The ethics of eight (babies that is)

All over the blogosphere people are discussing the California woman who gave birth to 8 babies.  The media was quick to call it a miracle, but it seems it only took a few hours before bloggers, journalists, and doctors began to seriously question the mother’s intentions.  It seems crazy enough to want 8 kids at once, but now rumor has it that the mom is single, living with her parents in a 2 bedroom house, and already has six kids (all under the age of 7 nonetheless).

If you want to be entertained (or appalled), I recommend reading the comments section on articles discussing this woman.  You’ll see a variety of viewpoints expressed, from those who think we should just leave this woman alone, to those who think the government should mandate how many kids a person can have and restrict who can receive fertility treatments.

I guess I fall somewhere in the middle.  Read the rest of this entry »

Money (that’s what they want)

I’ve rounded the corner of my third year of medical school, where students have to start thinking about their future since we will begin applying for residency this summer/fall.  3rd year is a chance to try out a lot of the specialties, and hopefully find your niche.  You decide what you like or dislike about each area (internal medicine, surgery, pediatrics, neurology, etc) and decide how that fits into your needs or desires.

Some students are lucky – they knew, for example, that they wanted to be a neurologist right from the beginning of med school, they were fortunate to love it during their 3rd year rotation, and can now focus on arranging their 4th year electives to reflect this choice.  Maybe they weren’t sure what they wanted to do, but they loved pediatrics and can’t imagine doing anything else.

Other students thought they knew what they wanted to do, rotated in the specialty and hated it, and are now completely clueless and a bit panicked as to how they will approach their last year of medical school. (a lot of my future-surgeon friends seem to fall into this category)

Then there are students such as the one currently rotating with me on pediatrics.  Read the rest of this entry »

When you wish patients would die

I haven’t blogged in quite a while, and my husband was harassing me to post something new.  I’m currently in my third year of medical school rotating through various specialties in the hospital.  It’s not that I’m too busy to blog (though I’m quite busy between hospital scut work and studying), it’s just that this year feels like such a whirlwind of emotions sometimes that it’s hard to put them out into the blogosphere without feeling a little exposed.  But maybe those are the types of topics that make for the most interesting read.  So I give you a topic that reflects what was going through my mind a few days ago: when you wish patients would die.

Try not to read too much into that – I don’t want to harm or kill my patients.  But sometimes you see people who have been suffering for so long, that you wish for an end to their suffering.  Unfortunately for some people, the only end that would provide this is death.

Read the rest of this entry »

The Specter of Science as a Shield for a Cowardly Court

In the 2004-2005 edition of the Cato Supreme Court Review, James W. Ely Jr. took on the formidable task of evaluating the court’s opinions on some of the key cases involving property rights from the prior term.  In the context of his discussion of Lingle v. Chevron USA he notes Justice O’Connor’s assertion that the courts “‘are not well suited’ to scrutinize economic actions” to which he responds with an excellent question: “Why are courts somehow competent to enforce non-economic rights, which often turn upon value judgments, but not economic rights?”  The question is rhetorical with the obivous (and correct) implication that courts are perfectly competent to preside over questions relating to economic rights.  Still, the question itself got me to thinking, how could a committed Progressive attempt to defend the O’Connor view?  

One possibility that occurred to me is that you might find someone arguing that economic theory and calculation have become so complex that only an expert in the field can speak to economic concerns with any sort of legitimate authority.  Of course, if this were true (and in a sense, which I’ll explain promptly, I think it is), it still begs the question of why legislatures not populated by economists should be permitted to pass economic regulations.  I do think that modern mathematical economics and econometrics involve some very difficult concepts and techniques; however, the economic relations conceived by the founders and enshrined for protection in the Constitution have not changed over the years and remain as scrutable as they have ever been.  Derivatives contracts may require heavy number-crunching to determine the values involved, but they are still contracts and any judiciary worthy of the name ought to be able to speak to contractual obligations and priviledges.  I may be showing my Austrian colors here, but I feel that economists concerned with liberty have done the pursuit of that value a disservice by emphasizing mathematics as the fundamental tool of exploring economic theory as opposed to being an ancillary but invaluable aid to the explanation of insights gleaned primarily from mostly verbal logical deduction.  We all know what it is like to be forced to choose between two competing alternatives, and any position that gives cover to otherwise responsible individuals to deny that they understand that choice ought to be condemned.

