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.
 

Coming into Paris by cab gets you thinking about the riots there a couple of years ago, because the outer rings of the city seem to be overwhelmingly populated by Arabic/Muslims and are uniformly bleak in appearance.   This is not the tourist Paris; it is a depressing cityscape just to drive through.  Of course the French have a very difficult relationship with their–very large–Muslim population, which has not been assimilated and is struggling to adjust to the increasingly tight strictures imposed by the secular French state on some forms of religious observance.  Chadors are not allowed in public, headscarves are banned in schools, and now there is talk of banning even headscarves in the public sphere altogether. France (terrorism aside) has a really volatile history with the Muslim world, including the Algerian and a hideous Paris flare-up in 1960 in which the French police killed several hundred Algerian immigrants and dumped their bodies in the Seine.  How did I get off on this history tangent?  I’ll stop here.  Back to Paris.

The contrast between the outer rings and the central core of the city is stark. Everywhere we went, and we covered large swathes of the city on foot, the place was humming with a diverse, multiethnic polyglot of vitality and prosperity.  It helped that we had beautiful, balmy weather, but the streets are packed with seemingly prosperous people, the restaurants and humming, and there are none of the rows of shuttered storefronts so common to many American cities.  European economic woes aside, this is no Detroit.  Far from it.  Part of this prosperity, though, comes from the uniformities imposed by a papering over globalization: Starbucks and other chains are everywhere. In some places this almost gives the feeling of walking down 5th Avenue in Seattle (one thing conspicuously lacking in the core city was observant Muslim women in headscarves. Central Paris shows a very diverse racial/ethnic mix, but some forms of discrimination/segregation look alive and well).

Of course not all is affluence and prosperity, even to the casual stroller.  There are street people here, looking just as wracked and desperate as their American counterparts, but in significantly fewer numbers.   I found myself doing the same sort of four step shuffle around them: first step sympathy, second step embarrassment, third step guilt, fourth step gone.  To all appearances the French give these unfortunates a similarly wide berth, with the same sort of body language.  Just a discouraging bit of cross-cultural commonality. There is less crime there–especially violent crime–but the same big city tensions pertain.  We talked to a shop owner who had lived many years in Daytona Beach, and returned to Paris in the last couple of years.  He had recently been mugged in the square outside his T-shirt shop, and said the stresses of living in the city were about to drive him back to Florida.

This brings me to the police.  They are everywhere, clad in a bewildering array of uniforms to guard public buildings, stroll the streets, roar around on motorcycles.  We even saw two uniformed police serving as crossing guards at an elementary school, and this on a sleepy side street about 15 feet wide.  The most striking thing about them–besides their colorful costuming–is that by our count they are about 99% white males.  A few women, but we didn’t see one face of color in uniform.  Not one.  In a city as diverse as Paris, this can’t be good.

I’ll give you a couple of serendipitous tourist moments illustrating the vitality of the city. We were walking along the Seine and happened on a large global photography exhibit stretched along the river.  Some of the images were quite powerful and haunting–kids in limbo in a lonely Russian orphanage, depressed Japanese self-scarring flaggelents (a phenonema I didn’t even know existed).  We happened to step into St Eustache, a Renaissance Catholic Church–more like a cathedral–during services.  A woman got up to sing, and her transcendently beautiful voice soaring through those high stone arches was almost enough to make a believer of me.  These two things happened on one day, which just shows what a heady mix of aesthetic and even moving stimulation Paris can be, and I haven’t even mentioned the museums.

In a way there isn’t much to say about the museums of Paris just because there is so much to say: they are a parallel world within the wider city world, a sort of gulag of art and history that Stalin might have imagined if he had been a humanist.  Here are a few fragments. There is series of Rembrandt self-portraits in the Louvre from youth to old age that in their own pictorial was suggest the liniments of that life and mind developing as powerfully as any print autobiography.  The huge, wraparound series of Monet Water Lilies in the Orangerie Museum are almost hallucinatory: you can become mesmerized and drown in those blue depths.  In the Pompidou Centre, there is a fascinating little documentary film covering a group of twelve year old Liverpool schoolchildren discussing an (unseen)
Picasso painting.  Somehow these kids, casually draped all over each other, burrow down into the heart of how Picasso uses form, emotion, and color.

Of course some things are a bit more earthy, such as the hordes of big black motorcycles blasting through the streets. It is apparently a Parisian law that these bikes are required to go from 0 to 60 between stop lights, making as much noise as possible (which is deafening). The curious thing is the cross walks actually work–the motorcycles bearing down like a pack of hungry sharks calmly halt and allow you to cross the street alive.  Paris has a thriving rent-a-bike program, in which Parisians check out bicycles from innumerable kiosks and placidly pedal around through the ravening, snarling traffic.  They look nothing like Americans ripping around on their $2,000 bikes and $500 biking outfits–Parisian bikes look like 1960 vintage Schwinns and they just pedal about slowly in their street clothes.  One American idea they should adopt is bike helmets. Parisians don’t wear them.  Still, I didn’t see any shattered bikes or squashed heads on the streets, and I was looking.

