February 23, 2011

Civics Lesson

A bunch of Godly white men, many of them slaveholders, met in various eastern cities. They made this document after a constitutional convention or two. They said, "Il sera!" and then l'etais. The law has always followed their intent ...or not

The elementary civics lesson is that the government is like paper-rock-scissors, with each branch having some control over the others. The dual chambers in the legislative branch make the rules, but the executive branch has to say it is ok. Then, if someone thinks they were wrong, they can bring it to the judicial branch, which is like climbing steep stairs. If you can appeal to the Supreme court and they agree with you, the law is overturned. If they don't agree with you, or don't bother to listen to you, you are essentially wrong. And you remain wrong unless someone in the future has a similar problem and takes the same steps and this time there's a different make-up of the court. Then you can be right where you were once wrong.

For example, black people were once property even though they counted in the census (native Americans were 'untaxed people' and didn't count at all!). A black who was not property sued, asking "Can I be a citizen?" And the infinitely wise court told Dredd Scott "I don't think so." That's case law.

A dozen years and a war later we passed through legislation saying, "Sorry about that. You can be a citizen if you were born in the country."

And fifty years later we let ladies vote too.

All questions are the wrong questions

Of course, he will recommend a transition. That's his job. I bet he makes extra on the transition also.

We know that we would ultimately benefit from making the transition too, but I retire in three years. I have zero interest in learning a new system when I'm comfortable with the old way and highly proficient with the paper records. I know all the patients and their kids. Dr. Johnson delivered all of them. Now some big shot from the city will come in and tell me that we're doing it all wrong. We may not be doing it your way, Mr. Big Shot, but we're doing just fine, thank you.

How much is this going to cost anyway? Is it worth it? To tell you the truth, Dr. Johnson's been slipping lately. He didn't retake his boards. Anything more difficult than a cold we refer to the county seat and their fancy hospital. They have electronic records there. They also have buildings that are three and four stories tall. Is that the way we do it here? Of course not, but it works just fine.

Oh, we'll do it. It's just ... you ever feel like you've been left behind? That's how I feel every day now. I'm just another milk cow that will be put out to pasture.

I think Doc is retiring soon. And this...this will close up. We haven't found anyone to take over the practice. It’s the whole town. The only ones here are the elderly, the kids, and the sad cases who wanted nothing more than to get out...they never did. You see them down at the Sports Page more than you see them at any church. My kids made it. All three went to the university. They don't come back....

My kids never call me, and you ask me about medical records? At least I have my cats.

February 17, 2011

Advance Healthcare Directives: Power of Attorney for Healthcare and Living Wills

In an episode of the sit-com “Seinfeld,” the character of Kramer rents the movie The Other Side of Darkness, a fictional straight-to-video movie that deals with a woman in a coma. Frightened by the movie, he has a living will drawn up. At first, he considers making Jerry his executor, but decides that he is too sentimental after Jerry refuses to throw away his old tennis racquet. Kramer decides Elaine should be his executor instead and they meet with a lawyer After Kramer finishes watching the movie, when the woman miraculously comes out of the coma, he decides he needs to get his living will annulled, but he misses his appointment because he drives so slowly for fear of getting in an accident (‘The Jerk Store”).
The height of the plot is revealed when Kramer talks to Jerry and reveals his own ignorance on the topic. Kramer says, "I finished watching The Other Side of Darkness and the coma woman wakes up. I didn't know it was possible to come out of a coma."
Jerry surprised at Kramer’s ignorance, retorts, "I didn't know it was possible not to know that."
In this episode, the character’s past history as a lovable bumbling fool are played for laughs, but in reality the issues surrounding Kramer’s fears are very real. In our society talking about death can be a touchy and tricky subject, but death and near-death situations are things that will happen to everyone so it is best that we shed our shame and fear and talk about the extinguishing of our candle in a responsible manner. I talk not to coming to terms with your God, but at looking at the necessities we have in this world. A responsible adult will have pre-defined both power of attorney and a living will.

