at Walter Reed, who's close to the policy committee, told me that they - some of the members sat around saying, and how would it look if we kick out one of the few Muslim residents in our program?

......

You have to show that you've tried to remediate his behavior. Two committees have to vote on it. Then the resident can hire a lawyer and appeal, there are hearings. So psychiatrists at Walter Reed tell me that residents are hardly ever kicked out of the program, even when they've done something really egregious.

Plus, one of the key officials at Walter Reed, who's close to the policy committee, told me that they - some of the members sat around saying, and how would it look if we kick out one of the few Muslim residents in our program?

MSNBC has just announced that Hasan is charged with 13 counts of murder:

Military prosecutors charged Fort Hood shooting suspect Maj. Nidal Malik Hasan with 13 counts of premeditated murder Thursday.

Hasan, 39, is accused of opening fire at Fort Hood's crowded Soldiers Readiness Processing Center, where troops get medical checkups before deploying abroad. The rampage is described as one of the worst mass shootings on an American military base.

Hasan will be tried in a military court.  This is an NPR interview with his lawyer, Retired Col. John P. Galligan:

Can he get a fair trial at Fort Hood? I have my doubts. Ill just say that your listeners should join me in requesting that everybody make sure, as we go down this road that we call military justice, that we make sure that we stay on track so that Major Hasan gets a fair, impartial hearing and trial. Thats what we want, not just for him because its also what we want for each and every one of us.

ABC News took a tour of Hasan's apartment and reports on what they found here.

Remembering the Fallen

The following 12 soldiers and 1 civilian perished at Fort Hood on November 5th, 2009:

Lt. Col. Juanita L. Warman, 55, of Havre De Grace, Md. She was assigned to the 1908th Medical Company, Independence, Mo.
 
Maj. Libardo Caraveo, 52, of Woodbridge, Va. He was assigned to the 467th Medical Detachment, Madison, Wis.
 
Capt. John P. Gaffaney, 54, of San Diego, Calif. He was assigned to the 1908th Medical Company, Independence, Mo.
 
Capt. Russell Seager, 51, of Racine, Wis. He was assigned to the 467th Medical Company, Madison, Wis.
 
Staff Sgt.  Justin Decrow, 32, of Plymouth, Ind. He was assigned to the 16th Signal Company, 62nd Signal Battalion, 11th Signal Brigade, Fort Hood,
Texas.
 
Sgt. Amy Krueger, 29, of Kiel, Wis. She was assigned to the 467th Medical Company, Madison, Wis.
 
Spc. Jason Hunt, 22, of Tillman, Okla. He was assigned to the 1st Brigade, 1st Cavalry Division, Fort Hood, Texas.
 
Spc. Frederick Greene, 29, of Mountain City, Tenn. He was assigned to the 510th Engineer Company, 20th Engineer Battalion, Fort Hood, Texas.
 
Pfc. Aaron Nemelka, 19, of West Jordan, Utah. He was assigned to the 510th Engineer Company, 20th Engineer Battalion, Fort Hood, Texas.
 
Pfc. Michael Pearson, 22, of Bolinbrook, Ill. He was assigned to the 510th Engineer Company, 20th Engineer Battalion, Fort Hood, Texas.
 
Spc. Kham Xiong, 23, of St. Paul, Minn. He was assigned to the Forward Support Company, 20th Engineer Battalion, Fort Hood, Texas. 

Pvt. Francheska Velez, 21, of Chicago, Ill. She was assigned to the 15th Combat Support Battalion, Fort Hood, Texas.
 
Chief Warrant Officer retired Michael Cahill of Cameron, Texas. He was a civilian employee on Fort Hood.
 

They were were the beloved of 13 different families.  They were fathers, mothers, sisters, brothers, husbands, wives, lovers, friends.  They represented 11 different states.  Their surnames are a mix of asian, european and latino names, as befits the nation they had volunteered to serve.

We are the poorer for their loss.

The official Fort Hood website can be found here.

 

The (Non)-Persistence of Memory

"How much of our past lives- the thousands of moments we experience- help to make us who we are?  if you took all of these remembrances- these memories- away, what would be left? How much is our personality, our identity, determined by the experiences we have, and how much is already there, pure us?"

Rupert Murray

Unknown White Male

  At about 12:30 a.m. on October 9, a security guard noticed a girl wandering aimlessly on the sidewalk in front of Covenant House, a youth shelter in Manhattan.  He tried to talk to her but when she did not respond he called the New York City Police Department.  When the police tried to talk to her she was unable to tell them her name or any other authobiographical information.  They dubbed her "Jane Doe" and guessed she was 14- 18 years old.

Jane Doe did not know her name, address, or when and how she arrived in the city, but she could recite passages from the novel Fool's Fate and said she was writing a fantasy story of her own.  When CNN reported the story a viewer in Maryland recognized the girl as 18-year-old Kacie Aleece Peterson of Hansville, Washington.  As family travelled to claim her it was revealed that she had suffered a similar incident in the past, when she was found lying beside a stream with only partial memories of who she was and how she got there. 

What this story describes is an incident of dissociative fugue- a rare form of amnesia.  Although many people associate the word fugue with music, in this case fugue is derived from the word Latin word for flight, fugere.  Dissociative fugue is marked by flight.  Sufferers literally become fugitives, often travelling many miles from home.  From psychcentral.com:

Dissociative Fugue is one or more episodes of amnesia in which the inability to recall some or all of one's past and either the loss of one's identity or the formation of a new identity occur with sudden, unexpected, purposeful travel away from home.

Specific symptoms include:

The predominant disturbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's past.

Confusion about personal identity or assumption of a new identity (partial or complete).

The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

People undergoing dissociative fugue are literally fleeing their lives.  It's not uncommon to hear a recovering patient describe themselves as 'waking up' in a new place.  They were not asleep.  In many cases they were functioning well enough to purchase train or airline tickets without attracting any notice.  Again, from psychcentral.com:

The length of a fugue may range from hours to weeks or months, occasionally longer. During the fugue, the person may appear normal and attract no attention. The person may assume a new name, identity, and domicile and may engage in complex social interactions.

...

A fugue in progress is rarely recognized. It is suspected when a person seems confused over his identity, puzzled about his past, or confrontational when his new identity or the absence of an identity is challenged. Sometimes the fugue cannot be diagnosed until the person abruptly returns to his prefugue identity and is distressed to find himself in unfamiliar circumstances.

