Wednesday, August 31, 2005

The Tao of Republicanism

Being a Taoist Unitarian informs my politics as a Republican. At their best, political conservatives have been taoistic in outlook, if we look closely.

The taoist doctrine of wu wei is often translated as 'inaction' or 'not-doing' but these are misleading terms. Lao Tze lived in the Warring States period, when scores of small kingdsoms constantly battled, and whole cities were routinely put to the sword. His answer to the central question of his time--how can this be stopped?--was to observe that whenever a state acts against another, equal and opposite forces are raised up. There is an 'inertia' in human affairs; people resist any change.

What is it about a given action which creates the resistance? It is aggression, the attitude or intent to subject another, to make him inferior. This cause-and-effect law can be applied to other state activities in economics, law, and diplomacy (or interpersonal relations, but that's beyond the scope of the post). These views generalize beyond being a brand of pacifism.

Lao Tze specifically counselled rulers to rule as little as possible. This was not out of some proto-Enlightenment notion of checks and balances[ or laissez-faire, but an observation that attraction (the modern term might be 'incentives' but this does not capture it) is a more reliable and durable method of getting what you want than compulsion is. So conservatives would not support many of the New Deal proposals, not because they disagree with the goal of employing people and ending poverty, but because compelling the economy to do those things is not a sustainable solution if they work through subjection of the economy's natural processes to the political goals of the state. The economy will push back, through inefficiency and decreasing marginal returns.

In international relations, Lao Tzu wrote that the large kingdom's relation with small kingdoms should be like the large river being lower than the tributaries but allowing gravity to attract them. In like fashion, Eisenhower's dealing with our post-WW2 allies kept them loyal, by treating them with humility though we were clearly superior by any measure of national power.

Wu wei has been criticized as a doctrine which paralyzes one into inaction--that a Taoist would stand idly if a burglar threatened to kill his family for instance. But a Taoist does not eschew all violence, though he sees any exertion of aggression as regrettable, the result of an unfortunate inability (hopefully not unwillingness) to wait for the effects of wu wei. He would intervene and even kill the burglar, or support a necessary war, or support an economic band-aid for the Depression, but it would be with regret and with an eye to ending the aggression as soon as possible. It bears repeating that the attitude of regret toward aggression is what makes taoistic aggression less harmful. If the Iraq and Afghani people percieved our occupations as reluctant it would be more palatable and engender less opposition--but instead we announced our arrival into Afghanistan by leaving photocopies of scenes of 9/11, as if to say with glee "Payback time."

Rather than picking out microgoals and muscling toward them through bold policies and massive resource allocation, a Republican prefers to tweek the incentives to bring about the desired results. Instead of funding free clinics in inner cities nationwide, let's make it profitable for doctors to provide healthcare to that population. Instead of cleaning up Superfund sites and listing endangered species, let's create an infrastructure where it is more cost-effective to participate in clean disposal of waste than to dump, and build environmental strategy around ecosystems rather than species. Instead of declaring Bin Ladin evil and only taking him on militarily, let's act towards ambivalent Muslims with humility and compassion, so that they would rather live in our sort of pluralistic society than an Islamist one. This approach is slower, but more effective over time.

Wu wei is a bit of 2500 year old practical advice, not merely abstruse mysticism. I hope that modern politicians begin to take it to heart.

For a great discussion of wu wei, see Taoism: Parting of the Way. For a light read on Taoism itself, I recommend The Tao is Silent.

In Katrina's Wake

The victims of Katrina are in our thoughts and prayers. I hope that all you know in the area are safe. My brother's girlfriend and her family live near Biloxi, and one of my close colleagues' family lives in New Orleans; all are safe though there is enormous property damage and a shortage of water, food and clothes.

Please consider contributing to Red Cross.

UPDATE] See this update on the hospital evacuation situation in New Orleans. Thanks to MedPundit.

UPDATE] See The Times-Picayune Weblog for running local coverage. Recent articles detail such topics as the dramatic radio coverage of the rising downtown water, and red ant colonies forming floating balls.

Tuesday, August 30, 2005

Intelligent Design--Not Just for Biology Anymore

I'll let this article on Deometry speak for itself.