Power of Attorney for Healthcare and Living Wills Defined
Before we delve too much further into the examination of why these tools are important, we should have a look at just what they are. A living will is defined as a written, legal document that spells out the types of medical treatments and life-sustaining measures you do and don't want, such as mechanical breathing (respiration and ventilation), tube feeding or resuscitation. In some states, living wills may be called health care declarations or health care directives (“Living wills and advance directives for medical decisions”). An important thing to notice here is that a living will does not necessitate any procedure be done or not done. The treatments you wish to have done to you as you look at the possible terminal issues are drawn up in advance with a lawyer who specializes in end-of-life care. Drawing up a living will allows you as a future patient to make some of the hard decisions beforehand so that some of the most meaningful decisions you will ever make are not made in a rushed panic. Having a living will allows you to set the terms at which you live.
The situations covered in a Living Will are not exhaustive. Situations may arise when what is covered in the Living Will does not happen and what is happening was completely unforeseen. If this happens, and you are not capable of making a decision, you need someone who will act in your best interests. In this case, going hand-in-hand with the Living Will is the Power of Attorney. The Medical Power of Attorney is defined as “a legal document that designates an individual — referred to as your health care agent or proxy — to make medical decisions for you in the event that you're unable to do so. A medical POA is sometimes called a durable power of attorney for health care. However, it is different from a power of attorney authorizing someone to make financial transactions for you” (“Living wills and advance directives for medical decisions”). Both the Power of Attorney and Living Wills are called advance directives (along with a Do Not Rusticate order). Advance directives ensure that you care will be along the lines of your wishes. You can make sure that no expense is spared, or you can make sure you go gently into that good night. The key is that you give yourself agency beforehand so you live and die as you please.

Advance Directives in the real World
Kramer’s fictional situation may have been played for laughs, but in the real world a lack of advance planning for end-of-life situations can be very tragic. The most notable situation in recent memory where such issues came up was in the case of Terry Schiavo. In the spring of 2005, Ms. Schiavo came to the national attention but her struggle and the struggle between her loved ones persisted for years prior to the media frenzy. “Schiavo suffered severe brain damage in 1990 after her heart stopped because of a chemical imbalance that was believed to have been brought on by an eating disorder. Court-appointed doctors ruled she was in a persistent vegetative state, with no real consciousness or chance of recovery” (Terri Schiavo dies, but battle continues). The struggle over her life was born out between her husband and her parents. Her husband, Michael long maintained that Terry had specifically stated that she would never wish to live in a condition like the one she had deteriorated to. Her parents fought Michael at each step of the process, involving the state supreme court and even in the end the United States Congress before it went to the federal courts. A judge eventually sided with the husband – her feeding tube was removed – and she was allowed to pass on as the Supreme Court declined to hear the case.

The Schiavo case became a circus. The media engulfed the small town the hospice was located in, it made the dedicated workers feel like prisoners as media and various hangers-on of wide-ranging interests made the Schiavo bed a proxy for so many other issues raging in the ongoing culture wars. The Schiavo case was a circus that did not have to be. The only reason it was a circus was because of the lack of legal documentation prior to the 1990 incident that endangered Ms. Schiavo’s health. Had she planned ahead, like Kramer, then the ensuing circus would never have taken place. The acrimony between the two warring parties would have been avoided because the true intent of the patient would have been known and the person she would have wanted to speak for her would be allowed to speak. Unfortunately, episodes like this need to happen in our society before people are willing to talk about such a sensitive topic. A 2006 study, taken a year after the Schiavo case brought the need for advance directives into the public consciousness, showed that only about a quarter of adults in the United States had living wills (“A year after Schiavo's death, 'living will' quandary remains”). A quarter is far too low a rate for a country that will not talk about death. Please, make sure you have your advance directives in place now and not later. Later may be too late. Do not do it for your loved ones. Do it for yourself.

Works Cited

Mayoclinic.com. “Living wills and advance directives for medical decisions” http://www.mayoclinic.com/health/living-wills/HA00014 Accessed February 2, 2011.
MSNBC. “Terri Schiavo dies, but battle continues” http://www.msnbc.msn.com/id/7293186/.Accessed February 2, 2011.
USAToday. “A year after Schiavo's death, 'living will' quandary remains” http://www.usatoday.com/news/health/yourhealth/2006-04-02-your-health_x.htm. Accessed February 2, 2011
Wikipedia, “Jerkstore” http://en.wikipedia.org/wiki/Jerkstore Accessed February 2, 2011.
Youtube. “Seinfeld The Comeback: Coma” http://www.youtube.com/watch?v=c0snC9_E_no Accessed February 2, 2011.