Experts theorize that such sudden flight is a reaction to severe trauma.  Unable to process a terrible experience, the mind rejects not just that memory, but all memories.

Maybe the quickest way to put horror behind you is to simply become another person.

Dissociative fugue has been romanticized in films like the Bourne Identity and The Long Kiss Goodnight, which depict screen heroes who recover their memories and go on to wreak righteous vengeance.

The reality is often less glamorous.

Consider the case of Hannah Emily Upp, a schoolteacher from New York City.  Ms. Upp disappeared in late August 2008 and was found floating in the Hudson River on Septmber 16, 2008 in what appeared to be a suicide attempt:

The young woman was floating face down in the water, about a mile southwest of the southern tip of Manhattan. Wearing only red running shorts and a black sports bra, she was barely visible to the naked eye of the captain of the Staten Island Ferry: When he caught sight of her bobbing head, it was like glimpsing the tip of a ballpoint pen across a busy city street. Less than four minutes later, a skiff piloted by two of the ferry’s deckhands pulled up alongside the woman. One man took hold of her ankles while the other grabbed her shoulders. As she was lifted from the water, she gasped.

“I went from going for a run to being in the ambulance,” the woman said several months later in describing her ordeal. “It was like 10 minutes had passed. But it was almost three weeks.”

Roommates and family had been frantically searching for Ms. Upp during those three weeks.  Security cameras eventually captured footage of her checking her gmail, which lead many to believe her disappearance was a fake, not a dissociative fugue.  But people in a fugue state often retain unconnected scraps of information and can perform simple habitual acts, like logging into a computer account. (Recall Jason Bourne saying "I know I can run a mile flat out before my hands begin to shake.") In Ms. Upp's case, while she was able to access the account, she could not make any sense of the messages in it and did not understand why she felt compelled to check it:

The memory of how to perform mundane tasks like hailing a cab or even using the Internet remains intact. Victims lose only the memories tied to their identity.

“It’s as if a whole set of information about one’s self, our autobiography, goes off line,” said Dr. Richard Loewenstein, one of the nation’s few experts on dissociative fugue.

I suspect everyone has experienced a tiny piece of this.  How often have you strode purposefully into a room and then stood there blankly, thinking, "I know I came in here for a reason, but I can't remember what it was."?  Have you ever found yourself suddenly struggling to recite your own phone number, then apologizing by saying, "You asked me too fast!"

Now imagine if all that- and more- suddenly vanished.  Without warning you are left gazing at your surroundings, heart fluttering, thinking, "Where am I?"  And your only answer is: "I have to get out of here- right now!"

“We tend to experience our identity as a thing, as if it’s a constant,” added Dr. Loewenstein, who is medical director of the trauma program at Sheppard and Enoch Pratt Hospital in Baltimore, and has treated five patients with dissociative fugue. “But it’s a lot less stable and has less unity than we want to believe.”

Dissociative disorders often appear to run in families and many people who enter the fugue state will experience another dissociative event later in life.  Patients identified as at risk for such incidents often develop strategies that will enable their family and friends to locate them in the event of a relapse.

In 2005 the Sundance Film Festival was riveted by a documentary titled Unknown White Male which purported to describe the experiences of Douglas Bruce, who claimed to have undergone an episode of dissociative fugue.  Doubts have been raised about its veracity, but the film is still a good introduction to the concept of dissociative fugue- and the haunting questions it raises about who we really are.

 

Circling the Wagons Around the Ivory Tower

What we have here is a failure to communicate.

On July 24th, 2009 the New York Post published an editorial titled "Deadly Doctors".  In it, Betsy McCaughey quoted from papers authored or co-authored by Dr. Ezekiel Emanuel, health policy advisor at the White House's Office of Management and Budget.

Here are two of the now-infamous quotes:

"Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed.  An obvious example is not guaranteeing health services to patients with dementia." ("Where Civic Republicanism and Democracy Meet", Hastings Center Report, Nov.-Dec. 1996)

"Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age.  Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years." ("Principles for Allocation of Scarce Medical Interventions", The Lancet, Jan. 31, 2009)

When controversial statements like these became public, journalists and White House officials lined up to the reassure the American people that Dr. Emanuel never really wrote what they read.  Or that what they read wasn't what he really meant.

Or something like that.

 Jake Tapper of ABC News said the quoted papers could be called "exercises in philosophy" and wrote:

"Anyone who enters public life is subject to sentences being taken out of context.  But for academics it may be an even more dangerous situation."

Mr. Tapper quoted Dr. Emanuel on the controversy:

"...a lot of philosophy can sometimes seem extremely abstract to people and hard to follow- even well-educated people.  [Philosophical treatises]are not necessarily the easiest thing to read."

I was offended by this line of defense.   First, it absolves Dr. Emanuel of the responsibility to be clear and unambiguous in his writing. 

To be fair, Dr. Emanuel isn't the first academic to spew murky prose.  According to Gail A. Hornstein, professor of psychology at Mount Holyoke College, murkiness isn't just an occupational hazard for academic authors, it's a fashion statement:

"We have a kind of reverse aestheticism- if our writing is dense and unwieldy, filled with technical terms and convoluted sentences, we wear its lack of accessibility as a badge of honor."

Camille Paglia recently posted an example of this 'reverse aestheticism.'  The lines below were taken from the homepage of a professor at Rice University:

"How do we articulate what we have learned in recent decades from a "cultural constructionism" of subjectivity and literary canons with aesthetic ecstasy (both the "old" and the "new" aestheticism)?  Deleuze's and Derrida's notions of a "dissolved cogito" and "non-egological" consciousness in the context of aesthetic ecstasy.  More generally, in what might life "after the subject" consist?  A reevaluation of both the continuities and apparent standoff between phenomenology- Husserl, Heidegger, Sartre, Michel Henry- and poststructuralism..."

This is "lack of accessibility" at its finest.  As Ms. Hornstein points out:

"Academic writing derives its authority from certain conventions, some of them bordering on arrogance.  When you're a young professor, it can make you feel powerful to sound as if you know so much."

Or, as a ten-year-old might put it : Hey, Rusty!  You can't join the club 'till you tell me the secret password!

A person sufficiently educated to write about 'difficult' subjects should also be expected to write about them coherently.  Blaming the audience is not an acceptable excuse.

But perhaps the concept of the 'audience' is itself part of the problem.  According to Dr. Emanuel, people in the rarified world of academia "tend to know your whole body of work, and when they make a response it tends to be to one line of argument in context."

