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Civility is the ability to disagree with others while respecting their sincerity and decency. Civility begins with understanding. We can best understand our political differences by first understanding the moral foundations upon which political views are built. This site features research, resources, and commentary related to the pursuit of Civility through understanding.


California’s 2/3 supermajority rule for spending legislation is addressed in an article for by George Lakoff, Professor of Linguistics at the University of California, Berkeley.

To paraphrase George Tenet, this should be a slam dunk.  As a simple principle of democratic rule, legislation should be enacted by majority vote.  Lakoff is absolutely right that California law as it now stands in effect gives a one third minority of legislators veto power over the will of the majority.

Of course it is true that rule by simple majority at the moment would give Democrats the legislative advantage, but this will not always be so, depending on which way the electoral winds blow.  Whatever one thinks of pending legislation, budgets, etc., Lakoff has a strong case that the supermajority rule as it now stands is a recipe for gridlock and undemocratic on its face.



Choice works.  Just ask La Crosse, WI.

The folks there deserve credit for more than their famous boots, they have also pioneered ‘end of life’ care that works at the Gundersen Lutheran Health System; it preserves choice and dignity.  And it also happens to be less expensive.

From the Washington Post:

La Crosse became a pioneer in addressing end-of-life questions in the mid-1980s, after Hammes, a native of the city who has a doctorate in philosophy from Notre Dame, arrived at Gundersen as the director of medical humanities, charged with educating resident physicians about ethics. He noticed a “troubling pattern,” he said, in which family members struggled to make medical decisions, such as whether to continue dialysis after a stroke.

“We’d turn to the family and say, ‘We need your input. If your mother or father could speak now, what would they tell you?’ And the family would say, ‘If we only knew,’ ” said Hammes, 59. “I could see the distress. They were going to have to live with themselves, with the worry about making a mistake. This was unacceptable.”

The hospital began urging families to plan while people are healthy. For those who want help writing a directive, a physician will discuss the powers and limits of medicine and explain to family members what it means if they agree to serve as the “health-care agent.” They will also help people define the conditions under which they would no longer want treatment. Hammes said people often define this as “when I’ve reached a point where I don’t know who I am or who I’m with, and don’t have any hope of recovery.”

The directives are power-of-attorney forms that protect physicians and family members against liability, and the hospital makes clear to its doctors that they are expected to follow them. Today, more than 90 percent of people in town have directives when they die, double the national average…

…locals say it is because Gundersen and the town’s other hospital, Franciscan Skemp, have urged planning. “People here have their feet planted in the ground,” said Barbara Frank, a retired teacher. “They’re no-nonsense sorts of people, without a lot of illusion. That was the fertile soil upon which it was planted. But there’s no question it was helped by the two medical centers taking the lead and saying, ‘This is a good thing for you to do.’ “

By creating a culture of planning, this community has improved it’s citizens control of health care choices.  And by coincidence, it’s also turned out to be less expensive, as none other than Newt Gingrich explains:

Let me give you an example that I find fascinating. In LaCrosse, Wisc., the Gundersen Lutheran Hospital system is, according to the Dartmouth [Atlas of Health Care], the least expensive place in America for the last two years of life. They have an advanced directive program, and over 90 percent of their patients have an advanced directive. They have electronic health records, so everybody on the staff knows what the advanced directive is. They have a very strong palliative care program for using drugs to manage pain. They have a hospice program.The result is today, the last two years of your life in costs are about $13,600. The last two years of your life at UCLA are $58,000. Now, why should Medicare pay $58,000 for the same outcome if it could pay $13,600? You can say, well, Los Angeles is more expensive; they do a couple of more complicated things. So fine. So let’s say it ought to be $20,000 at UCLA. That’s still [$38,000] less than it currently is. …

The Gundersen experience demonstrates two things: 1) End of life planning can work, and 2) We don’t need government help to do it.  The Gundersen success begs the question why couldn’t Britain’s government run health care get this right (see Is ‘end of life care’ pro end of life)?  Mr. Gingrich suggests:

We don’t think the politicians can ever fix this because the hospital lobby is so powerful, and the doctor lobby is so powerful, and the pharmaceutical lobby is so powerful, and the medical technology lobby is so powerful. You’re not going to politically solve this, but if I could empower you to know that, people start making choices. We know, for example, that if a doctor knows price, 60 percent of the time they will prescribe the less expensive drug, just because of their common sense. It’s practical. We know that people are willing to look at practical outcomes.

