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.  I don’t think we should leave this woman alone – that doesn’t mean I think we should all go and teepee her house, but I do think what she did was irresponsible and the situation deserves attention and discussion.  Coming from the medical perspective, each of those 8 babies are really tiny and will face a plethora of medical problems immediately and in the long-term (google “very low birth weight” to get an idea).  Already it has been mentioned that several of the babies are not tolerating feeding tubes.  Think about how serious that is – we’re not talking about a baby not yet ready for taking a bottle because it doesn’t have good motor control to suck, but rather one whose digestive system is so underdeveloped it cannot even have formula placed in it’s stomach without the risk of necrotizing enterocolitis.  These feeding tubes are only part of the picture – these babies must stay in incubators because their skin is so thin and cannot maintain their temperature, and they are likely to be on ventilators to help them breathe (which they will be on for many weeks to come), and monitors to notify a nurse when they stop breathing so she can give them a good pat and get them to start again (and they likely will stop breathing on many occasions – it’s called apnea of prematurity and it’s not rare).  Consider all of the physical and intellectual disabilities these babies are at risk for.  It’s difficult for a parent to manage one child with a disability, but this mother could end up with multiple children who have life-long developmental issues.

Then you have the issue of fertility.  It hasn’t been verified (to my knowledge) that this mother received fertility treatment, but I think the odds are that it is practically impossible for her to have conceived 8 naturally.  I would like to know which doctor prescribed her fertility meds.  Did they know she already had 6 little ones at home?  Did they evaluate her ovaries after giving her hormones to see how many follicles would have a potential of being fertilized?  The woman’s neighbor claimed that she “lied to the doctors who impregnated her“, and for the sake of the doctor, I hope this is true.  If it’s not, then I think the medical licensing board should investigate the doc for their role in this situation.  It is simply irresponsible for someone with the medical knowledge of very-low-birth-weight outcomes to allow an already fertile woman to undergo fertility treatments which place her at high risk for multiples.  I’m not saying women shouldn’t be allowed to have multiples, but you have to apply some judgement to the situation – are they married or do they possess a significant support system, are they financially able to support that many kids, are they prepared to care for kids with disabilites?  I hope a doctor takes these things into consideration before taking someone’s money and giving them hormone shots.

As for the people who suggest the government should somehow intervene and mandate how many kids people can have, and who should or should not be allowed to receive fertility treatments, that seems a bit ridiculous.  If we allow the government to start intervening in the fertility choices of people, it is likely to have unintended consequences (should the government have forced her to selectively abort a few of those babies?  no).  IF someone is self-supportive, it shouldn’t matter to a stranger how many kids that person has.  The problem is that it’s likely this mother of 8…no wait, it’s actually 14 total…is benefiting significantly from the support of the government (which means the support of you – the taxpayer).  Whether it’s the millions of dollars (per kid) of care that is currently being provided by the hospital, the many years of public education these kids will use, or perhaps the medicaid, WIC, or welfare which she may collect in the future to support her brood, you can bet that we’re all paying for it somehow and will for at least the next 18 years (or at least the citizens of California will be).

So, what are your thoughts on the matter?  Are the actions of this woman ok?  Does it change your opinion to know that your tax dollars might be paying for it?

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.  This student is a gunner (in medical school, a gunner is someone who likes to throw fellow students under the bus in order to make themselves look good; they tend to study excessively and boast of their superior knowledge, as well).  This student was talking with some of the pediatric residents and attendings, who asked him what specialty he wanted to go into.  He began a speech about how he LOVED pediatrics, including the time he recently spent on the neonatal ICU, where he,  no joke,  volunteered to take call overnight for “educational” purposes (read:  he probably took the overnight call because he thought it would impress the docs who would thus award him with a higher grade).  Now, I have nothing wrong with pediatrics, but it seemed pretty obvious to me that this guy did not possess the typical peds personality (easy going, loves kids) and was thus bullshitting the attendings so they would think he was really interested in their specialty (and…perhaps give him a higher grade because of this). But what do I know…maybe he really does want to be a pediatrician.

The attendings and residents leave the room, and this student turns to me and asks what specialty I’m considering.  I tell him which one (it’s not pediatrics), and his reply?  “Me too!”  WTF?  So he either has multiple personalities (with very diverse preferences) or he’s full of shit.  Any guesses on where I’d bet money?  He then starts telling me that he is considering a lot of different specialties.  He thinks being a hospitalist would be really interesting, but he “needs to make a lot more than $150,000 per year”, and starts discussing which specialties he’s most interested in based on the salaries they command.  At some point he must have realized what a d-bag he was starting to look like, got flustered for a second, and quickly muttered “but I need to find something I really love, too.”  Wow.