I am reminded of the medieval Church's resistance to translating the Latin Bible into the vernacular.  Speaking simply releases ideas into the mainstream- a mainstream, Ms. Hornstein suggests, that academics just don't respect:

"We assume they're unable to grasp the subtlety of our thought.  We think that writing for a broad audience requires "dumbing down" our arguments.  But that's wrong.  Popular audiences are tougher critics than fellow academics are."

This brings me to my second objection to the Tapper/Emanuel defense.  Convincing the American public that they are incapable of understanding these papers ensures that most people will never try to read them.

That may protect academics from tough popular criticism, but it does nothing to advance the debate about health care reform.

White House officials, the press and Dr. Emanuel himself have tried to settle the controversy by saying that the papers quoted by Ms. McCaughey were purely theoretical.  Referring to "Priniciples for the Allocation of Scarce Medical Interventions," the Lancet paper which proposed the controversial 'Complete Lives System' for rationing health care, a White House official said:

"The article is not about medical policy but about what constitutes discrimination.  It's a highly theoretical piece."

Dr. Emanuel said of the same article:

"It doesn't apply to health care services more broadly."

It's true that Principles for the Allocation of Scarce Medical Interventions deals primarily with procedures like organ transplants and the distribution of vaccines during epidemics.  The 'Complete Lives System' is offered as a model for determining which patients receive scarce resources.

Yet this sentence appears on the last page of the article:

"Accepting the complete lives system for health care as a whole would be premature.  We must first reduce waste and increase spending."

Not unthinkable; merely premature. Also, according to Jake Tapper:

"Emanuel points out that there is some support for the positions he takes in that article from public polling, and that none of these discussions are removed from the world..."

That does not sound like philosophers discussing how many angels can dance on the head of a pin.

Before these papers emerged, most Americans had never heard of Dr. Emanuel. They didn't know his views on health care reform.  They didn't know he was an influential advisor to the Obama administration.

They were entitled to know.  They were entitled to demand, in clear language and in great detail, the names and views of all the important administration figures shaping health care reform. 

The Obama administration has not seen fit to provide this information.  They should not be surprised that the American public is clamoring for it now. 

And if they don't provide it, they're in no position to whine about misinterpretation.

References

When Academic Words Become Political Ammunition- Jake Tapper/ABC News

Zeke Emanuel on Sarah Palin's Accusation of Death Panels- Jake Tapper/ABC News

Prune That Prose- Gail A. Hornstein/Chronicle Review

Subject: Mind-Numbing French Professor- Camille Paglia/Salon.com

Under the Skin of Health Care Reform: Dr. Ezekiel Emanuel in His Own Words, Pt. 2

Under the Skin of Health Care Reform: Dr. Ezekiel Emanuel in His Own Words, Pt. 6

Under the Skin of Health Care Reform: Dr. Ezekiel Emanuel in His Own Words, Pt. 3

Child Rape is Always Wrong, No Matter Who Does It

Via Anne Althouse comes this link to an editorial by Marci A. Hamilton at findlaw.com:

First, as I discussed in a prior column, we had Tom Hanks and Rita Wilson producing HBO's "Big Love," which merely winks at the sexual degradation of girls in the Fundamentalist Latter-Day Saints enclaves, but never shows the system in an accurate light that would reveal its true, abhorrent nature. If the pretty fictions were stripped away, the show would be unrelentingly bleak and horrifying: a portrait of a male-dominated society that is inherently inimical to women's rights, progress, and power.

Now, we have the specter of many in Hollywood rushing to Roman Polanski's defense for his proven statutory rape. Three decades ago, as has been widely reported, Polanski admitted to drugging a 13-year-old girl with quaaludes and alcohol before proceeding to have sex with her. After being turned in, he first pled down the charge and then skipped the country to avoid his punishment. Yet much of Hollywood seems to think his evasion of justice is just fine, and ought to continue forever.

.................................

Therein lies the recipe for the perpetuation of child sex abuse. If you close your eyes to the first known victim, then you are choosing to let the child predator move on to the next one. Adults who prey on adolescent and teenage children rarely limit themselves to one victim, and Polanski is no different. He had a "romantic relationship" – to use the common euphemism here -- with Nastassja Kinski when she was only 15. Do the Hollywood icons rushing to his defense believe that he limited himself to sex with only two underage girls? Come on. The safe money is that they even know of some of the other victims.

(I confess I have been wondering about this myself.  The European government spokesmen seemed so at ease with the charges and so dismissive of the crime- could they be accustomed to looking the other way?  But in fairness, we have no proof of this.)

..............................

The nub of the problem is this: As adults, we value high achievers and we trivialize the profound effect of childhood sexual abuse on the victims, and on society as a whole. Polanski is a great artist; priests and bishops are revered for their sacrifices for God.

This is how adults permit themselves to be duped by the likes of Polanski: Child predators are, all too often, charming and attractive. That is how they get what they want. He is obviously no different from the mainstream abuser who gains the child's and the family's trust to obtain the sexual favors he or she seeks. The difference is that he has snookered most of an industry to his crooked and debauched behavior.

So if Hollywood's elite is going to whitewash fundamentalist polygamy and excuse Polanski because of his artistic achievements and his charm – while ignoring their predatory sexual acts -- then its members must also excuse most of the rest of the child predators in the United States, too. Let us be absolutely clear: Those shielding Polanski are choosing the sex abusers over children. It is an either-or choice.

Read the whole thing, as they say.

And from The Daily Beast, there is this editorial, written by a survivor of child sex abuse:

Define Artist. Not so easy to do. Now define pedophiliac child rapist. Pretty simple. If Polanski had been, say, a bus driver in Cleveland who had fed Quaaludes and Champagne to a thirteen-year-old girl and then raped and sodomized her, I doubt Jack Lang would be so quick to tell the rest of us about the privileges that come with driving a bus. Jack Lang doesn’t care about bus drivers. Jack Lang cares about Artists.

.............................

I am not alone. The number of my companions may startle you. A Canadian study indicated that almost one-third of all men are sexually abused by the time they are sixteen, usually by a figure of authority—a priest, a cop, a coach, a parent. Or a stupid film director. I don’t know the figures for women, but they are probably even higher.

These children grow up damaged. They are far more likely to be drunks, addicts, failures, misfits. They are even, strangely, far more likely to be heavily addicted to cigarettes.

(Remember the example of Evelyn Nesbit?  This was her lot in later life.)

..........................

