There are a few principles that will dictate the future of the American healthcare system:
1. There will always be a two-tiered system. This will not be due to a flaw in system design or implementation, but is due to the unalterable dynamics of societies. there is not a country on earth that does not have multi-tiered healthcare. The United States will not have a single tiered system for the same reason that it does not have, in fact, a single tiered educational system, or a single tiered legal system, or a single tiered social welfare system. Economics, technology and data management will have a much greater influence on the shape of the American healthcare system than will politics. Politics however, will have a much greater influence on who becomes rich as a result.
2. Healthcare in general, and medical care in particular, can be divided up into three functional categories:
i. The technical or procedural aspect. This is the part of healthcare where someone takes out your appendix, adminsters chemotherapy, does endoscopy, or performs a CT scan;
ii. The cognitive aspect. This is where someone interprets data and makes decisions about interventions, and
iii. The clerical aspect. This is where data is collected, collated,and and packaged.
These three aspects will become more distinct and regardless of what type of healthcare reform or payment system is implemented, will dictate the future of healthcare.
The procedural aspect will be taken over by technicians. this trend has been underway for a couple of decades and has resulted in niche practices by "proceduralists.: It is also apparent in the now common practice of attending physicians or primary care providers referring patients to specialists who perform procedures on request, with no other role in diagnosing or managing a patient;s condition. In the future, these people will be less educated in broad aspects of medicine and will be hyper-specialized technicians. Since these procedures will be will established and understood, the practitioners performing them will be more like tradesmen than professional decison makers. They will have less education and more procedural training, and consequently will be expected to do less and will be paid less.
The cognitive aspect will largely be displaced by massive data management systems. This will commonly be referred to as AI, but will involve computer algorithms classifying each patient and processing huge amounts of epidemiologic, genetic, and clinical data to arrive at diagnostic and treatment plans for individual patients. These systems will become more reliable as experience is gained and they will drive down the costs associated with routine care. One offshoot of this will be a new medical specialty: the "outlierist" or the "anomalist" who will be looked to for the artisanal elements of medicine when the data driven computer algorithms are unsuccessful.
The clerical aspect is taking up a larger portion of providers time right now. They spend significant time gathering and entering data that eventually will form the databases on which the artificial neural networks, inference engines, Bayesian belief networks, and other computer modeling systems will operate. Provider systems and payers will soon realize that these tasks can be both largely automated and performed by medium skilled workers without medical degrees.
Sunday, March 26, 2017
Respect
If you earn respect, you will have self respect.
If you demand respect, you will have self pity.
There are two things with which self respect should never be confused: self pity and self esteem.
When faced with challenges, self esteem often becomes self pity; self respect becomes courage and determination.
If you demand respect, you will have self pity.
There are two things with which self respect should never be confused: self pity and self esteem.
When faced with challenges, self esteem often becomes self pity; self respect becomes courage and determination.
Sunday, March 12, 2017
Monday, February 20, 2017
Speech as action
A piece by David Solway entitled "Free Speech vs. 'Hate Speech'" makes the following assertion:
Of course, speech itself can be an act, as philosopher J.L. Austin has shown in How to Do Things with Words: in his most famous example, when the minister states “I now pronounce you husband and wife,” an act has been performed since it changes the status of the participants.
This is wrong. The words themselves are innocuous absent other considerations. If a second grader speaks the quoted words to two other second graders,the latter are not thereby married. More importantly, if a minister says the words to two people who do not wish to be married, or in fact merely disagree with those words, their status does not change. In the former case, the words are powerless because of the status of the speaker. She has no authority to change the status of her classmates, regardless of the words used. The latter case is more fundamental, because it is an example of a larger principle: the effect of words in the absence of external force is dependent on the acceptance of the hearer. Certainly, when a judge pronounces a sentence, the words used wold be of little significance apart from a mechanism to enforce them. The same result holds if the judge has no authority to pass such a sentence, as for example if jury had acquitted the accused.
The effect of words in such case would depend on the subjective acceptance of their object. To put the matter more succinctly, no one is obligated to be offended by speech, and no one is required to perceive injuries in mere opinions.
Of course, speech itself can be an act, as philosopher J.L. Austin has shown in How to Do Things with Words: in his most famous example, when the minister states “I now pronounce you husband and wife,” an act has been performed since it changes the status of the participants.
This is wrong. The words themselves are innocuous absent other considerations. If a second grader speaks the quoted words to two other second graders,the latter are not thereby married. More importantly, if a minister says the words to two people who do not wish to be married, or in fact merely disagree with those words, their status does not change. In the former case, the words are powerless because of the status of the speaker. She has no authority to change the status of her classmates, regardless of the words used. The latter case is more fundamental, because it is an example of a larger principle: the effect of words in the absence of external force is dependent on the acceptance of the hearer. Certainly, when a judge pronounces a sentence, the words used wold be of little significance apart from a mechanism to enforce them. The same result holds if the judge has no authority to pass such a sentence, as for example if jury had acquitted the accused.