Schizophrenia: Causes and Consequences


In our country, diseases of the mind are often stigmatized. To have any sort of mental defect is a character flaw that one should be able to work away through an effort of the will. If you cannot work through this, you are less of a person and are often left on the outside of normal working society. This bias seeps into the apparatus of medical care in America also. Until very recently, it was common for medical insurance plans to lack compensation for mental disorders at the level they compensated for physical ‘organic’ illnesses and accidents. The irony in such an unbalanced healthcare system is that mental disorders themselves are organic diseases. People who suffer from conditions as varying as bi-polar disorder, anxiety attacks, and anorexia nervosa do not just suffer; they often suffer in silence and suffer alone.

Figure 1: Mental Illness is often suffered alone

A personal connection
I write this because I do not want those who suffer to have to suffer in silence. We as a society have begun to normalize conditions such as depression and ADHD. I personally feel that this is because pharmaceutical companies have found particular chemicals that are able to treat those conditions and on some level ‘normalize’ the victims so that they can participate in society and not be defined by their disease.
I write this because I have been touched and my own life has been affected by mental illness. I have been fortunate in that I personally have not suffered but I have been affected. I have had friends, colleagues, coworkers, and family members suffer. I would not know though if those people had not been comfortable enough to discuss with me their situations. Everyone is in the same boat whether he or she is aware of it or not. In fact, the only things more shocking than the prevalence of mental illness are the silence that surrounds those who suffer and the stigma of having a disease.
I write this for my friend Steve . Steve was diagnosed in 2005 with schizophrenia. He is an honest and loving man, but as long as I have known him both before and after his diagnosis, he has been in a continual process of piecing his life together after his disease broke it apart. He has lost friends, jobs, and even access to his own children due to his disease. His diagnosis helped explained and give reasons for his behavior. His diagnosis also helped to show a path to recovery and treatment that was not there for him before. He has had his vicissitudes; his disease is now largely controlled through medication and therapy. Steve’s self-awareness helps both him and everyone around him. When he was first diagnosed, I taught myself as much as I could about his condition so I could understand him better. I hope that I can do the same for my readers here, so we can help the process of walking mental illness from the shadows.