Artists, instead of weeping into their expensive handkerchiefs and flailing their oh-so-delicate arms, should realize that the very notion of art is antithetical to Polanski’s actions, and to use his creativity as an excuse for them is disgusting. For people like Woody Allen, David Lynch, and Martin Scorsese to even hint that Polanski is some kind of harried martyr is despicable. Just ask any one of the thousands upon thousands of children who have been raped. Just ask me.

........................

And irony upon irony: Elizabeth Smart testified about her own child rape ordeal in court today.  And piling on more irony: Ms. Smart will soon be sent to France as Mormon missionary.

Oh, and apparently her captor used the Polanski technique:

Smart said Mitchell plied her with alcohol and drugs to lower her resistance.

Holy Cow! The New York Times Gets It Right!

Somebody pinch me.  Via Newsbusters comes a link to an NYT editorial re: Roman Polanski:

"Yet where is the injustice in bringing to justice someone who pleads guilty to statutory rape and then goes on the lam, no matter how talented he may be?

In Europe, the prevailing mood — at least among those with access to the news media — seemed to be that Mr. Polanski has already “atoned for the sins of his young years,” as Jacek Bromski, the chief of the Polish Filmmakers Association, put it.

We disagree strongly, and we were glad to see other prominent Europeans beginning to point out that this case has nothing to do with Mr. Polanski’s work or his age. It is about an adult preying on a child. Mr. Polanski pleaded guilty to that crime and must account for it." (my emphasis)

Let's hope this kind of thinking begins to gain ground.

It's a pretty short piece, so it won't take long for you to go read the whole thing.

Confusion in the Valley of the Dolls

Cap. But saying o'er what I have said before: My child is yet a stranger to the world:

She hath not seen the change of fourteen years;

Let two more summers wither in their pride,

Ere we may think  her ripe to be a bride.

Par. Younger than she are happy mothers made.

Cap. And too soon marr'd are those so early made.

William Shakespeare

Romeo and Juliet, Act I Scene II

 

Roman Polanski has been arrested in Switzerland.

The acclaimed director, now 76, pleaded guilty in 1977 to having "unlawful sex with a minor".

That is a sanitized way of saying that he admitted to plying a 13-year-old girl with quaaludes and champagne and then forcing her to submit to a series of sex acts.

Polanski served 42 days in jail but fled the United States when a judge attempted to extend his sentence.

After his arrest, French Culture Minister Frederic Mitterrand declared that Polanski had been "thrown to the lions."

Not really.  It might be closer to the truth to say that Polanski has resumed his role in the great American fistfight over virginity, the definition of rape and the age of consent.

It's a longstanding brawl.

One of the earliest battles took place when Evelyn Nesbit (pictured at left) stepped to the stand in 1906 to testify on behalf of her husband, Henry Kendall Thaw.

Historians have described Ms. Nesbit as the first 'it' girl. Ms. Nesbit and her mother arrived in New York City in 1901.  When her mother could not find work as a seamstress, Evelyn, 16, began working as an artist's model, posing for painters and sculptors (sometimes in the nude.)  Her seductive, winsome beauty soon made her a great success.  She was the model for Charles Dana Gibson's "Gibson Girl," an icon of the period, and a sought-after fashion model.

According to her 1906 court testimony, Ms. Nesbit met architect Stanford White while performing in the chorus of a broadway show.  At first White, 47, cultivated a platonic relationship with the 16-year-old model, entertaining her at one of his many apartments (ironically, located over a toy shop) and even paying for her to see a dentist.

But when Nesbit's mother left town on a trip, the situation changed.  According to Nesbit's testimony, White lured her to his apartment, plied her with champagne until she passed out, then raped her.  By some accounts she woke to find White leaning over her, hissing, "You're mine now!  Mine!"

Ms. Nesbit testified that White manipulated her into serving him sexually until she was 17.

By 1905 Ms. Nesbit had left White and married Harry Kendall Thaw.  Now 20, she confessed her previous relationship with White to her new husband.  Never stable, Thaw took the news badly.  He "wept like a child," according to Ms. Nesbit.  On June 25, 1906, the couple was dining together in a restaurant when White happened to enter.  Thaw took out a gun, allegedly screamed, "You ruined my wife!"  and shot White point blank in the face, killing him.

That is the gist of Ms. Nesbit's testimony.  But it is not the entire story.

Henry Thaw's family was extremely wealthy.  Some sources believe that Thaw's mother bribed Ms. Nesbit into claiming White had raped her, to improve her son's chances at trial.  It is also known that Thaw had a violent temper and a cocaine habit- some sources claim he literally beat the confession out of his young wife.

And at the end of her life, Ms. Nesbit would claim that Stanford White was the only man she ever loved.

Taken one way, the story of Evelyn Nesbit could seem to score a point in Polanski's favor.  Evelyn Nesbit can be portrayed as a wiley teenage seductress, manipulative beyond her years, ready to defame her ex-lover in court for money.

But on the other hand, Ms. Nesbit's later life was riven by alcoholism, drug abuse and multiple suicide attempts- all hallmarks of childhood sexual abuse.  It is possible that she herself was never certain who was the victor and who was the victim.

Loudly declaring who is the 'real' victim is often the first blow struck in this great American fistfight.  Consider the case of the Fundamentalist Church of Jesus Christ of Latter Day Saints.  For generations this  religious group has practiced polygamy (which is illegal in all 50 states), and shunned contact with the outside world.  Ex-members have claimed that girls as young as twelve are forced into marriage with men four and five decades their senior- marriages often marked by severe beatings.

On April 9, 2008 Texas Child Protective Services raided the FLDS Yearning for Zion ranch just outside Eldorado.  On March 29 a caller identifying herself only as 'Sarah' had contacted a domestic violence shelter.  'Sarah' described a life of underage marriage, beatings and sexual abuse that seemed to confirm the accounts of ex-FLDS members.

Aided by local law enforcement, Texas CPS removed 534 women and children from the ranch, declaring that they were all at risk of abuse.  The affair became a circus, with aggrieved FLDS mothers appearing on Larry King Live and mass child custody hearings taking place in local courtrooms.

The authorities had searched the ranch for evidence documenting underage marriage.  Among other items, they found this photo:

The man pictured is Warren Jeffs, the 50-something spiritual leader of the group.  With him is one of his dozens of wives, a girl alleged to be between 12 and 14 at the time of the photo.