The effect of words in such case would depend on the subjective acceptance of their object. To put the matter more succinctly, no one is obligated to be offended by speech, and no one is required to perceive injuries in mere opinions.
Saturday, February 18, 2017
Safe spaces
The concept of civilization only makes sense in the context of interactions between humans. A solitary individual having no interactions with others would have no use for norms and traditions that are useful in public life. A civilized society is one in which the clashes and confrontations that inevitable arise when human beings interact are managed by certain understandings regarding tolerance, accommodation and compromise. The norms and institutions of civilization are means by which the clashes of individual interests and diversity of opinions are processed so as to make social interactions worthwhile. Civilization is a consequence of the public benefits which arise from preserving individuality. Civilization thrives when individual differences are allowed to compete.
A "safe space," in the current usage of the term, is a place that is free from distressing opinions or disquieting deviations from uniformity. They are precincts where feeble ideas are allowed to persist unchallenged and unimproved, not because of the intellectual validity of those ideas but because of the emotional discomfort occasioned by alternative views. Safe spaces only appear so because of uniformity and conformity, and as such are intellectually stagnant. The aversion to individual thought and dispute makes them intellectually inert and emotionally anesthetic. The adjective "safe" is a euphemism intended to disguise an environment that is intellectually desolate, intolerant and craven.
A "safe space," in the current usage of the term, is a place that is free from distressing opinions or disquieting deviations from uniformity. They are precincts where feeble ideas are allowed to persist unchallenged and unimproved, not because of the intellectual validity of those ideas but because of the emotional discomfort occasioned by alternative views. Safe spaces only appear so because of uniformity and conformity, and as such are intellectually stagnant. The aversion to individual thought and dispute makes them intellectually inert and emotionally anesthetic. The adjective "safe" is a euphemism intended to disguise an environment that is intellectually desolate, intolerant and craven.
Outcomes
The most significant difference between Donald Trump and Hillary Clinton, at least as it concerns practical politics, is that there was a significantly greater risk of corruption being normalized under a Clinton administration than under Trump. This is independent of whether a Clinton led government would be any more or less corrupt than the current administration. In the former case, corruption would be viewed by institutions such as the media and entrenched interests as a price to be paid for favorable policies; in the latter case, it is a target of opportunity by which to advance one's agenda and protect one's interests. Normalization of corruption is far more damaging than any policy which could be reasonably implemented by either candidate.
Sunday, February 12, 2017
Thought experiment
Consider a woman, a citizen in a western democracy, Now consider that it is desirable to someone, for whatever reason, to have her behave in a particular way, to conform to some model, or submit to some reform. One way to accomplish this would be to use coercion, to invoke force or the prospect of undesirable consequences to influence her in the desired direction. Another alternative would be to use persuasion, appeal to reason, and try to convince her of the wisdom and benefit of the desired behavior, model or reform.
The first method is the resort to force. She will be made to conform regardless of her her own reason, values or choice. The second is a resort to rational discourse, to principles of analysis and evidence. Only the second of these is consistent with a respect for dignity; i.e. that a person is worthy, all else being equal, of living her life in accord with her own conscience.
Now image that the second method, the use of persuasion, is discouraged on grounds that the method of persuasion, i.e. free speech, might cause offense to someone. Thus we have in stark relief the malignancy at the heart of political correctness: that it is better to use force and the threat of personal consequences to bring about some policy or other, because to allow reasoned debate might offend subjective sensibilities. Rejection of political correctness is rejection of the notion that the benefits and individual dignity must be surrendered to protect the sensitive from disquieting opinions..
The first method is the resort to force. She will be made to conform regardless of her her own reason, values or choice. The second is a resort to rational discourse, to principles of analysis and evidence. Only the second of these is consistent with a respect for dignity; i.e. that a person is worthy, all else being equal, of living her life in accord with her own conscience.
Now image that the second method, the use of persuasion, is discouraged on grounds that the method of persuasion, i.e. free speech, might cause offense to someone. Thus we have in stark relief the malignancy at the heart of political correctness: that it is better to use force and the threat of personal consequences to bring about some policy or other, because to allow reasoned debate might offend subjective sensibilities. Rejection of political correctness is rejection of the notion that the benefits and individual dignity must be surrendered to protect the sensitive from disquieting opinions..
Wednesday, March 02, 2016
Racism
Charges of racism seem to be an inexhaustible element of public discourse in the United States. Race is injected into a wide swath of public debates and the allegations of racist motives are regularly used to discredit and silence opposing views. Some people claim that the United States is an inherently racist country; others that the single minded search for any hint of potentially racist or race-tinged thought has reached the point that it is doing more harm than good.
Certainly, overt and institutionalized racism has declined steadily since the second World War. Certainly there are those, in all races who still harbor racist attitudes, and there is a corresponding disparity in perceptions of just how racist America really is. A simple explanation for this phenomenon is found not in comparing attitudes and conduct to some mythical non-racist standards, but in understanding different peoples' priorities in considering matters of race.
