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Shelby Foote, The Civil War

Herman Melville, Moby-Dick, or the Whale

Michael Punke, The Revenant

Bill Bryson, Notes from a Small Island



The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project

Jimmy Kimmel and Pre-Existing Conditions

Late night comedian Jimmy Kimmel delivered a powerful and important message last, an argument I have been making for years: There are some people who will never be able to afford their health insurance obligations. They lack the financial resources to pay for their treatment, and they always will. But society at large can afford to pay for these treatments, and should.

This seems self-evident. I don't have to go far on my daily hospital rounds to run into people who have medical problems that will cost more to treat than the patient can ever earn. Many stroke patients and most cancer patients fall into this category. Almost all children born with serious congenital diseases fall into this category as well.

This was Jimmy Kimmel's point. That children with serious medical problems will never be able to pay back their medical bills, and shouldn't be required to. Everyone has a basic right to life -- after all, the Declaration of Independence argued for the basic human rights of "life, liberty, and the pursuit of happiness." I do not think it was accidental, either, that the Founders put life first on the list.

No one can be faulted for wanting to live. Survival and the avoidance of pain, both goals of medical treatment, are the most basic instincts humans have. As a free society, we ought to be all about helping people to live when they want to, since all other freedoms depend on the right to live. After all, a dead person can't have rights. To have other any other right -- speech, religion, or voting -- you have to be alive first.

So, since all human rights flow from life itself, it makes sense to argue that the right to live -- that is, the right to life-saving healthcare access -- should be one of the chief goals of a free society. The fact that it costs a lot to insure everyone doesn't seem like much of an excuse. Defending the country is expensive. Educating children is expensive. Incarcerating millions for the maintenance of civil order is expensive. This hasn't stopped us before.

Critics of Kimmel and of health reform in general have argued that no person should be forced to pay for the health problems of another. That forcing a free individual to pay for another's health is a violation of liberty, just as it would be unfair to force me to buy my neighbor's shoes, or repair his car. In a free society, the argument goes, every individual should be responsible for himself.

This philosophy makes sense in theory. We are, after all, a free country. Why should I be required to pay for someone else's medical problems?

The problem is that the theory breaks down when faced with reality. If I don't pay a police force to protect someone else's home, there will be no police to protect me when my home is threatened. If I don't pay to educate other people's children, who will be educated enough to be my doctor, fix my computer, fly my airplane, educate my own children?

If I don't fund a health care system to take care of others while I am well, what reason do I have to expect it to exist when I get sick? Hospitals don't just pop into existence when we need them, like scenery props in a cheap movie. They need to exist all the time, so they can exist when rich people are in need.

And then there is the problem of consequences, which was also Kimmel's point. It is one thing to stand for the theory that the government shouldn't tax me or force me to buy health insurance, but it is another thing to face the outcome of that decision: A newborn baby with heart disease who must die because his parents can't afford the operation.

Kimmel was speaking out of experience. This is what we need in the health care debate, more people speaking out of experience. More people who have been denied care, who have had their care limited, or who have been frustrated by the shortcomings of the system that we have now. Healthcare reform cannot be about pie-in-the-sky political theories. Healthcare is about what happens to real people, in real situations.

One of the things that attracted me to medicine in the first place was its practicality. Medicine is conducted in the real world and is concerned with real people. No patient cares if an antibiotic will work on her disease in theory. She wants to know when she takes the antibiotic, if it will make her feel better. This is what medicine is all about. It is all medicine has ever been about.

As a doctor, I don't give a flip about constitutional arguments over health insurance. I don't care whether Mr. Jefferson thought it was fair or unfair to tax one person to treat the illness of another, or if Mr. Madision thought health administration should be a federal or a state responsibility. I care only that the system works, and that it works for a price that my patients can afford. My concerns are purely practical. Will it help me to take care of patients, and to help heal sick people?

For this reason, I think it is wrong to deny people insurance because of pre-existing conditions. As a doctor, it is my job to discover medical problems, which means I am in the business of finding pre-existing conditions. It is not acceptable that doctors do what they are trained to do, and in doing so, exclude patients from further care. It is, to say the least, impractical.

