Wednesday, January 28, 2009

Politics and Human Nature: Sometimes It Doesn't Pay to Take Over Completely

While this post may be peripherally related to some of the content on this blog, I'm going to admit that this is me just taking some liberty and putting down some sleep deprived thoughts. It's my blog. I'll do what I want.

Before I entered the hallowed halls of what has become the modern hospital, I lived another life. After some youthful impetuousness (and a lack of capacity to get rich quick in my late teens), I decided to go to college. I was a pretty big screw up in my earlier years, and I had to spend a couple of years at a community college to develop the credentials necessary to attend any sort of quality university. Going into medicine was not something that I really thought about, and I would have questioned whether such an undertaking was even possible considering my background.

In those early years of college, I studied some programming, some music, and some other hard disciplines. In the end however, I pursued a degree in anthropology. My wife earned a degree with a double major in anthropology and classical studies. This made for interesting dinner conversation, absurdly intellectual with very limited life experience to back up anything that we talked about. I will now, dear reader, impose some more of that esoteric armchair theory on you. At least I've now got some genuine experience to back it up.

The Giants of History

Leadership is really a very treacherous thing. If you think about it, the rate of assassination amongst kings, presidents, etc... is so high that one wonders why anyone would want that sort of job. These individuals are often in very complex political positions. They have to promise things to attain their positions that they have limited capacity to deliver. They become figureheads for blame when things go wrong. Leadership styles and the power in the hands of an individual leader vary, from the dictators to the "presidents" of countries largely in anarchy.

The thing about being a dictator is that you get to have what is essentially absolute power. This isn't just economic. Dictators largely attempt to alter the very fiber of the culture over which they rule. Most first generation dictators encounter a people with some measure of independence interwoven into the common fabric of society, and this is the sort of thing that an iron fisted ruler would want to eliminate. If not, these people might very well take it upon themselves to form a revolution, and that sort of thing is looked down upon by the type of person that wants absolute power. This is of course the downside to being a dictator, because you're the only guy with enough power to blame when things go wrong.

This can easily be contrasted to the modern democracy, where who gets the blame is not so clear. Every errant happening results in a chorus of "it's not my fault," followed by a game of circular finger pointing. Who actually did what becomes secondary. People take the fall for things that they had no capacity to control, and people who can be directly connected to a crisis often walk free. There's always a way out, but no one is safe.

Staying in power is usually a struggle, even for one individual. When a similar line of rulers keep in power for an extended period of time (or when a single kingdom maintains dominance over other kingdoms for an extended period of time), it usually comes about as the result of some unique circumstances. There are some common threads that unite these sorts of rulers. We'll call them the giants of history.

The Romans

The Romans (of the famed Roman Empire) started as little mini-kingdoms dominated by hovel dwelling farmers in an earthquake prone peninsula. The degree of dominance exerted by the Romans was so profound and longstanding, that one might argue that we still haven't really outlived it. The Romans eventually came to develop this international power with the convergence of a couple of unique philosophies and the right circumstances.

Roman prestige was largely tied to military success. There was also a dominant sense of the local culture. The Romans, like all great conquering empires, were extreme xenophobes. This success however did not drive a huge amount of micromanagement. Content to simply be the dominant culture, the Romans never really attempted to make all of their conquered territories Roman. Conquered states became sources of revenue and sometimes slaves. Romans often set up local figureheads who shared a common culture with the local population (think King Herod of Israel). Over time, Roman influences worked their way into some of the farthest reaches of the empire, but this was a natural acculturation developed due to the relative ease and free flowing of ideas through the relatively safe avenues behind the Roman front line. In this respect, the empire made everyone more Roman precisely by not trying to make them so.

Future conquerors were successful for a time using variations of this technique. Genghis Khan used to present an ultimatum to cities as he would pass. Submit to me and pay some taxes or die. Those that agreed would live life the same as they did before, accepting the mild hardship of a foreign imposed tax. Those that disagreed usually found themselves decapitated with a large pile of skulls set at the front of their respective villages. After each scenario played out a few times, people decided that they preferred the former and the empire exploded. The relatively short life span of the Mongol Empire was largely due to the inability to pass on leadership. The nomadic pastoralist ideals of what makes a good leader and succession were simply not in keeping with controlling a vast stable empire.

