Monday, May 25, 2009

State of the "Union:" Genders, Numbers, and the Taboo

The question of allowing same-sex marriage raises troubling points.  The trouble is the question of what freedoms Americans should be granted, and what the definition of marriage is.  As mentioned in my earlier posting, the Bill of Rights explicitly allows for the freedom of religion.  This is to say that the state will not sponsor or advantage any religion or faith above any other.

Those who argue that marriage is the union between a man and a women predicate their argument on religious grounds.  The trouble with this argument is twofold:  Over time, the religious definition of marriage has evolved and there is that bit in the Bill of Rights that grants freedom of religion. 

The Bible neither endorse nor condemns polygamy.  And, while it includes passages that describe a relationship between only a single man and woman, it does not specifically prescribe monogamy.  Likewise, it includes passages regarding Abraham, Jacob, David, and Solomon, all of whom had multiple wives. Moses has a sort of an odd warning to Solomon in Deuteronomy 17:17 regarding polygamy:  "He must not take many wives."  What is not clear is whether the meaning of "many" is "more than one" or "more than what Solomon could afford."  But these minutia are besides the point, the point being the lack of definitive rejection of polygamy in the Bible.  It should be noted that polygamy has been in common practice throughout the ages, and still is in many faiths around the world.  Therefore, one cannot claim monogamy as "God's way" by claiming residence or Biblical prescription.

That aside, the Bill of Rights does grant Americans freedom of religion.  This right prohibits the enforcement of an ideal justified through religious teachings of any sort.  In other words, it should not matter what the Bible - or any particular religious text - says when it comes to the creation of laws and granting of rights in the US.  The paramount issue is individual rights; namely, can individuals willingly join and leave unions without any coercion or credible threats?  If I, as an adult, am free to marry whomever I want and can leave that person by my free will, then that marriage should be allowed as I am ultimately exercising individual rights.

This is the crux of the argument for same-sex marriage:  It is the wish of two adults to marry in accordance to their free will.  Same-sex marriage is a question of individual rights; it is ultimately the American way.

But, when it comes to individual rights, namely the wish and ability of an adult to make a decision for his betterment without coercion or a credible use of force*, why should the American way only extend to monogamy (single man-woman, man-man, or woman-woman relationships)?  If it is the wish of multiple, freely willing adults to engage in polygamy, why should the American way stop that choice? One can imagine marriages where are the traditional polygamous type, the non-traditional polyandrous (one wife, many husbands) type, or the tribal kind where multiple men and women are in a marriage, with "multiple" defined as "as few as zero and with no upward bound," making it possible for exclusive groups of many men or many women to be in a tribal marriage together.  

Call this modern love or taboo.  Despite its moniker, polygamy, polyandry, and tribal marriage clearly extends beyond most Americans' sensibilities and comfort zones.  Which, of course, begets the question of whether the existence of something uncomfortable or unusual make it un-American.  Coming back to the central point, if we wish to respect individual rights and adults are free to make choices* without coercion or a credible threat, then adults should have that right.  

We, Americans, have a long way to go before we fully digest our constitution and understand its ramifications.  And we, Americans, have a long way to go before we grant individual rights as they should be granted.

* Examining the notion of individual rights will be the topic of the next blog.

Saturday, May 23, 2009

Choose One: Outlaw Divorce or Allow Gay Marriage

Over a cup of coffee, an Italian friend was explaining Italian relationships; more precisely, how the termination of Italian marital relationships plays out.  The state has to grant the right for divorce given probable cause.  And, as it turns out, marital infidelity is not probable cause.  Piecing the information that my friend relayed to me, were it the case that cheating hearts constituted grounds for divorce, about half of Italian marriages would dissolve.

We, in the US, are self-critical because of our high divorce rate.  The infamous statistic that is bantered about is that nearly one out of every two marriages fail.  This is "about half;" so, Americans and Italians are far more alike than divorce statistics would have you believe.

Yet, just focusing on the statements above, there is something profoundly different between the US and Italy.  In the US, it is easy to get married; a couple can simply go through a Las Vegas drive-through church to declare themselves husband and wife.  It is nearly as easy to get divorced (assuming willing parties and no legal or financial vengeance in the mix).  In Italy, the state grants the right for divorce upon sufficient grounds; accordingly, the state requires that a couple be schooled in marriage prior to tying the knot precisely because it is difficult to legally separate.

This brings the question of relationships onto a broader stage; namely, what should the relationship between the state and the individual be?  Shall the state prescribe details of people's lives, or shall people be let free, make their own decisions, assume their own responsibilities, and keep the state as intrusive as possible?  