Now there are some legitimate quantum theorists who speculate that the ordering forces of elementary particles resemble something like 'intelligence.' But this is not the argument being used by proponents of Intelligent Design, or of Deometry, to promote their incorporation into curricula. They are quite explicit about using these theories to provide another avenue to talk about God in the classroom. Whether it's appropriate or not is separate from the question of whether this is back-door creationism, and the both the evidence and the rhetoric so far point to the answer being yes.

Hat tip to Returning

Watching the Neo-conservative Bulldogs

Check out this smart running commentary on Fox News Channel at Guarding the Henhouse. Here's their take on the term 'homocide bomber'--

First, it is redundant. All variations on the word 'bombing(er)' imply using explosives with, at least, disregard for human life (otherwise, it would just be 'demolition'). News reports will usually mention when a bombing takes lives or its proximity to other people. Putting 'homicide' on the front of it would be like the third mention of the same concept.

Second, this format is not being used consistently in other contexts. What could justify a journalist, stylistically or in fairness, using the phrase 'homicide bomber', but not 'homicide stabber', 'homicide poisoner', 'homicide drowner'... ? They are all deaths, and the context in which they were committed shouldn't dictate a stylistic variation. Unfortunately, I suspect that the political context of these bombings is exactly the reason for its use.

Third, 'homicide bomber' is not as specific as 'suicide bomber'. The Unabomber and Timothy McVeigh are accurately described by 'homicide bomber', even though they bombed remotely. More description is necessary to succinctly convey the details of their crimes. In news reports, you may have heard the Unabomber being described as a 'mail bomber' and McVeigh as a 'truck bomber'. In the same style, 'suicide bomber' dispassionately and compactly conveys that the person brought and detonated the bomb on his person.

Finally, and I think most important, journalists should not latch onto buzz words created by one particular interest group. 'homicide bomber' was coined in the 'pro-Israel' activist community, and spread throughout conservative circles that were pointedly trying to show their solidarity. Given that almost no other non-Murdoch owned news media outlet uses this term, I believe Fox News should think again before further compromising their neutrality.

I agree that the final point is the most important, but it is also the most important reason that they use the term. Fox News explicitly does not consider itself neutral--the term serves the viewpoint they espouse. While there may be a bit of a liberal tinge to other media outlets, it's worse journalism ethics to consciously choose to take sides on the news.

Hat tip to The Moderate Voice.

Do Liberal Law Professors Make Liberal Lawyers?

According to a new study to be published in the Georgetown Law Journal, law professors in America contribute overwhelmingly to Democrats, says a recent NY Times article. At Redstate this is being taken as just more evidence that academia is biased. However, the Times also reports:

If the liberal law professors mean to indoctrinate students, though, they have failed spectacularly in some notable cases. The United States Supreme Court's two most conservative members, Justices Antonin Scalia and Clarence Thomas, are products of Harvard and Yale, respectively. And if John G. Roberts Jr., another conservative, is confirmed this fall, another conservative graduate of Harvard Law will be added to the court.

Whatever may be said about particular schools and students, professors and deans of all political persuasions agreed that the study's general findings are undeniable...

Law professors' politics may be similar to those of other academics, but they are not representative of people with similar credentials and incomes. In the 2000 election cycle, according to data from the National Election Study produced at the University of Michigan, 34 percent of people with advanced degrees and 44 percent of those earning $95,000 to $200,000 gave exclusively to Democratic candidates. For law professors, the new study finds, it was 78 percent.

The figures suggest that liberal law professors do not always produce liberal lawyers.

In other words, lawyers as a whole are not as liberal as law professors. Most people's politics are fairly well formed before they get to law school--it's not surprising that law professors have so little influence on lawyers' ultimate political views. What's more, in an era where conservatism is on the ascendency, it's baffling that conservatives still are upset with the liberals' hold on college faculties, since this obviously has not swayed most Americans to become liberal.

Holding a liberal establishment in contempt is so central to neoconservative solidarity that they are compelled to magnify the pervasiveness of that establishment in academia and the media consistantly, until their histrionics become patently absurd.