~Fox

Immigrants are Great, Foreigners (apparently) Suck

I had an interesting encounter over the Thanksgiving holiday.  I met a man who worked for a non-profit organization dedicated to the advocacy of equal rights for immigrants.  He was also an enthusastic supporter of Barack Obama.  I found the combination strange, so I asked him whether he felt Obama’s suggestions that NAFTA be renogitiated to conform to “fair trade” as opposed to “free trade” were inconsistent with his view that immigrants should receive better treatment.  We didn’t get to carry the conversation very far forward before we were dragged away to the food which is probably just as well, because he didn’t seem to respond to my question very well.  At first he seemed puzzled that anyone could see any relation between the two, and then began to argue that the two positions were entirely consistent since demanding that other countries match the United States’ labor and environmental standards would only improve the lot of everyone invovled. I did not expect to encounter such startling ignorance of economics in a Yale law grad, but there it was.

I don’t know why he worked to promote immigrants’ rights, but I assummed it was because he wished to ensure that everyone, and particularly the least-privileged among us, have the same opportunity to pursue happiness free from unwarranted obstructions.  Immigrants are often at a tremendous disadvantage relative to their native-born peers, so it seems reasonable that someone interested in equality before the law would see a chance to make a meaningful difference by focusing their attention on that group.  However, a genuine sense of compassion should extend equally to all men, both those resident in one’s home country and those residing elsewhere perhaps trying to join your community.  Artificially raising the costs associated with employing workers leads to higher unemployment relative to the status quo ante.  “Fair trade” is protectionism by any other name and ought to be roundly condemned by anyone seeking to improve the conditions of people living in regions without the wealth and resources to be able to afford to meet U.S. government standards (even if they happen to be living in the U.S.).

My encounter reminded me of what a truly incoherent political viewpoint American liberalism has become.

~Fox

Now you see it…

CNN is reporting that President-elect Barack Obama has announced the outline of his plan to create 2.5 million jobs by 2011.  The first question that comes to my mind is how does he intend to measure the number of jobs created?  Is he suggesting that he will increase the total number of employed people relative to today by 2.5 million?  Or is he instead suggesting that he will authorize the creation of 2.5 million more government positions?  My guess is that he intends the latter, but wants people to believe the former.

Question 2: How does Obama intend to pay for the jobs he wants to create?  The government is not a business.  It doesn’t have independent capital reserves that it can call on to fund expansion.  If it grows, it must do so by raising revenues in the form of taxation (with borrowing being the promise of future taxation).  Frederic Bastiat had a few things to say about government job creation schemes.  For every wind-turbine engineer, solar-panel installer, and green car mechanic employeed by the government, there will be a myriad of other private sector jobs like computer programmers, fry cooks, and brokers that either never get created, or are forced to pay less.  Due to the inherent deadweight loss of taxation, this is almost always a negative sum game in which the growth in government fails to offset the decline in living standards of the population at large.

Question 3: What does Obama know about advanced energy technologies that people actively working in the industry do not?  If it was possible to create viable alternatives to the internal combustion engine and coal-fired power plants, why has no one done so already?  I didn’t read anything in Obama’s outline about the specific strategies he has in mind for overcoming the technological hurdles associated with converting solar energy to portable fuel.  Instead what I saw was a desire that we lived in a different kind of world and a willingness to forcibly extract and spend other people’s money in the attempt to move in the desired direction.  Just because you perceive a problem doesn’t mean there is a solution.  If this is what was meant by the “Audacity of Hope” consider me thoroughly offended.  I assume what Barack Obama wanted to convey with that title was simply the idea of courage founded upon the faith in one’s own abilities; at least, that is a message that I could understand wanting to communicate.  Unfortunately, the most sensible reading of the words he chose suggests instead that he is willing to aggressively pursue his dreams regardless of the costs he might impose on others.

~Fox

Obama Aides: No Money, No Problem

What exactly are we to make of this: Economy won’t stop Obama’s priorites, aides say.  Apparently, being broke doesn’t mean you can’t spend like a drunken sailor…except that is exactly what it means.  With China just announcing its own $586 billion stimulus package, the spigot of foreign savings that’s been flooding the leaky government trough is about to dry up at exactly the same time that all those tiny pin-pricks, like social security and medicare, are showing signs of imminent rupture into gaping holes.