Seems practical  to leave government out of it.



Where Did “We” Go?  By Thomas Friedman



The man who saw the meltdown coming had another troubling insight: it will happen again.



A specter is haunting Europe — the specter of Socialism’s slow collapse. Full article



David Brooks contributes to the case for obsoleting Left/Right labels. 

When democracy was an infant there was much discussion about the ability of an electorate to self-govern.  Would the voters have sufficient ‘virtue’, in the vernacular of the times, to govern themselves?  Would democracy replace tyrants, or become a new tyranny of the majority?  It depended on the virtue of the electorate.  

Mr. Brooks approaches the call to virtue from an even larger view:

Centuries ago, historians came up with a classic theory to explain the rise and decline of nations. The theory was that great nations start out tough-minded and energetic. Toughness and energy lead to wealth and power. Wealth and power lead to affluence and luxury. Affluence and luxury lead to decadence, corruption and decline.

He puts the contemporary problem nicely:

Our current cultural politics are organized by the obsolete culture war, which has put secular liberals on one side and religious conservatives on the other. But the slide in economic morality afflicted Red and Blue America equally.

If there is to be a movement to restore economic values, it will have to cut across the current taxonomies. Its goal will be to make the U.S. again a producer economy, not a consumer economy. It will champion a return to financial self-restraint, large and small.

It will have to take on what you might call the lobbyist ethos — the righteous conviction held by everybody from AARP to the agribusinesses that their groups are entitled to every possible appropriation, regardless of the larger public cost. It will have to take on the self-indulgent popular demand for low taxes and high spending.

Here here.  Let’s never mind left/right, blue/red.  Perhaps we start by asking of ourselves, what can we afford?




Sep 292009









A look at national health care systems around the world





Timothy Egan’s article about Gov. John Kitzhaber and his family is touching and well written.  The article intertwines two narratives, death with dignity, and universal healthcare.   The implication is that the two are somehow linked, but are they really?

Can’t we have dignified death without state control of healthcare?   Gov. Kitzhaber and his family were able to make their own choices regarding his parents end of life decisions.   Isn’t that freedom part of the sanctity of life?  Britian’s experience is that state control diminishes individual freedom, with horrifying consequences at end of life.



Hillary’s Honduras Obsession By Mary O’Grady




renocol_ThomasFrankLiberals and Civility      By Thomas Frank


ELITISM once featured an article by Raymond J. Learsy (a successful oil trader turned analyst).   He makes an argument that if we could only be more like France , well, everything would be better.  Why?  Because France is  ruled by elites.

Mr. Learsy seems to follow in the footsteps first laid down by Walter Lippman in Public Opinion.  Published in 1922 (when the author was 33 years old), it is one of the earliest and most explicit calls for elitism.  Lippman  believed the common man lacked sufficient understanding to enable him to participate meaningfully in public decisions.  From Wikipedia

Early on Lippmann said the herd of citizens must be governed by “a specialized class whose interests reach beyond the locality.”  This class is composed of experts, specialists and bureaucrats. The experts, who often are referred to as “elites,” were to be a machinery of knowledge that circumvents the primary defect of democracy, the impossible ideal of the “omnicompetent citizen”.

The clarion call from the 1920′s is taking up by Mr. Learsy, who seems to be channeling Mr. Lippman when he writes

France’s governance emanates from an elite corp of public servants, graduates of the “grands ecoles” who run the sinews of the Ministries of State. It has given France a government whose dedication and commitment to the general weal is keenly suited to a fiercely competitive world…France has a government with vision, having the welfare of the general public foremost in its sights.

Successful rule by elite is not limited to France, he continues

…consider China. Here is a society with an elite corps of public servants. Only the best and the brightest from the very top schools gain access to what is today the almost ludicrously misnamed the “Communist Party.”

Curiously, Mr. Learsy goes on to quote an article by David Brooks, which was plainly intended to poke fun at elitism.  From Brooks…

The top 1 percent will go to the elite universities. Some of the others will go to second-tier schools, at best. These unfortunates will find that, while their career prospects aren’t permanently foreclosed, the odds of great success are diminished. Suicide rates at these schools are high, as students come to feel they have failed their parents…  You are truly a golden child, because you succeed in university as well. You have a number of opportunities… you decide to enter government service, which is less risky and gives you chances to get rich (under the table) and serve the nation.