The women.  The stereotype goes that Parisian women have a certain attractiveness.  Believe it. I view it as a form of harassment.  For instance, I looked up from my menu at a sidewalk cafe to see a server who was one of the most beautiful women I’d ever seen, wearing a sweater off (way off) one shoulder.  I thought to myself, Really?  I’m just trying to order lunch here!  Please to stop assaulting me with your stunningness!  This sort of harrowing experience was repeated everywhere.  They come at you in waves.  (P.C. Note: I’m aware that the Strauss-Kahn adventures in New York have helped blow the lid off the real problem of French sexual harassment.)

This little report has been an impressionistic hodgepodge, but that is the sort of thing encouraged by the experience of Paris.  This is a city that is all surface and all depth, all present and all past. It sets off echoes in your head.  You can stand on a bridge over the Seine looking down at Notre Dame looming in the distance, or stroll down one of the innumerable narrow little streets lined with shops and restaurants, and suddenly start thinking about a counterpoint of Liverpool kids and Russian kids, calmly studying art on the one hand, desperately holding it together on the other.  Or you might find yourself trying to backpedal several centuries and imagine what it would be like for Parisians circa 1640 entering St Eustache from very different streets and hearing a woman’s singing voice echoing off those cavernous vaults.

 

 

Anwar al-Awlaki, then and now

 

The Wall Street Journal provides a retrospective look at the extensive positive media coverage received by Anwar al-Awlaki, an American citizen recently killed by drone attack in Yemen.

In the early 2000′s, al-Awlaki was hailed as a moderte Muslim capable of bridging the cultural gap between Islam and the West.  Some excerpts…

 

New York Times:

…Mr. Al-Awlaki, who at 30 is held up as a new generation of Muslim leader capable of merging East and West: born in New Mexico to parents from Yemen, who studied Islam in Yemen and civil engineering at Colorado State University.

 

Baltimore Sun:

“Al-Awlaki bridges the two worlds as easily as he shifts from lecturing on the lives of the prophets to tapping phone numbers into his Palm Pilot [a now-antiquated electronic device],” reported the paper on October 28, 2001. “He and other Muslims say they support action against terrorist leader Osama bin Laden in retaliation for the Sept. 11 terrorist attacks[.]”

 

NPR:

“Awlaki, whose mosque is one of the largest in the U.S., sees himself as a Muslim leader who could help build bridges between Islam and the West. [B]ut political scientist Telhami says these are difficult days for Muslim moderates”

 

 

Interesting background information on (reportedly) the first American citizen to be assassinated abroad.

 

Esquire argues Jon Stewart needs to take a stand.

 

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Ross Douthat takes on the income inequality issue in a NY Times op-ed piece.   The issue of income inequality is at the very heart of liberal thought development.  It stems from the early 1800′s, when the excesses of capitalism (long hours, low wages, child labor, etc) demanded reform.  Britain passed the Poor Law to provide subsistence level support for all citizens.  By 1900 the call expanded beyond subsistence to an argument that all members of a just society had a right to a ‘living wage’, and that if the economy did not provide a job with a ‘living wage’ it was by no fault of the worker, and the just state should step in to ”make good” the promise of a living wage.   This was to be provided by taxing the rich; redistribution of income.

The problem was, how much redistribtion was the right amount?  The early writers took no position, and essentially adopted the Utilitarian principle of the ‘greater good’.  Applied, the idea was we should tax the wealthy and redistribute their income until it caused more harm than good.  This cavernous gap in ideology has remained an open question for over 100 years.  How to resolve it?

One of the more popular methods became comparasions of income between the top and bottom tiers.  I have not yet come to the exact argument as to why a widening gap between top and bottom is a de facto social injustice.  Nonetheless, it is widely considered a ‘bad thing’.  But is it?

Mr. Douhat introduces us to factors that effect changes in income inequality:

For instance, inequality is driven in part by low-skilled immigration: it nudges wages downward for native workers, and the immigrants themselves are taking longer to achieve upward mobility than earlier generations did…

Inequality is also driven by the collapse of the two-parent household, which disproportionately affects the poor and working class, depriving them of the social capital they need to rise…

Inequality is perpetuated by our failing education system — and especially by the bloated cartel responsible for educating the nation’s poorest children.

Lacking an objective statement of the ideal income equality, the US is usually compared unfavorably to European countries.  A 1994 paper by Richard Freeman and Lawrence Katz addresses the comparasion:

Why did wage inequality and educational wage differentials rise more in the United States than in other advanced countries?  We attribute the exceptional experience of the United Sates to the way shifts in the supply of and demand for skills work themselves out in the decentralized U.S. labor market, compared with how they operate in other labor markets.  Our explanation has three parts…

The first is that changes in the supply of and demand of labor skills substantially alter wages and employment of different groups of workers in the manner predicted by economists’ supply and demand market-clearing model…We further expect supply and demand to have their largest effect on young or less experienced workers on the active job market as opposed to experienced workers with substantial job tenure…

The second part of our explanation identifies…differences in wage setting and other labor market institutions across countries…The stronger the role of institutions in wage determination, the smaller will be the effect of shifts in supply and demand on relative wages…[E]ducation and training institutions also mediate the effect of market forces…Social insurance and income maintenance institutions also affect labor outcomes…generous income maintenance or unemployment benefits that allow workers to remain unemployed for a long period can reduce their willingness to take low wages to obtain work… 

For the third part of our explanation we turn to institutional changes, such as product market deregulation and changes in unionization…The important institutional changes in the 1980’s were the decline in trade union power, which was exceptional in the United States, and the decentralization of collective bargaining that characterized diverse European countries.  Both of these developments are likely to produce greater earnings differentials. 