Let us assume you have two people of different races, each of whom honestly considers herself non-racist. Now construct a list of attitudes and actions that are, or could potentially be considered racist, and rank them, from most obviously racist to spurious at best. this list would range from the egregious, such as lynching a teenager for kissing a person of a different race, to things like refusing to hire a person because of their race, to telling stereotyping jokes, etc, to the silly, such as objecting to terms like "black sheep" or "black mark, to the weird, like complaining about "cultural appropriation" to the just plain ignorant, such as claiming that the word "niggardly" has anything at all to do with race.
If we take our two subjects and present them with this list and ask them to prioritize each item on the list against other social concerns, such as economic efficiency or freedom of expression, it is likely that there would be a great deal of agreement at the more flagrant examples; both would agree that lynching is abhorrent racism. There would most likely be agreement that discrimination in employment and housing are improper, and that stereotyping jokes do reflect racist attitudes. But as you go down the list, it would be expected that there will be a point that the two people will disagree on whether a particular act or attitude is sufficiently serious that it should override other concerns. there will be a disagreement on the priority that a potential racist thought or action should be given in everyday life, and it is at this point that one person will accuse the other of racism. And it is not just an accusation as to that contested point; it will be assumed that the point of disagreement, e.g. that "Taco Tuesday" should be condemned is simply the point where the closet racist lets the mask slip, Thus, what should be simply a good faith disagreement as to whether an arguably innocuous, or even an obviously innocuous view can be transformed by racial prospectors into invidious racism. This is why the vast majority of people honestly do not consider themselves racist, and those who suspect others of racism readily think they have evidence to support their suspicions.
The clearest example of this is affirmative action. There are competing priorities here: countering the prospect that qualified minorities will be denied opportunity because of their race, and ensuring that race-neutral merit is the basis for allocating potentially limited opportunities. Neither view is necessarily racist. The allegation of racism, when it inevitably comes out is not directed at the principles underlying either position, rather it is directed solely at opposition to the accuser's position. The allegation is not that merit is racist it is that prioritizing merit over racial considerations is.
Of course, there are racists. There are those who believe that there are certain genetic traits that justify treating races differently. But for the majority of people what determines how they treat one another regardless of race depends on their experiences. It is much more likely that a black man who loves his wife and raises his children, and respects others has much more in common with a white man who loves his wife and raises his children and respects others than either has with a black drug dealer who abuses women or with a white methamphetamine addict who steals to support his habit and abuses women.
Sure, there are racists. There are also race hustlers who would contort facts and logic to smear otherwise decent people in support of a cynical narrative that is destructive to people of all races.
Certainly, overt and institutionalized racism has declined steadily since the second World War. Certainly there are those, in all races who still harbor racist attitudes, and there is a corresponding disparity in perceptions of just how racist America really is. A simple explanation for this phenomenon is found not in comparing attitudes and conduct to some mythical non-racist standards, but in understanding different peoples' priorities in considering matters of race.
Let us assume you have two people of different races, each of whom honestly considers herself non-racist. Now construct a list of attitudes and actions that are, or could potentially be considered racist, and rank them, from most obviously racist to spurious at best. this list would range from the egregious, such as lynching a teenager for kissing a person of a different race, to things like refusing to hire a person because of their race, to telling stereotyping jokes, etc, to the silly, such as objecting to terms like "black sheep" or "black mark, to the weird, like complaining about "cultural appropriation" to the just plain ignorant, such as claiming that the word "niggardly" has anything at all to do with race.
If we take our two subjects and present them with this list and ask them to prioritize each item on the list against other social concerns, such as economic efficiency or freedom of expression, it is likely that there would be a great deal of agreement at the more flagrant examples; both would agree that lynching is abhorrent racism. There would most likely be agreement that discrimination in employment and housing are improper, and that stereotyping jokes do reflect racist attitudes. But as you go down the list, it would be expected that there will be a point that the two people will disagree on whether a particular act or attitude is sufficiently serious that it should override other concerns. there will be a disagreement on the priority that a potential racist thought or action should be given in everyday life, and it is at this point that one person will accuse the other of racism. And it is not just an accusation as to that contested point; it will be assumed that the point of disagreement, e.g. that "Taco Tuesday" should be condemned is simply the point where the closet racist lets the mask slip, Thus, what should be simply a good faith disagreement as to whether an arguably innocuous, or even an obviously innocuous view can be transformed by racial prospectors into invidious racism. This is why the vast majority of people honestly do not consider themselves racist, and those who suspect others of racism readily think they have evidence to support their suspicions.
The clearest example of this is affirmative action. There are competing priorities here: countering the prospect that qualified minorities will be denied opportunity because of their race, and ensuring that race-neutral merit is the basis for allocating potentially limited opportunities. Neither view is necessarily racist. The allegation of racism, when it inevitably comes out is not directed at the principles underlying either position, rather it is directed solely at opposition to the accuser's position. The allegation is not that merit is racist it is that prioritizing merit over racial considerations is.