What I think this means is that the Obama administration will attempt to accomplish through regulation the goals it might have preferred to pursue via spending.  Bureaucratic rationing will be the order of the day.  I’m sure everyone will be much more satisfied with the results.

I can only hope that Obama will be too busy playing the Dutch boy that he won’t actually be able to spare a finger to hold down the knot of red-tape he’s planning on using to bind up our economy.

~Fox

Ideas Matter

I’ve recently taken up reading The Austrian Economists, and I must say that I’ve been most pleased.  Peter Boettke in particular has a demonstrated knack for perceiving and communicating useful insights.  Following up on that, I would point anyone that stumbles across this, here, as I was so directed by Dr. Boettke.  There is a war of ideas going on here in America that encompasses the one in Iraq and will have far reaching consequences for all of us.  Consider this one more attempt to strengenthen the current volley from the advocates of reason.

~Fox

With Friends Like These…

I usually really enjoy reading Megan McArdle’s blog.  I find her to be one of the most consistently interesting and entertaining writers out there.  I also appreciate her customary libertarian perspective, which is why in recent days I’ve been very disappointed by the manner in which she has endorsed the bevy of government schemes being hurled out of Washington in the hopes of averting a recession.

It’s really not so much that she thinks the government needs to intervene to save the market.  I surely disagree with her, but reasonable have been known to do so from time to time.  What troubles me most is the intensity of her rhetoric, see here and here.  It’s not often that you’ll find me celebrating the wisdom of FDR, but do think he had some sage advice to offer when he counseled the nation that “the only thing we have to fear is fear itself.”  He may have overstated the case when he called it the “only thing,” it turned out the Nazis were a pretty dangerous threat after all, but given the calamaties we’ve already precipitated by acting too hastily over the last decade, taking a step back to assess the distance across the gorge one more time before we leap hardly seems like the worst thing we could be doing right now.

I can only hope that in time things will be resolved sensibly and with only modest pain and that Megan can offer a brief apology for her moment of hysteria before returning to more fascinating topics.

~Fox

The Bailout is an Affront to Liberty

Like most people, I have been intensely interested in the developments surrounding the proposal put forward by Treasury Secretary Paulson to spend up to $700 billion of taxpayer money in an effort to prop up elements of the financial industry.  I find the situation very disturbing, so much so that I wish I just ignore it and focus on something else like success of my alma mater’s football team (Mizzou-rah!).  Unfortunately, the stakes are so high and have such terrifying implications that looking the other way, no matter how powerless we may feel, seems almost morally wrong.  Allowing the biggest government intervention in the American economy since the Great Depression to pass without raising a protest would leave me feeling both cowardly and impotent.  I may have to deal with the realization that most of the contours of my life are shaped by forces beyond my control, but acceptance does not necessitate resignation.  To all those in government who would impose their will upon the innocent citizens of the United States, I say “Stop!  You may have the power, but you have neither the right to dispose of our resources according to your whim, nor the competence to improve upon the allocation we would choose ourselves.”

Others have dealt with the economic impracticality of the schemes currently being considered better than I can.  In particular, I would recommend Arnold Kling for illuminating the confusion and foolishness upon which the government’s plans are founded.  For my own part, the most troubling part of this whole debacle has been the blatant disregard for the rule of law demonstrated by the executive branch and condoned by the legislature.  Are there even words strong enough to properly condemn the audacity, arrogance, and autocratic intentions on display in the actual text of the Paulson plan?

“Decisions by the Secretary pursuant to the authority of this Act are non-reviewable and committed to agency discretion, and may not be reviewed by any court of law or any administrative agency. The Secretary is authorized to take such actions as the Secretary deems necessary to carry out the authorities in this act without regard to any other provision of law regarding public contracts”

I do not begrude Bill Gates or Warren Buffet one cent of the $50 billion they have earned, and if they were so productive as to grow their wealth by an order of magnitude I would be far more impressed than concerned; but no one should be put in charge of $700 billion dollars without even the specter of oversight.  No one should dare even request such authority, yet such a request has been made and seems all but certain to be granted.