From the beginning, pundits called the raid unConstitutional and said that the FLDS were being deprived of equal rights under the law.  By May 22, an appeals court ruled that all the children must be returned to the ranch.  Public opinion, at first shocked by the allegations of sexual abuse, began to swing back toward the FLDS. Life on the ranch was described as old-fashioned, pastoral, all-American.  The FLDS, it was now said, were the real victims-- not the underage girls.

It was also said that prejudice against FLDS marriage practices was hypocritical.  Conservative blogger Robert Stacy McCain wrote at the time:

"Considering the everyday sexual realities of 21st-century American life, it is hard to locate any solid logical, moral, or legal justification for the way Texas officials went after the FLDS. In a society where adultery and fornication are tolerated, and where sodomy is declared a constitutional by the Supreme Court (in a Texas case, coincidentally), it becomes increasingly impossible to use the law as an instrument to enforce any societal standard of sexual conduct without incurring the accusation of arbitrary prosecution."

This statement raises some interesting questions.  If a child is born into a society determined to make her a sexual commodity as soon as possible, is she simply entitled to fewer years of childhood?  Who decides when a child is no longer a child- her parents?  The local community?  Greater national society?

Further, if the society is already steeped in sexual permissiveness, does it lose the right to make and enforce laws punishing child rape?

If so, score another point for Polanski.

(To be fair, I believe Mr. McCain was complaining about the state of U.S. sexual mores, not condoning child rape.)

This is what Pajamas Media founder Roger L. Simon wrote about the raid:

"Sending kids back into the same situation — while giving the cult a sense of empowerment that God is indeed on their side, no matter what they do to their children — is both frightening and irresponsible, but it seems that Texas courts think they’re just looking at the “alternative lifestyle” of a “new religious movement.”

It’s easy to point the finger at Child Protective Services for separating FLDS kids from parents, but pause to consider those who wish that, as children, someone had taken enough notice to remove them from an abusive home — before conducting the investigation that would just incite fury in a guilty parent, causing a painful backlash."

Mr. Simon's statement places the focus on individual parent/child relationships.  This is important, because the idea of "proper" and "improper" parenting has long been a weapon in the fight.

Consider this picture:

I'm old enough to remember the furor over the film Pretty Baby.  Twelve-year-old Brooke Shields (who may have been 11 during the actual filming) was cast as Violet, the daughter of a prostitute who lived in a whorehouse in New Orleans at the turn of the century.  The script insinuated that Violet offered the customers oral sex and contained a scene where she offers herself to an adult man:

"Everybody says I'm pretty.  Gettin' to be filled out soon.  And all the other men like me...Don't  you like me?"

Ms. Shield's mother was criticized by some as a callous stage mother exploiting her young daughter's beauty for profit.  The criticism reached a crescendo with the release of The Blue Lagoon, filmed when Ms. Shields was 14.  Ms. Shields had to testify during a Congressional Inquiry that body doubles were used during the film's nude scenes.

By the age of 15 Ms. Shields had appeared on the cover of Vogue and other fashion magazines, where she was marketed as an adult.  She became the spokemodel for Calvin Klein jeans, uttering the breathless tagline:

"Want to know what comes between me and my Calvins?  Nothing."

Congressional inquiries and gossip about her mother did not stop the American public from buying movie tickets, magazines, and Calvin Klein jeans.  Lots of Calvin Klein jeans.

But successful marketing could only paper over the societal conflict for a limited time.  Nearly thirty years later this picture would raise the same controversial issues:

The public was comfortable with Miley Cyrus as a Disney character.  They weren't ready to see her wrapped in a sheet. 

Famed photographer Annie Leibovitz was, however, and called the photograph "beautiful":

"The photograph is a simple, classic portrait, shot with very little makeup, and I think it is very beautiful."

The public outcry (and pressure from Disney officials) led Ms. Cyrus to make a public apology about the photo.

Does glamorizing beautiful young girls (and the mixed messages that sends)excuse child rape?  Of course not.  If it did, theft could be excused by the existence of wallets and houses would be held responsible for arson.

It reminds us, however, of our confusion about the line between childhood and adulthood, manipulation and consent.  But until we resolve these issues there will always be some "wiggle room" for the Roman Polanskis of this world.

And, for the record, my sympathy for Polanski is not limited.  It is non-existent.

Under the Skin of Health Care Reform: Dr. Ezekiel Emanuel in His Own Words, Pt. 6

Principles for Allocation of Scarce Medical Interventions is a paper published in The Lancet on January 31, 2009, Volume 373, No. 9661, pgs. 423-431.

Three authors are credited: Govind Persad BS, Alan Wertheimer PhD, and Ezekiel J. Emanuel MD.

The purpose of this paper is to discuss the ethical systems used to distribute scarce medical resources.  The examples most frequently used to define "scarce" in this document are transplant organs and vaccines during epidemics.

The opening abstract outlines the paper's content:

"Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge.  We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting social usefulness.  No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems.  We evaluate three systems: the United Network for Organ Sharing point systems, quality-adjusted life-years, and disability-adjusted life-years.  We recommend an alternative system- the complete lives system- which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery and instrumental value principles."

The authors begin by describing various ethical perspectives that can be used to decide which patients receive treatment.  They list the shortcomings of each perspective:

"When evaluating principles, we need to distinguish between those that are insufficient and those that are flawed.  Insufficient principles ignore some morally relevant considernations.  Conversely, flawed principles recognise morally irrelevant considerations...Principles that are individually insufficient could form part of an acceptable multiprinciple system, whereas systems that inlcude flawed principles are untenable..."

The authors examine the following principles:

Treating People Equally

a. Lottery

b. First-come, First-served

Favouring the worst-off

a. Sickest first

b. Youngest first

Maximising Total Benefits

a. Number of lives saved

b. Prognosis or life-years saved

Promoting and Rewarding Social Usefulness

a. Instrumental Value

b. Reciprocity

Their conclusions are summarized in a chart that appears on page 424. (Unfortunately, due to some obscure formatting problem, I am unable to scan the chart into this post.  I apologize.  Please use the hotlink above to access the paper in PDF form and scroll down to the chart. It appears on page 2 of the PDF.)

Lottery

The authors define a lottery system of allocation by using examples such as military conscription and immigration.  They say that a lottery system, because it works at random, is resistant to corruption.  They also say it is quick and easy to apply.

However, they disagree with the notion that:

"Equal moral status supports an equal claim to scarce resources."

Their understanding of equality seems to be extremely conditional, and trying to explain their concept of equality leads to the following sentence:

"Random decisions between someone who can gain 40 years and someone who can gain only 4 months, or someone who has already lived only 20 years, are inappropriate.  Treating people equally often fails to treat them as equals." (my emphasis.)