Sunday, August 28, 2005


There's a pervasive myth that prior to 'patriarchal' civilization, in the mists of prehistory people lived in greater harmony with nature, worshiping 'the goddess' in a matriarchal society. This myth is exploded by Cynthia Eller's The Myth of Matriarchal Prehistory. I for one have long held this theory counterintuitive as our closest relative the chimp is essentially patriarchal, and given that current human societies are largely patriarchal the trajectory of gender organization hardly suggests a matriarchal phase. For more on this line of reasoning, why male violence is more prevalent than female violence, and the curious case of the bonobo, see Demonic Males.

But the main point of this post is to highlight something of the history of feminism so that those who are alienated by some aspects of it don't throw away its valuable components. Eller describes three major schools of feminism:

1. Liberal Feminism: Historically linked to the sufferage movement, this view focussed on securing rights for women that men already were believed to have--equal pay for equal work, eliminating discrimatory laws/policies, in general being recognized as equal members of a democracy. The ultimate goal is to permit more 'women in the boardroom.'

2. Radical Feminism: Rooted in the 1960s New Left movement, these folks didn't want women participating in 'late capitalist' society already poisoned at its roots in terms of race and class issues. They held that exploitation of women--like exploitation of the working class--were fundamental features of capitalism, and that this economic system thus needed revolutionary change.

3. Cultural Feminism: Like radical feminists these folks didn't want women to simply take on men's roles, but focussed on who women are. They believed that women are distanced by patriarchal society from their true female selves, and that femininity is simply better than masculinity. The possibility of a 'matriarchal prehistory' particularly appeals to these particular feminists.

Again, this is a synopsis of a very complex subject, one which Eller is more familiar with than I. But I do think it's useful to separate out different strands of feminism, and remember that while the feminist movement is a coalition like any movement, the fact that there are brands of feminism that one finds extreme should not overly sully the goals of the movement in general.

Thursday, August 25, 2005

Medical Malpractice Primer

Let's look at how we got to our current malpractice system, and then step back and see how well it meets its goals. In general, tort law is designed to do three things:

1. Allow victims to recoup financial losses.
The problem is that most malpractice lawyers work on retainer, so when the lawyer's fees can often comprise about half the settlement, this goal is not well served.

2. Punish negligent or bad people
But since most doctors have malpractice insurance, they are largely insulated financially.

3. Provide incentive for avoiding bad outcomes
However, the threat of lawsuits often actually impedes the flow of information about medical errors and system inefficiencies that could lead to improved healthcare delivery.

There have been three different 'crises' of medical malpractice. In the 1970s, there was a marked increase in claim frequency and severity, leading many malpractice insurance carriers to drop out of the business and increasing the cost of insurance. Then in the 1980s, there was a trend of physician-owned malpractice companies, which had high costs and premiums again increased. Today's malpractice problem is more complex though.

1. Investment income of malpractice insurance companies took a steep dive in the tech bubble burst. This is perhaps the most important factor in the current market, as the primary driver of increased premiums--more so than claims costs.

2. Frequency of claims per insured physician has risen from 1.5 claims per 100 in 1956, to 15 per 100 in 1990. 17% of all OB/GYNs in the US have a claim filed against them in a given year.

3. Cost of selling malpractice insurance is increasing due to rising defense and administrative costs.

4. Managed care has placed a never-before-seen ceiling on the ability of physicians' ability to raise fees to offset premium and loss of productivity expenses.

Finally, it's worth noting that 80% of malpractice cases at trial are found in favor of the physician. The cost to the healthcare system of a physician's time lost to work, and the doc's own personal toll, are difficult to calculate. But more fundamentally, if the system doesn't meet its stated goals well, we have a lot of thinking to do.

Certainly this complex problem requires targeted solutions, but we need to have a clear understanding of the incentives built into the malpractice system and its actual cost burden before relying too much on malpractice reform to relieve the broader problem of the nation's healthcare costs. More later on why caps on damages don't make sense.

Thanks to Martin Palmieri MD, on whose presentation much of these data are based. More references in comments.

Iraq: More circular alliances?

Tom Hayden suggests developing an anti-war alliance between the old-school liberals and the isolationist right:

William Buckley and Pat Buchanan are against this war, along with a silent minority in the armed forces. New converts include representatives like Walter Jones (R-N.C.), who once called for re-naming the French fry the “freedom fry.” Having become deeply disturbed by the funerals in his district, Jones has decided to co-author with Democrats a bill calling for a 2006 withdrawal timetable.