This does not bode well for the prospects of liberty in America.  I asked Lily this morning if she thought our children would someday live in a world with more or less freedom than the one we have known.  She seemed hopeful that they might, and given the amazing technological advances that we have witnessed over the past few decades, I agree with her that there is still room for such hope.  Yet I feel the horizons have grown more obscure and the air thicker for all of us still “yearning to breathe free.”  We are presently confronted with a deep valley that we can see clearly separating us from our course of future prosperity, but the government of the United States has offered to plunge us into an oppressive fog that they assure us holds a shortcut they can lead us through if only we fasten ourselves securely to the lead of their inspired intuitions.  I for one will have to be dragged into this miasma kicking and screaming.

~Fox

More than one problem? Make another appointment

So I’m currently rotating through an outpatient medical clinic, and despite all the hand-holding, kumbaya-ing, and “the patient is a person” mentality, beneath the surface an insidious beast lurks. This “beast” is the closely held belief that the patient is only allowed one complaint for each scheduled appointment. You made your appointment to get your blood-pressure meds refilled but you also have seasonal allergy concerns? Too bad, make another appointment so we can discuss the issue on a separate occasion.

Just recently I was (politely) scolded by my resident because I presented a 7-week-old baby whose mother had 3 concerns – the child had been throwing up his milk at each feeding for the past few weeks, he had a rash across his entire body for the same amount of time, and she was concerned that he might also have an umbilical hernia. “Try to keep them to one complaint” my resident told me. But the rash and difficulty feeding were likely related (milk-allergy), and the hernia concern arose because she was a new mother and didn’t realize kids usually outgrow those things – it took 2 seconds to say “oh, that’s normal and he’ll probably outgrow it. don’t worry.”

I have difficultly understanding where this idea, that we can only allow the patient one problem per visit, comes from. I understand that the appointments are booked closely together, generally with 15-20 minutes per patient (which includes the time it takes to fill out any necessary paperwork), but have these doctors lost their minds? Do they not realize that people who come into their clinics must take off work to get there, rearrange child-care schedules, etc? Even if they are retired or stay at home to take care of their children, they still have lives and would prefer not to spend most of it at the doctors office waiting in boring stimulus-free rooms.

I have to believe that if we actually had a free-market health care system many of these problems wouldn’t exist. Our society is accustomed to getting it all done at once – this is why stores such as WalMart or Target have achieved their level of success – you can get your grocery shopping done and stock up on anything else you need in one trip. People expect the same thing from their doctors, and I’m siding with the patients on this one. There is no reason why our system couldn’t adjust to accommodate the person who has a couple different medical problems going on. A more market-based approach would simply charge a bit more for the larger amount of doctor’s time the visit uses. As it sits right now the system is too rigid to adjust to these demands – everything must fit neatly into a 4-5 digit “code” for what the visit accomplished, and the doctor is paid according to that code. I understand doctors don’t like it when a visit they thought would take 15 minutes all of a sudden takes 45 because the patient has a lot of issues to bring up, but if you took your car to the mechanic to get the oil changed and they found a problem with your engine, wouldn’t they offer to fix it on the spot while you waited? Wouldn’t you be pissed if the mechanic told you to make another appointment (which would be at least 2-4 weeks from now) to get your engine fixed, and that in the meantime you would just need to deal with it and keep your fingers crossed while hoping that your car doesn’t break down? I would be pissed. No wonder people don’t like going to the doctor.

~ Lily

3rd year medical student extraordinaire (at least in my mind)

Ethics in medicine – real life experiences

I haven’t been posting very regularly on this blog since starting my third year of medical school because I’ve been a bit busy adjusting to the new routine of seeing patients every day. I must say that although the hours required during the clinical years of med school are worse than the classroom years (overnight calls, long shifts of standing, etc), it is also much more interesting seeing patients every day and applying everything we’ve learned up to this point (hello steep learning curve!). With this intense clinical exposure comes a lot of scrutiny of my future colleagues – I look at each of the doctors I work with and see traits I would like to possess, and also those I do not. While I can say that most of the doctor’s I’ve worked with have been fantastic both with their patients and with their interest in teaching us students, a few have been downright awful and possibly unethical. Here is a sample of the worst that I’ve encountered these past few months:

The first is a doctor that takes no interest in the students and barely listens to what we have to say after we interview her patient and give a report before she examines them. I have to wonder why someone like this doc is working for a teaching hospital if she obviously despises the students. To make matters worse, a few of the students who have worked with her more frequently have commented on how she treats patients differently depending on their race. While I haven’t witnessed this first-hand (I’ve only been with her on a few occasions), I can’t say it would come as much surprise…I understand everyone has personal biases, but when you care for such a diverse patient population as ours it is necessary to work extra hard not to let your biases influence care. I hope I don’t turn out like her.