I have read this paper many times and I still find that final sentence incomprehensible.  How does treating people equally fail to treat them as equals?  The logic of the previous sentence- while I don't  agree with it- I can understand. 

The only meaning I can assign to that sentence is that the authors view equality strictly in terms of years lived.  If you have lived 20 years and could gain 4 months more by having a certain medical treatment, then you are equal to another person who has lived 20 years and could gain 4 more months.  But you are not equal to someone who has lived 40 years.

Does this mean that someone who has only lived 20 years is "more equal" than someone who has lived 40 years?  This issue will reappear many times in this paper.

First-come, First-served

The authors reject the first-come/first-served model on the grounds that it favors the wealthy and well-connected:

"First-come, first-served allows morally irrelevant qualities- such as wealth, power and connections- to decide who receives scarce interventions, and is therefore practically flawed."

I agree with this.  What I find interesting, however, is a sentence from a previous paragraph supporting this conclusion:

"[First-come/first-served] favours people who...can queue for interventions without competing for employment or child-care concerns.

 While examining Dr. Emanuel's paper The Perfect Storm of Overutilization, I pointed out that the constraints of employment and child-care duties discourage many people from "overutilizing" health care resources:

There is a hidden cost as well, a cost the authors do not address.  A visit to the doctor's office often means time away from work.  Repeated "interventions"- no matter how inexpensive they appear on paper- can cost an employee job security.  Extended hospital stays take a toll on families in terms of child care and other responsibilities.

I find it extremely interesting that when making the case that Americans "overutilize" health care resources, Dr. Emanuel and his colleagues don't acknowledge the constraints of work and child care.  Yet when they need an argument to support rejecting first-come/first-served medical allocation, they immediately cite "employment or childcare concerns."

Are employment and childcare concerns a significant restrain on utilizing health care or not?  Is Dr. Emanuel trying to 'have it both ways' or did his colleagues point these constraints out to him?

Is his reasoning inconsistent or have his views evolved?

Putting that aside, I do agree with the authors' assessment of first-come/first-served allocation:

"First-come, first-served allows morally irrelevant qualities- such as wealth, power, and connections- to decide who receives scarce interventions, and is therefore practically flawed."

Sickest First

The authors define the Sickest First approach this way:

"Treating the sickest people first prioritises those with the worst future prospects if left untreated.  The so-called rule of rescue, which claims that "our moral response to the imminence of death demands that we rescue the doomed," exemplifies this principle. Transplantable livers and hearts, as well as emergency-room care, are allocated to the sickest individuals first."

The authors completely reject the Sickest First approach. They argue that a Sickest First system does not take prognosis into account:

"Sick recipient's prognoses are wrongly assumed to be normal, even though many interventions- such as liver transplants- are less effective to the sickest people."

A hypothetical liver transplant is used as an example.  A morbidly ill person might be helped in the short term by a liver transplant, but that transplant denies a liver to another patient who has progressive liver disease, but is currently healthier.  The healthier patient has a better chance of recovery if given the liver, and should get it instead:

"Sick recipient's prognoses are wrongly assumed to be normal, even though many interventions-- such as liver transplants- are less effective for the sickest people."

It is easy to see how this logic applies to organ transplants, but I am wary of stretching it too far.  It requires doctors to predict the future.  Medical literature has its share of 'unexpected recovery' stories, and the bold treatment of 'hopeless' patients can result in medical advances.  As an example, I would offer Dr. Oliver Sacks' work with 'sleeping sickness' patients in the 1960s.  In his book Awakenings, Dr. Sacks describes treating patients trapped in a trance-like paralysis for 50 years or more with L-dopa.  Locked away in nursing homes for decades, many of these patients responded dramatically to the treatments, and the data collected during their treatment has expanded our understanding of brain disorders.

"[Sickest First] myopically bases allocation on how sick someone is at the current time- a morally arbitrary factor in genuine scarcity."

In a situation of genuine scarcity I can understand this point.  But I would also ask that doctors not regard their predictions as inviolate.

Youngest First

Here the paper first enters controversial territory.  It also introduces a phrase that will have great importance throughout the rest of the text: life-years.

"...youngest-first allocation directs resources to those who have had less of something supremely valuable- life-years."

Think back to the paragraph I highlighted earlier:

"Random decisions between someone who can gain 40 years and someone who can gain only 4 months, or someone who has already lived only 20 years, are inappropriate.  Treating people equally often fails to treat them as equals." (my emphasis.)

We can now read this paragraph as comparing 20 life-years to 40 life-years.  If life-years are "supremely valuable" then an individual who has consumed 40 of them is not the same as an individual who has consumed 20 of them.

The distribution of life-years is the primary concern of the rest of the text.  Who has had enough already and who should be granted more is the driving preoccupation of the authors.

(One personal note: as a writer and a reader I despise the term "life-years."  What other kinds of years are there?  Death-years?  This is numbing language that distracts us from the authors' real subject: who should live and who should die.)

The authors find Youngest First insufficient as a distribution model.  They agree it tends to favor the worst-off and avoids discriminating against minorities and the poor, but point out that it discriminates against older people.

Had they left it there, most readers would agree. But it is the details that get them into trouble:

"Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect."

Take a moment to absorb that statement before reading the rest of the paragraph. Saving infants is incorrect.

It paralyzes the mind.

All right- let's take a deep breath and give the authors a chance to explain themselves in the rest of the paragraph:

"The death of a 20-year-old young woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life.  The 20-year-old has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects."

Is the death of a 20-year-old intuitively worse?  Why?  Because she has a "more developed personality"?  That makes a life and death choice sound like a popularity contest.  What if your "developed personality" does not appeal to the judges?  What your "developed personality" includes lying and cheating as basic traits?

I am also uncomfortable with the idea of saving a life in order to recoup "the investment of others."  It smacks of leaving life and death decisions to shareholders.

I also think it is incorrect.  An infant has received a huge investment from others: 9 months of pregnancy, labor and delivery, nursing, bathing and protecting.  These activities require great dedication and commitment.  And a baby is in itself an "as-yet-unfulfilled project."

Neither the infant nor the girl can be regarded as intrinsically more worthwhile by these criteria, in my view.

Save the Most Lives

The life-years issue appears again when the authors discuss the Save the Most Lives model of resource allocation. 