But Brooks concludes:

Perhaps it’s simply impossible for a top-down memorization-based elite to organize a flexible, innovative information economy, no matter how brilliant its members are.

Mr. Lippman made innumerable contributions to public discourse during his career.  Often cited as the father of American political commentary, he won two Pulitzers during his ensuing 30 year career.  However, elitism is such a charged term that a google search of Mr. Lippman today inevitably references his contributions to elitism, rarely approvingly.

It’s possible that elitism defines an interesting distinction between the proclivities of liberals and non-liberals.  Liberals are comfortable with, even welcome, the idea of an informed elite making decisions for them.   Non-liberals,  probably disinclined to believe the benevolent  and public spirited assumptions, are disinclined to trust such an elite.


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I believe we have to figure out our imigration problems, but we also have to take care of people (old, young, whatever) who are sick and or/ broken. Is the ER the only recourse? All of us end up paying for that, too.

What does your moral compass say?

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Maureen Dowd’s NYT column about Joe Wilson…

In August, Clyburn picked up a newspaper to see that Wilson was
holding his first town hall meeting in Clyburn’s district, three
minutes from his house, at the high school Clyburn’s children went to
— an “in your face” breach of Congressional protocol.

“He was being confrontational and combative,” Clyburn said. “And
Wednesday night was just bringing his town hall meeting antics to the
floor of the House of Representatives.”

The black members of Congress were fed up, after a long, hot summer of
sulfurous attitudes toward the first black president. Clyburn
privately pressed Wilson three times last Thursday to apologize for
breaking the rules — Wilson’s own wife asked him who the “nut” was who
was hollering at the president — but the Republican was getting chesty
with his unlikely new role as king of the rowdies.

He was regarded as a hero at the anti-Obama rally in Washington last
weekend that featured such classy placards as, with a picture of a
lion, “The Zoo has an African and the White House has a Lyin’
African;” “Bury Obamacare with Kennedy;” “We came unarmed (this time)”
and “ ‘Cap’ Congress and ‘Trade’ Obama back to Kenya!”

A camera also caught Wilson in Washington signing for a fan a picture
of himself confronting the president, and he has raised $2 million in
the last week.

Former President Jimmy Carter weighed in with Brian Williams of NBC
News on Tuesday: “I think an overwhelming portion of the intensely
demonstrated animosity toward President Barack Obama is based on the
fact that he is a black man.” He said he felt that was true in the
South and elsewhere.

Clyburn won the manners round, but Wilson was back Tuesday night
tweeting his rude new fans, people who, as the minority leader, John
Boehner, put it, are “scared to death that the country that they grew
up in is not going to be the country that their kids and grandkids
grew up in.”

It’s not. That country is gone. And in terms of biases that have
faded, that’s a good thing. But partly due to the Internet, the
standards of behavior in this new country are terrible.

If Beaver and Wally were around today, they’d likely be writing
snarky, revealing blogs about June and Ward.Rich Text AreaToolbarBold (Ctrl / Alt+Shift + B)Italic (Ctrl / Alt+Shift + I)Strikethrough (Alt+Shift+D)Unordered list (Alt+Shift+U)Ordered list (Alt+Shift+O)Blockquote (Alt+Shift+Q)Align Left (Alt+Shift+L)Align Center (Alt+Shift+C)Align Right (Alt+Shift+R)Insert/edit link (Alt+Shift+A)Unlink (Alt+Shift+S)Insert More Tag (Alt+Shift+T)Toggle spellchecker (Alt+Shift+N)▼
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Maureen Dowd’s NYT column about Joe Wilson…
In August, Clyburn picked up a newspaper to see that Wilson was
holding his first town hall meeting in Clyburn’s district, three
minutes from his house, at the high school Clyburn’s children went to
— an “in your face” breach of Congressional protocol.

“He was being confrontational and combative,” Clyburn said. “And
Wednesday night was just bringing his town hall meeting antics to the
floor of the House of Representatives.”

The black members of Congress were fed up, after a long, hot summer of
sulfurous attitudes toward the first black president. Clyburn
privately pressed Wilson three times last Thursday to apologize for
breaking the rules — Wilson’s own wife asked him who the “nut” was who
was hollering at the president — but the Republican was getting chesty
with his unlikely new role as king of the rowdies.