The British

The British Empire took control of vast lands through military conquest in the same manner as the Romans. These lands were even more spread out and vast, owing to advances in technology between the two time periods. The primary difference between these two empires was in what happened after the conquest. While the Romans were relatively hands off, the British were very hands on. As was said, the goal was to, "make the world England." While the Romans taxed remote regions to bring wealth back to Rome, the British would largely use pilfered resources to continue campaigns to make more of the world British. In keeping with the general social shake-ups of the early industrial revolution, London became full of sick people, living in filth. As the capital got sicker, Britain got bigger. As the saying went, "The sun never sets on the British Empire, but it never rises over the streets of London."

Unlike the Romans, who could often maintain amazing degrees of social harmony between conquered groups behind the battle lines for centuries, the British were constantly dealing with uprisings. As illustrated by the American Revolution, the British social policy was stifling enough to turn colonists of British descent against England. Thus, the very large British Empire really didn't last all that long by historical standards. Remnants of British culture are unmistakeable in countries from the US, to South Africa, to India, but these places did not remain England.

The Leaders Themselves

Living in South Florida, I have spent the majority of my life very close to one of the most enigmatic dictators in recent history. Fidel Castro led an internal revolution, consistent with values (right or wrong being irrelevant) that were found within portions of the local population. In this case, Fidel attempted to internally change pieces of the Cuban culture, but there was no attempt to impose an outside view on the people. In a funny way, his leadership remained so dominant because the aggressive sorts who might have challenged him escaped here to Miami. As he has become frail recently and passed off some of his power to his brother (also old and not too far from becoming frail as well) it will be interesting to see how it all plays out. I suspect that change is brewing, though only time will tell.

One can come up with a veritable laundry list of ruling parties or dictators that came to power, attempted to control the dominant culture, and fell as a result. Sometimes they never really took power completely, other times it took 50 years, but the result was the same. The USSR, the taliban, etc...

The United States

There is one final approach that we haven't mentioned. At its inception, the US began to grow rapidly. The US largely didn't conquer. They displaced. Early American conquest had less to do with subjugating people and more to do with killing them or moving them out of the way. Good or bad, this is a relatively effective approach if you have a population with enough size (or growing at a rapid enough rate) to control the lands you've taken. It is very clear that much of the US in the future will never return to being Seminole land or part of the Iriquois Nation.

The modern US approach to conquest (both internally and externally) is very different. The export of American ideals (democracy by force) and the internal conflict between similar (though not so similar) sub-cultures within the US have created a very different America in the last 60 years than the one that existed before. We implement policy from Washington DC where we attempt to tell people on the other side of the world when they can walk outside. We implement policy from Washington where we tell people in Spokane, Washington how much water they can use when they flush the toilet. The degree to which we attempt to centrally micromanage every facet of daily existance is frankly unheard of in human history. Historically, most dictators just didn't care enough about these little nuances of daily living.

The Conclusion to the Ramble

Just remember that the Romans had wild success with economic subjugation utilizing military force. The British on the other hand (and the Russians) couldn't hold social subjugation together. While people will complain about, but tolerate, virtually every tax or economic burden that is imposed which does not impair their ability to attain a reasonable standard of living, people defend their culture vehemently. The rambling point is that the unless the US intends to anhialate everyone both internally and externally who disagrees with the prevailing politically correct point of view, history tells us that our current policy might not bring us down the road of ongoing leadership.

Wednesday, January 21, 2009

When Morality Meets Scarcity in Medicine

The only thing universal about individual morality is that it is in fact individual. Regardless of whether you believe in absolute truth, a religious code, the golden rule, etc, the fact of the matter remains that everyone interprets these things differently. What is or is not truth is secondary in the scheme of what actually happens. This becomes even more complex when considering that certain codes diametrically oppose each other, and some codes clearly sacrifice other people who do not subscribe to the code. There's an interesting conversation about abortion for example over at in the topics in healthcare forum debating this very topic. One side essentially claims that failure to perform abortion or refer for it is in some way a direct violation of medical ethics. The other side claims that doing these exact same things is a violation of the will of God. Often, neither side believes in an allowance for a differing opinion.