Of course, there are racists. There are those who believe that there are certain genetic traits that justify treating races differently. But for the majority of people what determines how they treat one another regardless of race depends on their experiences. It is much more likely that a black man who loves his wife and raises his children, and respects others has much more in common with a white man who loves his wife and raises his children and respects others than either has with a black drug dealer who abuses women or with a white methamphetamine addict who steals to support his habit and abuses women.
Sure, there are racists. There are also race hustlers who would contort facts and logic to smear otherwise decent people in support of a cynical narrative that is destructive to people of all races.
Tuesday, March 01, 2016
Libertarians
A libertarian view begins with the premise that liberty is incompatible with coercion, and that a civil society should not substitute instruments of violence for persuasion. This view requires that all uses of force be justified, because force is never assumed to be just. There are certain categories of force, such as government force used against one person for the exclusive private advantage of another, or force used to protect subjective sensibilities, or to vindicate matters of etiquette that should never be justified.The rules for use of force should be predictable and of general application, neither singling out nor exempting particular parties. No person who is capable of reason should be subjected to force solely on grounds that it is for his or her own good.
Force and governmental violence is sometimes necessary but its legitimate use usually signals the breakdown of reason. The lapse of reason is not always on the part of the person against whom the force is directed. Force, or the ability to resort to force by authorities, is a tempting shortcut to assure compliance with questionable policies or to promote partisan interests, or worse, to attempt to compensate for incompetence in administering the laws. It is the enabler of oppressive laws and a hallmark of governing interests at odds with the will of the people.
Force is inherently inelegant and imprecise. There is no guarantee that "non-lethal" force will remain "non-lethal" just because the circumstances do not justify more severe measures.
Force and governmental violence is sometimes necessary but its legitimate use usually signals the breakdown of reason. The lapse of reason is not always on the part of the person against whom the force is directed. Force, or the ability to resort to force by authorities, is a tempting shortcut to assure compliance with questionable policies or to promote partisan interests, or worse, to attempt to compensate for incompetence in administering the laws. It is the enabler of oppressive laws and a hallmark of governing interests at odds with the will of the people.
Force is inherently inelegant and imprecise. There is no guarantee that "non-lethal" force will remain "non-lethal" just because the circumstances do not justify more severe measures.
Friday, November 01, 2013
Hostile
Of all the drawbacks of an excessive regulatory, bureaucratic state, perhaps the most significant is that all of the necessary mandates and prohibitions eventually mkes the government adverse to the citizenry.
Friday, October 11, 2013
Restorative forces
There is a corollary to yesterday's post on stability. When a stable system is perturbed, forces inherent in the system act to return it to equilibrium. In political systems, these forces are popular reactions against reform. Political systems differ from physical ones, in that the public responses are often delayed as a result of public perception, remoteness of experience, or initial misperception of the scope and purpose of the reform. The forces seeking equilibrium are present and relentless however, and eventually overcome the transient and artificial dispruptions imposed by authorities. This is why dictatorships fall, or stagnate, and why socialist utopias eventually encounter crises between promises and realities.
Thursday, October 10, 2013
Stability
An essential characteristic of a stable system is the tendency to return to a state of equilibrium after being disturbed by some influence. This is true not only of physical systems but biological and political ones as well. The baseline or ground state is an inherent property of the system, and determines the response to perturbation.
Societies are highly complex and heterogeneous systems that, if they are to be stable, will have defined baselines in terms of institutions, economics, and social values. It is of course possible for these to evolve over time, but this evolution tends to be a response to environment and a constellation of circumstances rather than a discrete influence. When reformers and idealists seek to alter these fundamental characteristics of a society they often succeed in achieving only a transient and artificial change that cannot persist without the threat and use of force. Such enterprises, even if they initially have popular approval, eventually collapse under the strain of human nature.
It is difficult, almost to the point of impossibility, to "fundamentally change" a society through legislation or political machination. The natural tendency is for politics to eventually reflect the underlying values of the society, rather than to shape them. The fact is it is not possible for politicians of any type, whether they be tyrants, democratically elected legislators and executives, or appointed functionaries to prescribe what people want or what people value.
The forces necessary to fundamentally change a society, that is to change the baseline or ground state at which a society functions in the absence of force or duress, ultimately derive from people's experience and subjective interests. The instincts and subjective experiences that influence how people interact with each other are much more robust and enduring than political policies or ideological ambition.
Societies are highly complex and heterogeneous systems that, if they are to be stable, will have defined baselines in terms of institutions, economics, and social values. It is of course possible for these to evolve over time, but this evolution tends to be a response to environment and a constellation of circumstances rather than a discrete influence. When reformers and idealists seek to alter these fundamental characteristics of a society they often succeed in achieving only a transient and artificial change that cannot persist without the threat and use of force. Such enterprises, even if they initially have popular approval, eventually collapse under the strain of human nature.
It is difficult, almost to the point of impossibility, to "fundamentally change" a society through legislation or political machination. The natural tendency is for politics to eventually reflect the underlying values of the society, rather than to shape them. The fact is it is not possible for politicians of any type, whether they be tyrants, democratically elected legislators and executives, or appointed functionaries to prescribe what people want or what people value.