Don’t get me wrong, money definitely comes into the picture when picking a specialty, given that virtually every student will graduate with between $100,000-200,000 worth of debt.  I also think lifestyle (meaning a M-F, 40-50 hour workweek) plays a role in future life-satisfaction and should be taken into consideration (particularly for those who want to have kids someday and still be happily married).  But those should not be THE determining factors.  I just couldn’t believe this classmate of mine going on and on about how much money he needed to make and how that was his main criteria for his future career.  It was disgusting, not to mention frustrating to think that he might be applying to and interviewing at the same programs as myself (if he deems my future specialty worthy enough).  Surely program directors see through the bullshit of students such as this guy, right?  I hope so.

So, in dedication to my money-obsessed classmate:

May he realize that, though money is necessary in many ways, there is more to life than a multi six-figure paycheck.  (and may doctors and residents see through his fake personality as he hits the interview trail at the end of this year).

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.

The patient that made me feel this way had end-stage cancer.  He had been battling his cancer for years, received numerous rounds of chemotherapy and radiation including experimental therapies, was no longer a surgical candidate, and was at this point receiving only palliative treatments.  He was cachectic (type that into google image to get a visual idea of what this looks like) and unable to tolerate much food.  He came to us in pain, which we can kind of control, but he had no family to support him and was refusing hospice care.  There was nothing left for my medical team to do for him.

The resident doctor sent me upstairs to speak with the patient – we were going to discharge him from the hospital and have him follow-up with his oncologist in a few days.  As I delivered the news the patient started crying, pleading with me not to discharge him.  “I have nowhere to go”, he cried.  He did have a home…but he didn’t have any relatives willing to help him once he was there.  He was admitted to us in pain, we controlled the pain, but I knew as soon as he left he would be unable to care for himself and would return again in a few weeks – this had been his cycle for the past few months.  “Please doctor”, he begged, “don’t send me home yet!”  I’m not a doctor, just a student, and do not make the decisions about when someone stays or goes home.  With someone like this man, we say the phrase “there is no medical reason to keep him here”, which was true.  We weren’t going to do anything new for him.  He was occupying a bed in a highly sought-after tertiary care facility.  We are usually filled close to capacity, and his discharge would mean someone more sick, or at least someone who had not exhausted treatment options, could have that spot and receive care.  But I’m human, and the doctors on my team are human – we saw a frail man crying and pleading with us to let him stay a few more days, so we did.

The next day, while sitting in the “team room” (hospitals generally have multiple medical “teams” who admit and care for patients together), a “code blue” was called over the intercom system.  When a code is called over the system they inform you of the location, and the floor they called on this day happened to be one where our team had 6 patients.  We went running.  As I rounded the corner by the nurses station, I could see the room that was filling with white coats.  It was my patient’s room.  My heart skipped a beat.  Simultaneously, I was both fearful and hopeful that it would be him. Fearful because no one wants their patient to die.  Fearful because I’ve seen a few codes at this point and they’re not pretty.  It’s not exactly like on TV where there is a doctor performing CPR yelling “clear!” before delivering an electrical jolt, with a few other doctors and nurses standing around.  There can be 20-50 people in those rooms, running around looking for supplies, grabbing the defibrillator in case the patient needs to be “shocked”, putting various tubes and needles into the patient, or just standing and staring because they don’t have a lot of experience with running a code and want to learn how it’s done.  A code is not pretty – it is ugly and violent.

I hoped it was not my patient because I didn’t want him to go through this, and because in medicine the instinct is to save lives; but at the same time a part of me hoped that it was him because it would mean he might die, and that his suffering would be ended.  Is it the proudest moment of my life to wish he were dead?  No…but he was going to die soon, and since he was refusing hospice care I knew his death would likely be painful.  I just didn’t want any more pain for him.

It turns out that the code was not for my patient, but for his roommate.  By the time we had arrived they had already moved my patient out of the way and into a different room so he wouldn’t be traumatized by the scene.  I couldn’t do anything to help the guy who coded because there was already a plethora of doctors and nurses in the room, so I went back to our team room and tried not to dwell too much on what had happened.  There were a lot of thoughts going through my head, and as I tried to sort them out I decided that despite my patient’s suffering, I’m glad he’s still alive, because it will give us more time to re-visit the idea of hospice care.  He deserves to have his needs met, but our hospital is not the best place for him.  Hopefully with a few more days of discussion he will see the benefits of hospice and can die without too much physical or emotional suffering.  This is my young and idealistic hope for him.  Reality, however, often has different plans.

~ Lily

med-student; sometimes confident, sometimes insecure…coming to grips with the emotions that patient-care entails

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

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

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

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

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

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

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