He was regarded as a hero at the anti-Obama rally in Washington last
weekend that featured such classy placards as, with a picture of a
lion, “The Zoo has an African and the White House has a Lyin’
African;” “Bury Obamacare with Kennedy;” “We came unarmed (this time)”
and “ ‘Cap’ Congress and ‘Trade’ Obama back to Kenya!”

A camera also caught Wilson in Washington signing for a fan a picture
of himself confronting the president, and he has raised $2 million in
the last week.

Former President Jimmy Carter weighed in with Brian Williams of NBC
News on Tuesday: “I think an overwhelming portion of the intensely
demonstrated animosity toward President Barack Obama is based on the
fact that he is a black man.” He said he felt that was true in the
South and elsewhere.

Clyburn won the manners round, but Wilson was back Tuesday night
tweeting his rude new fans, people who, as the minority leader, John
Boehner, put it, are “scared to death that the country that they grew
up in is not going to be the country that their kids and grandkids
grew up in.”

It’s not. That country is gone. And in terms of biases that have
faded, that’s a good thing. But partly due to the Internet, the
standards of behavior in this new country are terrible.

If Beaver and Wally were around today, they’d likely be writing
snarky, revealing blogs about June and Ward.

Huffington Post published top 10 wealthiest members of Congress, 8 are Dems, 2 Republican.  Interesting comments from readers include this:

“Capitalism — A brain-power dictatorship
Brains like handsome good looks pass from father to son, those with excessive wealth run things and until we reach the ultimate conclusion of evil they always shall.
For we are all given a different ability to earn income as a test, to see if we pass our excessive wealth down to those less fortunate where it belongs.”


This from the WSJ…
“Last week, I asked…Congressman James Clyburn…where in the Constitution it authorizes the federal government to regulate the delivery of health care. He replied: “There’s nothing in the Constitution that says that the federal government has anything to do with most of the stuff we do.”  Then he shot back: “How about [you] show me where in the Constitution it prohibits the federal government from doing this?”"  ( )
Sigh.  It goes without saying that ignorance of the 9th & 10th amendments and no acknowledgement of constraint on federal power is a problem.       
A really big problem. 
I’m convinced this is not a partisan issue.  I believe the same attitude prevails amongst Republicans.  A few years ago liberals considered the Patriot Act tyranical, and we’re probably right.  The NYT called “Bush’s tyrannical law” a “low point in American Democracy”.  ( )
Looking historically, what today is a Democratic position was yesterday a Republican position.  The “progressive movement” was led by Teddy Roosevelt and the Republican party in the early 1900′s.  The progressive movement is largely responsible for the income tax, women’s right to vote, the direct election of senators, and generally argued for increased government to promote social justice.  The last protectionist President was Hoover, a Republican.  Milton Friedman convinced the IRS to withhold wages.  The political parties are more akin to snails that occupy ideological shells according to the political exigencies of the day.  The constitutional checks and balances have been severely weakened, and it should not give any of us comfort if our particular party is the fashion of the day.  It is in their nature to grow government, and there is no better time to increase the scope of government than times of perceived crisis.  


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Jonathan Chait critiques Ayn

Rand in The New Republic…have at it.


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Using current ‘Tax Freedom Day’ calculations, Tessie can expect to spend the first 20 years* of her working life as a slave to a ‘just’ society.

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Social welfare is a huge burden on our freedom and our children’s future. In Tessie’s case it means 20 years of indentured servitude.

20 years of her future stolen from her.

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Does it bother anyone that the Republican Party, with Sarah Palin and Rush Limbaugh
as standard bearers, so eagerly traffics in hate and fear and not much else?  This strategy is of course
effective, because hate and fear are easily packaged into sound bites for media consumption. Still,
I should think thoughtful Republicans would be dismayed by the ascendancy of the rabid right.




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Is the role of government to provide equality of opportunity, or equality of outcome?   They are mutually exclusive.

Equality of opportunity necessarily means inequality of outcome.  People are not born with equal ability, equal circumstances, and equal luck.

Equality of outcome necessarily means individual success must either be prevented or appropriated back to the average, so that others may be lifted.

Which is more fair? Much depends on how fairness is understood.

Fairness is proportionality.  The Left (progressives), who rely on the moral foundations related to Compassion, tend to view proportionality in terms of outcomes, therefore disproportionate wealth accumulation is seen as unfair.  The Right (conservatives), who rely on moral foundations related to both Compassion and social Harmony, tend to view proportionality in terms of effort, so wealth unevenly distributed yet proportionate to effort is fair.