"Since each life is valuable, this principle seems to need no special justification...Other things being equal, we should always save five lives rather than one.

However, other things are rarely equal.  Some lives have been shorter than others; 20-year-olds have lived less than 70-year-olds.  Similarly, some lives can be extended longer than others.  How to weigh these other relevant considerations against saving more lives- whether to save one 20-year-old, who might live another 60 years if saved, or three 70-year-olds who could only live for 10 years each- is unclear."

I'm glad the authors have decided this idea is unclear, but the most significant part of this section to me is that they are now applying the "maximum life-years" prism to the idea of simply saving the most lives.  The life-year concept continues to dominate their thinking for the rest of the paper. 

Prognosis or Life-Years

This strategy for distributing scarce resources aims to save the largest total of life-years.  As such it is an opportunity for the authors to talk about the life-years concept in greater detail:

"Maximising life-years has intuitive appeal.  Living more years is valuable, so saving more years also seems valuable."

"...why give an extra year to a person who has lived for many when it could be given to someone who would otherwise die having few?"

I would like to remind readers that the paper is discussing scarce resources and emergency situations.  It's important to keep that in mind while absorbing these concepts.  This is not being presented as a Master Plan for the human race.

Instrumental Value

This section discusses saving people based on their value to society.  It is by nature a very controversial idea.  To their credit, the authors address this in the opening paragraphs:

"Unlike the previous values, social value cannot direct allocation on its own."

"...social value allocation must not legislate socially conventional, mainstream values."

They describe the principle of Instrumental Value:

"Instrumental value allocation prioritises specific individuals to enable or encourage future usefulness."

The example given is prioritizing workers in vaccine production during an epidemic, or health workers during a similar emergency:

"..all whose continued existence is clearly required so that others might live..."

This statement has the ring of common sense.  The authors also caution that such a system is open to abuse, and use student military deferments as an example.

This section ends with a bit of unintentional humor:

"People also disagree about usefulness: is saving all legislators necessary in an influenza pandemic?"

(Congressional leaders, please call your offices...)

Reciprocity

"Reciprocity allocation is backward-looking, rewarding past usefulness or sacrifice."

The authors seem to realize that this is a sensitive subject and name some obvious candidates for reciprocity allocation: organ donors, nurses who treat contagious patients, military veterans. 

Ultimately, however, they reject reciprocity:

"Reciprocity allocation...might potentially require time-consuming, intrusive, and demeaning inquiries, such as whether a person adhered to a healthy lifestyle."

(It strikes me that depending on honest answers to such questions would also leave a reciprocal system open to fraud, but the authors don't mention this.)

 "Furthermore, unlike instumental value, reciprocity does not have the future-directed appeal of promoting important health values."

In rejecting reciprocity, the authors return to their emphasis on the future, which would presumably be reserved for those who have "consumed" the fewest "life-years."

Assessing Principles: Allocation Systems

Having examined individual allocation principles, the authors now look at systems that combine selected principles.  (A chart summarizing their views appears on page 427; again, I could not reproduce it here due to technical difficulties.)

UNOS- United Network for Organ Sharing points systems.

From the UNOS website:

UNOS brings together medicine, science, public policy and technology to facilitate every organ transplant performed in the United States. Every day, UNOS assists transplant doctors, patients, and members of the public by helping to ensure that organs are procured and distributed in a fair and timely manner.

The paper describes the UNOS points system as combining the first-come/first-served, sickest-first and prognosis principles.  It also calles the UNOS system flexible.

Nevertheless, the authors reject the system as flawed and open to corruption:

"Taking advantage of the first-come, first-served principle, well-off patients place themselves on multiple waiting lists.  Exploiting the sickest-first element, some transplant centres have temporarily altered or misrepresented their patient's health state to get them scarce organs..."

"...Most dramatically, multiple-organ transplants to one individual are permitted, even when a heart-lung-liver combination could save three lives if transplanted separately."

The criticism I find most intriguing is the author's characterization of attempts to improve the UNOS system as "covert and haphazard":

"Explicit and public acknowledgment of allocation strategies would be preferable to this surreptitious and piecemeal approach."

This criticism harkens back to Dr. Emanuels' Hastings Center paper, Where Civic Republicanism and Deliberative Democracy Meet.  In that paper he envisions "...public forums to deliberate about which health services should be considered basic and should be socially guaranteed."

Granted, the debates in those public forums would be influened solely by overlapping liberal/communitarian principles, but in these two papers Dr. Emanuel does show a consistent concern with transparency.  Allocation principles, in his view, should be open, and openly discussed.

Quality-Adjusted Life-Years

This system, known as QALY, is used by the National Health Service in the U.K.  From the NHS website:

With the rapid advances in modern medicine, most people accept that no publicly funded healthcare system, including the NHS, can possibly pay for every new medical treatment which becomes available. The enormous costs involved mean that choices have to be made.

It makes sense to focus on treatments that improve the quality and/or length of someone’s life and, at the same time, are an effective use of NHS resources...

A number of factors are considered when measuring someone’s quality of life, in terms of their health. They include, for example, the level of pain the person is in, their mobility and their general mood. The quality of life rating can range from negative values below 0 (worst possible health) to 1 (the best possible health).

The authors provide this example to describe the QALY system calculations:

"As an example, the quality-of-life measure used by the UK National Health Service rates moderate mobility allocation as 0.85 times perfect health.  QALY allocation therefore equates 8.5 years in perfect health to 10 years with moderately impaired mobility."

The authors reject the concept of years in perfect health vs. years of impaired mobility as an allocation strategy:

"...someone adapted to wheelchair use might reasonably value an additional life-year in a wheelchair as much as a non-disabled person would value an additional life-year without disability."

This is precisely the argument I would make.

The author's final rejection of QALY then returns to their preoccupation with consumption of life-years:

"Likewise, giving QALYs to someone who has had few life-years differs morally from giving them to someone who has already had many."

Disability-Adjusted Life-Years

DALY was developed by the World Health Organization.  From the WHO website:

One DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.

DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for incident cases of the health condition[.]

Dr. Emanuel and his colleagues give this example of a DALY calculation:

"DALY systems also incorporate quality-of-life factors- for instance, they equate a life-year with blindness to roughly 0.6 healthy life-years."

The authors point out that one concept in the DALY calculation is the idea that certain age groups are necessary in order for a society to flourish.  They disagree with this reasoning.

"This argument, although used to justify age-weighting, would equally justify counting the life-years of economically productive people and those caring for others for more."