What is Schizophrenia?
As a result of the too-common silence on mental disorders, many are poorly understood. They are often depicted in the media in a poor or untrue light, to be demonized when someone acts poorly as a result of the condition. This is not to excuse people of their acts, such as the shooters at Virginia Tech, Northern Illinois University and the recent tragedy in Arizona. People are ultimately responsible for their actions, but lack of treatment and silence on the issues creates situations where tragedies happen when early intervention would have helped. Before we can come to an understanding of any disease, we have to look at the broad definition what the disease is. Schizophrenia is defined as: “Schizophrenia is a group of severe brain disorders in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions and disordered thinking and behavior. The ability of people with schizophrenia to function normally and to care for themselves tends to deteriorate over time.
“Contrary to some popular belief, schizophrenia isn't split personality or multiple personality. The word "schizophrenia" does mean "split mind," but it refers to a disruption of the usual balance of emotions and thinking
“Schizophrenia is a chronic condition, requiring lifelong treatment” (Definition). The important thing to note here is that there is no one schizophrenia but we see that it is a cluster of related disorders that are often defined through the symptoms that occur.
The symptoms that characterize schizophrenia are varied. They include the stereotypical ‘voices in the head’ but such auditory hallucinations are not always present. WebMD describes the symptoms well: “Typically with schizophrenia, the victim’s inner world and behavior change notably. Behavior changes might include the following: social withdrawal, depersonalization (intense anxiety and a feeling of being unreal), loss of appetite, loss of hygiene, delusions, hallucinations (hearing or seeing things that aren't there), and the sense of being controlled by outside forces.
“Oftentimes, a person with schizophrenia may not have any outward appearance of being ill. In other cases, it may be more apparent, causing bizarre behaviors. For example, a person with schizophrenia may wear aluminum foil in the belief that it will stop one's thoughts from being broadcast and protect against malicious waves entering the brain.
“People with schizophrenia vary widely in their behavior as they struggle with an illness beyond their control. In active stages, those affected may ramble in illogical sentences or react with uncontrolled anger or violence to a perceived threat. People with schizophrenia may also experience relatively passive phases of the illness in which they seem to lack personality, movement, and emotion (also called a flat affect). People with schizophrenia may alternate in these extremes. Their behavior may or may not be predictable” (Types and Symptoms).Schizophrenia touches every aspect of the victim’s life. The symptoms are not just delusions and hallucinations, but all the symptoms negatively affect the potential for living a ‘normal’ life.
The symptoms of schizophrenia cluster around different elements of a sufferer’s personality. This aspect of the disease has led to the development and diagnosis of several different types of schizophrenia, including aspects of behavior that would surprise most people as being lumped under schizophrenia. The various types of schizophrenia are defined here and on WebMD as: “Paranoid-type schizophrenia is characterized by delusions and auditory hallucinations but relatively normal intellectual functioning and expression of affect. The delusions can often be about being persecuted unfairly or being some other person who is famous. People with paranoid-type schizophrenia can exhibit anger, aloofness, anxiety, and argumentativeness.
“Disorganized-type schizophrenia is characterized by speech and behavior that are disorganized or difficult to understand, and flattening or inappropriate emotions. People with disorganized-type schizophrenia may laugh at the changing color of a traffic light or at something not closely related to what they are saying or doing. Their disorganized behavior may disrupt normal activities, such as showering, dressing, and preparing meals.
“Catatonic-type schizophrenia is characterized by disturbances of movement. People with catatonic-type schizophrenia may keep themselves completely immobile or move all over the place. They may not say anything for hours, or they may repeat anything you say or do senselessly. Either way, the behavior is putting these people at high risk because it impairs their ability to take care of themselves.
“Undifferentiated-type schizophrenia is characterized by some symptoms seen in all of the above types but not enough of any one of them to define it as another particular type of schizophrenia.
“Residual-type schizophrenia is characterized by a past history of at least one episode of schizophrenia, but the person currently has no positive symptoms (delusions, hallucinations, disorganized speech or behavior). It may represent a transition between a full-blown episode and complete remission, or it may continue for years without any further psychotic episodes” (Types and Symptoms). As you see, there is a surprisingly wide range and a very open definition of just what it means to be schizophrenic. The intensity of the disease varies and how people cope with their symptoms vary. You can learn to live with it or you can try to drown it out with alcohol, but ultimately the need is for victims to seek treatment.

Before we can treat a disease though, we have to know what causes a disease. That way we can disrupt the disease’s pathway and short-circuit the disease before it can act out. This is as true for bacterial infections as it is for mental disorders. When looking for an organic cause of schizophrenia though you will be disappointed: “It's not known what causes schizophrenia, but researchers believe that a combination of genetics and environment contributes to development of the disease.
“Problems with certain naturally occurring brain chemicals, including the neurotransmitters dopamine and glutamate, also may contribute to schizophrenia. Neuroimaging studies show differences in the brain structure and central nervous system of people with schizophrenia. While researchers aren't certain about the significance of these changes, they support evidence that schizophrenia is a brain disease (Causes).
Unfortunately, mental disorders are poorly understood, even though progress is being made every day. The national institute of mental health notes its obscure cause, but notes the genetic aspect of the disease: “Scientists have long known that schizophrenia runs in families. The illness occurs in 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. The risk is highest for an identical twin of a person with schizophrenia. He or she has a 40 to 65 percent chance of developing the disorder” (What causes schizophrenia?).
Luckily, for the sufferers of the disease, there are treatments for schizophrenia, even though the cause is unknown. In treating schizophrenia, the attack is like that of treating the common cold. You cannot fully treat the disease, but you can treat the symptoms. There is a variety of medicines available to treat the symptoms. For example, “Antipsychotic medications have been available since the mid-1950's. The older types are called conventional or "typical" antipsychotics. Some of the more commonly used typical medications include: Chlorpromazine (Thorazine); Haloperidol (Haldol), Perphenazine (Etrafon, Trilafon); Fluphenazine (Prolixin)” (How is schizophrenia treated?). There have been advances in the chemicals used to treat the disease, but they all exist to limit the psychotic symptoms, hallucinations, and breaks with reality that characterize the disease.
Unfortunately, the medicines used to treat schizophrenia have side effects that may make the victim discontinue use of the medicine, or perhaps they need a different drug or dosage for their medicine to be effective. For this reason, it is necessary that effective treatment of schizophrenia must include a trusting relationship between the doctor and the patient. Once psychotic episodes are controlled then the patient can move on to psychosocial treatments, which “can help people with schizophrenia who are already stabilized on antipsychotic medication. Psychosocial treatments help these patients deal with the everyday challenges of the illness, such as difficulty with communication, self-care, work, and forming and keeping relationships. Learning and using coping mechanisms to address these problems allow people with schizophrenia to socialize and attend school and work” (How is schizophrenia treated?).
By understanding and being aware about mental diseases, we as a culture can move past the stigmatization of those who suffer from the disease. Although the disease, such as schizophrenia, may be hard to define and poorly understood, we can at least make an attempt to understand that one percent that suffers with it. We can stop pointing fingers at the failings of those around us and instead point them towards a place of treatment so that they can steady their symptoms and rejoin society as productive members. My friend Steve did and we need to help everyone who suffers to be able to take the same path.