To simplify, one explanation for income inequality is that the U.S. labor market is shifting towards higher paying jobs requiring education and away from lower paying jobs.  A bad thing?  Should we ‘fix’ the ‘problem’ by taxing the higher paid?  Mr Douthat concludes:

The European experience suggests that specific policy interventions — the shape of the tax code, the design of the education system — may matter less in the long run than the sheer size of the state. If you funnel enough of a nation’s gross domestic product through a bureaucracy, the gap between the upper class and everybody else usually compresses.  But economic growth often compresses along with it.  This is already the logic of our current fiscal trajectory: ever-larger government, and ever-slower growth.  That combination could eventually create the more egalitarian America that Democrats have long promised to deliver. The question is whether Americans will thank them for it.

 

 

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The baseline goal of health care reform is to provide quality care to the maximum number of people at an affordable cost.  Seems obvious, but in the endless debate about public versus private, death panels, the heavy hand of government or rapacious health insurance companies that basic goal vanishes into verbiage.

To this end, this article about the Swiss system is a useful tonic. It has the flexibility of  a private system, with the proviso that requires everyone to carry insurance and sets basic parameters regarding profitability and costs of coverage. Of course there are problems–how could there not be? Cost to individual citizens tends to run high, and there is some friction between doctors and insurance companies about allowable procedures. Still, the overall cost of the system is far below ours, and the quality of care is generally high. These virtues entitle the Swiss system at least to a hard look.

 

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California’s 2/3 supermajority rule for spending legislation is addressed in an article for truthout.org 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.

 

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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.

 

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Where Did “We” Go?  By Thomas Friedman

 

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

 

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

 

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A look at national health care systems around the world

 

 

 

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Hillary’s Honduras Obsession By Mary O’Grady

 

renocol_ThomasFrankLiberals and Civility      By Thomas Frank

 

Compass2 

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?

 

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?”"  ( http://tinyurl.com/ord3sg )
 
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”.  ( http://tinyurl.com/jxfev )
 
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.  
 

Tessie’s birthday is today; she’s 5.

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.

20 years.

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.

 

*41% of 45 years of 5 day work weeks = 18.75 work week years, rounded to 20 to account a bit for earning more at the end of her life than the beginning

 

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.

 

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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‘.

 

Hayek

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.

 

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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.

 

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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…

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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

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

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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.

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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

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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

 

Portrait_of_Robert_Owen_(1771_-_1858)_by_John_Cranch,_1845

Robert Owen (14 May 1771–17 November 1858), born in Newtown, Montgomeryshire, Wales was a social reformer and one of the founders of socialism and the cooperative movement.

Owen’s philosophy was based on three intellectual pillars:

  1. First, no one was responsible for his will and his own actions, because his whole character is formed independently of himself; people are products of their environment, hence his support for education and labour reform, rendering him a pioneer in human capital investment.
  2. Second, all religions are based on the same absurd imagination, that make man a weak, imbecile animal; a furious bigot and fanatic; or a miserable hypocrite; (in dotage, he embraced Spiritualism).
  3. Third, support for the putting-out system instead of the factory system.  (This a reference to outsourcing to contractors)

This is from the opening of his wiki article, check out the full article.   His utopian community at New Lanark mill was circa 1810.   He started two others in 1825 one at  New Harmony, Indiana, and another near Glasgow, Scotland.   So far in this inquiry, these are the earliest dates found in the implementation of western socialist ideas, though “Owen’s new views theoretically belong to a very old system of philosophy, and his originality is to be found only in his benevolent application of them”.  The term socialism was first used by Henri de Saint Simon (1760-1825), and came into popular usage around 1835.   I have also found a book published in 1869, History of American Socialisms,  which sites Owen as the earliest examples of the “movement”.

Owen’s first pillar is particularly interesting in light of modern psychology as we’ve discussed in Are we born Liberal?  Wouldn’t it be fascinating if the difference between liberals and conservatives comes down to one’s opinion of an individuals responsibility for his character?  Is this free will vs determinism?

 

Odds of dying calculator found here.

Not surprisingly, if you enter age 50-59, all causes, and compare US and Europe, you’re twice as likely to die in the next year if you live in Europe vs the US.

 

Regarding abortion I have alway been pro-choice. While researching liberal thought, quite by accident came across this idea…

“the worth of a human fetus, whether it is allowed to live or to be extinguished, is entirely based on the feelings of the mother. If the mother wants to give birth, the fetus is of incomparable worth; if the mother doesn’t, the fetus has the value of a decayed tooth.”
 
Doesn’t that just make you think?

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