Where the two find common ground is opposing wealth accumulated not by effort, but by cheating, illegallity, gaming of the system, political manipulation, etc..  Wrongful wealth is universally seen as unfair.  Wrongful wealth violates equality of outcomes and equality of opportunity.

Few people would take equality of opportunity so far as to insure that each citizen received exactly the same amount of society’s production.  Most people favor equality of opportunity unless the results become so unbalanced they cross some undefined line representing that person’s perception of fairness.   This line often involves a sense that not only are the have not’s under participating in the nations wealth, but are prevented from rising.  The cure is actions to improve the equality of opportunity.  Affirmative action is an example.

It’s important to note that this equality question is not a social welfare question.  Social welfare refers to a safety net of services a society makes available to individual’s who are not able to care for themselves, either temporarily or permanently.

Much is written today about historical levels of income/wealth inequality.  The root cause is not really income per se, but wealth in the form of stocks, bonds, and real estate; capital assets.   Those individuals who are experiencing large gains in wealth are people who hold capital assets.

Goods and services are produced with labor and capital.  The costs of production are divided between labor and capital in some ratio.   What we are experiencing now is a monumental shift in this ratio.  By example, numbers used to be added up by people (labor) using adding machines.  Now number are added up by computers (capital).  In the adding up business, labor lost income and those who owned stock in the computer companies gained.  Repeat the implementation of technology across the entire economy, and there has to be a huge shift of income from labor toward capital.

The news is now delivered in real time via the internet.  Newspapers, and all the people it takes to print and deliver them, are in trouble.  Should we punish or reward those who invested in the internet?  There were once 2000 commercial ice plants in the U.S., delivered to your home by iconic ice trucks if you put out your “Ice Today” sign.  Home refrigeration ruined the ice business.  We are experiencing some type of this phenomenon across almost all sectors of the economy.

Given the massive shift, we are bound to have a period of excess labor.  This means wages must stagnate (they already have) or even fall.  And it isn’t anyones fault because nothing is wrong.

For many this will feel “unfair”.  After all, it is not their fault the ice business is going away, but it is their fault they can’t pay the mortgage.  In a sense they are the victims of a calamity, not the victims of an injustice.   If society wants to alleviate their circumstances, it is important to understand we would be providing social welfare to unfortunate victims of a calamity, not correcting some fatal flaw in how income is distributed.   With this distinction we can have a civil conversation that honors the Left’s Compassion along with the Right’s interest in Harmony.







Originally, anyway.  It was made legal with the passage of the 16th Amendment in February of 1913.

Upon passage, the new President Wilson immediately called a special session of Congress and the Revenue Act of 1913 passed in May of 1913.  The tax rate was 1-7%.  By 1918 rates were 12-77%, justified by WW I.  A history of income tax in America can be found here.

Inflation since 1913 is 2,180%.   Between 1913 and 1994 government spending grew 13,592%.

Interesting perspective.  Here’s a fun game, ask your friends if they knew the income tax was originally unconstitutional!


Well, actually Camille Paglia’s piece is something of a liberal on liberal rant, but it does contain a call to think…

But affluent middle-class Democrats now seem to be complacently servile toward authority and automatically believe everything party leaders tell them. Why? Is it because the new professional class is a glossy product of generically institutionalized learning? Independent thought and logical analysis of argument are no longer taught. Elite education in the U.S. has become a frenetic assembly line of competitive college application to schools where ideological brainwashing is so pandemic that it’s invisible. The top schools, from the Ivy League on down, promote “critical thinking,” which sounds good but is in fact just a style of rote regurgitation of hackneyed approved terms (“racism, sexism, homophobia”) when confronted with any social issue. The Democratic brain has been marinating so long in those clichés that it’s positively pickled.

Ditto that for Republicans.



As proposed in HR3200 we would have a Health Choices Administration, described this way by U.S. News;

Congress proposes a new, independent federal agency called the Health Choices Administration, whose commissioner would create standards for insurance that you and some 285 million Americans (15 million would still not be covered) would be required to have. The commissioner would also qualify plans that meet federal requirements and determine which individuals are eligible for subsidies.