There has been a pitched debate over the funding of health care in this country for as long as I have been an adult, and it is ridiculous. American citizens don't want to think about their health insurance any more than they have to think about electricity, or roads, or running water. They just want to have it, and pay a reasonable price for it. When an intersection needs a stoplight, citizens expect government to put one in. When there is a fire, they expect the fire department to show up. What they do not expect when a fire breaks out is for a carload of politicians to drive up and lecture them about the constitution.

This should not be so hard. The only reason it is hard is because the discussion is dominated by people who can afford good doctors and who have adopted the principle that everyone else should be as rich as they are, not matter their age, genetics, or social condition. These people of high priniciples will raise taxes to put the poor in jail, but not a finger to help them with their doctor bills.

This is and always has been about money. About who has to pay what and when. For once in my life, I'd love to see the U.S. government grow up, make a fair estimate of what it would cost to insure everyone, figure out how to pay it, and then move on without further whining. This is not about "us" and "them." There is no "them;" it is all "us." Everyone wants health insurance.


Book Catechism: Colorless Tsukuru Tazaki and His Years of Pilgrimage, by Haruki Murakami

Describe this book in one word.

Can't do it. I hate reductionism, anyway.

But on the topic of reductionism: There is a great passage in this book about the massive Shinjuku train station in Tokyo. It describes a photograph that was taken at the station in the 1990s that was widely published in the United States, with an accompanying article that said, "Japan may be affluent, but most Japanese look like this, heads downcast and unhappy-looking." The main character of the novel, Tsukuru, disputes this observation: "The real reason that most passengers descending the stairs at Shinjuku Station during their packed morning commute were looking down was less that they were unhappy than that they were concerned about losing their footing."

That is to say, the station was so busy that in rush hour the crush forced people to look down to avoid being run over. It had nothing to be with being unhappy.

This is the non-reductionism at the heart of this fine novel. Murakami never allows us to settle into easy judgments. Tsukuru isn't really colorless. But in a way, he is. He goes on a long pilgrimage, but in the end he finds himself back where he was at the beginning. In many ways, at the end of the story he is the same person he was. But in another way, he undergoes profound change.

Well, that's awfully vague of you.

Ok. How about suspense as a one word description? It doesn't entirely fit but it's as good as a reductionist is going to get.

Now we are getting somewhere. Why suspense?

The book starts out with an inciting event and then slings the reader forward from big scene to big scene. It is very well plotted. It begins with Tsukuru being kicked out of a very close group of five friends he had in high school. His friends shun him from then on, with no explanation whatsoever. This completely unexpected event leaves him in shock.

After a few months of suicidal depression, Tsukuru rebounds with an unexpected friendship with a college student. This relationship ends as unexplicably as the loss of his high school friends. Years later, at the urging of Sara, his rather enigmatic girlfriend, he begins to look into his past, to find out what happened. One by one, he encounters his old friends, and has he does, the revelations mount. Each encounter with an old friend pushes Tsukuru on into the next one. And each encounter drives the reader forward as well.

I kept asking myself, What will happen when he meets the next one? To heighten the suspense, Murkamani sets the final encounter in rural Finland, making the last interview a spiritual and physical encounter. It is nicely done, a simple setup for an intensifying series of interactions, the stakes rising each time. I was surprised to find that the book was a real page-turner, not something I expected at all.

So the book is a mystery novel?

In a way. But some mysteries were never solved. In fact, several of the biggest questions raised by the plot were never answered.

In the hands of an inferior writer, this would be a real problem. But Murakami makes it clear that answering all the questions is not Tsukuru's quest. His quest is to learn to live with unanswered questions.

That is something we all must do. Learn to live with unanswered questions.

If that is true, why bother to read the book at all? In fact, why bother to write a book if you don't intend to answer questions?

It would be grossly unfair to the book to say it didn't answer any questions. It answered many. Just not all of them.

For example, Tsukuru inherits a Heuer watch from his father. It is an old watch, expensive. It doesn't keep perfect time, although it is pretty accurate. It has to be wound all the time or it will stop. Slightly temperamental, impractical, not at all like the rest of Tsukuru's life. Somehow this odd watch says something about Tsukuru, and about his father who wore it before him, but we never really understand what. But this is all right. We are not supposed to understand all of the vagaries about our lives. Tsukuru likes the watch; it is not like him, but not entirely different either. We can assume the same was probably true about his father, whom we never get to know.