The forces necessary to fundamentally change a society, that is to change the baseline or ground state at which a society functions in the absence of force or duress, ultimately derive from people's experience and subjective interests. The instincts and subjective experiences that influence how people interact with each other are much more robust and enduring than political policies or ideological ambition.
Wednesday, October 09, 2013
A technological paradox
An article published in the medical literature in 2011 documented a significant increase in the number of pulmonary emboli that were diagnosed since the introduction of sensitive tests for them. The mortality associated with that condition, however, did not improve significantly over the trends that had existed prior to the adoption of more sensitive diagnostic methods. The number of complications associated with therapy of pulmonary embolism did increase in the same manner as the number of diagnoses. The implication of this is that the introduction of sensitive diagnostic technology led to a dramatic increase in the number of cases diagnosed, but that that increase did not have a significant impact on patient outcomes. Pulmonary embolism began to be overdiagnosed, and some patients experienced significant complications from therapy that previously would have been unnecessary.
This circumstance is not limited to pulmonary embolism, nor to a small number of similar conditions. Diagnostic technology has advanced to the point that resolution of diagnostic studies has out-paced our ability to interpret them. We are finding more minute and unanticipated anomalies for which we do not know the significance. As a result, physicians are making diagnoses, often based on incidental findings, and providing treatments where they would not have only a few years ago. The benefits and risks associated with making these diagnoses and treating these patients is unclear. In the case of pulmonary embolism, increase diagnostic sensitivity clearly carries the risk of overdiagnosis, providing treatment where none is required, and causing unnecessary complications.
The tendency to overdiagnosed and over treat arises not only from technological advancement. Fear of litigation, patient expectation, and the proliferation of protocols and algorithms also influences medical decision-making in the direction of more frequent and less efficacious treatment. Paradoxically, while diagnostic technology enables greater detail of unclear significance, the use of protocols and algorithms homogenizes diagnostic data and disregards other clinical information of significance to a particular patient.
These factors contribute to an undesirable praxis in American medicine. The desire to provide diagnostic certainty when there actually is none, to medicalize everyday difficulties and consider them as diseases leads to such excesses as overprescribing antidepressants and stimulant medications, a proliferation of unnecessary procedures for treatment of ill-defined "syndromes," and an explosion in the number of patients claiming disabilities of one type or another. A peculiarity of American medicine is that many diseases and medical conditions are associated with their own interest groups. Diseases have lobbies. It is an undeniable and likely inescapable fact of American medicine that some interests benefit from overdiagnosis and overtreatment, and those interests are active in perpetuating what is fundamentally bad medicine.
This is only one of an innumerable number of factors for which the affordable care act provides no answer.
This circumstance is not limited to pulmonary embolism, nor to a small number of similar conditions. Diagnostic technology has advanced to the point that resolution of diagnostic studies has out-paced our ability to interpret them. We are finding more minute and unanticipated anomalies for which we do not know the significance. As a result, physicians are making diagnoses, often based on incidental findings, and providing treatments where they would not have only a few years ago. The benefits and risks associated with making these diagnoses and treating these patients is unclear. In the case of pulmonary embolism, increase diagnostic sensitivity clearly carries the risk of overdiagnosis, providing treatment where none is required, and causing unnecessary complications.
The tendency to overdiagnosed and over treat arises not only from technological advancement. Fear of litigation, patient expectation, and the proliferation of protocols and algorithms also influences medical decision-making in the direction of more frequent and less efficacious treatment. Paradoxically, while diagnostic technology enables greater detail of unclear significance, the use of protocols and algorithms homogenizes diagnostic data and disregards other clinical information of significance to a particular patient.
These factors contribute to an undesirable praxis in American medicine. The desire to provide diagnostic certainty when there actually is none, to medicalize everyday difficulties and consider them as diseases leads to such excesses as overprescribing antidepressants and stimulant medications, a proliferation of unnecessary procedures for treatment of ill-defined "syndromes," and an explosion in the number of patients claiming disabilities of one type or another. A peculiarity of American medicine is that many diseases and medical conditions are associated with their own interest groups. Diseases have lobbies. It is an undeniable and likely inescapable fact of American medicine that some interests benefit from overdiagnosis and overtreatment, and those interests are active in perpetuating what is fundamentally bad medicine.
This is only one of an innumerable number of factors for which the affordable care act provides no answer.