The second involved a primary care physician who was treating a morbidly obese patient with osteoarthritis of both knees. This patient’s insurance would not cover a particular injection the doctor wanted to give to alleviate the pain/inflammation of her joints, so the doctor was in the process of setting up a situation where she would order the injection for another patient whose insurance would pay for it, but give it to the first patient. I’m pretty sure that counts as some form of insurance fraud, but my guess is a lot of people would look the other way because of the general public perception of the “evil insurance company.” While I certainly sympathized with the pain this patient must be going through with her knees and the impact it has on her quality of life, I couldn’t help but think that if she would lose even a little weight she would feel a lot better all around. Perhaps the insurance company wouldn’t cover the shot because it likely wouldn’t make much difference given the severity of her obesity and arthritis. But what do I know?

The third doctor was a specialist performing an endoscopy-type procedure on a middle-aged woman. If you’re not familiar with how those procedures work, you are basically putting the patient under partial anesthesia so that they are awake but heavily sedated. Most people don’t remember much afterwards, though their eyes are open and they can talk a bit throughout the entire thing. This doc was chatting with his fellow nurses and technicians when politics came up. I was always raised never to bring up “religion and politics” while at work, but I figured since these people worked together for so long they must be comfortable discussing their views. The doctor was a republican, while most of his coworkers in the room were democrats…to be honest I think they were all a bit stupid when it came to understanding federal policy, as none of them sounded very educated on the issues (but I digress…). Of course Barack Obama comes up, to which the doctor makes some remark about how “Obama’s a muslim, and I just don’t think it’s right to have a muslim in office with terrorism being such a issue” etc. I’m probably wording things a bit more eloquently than what came out of this guy’s mouth. I am not an Obama fan for various reasons, but I couldn’t stand by quietly while this doc was spouting lies. I made some comment about how Obama is actually a christian, but how some keep trying to spread the rumor that he is a muslim because they think it will deter people from voting for him. Then the doc starts rambling about muslims, saying what essentially amounts to “muslim = terrorist”. Suddenly he becomes aware of what he’s saying, and he looks down at the patient and asks, “are you a muslim, ma’am?”. This poor woman, in her drugged state shakes her head “yes” and says something unintelligible. The doc’s face loses a bit of color, and then he turns to one of his nurses and asks if she would please administer more of the drug that produces amnesia (so the patient won’t be able to remember the offensive things he said). The nurse looks at him thinking he’s joking, but the doc is entirely serious, so she administers more of the drug. Would the extra dose of this drug harm the patient? Probably not, though it is still plausible that it might have. I guess “first do no harm” goes out the window for this guy when you say something offensive to your patient who is completely incapacitated. It made me really sick to my stomach to witness the entire thing, and I hope I’m never paired with this doctor in the future.

I still think most doctors are good people, and this has been confirmed numerous times for me in the past couple of months as I’ve worked with a variety of different practitioners, but it’s hard to look at them the same way when there are a few rotten apples spoiling the perception. I may not know what kind of doctor I want to be at this point, but I’m starting to get a good idea of what kind I don’t want to be. From your perspective, what are traits that make a doctor good or bad? Any comments are appreciated!

~Lily

Sweden is Smarter on Schools than U.S.

I came across this article in today’s Washington Post.  Apparently the folks in Stockholm have a better grasp on the power of markets to improve performance than most of us here in the states.  Well, at least some of them do.  Take Barbro Lillkaas who had this to say, “If you run a good operation then you make a profit. But you won’t get any students if you are bad,” she said. “You have to do a good job to get money; that is even more important for a private school.”  My sentiments exactly.  I can only hope that this convinces some of the left-leaning public-school advocates in this country who hold the Scandinavian countries in such high regard to rethink some of their positions.  I’m not holding my breath, but I may be breathing a little bit shallower.