And that is fine. Every loop does not have to be closed. Every watch does not have to run exactly on time.


Other Quote of the Week

Today after a quiet lunch in Madison, Mississippi, I went shopping with my wife at a second hand bookstore and picked up, for the princely sum of $1, a copy of of one of my favorite books, Dubliners.

The outcome of this pleasant adventure is that I get to share what in my opinion is one of the greatest closing paragraphs in the history of the English language.


A few light taps upon the pane made him turn to the window. It had begun to snow again. He watched sleepily the flakes, silver and dark, falling obliquely against the lamplight. The time had come for him to set out on his journey westward. Yes, the newspapers were right: snow was general all over Ireland. It was falling on every part of the dark central plain, on the treeless hills, falling softly upon the Bog of Allen and, farther westward, softly falling into the dark mutinous Shannon waves. It was falling, too, upon every part of the lonely churchyard on the hill where Michael Furey lay buried. It lay thickly drifted on the crooked crosses and headstones, on the spears of the little gate, on the barren thorns. His soul swooned slowly as he heard the snow falling faintly through the universe and faintly falling, like the descent of their last end, upon all the living and the dead.


-- James Joyce, "The Dead" (from the short story collection Dubliners.)


Quote of the Week

"Data describes humans, but data itself is not human. Stories are human."

                                                                     -- Me


Health Care Reform, by William Shakespeare

The battle over the repeal of Obamacare is in a ceasefire, but it is hardly over. And there is still immigration reform, and a Supreme Court nomination, and who knows what other political melees pending.

This time, rather than expound my own views on politics, I thought I would allow a few words from an old friend.

The quality of mercy is not strain'd,
It droppeth as the gentle rain from heaven
Upon the place beneath: it is twice blest;
It blesseth him that gives and him that takes:
'Tis mightiest in the mightiest: it becomes
The throned monarch better than his crown;
His sceptre shows the force of temporal power,
The attribute to awe and majesty,
Wherein doth sit the dread and fear of kings;
But mercy is above this sceptred sway;
It is enthroned in the hearts of kings,
It is an attribute to God himself;
And earthly power doth then show likest God's
When mercy seasons justice....
Though justice be thy plea, consider this,
That, in the course of justice, none of us
Should see salvation: we do pray for mercy;
And that same prayer doth teach us all to render
The deeds of mercy.

          -- William Shakespeare,
              The Merchant from Venice
              Act IV, Scene 1, ll. 182-200

Here Shakespeare, in one of his greatest speeches, makes a heartfelt case for justice tempered with mercy.

But he is after all Shakespeare. Which is to say, messy. Shortly after the character Portia delivers this sparkling speech, she uses the law to strip the Jew Shylock of half his fortune and force his conversion to Christianity. To make things worse, Portia is not even a judge, but instead a wealthy heiress fraudulently posing as a judge. Any legal decision she renders as a fake judge is illegal, and thus hardly an act of mercy.

Shakespeare's audience would have found this hilarious, but today the humor is tempered by the cruel and anti-semitic treatment Shylock receives. Yes, Shylock is a villain and yes, he does try to kill one of the main characters. But for all their boasting about superior Christian values, the Christians in the play do not exactly live up to their Christian values when they mete out punishment.

Portia admits as much in the first act, when she says, "I can easier teach twenty what were good than be one of the twenty to follow mine own teaching." That is, it is easier to teach others right from wrong than to follow the teaching yourself.

But then, that is the point of mercy, isn't it? "In the course of justice, none of us should see salvation" in Portia's speech means that if God is just, we have no chance of escaping punishment. Justice has very little meaning without mercy, because if all of us were punished fairly every time we did wrong, we would all be in jail -- or worse.

As Shakespeare argues, far from being a sign of weakness, mercy is a sign of strength: "Mercy is above this scepter sway; It is enthroned in the hearts of kings, It is an attribute of God himself."

If I were in charge of health care reform, I would, like Shakespeare, be more concerned with mercy than justice. And should I fail, I should seek mercy myself, and then make a second attempt.

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