We Americans like to think of ourselves as members of a free society where the state is small and relatively unobtrusive.  Witness our Bill of Rights, abridged for readability:
  • Freedom of religion
  • Freedom of speech
  • Freedom for peaceful assembly
  • Freedom to petition the government for grievances
  • The right to bear arms
  • Freedom from arbitrary government seizure of property
  • Freedom against unreasonable searches without probable cause
  • The right to be tried in a court of law
Basically, we do not like our government dictating what we can do within certain limitations.  Unfortunately, those boundaries are rather murky.  

Going back to the marriage question, it is not clear why same gender marriages are unlawful in 45 out of the 50 states given that we prize our freedom (the quibbles centering on the religious definition of "marriage" being the "union of a man and a woman," which makes for a poor argument given than the religion definition of marriage has changed significantly over time and that there is freedom of religion).  So, we Americans are a bit tortured on how much we prize our freedom and whether we want to accept the inconvenient consequences of being free.

Sunday, May 3, 2009

Hypocrisy and the Hippocratic Oath

The current health care reform debate prompted me to query the doctors in family about their profession.  The doctors in my family provided refreshingly frank feedback, and  devoid of the facade that they would naturally put up if speaking with less familiar individuals.  

I walked away from the conversations with a new regard for medical doctors.  Namely, whereas I had perceived doctors as selfless individuals who worked endless hours for the benefit of others (and who happened to earn a nice living in the meanwhile), my new perception puts medical doctors in the same class as consultants.

Having been a consultant, I have an understanding for the inherit conflict of interest that consultants must deal with.  On one hand, the consultant has to solve a problem for the client.  On the other, the consultant has the goal to maximize his revenue.  The conflict of interest comes when a problem could be solved in a very efficient way (perhaps due to the absence of an actual problem); under this condition, revenue takes a hit.  Being goaled with maximizing revenues often means that the consultant will take a less efficient path or "discover" new problems in an effort to extend the engagement, and thereby aggrandize the bill.  With that, let's take a look at how incentives are created for medical doctors  and why the Hippocratic oath takes a back seat to the almighty dollar.

First, it is important to understand medical billing practices.  This is not a comprehensive study, rather a sketch based on various data points:
  • Billing rate is associated with the doctor's expertise.  Pediatricians make less and intensive care (IC) doctors.  IC doctors with multiple certifications, such as pulmonary disease, make even more.  A pediatrician makes around $150,000 per year.  A high-end specialist can make into the seven figures.
  • Per-minute billing rates are very high.  The figure that was quoted to me was $35/minute.  This makes the hourly rate $2,100 for the average doctor.  Just for comparison sakes, a named partner in California's largest law firm collects less than half this rate.
  • While billing is quoted at a per-minute basis, there is a minimal period for which the patient (or the patient's insurance company) is billed.  The minimum time blocks is 10 minutes.  However, most doctors visit 2 or three patients during the same 1o minute period, effectively tripling the billing rate.
So far, it should be clear that with these billing practices, patients should expect little love from their doctor.  The doctor will be motivated by visiting as many patients as he can during the shortest period of time.  Hopefully, the diagnosis will be accurate.

Another contorting factor is the division of labor among doctors.  As I mentioned above, an IC doctor collects at a specific rate, but an IC doctor with pulmonary disease certification increases his rate by about $100,000 per year.  The distinction between a regular IC doctor and an IC doctor with pulmonary disease certification is the ability to diagnose and treat lung infections.  

Here is the rub:  It is an accepted fact that any patient that spends any appreciable time inside the IC unit will develop a lung infection.  So, the rational IC doctor will want to get a pulmonary disease certification because, if he does not, he will allow the next person to collect the fees for diagnosis and treatment.  Judging by the extra $100,000 per annum increase to the doctor's take home, one can expect a $400,000 total billing that this doctor generates in totality, which is then split between insurance companies, pharmaceuticals, the medical facility, and other administrative costs.

But, if it is an accepted "fact" that any patient that spends any appreciable time inside the IC unit will develop a lung infection, the question is why isn't the medical community working to prevent these infections in the first place?  The way the game is devised, it is far more lucrative to diagnose (or misdiagnose) and prescribe a (hopefully) cure instead of preventing the disease in the first place.  

Which brings me to the Hippocratic Oath.  According to PBS, the modern version of the Hippocratic Oath (written by Luis Lasagna in 1964), has the following directives:

  • I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism.
  • I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
  • I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
  • I will prevent disease whenever I can, for prevention is preferable to cure.
Without diving into the details, I believe I have demonstrated how the four directives are easily violated - not because medical doctors are callous  - because the way medical establishment practices its business today.  You may be interested to know that there are eight directives altogether, which makes the final clause of the modern oath laughable:

  • If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

The medical establishment has said that at most 50% compliance with the oath is good enough.  We, the patients, just hope that disease diagnosis and treatment has a far better success rate.  

Cough, cough.