They state that favoring wage earners and those caring for others is innapropriate, and that "Priority for young people is better justified on grounds of distributive justice."

The Complete Lives System

The stage has now been set for the authors to promote their alternative: the Complete Lives System. This system incorporates the following principles:

Youngest First

Prognosis

Save the Most Lives

Lottery

Instrumental Value

"Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritising adolescents and young adults over infants.  Adolescents have received substantial  education and parental care, investments that will be wasted without a complete life.  Infants, by contrast, have not yet received these investments."

Again, I question the ethics of a society that calculates only the risk of losing 'investments' in its members.  I would suggest that one mark of a truly ethical society is the steps it takes to protect its most vulnerable members rather than its "investments."

The authors argue that this age consideration is an expression of social justice:

"Importantly, the prioritisation of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo.  Consequently, poor adolescents should be treated the same as wealthy ones, even though they may have received less investment owing to social injustice."

This justice only applies to young people with a good chance of recovery, however:

"A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life.  Considering the prognosis forestalls the concern that disproportionately large amounts of resources will be directed to young people with poor prognoses."

I will repeat my previous cautionary note: at this point the authors are only discussing the distribution of scarce resources during a dire emergency.

"In a public health emergency, instrumental value could also be included to enable more people to live complete lives.  Lotteries could be used when making choices between roughly equal recipients, and also potentially to ensure that no individual- irrespective of age or prognosis- is seen as beyond saving."

Now we come to the infamous "attenuation" sentence which has been quoted so often by others:

"When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attentuated."

This single sentence has spawned numerous online references to Logan's Run and Soylent Green, inspired  handpainted signs at health care reform protests, and been quoted to Congressmen at townhalls.

The authors are probably thoroughly sorry they ever wrote it.  It is rivalled in controversy only by this sentence:

"Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age.  Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years."

Whenever these two quotes are cited, Dr. Emanuel's supporters always retort that the entire paper was only intended to discuss rationing in emergency situations.  I'm inclined to agree, but this paper repeats ideas discussed in earlier papers- papers not devoted to emergency rationing.

And the final page contains these words:

"Accepting the complete lives system for health care as a whole would be premature.  We must first reduce waste and increase spending...Although it may be applicable more generally, the complete lives system has been developed to justly allocate persistently scarce life-saving interventions." (my emphasis.)

If the authors are going to leave this kind of rhetorical door open, they must be prepared to take responsibility for it.  Do they envision wholesale implementation of the complete lives system?  When?

If they do envision wholesale implementation, the distribution and discussion of this paper would seem to be a necessary first step, by their own account:

"Legitimacy requires that people see the allocation system as just and accept actual allocations as fair.  Consequently, allocation systems must be publicly understandable, accessible, and subject to public discussion and revision."

My emphasis.  Their words.

 

 

Under the Skin of Health Care Reform: OECD Statistics on the U.S., U.K. and Canada, Pt. 5

In part 4 of this series I examined a chart used by Dr. Ezekiel Emanuel to support his arguments in a paper titled The Perfect Storm of Overutilization.  His chart compared OECD healthcare statistics for the U.S., Switzerland, France, Japan, and Norway as well as the OECD averages.  In the post, I asked why OECD figures for Canada and the U.K. were not included.  I found their omission strange because politicians and pundits have spent so much ink and airtime alluding to the nationalized healthcare systems of the U.K. and Canada during our current healthcare controversy.

So I decided to return to the OECD charts and look up a few figures for myself.  As before, these are based on the Health at a Glance 2007 OECD charts, and, as before, I will provide links to all the charts I reference.

I repeat: I am not a statistician.  I would also like to emphasize that this is not a comprehensive look at all OECD health statistics.  You could argue with my selection of data.

I'll start with nationwide supply of some advanced medical equipment:

CT Scanners Per Million Population, 2005

Canada: 11.2

UK: 7.5

US: 32.2

MRI Units Per Million Population, 2005

Canada: 5.5

UK: 5.4

US: 26.6

Acute Care Beds Per 1000 Population, 2005

Canada: 2.9

UK: 3.1

US: 2.7

Practicing Physicians Per 1000 Population, 2005

Canada: 2.2

UK: 2.4

US: 2.4

(Intriguingly, of all listed nations, Greece had the most practicing physicians per 1,000 population in 2005: 4.9.)

(I'm also forced to wonder if increasing the number of practicing physicians and hospital beds would help lower the cost of U.S. healthcare.)

I looked at some cancer surival rates as well.

A quick word about reading these figures from the OECD:

Relative cancer survival rates reflect the proportion of patients with a certain type of cancer who are still alive after a specified time period (commonly five years) compared to a non-diseased comparison group of similar age structure. This means that relative survival rates capture the excess mortality that can be attributed to a diagnosis. To illustrate, a relative survival rate of 80% does not mean that 80% of the cancer patients are still alive after five years, but that 80% of the patients that were expected to be alive after five years, given their age at diagnosis, are in fact still alive. (My emphasis.)

Cervical Cancer, 5-year Survival Rates, Latest Period Available

Canada: 73.0%

UK: 72%

US: 72%

Breast Cancer, 5-year Survival Rates

Canada: 86.0%

UK: 80.0%

US: 88.9%

Colorectal Cancer, 5-year Survival Rates, by Gender, Latest Period Available

Canada is not included in this chart.

UK: Males-49.0%, Females-49.0%

US: Males-65.2%, Females-64.6%

There are many more charts available at the OECD site; I recommend anyone interested in thinking about healthcare outcomes go there and take a long look.

One thing that struck me: In nearly every survival, equipment supply or treatment effectiveness chart, the UK is in the lowest-performing third of all countries surveyed.  After a few days examining the OECD statistics, I found myself automatically searching the bottom of every graph first when looking for UK numbers.

And nearly always finding them.

The US seems to have a very mixed showing in the OECD charts; outstanding in many areas and lagging behind in others.  However, as I pointed out in part 4, statistical proof can be in the eye of the beholder.  It's important to consider the geographical and demographic circumstances of nations as well.  For example, both Japan and Iceland have fairly homogenous populations.  Could this affect some rates of disease?  Is the rate of cancer mortality in some nations elevated due to an aging population? What role does infrastructure such as roads and public transportation play in giving rural populations access to care, and in turn affecting mortality rates? 

All of these are questions that should be asked when interpreting healthcare statistics.  They are important pieces of the puzzle that will tell us the hows and whys of improving US healthcare.

I wish more people would ask them.