The HCA would be guided by the recommendations of the Health Benefits Advisory Committee, from the same article;

Recommendations for the essential benefits your insurance would cover, which would change with new knowledge and technology, would rest largely with the secretary of health and human services’ Health Benefits Advisory Committee. This group of up to 27, more than half of whom would be appointed by the president, would come up with lists of treatments and services that must be covered and set your copayments for any of the covered services.

In Britain, the National Health Service has what sure sounds like an equivalent to the proposed HBAC, the National Insitute for Health & Clinical Excellence, or NICE.  From the NICE website:

NICE produces guidance in three areas of health:

  • public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
  • clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

You can’t please all the people all the time, but are we prepared for headlines like this, Restrictions on prescription of osteoporosis drug ‘defy belief‘.



Friedrich August von Hayek CH (8 May 1899 – 23 March 1992), was an Austrian and British economist and philosopher known for his defense of classical liberalism and free-market capitalism against socialist and collectivist thought. He is considered to be one of the most important economists and political philosophers of the twentieth century.  Hayek’s account of how changing prices communicate signals which enable individuals to coordinate their plans is widely regarded as an important achievement in economics. (from wikipedia)

He was also awarded the Nobel Prize in 1974.  He is one of the most important conservative economists of this century (the title probably goes to Milton Friedman, who said he considered Hayek his most important influence, and Ayn Rand had a wider influence).  Hayek’s classic the Road to Serfdom, first published in 1944, remains as topical as ever.

In it, Hayek makes the case against ambiguous legislation.  He argues society is underpinned by the Rule of Law.  “[The Rule of Law] means that government in all its actions is bound by rules fixed and announced beforehand – rules which make it possible to foresee with fair certainty how the authority will use its coercive powers in given circumstances and to plan one’s individual affairs on the basis of knowledge”.

He discusses one way in which the Rule of Law is degraded, “When we have to choose between higher wages for nurses or doctors and more extensive services for the sick…nothing short of a complete system of values in which every want of every person or group has a definite place is necessary to provide an answer…[A]s planning becomes more and more extensive, it becomes regularly necessary to qualify legal provisions increasingly by reference to what is “fair” or “reasonable”; this means that it becomes necessary to leave the decision of the concrete case more and more to the discretion of the judge or authority…One could write a history of the decline of the Rule of Law…in terms of the progressive introduction of these vague formulas into legislation and jurisdiction, and of the increasing arbitrariness and uncertainty of… the law and the judicature, which in these circumstances could not but become an instrument of policy.”

This point is quintessentially non-partisan.  The passage of ambiguous legislation leading to policy decided not by elected representatives but by bureaucrats, or left to judges, would seem to define the last 60 years no matter which party dominated politics.



Does this not ring a bell…

“Schumpeter’s theory is that the success of capitalism will lead to a form of corporatism and a fostering of values hostile to capitalism, especially among intellectuals. The intellectual and social climate needed to allow entrepreneurship to thrive will not exist in advanced capitalism; it will be replaced by socialism in some form. There will not be a revolution, but merely a trend in parliaments to elect social democratic parties of one stripe or another. He argued that capitalism’s collapse from within will come about as democratic majorities vote for the creation of a welfare state and place restrictions upon entrepreneurship that will burden and destroy the capitalist structure. Schumpeter emphasizes throughout this book that he is analyzing trends, not engaging in political advocacy. In his vision, the intellectual class will play an important role in capitalism’s demise. The term “intellectuals” denotes a class of persons in a position to develop critiques of societal matters for which they are not directly responsible and able to stand up for the interests of strata to which they themselves do not belong. One of the great advantages of capitalism, he argues, is that as compared with pre-capitalist periods, when education was a privilege of the few, more and more people acquire (higher) education. The availability of fulfilling work is however limited and this, coupled with the experience of unemployment, produces discontent. The intellectual class is then able to organise protest and develop critical ideas.”

Had he only foreseen the internet!

This from the wikipedia page of economist Joseph Schumpeter.  Here’s the full text of his book Capitalism, Socialism, and Democracy.



End of life care is the subject at the heart of the notorious comments made by she that shall not be named (the original facebook post can be found here).  Though she does not refer to it, it is alleged in the media that she was referring to HR3200‘s section 1233, Advanced Care Planning Consultation.   The reading of the bills is quite involved and I will not try to retrace the path.