Tuesday, October 08, 2013
Government healthcare
With all of the angst accompanying the roll out of the Affordable Care Act, the foibles, the unintended consequences, the unanticipated costs; it may be instructive to review the findings of a previous investigation into government run healthcare. These were the findings of a Senat Committee on Indian Affairs investigation into the operation of the Indian Health Service in the Aberdeen Area in 2010:
Among the investigation’s major findings:
• Chronic mismanagement, lack of employee accountability and financial integrity;
• Several service units experienced substantial and recurring diversions of reduced
health care services, due to lack of qualified providers or funds;
• Five IHS hospitals in the Aberdeen Area are at risk of losing their accreditation or
certification from the Centers for Medicare and Medicaid Services (CMS);
• Several facilities have been cited as having health care providers on staff who
lacked proper licensing or credentialing;
• Key senior staff positions remained vacant for long periods of time, contributing to
the lack of proper management;
• Employees with a record of misconduct or poor performance being transferred to
different health facilities within the Indian health system;
• Pharmaceutical audits of narcotics and other controlled substances are not
regularly performed, and three service units within the region have a history of
missing or stolen narcotics. Source: http://www.indian.senate.gov/news/pressreleases/2010-12-28.cfm
Among the investigation’s major findings:
• Chronic mismanagement, lack of employee accountability and financial integrity;
• Several service units experienced substantial and recurring diversions of reduced
health care services, due to lack of qualified providers or funds;
• Five IHS hospitals in the Aberdeen Area are at risk of losing their accreditation or
certification from the Centers for Medicare and Medicaid Services (CMS);
• Several facilities have been cited as having health care providers on staff who
lacked proper licensing or credentialing;
• Key senior staff positions remained vacant for long periods of time, contributing to
the lack of proper management;
• Employees with a record of misconduct or poor performance being transferred to
different health facilities within the Indian health system;
• Pharmaceutical audits of narcotics and other controlled substances are not
regularly performed, and three service units within the region have a history of
missing or stolen narcotics. Source: http://www.indian.senate.gov/news/pressreleases/2010-12-28.cfm
Morbid curiosity
There is perhaps an intuitive sense that human life is protected by the odds. It seems reasonable that the risk of cataclysm is sufficiently small to have enabled human beings to thrive for millennia, and expect to do so for many more. Most commonly perceived threats are associated with vanishingly small likelihood of occurrence. A worldwide extinction such as that which befell the dinosaurs is likely rare enough to have been considered a one off. This perception applies to most conventional threats, such as a catastrophic asteroid impact or nuclear calamity. The odds, simply, appear he to be in our favor.
It may however be the case that there are mortal threats lurking in far more likely scenarios. To take one such example, it is reasonable to assume that there is at least one, and likely several amino acid sequences that would code for a pathogen that would be devastating to human life. Imagine, for example if the human immunodeficiency virus had a genetic makeup that would allow it to be passed by casual contact, or to be transmitted with the ease of the common cold. It is possible to conjecture the existence of such a genome and wonder how likely random mutation is to produce it. Is such a peril thirty base pairs away? ten thousand? A million? It is also possible to consider that such a fateful genetic sequence might be the result of human manipulation.
This is not to imply that human beings are necessarily doomed, or that a biological catastrophe will wipe out the species. It is to suggest however that it might not be unreasonable to wonder what the true odds of disaster are, and when luck might run out.
It may however be the case that there are mortal threats lurking in far more likely scenarios. To take one such example, it is reasonable to assume that there is at least one, and likely several amino acid sequences that would code for a pathogen that would be devastating to human life. Imagine, for example if the human immunodeficiency virus had a genetic makeup that would allow it to be passed by casual contact, or to be transmitted with the ease of the common cold. It is possible to conjecture the existence of such a genome and wonder how likely random mutation is to produce it. Is such a peril thirty base pairs away? ten thousand? A million? It is also possible to consider that such a fateful genetic sequence might be the result of human manipulation.
This is not to imply that human beings are necessarily doomed, or that a biological catastrophe will wipe out the species. It is to suggest however that it might not be unreasonable to wonder what the true odds of disaster are, and when luck might run out.
Monday, October 07, 2013
Thursday, October 03, 2013
The limited competence of public institutions
One thing that you learn from coaching or watching football is that not everyone can do everything well. Certain players can do certain things well that other players cannot do at all. The same applies to entire teams. You also learn that not everyone who does something well does so indefinitely. Players age, skills fade, and times change. Likewise, even though someone may do something very well there is always the possibility that someone will come along and do it better. These principles apply not only to sporting contests but in civic life. No one institution does everything better than the others. Institutions that do something well initially may get progressively worse at it as time goes on. Institutions may be so hampered by bureaucracy that they are unable to adapt to changing conditions, or they may assume responsibilities for which they are wholly unsuited.
These principles weigh against the progressive notion that the government should be relied upon for nearly all important endeavors. The fact is that there are some things that charities, and private enterprise do much better than public institutions. There are also things that public institutions may have initially done well that they have increasing difficulty doing competently. There are things that may best be done by government initially that private enterprise, or dedicated nonprofit organizations eventually do better.
The list of things that require public institutions because private or charitable institutions tried and failed is vanishingly short. There are of course some things which, on the whole, are proper objects of public enterprise; these include such things as law-enforcement, management of roads and thoroughfares, and providing fire protection services. Other areas in which public institutions to have a role, but which benefit from the participation of other entities include such things as managing hospitals and education. Scientific research likewise benefits from not being reliant on a single source of support, and undertakings such as space exploration are areas in which public institutions have been largely left behind.