The problem I see is that each group would favor very different manners of disengagement, based on differing perceptions of what sustains the cycle of violence. Liberals by and large think that our very presence is what prompts violence against our 'occupying army', so they would conclude that rapid withdrawal of our troops and limited peacekeeping would be the most stablizing strategy. Isolationist conservatives are more likely to believe that individual looting and Islamist ideology fan most of the flames, so that without adequate security forces, Iraq will be another Somalia. They would favor handing off gradually to the Europeans or even the Russians--just find someone else to take over to keep the region (and our oil supply) from falling apart.

These may seem like superficial differences of vision, but in practice as the particulars of any potential political alliance are drawn up I would forsee an amplification of disagreement to permit the 'cautious' middle to follow through with continued stabilization and gradual disengagement. Whether that's the correct strategy is moot--it will be dictated by political reality.

Hat tip to Centerfield.

Tuesday, August 23, 2005

Sugar Industry Denies Link to Obesity

With the growing obesity 'epidemic' (I would argue that it's endemic), the sugar industry is busy fighting off bad PR. A recent statement blames obesity on increased consumption plus poor exercise, rather than on sugar per se. However, as this, this, and other studies have found, high sugar content diets do promote higher total calorie consumption, probably through appetite stimulation.

I think there are two levels of nutrition advice--public health and individualized medical advice. Marion Nestle is right that the public health message should be short and sweet, and avoid getting lost in trans-fats and micronutrients:

1. Eat less calories
2. Eat more vegetables
3. Move more

Anything more specific than that should come from your primary care provider or nutritionist, tailored to your own age, gender, cholesterol level, etc.

Friday, August 19, 2005

Mystery Meningitis

Another call night hijinx:

We admitted a 48 year old man from the West Coast with 3 weeks of stiff neck, high fever, headache, and new confusion with full-body twitching called myoclonus. Likely meningitis, but unclear what type. The nurses called me at least twice over the night to ask about putting him on contact precautions, and each time I responded that since meningococcus is ruled out due to the length of his illness, standard universal precautions were all that were necessary.

Of course the next morning I come by and he's on full contact precautions. The nurse explains, "but don't you see how sick he is?" Well, yes, but unless you plan to release a swarm of mosquitoes into the room and stand there with him, or to do things which would give you herpes, there's no chance of getting either of the two most likely things he has just by taking care of him.

These days it's easy to get self-righteous about people who are afraid of getting AIDS from handshakes and sharing silverware, but confronted by a poorly understood disease, even fully trained healthcare workers are potentially just a step away from germ hysteria.

Saturday, August 13, 2005

Call Night

Here's a day-and-a-half in the life of a doctor: a typical call day last week as a senior resident on an inpatient general medicine service.

7:00 AM Arrive at hospital, check labs quickly. Today there's only two patients in the hospital being taken care of by our team (myself the senior resident, my intern, two medical students and an attending, the boss). But we're on call today, so new patients will soon be coming our way...

7:30 Resident Report: Case presentation, reviewed recent JAMA review on the evidence for medication treatment for neuropsychiatric symptoms of dementia. Bottom line--risperidone and olanzapine have the best evidence but both come with increased stroke risk, and carbamazepine has some good evidence too. Discussion--is dementia best thought of as a terminal illness like untreatable cancers, where treatments can be used to improve quality of life even if they come with increased risk of death?

8:30 Morning work rounds: One retired physician who has been recovering from a complicated gallbladder infection is still running low-grade fevers can't go home yet, another man recovering from hypertensive emergency is now under control but we can't find a rehab place to take him that can get him to dialysis.

9:00 CODE BLUE: Patient down in hallway, we run upstairs and give ativan for apparent seizure. No airway/cardiovascular issues, situation under control, we sign off.

10:30 The attending decides to do impromptu lecture on pneumonia. He spent 3 years in Africa, and has ideas about making cheaper antibiotic choices.

11:00 My intern's off to intern report, and the students have some meeting, so I spend the usual teaching hour doing some reading on HIV dementia... Then I find out that since the non-teaching service is full of patients, we're up for admissions early. Here we go.