Section 1233 provides funding for end of life planning every five years, or more frequently if health changes suddenly.  While such counseling is not itself required, the Act does require “quality” measurements of physicians regarding their end of life care practices and whether or not they are following such guidance.   It also provides for the optional issuance of medical orders resulting from the consultation, subject to the patients approval, including control of nutrition and hydration.   Overall, Section 1233 does not strike me as overtly threatening.

More concerning is the Independent Medicare Advisory Council Act of 2009, endorsed and proposed separately by the administration.   This Act provides for a 5 member commission, appointed by the President and approved by the Senate, to recommend changes to Medicare each year.  Subject to the Presidents approval, the recommendations would automatically become law unless Congress intervenes.  Once enacted, the Councils actions are not reviewable in court, with very narrow exceptions.  The main intent is to control costs, and most of the bill is concerned with the details of payment schedules.  However, the Council may also “…submit, under separate cover, a report containing recommendations for reforms to the Medicare program…”.  There follows a long list of specific regulations the Council may not review.   The Congressional Budget Office’s review essentially concludes the Council is not likely to save much money, if any at all.   To increase the chances of the IMAC effecting real results, the CBO is recommending “Providing clear authority for the council to recommend broad changes in coverage, benefit design, and payment and delivery systems”, and “Expanding the council’s mandate to include making recommendations for changes to the broader health care system”.

And finally, there is the “Health Choices Commissioner“, who would determine, well, our choices.

For many the concerns are intuitive, almost gut felt.  For the rest of us, here’s a presentation of the concerns that these proposal’s may lead us toward:

Step 1.  Advance Care Planning in a compassionate voice. The webpage helping us to understand might look like this…


Advance Care Planning

Caring for people at the end of their lives is an important role for health and social care professionals. One of the elements to support people at the end of their lives is to find out what their preferences and wishes are in relation to their future care.

Advance Care Planning

Advance Care Planning (ACP) is a voluntary process of discussion between an individual and their care providers irrespective of discipline. If the individual wishes, their family and friends may be included in the discussions. With the individual’s agreement, this discussion should be recorded, regularly reviewed and communicated to key persons involved in their care.

An ACP discussion might include:

  • the individual’s concerns
  • their important values or personal goals for care
  • their understanding about their illness and prognosis
  • preferences for types of care or treatment that may be beneficial in the future and the availability of these



Step 2.  The development of end-of-life protocols.  Perhaps the webpage would be thus…


Compassionate Care Pathway

The Compassionate Care Pathway (CCP) for the dying patient has been developed to transfer the hospice model of care into other care settings.

The Ronald McDonald Hospice Care Institute  has pioneered the implementation of the Compassionate Care Pathway for the Dying Patient (CCP). This program is recognised nationally and internationally as leading practice in care of the dying to enable patients to die a dignified death and provide support to their relatives.

The CCP provides a useful template to guide the delivery of care for the dying to complement the skill and expertise of the practitioner using it. Once commenced the goals of care prompt staff to consider the continued need for invasive procedures and whether current medications really are conferring benefit. The health care professional is free to use his or her own clinical judgment in this process.

The use of the CCP does not preclude use of antibiotics or artificial nutrition or hydration but it does ask the professional to consider an appropriate decision for that moment in time and document the reason for decisions made.


Step 3. Outcomes we didn’t expect.  The headlines might look like these….

Sentenced to Death on CCP

The Compassionate Care Pathway may be the slippery slope to backdoor euthanasia

Terminally ill care crisis


You just can’t make this stuff up.  Step 1 can be found here,  Step 2 is here, and Step 3 is here and here.

No Healthcare bill has passed, it’s unclear exactly what is proposed and who is supporting it.  But it is difficult to read the hundreds of comments on the Liverpool Care Pathway article and not feel empathy for those whose fates were decided by a distant committee/council/agency/department/commission.   Think what you will about the present proposals, none of us want to be placed on the Liverpool Pathway without our consent.   The sequence of events that led Britain to it’s present circumstance were not carried out by evil men and women, those involved in hospice care may be the most compassionate among us.  But if we are to avoid a similar fate, doesn’t it seem we need to pay attention now?

Update 9/3/2009- See new post on The Danger of Ambiguous Legislation

Update 9/18/2009 – Administrator of Liverpool Care Pathway response to media reports.  Feel better?

Update 9/30/2009 – Wisconsin solves the problem, this will make you feel better…End of Life Care That Works

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