~Fox

(Un)settling Down

Will Wilkinson reminds me of Reverend Merrill in A Prayer for Owen Meany.  Both are preoccupied with emotional concepts that most men accommodate as a matter of course, and both insist on viewing these ideas through the lense of their antitheses.  For the reverend faith and doubt were the two aspects of the inseparable duality.  For Will, its kids and happiness.  Responding to an article that appeared in Newsweek, he writes:

…the profundity of the experience of loving a child I think blinds many people to the very real costs of raising them. To accept that we have been made less happy in a real sense by our children threatens our sense of the profundity and the value of that bond. So people get upset when they hear this. But that’s not counter-evidence. Not all values move in one direction and it is a mark of maturity to be able to admit that some of the things we value most comes at a sometimes steep cost. We yearn to love our choices, and our lives, with whole hearts. But to do so is to lie to ourselves about ourselves, to close our eyes and cover our ears like children to the profundity of what we have given up.

I’m with him all the way to the final sentence which I find hard to interpret.  I think he is trying to express something akin to the socratic dictum that the unexamined life is not worth living.  If that is the case, I can understand and appreciate the sentiment, but I wouldn’t classify the desire to harmoniously integrate our past decisions with our present lives and future prospects as an instance of willful self-deception or woeful ignorance.

Recognizing opportunity costs when presented with a choice is good to the extent that it helps move you to a more efficient allocation of resources, but once the decision has been made (especially with respect to having children) those foregone alternatives become sunk costs–the hole down which they descend may well be deep, but spending time contemplating its profundity strikes me as a rather futile endeavor.  Just as Reverend Merrill eventually found his position advocating the dynamic juxtaposition of faith and doubt untenable, I’m not sure how Will can sustain the view that the essence of appreciation is regret.  Children and parents deserve wholehearted love that does not entail a nagging reminder of how good life would have been without the other.

~Fox

iPhone 3G goodness

I caved to the pressures of society and bought an iphone yesterday. There was no camping out or waiting in line to get one of the first phones, but I’m glad I made an effort to get to the AT&T store relatively early yesterday morning since I got the last iphone in stock at that particular location. I’ve never owned an apple product in my life, but thought since I was going to have to buy a smart phone or PDA to run the highly useful Epocrates program (a drug reference library – particularly handy for medical students, though more and more doctors are also on board these days) I might as well get a cool one.

After about an hour or so of fiddling around with it, downloading the latest version of iTunes, and synching it with my computer, I finally got it to work and started looking for cool applications. Even then I was having some problems getting a few of the apps to load, which I chalked up to the boatload of other people sitting at home trying to do the exact same thing. Fortunately as of late last night they were all up and running, and everything has been smooth sailing ever since.

So what do I have on my phone so far? First and foremost I downloaded Epocrates Rx…I figured since it’s the reason I wanted a smart phone in the first place I should at least make it appear as though I’m using my phone for “educational” purposes. :) Hopefully Epocrates will adapt their entire product line for the iphone in the next few months, so I can start surfing diagnoses and treatment plans from the convenience of my hand-held device. The other more practical apps I added include Zenbe lists (which I used this morning for my grocery shopping) and YPmobile (yellowpages, which I might delete since you can search for businesses through the GPS that comes with the phone). For fun I added Pandora (finds radio stations for you to listen to based on your favorite artists or songs), TapTap (sort of like guitar hero or dance dance revolution for your phone), PhoneSaber (a light saber…while this one doesn’t really do anything, it is fun to swing at my husband as it makes the cool sound effects), and UrbanSpoon (sort of like a magic 8 ball that takes advantage of the accelerometer to randomly pick a restaurant near your GPS location).

So far I’ve enjoyed the apps (including ease of installation), and I’ll definitely be testing out Epocrates this week to see whether it is easier than hunting down a free computer and checking for drug dosages or interactions (plus the iphone version of epocrates includes a pill identifier – pretty cool, though I’m not sure how many times I’ll actually need to use it). I also noticed, while depositing a check this morning at the atm, that my bank has an online banking system set up to access from the iphone, so I’ll probably try and install that in the next few days. Seems like a good investment up to this point. Any suggestions for other cool or useful applications that I should add to my new phone?

~Lily

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