12:00 Noon First admission comes, a lady with Alzheimer disease and cholangitis--going straight to ERCP to look for and retrieve the gallstones. I'll see her after the procedure.

12:15 Morbidity and Mortality Conference: Over lunch, the whole Internal Medicine department gathers to hear a blow-by-blow presentation of a case from start to finish, with running commentary and questions from the professors. Traditionally they follow the format of someone's outpatient course, getting sicker, goes to 'outside hospital' but they can't figure it out so they send the patient to our academic medical center, and things either get better, or they die and we see the autopsy presentation by the pathologist. Today it was a guy with hypertrophic cardiomyopathy who they ended up doing an alcohol injection to kill off part of his heart muscle in order to improve the blood outflow tract, and he survived.

1:15 Taking admissions: A few folks in the emergency room coming to our team. One 90 year old man with an enormous nosebleed, and some blood in his stool coming in to rule out a colon bleed. Admitted to the hospital more for his physician daughter's worry more than for real medical necessity.

3:00 We're up to 5 new patients now. One is a 93 year old lady with 2 weeks of 'the dwindles'. We'll get a CT scan to evaluate some belly tenderness.

4:00 Now up to 7 new patients. We can only get up to 10, and only until 11pm, whichever comes first. The attending suggests that we try to get the non-teaching service to take 1 or 2, but I gamble that we'll get the full ten and decide to keep them so we cap early.

6:00 When the tech came to get the lady for her CT scan, the nurse hadn't yet hung her IV bicarbonate to protect her kidneys because she was always in the bathroom when she came by. The daughter is livid, and won't even talk to me, demanding the attending. Just what we need.

7:00 There's something strange about her CT scan, looks like either an infection or new cancer. OB/GYN will see her in the morning.

7:15 A man in the ER dropped his hemoglobin, probably an ulcer bleed from taking 650mg of aspirin every 4 hours for arthritis. My psychiatry training tells me he's hypomanic, but diagnosis doesn't make him any easier to deal with. He won't let my med student put in an NG tube (to suck fluid out of the stomach to look for blood) so I just do it. He'll have to learn on someone else, but he's running out of time before he rotates off the service.

7:30 My wife and daughter page me, 'any time for dinner?' With this GI bleeding guy in the ER, not really. See you tomarrow afternoon...

9:00 Up to 8 patients now, a lady with meningitis just came in.

11:00 Well, we lost the gamble, took just 8 tonight. Finally got to see the lady with the gallstones, doing OK after her procedure. On my way to see a guy with several blood clots in his lung--the intern had seen him and he was stable but we don't know where these clots are coming from.

11:45 Finally getting a chance to spend a little more time with the pleasant Christian Scientist lady we admitted for falls at home. Sounds like peripheral neuropathy, but why?

12:30 The man with the blood clots has an irregular rhythm despite his pacemaker--the question is if his pacer is malfunctioning. The cardiologists are unhelpful, just keep telling me not to worry. We'll keep a close eye on him and have the cardiology consultant team see him in the morning.

1:00am Sit down with intern to review the list of things going on, need coffee.

2:00 Reviewing the medical students' writeups of their patients. One of the patients has a heart rate of 160, but hemoglobin is down--we'll give some blood.

3:00 Get a call from the attending, review over the phone a few issues. My computer crashed, lost a long admission note I was writing. Blast it all.

4:00 Things are settling down. Will try to get a little sleep.

5:30 Get call from nurse: need to do informed consent form for a patient's blood transfusion. Can't believe it's taking so long to get the blood-- back to bed.

7:00 Rise and shine, grab some coffee, ready for rounds.

7:30 AM work rounds start, looks like we're skipping all the teaching today. Turns out the lady with peripheral neuropathy has a low B12, the neurologists are ecstatic--it's not every day they find something treatable in their specialty. The other lady still hasn't gotten her blood, we chase this problem down.

8:30 The lady with the gallstones has a low blood pressure and fever, may be crashing. Bolus fluids, constant vigilance.

10:00 Visit radiology: the guy with the blood clots may have a cancerous mass, will have to get another scan. The lady with the 'dwindles' may have cancer too, need to biopsy.