The fallacy that, unless the government does something, it will not get done, or alternatively, that unless the government does something it will not be done well, is detrimental to both progress and to civic life in general. Governments and public institutions are inherently bureaucratic and hence inherently limited. There is no reason for a free and thriving society to inflict such limitations upon itself without good cause.
These principles weigh against the progressive notion that the government should be relied upon for nearly all important endeavors. The fact is that there are some things that charities, and private enterprise do much better than public institutions. There are also things that public institutions may have initially done well that they have increasing difficulty doing competently. There are things that may best be done by government initially that private enterprise, or dedicated nonprofit organizations eventually do better.
The list of things that require public institutions because private or charitable institutions tried and failed is vanishingly short. There are of course some things which, on the whole, are proper objects of public enterprise; these include such things as law-enforcement, management of roads and thoroughfares, and providing fire protection services. Other areas in which public institutions to have a role, but which benefit from the participation of other entities include such things as managing hospitals and education. Scientific research likewise benefits from not being reliant on a single source of support, and undertakings such as space exploration are areas in which public institutions have been largely left behind.
The fallacy that, unless the government does something, it will not get done, or alternatively, that unless the government does something it will not be done well, is detrimental to both progress and to civic life in general. Governments and public institutions are inherently bureaucratic and hence inherently limited. There is no reason for a free and thriving society to inflict such limitations upon itself without good cause.
Friday, September 27, 2013
Debts
President Obama has indicated, in discussions regrding the debt ceilling that "America pays its debts." The fallacy of this appeal lies in the fact that, if you are borrowing money to pay off your debts, you are not paying off your debts, you are just shifting them around.
Thursday, September 26, 2013
The end of Islamism
I An interesting biological phenomenon is that simple organisms such as bacteria, viruses, and fungi are capable of wreaking havoc on more complex and highly developed beings. This is not surprising, as entropy favors destruction and decay. It is always easier to destroy than to build. This concept applies not only to biological organisms but to societies and cultures as well.
The destinies of civilizations are not always in the direction of greater advancements. There is no guarantee that the future is limited to greater artistic, intellectual and humanitarian achievement. The triumphs of civilization are often fragile and barbarism is always a threat.
GK Chesterton observed that barbarism does not always describe only those cultures that are insufficiently advanced in civilization, but also describes those that, having advanced, become hostile and threatening toward it. The source of this contempt and enmity for values and traditioms that oppose, for example terrorism, genocide, and religious persecution vary from time to time and place to place. The most prominent doctrine that now opposes liberal values is that of radical Islam. The stated goal of this movement is to establish worldwide sharia law and dominance of political Islam. The ideological springboard for this regressive and destructive movement is not based in religious piety but in an emotional, supremacist fantasy.
There in fact will never be a worldwide caliphate. There are many reasons for this which include:
1.) Sharia law results in relatively weak political systems, that are not well suited to the complexities and rapid change of modernity.
2.) The present worldwide Islamic terrorist movement is not capable of achieving and maintaining power, as terrorism itself is unstable..
3.) The strategy of attempting to establish demographic dominance by emigration to Western countries fosters an atmosphere of dependence and insularity that is inherently unstable.
4.) While religion has provided an organizing framework for many cultures and societies, there is a limit to the influence of any particular religious doctrine in pluralistic societies. Human beings are simply not religious enough to accede to religious dominance in all areas of life.
5.) If political Islam were capable of creating and maintaining desirable cultures and societies, the net immigration would be from Western societies to Muslim ones rather than the other way around.
6.) Chauvinism is a poor basis for a system of government.
7.) There's a reason why Ataturk ditched the agonal Caliphate about eighty years ago. The present campaign to reestablish political Islam through terrorism, wanton violence, demographic hegemony and narcissistic complaint is a doomed effort to reinvigorate a failed idea.
8.) The more establsihed that Islamism becomes, the more susceptible it is to the barbaric instincts that inhere in human nature. It will become the target, rather than the aggressor.
9.) Threatening to behead those who "insult" you or cause you offense is a hallmark of weakness; any doctrine that cannot accommodate ridicule cannot accommodate reality.
The destinies of civilizations are not always in the direction of greater advancements. There is no guarantee that the future is limited to greater artistic, intellectual and humanitarian achievement. The triumphs of civilization are often fragile and barbarism is always a threat.
GK Chesterton observed that barbarism does not always describe only those cultures that are insufficiently advanced in civilization, but also describes those that, having advanced, become hostile and threatening toward it. The source of this contempt and enmity for values and traditioms that oppose, for example terrorism, genocide, and religious persecution vary from time to time and place to place. The most prominent doctrine that now opposes liberal values is that of radical Islam. The stated goal of this movement is to establish worldwide sharia law and dominance of political Islam. The ideological springboard for this regressive and destructive movement is not based in religious piety but in an emotional, supremacist fantasy.