There is one thing however, that holds universally true, and no amount of denying it changes it. Resources are scarce and limited. They may be used ever more efficiently and/or prudently, but there is only so much matter in the universe. This example can be applied to medicine. In its current state, medicine in its attempt to be all things to all people is rapidly becoming nothing to anybody. It's becoming a sort of service black hole and an expensive black hole at that. Rising from ~5-6% of GDP in the days before Medicare, healthcare costs are now estimated at about 16% of GDP. Sure there have been some technological advances, but there are clearly some changes in our approach to healthcare distribution that perpetuate these deficits. Let's consider some of the paradox into which we are plunging ourselves:

Many people advocate doing everything that people need. This is all well and good, except that defining "need," is not all that easy, and there are many times that the "needs," of two individuals conflict. Let's look at the following example:

Two middle aged men walk into a community emergency room. One has terrible crushing chest pain, radiating to the left arm. He has specific V2-V5 ST-segment EKG changes consistent with an anterior wall MI (heart attack) and his cardiac enzymes are through the roof. The other man has a non-compound humeral fracture (a broken arm) and is in considerable pain. The ER is currently full of other patients. What to do? In this case, the usual response is that we have to triage. Even with the full ER, we will make room for the man having the heart attack. We'll start treatment. The man with the broken arm will have to wait. In fact, some of the patients who were already brought back will have to wait.

In this example, it is clear that the man with the heart attack is receiving a benefit at the expense of the man with a broken arm. In this particular example, we've sort of attempted to minimize "badness." The long term outcome for a delay in treatment for the fracture of a few hours is probably nothing, while a similar delay in the treatment of the heart attack is potentially fatal.

Triage is sort of the original approach to the collision of scarcity and morality. If we can't do right by everyone, we'll attempt to get the most right out of the situation. The original concept was that we would go after the sickest who could be saved first and then in order of decreasing severity so as to maximize the chances of the most good outcomes.

In modern day medicine, we have no real triage outside of the emergency room. We attempt to just give everyone everything, the cost be damned. It's the equivalent of building another room onto the ER and hiring another doc every time another broken arm comes in the door. It's incredibly expensive, and it doesn't necessarily improve anyone's long term outcome. We also tend to ignore the most important rule of triage, in which we do not waste scarce resources on individuals beyond repair. Every severely demented nursing home resident who takes a two week vacation in the ICU costs the system tens of thousands of dollars in order to "save" a person who is beyond repair. This is partly why healthcare is 16% of GDP.

Another question is how far do we go to ensure 100% accuracy. In other words, how much money are we spending over progressively smaller benefits in diagnosis and treatment? This is the question that comes about in the current predatory legal environment. The added cost of testing in an environment in which every individual miss imposes a nearly insurmountable burden on the system creates a system in which every low yield test in the system is ordered in order to avoid error. Is it right to tax a large segment of the population solely to fund CT scans of the brain for low risk falls in alcoholics? We surely pay for them now.

It's very simple. In any type of collectivist system, the "morality' of what is being provided will eventually bump into scarcity. There has to be some sort of rationing. There has to be some sort of triage. Someone's rights will have to take a back seat to the more critical or those with better long term potential. Period. If not, any system goes bankrupt and no one benefits.

The alternative is a non-collectivist system. In this system, individual choices determine what happens. Individual morality may factor in, but there is no "morality of the system." This is where competition comes into play. In our above example, the man with the broken arm may go to a different hospital. He may have to pay more. Perhaps the number of people waiting for treatment with broken arms leads a group of entrepaneurial orthopods to open a special orthopedic ER that caters to broken arms and doesn't treat heart attacks. Then there's no conflict at all. If someone felt morally compelled to treat heart attacks, they could go around treating all heart attacks, regardless of ability to pay. This is rationing in a way, but the rationing is done by individual preference and morality. In this particular approach, no one individual can impose a specific morality on everyone else within the system.

Regardless of how you approach it, no code or philosophy on whom is entitled to treatment can overturn the laws of nature. Matter can neither be created or destroyed. Resources have to be rationed. The only question is whether that rationing occurs by an imposed centralized system or the individual codes of the individuals involved.