Works Cited
“Causes”. MayoClinic.com http://www.mayoclinic.com/health/schizophrenia/DS00196/DSECTION=causes Accessed February 13, 2011.

“Definition”. MayoClinic.com http://www.mayoclinic.com/health/schizophrenia/DS00196 accessed February 13, 2011.

“How is schizophrenia treated?” National Institute of Mental Health http://www.nimh.nih.gov/health/publications/schizophrenia/how-is-schizophrenia-treated.shtml Accessed February 13, 2011.

“Photograph”. Prison Advice and Care Trust http://www.prisonadvice.org.uk/?q=volunteerstory Accessed February 13, 2011.

“Schizophrenia Types and Symptoms”. WebMD.com. http://www.webmd.com/schizophrenia/guide/schizophrenia-symptoms Accessed February 13, 2011

“What causes schizophrenia”? National Institute of Mental Health. http://www.nimh.nih.gov/health/publications/schizophrenia/what-causes-schizophrenia.shtml Accessed February 13, 2011.

February 9, 2011

Depressions are not Acts of God: on the Lords of Finance

Ahamed, in this book, lays out just what happened in the time period covering the run-up to the First World War to the run-up of the second. The subtitle of the work speaks of the bankers who broke the world, and I can imagine it felt something like that, both for the workers, the reinters and the capitalists. There’s a good bit of economic history here but a paucity of the political history – you need to know that for context. What you get here is the economic driver of that context that happened (If you believe in economic determinism).


Late in the book, the author quotes the newly-sworn-in president, Franklin Roosevelt in context of temporarily unpegging the dollar from the gold standard. He supposedly joked that reporters can ask all they want about the gold standard because no one in the public knows what the gold standard is. (Broadly, it is keeping a fixed exchange rate between a currency and gold. Naturally it becomes more complicated in practice.) The gold standard is the center of this book. In this book, it is the devil – once the central banks allow for floating exchange rates economic prosperity starts to work out. In fact, where at one point the French central bank’s gold holding made it the strongest developed country economically and politically, once everyone started going off the gold standard the holdings became a liability and the Franc was too strong.

I may be a little reductive here (because thick book > short review) but the author’s insistence is that the central banks were too stuck on the gold hoarding orthodoxy and too slow to listen to the genius that was J. M. Keynes (and even Irving Fischer). Ahamed even draws the parallels to contemporary situations. It’s an imperfect parallel – there’s no large economy suffering under the yoke of reparations. However, we may be able to learn from past history and correct our policies even at this late date in our generation’s depression. Central Banks are not a Panacea, but our Federal Reserve System is not a monster from Jekyll Island either. It could use some more oversight, but it can be a powerful tool in policy. Those who love the idea of hard money should read this, at least for a little context – especially since the global population and economic growth have boomed in the last 80 years and the gold supply has not. Inelastic supply stays that way.