12 Noon: The MD patient recovering from his infection is better, ready to go.

2:00 The man with the nose bleed did well and is ready to go, but his MD daughter is furious that we haven't talked, but whenever we try to call her we just get her answering machine. Finally get a message she demands an ENT consultation before we send him back to the nursing home, but we don't think he needs it. We agree to 'curbside' consult them, and they recommend a brief type of exam. My intern dutifully does this. We should have left an hour ago by the rules governing resident work hours, but guilt over violating the rules is easily trumped by potential guilt over taking bad care of our patients. we work on...

2:30pm Finally ready to sign out. I give a special heads-up to the nightfloat about the unstable gallstone lady. I do a final check with my intern to make sure everything is OK and find her near tears, upset over the ENT consult incident. A little reassurance is in order, and we're outa there.

Friday, August 12, 2005

PA Payraises

Hi, folks, I'm back--sorry, work has been demanding.

Isn't it amazing how partisanship can make intellectual midgets of us all?

Note this thread from Redstate about payraises in the Pennsylvania legislature that Gov. Rendell recently signed. The text suggests that Rendell is hurting from this, that the grassroots are mobilized against him.

Yet nobody has quite explained how an act of a Republican Legislature which a Democratic Governor signed is properly the political liability of the Governor alone. If anything, PA Clean Sweep ought to be a threat to the Republicans, with its stated mission of ousting all incumbants.

Perhaps someone closer to the PA scene can explain how this makes sense, but as a former Pennsylvanian I'm a bit astonished to learn that, apparently, Keystone State politicians now take any opportunity they can to score a cheap shot against an opponent even when themselves complicit in the very policy criticized. What a strange mix of the dangerous and the unscrupulous.

It seems so long ago now to remember the day when John Heinz stood on the floor of the US Senate and authoritatively assured President Reagan, a fellow Republican, that ketchup was a condiment. Moments of startling honesty can expose the absurd in a way that standard polemics cannot, and honesty is the first casualty of partisanship.

Thursday, August 04, 2005

The Quaker Economist

I recently found an online journal with a distinctive combination of pragmatic pro-capitalist economic views and Quaker concern for the poor and oppressed. Here are a few provocative articles.

On Globalization: It's no news that low wage jobs are being outsourced to developing countries. The data show that contrary to anti-globalism rhetoric, on average developing countries benefit from this process in terms of standard of living. Here's an argument that the moral approach is to allow and even promote the globalizing trend which tends to equalize living standards between poor and rich nations.

Systematic Peace: This article touches on the effect of the 'spoils system' on corruption and social strife especially in Latin America. It also argues that attributing social ills to immorality has a bad track record, and advocates ways of addressing malfunctioning social systems.

Culture of Democracy Aspects democratic cultures share are examined, including emphasis on contracts, compassion, rule of law, private property. Of interest, as a Quaker Libertarian the author departs from the common libertarian view that redistribution of wealth is always 'confiscation' or theft; he feels that when done in the context of the rule of law, it is justified at times.

Recycling: Despite the feel-good aspect of recycling, it's not uniformly, or even mostly, better for the environment, and has significant costs which might be better spent on other environmental measures.

Unjustified Violence: Quote--"History shows us that governments that take power and order citizen/producers about, not only do not end poverty but worsen it... To me, violence is abhorrent, whether conducted by the Symbionese Liberation Army, Zapata, Guevara, Lenin, Stalin, Arafat, Sharon, Bush, or the French Revolution of 1789. Whoever uses violence to "promote the poor" does not, by definition, have his or her "heart in the right place." It saddens me when people of peace, carrying a deep concern for the poor, should honor those violent revolutionaries who had cruelly killed many and who, by grabbing power, increased the poverty they allegedly decried."

Tuesday, August 02, 2005

Redistricting Update

There are several initiatives in the works for redistricting, reports New Donkey.

1. Ohio: A petition is being circulated for a reform plan that puts a high priority on establishing districts with truly competitive elections.

2. Florida: A set of reforms are likely to make it to the ballot for 2006

3. Colorado: A federal court upheld the districts set up on schedule for its 10 year cycle against local GOP attempts to redraw the map early (now that it controls the legislature).

Stay tuned for more on these promising developments.