There in fact will never be a worldwide caliphate. There are many reasons for this which include:
1.) Sharia law results in relatively weak political systems, that are not well suited to the complexities and rapid change of modernity.
2.) The present worldwide Islamic terrorist movement is not capable of achieving and maintaining power, as terrorism itself is unstable..
3.) The strategy of attempting to establish demographic dominance by emigration to Western countries fosters an atmosphere of dependence and insularity that is inherently unstable.
4.) While religion has provided an organizing framework for many cultures and societies, there is a limit to the influence of any particular religious doctrine in pluralistic societies. Human beings are simply not religious enough to accede to religious dominance in all areas of life.
5.) If political Islam were capable of creating and maintaining desirable cultures and societies, the net immigration would be from Western societies to Muslim ones rather than the other way around.
6.) Chauvinism is a poor basis for a system of government.
7.) There's a reason why Ataturk ditched the agonal Caliphate about eighty years ago. The present campaign to reestablish political Islam through terrorism, wanton violence, demographic hegemony and narcissistic complaint is a doomed effort to reinvigorate a failed idea.
8.) The more establsihed that Islamism becomes, the more susceptible it is to the barbaric instincts that inhere in human nature. It will become the target, rather than the aggressor.
9.) Threatening to behead those who "insult" you or cause you offense is a hallmark of weakness; any doctrine that cannot accommodate ridicule cannot accommodate reality.
Tuesday, September 24, 2013
Common sense gun legislation
Advocates of gun control legislation frequently feel the need to burnish their proposals with the adjective "common sense." Thus, appeal is often made to public support for "common sense gun control legislation." One of the first requirements of common sense legislation is that it accomplish its intended purpose. "Gun control" legislation that does not control guns, or more specifically, does not reduce criminal gun violence does not legitimately bear the appellation "common sense."
Cosmetic legislation that serves only as an emotional bromide can legitimately be called neither common sense nor gun control. Gun violence is first and foremost violence, and it is the pathologies that predispose certain individuals to violence that are at the heart of the crisis. Seung Hui-Cho, Eric Harris, James Holmes, Anders Breivik, Jared Lee Loughner, and Aaron Alexis all perpetrated mass shoootings of strangers, and all had previously been referred for psychiatric evaluation. What is equally troubling, is that all were relatively intelligent and capable of intricate planning. It is inobvious how magazine capacity limits or ammunition surcharges, or outlawing firearms with flash suppressors would have thwarted disturbed but cunning minds. It is quite likely that they would outsmart the most heartfelt of firearm restrictions. It is also worth noting that Anders Breivik killed eight people with a bomb, and that James Holmes rigged his apartment with incendiary devices. The essence of a mass murderer is a malignant motive and will. The weapon to be used is secondary.
Whether or not some idea qualifies as "common sense" depends upon context. If a community were suddenly gripped by a violent crime wave, in which the authorities could do little more than show up after the fact, it might certainly be "common sense" that the citizenry be armed in its own defense.
The people who insists on retaining the right to own firearms for their own personal use do not thereby condone the actions of psychotic murderers; they do not provide the impetus to slaughter by mentally unstable, but quite resourceful miscreants. They do not excuse the acts of madmen; the people who focus on the weapon rather than the act do. The people who support the Second Amendment do not condone the lawless gunfire in gun control venues such as Chicago or Washington DC. They do not assume moral culpability for refusing to play along with the deluded fantasy that "common sense" gun control legislation is anything of the sort.
Cosmetic legislation that serves only as an emotional bromide can legitimately be called neither common sense nor gun control. Gun violence is first and foremost violence, and it is the pathologies that predispose certain individuals to violence that are at the heart of the crisis. Seung Hui-Cho, Eric Harris, James Holmes, Anders Breivik, Jared Lee Loughner, and Aaron Alexis all perpetrated mass shoootings of strangers, and all had previously been referred for psychiatric evaluation. What is equally troubling, is that all were relatively intelligent and capable of intricate planning. It is inobvious how magazine capacity limits or ammunition surcharges, or outlawing firearms with flash suppressors would have thwarted disturbed but cunning minds. It is quite likely that they would outsmart the most heartfelt of firearm restrictions. It is also worth noting that Anders Breivik killed eight people with a bomb, and that James Holmes rigged his apartment with incendiary devices. The essence of a mass murderer is a malignant motive and will. The weapon to be used is secondary.
Whether or not some idea qualifies as "common sense" depends upon context. If a community were suddenly gripped by a violent crime wave, in which the authorities could do little more than show up after the fact, it might certainly be "common sense" that the citizenry be armed in its own defense.
The people who insists on retaining the right to own firearms for their own personal use do not thereby condone the actions of psychotic murderers; they do not provide the impetus to slaughter by mentally unstable, but quite resourceful miscreants. They do not excuse the acts of madmen; the people who focus on the weapon rather than the act do. The people who support the Second Amendment do not condone the lawless gunfire in gun control venues such as Chicago or Washington DC. They do not assume moral culpability for refusing to play along with the deluded fantasy that "common sense" gun control legislation is anything of the sort.
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